Female RS n Breast1

Question 1

A22 yr old female came with worsening RUQP. She started having lower abdominal pain 5days back. She now has fever(38.9), chills, vomiting. She’s currently on her periods but reports having irregularities n occasional spotting over the last 3months. P/E- RUQ and diffuse lower abdominal tenderness without guarding. Px test is negative
Dx?
Rx?

Answer 1

Complicated PID ( perihepatitis/ Fitz Hugh-Curtis disease)
- hospitalizations n iv abx

Question 2

A 66 yr old female came with malodorous vaginal discharge mixed with blood. She has hx of exposure to diethylstilbestrol in utero. She has smoked cigarettes daily for 40yrs. She has maternal hx of endometrial ca. Ulcerated lesion is seen on the posterior vaginal wall biopsy showing squamous cell ca.
Which of the above is the greatest risk factor for this pt’s Dx?

Answer 2

Smoking!

DES exposure is a risk factor for clear cell adenocarcinoma not squamous.

Question 3

A 67 yr old woman comes with severe vulvar itching and burning for the past 6months. P/E shows thin, dry, white plaque-like vulvar skin with loss of the labia minora , overlying excoriation
The best next step in evaluation of this patient?

Answer 3

Vulvar punch biopsy

• vulvar lichen sclerosus - can b diagnosed clinically but to confirm the dx n rule out vulvar cancer, which can occur in pts with prolonged lichen sclerosus due to chronic inflammation, biopsy should b done
• Rx is high dose steroids
• can also occur in premenarcheal girls, in which case biopsy is not indicated

Question 4

During mx of sexual assaults, how is the issue of STIs dealt with?

Answer 4

Empiric Rx ( post exposure prophylaxis)

Question 5

A 34 yr old comes for evaluation of amenorrhea for the past 6 months. She has generalized anxiety disorder. Her older brother has fragile X syndrome. TSH is normal but FSH is elevated. A progesterone challenge is performed n pt has no withdrawal bleeding
The most likely dx is?

Answer 5

Primary ovarian insufficiency
- pt has secondary amenorrhea and an elevated FSH level suggestive of ovarian failure, which in women <40, is consistent with the dx of POI
Lack of estrogen -> no endometrial proliferation-> lack of withdrawal bleeding after progesterone challenge
POI is common in those who r fragile X syndrome permutation carriers and neurobehavioral disorders like GAD

Question 6

The only current indication for HRT is —?

Answer 6

Vasomotor sxs eg, hot flashes, sleep disturbances, night sweat
Otherwise, it’s no longer recommended in the prevention of CHD, osteoporosis.,.

Question 7

HPV vaccine is given in which age group? C/in?

Answer 7

11-26 but may b given 9-45

• not given in Px.
• previous or current infection isn’t a contraindication

Question 8

Asymptomatic endometriosis is managed as?

Answer 8

Reassurance n observation

Question 9

Which of the following is not a side effect of OCPs?
Breakthrough bleeding
Hypertension
Increased risk of venous thromboembolism
Weight gain

Answer 9

Weight gain.

Question 10

Bilateral gray non bloody nipple discharge is consistent with?
- subsequent evaluation includes?

Answer 10

Galactorrhea

- pregnancy test, serum prolactin n TSH, consider pituitary MRI

Question 11

A unilateral Bloody nipple discharge without breast mass or nipple changes in the setting of normal mammography is the classic presentation of ?

Answer 11

Intraductal papilloma

Question 12

Androgen insensitivity syndrome
Clinical features
- presentation( clinical, testosterone level), pheno & genotype
-pathogenesis
- at puberty- breast, pubic n axillary hair development

Answer 12

• ~16 yr old female with primary amenorrhea, male range testosterone levels. Genotypically male(46, XY).
• during fetal life, the functioning cryptorchid testes produce antimulerian hormone(AMH) which causes regression of muletian structures( uterus, cervix…) and testosterone but due to nonfunctional receptors on wolffian duct n urogenital sinus, male external genitalia can’t develop; patients default to female external genitalia.
• at puberty testosterone increases n aromatized into estrogen-> breast development.
• minimal or no axillary or pubic hair due to peripheral androgen resistance

Question 13

A pt with a hx of admission for a pelvic infection in her late teens comes for infertility evaluation, no other abnormalities. husband’s semen analysis is normal. The best next step is?

Answer 13

Hysterosalpingogram

Question 14

Regular monthly menses and additional intermentstrual bleeding in an otherwise healthy women, uterus is small, mobile n nontender
Most likely Dx?
Mx?

Answer 14

Endometrial polyp.
Asymptomatic-no Rx needed
Symptomatic- hysteroscopic polypectomy

Question 15

A 29 yr old female came for infertility evaluation. She has dysmenorrhea. On PV uterus is small with cervix that appears laterally displaced and there is pain with cervical manipulation. Most likely Dx?

• most appropriate diagnostic test
• Rx?

Answer 15

Endometriosis

• laparoscopy
• medical therapy with NSAIDs+/-OCP , if this doesn’t help, or infertility, then laparoscopic removal
• it may regrow so the definitive therapy in women who have completed childbearing is hysterectomy n oopherectomy

Question 16

A failed progestin challenge test in a young, athletic girl with secondary amenorrhea, normal TSH n prolactin levels is suggestive of?

