Gynecology

Question 1

What is the most common cause of preventable infertility in the United States?

Answer 1

PID

Question 2

What is the most likely cause of infertility in a normally menstruating woman younger than age 30 years?

Answer 2

PID

Question 3

What is PID? How do you recognize it?

Answer 3

ascending STI of the upper female genital tract that may involve the

• endometrial cavity (endometritis)
• fallopian tubes (salpingitis)
• ovaries (oophoritis)
• parametrial tissues/ligaments (parametritis)
• peritoneal cavity (peritonitis)

Look for female aged 13 to 35 years with the following symptoms:

1. abdominal pain,
2. adnexal tenderness,
3. cervical motion tenderness.

All three criteria must be present! In addition, one or more of the following should be present: elevated ESR/CRP, leukocytosis, fever, or purulent cervical discharge.

Question 4

How is PID treated?

What are the common sequelae and how are these managed?

Answer 4

Treat PID to cover multiple organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis (most common organisms).

Outpatient: ceftriaxone + doxycycline

Inpatient: cefoxitin or cefotetan + doxycycline to cover multiple organisms

Sequelae:

• infertility caused by scarring of the fallopian tubes
• progression to tuboovarian abscess that may rupture (palpable with exam, may respond to antibiotics alone)

Question 5

Define endometriosis.

What age group does it usually present in and what are the symptoms and signs?

Answer 5

ectopic endometrial glands (usually in the ovaries, broad ligament, peritoneal surface)

usually nulliparous and > 30 yo with the following symptoms:

• dysmenorrhea (painful menstruation)
• dyspareunia (painful intercourse)
• dyschezia (painful defecation) perimenstrual spotting

Question 6

How is endometriosis diagnosed and treated?

Answer 6

laparoscopy with visualization of the endometriosis (gold standard)

treatment:

• birth control pills (1st line)
• danazol and GnRH agonist (leuprolide)
• surgery + cautery
• TAH+BSO (in older patients)

Question 7

What is the most likely cause of infertility in a menstruating woman older than age 30 without a history of PID?

Answer 7

Endometriosis

Question 8

specify the findings and treatment for Candida

Answer 8

Findings: “Cottage cheese” appearance; pseudohyphae seen on KOH preparation; history of diabetes, antibiotic treatment, or pregnancy

Trmt: Topical or oral antifungal

Question 9

specify the findings and treatment for Trichomonas vaginalis

Answer 9

Findings: Trichomonads can be seen swimming under microscope; pale green, frothy, watery discharge; “strawberry” cervix

Trmt: Metronidazole

Question 10

specify the findings and treatment for Gardnerella vaginalis

Answer 10

Findings: Malodorous discharge; fishy smell on KOH preparation; clue cells

Trmt: Metronidazole

Question 11

specify the findings and treatment for HPV

Answer 11

Findings: Venereal warts, koilocytosis on Pap smear

Trmt: Many (acid, cryo therapy, laser, podophyllin)

Question 12

specify the findings and treatment for herpes

Answer 12

Findings: Multiple shallow, painful ulcers; recurrence and resolution

Trmt: Acyclovir, valacyclovir

Question 13

specify the findings and treatment for Syphilis (stage 1)

Answer 13

Findings: Painless chancre, spirochete on dark- field microscopy

Trmt: Penicillin

Question 14

specify the findings and treatment for Syphilis (stage 2)

Answer 14

Findings: Condyloma lata, maculopapular rash on palms, serology

Trmt: Penicillin

Question 15

specify the findings and treatment for Chlamydia trachomatis

Answer 15

Findings: Most common STD; dysuria, positive culture and antibody tests

Trmt: Doxycycline or azithromycin*

• ^{*Chlamydia can be treated with erythromycin if the patient is pregnant.}
• ^{If compliance is an issue (alcoholic, drug abuse, homeless, or unreliable patient), give azithromycin 1 g orally in a single dose so that you can watch the patient take it.}
• ^{Patients with gonorrhea should be treated for presumed chlamydial co-infection (but the opposite is not true).}

