Quizzes

Question 1

Leiomyomas respond well to naturopathic interventions that address unopposed estrogen, which include:

Select one:

a. sitz baths and rotating seeds diets
b. rotating seeds diet and weight gain
c. anti-estrogen diet and l-glutamine
d. Silymarin marianum and NAC
e. anti-estrogen diet and Silymarin marianum

Answer 1

The correct answer is:

c. anti-estrogen diet and Silymarin marianum

Question 2

Which of the following is TRUE regarding diagnosing and testing for UTIs:

Select one:

a. Routine urine cultures are required to diagnose UTIs.
b. Clinical suspicion of UTI requires lab testing in young, non-pregnant women with uncomplicated cystitis and no vaginal symptoms.
c. While NOT required to diagnose and treat a UTI, laboratory testing can include: UA dipstick, UA microscopy, and urine culture.
d. There is not current recommended testing for a suspected UTI. Diagnosis is based on clinical symptoms only.

Answer 2

The correct answer is:
c. While NOT required to diagnose and treat a UTI, laboratory testing can include: UA dipstick, UA microscopy, and urine culture.
UA dipstick is 75-82% accurate when positive for either leukocyte esterase or nitrites. If all other indicators suggest UTI, then a negative result is likely a false negative.

Question 3

Which of the following increases the incidence of cystitis?
Select one:
a. Recent sex and use of antibiotics.
b. Pregnancy
c. All of the above. 
d. Diabetes

Answer 3

The correct answer is:

c. All of the above.

Question 4

Which of the following statements is TRUE?
Select one:
a. The ovary is the only source for estradiol
b. In breast tissue ER alpha is stimulatory and ER beta is inhibitory
c. Increased testosterone levels increases SHBG production
d. Estriol is thought to be stimulatory in breast tissue

Answer 4

The correct answer is:

b. In breast tissue ER alpha is stimulatory and ER beta is inhibitors

Question 5

The most common causative organism in lower genital urinary infections is:

Select one:

a. H. pylori
b. Staphylococcus species
c. E. coli
d. Klebsiella sp

Answer 5

The correct answer is:

c. E. coli Yes. E. coli is responsible for 75-95% of urethritis and cystitis in women.

Question 6

The best technique for a clinical breast exam is:

Select one:

a. Using three fingers, and light/medium/deep pressure variation, use the vertical strip method from breast border to breast border. Do not separately elicit nipple discharge.
b. Using three fingers, and light/medium/deep pressure variation, use the vertical strip method from breast border to breast border. Be sure to attempt to elicit nipple discharge.
c. Using three fingers, and light/medium/deep pressure variation, use the wedge method from breast border to breast border
d. Using three fingers, and light/medium/deep pressure variation, use the circular method from breast border to breast border.

Answer 6

The correct answer is:

b. Using three fingers, and light/medium/deep pressure variation, use the vertical strip method from breast border to breast border. Do not separately elicit nipple discharge.

Yes. The 1999 JAMA retrospective study found that the vertical strip method improved the detection of breast masses, and is now the recommended technique for breast exams for greater accuracy.

Question 7

Question 7
When is it appropriate to conduct a pelvic exam on your patient?
Select one:
a. It is appropriate to conduct a pelvic exam on your patient when she is experiencing menopausal symptoms
b. It is appropriate to conduct a pelvic exam on your patient at anytime she is not pregnant.
c. It is appropriate to conduct a pelvic exam on your patient when she is experiencing abnormal uterine bleeding.
d. annual as part of her preventive care.
e. It is appropriate to conduct a pelvic exam on your patient after she has been diagnosed with an STD.

Answer 7

The correct answer is:
It is appropriate to conduct a pelvic exam on your patient when she is experiencing abnormal uterine bleeding.

Yes. It is appropriate to conduct a pelvic exam when your patient has abnormal uterine bleeding, vulvar or vaginal complaints, abdominal pain, suspicion of STDs, during pregnancy, or as part of her preventive health exam.

Question 8

Naturopathic treatment of uncomplicated UTI’s in women include:

Select one:

a. Uncomplicated UTIs should first be treated with antibiotics such as nitrofurantoin.
b. Elimination diet
c. Douching daily and waiting at least 30 minutes before urinating after sex.
d. Hydration, post-coital hygiene education, pure cranberry juices diluted, D-mannose, Vitamin C, beta-carotenes and probiotics.

Answer 8

The correct answer is:
d. Hydration, post-coital hygiene education, pure cranberry juices diluted, D-mannose, Vitamin C, beta-carotenes and probiotics.

Question 9

One possibility for alleviating the pain of the speculum exam in some postmenopausal women would be:
Select one:
a. to have the patient start a daily local application of low-dose estradiol vaginally for a month prior to the exam.
b. to provide Rescue Remedy for her prior to the exam.
c. to defer the exam for another year.
d. to offer her lidocaine cream to apply to the vaginal introitus prior to the exam
e. to perform the speculum with the patient side lying to reduce pelvic floor strain.

Answer 9

The correct answer is:
a. to have the patient start a daily local application of low-dose estradiol vaginally for a month prior to the exam.

Yes. When it is time for her to have her Pap test, this is a way to help her feel more comfortable during the exam and ensure she dies not avoid the exam due to discomfort.

Question 10

Which of the main estrogens is the most abundant in a woman’s body?

Select one:

a. E2, estradiol
b. 16 hydroxy estradiol
c. E3, estriol
d. E1, estrone

Answer 10

The correct answer is:
d. E1, estrone
Yes this is the most abundant form of estrogen present in a woman’s body throughout her lifetime. After menopause it is also the most important source of estrogen activity.

Question 11

Which of the estrogen metabolites is carcinogenic due to the production of DNA damaging quinones?

Select one:

a. 4 Hydroxy estrogens
b. 16 Hydroxy estrogens
c. 2 Hydroxy estrogens
d. estrogen sulfate

Answer 11

The correct answer is:

a. 4 Hydroxy estrogens

Question 12

Estrogen has the following effects on the uterus.
Select one:
a. Estrogen stimulates the uterus to mature at puberty, and stimulates the endometrial lining to thicken in anticipation of embryo implantion.
b. Estrogen has no effect on the uterus until after puberty.
c. Estrogen is a pro-inflammatory in the uterus, causing an increase in cytokine producing cells.
d. Estrogen inhibits thickening of the uterine lining.
e. Estrogen inhibits collagen hyperplasia and increases smooth muscle activity in the uterus.

Answer 12

a. Estrogen stimulates the uterus to mature at puberty, and stimulates the endometrial lining to thicken in anticipation of embryo implantion.

Yes, Estrogen stimulates the development of the endometrial lining

Question 13

A normal breast examination includes notes on:
Select one:
a. breast symmetry of size and color, symmetry of skin appearance, absence of axillary and clavicular lymphadenopathy, breast tissue absent of masses and tenderness
b. absence of cervical lymphadenopathy, skin puckering, breast tissue absent of masses and tenderness
c. breast symmetry of size, shape, and skin appearance, central lymphadenopathy, areolar density
d. breast symmetry, absence of nipple discharge on elicitation, focal and uneven texture of unilateral breast
e. inverted nipple, skin contours, breast tissue absent of masses and tenderness

Answer 13

The correct answer is:
breast symmetry of size and color, symmetry of skin appearance, absence of axillary and clavicular lymphadenopathy, breast tissue absent of masses and tenderness
Yes. This is an accurate and comprehensive description of normal exam findings on a breast exam..

Question 14

When taking a history for a women’s wellness exam, your questions should include:
Select one:
a. Information on her menstrual cycle; pregnancy history; presence of pelvic, breast or vaginal symptoms; sexual status; and contraceptive status.
b. It is only necessary to inquire about current symptoms of her breast and pelvis since her gynecological history is not relevant to her current complaints.
c. Information on her menstrual cycle; pregnancy history; history of vaginal and pelvic infections; family history of gynecological issues; urological issues; and contraceptive status.
d. Your questions would be no different than for any annual exam for either gender
e. Information on her menstrual cycle; pregnancy history; history of vaginal and pelvic infections; history of gynecological surgeries; family history of gynecological or breast issues; urological issues; presence of pelvic, breast or vaginal symptoms; sexual status; and contraceptive status

Answer 14

The correct answer is:
Information on her menstrual cycle; pregnancy history; history of vaginal and pelvic infections; history of gynecological surgeries; family history of gynecological or breast issues; urological issues; presence of pelvic, breast or vaginal symptoms; sexual status; and contraceptive status

Yes. All aspects of a woman’s breast and gynecological health, past and present, are important to cover in a woman’s wellness exam.

Question 15

Your patient with endometriosis may benefit from the “anti-estrogen” diet because of the reduction of stimulation of estrogen receptors through competitive inhibition. You recommend she focus on the following foods to reduce her symptoms.
Select one:
a. She would likely feel better if she increased her caloric intake.
b. She would likely feel better if she increased the intake of arginine-containing foods.
c. She would likely feel better if she increased her carbohydrate intake.
d. She would likely feel better if she increased her cruciferous vegetable and flaxseed intake.
e. She would likely feel better if she increased her soy intake to include several servings a day

Answer 15

The correct answer is:
She would likely feel better if she increased her cruciferous vegetable and flaxseed intake.
Yes. These nutrients would benefit her 2:16 hydroxylated estrogen levels, provide valuable fiber, and compete for estrogen receptor sites.

