FINALS GYNE Flashcards

Question

Question: A 30-year-old G0 complained of severe right hypogastric pain 1 day before consultation. She has a history of missed menses of a few days and is on Day 26 of her cycle. Serum β-hCG is within the non-pregnant level. There were no other symptoms. Pertinent PE revealed that the cervix is closed and firm, and the uterus is not enlarged. There were no adnexal masses, but tenderness was present on deep palpation. What is your diagnosis? A. Ectopic Pregnancy B. Ruptured Corpus Luteum Cyst C. Adnexal Torsion D. Endometrioma

Answer 1

B. Ruptured Corpus Luteum Cyst Rationale: A ruptured corpus luteum cyst can present with acute pelvic pain around the luteal phase (Day 26), especially in non-pregnant women. The absence of adnexal masses and a negative β-hCG make ectopic pregnancy unlikely.

Answer 2

C. 16 and 18 Rationale: HPV types 16 and 18 are the most oncogenic and responsible for the majority of cervical cancer cases. HPV 6 and 11 are associated with genital warts rather than malignancy.

Answer 3

B. Wolffian duct Rationale: Gartner duct cysts arise from remnants of the Wolffian duct, which normally regresses in females but may persist as cystic structures in the lateral vaginal wall.

Answer 4

A. Breast budding, pubic hair, growth spurt, menarche Rationale: The typical sequence of female puberty is thelarche (breast budding) → pubarche (pubic hair growth) → growth spurt → menarche. Menarche usually occurs around Tanner stage 4.

Answer 5

A. Obesity and Dyslipidemia Rationale: The Rotterdam criteria for PCOS diagnosis require two out of three: (1) Hyperandrogenism, (2) Oligo/anovulation, and (3) Polycystic ovaries on ultrasound. Obesity and dyslipidemia are common but not diagnostic criteria.

Answer 6

D. Upper 2/3 of the vagina Rationale: The Müllerian (paramesonephric) duct gives rise to the fallopian tubes, uterus, and upper 2/3 of the vagina. The urogenital sinus contributes to the lower 1/3 of the vagina.

Answer 7

C. Topical estrogen cream Rationale: Labial adhesions in prepubertal girls are usually asymptomatic and resolve spontaneously. If symptomatic, topical estrogen cream is first-line therapy to separate the adhesion non-surgically.

Answer 8

B. Days 14-28 Rationale: The secretory phase occurs after ovulation (Days 14-28) and is dominated by progesterone, which prepares the endometrium for implantation.

Answer 9

D. Punch biopsy Rationale: The figure-8/hourglass pattern is characteristic of lichen sclerosus, a chronic inflammatory skin disorder. Punch biopsy is diagnostic to rule out malignancy or other dermatoses.

Answer 10

A. Negative for 3 receptors: HER2, estrogen, progesterone Rationale: Triple-negative breast cancer (TNBC) lacks estrogen receptor (ER), progesterone receptor (PR), and HER2 expression. It is an aggressive subtype with limited targeted treatment options.

Answer 11

A. Stage 0 Rationale: According to the International Continence Society (ICS) Pelvic Organ Prolapse Quantification (POP-Q) system, Stage 0 indicates no prolapse, and all measured reference points remain in their normal anatomic positions. The key points in this system are: • Aa and Ap: Points on the anterior and posterior vaginal walls, respectively, located 3 cm proximal to the hymen. • Ba and Bp: The most distal points of the anterior and posterior vaginal walls, respectively. When Aa, Ap, Ba, and Bp are all measured at -3 cm, it means they are all positioned 3 cm above the hymenal ring, which reflects normal anatomy without any descent or prolapse. In POP-Q: • Stage 0 = No prolapse; all points are at -3 cm • Stage I = Most distal portion of the prolapse is >1 cm above the hymen • Stage II = Within 1 cm above or below the hymen • Stage III = More than 1 cm beyond the hymen but not complete eversion • Stage IV = Complete vaginal eversion Since all the relevant points are at -3 cm, this matches the criteria for Stage 0, confirming no prolapse is present. Correct answer: A. Stage 0

Answer 12

C. 4-5 Rationale: Anti-Müllerian Hormone (AMH) declines before menopause and becomes undetectable about 4-5 years before menopause, making it a useful predictor of ovarian reserve and reproductive lifespan.

