Gynecology

Question 1

Autosomal recessive disease, adrenal insufficiency and genital ambiguity in early infancy in females

Answer 1

Classical CAH

Question 2

• Less severe form of the classical disorder - 20 to 50 percent 21-hydroxylase enzyme activity compared with 0 to 2 percent in classical - No Salt wasting - androgen excess - adolescent females present with hirsutism, oligomenorrheaa, acne

Answer 2

Nonclassic CAH

Question 3

Upper body obesity, hypertension, striae, bruising, hyperglycemia: which feature of Cushing syndrome is missing?

Answer 3

Proximal myopathy

Question 4

Management of asymptomatic, unilateral cyst measuring less than 10 cm in pre-menopausal woman

Answer 4

Observation: repeat exam and ultrasound in 3 months

Question 5

Ovarian cyst features which are concerning

Answer 5

septation, mix of cystic and solid components, thickened walls

Question 6

Significance CA 125 in pre-menopausal woman with ovarian cyst

Answer 6

Frequently false positive in pre-menopausal women

Question 7

Role of aspiration of fluid from ovarian cyst

Answer 7

Not advisable because of inefficacy (re-accumulation), malignant seeding

Question 8

Measured parameter on gynaecological ultrasound and MRI. Appearance and thickness of the endometrium depends on phase of cycle; menopausal status

Answer 8

Endometrial stripe

Question 9

Post-menopausal bleeding causes

Answer 9

vaginal/endometrial atrophy polyp hyperplasia cervical/endometrial cancer

Question 10

Endometrial stripe is less than 4 mm transvaginal ultrasound. Negative predictive value for endometrial cancer approaches:

Answer 10

99%

Question 11

Progesterone challenge test

Answer 11

Evaluation of amenorrhea in pre-menopausal women

Question 12

Estrogen status over time can be assessed with a _____ Withdrawal bleeding confirms endogenous estrogen exposure. Absence of bleeding can be due to either hypoestrogenism or an outflow tract disorder.

Answer 12

progestin withdrawal test (medroxyprogesterone 10 mg for 10 days)

Question 13

absence of menses for more than three months in girls or women who previously had regular menstrual cycles or six months in girls or women who previously had irregular menses

Answer 13

Secondary amenorrhea

Question 14

Initial laboratory testing for women with amenorrhea without hyperandrogenism should include:

Answer 14

PRL, FSH, TSH

Question 15

Work up of secondary amenorrhea + hirsuitism, acne

Answer 15

Testosterone + (PRL, FSH, TSH)

Question 16

Post-menopausal bleeding + greater than 4 mm stripe on vaginal ultrasound: mx?

Answer 16

Endometrial biopsy

Question 17

Dyschezia

Answer 17

Ineffective defecation, manifested as straining in the absence of constipatio

Question 18

Weight loss in pregnancy greater than _% due to morning sickness is concerning

Answer 18

5

Question 19

Hyperemesis gravidarum: criteria

Answer 19

• more than three episodes per day - severe dehydration, ketonuria, electrolyte abns. - weight loss more than 5%

Question 20

Vitamin _ should be prescribed as first-line treatment for nausea and vomiting of pregnancy.

Answer 20

Vitamin B6 should be prescribed as first-line treatment for nausea and vomiting of pregnancy.

Question 21

Physicians should consider prescribing doxylamine + vitamin B6 for treatment of nausea and vomiting of pregnancy because the combination reduces symptoms by 70%.

Answer 21

doxylamine

Question 22

Which anti-emetic for emesis in pregnancy?

Answer 22

• Doyxlamine + B6 - diphenhydramine or meclizine - Can add prochlorperazine, metoclopramide - Requiring hospitalization: ondansetron

Question 23

Etonogestrel implant

Answer 23

is a single-rod progestin contraceptive placed subdermally in the inner upper arm for long-acting (three years) reversible contraception

Question 24

Reversible, highly effective contraception

Answer 24

• IUD - Etonogestrel implant

Question 25

Why bimanual examination before IUD insertion?

Answer 25

Active cervicitis is contra-indication

Question 26

Most effective Rx for post-menopausal vasomotor symptoms

Answer 26

Estrogen

Question 27

Rx: postpartum depression

Answer 27

SSRI

Question 28

Rx: post-menopausal vasomotor symptoms + contraindication to estrogen

Answer 28

Paroexetine

Question 29

Common vaginoses

Answer 29

Bacterial, candidiasis, Trichomoniasis

Question 30

Thin white gray discharge + odor

Answer 30

Bacterial vaginosis

Question 31

Thick white discharge, dysuria, burning + vaginal erythema

Answer 31

Candidiasis

Question 32

Frothy discharge, + odor, pruritus, dysuria

Answer 32

Trichomonas

Question 33

Amine odor after mixing KOH with discharge

Answer 33

Bacterial vaginosis

Question 34

Cervicitis caused by N gonorrhea and C trachomatis. Typical symptoms

Answer 34

• Usually asymptomatic - Possible mucopurulent discharge +- bleeding from cervix

Question 35

Cervicitis caused by N gonorrhea and C trachomatis.: Dx method?