Question 16

The most frequently reported STI is:

Select one:

a. Gonorrhea
b. Treponema pallidum
c. Chlamydia
d. HIV
e. HSV 2

Answer 16

The correct answer is:
Chlamydia
Yes. This is the most commonly reported STD. Consider that your patient may be symptomatic, this emphasizes the value of screening recommendations for CT.

Question 17

DEXA scans are recommended by ACOG to start at:
Select one:
a. age 65 if a woman has a prior history of fractures
b. age 65 for a woman at increased risk for osteoporosis
c. age 60 in a woman with increased risk factors for osteoporosis
d. when a woman has a fracture
e. age 75

Answer 17

The correct answer is:

age 60 in a woman with increased risk factors for osteoporosis. Yes. Age 65 if no risk factors.

Question 18

Which of the following is NOT true about Mycoplasma genitalium:
Select one:
a. Female patients are often symptomatic with vaginal itching and pain during sex.
b. M. genitalium is more common than GC and less common than CT.
c. Mycoplasma genitalium should be included in your ddx list in cases of persistent or recurrent urethritis, cervicitis, and PID in women.
d. A vaccine is not available.

Answer 18

The correct answer is:
Female patients are often symptomatic with vaginal itching and pain during sex.
Correct. This is false. Patients with M. genitalium are often asymptomatic.

Question 19

General screening guidelines for STDs would include:
Select one:
a. Patients who have been at an inpatient clinic
b. Inconsistent use of OCPs
c. Presence of symptoms or suspicion of exposure at any time
d. Women under the age of 20.
e. Women with a new partner in the last 6 months

Answer 19

The correct answer is:
Presence of symptoms or suspicion of exposure at any time
Yes. Regardless of age, barrier use, or number of partners, any suspicion warrants testing

Question 20

According to the ACOG guidelines for Pap screening for cervical cancer, which of the following is true? Paps should be done:
Select one:
a. every three years after age 21 unless after age 30 the HPV test is included, in screening; then every 5 years if prior tests negative
b. every two years after the age of thirty
c. every year for all ages whether or not she’s had the HPV vaccine
d. every three years after hte age of thirty if the lastest test was positive
e. every three years once sexually active

Answer 20

The correct answer is:
every three years after age 21 unless after age 30 the HPV test is included, in screening; then every 5 years if prior tests negative

Question 21

According to the ACOG guidelines which of the following is true for mammograms. They should be done:
Select one:
a. only if patient is not doing self breast exams
b. starting at the age of 50
c. every other year from ages 50-74
d. every year for ages 40-49
e. only if findings on clinical breast exam and self breast exam are suspicious

Answer 21

The correct answer is:
every year for ages 40-49
Their recommendation is based on three factors: the incidence in this age group, the sojourn of the disease in this age group, and the rate of cure of the disease.

Question 22

Is it necessary to retest for Chlamydia and Gonorrhea, and if it is, how soon?
Select one:
a. Retesting for Gonorrhea is not necessary unless the patient is pregnant, continuing sexual encounter with an infected and untreated partner, or was non-compliant with medication. You should always retest for Chlamydia.
b. Retesting for Chlamydia is not necessary unless the patient is pregnant, continuing sexual encounter with an infected and untreated partner, or was non-compliant with medication. You should always retest for Gonorrhea
c. Retest for Chlamydia and Gonorrhea at 6 months.
d. Do not retest for Chlamydia or Gonorrhea.
e. Retest for Chlamydia and Gonorrhea at 3 months

Answer 22

Retesting for Chlamydia is not necessary unless the patient is pregnant, continuing sexual encounter with an infected and untreated partner, or was non-compliant with medication. You should always retest for Gonorrhea.

For Chlamydia, during pregnancy, you are testing for cure due to complications to the infant. In the other scenarios, you are testing for reinfection. For Gonorrhea, while it is not necessary to test for cure, the rate of reinfection is high and all patients should be retested at 3 months.

Question 23

How is a “Test of Cure” different from “Rescreening” for GC and CT?
Select one:
a. Test of Cure indicates that a patient’s treatment was successful, and they are no longer infected. Rescreening is done if there is suspicion of reinfection.
b. Test of Cure indicates that the infection has gone dormant. Rescreening indicates that the infection is active again.
c. Rescreening is done for woman under the age of 25, while Test of Cure is done at age 30 or above
d. Rescreening is done for woman under the age of 25, while Test of Cure is done at age 30 or above

Answer 23

The correct answer is:

Test of Cure indicates that a patient’s treatment was successful, and they are no longer infected. Rescreening is done if there is suspicion of reinfection.

Question 24

Which of the following is NOT a general risk factors for sexually transmitted disease:
Select one:
a.	Having multiple partners
b.	Being an adolescent
c.	Mother to infant transmission
d.	Nulliparity
e.	Abusing Alcohol

Answer 24

The correct answer is:
Nulliparity
Yes. This is not a risk factor for STDs.

Question 25

Trichomoniasis requires the following management consideration
Select one:
a. Women with Trich can be treated naturopathically without further intervention.
b. Women with Trich do not need to have their case called in to the State STD notification department. However they do need to be tested for cure at 3 months due to the high reinfection rate.
c. Women with Trich need to be retested at 6 months to ensure they are cured.
d. Women with Trich can continue to be sexually active after treatment as long as their partner is also treated.
e. Women with Trich do not need to be retested at three months to ensure they are cured.

Answer 25

The correct answer is:
Women with Trich do not need to have their case called in to the State STD notification department. However they do need to be tested for cure at 3 months due to the high reinfection rate.

Question 26

Which of the following is associated with vulvovaginal itching?
Select one:
a.	Condyloma acuminatum
b.	Lichen sclerosis
c.	Syphillis
d.	Bartholin's cyst
e.	Molluscum contagiosum

Answer 26

The correct answer is:

Lichen sclerosis. Yes. Very pruritic.

Question 27

The following is a self-limiting contagious pox virus commonly transmitted venereally:
Select one:
a.	Human Papiloma Virus
b.	Treponema pallidum
c.	Molluscum contagiosum 
d.	Chlamydia trachomatis
e.	Herpes Simplex Virus

Answer 27

The correct answer is:

Molluscum contagiosum

Question 28

What presents as a cauliflower-shaped smooth papular 1-4 mm flat lesion localized on the labia, vagina or cervix?
Select one:
a.	Klebsiella granulomatis
b.	Condyloma acuminatum 
c.	Herpes Simplex virus
d.	Haemophilus ducreyi
e.	Treponema pallidum

Answer 28

The correct answer is:
Condyloma acuminatum
Yes, also know as HPV genital herpes.

Question 29

What presents as a recurrent curdy discharge, itching and discomfort around the genitals and how would you treat it. Your patient had these symptoms which began three months ago after a pneumonia infection treated with antibiotics. She has delayed seeking care because the infection seems to disappear after her menses. She uses the Nuva ring for birth control. On physical exam, there is mild bilateral inguinal lymphadenopathy, and a white heterogeneous discharge is noted coming from the introitus. Her labia minora and majora are erythematous and edematous. On speculum exam the heterogeneous discharge is copious and adheres to the vaginal walls without any emitting from the cervical os. Wet mount reveals a pH of 4.0 and a negative Whiff test. Microscopic exam reveals the presence of healthy epithelial cells at 5-10 pf, white blood cells 5-10 pf, a normal amount of bacterial rods and an absence of Trichomoniasis. KOH prep side shows lysed epithelial cells, and hyphae with budding yeast..

Select one:

a. condyloma acuminatum, treated with salicyclic acid topically, and oral vitamin C at 2 grams, and mixed carotenes at 150,000IU a day.
b. Candida albicans, treated with oral probiotics, avoidance of refined carbs, and wiping the area with witch hazel.
c. Bacterial vaginosis, treated with probiotic suppositories and Vitamin A&E suppositories inserted daily for seven days.
d. herpes simplex virus, treated with high lysine/low arginine diet, oral Lysine at 1500mg a day, and oral Vitamin C at 2g a day.
e. lichen sclerosis, treated with topical vitamin A, sitz baths with oatmeal, and cold packs before bed.

Answer 29

The correct answer is:

Candida albicans, treated with oral probiotics, avoidance of refined carbs, and wiping the area with witch hazel.

Question 30

Leukoplakia is a concern because:
Select one:
a. it is caused by toxic shock syndrome
b. it is considered a sexually transmitted infection
c. it causes intolerable itching and patient discomfort
d. it is considered a precancerous lesion
e. it requires a cervical biopsy to assess

Answer 30

The correct answer is:

it is considered a precancerous lesion

Question 31

What condition presents as a pruritic, erythematous, warm, and superficial infection of the vulva with potential heterogeneous discharge from the vagina?
Select one:
a.	Trichimoniasis vaginalis
b.	Bacterial vaginosis
c.	Eczema
d.	Candidiasis 
e.	Folliculitis

Answer 31

The correct answer is:

Candidiasis

Question 32

Testing for genital herpes simplex ideally should include:
Select one:
a. wet mount
b. microscopic examination of a KOH prep of the sore
c. microscopic examination of the crust of the sore
d. acetowhitening on the lesion
e. viral culture of the vescicular fluid

Answer 32

The correct answer is:

viral culture of the vescicular fluid

Question 33

The procedure for a wet mount is done in the following order:
Select one:
a. add saline, put two drops on slide, and examine for yeast budding
b. add KOH to test tube, sample pH, then drop onto slide for microscopic examination
c. check pH with one swab, add saline then KOH to tube, and exam under microscope
d. check pH, add saline, add two drops to slide, and add KOH to one side
e. wipe swab sample on slide in two areas, check one side for pH and add KOH on other side

Answer 33

The correct answer is:

check pH, add saline, add two drops to slide, and add KOH to one side

Question 34

Uncomplicated vulvlovaginal candidiasis is characterized by:
Select one:
a. Lesions that are unresponsive to initial short courses of topical anti-fungal treatments
b. Extensive vulvar erythema and edema, evidence of excoriation and the presence of fissures.
c. Irritation unresponsive to naturopathic interventions.
d. Sporadic or infrequent presentation, mild to moderate symptoms, and diagnosed in non-immunocompromised women.

