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Master the Boards Step 3 > Gynecology COPY > Flashcards

Gynecology COPY Flashcards

1
Q

List 5 benign breast diseases

A
  1. Fibroadenoma
  2. Fibrocystic disease
  3. Intraductal papilloma
  4. Fat necrosis (think of this with trauma to the breast)
  5. Mastitis (inflamed, painful breast in women who are breastfeeding)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13685-13704). Kaplan Publishing. Kindle Edition.

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2
Q

List 6 primary malignant breast diseases

A
  1. Ductal carcinoma in situ (DCIS)
  2. Lobular carcinoma in situ (LCIS)
  3. Invasive ductal carcinoma
  4. Invasive lobular carcinoma
  5. Inflammatory breast cancer
  6. Paget’s disease of the breast/ nipple

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13685-13704). Kaplan Publishing. Kindle Edition.

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3
Q

Nipple Discharge (ND)

  1. Most common cause of unilateral nonbloody nipple discharge
  2. When is cancer more likely with (1)
  3. Circumstances when further work up is required ND
A
  1. Intraductal papilloma
  2. When there is a palpable mass, involement of more than one duct or bloody discharge
  3. ND requiring further workup
    • Unilateral
    • Spontaneous
    • Bloody
    • Associated with mass

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13685-13704). Kaplan Publishing. Kindle Edition.

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4
Q

Nipple Discharge

List the diagnostic steps

A

Mammogram: Look for underlying masses or calcifications

Surgical duct excision: Perform this for definitive diagnosis

Cytology is not helpful in the diagnosis and is never the answer for nipple discharge

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13705-13724). Kaplan Publishing. Kindle Edition.

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5
Q

List (1) the diagnosis and (2) Rx of the following condition:

  • Female
  • 20– 50 years old
  • Cyclical, bilateral painful breast lump( s). Pain will vary with the menstrual cycle
  • Cyst with sharp margins and posterior acoustic enhancement on ultrasound
  • Collapse on fine-needle aspiration FNA
A
  1. Fibrocystic Disease
  2. Oral contraceptive pills/ medications (OCP)
    • In patients with severe pain, danazol may be used

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13705-13724). Kaplan Publishing. Kindle Edition.

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6
Q

List (1) the diagnosis, (2) diagnostic test and (3) Rx of the following condition:

  • Discrete, firm, nontender, and highly mobile breast nodule
  • FNA will show epithelial and stromal elements
A
  1. Fibroadenoma
  2. Ultrasound or Mammography if older than 40 years; FNA biopsy
  3. Surgery (diagnostic and curative)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13705-13724). Kaplan Publishing. Kindle Edition.

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7
Q

A 30-year-old woman complains of bilateral breast enlargement and tenderness, which fluctuates with her menstrual cycle. On physical examination, the breast feels lumpy, and there is a painful, discrete 1.5-cm nodule. A fine-needle aspiration is performed, and clear liquid is withdrawn. The cyst collapses with aspiration. Which of the following is the next step in management?

a. Clinical breast exam in 6 weeks
b. Core needle biopsy
c. Mammography
d. Repeat FNA in 6 weeks
e. Ultrasound in 6 weeks

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13725-13746). Kaplan Publishing. Kindle Edition.

A

A. Clinical breast exam in 6 weeks is appropriate follow-up for a cystic mass that disappears after FNA. If the mass recurs on the 6-week follow-up, FNA may be repeated, and a core biopsy can be performed

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13725-13746). Kaplan Publishing. Kindle Edition.

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8
Q

True or False:

Never diagnose a simple cyst on clinical exam alone. Diagnosis must be confirmed with either ultrasound or FNA

A

True

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9
Q

Indications for ultrasound in breast mass

A
  • First step in workup of a palpable mass that feels cystic on exam
  • Imaging test for younger women with dense breasts

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13747-13771). Kaplan Publishing. Kindle Edition.

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10
Q

Cystic Breast Mass

Indications for mammography (> 50 years) and Biopsy

OR

Biopsy alone if < 40 years

A
  • Cyst recurs > twice within 4 to 6 weeks
  • There is bloody fluid on aspiration
  • Mass does not disappear completely upon FNA
  • There is bloody nipple discharge (excisional biopsy)
  • There are skin edema and erythema suggestive of inflammatory breast carcinoma (excisional biopsy)

Mammogram should be done before biopsy. Biopsy distorts radiography

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13747-13771). Kaplan Publishing. Kindle Edition.

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11
Q

True or False:

Fine-needle aspiration or core biopsy is needed for a palpable mass

A

True. May be done after ultrasound or instead of ultrasound.

Core biopsy is superior to FNA

Cytology: – Any aspirate that is grossly bloody must be sent for cytology. Observation with repeat exam in 6– 8 weeks: – Cyst disappears on aspiration, and the fluid is clear.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13747-13771). Kaplan Publishing. Kindle Edition.

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12
Q

Breast Mass:

Indication(s) for cytology

A

Grossly bloody aspirate

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13747-13771). Kaplan Publishing. Kindle Edition.

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13
Q

Breast mass:

Indications for observationn with repeat exam in 6-8 weeks

A
  • Cyst disappears on aspiration, and the fluid is clear
  • Needle biopsy and imaging studies are negative

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13772-13792). Kaplan Publishing. Kindle Edition.

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14
Q

A 47-year-old woman completes her yearly mammogram and is told to return for evaluation. The mammogram reveals a “cluster” of microcalcifications in the left breast. What is the most appropriate next step in management?

a. Excision biopsy
b. Core needle biopsy
c. Repeat screening mammogram in 6 months
d. Repeat screening mammogram in 12 months
e. Ultrasound

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13772-13792). Kaplan Publishing. Kindle Edition.

A

B. A cluster of microcalcifications are mostly benign; however, approximately 15– 20 percent represent early cancer. The next step in workup is core needle biopsy under mammographic guidance

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13772-13792). Kaplan Publishing. Kindle Edition.

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15
Q

Both ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS) increase the risk of invasive disease.

If biopsy reveals DCIS, what is the next step?

A

Surgical resection with clear margins (lumpectomy; i.e., breast conserving surgical resection) and give radiation therapy (RT) and tamoxifen for 5 years to prevent the development of invasive disease

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13772-13792). Kaplan Publishing. Kindle Edition.

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16
Q

Both ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS) increase the risk of invasive disease.

If biopsy reveals LCIS, what is the next step?

A

Tamoxifen alone given for 5 years to reduce risk of development of breast cancer.

It is not necessary to perform surgery

LCIS is classically seen in premenopausal women

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13772-13792). Kaplan Publishing. Kindle Edition.

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17
Q

Tamoxifen:

  1. List risks associated with its use
  2. List contraindications
A
  1. Risks associated with tamoxifen use
    • Endometrial carcinoma
    • Thromboembolism
  2. Contraindications:
    • Patient is active smoker
    • Previous thromboembolism
    • High risk for thromboembolism

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13792-13812). Kaplan Publishing. Kindle Edition.

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18
Q

True or False:

  1. Invasive ductal carcinoma (IDC) is the most common form of breast cancer
  2. IDC is unilateral
  3. IDC metastasizes to bone, liver, and brain
  4. Invasive lobular carcinoma (ILC) accounts for 10 percent of breast carcinomas
  5. ILC tends to be multifocal (within the same breast) and is bilateral in 20 percent of cases
  6. Inflammatory breast cancer is uncommon, grows rapidly, and metastasizes early
  7. Paget’s disease of the breast/ nipple presents with a pruritic, erythematous, scaly nipple lesion. It’s often confused with dermatosis-like eczema or psoriasis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13792-13812). Kaplan Publishing. Kindle Edition.

A
  1. True. (85 percent of all cases)
  2. True
  3. True
  4. True
  5. True
  6. True. Look for a red, swollen, and warm breast and pitted, edematous skin (classic peau d’orange appearance)
  7. True. Look for an inverted nipple or discharge

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13792-13812). Kaplan Publishing. Kindle Edition.

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19
Q

List the established risk factors for breast cancer

A
  1. Age ≥ 50 years old
  2. Familial BRCA1/ BRCA2 mutation carrier
  3. Benign breast disease, especially
    • Cystic disease
    • Proliferative types of hyperplasia
    • Atypical hyperplasia
  4. Exposure to ionizing radiation
  5. First childbirth after age 30 or nulliparity
  6. Higher socioeconomic status
  7. History of breast cancer
  8. History of breast cancer in a first-degree relative
  9. Hormone therapy
  10. Obesity (BMI ≥ 30 kg per m2)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13812-13831). Kaplan Publishing. Kindle Edition.