Answer 13

C. Presence and number of axillary node metastasis Rationale: The number of axillary lymph nodes involved is the most powerful prognostic factor in breast cancer, as lymph node metastasis increases the risk of systemic spread.

Answer 14

D. 6.5 - 7.5 Rationale: In prepubertal girls, the vaginal pH is neutral to slightly alkaline (6.5 - 7.5) due to low estrogen levels, which limit lactobacilli proliferation.

Answer 15

A. Uterine didelphys Rationale: Uterine didelphys occurs due to complete failure of Müllerian duct fusion, resulting in two uteri and two cervices.

Answer 16

B. Using Male Privilege Rationale: Using male privilege is a form of abuse where a partner exerts dominance by making all major decisions, treating the woman as subordinate.

Answer 17

B. B3, PH3 Rationale: Tanner Stage 3 involves breast contour separation (breast mound enlargement beyond areola) and coarse, dark pubic hair extending over the pubic area.

Answer 18

D. Physical Abuse Rationale: Physical abuse involves intentional bodily harm (e.g., slapping, head-banging, and throwing). It is the most recognizable form of domestic violence.

Answer 19

B. Lichen simplex chronicus Rationale: Lichen simplex chronicus is a chronic inflammatory skin condition due to repetitive scratching, leading to thickened, leathery skin with erythema.

Answer 20

D. 2:1 Rationale: In prepubertal girls, the cervix is twice the size of the uterine corpus (2:1 ratio). This changes at puberty when the uterine body enlarges.

Answer 21

A. Ovaries Rationale: Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) results in absent uterus, fallopian tubes, and upper vagina but normal ovaries because the ovaries derive from the gonadal ridge, not the Müllerian ducts.

Answer 22

A. Non-specific vulvovaginitis Rationale: Non-specific vulvovaginitis is the most common cause in prepubertal girls due to poor hygiene, irritants, or lack of estrogen, leading to susceptibility to infections.

Answer 23

A. Cystocele Rationale: Cystocele is the most common pelvic organ prolapse, where the bladder herniates into the anterior vaginal wall due to weakened pelvic support.

Answer 24

D. Stage IV Rationale: Stage IV pelvic organ prolapse occurs when the prolapsed organs completely evert beyond the total vaginal length.

Answer 25

A. Transabdominal ultrasound Rationale: A full bladder helps displace the intestines and serves as an acoustic window for better visualization of pelvic structures in transabdominal ultrasound.

Answer 26

B. Mayer-Rokitansky-Küster-Hauser syndrome Rationale: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital condition characterized by Müllerian agenesis (absent uterus and upper vagina) in a phenotypically normal XX female with normal ovarian function.

Answer 27

B. The life span of the corpus luteum is limited to a period of about 14 days Rationale: The corpus luteum produces progesterone to maintain the endometrium for implantation. If fertilization does not occur, it degenerates after ~14 days, leading to a drop in progesterone and the onset of menstruation.

Answer 28

A. Absent right kidney Rationale: Unicornuate uterus is due to incomplete Müllerian duct development and is frequently associated with renal anomalies, particularly renal agenesis on the same side as the missing uterine horn.

Answer 29

B. Plateau Phase Rationale: During the plateau phase, the clitoris retracts under the clitoral hood and becomes highly sensitive in preparation for orgasm.

Answer 30

C. Bisphosphonates Rationale: A T-score ≤ -2.5 confirms osteoporosis, and bisphosphonates (e.g., alendronate, risedronate) are first-line treatment for postmenopausal osteoporosis by inhibiting bone resorption.

Answer 31

B. The couple can start an infertility work-up anytime Rationale: In women ≥35 years old or with known risk factors (e.g., endometriosis), an infertility work-up is recommended after 6 months of unprotected intercourse instead of the standard 12 months.

Answer 32

B. Plateau Phase Rationale: Breast enlargement and areolar swelling occur during the plateau phase as part of increased blood flow and arousal.

Answer 33

D. Nucleic acid amplification test (NAAT) Rationale: Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis (serovars L1, L2, L3) and is best diagnosed with NAAT, the most sensitive test for chlamydial infections.