Answer 34

The correct answer is:

Sporadic or infrequent presentation, mild to moderate symptoms, and diagnosed in non-immunocompromised women.

Question 35

Naturopathic treatment for HPV genital warts could include everything, EXCEPT:
Select one:
a. cryotherapy
b. topical estrogen application
c. Vitamin C 4 grams a day
d. folic acid at 10mg/day
e. topical Glycyrrhiza glabra twice a week

Answer 35

The correct answer is:

topical estrogen application

Question 36

Approaches to treat Bartholin’s cyst would include:
Select one:
a. Glycyrrhiza glabra applied twice a day
b. Podophyllum 0.5% cream applied twice a day
c. Sitz baths three times a day
d. cryotherapy
e. culture

Answer 36

The correct answer is:

Sitz baths three times a day

Question 37

A painless genital ulcer is caused by:
Select one:
a.	Haemophilus ducreyi
b.	Treponema Pallidum 
c.	Herpes simplex
d.	fixed drug reaction
e.	Crohn's disease

Answer 37

The correct answer is:

Treponema Pallidum

Question 38

According to the Amsel criteria, bacterial vaginosis is diagnosed by all of the following EXCEPT:
Select one:
a.	Strawberry cervix 
b.	Clue cells
c.	pH of 5.0
d.	positive Whiff test
e.	homogenous discharge

Answer 38

The correct answer is:

Strawberry cervix

Question 39

What presents with with intense burning and pain on the genitalia and what is an appropriate treatment. The area is uncomfortable to sit on for the visit. Your patient has had a new sexual partner a week ago, and used a condom. She didn’t notice any sores on his penis, but didn’t ask his sexual history. You notice numerous 2-3mm ulcerated sores and vesicles on an erythematous base on her labia. There are several sores with crusts and several weeping pustules as well.
Select one:
a. Bacterial vaginosis, treated with probiotic suppositories and Vitamin A&E suppositories inserted daily for seven days.
b. Condyloma acuminatum, treated with salicyclic acid topically, and oral vitamin C at 2 grams, and mixed carotenes at 150,000IU a day.
c. Herpes simplex virus, treated with high lysine/low arginine diet, oral Lysine at 1500mg a day, and oral Vitamin C at 2g a day.
d. Lichen sclerosis, treated with topical vitamin A, sitz baths with oatmeal, and cold packs before bed.
e. Candida albicans, treated with oral probiotics, avoidance of refined carbs, and wiping the area with witch hazel.

Answer 39

The correct answer is:
Herpes simplex virus, treated with high lysine/low arginine diet, oral Lysine at 1500mg a day, and oral Vitamin C at 2g a day.

Question 40

Normal vaginal discharge would be described as:
Select one:
a. heterogenous discharge with fishy odor
b. frothy discharge with pH of 4.0
c. hetergenous white discharge
d. pH of 5.0 and homogenous
e. homogenous white discharge with a pH of 4.5

Answer 40

The correct answer is:

homogenous white discharge with a pH of 4.5

Question 41

The advantages of an ultrasound of the breast include:
Select one:
a. Interpretation does not rely on the radiologist’s experience
b. It is the least expensive screening tool available for breast imaging.
c. It’s ability to detect microcalcifications of the breast
d. No ionizing radiation, affordability, and the ability to distinguish from cystic versus solid masses.

Answer 41

The correct answer is:

No ionizing radiation, affordability, and the ability to distinguish from cystic versus solid masses.

Question 42

Which of the following is correct about MRI of the breast?
Select one:
a. MRI’s should only be used for assessing the extent of the disease of the breast.
b. MRI’s are an inexpensive routine screening and diagnostic tool for the breast in low risk patients.
c. MRI is used for detecting and characterizing breast tissue, assessing extent of the disease in breast tissue, evaluating efficacy of treatment in breast cancer cases and guiding biopsy. It is also used in high risk patients as a screening tool.

Answer 42

The correct answer is:
MRI is used for detecting and characterizing breast tissue, assessing extent of the disease in breast tissue, evaluating efficacy of treatment in breast cancer cases and guiding biopsy. It is also used in high risk patients as a screening tool.

Question 43

A 25 year old woman presents with concerns about a singular bump in her left breast. On palpation, the rubbery mass is 2.3 cm2 at 2 o’clock on the left breast 3 cm from her nipple. The ultrasound you ordered reveals a well-demarcated 2.4cm mass at that location. The most likely diagnoses is:
Select one:
a.	DCIS
b.	fibroadenoma 
c.	ductal hyperplasia
d.	lobular hyperplasia
e.	fibrocystic disease of the breast

Answer 43

The correct answer is: fibroadenoma

Yes. A fibroadenoma typically feels rubbery on palpation, ranges in size from 2-3 cm, and appears in younger women as a singular mass. It will also appear as a well-demarcated mass on ultrasound.

Question 44

BIRADS stands for “Breast Imaging Reporting and Database System”. A BIRADS of 3 means:
Select one:
a. The radiologist is indicating that image detect by either ultrasound or mammogram needs additional imaging.
b. The radiologist is indicating that image detect by either ultrasound or mammogram is highly suspicious.
c. The radiologist is indicating that image detect by either ultrasound or mammogram is negative.
d. The radiologist is indicating that image detect by either ultrasound or mammogram is likely benign.

Answer 44

The correct answer is:
The radiologist is indicating that image detect by either ultrasound or mammogram is likely benign.

Yes. The radiologist is indicating that while the image detect by either ultrasound or mammogram is likely benign, a short-course follow up for additional imaging, usually at 3-6 months, would be prudent.

Question 45

For your 35 year old patient with spontaneous nipple discharge, if you are still suspicious of unilateral discharge after history and physical exam, the next step is:
Select one:
a.	serum prolactin levels
b.	nipple biopsy referral
c.	mammogram
d.	CBC
e.	cytology

Answer 45

The correct answer is:
mammogram

Yes, this is correct. Unilateral discharge of the breast always carries a concern for underlying malignancy, best detected by ordering a diagnostic mammogram.

Question 46

Which of the following is NOT considered a risk factor for breast cancer?
Select one:
a. menopause at age 54
b. prior history of atypical hyperplasia of the breast
c. oral birth control
d. menarche at age 9
e. nulliparity

Answer 46

The correct answer is:
oral birth control

A 2014 BMJ article reported research from 121,701 women in the Nurse’s Health Study comparing users to non-users of OCPs from 1976-1982. This study looked at health outcomes over the next 36 years, and concluded that all cause mortality did not differ between the groups. However, OCPs were associated with certain causes of death, including deaths from breast cancer. It showed a reduction in ovarian cancer. The authors clarify though that this correlated with the older formulations of OCPs which included higher amounts of estrogen hen current formulations. The small increased risk of breast cancer was found to disappear ten years after cessation of use.

Question 47

What should be included in your request for a diagnostic mammogram?
Select one:
a. Full medical history including past and current diagnoses, most current labs, relevant family history, current signs and symptoms, and your most recent chart note.
b. Signs, symptoms, relevant history (including known diagnoses) and any other information needed to demonstrate medical necessity for the imaging.
c. Naturopaths in Washington State CANNOT request diagnostic mammograms. You must refer the patient to an MD.
d. Age of patient and your diagnosis or ddx. Radiologists are busy and don’t have time to read any detailed information.

Answer 47

The correct answer is:
Signs, symptoms, relevant history (including known diagnoses) and any other information needed to demonstrate medical necessity for the imaging.

Question 48

Whether you are suspicious of a fibroadenoma or fibrocystic breast disease regarding a breast mass, the next management step is for a woman under the age of 30 is:
Select one:
a.	ultrasound 
b.	nipple cytology
c.	surgical consult
d.	mammogram
e.	referral for cyst aspiration

Answer 48

The correct answer is:
ultrasound

Yes. The ultrasound will quickly and without radiation determine the nature of the palpable mass. It is the most appropriate image to order for a young woman whose breasts are denser due to her age. It would also be appropriate to assess if the mass is still present at a follow up visit in one month before ordering the image.

Question 49

In a patient who is 35 years old, if she presents with a singular suspicious breast mass, what imaging would you order to aid your diagnosis?
Select one:
a. You would only need to order a diagnostic mammogram.
b. Order a screening ultrasound of both breasts.
c. You would only need to order a diagnostic ultrasound.
d. Order a screening mammogram and ultrasound on the breast of concern.
e. You would order a diagnostic ultrasound and mammogram.