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20
Q

Indications for BRCA1 and BRCA2 gene testing

A
  • Family history of early-onset (< 50 years of age) breast cancer or ovarian cancer
  • Breast and/ or ovarian cancer in the same patient
  • Family history of male breast cancer
  • Ashkenazi Jewish heritage

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13812-13831). Kaplan Publishing. Kindle Edition.

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21
Q

List the breast cancer screening guidelines per the U.S. Preventive Services Task Force (USPSTF)

A
  • Mammogram every 1– 2 years recommended for ages 50– 74
  • Screening before age 50 is no longer routinely recommended
  • Women < 50 should only consider mammographic screening based on high individual risk for early onset breast cancer
  • Teaching breast-self exam is no longer encouraged
  • Clinical breast exams are no longer routinely advised

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13832-13852). Kaplan Publishing. Kindle Edition.

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22
Q

Breast cancer treatment

  1. Primary treatment of invasive carcinoma when tumor size < 5 cm
  2. True or Fasle: Sentinel node biopsy is preferred over axillary node dissection
  3. Hormonal tests to do with breast cancer management
  4. Primary treatment of inflammatory, tumor size > 5 cm, and metastatic disease
A
  1. Lumpectomy + radiotherapy ± adjuvant therapy ± chemotherapy
  2. True
  3. Always test for
    • Estrogen and progesterone receptors
    • HER2/ neu receptor protein
  4. Systemic therapy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13832-13852). Kaplan Publishing. Kindle Edition.

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23
Q

A 68-year-old woman visits her primary care physician with a solid peanut-shaped hard mass in the upper outer quadrant of the left breast. A biopsy of the lesion reveals “infiltrating ductal breast cancer.” What is the next step in management?

a. Lumpectomy plus radiotherapy
b. Modified radical mastectomy
c. Modified radical mastectomy plus radiotherapy
d. Neoadjuvant chemotherapy plus lumpectomy plus radiotherapy
e. Tamoxifen and radiotherapy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13832-13852). Kaplan Publishing. Kindle Edition.

A

A. Breast-conserving surgical therapy (lumpectomy) plus radiotherapy is the standard of care for invasive disease. There is no survival benefit with modified radical mastectomy.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13852-13868). Kaplan Publishing. Kindle Edition.

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24
Q

Breast cancer Rx

Contraindications to breast-conserving therapy

A
  • Pregnancy
  • Prior irradiation to the breast
  • Diffuse malignancy or ≥ 2 sites in separate quadrants
  • Positive tumor margins
  • Tumor > 5 cm

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13852-13868). Kaplan Publishing. Kindle Edition.

