Module 5 BBB Practice Questions

Question 1

An 18 year old patient presents to an appointment for “no period”. What information would you want to gather right away?

Answer 1

Has she ever had one?
Is she sexually active?

Question 2

Your patient had menarche at age 13 and now has not had a period in 9 months. What does she have?

Answer 2

Secondary amenorrhea

Question 3

When a patient presents with secondary amenorrhea, what differentials come to mind?

Answer 3

*Pregnancy
*PCOS
*Anorexia or orthorexia
Medication-caused iatrogenic causes (ex. Depo)
Thyroid Dysfunction
Pituitary Tumor
Stress
Outflow tract obstruction
Ovarian Insufficiency (often linked to autoimmune disorders)

Question 4

A patient presents with secondary amenorrhea. What ROS/history should you gather?

Answer 4

-What medications are you on? And for how long?
-What was happening around the time your period started?
-Describe your cycles before they stopped?
-Could you tell me about your typical diet and exercise?
-Any weight loss or gain?
-Any chance of pregnancy?
-Thyroid symptoms?
-Any nipple discharge?
-Any headache or vision changes?
-Hair changes? Ance?
-Nipple stimulation?
-Any surgical procedures on cervix?

Question 5

When do we expect periods to become regular after menarche?

Answer 5

By 2-3 years after menarche

Question 6

What MUST be present to diagnose PCOS per the Rotterdam criteria?

Answer 6

Two of the following must be present AND other conditions are excluded1
1) Anovulation or oligomenorrhea with fewer than 9 period/year
2) Androgen excess (hirsutism, acne, alopecia, hyperandrogenemia)
3) Polycystic ovaries on ultrasound

Question 7

What endocrine organ produces DHEA-S?

Answer 7

The adrenals

Question 8

What does 17-OHP test for?

Answer 8

Congenital adrenal hyperplasia

Note: this is not common

Question 9

What labs should ALWAYS be done for secondary amenorrhea?

Answer 9

TSH and prolactin

Question 10

You prescribe a progestin challenge test for your patient and she reports 7 days of moderate bleeding that then stopped after the progestin dosing ended. What does this indicate?

Answer 10

It is a positive test, she has estrogen in her system
Also she has a patent outflow tract

This is also decreases her risk for hyperplasia

Question 11

You diagnose your patient with PCOS. What can be given for her PCOS symptoms?

Answer 11

COC low androgen pills. Have a first pass effect so they help bind some of the free-floating androgens/testosterone

Question 12

What should we assess when prescribing a COC?

Answer 12

Is she high risk for CAD/DVT. Does she have migraines with aura, history of BC/liver dx/gallbladder dx

Is she a smoker-this is not a contraindication but is good to know

Question 13

At what age would we be concerned for primary amenorrhea?

Answer 13

13/14 years old with no secondary sex characteristics

16 years old with secondary characteristics

Question 14

What is a good first step in assessing primary amenorrhea?

Answer 14

An ultrasound to assess for a structural problems

Question 15

If a patient has light bleeding for two days after a progestin challenge test, what is the result?

Answer 15

Positive result. Estrogen present and no outflow tract obstruction

Question 16

How much bleeding would typically be seen for a patient with PCOS when given a progestin challenge test?

Answer 16

Significant bleeding!

Question 17

A patient reports A sudden onset of hirsutism that progressed quickly. What should we consider? And what should we do?

Answer 17

REFER

Possible virilizing tumors that may be cancerous. This is a big RED FLAG. They should be seen the same week.

Question 18

A 45-year-old patient presents with PCOS that has not been treated. What should we be concerned for?

Answer 18

Hyperplasia and Cancer!

Question 19

A 18 y/o patient presents with 5 months of secondary amenorrhea followed by bleeding for three weeks of continuous bleeding. What is this? What causes it? How do we manage it?

Answer 19

Prolonged Bleeding (anything >8 days)

In this case the endometrium has outgrown its blood supply and is randomly sloughing off.

Give her estrogen/progestin (monophasic COC TID until bleeding is under control, then taper) to stop the bleeding to prevent anemia. Bleeding should resolve in 24 hours. She should have an organized withdrawal bleeding after stopping the COC.

Question 20

At what age do we begin to consider hyperplasia and workup the patient first before considering giving them hormones?

Answer 20

45 y/o

Question 21

A 44 y/o patient presents with “horrible periods” with heavy bleeding and pain. What differentials come to mind?

Answer 21

-Endometriosis (may or may not have heavy bleeding)
-Adenomyosis (Both)
**-Cancer (Endometrial hyperplasia)
-Fibroids
-Coagulation disorder (heavy bleeding)
-PCOS
-Polyps (Endometrial polyp will cause heavier bleeding)
-Thyroid Problem
-Perimenopause

Question 22

What ROS/history should be reviewed for a patient with “horrible periods”?

Answer 22

-LMP?
-What is the timing of the bleeding?
-How long has it been going on?
-Did the heaviness and pain start at the same time?
-What were your periods like before this?
-Was it a sudden change or gradual?
-Any changes in life, medical conditions, or medications?
-Is the pain only present during your period?
-Point to the period?
-Thyroid symptoms?
-Vasomotor symptoms?
-Change in abdominal size, clothes fitting normally?
-Is sex painful?
-How much bleeding? How long?
-Do you only bleed with periods?
-Easy bruising, long bleeding?
-Symptoms of anemia (dizziness on standing, SOB, fainting, fatique, sore tongue)?

Question 23

What condition is more likely in someone who has had multiple babies?

Answer 23

Adenomyosis

Question 24

What can cause unscheduled bleeding?

Answer 24

Hyperplasia, polyps, fibroids, cervical infection/cancer

Question 25

The patient presents with horrible bleeding and pain with periods. What should we include in our physical exam?

Answer 25

-Weight/vital signs
-Palpate thyroid
-Palpate abdomen
-Bimanual exam
-Speculum exam (pap if >5 years)

Question 26

When assessing a symptomatic patient by speculum exam, you visualize a polyp. What do you think you should do?

Answer 26

With pt consent, It can be removed and sent for pathology

Question 27

What size would expect a uterus to be if the patient has had multiple babies?

Answer 27

The size of a fist or 6-8w size uterus

Question 28

When assessing a patients cervix, you see ectropion (redness at the opening of the cervix). How should you respond?

Answer 28

This is normal, but could cause spotting

Question 29

What testing can be performed for a patient presenting with heavy bleeding and painful periods?

Answer 29

-CBC to assess for anemia
-Pregnancy test
-TSH
-TVUS/Endometrial ultrasound (to assess for hyperplasia)
-Ultrasound to look for fibroids

Question 30

Your patient has a cervical polyp that you send for testing. She is crying and states that she is afraid she has cancer. What can you tell her?

Answer 30

99.9% of cervical polyps are not cancerous but we are sending it to be sure. It is likely you do not have cancer

Question 31

What cycle day do we assess endometrial lining? Why?

Answer 31

-Day 7.
-We want to assess how big the endometrium is after the shedding

Question 32

When do we become concerned about the thickness of the endometrium?

Answer 32

4-5 mm

Question 33

How can we manage AUB-A for a patient with heavy bleeding and pain?

Answer 33

Continuous CHC, POPs, LIUD, NSAIDs, uterine ablation, TXA

If nothing else works: Hysterectomy

Question 34

When do we not use progestin?

Answer 34

history of breast CA