Answer 49

The correct answer is:
You would order a diagnostic ultrasound and mammogram.

You need to order “diagnostic” procedures to focus the radiologist on your area of concern. At her age there is a concern that it could be cancer, which requires a mammogram for evaluation.

Question 50

Some of the herbs that may cause galactorrhea in a patient reporting bilateral nipple discharge include:
Select one:
a. raspberry leaf, chamomile, and green tea.
b. cloves, cardamom, and cinnamon
c. alfalfa, red clover, and vitex.
d. fenugreek, nettles, and marijuana

Answer 50

The correct answer is:

fenugreek, nettles, and marijuana

Question 51

A normal breast examination includes notes on:
Select one:
a. breast symmetry of size and color, symmetry of skin appearance, absence of axillary and clavicular lymphadenopathy; breast tissue absent of masses and tenderness
b. breast symmetry of size, color, and skin appearance, central lymphadenopathy, areolar density
c. absence of cervical lymphadenopathy, skin puckering, breast tissue absent of masses and tenderness
d. breast symmetry, absence of nipple discharge on elicitation, focal uneven texture of unilateral breast
e. inverted nipple, skin contours, breast tissue absent of masses and tenderness

Answer 51

The correct answer is:
breast symmetry of size and color, symmetry of skin appearance, absence of axillary and clavicular lymphadenopathy; breast tissue absent of masses and tenderness

Question 52

When is a CT (computed tomography) of the breast most appropriate?
Select one:
a. A CT of the breast is most appropriate when you palpate a swollen lymph node as well as a suspicious breast mass on your CBE.
b. A CT of the breast is most appropriate when it is necessary to clarify a lesion close to the chest wall, to assess treatment for a patient diagnosed with breast cancer, to assess metastasis,or to assess a patient after treatment for breast cancer.
c. A CT of the breast is most appropriate when it is necessary to screen an obese patient for breast cancer.
d. A CT of the breast is most appropriate when screening a patient with a high-risk of breast cancer.

Answer 52

The correct answer is:
A CT of the breast is most appropriate when it is necessary to clarify a lesion close to the chest wall, to assess treatment for a patient diagnosed with breast cancer, to assess metastasis,or to assess a patient after treatment for breast cancer.

Yes. All of these are true, and make it unlikely that we would be the ordering physician for this image study.

Question 53

According of the ACOG guidelines, which of the following is the best screening tool for breast cancer in women at low risk for breast cancer.
Select one:
a.	Breast MRI
b.	Breast Thermography
c.	Breast Mammography 
d.	Breast ultrasound

Answer 53

The correct answer is:
Breast Mammography

True. Mammogram has been studies extensively in large scale studies. It is the only imaging technique that can detect microcalcifications that result at the center of necrotic tissue often found at the center of cancer growth. Most invasive cancer (~70%) is associated with DCIS, which is found be detection of microcalcifications.

Question 54

A stereotactic biopsy is:
Select one:
a. A stereotactic biopsy is a biopsy done with the use of an ultrasound to guide the biopsy procedure.
b. A stereotactic biopsy is a biopsy done without the use of additional imaging technology to add the surgeon in localizing the area of concern.
c. A stereotactic biopsy is a term used to describe a biopsy done when there is suspicion of breast cancer.
d. A stereotactic biopsy is a biopsy done with the use of a mammogram to guide the biopsy procedure.

Answer 54

The correct answer is:
A stereotactic biopsy is a biopsy done with the use of a mammogram to guide the biopsy procedure.

Correcct. A stereotactic biopsy is done in a case where suspicious microcalcifications are witnessed on mammogram, without an association of a mass seen on ultrasound. Therefore, these mamogram-guided biopsies ensure that the area of microcalcifications is caught in the biopsied tissue for accurate evaluation by the pathologist.

Question 55

A 35 year old woman presents with concern about a particular breast bump that is tender before her menses. She has noticed lumps before, and avoids BSE because her breasts are always bumpy. Physical exam reveals a hard mobile 1 cm2 mass at the 5 o’clock position of the right breast, 3 cm from the nipple. The ultrasound you ordered reveals a 1.2cm2 mass with well-demarcated borders. The most likely diagnoses is:

Select one:

a. DCIS
b. lobular hyperplasia
c. ductal hyperplasia
d. fibroadenoma
e. fibrocystic breast disease

Answer 55

The correct answer is: fibrocystic breast disease

Yes, this is a good description of fibrocystic change of the breast. There are usually multiple nodules, ranging 1-1.5 cm in size, and have a hard nodular feel on palpation.

Question 56

The lab test for C. Trachomatis with the highest sensitivity is:
Select one:
a. Serology
b. Culture of cervical swab
c. Urine test
d. PCR Test performed on vaginal swab that patient has self-obtained

Answer 56

The correct answer is:

PCR Test performed on vaginal swab that patient has self-obtained

Question 57

Which of the following concerning squamous intraepithelial lesions (SIL) is TRUE?
Select one:
a. For women over 30 with low grade SIL (LSIL), the best option should be referred immediately for colposcopy, even if they have a negative HPV
b. Women with LSIL are at moderate risk for having CIN2+.
c. SILs are found mostly in older women
d. HPV viral DNA is found in less than 50% of SILs and invasive cancer

Answer 57

The correct answer is:
Women with LSIL are at moderate risk for having CIN2+.

Yes. There is a 77% risk of having a positive HPV test with LSIL results. This increases the likelihood of progression to cancer.

Question 58

Liquid preparations (SurePath and ThinPrep) for Pap samples are superior over the conventional wood spatula and slide method because:
Select one:
a. The collection device (cytobroom) is discarded with the specimen
b. The orientation of cells on the slide is consistent with their cervical location
c. There is an increased unsatisfactory specimen rate
d. The specimen can be examined in the container
e. A monolayer of cells allows for more accurate assessment of the specimen

Answer 58

The correct answer is: A monolayer of cells allows for more accurate assessment of the specimen

Yes. Liquid Pap specimens are an improved Pap collection system over the conventional slide method due to the monolayer of cells that can be created after processing the specimen

Question 59

Which of the following is a method to diagnose gonorrheal infection?
Select one:
a. Gram Stain
b. Nucleic acid amplification technique (NAAT)
c. All of the above
d. Urine NAAT test
e. Culture

Answer 59

The correct answer is:

All of the above

Question 60

Which of the following is the appropriate next step for a patient over the age of 24 with HSIL result on her Pap cytology?
Select one or more:
a. Referral for hysterectomy
b. Start escharotic treatment
c. Repeat Pap with HPV testing in 3 months
d. Colposcopy and possible immediate LEEP intervention

Answer 60

The correct answer is:
Colposcopy and possible immediate LEEP intervention

Yes. It is crucial that your patient have further evaluation of her cervix to assess the extent of the cervical dysplasia, and may require a more immediate intervention to prevent further HPV invasion.

Question 61

Which of the following is true for sex partners of a patient diagnosed with Chlamydia?
Select one:
a. All partners exposed in the last 60 days should be referred for treatment
b. Only symptomatic partners need to be referred for treatment
c. No partners need to be referred since Chlamydia is not efficiently transmitted.
d. Only the most recent sex partner needs to be referred for treatment.

Answer 61

The correct answer is:

All partners exposed in the last 60 days should be referred for treatment

Question 62

Which clinical sign is indicative of gonorrhea in women?
Select one:
a.	Dysuria
b.	None of the above.
c.	Cervicitis 
d.	Dyspareunia

Answer 62

The correct answer is:

Cervicitis Correct. Inflammation of the cervix may be present with gonorrhea.

Question 63

Complications of untreated chlamydial infection in women include all of the following EXCEPT:
Select one:
a.	PID
b.	Infertility
c.	Pruritus
d.	Ectopic pregnancy.

Answer 63

The correct answer is:
Pruritus

This answer is correct. CT is usually asymptomatic in women

Question 64

When gonorrhea is diagnosed, what is the next course of action?
Select one:
a. Treat and screen for Chlamydia and other STDs
b. Discuss risk reduction behaviors
c. Contact, test and treat sexual contacts from the past 60 days
d. Repeat testing for gonorrhea in 3 months
e. All of the above

Answer 64

The correct answer is:

All of the above

Question 65

What is the best intervention to support the resolution of cervical dysplasia in a woman taking oral contraceptives?
Select one:
a.	Folic acid and Vitamin B12 orally
b.	Green tea suppositories once a week
c.	Vitamin A orally at 10,000IU a day
d.	Indole-3-carbole at 300mg

Answer 65

The correct answer is:
Folic acid and Vitamin B12 orally
Correct. Folic acid increases DNA methyltranferase-1 in the cervix, and has a significant impact on resolving HPV status in women on OCPs. B12 is currently being studied as even more important in enhancing methylation that decreases progression to more advanced cervical dysplasia.

Question 66

The anti-viral treatment approach to HPV infection could include which of the follow non-vaginal approaches?
Select one:
a. Vitamin C at 3000mg a day, beta-carotene at 150,00IU a day, and a B-complex with high levels of folic acid and B12.
b. The use of topical estrogen, inserted into the vagina.
c. A tincture of Vitex agnus castus.
d. A phytoestrogen diet with a focus on liver-supporting foods.

Answer 66

The correct answer is: Vitamin C at 3000mg a day, beta-carotene at 150,00IU a day, and a B-complex with high levels of folic acid and B12.