Answer 16

Functional hypothalamic amenorrhea- low GnRH, LH, FSH and estrogen

Question 17

A large pelvic mass with one or more signs of virilization ( bitemporal hair thinning, voice deepening, increased mm mass, clitoronegaly)
Most likely consistent with?
They can also have AUB- amenorrhea or intermenstrual spotting…
Rx?

Answer 17

Sertoli-leydig cell tumor- testosterone secreting sex cord straumal tumor.
The elevated testosterone levels suppress FSH n LH resulting in anovulation n amenorrhea
Rx- surgical removal

Question 18

AUB and irregular pelvic/uterine mass in a postmenopausal women is most likely due to
May have hx of tamoxifen use or exposure to radiation

Answer 18

Uterine sarcoma

Question 19

Difference between HSV n h. Ducreyi genital ulcers

Answer 19

HSV- multiple painful ulcers with erythematous base, tender inguinal LAP
Chancroid- large painful ulcers gray/yellow exudate with friable base. Lymph nodes classically undergo suppuration

Question 20

Amenorrhea in obese women is due to?

Answer 20

Anovulation.
Insulin resistance-> decreased production of sex hormone binding globulin-> elevated free androgen-> aromatized in the adipose tissue to estrone which stays persistently elevated-> disruption of the pulsatile release of GnRH… anovulation

Question 21

In 44yr old female with vasomotor sxs( hot flashes, night sweats), insomnia and irregular menses, what should b the next step in the mx?

Answer 21

Serum FSH n TSH
Because menopause n hyperthyroidism can present similarly.
Menopause can b diagnosed clinically in women>45 with a 12 month hx of amenorrhea without other physiologic causes

Question 22

5-alpha-Reductase deficiency
Genotype,
Clinical features- at birth n puberty including breast development, pubic n axillary hair

Answer 22

46,XY
Due to deficiency of the enzyme, testosterone can’t b converted to DHT- failure to develop male external genitalia and have FEG at birth and raised as females.
At puberty, increased level of testosterone causes virilization( acne, clitoromegaly, voice…)
- normal development of axillary n pubic hair but no breast development because testosterone binds to breast androgen receptors n inhibit breast tissue proliferation

Question 23

A 16yr old girl comes with amenorrhea. Breast development is tanner stage lll, pubic hair- tanner stage lll, normal female external genitalia. Absent uterus. Normal FSH levels
The best next step in the mx?
Dx?

Answer 23

Dx- mullerian agenesis- absent uterus n cervix with otherwise normal secondary sexual cxs
- concomitant renal anomalies r common so renal U/S should b done

Question 24

A 31 yr old comes for fallow up of an abnormal Pap test which revealed a high grade squamous intraepithelial lesions ( HSIL). Colposcopy reveals a nulliparous cervix with no lesions. The entire squamocolumnar junction can’t b visualized . The best next step in the evaluation of this pt is?

Answer 24

Endocervical curettage
-HSIL In Pap testing is concerning for high grade cervical intraepithelial neoplasia ( CIN) or invasive cancer therefore pts require COLPOSCOPY.
Colonoscopy in this pt is unsatisfactory because the transitional zone, the most at risk area, is not fully visualized. Therefore the next step is ENDOCERVICAL CURETTAGE which can sample tissue

Question 25

A pt had 3 miscarriages due to antiphospholipid antibody syndrome. The best contraceptive method for her is?

Answer 25

Hormone free, I.e, copper intrauterine device or tubal ligation
- hormone containing contraceptives r also contraindicated in breast ca

Question 26

On Pap testing, if endometrial cells r seen, what’s the next step?

Answer 26

Age<45- it’s a benign n common finding n it’s not even reported but >|=45 yrs or menopause, endometrial biopsy should b done to rule out endometrial ca or hyperplasia

Question 27

Which of the ff is the most common risk factor for endometrial ca?

• obesity
• OCPs -tobacco
• age at menarche

Answer 27

Obesity

Question 28

A 12 yr old who hasn’t reached menarche, presenting with a tender suprapubic mass and blue tinged bulge between the labia most likely has

Answer 28

Imperforate hymen

Hymenal incision n drainage is the treatment

Question 29

Dyspareunia, thin vulvar skin, shrinkage of clitoral tissue, narrow vaginal introitus, pale vaginal mucosa in a postmenopausal or had hx of exposure to radiation
Dx

Answer 29

Atrophic vaginitis

-lubricants or moisturizers r first line. Persistent sxs r treated with vaginal estrogen

Question 30

How can u differentiate between hypothalamic amenorrhea and androgenic steroid use in a young, muscular, athletic girl?

Answer 30

Androgen use- virilization , aggressive sxs

Mild acne can b seen as part of her puberty ( without androgen use)

Question 31

Postmenopausal bleeding is evaluated with either — or —

Answer 31

Transvaginal u/s or endometrial biopsy.

If transvaginal u/s shows endometrial thickness of>4, biopsy is indicated.