Question 16

specify the findings and treatment for Neisseria gonorrhoeae

Answer 16

Findings: Mucopurulent cervicitis; gram-negative bacteria on Gram stain

Trmt: Ceftriaxone

Question 17

specify the findings and treatment for Molluscum

Answer 17

Findings: skin colored, umbilicated papules, intracellular inclusions

Trmt: Curette, cryotherapy, or electrocauterization/ coagulation

Question 18

specify the findings and treatment for Pediculosis

Answer 18

Findings: “Crabs”; look for itching; lice can be seen on pubic hairs

Trmt: Permethrin cream (or malathion)

Question 19

True or false: Patients with gonorrhea usually are treated for presumed chlamydial infection.

Answer 19

True. A common current treatment strategy is to give both ceftriaxone (for gonorrhea) and doxycycline (for chlamydia) together to patients with gonorrhea.

NOTE: the reverse is not true; do not automatically give gonorrhea treatment to patients with chlamydial infection.

Question 20

Define adenomyosis. How does it classically present?

What is the treatment?

Answer 20

endometrial glands within the uterine musculature, resulting in a large boggy uterus

usually present in women >40 yo with dysmenorrhea and menorrhagia

Treatment: D&C first to r/o endometrial cancer. Consider TAH to relieve severe symptoms; GnRH may also relieve symptoms.

Question 21

What are fibroids?

How common are they?

How often do they become malignant?

Answer 21

Fibroids (i.e., leiomyomas) are benign uterine tumors

Most common tumors in women (up to 40% of women have fibroids by age 40 years)

Malignant transformation is rare (<1%).

Question 22

Explain the relationship between uterine leiomyomas and hormones.

How do leiomyomas present?

What is the diagnostic tests and treatment?

Answer 22

Leiomyomas of the uterus are estrogen-dependent; may see rapid growth during pregnancy or use of OCPs and regression after menopause.

may cause infertility, pain, menorrhagia, or metrorrhagia. Anemia due to leiomyoma is an indication for hys- terectomy.

dx: D&C are needed to r/o endometrial cancer in women who present after the age of 35 years.

trmt: surgical/myomectomy can sometimes maintain or even restore fertility; the alternative is hysterectomy.

Question 23

What is the first test to order in any woman of reproductive age with abnormal uterine bleeding?

Answer 23

A pregnancy test.

Question 24

Define dysfunctional uterine bleeding (DUB).

When is it physiologic/most common?

What is the most common non-physiologic cause of DUB?

Answer 24

diagnosis of exclusion - abnormal uterine bleeding not associated with a tumor, inflammation, or pregnancy; up to 70% of cases are associated with anovulatory cycles (unopposed estrogen).

Physiologic after menarche and immediately before menopause

non-physiologic cause PCOS

Question 25

Why is dilation and curettage done in women older than age 35 years with DUB?

What other test should be ordered in all women with DUB (regardless of age)?

Answer 25

to r/o endometrial cancer

order H/H (or CBC) to ensure that the patient is not anemic from excessive blood loss

Question 26

What causes DUB other than PCOS?

How is DUB treated?

Answer 26

infections, endocrine disorders (thyroid, adrenal, pituitary/prolactin), coagulation defects, and estrogen-producing neoplasms

In the absence of treatable pathology:

• NSAIDs (1st-line agents) for DUB and dysmenorrhea
• OCP (1st-line agents) for menorrhagia and DUB if pt does not desire pregnancy and menstrual cycles are irregular
• Monotherapy with progesterone for severe bleeding

Question 27

Define PCOS. How do you recognize it (exam and lab)

Answer 27

endocrine imbalance characterized by androgen excess; LH to FSH > 2:1

enlarged ovaries with multiple peripherally oriented cysts seen on US

watch for an overweight woman who has acne, hirsutism, amenorrhea, and/or infertility.

Question 28

What is the most likely cause for infertility in a woman younger than 30 years with abnormal menstruation?

Answer 28

PCOS

Question 29

How is PCOS treated?

With what risk is it associated?

Answer 29

OCPs or cycilc progesterone

Clomiphene to induce ovulation

Spironolactone to treat hirsutism.