Answer 35

Urine or Cervical or vaginal swab

Question 36

The diagnostic test of choice for chlamydial infection of the genitourinary tract is

Answer 36

nucleic acid amplification testing (NAAT) of vaginal swabs for women or urine for men.

Question 37

Three tests for women with recurrent miscarriage

Answer 37

• Antiphosopholipid antibody - Hysterosalpingogram (or sonohysterogram) - Parental karyotype

Question 38

Why is a thrombophilia work up not needed for recurrent miscarriage?

Answer 38

• Associated with fetal death and miscarriage after 20 weeks

Question 39

Inhaled steroid for pregnant women

Answer 39

Budesonide

Question 40

Most appropriate first test for second trimester loss

Answer 40

Pathology and Karyotype fetus,

Question 41

Penicillin allergy; pregnant woman with post-coital UTI. Rx:

Answer 41

Nitrofurantoin (Post-coital cephalexin for pen non-allergic)

Question 42

Is cipro safe in pregnancy?

Answer 42

Best avoided: safety not established

Question 43

Second semester TSH of 5 to 10; Mx

Answer 43

Measure thyroxine level

Question 44

• member of the TGF-beta family - expressed by preantral and early antral follicles - level reflects the size of the primordial follicle pool, and may be the best marker of ovarian function

Answer 44

Anti-müllerian hormone

Question 45

Why is cervical cancer in the absence of heterosexual activity extremely rare?

Answer 45

probably because sperm assist HPV infection of cervical epithelium

Question 46

HPV serotypes 16, 18, 33, 35, and 39 confer are often associated with

Answer 46

high-grade neoplasia and invasive cancer

Question 47

HPV serotypes 6, 11, and 42 are more often associated with

Answer 47

low-risk lesions and condylomata

Question 48

Gardasil: Recommended for women younger than __ years of age, and is most effective in women never exposed to __

Answer 48

26, HPV

Question 49

Cause of lesions anus

Answer 49

HPV infection: Condylomata acuminata (verrucous-like lesions; Fig. 64-2)

Question 50

Pap smear screening should be initiated in all women once ___ or at age __ years (whichever is first)

Answer 50

Pap smear screening should be initiated in all women once sexually active or at age 21 years (whichever is first)

Question 51

Cervical cancer screening

Screen every _ years in women age 21 to 29 (more frequently in women with _, immunosuppression, diethylstilbestrol exposure, history of CIN)

Women over the age of _ who have had at least __ negative smears can be screened every 3 years

Women at high risk (see preceding risk factors) require annual Pap smear screening ___.

In women who have undergone hysterectomy without a cervical remnant, Pap smears are no longer required unless the hysterectomy was performed for _

Because cervical cancer develops slowly and risk factors decrease with age, it is reasonable to discontinue cervical cancer screening over age 65 in women who have three or more negative cytology test results in a row and no abnormal test results in the past 10 years

Answer 51

Screen every 2 years in women age 21 to 29 (more frequently in women with HIV, immunosuppression, diethylstilbestrol exposure, history of CIN, or other risk factors)

Women over the age of 30 who have had at least three negative smears can be screened every 3 years

Women at high risk (see preceding risk factors) require annual Pap smear screening indefinitely

In women who have undergone hysterectomy without a cervical remnant, Pap smears are no longer required unless the hysterectomy was performed for cervical cancer

▪

Because cervical cancer develops slowly and risk factors decrease with age, it is reasonable to discontinue cervical cancer screening over age 65 in women who have three or more negative cytology test results in a row and no abnormal test results in the past 10 years

Question 52

Used for classification of Pap smear adequacy and results (Table 64-1)

Answer 52

Bethesda System

Question 53

Bethesda system

Answer 53

1. ASCUS
2. AGUS
3. LGSIL
4. HGSIL
5. Invasive Cancer

Question 54

AGUS: Significance

Answer 54

More related to endometrial rather than cervical cancer

Question 55

Mx: AGUS

Answer 55

1. Colposcopy with directed biopsy
2. Endometrial biopsy
3. If all normal, repeat Pap in 3–6 mo

Question 56

Mx: LGSIL, HGSIL

Answer 56

Colposcopy and directed biopsies

Question 57

Three management options in ASCUS

Answer 57

1. Repeat Pap smear in 4–6 months:
   
   1. If 2 repeats normal, yearly screening
   2. If ASCUS obtained before two normal repeats, refer for colposcopy
2. Colposcopy:
   
   1. If normal, resume annual Pap screening
   2. If abnormal, perform biopsies
3. DNA testing for HPV
   
   1. If positive, refer for colposcopy
   2. If negative, repeat Pap smear in 1 year

Question 58

Commonest finding on abnormal Pap smears

Answer 58

ASCUS

Question 59

Majority of women with ASCUS have __ findings on colposcopy

Answer 59

Benign

Question 60

ASCUS, immunosuppressed should always prompt

Answer 60

colposcopy

Question 61

Percentage of ASCUS and AGUS are cancer?