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25
Breast cancer Rx Indication for hormonal therapy 1. True or False: There is the greatest benefit when both ER + and PR + receptors are present 2. True or False: Therapy is nearly as good when there are only ER + estrogen receptors 3. True or False: Adjuvant hormonal therapy has the least benefit when only PR + receptors are present.
In any hormone receptor-positive (HR +) tumors, regardless of age and regardless of menopausal status, stage, or type of tumor 1. True 2. True 3. True Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13852-13868). Kaplan Publishing. Kindle Edition.
26
**Tamoxifen** competitively binds estrogen receptors What is the five-year treatment effect on disease recurrence and mortality True or False: May be used in pre- or post-menopausal patients
50 percent decrease in the recurrence, 25 percent decrease in mortality True. May be used in pre- or postmenopausal patients. Aromatase inhibitors (anastrozole, exemestane, letrozole) block peripheral production of estrogen. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13852-13868). Kaplan Publishing. Kindle Edition.
27
**Aromatase inhibitors** (AI) block peripheral production of estrogen. 1. List 3 examples of AI 2. Indication 3. Adverse effect Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13852-13868). Kaplan Publishing. Kindle Edition.
1. Examples of AIs: * Anastrozole * Exemestane * Letrozole 2. HR+ postmenopausal women 3. Osteoporosis Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13852-13868). Kaplan Publishing. Kindle Edition.
28
List alternative Rx or additional Rx to Tamoxifen in premenopausal women
* **LHRH analogs** (e.g., **goserelin**) * **Ovarian ablation** (surgical oophorectomy or external beam RT) Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13869-13896). Kaplan Publishing. Kindle Edition.
29
List the benefits of tamoxifen
* ↓ incidence of contralateral breast cancer * ↑ bone density in postmenopausal women * ↓ fractures * ↓ serum cholesterol * ↓ cardiovascular mortality risk Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13869-13896). Kaplan Publishing. Kindle Edition.
30
Adverse effects of tamoxifen
* Exacerbates menopausal symptoms * ↑ ↑ risk of endometrial cancer (1% in postmenopausal women after 5 yrs therapy) * ↑ ↑ risk of thromboembolism **All women with a history of tamoxifen use and vaginal bleeding need evaluation & endometrial biopsy** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13869-13896). Kaplan Publishing. Kindle Edition.
31
**Breast Cancer Rx** Indications for chemotherapy Indications for Trastuzumab
Indications for chemotherapy * Tumor size \> 1 cm * Lymph node-positive disease Indications for Trastuzumab * It is indicated for **metastatic breast cancer overexpressing HER2/ neu**. Trastuzumab is a monoclonal antibody directed against the extracellular domain of the HER2/ neu receptor and is used to treat and control visceral metastatic sites. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13869-13896). Kaplan Publishing. Kindle Edition.
32
Invasive breast cancer List the Rx for the following specific scenarios: 1. **HR-negative, pre- or postmenopausal** woman 2. **HR-positive, premenopausal** woman 3. **HR-positive, postmenopausal** woman
1. Chemotherapy ± RT alone 2. Chemotherapy ± RT + tamoxifen 3. Chemotherapy ± RT + aromatase inhibitor Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13897-13919). Kaplan Publishing. Kindle Edition.
33
1. What is the first test to order for an enlarged uterus? 2. Asymmetric and nontender uterus = ? 3. Symmetric and tender uterus = ? 4. True or False: Never give estrogen alone to a woman with a uterus 5. True or False: All reproductive age women with chronic anovulation (e.g., PCOS) are at high risk of endometrial carcinoma
1. Beta-hCG 2. Leiomyoma 3. Adenomyosis 4. True. **Always combine with progestins to prevent unopposed endometrial stimulation** 5. True. **Give progestins to prevent endometrial hyperplasia and cancer.** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13995-14019). Kaplan Publishing. Kindle Edition.
34
A 65-year-old obese patient complains of vaginal bleeding for 3 months. Her last menstrual period was at age 52. She has no children. She has type 2 diabetes and chronic hypertension. Physical examination is normal with a normal-sized uterus and with no vulvar, vaginal, or cervical lesions. What is the next step in management? a. Begin progestin therapy b. Begin estrogen and progestin therapy c. Perform an endometrial biopsy d. Perform a Pap smear and endocervical sampling e. Prescribe topical estrogen cream Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13995-14019). Kaplan Publishing. Kindle Edition.
**C**. The most common cause of postmenopausal bleeding is vaginal or endometrial atrophy, but the most important diagnosis to rule out is endometrial carcinoma (the most common gynecologic malignancy). ***_All postmenopausal bleeding is suspected endometrial carcinoma until proven otherwise_*** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13995-14019). Kaplan Publishing. Kindle Edition.
35
1. First step in management of any patient with postmenopausal bleeding 2. **The most important risk factors for endometrial carcinoma are unopposed estrogen states.** List them. 3. True or False: All postmenopausal bleeding is suspected endometrial carcinoma until proven otherwise Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13995-14019). Kaplan Publishing. Kindle Edition.
1. Endometrial biopsy 2. Important risk factors for endometrial carcinoma: * Obesity * Nulliparity * Late menopause/ early menarche * Chronic anovulation 3. True Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 13995-14019). Kaplan Publishing. Kindle Edition.
36
A 31-year-old woman is taken to the emergency department complaining of severe, sudden lower abdominal pain that started 3 hours ago. On examination, the abdomen is tender, no rebound tenderness is present, and there is an adnexal mass in the cul-de-sac area. An ultrasound evaluation shows an 8-cm left adnexal mass. Beta-hCG is negative. What is the next step in management? a. Appendectomy b. Give high-dose estrogen and progestin c. Laparoscopic evaluation of ovaries d. Observation e. Perform oophorectomy Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14071-14090). Kaplan Publishing. Kindle Edition.
**C**. Sudden onset of severe lower abdominal pain in the presence of an adnexal mass is presumed to be ovarian torsion. Laparoscopy and detorsioning of the ovaries is needed. If blood supply is not affected, cystectomy can be done. If there is necrosis, oophorectomy is needed. She should then receive a 4-week follow-up and yearly evaluation to ensure there is complete resolution Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14090-14122). Kaplan Publishing. Kindle Edition
37
**Prepubertal or Postmenopausal Ovarian Mass** ***_Any ovarian enlargement in prepubertal or postmenopausal women is always suspicious for an ovarian neoplasm_*** List the risk factors for ovarian mass
* BRCA1 gene * Positive family history * High # of lifetime ovulations * Infertility * Use of perineal talc powder Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14090-14122). Kaplan Publishing. Kindle Edition.
38
**Prepubertal or Postmenopausal Ovarian Mass** ***_Any ovarian enlargement in prepubertal or postmenopausal women is always suspicious for an ovarian neoplasm_*** List the factors protective against ovarian mass
**Conditions that decrease # of ovulations** * Oral contraceptive pills (OCPs) * Chronic anovulation * Breastfeeding * Short reproductive Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14090-14122). Kaplan Publishing. Kindle Edition.
39
**Prepubertal or Postmenopausal Ovarian Mass** ***_Any ovarian enlargement in prepubertal or postmenopausal women is always suspicious for an ovarian neoplasm_*** List the initial workup of an ovarian mass
* ß-hCG * Ultrasound * Laparoscopy/ laparotomy if complex or \> 7 cm Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14090-14122). Kaplan Publishing. Kindle Edition.
40
A 68-year-old woman presents with weakness and bloated feeling in her abdomen. She is found to have abdominal distention, shifting dullness, and a large right adnexal mass. Pelvic ultrasound reveals a 7-cm irregular and solid mass in the right ovary. Which of the following is the next step in the management? a. Abdominal paracentesis b. CT of the abdomen c. Endometrial biopsy d. Laparoscopy e. Laparotomy Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14090-14122). Kaplan Publishing. Kindle Edition.
**B**. In a postmenopausal woman with abdominal distension, an ovarian mass, the first step is CT of the abdomen to evaluate the mass and confirm the presence of ascites (indicating peritoneal seeding). If ascites is present, the next step is laparotomy, oophorectomy, and surgical staging. Oophorectomy may be done by laparoscopy if no ascites is present Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14122-14145). Kaplan Publishing. Kindle Edition.
41
State the diagnosis and list the tumor markers based on the following scenarios: 1. A 9-year-old girl presents with right adnexal pain and complex cystic mass on ultrasound 2. A 67-year-old woman presents with progressive weight loss, distended abdomen, and left adnexal mass 3. A 58-year-old woman presents with postmenopausal bleeding. Endometrial biopsy shows endometrial hyperplasia. Pelvic ultrasound reveals a right ovarian mass 4. A 48-year-old woman complains of increased facial hair and deepening of her voice. An adnexal mass is found on examination 5. A 64-year-old woman with history of gastric ulcer and recent worsening dyspepsia presents with weight loss and abdominal pain. An adnexal mass is found Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14146-14169). Kaplan Publishing. Kindle Edition.
