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32 Cards in this Set
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A 35-year-old G0 presents with irregular menstrual periods occurring every six to twelve weeks with occasional inter-menstrual bleeding. Currently, she has been bleeding daily for the last four 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?
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Endometrial biopsy. 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. While an ultrasound may be helpful, a pelvic CT is not useful in the workup for potential endometrial neoplasia. LH and FSH levels would not aid in the diagnostic workup and testosterone levels would not be useful, unless signs of hirsutism or virilization are present
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A 34-year-old G2P2 presents with inter-menstrual bleeding for one year. The bleeding typically occurs two weeks after her menses and last two to three days. The symptoms began one 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?
A. Prolactin level B. Progesterone level C. Hysterosalpingogram (HSG) D. Pelvic ultrasound E. Colposcopy |
Pelvic ultrasound. Intermenstrual bleeding is frequently caused by structural abnormalities of the endometrial cavity, such as myomas, polyps or malignancy. An ultrasound would be helpful as the next step in diagnosis. Although an HSG might reveal structural abnormalities, it is too invasive for a next step. A colposcopy would not be helpful in the diagnosis, nor would obtaining a Prolactin level, as it would be indicated for the evaluation of anovulatory bleeding. Progesterone levels are not helpful in a patient on oral contraceptives.
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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 three 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?
A. Endometrial biopsy B. Pelvic MRI C. Pelvic sonography D. Abdominal CT Scan E. Urine pregnancy tes |
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. Abdominal CT or MRI would not be performed in this patient unless advanced adnexal pathology was found on pelvic sonography. Endometrial biopsy would rarely be indicated in a teen with abnormal bleeding, unless morbidly obese and anovulatory.
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A 45-year-old G2P2 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 three 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?
A. Polycystic ovarian syndrome B. Mid-cycle bleeding C. Dysfunctional uterine bleeding D. Benign cystic teratoma E. Ovarian cancer |
Dysfunctional uterine bleeding. Dysfunctional uterine bleeding is 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. Mid-cycle bleeding at the time of ovulation is due to the drop in estrogen. Ovarian teratomas are not associated with abnormal menses. They typically present with abdominal or pelvic pain which may be associated with torsion. The 2 cm cyst is a functional cyst and is a common finding in ovulatory patients.
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A 35-year-old G2P2 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 one 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?
A. Hysteroscopy with myoma resection B. Laparoscopic myomectomy C. Endometrial ablation D. Oral contraceptives E. Dilation and curettage |
Hysteroscopy with myoma resection. Hysteroscopic myomectomy preserves the uterus, while removing the pathology causing the patient’s symptoms. A laparoscopic approach is not indicated as the myoma is submucosal and not accessible using a laparoscopic approach.
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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 four 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?
A. Creating endometrial atrophy B. Decreasing inflammation C. Increasing prolactin levels D. Decreasing inhibin levels E. Thickening cervical mucous |
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.
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A 23-year-old G0 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?
A. Blue-domed cysts greater than 3 mm B. Decidual effect in the endometrium C. Endometrial glands/stroma and hemosiderin-laden macrophages D. Invasion of endometrial glands into the myometrium E. Well-circumscribed, non-encapsulated myometrium |
Endometrial glands/stroma and hemosiderin-laden macrophages
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A 42-year-old G4P4 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?
A. Adenomyosis B. Endometrial carcinoma C. Endometriosis D. Primary dysmenorrhea E. Endometrial hyperplasia |
Adenomyosis. This is a typical presentation of 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. Endometrial hyperplasia and carcinoma are less likely in a woman with regular menses and no inter-menstrual spotting. Endometriosis would most likely have presented earlier in life and would not explain the enlarged uterus.
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A 22-year-old G0 presents with painful menstruation that limits her activities each month. She describes the pain as spasmodic occurring on days one to three of bleeding since her cycles began. Other symptoms include nausea, nervousness, diarrhea, and headache. Her physical exam is normal with a soft, non-tender abdomen. Bimanual exam reveals a fixed uterus with uterosacral ligament nodularity. There are no adnexal masses noted. What is the most likely diagnosis in this patient?