Answer 61

Small

Question 62

Risk of high grade lesion with follow up histology for LSIL and HGSIL

Answer 62

LSIL: 15-30%

HGSIL: 70-75%

Question 63

ASCUS

Answer 63

Atypical squamous cells of undetermined significance (ASCUS)

Question 64

AGUS

Answer 64

Atypical glandular cells of undetermined significance (AGUS)

Question 65

LGSIL, HGSIL

Answer 65

Low-grade squamous intraepithelial lesion (Risk:15-30%)

High-grade squamous intraepithelial lesion (Risk: 70-75%)

Question 66

The cervical epithelium most often affected by malignant transformation is where the __ cells of the endocervical canal are undergoing transformation into the __ cells of the exocervix (called the “transformation zone”) (Fig. 64-1)

Answer 66

The cervical epithelium most often affected by malignant transformation is where the columnar cells of the endocervical canal are transforming into the squamous cells of the exocervix (called the “transformation zone”) (Fig. 64-1)

Question 67

If LGSIL is confirmed by colposcopy and histology, treatment can be expectant with quarterly Pap smears because:

Answer 67

Majority revert to normal without treatment

Question 68

Rx: HGSIL

Answer 68

1. conization: if pathology negative for invasive cancer, and the margins free of disease, treatment is considered complete
2. LEEP, CKC, laser conization, or cryosurgery

Question 69

Rx: Invasive cervical cancer

Answer 69

1. Stage I : hysterectomy +- radiation
2. Stages II and III: radiation
3. Stage IV: radical surgery + radiation, or palliative chemotherapy or radiation

Question 70

Hemolysis
Elevated liver enzymes (AST and ALT up to 4000 U/L)
Low platelet count (as low as 6000/mm3)
Other symptoms
Epigastric pain
Nausea, vomiting
Headache
Edema

Answer 70

HELLP Syndrome

Question 71

Antihypertensive therapy not indicated for mild hypertension in pregnancy (generally defined as less than ___ mm Hg),

Answer 71

150/100

Question 72

Rx: hypertension in pregnancy

Answer 72

Methyldopa

Question 73

Anti-hypertensives which are absolutely contraindicated in pregnancy

Answer 73

ACEI and ARBs

Question 74

A reasonable goal is to keep maternal blood pressures in the ___ range

Answer 74

140–160/90–100 mm Hg

Question 75

Preeclampsia: hypertension occurring for the first time after __ weeks’ gestation with proteinuria (__mg/24 hr) and edema

Answer 75

Preeclampsia: hypertension occurring for the first time after 20 weeks’ gestation with proteinuria (>300 mg/24 hr) and edema

Question 76

HELLP Syndrome

Answer 76

Variant of preeclampsia : microangiopathic anemia, thrombocytopenia, or hepatocellular necrosis

Question 77

Ddx: HELLP Syndrome

Answer 77

1. HUS
2. TTP

Question 78

Benefit of blood glucose values well controlled in gestational diabetes

Answer 78

Shoulder dystocia and macrosomia rates are decreased

Question 79

Rx: gestational diabetes

Answer 79

Metformin, sulfonylurea, insulin

Question 80

Risks of antithyroid meds in pregnancy

Answer 80

1. Propylthiouracil and methimazolemay be teratogenic
2. Radioiodine is contraindicated

Question 81

___ : safest SSRI in pregnancy; avoid ___, which has been associated with congenital heart defects

Answer 81

Fluoxetine: safest SSRI in pregnancy; avoid paroxetine, which has been associated with congenital heart defects

Question 82

Which category drugs may be given in pregnancy after weighing risks versus benefits; which cannot be given in pregnancy?

Answer 82

C and D

Category X: Studies in humans and animals demonstrate significant fetal risk; contraindicated in pregnancy

Category A: Controlled studies in women fail to demonstrate risk to fetus in first trimester; unlikely to cause fetal harm

▪

Category B: Studies of animal reproduction have not demonstrated risk to fetus, but no controlled studies in pregnant women; or animal studies have shown effect, but no controlled studies in pregnant women

▪

Category C: Animal studies have revealed adverse effects in fetus; no controlled studies in women; should be given only if potential benefit justifies risk

▪

Category D: Evidence for fetal risk, but benefits may be acceptable in pregnant women despite risk

▪

Category X: Studies in humans and animals demonstrate significant fetal risk; contraindicated in pregnancy

Question 83

Rx: acne in pregnancy

Answer 83

Topical clindamycin, erythromycin, or benzoyl peroxide

Question 84

Allergic rhinitis

Answer 84

1. Topicals
2. Antihistamines
3. Pseudoephedrine

Question 85

Cough in pregnancy

Answer 85

Guaifenesin and dextromethorphan

Question 86

GERD in pregnancy

Answer 86

CaCO3, ranitidine

Question 87

Bronchitis in pregnancy

Answer 87

Amoxicillin and azithromycin

Question 88

UTI in pregnancy

Answer 88

Nitrofurantoin

Question 89

Thrombophlebitis in pregnancy

Answer 89

Heparin

Question 90

Antimicrobials contraindicated in pregnancy

Answer 90

Tetracyclines (brittle bones and cartilage and yellow teeth)

Fluoroquinolones (arthropathies

Question 91

Anticonvulsants contraindicated in pregnancy

Answer 91

1. Phenytoin
2. Carbamazepine
3. Valproic acid

Question 92

Why are loop diuretics contraindicated in pregnancy?

