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358 Cards in this Set

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Patients with a uterus can discontinue cervical cancer screening (Pap smears) between the ages of?
-- 65 to 70 if they have had three consecutive negative smears and no history of high-grade cervical intraepithelial neoplasia or cancer

-- Patients still need yearly bimanual and rectovaginal exam.

-- Mammograms are done annually, as breast cancer increases with age.

-- Colon cancer screening is recommended at age fifty.

-- if the patient has an exaggerated thoracic spine curvature, termed a dowager’s hump, likely secondary to thoracic compression fractures secondary to osteoporosis. If this is confirmed on a bone density test, she may benefit from the addition of bisphosphonates
Guidelines for initiation of cervical cancer screening is recommended at?
-- age 21 regardless of coitarche (virginity)
17yo admits to having sex for 3 yrs -- pregnancy test is negative -- next best step?
-- Counseling about and screening for sexually transmitted infections is the best next step

-- Discussions about various contraceptive methods are always recommended in this setting.

-- no Pap --> guidelines for initiation of cervical cancer screening is recommended at age 21 regardless of coitarche
49 year-old G3P2 who is thin, tachycardic with frequent irregular menses, temperature instability, and anxiety and sleep disturbance?
-- This patient has signs and symptoms very suspicious for hyperthyroidism; therefore, a thyroid stimulating hormone test and a pregnancy test would be the most appropriate choice

-- Another possible explanation would be perimenopause

-- Since she has active heavy vaginal bleeding, the Pap smear should be rescheduled for a time when she is not bleeding. Blood, inflammation and drying artifact can hamper the cytopathologist’s ability to interpret the smear.
What gives lower abdominal pain, adnexal tenderness, fever, cervical motion tenderness, and vaginal discharge?
Acute salpingitis (pelvic inflammatory disease)
Mucopurulent cervicitis with exacerbation of the symptoms during and after menstruation?
classically gonorrhea
What is frequently associated with gonorrhea and also causes cervicitis and pelvic inflammatory disease?
Chlamydia
What has a frothy, yellow-green discharge but would not cause cause fever and abdominal pain? May have a strong odor?
Trichomonas
What has a thick white cottage cheese like discharge but would not cause cause fever and abdominal pain?
Candida
What is the Initial triage of the finding of atypical squamous cells of undetermined significance (ASCUS) on a Pap smear?
HPV typing
If a high-risk HPV type is detected, then?
-- the patient needs a colposcopy with biopsies

-- An alternative approach can be close surveillance with repeat Pap smears in 6 months and 12 months and if both are negative, she may return to annual screening. Colposcopy is indicated for any cytological abnormality
When do you initiate treatment by way of cone biopsy, LEEP, or cryotherapy?
-- with a biopsy-confirmed diagnosis of cervical dysplasia
Erythematous patches on the cervix?
-- characteristic “strawberry cervicitis” of Trichomonas
What do you see under the microscope with Trich?
-- unicellular, ovoid protozoans, which are easily seen moving across the slide with flagella

-- The slide must be examined immediately. The discharge is mixed with saline and placed on the slide with a cover slip.
What do you see under the microscope with BV?
-- Clue cells are seen on a saline wet mount

-- adherent coccobacillary bacteria that obscure the edges of the cells

-- A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial vaginosis is present
Yeast vaginitis is characterized by?
-- a thick white clumpy discharge which results in erythema, swelling and intense pruritus
What do you see under the microscope with HSV?
-- Multinucleate giant cells and inflammation
Classic primary herpes s/s?
-- painful genital ulcerations, fever and dysuria
Misc TX of HSV outbreak?
-- Given the presence of one sexually transmitted infection, screening should be offered for other STIs

-- Resolution of the acute episode is required before a speculum can be inserted to allow endocervical sampling for gonorrhea and chlamydia

-- ff it was a high-risk exposure, prophylactic empiric treatment could be offered to cover gonorrhea and chlamydia (ceftriaxone & azithro)

-- counseled that primary herpes can be acquired despite condoms and even by oral-genital inoculation

--Hepatitis B vaccination should be offered to protect her against any future exposures

-- encouraged to discuss her diagnosis with all sexual partners and to continue to reliably use latex condoms
Herpes dx?
-- Culture is the gold standard

-- highly specific, yet sensitivity is limited

-- best to culture the lesion very early in the course. The blister is unroofed and the base is vigorously scraped. The herpes virus can theoretically be isolated from both primary and recurrent infections

-- Serum antibody screening only indicates lifetime exposure and would not answer the question as to the etiology of the specific lesion a pt may have

-- Alternatively, DNA studies such as the polymerase chain reaction can be done, if available.
Cervical cancer risk factors?
-- tobacco use and a poor screening history, lots of partners and early onset sexual activity
Postmenopausal and postcoital bleeding with a cervical lesion, next step?
-- cervical biopsy of lesion

-- Pap smear should not be used to exclude cervical cancer, as it is a screening test and not a diagnostic test

-- colposcopy would not be useful since a clinically visible lesion is already present

-- Ultrasonography may be helpful in the diagnostic evaluation of post-menopausal bleeding, but not in the setting of an obvious cervical lesion
Cervical lesion with fixation of the uterus and thickening of the rectovaginal septum and back pain suggests?
-- suggests involvement of the parametria (Stage II) and possible extension to the sidewall (Stage III)
Syphilis diagnosis?
-- serologic testing

-- non-treponemal tests (VDRL or RPR) are non-specific

-- In patients with high suspicion for syphilis, specific testing with treponemal antibody can confirm infection

-- classic coiled spirochete is easily seen with dark-field microscopy but availability is limited

-- Colposcopy would not be diagnostic, but certainly is helpful to evaluate for any vulvar lesions thought to be dysplastic

-- Biopsies can be stained for spirochetes and may show a necrotizing vasculitis, but certainly would not be the most expedient way to make the diagnosis
Syphilis s/s?
-- characteristic finding is a brownish, macular rash on the palms and soles that are often described as copper penny lesions

-- non-tender spots on genital areas

-- No pruritus or pain
Emergency contraceptive pills
-- not an abortifacient, and they have not been shown to cause any teratogenic effect if inadvertently administered during pregnancy

-- more effective the sooner they are taken after unprotected intercourse, and it is recommended that they be started within 72 hours, and no later than 120 hours

-- Plan B, the levonorgestrel pills, can be taken in one or two doses and cause few side effects

-- Emergency contraceptive pills may be used anytime during a woman’s cycle, but may impact the next cycle, which can be earlier or later with bleeding ranging from light, to normal, to heavy --> give emergency contraceptive pills, then restart OCPs immediately
Levonorgestrel intrauterine device
-- has lower failure rates within the first year of use than does the copper containing IUD

-- It causes more disruption in menstrual bleeding, especially during the first few months of use, although the overall volume of bleeding is decreased long-term and many women become amenorrheic

-- is protective against endometrial cancer due to release of progestin in the endometrial cavity
Contraindications for OCPs?
-- poorly controlled chronic hypertension
-- smoker
-- h/o DVT/PE
-- >35 y/o
-- lactating women
-- women who develop severe nausea with combined OCPs
A 35 year-old G3P3 comes to the office because she desires contraception. Her past medical history is significant for Wilson’s disease, chronic hypertension and anemia secondary to menorrhagia. She is currently on no medications. Her vital signs reveal a blood pressure of 144/96. Ideal contraceptive for her?
-- levonorgestrel IUD

-- not a candidate for oral contraceptive pills because of her poorly controlled chronic hypertension
-- progestin only pills have a much higher failure rate than the progestin IUD
-- not a candidate for the copper-containing intrauterine device because of her history of Wilson’s disease
What is the strongest predictor of post-sterilization regret?
-- Age --> Approximately 10% of women who have been sterilized regret having had the procedure with the strongest predictor of regret being undergoing the procedure at a young age

-- percentage expressing regret was 20% for women less than 30-years-old at the time of sterilization

-- For those under age 25, the rate was as high as 40%

-- regret rate was also high for women who were not married at the time of their tubal ligation, when tubal ligation was performed less than a year after delivery, and if there was conflict between the woman and her partner.
Form of birth control that also significantly decrease her risk of having a gynecological malignancy?
-- Oral contraceptives will decrease a woman’s risk of developing ovarian and endometrial cancer

-- Women who use oral contraceptive pills have a slightly higher risk of developing cervical intraepithelial neoplasia, but their risk of developing PID, endometriosis, benign breast changes and ectopic pregnancy are reduced.

-- Although the mechanism is unclear, an association of tubal ligation and a lower incidence of ovarian cancer in BRCA-1 positive women has been reported.
Potential side effects from using OCPs?
-- Both hypertension and thromboembolic disorders
Six weeks ago, pt. had her first Depo-Provera injection and now she has unpredictable bleeding. She is concerned by these symptoms. Which of the following is the most appropriate next step?
-- The patient should be reassured since initially after Depo-Provera injection there may be unpredictable bleeding.

-- This usually resolves in 2 or 3 months.

-- In general, after 1 year of using Depo-Provera, nearly 50% of users have amenorrhea.
Strongest risk factor for cardiac disease?
-- Smoking!!!

-- Although OCPs are contraindicated in women with coronary vascular disease, past use of the pill does not increase current risk

-- Mild red wine consumption can potentially decrease her risk, and other alcohol consumption does not pose a significant increased risk.
A 32 year-old G3P3 comes to the office to discuss permanent sterilization. She has a history of hypertension and asthma (on corticosteroids). She has been married for 10 years. Her blood pressure is 140/90; weight 280 pounds; height 69 inches; and BMI 41.4kg/m2. You discuss with her risks and benefits of contraception. Which of the following would be the best form of permanent sterilization to recommend for this patient?
-- vasectomy for the hubs

-- Both vasectomy and tubal ligation are 99.8% effective. Vasectomies are performed as an outpatient procedure under local anesthesia, while tubal ligations are typically performed in the operating room under regional or general anesthesia; therefore carrying slightly more risk to the woman, assuming both are healthy.

-- She is morbidly obese, so the risk of anesthesia and surgery are increased.

-- In addition, she has chronic medical problems that put her at increased risk of having complications from surgery.
Ideal candidates for progestin-only pills?
-- women who have contraindications to using combined oral contraceptives (estrogen and progestin containing)

-- Contraindications to estrogen include a history of thromboembolic disease, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined oral contraceptive pills.

-- Progestins should be used with caution in women with a history of depression.
What is the most compelling reason for a pt. to use a different method of contraception from the patch?
-- Weight --> the patch has comparable efficiency to the pill in comparative clinical trials, although it has more consistent use.

-- It has a significantly higher failure rate when used in women who weigh more than 198 pounds
The patch (Ortho-Vera)?
-- a transdermal system that is placed on a woman’s upper arm or torso (except breasts)

-- it slowly releases ethinyl estradiol and norelgestromin, which establishes steady serum levels for 7 days

-- A woman should apply one patch in a different area each week for 3 weeks, then have a patch-free week, during which time she will have a withdrawal bleed

-- Patients should be informed about the risks of using a transdermal delivery system including higher estrogen levels (60% more estrogen as compared to a 35 mcg pill) and increased risk of thromboembolic events.

-- has a significantly higher failure rate when used in women who weigh more than 198 pounds
What are the non-contraceptive health benefits of female sterilization?
-- There is a slight reduction in the risk of ovarian cancer, but the mechanism is not yet fully understood

-- Tubal ligation has not been shown to reduce the risk of endometriosis, sexually transmitted infections or endometrial cancer, nor is there a decrease in menstrual blood flow in women who have undergone a tubal ligation
Management of septic abortion?
-- broad-spectrum antibiotics and uterine evacuation
A 22 year-old G1P0 with LMP 6 weeks ago presents for elective termination of pregnancy. She is healthy with no medical problems. Her pregnancy thus far has been uncomplicated. An ultrasound performed in the office shows an 8 mm endometrial stripe with no intrauterine gestational sac and no adnexal masses. Which of the following is the most appropriate next step in the management of this patient?
-- Obtain a Beta-hCG level -- Even though the patient reports being pregnant, she is asymptomatic with no gestational sac in the uterus. First step in her management is to establish pregnancy by obtaining a Beta-hCG level

-- One should not assume she has an intrauterine pregnancy and perform a dilation and curettage or assume that she has an ectopic pregnancy and treat her with methotrexate or surgery until the pregnancy is confirmed
Recurrent pregnancy loss and h/o DVT, what next?
-- check antiphosphospholipid antibodies -- they are associated with recurrent pregnancy loss

--
Workup for antiphospholipid syndrome?
-- includes assessment of anticardiolipin antibody status, PTT, and Russell viper venom time (prolonged)
Definition of recurrent pregnancy loss and etiologies?
-- >2 consecutive or >3 spontaneous losses before 20 weeks gestation

-- There are multiple etiologies for recurrent pregnancy loss including anatomic causes, endocrine abnormalities such as hyper or hypothyroidism and luteal phase deficiency, parental chromosomal anomalies, immune factors such as lupus anticoagulant and idiopathic factors
Cervical incompetence?
-- diagnosed by history, physical exam and other diagnostic tests, such as ultrasound

-- The treatment is placement of a cerclage.
Patient is having heavy bleeding as a complication of medical termination of pregnancy?
-- managed best by performing a dilation and curettage

-- It is not appropriate to wait 6 hours before making a decision regarding next step in management, or to just admit her for observation

-- Since the patient is not symptomatic from her anemia, it is not necessary to transfuse her at this time.
Septic abortion?
-- fever, vaginal bleeding and abdominal pain with a dilated cervix are findings seen with septic abortion
Threatened abortions?
-- clinically have vaginal bleeding, a positive pregnancy test and a cervical os closed or uneffaced
Missed abortions?
-- have retention of a nonviable IUP for an extended period of time (i.e. dead fetus or blighted ovum
Ectopic pregnancy would likely present with?
-- bleeding, abdominal pain and possibly have an adnexal mass

-- the cervix would typically be closed
Antiphospholipid antibody syndrome tx?
-- aspirin plus heparin

-- roughly a 75% success rate with combination therapy versus aspirin alone

-- conflicting evidence regarding steroid use for treatment
A 24 year-old G2P1 who underwent an elective termination two days ago presents to the emergency room with abdominal and pelvic pain -- feeling nauseated and reports a fever at home -- blood pressure is 100/60; pulse 100; respiration 16; temperature 102°F (38.9°C). -- Physical examination reveals diffuse abdominal tenderness and, on pelvic examination, she has marked cervical motion tenderness. What is it?
-- postoperative endometritis

-- could be due to introduction of bacteria into the uterine cavity at the time of dilation and curettage
Postoperative endometritis tx?
-- important to begin antibiotics immediately

-- After starting antibiotics, an ultrasound should be obtained to look for products of conception. If found, the patient would then require a repeat dilation and curettage.

-- A Beta-hCG level would not be helpful 2 days after the termination. Hysterosonogram is contraindicated when infection is present.
Medical abortion (with misoprostol and mifepristone) vs. surgical abortion?
-- Medical abortion is associated with higher blood loss than surgical abortion

-- Early in pregnancy (less than 49 days) both medical and surgical procedures can be offered

-- Any termination of pregnancy, whether medical or surgical, can have psychological sequelae
Medical abortion?
-- Mifepristone (an antiprogestin) can be administered, followed by misoprostol (a prostaglandin) to induce uterine contractions to expel the products of conception

-- This approach has proven to be effective (96%) and safe

-- Medical termination seems to be more desirable by some patients since they do not have to undergo a surgical procedure

-- A surgical termination is required in the event of failure or excessive blood loss

-- It does not affect future fertility
Manual vacuum aspiration?
-- more than 99% effective in early pregnancy (less than 8 weeks)

-- Age, parity and medical illnesses are not contraindications for manual vacuum aspiration

-- Complications of pregnancy termination increase with increasing gestational age
Asherman’s syndrome
-- adhesions and/or fibrosis within the uterine cavity due to polyps

-- Asherman's syndrome, AS, occurs most frequently after a D&C is performed on a recently pregnant uterus, following a missed or incomplete miscarriage, birth, or elective termination (abortion) to remove retained products of conception

-- risk increases with each subsequent pregnancy termination
A 25 year-old G1P0 at 20 weeks gestation desires termination of the pregnancy. Her prenatal course has been unremarkable except for a chromosomal analysis positive for Trisomy 18. She desires an autopsy of the fetus. Which of the following is the most appropriate next step in the management of this patient?
-- Perform an induction with intravaginal prostaglandins

-- Both medical and surgical abortions are options for this patient, depending on her personal preferences. However, if she desires an autopsy, she must undergo a medical abortion in order to have an intact fetus

-- Abortion is legal until viability is achieved (24 weeks gestation) unless a fetal anomaly inconsistent with extrauterine life is identified.

