Question 1

A 19-year-old woman comes to the student health center after a sexual assault 2 days ago. She has no fevers, chills, abdominal pain, or abnormal vaginal discharge. The patient was sexually assaulted by a man she has seen multiple times, who also attends the university. Menses are regular and occur every 29 days; her last menstrual period was 2 weeks ago. She has no known medical conditions and has had no surgeries. The patient takes no medications and has no drug allergies. She smokes cigarettes and drinks alcohol socially. There is no family history of any illness. She is sexually active with a long-term male partner, and they use condoms for contraception. The patient has no history of sexually transmitted infections. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 65/min. BMI is 20 kg/m². The abdomen is soft and nontender, with no palpable masses. Bruises and abrasions are present over the inner thighs, perineum, and vulva. Pelvic examination reveals a friable cervix that bleeds easily on contact. The vaginal mucosa is erythematous with no evidence of hematoma. The uterus is small and nontender on bimanual examination; no adnexal masses are palpated. Microscopy shows an abundance of polymorphonuclear leukocytes. Urine pregnancy test is negative. A sexual assault forensic examination is performed and evidence is collected. In addition to providing psychosocial support, which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf13_a968_8f63_1dddbbdb032f_MD0005_00 Victims of sexual assault should be offered information about emergency contraception to prevent pregnancy. In women with regular ovulatory cycles, the probability of pregnancy is as high as 30% prior to ovulation (eg, 2 weeks after the last menstrual period). A negative pregnancy test in this setting does not exclude the possibility of pregnancy as testing is positive only after implantation (eg, 4 weeks after last menstrual period). Oral emergency contraceptives prevent pregnancy by delaying ovulation. Ulipristal, an antiprogestin, is the most effective oral emergency contraceptive and may be taken up to 5 days after unprotected intercourse. Its efficacy does not decrease with time, as occurs with levonorgestrel (Plan B) and combined hormonal contraceptives. (Choice B) The copper intrauterine device (IUD) prevents fertilization by interfering with sperm function and can be placed within 5 days of unprotected intercourse for emergency contraception. The copper IUD is the most efficacious form of emergency contraception at 99% pregnancy prevention, but it is contraindicated in the setting of acute cervicitis (eg, friable cervix, multiple polymorphonuclear leukocytes on microscopy). (Choice C) The etonogestrel subcutaneous implant is a long-acting, reversible contraceptive; it is not a form of emergency contraception. (Choice D) Pelvic ultrasound is appropriate to evaluate suspected pelvic pathology (eg, ectopic pregnancy, adnexal mass, appendicitis). This patient's infectious cervicitis symptoms involve only the lower reproductive tract (eg, cervix, vagina, vulva) and can be diagnosed clinically. (Choice E) Oral contraceptive pills with progesterone doses equivalent to levonorgestrel (second-line treatment) can be used as a form of emergency contraception. However, oral contraceptive pills are less effective than ulipristal (75% compared to >85% efficacy) and have more side effects (eg, nausea, vomiting) when used in emergency contraception doses. Educational objective: Emergency contraception should be offered to patients within 5 days after unprotected intercourse. Ulipristal is the most effective oral emergency contraceptive. The copper intrauterine device is more effective than emergency oral contraceptives, but it is contraindicated in women with acute cervicitis. References: Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/20116841) ACOG committee opinion no. 592: sexual assault. (http://www.ncbi.nlm.nih.gov/pubmed/24785635) Emerging options for emergency contraception. (http://www.ncbi.nlm.nih.gov/pubmed/24453516)

Question 2

A 68-year-old woman comes to the office due to vaginal spotting. The patient first noticed dark brown blood stains on her underwear several months ago. She now wears a perineal pad that is partially stained by the end of the day. Occasionally she notices bright red blood on the pad as well. The patient has had no passage of clots or heavy bleeding. For the past year she has been sexually active with a new partner and recently noticed some postcoital bleeding. The patient has no dyspareunia, abnormal vaginal discharge, dysuria, or hematuria. She has constipation that is responsive to a high-fiber diet and stool softeners. In addition, the patient has type 2 diabetes mellitus that is managed with an oral agent. She had a cervical conization 20 years ago for cervical intraepithelial neoplasia; all subsequent Pap tests have been normal, including her most recent test 4 years ago. The patient is a former smoker but does not use alcohol or illicit drugs. Vital signs are normal. BMI is 30 kg/m². Speculum examination shows no active vaginal bleeding. There is an erosion near the posterior fornix. The cervix is erythematous but there are no nodules or lesions. The uterus is small, mobile, and nontender. There are no adnexal masses or tenderness. On Valsalva, a mass is noted to protrude past the hymenal ring. Anal sphincter tone is normal on rectal examination. Which of the following is the most likely diagnosis for this patient?

Accepted Answer

Explanation: 11ec2b69_bf07_4d53_8f63_bdbdf6442746_MD0005_00 This patient's postmenopausal bleeding is likely due to pelvic organ prolapse (POP). POP occurs as a result of damage to or atrophy of the ligaments, muscles, and nerves that support the pelvic organs. This damage leads to herniation of the uterus (apical prolapse), bladder (cystocele), or rectum (rectocele) through the vagina, resulting in vaginal pressure and a bulging mass at the introitus. Although POP can be asymptomatic, patients often have associated urinary (eg, incontinence, retention), defecatory (eg, constipation), or sexual dysfunction (eg, dyspareunia). Patients with severe, prolonged prolapse can develop vaginal or cervical erosions if the cervix and vaginal apex protrude through the introitus, rub on clothing, and become inflamed and denuded. These erosions often cause abnormal vaginal bleeding (eg, postcoital, postmenopausal). apical prolapse cystocele rectocele Risk factors for POP include obesity, increasing age, high parity, and history of operative vaginal delivery. Management options for POP include a pessary and surgical correction, which are equally efficacious. In addition, administration of vaginal estrogen is indicated to facilitate healing of cervicovaginal erosions. pessary (Choice A) Cervical cancer can present with vaginal bleeding; however, speculum examination typically shows an exophytic cervical lesion rather than a posterior vaginal fornix lesion. In addition, this patient's normal Pap tests and postmenopausal status make cervical cancer less likely. exophytic cervical lesion (Choice B) An endocervical polyp can present with abnormal vaginal bleeding and postcoital spotting; however, endocervical polyps typically have a smooth, vermiform appearance and are visible protruding through the cervical os during speculum examination. (Choice C) Endometritis presents with vaginal bleeding and is associated with new sexual partners; however, there is also uterine and cervical motion tenderness rather than a vaginal mass or erosion. (Choice E) Uterine leiomyoma can cause abnormal uterine bleeding (eg, heavy menstrual bleeding); however, examination typically reveals an enlarged, irregularly shaped uterus. Uterine leiomyoma Educational objective: Severe or prolonged pelvic organ prolapse can cause vaginal erosions that lead to abnormal vaginal bleeding (eg, postmenopausal bleeding, postcoital spotting). Treatment of prolapse is via pessary or surgical correction; erosions can be treated with vaginal estrogen. References: Pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/17382829) Practice bulletin no. 176: pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/28333818)