Metformin to treat insulin resistance and to help restore ovulation

Chronic unopposed estrogen (i.e., not enough progesterone; hence, infrequent menses) increases the risk of endometrial cancer.

Question 30

Is infertility usually a male or a female problem?

Answer 30

2/3 of cases are due to a female problem, 1/3 to a male problem.

Question 31

Assuming that the history and physical exam offer no clues, what is the first step in evaluating a couple for infertility?

Answer 31

Semen analysis, which is cheap, easy, and noninvasive

Question 32

List the relevant characteristics of normal semen.

Answer 32

• Ejaculate volume > 1 mL
• Sperm concentration > 20 million/mL
• Initial forward motility > 50% of sperm
• Normal morphology > 60% of sperm

Question 33

What is the next step after semen evaluation?

Answer 33

Documentation of ovulation - history may suggest an ovulatory problem (irregular menstrual cycle length, duration, or amount of flow; lack of premenstrual syndrome symptoms).

Basal body temperature, luteal phase progesterone levels, and/or endometrial biopsy can be done to check for ovulation.

Question 34

What radiologic test is commonly used to examine the fallopian tubes and uterus?

What points in the history may lead you to suspect a uterine or tube problem?

Answer 34

hysterosalpingogram

The history may suggest a tubal problem (PID, previous ectopic pregnancy) or a uterine problem (previous D&C that caused intrauterine synechiae, history of fibroids, or symptoms of endometriosis).

Question 35

What test is the last resort in the work-up for infertility?

Answer 35

Laparoscopy can be done as a last resort or with a history suggestive of endometriosis.

Lysis of adhesions and destruction of endometriosis lesions often restore fertility.

Question 36

Which two medications can be used to restore female fertility?

In what situations are they effective?

Answer 36

clomiphene citrate to induce ovulation, but this approach requires adequate production of estrogen. If the woman is hypoestrogenic, use human menopausal gonadotropin (which is a combination of FSH and LH).

If medications fail, in vitro fertilization can be attempted.

Question 37

What is the main risk associated with medical induction of ovulation?

Answer 37

Multiple gestation pregnancies.

Question 38

Distinguish between primary and secondary amenorrhea.

Answer 38

primary amenorrhea - has never menstruated or had a menstrual period

secondary amenorrhea - used to menstruate but has stopped

Question 39

What is the usual cause of secondary amenorrhea in a previously menstruating woman of reproductive age?

Answer 39

Pregnancy. Always order hCG to rule out pregnancy as the first step in your evaluation of secondary amenorrhea.

Question 40

True or false: Excessive exercise may cause amenorrhea.

Answer 40

True. It results from an exercise-induced depression of GnRH

Question 41

What are other common causes of secondary amenorrhea?

Answer 41

• PCOS
• Anorexia (amenorrhea is required for a diagnosis of anorexia)
• Endocrine disorders (HA, galactorrhea, and visual field defects may indicate a pituitary tumor)
• Antipsychotics (due to increased prolactin)
• Previous chemotherapy (causes premature ovarian failure and menopause)
• Although not considered secondary amenorrhea, menopause should be kept in mind

Question 42

After ruling out pregnancy, if the cause of secondary amenorrhea is not obvious from the history and physical exam, what is the next step in your evaluation?

Answer 42

Administer progesterone to assess the patient’s estrogen status.

• If vaginal bleeding develops within 2 weeks of administering progesterone, the patient has sufficient estrogen. In this case, check the LH level.
  
  • If it is high, consider PCOS.
  • If it is low or normal, check the levels of prolactin and TSH
    
    • high TSH level in hypothyroidism causes high prolactin levels
    • If high prolactin with normal TSH, get a brain MRI to r/o pituitary prolactinoma
    • If normal prolactin, look for low levels of GnRH, which may be induced by drugs, stress, or exercise; in these patients, clomiphene can be used in an attempt to facilitate pregnancy.
• No vaginal bleeding, estrogen levels are inadequate. In this case, check the FSH level
  
  • ​if high FSH, then premature ovarian failure is the problem; check for autoimmune disorders, karyotype abnormalities, and a history of chemotherapy.
  • if low/normal FSH, the problem may be a brain tumor (e.g., craniopharyngioma); get a brain MRI to look for a brain tumor (ie craniopharyngioma); in these patients, clomiphene is ineffective

Question 43

True or false: Pregnancy can present as primary amenorrhea.