-- A dilation and curettage is performed if the fetus is less than 16 weeks, while dilation and evacuation can be performed after 16 weeks by those trained in the procedure.

-- Inductions with hypertonic saline have a high morbidity, so are no longer performed.
Herpes
-- Two serotypes of HSV have been identified: HSV-1 and HSV-2.

-- Most cases of recurrent genital herpes are caused by HSV-2.

-- Up to 30% of first-episode cases of genital herpes are caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than genital HSV-2 infection.

-- Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic.
Systemic symptoms of a primary herpes infection?
-- fever, headache, malaise and myalgias, and usually precede the onset of genital lesions.

-- Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base
Initial, nonprimary genital herpes?
-- the first recognized episode of genital herpes in individuals who are seropositive for HSV antibodies

-- Prior HSV-1 infection confers partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection.

-- The severity and duration of symptoms are intermediate between primary and recurrent disease, with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding

-- Systemic symptoms are rare
Initial, or first-episode primary genital herpes?
-- a true primary infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV antibodies)
Recurrent episodes of herpes?
-- involve reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity
Clinical diagnosis of genital herpes?
-- should be confirmed by viral culture, antigen detection or serologic tests.
Genital herpes treatment?
-- Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.
Bacterial vaginosis
-- the most common cause of vaginitis

-- The infection arises from a shift in the vaginal flora from hydrogen peroxide-producing lactobacilli to non-hydrogen peroxide-producing lactobacilli, which allows proliferation of anaerobic bacteria
BV s/s?
-- majority of women are asymptomatic

-- however, patients may experience a thin, gray discharge with a characteristic fishy odor that is often worse following menses and intercourse
BV dx?
-- Modified Amsel criteria for diagnosis include three out of four of the following:

1) thin, gray homogenous vaginal discharge

2) positive whiff test (addition of potassium hydroxide releases characteristic amine odor)

3) presence of clue cells on saline microscopy

4) elevated vaginal pH >4.5
BV tx?
-- Metronidazole 500 mg orally BID for 7 days


-- or vaginal Metronidazole 0.75% gel QHS for 5 days
Genital condylomata?
-- aka warts --> typically caused by HPV types 6 or 11

-- Other HPV types in the anogenital area (e.g. types 16, 18, 31, 33 and 35) have been strongly associated with cervical neoplasia and cancer

-- Genital condylomata that do not respond to topical therapies should be biopsied
Pt w/ history of cervical dysplasia, tobacco use and HIV status with 3 cm non-ulcerated, hyperkeratotic lesion on the right labia minora, as well as multiple papillary growths on the posterior fourchette and perineum?
-- Vulvar intraepithelial neoplasia (VIN) is a possibility in this patient, given her history of cervical dysplasia, tobacco use and HIV status.

-- vulvar biopsy is indicated to evaluate the hyperkeratotic lesion in this patient and rule out the possibility of vulvar neoplasia.
Mucopurulent cervicitis (MPC)?
-- characterized by a mucopurulent exudate visible in the endocervical canal or in an endocervical swab specimen

-- MPC is typically asymptomatic, but some women have an abnormal discharge or abnormal vaginal bleeding

-- MPC can be caused by Chlamydia trachomatis or Neisseria gonorrhoeae; however, in most cases neither organism can be isolated

-- Patients with MPC should be tested for both of these organisms. The results of sensitive tests for C. trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid amplification tests) should determine the need for treatment, unless the likelihood of infection with either organism is high or the patient is unlikely to return for treatment
Mucopurulent cervicitis (MPC) tx?
-- Antimicrobial therapy should include coverage for both organisms --> azithromycin or doxycycline for chlamydia and a cephalosporin or quinolone for gonorrhea

-- Uncomplicated cervicitis would require only 125 mg of Ceftriaxone in a single dose. Ceftriaxone 250 mg is necessary for the treatment of upper genital tract infection, or pelvic inflammatory disease (PID).

-- The results of sensitive tests for C. trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid amplification tests) should determine the need for treatment, unless the likelihood of infection with either organism is high or the patient is unlikely to return for treatment
Lichen sclerosus
-- a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women

-- The exact etiology is unknown, but is most likely multifactorial

-- There is less than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus.
Lichen sclerosus s/s?
-- Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia.

-- Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation.

-- The vagina is not involved.

-- More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema and surface vascular changes and, ultimately, scarring with loss of normal architecture, such as introital stenosis, and resorption of the clitoris (phimosis) and labia minora.
Lichen sclerosus tx?
-- use of high-potency topical steroids
A 64 year-old G2P2 presents with a 12-month history of severe vulvar pruritus. She has applied multiple over-the-counter topical therapies without improvement. She has no significant vaginal discharge. She has severe introital dyspareunia and has stopped having intercourse because of the pain. Her past medical history is significant for allergic rhinitis and hypertension. On pelvic examination the external genitalia show loss of the labia minora with resorption of the clitoris (phimosis). The vulvar skin appears thin and pale and involves the perianal area as in the picture below. No ulcerations are present. The vagina is mildly atrophic, but appears uninvolved. Dx?
Lichen sclerosus
Vulvar vestibulitis syndrome
-- a constellation of symptoms and findings limited to the vulvar vestibule, which include severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees

-- Symptoms often have an abrupt onset and are described as a sharp, burning and rawness sensation

-- Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia

-- Vestibular findings include exquisite tenderness to light touch of variable intensity with or without focal or diffuse erythematous macules

-- Often, a primary or inciting event cannot be determined
Vulvar vestibulitis syndrome tx?
-- tricyclic antidepressants to block sympathetic afferent pain loops

-- pelvic floor rehabilitation

-- biofeedback

-- topical anesthetics

-- Surgery with vestibulectomy is recommended for patients who do not respond to standard therapies and are unable to tolerate intercourse
Trichomoniasis bug and s/s?
-- caused by the protozoan T. vaginalis

-- Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green discharge with vulvar irritation

-- However, some women have minimal or no symptoms

-- strawberry cervicitis
Trichomoniasis dx and tx?
-- Diagnosis of vaginal trichomoniasis is performed by saline microscopy of vaginal secretions, but this method has a sensitivity of only 60% to 70%

-- CDC recommended treatment is metronidazole 2 grams orally in a single dose

-- An alternate regimen is metronidazole 500mg orally twice daily for seven days

-- The patient’s sexual partner also should undergo treatment prior to resuming sexual relations
Vulvovaginal candidiasis (VVC) bug and s/s?
-- usually is caused by C. albicans

-- Typical symptoms include pruritus and vaginal discharge

-- Other symptoms include vaginal soreness, vulvar burning, dyspareunia and external dysuria

-- None of these symptoms are specific for VVC
Vulvovaginal candidiasis (VVC) dx?
-- diagnosis is suggested clinically by vulvovaginal pruritus and erythema with or without associated vaginal discharge

-- The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either: a) a wet prep (saline or 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae; or b) a vaginal culture or other test yields a positive result for a yeast species

-- Microscopy may be negative in up to fifty percent of confirmed cases.
Vulvovaginal candidiasis (VVC) tx?
-- for uncomplicated VVC --> short-course topical Azole formulations (1-3 days)

-- results in relief of symptoms and negative cultures in 80%-90% of patients who complete therapy
Lichen simplex chronicus
-- a common vulvar non-neoplastic disorder, results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier

-- Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching
Lichen simplex chronicus s/s and clinical findings?
-- severe vulvar pruritus, which can be worse at night

-- Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema

-- The skin changes can be localized or generalized

-- no significant vaginal discharge or dyspareunia
Lichen simplex chronicus dx and tx?
-- diagnosis is based on clinical history and findings, as well as vulvar biopsy

-- Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus
Lichen planus
-- a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva

-- This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares

-- The exact etiology is unknown, but is thought to be multifactorial
Lichen planus s/s?
-- Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia

-- Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well

-- With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated

-- Patients may also experience oral lesions, alopecia and extragenital rashes
Lichen planus tx?
-- Treatment is challenging, since no single agent is universally effective

-- consists of multiple supportive therapies and topical superpotent corticosteroids
Salpingitis
-- most often caused by sexually transmitted agents such as gonorrhea and chlamydia, any ascending infection from the GU tract or GI tract can be causative

-- The infection is polymicrobial consisting of aerobic and anaerobic organisms such as E. coli, Klebsiella, G. vaginalis, Prevotella, Group B streptococcus and/or enterococcus
A 36 year-old G0 presents to the emergency department accompanied by her female partner. The patient notes severe belly pain. She states that this pain began 2-3 days ago and was associated with diarrhea as well as some nausea. It has gotten progressively worse and she has now developed a fever. Neither her partner, nor other close contacts report any type of viral illness. She had her appendix removed as a teenager. On examination, her temperature is 102.0°F (38.9°C), her abdomen is tender with mild guarding and rebound, and she has an elevated white count. On pelvic examination, she is exquisitely tender, such that you cannot complete the examination. Pelvic ultrasound demonstrates bilateral 3-4 cm complex masses. What is the most likely underlying pathogenesis of her illness?
-- bilateral tubo-ovarian abscesses from an ascending infection

-- Even though this patient does not have the typical risk factors for salpingitis, the diagnosis should be considered and explained to the patient in a sensitive and respectful manner

-- The patient should also be questioned separate from her partner regarding the possibility of other sexual contacts
A 16 year-old G0 presents to the emergency department with a two-day history of “belly pain”, nausea and vomiting. She is sexually active with a new partner and is not using any form of contraception. On examination, her temperature is 100.2°F (37.9°C), and she has bilateral lower quadrant pain, with slight rebound and guarding. On pelvic examination, she has purulent cervical discharge and cervical motion tenderness. Her white count is 14,000/mcL. What is the most appropriate next step in the management of this patient?
-- IV abx

-- Although some patients can be treated with an outpatient regimen, this patient should be hospitalized for IV treatment, as she is young, nulliparous, and has nausea and vomiting so she might not be able to tolerate oral medications

-- She is also at risk for non-compliance with an outpatient treatment regimen

-- It is important to treat aggressively in order to prevent the long-term sequelae of acute salpingitis

-- Her recent sexual contacts should also be informed (by her and/or with her consent) and treated
According to the 2010 CDC treatment guidelines, there are two options for parenteral antibiotics covering both gonorrhea and chlamydia?
-- Cefotetan or Cefoxitin PLUS Doxycycline

or

-- Clindamycin PLUS Gentamicin
For outpatient treatment of GC/CT, the 2010 CDC guidelines recommend?
-- Ceftriaxone, Cefoxitin, or other third-generation cephalosporin (such as ceftizoxime or cefotaxime)

PLUS

-- Doxycycline

WITH or WITHOUT

-- Metronidazole
A 17 year-old G0 sexually active woman presents to the emergency room with pelvic pain that began within the last day. She reports menarche at the age of 15 and coitarche soon thereafter. She has had 4 male partners, including her new boyfriend of a few weeks. Her blood pressure is 100/60, pulse 100, and temperature 102.0°F (38.9°C). On speculum examination, you note a foul-smelling mucopurulent discharge from her cervical os and she has significant tenderness with manipulation of her uterus. What is the next best step in the management of this patient?
-- Inpatient treatment and intravenous antibiotics

-- The most likely cause of the s/s in this patient is infection with a sexually transmitted organism --> the most likely organisms are both GC/CT, and the patient should be treated empirically for both after appropriate blood and cervical cultures are obtained

-- Since the patient also has a high fever, inpatient admission is recommended for aggressive IV antibiotic therapy in an effort to prevent scarring of her fallopian tubes and possible future infertility
Salpingitis
-- can develop in 15-30% of women with inadequately treated gonococcal or chlamydial infections

-- Unrecognized salpingitis can result in significant long-term sequelae --> chronic pelvic pain, hydrosalpinx, tubal scarring and ectopic pregnancy

-- This emphasizes the importance of aggressive screening and treatment protocols for sexually transmitted infections, as well as counseling regarding abstinence and safer sex practices
Acute salpingitis s/s?
-- can vary and be very subtle with mild pain and tenderness, or the patient can present in much more dramatic fashion with high fever, mucopurulent cervical discharge and severe pain

-- Important diagnostic criteria include lower abdominal tenderness, uterine/adnexal tenderness and mucopurulent cervicitis
Urinary tract infections
-- Mildly symptomatic or asymptomatic urinary tract infections are common in female patients

-- UTIs must be considered in patients who present with low pelvic pain, urinary frequency, urinary urgency, hematuria or new issues with incontinence

-- In addition, routine screening of pregnant patients for asymptomatic UTIs at each prenatal visit is recommended in order to prevent UTI, which can cause preterm labor
A 26 year-old G2P2 reports that she is sexually active with a new male partner. She is using oral contraception for birth control and, as such, did not use a condom. She reports the new onset of vulvar burning and irritation. She thought she had a cold about 10 days ago. Given her history, which of the following is the most likely diagnosis in this patient?
HSV -- a highly contagious DNA virus
S/S of initial infection with HSV?
-- viral like symptoms preceding the appearance of vesicular genital lesions

-- A prodrome of burning or irritation may occur before the lesions appear

-- With primary infection, dysuria due to vulvar lesions can cause significant urinary retention requiring catheter drainage

-- Pain can be a very significant finding as well
HSV tx?
-- Treatment is centered on care of the local lesions and the symptoms

-- Sitz baths, perineal care and topical Xylocaine jellies or creams may be helpful

-- Anti-viral medications, such as Acyclovir, can decrease viral shedding and shorten the course of the outbreak somewhat. These medications can be administered topically or orally
Syphilis
-- a chronic infection caused by the Treponema pallidum bacterium

-- Transmission is usually by direct contact with an infectious lesion
Early syphilis?
-- includes the primary, secondary, and early latent stages during the first year after infection
Latent syphilis?
-- patient usually has a normal physical exam with positive serology
Primary syphilis?
-- a painless papule usually appears at the site of inoculation

-- This then ulcerates and forms the chancre, which is a classic sign of the disease

-- Left untreated, 25% of patients will develop the systemic symptoms of secondary syphilis
Secondary syphilis systemic s/s?
-- low-grade fever, malaise, headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias
HIV
-- an RNA retrovirus transmitted via sexual contact or sharing intravenous needles
Acute cystitis in a healthy, non-pregnant woman?
-- considered uncomplicated

-- very common

-- E. coli causes 80-85% of cases

-- The other major pathogens are Staphylococcus saprophyticus, Klebsiella pneumoniae, and Proteus mirabilis, with Citrobacter and Enterococci causing only occasional cases

-- The physician must consider antibiotic resistance when determining treatment
Which STI can only be diagnosed using a blood sample?
-- Hep B

--
Hepatitis B screening?
-- done through a blood sample

-- detects the outer shell of the Dane particle of the virus (HBsAg)

-- Patients who have been immunized should have detectable antibody to Hepatitis B, but will NOT have antigen present
Central and lateral cystoceles are repaired by?
-- by fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line
What is repaired in rectoceles?
-- Defects in the rectovaginal fascia
How is uterine prolapse surgically treated?
-- vaginal hysterectomy
Enteroceles are repaired by?
-- either vaginal or abdominal enterocele repairs
Vaginal vault prolapse is treated by?
-- either by supporting the vaginal cuff to the uterosacral ligaments, sacrospinous ligament or sacrocolpopexy
Does urethral diverticulum present with severe pelvic protrusion?
No
Symptomatic pelvic prolapse tx?
-- Pessary fitting is the least invasive intervention

-- Although a sacrospinous ligament suspension would be an appropriate procedure for this patient, it is invasive and not an appropriate first step

-- An anterior repair can potentially help with her symptoms, depending on what is contributing most to her prolapse but, again, it is invasive
What is transvaginal tape used for?
Urinary incontinence
Overflow incontinence?
-- characterized by failure to empty the bladder adequately

