Female RS...3

Question 1

A 62 yr old postmenopausal woman’s pelvic u/s reveals a 5cm rt ovarian cyst. The best next step in the evaluation of this pt is?

Answer 1

Serum CA-125 level measurement.
Even if the mass has no malignant features on ultrasound, elevated CA-125 is concerning for malignancy n requires further imaging n possible surgical exploration.

Question 2

A 2 yr old who has had multiple diaper rashes over the last 6months comes for evaluation. On pelvic examination the labia minora appear thin, r fused together at the midline. Multiple excoriation r seen, but there’s no rash or perianal involvement.
The most likely dx is?

Answer 2

Labial adhesions
- commonly seen in prepubertal girls due to low estrogen production. Inflammation from poor hygiene, infection, trauma… contribute to the development of adhesion.
Lichen sclerosus can predispose to adhesions but the classic hypopigmented labial lesions r lacking in this pt.

Question 3

Any screening for c. Trachomatis n N. Gonorrhoeae in non pregnant women?
When?
What test?

Answer 3

• all sexually active women<25 yr;
• > 25 with high risk sexual behavior
• annually with nucleic acid amplification test

Question 4

A 16 yr old comes with nodule-cystic acne on her face, chest n back. She has irregular menses. Terminal hair r notable on the upper lip n around the nipple. Development is tanner stage V. Abdomen is obese. Testosterone n DHT r normal. She is at increased risk of developing which malignancy?

Answer 4

Endometrial ca- unopposed estrogen from chronic anovulation

PCOS

Question 5

Unovulatory cycles with heavy irregular menses in adolescents is treated with?

Answer 5

Progesterone pills

Question 6

A high grade squamous intraepithelial lesions r seen on Pap test of a 27 yr old pregnant on her 29th weeks of gestation. Best next step in the mx?

Answer 6

Immediate colposcopy! and biopsy.

Surgical excision is done only if evidence of invasive cancer is found because of risk of preterm delivery

Question 7

A 34 yr old para 1 mother comes for infertility evaluation; irregular menstrual cycles for the past 3months. Has hot flashes. She has controlled hypothyroidism n TSH is normal. BMI is 24. No other abnormalities.
Dx?

Answer 7

Primary ovarian insufficiency!

Hot flashes indicate low estrogen levels, in <40yr old…

Question 8

A 37 yr old para 1, aborta1 pt comes for infertility evaluation. She has regular menses. BMI is 23
She is an aerobics instructor and teaches 2hrs daily. No other abnormalities. Underlying cause of her infertility is?

Answer 8

Decreased ovarian reserve ( oocyte number or quality)- after age 35 spontaneous conception rates decrease. Regular periods can still occur due to ovulation but conception is decreased because of low quality.
- had it been the intense exercise causing hypothalamic dysfunction, she would have had irregular menses ( amenorrhea…)

Question 9

A 53 yr old comes with itchy, eczematous plaque on her left nipple n areola for 1 month. The most likely underlying condition is?

Answer 9

Breast adenocarcinoma

- she is having mammary paget disease, which in 80% of the cases is associated with underlying adenocarcinoma

Question 9

A 59 yr old woman presenting with breast tenderness with bilateral diffuse fibrocystic changes. She also has abdominal distention n u/s shows a complex rt ovarian mass with solid components n multiple septations. Uterus is slightly enlarged, endometrial stripe is 9cm. The tumor marker elevated in this pt is?
Dx?

Answer 9

Granulosa cell tumor - a malignant sex cord straumal tumor
- ESTRADIOL is elevated- granulosa cells r normally responsible for conversion of testosterone to estradiol via aromatase => pt can have breast changes n enlarged uterus (>4mm endometrial stripe)

Question 10

A 24 yr old woman comes with dyspareunia. She has been unable to use tampon due to vaginal pain. Pelvic examination is attempted but not completed due to pt’s intolerance. No lesions on the external genitalia
Dx?