1. **Germ cell tumor**: These are most common in young women and present in early-stage disease. The most common malignant epithelial cell type is dysgerminoma. **Tumor markers**: **LDH, ß-hCG, a-FP** 2. **Epithelial tumor**: This is the most common ovarian cancer in postmenopausal women. The most common malignant subtype is serous. **Tumor markers: CA-125, CEA** 3. **Granulosa-theca (stromal tumor)**: This ovarian tumor secretes estrogen and can cause endometrial hyperplasia. **Tumor markers: Estrogen** 4. **Sertoli-Leydig cell (stromal tumor)**: This ovarian tumor secretes testosterone. Patients present with masculinization syndromes. **Tumor markers: Testosterone** 5. **Metastatic gastric cancer** to the **ovary (Krukenberg tumor)** **Tumor markers: CEA** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14146-14169). Kaplan Publishing. Kindle Edition.
42
Outline the management of ovarian mass
* **Sonogram** (and CT scan for postmenopausal women) * **Biopsy** via laparoscopy for simple cysts suggestive of malignancy (no septations or solid components) or postmenopausal without ascites * **Tumor markers** * **Cystectomy** for benign tissue * Premenstrual women: **Salpingo-oophorectomy** * Postmenopausal women: **Total abdominal hysterectomy (TAH)**; bilateral salpingo-oopherectomy (BSO) and postoperative chemotherapy for malignant tissue Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14169-14190). Kaplan Publishing. Kindle Edition.
43
1. List the human papilloma virus (HPV) types associated with **cervical cancer** 2. List the human papilloma virus (HPV) types associated with **benign condyloma acuminata**
1. HPV **16, 18, 31, 33,** and **35** 2. HPV 6 and 11 Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14169-14190). Kaplan Publishing. Kindle Edition.
44
Outline the pap smear classifications
**Indeterminate smears**: – Atypical squamous cells of undetermined significance (ASCUS) **Abnormal smears**: * Low-grade squamous intraepithelial lesion (**LSIL**): **HPV, mild dysplasia, or CIN 1** * High-grade squamous intraepithelial lesion (**HSIL**): **Moderate dysplasia, severe dysplasia, CIS, CIN 2 or 3** * Cancer: **Invasive cancer** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14169-14190). Kaplan Publishing. Kindle Edition.
45
Risk factors associated with cervical neoplasia
Early age of intercourse Multiple sexual partners Cigarette smoking Immunosuppression Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14169-14190). Kaplan Publishing. Kindle Edition
46
**Screening for cervical neoplasia** 1. When is screening started? 2. What screening is used 3. What is the frequency of screening? Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14190-14204). Kaplan Publishing. Kindle Edition.
1. Age 21, regardless of the onset of sexual activity 2. Screening used: * **Conventional method**: 50 percent sensitivity * **Liquid-based prep**: Sensitivity is increased to 75– 80 percent * **HPV DNA testing**: Useful in management of ASCUS 3. Frequency of screening: * **If \< 30 years old**, annually for conventional Pap or every 2 years for liquid-based * **If \> 30 years old**, screen every 2 to 3 years if \> 3 consecutive negative Pap smears Cervical cancer screening guidelines per the USPSTF: * Pap screening not recommended for women \> 65 with recent normal Pap smear * Pap smear not recommended for women with total hysterectomy for benign disease * **HPV testing alone** is not sufficient for screening Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14190-14204). Kaplan Publishing. Kindle Edition.
47
A 35-year-old woman is referred because of a Pap smear reading of ASCUS. The patient states that her last Pap smear, done approximately 1 year ago, was negative. She has been sexually active, using combination oral contraception pills for the last 4 years. A repeat Pap smear after 3 months again reveals ASCUS. Which of the following is the next step in evaluation? a. Endocervical curettage b. Colposcopy and biopsy c. HPV DNA typing d. Repeat Pap smear in 6 months e. Repeat Pap smear in 12 months Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14205-14224). Kaplan Publishing. Kindle Edition.
**B**. ASCUS is most commonly found in women with inflammation due to early HPV infection. Approximately 10– 15 percent of patients with ASCUS have premalignant or malignant disease. Two Pap smears revealing ASCUS must be followed up with colposcopy and biopsy Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14205-14224). Kaplan Publishing. Kindle Edition.
48
Management 1. If the case describes a patient with atypical squamus cells of undetermined significance (ASCUS) on the Pap smear and follow-up is certain, what is the next step?
1. **Repeat the Pap smear in 3– 6 months and order HPV DNA typing** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14205-14224). Kaplan Publishing. Kindle Edition.
49
If the case describes a patient with atypical squamus cells of undetermined significance (ASCUS) on the Pap smear and repeat pap smear result is negative, what next?
Carry out routine follow-up Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14205-14224). Kaplan Publishing. Kindle Edition.
50
If the case describes a patient with atypical squamus cells of undetermined significance (ASCUS) on the Pap smear and repeat pap smear result is again ASCUS, or HPV 16 and 18, what next?
Order colposcopy and biopsies. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14205-14224). Kaplan Publishing. Kindle Edition.
51
If the case describes a patient with ASCUS on Pap smear and follow-up is uncertain (i.e., patient is not reliable to return for follow-up), what next? Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14205-14224). Kaplan Publishing. Kindle Edition.
Order colposcopy and biopsies. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14205-14224). Kaplan Publishing. Kindle Edition.
52
Indications for: 1. Repeat pap smear 2. HPV DNA testing 3. Colposcopy and ectocervical biopsy 4. Endocervical curettage
1. **First ASCUS Pap** 2. **First ASCUS Pap** 3. **An abnormal Pap smear; Two ASCUS Pap smears** 4. **All NONpregnant patients with an abnormal Pap smear** **NOTES** Note on 1 * Repeat Pap at 4- to 6-month intervals until there are 2 consecutive, negative Paps * If a repeat Pap is again ASCUS, refer for colposcopy Note on 2 * If liquid-based cytology was used on the initial Pap, use specimen for DNA testing * If conventional methods were used, a second Pap needs to be performed * Colposcopy is then performed only if HPV 16 and 18 identified Notes on 3 * Colposcopy and ectocervical biopsy – Colposcopy is a magnification of the cervix (10– 12 times) * Abnormal lesions (e.g., mosaicism, inflammatory punctation, white lesions, abnormal vessels) are biopsied and sent for histology Notes on 4 * All nonpregnant patients undergoing colposcopy for an abnormal Pap smear must undergo an ECC to rule out endocervical lesions Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14226-14258). Kaplan Publishing. Kindle Edition.
53
Indications for cone biopsy
* **Performed after colposcopy or ECC if Pap smear and biopsy findings are not consistent** (suggests abnormal cells were not biopsied) * **Abnormal ECC histology** * An **endocervical lesion** * A biopsy showing **microinvasive carcinoma of the cervix** NOTE: Deep cone biopsies can result in an ***incompetent cervix*** or ***cervical stenosis*** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14226-14258). Kaplan Publishing. Kindle Edition.
54
What is the management of: * **CIN 1** * **CIN 2 or 3 after ablation or excision**
**Observation and follow-up** Follow-up repeat Pap smears, colposcopy + Pap smear, or HPV DNA testing every 4 to 6 months for 2 years Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14262-14298). Kaplan Publishing. Kindle Edition
55
What is the management of the following abnormal cervical histology: * **CIN 2 or 3**
**Ablative modalities** * Cryotherapy * Laser vaporization * Electrofulguration **Excisional procedures** * LEEP (loop electrosurgical excision procedure) * Cold-knife conization Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14262-14298). Kaplan Publishing. Kindle Edition.
56
What is the management of the following abnormal cervical histology: * **Biopsy confirmed** * **Recurrent CIN 2 or 3**
Hysterectomy Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14262-14298). Kaplan Publishing. Kindle Edition.
57
**Invasive Cervical Cancer** The average age of diagnosis is 45 years 1. List the diagnostic test 2. What is the most common histology type of invasive cervical cancer 3. List the metastatic work-up 4. Rx? 5. Indications for adjuvant therapy (radiation therapy and chemotherapy)
1. **Cervical biopsy** 2. Squamous cell carcinoma 3. **Metastatic workup**: * Pelvic exam * CT scan (to look for metastatic disease) * Cystoscopy * Proctoscopy 4. Treatment: **simple or modified radical hysterectomy** 5. Adjuvant therapy: * **Metastasis to lymph nodes** * **Tumor size \> 4 cm** * **Poorly differentiated lesions** * **Positive margins** * **Local recurrence** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14262-14298). Kaplan Publishing. Kindle Edition.
58
A 25-year-old woman with a 15-week pregnancy by dates is found to have HGSIL (high-grade squamous intraepithelial lesion) on a recent Pap smear. On pelvic examination there is a gravid uterus consistent with 15 weeks’ size, and the cervix is grossly normal to visual inspection. What is the next step in management? a. Colposcopy and biopsy b. Cone biopsy c. Endocervical curettage d. Hysterectomy e. Repeat Pap after pregnancy Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14298-14321). Kaplan Publishing. Kindle Edition.