-- This is due to an underactive detrusor muscle (neurologic disorders, diabetes or multiple sclerosis) or obstruction (postoperative or severe prolapse)

-- associated with symptoms of pressure, fullness, and frequency

-- usually a small amount of continuous leaking

-- not associated with any positional changes or associated events

-- an elevated PVR, usually >300 cc
Normal post-void residual (PVR)?
50-60 cc
Stress incontinence?
-- occurs when the bladder pressure is greater than the intraurethral pressure

-- Overactive detrusor contractions can override the urethral pressure resulting in urine leakage

-- caused by an increase in intra-abdominal pressure (coughing, sneezing) when the patient is in the upright position

-- This increase in pressure is transmitted to the bladder that then rises above the intra-urethral pressure causing urine loss

-- Associated structural defects are cystocele or urethrocele
Mixed incontinence?
-- includes symptoms related to stress incontinence and urge incontinence

-- occurs when increased intra-abdominal pressure causes the urethral-vesical junction to descend causing the detrusor muscle to contract

-- A vesicovaginal fistula typically results in continuous loss of urine.
A 56-year-old G3P3 woman presents to the office for her annual health maintenance exam. She is in good health and is not taking any medications. She has been postmenopausal for 3 years. She had an abnormal Pap smear 10 years ago, but results have been normal every year since. She is sexually active with her husband and uses lubricant during intercourse due to mild vaginal dryness. On examination, her cervix was 1 cm above the vaginal introitus and she was noted to have a moderate bladder prolapse. Her uterus is normal in size and she has no adnexal masses, and she was non-tender. In addition to performing a Pap smear and recommending a mammogram, what is the most appropriate next step in the management of this patient?
-- Observation --> This patient is asymptomatic from her prolapse; therefore, no intervention is necessary at this point
A 57-year-old G2P2 woman presents to the office with a six-month history of leaking urine, urgency, and nocturia. She describes the amount of urine loss as large and lasting for several seconds. The urine loss occurs when she is standing or sitting and is not associated with any specific activity. What is the most likely cause of this patient’s symptoms?
Urge Incontinence
Urge incontinence?
-- overactivity of the detrusor muscle resulting in uninhibited contractions, which cause an increase in the bladder pressure over urethral pressure resulting in urine leakage

-- detrusor instability --> is due to the overactivity of the bladder muscle

-- Though the testing may be simple (using a Foley catheter and attached large syringe without the plunger, filling with 50-60 cc of water at a time) or complex (using computers and electronic catheters,) the uninhibited contraction of the bladder with filling makes the diagnosis
Genuine stress incontinence (GSI)?
-- the loss of urine due to increased abdominal pressure in the absence of a detrusor contraction

-- The majority of GSI is due to urethral hypermobility (straining Q-tip angle >30 degrees from horizon.)

-- Some (<10%) of GSI is due to intrinsic sphincteric deficiency (ISD) of the urethra

-- Patients can have both hypermobility and ISD
Best 5-year success rates for patients with GSI due to hypermobility?
-- Retropubic urethropexies (Burch and Marshall Marchetti) and sling procedures are best

-- Needle suspensions and anterior repairs have lower 5-year success rates for GSI
What procedures are best for patients with ISD, but with little to no mobility of the urethra?
-- Urethral bulking
Colpocleisis used for?
-- one option to treat uterine prolapse, and is not indicated for urinary incontinence.
Urge incontinence tx?
-- Oxybutynin

-- The parasympathetic system is involved in bladder emptying and acetylcholine is the transmitter that stimulates the bladder to contract through muscarinic receptors --> Thus, anticholinergics are the mainstay of pharmacologic treatment

-- Although the tricyclic antidepressant --amitriptyline -- has anticholinergic properties, its side effects do not make it an ideal choice

-- Vaginal estrogen has been shown to help with urgency, but not urge incontinence
Stress incontinence tx?
-- Pseudoephedrine has been shown to have alpha adrenergic properties and may improve urethral tone in the treatment of stress incontinence

-- Kegel exercises or pelvic muscle training are used to strengthen the pelvic floor and decrease urethral hypermobility for the treatment of stress urinary incontinence.
A 70-year-old G3P3 woman presents with a 4-year history of constant leakage. Her history is significant for abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She has had four anterior repairs in the past for recurrent cystocele. The leakage started six months after her last anterior repair. Pelvic exam showed no evidence of pelvic relaxation. The vagina was well-estrogenized. Q-tip test revealed a fixed, immobile urethra. Cystometrogram showed no evidence of detrusor instability. Cystourethroscopy showed no evidence of any fistula and revealed a “drain pipe” urethra. Which of the following is the best first treatment for this patient?
-- Urethral bulking procedure

-- This is a classic example of intrinsic sphincteric deficiency
Success rates for retropubic urethropexies, needle suspension and slings?
-- less than 50%

-- An “obstructive or tight” sling can be performed to increase the success rate, but the voiding difficulties are significant, even requiring prolonged or lifelong self-catheterization
Intrinsic sphincteric deficiency tx?
-- Urethral bulking procedures

-- minimally invasive and have a success rate of 80% in these specific patients. Artificial sphincters should be used in patients as a last resort
A 90-year-old G7P7 woman presents with severe vaginal prolapse. The entire apex, anterior and posterior wall are prolapsed beyond the introitus. She cannot urinate without reduction of the prolapse. Hydronephrosis was noted on ultrasound of the kidneys and it is thought to be related to the prolapse. She has a long-standing history of diabetes and cardiac disease. She is not a candidate for general or regional anesthesia. She has failed a trial of pessaries. Which of the following is the next best step in the management of this patient?
-- Colpocleisis --> because of the hydronephrosis due to obstruction, intervention is required --> a procedure where the vagina is surgically obliterated and can be performed under local anesthesia. Recurrence is minimal

-- Anterior and posterior repairs provide no apical support of the vagina. She will be at high risk of recurrent prolapse.

-- The sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or sacrocolpopexy (cuff to sacral promontory using interposed mesh) require regional or general anesthesia
Colpocleisis?
-- a procedure where the vagina is surgically obliterated and can be performed under local anesthesia

-- Recurrence is minimal
A 76-year-old G3P3 presents to the office with worsening stress urinary incontinence for the last 3 months. She reports an increase in urinary frequency, urgency and nocturia. On exam, she has a moderate size cystocele and rectocele. A urine culture is negative. A post-void residual is 50 cc. A cystometrogram shows two bladder contractions while filling. Which of the following is the most likely diagnosis in this patient?
-- Urge incontinence, aka detrusor overactivity incontinence
A 48-year-old G0 woman comes to the office for a health maintenance exam. She is healthy and not taking any medications. She has no history of abnormal Pap smears or sexually transmitted diseases. She is not currently sexually active. Her menstrual cycles are normal and her last cycle was three weeks ago. She smokes one pack of cigarettes per day. Her mother was diagnosed with endometriosis and had a hysterectomy and removal of the ovaries at age 38. She is 5 feet 4 inches tall and weighs 130 pounds. On pelvic examination, the patient had a palpable left adnexal mass. An ultrasound was obtained, which showed a 4 cm complex left ovarian cyst and a 2 cm simple cyst on the right ovary. What is the most appropriate next step in the management of this patient?
-- repeat US in 2 months

-- this is most likely a hemorrhagic cyst which will resolve on its own

-- A CAT scan or MRI of the pelvis will not add any more information. There is no indication to proceed with a TAH/BSO. Oral contraceptives are contraindicated in this patient, as she is older than 35 and smokes.
Typical symptoms of endometriosis?
-- dysmenorrhea (painful periods)

-- dyspareunia (painful sex)

-- nodularity on the back of the uterus is suggestive of endometriosis
Adenomyosis
-- endometrial glands embedded in the wall of the uterus
Endometritis
-- an infection of the endometrium
A complex ovarian mass in a postmenopausal patient?
-- needs to be surgically explored

-- A CAT scan or MRI will not add more information and ultrasounds are typically the best imaging studies for the uterus and adnexa
Endometriosis
-- the presence of endometrial glands and stroma outside of the uterus

-- present in about 30% of infertile woman

-- complex ovarian cyst a/w endometriosis is most likely an endometrioma
S/S of polycystic ovarian syndrome?
-- typically presents with oligomenorrhea in overweight patients
Definitive diagnosis of endometriosis?
-- based on exploratory surgery and biopsies, although endometriosis is usually initially treated based on the clinical presentation

-- Although often used when implementing initial treatment, history and physical exam are not sufficient to confirm the diagnosis as patients present in diverse ways.
Two most common treatments for endometriosis?
-- NSAIDS and OCPs
How do OCPs help endometriosis?
-- They provide negative feedback to the pituitary-hypothalamic axis which, in turn, stops stimulating the ovary to produce sex hormones, such as estrogen which, in turn, stimulates endometrial tissue located outside of the endometrium and uterus
A 48-year-old G0 woman comes to the office for a health maintenance exam. She is healthy and not taking any medications. She has no history of abnormal Pap smears or sexually transmitted infections. Her menstrual cycles are normal and her last cycle was three weeks ago. Her mother was diagnosed with endometriosis and had a hysterectomy and removal of the ovaries at age 38. She is 5 feet 4 inches tall and weighs 130 pounds. On pelvic examination, the patient had a palpable left adnexal mass. An ultrasound was obtained, which showed a 4 cm complex left ovarian cyst and a 2 cm simple cyst on the right ovary. What is the most likely diagnosis in this patient?
-- hemorrhagic cyst

-- Ovarian carcinoma would need to be ruled out, but it is unlikely in an otherwise asymptomatic premenopausal patient.
A 26-year-old G0 woman presents to the emergency room with 8 hours of severe right lower quadrant pain associated with nausea. She has a history of suspected endometriosis, which was diagnosed 2 years ago, based on severe dysmenorrhea. She has been using NSAIDs with her menses to control the pain. She is not sexually active. She is otherwise in good health. Her menstrual cycles are normal every 28 days and her last menstrual period was 3 weeks ago. She has no history of sexually transmitted infections. Her blood pressure is 145/70; pulse is 100; temperature is 99.2°F. She appears uncomfortable. On abdominal exam, she has moderate tenderness to palpation in the right lower quadrant. On pelvic exam, she has no lesions or discharge. A complete bimanual exam was difficult to perform due to her discomfort. Labs: BHCG <5, hematocrit 29%. A pelvic ultrasound showed a 6cm right ovarian mass. The uterus and left ovary appeared normal. There was a moderate amount of free fluid in the pelvis. What is the most appropriate next step in the management of this patient?
-- Surgical exploration --> patient most likely has ovarian torsion and needs to be surgically explored

-- Further imaging studies will not help beyond the information obtained on the ultrasound

-- A Doppler ultrasound to check the blood flow to the ovaries is controversial, as normal flow does not rule out ovarian torsion

-- Although oral contraceptives can help decrease the development of further cyst formation and control the pain associated with endometriosis, this patient needs immediate surgical attention due to suspected ovarian torsion.
Sudden onset of pain and nausea, as well as the presence of a cyst on ultrasound?
-- ovarian torsion

-- Although appendicitis is on the differential, it is unlikely to have such a sudden onset of pain and a normal white count
A patient with a known history of endometriosis who is unable to conceive and has an otherwise negative workup for infertility, next step?
-- ovarian stimulation with Clomiphene Citrate, with or without intrauterine insemination
GnRH agonist and endometriosis?
-- used to control pelvic pain in endometriosis patients unresponsive to other hormonal treatments
Irritable bowel syndrome (IBS)
-- a common functional bowel disorder of uncertain etiology

-- It is characterized by a chronic, relapsing pattern of abdominal and pelvic pain, and bowel dysfunction with constipation or diarrhea

-- IBS is one of the most common disorders associated with chronic pelvic pain

-- IBS appears to occur more commonly in women with chronic pelvic pain than in the general population
Irritable bowel syndrome (IBS) dx?
-- based on the Rome II Criteria for IBS, which includes at least 12 weeks (need not be consecutive) in the preceding 12 months of abdominal discomfort or pain that has 2 of 3 features:

1) relief with defecation
2) onset associated with a change in frequency of stool
3) onset associated with a change in stool form or appearance
A 29 year-old G0 presents with pelvic pain. She was hospitalized for pelvic inflammatory disease and right tubo-ovarian abscess (TOA) 14-months ago and was treated with parenteral antibiotics. She now has a 10-month history of pelvic pain and deep thrust dyspareunia, as well as a persistent right adnexal tubular mass on ultrasound. She desires future fertility. Pelvic examination reveals a retroverted, normal-sized uterus with limited mobility and marked tenderness and fullness in the right adnexa. Findings at the time of laparoscopy include multiple filmy and dense adhesions between the posterior uterus and cul-de-sac, normal left fallopian tube and ovary, and large right hydrosalpinx, with a few filmy adhesions between the right ovary and distended fallopian tube. What is the most appropriate treatment for this patient?
-- Right salpingectomy and lysis of adhesions

-- if pt desires future fertility, conservative surgical intervention is indicated with lysis of adhesions

-- Retention of the patient’s ovaries is also possible, given the limited involvement with adhesions

-- Since the patient has a persistent hydrosalpinx and pelvic pain, the right fallopian tube should be removed with conservation of the right ovary

-- Neither a salpingostomy (an incision in the tube) nor aspiration of the tubal fluid would be adequate treatment for this patient
Does acute pelvic inflammatory disease (PID) develop into chronic pelvic pain?
-- Approximately 18-35% of all women with acute pelvic inflammatory disease (PID) develop chronic pelvic pain

-- The actual mechanisms by which chronic pelvic pain results from PID are not known and not all women with reproductive organ damage secondary to acute PID develop chronic pelvic pain
Chronic pelvic pain
-- the indication for at least 40% of all gynecologic laparoscopies

-- Endometriosis and adhesions account for more than 90% of the diagnoses in women with discernible laparoscopic abnormalities

-- laparoscopic evaluation of chronic pelvic pain in adolescents should not be deferred based on age
Given the patient’s age (62), nonspecific abdomino-pelvic symptoms, recent postmenopausal bleeding episode and family history of ovarian cancer, next step?
-- transvaginal ultrasound as it is more sensitive than CT for evaluation of the uterus and adnexa
Nerve entrapment syndrome
-- a commonly misdiagnosed neuropathy that can complicate pelvic surgical procedures performed through a low transverse incision

-- The nerves at risk are the iliohypogastric nerve (T-12, L-1) and the ilioinguinal (T-12, L-1) nerve

-- These two nerves exit the spinal column at the 12th vertebral body and pass laterally through the psoas muscle before piercing the transversus abdominus muscle to the anterior abdominal wall.

-- Once at the anterior superior iliac spine, the iliohypogastric nerve courses medially between the internal and external oblique muscles, becoming cutaneous 1 cm superior to the superficial inguinal ring.

-- The iliohypogastric nerve provides cutaneous sensation to the groin and the skin overlying the pubis.

-- The ilioinguinal nerve follows a similar, although slightly lower, course as the iliohypogastric nerve where it provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh.