A. Premenstrual syndrome B. Premenstrual dysphoric disorder C. Primary dysmenorrhea D. Secondary dysmenorrhea E. Adenomyosis |
Secondary dysmenorrhea. The physical examination in patients with primary dysmenorrhea is normal. There should not be any palpable abnormalities on abdominal, speculum, pelvic, bimanual, and rectal examinations. The restricted uterine motion found on exam suggests the possibility of endometriosis or pelvic scarring from inflammation or adhesions. These conditions must be considered in establishing the etiology of her diagnosis. Childbearing does not affect the occurrence of either diagnosis. Although the patient’s symptoms, including the associated symptoms, timing of initial onset, and cyclic nature of her pain are consistent with primary dysmenorrhea, the finding on physical examination makes secondary dysmenorrhea the likely diagnosis.
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A 41-year-old G2P2 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?
A. CA125 assay B. CT scan of the pelvis C. Endometrial biopsy D. GnRH agonist E. Hysterectomy |
Endometrial biopsy. This patient has classic symptoms of leiomyomata, including menorrhagia. An endometrial biopsy should be performed on all women over age 40 with irregular bleeding to rule out endometrial carcinoma. The CA125 assay measures the level of CA125 in the blood and is increased in some types of cancer, including ovarian cancer or other conditions. This non-specific marker is not indicated in this patient. A CT scan of the pelvis is also not indicated. 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
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A 42-year-old G2P2 undergoes a hysterectomy for definitive treatment of her dysmenorrhea and large uterine fibroids. The uterus is sent to pathology. Which of the following would confirm the diagnosis of fibroids?
A. Blue-domed cysts greater than 3 mm B. Decidual effect in the endometrium C. Endometrial glands/stroma and hemosiderin-laden macrophages D. Invasion of endometrial glands into the myometrium E. Well-circumscribed, non-encapsulated myometrium |
Well-circumscribed, non-encapsulated myometrium
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A 53-year-old G2P2 comes to your office complaining of six months of worsening hot flashes, vaginal dryness, night sweats and sleep disturbances. Her last normal menstrual period was six months ago and she has been experiencing intermittent small amounts of vaginal bleeding. Her medical history is significant for hypertension, which is well-controlled by a calcium-channel blocker, adult onset diabetes, for which she takes Metformin, and hyperthyroidism, for which she takes Propylthiouracil. The patient is 5 feet 7 inches tall and weighs 140 pounds. Blood pressure is 120/70. Physical examination is unremarkable. Which of the following medical conditions in this patient is a contraindication to treatment of menopausal symptoms with hormone therapy?
A. Vaginal bleeding B. Hypertension C. Diabetes D. Osteoporosis E. Hyperthyroidism |
Vaginal bleeding. The principal symptom of endometrial cancer is abnormal vaginal bleeding. Although the patient’s worsening symptoms make 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.
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A 54-year-old G2P2 presents to your office for a health maintenance examination. Her last menstrual period was eight 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 and has no significant past medical or 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=130/78, Pulse=84, BMI=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?
A. Lowest effective dose of combination hormone replacement therapy for the shortest duration possible B. Long term hormone replacement therapy to treat her vasomotor symptoms and prevention of oste |
A. (ACOG) recommendations on hormone replacement therapy considers hormone replacement therapy (HRT) the most effective treatment for severe menopausal symptoms that include hot flashes, night sweats and vaginal dryness. 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.
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A 52-year-old G3P3 woman presents to your office with severe hot flashes and vaginal dryness for six 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?
A. Vaginal bleeding B. Development of breast cancer C. Hirsutism D. Nausea E. Relief of menopausal symptoms |
Vaginal bleeding. Most irregular bleeding due to initiation of hormone therapy occurs in the first six 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.
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A 49-year-old G2P2 status post hysterectomy at age 45 for fibroids presents to your office complaining of severe vasomotor symptoms for three months. Hot flashes are affecting her quality of life and she would like to discuss options for treatment. What treatment option for hot flashes associated with menopause do you recommend as the most effective?
A. Lifestyle modifications such as dressing in layers B. Estrogen C. Selective estrogen receptor modulator (SERMs) D. Selective serotonin reuptake inhibitors (SSRIs) E. Treatment with phytoestrogen (soy) |
Estrogen. Except for estrogen receptor modulator therapy, all of the above treatment options will improve hot flash symptoms. Treatment with estrogen is most effective, and the current recommendation is for the lowest dose for the shortest duration of time.