Answer 92

Fetal growth restriction and distress

Question 93

Only one live vaccine, the _ , is safe in pregnancy

Answer 93

OPV

Question 94

A 33-year-old patient has questions about the different types of oral contraceptives on the market and the dosing of the pill. In particular, she is worried that if she misses a day, she might become pregnant. Which of the following is correct advice?

1. Given her age, the mini-pill would be a good option for her because it contains only estrogen
2. Combination pills are more effective than the mini-pill because they contain both estrogen to inhibit ovulation and progestin to affect cervical mucus
3. Monophasic pills usually contain constant doses of progestin but escalating doses of estrogen
4. If she misses only one pill in the cycle, she does not need to worry about taking it when she realizes it
5. The mini-pill is significantly more effective than combination pills but is used less often because of side effects

Answer 94

2

Combination pills are more effective than the mini-pill because they contain both estrogen and progestin. The mini-pill, which contains progestin only, is probably somewhat less effective but is a good choice in older women with cardiac risk factors or in lactating women (not this patient). Monophasic pills contain constant doses of both estrogen and progestin. Finally, if a woman misses even one pill, she should take it immediately upon realizing this.

Question 95

An 18-year-old woman presents for a routine Papanicolaou (Pap) smear because she has been sexually active for a year. She has had one sexual partner. Her pelvic examination is unremarkable. You obtain a liquid-based Pap smear. The result returns as “atypical squamous cells of unknown significance” (ASCUS). What is your advice?

1. Treat with metronidazole and repeat the Pap smear in 2 months
2. Recommend colposcopy
3. Request human papillomavirus (HPV) testing on the sample; if positive, repeat the Pap smear in 3 to 6 months
4. Request HPV testing on the sample; if positive, refer to colposcopy
5. Request HPV testing on the sample; if negative, repeat the Pap smear in 1 to 2 months

Answer 95

4

ASCUS is a very common finding on routine Pap smears. There was no evidence of infection or inflammation on examination, so treatment with metronidazole is unnecessary. Referring directly to colposcopy will result in overuse of this procedure. Because a liquid-based cytology was obtained, HPV testing can be performed, and the information about HPV status will greatly aid in managing the patient. If positive, the patient should be referred for colposcopy rather than repeating the Pap smear in 3 to 6 months. If negative, the Pap smear can be repeated in 1 year, not 1 to 2 months.

Question 96

A 29-year-old woman with mild persistent asthma is 10 weeks pregnant. She calls the office urgently with increasing shortness of breath. You bring her in for urgent evaluation. Her dyspnea began 3 days ago with exposure to a neighbor’s cat. She denies chest pain, fever, or cough, and feels her current symptoms are typical of an asthma flare. She has been using her albuterol inhaler with increasing frequency but no clear benefit. Her past medical history is unremarkable. In addition to the albuterol, she also uses inhaled fluticasone 44 μg twice daily. On exam, she has audible wheezes diffusely but no other findings. Her oxygen saturation in the office is 94% on room air. What is the most appropriate intervention?

1. Discontinue inhaled fluticasone, as use during the first trimester can lead to fetal growth retardation, and add albuterol nebulizer treatments
2. Prescribe a short course of oral prednisone with a taper
3. Increase inhaled fluticasone to 110 μg twice daily
4. Send her to the emergency department immediately for intravenous methylprednisolone, as oral prednisone is contraindicated in pregnancy
5. Add salmeterol 1 inhalation twice daily to avoid increasing short-acting β-agonist therapy with its detrimental effects on the fetus

Answer 96

2. Prescribe a short course of oral prednisone with a taper

The patient presents with an acute asthma exacerbation and stable oxygenation. She requires aggressive therapy, however, to avoid deterioration with subsequent decreased oxygenation to the fetus.

In general, all asthma medications are reasonable to use in pregnancy, as the risk to the fetus from hypoxemia far outweighs the risk of any asthma medications. Given that she already is taking inhaled corticosteroids (fluticasone) and using an inhaled β-agonist frequently, she requires more aggressive therapy with a prednisone taper. Intravenous methylprednisolone offers no advantage over oral prednisone with regard to safety in pregnancy. Inhaled fluticasone does not require discontinuation, as it is not known to be associated with fetal growth retardation. Conversely, increasing the dose of inhaled fluticasone is not adequate or appropriate to treat an acute asthma exacerbation. Finally, a long-acting β-agonist, such as salmeterol, is not safer for the fetus than short-acting β-agonist therapy and is also not indicated for acute asthma flares.

Question 97

A 23-year-old woman, pregnant for the first time, is admitted at 32 weeks’ gestation after an office visit where her blood pressure is 170/110 mm Hg. She has had epigastric pain and vomiting since last night. Examination reveals significant edema. On admission, her platelet count is 45,000/mm3 and her aspartate aminotransferase (AST) is 2300 U/L. Which of the following would you not expect?