**A**. A pregnant woman with abnormal Pap smear is managed in the same way as a nonpregnant woman with the exception of endocervical curettage, which is not performed because of increased cervical vascularity. An abnormal Pap smear is evaluated with colposcopy and biopsy. Pregnancy does not predispose to abnormal cytology and does not accelerate precancerous lesion progression into invasive carcinoma Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14298-14321). Kaplan Publishing. Kindle Edition.
59
Management of Abnormal Cervical Histology During Pregnancy: * **CIN/ dysplasia**
* Pap smear and colposcopy every 3 months during pregnancy * Repeat Pap and colposcopy 6– 8 weeks postpartum. **Any persistent lesions are then definitively treated postpartum** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14307-14340). Kaplan Publishing. Kindle Edition.
60
Management of Abnormal Cervical Histology During Pregnancy: * **Microinvasive cervical cancer**
* Cone biopsy to ensure no frank invasion * Deliver vaginally, reevaluate and treat 2 months postpartum Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14307-14340). Kaplan Publishing. Kindle Edition.
61
Management of Abnormal Cervical Histology During Pregnancy: 1. **Invasive cancer diagnosed *_before_* 24 weeks** 2. **Invasive cancer diagnosed *_after_* 24 weeks**
1. Definitive treatment (**radical hysterectomy** or **radiation therapy**) 2. **Conservative management up to 32– 33 weeks** – Cesarean delivery and begin definite treatment Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14307-14340). Kaplan Publishing. Kindle Edition.
62
**Prevention of Cervical Dysplasia** 1. Type of vaccine 2. Who receives it? 3. What subtypes of HPV does it prevent againts 4. True or False: Testing for HPV before vaccination can be given 5. True or False: Sexually active women can receive the vaccine 6. True or False: Women with previous abnormal cervical cytology or genital warts can receive the vaccine, but it may be less effective 7. True or False: It can be given to patients with previous CIN, but benefits are limited 8. True or False: The vaccine is recommended for pregnant, lactating, or immunosuppressed women 9. True or False: Females who have been vaccinated for HPV ***_need not_*** follow Pap smear recommendations 10. True or False: **Gardasil** is also indicated for males age 9– 26 for the prevention of genital warts caused by HPV.
1. **Quadrivalent HPV recombinant vaccine (Gardasil)** 2. All females 8– 26 years of age 3. 4 HPV types: (6, 11, 16, 18) **that cause 70 percent of cervical cancer and 90 percent of genital warts** 4. False. Testing not needed 5. True 6. True 7. True 8. False. Not recommended 9. False. They must still follow Pap smear recommendations 10. True Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14341-14358). Kaplan Publishing. Kindle Edition.
63
List the differential diagnosis for a woman with pelvic pain
* Cervicitis * Acute salpingo-oophoritis * Chronic PID * Tuboovarian abscess Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14341-14358). Kaplan Publishing. Kindle Edition.
64
List the initial workup for pelvic pain
* Pelvic exam * Cervical culture * Laboratory: **ESR** (sedimentation rate), **WBC** (include **blood culture if fever is present**) * Sonogram Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14341-14358). Kaplan Publishing. Kindle Edition.
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Rx for cervicitis
A single dose of oral cefixime and azithromycin **Always treat cervicitis to cover both chlamydia and gonorrhea** **Antibiotics that treat gonorrhea:** * Ceftriaxone IM * Cefixime PO **Antibiotics that treat chlamydia:** * Azithromycin PO * Doxycycline PO Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14359-14382). Kaplan Publishing. Kindle Edition.
66
What is (1) diagnosis, (2) Outpatient Rx and (3) Inpatient Rx based on the following presentation: * Cervical motion tenderness on exam * Lower pelvic pain after menstruation * Positive cervical cultures * WBC and ESR are elevated * Pelvic abscess ruled out on sonogram
1. Acute Salpingo-oophoritis 2. Outpatient: **Two oral antibiotics** (e.g., ofloxacin and metronidazole) 3. Inpatient: **Three intravenous antibiotics** * IV cefoxitin or cefotetan **and** * IV doxycycline or clindamycin **and** * gentamicin Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14359-14382). Kaplan Publishing. Kindle Edition.
67
Pelvic pain 1. When are outpatient antibiotics the answer? 2. When are inpatient antibiotics the answer?
1. Outpatient: * All cases of cervicitis * Acute salpingo-oophoritis when there is **no systemic infection or pelvic abscess** 2. Inpatient antibiotics: * Acute salpingo-oophoritis in a **nulligravida or adolescent patient, previous outpatient treatment failure, intrauterine device (IUD) in place, presence of fever, or pelvic abscess** * All cases of tuboovarian abscess Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14399-14422). Kaplan Publishing. Kindle Edition.
68
A 21-year-old female presents to the emergency department with lower abdominal pelvic pain starting 1 day ago. Symptoms began after her menstrual period completed. She is sexually active but using no contraception. Speculum examination reveals mucopurulent cervical discharge. Bimanual pelvic examination shows bilateral adnexal tenderness and cervical motion tenderness. She is afebrile. Her qualitative urinary β-hCG test is negative. Complete blood cell count (CBC) shows a WBC of 14,000. ESR is elevated. What is the most appropriate management? a. Outpatient PO cefixime and azithromycin b. Inpatient IV cefotetan, clindamycin, and gentamicin c. Inpatient IV clindamycin and gentamicin d. Exploratory laparotomy e. Percutaneous drainage Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14399-14422). Kaplan Publishing. Kindle Edition.
**B**. This patient has acute salpingo-oophoritis. Her nulligravid status is an indication for inpatient IV antibiotic triple-therapy Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14399-14422). Kaplan Publishing. Kindle Edition.
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* Recurrent, crampy lower abdominal pain * Nausea * Vomiting * Diarrhea * Occur during menstruation * Symptoms begin 2– 5 years after onset of menstruation (ovulatory cycles) 1. Diagnosis 2. Pathophysiology 3. Firts line Rx 4. Second line Rx
1. Primary dysmenorrhea 2. **Excessive endometrial prostaglandin F2**, which causes uterine contractions and acts on gastrointestinal smooth muscle 3. NSAIDs 4. Combination oral contraceptives Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14422-14444). Kaplan Publishing. Kindle Edition.
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**It classically presents in women over 30** with * Dysmenorrhea * Dyspareunia * Dyschezia (painful bowel movements) and * Infertility 1. Diagnosis 2. Most common site 3. Second most sommon site 4. Definitive diagnosis 5. First line Rx 6. Second line Rx 7. Other Rxs
1. Endometriosis 2. Ovary - (endometriomas or chocolate cyst) 3. **Cul-de-sac**, causing uterosacral li 4. Laparoscopy 5. C**ontinuous oral progesterone** or **oral contraceptive pill (OCP)** 6. _Testosterone derivatives_ (**Danocrine** or **danazol**) or _GnRH analogs_ (**Lupron** or **leuprolide**) 7. Other Rxs: * **Laparoscopic lysis adhesions**: Laser vaporization of lesions can improve fertility * **TAH and BSO** can be done for severe symptoms when fertility is not desired Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14422-14444). Kaplan Publishing. Kindle Edition.
71
Causes of elevated CA-125
* Ovarian cancer * Cirrhosis * Endometriosis * Peritonitis * Pancreatitis **Not all elevations of CA-125 are due to ovarian cancer** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14444-14462). Kaplan Publishing. Kindle Edition.
72
**Premenarchal Vaginal Bleeding** This is bleeding that occurs before menarche. The average age at menarche is 12 1. Causes 2. List the diagnostic workups 3. Diagnosis when workup is negative
1. Causes are as follows: * Foreign body (most common) * Sarcoma botryoides (cancer of vagina or cervix suggested by a grapelike mass arising from the vaginal lining or cervix) * Tumor of the pituitary adrenal gland or ovary * Sexual abuse 2. Diagnostic tests: * Perform pelvic exam under sedation * Order CT or MRI of pituitary, abdomen, and pelvis to look for estrogen-producing tumors 3. Idiopathic precorcious puberty Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14444-14462). Kaplan Publishing. Kindle Edition.
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A 31-year-old woman complains of 6 months of metromenorrhagia. The patient states that she started menstruating at age 13 and that she has had regular menses until the past 6 months. The pelvic examination, including a Pap smear, is normal. She has no other significant personal or family history. What is the next step in management? a. Obtain ß-hCG b. Obtain LH, FSH levels c. Perform a pelvic ultrasound d. Recommend oral contraceptive pill e. Recommend progestin-only pill Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14462-14503). Kaplan Publishing. Kindle Edition.
**A**. Irregular bleeding in reproductive age should always be evaluated first for pregnancy. If pregnancy is ruled out, workup for anatomical causes of bleeding or anovulation can be started Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14462-14503). Kaplan Publishing. Kindle Edition.
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Primary Amenorrhea 1. Define it 2. Outline the workup 3. What does presence of breasts indicate?
1. Absence of menses at **age 14 without secondary sexual development** or at **age 16 with secondary sexual development** 2. Diagnostic Testing * Physical exam (**breasts present or absent?**) * Ultrasound **(uterus present or absent?**) * Karyotype * Testosterone * FSH 3. Adequate estrogen production Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14462-14503). Kaplan Publishing. Kindle Edition.
