Gyn (Blueprints)

Question 1

40yo woman (pre-menopausal) presents with chronic shiny purple papules with white striae on the inner aspects of labia minora and vagina. She has similar lesions on extensor surfaces of body. Dx? Rx?

Answer 1

Lichen planus. Rx: vaginal hydrocortisone suppositories

NTBCw/ lichen sclerosus typical in post-menopausal women, tend to also have itching and white atrophic labia.

Question 2

41yo patient presents with a cyst-like mass at the vaginal orifice at the 4-o’clock position (posteriolateral). She doesn’t complain of any symptoms though it has been increasing in size. Diagnosis? Rx? What if she was symptomatic?

Answer 2

Bartholin’s duct cyst (these ducts located at 4 and 8 o’clock positions).
Rx: Biopsy to r/o cancer (if over 40yo). Often resolves on its own, suggests sitz baths.
Symptomatic: Be wary as these can become infected and become abscesses (patient will be symptomatic). Rx: I&D + wood catheter placement. Avoid Abx unless Neisseria gonorrhea culture positive

Question 3

3 types of leiomyomas? Most common? Strongly associated with heavy bleeding?

Answer 3

Types (from outside to inside): subserosal, intramural, submucosal.
Intramural most common. Submucosal most associated with heavy & prolonged bleeding

Question 4

HPV serotypes associated with cervical cancer? Genital warts?

Answer 4

Cancer: HPV 16, 18, 31.
Warts: HPV 6, 11. No need to test for more dangerous strains in patients with warts….it’s probably not HPV 16, 18, 31

Question 5

Young patient presents with vessicles, burrows, and excoriated patches of skin in pubic hair region. Diagnosis? Rx?

Answer 5

Phthirus pubis (Pediculosis).  Very similar to Sarcoptes scabiei (Scabies)
Rx: permethrin cream over affected area (Pediculosis) or over entire body (Scabies)

Question 6

Young patient presents who had recently been on broad-spectrum antibiotics with decreased vaginal discharge, pruritis, and pain/discomfort during sex. Exam reveals vulvar edema and erythema. KOH prep of discharge reveals branching hyphae & spores. Dx? Rx?

Answer 6

Dx: candidiasis (yeast infection). Remember they get itchy!
Rx: any of the azoles topical or oral. (Oral fluconazole one dose is really good option)

Question 7

Patient presents with increased vaginal discharge recently that is malodorous. On exam the copious discharge is yellow to green, frothy, with pH: 6-7, and there is vulvar erythema & edema. The cervix has small punctate epithelial papillae. Diagnosis? Confirmatory test? Cervix finding? Rx?

Answer 7

Trichomonas vaginalis.  Confirm with wet-prep (70% sensitive) and/or culture (definitive)
Strawberry cervix (characteristic, tho present in only 10% of time)
Rx: metronidazole PO 2g once.  You must treat the sex partner too! (Less than BV regimen).

Question 8

Treatment of severe endomyometritis? Common cause of endomyometritis? Diagnostic finding?

Answer 8

Rx: clindamycin + gentamicin
Cause: instrumentation of uterus (e.g. D&C, C-section) or retained POC
Dx: endometrial biopsy showing plasma cells

Question 9

20 something patient presents with fever and unilateral adnexa pain. They have a history of bangin a lotta dudes unprotected and does not do STI testing regularly. On exam you elicit cervical motion tenderness. Finally she adds that she’s been having right upper quadrant pain as well. Diagnosis? Rx?

Answer 9

Pelvic inflammatory disease from an STI (e.g. chlamydia, gonorrhea, etc)
Fitzhugh-Curtis syndrome: perihepatitis caused from PID
Rx: hospital admission, IV abx broad spectrum cephalosporin + doxycycline for 14days after hospital stay

Question 10

General approach to treating a pregnant woman with HIV

Answer 10

HAART therapy starting in 2nd trimester (avoid 1st trimester exposure to fetus if possible), given during labor, and given to the newborn as well
C-section is only effective with viral loads >1k. Otherwise not necessary

Question 11

Definition of premature ovarian failure

Answer 11

Onset of menopause before age 40.

Menopause defined as 12months amenhorrhea usually accompanied by vasomotor symptoms

Question 12

Class of drugs (etidronate, alendronate, risedronate) and their utility?

Answer 12

Bisphosphanates used in the prevention & treatment of osteoporosis

Question 13

52yo woman with recent onset menopause complains of recurrent hot flashes that are debilitating. She would like a medication to treat her hot flashes, but is hesitant to use hormone replacement therapy b/c she knows it may be dangerous if used for >12mos. Options?