Question 3

A 17-year-old girl comes to the office for increasing malodorous vaginal discharge over the past week. The patient has had no fevers, chills, nausea, dysuria, hematuria, vulvar pruritus, or postcoital bleeding. Her last menstrual period was 2 weeks ago. The patient's menses have become irregular since a progestin-containing intrauterine device was placed 8 months ago. She has no chronic medical conditions or previous surgeries. The patient is sexually active with a male partner and has had 2 lifetime partners. She does not use tobacco, alcohol, or illicit drugs. The patient has no known drug allergies. She is currently a senior in high school and will be going to a local university in the fall. Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 76/min. BMI is 20 kg/m². Pelvic examination shows normal external genitalia with no lesions, erythema, or inguinal lymphadenopathy. Bimanual examination reveals no cervical motion tenderness, a mobile uterus, and no adnexal masses. On speculum examination, there is purulent discharge from the cervical os, and the ectocervix bleeds easily when touched with a cotton swab. The intrauterine device strings are visible in the cervix. A urine pregnancy test is negative. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf04_8e32_8f63_93e1c65c615d_MD0005_00 This patient has purulent cervical discharge and cervical friability, findings consistent with acute cervicitis. Other symptoms of acute cervicitis include intermenstrual and/or postcoital spotting, dysuria, and dyspareunia; however, women are often asymptomatic. Nucleic acid amplification testing is indicated for all patients with suspected cervicitis to confirm infection; however, treatment is administered empirically based on examination alone and does not require waiting for results (Choices A and D). Empiric treatment allows for earlier symptomatic relief and decreases the risk for transmission to sexual partners. A delay in treatment increases the risk for ascending infection (eg, pelvic inflammatory disease) and long-term sequelae (eg, tubal scarring, infertility). acute cervicitis infertility First-line empiric treatment is dual therapy with ceftriaxone plus doxycycline, which provides coverage against the 2 most common pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae. The patient's sexual partner(s) should also be treated. To prevent reinfection, the patient and her partner(s) should abstain from sexual intercourse for a week after completion of treatment. (Choice C) Metronidazole is used in the treatment of bacterial vaginosis and trichomoniasis. Bacterial vaginosis presents with a thin, gray vaginal discharge without associated cervical inflammation. Clue cells are observed on wet mount microscopy. Trichomoniasis can present with a friable, punctate cervix (eg, strawberry cervix) and green, frothy vaginal discharge; protozoa are visualized on wet mount microscopy. Clue cells protozoa (Choice E) For patients with an intrauterine device (IUD) who develop acute cervicitis or pelvic inflammatory disease, IUD removal does not improve clinical outcomes and therefore is not indicated. However, IUD removal can be considered in a patient whose condition does not improve with antibiotics. Educational objective: Acute cervicitis typically presents with purulent cervical discharge and a friable cervix. Management includes nucleic acid amplification testing for chlamydia and gonorrhea and empiric treatment with ceftriaxone plus doxycycline. References: Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae-2014. (http://www.ncbi.nlm.nih.gov/pubmed/24622331) Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296) Sexually transmitted diseases treatment guidelines, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26042815)

Question 4

A 19-year-old woman comes to the student health center after a sexual assault 2 days ago. She has no fevers, chills, abdominal pain, or abnormal vaginal discharge. The patient was sexually assaulted by a man she has seen multiple times, who also attends the university. Menses are regular and occur every 29 days; her last menstrual period was 2 weeks ago. She has no known medical conditions and has had no surgeries. The patient takes no medications and has no drug allergies. She smokes cigarettes and drinks alcohol socially. There is no family history of any illness. She is sexually active with a long-term male partner, and they use condoms for contraception. The patient has no history of sexually transmitted infections. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 65/min. BMI is 20 kg/m². The abdomen is soft and nontender, with no palpable masses. Bruises and abrasions are present over the inner thighs, perineum, and vulva. Pelvic examination reveals a friable cervix that bleeds easily on contact. The vaginal mucosa is erythematous with no evidence of hematoma. The uterus is small and nontender on bimanual examination; no adnexal masses are palpated. Microscopy shows an abundance of polymorphonuclear leukocytes. Urine pregnancy test is negative. The patient undergoes a sexually transmitted infection workup, including viral hepatitis, HIV, syphilis, chlamydia, and gonorrhea. She completed a hepatitis B vaccination series prior to college, and all other vaccines are up to date. Based on her history and examination, which of the following medications should be administered?

Accepted Answer

Explanation: 11ec2b69_bf14_45a9_8f63_7dff672bab38_MD0005_00 Sexual assault victims should be provided empiric post-exposure prophylaxis for chlamydia (azithromycin), gonorrhea (ceftriaxone), trichomoniasis (metronidazole), and HIV (tenofovir-emtricitabine with raltegravir). Post-exposure prophylaxis with the hepatitis B vaccination is dependent on vaccination status and is not indicated in this patient due to her recent vaccination. In addition, this patient does not require metronidazole due to a microscopic examination without evidence of trichomoniasis (eg, flagellated, motile organisms). (Choice A) HIV post-exposure prophylaxis should be offered to sexual assault victims within 72 hours of the assault, particularly if there is evidence of genital trauma, anal intercourse, or multiple assailants due to increased risk of acquisition of HIV. (Choices B and C) Hepatitis B immune globulin is not indicated for patients who have been vaccinated against hepatitis B. In nonimmune patients, hepatitis B vaccination is administered after exposure; hepatitis B immunoglobulin is added if the assailant is hepatitis B positive. (Choice D) Penicillin is used to treat syphilis. Currently, syphilis post-assault prophylaxis is not recommended. Management is with serologic testing at initial evaluation and repeat serologies at 6 weeks and 3 months. Educational objective: Sexual assault victims are treated empirically for chlamydia, gonorrhea, and trichomoniasis. Post-exposure prophylaxis for hepatitis B depends on immunity. HIV prophylaxis is offered up to 72 hours after the assault. References: ACOG committee opinion no. 592: sexual assault. (http://www.ncbi.nlm.nih.gov/pubmed/24785635)

Question 5

A 26-year-old woman is brought to the emergency department due to lower abdominal pain for the past 2 days. She reports intractable nausea and vomiting over the last day, but has no fever, chills, sick contacts, or diarrhea. She recently had an hCG injection in preparation for an egg retrieval for infertility treatment. The patient has a history of polycystic ovarian syndrome and has had no surgeries. Family history is noncontributory. She takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs. Blood pressure is 90/50 mm Hg and pulse is 110/min. BMI is 35 kg/m². Physical examination shows a distended abdomen with normal bowel sounds and diffuse lower abdominal tenderness to deep palpation. There is no rebound, guarding, or costovertebral angle tenderness. Urine pregnancy test is positive. Transvaginal ultrasound shows bilateral ovarian enlargement with multiple cysts measuring up to 8 x 8 cm and intraabdominal fluid consistent with ascites. Doppler shows preserved blood flow to both ovaries. Which of the following is the most likely cause of this patient's condition?