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Differential diagnosis of amenorrhea with breasts and uterus present
* Imperforate hymen * Vaginal septum * Anorexia nervosa * Excessive exercise * Pregnancy before first menses **Workup as secondary amenorrhea** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14462-14503). Kaplan Publishing. Kindle Edition.
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Differential diagnosis of amenorrhea with **breasts present** but **uterus** is **absent** What is the workup?
**Müllerian agenesis** * XX karyotype * Normal testosterone for female **Complete androgen insensitivity (testicular feminization)** * XY karyotype * Normal testosterone for male Workup: **Order testosterone levels and karyotype** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14462-14503). Kaplan Publishing. Kindle Edition.
77
Differential diagnosis of primary amenorrhea with breasts absent but uterus is present What is the workup?
**Gonadal dysgenesis (Turner’s syndrome)** * X0 karyotype * FSH elevated **Hypothalamic–pituitary failure** * XX karyotype * FSH low Workup: **Order FSH level and karyotype** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14496-14539). Kaplan Publishing. Kindle Edition.
78
Differential diagnosis of primary amenorrhea with breasts and uterus absent What is the workup?
RARE. **Not clinically relevant**
79
A 17-year-old girl is brought to the clinic by her mother concerned because her daughter has never had a menstrual period. She reports that her daughter has good grades, studies hard but seems stressed out most of the time which is why she believed her period was delayed. On examination she seems to be well-nourished, with adult breast development and **pubic hair present**. Pelvic examination reveals a foreshortened vagina. No uterus is seen on ultrasound. What is the most appropriate advice? a. CT scan of the brain is indicated to evaluate a pituitary tumor b. Estrogen and progesterone supplementation is indicated c. In vitro fertilization is an option for future fertility d. Surgical removal of intra-abdominal testes is recommended e. Vaginal reconstruction may be performed Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14496-14539). Kaplan Publishing. Kindle Edition.
**E**. This patient has Müllerian agenesis resulting in **an absence of uterus, cervix and upper vagina**. Ovaries are intact and normal levels of estrogen are present. Vaginal reconstruction may be performed to elongate the vagina for satisfactory sexual intercourse Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14496-14539). Kaplan Publishing. Kindle Edition.
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Management of: 1. Müllerian agenesis 2. Complete androgen insensitivity (testicular feminization) 3. Gonadal dysgenesis (Turner’s syndrome) 4. Hypothalamic– pituitary failure
1. **Surgical elongation of the vagina for satisfactory sexual intercourse and counseling about infertility** 2. **Removal of testes before age 20** because of increased risk of testicular cancer. **Estrogen replacement** will then be needed 3. **Estrogen** and **progesterone replacement** for development of secondary sexual characteristics 4. **Estrogen** and **progesterone** **replacement** for development of secondary sexual characteristics *_Müllerian duct derivatives (fallopian tubes, uterus, cervix, and upper vagina) are absent in Müllerian agenesis_* *_There are no pubic or axillary hair in Androgen insensitivity (Testicular feminization)_* Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14496-14539). Kaplan Publishing. Kindle Edition.
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Criteria for diagnosis of secondary amenorrhea
* **Regular menses** are replaced by an **absence of menses for 3 months** * **Irregular menses** are replaced by an **absence of menses for 6 months**. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14540-14570). Kaplan Publishing. Kindle Edition.
82
Outline the steps in the workup of secondary amenorrhea in a tabular form
Steps in the workup of secondary amenorrhea
83
Rx of premenstrual syndrome
* SSRIs * Low dose of vitamin B6 (pyridoxine) may improve symptoms
84
List the workups for secondary amenorrhea
* Pregnancy Test (ß-hCG) * Thyrotropin (TSH) (rule out hypothyroidism) * Prolactin (rule out elevation) * Progesterone Challenge Test (PCT) * Estrogen–Progesterone Challenge Test (EPCT) Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14568-14612). Kaplan Publishing. Kindle Edition.
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Why does hypothyroidism lead to amenorrhea? Rx of amenorrhea in hypothyroidism
In primary hypothyroidism there is an elevated TRH (thyrotropin releasing hormone) level which leads to ↑ prolactin Rx: Thyroid replacement Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14540-14570). Kaplan Publishing. Kindle Edition.
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Appropriate steps to take when there is hyperprolactinemia (elevated prolactin) in the workup of secondary amenorrhea
1. **Review medications**: **Antipsychotics** and **antidepressants** have antidopamine side effect **→ ↑ prolactin** 2. **CT or MRI of head to rule out pituitary tumor** * **Tumor \< 1 cm**: give bromocriptine (dopamine agonist) * **Tumor \> 1 cm**: treat surgically 3. If the cause of elevated prolactin is **idiopathic**, treat with **bromocriptine** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14568-14612). Kaplan Publishing. Kindle Edition.
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1. What does a positive progesterone challenge test (PCT) indicate? 2. What is the Rx of (1)? 3. What does a negative PCT indicate?
1. _Any withdrawal bleeding_ is *diagnostic of* **anovulation** 2. Treatment: **Cyclic progesterone** to prevent endometrial hyperplasia. _**Clomiphene** ovulation induction_ is done if pregnancy is desired 3. **Inadequate estrogen** or **outflow tract obstruction** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14568-14612). Kaplan Publishing. Kindle Edition.
88
Estrogen–Progesterone Challenge Test (EPCT) 1. How is this done? 2. What does a poitive EPCT indicate? 3. What is the next line of action after (2)? 4. Interpret the results from (3) and Rx accordingly 5. What does a negative EPCT indicate? 6. What is the Rx for (5)?
1. 3 weeks of oral estrogen followed by 1 week of progesterone 2. Positive EPCT: _Any withdrawal bleeding_ is *diagnostic of* **inadequate estrogen** 3. Get an FSH level 4. **↑ FSH is ovarian failure**. Y chromosome mosaicism may be the cause if patient is \< 25 years. **Order a karyotype for confirmation** * ↓ **FSH is hypothalamic– pituitary insufficiency** Order a brain **CT/ MRI to rule out a tumor.** ***_Give estrogen-replacement therapy to prevent osteoporosis and cyclic progestins to prevent endometrial hyperplasia_*** 5. An **outflow tract obstruction** or **endometrial scarring** (e.g., Asherman syndrome) 6. Order a **hysterosalpingogram** to identify the lesion. Management: **Adhesion lysis** followed by **estrogen stimulation of the endometrium**. An **inflatable stent** prevents re-adhesion of the uterine walls Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14568-14612). Kaplan Publishing. Kindle Edition.
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1. **Diagnosis**: Amenorrhea + Positive Estrogen-Progesterone Challenge test + ↑ FSH 2. Test to order for (1) 3. **Diagnosis**: Amenorrhea + Positive Estrogen-Progesterone Challenge test + ↓ FSH 4. Test to order for (3) 5. Rx for (3)
1. **Ovarian failure**. Y chromosome mosaicism may be the cause if patient is \< 25 years 2. Order a karyotype for confirmation 3. Hypothalamic– pituitary insufficiency 4. Order a brain CT/ MRI to rule out a tumor 5. Give **estrogen-replacement therapy to prevent osteoporosis** and **cyclic progestins to prevent endometrial hyperplasia** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14568-14612). Kaplan Publishing. Kindle Edition.
90
1. Define hirsutism 2. The two major causes of hirsutism 3. What must be excluded in the workup of hirsutism?
1. Excessive male-pattern hair growth in a woman 2. **PCOS** or **idiopathic** 3. Androgen-secreting tumors Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14612-14634). Kaplan Publishing. Kindle Edition.
91
Define virilization
Excessive male-pattern hair growth in a woman plus other **masculinizing signs**, such as **clitoromegaly, baldness, lowering of voice, increasing muscle mass, and loss of female body contours** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14612-14634). Kaplan Publishing. Kindle Edition.
92
List the initial workup for hirsutism/virilization
* Testosterone * DHEAS * LH/ FSH * 17-hydroxyprogesterone Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14612-14634). Kaplan Publishing. Kindle Edition.
93
* Gradual-onset hirsutism * Obesity * Acne * Irregular bleeding * Infertility. There are **chronic anovulatory cycles** and **infertility** 1. Diagnosis? 2. How is the diagnosis confirmed? 3. Pelvic ultasound and exam finding?
1. Polycystic Ovarian Syndrome (PCOS) 2. An elevated LH/ FSH ratio 3. Bilaterally enlarged ovaries Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14612-14634). Kaplan Publishing. Kindle Edition.
94
List the differentials of the following classic presentation * Anovulation * A history of amenorrhea *followed by* * Unpredictable bleeding
* Polycystic ovary syndrome (PCOS) * Hypothyroidism * Pituitary adenoma * Elevated prolactin * Medications (e.g., antipsychotics, antidepressants) (prolonged unopposed estrogen stimulates the endometrium) Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14634-14657). Kaplan Publishing. Kindle Edition.
95
How does anovulation leads to irregular bleeing and predispose to endometrial cancer?