Answer 43

True. Always assess the hCG level in the evaluation of any type of amenorrhea.

Question 44

At what age can primary amenorrhea be diagnosed? What is the first step in evaluation?

Answer 44

Primary amenorrhea is diagnosed when a girl has not menstruated by age 16 years. However, patients also should be evaluated in the absence of secondary sexual characteristics by age 14 years OR in the absence of menstruation within 2 years of developing secondary sex characteristics (breast development, axillary and pubic hair).

Question 45

In a patient older than 14 years with no secondary sexual characteristics or development, what is the most likely cause of amenorrhea?

Answer 45

In the presence of normal breast development and a uterus, the first step is to assess the prolactin level to rule out pituitary adenoma.

• If high prolactin, order an MRI scan.
• If normal prolactin, administer progesterone and follow the same procedure as in the evaluation of secondary amenorrhea.

In a phenotypically normal female with normal breast development but no axillary or pubic hair, think of androgen insensitivity syndrome. In such patients, the uterus is absent.

Question 46

When in doubt, what is the best way to evaluate any type of amenorrhea?

Answer 46

First, order a pregnancy test. If it is negative, administer progesterone. Further testing depends on the results of the progesterone challenge (bleeding or no bleeding).

TSH level and/or prolactin level should also be ordered, especially with symptoms of hypothyroidism or pituitary tumor.

Question 47

When does menopause occur?

What are the symptoms and signs?

Answer 47

Average age of menopause: ~51 yo.

Patients have

• irregular cycles or amenorrhea
• hot flashes and mood swings
• elevated FSH level.
• dysuria, dyspareunia
• incontinence
• vaginal itching, burning, or soreness (often are due to atrophic vaginitis; look for the vaginal mucosa to be thin, dry, and atrophic with increased parabasal cells on cytology)
  
  • Topical estrogen improves vaginal symptoms, but other symptoms require oral therapy.

Question 48

What is the current state of hormone replacement therapy?

Answer 48

recommended short-term for the management of moderate-to-severe vasomotor flushing (hot flashes)

Question 49

When a woman presents with a nipple discharge, what historical points are important?

Answer 49

• history of OCPs, hormone therapies, antipsychotic medications or symptoms suggestive of hypothyroidism
• color of the discharge
• if discharge is unilateral or bilateral
  
  • if nipple discharge is bilateral + nonbloody, it is not due to breast cancer, but it may be due a prolactinoma (check prolactin level) or endocrine disorder (check TSH level)
  • If nipple discharge is unilateral + bloody +/- mass, this should raise concern about possible breast cancer. Do a biopsy of any mass if present.

Question 50

What are the 4 most likely causes of a breast mass in a woman younger than age 35 years? What is the general work up or treatment for these?

Answer 50

1. Fibrocystic disease: bilateral, multiple, cystic lesions that are tender to the touch, especially pre-menstrually; most common
   
   • no work-up is needed other than routine follow-up.
   • OCPs, progesterone, or danazol may help relieve symptoms.
2. Fibroadenoma: painless, discrete, sharply circumscribed, unilateral, rubbery, mobile mass; most common benign tumor
   
   • observed for one or more menstrual cycles in the absence of symptoms. Because tumors are estrogen-dependent, pregnancy and OCPs may stimulate growth, whereas menopause causes regression.
   • Excision is curative but not required except for cosmetic reasons.
3. Mastitis/abscess: typically postpartum, lactating women may develop a painful, swollen, erythematous breast; nipple may be cracked or fissured
   
   • treat with analgesics (e.g., acetaminophen, ibuprofen) + antistaphylococcal antibiotic (e.g., dicloxacillin, cephalexin) if symptoms are more than mild; if MRSA(+), use TMP-SMX or clindamycin.
   • If a fluctuant mass develops or there is no response to antibiotics within a few days, an abscess is likely present and must be drained.
   • instruct to continue breastfeeding with the affected breast(s) to prevent further milk duct blockage and abscess formation.
4. Fat necrosis: Patients have a history of trauma in the area of the mass.