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A 49-year-old G1P1 comes to your office for menopause counseling. She has been experiencing severe sleep disturbances and night sweats for the past four months. She would like to begin hormone therapy, but is concerned because she has elevated cholesterol levels for which she takes medication. You explain to her that hormone therapy has the following effect on a lipid/cholesterol profile:
A. Both LDL and HDL levels increase B. Both HDL and LDL levels decrease C. HDL and LDL levels are unaffected D. HDL levels increase and LDL levels are unaffected E. HDL levels increase and LDL levels decrease |
HDL levels increase and LDL levels decrease
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9. A 58-year-old G3P3 who has been menopausal since age 50 comes to you for a health maintenance examination. She is in good health, eats a balanced diet, exercises regularly, and has an unremarkable physical exam. Her bone mineral density as determined by central dual energy X-ray absorptiometry is -1.7. She wants to discuss treatment for her osteopenia. What is the next step in the management of this patient?
A. Evaluate her risk factors for fracture B. Determine her frequency of exercise C. Assess her exogenous dietary intake of estrogen D. Measure her BMI E. Take a complete family history |
Evaluate her risk factors for fracture. osteopenia (low bone mass) as -1 to -2.5. The American College of Ob-Gyn (ACOG)) Committee Opinion recommends that physicians interpret T scores between −1.5 and −2.0 in combination with the patient’s risk factors for fracture. The authors state: “Clinicians must be careful because the diagnosis of osteopenia often is interpreted as indicating a pathologic skeletal condition or significant bone loss, neither of which is necessarily true. Until better models of absolute fracture risk exist, postmenopausal women in their 50s with T scores in the osteopenia range and without risk factors may well benefit from counseling on calcium and vitamin D intake and risk factor reduction to delay initiation of pharmacologic intervention.” Some of the risk factors for fracture include prior fracture, family history of osteoporosis, race, dementia, history of falls, poor nutrition, smoking, low body mass index, estrogen deficiency, alcoholism, low phys activity
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A 27-year-old G0 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 two weeks ago. She has no history of abnormal Pap smears. Her husband is also healthy with no medical problems. She is 5 feet 4 inches 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?
A. Hysteroscopy B. Hysterosalpingogram C. Progesterone level mid-cycle D. Clomiphene citrate challenge test E. Cervical mucous monitoring |
Hysterosalpingogram. . This patient is having difficulty conceiving after trying for one year. Based on her history, the most likely underlying factor is tubal disease, as she has a history of being hospitalized for a pelvic infection, most likely pelvic inflammatory disease.
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A 37-year-old G2P1 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 one 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?
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Wean off imipramine. his patient has hyperprolactinemia due to imipramine. The patient has to be weaned off imipramine and 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. Although MRI of the brain would be a reasonable step, it would be premature, and visual field examination does not aid in the diagnostic work-up. It would be premature to obtain an MRI or begin bromocriptine without this intermediate step. An endometrial biopsy is not indicated at this point, especially since the patient had normal cycles on OCPs. Although Clomid is used to help with ovulatory dysfunction, the hyperprolactinemia must be addressed first.
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A 27-year-old G0 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 six months ago. At that time, she began to have irregular menses every two to three 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?
A. Begin Synthroid B. Begin bromocriptine C. Order a Clomid ovulation challenge test D. Obtain a brain MRI E. Order a thyroid gland ultrasound |
Begin Synthroid. his patient is having abnormal cycles due to hypothyroidism, which is also the most likely cause of her hyperprolactinemia. The best treatment at this point is to correct the hypothyroidism. It is not necessary to treat the hyperprolactinemia with bromocriptine or order a brain MRI until the hypothyroidism is first corrected. There is no reason to obtain a thyroid ultrasound, as the diagnosis of hypothyroidism is clear from the laboratory results.
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A 23-year-old G0 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 three years ago, when she started having periods irregularly every three months until it stopped two years ago. She has no history of pelvic infections or abnormal Pap smears. She exercises every day by running and has run four marathons in the last three years. She is 5 feet 10 inches 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?
A. Check cortisol levels B. Order a brain MRI C. Obtain a pelvic ultrasound D. Check estrogen |
Check estrogen. This patient most likely has exercise-induced hypothalamic amenorrhea, which is characterized by normal FSH and low estrogen levels. The other studies will not help determine the diagnosis. The best treatment is to 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.
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A 45-year-old G3P3 comes to the office because she has been unable to conceive for the last two years. She is healthy and has three 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?