**Anovulation** → no corpus luteum production of progesterone → unopposed estrogen → ***_hyperplastic endometrium and irregular bleeding_*** → **predisposition to endometrial cancer**. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14612-14634). Kaplan Publishing. Kindle Edition.
96
1. Explain the pathphysiology of increased testosterone in PCOS 2. Explain the pathogenesis of ovarian enlargement in PCOS
1. ↑ **LH levels** → ↑ theca cell production of androgens → **hepatic production of SHBG is suppressed** → ↑ total testosterone and ↑ free testosterone 2. **↑ androgens** → multiple follicles in various stages of development, stromal hyperplasia, and a thickened ovarian capsule → **bilaterally enlarged ovaries** ***_Ultrasound shows a necklacelike pattern of multiple peripheral cysts (20– 100 cystic follicles in each ovary)_*** SHBG=Sex Hormone Binding Globulin Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14634-14657). Kaplan Publishing. Kindle Edition.
97
1. Beyond the history and exam findings, list the diagnostic findings in PCOS 2. Mgnt of PCOS
1. Diagnostic Testing * **LH:FSH ratio** = 3: 1 (normal is 1.5: 1) * **Testosterone** level is **mildly elevated** * Pelvic ultrasound shows **bilaterally enlarged ovaries with multiple subcapsular small follicles and increased stromal echogenicity** 2. Treatment * **Oral contraceptive pill** treats irregular bleeding and hirsutism. The progestin component prevents endometrial hyperplasia * **Spironolactone** may also be used to suppress hair follicles * **Clomiphene citrate** or **human menopausal gonadotropin (HMG)** is the treatment of choice for infertility * **Metformin** enhances ovulation and manages insulin resistance. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14634-14657). Kaplan Publishing. Kindle Edition.
98
1. Diagnosis: **Rapid onset hirsutism** and **virilization *_without_* a family history**. **DHEAS** is **markedly elevated**. 2. Diagnosis: **Rapid onset hirsutism** and **virilization *_without_* a family history**. **Testosterone** is **markedly elevated**. 3. Rx of (1) 4. Rx of (2)
1. Adrenal Tumor 2. Ovarian Tumor 3. Surgical removal of tumor 4. Surgical removal of tumor Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14658-14716). Kaplan Publishing. Kindle Edition.
99
1. Diagnosis: **Gradual-onset hirsutism** *_without_* **virilization** in the second or third decade that is associated with **menstrual irregularities** and **anovulation**. **Serum 17-hydroxyprogesterone level** is **markedly elevated**. **Precocious puberty** with **short stature** is common. **Family history may be positive**. 2. Management?
1. Congenital Adrenal Hyperplasia (21-Hydroxyolase Deficiency) 2. **Corticosteroid replacement**, which will arrest the signs of androgenicity and restore ovulatory cycles Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14658-14716). Kaplan Publishing. Kindle Edition.
100
* Hirsutism * No virilization * All lab tests are normal 1. Diagnosis? 2. Management?
1. **Idiopathic Hirsutism**. It is the most common cause of hirsutism. 2. Treatment: * **Spironolactone** is the treatment of choice * **Eflornithine (Vaniqa)** is the first-line topical drug for the treatment of unwanted facial and chin hair. Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14658-14716). Kaplan Publishing. Kindle Edition.
101
Fill in the levels of the following lab values indicating whether thay are elevated. decreased or normal for PCOS, CAH, ovarian tumor or adrenal tumor. The lab tests are testosterone, DHEAS, LH/FSH and 17-OHP. Also indicate the next step in managment
See result in table.
102
1. Define menopause 2. Mean age of menopause 3. True or False: Smokers experience menopause up to 2 years earlier 4. How is the diagnosis of menopause made? 5. Menopause occurring between 30 and 40 years of age. 6. Causes of (5) 7. Menopause before age 30 8. Causes of (7)
1. **12 months of amenorrhea** with elevation of FSH and LH 2. 51 years 3. True 4. With **serial levels of elevated gonadotropins (FSH \> 50 IU/ mL)** 5. Early menopause 6. Causes of early monopause: * Idiopathic (most often) * Radiation therapy * Surgical oophorectomy 7. Premature ovarian failure 8. Causes of Premature ovarian failure: * Autoimmune disease * Y chromosome mosaicism Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14716-14739). Kaplan Publishing. Kindle Edition.
103
List and explain the menopausal symptoms due to estrogen
**Amenorrhea**: Menses become anovulatory and decrease in the 3– to 5-year period known as perimenopause **Hot flashes**: This is unpredictable, profuse sweating and heat that occurs in 75 percent of women. *_Obese women are less likely to undergo hot flashes (due to peripheral conversion of androgens to estrone)_* **Reproductive tract**: *_Decreased vaginal lubrication*_, _*increased vaginal pH_*, and *_increased vaginal infections_* can occur **Urinary tract**: *_Increased urgency*_, _*frequency*_, _*nocturia_*, and *_urge incontinence_* can occur **Psychic**: *_Depressed mood,*_ _*emotional lability,*_ and _*sleep disorders_* can occur **Cardiovascular disease**: This is the *_most common cause of mortality (50 percent)_* in postmenopausal women **Osteoporosis** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14716-14739). Kaplan Publishing. Kindle Edition.
104
Common sites for osteoporosis in postmenopausal women
1. **Vertebral bodies**, leading to crush fractures, kyphosis, and decreased height 2. **Hip** and **wrist** fractures are the next most frequent sites Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14739-14765). Kaplan Publishing. Kindle Edition.
105
Risk factors for osteoporosis
1. **Positive family history** in a *_thin_*, *_white female_* (most common) 2. Steroid use, 3. Low calcium intake 4. Sedentary lifestyle, 5. Smoking 6. Alcohol Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14739-14765). Kaplan Publishing. Kindle Edition.
106
How to prevent osteoporosis?
* Calcium and vitamin D supplementation * Weight-bearing exercise * Smoking cessation * Alcohol cessation Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14739-14765). Kaplan Publishing. Kindle Edition.
107
How is the diagnosis of osteoporosis made?
**Bone density** is assessed with a **DEXA** scan (**dual-energy x-ray absorptiometry**). The results are reported as a T-score: **T-score ≥ –2.5** indicates the presence of osteoporosis * T-score –1.5 to –2.5 = osteopenia * T-score ≥ –2.5 = osteoporosis **Calcium loss** is assessed with a **24-hour urine hydroxyproline or NTX (N-telopeptide, a bone breakdown product)** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14739-14765). Kaplan Publishing. Kindle Edition.
108
Outline the management of osteoporosis
1. *_First-line therapy_* is **bisphosphonates** and **SERMs** * Bisphosphates (e.g., alendronate, risedronate) **inhibit osteoclastic activity** * Selective estrogen receptor modulators (SERMs) **increase bone density** * SERMs are **protective against the heart and bones** but are not effective for vasomotor symptoms of menopause * **Tamoxifen** (Nolvadex) has endometrial and bone agonist effects but breast antagonist effects * **Raloxifene** (Evista) has bone agonist effects but endometrial antagonist effects 2. **Calcitonin, denosumab,** and **teriparatide** are second-line therapy. Teriparatide is a PTH analog that is used when biphosphates fail 3. Estrogen is *_never_* the primary treatment of osteoporosis because of associated risks of clots and endometrial cancer ***_Denosumab is a RANKL inhibitor that inhibits osteoclast function_*** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14765-14802). Kaplan Publishing. Kindle Edition.
109
1. Rx indications of hormone replacement therapy (HRT) 2. Contraindications of HRT 3. True or False: HRT is used in the Rx of osteoporosis
1. Rx indications of HRT * Menopausal vasomotor symptoms (hot flashes) * Genitourinary atrophy * Dyspareunia 2. Contraindications of HRT * Estrogen-sensitive cancer (breast or endometrial) * Liver disease * Active thrombosis * Unexplained vaginal bleeding 3. False Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14765-14802). Kaplan Publishing. Kindle Edition.
110
1. List the benefits of HRT 2. List the risks of HRT 3. True or False: Women without a uterus can be given continuous estrogen 4. True or False: All women with a uterus must also receive progestin therapy. Why?
1. Benefits of HRT * ↓ Rate of osteoporotic fractures * ↓ Rate of colorectal cancer 2. Risks of HRT * ↑ Risk of DVT * ↑ Risk of heart attacks * ↑ Risk of breast cancer in combination therapy. **_Risk of breast cancer is only associated with therapy \> 4 yrs_** 3. True 4. True. Prevents endometrial hyperplasia Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14765-14802). Kaplan Publishing. Kindle Edition.
111
List the guidelines for HRT
* Only start HRT for vasomotor symptoms * Never give HRT for the prevention of cardiovascular disease * Use the lowest dose of HRT to treat symptoms * Use the shortest duration of HRT to treat symptoms; reevaluate annually * Do not exceed 4 years of therapy (**increased risk of breast cancer after 4 years of therapy**) Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14804-14858). Kaplan Publishing. Kindle Edition.
112
True or False: Low-dose contraceptive pills do not increase the risk of cancer, heart disease, or thromboembolic events in women with no associated risk factors (hypertension, diabetes, or smoking) Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14804-14858). Kaplan Publishing. Kindle Edition.
True Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14804-14858). Kaplan Publishing. Kindle Edition.
113
List (1) examples, (2) absolute contraindications, (3) relative contraindications and (4) benefits of **barrier methods of contraception**
1. Condoms, Vaginal diaphragm, **± spermicides** 2. N/ A 3. N/ A 4. Protective against STDs Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14804-14858). Kaplan Publishing. Kindle Edition.
114