Accepted Answer

Explanation: 11ec2b69_befd_fe80_8f63_afb260c4e615_MD0005_00 This patient is most likely experiencing ovarian hyperstimulation syndrome (OHSS), a rare but potentially devastating complication of ovulation induction. Ovulation induction agents (eg, hCG injections) are used to stimulate multiple follicle production in preparation for egg retrieval in patients undergoing in vitro fertilization (IVF) for infertility treatment. When the follicles undergo artificial maturation via the hCG injection, the ovaries overexpress vascular endothelial growth factor (VEGF), resulting in increased vascular permeability and capillary leakage. This increased permeability causes a fluid shift to the extravascular space (eg, third spacing). Patients with OHSS typically present 1-2 weeks after ovulation induction treatment with nausea, vomiting, abdominal pain, and bilaterally enlarged ovaries with multiple follicles. Other features include rapid weight gain, dyspnea, and oliguria/anuria. In these patients, the increased extravascular volume results in ascites, pleural and pericardial effusions, and electrolyte imbalances. The concomitant intravascular volume depletion causes hemoconcentration, hypercoagulability, and hypovolemic shock in severe cases. Complications of OHSS include renal failure, acute respiratory distress syndrome, disseminated intravascular coagulation/thromboembolism, and death. Initial workup includes complete blood count, serum electrolytes, coagulation studies, and β-hCG levels. Treatment includes correcting electrolyte imbalances, performing therapeutic paracentesis or thoracentesis, and monitoring fluid balances. (Choice A) Ruptured ectopic pregnancy may cause abdominal pain with a positive pregnancy test; however, ultrasound shows a unilateral, complex, adnexal mass rather than bilateral, enlarged ovaries. The hCG injection for IVF causes a positive urine pregnancy test; however, it is a false-positive result. (Choice B) A normal course of IVF may cause mild symptoms, including breast tenderness, bloating, abdominal cramping, and constipation. (Choice D) Ovarian torsion may occur in patients with OHSS due to ovarian enlargement. However, the typical presentation is a sudden onset of unilateral pelvic pain and absent Doppler flow to the ovary. This patient has preserved blood flow to the ovaries, making this diagnosis less likely. (Choice E) Patients with a ruptured ovarian cyst can have sudden onset of pelvic pain and free fluid on ultrasound; however, there is an associated acute abdomen (eg, rebound, guarding) from hemoperitoneum, and acute blood loss anemia (not hemoconcentration). Educational objective: Ovarian hyperstimulation syndrome is a complication of ovulation induction therapy for infertility. Patients have bilateral enlarged ovaries, ascites, hemoconcentration, hypercoagulability, and possible multiorgan failure. References: A review on ovarian hyperstimulation syndrome (OHSS) management strategies. (http://www.ncbi.nlm.nih.gov/pubmed/28322539) Volume expanders for the prevention of ovarian hyperstimulation syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/27577848)

Question 6

A 14-year-old girl is brought to the office by her mother due to irregular menses. The patient's first menstrual period occurred a year ago. Her menses since then have been irregular and unpredictable, occurring every 3-8 weeks. The patient says that when she does have a period, the bleeding lasts 3-7 days. When she has a >6-week lapse in menses, the heavy bleeding often soaks through a tampon and large pad overnight. The patient also has passage of small clots during the first 2 days. She has had no nausea, breast tenderness, or cramping. The patient has no chronic medical conditions and takes no medications. She is not sexually active and does not use tobacco, alcohol, or illicit drugs. Family history is significant for an aunt who had a hysterectomy for endometrial hyperplasia. Blood pressure is 100/60 mm Hg and pulse is 68/min. BMI is 24 kg/m². Mild comedonal acne is present on the forehead. Skin examination is otherwise unremarkable. Breast development is Tanner stage 4. The abdomen is soft and nontender with no palpable masses. Examination of external genitalia shows Tanner stage 4 pubic hair. Urine pregnancy testing is negative. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf12_e617_8f63_77fa2fba3afb_MD0005_00 Anovulatory bleeding is the most common reason for abnormal uterine bleeding in adolescents during the first few years after menarche. In early puberty, the immature hypothalamic-pituitary-ovarian axis produces insufficient amounts of GnRH. This insufficiency results in the inability to mount an LH surge for ovulation. When ovulation fails to occur, the corpus luteum does not form, progesterone production does not occur, and the normal, synchronized endometrial sloughing triggered by progesterone withdrawal (ie, menses) does not happen. hypothalamic-pituitary-ovarian axis The result is a noncyclical, unopposed production of estrogen that leads to estrogen breakthrough bleeding, a dyssynchronous sloughing of varying portions of the endometrium. This leads to irregular bleeding that can range from light to heavy with passage of clots and is typically without premenstrual symptoms (eg, cramping, breast tenderness, nausea). estrogen breakthrough bleeding Because anovulatory bleeding typically resolves within 1-2 years of menarche with maturation of the hypothalamic-pituitary-ovarian axis, management is with reassurance and observation. Hormonal contraception can be considered for menstrual cycle control for severe symptoms or patient preference. (Choice A) Endometrial biopsy is indicated to exclude endometrial cancer and/or hyperplasia in adolescents with abnormal uterine bleeding that persists despite medical management (eg, oral contraceptives) or after 2-3 years of untreated anovulatory bleeding in patients with risk factors (eg, obesity). Although this patient has a family history of endometrial hyperplasia, her normal BMI decreases her risk for endometrial cancer; therefore, biopsy is not indicated. (Choice B) Pelvic ultrasound is indicated to evaluate for structural uterine anomalies (eg, leiomyoma, polyps) in adolescents with abnormal menstrual bleeding that does not normalize with conservative management and/or oral contraceptive use. However, these anomalies are uncommon in adolescents. (Choice D) Ristocetin cofactor activity is used to evaluate for von Willebrand disease (vWD), which can present with heavy, prolonged (>7 days) menstrual periods. However, patients with vWD have regular, rather than irregular, menses, making this diagnosis less likely. (Choice E) A testosterone level is indicated in the evaluation of amenorrhea/oligomenorrhea when polycystic ovary syndrome is suspected based on clinical features suggestive of hyperandrogenism (eg, hirsutism) and/or insulin resistance (eg, acanthosis nigricans, obesity). Educational objective: In adolescents, the most common cause of irregular menstrual bleeding is anovulation, a result of an immature hypothalamic-pituitary-ovarian axis. First-line treatment is reassurance and observation. Hormonal contraception can be considered for severe symptoms or according to patient preference. References: Evaluation and management of adolescents with abnormal uterine bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/26431240) Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/23787936)