Yes. All of these options have research supporting there affect on HPV infection of the cervix.

Question 67

A complication of untreated gonorrhea in women is:

Select one:

a. All of the above
b. Skene’s abscess
c. Pelvic Inflammatory Disease
d. Bartholin’s cyst

Answer 67

The correct answer is:

All of the above

Question 68

Which of the following best describes the clinical signs and symptoms of chlamydial infection in women?
Select one:
a. Most women complain of urinary symptoms
b. Clinical signs and symptoms depend on the duration of the infection
c. Most women are asymptomatic
d. Most women complain of a discharge

Answer 68

The correct answer is: Most women are asymptomatic

Correct. This is why it is necessary to screen for chlamydia in younger women, under age 25, who may have more frequent partners or may engage in unprotected sex with new partner(s).

Question 69

A mother comes in to see you about her 19 year old daughter because she is wondering if she should tell her to get the HPV vaccine. She is really scared about cervical cancer as her mother had to have a hysterectomy for invasive cervical carcinoma. Which of the following statements is TRUE:
Select one:
a. The risk of vaccine side effects is reduced if she is on oral contraceptives
b. If your daughter has regular Pap smears, she will be protected against most cases of cervical cancer without vaccination.
c. The Gardasil vaccine protects against genital warts but not cervical carcinoma
d. If her partner is vaccinated, she does not need to be

Answer 69

The correct answer is:
If your daughter has regular Pap smears, she will be protected against most cases of cervical cancer without vaccination.

Correct. Routine PAP screening will prevent most cases of cervical cancer. However, be aware that she may still be at increased risk of colposcopies, biopsies, and LEEP procedures if she contracts the infection and does not resolve the infection.

Question 70

The cytobrush for liquid Pap collection is turned how many times for collection of cervical cells?
Select one:
a.	1/2 turn 
b.	2 turns
c.	5 turns
d.	6 turns
e.	3 turns

Answer 70

The correct answer is:

1/2 turn

Question 71

Your 24 year old female patient comes in for an urgent visit due to pelvic pain 7/10 that is new to her on her lower left side. She has felt lightheaded since yesterday. The pain is worse when she has a bowel movement. On physical exam, there is positive rebound tenderness on the right side, negative CMT, and tenderness on bimanual exam of the right pelvic region. Her urine beta hCG is negative. The lab calls in 2 hours with no abnormal results on your STAT CBC. The transvaginal ultrasound returns with a hypoechoic mass of 3cm without evidence of hemorrhaging or free fluid in the pelvis, suggesting of an unruptured corpus luteal cyst. Your intervention could include:

Select one:

a. topical estrogen creams
b. broad spectrum antibiotic treatment
c. rest, castor oil packs, and 10- drops Turska’s formula every 6 hours
d. arnica 1M and ice packs
e. referral to gynecological for immediate laparoscopic surgery

Answer 71

The correct answer is:
rest, castor oil packs, and 10- drops Turska’s formula every 6 hours
Yes. This would be an appropriate protocol of a follicular ovarian cyst.

Question 72

The difference between acute and chronic pain is:

Select one:

a. the severity of the pain
b. CBC STAT results
c. the duration of the pain
d. the presence of vaginal discharge
e. the location of the pain

Answer 72

The correct answer is:
the duration of the pain
Yes. Chronic pelvic pain is pain occurring for longer than 6 months.

Question 73

What would NOT be included in your ddx list for a 37 year old female presenting with cyclic and progressing chronic central pelvic pain occurring primarily before menses, and heavy menses with intermenstrual spotting? She has not been sexually active in the last year.
Select one:
a.	follicular ovarian cyst
b.	adenomyosis
c.	chronic PID
d.	endometriosis
e.	ovarian torsion

Answer 73

The correct answer is:
ovarian torsion
Correct. Ovarian torsion presents as acute pain, usually unilateral, and rapidly progressing in severity.

Question 74

Which of the following pelvic conditions is an indication for a pelvic CT?
Select one:
a. Suspected urinary calculi in a 35 year old female experiencing flank pain.
b. Acute pelvic pain in a 35 year old pregnant female.
c. Abnormal menstrual bleeding of 2 months in a 28 year old female with no previous workup.
d. The diagnosis and biopsies of pelvic masses or ovarian cysts, endometriosis, organ removal or repair, tubal ligation, management of ectopic pregnancy, assessing infertility.

Answer 74

The correct answer is:

Suspected urinary calculi in a 35 year old female experiencing flank pain.

Question 75

A 34-year-old patient presents with acute pain, onset yesterday, with concurrent dizziness. Last menstrual period was 26 days ago. Physical exam reveals a heart rate of 112, BP 90/56, TTP in lower abdomen, and CMT. What test will give you the most information quickly?
Select one:
a.	transvaginal ultrasound
b.	CBC
c.	wet mount
d.	urine quantitative hCG 
e.	PCR Ct/GC

Answer 75

The correct answer is:

urine quantitative hCG

Question 76

Which of the following is true regarding pelvic ultrasounds?
Select one:
a. Ultrasound should only be considered for pelvic complaints and in non-pregnant women.
b. Ultrasound with Doppler is only indicated to assess abnormal uterine bleeding.
c. Pelvic ultrasound is indicated for any of the following: pelvic pain, pelvic masses, pelvic infections, PCOS, dysmenorrhea, abnormal uterine bleeding, evaluation of infertility, assessment of incontinence, and evaluations of abnormalities after pelvic surgery, delivery or abortion.
d. Pelvic ultrasounds are best in the following situations: when pelvic organs obstruct images from other diagnostic imaging or limitations created by patient size.

Answer 76

The correct answer is:
Pelvic ultrasound is indicated for any of the following: pelvic pain, pelvic masses, pelvic infections, PCOS, dysmenorrhea, abnormal uterine bleeding, evaluation of infertility, assessment of incontinence, and evaluations of abnormalities after pelvic surgery, delivery or abortion.

Question 77

Ovarian Torsion as the cause for acute abdominal pain can be difficult to determine from signs and symptoms. What test is crucial to aid you diagnosis?
Select one:
a. transvaginal ultrasound with color Doppler
b. beta hCG
c. serum CA 125 levels
d. urine hCG
e. STAT CBC

Answer 77

The correct answer is:
transvaginal ultrasound with color Doppler

Yes. TVUS and color Doppler will detect the adnexal mass and the disruption of blood flow caused by ovarian torsion.

Question 78

A 34-year-old patient presents with acute pain, onset yesterday, with concurrent dizziness. Last menstrual period was 26 days ago. Physical exam reveals a heart rate of 112, BP 90/56, TTP in lower abdomen, and CMT. What test will give you the most information quickly?
Select one:
a.	transvaginal ultrasound
b.	CBC
c.	wet mount
d.	urine quantitative hCG 
e.	PCR Ct/GC

Answer 78

The correct answer is:

urine quantitative hCG

Question 79

Which of the following is true regarding pelvic ultrasounds?
Select one:
a. Ultrasound should only be considered for pelvic complaints and in non-pregnant women.
b. Ultrasound with Doppler is only indicated to assess abnormal uterine bleeding.
c. Pelvic ultrasound is indicated for any of the following: pelvic pain, pelvic masses, pelvic infections, PCOS, dysmenorrhea, abnormal uterine bleeding, evaluation of infertility, assessment of incontinence, and evaluations of abnormalities after pelvic surgery, delivery or abortion.
d. Pelvic ultrasounds are best in the following situations: when pelvic organs obstruct images from other diagnostic imaging or limitations created by patient size.

Answer 79

The correct answer is:
Pelvic ultrasound is indicated for any of the following: pelvic pain, pelvic masses, pelvic infections, PCOS, dysmenorrhea, abnormal uterine bleeding, evaluation of infertility, assessment of incontinence, and evaluations of abnormalities after pelvic surgery, delivery or abortion.

Question 80

Ovarian Torsion as the cause for acute abdominal pain can be difficult to determine from signs and symptoms. What test is crucial to aid you diagnosis?
Select one:
a. transvaginal ultrasound with color Doppler
b. beta hCG
c. serum CA 125 levels
d. urine hCG
e. STAT CBC

Answer 80

The correct answer is:
transvaginal ultrasound with color Doppler

Yes. TVUS and color Doppler will detect the adnexal mass and the disruption of blood flow caused by ovarian torsion.

Question 81

What is an appropriate referral for a patient with a suspicion of ovarian cancer based on intake, physical exam, and imaging results?
Select one:
a. referral to a radiologist for MRI of abdomen
b. a referral to a genetic counselor to assess cancer risk
c. a referral to a gynecologist for colposcopy
d. a referral to an oncologist for an endometrial biopsy
e. surgical consult with expected laparoscopy with a gynecology oncologist;

Answer 81

The correct answer is:
surgical consult with expected laparoscopy with a gynecology oncologist;

When working with the suspicion of ovarian cancer, your patient would be best serve by seeing an gynecological oncologist because definitive diagnosis will come from laparoscopic surgery. If cancer is seen during laparoscopic surgery, the gynecology oncologist may be able to address this in the same surgical procedure, rather than further invasive procedures for your patient.