-- These nerves may become susceptible to injury when a low transverse incision is extended beyond the lateral border of the rectus abdominus muscle, into the internal oblique muscle.
Ilioinguinal nerve cutaneous sensation?
-- to the groin, symphysis, labium and upper inner thigh.
Iliohypogastric nerve cutaneous sensation?
-- groin and the skin overlying the pubis
Nerve entrapment syndrome s/s are attributed to?
-- suture incorporation of the nerve during fascial closure

-- direct nerve trauma with subsequent neuroma formation

-- neural constriction due to normal scarring and healing
Lymph node resection can damage what nerve and cause what s/s?
-- Damage to the obturator nerve

-- result in the inability of the patient to adduct the thigh
Interstitial cystitis (IC)
-- a chronic inflammatory condition of the bladder

-- clinically characterized by recurrent irritative voiding symptoms of urgency and frequency, in the absence of objective evidence of another disease that could cause the symptoms

-- Pelvic pain is reported by up to 70% of women with IC and, occasionally, it is the presenting symptom or chief complaint

-- Women may also experience dyspareunia

-- The specific etiology is unknown, but IC may have an autoimmune and even hereditary component
What accounts for more than 90% of the diagnoses in women with discernible laparoscopic abnormalities?
-- Endometriosis and adhesions
How a gonadotropin releasing hormone (GnRH) agonist would help alleviate her symptoms of endometriosis?
-- they are analogues of naturally occurring gonadotropin-releasing hormones that down-regulate hypothalamic-pituitary gland production and the release of LH and FSH leading to dramatic reductions in estradiol level

-- Numerous clinical trials show GnRH agonists are more effective than placebo and as effective as Danazol in relieving endometriosis-associated pelvic pain
GnRH agonists available in the United States?
-- Nafarelin, Goserelin and Leuprolide
Danazol
-- a 17-alpha-ethinyl testosterone derivative

-- suppresses the mid-cycle surges of LH and FSH Combined estrogen and progestin therapy in oral contraceptives produces the pseudopregnancy state.
OCPs
-- Combined estrogen and progestin therapy in oral contraceptives produces the pseudopregnancy state
Physical and sexual abuse with various chronic pain disorders?
-- Most published evidence suggests a significant association of physical and sexual abuse with various chronic pain disorders

-- arguments with the new partner allude to possible abuse

-- Studies have found that 40-50% of women with chronic pelvic pain have a history of abuse

-- Whether abuse (physical or sexual) specifically causes chronic pelvic pain is not clear, nor is a mechanism established by which abuse might lead to the development of chronic pelvic pain

-- Women with a history of sexual abuse and high somatization scores have been found to be more likely to have non-somatic pelvic pain, suggesting the link between abuse and chronic pelvic pain may be psychologic or neurologic

-- However, studies also suggest that trauma or abuse may also result in biophysical changes, by literally heightening a person's physical sensitivity to pain.
A 48 year-old G4P4 with last menstrual period 4 weeks ago presents with a 1-year history of non-cyclical pelvic pain, dysmenorrhea and dyspareunia. She has a past history of endometriosis, diagnosed 10-years ago by laparoscopy. She had previously been on oral contraceptives for both birth control and menstrual cycle regulation, but elected for permanent laparoscopic sterilization 14 months ago. Minimal endometriosis was noted at the time of laparoscopy. She now has recurrent symptoms and desires definitive treatment. The most appropriate surgical option for this patient is:
-- Hysterectomy with bilateral salpingo-oophorectomy

-- It is estimated that chronic pelvic pain is the principal preoperative indication for 10-12% of hysterectomies

-- Since the patient had a tubal ligation, and does not desire any more children, the best option is removal of ovaries with or without a hysterectomy

-- Repeat laparoscopy with treatment of endometriosis and adhesions can be helpful; however, the patient will continue to be at increased risk of recurrent disease

-- An endometrial ablation or removal of ovaries alone would not be very helpful in the setting of non-cyclical pain
Pelvic congestion syndrome
-- a cause of chronic pelvic pain occurring in the setting of pelvic varicosities

-- The unique characteristics of the pelvic veins make them vulnerable to chronic dilatation with stasis leading to vascular congestion

-- These veins are thin walled and unsupported, with relatively weak attachments between the supporting connective tissue
Cause of Pelvic congestion syndrome?
-- The cause of pelvic vein congestion is unknown

-- Hormonal factors contribute to vasodilatation when pelvic veins are exposed to high concentration of estradiol, which inhibits reflex vasoconstriction of vessels, induces uterine enlargement with selective dilatation of ovarian and uterine veins
S/S of pelvic congestion syndrome?
-- This pain may be of variable intensity and duration

-- pain is worse premenstrually and during pregnancy

-- pain is aggravated by standing, fatigue and coitus

-- The pain is often described as a pelvic “fullness” or “heaviness,” which may extend to the vulvar area and legs

-- Associated symptoms include vaginal discharge, backache and urinary frequency
Physical exam reveals a 2-centimeter dominant breast mass. The remainder of the exam is normal. A mammogram obtained today shows no abnormalities. What is the most appropriate next step in the management of this patient?
-- evaluated cytologically, with a fine needle aspiration (FNA) or histologically, with an excisional biopsy

-- In this scenario, an MRI should not be part of the initial work-up for the patient’s palpable breast mass

-- Testing for genetic mutations is indicated for patients with a strong family history of breast cancer, but diagnosis is the most important next step in the management of this patient

-- A normal mammogram does not rule out the presence of cancer, and there is no reason to repeat the mammogram in two months, especially considering that the first one was normal.
Greatest risk factors for developing breast cancer?
-- age and gender

-- Having one first-degree relative with breast cancer does increase the risk, but genetic mutations occur in a low percentage of the general population. There is no indication for a mammogram since the patient’s last mammogram was normal 4 months ago. Ultrasound and MRI would not add valuable information especially in the setting of a normal mammogram and no masses on physical examination. Genetic testing is not indicated in this case as there is no strong family history and the sister with breast cancer was postmenopausal at time of diagnos
A 68 year-old G3P3 woman comes to the office due to breast tenderness. She is in good health and not taking any medications. Family history is significant for her 70 year-old sister being diagnosed with breast cancer. On breast examination, her breasts have no lesions; there are no palpable masses, nodules or lymphadenopathy. Her last mammogram was 4 months ago and was normal. What is the most appropriate next step in the management of this patient?
-- reassurance

-- Having one first-degree relative with breast cancer does increase the risk, but genetic mutations occur in a low percentage of the general population

-- There is no indication for a mammogram since the patient’s last mammogram was normal 4 months ago

-- Ultrasound and MRI would not add valuable information especially in the setting of a normal mammogram and no masses on physical examination

-- Genetic testing is not indicated in this case as there is no strong family history and the sister with breast cancer was postmenopausal at time of diagnosis
A 54 year-old woman presents with a breast mass she noticed two months ago. She has no family history of breast cancer. On exam, there is a 2 cm mass palpable in the upper outer quadrant of the left breast. There are no other masses noted and no lymphadenopathy. A fine needle aspiration returns bloody fluid and reduces the size of the mass to 1 cm. In addition to obtaining a mammogram, what is the most appropriate next step in the management of this patient?
-- Excisional biopsy of the mass

--the first noticeable symptom of breast cancer is typically a lump that feels different from the rest of the breast tissue. More breast cancer cases are discovered when the woman feels a lump

-- Breast cancer can also present with a spontaneous bloody nipple discharge.

-- Even though the mass decreased in size after aspiration, the bloody discharge obtained obligates an excisional biopsy to be performed to rule out breast cancer

-- If clear discharge is obtained on aspiration and the mass resolves, reexamination in 2 months is appropriate to check that the cyst has not recurred

-- An MRI is not the appropriate next step and lumpectomy with lymph node dissection is not yet indicated in this case

-- A normal mammogram does not rule out breast cancer, especially in the presence of bloody discharge.
The first noticeable symptom of breast cancer is typically?
-- a lump that feels different from the rest of the breast tissue. More breast cancer cases are discovered when the woman feels a lump

-- Breast cancer can also present with a spontaneous bloody nipple discharge.
Most postpartum mastitis is caused by?
-- staphylococcus aureus

-- so a penicillin-type drug is the first line of treatment

-- Dicloxacillin is used due to the large prevalence of penicillin resistant staphylococci

-- Erythromycin may be used in penicillin-resistant patients.
A 42 year-old G3P3 patient comes to the office after noticing a breast mass while performing a breast self-exam. She is in good health and has normal menstrual cycles. Physical exam is significant for a 2 cm dominant breast mass. The remainder of the exam is normal. A mammogram obtained today shows no abnormalities. A fine needle aspiration was negative, and the mass persisted. What is the most appropriate next step in the management of this patient?
-- Perform an excisional biopsy

-- A specimen obtained on fine-needle aspiration is examined both histologically and cytologically

-- An excisional biopsy should be performed when the results are negative, due to the possibility of a false-negative result

-- A FNA can, however, prevent the need for other diagnostic testing and is the appropriate next step
Breast ultrasound
-- used to distinguish between a cyst and a solid mass
Fine needle aspiration under ultrasound guidance
-- can help distinguish a fibroadenoma from a cyst and exclude cancer in certain situations
The most common breast infection?
-- Mastitis that accompanies pregnancy or nursing
Puerperal mastitis
-- most commonly occurs during the second to fourth week after delivery

-- Patients are treated with oral or IV antibiotics, depending on the severity of infection

-- Patients may use ibuprofen in addition to acetaminophen for pain relief

-- Patients are encouraged to continue breast feeding or expressing their milk during treatment

-- usually treated as an outpatient

-- Patients may be admitted to the hospital in severe cases and will be administered intravenous antibiotics

-- A breast ultrasound is not indicated if there is no suspicion of a breast abscess
A 48 year-old woman presents with complaints of a white, watery nipple discharge for 4 months. She has been told in the past she had fibrocystic breast changes, but otherwise has no significant medical problems or surgical history. The white nipple discharge is noted on manual expression, but the exam is otherwise normal. Her serum prolactin level was 45 ng/ml (normal below 40 ng/ml). What is the most appropriate next step in the management of this patient?
-- Obtain a fasting prolactin level

-- Stimulation of the breast during the physical examination may give rise to an elevated prolactin level.

-- Accurate prolactin levels are best obtained with patients fasting.

-- If these are still elevated, then a brain MRI would be indicated to rule out a pituitary tumor.
What can elevate prolactin levels?
-- hypothyroidism

-- hypothalamic disorders

-- pituitary disorders (adenomas, empty sella syndrome)

-- chest lesions (breast implants, thoracotomy scars, and herpes zoster)

-- renal failure

-- a non-significant benign elevation needs to be ruled out first
Ductogram?
-- indicated in patients who have bloody discharge from the nipple.
A properly performed clinical breast exam includes?
-- inspection and palpation of the breasts

-- Leaning forward facilitates the inspection for asymmetry even if the patient has large and pendulous breasts (this position allows the breasts to hang from the chest wall)

-- A clinical breast exam should include inspection of the patient in an upright, sitting position, while pressing her hands on her hips, placing hands above the head and leaning forward.

-- Moving the pectoralis muscle elicits skin changes that can be associated with invasive breast cancer, such as skin puckering or dimpling.

-- When the patient is supine with her hands above her head, the breast tissue rests on the chest wall and is easier to palpate for masses.

-- If the patient has large breasts, placing a pillow under her shoulder can assist with maintaining an even distribution of the breast tissue on the chest wall.

-- Differences between the two breasts, such as differences in breast contour or sizes, nipple inversion or retraction, may be other physical findings suggestive of an underlying mass.

-- Inspection of the patient in the lateral decubitus position is not usually helpful
Fibrocystic breast changes?
-- the most common type of benign breast conditions and occur most often during the reproductive years

-- There is an increased risk of breast cancer when atypia is present

-- The changes do not appear distinct histologically (3 stages) or mammographically

-- often associated with cyclic mastalgia, possibly related to a pronounced hormonal response

- Caffeine intake can increase the pain associated with fibrocystic breast changes
Axillary lymphadenopathy?
-- can be a presenting sign for breast cancer, but a tender mobile axillary lymph node is more typically associated with an infectious process

-- A clogged milk duct can be present in the axillary region, but it is typically present in a woman who is breast feeding.
Adenopathy associated with carcinoma?
-- usually firm, non-tender and fixed
Fibroadenomas?
-- are common, but are usually firm, painless and freely movable
LEEP procedure
-- usually done in the office under local intracervical anesthesia

-- It involves using an electrosurgical unit (similar to the Bovie in the operating room), along with a wire loop of varying sizes to remove the entire transformation zone and the dysplastic area(s) identified during colposcopy

-- This tissue is then sent to pathology so that the area of dysplasia can be fully evaluated
Invasive cervical carcinoma stage Ia2 through II a tx?
-- radical hysterectomy
A 34 year-old G2P2 woman who recently underwent colposcopy with biopsy following a Pap smear which showed low-grade squamous intraepithelial lesion, comes in to discuss her results. The biopsy results showed HGSIL (CIN III). Endocervical curettage showed benign endocervical cells. What is the most appropriate next step in the management of this patient?
-- LEEP

-- This patient has only cervical dysplasia (not invasive cancer), so a radical hysterectomy is not needed

-- A simple hysterectomy is not needed, as it is more involved than a LEEP

-- It is not generally recommended to conservatively offer serial Pap testing for patients with biopsy proven CIN III or HGSIL

-- Although spontaneous regression of dysplasia may occur with a high-grade lesion, the rate of regression is much lower than with LGSIL

-- On the other hand, the progression rate of HGSIL to invasive cancer is much higher (up to 12%)

-- High risk HPV testing can be recommended as an adjunct to Pap smears such as with ASCUS Pap smears. It would not offer further information in this patient’s scenario.
A 26 year-old G0 was found to have a low-grade squamous intraepithelial lesion (LGSIL) on routine Pap smear. She underwent a colposcopy with cervical biopsy. Her colposcopy was adequate and biopsy results showed CIN-I. There was no endocervical glandular involvement. Endocervical curettage showed benign cells. Which of the following is the most appropriate treatment for this patient?
-- The patient should be followed with Pap smears at 6 and 12 months or undergo HPV DNA testing at 12 months

-- Excisional or ablative procedures are not indicated for LGSIL

-- It is unusual to manage low grade lesions by CKC or LEEP
Indications for cold knife conization (CKC) and include:
-- positive endocervical curettage

-- HGSIL lesion either too large for LEEP

-- patient not tolerant of examination in office

-- lesion extending into the endocervical canal beyond vision

-- to rule out invasive cancer (classify the depth of invasion if biopsy shows invasion)
Indications for LEEP and include:
-- similar to those for CKC

-- positive endocervical curettage

-- HGSIL lesion either too large for LEEP

-- patient not tolerant of examination in office

-- lesion extending into the endocervical canal beyond vision

-- to rule out invasive cancer (classify the depth of invasion if biopsy shows invasion)
Management of LGSIL (unless the woman is pregnant, postmenopausal or an adolescent) is:
-- initial colposcopic examination

-- An excisional procedure, such as cold knife biopsy or LEEP, is not warranted without a tissue diagnosis of dysplasia

-- The Pap smear is merely a screening tool and, as such, cannot formulate a definitive diagnosis

-- In fact, up to 20% of patients with LGSIL on Pap smear have HGSIL on colposcopically-directed biopsy

-- In contrast, up to 50% of patients with LGSIL on Pap smear have a negative colposcopy

-- If a Pap smear is repeated prior to 6-8 weeks following the last one, reparative changes may still be happening to the cervix. This reduces the ability of the test to be a good screening tool. (The false positive and/or false negative rates can be affected)

-- In some instances, LGSIL may be followed with serial Pap smears; however, a tissue diagnosis or a colposcopy without evidence of HGSIL changes must be done initially
A 30 year-old woman comes to the office because she desires removal of her IUD. She had a Paragard (Copper T) Intrauterine Device placed for contraception 4 years ago and now she desires pregnancy. She is in good health and has no history of abnormal Pap smears or sexually transmitted infections. Pelvic exam shows a normal appearing cervix and no IUD string visible. Ultrasound shows the IUD in the uterine cavity. An attempt is made to remove the IUD with an IUD hook and failed. What is the most appropriate next step in the management of this patient?
-- A hysteroscopy would be easily performed either in the office or in the operating room, and the IUD could then be removed under direct visualization

-- If the IUD had been seen outside the uterus via ultrasound, laparoscopy could be offered for removal of the IUD
Definitive treatment for a patient with pelvic pain due to endometriosis?
-- hysterectomy with bilateral salpingo-oophorectomy

-- In 60% of cases, when a patient with endometriosis undergoes a simple hysterectomy without bilateral salpingo-oophorectomy for pelvic pain, re-operation for continued pain will be necessary

-- Even if the patient requires hormone replacement therapy postoperatively, her pain is unlikely to return

-- A radical hysterectomy, usually used to treat cervical cancer, is too invasive for the treatment of endometriosis

-- Although Levonorgestrel IUD may effectively relieve endometriosis, it is unlikely to do so in a patient who has been on progestins and oral contraceptives without relief
Workup of pelvic pain?
-- laparoscopy is indicated in order to determine the etiology of the pain