Answer 13

Clonidine, SSRIs (e.g. paroxetine), and SNRIs (e.g. venlafaxine).
Don’t ask me why paroxetine is an option….terrible drug

Question 14

Definition of amenorrhea primary and secondary?

Answer 14

Primary: failure of onset of menses by age 16 or 4 years after thelarche (breast bud development)
Secondary: absence of menses for 3mos

Question 15

Amenorrhea patient diagnosed with savage syndrome. Pathophysiology?

Answer 15

Ovaries are insensitive to FSH & LH and thus don’t develop follicles nor estrogen

Question 16

Only congenital disease of interest to you with hypogonadotropic hypogonadism associated with anosmia (inability to smell/absent olfactory bulbs)?

Answer 16

Kallmann syndrome

Question 17

Young patient diagnosed with primary amenorrhea. They show breast development but ultrasound reveals no uterus, undescended testes, and karyotype analysis reveals 46 XY. Diagnosis?

Answer 17

Testicular feminization AKA androgen insensitivity

Be aware they can have breast development!

Question 18

Patients with polycystic ovarian syndrome (PCOS) are at increased risk for what cancer and why?

Answer 18

Endometrial cancer. PCOS patients have elevated estrogen (and androgen) levels. Unopposed estrogen causes endometrial hyperplasia → cancer
Remember all these follicles secrete estrogen! Patients are still naturally anovulatory because of cocontaminant abnormal LH/FSH ratio (commence “hand-wave”)

Question 19

Patient presents with nipple discharge and is diagnosed with hyperprolactinemia. Subsequent imaging (brain MRI) reveals a macroadenoma. Bromocriptine therapy is initiated. Mechanism?

Answer 19

Bromocriptine is a dopamine agonist which can be used to shrink some prolactinomas. Remember dopamine naturally inhibits prolactin production (hence why dopamine antag from resperidone causes hyperprolactinemia)

Question 20

27yo woman complains of issues of irritability, mood swings, and fatigue severe enough to impair her ability to complete her work. This happens around the same time every month in the days before her period. Diagnosis? FDA approved treatment?

Answer 20

Premenstrual syndrome. Must have occurred with at least 2 menstrual cycles.
Fluoxetine (SSRI, Prozac) is only FDA approved Rx specifically for premenstrual dysphoric disorder (more severe form of PMS)

Question 21

A patient with regularly timed menstruation that lasts for >7days, soaks through 1+pad/hour or >80mL total in a cycle is said to have what?

Answer 21

Menorrhagia (pay attention to the cutoffs/criteria)

Question 22

Women with hypertension, thrombophilia, history of DVT or PE, and women >35yo who also smoke. In this group of women, what pharmacotherapy is contraindicated?

Answer 22

Any estrogen containing oral contraceptive pills, as they increase the risk for thromboembolism and HTN (Progesterone mini-pills are okay)

Question 23

62yo woman presents to clinic with complaint of vaginal bleeding. Her last menstrual cycle was over a decade ago. What are two most common causes of her bleeding? What would be a reassuring measurement on ultrasound of her endometrial stripe?

Answer 23

Post-menopausal bleeding caused by: 1)vaginal atrophy (vaginal mucosa becomes very thin and easily traumatized) or 2)exogenous hormone usage (think hormone replacement therapy for vasomotor symptoms).
Stripe of 3cm or less is considered normal in a post-menopausal woman

Question 24

FYI, mechanism of hyperadrogenism in PCOS

Answer 24

Remember PCOS has elevated LH/FSH ratio
LH stimulates theca cells in the ovaries to produce androgens (androstenedione & testosterone), and FSH stimulates granulosa cells to aromatise androgens to estrone & estriol. Thus too much LH relative to FSH causes excess androgens

Question 25

22yo woman presents with oligomenorrhea. The only labwork you have for her indicates an LH:FSH ratio > 3:1 an hemoglobin A1c = 7.0. Most likely diagnosis?

Answer 25

Polycystic ovarian syndrome (PCOS). Remember, LH:FSH ratio > 3 is pretty much diagnostic

Question 26

22yo woman presents with 3 missed periods and increasingly concerning signs like facial hair and hair on inner thighs. She was regular up until recently. Urine preg test is negative and an ultrasound reveals an ovarian cyst. What type of cyst is this most likely?

Answer 26

Theca lutein cysts. Theca cells of ovaries produce androgens in response to LH, and thus can create this picture of hyperandrogenism.