Question 7

A 60-year-old woman comes to the office due to new-onset pelvic pressure. The patient reports increasing pelvic pressure over the last 3 months, now with associated urinary frequency. She has no abdominal pain, dysuria, or hematuria. The patient reports some dyspnea on exertion; review of systems is otherwise negative. The patient has a history of breast cancer at age 45; it was treated with radical mastectomy, chemotherapy, and adjuvant tamoxifen therapy. The cancer has since been in remission and she had a normal mammogram last year. The patient has no other chronic medical conditions. She underwent menopause 8 years ago and has had no episodes of postmenopausal vaginal bleeding. The patient has had no abnormal Pap tests, the last of which was 3 years ago. She does not use tobacco, alcohol, or illicit drugs. Blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 18/min. BMI is 26 kg/m². Decreased breath sounds are noted over the lower base of the right lung. Abdominal examination reveals normoactive bowel sounds and mild distension but no tenderness. On bimanual examination, a 12-week-sized, irregularly shaped uterus is noted, but there are no adnexal masses. Urinalysis is within normal limits. Pelvic ultrasound shows a dense focal mass measuring 9 cm in the anterior fundus of the uterus, normal ovaries bilaterally, and a moderate amount of free fluid in the posterior cul-de-sac. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf17_a10e_8f63_8ba32194aa73_MD0005_00 This patient has metastatic uterine sarcoma, a malignancy originating from the myometrium or endometrial connective tissue. The ultrasonographic appearance of sarcomas is often indistinguishable from that of leiomyomas. Therefore, sarcomas are often incidentally diagnosed via histopathologic evaluation of specimens removed from patients who underwent surgery for presumed benign disease (eg, leiomyomas). However, uterine sarcoma should be suspected in postmenopausal patients with new-onset pelvic pressure or pain, uterine mass, and ascites (eg, free fluid in the posterior cul-de-sac). Other clinical features include postmenopausal or abnormal uterine bleeding and abdominal distension. The most common site of metastasis is the lungs (eg, pleural effusion). Risk factors for uterine sarcoma include tamoxifen use and pelvic radiation. A hysterectomy is performed to confirm the diagnosis and stage the disease. Adjuvant chemotherapy and/or radiation therapy may be indicated. Uterine sarcoma is an aggressive tumor with a high risk of recurrence and poor prognosis. (Choices A and B) Gonadotropin-releasing hormone (GnRH) agonists temporarily cause amenorrhea and decrease leiomyoma size in patients with leiomyomas that are causing symptoms (eg, heavy bleeding). GnRH agonists are used primarily as preoperative therapy in patients with benign disease. In patients with suspected malignancy, observation and GnRH agonist therapy delay diagnosis and allow disease progression. (Choices D and E) Myomectomy and uterine artery embolization are indicated for patients who have symptomatic leiomyomas that failed medical management and who would like uterine conservation. However, in patients with malignancy, both surgeries result in incomplete cancer staging and inadequate tumor debulking. Educational objective: Uterine sarcoma typically presents in postmenopausal patients with a history of previous tamoxifen use or pelvic radiation. Presenting symptoms can include new-onset pelvic pressure or pain, a uterine mass, ascites, and symptoms of metastasis (eg, pleural effusion). Treatment is with hysterectomy. References: Uterine leiomyosarcoma: epidemiology, contemporary treatment strategies and the impact of uterine morcellation. (http://www.ncbi.nlm.nih.gov/pubmed/28209496) Uterine leiomyosarcoma: a review article. (http://www.ncbi.nlm.nih.gov/pubmed/25304676)

Question 8

A 33-year-old woman comes to the emergency department due to abdominal pain.  The pain began 2 weeks ago and was initially mild, episodic, confined to the right lower quadrant, and resolved spontaneously without intervention.  For the past 6 hours, the pain has been severe, constant, unrelieved by ibuprofen or acetaminophen, and radiating to the right flank.  The pain is now accompanied by constant nausea and multiple episodes of emesis.  The patient has had no diarrhea or recent travel.  She has no chronic medical conditions but did have an appendectomy.  The patient was treated for Chlamydia trachomatis cervicitis as a teenager.  She is not currently sexually active.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38 C (100.4 F), blood pressure is 130/80 mm Hg, pulse is 83/min, and respirations are 16/min.  Abdominal examination shows tenderness and guarding in the right lower quadrant but no suprapubic or costovertebral angle tenderness.  Pelvic examination shows a small, nontender, retroverted uterus and a tender right adnexal mass.  Speculum examination is normal.  Urine pregnancy test is negative.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf01_80f1_8f63_5b27f88c8bd2_MD0005_00 This patient's presentation of right-sided pelvic pain with a tender adnexal mass is concerning for ovarian torsion, a surgical emergency that typically affects reproductive-age women. Ovarian torsion is the partial or complete rotation of the ovary around the infundibulopelvic (suspensory ligament of the ovary) and utero-ovarian ligaments, which can affect ovarian blood supply as the ovarian vessels travel in the infundibulopelvic ligament. Right-sided torsion is more common due to the greater length of the right utero-ovarian ligament and because the rectosigmoid colon occupies the space around the left ovary. Risk factors for torsion include pregnancy, ovulation induction during infertility treatment, and ovarian masses >5 cm. Ovarian torsion Patients usually develop intermittent pelvic pain followed by an acute onset of moderate to severe pelvic pain, nausea, and vomiting. Fever and leukocytosis indicate possible adnexal necrosis. Pelvic examination may reveal a palpable tender adnexal mass. Initial evaluation includes complete blood count, electrolytes, and serum β-hCG (to exclude ectopic pregnancy). First-line imaging is a pelvic ultrasound with color Doppler, which typically reveals an enlarged, edematous ovary with impaired ovarian blood flow. Management includes detorsion with emergent surgery, which also provides a definitive diagnosis. Salpingo-oophorectomy is reserved for obvious adnexal necrosis or suspected ovarian malignancy. Untreated torsion may lead to chronic pelvic pain and infertility. (Choices A, B, and C) Risk factors for pelvic inflammatory disease (PID) and a tubo-ovarian abscess include multiple sex partners, younger age (15-25), and prior history of PID. Patients with a tubo-ovarian abscess typically present with fever, purulent cervical discharge, and cervical motion or uterine tenderness, which are not seen in this patient. Diagnostic evaluation includes chlamydia and gonorrhea nucleic acid amplification testing. Management of a tubo-ovarian abscess includes intravenous antibiotics and possible CT-guided aspiration, which may be used to drain a small, unilocular pelvic abscess and guide antibiotic therapy. (Choice D) Although analgesia is important for patients with pain, ovarian torsion must be evaluated prior to discharging the patient due to the risk of ischemia resulting in loss of ovarian function. Educational objective: Ovarian torsion typically occurs in reproductive-age women and presents with sudden onset of unilateral pelvic pain and a tender adnexal mass. First-line imaging is a pelvic ultrasound with color Doppler, which typically shows an enlarged, edematous ovary with decreased blood flow. References: Adnexal torsion: review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/24126258) Sonographic diagnosis of ovarian torsion: accuracy and predictive factors. (http://www.ncbi.nlm.nih.gov/pubmed/21876091)