Question 51

What are the 5 likely causes of a breast mass in a woman older than age 35 years? How is the management different than that if it were to present in women younger than 35 yo?

Answer 51

1. Fibrocystic disease: bilateral, multiple, cystic lesions that are tender to the touch, especially pre-menstrually; most common
   
   • aspirate cyst fluid + baseline mammography
     
     • if cyst fluid is non-bloody -> reassurance + follow-up
     • if cyst fluid is bloody or cyst recurs quickly -> b
2. Fibroadenoma: painless, discrete, sharply circumscribed, unilateral, rubbery, mobile mass; most common benign tumor
   
   • get a baseline mammogram and observe briefly if mass is small and seems benign clinically and if the woman is premenopausal and has no risk factors for breast cancer
   • do a biopsy (Phyllodes tumors may masquerade as a fibroadenoma)
3. Mastitis/abscess: typically postpartum, lactating women may develop a painful, swollen, erythematous breast; nipple may be cracked or fissured
   
   • treat with analgesics (e.g., acetaminophen, ibuprofen) + antistaphylococcal antibiotic (e.g., dicloxacillin, cephalexin) if symptoms are more than mild; if MRSA(+), use TMP-SMX or clindamycin.
   • If a fluctuant mass develops or there is no response to antibiotics within a few days, an abscess is likely present and must be drained.
   • instruct to continue breastfeeding with the affected breast(s) to prevent further milk duct blockage and abscess formation.
4. Fat necrosis: Patients have a history of trauma in the area of the mass.
5. Breast cancer: nipple retraction +/- peau d’orange in a nulliparous woman with a strong family history. In a woman 35 years old or older, do a biopsy of any mass.

Question 52

True or false: Mammography should be done for any suspicious breast lesion in a woman younger than age 30 years.

Answer 52

False. Mammography is usually not done in women younger than age 30 years because breast tissue is often too dense to discern a mass. If you are suspicious of breast cancer, which is very rare in this age group, proceed to ultrasound imaging or directly to biopsy.

Question 53

True or false: If a patient is postmenopausal or older than age 50 years and a new breast mass develops, you should assume cancer “until proven otherwise.”

Answer 53

True. After menopause, the risk of breast cancer begins to increase sharply, and the incidence of benign disorders begins to decrease sharply. Most benign disorders are caused by reproductive hormones that are present in younger women.

Question 54

True or false: Mammography is best used as a tool to evaluate a palpable breast mass.

Answer 54

False!

Mammography is best used as a tool to detect nonpalpable breast masses (as a screening tool). A suspicious lesion found on mammography should be biopsied, even if it seems benign or is inapparent on physical exam. Additionally, a clinically suspicious mass should be biopsied unless imaging demonstrates unequivocally benign findings (e.g., a cyst).

Question 55

What causes pelvic relaxation or vaginal prolapse?

What are the symptoms and signs?

Answer 55

weakening of pelvic supporting ligaments

Look for a history of several vaginal deliveries, feeling of heaviness or fullness in the pelvis, HA, worsening of sx with standing, and resolution of sx with supine position.

Question 56

What are the 4 types of pelvic relaxation seen clinically and how do they present?

How are they treated?

Answer 56

• Cystocele: bladder bulges into the upper anterior vaginal wall.
  
  • sx: urinary urgency, frequency, and/or incontinence.
• Rectocele: rectum bulges into the lower posterior vaginal wall.
  
  • sx: difficulty with defecation.
• Enterocele: loops of bowel bulge into the upper posterior vaginal wall.
  
  • sx: pulling sensation in pelvs that eases with supine position, feeling of pelvic fullness, low back pain, dyspareunia
• Urethrocele: urethra bulges into the lower anterior vaginal wall
  
  • sx: urinary urgency, frequency, and/or incontinence.

