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25 Cards in this Set
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A 26-year-old G2P2 woman presents with a new onset of vulvar burning and irritation. She is sexually active with a new male partner. She is using oral contraception for birth control and did not use a condom. She thought she had a cold about 10 days ago. Which of the following is the most likely diagnosis in this patient?
A. Herpes simplex virus B. Primary syphilis C. Secondary syphilis D. Human immunodeficiency virus E. Trichomonas |
Herpes simplex virus
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A 33-year-old G3P3 woman presents to the office complaining of a new onset vaginal discharge of 4 days duration. The discharge is thick and white. She has noted painful intercourse and itching since the dischage began. Her vital signs are: blood pressure 120/76 and pulse 78. The pelvic examination reveals excoriations on the perineum, thick white discharge, and is otherwise non-contributory. What is the most likely diagnosis in this patient?
A. Herpes simplex virus B. Primary syphilis C. Candida vaginalis D. Bacterial vaginosis E. Trichomonas |
Candida vaginalis. The patient is most likely has candida vaginalis. Clinically women have itching and thick white cottage cheese like discharge. They may also have burning with urination and pain during intercourse.
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A 32-year-old G3P1 woman presents to your office today because of exposure to hepatitis B. She had vaginal and anal intercourse with a new partner three days ago and did not use condoms. The partner informed her today he was recently diagnosed with acute hepatitis B acquired from intravenous drug use and needle sharing. She has no prior history of hepatitis B infection and has not been vaccinated. She is currently aymptomatic and her examination is normal. Her urine pregnancy test is negative. What is the next best step in the mangement of this patient?
A. Check AST, ALT, and HBsAg B. Administer HBIG one dose C. Administer HBIG two doses D. Administer HBIG and start hepatitis B vaccine series E. Administer hepatitis B vaccine series only |
. Administer HBIG and start hepatitis B vaccine series
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A 17-year-old nulliparous sexually active female presents to the emergency department with pelvic pain that began 24 hours ago. She reports menarche at the age of 15 and coitarche soon thereafter. She has had four 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?
A. Outpatient treatment with oral broad spectrum antibiotics B. Outpatient treatment with intramuscular and oral broad spectrum antibiotics C. Intravenous antibiotics and dilation and curettage D. Inpatient treatment, laparoscopy with pelvic lavage E. Inpatient treatment and intravenous antibiotics |
Inpatient treatment and intravenous antibiotics. The most likely cause of the symptoms and signs in this patient is infection with a sexually transmitted organism. The most likely organisms are both N. gonorrhoeae and chlamydia, 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 intravenous antibiotic therapy in an effort to prevent scarring of her fallopian tubes and possible future infertility.
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A 36-year-old G0 woman presents to the emergency department accompanied by her female partner. The patient notes severe abdominal 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?
A. Diverticulitis B. Gastroenteritis C. Reactivation of an old infection D. Ascending infection E. Pyelonephritis |
Ascending infection. Correct! Although salpingitis is most often caused by sexually transmitted agents such as gonorrhea and chlamydia, any ascending infection from the genitourinary tract or gastrointestinal 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. Although diverticulitis and gastroenteritis should be part of the differential diagnosis initially, the specific findings on examination and ultrasound are more suggestive of bilateral tubo-ovarian abscesses. 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.
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A 16-year-old nulliparous female presents to the emergency department with a two-day history of abdominal pain. She is sexually active with a new partner and is not using any form of contraception. Temperature is 101.8°F (38.8°C). On examination, she has lower abdominal tenderness and guarding. On pelvic exam, she has diffuse tenderness over the uterus and bilateral adnexal tenderness. Beta-hCG is <5. What is the most likely diagnosis in this patient?
A. Ectopic pregnancy B. Appendicitis C. Acute cystitis D. Endometriosis E. Acute salpingitis |
Acute salpingitis. The signs and symptoms of acute salpingitis 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.
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A 16-year-old nulliparous female presents to the emergency department with a two-day history of abdominal 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?
A. Oral amoxicillin clavunate and doxycycline B. Oral metronidazole and doxycycline C. IV metronidazole and doxycycline D. IV cefotetan and doxycycline E. No treatment until culture results are back |
IV cefotetan and doxycycline. Although some patients can be treated with an outpatient regimen, this patient should be hospitalized for IV treatment, as she 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. You would not wait for culture results before initiating treatment. 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, the 2010 CDC guidelines recommend Ceftriaxone, Cefoxitin, or other third-generation cephalosporin (such as ceftizoxime or cefotaxime) PLUS Doxycycline WITH or WITHOUT Metronidazole.