Question 9

A 17-year-old girl, gravida 0 para 0, comes to the office for routine examination and an oral contraception prescription.  Her menses occur every 28 days and her last menstrual period was 3 weeks ago.  She is feeling well and is preparing to leave for college in 5 months.  The patient has no chronic medical conditions or previous surgeries.  She has no history of migraine headaches or thromboembolism.  The patient is up to date on all vaccinations.  Her maternal grandmother has hepatitis B; family history is otherwise noncontributory.  The patient currently takes no medications and does not use tobacco, alcohol, or illicit drugs.  She has no known drug allergies.  She has been sexually active with one partner for the past 2 years and uses condoms for contraception.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 72/min.  Weight is 60 kg (132.3 lb) and height is 162.5 cm (5 ft 4 in).  Cardiopulmonary examination is normal.  The abdomen is soft and nontender with no hepatosplenomegaly.  On pelvic examination, no vulvar or cervical lesions and no cervical discharge are present.  On bimanual examination, the uterus is small and without cervical motion tenderness.  Bilateral adnexa are small, mobile, and nontender.  In addition to an oral contraception prescription, which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf14_bada_8f63_a52295363135_MD0005_00 Chlamydia trachomatis is a common sexually transmitted infection with clinical manifestations that range from asymptomatic infection to cervicitis and pelvic inflammatory disease. Because of reproductive complications from pelvic inflammatory disease due to untreated C trachomatis infection (eg, tubo-ovarian abscess, ectopic pregnancy, infertility), detection of asymptomatic infection with routine screening is performed as part of preventive care. Sexually active women age <25 should be screened annually for gonorrhea and chlamydia with either vaginal or endocervical nucleic acid amplification testing (NAAT). Women age ≥25 with risk factors (eg, multiple sexual partners, sex workers) should also be screened. Treatment of C trachomatis infection is with azithromycin or doxycycline. In addition, patients are instructed to have either partner testing or empiric expedited partner treatment; they are also advised to abstain from sexual intercourse for at least 7 days after completion of therapy to avoid reinfection. If NAAT testing for C trachomatis is positive, screening for other sexually transmitted infections (eg, HIV, syphilis) is also indicated. (Choice A) One-time screening for hepatitis C virus is recommended in adults age 18-79 and for patients at high risk for infection (eg, injection drug users, blood transfusion recipients prior to 1992). (Choice B) In patients who are not sexually active, screening for C trachomatis may be omitted. This patient is sexually active. (Choice D) Pap testing screens for cervical dysplasia and cervical cancer. Screening is initiated at age 21 regardless of age of onset of sexual activity. This patient is age 17. (Choice E) Routine screening for syphilis with rapid plasma reagin (RPR) is indicated for high-risk individuals: men who have sex with men, patients with co-existing HIV infection, individuals with a history of incarceration, and sex workers. Pregnant women are also routinely screened. This patient has no risk factors. Educational objective: Untreated Chlamydia trachomatis infection in women can lead to complications (eg, pelvic inflammatory disease, tubo-ovarian abscess, ectopic pregnancy, infertility). Routine screening with nucleic acid amplification testing is required in sexually active women age <25. References: Sexually transmitted infections: recommendations from the U.S. Preventive Services Task Force. (http://www.ncbi.nlm.nih.gov/pubmed/27929270) CDC recommendations for hepatitis C screening among adults - United States, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/32271723)

Question 10

A 27-year-old woman comes to the physician with a 1-year history of periodic irritability, anger, tension, and sleep disturbance.  The symptoms begin predictably a week before her periods and resolve with menstrual bleeding.  She has increased appetite, headaches, breast tenderness, and ankle swelling before her periods.  The symptoms are severe enough to impair her performance at work.  The patient's past medical history is insignificant.  Her cycles are regular and last 29 days.  She has no intermenstrual bleeding or vaginal discharge.  She has never been pregnant.  The patient does not use tobacco, alcohol, or illicit drugs.  She has been sexually active with 1 partner for the last 3 years and uses condoms for contraception.  The physician prescribes fluoxetine 20 mg/day.  The patient returns after 4 months and says that her symptoms have not improved significantly.  She stopped taking fluoxetine 5 days back. 
What is the best next step in management of this patient?

Accepted Answer

Explanation: Premenstrual syndrome (PMS) is characterized by emotional and physical symptoms that occur in the second half of the menstrual cycle and resolve promptly with the onset of menses. Typical symptoms include depression, anxiety, irritability, bloating, and breast tenderness. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS characterized by predominant anger and irritability. Selective serotonin reuptake inhibitors (SSRIs) are the first-line therapy for PMS/PMDD. Fluoxetine has been studied best and has been demonstrated to relieve both affective and physical symptoms in patients with PMS/PMDD. Any single SSRI may fail to relieve symptoms in about 1/3 of patients, and so a trial of a second SSRI is usually warranted given their overall effectiveness and favorable side effect profile. If SSRIs fail and the patient does not wish to become pregnant, oral contraceptives containing estrogen and progestin are a reasonable second-line therapy (progestin-only contraceptives have not been proven effective). (Choice A) Benzodiazepines such as alprazolam are effective in treating symptoms of PMS/PMDD. However, the risk of sedation and dependence is significant, and they are usually recommended only if SSRIs fail. (Choice B) Bupropion is effective in treating depression. It also very useful in combination with SSRIs in women as it can reverse many of the SSRI sexual side effects. However, bupropion alone has only limited benefit in PMS/PMDD. (Choice D) GnRH agonists such as leuprolide suppress production of estrogen and induce a hormonal state similar to menopause. They are effective in the management of PMS/PMDD but, due to significant side effects and cost, are not generally used unless better-tolerated options fail. (Choice E) Spironolactone has anti-aldosterone and anti-testosterone effects. It is useful in reducing androgen-related symptoms such as acne and hirsutism in women. It may have some benefit for bloating and breast tenderness in PMS but otherwise is not effective in PMS/PMDD, which is not driven by testosterone. Educational objective: Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line therapy for premenstrual syndrome/premenstrual dysphoric disorder. If the first SSRI is ineffective, another SSRI or an estrogen-progesterone oral contraceptive may be tried. Benzodiazepines and GnRH agonists such as leuprolide can also be effective but have more significant adverse effects. References: Premenstrual syndrome and premenstrual dysphoric disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22010771)