Question 82

What labs are standard laboratory testing when working up a patient with chronic pelvic pain?
Select one:
a. urine and serum beta hCG, and CBC
b. CBC, UA with culture, urine hCG, and PCR GC/CT
c. VDRL, GC/CT PCR, HSV IgM and IgG, HCV Ab
d. CBC, TSH, ESR, CT/GC PCR, Pap, HPV genotyping and UA
e. ANA, ESR, and hormone testing

Answer 82

The correct answer is:

CBC, UA with culture, urine hCG, and PCR GC/CT

Question 83

MRIs are:
Select one:
a. completely safe in pregnancy.
b. a great option for further work-up of pelvic pain and might be more accurate than TVUS in diagnosis PID, if Doppler US is not performed.
c. best at diagnosing GI and urinary complaints in cases of acute pelvic pain.

Answer 83

The correct answer is:
a great option for further work-up of pelvic pain and might be more accurate than TVUS in diagnosis PID, if Doppler US is not performed.

Question 84

In a patient with acute pelvic pain and a positive quantitative urine hCG, your next action step should be:
Select one:
a.	immediate transvaginal ultrasound
b.	STAT CBC
c.	serum quantitative hCG
d.	appointment for surgical consult
e.	course of antibiotics

Answer 84

The correct answer is:
immediate transvaginal ultrasound
Yes, as we are concerned about ectopic pregnancy.

Question 85

What would be an appropriate treatment intervention for treating pelvic inflammatory disease:
Select one:
a.	analgesics
b.	herbal antibacterial suppositories
c.	broad spectrum antibiotics 
d.	methotrexate
e.	abdominal massage

Answer 85

The correct answer is:
broad spectrum antibiotics

Yes. Absolutely necessary. Often IV antibiotics are necessary, to assess patient’s severity and response to oral treatment.

Question 86

In a patient with sudden onset unilateral pelvic pain, nausea and vomiting, and elevated temperature, BP, and HR, what is NOT included in your ddx list?

Select one:

a. endometritis
b. ovarian torsion
c. pelvic inflammatory disease
d. salpingitis
e. ectopic pregnancy

Answer 86

The correct answer is:
endometritis

No. This infection would not present with unilateral symptoms.

Question 87

When is it appropriate to refer to the emergency department in a woman with acute pelvic pain?
Select one:
a. for any case of acute pelvic pain
b. for any case with concurrent vital sign distress
c. for endometriosis
d. for pelvic inflammatory disease suspicion
e. for transvaginal ultrasounds

Answer 87

The correct answer is:
b. for any case with concurrent vital sign distress
Yes. Vital sign distress indicates a physiological crises. Combined with acute pelvic pain, these patients like need immediate assessment and care available at an ED.

Question 88

In a patient with acute pelvic pain, negative urine quantitative hCG, and positive CMT, your work up should include:
Select one:
a. STAT CBC, UA dip, abdominal ultrasound, and serum HSV IgM and IgG
b. UA dip, urine CT/GC, CBC
c. wet mount, PCR GC/CT, STAT CBC, and transvaginal ultrasound
d. immediate transvaginal ultrasound
e. serum hCG, immediate gynecology referral

Answer 88

The correct answer is:

c. wet mount, PCR GC/CT, STAT CBC, and transvaginal ultrasound
Yes. You are screening for PID: with the wet mount and GC/CT to assess for source organism(s) of the infection, assess for infection with the CBC, and looking for adnexal fluid with the TVUS.

Question 89

What are thought to be the most common causes of PCOS?
Select one:
a. A reduced expression of LH receptors on the theca cells, that causes an increase in androgen production.
b. Abnormal GnRH pulsatility, increased luteinizing hormone pulsatility, and/or hyperinsulinemia secondary to insulin resistance.
c. Elevated insulin levels result in reduced glucose availability, a necessary nutrient for ovarian development of grafiaan follicles.
d. The polycystic ovaries produce increased amount of estrogen that suppress GnRH production
e. The chromosomal abnormality of Turner’s Syndrome

Answer 89

The correct answer is:
Abnormal GnRH pulsatility, increased luteinizing hormone pulsatility, and/or hyperinsulinemia secondary to insulin resistance.

Question 90

Which of the following statement about Premature Ovarian Insufficiency is CORRECT?
Select one:
a. Progesterone replacement is needed until the age of menopause to manage the side effects of POI
b. The risk for endometrial cancer is increased
c. Cardiovascular Disease is increased in POI
d. POI usually presents with regular menstrual cycles

Answer 90

The correct answer is:
Cardiovascular Disease is increased in POI

In the Framingham Heart Study, women with POI had twice the incidence of myocardial infarction and coronary heart disease than other premenopausal women under the age of 55. As of yet, there are no double-blind studies showing that estrogen therapy reduces this risk.

Question 91

What is the most common cause of primary amenorrhea?
Select one:
a.	Gonadal failure
b.	Chronic anovulation
c.	Hypothyroidism
d.	Congenital defect
e.	Turner syndrom

Answer 91

The correct answer is:

Gonadal failure

Question 92

With all kinds of amenorrhea, what is the first thing that should be ruled out?
Select one:
a.	Turner syndrome
b.	Pregnancy 
c.	Prescribed and illicit medications
d.	Pituitary tumor
e.	Asherman’s syndrome

Answer 92

The correct answer is:

Pregnancy

Question 93

Which of the following herbal supplements could be implicated in abnormal uterine bleeding?
Select one:
a.	Gingko biloba.
b.	Oenothera biennis
c.	Urtica dioica
d.	Vitex agnus castus
e.	Achillea millefolium

Answer 93

The correct answer is: Gingko biloba

Correct. This may increase bleeding in some woman if taken at higher than usual therapeutic levels, or if on a blood thinner such as Warfarin

Question 94

Additional testing to assess abnormal uterine bleeding may include:
Select one:
a. laparoscopy and TVUS
b. TVUS and hysterosalpingogram
c. polypectomy and Pap
d. endometrial biopsy and vaginal culture

Answer 94

The correct answer is:
TVUS and hysterosalpingogram
Yes. Both of these imaging tests are appropriate to work up AUB.

Question 95

Abnormal uterine bleeding in pre-puberty girls is often due to
Select one:
a.	endogenous estrogen hormone exposure
b.	endometrial polyps
c.	genital disease
d.	leiomyomas
e.	pregancy

Answer 95

The correct answer is:

genital disease

Question 96

If abnormal uterine bleeding does not stop with naturopathic and conventional methods, assess condition next through:
Select one:
a.	laparascopic surgery
b.	endometrial biopsy
c.	wet mount
d.	pelvic MRI
e.	transvaginal ultrasound

Answer 96

The correct answer is:
transvaginal ultrasound
Yes, this is the best next step in your diagnostic work up.

Question 97

Endometrial cancer risk does NOT include:
Select one:
a.	chronic anovulatory cycles
b.	older than 35 yoa
c.	obesity
d.	nulliparity
e.	family history of breast cancer

Answer 97

The correct answer is:

family history of breast cancer

Question 98

Endometrial biopsy is appropriate in all the following situations EXCEPT:
Select one:
a. abnormal bleeding for 1 month in perimenopausal women not on HRT
b. presence of cycles less than 21 days for greater than 6 months
c. when there is evidence of endometrial cells on PAP results
d. when there is endometrial thickening noted on ultrasound
e. for postmenopausal woman not on HRT with AUB

Answer 98

The correct answer is:
abnormal bleeding for 1 month in perimenopausal women not on HRT
Correct. This is not a reason for concern about menstrual bleeding.

Question 99

Styptic herbs that may be effective to stop DUB include:
Select one:
a. Cinnamomum zeylanicum, Vinca major, and Hypericum perforatum
b. Geranium robertianum, Cinnamomum zeylanicum, and Vitex castus agnus
c. Achillea millefolium, Zingiber officinalis, and Capsella bursa pastoris
d. Geranium robertianum Capsella bursa pastoris, and Rubus idaeus

Answer 99

The correct answer is:
Achillea millefolium, Zingiber officinalis, and Capsella bursa pastoris

Correct. These are effective styptic herbs that can be used to stop dysfunctional uterine bleeding.

Question 100

A 36 year old obese woman with a known PCOS diagnosis from the age of 24 presents for the first time in your practice. She has been seen regularly for annual exam by her gynecologist, who has had her on oral contraceptive pills throughout this time to maintain her menses. She reports she is otherwise healthy. She wants to know what else she should be doing to care for her health. What is your first recommendation?

Select one:

a. DEXA scan
b. 2 hour post prandial glucose tolerance test, fasting glucose and insulin tests, and a HcA1c.
c. Serum free and total testosterone.
d. Endometrial biopsy
e. Transvaginal Ultrasound

Answer 100

The correct answer is:
2 hour post prandial glucose tolerance test, fasting glucose and insulin tests, and a HcA1c.

Yes. PCOS patients can develop insulin sensitivity, and even diabetes. This would be important to evaluate her health.

Question 101

Which of the following represents part of the possible presentation of dysmenorrhea?
Select one:
a. Symptoms such as depression that interfere with social and occupational functioning.
b. Menstrual related symptoms that can be controlled by SSRIs
c. Symptoms such as bloating and constipation that occur day 14-28 and resolve after menses
d. Symptoms such as diarrhea and back pain that occur after the onset of menstruation.

Answer 101

The correct answer is:
Symptoms such as diarrhea and back pain that occur after the onset of menstruation.

Yes. This can be part of the presentation of dysmenorrhea.