Treatment:

• Conservative management: pelvic strengthening exercises and/or a pessary.
• Surgery for refractory or severe cases or by patient choice.

Question 57

Other than abstinence, what are the most effective forms of birth control (when used properly)?

Answer 57

In order of effectiveness:

• sterilization (e.g., tubal ligation, vasectomy)
• implants (etonogestrel implant)
• intrauterine device
• injectable hormone depot preparations (progesterone)
• birth control pills/patch
• hormonal vaginal ring.

Question 58

Which forms of birth control prevent STDs?

Answer 58

Abstinence and condoms.

Question 59

What are the major problems with intrauterine devices?

Answer 59

increased risk of ectopic pregnancies and PID (watch for Actinomyces spp)

Question 60

What is the classic cause of ambiguous genitalia on the Step 2 exam?

How do these patients usually present?

What are some typical lab findings in these patients?

How are are they treated?

Answer 60

congenital adrenal hyperplasia - 21-hydroxylase deficiency (90% cases).

Girls present as neonates with ambiguous genitalia.

Boys present as neonates with salt-losing adrenal crisis or as toddlers with precocious sexual development.

both usually are hypotensive

Typical lab findings: hyponatremia, hyperkalemia, and elevated 17-hydroxyprogesterone

Treatment: steroids + IVF immediately to prevent death

Question 61

What should you tell the parents of a child with ambiguous genitalia?

Answer 61

Tell the parents the truth: you do not know the child’s gender.

No patient with ambiguous genitalia should be assigned a sex until the work-up is complete. A karyotype must be done.

Question 62

What is indicated by a “bunch of grapes” protruding from a pediatric vagina?

Answer 62

Sarcoma botryoides, a malignant tumor (a type of embryonal rhabdomyosarcoma).

Question 63

Define precocious puberty. What causes it? How should it be treated?

Answer 63

definition: precocious puberty occurs in girls < 8 yo or boys < 9 yo
causes: idiopathic, hormone-secreting tumor (e.g., Leydig cell tumor) or CNS disorder (e.g., hamartoma, astrocytoma)
treatment: treat underlying cause
* If idiopathic - GnRH analog to prevent premature epiphyseal closure and arrest or reverse puberty until an appropriate age

Question 64

What causes vaginitis or discharge in prepubescent girls?

Answer 64

Most cases are nonspecific or physiologic, but look for a

• vaginal foreign body
• sexual abuse (especially if an STD is present)
• candidal infection
  
  • may be a presentation of diabetes; check the serum glucose level and/or the urine for glycosuria

Question 65

How do you recognize and treat an imperforate hymen?

Answer 65

classically presents at menarche with hematocolpos (blood in the vagina) that cannot escape; thus, the hymen bulges outward.

Treatment: surgical opening of the hymen.

Question 66

What is the usual cause of vaginal bleeding in neonates? How is it treated?

Answer 66

usually physiologic and due to maternal estrogen withdrawal.

No treatment is needed because the bleeding resolves on its own.

Question 67

Which women are candidates for hormone replacement therapy?

Answer 67

best used only as a means of symptom relief in women who have weighed the risks and benefits of HRT

Question 68

What are the known benefits of estrogen therapy?

Answer 68

• Decreased osteoporosis and decreased fractures
• Reduced hot flashes and GU symptoms of menopause (dryness, urgency, atrophy-induced incontinence, frequency)
• Decreased risk of colorectal cancer (according to the Women’s Health Initiative, when combined estrogen and progesterone therapy is used)

Question 69

What are the known risks of estrogen therapy?

Answer 69

• Increased risk of endometrial cancer (eliminated with combined E/P therapy)
• Small increase in risk of coronary heart disease with combined E/P therapy, although the risk is not increased in women who are less than 10 years postmenopausal or 50 to 59 years of age
• Increased risk of venous thromboembolism
• Increased risk of breast cancer (with combined E/P therapy; slightly decreased risk of breast cancer with estrogen only, although this decrease was not statistically significant)
• Increased risk of stroke (either estrogen only or combined E/P therapy)
• Increased risk of gallbladder disease

Question 70

What are the most common side effects of estrogen therapy?