-- If endometriosis is noted, it may be excised, fulgurated or burned by laser. This may offer some relief of the patient’s pain; however, relief is usually temporary in a pre-menopausal female
A 50 year-old G3P3 female comes to the office due to heavy periods, spotting between menses, fatigue and weakness. Over the past 6-8 months, she has noticed a significant increase in the amount of her menstrual bleeding, currently requiring a box of 30 pads for each month. She has noticed an increase in the amount of blood clots and cramping pain during menses. Her previous history is significant for hypertension for 10 years, controlled with hydrochlorothiazide and a postpartum bilateral tubal ligation 20 years ago. She has no history of abnormal Pap smears and no sexually transmitted infections. Blood pressure is 138/84; pulse 82; respirations 20; weight 220 pounds; height 68”. On pelvic exam, uterus is approximately 10-week size. She is nontender on bimanual exam and no adnexal masses are appreciated. A Pap smear 1 month ago was normal, and her hematocrit is 30. What is the next best step in the management of this patient?
-- endometrial biopsy
Endometrial biopsy?
-- typically an office procedure which does not cause extreme discomfort for the patient

-- It results in information necessary to tailor the patient’s care, such as presence of endometritis, endometrial polyps or endometrial carcinoma

-- In a patient with significant risk factors for endometrial carcinoma, this should be done prior to a hysterectomy or ablation, if at all possible
A 42 year-old woman presents to the office with a breast mass. She noticed a firm, slightly tender mass on her right breast during a self breast exam 2 months ago. She has not noticed nipple discharge or skin changes. It has not enlarged nor decreased in size. The review of systems is negative. She does not use tobacco, alcohol or drugs, and she drinks 5 cans of caffeinated soda per day. She has a maternal aunt with breast cancer, who was diagnosed at age 50. On examination, the left breast is normal; right breast has a 1 cm x 2 cm rubbery mobile mass in the upper outer quadrant. There was no nipple discharge, no visible skin changes, and no axillary or supraclavicular lymphadenopathy. A mammogram three months ago was normal and showed dense breast tissue bilaterally. What is the best next step in the management of this patient to help determine her diagnosis?
-- FNA of a palpable breast mass or lymph node allows for pathologic diagnosis of the mass with minimal discomfort to the patient. Results correlate well with excisional biopsy results

-- Observation or waiting for the patient to decrease caffeine intake would not be recommended for a patient with a new finding of a palpable breast mass, especially in a patient with a family history of breast cancer

-- A mammogram does not need to be repeated, since one was performed 3 months ago

-- Excisional biopsy is not necessary at this point although she might ultimately require it
Incidental finding of an adnexal mass workup?
-- transvaginal ultrasound to distinguish an adnexal mass from other structures, as well as note the characteristics of the mass (simple vs. complex, solid vs. cystic, thin or thick walled, size, structures involved)

-- Using this information, a management plan may be constructed
Mammogram guidelines?
-- Women should be offered mammograms yearly starting at age 50 and at least every 2 years between age 40 and 50
A 25 year-old woman presents complaining of a “wart” on her vulva for one year. The area has been treated several times in the past year with several applications of trichloroacetic acid in the office, as well as a 12-week course of Imiquimod cream at home. The lesion never fully resolved with either treatment. On examination, an area of verrucous lesions approximately 1 cm x 1.5 cm is noted on the left labia majora near the fourchette. Upon application of 5% acetic acid, the area becomes acetowhite. There are no other colposcopic abnormalities. Remainder of the exam is normal. A Pap smear 6 months ago is normal. What is the most appropriate next step in the management of this patient?
-- A vulvar lesion unresponsive to treatment needs a biopsy

-- In addition to testing for invasive cancer, the biopsy can also ensure that your diagnosis and treatment are correct

-- If the initial diagnosis of condyloma is unsure, a biopsy should be performed prior to initiating therapy

-- Imiquimod would not be recommended, as this patient previously had a full treatment without total response

-- Prior to initiating treatment again, a tissue diagnosis is recommended

-- A repeat Pap is not indicated for a vulvar lesion

-- prior to using laser vaporization to destroy the lesion, a biopsy should be done to ensure that the lesion is not cancer

-- Interferon is not effective in the treatment of HPV
A 13 year-old girl is brought to the physician for increasingly severe abdominal pain. The pain is now a constant low discomfort, but every month she has a week when it is more severe. She has Tanner stage II breast and pubic hair development. On genital examination, there is a bluish mass pushing the labia open. What is the most likely cause of this patient’s abdominal pain?
-- imperforate hymen
Lower genital tract malformations
-- occur in 1 in 10,000 females

-- most commonly an imperforate hymen where the genital plate canalization is incomplete
Imperforate hymen
-- menstrual blood will collect in the vagina and uterus causing pain

-- Treatment involves surgical correction
Transverse vaginal septum
-- a normal vaginal opening with a short blind vagina and pelvic mass may be located above the level of the obstruction found on exam
Asherman’s syndrome
-- condition characterized by adhesions and/or fibrosis within the uterine cavity due to polyp

-- associated with secondary amenorrhea resulting from intrauterine scarring/synechiae
A 4 year-old girl is being evaluated for premature hair growth in the pubic area. She has no breast development and has not had any menstrual bleeding. Laboratory evaluation revealed high DHEA and DHEAS levels and low levels of LH and FSH. Which of the following is the most likely cause of this girl’s premature adrenarche?
-- Congenital adrenal hyperplasia of the 21-hydroxylase type results in the adrenal being unable to produce adequate cortisol as a result of a partial block in the conversion of 17-hydroxyprogesterone to desoxycorticosterone, with the accumulation of adrenal androgens

-- This leads to precocious adrenarche
CAH (21-hydroxylase deficiency) tx?
-- steroid replacement
Idiopathic isosexual precocious puberty
-- GnRH dependent

-- leads to an appropriate (although early) order of pubertal events
Kallmann Syndrome
-- less common cause of hypothalamic dysfunction

-- arcuate nucleus does not secrete GnRH --> results in the failure to commence or the non-completion of puberty

-- hypogonadism and by a total lack of sense of smell (anosmia)

-- characterized by olfactory tract hypoplasia and the arcuate nucleus does not secrete GnRH

-- Therefore these females have no sense of smell and do not develop secondary sexual characteristics

-- The diagnosis is often one of exclusion found during the workup of delayed puberty

-- The presence of anosmia with delayed puberty should suggest Kallmann syndrome
True precocious puberty
-- a diagnosis of exclusion

-- the sex steroids are increased by the hypothalamic-pituitary-gonadal axis, with increased pulsatile GnRH secretion

-- premature secretion of GnRH hormone in a pulsatile manner
CNS abnormalities associated with precocious puberty include?
-- tumors (e.g., astrocytomas, gliomas, germ cell tumors secreting human chorionic gonadotropin [HCG])

-- hypothalamic hamartomas

-- acquired CNS injury caused by inflammation, surgery, trauma, radiation therapy, or abscess

-- congenital anomalies (e.g. hydrocephalus, arachnoid cysts, suprasellar cysts)
True precocious puberty tx?
-- GnRH agonist to suppress pituitary production of LH and FSH

-- Observation is acceptable if the precocious puberty is within a few months of the routinely expected puberty

-- The process should be treated if the bone age or puberty is advanced by several years
3 known critical elements for secondary sexual characteristics?
-- adequate body weight

-- sleep

-- optic exposure to sunlight

-- These factors especially can delay the onset of menarche

-- A body weight of 85 to 106 pounds is needed before menses begins
A 17 year-old is brought to the physician because she has never had a menstrual cycle. She has normal breast and pubic hair development. Physical examination reveals a small vaginal opening with a blind pouch. Pelvic ultrasound reveals normal ovaries, but absence of uterus and cervix. Which of the following is the most appropriate next study in this patient?
-- renal US

-- Renal anomalies occur in 25-35% of females with Mullerian agenesis
Mullerian agenesis
-- The uterus and cervix are absent, but the ovaries function normally and, therefore, secondary sexual characteristics are present

-- You would expect the karyotype in this patient to be 46,XX

-- -- Renal anomalies occur in 25-35% of females with Mullerian agenesis
A 15 year-old adolescent discusses with her doctor that she has not had a menstrual cycle. She is healthy, active in school activities and eats a normal diet. She denies ever being sexually active. On physical examination, she has Tanner stage II breast and pubic hair growth, and average weight and height. Vaginal opening is present and appears normal. What is the most appropriate next step in her management?
-- Reassurance

-- Normal age for menarche is between 9 and 17

-- Since this patient has secondary sexual characteristics and normal anatomy, she should be offered reassurance that she is normal and her menses will probably start soon
Turner’s syndrome
-- absence of one of the X chromosomes

-- These females will have failure to establish secondary sexual characteristics

-- have short stature

-- characteristic physical features: pterygium colli (webbed neck), shield chest and cubitus valgus (elbows turned in)
Partial deletion of the long arm of the X chromosome
-- premature ovarian failure
Rokitansky-Kuster-Hauser Syndrome
-- causes vaginal and uterine agenesis
Normal and predictable sequence of sexual maturation?
-- Thelarche-Adrenarche-Growth spurt-Menarche

-- breast budding, then adrenarche (hair growth), a growth spurt and then menarche
Breast development begins around the age of?
10
Average age of menarche?
-- 11.75 years

-- earlier for heavier girls and later for thinner, physically active girls
Kallman Syndrome tx?
pulsatile GnRH therapy.
A 23 year-old female college student presents with amenorrhea for 10 months. She had menarche at age 14 and normal regular menses every 28 days until this year. She is in good health and not taking any medications. She is 5 feet 4 inches tall and weighs 130 pounds. Her examination, including a pelvic exam, is normal. Beta-hCG is < 5 mIU/mL, and TSH is 5.0 mU/L (normal 0.35-6.7 mU/L). What is the most appropriate next diagnostic test to help determine the cause of amenorrhea in this patient?
-- Measurement of serum prolactin level --> part of the initial laboratory assessment for a patient with amenorrhea and no other symptoms or findings on physical exam

-- A pelvic ultrasound is not typically helpful in a young patient with a normal pelvic examination

-- A brain MRI might be indicated if prolactin levels return elevated

-- 17-hydroxyprogesterone, LH and FSH levels might need to be obtained in the work-up of this patient, if other tests return normal
Prolactinoma
-- the most common pituitary tumor causing amenorrhea

-- Galactorrhea may be present when hyperprolactinemia is the cause of anovulation and amenorrhea
Most common cause of amenorrhea?
-- Pregnancy

-- important to consider it early in the workup to avoid unnecessary tests, procedures and treatments that may be contraindicated during pregnancy
Causes of hypothalamic-pituitary amenorrhea?
-- functional (weight loss, obesity, excessive exercise)

-- drugs (marijuana and tranquilizers)

-- neoplasia (pituitary adenomas)

-- psychogenic (chronic anxiety and anorexia nervosa)

-- and certain other chronic medical conditions
A 23 year-old G0 presents to the office because she has not had any menses for 4 months. She has a long history of irregular menstrual cycles since menarche at age 14. She is otherwise in good health and is not taking any medications. She is thin and has chronic anxiety. Her Beta-hCG is < 5mIU/mL, and her prolactin and TSH levels are normal. What would be the next best diagnostic test to order?
-- obtain FSH and LH levels, which would be expected to be in the low range
primary amenorrhea, with normal secondary sexual characteristics, development and cyclical abdominal pain points to?
-- an anatomical cause of amenorrhea, which is preventing menstrual bleeding (genital tract outflow obstruction)

-- An imperforate hymen commonly causes this and the treatment is surgical

-- In Mϋllerian agenesis, or Mayer-Rokitansky-Kϋster-Hauser syndrome, there is congential absence of the vagina and usually an absence of the uterus and fallopian tubes

-- Ovarian function is normal and all the secondary sexual characteristics of puberty occur at the appropriate time
A 33 year-old G0 presents with amenorrhea for the past 12 months. She also reports a recent onset of dyspareunia, causing her to feel anxious about having intercourse. She had menarche at age 15. Her cycles were normal until two years ago when she began skipping menses. She is otherwise in good health. She is 5 feet 4 inches tall and weighs 130 pounds. Her physical examination is completely normal. TSH and prolactin levels are normal. Urine pregnancy test is negative. What is the most likely cause of this patient’s amenorrhea?
-- Premature ovarian failure

-- symptom of dyspareunia is likely caused by vaginal dryness, which is associated with estrogen deficiency

-- Hypergonadotropic amenorrhea is the result of ovarian failure or follicular resistance to gonadotropin stimulation

-- The history, physical exam and labs make the other possibilities less likely: psychogenic disorder (no chronic anxiety or anorexia nervosa), outflow obstruction (previously had periods), Asherman’s syndrome (no history of pregnancy or intrauterine procedures), or a pituitary tumor (normal labs)
A 24-year-old G0 comes into the office because she has not had her menses for 6 months. She is in good health and not taking any medications. She is not sexually active. She does well in graduate school, despite her demanding new program. Her height is 5 feet 6 inches and her weight is 104 pounds. Her blood pressure is 140/80, with other vital signs being stable. Her physical examination, including a pelvic examination, is completely normal. What is the most likely reason for her amenorrhea?
-- hypothalamic-pituitary dysfunction

-- anorexia nervosa or significant weight loss may cause hypothalamic-pituitary dysfunction that can result in amenorrhea

-- A lack of the normal pulsatile secretion of GnRH leads to a decreased stimulation of the pituitary gland to produce FSH and LH

-- This leads to anovulation and amenorrhea

-- Although testing for thyroid dysfunction may be indicated, she has no other symptoms to suggest thyroid disease
A 22-year old G0 presents with 5 months of amenorrhea since discontinuing her oral contraceptive pills. She had been on the pill for the last 6 years and had normal menses every 28 days while taking them. She is in good health and not taking any medications. She is 5 feet 4 inches tall and weighs 140 pounds. Her examination, including a pelvic examination, is normal. Which of the following history elements would be most useful in determining the cause of amenorrhea in this patient?
-- History of oligo-ovulatory cycles

-- Since most women resume normal menstrual cycles after discontinuing OCPs, they are not usually considered the cause of the amenorrhea

-- A history of irregular cycles prior to pill use may increase the risk of amenorrhea upon discontinuation. This is sometimes referred to as “post pill amenorrhea”

--A complete work-up should be performed to properly find the cause
Amenorrhea associated with exercise falls under the category of?
-- hypothalamic amenorrhea, which causes chronic anovulation

-- Although it may be related to energy requirements, alterations in the hypothalamic-pituitary-ovarian axis have been described in athletic women
Most appropriate treatment for PCOS?
-- OCPs
Clinical diagnosis of PCOS?
-- irregular cycles

-- obesity

-- hirsutism
When a PCOS pt. desires pregnancy, she will most likely need?
-- treatment for ovulation induction due to the anovulatory cycles as the leading cause of her oligomenorrhea

-- Clomiphene citrate
Asherman’s syndrome can be caused by?
-- curettage or endometritis

-- The intrauterine synechiae or adhesions result from trauma to the basal layer of the endometrium, which causes amenorrhea
Chronic endometritis may be associated with?
-- abnormal uterine bleeding
Sheehan’s syndrome?
-- typically due to severe postpartum hemorrhage leading to pituitary apoplexy
Hirsutism tx?
-- OCPs and Spironolactone (aldosterone antagonist diuretic)

-- Lupron and Depo-Provera are also reasonable as second-line treatments of hirsutism
Danazol
-- primarily used for the treatment of endometriosis

-- may actually worsen hirsutism and acne
Spronolactone
-- aldosterone antagonist diuretic

-- can be used to tx hirsutism
A 35 year-old Asian woman presents with irregular menses and hirsutism of 3 months duration. The patient has no family history of hirsutism. On exam, the patient was noted to have terminal hair growth on her chest and recently had laser treatment to remove similar hair on her chin. Her total testosterone is 76 ng/dl (normal) and her DHEAS is 1500 µg/dl (elevated). Which of the following is the most likely diagnosis in this patient?
-- Adrenal tumor --> the short duration of symptoms and the significantly elevated DHEAS
A 36 year-old woman comes to the office due to hair loss. She delivered a healthy infant girl three months ago. She is currently on a progestin-only oral contraceptive pill since she is breast feeding. In the last month, she has noticed a large amount of hair on her brush each morning. Her father has male pattern baldness and her mother, who is postmenopausal, has also had some thinning of her hair, as well. Testosterone and TSH levels are within the normal range. Which of the following is the most likely underlying cause for alopecia in this patient?
-- High estrogen levels in pregnancy increase the synchrony of hair growth