Question 11

A 27-year-old woman comes to the physician with a 1-year history of periodic irritability, anger, tension, and sleep disturbance.  The symptoms begin predictably a week before her periods and resolve with menstrual bleeding.  She has increased appetite, headaches, breast tenderness, and ankle swelling before her periods.  The symptoms are severe enough to impair her performance at work.  The patient's past medical history is insignificant.  Her cycles are regular and last 29 days.  She has no intermenstrual bleeding or vaginal discharge.  She has never been pregnant.  The patient does not use tobacco, alcohol, or illicit drugs.  She has been sexually active with 1 partner for the last 3 years and uses condoms for contraception.  The physician prescribes fluoxetine 20 mg/day.  The patient returns after 4 months and says that her symptoms have not improved significantly.  She stopped taking fluoxetine 5 days back. The patient returns in 6 months and says that she feels much better.  Her symptoms are less disabling, and she is able to work without significant discomfort.  She is concerned about the long-term prognosis and future risk of other disorders that may be associated with her condition.  The patient is at increased risk for which of the following?

Accepted Answer

Explanation: Premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) has a significant association with a number of primary psychiatric disorders, primarily mood and anxiety disorders. It has been estimated that the lifetime risk of a psychiatric disorder in patients with PMS approaches 80% and is elevated in the years both before and after PMS symptoms. Underlying primary mood or anxiety disorders that worsen intermittently before menses are often misdiagnosed as PMS. Other conditions, such as migraine, irritable bowel syndrome, or chronic fatigue, may also be exacerbated prior to menses. However, these symptoms alone do not necessarily denote PMS/PMDD. (Choice A) Premenstrual alcohol consumption is increased in some patients with PMS/PMDD, and premenstrual symptoms may be a trigger for alcohol abuse in those with underlying alcoholism. Conversely, alcohol consumption may aggravate the affective symptoms of PMS/PMDD. However, studies on PMS/PMDD as an independent risk factor for alcoholism have had mixed results. (Choice C) Endometriosis can produce symptoms such as bloating and pelvic pain that may follow a cyclical pattern related to menses. Endometriosis should be considered in patients whose symptoms correlate with menses, especially if there is prominent pain. However, PMS/PMDD does not indicate the presence of endometriosis and does not increase the lifetime risk. (Choice D) Thyroid disorders often present with nonspecific symptoms, including bloating and depression, which may mimic PMS. Many clinicians advise checking thyroid function early in the evaluation of patients with prominent affective symptoms. Patients with PMS/PMDD do not otherwise have an increased risk of thyroid disorders. (Choice E) Osteoporosis is a potential risk in PMS/PMDD patients treated with GnRH agonists as these agents suppress endogenous estrogen production. Patients who are not treated with GnRH agonists have normal sex hormone levels and are not at increased risk for osteoporosis. Educational objective: The lifetime risk of a psychiatric disorder in patients with premenstrual syndrome approaches 80%. These include primarily mood and anxiety disorders. References: Premenstrual syndrome and premenstrual dysphoric disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22010771)

Question 12

A 38-year-old woman, gravida 3 para 3, comes to the office for evaluation of vaginal discharge. She underwent a total laparoscopic hysterectomy 2 weeks ago for symptomatic uterine fibroids. The patient had an uncomplicated postoperative course. She was able to ambulate, void, and tolerate a regular diet within 12 hours of surgery and went home on postoperative day 1. However, over the past week, the patient has had persistent malodorous vaginal discharge, requiring her to change pads multiple times a day. She has also been voiding frequently in small volumes and is having increasing vulvar pruritus. She has had no fever, chills, hematuria, or dysuria. The patient has type 2 diabetes mellitus controlled with oral medications. Her other surgeries include 2 cesarean deliveries and laparoscopic cholecystectomy. The patient does not use alcohol or illicit drugs, but she smokes 1 or 2 cigarettes a day. Temperature is 37.1 C (98.8 F), blood pressure is 130/86 mm Hg, and pulse is 80/min. BMI is 32 kg/m². Abdominal incision sites are clean, dry, and intact. External genitalia are diffusely erythematous with superficial excoriations. Sterile speculum examination reveals a pool of clear, thin fluid in the vaginal vault. Nitrazine paper indicates a pH of 5. The vagina has a small, red area of granulation tissue over the anterior aspect; the cuff at the vaginal apex appears intact. On bimanual examination, there are no palpable masses in the vaginal vault. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf16_1a6c_8f63_cb651be64e74_MD0005_00 Following pelvic surgery (eg, hysterectomy), a small amount of serosanguinous vaginal discharge is expected (Choice E). However, this patient's continuous, clear vaginal discharge is concerning for a vesicovaginal fistula, an abnormal tract between the vagina and bladder. Postsurgical vesicovaginal fistulas are typically caused by unidentified intraoperative injuries to bladder or vaginal tissue, which become devascularized and necrotic, leading to a tissue defect and the aberrant connection. Risk factors include scarring from prior pelvic surgery (eg, cesarean deliveries) and poor tissue healing (eg, diabetes mellitus, smoking). vesicovaginal fistulas This surgical complication causes painless urinary leakage into the vagina, resulting in malodorous discharge that presents within days to weeks of surgery. The discharge has an elevated pH compared to the highly acidic vaginal secretions (eg, pH 4.0-4.5). Because some urine is lost through the vagina, patients may also have small-volume voids and erythematous, pruritic vulvar skin from constant contact with urine and a need for frequent sanitary pad changes. On speculum examination, large fistulas may appear as visible defects on the anterior vaginal wall. Smaller fistulas, however, often appear as subtle areas of red granulation tissue with fluid pooling, as in this patient. Clinical suspicion for a small fistula requires evaluation with bladder dye testing, which is performed by instilling a dyed fluid (eg, methylene blue) into the bladder. Staining of cotton swabs placed in the vagina is diagnostic. Minor fistulas sometimes heal on their own with continuous bladder drainage; otherwise, repair is surgical. bladder dye testing (Choice A) Gonorrhea and chlamydia are sexually transmitted infections that can cause vaginal discharge and, less commonly, vulvar pruritus or frequent voiding due to urethritis. However, these pathogens usually cause thick, mucopurulent discharge due to acute cervicitis. acute cervicitis (Choice C) CT scan of the abdomen and pelvis is used to identify postoperative complications such as bowel obstruction, intraabdominal bleeding, or abscess. However, these typically cause abdominal pain and systemic symptoms (eg, fever, hypotension), which are not seen in this patient. CT scan usually cannot detect small vesicovaginal fistulas. (Choice D) Urodynamic studies can differentiate between stress and urge incontinence by assessing bladder function (eg, storage, evacuation). However, neither type of incontinence is associated with pooling of urine in the vagina. incontinence Educational objective: A vesicovaginal fistula is a potential complication of pelvic surgery that presents as painless, continuous leakage of urine (eg, clear, malodorous fluid) into the vagina. Small vesicovaginal fistulas may be subtle on examination (eg, red area of granulation tissue) and require evaluation (eg, bladder dye testing). References: Management of vesicovaginal fistulas (VVFs) in women following benign gynaecologic surgery: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/28225769) Urologic complications following obstetrics and gynecological surgery: our experience in a tertiary care hospital. (http://www.ncbi.nlm.nih.gov/pubmed/26834397) Management of genitourinary fistulas following benign gynecological and obstetric procedures: a single surgeon experience. (http://www.ncbi.nlm.nih.gov/pubmed/33384539)