Question 102

Which of the following is NOT one of the key symptoms that must be present to diagnosis PMDD?
Select one:
a. Persistent and marked anger or irritability
b. Marked anxiety and tension
c. Marked depressed mood and feeling of hopelessness
d. Marked change in appetite
e. Marked changes in mood, such as a feeling suddenly sad

Answer 102

The correct answer is: Marked change in appetite

Correct. While this is one of the total 11 criteria for PMDD that maybe present, it not one of the four KEY criteria that must be meet to diagnose PMDD.

Question 103

Supplement considerations for PMS would include:
Select one:
a. Vitamin C to affect pelvic inflammation, Melatonin to inhibit prostaglandin production, progesterone cream to balance estrogen levels
b. Magnesium for metabolism of hormones, calcium for enhanced muscle/uterine performance, B1 aB6 for the metabolism of hormones and synthesis of neurotransmitters, EPO for anti-inflammatory
c. Fish oils at 2 grams a day, Saint John’s Wort for depression, TENS unit for pain
d. Cramp bark at 1/2 tsp every 2-3 hours for pain, Rose tea 2-3 times a day, Zingiber officinalis to affect inflammatory process.

Answer 103

The correct answer is:
Magnesium for metabolism of hormones, calcium for enhanced muscle/uterine performance, B1 aB6 for the metabolism of hormones and synthesis of neurotransmitters, EPO for anti-inflammatory
Yes. There is research behind both of these options.

Question 104

Which is true about spermicides?
Select one:
a. Women at high risk of contracting HIV infection should NOT use spermicides.
b. Spermicidal condoms are more effective at preventing pregnancy than condoms without spermicide.
c. Sermicides used without other forms of birth control can be effective to stop pregnancies.
d. Spermicides with non-oxynol 9 are effective at protecting against sexually transmitted infections.

Answer 104

The correct answer is:
Women at high risk of contracting HIV infection should NOT use spermicides.

Yes, this is correct. There is evidence that spermicides with non-oxynol 9 causes genital irritation that increase the risk of contracting HIV.

Question 105

A 29 year old, gravida 2, para 2 female has been attempting to conceive for the last two years. She and her husband are otherwise healthy, denying smoking, drinking and drugs. He has been tested and has a normal sperm count and sperm morphology. She menstruate every 28 days, for 3-4 days, as she has for years. She did have surgery five years ago for a ruptured appendix. The likely cause of her infertility is:

Select one:

a. Oocyte quality
b. Tubal factors
c. Unexplained infertility
d. Uterine mechanical factors
e. Ovulation issues

Answer 105

The correct answer is:
Tubal factors

Yes. There is an increase in adhesions possible for any pelvic infection, whether PID or appendicitis. The fallopian tubes could be affected by scarring. This diagnosis could be confirmed with hysterosalpingogram.

Question 106

How does oral hormonal contraception prevent pregnancy?
Select one:
a. Oral birth control prevent pregnancy by altering the timing of the LH surge so that there is no longer an adequate luteal phase for the egg to sufficiently implant.
b. Oral birth control prevent pregnancy by stimulating FSH and LH levels, thus suppressing estrogen and progesterone production necessary to maintain pregnancy.
c. Oral birth control prevent pregnancy by decreasing the vicsousity of the cervical mucus, and making the mucus more alkaline, thus making the environment more hospitable to the sperm.
d. Oral birth control prevent pregnancy by altering the timing of the LH surge so that there is no longer an adequate luteal phase for the egg to sufficiently implant.
e. Oral birth control prevents pregnancy by suppression of FSH and LH, thickening of the cervical mucus, and thinning of the endometrial lining.

Answer 106

The correct answer is:
e. Oral birth control prevents pregnancy by suppression of FSH and LH, thickening of the cervical mucus, and thinning of the endometrial lining

Question 107

Which of the following birth control methods has typically lowest use failure rate?
Select one:
a.	IUD 
b.	Condoms
c.	Diaphragm
d.	Cervical cap
e.	Combination oral contraceptive pills

Answer 107

The correct answer is:
IUD
Yes. IUD’s have only a 0.1-2% failure rate.

Question 108

Which of the following statements about infertility is CORRECT?
Select one:
a. A 37 year old woman that has not achieved pregnancy in 3 months should be worked up for infertility
b. Male infertility account for about 40% of the infertility in couples
c. A Clomid challenge test should be used first to asses infertility in a woman of any age
d. The first step in working up infertility would NOT include testing TSH levels.

Answer 108

The correct answer is:
Male infertility account for about 40% of the infertility in couples

Yes. Any couple experiencing infertility would include a male semen analysis in the work up for the cause of their infertility.

Question 109

A 42 year old woman gravida 1 and para 0 presents having attempted pregnancy with her husband for the last year. She had a spontaneous abortion 4 years ago, so has secondary infertility. Her and her husband are otherwise healthy. Her husband has a healthy sperm count and morphology. She menstruates every 28 days, and bleeds for 4-5 days, without any changes. On lab work, her FSH and LH are within normal limits. Her AMH is <1.0ng/mL. What is her dx?

Select one:

a. Uterine factors
b. Oocyte quality and quantity
c. Tubal factors
d. Unexplained infertility
e. Ovulation dysfunction.

Answer 109

The correct answer is:
Oocyte quality and quantity

Yes. She is demonstrating decreasing ovarian reserve as indicated by the low AMH value, and her ovarian quality will have declined by this age.

Question 110

What birth control method is thought to deplete B6, and possibly folic acid?
Select one:
a.	Oral Contraceptive pills
b.	Implanon
c.	Depo-provera shots
d.	Vaginal Estrogen Ring
e.	Intrauterine Devices

Answer 110

The correct answer is:
Oral Contraceptive pills

Yes. OCPs are being shown in recent studies to deplete B6 levels, which is of particular concern as women may still become pregnant on OCPs, and would now enter pregnancy with B6 deficiencies. Older non-placebo controlled studies also suggested folic acid deficiency in women taking OCPs. There is question now about whether these women had folic acid deficiencies before entering the studies. Folic acid depletion by OCPs is currently under further investigation.

Question 111

If a woman is a 37 year old smoker, which of the following birth control methods would carry the highest risk?

Select one:

a. Monophasic low dose pill
b. Orhto Evra Patch
c. The mini pill
d. FemCap
e. Depo Provera injection

Answer 111

The correct answer is:
Orhto Evra Patch
Yes, A recent black box warning found that patches cause the highest circulating levels of estrogen, and estrogen’srisk for thromboembolism is increased with smoking, so an estrogen patche would present the highest risk

Question 112

What are some of the physiological traits necessary for pregnancy to occur?
Select one:
a. In order for pregnancy to occur, ovulation needs to be prevented through the suppression of FSH and LH, the cervical mucus needs to be scant and viscous, and the endometrial lining needs to be thin.
b. In order for pregnancy to occur, the sperm must contact the egg in the uterus, the vaginal mucus needs to be acidic, and the endometrial lining needs to be thin to allow implantation.
c. In order for pregnancy to occur, the vaginal mucus must be alkaline and hospitable to the sperm, the egg needs to be present and able to pass through the fallopian tubes, the endometrial lining must be thick enough for implantation, and hormone levels must be appropriate to maintain pregnancy.

Answer 112

The correct answer is:
c. In order for pregnancy to occur, the vaginal mucus must be alkaline and hospitable to the sperm, the egg needs to be present and able to pass through the fallopian tubes, the endometrial lining must be thick enough for implantation, and hormone levels must be appropriate to maintain pregnancy.

The complete list includes: the semen must be able to deliver sperm to the cervix, the sperm must be mobile and healthy, the vaginal mucus must be hospitable to the sperm, the egg neds to be present and able to pass through the fallopian tubes, fertilization and implantation must be able to occur, and hormone levels must be appropriate to maintain pregnancy.

Question 113

The ACHES acronym helps to assess risk of harm in the use of one particular birth control method.  For which BCM would you use this tool?
Select one:
a.	Oral Contraceptive pills 
b.	Depo-Provera Shots
c.	FemCap device
d.	Intrauterine Devices
e.	Implanon

Answer 113

The correct answer is:
Oral Contraceptive pills

Yes. ACHES stands for (A) Abdominal Pain; (C) Chest Pain; (H) Headaches; (E) Eyes/Vision changes; (S) Severe Leg Pain/DVT. All of these symptoms suggest increased clotting which can occur due to increased levels of estrogen from ingesting OCPs. If your patient responds positive to any of these questions asked annually when renewing their prescription, then the OCPs should be stopped to rule out OCP as the causative factor. If a patient has these symptoms in response to OCPs, they are NOT a candidate for HRTs during menopause.

Question 114

A diaphragm needs to be refit for your patient…
Select one:
a. anytime a patient has a pelvic infection
b. anytime your patient has a yeast infection.
c. anytime the patient has a 15-pound weight change.
d. anytime a patient has a new partner.

Answer 114

The correct answer is:

anytime the patient has a 15-pound weight change.

Question 115

What is the significant health warning against the use of the progesterone/estrogen patch?
Select one:
a. The hormonal patch is associated with an increased risk of contracting HIV.
b. The hormonal patch may lead to higher levels of circulating estrogen levels.
c. The hormonal patch has a higher failure rate due to the need for women to apply it for three weeks, remove it for one week, and then attach another one after that one week period.
d. The hormonal patch is associated with higher risk of breast cancer than other hormonal birth control methods.