1. Hematocrit of 24%
2. Urine protein of 4+ (3 g/24 hr)
3. No increase in risk of seizure
4. Peripheral blood smear consistent with thrombotic thrombocytopenic purpura (TTP)
5. Possible recurrence with subsequent pregnancies

Answer 97

3, No increase in risk of seizure

This patient has severe preeclampsia and probable associated HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. It would not be surprising to find a low hematocrit secondary to hemolysis. The peripheral blood smear in HELLP is nondiagnostic and is also consistent with TTP or hemolytic uremic syndrome. The elevated urine protein is expected with preeclampsia. Severe preeclampsia puts this patient at high risk of seizure, and intravenous magnesium sulfate should be started. She is also at risk of recurrence of the preeclampsia with subsequent pregnancies.

Question 98

A 27-year-old women who has had diabetes since age 8 years and chronic hypertension since age 22 years, and who has had no previous pregnancies, comes to you for prepregnancy consultation. Her current medications include ramipril and glipizide. Which of the following advice would be incorrect to give your patient?

1. Continue the ramipril through the pregnancy to protect renal function from diabetes
2. Tight glycemic control should be in place before conception
3. Optimal blood sugars before and during pregnancy are 60 to 80 mg/dL fasting and 60 to 120 mg/dL 2 hours postprandial
4. Sulfonylureas and metformin are often used to treat diabetes in pregnancy, but sometimes insulin is required to maintain tight control
5. Her diabetes, if not controlled, could lead to fetal macrosomia

Answer 98

Continue the ramipril through the pregnancy to protect renal function from diabetes

Angiotensin-converting enzyme inhibitors (e.g., ramipril) are contraindicated in pregnancy; it should be discontinued before attempting conception. Uncontrolled diabetes can lead to fetal macrosomia or growth retardation, as well as other fetal abnormalities, including death. Tight control to prevent such complications is crucial, and the goals outlined in Answer C are appropriate. Insulin is the preferred drug for diabetes in pregnancy.

Question 99

A 19-year-old college student presents to your office for a routine health checkup. She has no significant medical history. She lives in a dormitory room with several friends and drinks alcohol on the weekends. She is sexually active with her boyfriend and uses condoms for birth control. Her physical examination, including pelvic exam, is normal. The Papanicolaou (Pap) smear results return in 1 week as “low-grade squamous intraepithelial lesion” (LGSIL). Which of the following is true regarding her condition?

1. She will most likely require a surgical procedure, such as a laser conization, but cure is likely
2. HPV testing will be helpful in decision-making regarding colposcopy referral
3. If a repeat Pap smear in 6 months shows “high-grade squamous intraepithelial lesion” (HGSIL), she will need colposcopy
4. Her risk for cervical cancer is low; repeat Pap testing in 12 months is appropriate
5. The finding of LGSIL has a high likelihood of regressing to normal

Answer 99

The finding of LGSIL has a high likelihood of regressing to normal

This patient’s Pap smear result, LGSIL, confers a 15% to 30% risk of having an HGSIL on colposcopy. In the majority of instances, LGSIL actually regresses to normal and has a benign prognosis. The need for eventual laser conization is unlikely. Nevertheless, the result does require further evaluation with colposcopy. Simply repeating the Pap smear in 6 to 12 months or using HPV testing to help triage the need for colposcopy (as with atypical squamous cells of unknown significance [ASCUS]) would not be aggressive enough or appropriate in this situation. You will also want to offer her the HPV vaccine if she hasn’t had it already.

Question 100

A 38-year-old woman is currently on an oral contraceptive for birth control. She is married and monogamous with her husband. Her sons are 10 and 7 years old, and she is not interested in having any more children. Lately, she has become concerned about how the oral contraceptive makes her feel and is worried that it might cause breast or ovarian cancer. Her family history is notable for an older sister who died of ovarian cancer at age 50. The patient does not drink or smoke. Her physical examination is unremarkable. What do you tell her about her contraceptive options?

1. The oral contraceptive agent will not increase her risk of ovarian cancer; in fact, it may be protective
2. She should discontinue the oral contraceptive as it is contraindicated in women over the age of 35 years
3. Injectable long-acting progesterone may be a better option as it will help protect against bone mineral density loss
4. An intrauterine device (IUD) would not be a good option given the increased risk of ectopic pregnancy at her age
5. Administering the contraceptive as a patch rather than a pill will avoid the increased risk of breast cancer

Answer 100

1. The oral contraceptive agent will not increase her risk of ovarian cancer; in fact, it may be protective

This woman has many options for contraception. Certainly, continuing her current oral contraceptive would be acceptable—as long as her anxiety with it is alleviated. Oral combination contraceptives are relatively contraindicated only in women over 35 years who smoke. They are not associated with ovarian cancer and, in fact, may be protective. The association of oral contraceptive with breast cancer is less clear, but probably not significant. Using a patch rather than a pill will do nothing to attenuate this risk. Long-acting (depot) progesterone has been linked to reversible bone mineral density loss and thus may not be the best first-line choice for this older woman. Finally, an IUD is a very reasonable option for her and is not associated with an increased risk of ectopic pregnancy in any age group.

Question 101

A 20-year-old young woman presents to your office for an urgent appointment. She is distraught as she recently discovered her boyfriend, with whom she is sexually active, has genital warts. She is worried that she may contract these and that she might develop cervical cancer. She has been in a monogamous relationship with her boyfriend for about 9 months. She is otherwise healthy. What do you recommend for cervical cancer screening?