Answer 10

Genito-pelvic pain/penetration disorder- previously known as vaginismus
- endometriosis May cause deep dyspareunia but not insertional vaginal discomfort

Question 11

A 19 yr old comes due to continuous, clear, slightly malodorous vaginal discharge for the past few weeks. There r no associated sxs. She is 6 weeks postpartum from a vaginal delivery of a stillborn after 3 days of labor and four hours of pushing. On speculum examination, there is a small area of granulation tissue on the anterior vaginal wall. No cervical lesions and there’s a pool of clear fluid in the vagina with a pH of 6
Diagnostic test?

Answer 11

BLADDER DYE TEST

Vesicovaginal fistula- a complication of obstructed labor

Question 12

A 44 yr old woman comes with 6 months hx of painful sexual intercourse. She takes saline eye drops for chronic dry eyes. She has mild dental caries. Vaginal mucosa is dry on examination. She has no other abnormalities
Most likely cause is?

Answer 12

Inadequate lubrication secondary to sjogren syndrome- inflammation of the exocrine glands. Sicca syndrome- generalized dryness of mucous membranes can cause dry eyes, dental caries, respiratory sxs, dyspareunia.
- SS can occur as an isolated disorder or in association with RA…; is associated with significant risk for NHL

Question 13

A 38 yr old nulliparous comes with persistent AUB. She has intermenstrual spotting n bleeding that occurs at varying intervals in the past 8months. She was started on OCP but no improvement. No other abnormalities. U/S is normal. The best next step in the evaluation?

Answer 13

Endometrial biopsy

Women<45 yr with AUB who have failed medical mx ,obesity, tamoxifen therapy need endometrial biopsy

Question 14

Cause of stress urinary incontinence is? ( incontinence with increased intraabdominal pressure eg coughing, sneezing)

Answer 14

URETHRAL HYPERMOBILITY- the bladder n urethra r normally maintained in the appropriate anatomical position by the pelvic floor mm( lavator ani). Pelvic floor mm wkness …
- stress incontinence can also occur due to direct pressure on the bladder from an irregularly enlarged uterus, eg fibroids.-pelvic u/s will help to make the dx

Question 15

A 42 yr old woman comes with recurrent abdominal bloating fatigue hot flashes that improve after menses. Sxs make her extremely cranky n has missed work due to these sxs. Menses is regular; no other abnormalities
Next step in the evaluation?

Answer 15

Dx- premenstrual syndrome (PMS)

• she should return to the office with SYMPTOM DIARY over two menstrual cycles. - presence of sxs ( bloating, fatigue, hot flashes, breast tenderness…, mood sxs) during the luteal phase n resolution of sxs during follicular phase( onset of menses or shortly thereafter)
• Rx - SSRI

Question 16

A 43 yr old multipara comes for routine health maintenance examination. Her mother had breast ca at the age of 67. She doesn’t smoke; drinks 2 glasses of wine with dinner every evening. She is concerned about her likelyhood of getting breast ca. The best recommendation for this pt?
- decrease alcohol. - BRCA genetic testing - prophylactic mastectomy

Answer 16

Decrease alcohol intake - moderate alcohol intake in a woman is said to be <2 drinks per day or <7 per week. Even low alcohol intake in women confers an increased risk for breast ca.
- if the mother had been diagnosed with breast ca at age <50, genetic testing would have been useful

Question 17

Cervical ca screening starts at the age of? HPV cotesting?

Answer 17

Starts at 21 yrs with Pap test.

HPV cotesting is not recommended for ages21-29 yrs as the infection spontaneously clears in these pts.

Question 19

A sexually active women presenting with repeated episodes of UTI ( recurrent UTI- >|=2 episodes in 6months or >|=3 episodes in a year.) sxs resolve with Rx n culture results will also become negative after Rx. The best next step in the mx of such pts is?

Answer 19

Postcoital abx prophylaxis, as sexual intercourse is a significant risk factor ( cotrimoxazole or nitrofurantoin )
- daily abx prophylaxis is also another option.