Question 13

A 22-year-old woman comes to the office with right lower quadrant pain for the past 3 weeks. The pain is exacerbated with bowel movements, but there is no associated nausea, vomiting, diarrhea, constipation, or melena. She has no chronic medical conditions and has never had surgery. Family history is noncontributory. The patient has regular menstrual periods every 28-30 days. She is sexually active and uses condoms for contraception. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 80/min. BMI is 24 kg/m². Physical examination shows a well-appearing woman in no apparent distress. The abdomen is soft with normal bowel sounds. There is tenderness to deep palpation in the right lower quadrant without rebound or guarding. The uterus is small, nontender, and anteverted; there is no cervical discharge or cervical motion tenderness. The right adnexa is enlarged and tender. There is nodularity and tenderness on rectovaginal examination. This patient is at increased risk for which of the following conditions?

Accepted Answer

Explanation: 11ec2b69_bef5_25dc_8f63_45af819a26e7_MD0005_00 This patient has pelvic pain with exacerbation by bowel movements (dyschezia) and rectovaginal nodularity on pelvic examination, classic findings of endometriosis. Endometriosis is an extrauterine implantation of endometrial tissue that causes inflammation and fibrosis as implants cyclically shed in the ectopic location. The most frequent sites of involvement are the ovaries, cul-de-sac, broad ligaments, uterosacral ligaments, fallopian tubes, and sigmoid colon. Ovarian involvement typically presents with unilateral pelvic pain and a tender adnexal mass (eg, endometrioma). Endometriosis causes pelvic adhesions and inflammation, which can cause infertility and chronic pelvic pain. Treatment is with nonsteroidal anti-inflammatory drugs, oral contraceptives, GnRH agonists, or surgical resection. Infertility due to endometriosis is treated with surgical resection or in vitro fertilization. extrauterine implantation (Choice A) Cervical dysplasia is caused by human papillomavirus (HPV); infection is typically asymptomatic. However, when symptomatic, cervical dysplasia presents with postcoital bleeding rather than pelvic pain. (Choice C) Primary ovarian insufficiency typically occurs in patients with a history of autoimmune disease, previous chemoradiation, or Turner syndrome. Typical presentation is secondary amenorrhea and symptoms of menopause (eg, hot flashes, vaginal dryness). (Choice D) A tubo-ovarian abscess is a complication of pelvic inflammatory disease and may present with pelvic pain and an adnexal mass; additional findings required for diagnosis are fever and leukocytosis. This patient is at decreased risk due to condom use. (Choice E) Uterine sarcoma (eg, leiomyosarcoma) is a rare gynecologic malignancy associated with a history of pelvic radiation and tamoxifen use. Typical presentation is with postmenopausal or abnormal uterine bleeding and an irregularly shaped, rapidly enlarging uterus. Educational objective: Endometriosis may present with pelvic pain, dyschezia, rectovaginal nodularity, and an ovarian mass (endometrioma). Endometriosis causes pelvic adhesions and inflammation, leading to infertility and chronic pelvic pain. References: When love hurts. A systematic review on the effects of endometriosis surgical and pharmacological treatments on female sexual functioning. (http://www.ncbi.nlm.nih.gov/pubmed/27687240) Safety of medical treatments for endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/26576479) Endometriosis-associated infertility: aspects of pathophysiological mechanisms and treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/27998009)

Question 14

An 86-year-old woman comes to the office due to a vaginal bulge and difficulty urinating. The patient first noticed the bulge several years ago but did not seek care. Over the last few months, as the bulge has enlarged, she has experienced increasing pelvic pressure. In addition, she now has to manually elevate the bulge to urinate. The patient has no vaginal bleeding or difficulty with defecation. She has chronic obstructive pulmonary disease managed with an inhaled combined long-acting beta agonist and corticosteroid. She had 2 vaginal deliveries in her early 20s; the second was complicated by a fourth-degree perineal laceration. The patient has a 50-pack-year smoking history, but quit 15 years ago; she does not use alcohol or illicit drugs. Blood pressure is 150/90 mm Hg, pulse is 78/min, respirations are 20/min, and pulse oximetry is 91% on room air. BMI is 34 kg/m². Auscultation of the lungs reveals decreased breath sounds bilaterally. Pelvic examination reveals anterior vaginal wall prolapse and protrusion of the cervix through the vaginal introitus. During the examination, the uterus is elevated and the prolapse is reduced; the patient is asked to cough and no leakage of urine is observed. Post-void residual urine volume is 40 mL. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bf0c_2f55_8f63_3b38df15fb28_MD0005_00 This patient has severe, symptomatic pelvic organ prolapse (POP) that is caused by the uterus and bladder (eg, cystocele) herniating through the vagina, resulting in vaginal pressure and a bulging mass. Patients with POP often have associated urinary, defecatory, and sexual dysfunction. POP is a result of damage or atrophy of the ligaments, muscles, and nerves that support the pelvic organs. Risk factors for POP include obesity, increasing age, high parity, and history of operative vaginal delivery. herniating through the vagina Patients with symptomatic POP can be treated with either surgical or nonsurgical management, and both are equally efficacious. Therefore, treatment choice is dependent on patient preference and surgical risk assessment. Patients who are poor surgical candidates due to cardiovascular or pulmonary comorbidities are managed conservatively. Therefore, this patient would be better managed with the nonsurgical option of a pessary, a medical device that, when placed in the vagina, helps support the prolapsing pelvic organs and restore normal anatomy. Most patients using a pessary have resolution of the prolapse and bowel and bladder symptoms. pessary (Choice A) Surgical management (eg, hysterectomy with prolapse repair) is indicated for patients who have not improved despite conservative management and have no contraindications to surgery. (Choice B) Intermittent self-catheterization is indicated for management of urinary retention, which is diagnosed by an elevated post-void residual (>200 mL). POP can cause distortion of the bladder and urethra that results in urinary obstruction and incomplete bladder emptying. To facilitate urination, patients often manually elevate the bladder to relieve the obstruction (splinting). This patient's obstruction is reducible, allowing for a normal post-void residual (ie, no retention). (Choice C) Pelvic floor muscle exercises improve pelvic organ support and decrease symptoms associated with stress urinary incontinence and mild POP. Advanced POP requires mechanical correction via a pessary or surgery. (Choice D) A mid-urethral sling procedure is indicated in the management of stress urinary incontinence, which presents with involuntary leakage of urine associated with increased intraabdominal pressure. Patients with stress incontinence have a positive cough-stress test (ie, leakage with coughing). Educational objective: Pelvic organ prolapse can present with a vaginal bulge and urinary, defecatory, or sexual dysfunction. Patients who are poor surgical candidates can usually be treated with pessary placement. References: Prevention and management of pelvic organ prolapse. (http://www.ncbi.nlm.nih.gov/pubmed/25343034)