-- Therefore, hair grows in the same phase and is shed at the same time

-- Occasionally, this can result in significant postpartum hair loss

-- in the non-pregnant state, asynchronous hair growth occurs such that a portion of hair is in one of the three hair growth cycles at all times
A 17 year-old patient presents with hirsutism, irregular menses and obesity. Her mother is moderately obese with mild hirsutism. Recently the patient’s hirsutism has worsened and she has been depressed. She has also gained 20 pounds in the past two months and has noticed stretch marks on her abdomen. At the time of your examination, you note that she has terminal hair growth on her chin and hair growth on the back of her hands. Her cheeks appear flushed. Her stretch marks are purplish in color. The rest of her exam is normal. Which of the following is the most appropriate first test to order for this patient?
-- Overnight dexamethasone suppression test or a 24-hour urinary measurement for cortisol can be performed, since Cushing's syndrome is suspected

-- Elevated cortisol would be indicative of Cushing's syndrome
A 22 year-old G0 woman presents with hirsutism, which has been present since menarche. She states that she has laser treatments done to remove the hair on her chin every couple of months, and was wondering if there are additional treatments which might help her. She is otherwise in good health. She has normal menstrual cycles every 28 days. She is sexually active and uses birth control pills for contraception. The patient is adopted and has no information about family history. She is 5’4” tall and weighs 125 pounds. On examination, the patient was noted to have terminal hair growth on her chest. Her TSH, Prolactin, total testosterone, DHEAS, 17-Hydorxyprogesterone levels are normal. Which of the following is the most likely underlying etiology for the hirsutism in this patient?
-- patient most likely has idiopathic hirsutism

-- She has no other clinical signs of polycystic ovaries, such as irregular cycles or obesity

-- Normal laboratory values rule out other pathogenic causes of hirsutism, such as Cushing’s syndrome or adrenal tumor

-- Oral contraceptives are actually used for the treatment of hirsutism
A 34 year-old G2P2 presents with concerns of hormonal changes. She is worried about facial hair growth, worsening acne, and deepening of her voice. She also realized that she has missed her period for 2 months, and has been sexually active and had tubal ligation for contraception. On examination, she is moderately obese and noted to have severe acne, upper lip and chin terminal hair. Her abdomen is obese with moderate hair growth. Pelvic examination is most notable for an enlarged clitoris, and pelvic exam reveals an enlarged right sided adnexal mass. Which of the following is the most likely diagnosis in this patient?
-- Sertoli-Leydig cell tumors --> a testosterone-secreting ovarian tumor
Sertoli-Leydig cell tumors
-- commonly diagnosed in women between the ages of 20-40

-- most often unilateral

-- Rapid onset of hirsutism and virilizing signs are hallmarks of this disease (including acne, hirsutism, amenorrhea, clitoral hypertrophy, and deepening of the voice)

-- Abnormal laboratory findings include suppression of FSH and LH, marked elevation of testosterone, and presence of an ovarian mass

-- The constellation of findings is most consistent with a testosterone-secreting tumor, and a pelvic ultrasound will confirm the presence of an ovarian mass
Granulosa cell tumors
-- estrogen secreting
Choriocarcinoma
-- elevated BHCG
Hyperthecosis
-- a more severe form PCOS

-- associated with virilization due to the high androstenedione production and testosterone levels

-- signs of virilization include clitoral enlargement, deepening of the voice, and temporal balding

-- Hyperthecosis is more difficult to treat with OCPs

-- It is also more challenging to achieve successful ovulation induction
A 34 year-old woman comes to you for a chief complaint of hirsutism. She states that this has been present since menarche, but has gotten worse in the past two years. Her menses have become more irregular, now every 28-45 days apart. She states that she quit smoking and gained approximately thirty pounds in the past three years. Her mother is obese, diabetic and has hirsutism. There is no hair seen on her chin, but she shaves every few days. TSH, prolactin, 17-hydroxyprogesterone and DHEAS are normal. Testosterone is mildly elevated. Which of the following is the most likely etiology of her hirsutism?
-- PCOS, based on her clinical symptoms and her mildly elevated testosterone

-- The normal laboratory data above rule out the other causes of hirsutism
An 18 year-old G0 woman presents with a 1-year history of hirsutism and acne. She had menarche at age 14 and her menses have been irregular every 26-60 days. Her sister has a similar pattern of hair growth. The patient is 5’4” tall and weighs 180 pounds. On exam, a few terminal hairs were identified on her chin and upper lip. TSH, prolactin, total testosterone, and DHEAS levels are normal. Which of the following is the most appropriate next test to evaluate this patient’s condition?
-- Checking 17-hydroxyprogesterone would rule out late onset 21-hydroxylase deficiency

-- Normal TSH, prolactin, total testosterone and DHEAS levels rule out pituitary or adrenal tumors

-- The patient could have polycystic ovarian syndrome; however, normal serum testosterone levels make it less likely
A 26 year-old woman presents with hirsutism and irregular menses. Her mother, who is diabetic, had similar complaints prior to menopause. On physical exam, this patient is noted to have terminal hair on her chin and a gray-brown velvety discoloration on the back of her neck. This lesion is acanthosis nigricans. Which of the following is the most appropriate first test to order for this patient?
-- Fasting insulin

-- Since this woman has a family history of diabetes and also has acanthosis nigricans, the most appropriate test of those listed would be the fasting insulin. The other tests would also be reasonable, but hyperinsulinemia is most likely in this patient.
Acanthosis nigricans is associated with?
-- elevated androgen levels and hyperinsulinemia
A 14-year old G0 adolescent reports menarche six months ago, with increasingly heavy menstrual flow causing her to miss several days of school. Three months ago, her pediatrician started her on oral contraceptives to control her menstrual periods, but she continues to bleed heavily. Her previous medical history is unremarkable. The patient has a normal body habitus for her age. Appropriate breast and pubic hair development is present. Her hemoglobin is 9.1 mg/dl, hematocrit 27.8%, urine pregnancy test negative. Which of the following etiologies for menorrhagia is most likely the cause of her symptoms?
-- Coagulation disorder --> disorders of clotting may present with menstrual symptoms in young women, with Von Willeberand disease being most common
Leiomyomas typically present at what age?
-- 30s to 40s
By which mechanism does Medroxyprogesterone Acetate MPA control periods?
-- Converts endometrium from proliferative to secretory

-- Patients with anovulatory bleeding have predominantly proliferative endometrium from unopposed stimulation by estrogen

-- Progestins inhibit further endometrial growth, converting the proliferative endometrium to secretory endometrium

-- Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium

-- Stimulation of rapid endometrial growth, conversion of proliferative to secretory endometrium, and regeneration of the functional layer describe effects of estrogen on the endometrium
Inhibin is increased during what phase?
-- Luteal
A 35 year-old G2P2 woman comes to the office due to heavy menstrual periods. The heavy periods started three years ago and have gradually worsened in amount of flow and duration. The periods are now interfering with her daily activities. The patient had two spontaneous vaginal deliveries. She smokes 1 pack of cigarettes per day. On pelvic examination, the cervix appears normal and the uterus is normal in size, without adnexal masses or tenderness. A urine pregnancy test is negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl. On pelvic sonography, a 2 cm submucosal leiomyoma is noted. An endometrial biopsy is consistent with a secretory endometrium; no neoplasia is found. Which of the following would be the best therapeutic option for this patient if she desires to have another child?
-- Hysteroscopic myomectomy preserves the uterus, while removing the pathology causing the patient’s symptoms

-- laparoscopic approach is not indicated as the myoma is submucosal and not accessible using a laparoscopic approach

-- Endometrial ablation destroys the endometrium and can create Asherman’s syndrome, thus it is reserved for patients who have completed childbearing

-- Dilation and curettage is unlikely to remove the myoma and is a blind procedure (carried out without direct visualization)

-- OCPs would typically help with heavy menses, but are contraindicated in this patient, who is over 35 and smokes
A 35 year-old G0 woman presents with irregular menstrual periods occurring every 6-12 weeks with occasional inter-menstrual bleeding. Currently, she has been bleeding daily for the last 4 weeks. She reports that her periods have always been irregular, but have become more so with heavier flow and cramping in the last year. She is sexually active with one partner. On physical exam, she is morbidly obese with no abnormalities detected on pelvic exam. Which of the following is the most appropriate next step in the management of this patient?
-- Endometrial biopsy should be performed to rule out endometrial hyperplasia or carcinoma given the history of irregular bleeding, coupled with the increased risk of these diagnoses in morbidly obese patients

-- A pelvic CT would not evaluate for the presence of endometrial neoplasia

-- LH and FSH levels would not aid in the diagnostic workup

-- testosterone levels would not be useful, unless signs of hirsutism or virilization are present
A 34 year-old G2P2 woman presents with inter-menstrual bleeding for one year. The bleeding typically occurs 2 weeks after her menses and last 2-3 days. The symptoms began 1 year ago and the bleeding has not changed recently. She is currently taking oral contraceptives. On pelvic examination, the cervix appears normal and the uterus is normal in size and shape. Her urine pregnancy test is negative; an endometrial biopsy is negative for neoplasia. Which of the following tests or procedures would be indicated for further work-up?
-- Pelvic ultrasound

-- Intermenstrual bleeding is frequently caused by structural abnormalities of the endometrial cavity, such as myomas, polyps or malignancy

-- Progesterone levels are not helpful in a patient on oral contraceptives
A 41 year-old G3P3 woman reports heavy menstrual periods occurring every 26 days lasting 8 days. The periods have been increasingly heavy over the last three months. She reports soaking through pads and tampons every 2 hours. She has a history of three uncomplicated spontaneous vaginal deliveries and a tubal ligation following the birth of her last child. On pelvic examination, the cervix appears normal and the uterus is normal in size. Which of the following tests or procedures would be most useful in further evaluation of this patient’s complaint?
-- pelvic ultrasound would image the endometrium and rule in or rule out uterine, and possibly endometrial, polyps

-- In the absence of menopausal symptoms, FSH is unlikely to be helpful

-- The patient is unlikely to have a coagulation disorder, as she has had three spontaneous vaginal deliveries without postpartum hemorrhage

-- Hyperprolactinemia is found with prolactin-secreting adenomas associated with amenorrhea
Dysfunctional uterine bleeding
-- defined as irregular or increased menstrual bleeding without identified etiology
A 45 year-old G2P2 woman comes to the office because of heavy and irregular menstrual periods. The heavy periods started three years ago and have gradually worsened in amount of flow over time. The periods are interfering with her daily activities. The patient has had two spontaneous vaginal deliveries, followed by a tubal ligation 3 years ago. On pelvic examination, the cervix appears normal and the uterus is normal in size without adnexal masses or tenderness. A urine pregnancy test is negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl. On pelvic sonography, she has a normal size uterus and a 2 cm simple cyst on the right ovary. Endometrial biopsy is consistent with a secretory endometrium; no neoplasia is found. What is the most likely diagnosis in this patient?
-- Dysfunctional uterine bleeding --> defined as irregular or increased menstrual bleeding without identified etiology

-- This patient had a complete workup, including TSH, Prolactin, pelvic ultrasound and endometrial biopsy, which were all normal

-- The 2 cm cyst is a functional cyst and is a common finding in ovulatory patients
Mid-cycle bleeding at the time of ovulation?
-- due to the drop in estrogen
Ovarian teratomas
-- typically present with abdominal or pelvic pain which may be associated with torsion

-- unlikely to present with abnormal menses
An 18 year-old woman comes to the office due to vaginal spotting for the last two weeks. Her menstrual periods were regular until last month, occurring every 28-32 days. Menarche was at age 13. She started oral contraceptives 3 months ago. On pelvic examination, the uterus is normal in size, slightly tender with a mass palpable in the right adnexal region. No adnexal tenderness is noted. Which of the following tests is the most appropriate next step in the management of this patient?
-- Urine pregnancy test --> It is vitally important to rule out pregnancy in the evaluation of abnormal uterine bleeding

-- Sonography could be considered as a next step if the pregnancy test is negative in order to evaluate the adnexal finding

-- Although a bleeding disorder could be a possibility, it is less likely with her previous history of normal cycles

-- Endometrial biopsy would rarely be indicated in a teen with abnormal bleeding, unless morbidly obese and anovulatory
Tx of dysfunctional uterine bleeding (DUB)?
-- Endometrial ablation is an effective surgical procedure for DUB

-- Leuprolide should not be used for more than 6 months because of the risk of osteoporosis

-- Dilation and curettage is not effective as a therapy for DUB in the long-term

-- Cyclic progestins are unlikely to work any better than oral contraceptives with ovulatory DUB

-- if Pelvic exam and ultrasound did not reveal any fibroids, a myomectomy is unnecessary
A 36 year-old G0 woman presents due to increasing facial hair growth and irregular menstrual cycles. She has gained 40 pounds over the last 3 years. Her symptoms began 3 years ago and have gradually worsened. She has never been pregnant and is not currently on any medications. On physical exam, she is overweight with dark hair growth at the sideburns and upper lip. The pelvic exam is normal. Which of the following would you expect to find in this patient?
-- Elevated free testosterone

-- This patient likely has PCOS --> patients have testosterone levels at the upper limits of normal or slightly increased

-- Free testosterone (biologically active) is elevated often because sex hormone binding globulin is decreased by elevated androgens

-- LH is increased in response to increased circulating estrogens fed by an elevation of ovarian androgen production

-- Insulin resistance and chronic anovulation are hallmarks of PCOS

-- Prolactin levels may be elevated in amenorrhea but are not elevated in patients with PCOS
A 42 year-old G4P4 woman presents with a history of progressively worsening severe menstrual pain. Menses are regular, but she complains of very heavy flow requiring both a menstrual pad and tampon with frequent bleeds through this protection on heavy days. She takes Oxycodone that her husband used for back pain to relieve her dysmenorrhea. She had a tubal ligation four years ago. Pelvic examination shows an enlarged, soft, boggy uterus. No masses are palpated. Pregnancy test is negative, hemoglobin 9.8 and hematocrit 28.3%. What is the most likely diagnosis?
-- Adenomyosis

-- Endometrial hyperplasia and carcinoma are less likely in a woman with regular menses

-- Endometriosis would most likely have presented earlier in life and would not explain the enlarged uterus
Adenomyosis
-- presence of endometrial glands and supporting tissues in the muscle of the uterus

-- the gland tissue grows during the menstrual cycle and, at menses, tries to slough, but cannot escape the uterine muscle and flow out of the cervix as part of normal menses

-- This trapping of the blood and tissue causes uterine pain in the form of monthly menstrual cramps
A 19 year-old G0 woman presents with severe menstrual pain that causes her to miss school. She takes 600 mg of ibuprofen every 4-6 hours to control the pain, but this does not relieve the discomfort. You started oral contraceptives, but her symptoms persisted. She also tried Depo-Provera for 3 months without much improvement. She still has menstrual pain and continues to miss some classes. What is the most appropriate next step in the management?
-- Diagnostic laparoscopy --> recommended to confirm the diagnosis of endometriosis and exclude other causes of secondary dysmenorrhea

-- Some authors suggest that a course of GnRH agonists are appropriate, with laparoscopy reserved for those women who have pain during or after completion of a 3-month course
Pathological hallmark of adenomyosis?
-- Invasion of endometrial glands into the myometrium
A 19 year-old G0 presents with severe menstrual pain which causes her to miss school. She takes 600 mg of ibuprofen every 4-6 hours to control the pain, but this does not relieve the discomfort. She is sexually active, with one present partner (two lifetime partners) and uses condoms for contraception. Examination is normal. What is the most appropriate next step in the management of this patient?
-- OCPs

-- Dysmenorrhea or painful menstrual cramps is often incapacitating

-- OCPs will not only relieve primary dysmenorrhea, but also provide more reliable contraception

-- COX-2 inhibitors have targeted action but have significant side effects, and are no longer routinely prescribed

-- Continuous oral Medroxyprogesterone may be effective, but will not provide contraception
Depo-Provera would be a better choice