Answer 34

B. Squamous Cell Carcinoma Rationale: Squamous cell carcinoma (SCC) accounts for ~80-90% of cervical cancers and is strongly associated with HPV infection, particularly types 16 and 18.

Answer 35

B. Mayer-Rokitansky-Küster-Hauser Syndrome Rationale: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is due to Müllerian agenesis, leading to congenital absence of the uterus and upper vagina while maintaining normal ovarian function and secondary sexual characteristics.

Answer 36

D. Upper and middle 1/3 of the vagina Rationale: A transverse vaginal septum results from partial failure of canalization and is most commonly found at the junction of the upper and middle third of the vagina, leading to primary amenorrhea and hematocolpos.

Answer 37

A. Uterine didelphys Rationale: Complete failure of Müllerian duct fusion leads to uterine didelphys, resulting in two separate uteri and two cervices, often associated with vaginal septa.

Answer 38

C. Osteopenia Rationale: A T-score between -1.0 and -2.5 indicates osteopenia, a condition of low bone mass that increases fracture risk but does not yet meet the criteria for osteoporosis (T-score ≤ -2.5).

Answer 39

C. Genital herpes Rationale: Genital herpes, caused by HSV-2, presents with painful vesicles and ulcers on an erythematous base that cluster together, often associated with tender inguinal lymphadenopathy.

Answer 40

C. Vaginal adenosis Rationale: Vaginal adenosis is the presence of glandular columnar epithelium in the vagina instead of normal squamous epithelium. It is a precursor for clear cell adenocarcinoma, strongly linked to in utero exposure to DES.

Answer 41

D. Hymen Rationale: The urogenital sinus gives rise to the hymen, lower 1/3 of the vagina, bladder, urethra, and external genitalia, while the Müllerian ducts form the uterus, fallopian tubes, and upper vagina.

Answer 42

B. B4 and PH5 Rationale: Tanner Stage 4 (B4) is characterized by secondary mound formation of the areola and papilla. Tanner Stage 5 (PH5) is defined by pubic hair extending onto the inner thighs.

Answer 43

D. Granulosa-theca cell tumor Rationale: Granulosa-theca cell tumors are sex cord-stromal tumors that secrete estrogen, causing precocious puberty or abnormal uterine bleeding.

Answer 44

B. T helper cells Rationale: HIV primarily infects CD4+ T helper cells, leading to immune system dysfunction and increased susceptibility to opportunistic infections.

Answer 45

A. 12% Rationale: The average lifetime risk of breast cancer in women with no significant risk factors is approximately 12% (1 in 8 women).

Answer 46

A. A patient who discloses to his doctor a plan to commit murderous acts on her relatives and neighbors Rationale: Confidentiality may be broken if a patient poses a serious threat to others (e.g., planned homicide or violence), aligning with the Tarasoff ruling on the duty to warn.

Answer 47

D. Sexual abuse Rationale: STIs (e.g., Trichomonas, Chlamydia) in prepubertal children are highly suspicious for sexual abuse and require mandatory reporting.

Answer 48

C. Hormone/estrogen therapy may lead to plaque destabilization and thrombosis Rationale: Estrogen therapy in postmenopausal women with established cardiovascular disease increases thrombotic risk and is not recommended.

Answer 49

A. FSH 50 mIU/L Rationale: Menopause is confirmed by an FSH level >40 mIU/L, as decreased estrogen production leads to loss of negative feedback on FSH.

Answer 50

B. 46,XX Rationale: Müllerian agenesis (MRKH syndrome) presents with a normal 46,XX karyotype, normal ovaries, and absent uterus.

Answer 51

C. Müllerian agenesis Rationale: Müllerian agenesis (MRKH syndrome) is due to Müllerian duct failure, resulting in absent uterus and upper vagina, but normal ovarian development.

Answer 52

D. BRCA1 and BRCA2 gene mutation testing Rationale: The triple test for breast mass evaluation includes: Clinical breast exam Imaging (Mammography or Ultrasound) Tissue sampling (Biopsy or Fine Needle Aspiration Cytology - FNAC) BRCA testing is only indicated in high-risk patients.

Answer 53

C. Principle of Beneficence Rationale: Beneficence refers to acting in the patient’s best interest, including providing life-saving treatment in emergencies under implied consent when the patient cannot consent.