1. After three annual Papanicolaou (Pap) smears that are normal, she can increase the screening interval to Pap smears every 3 years
2. The human papillomavirus (HPV) strains that cause cervical cancer do not cause genital warts; therefore, she can defer screening for another year
3. She should undergo a Pap smear with HPV testing
4. A finding of squamous metaplasia on Pap smear should prompt HPV testing
5. She does not require cervical cancer screening as she has not reached 21 years of age

NEXT QUESTION

Answer 101

She should undergo a Pap smear with HPV testing

This patient should undergo cervical cancer screening now as she is sexually active and has probable exposure to HPV. Guidelines suggest screening at age 21 or upon initiation of sexual activity, whichever is first. HPV testing in women less than 30 years of age is more controversial, given that many women will spontaneously clear the infection with no sequelae. This patient, however, has a known exposure, and HPV testing (with serotyping of low- vs. high-risk serotypes) will add in prognosticating her future risk of cervical cancer. It is true that the HPV strains that cause genital warts are usually low-risk strains, but that alone would not be sufficient to defer screening in this patient. Most guidelines do not recommend lengthening the screening interval to 3 years until a woman reaches 30 years of age, regardless of HPV status. A finding of squamous metaplasia is normal and does not require further testing of any kind. Even though she is already sexually active, you will want to consider offering the HPV vaccine, if she hasn’t had it already.

Question 102

A 50-year-old woman presents to your office with moderate hot flashes that began about 6 months ago. They are worsening in severity and wake her up many times throughout the night. She is becoming increasingly sleep-deprived and describes inability to concentrate at work. Her last menses was 10 months ago. She is on a small dose of a thiazide diuretic for mild hypertension but is otherwise healthy. Which of the following is true about the treatment of her hot flashes?

1. α-Adrenergic agents are the best-tolerated option and would be a good choice for her
2. Venlafaxine is the most effective alternative to estrogen
3. Coping mechanisms alone may not be enough for her; estrogen is reasonable to try
4. Gabapentin provides the quickest onset and the fewest side effects; it should be prescribed for her
5. Estrogen will work for her, but its use should be limited to under a year

Answer 102

3. Coping mechanisms alone may not be enough for her; estrogen is reasonable to try

This woman has moderate hot flashes associated with menopause that are now affecting her quality of life and ability to work. She deserves treatment. There is no “right” or “wrong” choice for therapy, although estrogen has the quickest onset and best efficacy. It is very reasonable to try it in this patient, given her moderate to severe symptoms. Coping mechanisms (such as wearing lightweight layers and keeping a fan on) may not be adequate. Estrogen use should be limited to 5 years, not 1 year. The other prescription alternatives are reasonable, but reduce hot flash frequency and severity by roughly 50%. It is not true that α-adrenergic agents are the best tolerated (they are the least well tolerated). Likewise, venlafaxine is not necessarily the most effective and gabapentin does not have the quickest onset or fewest side effects. Head-to-head trials for most estrogen alternatives are lacking.

Question 103

As a practicing internist, you see many pregnant women as patients. While they often call their obstetrician for advice regarding their pregnancy, you still receive many phone calls about common problems, such as allergic rhinitis, urinary tract infections, and reflux disease. Which of the following is not appropriate advice for a pregnant woman?

1. For a urinary tract infection, nitrofurantoin is a good choice
2. For allergic rhinitis, diphenhydramine is worth trying
3. For gastroesophageal reflux, omeprazole is recommended
4. For a severe headache, acetaminophen is an acceptable option
5. For acne, topical clindamycin is a reasonable strategy

Answer 103

PPIs are Category C and should be avoided if possible. New evidence has questioned whether they have risks in the second and third trimester, but generally H2 blockers (Category B) are preferred for GERD.

Question 104

Which of the following is true regarding cervical cancer screening with a Papanicolaou (Pap) smear?

1. A finding of atypical squamous cells of undetermined significance (ASCUS) on Pap smear with a negative DNA test for human papillomavirus (HPV) can be followed with a repeat Pap smear in 1 year
2. A finding of atypical glandular cells of undetermined significance (AGUS) is less serious that ASCUS and can be followed with a repeat Pap smear in 4 to 6 months
3. Cervical cancer screening with a Pap smear is recommended beginning at age 21 years, regardless of sexual activity
4. Trichomonas found on a routine Pap smear should be confirmed with a normal saline prep before initiating treatment
5. If a Pap smear shows ASCUS, but colposcopy reveals cervical intraepithelial neoplasia grade II, there was probably a sampling error and a repeat colposcopy should be performed

Answer 104

A finding of atypical squamous cells of undetermined significance (ASCUS) on Pap smear with a negative DNA test for human papillomavirus (HPV) can be followed with a repeat Pap smear in 1 year

HPV testing can be useful in triaging patients with a finding of ASCUS on Pap smear. If negative, repeating the Pap smear at 1 year is an appropriate course of management. If positive, the patient should be referred for colposcopy. AGUS is often related to more serious disease than ASCUS (usually endometrial rather than cervical cancer) and should be followed more aggressively. Colposcopy and biopsy are more appropriate than repeat Pap testing. Recommendations are to begin cervical cancer screening at age 21 years or when sexually active, whichever comes first. Any infection, such as Trichomonas, found on a routine Pap smear, should be treated. A normal saline prep is not necessary for confirmation. Finally, if there is a discrepancy between a Pap smear reading and a histologic finding by colposcopy, treatment should be initiated if the histologic diagnosis is more serious (as in this case). The patient should have definitive therapy with cold knife or laser conization or a loop electrosurgical excision procedure (LEEP). If the histologic diagnosis is less severe, a sampling error may have occurred and a larger biopsy should be taken.