Question 20

A 22 yr old female gymnast comes for routine examination. She sustained vulvar contusion during a competition 3months ago, otherwise feels fine. On examination there is mobile, soft nontender flesh colored 2cm cystic mass at the 4oclock position at the base of the labium majus. The most likely dx?

Answer 20

Bartholin duct cyst- bartolin glands are located bilaterally at the posterior vaginal introitus n have ducts that drain into the vulvar vestibule. They can get blocked from mucous accumulation, edema, trauma
Rx - asymptomatic cyst as in this case- observation , drains by itself.
- symptomatic cyst or abscess- incision n drainage.

Question 21

A 36 yr old obese woman had hysterectomy done a week back. She now complains of incisional pain. She is afebrile; abdomen is soft, there is diffuse tenderness of the incision, no palpable masses or defects; intact skin edges, no erythema drainage or flactuance.
The best next step?

Answer 21

Observation n reassurance
-mild induration n diffuse tenderness over the incision, the rest of the things being normal, is consistent with normal healing

Question 22

In a suspected ectopic pregnancy, b-hCG 1000 iu/l, Hb- 11, stable vital signs; transvaginal u/s shows no intrauterine, no extrauterine pregnancies.
The best next step is?

Answer 22

Repeat serum B-hCG in 2days
- B-hCG increases every 2 days in viable pregnancy, rise in a slower rate in ectopic or non-viable pregnancy.
B-hCG between 1500-2000, intrauterine pregnancy should b seen in TVUS. Therefore if the B-hCG is >1500, TVUS should also b repeated

Question 23

A 34 yr old has irregular menses occurring every 8-11 wks, with heavy bleeding n clots, she has intermittent light spotting in between. She was treated for STI at the age of 16. Which of the ff In this pt is a contraindication to a progestin releasing intrauterine device?

• prior STI
• menstrual bleeding pattern

Answer 23

menstrual bleeding pattern

• IUD Placement ( hormonal or non-hormonal) in pts with unexplained AUB can mask sxs n delay Dx. Therefore pts require further Ix ( pelvic us, STI, endometrial biopsy) before IUD
• active infection, not previous STI is a contraindication

Question 24

The stronger risk factor for breast ca from family hx in a second degree relative and chronological age is?

Answer 24

Chronological age. >=50 yr carries high risk

Question 25

An 18yr old obese female comes with heavy uterine bleeding and sxs of acute blood loss. She undergoes emergency dilation n curettage and bleeding resolves. Biopsy shows endometrial hyperplasia without atypia. The best next step in the mx is?

Answer 25

Progestin therapy eg. Progestin releasing IUD- to counteract estrogen effect

Question 26

A 42 year old comes with left breast swelling, pain worsened over the past month. A month ago she was diagnosed with mastitis for which she took abx. VS r normal. Left breast is diffusely warm and erythematous with some dimpling. The most likely dx?

Answer 26

Inflammatory breast carcinoma
Edematous, erythematous, painful, peau d’orange ( eg superficial dimpling, fine pitting.
- mammography, u/s, biopsy

Question 27

A 54 yr old woman comes with involuntary loss of urine n dribbling. She has had repeated UTI episodes. P/E - 2cm tender anterior vaginal mass is palpable n causes expression of a bloody discharge at the urethral meatus
Most likely Dx is?

Answer 27

Urethral diverticulum( localized outpouching of the urethral mucosa). 
Recurrent UTI-> inflammation-> outpouching 
- when the diverticulum gets infected-> tender, purulent, bloody urethral discharge

Question 28

The single most important prognostic factor in breast ca is?

Answer 28

Tumor burden which is based on TNM staging

Question 29

Initial evaluation of acute urinary retention in an elderly pt includes?

Answer 29

Consider reversible causes first especially if new onset. Fever may not be present with UTI ; initial evaluation should include URINALYSIS with CULTURE