-- GnRH agonists are too expensive and have too high a side effect profile to be used for this purpose
A 23 year-old G0 woman with severe dysmenorrhea that is unresponsive to non-steroidal anti-inflammatory agents and oral contraceptives is taken to the operating room for a laparoscopy. Blue-black powder burn lesions are seen in the pelvis. A biopsy is performed and sent to pathology. Which of the following pathologic lesions would you expect to see in this patient?
-- The lesions described are classic for endometriosis

-- One would therefore expect to see endometrial glands/stroma with hemosiderin-laden macrophages
A 42 year-old G4P4 woman presents for management of suspected adenomyosis. She had a tubal ligation four years ago. A pelvic examination shows an enlarged, soft, boggy uterus. A pregnancy test is negative and she is mildly anemic. An ultrasound shows an enlarged uterus with no fibroids. The patient desires definitive treatment for this condition. What is the most appropriate next step in her management?
-- Hysterectomy is nearly 80% effective in eliminating pain and abnormal bleeding, if she is willing to undergo surgery

-- GNRH agonists are the first choice for medical therapy for the pain, but the problem is that the adenomyosis seems to recur after discontinuing the therapy

-- Endometrial ablation and insertion of a levonorgestrel-containing intrauterine system are options in women who decline hysterectomy or desire to maintain fertility
A 41 year-old G2P2 woman presents with menstrual pain, menorrhagia, irregular periods and intermenstrual bleeding. She describes the pain as pressure and cramps. Ibuprofen improves the pain, but does not entirely eliminate the discomfort. Pelvic examination reveals a 14-week size uterus with irregular masses within the uterus. Pelvic ultrasound confirms the diagnosis of fibroids. What is the most appropriate next step in the management of this patient?
-- Endometrial biopsy --> should be performed on all women over age 40 with irregular bleeding to rule out endometrial carcinoma

-- A simple pelvic ultrasound could be used to help confirm the clinical diagnosis

-- GnRH agonist and hysterectomy are not used until the diagnosis of leiomyomata uteri is confirmed

-- Her desire for future fertility should be discussed
Classic symptoms of leiomyomata?
-- menstrual pain, menorrhagia, irregular periods and intermenstrual bleeding
CA125
-- serum marker for ovarian cancer
Pathologic confirmation of fibroids?
-- Well-circumscribed, non-encapsulated myometrium
Pathologic confirmation of leiomyosarcomas?
-- > than 10 mitotic figures per high power field.
A 21 year-old G0 presents with severe menstrual pain. She takes 600 mg of ibuprofen every 4-6 hours to control the pain, but this does not relieve the discomfort. She is sexually active with one present partner and has four lifetime partners. She uses condoms for contraception. Past medical history is unremarkable, except for breast cancer in her father’s sister. Examination is normal. In addition to a Pap smear, what is the most appropriate additional test needed for this patient?
-- chlamydia testing

-- U.S. Preventive Services Task Force recommends chlamydia and gonorrhea screening for all sexually active patients, age 25 and younger

-- Since pelvic inflammatory disease is a cause of secondary dysmenorrhea, it needs to be evaluated as a potential cause of her symptoms
A 15 year-old G0 presents with severe menstrual pain for the past 12 months. The pain is severe enough for her to miss school. The pain is not relieved with ibuprofen 600 mg every 4 hours. She is not sexually active and the workup reveals no pathology. The most appropriate next step in the management of this patient is to begin combination oral contraceptives. How do oral contraceptives relieve primary dysmenorrhea?
-- Creating endometrial atrophy

-- The progestin in oral contraceptives creates endometrial atrophy

-- Since prostaglandins are produced in the endometrium, there would be less produced

-- Dysmenorrhea should be improved
A 49 year-old G2P2 woman s/p hysterectomy at age 45 for fibroids presents to your office complaining of severe vasomotor symptoms for 3 months. Hot flashes are affecting her quality of life and she would like to discuss options for treatment. What treatment option for hot flushes associated with menopause do you recommend as the most effective?
-- Treatment with estrogen is most effective, and the current recommendation is for the lowest dose for the shortest duration of time. Hot flashes will resolve completely in 90% of patients receiving this therapy

--SSRI antidepressants, some anti-seizure medications and alternative treatments, such as soy products and herbs, have not been shown to be as effective as estrogen

-- Raloxifene, a SERM, may actually cause hot flashes to worsen in a patient who has not stopped having these symptoms completely
A 54 year-old G4P4 woman who has been menopausal for 4 years comes to you for an annual exam. She is in good health, eats a balanced diet, exercises regularly, and has never had any menopausal symptoms and wants to know why. You explain to her that some untreated postmenopausal women will have circulating estrogen levels that are adequate to prevent them from experiencing the symptoms of menopause. What is the most likely source of these circulating estrogens?
-- Aromatization of circulating androgens

-- Estrogen production by the ovaries does not continue beyond the menopause

-- Estrogen levels in postmenopausal women can be significant, due to the extraglandular conversion of androstenedione and testosterone to estrogen

-- This conversion occurs in peripheral fat cells and thus, body weight has been directly correlated with circulating levels of estrone and estradiol
The circulating estradiol level after menopause is?
-- approximately 10-20 pg/ml

-- This is derived from the peripheral conversion of estrone, which is mainly a result of the peripheral conversion of androstenedione

-- androstenedione --> estrone --> estradiol
A 52 year-old G3P3 woman presents to your office with severe hot flashes and vaginal dryness for 6 months. Her last menstrual period was 15 months ago. After discussing the risks and benefits of hormone therapy with this patient, she decides to begin treatment. This patient is most likely to stop hormone therapy secondary to what side effect?
-- vaginal bleeding

-- Most irregular bleeding due to initiation of hormone therapy occurs in the first 6 months

-- It has been cited as the most common reason as to why women stop hormone therapy

-- Women who are amenorrheic for some period of time are often disturbed by the resumption of any vaginal bleeding/spotting and find it intolerable
A 54 year-old G2P2 presents to your office for an annual visit. Her last menstrual period was 8 months ago. She complains of severe vasomotor symptoms, vaginal dryness, and dyspareunia and she desires treatment for her symptoms. She has otherwise been in good health. She has no significant past medical or past surgical history. Her family history is significant for a mother who has severe osteoporosis at the age of 75 and a grandmother who died of breast cancer at the age of 79. She does not report any smoking, alcohol or drug use. On physical exam her BP is 130/78, Pulse 84, BMI is 26. The remainder of her exam is within normal limits except for severe vaginal atrophy noted on the pelvic examination. The best recommendation for this patient would include which of the following?
-- Lowest effective dose of combination hormone replacement therapy for the shortest duration possible

-- ACOG 2004 report on HRT considers HRT the most effective treatment for severe menopausal symptoms that include hot flashes, night sweats and vaginal dryness

-- The physician should counsel the woman about the risks and benefits before initiating treatment

-- ACOG recommends “the smallest effective dose for the shortest possible time and annual reviews of the decision to take hormones.”

-- HRT should not be used to prevent cardiovascular disease due to the slight increase in risk of breast cancer, myocardial infarction, cerebrovascular accident, and thromoboembolic events

-- A woman with an intact uterus should not use estrogen-only therapy because of the increased risk of endometrial cancer

-- In addition to the same risks as FDA approved treatments, bioidentical hormones such as testosterone and progesterone cream may have additional associated risks

-- Bisphosphonates are used to treat osteoporosis and will not relieve her symptoms
A 58 year-old G3P1 woman presents to your office for her annual exam. She became menopausal at age 54. Her past medical history is significant for angina. She experienced a Colles’ fracture 14 months ago when she tripped and fell while running after her grandson. She has not had any surgeries. She takes no medications and has no known drug allergies. She smokes 10 cigarettes a day and drinks a glass of red wine at dinner. Her father was diagnosed with colon cancer at the age of 72. Physical exam revealed a BP =120/68, P=64, BMI= 22. Her heart, lung, breast and abdominal exams were normal. Pelvic exam was consistent with vaginal atrophy and a small uterus. There was no adnexal tenderness and no masses were palpated. What is the next step in the management plan for this patient?
-- Begin treatment with bisphosphonates

-- This patient has many of the major risk factors for osteoporosis including history of fracture as an adult, low body weight and being a current smoker

-- Patients who already have had an osteoporotic fracture may be treated on this basis alone, although a DEXA scan may be useful for other reasons, such as ruling out a pathologic fracture from metastatic disease

-- Hormone replacement therapy is not recommended long term for disease prevention especially in patients with cardiovascular disease

-- Prior to beginning treatment with bisphosphonates, a bone mineral density (BMD) should be documented and repeated at two -year intervals to monitor treatment
Major risk factors for osteoporosis?
-- history of fracture as an adult

-- low body weight

-- being a current smoker

-- Asian, then Caucasians
General recommendations for the prevention of osteoporosis include?
-- eating a balanced diet that includes adequate intake of calcium and vitamin D

-- regular physical activity

-- avoidance of heavy alcohol consumption

-- smoking cessation
Test of choice for measuring bone mineral density (BMD)?
-- DEXA
Which of the following medical conditions in a contraindication to treatment of menopausal symptoms with hormone therapy:
-- vaginal bleeding
-- HTN
-- diabete
-- osteoporosis
-- hyperthyroidism
-- vaginal bleeding

-- The principal symptom of endometrial cancer is abnormal vaginal bleeding

-- Although the patient’s worsening symptoms makes treatment an important consideration, the specific organic cause(s) of abnormal bleeding must be ruled out prior to initiating therapy

-- A tissue diagnosis consistent with normal endometrium or a pelvic ultrasound with an endometrial stripe of <4 mm ought to be documented

-- In addition, risks and benefits of hormone replacement therapy must be discussed with this patient at length prior to beginning treatment
HRT has the what effect on a lipid/cholesterol profile?
-- HDL levels increase and LDL levels decrease

-- Recent data have confirmed the overall positive effects of hormone therapy on serum lipid profiles

-- Estrogen increases triglycerides and increases LDL catabolism, as well as lipoprotein receptor numbers and activity, therefore causing decreased LDL levels

-- Hormones inhibit hepatic lipase activity, which prevents conversion of HDL2 to HDL3, thus increasing HDL levels

-- Hormone therapy is not currently recommended for the primary prevention of heart disease
Optimal daily calcium intake in post-menopausal women?
-- 1200 mg

-- Calcium absorption decreases with age because of a decrease in biologically active vitamin D

-- A positive calcium balance is necessary to prevent osteoporosis

-- Calcium supplementation reduces bone loss and decreases fractures in individuals with low dietary intakes

-- In order to remain in zero calcium balance, postmenopausal women require a total of 1200 to 1500 mg of elemental calcium per day
A 47 year-old G2P2 woman comes to your office because she has skipped her menstrual period for the past 3 months. She denies any menopausal symptoms. Review of symptoms and physical exam are unremarkable. Quantitative BHCG <5 mIU/ml, TSH= 1.2 mIU/L (normal). What is the most likely diagnosis in this patient?
-- Perimenopause

-- Although there has been a decline in the average age of menarche with the improvement in health and living conditions, the average age of menopause has remained stable

-- This patient is most likely perimenopausal and will probably have more menstrual periods in the future
Avg age of menopause?
-- 51.3
Premature ovarian failure occurs before age?
-- 35
A 27 year-old G0 woman presents to the clinic because of concerns that she has not been able to get pregnant for the last year. She has been married for two years and was using oral contraceptives, which she stopped a year ago to start a family. She is in good health and her only medication is a prenatal vitamin. She was hospitalized at age 19 for a “pelvic infection.” Her periods are regular, every 28 days with normal flow; her last period was 2 weeks ago. She has no history of abnormal Pap smears. Her husband is also healthy with no medical problems. She is 5’4” tall and weighs 130 pounds. Her examination, including a pelvic exam, is completely normal. Which of the following is the most likely diagnostic test to find out the cause of her infertility?
-- hysterosalpingogram

-- Based on her history, the most likely underlying factor is tubal disease s/s PID

-- This can cause adhesions and blockage of the tubes, which is best assessed with a hysterosalpingogram to evaluate the uterine cavity and tubes
After a single episode of salpingitis, what % of patients experience infertility?
15%
What does a hysteroscopy assess?
-- uterine cavity

-- no info on tubes/ovaries
Primary infertility?
-- inability to conceive for 1 year without contraception
The male factor plays a role in about what % of infertility cases?
35%
A 27 year-old G0 woman presents to the clinic because of concerns that she has not been able to get pregnant for the last year. She has been married for two years ago and was using birth control pills for contraception. She stopped using birth control pills when she decided to start a family one year ago. She is in good health and her only medication is a prenatal vitamin. Her periods are regular, every 28 days, with normal flow; her last period was 2 weeks ago. She has no history of sexually transmitted infections and no abnormal Pap smears. Her husband is also healthy with no medical problems. She is 5’4” tall and weighs 130 pounds. Her examination, including a pelvic exam, is completely normal. Laboratory results show normal thyroid function tests and normal prolactin level. What is the most appropriate next step in the management of this patient?
-- Order a semen analysis
A 27 year-old G0 woman comes to the clinic as she has been unable to conceive for the last year. She is in good health and has not used any hormonal contraception in the past. She had normal cycles in the past every 28 days until about 6 months ago. At that time, she began to have irregular menses every 2-3 months, with some spotting in between. She is not taking any medications. She has no history of abnormal Pap smears or sexually transmitted infections. Her physical examination is normal. Laboratory tests show: Results Normal Values TSH 10 mIU/ml 0.5-4.0 mIU/ml Free T4 0.2 ng/dl 0.8-1.8 ng/dl Prolactin 40 ng/ml <20 ng/ml FSH 6 mIU/ml 5-25 mIU/ml LH 4 mIU/ml 5-25 mIU/ml What is the most appropriate step in the management of this patient?
-- Begin Synthroid

-- patient is having abnormal cycles due to hypothyroidism, which is also the most likely cause of her hyperprolactinemia

-- It is not necessary to treat the hyperprolactinemia with bromocriptine or order a brain MRI until the hypothyroidism is first corrected
After 1 month, what % of couples will conceive?
20%
After 3 months, what % of couples will conceive?
50%
After 6 months, what % of couples will conceive?
75%
After 12 months, what % of couples will conceive?
90%
A 27 year-old G0 woman presents to the clinic because of concerns that she has not been able to get pregnant for the last 3 months. She married a year ago and was using condoms for contraception, which she stopped 3 months ago when she decided to start a family. She is in good health and her only medication is a prenatal vitamin. Her periods are regular every 28 days with normal flow; her last period was 2 weeks ago. She has no history of sexually transmitted infections and no abnormal Pap smears. Her husband is also healthy with no medical problems. She is 5’4” tall and weighs 130 pounds. Her examination, including a pelvic exam, is completely normal. What is the most appropriate next step in the management of this patient?
-- reassurance and observation
A 32 year-old G0 woman comes to the office due to the inability to conceive for last two years. She reports having been on oral contraceptives for 8 years prior. She had menarche at age 14 and has had irregular cycles about every 3 months until she started oral contraceptives, which regulated her cycles. In the last year, she has had about 5 cycles in total; her last menstrual period was 6 weeks ago. She is otherwise in good health and has not had any surgeries. She has no history of abnormal Pap smears or sexually transmitted infections. She is 5’4” tall and weighs 165 pounds. On general appearance, she seems to be hirsute on the face and the abdomen. The rest of her exam is otherwise normal. Which of the following is most likely to help identify the underlying cause of this woman’s infertility?
-- testosterone levels

-- patient most likely has PCOS (polycystic ovarian syndrome), based on her history of irregular cycles, her body habitus and hirsutism

-- Having normal cycles on the birth control pills (OCPs) supports the diagnosis as other causes, such as hypothyroidism, will not normalize the cycles on OCPs

-- Testosterone levels will be helpful to confirm the diagnosis, especially in the presence of hirsutism

-- Once a diagnosis is established, progesterone levels are helpful during medical treatment to check if the woman is ovulating

-- An increased LH/FSH ratio is observed to be elevated in PCOS patients but each test separately will not aid in the diagnosis
A 45 year-old G3P3 woman comes to the office because she has been unable to conceive for the last two years. She is healthy and has 3 children ages 10, 12 and 14, whom she conceived with her husband. She used a copper IUD after the birth of her last child and had it removed two years ago, hoping to have another child. She has no history of sexually transmitted infections or abnormal Pap smears. Her cycles are regular every 28 to 32 days. She is not taking any medications. She has been married for the last 16 years, and her husband is 52 years-old and in good health. Her physical examination, including a pelvic exam, is completely normal. What is the most appropriate next step in the management of this patient?
-- Order clomiphene challenge test