Question 105

A 25-year-old woman is 12 weeks pregnant with her second child. She presents to the emergency department with an acute onset of shortness of breath and wheezing. She has a history of mild, intermittent asthma for which she uses an albuterol metered-dose inhaler on an as-needed basis. On examination, her blood pressure is 130/85 mm Hg and her heart rate is 110 beats/min. She is tachypneic and has diffuse, polyphonic wheezes throughout her lung fields. Her oxygen saturation is 94% on room air. What is appropriate management?

1. Administer O2 by nasal cannula, prednisone, and β-agonist nebulizer treatments
2. Administer O2 by nasal cannula and theophylline, as it is Food and Drug Administration Pregnancy Risk Category B
3. Administer O2 by nasal cannula and β-agonist nebulizer treatments; avoid prednisone because of pregnancy and risk to the fetus
4. Administer O2 by nasal cannula and intravenous magnesium sulfate, as it is safe in pregnancy
5. Administer O2 by nasal cannula and prednisone; avoid β-agonist nebulizer treatments because she is in the first trimester

Answer 105

Administer O2 by nasal cannula, prednisone, and β-agonist nebulizer treatments

The risk to the fetus of hypoxemia from the asthma far outweighs any risk of treatment. She should be given oxygen by nasal cannula and treated aggressively, no matter what her trimester. Prednisone and β-agonist nebulizer treatments are both appropriate therapies. Theophylline is Pregnancy Risk Category C and should be avoided unless absolutely required. Magnesium sulfate has not been proven to be efficacious in asthma and alone would not be enough to treat the flare.

Question 106

Which of the following women would not be a good candidate for the use of combination oral contraceptive pills?

1. A 40-year-old woman with no smoking history
2. A 30-year-old woman with a strong family history of ovarian cancer
3. A 29-year-old woman with mild hypertension that is well controlled with a thiazide diuretic
4. A 32-year-old woman with a history of autoimmune hepatitis that is under reasonable control
5. A 34-year-old woman with heavy menses secondary to uterine fibroids

Answer 106

Women with a history of liver disease should be advised not to use them (Answer D). Other contraindications include a history of thromboembolic disease, a history of breast or endometrial cancer, and smokers over age 35 years. In Answer A, the woman does not smoke and would still be a candidate. For Answer B, oral contraceptives may actually decrease the risk of ovarian cancer. In Answer C, the hypertension is well controlled. Only uncontrolled hypertension is a contraindication. Finally, use of an oral contraceptive may actually decrease menstrual bleeding in a woman with uterine fibroids.

Question 107

A 19-year-old woman comes to your office for counseling regarding birth control. She has been using condoms, but does not like “depending on someone else for protection.” She also has “horrible” migraines that only occur premenstrually (once a month) but force her to stay in bed for a day. She is interested in trying a combination oral contraceptive. She is healthy with no chronic medical conditions. When initiating oral contraceptives, which of the following statements would be appropriate advice for the patient?

1. Explain that, if she misses a couple days of her oral contraceptive, she should take one immediately, and then one twice a day until all the missed tablets have been taken. If she does so, she will not need an additional form of contraception for that cycle
2. Inform her that the mini-pill may be a good option for her; because it contains estrogen only, it tends to have fewer side effects
3. She should start the oral contraceptive midcycle, roughly 14 days before her expected menstruation
4. Oral contraceptives are not necessarily contraindicated for premenstrual migraines; in fact, she may opt to have a withdrawal bleed only every 3 months on the pill to decrease the frequency of her migraines
5. Symptoms of premenstrual syndrome (nausea, irritability, headache, bloating) usually worsen after starting an oral contraceptive

Answer 107

Oral contraceptives are a reasonable choice for this healthy, young woman with no contraindications. While oral contraceptives may worsen migraines in general, they may actually alleviate premenstrual headaches and migraines. An added bonus is the ability to take the inert pills only every 3 months (perfectly safe to do), thus decreasing the frequency of premenstrual migraines. If she misses more than one dose, she should take the missed tablets as directed in Answer A, but she should also use an additional form of contraception that cycle. The mini-pill contains progestin only (not estrogen) and is associated with a higher incidence of breakthrough bleeding. It is used predominantly in breast-feeding women or women who cannot tolerate estrogen. Oral contraceptives should be started on the first day of menses, not midcycle. Finally, symptoms associated with premenstrual syndrome tend to improve on oral contraceptives, not worsen.

Question 108

A 31-year-old woman calls your office in October. She is pregnant at 35 weeks’ gestation and is wondering if she should get the advertised “shingles” vaccine (Zostavax). What vaccine should you offer her?