Answer 115

The correct answer is:
The hormonal patch may lead to higher levels of circulating estrogen levels.

Correct. In 2005, Ortho Evra patients were found to have up to 60% higher levels of total estrogen than those women taking an OCP with 35 mcg. This carries the increased risk of the main side effect, thromboembolism.

Question 116

Which of the following is NOT a normal change noted in menopause?
Select one:
a. Breast density decreases
b. Loss of pelvic tone
c. Uterus size reduced
d. Ovaries are palpable on bimanual exame. Decrease in vaginal rugae

Answer 116

The correct answer is:
D. Ovaries are palpable on bimanual exam. No. Ovaries usually diminish in size after menopause. A larger and palpable ovary warrants further investigation.

Question 117

Which of the following is a contraindication to hormone replacement therapy?
Select one:
	a. Tension headache
	b. Osteopenia
	c. Mastodynia
	d. Clinical depression
	e. Venous thrombosis

Answer 117

The correct answer is:

Venous thrombosis. Yes, since estrogen increases clotting risks, DVT is a contraindication

Question 118

Of the following natural support options, which ones are known to reduce hot flashes?
Select one or more:
a. Maca
b. Saint John’s Wort and Gingko biloba
c. Cimicifuga racemosa and Panax ginseng
d. Soy, Flaxseed, and Hesperidan Methyl Chalcone
e. Red clover

Answer 118

The correct answer is:

d. Soy, Flaxseed, and Hesperidan Methyl Chalcone. Yes, there is some evidence that supports the use of soy and hesperidan, and great evidence that flaxseed is beneficial.

Question 119

Which of the following statements concerning hormone replacement therapy, (HRT) is TRUE?
Select one:
a. HRT in high doses is indicated for long term support of bone density
b. The WHI found that HRT was contraindicated for the short term treatment of vasomotor symptoms
c. The WHI found that HRT was contraindicated for the prevention of CAD in menopausal women
d. Bio-identical estrogen and progesterone hormone replacement therapy has less risk than pharmaceutical hormone replacement therapy.

Answer 119

The correct answer is: The WHI found that HRT was contraindicated for the prevention of CAD in menopausal women.

Question 120

A 49-year-old woman presents with a 3-year history of decreased sexual desire, arousal, and orgasmic function. She had undergone a hysterectomy with bilateral salpingo-oophorectomy for endometrial hyperplasia 5 years previously. Which of the following would be an appropriate option?
Select one:
a. SSRI antidepressants
b. Biphosphonates
c. Vaginal estriol suppositories
d. Topical testosterone gel delivering a maximum of 300 ug/daily
e. HRT containing estrogens and progestins

Answer 120

The correct answer is: Topical testosterone gel delivering a maximum of 300 ug/daily. Yes with the removal of the ovaries, the circulating levels of androgens is decreased, resulting in female sexual dysfunction. One option is testosterone replacement.

Question 121

Which of the following lists are all common complaints experienced by women during the menopause transition?
Select one or more:
a. Osteoporosis, constipation and hypersomnia.
b. Vasomotor symptoms, weight gain, mood changes and insomnia.
c. Insomnia, menometrorrhagia, joint laxity.
d. Vision changes, breast density increases, and long-term memory loss.

Answer 121

The correct answer is: Vasomotor symptoms, weight gain, mood changes and insomnia.

Question 122

Which of the following is considered a marker for menopause?
Select one:
a.	FSH > 40 IU/uL 
b.	Progesterone <0.3 ng/ml
c.	 DHEA > 150 ng/dL
d.	Elevated TSH
e.	Estradiol <40 pg/ml

Answer 122

The correct answer is: FSH > 40 IU/uL. Yes. This would be lab evidence of menopause, although it is not necessary to diagnose menopause.

Question 123

Which of the following concerning post-menopausal estrogens is NOT correct?
Select one:
a. The ovarian stroma produces estradiol.
b. Aromatization in fat muscle and liver is a source of estrogen for menopausal women
c. Estrone from non-follicular sources is the major source of post-menopausal estrogen
d. The adrenal glands secrete androstenedione which is converted to estrone

Answer 123

The correct answer is: The ovarian stroma produces estradiol. The ovarian stroma produces androstenedione, which is converted to estrone. After menopause virtually all ovarian production of estradiol stops.

Question 124

A 64-year-old woman who had undergone a total abdominal hysterectomy/bilateral salpingo-oophorectomy(BSO) at age 52 years for menorrhagia presented with a 1-year history of worsening vaginal dryness and inability to have intercourse. Which of the following would be the best therapeutic option?
Select one:
a. High dose systemic estrogen
b. Systemic HRT with estrogen and progestins
c. Topical low dose estrogen preparation applied to the vagina
d. Vitamin A vaginal suppositories

Answer 124

The correct answer is: Topical low dose estrogen preparation applied to the vagina. Yes. While we would usually start with recommendations on lubricants and moisturizers, the severity of her symptoms would justify the use of low-dose topical estrogen to address her vaginal atrophy. It may only require a 1-3 month treatment duration to resolve her symptoms. We could try a course of Vitamin E suppositories first if she was not inclined toward hormone preparations.

Question 125

Overactive bladder can result due to the effects of declining estrogen on urinary mucosa. What is the recommended treatment for OAB symptoms?
Select one:
a. Ultra-low dose estrogen therapy in the transdermal form
b. Topical testosterone gel
c. Systemic estrogen therapy
d. Local application of estradiol

Answer 125

The correct answer is: Local application of estradiol. Yes. The local application of estradiol through such methods as the estradiol ring may impact the symptoms of overactive bladder.

Question 126

What serious negative sequelae can result with the use of HRT?
Select one:
a. Osteoporosis, osteopenia, and fractures
b. Diabetes, metabolic syndrome, and hypertension
c. Dementia, Alzheimer’s, and cognitive decline.
d. Venous thromboembolism, stroke, and coronary heart disease
e. Endometrial cancer, breast cancer, ovarian cancer, and coronary heart disease

Answer 126

The correct answer is: Endometrial cancer, breast cancer, ovarian cancer, and coronary heart disease. Unopposed estrogen therapy without progestins increases the risk of endometrial cancer by a relative risk of 2.3 overall. Breast cancer does increase with EPT use extending beyond 3-5 years. Ovarian cancer is only seen to increase if HRT is used for more than 10 years. Likewise, if EPT is used more than 10 years in post-menopausal women, there is an increase in CHD.

Question 127

Incontinence is generally more common in elderly women; as high as 32% in women over the age of 80. Which type is more common in younger women and what is the mechanism of this type of incontinence?
Select one:
a. Overactive bladder is more common in younger women. It is usually due to involuntary detrusor contractions of an idiopathic, neuropathic, or myopathic cause.
b. Urge incontinence is more common in younger women. It is usually due to intrinsic urethral sphincter deficiency and/or urethral hypermobility.
c. Mixed incontinence is more common in younger women. It is usually due to intrinsic urethral sphincter deficiency related to urethral hypermobility
d. Stress incontinence is more common in younger women. It is usually due to intrinsic urethral sphincter deficiency and/or urethral hypermobility.

Answer 127

The correct answer is: Stress incontinence is more common in younger women. It is usually due to intrinsic urethral sphincter deficiency and/or urethral hypermobility.

Question 128

Key points to make for your patients when they are learning Kegel’s exercise include all of the following EXCEPT:
Select one:
a. Use biofeedback to train slow and quick muscle fibers to aid in sphincter control.
b. Have them practice the Kegel’s exercise in office with your stimulation at the muscle so that they learn the area to mobilize.
c. No one should know they are doing the exercise.
d. Emphasize the importance of learning Kegel’s in patients with pelvic pain.

Answer 128

The correct answer is: Emphasize the importance of learning Kegel’s in patients with pelvic pain. Correct answer. You DO NOT want to encourage Kegel’s exercise in general for patients with pelvic pain because they usually have hypertonic pelvic floor muscles. Kegel’s would likely worsen their pelvic pain.

Question 129

When is it appropriate to refer your patient to a urologist for incontinence?
Select one:
a. If your patient is fatigued and has concurrent bladder spasms, it is appropriate to refer your patient to a urologist.
b. If your patient is mildly obese, has atrophic vaginitis and hesitancy, it is appropriate to refer your patient to a urologist.
c. If incontinence is concurrent with hematuria, recurrent gynecological or urological surgery, and/or recurrent urinary tract infections, it is appropriate to refer your patient to a urologist.
d. If your patient has a complicated UTI, history of vaginal birth(s), or recent onset of incontinence, it is appropriate to refer you patient to a urologist.

Answer 129

The correct answer is: If incontinence is concurrent with hematuria, recurrent gynecological or urological surgery, and/or recurrent urinary tract infections, it is appropriate to refer your patient to a urologist.

Question 130

Treatment for stress incontinence would be best to include:
Select one:
a. Pelvic floor rehabilitation, vaginal estrogen, pessaries and Kegel’s exercise.
b. Anti-inflammatory diet, reduction of nuts and seeds, and turmeric supplementation.
c. Elimination of bladder irritants, scheduled voiding, and herbal anti-spasmodics.

Answer 130

Your answer is correct.

The correct answer is: Pelvic floor rehabilitation, vaginal estrogen, pessaries and Kegel’s exercise.