A. Perform a hysteroscopy B. Order a hysterosalpingogram C. Order clomiphene challenge test D. Order a sperm penetration assay E. Basal body temperatures for six month |
Order clomiphene challenge test. This patient, most likely, has decreased ovarian reserve due to her age. A clomiphene challenge test, which consists of giving clomiphene citrate days five to nine of the menstrual cycle and checking FSH levels on day three and day 10, will help determine ovarian reserve. This will help counsel the patient on appropriate options 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.
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A 28-year-old G0 comes to the office for preconception counseling and the inability to conceive for one year. She and her husband of three 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?
A. Keep basal body temperatures and try to attempt intercourse immediately after the rise in body temperature B. Best to attempt intercourse after she is done with her menses C. Use ovulation predictor kits and attempt intercourse after it turns positive D. Take a leave from her work so she can have intercourse three times a week until she gets pregnant E. Attempt intercourse on day 18 of her cycle |
Use ovulation predictor kits and attempt intercourse after it turns positive. Women are most fertile 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. 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. Although having intercourse more frequently will increase her likelihood of conceiving, it is not a practical solution for a working person to stop their work in order to conceive.
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A 32-year-old G2P2 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?
A. Cyclic constellation of symptoms during the follicular phase B. Cyclic occurrence of a minimum of described symptoms and interference in social functioning C. Chronic, mild depressive symptoms that have been present for many years D. Depressed mood or the loss of interest or pleasure in activities E. Anxiety/nervousness interfering in social functioning |
Cyclic occurrence of a minimum of described symptoms and interference in social functioning. PMDD is a psychiatric diagnosis, describing a severe form of premenstrual syndrome in which the diagnostic criteria include five 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.
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A 37-year-old G1P1 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?
A. Folic acid B. Ginkgo C. Fish oil D. Vitamin B6 E. Potassium |
Vitamin B6
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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?
A. Pelvic ultrasound B. Estradiol level C. CAGE questionnaire D. Prospective symptom calendar E. Mini mental status examination |
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.
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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?
A. Oral contraceptive pills B. Reassurance and observation C. Methylphenidate (Ritalin) D. Gabapentin E. Ginkgo |
Oral contraceptive pills. This woman has premenstrual syndrome (PMS) with symptoms that warrant treatment. Patients with PMS and premenstrual dysphoric disorder (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 oral contraceptive pills. Ritalin and Ginkgo are not effective treatments for PMS. Gabapentin is used for neuropathic pain and will not help alleviate her symptoms.
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A 32-year-old G2P2 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. Physical examination is unremarkable. Which of the following conditions is the most likely explanation for this patient’s symptoms?
A. Panic disorder B. Anxiety disorder C. Anemia D. Hypothyroidism E. Premenstrual dysphoric disorder |
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 anemia, her presentation is not consistent with this diagnosis.
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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?
A. An endometrial ablation would be preferable B. Past medical history C. Influence of thyroid hormone on symptoms D. Influence of adrenal gland on symptoms E. Influence of ovaries on symptoms |
Influence of ovaries on symptoms. The patient’s mood swings are influenced by the hormonal shifts controlled by the hypothalamic-pituitary-ovarian axis. A hysterectomy or endometrial ablation would only resolve the menstrual bleeding component of this patient’s symptoms, and have no effect on the hormonal production of the ovaries.
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A 27-year-old G1P0 complains of mood swings and fatigue in the week prior to her menstrual period. These symptoms have worsened over the past six 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?
A. Obtain a symptom diary for two months B. Recommend dietary changes C. Begin treatment with an anxiolytic agent D. Refer for psychiatric consultation E. Obtain a pelvic ultrasound |
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. An anxiolytic agent or psychiatric consultation is not indicated.
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A 37-year-old G0 complains that she experiences mood swings, irritability, bloating and headaches monthly for two to three 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?
A. Endorphins B. Cortisol C. Progesterone D. Estrogen E. Androgen |
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.
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An 18-year-old G0 comes in for a health maintenance examination with her mother. The mother had severe PMS symptoms in her twenties and thirties and would like to know if her daughter would inherit this as well. Which of the following has the strongest association with premenstrual syndrome?
A. Obesity B. Positive family history C. History of early menarche D. Insulin dependent diabetes mellitus E. Vitamin K deficiency |
Positive family history. Risk factors for PMS include a family history of premenstrual syndrome (PMS) and 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 factors for developing premenstrual dysphoric disorder (PMDD). There is no known association between premenstrual syndrome and obesity or insulin dependent diabetes mellitus
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