1. Zoster vaccine
2. Intranasal influenza vaccine (FluMist)
3. Influenza injection vaccine
4. Measles, mumps, and rubella (MMR) vaccine
5. Pneumococcal vaccine

Answer 108

3. Influenza injection vaccine

Zoster, like varicella vaccine, is a live, attenuated virus, and as such it is contraindicated in pregnancy. MMR also falls into this category. It is important during preconception counseling to offer varicella and MMR vaccination to women found to be nonimmune, and conception should be postponed at by at least 4 weeks at a minimum. Injectable influenza vaccination is recommended to all pregnant women, regardless of trimester, and especially to those who will deliver during flu season. Nasal influenza vaccine is a live, attenuated virus and therefore contraindicated. Pneumococcal vaccination is not routinely indicated in the healthy, young adult population.

Question 109

A 28-year-old female patient calls the morning following unprotected intercourse with her partner of 3 years. She forgot to take her oral contraceptive pill for the past 2 weeks and is concerned that she may become pregnant. She asks if she should take all of the missed pills immediately to prevent a pregnancy. What advice do you offer?

1. Take 1 pill now and 1 pill twice daily until all 14 are taken
2. Check a urine pregnancy test in 2 weeks and call again if it is positive
3. Provide medroxyprogesterone 150-mg injection in the office in 1 week
4. Offer levonorgestrel 0.75 mg now and a second dose in 12 hours
5. Reassure her that conception is unlikely after 2 weeks of missed pills

Answer 109

Offer levonorgestrel 0.75 mg now and a second dose in 12 hours

She may benefit from emergency contraception: levonorgestrel in two doses of 0.75 mg or one dose of 1.5 mg. It is at least 75% effective at preventing pregnancy. If one pill is missed, a woman should be advised to take it as soon as it is remembered, but if more than 2 pills are forgotten, alternative contraception should be used as she is at high risk for unplanned pregnancy. Combined oral contraceptives are 98% effective at preventing pregnancy with perfect use. This efficacy drops when pills are missed, and the very low-dose (20-μg estrogen) pills are even more prone to failure when not taken exactly as prescribed as compared to standard-dose pills. Medroxyprogesterone injection is a form of contraception but not indicated as emergency contraception. In this patient, you would also want to identify a more reliable form of birth control for her in the future (e.g., IUD if not planning a pregnancy in the next year).

Question 110

Use of hysterosalpingography

Answer 110

SOL in the endometrial cavity (polyps, fibroids)

Question 111

Tests that can measure ovarian reserve

Answer 111

FSH on day 3 of cycle

Anti-Mullerian hormone

Question 112

Primary ovarian insufficiency

Answer 112

• Less than 40 years old
• amenorrhea for 4 months or more,
• two serum FSH levels (obtained at least 1 month apart) in the menopausal range

Question 113

In 90% of the cases of primary ovarian insufficiency, the cause

Answer 113

remains a mystery.

Question 114

Flibanserin

Answer 114

Only FDA drug used for female sexual dysfunction

Question 115

Most cases of mastitis are caused by

Answer 115

Staph aureus

Question 116

Menopause.Mx

Vasomotor symptoms in patient with contraindication to estrogens

Answer 116

Paroexetine

Question 117

Small cysts along the outer edge of the cervix

Answer 117

Nabothian cyst

• discrete cystic structures that form when a cleft of columnar epithelium becomes covered with squamous cells and the columnar cells continue to secrete mucoid material.
• microscopic to several centimeters
• may occur following minor trauma or childbirth.

The only indication for treatment is relief from pain or a bothersome feeling of fullness in the vagina. Ablation of the cyst using electrocautery is the usual approach; however, if the diagnosis is uncertain, excision to evaluate histopathology is advised.

Question 118

mass of the ovary, fallopian tube, or surrounding connective tissue

Answer 118

Adnexal mass

Question 119

Intractable pain from metastatic cancer: Mx

Answer 119

PCA

Question 120

Pregnancy: why no fluroquinolones or Bactrim?

Answer 120

quinolones: fetal arthropathy, Bactrim: early -> malformation, late -> kernicterus

Question 121

Ashkenazi Jewish woman: pre-conception screening

Answer 121

Tay-Sachs, Canavan,CF, Familial dysautonomia

Varying recs

Question 122

highly effective reversible contraception

Answer 122

IUD or etonogestrel

Question 123

HRT: status post hysterectomy: why estrogen-only Rx?

Answer 123

Progestin necessary only for women with a uterus

The idea is that the patient does not need the risks which progestin incurs.

Question 124

Recurrent first trimester miscarriage: Testing

Answer 124

Anti-phospholipid, parental karyotype + hysterosalpingogram

Question 125

Pregnant: Penicillin + cephalosporin allergy: Pyelonephritis: Rx

Answer 125

Aztreonam

Question 126

Cervical lesion: visible: Mx

Answer 126

Biopsy

Not LEEP or conization

Question 127

Pregnancy: Late: suspected appendicitis: Imaging?

Answer 127

MRI

Not CT, not US (less sensitive). If no MRI, low dose CT is OK.