Answer 54

A. Abnormal uterine bleeding - Polyp Rationale: Endometrial polyps are a common cause of abnormal uterine bleeding (AUB) and appear as hyperechoic masses in the endometrial cavity on ultrasound.

Answer 55

D. Principle of Double Effect Rationale: The Principle of Double Effect applies when a necessary medical treatment (hysterectomy for cancer) has an unintended but foreseen negative consequence (loss of pregnancy).

Answer 56

B. Letrozole Rationale: Letrozole (an aromatase inhibitor) is first-line therapy for ovulation induction in PCOS-related infertility, as it has a higher ovulation and pregnancy success rate compared to clomiphene citrate.

Answer 57

C. Size of breast mass Rationale: Tumor size is the most important predictor of axillary lymph node involvement, with larger tumors having a higher risk of lymphatic spread.

Answer 58

D. Spirochete Rationale: Treponema pallidum, a spirochete, is the causative agent of syphilis and is transmitted sexually or via vertical transmission.

Answer 59

A. Western Blot Test Rationale: The Western Blot Test is more specific than ELISA for detecting HIV antibodies and is used for confirmation of HIV infection.

Answer 60

C. Rectocele Rationale: Rectocele occurs when the rectum bulges into the posterior vaginal wall due to weakened pelvic support, causing difficulty with defecation.

Answer 61

B. Inguinal lymph nodes Rationale: Vulvar squamous cell carcinoma primarily metastasizes to the inguinal lymph nodes, as the vulva drains into the superficial inguinal nodes.

Answer 62

D. All of the above Rationale: In cases where a patient is incapacitated, the spouse, legal guardian, or parents may serve as proxy decision-makers based on legal and ethical guidelines.

Answer 63

C. Adenomyosis Rationale: Adenomyosis is a globular uterine enlargement due to ectopic endometrial glands in the myometrium, causing heavy, painful menstrual bleeding (AUB-HMB).

Answer 64

C. Myoma with carneous degeneration Rationale: Carneous (red) degeneration of a myoma occurs in pregnancy due to vascular compromise, leading to acute pain without contractions.

Answer 65

B. Day 3-5 of menses Rationale: Hysteroscopy is best performed during the early proliferative phase (Day 3-5) when the endometrial lining is thinnest, providing better visualization of the uterine cavity.

Answer 66

C. XY karyotype Rationale: Müllerian agenesis (MRKH syndrome) occurs in 46,XX females and presents with absent uterus and upper vagina but normal ovarian function and secondary sexual development. XY karyotype would suggest Androgen Insensitivity Syndrome (AIS) instead.

Answer 67

D. Hysteroscopy Rationale: A history of multiple D&Cs with decreasing menstrual flow and indistinct endometrial stripe suggests Asherman syndrome (intrauterine adhesions). Hysteroscopy is the gold standard for diagnosis.

Answer 68

D. Principle of Justice Rationale: The Principle of Justice emphasizes fair and equitable distribution of healthcare resources without discrimination.

Answer 69

A. Insulin resistance Rationale: Insulin resistance is the underlying driver of PCOS, contributing to hyperinsulinemia, ovarian androgen excess, and anovulation.

Answer 70

B. Karyotyping Rationale: Karyotyping is crucial for determining genetic sex and guiding gender assignment in cases of ambiguous genitalia.

Answer 71

C. Intrauterine adhesions Rationale: A history of miscarriages, D&Cs, and C-section increases the risk of Asherman syndrome (intrauterine adhesions), leading to secondary amenorrhea.

Answer 72

A. Sheehan’s syndrome Rationale: Sheehan’s syndrome is pituitary infarction due to postpartum hemorrhage, leading to hypopituitarism and menstrual irregularities (hypomenorrhea, amenorrhea).

Answer 73

D. Enterocele Rationale: Enterocele (herniation of the small bowel into the vaginal vault) can occur after hysterectomy due to loss of uterine support. Incorporating the uterosacral ligaments into the vault repair helps prevent this.

Answer 74

C. Ovarian Torsion Rationale: Ovarian torsion presents with sudden severe unilateral lower abdominal pain. A pre-existing ovarian mass (e.g., dermoid cyst) increases the risk of torsion, which is a surgical emergency.