-- patient, most likely, has decreased ovarian reserve due to her age

-- This will help counsel the patient on appropriate venues to have a child, as most women will not be able to conceive at this age and would not be good candidates for ovarian stimulation or IVF

-- Most likely this patient will have to use a donor egg, if she wants to carry the pregnancy herself
Clomiphene challenge test?
-- giving clomiphene citrate days 5 to 9 of the menstrual cycle and checking FSH levels on day 3 and day 10

-- will help determine ovarian reserve
Exercise-induced hypothalamic amenorrhea?
-- normal FSH

-- low estrogen levels
A 23 year-old G0 woman comes to the clinic because she is interested in becoming pregnant. She is in good health; however, she has not had any menses for the last two years. She had menarche at age 15, had normal periods until 3 years ago, when she started having periods irregularly every 3 months and then stopped 2 years ago. She has no history of pelvic infections or abnormal Pap smears. She exercises every day by running and has run 4 marathons in the last 3 years. She is 5’10” tall and weighs 115 pounds. Her examination including a pelvic exam is normal. Laboratory results show: Results Normal Values TSH 3.5 mIU/ml 0.5-4.0 mIU/ml Free T4 0.9 ng/dl 0.8-1.8 ng/dl Prolactin 10 ng/ml <20 ng/ml FSH 6 mIU/ml 5-25 mIU/ml LH 4 mIU/ml 5-25 mIU/ml BHCG 2 mIU/ml <5 mIU/ml What is the most appropriate next step in the management of this patient?
-- normal FSH and low estrogen levels

-- encourage the patient to gain weight by decreasing exercise and increasing caloric intake

-- If her menses fail to resume, she may be treated with exogenous gonadotropins (LH and FSH) to help her conceive

-- Clomiphene citrate tends not to work as well, due to the baseline hypoestrogenic state
Imipramine side effects?
-- hyperprolactinemia
A 37 year-old G2P1 woman comes to the clinic with her husband due to the inability to conceive for the last year. She reports being in good health and not having problems with her prior pregnancy two years ago, except for some postpartum depression for which she was placed on Imipramine and which she continues to take. She took birth control pills after her pregnancy and stopped 1 year ago, when she began trying to conceive. Her periods were regular on the pills, but have been irregular since she stopped taking them. She has no history of sexually transmitted infections or abnormal Pap smears. Her husband is also healthy and he fathered their first child. Her physical examination is completely normal. Laboratory tests show: Results Normal Values TSH 2.1 mIU/ml 0.5-4.0 mIU/ml Free T4 1.1 ng/dl 0.8-1.8 ng/dl Prolactin 60 ng/ml <20 ng/ml FSH 6 mIU/ml 5-25 mIU/ml LH 4 mIU/ml 5-25 mIU/ml What is the most appropriate next step in the management of this patient’s subfertility?
-- Wean off Imipramine and be placed on a more appropriate medication

-- Once she is off imipramine and the cause of her elevated prolactin levels is confirmed, her normal menses should resume

-- It would be premature to obtain an MRI or begin bromocriptine without this intermediate step

-- Although Clomid is used to help with ovulatory dysfunction, the hyperprolactinemia must be addressed first
A 28 year-old G0 woman comes to the office for preconception counseling and the inability to conceive for one year. She and her husband of 3 years are both in good health. She has normal cycles every 28-33 days. She has intercourse about once a month, depending on her schedule. She is an airline pilot and travels a lot. Her examination is normal. She asks about when to best have intercourse during her cycle to maximize her chances of pregnancy. What is the most appropriate advice to give her?
-- Use ovulation predictor kits and attempt intercourse after it turns positive

-- Since this patient has cycles that vary in length, she can best tell when she is ovulating by using an ovulation predictor kit

-- The basal body temperature charts tell when a patient ovulated retrospectively, so it cannot be used to time intercourse to conceive, as the egg is only viable for about 24 hours
Women are most fertile when?
-- during the middle of their cycle when they are ovulating

-- Assuming normal cycles every 28 days, a woman is most likely to ovulate on day 14

-- Since sperm can live for up to three days, intercourse up to three days before ovulation can still result in pregnancy
First-line of treatment for ovulatory dysfunction in PCOS patients?
-- Metformin and ovulation induction agents

-- losing weight
Premenstrual dysphoric disorder (PMDD)?
-- a psychiatric diagnosis, describing a severe form of premenstrual syndrome

-- diagnostic criteria include 5 out of 11 clearly defined symptoms, functional impairment and prospective charting of symptoms

-- All three areas of symptoms need to be represented for the diagnosis of PMDD
A 37 year-old G3P3 complains of severe premenstrual symptoms for the past two years. She finds her mood swings and irritability troubling and requests a hysterectomy, as she thinks that this procedure will alleviate her symptoms. Past medical history is only remarkable for high cholesterol and her physical examination, including pelvic examination, is normal. The patient’s physician does not recommend a hysterectomy. Which of the following is the most likely explanation for the physician’s recommendation not to perform a hysterectomy in this patient?
-- Influence of ovaries on symptoms

-- patient’s mood swings are influenced by the hormonal shifts controlled by the hypothalamic-pituitary-ovarian axis

-- A hysterectomy would only resolve the menstrual bleeding component of this patient’s symptoms, and have no effect on the hormonal production of the ovaries
A 32 year-old G2P2 woman is concerned about symptoms associated with her menstrual cycle. During the second half of her cycle, she feels anxious, sad and has difficulty sleeping. She has done research on the Internet and believes she suffers from premenstrual dysphoric disorder (PMDD). Which of the following symptoms of the patient is most consistent with this diagnosis?
-- Cyclic occurrence of a minimum of described symptoms and interference in social functioning
A 32 year-old G2P2 woman complains of depression, weight gain and premenstrual bloating. She has suffered from these symptoms for 18 months and they have not responded to dietary changes and avoidance of alcohol and caffeine. Her only medications are multivitamins and herbs to increase her energy. She is very concerned about fatigue that often interferes with caring for her two children. A prospective symptom diary completed by the patient indicates mood symptoms, fatigue and bloating almost every day of the past two months and regular menstrual cycles, accompanied by breast tenderness. She denies feelings of wanting to hurt herself or others, and she has been able to carry out her normal responsibilities. Physical examination is unremarkable. Which of the following conditions is the most likely explanation for this patient’s symptoms?
-- Hypothyroidism

-- Symptoms of hypothyroidism can mimic typical symptoms of PMS, but symptoms occur more constantly throughout the cycle

-- Diagnosis involves complete work-up to rule out medical illnesses, including hypothyroidism

-- Although fatigue can be associated with diabetes mellitus, this patient lacks other common symptoms such as weight loss, thirst, frequent urination, or neurological symptoms, thereby making this diagnosis less likely
A 42 year-old G2P2 woman complains of bloating, mood swings and irritability the week prior to her menses. She is convinced that something is wrong with her hormone levels. In addition to a complete physical examination, which of the following diagnostic tools would provide information to accurately determine the diagnosis?
-- Prospective symptom calendar --> a calendar of symptoms can clarify if there is a cyclic or constant nature of the symptoms

-- Often women will mistakenly attribute their symptoms to their menstrual cycle

-- Different self-reporting scales have been written to assist patients track their symptoms

-- Because she is menstruating regularly, there is no role for obtaining serum hormone levels

-- The CAGE questionnaire is a screening test for alcohol dependence
Risk factors for PMS include?
-- family history of PMS

-- Vitamin B6, calcium, or magnesium deficiency

-- PMS becomes increasingly common as women age through their 30s, and symptoms sometimes get worse over time

-- Previous anxiety, depression or other mental health problems are significant risk factor for developing premenstrual dysphoric disorder (PMDD)

-- There is no known association between premenstrual syndrome and obesity or insulin dependent diabetes mellitus
A 37 year-old G1P1 woman has experienced symptoms of depression and difficulty concentrating the week prior to her menstrual period for the last three years, since her tubal ligation. She kept a symptom diary for three months revealing symptoms clustered around her menstrual cycle. She was diagnosed with premenstrual syndrome and began a regular exercise routine with dietary modifications, but only noticed mild relief in her symptoms. Work-up is otherwise unremarkable. Which of the following will most likely alleviate her symptoms?
-- Fluoxetine hydrochloride --> SSRIs increase the amount of active serotonin in the brain and have been found to be effective in alleviating PMS and PMDD symptoms

-- Patients can take the medication either every day or for 10 days during the luteal phase
A 37 year-old G0 woman complains that she experiences mood swings, irritability, bloating and headaches monthly for 2-3 days prior to her menstrual cycle. Her medical history is unremarkable and physical examination is normal. The physician advises her to keep a calendar of her symptoms. He also recommends a balanced diet, avoidance of caffeine and alcohol, and daily regular exercise. The patient has never exercised regularly and wonders how this will help her mood swings and bloating. Which of the following would provide the best explanation for the benefits of exercise on her PMS symptoms?
-- Endorphins

-- Exercise increases circulating endorphins in the brain which are “feel good” hormones and act similar to serotonin

- Therefore, in addition to being a benefit to cardiovascular health, regular exercise can significantly decrease symptoms of PMS
A 22 year-old G0 college student returns for follow-up of mood swings and difficulty concentrating on her schoolwork the week before her menses for the past 12 months. Her past medical history is unremarkable and physical examination is normal. Which of the following would be an appropriate treatment option for this patient?
-- OCPs --> This woman has PMS with symptoms that warrant treatment

-- Patients with PMS and PMDD experience adverse physical, psychological and behavioral symptoms during the luteal phase of the menstrual cycle

-- PMS is characterized by mild to moderate symptoms, while PMDD is associated with severe symptoms that seriously impair usual daily functioning and personal relationships

-- Mild symptoms of PMS often improve by suppressing the hypothalamic-pituitary-ovarian axis with OCPs

-- Ritalin and Ginkgo are not effective treatments for PMS

-- Gabapentin is used for neuropathic pain and will not help alleviate her symptoms
A 27 year-old G1P0 woman complains of mood swings and fatigue in the week prior to her menstrual period. These symptoms have worsened over the past 6 months. Some months, the symptoms are so severe she misses several days of work. Her medical history is otherwise unremarkable and a physical examination is normal. Which of the following is the most appropriate next step in this patient’s management?
-- Obtain a symptom diary for two months

-- Obtaining further history with a menstrual calendar determines the cyclic nature of the PMS or PMDD symptoms and helps guide appropriate therapy

-- While dietary changes may help, it is first important to establish the diagnosis
A 37 year-old G1P1 woman suffers from severe mood swings the week before her menstrual cycle. The mood swings resolve after she stops bleeding. You diagnose her with premenstrual syndrome (PMS) after obtaining further history and a normal examination. In addition to exercise, which of the following might be suggested to help decrease this patient’s symptoms?
-- Vitamin B6

-- Vitamin deficiency of A, E and B6 have been associated with an increase in PMS

-- Replacement of these vitamins might improve PMS symptoms and avoid further medical therapy
Breast cancer screening recommendations?
-- Every 1-2 years from 40-49

-- then, every year starting at age 50
Risk factors for osteoporosis?
-- early menopause

-- glucocorticoid therapy

-- sedentary lifestyle

-- alcohol consumption

-- hyperthyroidism

-- hyperparathyroidism

-- anticonvulsant therapy

-- vitamin D deficiency

-- family history of early or severe osteoporosis

-- chronic liver or renal disease

-- These would institute early screening in a patient for osteoporosis

-- Hypothyroidism is not a risk factor for osteoporosis, but you should consider early screening if the patient had difficulty attaining proper treatment since over-repletion puts her at increased risk

-- A postmenopausal patient presenting with fractures should alert you to suspect osteoporosis
ACOG recommendation is for patients to have an annual Pap smear starting at?
-- 21 yo 009 ACOG recommendation is for patients to have an annual Pap smear starting at 21 years of age --> based in part on the very low incidence of cancer in younger women

-- It is also based on the potential for adverse effects associated with follow-up of young women with abnormal cytology screening results

-- Cervical neoplasia develops in susceptible individuals in response to a STI with a high-risk type of HPV

-- HPV causes carcinogenesis in the transformation zone of the cervix, where the process of squamous metaplasia replaces columnar with squamous epithelium

-- Squamous metaplasia is active in the cervix during adolescence and early adulthood

-- HPV infections are commonly acquired by young women shortly after the initiation of vaginal intercourse but, in most, they are cleared by the immune system within 1–2 years without producing neoplastic changes
A 28 year-old patient presents to the office for her first visit. She is currently on oral contraceptive pills, but reports a history of irregular menses prior to starting them. Her past medical history is otherwise non-contributory. On physical examination, she is 5’2” tall and weighs 180 pounds. She has an area of velvety, hyperpigmented skin on the back of her neck and under her arms. What is the next best step in the management of this patient?
-- Diabetes screen

-- patient is obese, with a BMI = 33. In addition, the skin changes are consistent with acanthosis nigricans, which is closely associated with insulin resistance. Given these risk factors, she should be tested for diabetes.
Pregnancy or the possibility of pregnancy within 4 weeks is a contraindication to what vaccine?
-- MMR and varicella vaccinations
Vaccines okay during pregnancy?
-- Tetanus

-- Hepatitis B

-- Polio

-- Pneumococcal
A 42 year-old patient presents for an annual visit. Her past medical history, physical exam and labs are normal. Her body mass index (BMI) is normal. Her family history is significant for hypertension and hypercholesterolemia in her father and diabetes mellitus in her mother. What lifestyle modification is most important for this patient?
-- Starting an aerobic exercise program (not starting a weight loss diet)

-- Heart disease is the number one killer of women

-- Lifestyle modifications to reduce her risk, especially considering her family history, are important proactive changes that she can make

-- Studies show an inverse relationship between the level of physical activity and incidence of death from coronary disease. Exercise would be an appropriate first step with this patient

-- She does not need to lose weight (normal BMI) and does not need to be on a special diet (normal labs)
Folate
-- lowers homocysteine levels

-- fewer nonfatal MIs and fatal coronary events in women with adequate intake doses of folate and vitamin B6

-- Folate can also help prevent neural tube defects

-- Studies have shown that diet alone is not effective in achieving adequate levels and routine folate supplementation is therefore recommended

-- Women of reproductive age should take a daily 400-microgram supplement

-- Adequate levels are especially important prior to pregnancy and during the first 4 weeks of fetal development
A 40 year-old patient presents for her first annual visit. She denies any new complaints or symptoms. She has no history of any gynecologic problems. Family history is significant for a father with hypertension and a mother, deceased, with breast cancer diagnosed at age 36. A maternal aunt has ovarian cancer. A physical exam is unremarkable. What screening test should be offered to this patient next?
-- Mammogram (not BRCA-1/BRCA-2 testing)

-- there are limitations in the ability to screen for cancer. Although the patient is young, her family history of a first-degree relative with premenopausal breast cancer means that she is considered high-risk. Given the patient’s family history of both breast and ovarian cancer, genetic counseling and a thorough pedigree analysis should be suggested for evaluation for BRCA testing and possible enrollment in a specialized ovarian cancer screening trial

- At present, though, transvaginal sonography and CA-125 testing are NOT recommended as first-line screening tools for the general population for ovarian cancer

-- The patient should, however, have a mammogram at this earlier than routine age, due to the family history

-- Ultrasound is a helpful adjunct for a young patient

-- Ultrasound and MRI are generally used as adjunctive studies when a patient has an abnormal or unsatisfactory mammogram
The contraceptive method most likely to prevent sexually transmitted infections is?
-- male condom
What protect against bacterial sexually transmitted infections?
-- Spermicide and a diaphragm with spermicide
Contraceptive methods with <1% pregnancy rates (typical use) are?
-- Depo-Provera

-- IUD

-- sterilization (male or female)

-- Implanon
OCPs have what % pregnancy rate with typical use?
3%
Male condons have what % pregnancy rate with typical use?
12%
Contraceptive ring have what % pregnancy rate with typical use?
-- 8% of women will experience an unintended pregnancy after 1 year
Diaphragm with spermicide have what % pregnancy rate with typical use?
18%