Answer 70

• Endometrial bleeding
• Bloating
• Breast tenderness
• Headaches
• Nausea

Question 71

What are the absolute contraindications to estrogen therapy?

Answer 71

• Unexplained vaginal bleeding
• Active liver disease
• History of thromboembolism
• Coronary artery disease
• History of endometrial or breast cancer
• Pregnancy

Question 72

What are the relative contraindications to estrogen therapy?

Answer 72

• Seizure disorder
• Hypertension
• Uterine leiomyomas
• Familial hyperlipidemia
• Migraine headaches
• Thrombophlebitis
• Endometriosis
• Gallbladder disease

Question 73

What test is often done before starting estrogen therapy?

Answer 73

endometrial biopsy, US, or D&C at the beginning of treatment to r/o endometrial hyperplasia and/or cancer

Question 74

True or false: Women without a uterus do not need to take progesterone with estrogen.

Answer 74

True. The main reason for giving progesterone with hormone replacement therapy is to eliminate the increased risk of endometrial cancer that accompanies unopposed estrogen therapy. If a woman has no uterus, then she has no need for progesterone.

Question 75

What are the absolute contraindications to oral contraceptive pills?

Answer 75

• Venous thromboembolism, current or past DVTs or PEs
• Cerebrovascular disease
• Coronary artery disease
• Complicated valvular heart disease
• Diabetes with complications
• Breast cancer
• Pregnancy
• Lactation (fewer than 6 weeks postpartum)
• Liver disease
• HA with focal neurologic symptoms
• Major surgery with prolonged immobilization
• >35 yo with ≥ 15 cigarettes/day
• Hypertension (blood pressure greater than 160/100 mm Hg or with concomitant vascular disease)

Question 76

What are the relative contraindications to oral contraceptive pills?

Answer 76

• Postpartum < 21 days
• Lactation (6 weeks to 6 months)
• Undiagnosed vaginal or uterine bleeding
• Age > 35 years and smoking ≤ 15 cigarettes/ day
• History of breast cancer but no recurrence in past 5 years
• Interacting drugs (certain anticonvulsants, rifampin)
• Gallbladder disease
• HA without aura, age 35 years or older
• Hypertension (well-controlled or blood pressure 140-159/90-99 mm Hg)

Question 77

What is the relationship between oral contraceptive pills and hypertension?

Answer 77

OCPs are one of the most common causes of secondary HTN.

Any patient taking birth control pills who is noted to have an increased BP should discontinue the pills, then have her BP rechecked at a later date.

Question 78

What do you need to know about oral contraceptive pills and surgery?

Answer 78

Because of the risks of thromboembolism, OCPs should be stopped 1 month before elective surgery and then restarted 1 month after surgery.

Question 79

What are the side effects of oral contraceptive pills?

Answer 79

• glucose intolerance (check for diabetes mellitus annually in women at high risk)
• depression
• edema (bloating)
• weight gain
• cholelithiasis
• benign liver adenomas
• melasma (“the mask of pregnancy”)
• nausea/vomiting
• headache
• hypertension
• drug interactions - rifampin and antiepileptics may induce metabolism of oral contraceptive pills and reduce their effectiveness.

Question 80

What is the relationship between oral contraceptive pills and breast and cervical cancer?

Answer 80

OCPs have little, if any, effect on the risk of developing breast cancer.

Cervical neoplasia may be increased in users of birth control pills, but this effect also may be due to the confounding factor of increased sexual relations or number of partners. Nonetheless, users of birth control pills should have regular Pap smears.

Question 81

What is the relationship between oral contraceptive pills and ovarian and endometrial cancer?

Answer 81

Oral contraceptive pills have been shown to reduce the incidence of ovarian cancer by 50% and incidence of endometrial cancer

Question 82

What are the other beneficial effects of oral contraceptive pills?

Answer 82

decrease the incidence of

• menorrhagia
• dysmenorrhea
• benign breast disease
• functional ovarian cysts (often prescribed for the previous four effects)
• premenstrual tension
• IDA
• ectopic pregnancy
• salpingitis