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A 19-year-old nulliparous woman presents to the office with a two-week history of low pelvic pain and cramping. She has a new sexual partner and is on oral contraception and uses condoms. She is one week into her cycle. She has noted no vaginal discharge, itch or odor. She denies fevers or chills. She does note that she is on a new diet and has started drinking lots of water. As such, she notes that she is urinating much more frequently. Her examination is entirely unremarkable. Which of the following is the most appropriate next step in the management of this patient?
A. Pelvic ultrasound B. Pap test C. Wet prep D. Urinalysis E. Testing for chlamydia |
Urinalysis. Mildly symptomatic or asymptomatic urinary tract infections are common in female patients. Urinary tract infection 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 urinary tract infections at each prenatal visit is recommended in order to prevent urinary tract infection, which can cause preterm labor. A pelvic ultrasound is not indicated at this point.
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A 76-year-old G3P3 woman presents to your office with worsening urinary incontinence for the past three months. She reports increased urinary frequency, urgency and nocturia. Her exam shows mild cystocele and rectocele. A urine culture is negative. A post-void residual is 400 cc. Which of the following is the most likely diagnosis in this patient?
A. Genuine stress incontinence B. Detrusor instability C. Overflow incontinence D. Functional incontinence E. Mixed incontinence |
Mixed incontinence. Overflow incontinence is 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). A normal post-void residual (PVR) is 50-60 cc. An elevated PVR, usually >300 cc, is found in overflow incontinence. 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. The mixed variety includes symptoms related to stress incontinence and urge incontinence.
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A 76-year-old G3P3 woman presents to the office with worsening stress urinary incontinence for the last three months. She reports an increase in urinary frequency, urgency and nocturia. On examination, 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?
A. Stress incontinence B. Urge incontinence C. Overflow incontinence D. Functional incontinence E. Mixed incontinence |
Urge incontinence is due to detrusor instability. 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) is 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. Overflow incontinence is associated with symptoms of pressure, fullness, and frequency, and is usually a small amount of continuous leaking. It is not associated with any positional changes or associated events. Mixed incontinence occurs when increased intra-abdominal pressure causes the urethral-vesical junction to descend causing the detrusor mus
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A 60-year-old G4P4 woman presents with a two-year history of urine leakage with activity such as coughing, sneezing and lifting. Her past medical history is significant for vaginal deliveries of infants over 9 pounds. She had a previous abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine fibroids. She is on vaginal estrogen for atrophic vaginitis. Physical exam shows no anterior, apical or posterior wall vaginal prolapse. Vagina is well-estrogenized. Post-void residual was normal. Q-tip test showed a straining angle of 60 degrees from the horizontal. Cough stress test showed leakage of urine synchronous with the cough. Cystometrogram revealed the absence of detrusor instability. The patient failed pelvic muscle exercises and was not interested in an incontinence pessary. Which of the following is the best surgical option for this patient?
A. Retropubic urethropexy B. Needle suspension C. Anterior repair D. Urethral bulking procedure E. Colpocleisis |
Retropubic urethropexy. Genuine stress incontinence (GSI) is 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. Retropubic urethropexy such as tension-free vaginal tape and other sling procedures have the best five-year success rates for patients with GSI due to hypermobility. Needle suspensions and anterior repairs have lower five-year success rates for GSI. Urethral bulking procedures are best for patients with ISD, but with little to no mobility of the urethra. Colpocleisis is one option to treat uterine prolapse, and is not indicated for urinary incontinence.
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A 70-year-old G3P3 woman presents with a four-year history of constant leakage of urine. Her history is significant for abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She 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?
A. Retropubic urethropexy B. Needle suspension C. Artificial urethral sphincter D. Urethral bulking procedure E. Sling procedure |
Urethral bulking procedure. This is a classic example of intrinsic sphincteric deficiency. Urethral bulking procedures are minimally invasive and have a success rate of 80% in these specific patients. The success rates for retropubic urethropexies, needle suspension and slings are 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. Artificial sphincters should be used in patients as a last resort.
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A 60-year-old G2P2 woman presents with complaints of urinary frequency and urge incontinence. Past medical history is unremarkable. She is on no medications. Pelvic exam shows no evidence of pelvic relaxation. Post void residual is normal. Urine analysis is negative. A cystometrogram revealed uninhibited detrusor contractions upon filling. Which of the following is the best treatment for this patient?
A. Amitriptyline B. Oxybutynin C. Topical (vaginal) estrogen D. Pseudoephedrine E. Kegel exercises |
Oxybutynin. the patient has the diagnosis of detrusor instability. 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. Oxybutynin is one example. 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. 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.
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A 67-year-old G3P3 woman presents with severe pelvic protrusion status post hysterectomy. She denies any incontinence. She failed conservative management with a pessary. She underwent a vaginal surgical repair where the pubocervical fascia was plicated in the midline as well as laterally to the arcus tendineus fascia (white line). What defect was repaired in this patient?