Question 27

Sex hormone binding globulin (SHBG) plays what function and is affected by what kind of hormones?

Answer 27

SHBG binds mainly testosterone, decreasing its effects (free testosterone is the active form)
SHBG levels are decreased in response to circulating androgens and corticosteroids in PCOS, and CAH, causing a vicious cycle.

Question 28

Female patient presents with clear hirsutism/virilization. What are two most likely sources for responsible hormones? Blood work to distinguish them?

Answer 28

Adrenal or ovarian sources of androgens. If DHEAS levels elevated, suggests adrenal source → image adrenals (abdominal CT) and suspect cushings or CAH
If DHEAS is normal or minimally elevated ovarian source of androgens is likely (e.g. PCOS). Ultrasound ovaries

Question 29

Complete molar pregnancy can be associated with thyroid abnormalities. What are they, what’s the pathogenesis?

Answer 29

Hyperthyroidism (high T3,T4) with a low/normal TSH. Complete moles produce high levels of HCG. The alpha subunit of HCG is the same as found in TSH, FSH, and LH.
Thus high HCG stimulates the thyroid like TSH resulting in negative feedback and normal or low TSH

Question 30

24yo female presents at 9 weeks gestation by last menstrual period. She has noted vaginal bleeding, BP 150/100, visual disturbances (e.g. scotoma), and a headache refractory to NSAIDs. Urine dipstick reveals protein/creatinine ratio > 0.3. Diagnosis?

Answer 30

Molar pregnancy! Note that preeclampsia appearing during the 1st trimester is pathognomonic for molar pregnancy!
By definition preeclampsia must occur after 20weeks gestation

Question 31

FYI: molar pregnancies (even after hysterectomy as treatment) have a high risk for persistence or recurrence.

Answer 31

Up to 25% of complete moles will have persistent disease after dilation and curettage.
HCG levels should be followed closely for resolution after D&C initially weekly then monthly for up to 6mos afterward

Question 32

Most common karyotype for partial and complete moles?

Answer 32

Complete moles: 46,XX from empty ovum fertilized by single X sperm and subsequent duplication. No genetic material from mother
Partial moles: 69,XXY (triploid) from normal X ovum fertilized by one X, one Y sperm. Remember these guys often have normal HCG levels!

Question 33

Woman with previous diagnosis of molar pregnancy 3mos ago was treated with D&C. Since then her HCG levels have been serially followed and in the last 2 weeks have begun climbing again. She has been on birth control on strict orders from her doc and is not pregnant (to her knowledge). U/s reveals intrauterine recurrence of persistent mole. Rx?

Answer 33

Methotrexate is usually good for persistent mole. This question highlights the importance of serial HCG follow-up after molar pregnancy, and strict contraception so the HCG is meaningful

Question 34

27yo woman with previous molar pregnancy last year presents with abnormal uterine bleeding. She also complains of hemoptysis. Imaging and endometrial biopsy reveal sheets of anaplastic cytotrophoblasts and syncytiotrophoblasts in the absence of chorionic villi. CXR reveals lung lesions. Diagnosis? Rx?

Answer 34

Choriocarcinoma (which can occur a while after molar or non-molar pregnancies) with lung metastasis
Rx: multi-agent chemotherapy (that may include methotrexate)

Question 35

FYI: Cervical intraepithelial neoplasia (CIN) I - III refers to which third of the epithelilal layer of the cervix shows abnormal/premalignant cells on histology (which is indicated after abnormal cytology from pap smear)

Answer 35

CIN III has premalignant cells on the entire thickness of the epithelium

Question 36

FYI: general approach to abnormal pap smears (ASC-US, ASC-H, LSIL, HSIL, SCC)

Answer 36

Atypical squamous cells of unknown significance, and possible high grade (ASC-US, ASC-H) → HPV testing → colposcopy and biopsy if HPV positive
Low-grade & high-grade squamous intraepithelial lesions (LSIL, HSIL) → colposcopy & cervical biopsy
Squamous cell carcinoma (SCC) → cut it out!

Question 37

24yo woman presents for her 2nd pap smear (1st one at 21 was normal). Cytology reveals atypical squamous cells of unknown significance (ASC-US). Subsequently a HPV test comes back positive. We then proceed to colposcopy and biopsy. Histology (NTBCw/ cytology) reveals cervical intraepithelial neoplasia I (CIN-I). Next step?

Answer 37

Close follow-up with pap smears every 6mos for a year. Note that CIN-I does not require a LEEP/cone procedure unless it persists for a year! But CIN-II and CIN-III definitely do