List (1) examples, (2) absolute contraindications, (3) relative contraindications and (4) benefits of intrauterine device
1. Examples: * **Combination** (estrogen + progesterone) * **Progestin only** (OCP called “mini-pill”, injectable, implant, morning after pill) 2. Absolute Contraindication – Pregnancy – Acute liver disease – Vascular disease (e.g., thromboembolism, DVT, CVA, SLE) – Hormone dependent cancer (e.g., breast CA) – Smoker \> 35 – Uncontrolled hypertension – Migraines with aura – DM with vascular disease – Thrombophilia 3. Relative Contraindication – Migraines – Depression – DM – Chronic HTN – Hyperlipidemia 4. Benefits: * ↓ ovarian and endometrial CA * ↓ dysmenorrhea * ↓ dysfunctional uterine bleeding * ↓ ectopic pregnancy Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14804-14858). Kaplan Publishing. Kindle Edition.
115
List (1) examples, (2) absolute contraindications, (3) relative contraindications and (4) benefits of intrauterine device
1. Examples: * Levonorgestrel-impregnated * Copper-banded 2. Absolute contraindications: * – Pregnancy – Pelvic malignancy – Salpingitis 3. Relative contraindications: * Abnormal uterine size or shape * Immune suppression (including steroid therapy) * Nulligravidity * Abnormal Pap smears * History of ectopic pregnancy 4. Benefits: Effective and **avoids side effects of hormonal therapy**
116
A 35-year-old woman comes to the gynecologist’s office complaining of infertility for 1 year. She and her husband have been trying to achieve pregnancy for \> 1 year and have been unsuccessful. There is no previous history of pelvic inflammatory disease, and she had used oral contraception medication for 6 years. The pelvic examination is normal. Semen analysis is low volume and shows decreased sperm density and low motility. What is the next step in management? a. Administer testosterone b. Measure serum testosterone c. Measure thyroid hormone d. Repeat semen analysis e. Refer for intrauterine insemination Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14860-14905). Kaplan Publishing. Kindle Edition.
**D**. Because semen samples are variable, an abnormal semen analysis is repeated in 4– 6 weeks to confirm findings . Infertility is defined as inability to achieve pregnancy after 12 months of unprotected and frequent intercourse. Steps in workup for infertility: 1. The first step is semen analysis. 2. If semen analysis is normal, work up for anovulation. 3. If semen analysis is normal and ovulation is confirmed, work up for fallopian tube abnormalities. Step Diagnosis Management 1. Semen Analysis Normal values: • Volume \> 2 mL; pH 7.2– 7.8; sperm density \> 20 million/ mL; sperm motility \> 50%; and sperm morphology \> 50% normal. • If values are abnormal, repeat the semen analysis in 4– 6 weeks. • Abnormal semen analysis: Intrauterine insemination, intracytoplasmic sperm injection (ICSI), and in vitro fertilization (IVF) are fertility options. • No viable sperm: Artificial insemination by donor may be used. 2. Anovulation • Basal body temperature (BBT) chart: NO midcycle temperature elevation • Progesterone: Low • Endometrial biopsy: Proliferative histology • Hypothyroidism or hyperprolactinemia are causes of anovulation that can be treated. • Ovulation induction: – Clomiphene citrate is the agent of choice. – Human menopausal gonadotrophin (hMG) is used if clomiphene fails – Most common side effect = ovarian hyperstimulation. Ovarian size must Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14860-14905). Kaplan Publishing. Kindle Edition.
117
**Infertility** is defined as inability to achieve pregnancy after **12 months of unprotected and frequent intercourse** List the steps in the workup of infertility Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14860-14905). Kaplan Publishing. Kindle Edition.
1. **Semen analysis** (first step) 2. If semen analysis is normal, work up for **anovulation** 3. If semen analysis is normal and ovulation is confirmed, work up for **fallopian tube abnormalities** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14860-14905). Kaplan Publishing. Kindle Edition.
118
State the normal values for semen analysis: 1. Volume 2. pH 3. Sperm density 4. Sperm motility 5. Sperm morphology
1. \> 2 mL 2. 7.2– 7.8 3. \> 20 million/ mL 4. \> 50% 5. \> 50% normal Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14860-14905). Kaplan Publishing. Kindle Edition.
119
Management of abnormal semen analysis: 1. Next best step following an abnormal semen analysis 2. Next step if (1) fails 3. Rx of no viable sperm
1. **Repeat** the semen analysis in **4– 6 weeks** 2. Abnormal semen analysis: * Intrauterine insemination * Intracytoplasmic sperm injection (ICSI) * In vitro fertilization (IVF) 3. Artificial insemination by donor may be used Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14860-14905). Kaplan Publishing. Kindle Edition.
120
Anovulation: 1. Diagnosis 2. List treatable causes of anovulation 3. Rx for ovulation induction 4. Most common side effect of ovulation induction
1. Diagnosis * Basal body temperature (BBT) chart: **NO midcycle temperature elevation** * Progesterone: **Low** * Endometrial biopsy: **Proliferative histology** 2. **Hypothyroidism** or **hyperprolactinemia** a 3. Ovulation induction: * **Clomiphene citrate** (is the agent of choice) * **Human menopausal gonadotrophin** (hMG) is used if clomiphene fails 4. **Ovarian hyperstimulation**. Ovarian size must be monitored during induction Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14860-14905). Kaplan Publishing. Kindle Edition.
121
Tubo abnormalities: 1. Diagnosis 2. How to rule out Chlamydia infection-induced tubal adhesions 3. True or False: No further testing is performed if the Hysterosalpingogram (HSG) shows normal anatomy 4. True or False: Laparoscopy: Performed with an abnormal HSG to visualize the oviducts and attempt reconstruction (tuboplasty) 5. Rx for severe tubal damage
1. Diagnosis: * Hysterosalpingogram and * Laparoscopy 2. **Chlamydia Antibody**: *_A negative IgG antibody test for chlamydia rules out infection-induced tubal adhesions_* 3. True 4. True 5. **IVF** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14905-14933). Kaplan Publishing. Kindle Edition.
122
* Normal semen analysis * Ovulation confirmed * Patent oviducts 1. Diagnosis 2. Rx of (1)
1. Unexplained Infertility 2. **No treatment** is indicated, and approximately **60 percent** of patients with unexplained infertility will achieve a spontaneous pregnancy within the next **3 years** Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14905-14933). Kaplan Publishing. Kindle Edition.
123
Outline the steps in in-vitro fertilization
1. **Eggs are aspirated** from the ovarian follicles using an ultrasound-guided transvaginal approach 2. They are f**ertilized with sperm in the laboratory**, resulting in the formation of embryos 3. Multiple embryos are **transferred into the uterine** **cavity** with a cumulative pregnancy rate of 55 percent after 4 IVF cycles Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14905-14933). Kaplan Publishing. Kindle Edition.
124
Gestational Trophoblastic Disease (GTN) This is an abnormal proliferation of placental tissue involving both the cytotrophoblast and/ or syncytiotrophoblast. It can be either benign or malignant. 1. Risk factors for GTN 2. Symptoms of GTN 3. Signs of GTN 4. Most common site of distance metastasis
1. Risk factors for GTN * From **Taiwan** and **the Philippines** (most common) * **Maternal age extremes** (\< 20 years old, \> 35 years old) * Folate deficiency 2. Symptoms of GTN: * **Bleeding \< 16 weeks gestation** and **passage of vesicles** **from the vagina** (most common) * Hypertension * Hyperthyroidism * Hyperemesis gravidarum * No fetal heart tones appreciated 3. Signs of GNT * Fundus larger than dates * Absence of fetal heart tones * Bilateral cystic enlargements of the ovary (theca-lutein cysts) 4. Lungs Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14933-14984). Kaplan Publishing. Kindle Edition.
125
Compare the complete and incomplete moles
Complete and incomplete moles compared
126
List and compare the different types of malignant moles
Malignant moles
127
A 32-year-old Filipino woman is 15 weeks’ pregnant by dates. She presents with painless vaginal bleeding associated with severe nausea and vomiting. Her uterus extends to her umbilicus but no fetal heart tones can be heard. Her blood pressure is 162/ 98 mm Hg. A dipstick urine shows 2 + proteinuria. Which of the following is the most likely diagnosis? a. Chronic hypertension b. Chronic hypertension with superimposed preeclampsia c. Eclampsia d. Molar pregnancy e. Preeclampsia
**D**. This patients presentation is typical for a molar pregnancy. Absence of fetal heart tones eliminates the other options Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14933-14984). Kaplan Publishing. Kindle Edition.
128
Outline the diagnosis and management of GTN
Diagnostic Testing **Sonogram** reveals **homogenous intrauterine echoes without a gestational sac or fetal parts** (“**snowstorm**” ultrasound) Management * **Baseline quantitative β-hCG titer** * **Chest x-ray** (rule out lung metastasis) * **Suction dilation and curettage (D& C)** (to evacuate the uterine contents) * Place the patient on **effective contraception** (oral contraceptive pills) toensure no confusion between rising β-hCG titers from recurrent disease and normal pregnancy Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 14984-14985). Kaplan Publishing. Kindle Edition.
129
Exercise-induced amenorrhea is due to a decrease in the pulsatile secretion of LH, which leads to a decline in estrogen production. List the consequences of exercise-induced amenorrhea
* Osteopenia * Ostoporosis * Breast atrophy * Vaginal atrophy * Mild hypercholesterolemia * Infertility

Master the Boards Step 3 (5 decks)

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