A. Cystocele B. Rectocele C. Uterine prolapse D. Enterocele E. Urethral diverticulum |
Cystocele. Central and lateral cystoceles are repaired by fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line. Defects in the rectovaginal fascia are repaired in rectoceles. Uterine prolapse is surgically treated by a vaginal hysterectomy, but this patient already had a hysterectomy. Enteroceles are repaired by either vaginal or abdominal enterocele repairs. Vaginal vault prolapse is treated either by supporting the vaginal cuff to the uterosacral ligaments, sacrospinous ligament or sacrocolpopexy. Urethral diverticulum does not present with severe pelvic protrusion.
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A 57-year-old G2P2 woman presents with a six-month history of urinary incontinence, 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?
A. Stress incontinence B. Overflow incontinence C. Urge incontinence D. Mixed incontinence E. Vesicovaginal fistula |
Urge incontinence. This patient has urge incontinence, which is caused by overactivity of the detrusor muscle resulting in uninhibited contractions, which cause an increase in the bladder pressure over urethral pressure resulting in urine leakage. Stress incontinence is 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. Overflow incontinence is associated with symptoms of pressure, fullness, and frequency, and is usually a small amount of continuous leaking. It is not associated with any positional changes or associated events. Mixed 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
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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 three 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 is 1 cm above the vaginal introitus and there is moderate bladder prolapse. Her uterus is normal in size and she has no adnexal masses or tenderness. In addition to recommending a mammogram, what is the most appropriate next step in the management of this patient?
A. Cystocele repair B. Pelvic ultrasound C. Total hysterectomy D Observation E. Topical estrogen |
Observation. This patient is asymptomatic from her prolapse; therefore, no intervention is necessary at this point. Cystocele repairs and hysterectomies are invasive procedures which are not indicated in this asymptomatic patient. It is not necessary to obtain a pelvic ultrasound, as her uterus is normal in size and she has no adnexal masses. Topical estrogen would not help improve the prolapse, although it might help with her vaginal dryness. She seems to be doing well with the lubricants and it is not necessary to expose her to the estrogen, especially since she still has her uterus, and estrogen treatment alone may increase her risk of endometrial cancer.
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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 has failed a trial of pessaries. Which of the following is the next best step in the management of this patient?
A. Do nothing and observe B. Anterior and posterior repair C. Colpocleisis D. Sacrospinous fixation E. Sacrocolpopexy |
Colpocleisis. Because of the hydronephrosis due to obstruction, intervention is required. Colpocleisis is a procedure where the vagina is surgically obliterated and can be performed quickly without the need for general anesthesia. 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 and is not the best option for this patient with high surgical morbidity.
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A 27-year-old G0 woman presents due to a one-year history of painful periods and intercourse. Pain, when present, is 7/10 in strength and requires that she miss work. She now avoids intercourse and no longer finds it pleasurable. She is otherwise in good health. Her last menstrual period was 17 days ago and her menses are typically 28 days apart. She had chlamydia once, at age 19. Physical examination is notable for some tenderness on abdominal and pelvic exams in the lower quadrants. Uterus is normal in size and there is some tender nodularity on the back of the uterus. What is the most likely diagnosis in this patient?
A. Adenomyosis B. Chronic pelvic inflammatory disease C. Endometriosis D. Endometritis E. Premenstrual dysphoric disorder |
Endometriosis. his patient has typical symptoms of endometriosis, including dysmenorrhea and dyspareunia. In addition, the nodularity on the back of the uterus is suggestive of endometriosis. Chronic pelvic inflammatory disease would not present this far out from a known infection.
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A 29-year-old G0 woman presents due to the inability to conceive for the last year. Her cycles are regular every 28 days, but she has very painful periods, occasionally requiring that she miss work despite the use of non-steroidal anti-inflammatory drugs (NSAIDs). She also reports painful intercourse, which is becoming a problem as she now tries to avoid intercourse, even though she would like to conceive. She is otherwise in good health and has been married for five years. She is 5 feet 4 inches tall and weighs 130 pounds. She has a history of pelvic inflammatory disease at age 19, for which she was hospitalized. Her mother had a history of ovarian cancer at age 49. On physical examination, she has abdominal and pelvic lower quadrant tenderness. Uterus is normal in size, but there is a slightly tender palpable left adnexal mass. A pelvic ultrasound shows a 5 cm left complex ovarian cyst and two simple cysts measuring 2 cm in the right ovary. What best explains the underlying pathophys
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he patient has typical signs of endometriosis which is characterized by the presence of endometrial glands and stroma outside of the uterus. Endometriosis is present in about 30% of infertile woman. She does not have the signs and symptoms of chronic pelvic inflammatory disease
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A healthy 63-year-old G0 woman comes to the office for a health maintenance exam. She has no history of abnormal Pap smears or sexually transmitted infections. She has a history of endometriosis and infertility in the past. She has been postmenopausal for 10 years and is not taking any medications. She is 5 feet 4 inches tall and weighs 130 pounds. On pelvic examination, the patient has a palpable left adnexal mass. An ultrasound shows a 5 cm complex left ovarian cyst. What is the most appropriate next step in the management of this patient?
A. Observation B. Repeat ultrasound in three months C. CT scan of the abdomen and pelvis D. MRI of the pelvis E. Exploratory surgery |
Exploratory surgery. A complex ovarian mass in a postmenopausal patient needs to be surgically explored. Although this could be an old endometrioma which never resolved, this cannot be assumed. If this is ovarian cancer, waiting three months can change this patient’s prognosis. This complex cyst most likely will not resolve, since this is not a physiological cyst. A CT scan or MRI will not add more information and ultrasounds are typically the best imaging studies for the uterus and adnexa.
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A 26-year-old G0 woman returns for a follow-up visit regarding endometriosis. She has been using NSAIDs to manage her pelvic pain, but had to miss four days of work in the last two months. She is sexually active with her husband of two years, although it has been more painful recently. She has regular menstrual cycles and is using condoms for contraception. On pelvic exam, she has localized tenderness in the cul de sac and there were no palpable masses. What is the most appropriate next step in the management of this patient?
A. GnRH agonist B. Danazol C. Oral contraceptives D. Laparoscopy and ablation of endometriosis E. Progesterone intrauterine device |
Oral contraceptives. Oral contraceptives will be the next best choice for this patient. They provide negative feedback to the pituitary-hypothalamic axis which stops stimulation of the ovary to produce sex hormones, such as estrogen, which stimulates endometrial tissue located outside of the endometrium and uterus.
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A 26-year-old G0 women returns for a follow-up visit regarding suspected endometriosis. She has been using NSAIDs and birth control pills to help manage her pelvic pain which has been getting worse. While discussing further treatment options, she asks if there is any test or procedure you can perform to confirm her diagnosis. Which of the following would you recommend?
A. Blood FSH/LH ratio and estradiol level B. Pelvic ultrasound C. CT scan of the abdomen and pelvis D. MRI of the pelvis E. Diagnostic laparoscopy |
Diagnostic laparoscopy
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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 has 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?
A. An endometrioma B. A hemorrhagic cyst C. Ovarian carcinoma D. A mature teratoma E. Polycystic ovaries |
A hemorrhagic cyst. This patient most likely has a hemorrhagic cyst, considering her history and where she is in her menstrual cycle. Her mother’s history of endometriosis does increase her risk; however, it is unlikely since she has never had any symptoms herself. Ovarian carcinoma would need to be ruled out, but it is unlikely in an otherwise asymptomatic premenopausal patient. A mature teratoma would have more pathognomonic findings on ultrasound. This patient does not have typical symptoms, body habitus or ultrasound findings for patients with polycystic ovaries.
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A 48-year-old G0 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. 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 has 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?
A. Oral contraceptives B. Repeat ultrasound in two months C. CT scan of the abdomen and pelvis D. Needle aspiration of the cyst E. Abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO |
A repeat ultrasound is the most appropriate next step, as this is most likely a hemorrhagic cyst which will resolve on its own. Oral contraceptives are contraindicated in this patient, as she is older than 35 and smokes. A CT scan of the pelvis will not add any more information. Needle aspiration is not the standard of care in this asymptomatic premenopausal patient. There is no indication to proceed with a TAH/BSO.
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A 29-year-old G0 woman presents due to the inability to conceive for the last 18 months. She has a known history of endometriosis, which was diagnosed by laparoscopy three years ago. She has pelvic pain, which is controlled with non-steroidal anti-inflammatory drugs. Her cycles are regular. She is otherwise in good health and has been married for five years. Her husband had a semen analysis, which was normal. She had a hysterosalpingogram, which showed patent tubes bilaterally. She is getting frustrated that she has not yet achieved pregnancy and asks to proceed with fertility treatments. What is the most appropriate next step in the management of this patient?
A. Reassurance and return in six months B. Administer a GnRH agonist C. Ovarian stimulation with clomiphene citrate D. Intrauterine insemination E. Proceed with in vitro fertilization |
Ovarian stimulation with clomiphene citrate. A patient with a known history of endometriosis who is unable to conceive and has an otherwise negative workup for infertility, benefits from ovarian stimulation with clomiphene citrate, with or without intrauterine insemination. A GnRH agonist is used to control pelvic pain in endometriosis patients unresponsive to other hormonal treatments. In vitro fertilization and adoption can be offered if other treatments fail.
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