Question 15

A 33-year-old woman comes to the office for a contraception prescription. The patient previously used oral contraceptive pills for menstrual regulation and acne treatment, but she frequently forgot to take them, resulting in an unintended pregnancy 2 years ago. During her pregnancy, she gained 36.3 kg (80 lb) and has been unable to return to her prepregnancy weight. Her postpartum course was complicated by severe postpartum depression requiring a brief hospitalization, and she does not want to become pregnant again. The patient has not been sexually active since the delivery but recently started a new relationship. She has no other chronic medical conditions and no previous surgeries. The patient has had normal routine Pap testing. Her menses occur every 45-90 days with 5-6 days of heavy bleeding and passage of large clots. The patient's mother has type 2 diabetes mellitus and her paternal grandmother had ovarian cancer. She does not use tobacco, alcohol, or illicit drugs. BMI is 33 kg/m². Physical examination is normal. Serum chemistries, prolactin, and TSH levels are normal. Urine pregnancy test is negative. Pelvic ultrasound reveals a small anteverted uterus and multifollicular ovaries bilaterally. Which of the following is the best contraceptive option for this patient?

Accepted Answer

Explanation: 11ec2b69_bf0f_1586_8f63_590cb8455e41_MD0005_00 Patients with polycystic ovary syndrome often have menstrual irregularities (eg, anovulation), signs of androgen excess (eg, acne), and polycystic ovaries on ultrasound. Chronic anovulation can lead to unopposed estrogen, resulting in uncontrolled endometrial proliferation and increased risk for endometrial hyperplasia and cancer. Typically, combined oral contraceptive pills (OCPs) are first-line therapy for women with irregular menses who do not desire pregnancy. OCP use provides both a predictable menstrual cycle and regular progestin exposure to counteract the effects of endometrial estrogen stimulation. However, women who are not candidates for OCPs (eg, forgetfulness, contraindications to estrogen) are offered alternate treatments (Choice D). A progestin-containing intrauterine device (IUD) is a long-acting contraceptive option that provides endometrial protection by thinning the endometrium and reversing hyperplasia. (Choice A) Copper-containing IUDs do not protect the endometrium. Furthermore, they typically increase menstrual bleeding and cramping, traits undesirable in patients who already have heavy menstrual bleeding. (Choice B) Cyclic progestin-only pills are taken for 10-14 days each month and provide endometrial protection by inducing monthly withdrawal bleeding. However, cyclic progestins are not an effective contraceptive as the alteration of the cervical mucus and impairment of sperm mobility caused by each pill last for approximately 24 hours. Therefore, patients using cyclic progestin-only pills lack contraception for a portion of each cycle. (Choice C) This patient does not desire future fertility, but surgical sterilization does not provide endometrial protection against hyperplasia or cancer. Educational objective: Patients with polycystic ovary syndrome typically have irregular menses, androgen excess, and polycystic ovaries on ultrasound. The unopposed estrogen excess caused by anovulation results in an increased risk for endometrial hyperplasia or cancer. The endometrium can be protected by use of a progestin-containing intrauterine device, which simultaneously provides contraception. References: Cancer risk and PCOS. (http://www.ncbi.nlm.nih.gov/pubmed/23624028)

Question 16

A 32-year-old woman comes to the office due to leakage of urine. The leakage started a year ago and occurred occasionally while the patient was exercising but recently has worsened significantly. She states, "I leak urine every time I work out, particularly when I lift weights. I have been training for a triathlon and wanted to increase my strength, but now if I lift more than 15 kg (33 lb), I soak through my underwear." For the past month she has skipped workouts due to embarrassment from the leakage. The patient reports frequent urination and awakens 1 or 2 times at night to urinate. She has no dysuria or hematuria. The patient has no chronic medical conditions. She has had 2 cesarean deliveries but no other surgeries. The patient takes oral contraceptives and a daily multivitamin. She drinks 4 L (1.06 gal) of water daily but can double her intake on workout days. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 110/70 mm Hg and pulse is 58/min. BMI is 26 kg/m². Pelvic examination reveals a normal-sized, anteverted uterus and no adnexal masses. Speculum examination shows a well-rugated vagina and no evidence of pelvic organ prolapse. Leakage of urine is observed when the patient is asked to cough. Serum electrolytes are normal. A urinalysis has a specific gravity of 1.001 but is otherwise within normal limits. Which of the following is the most likely cause of this patient's symptoms?

Accepted Answer

Explanation: 11ec2b69_bf15_571b_8f63_f1f958963402_MD0005_00 This patient has stress urinary incontinence (SUI) based on urinary leakage with Valsalva (eg, weight lifting) and a positive cough-stress test. SUI is typically a sequela of pelvic trauma (eg, vaginal delivery), age-related connective tissue loss, or chronic elevated intraabdominal pressure (eg, high-impact exercise), all of which can cause inadequate urethral support. With inadequate support, the urethra becomes hypermobile and unable to close adequately. SUI is a common cause of urinary incontinence in younger women. Additional risk factors include obesity, increased parity, increasing age, tobacco use, and caffeine use. Initial treatment for SUI includes pelvic floor muscle exercises (Kegel) and lifestyle changes such as caffeine restriction, weight loss, and smoking cessation. This patient's water intake is likely contributing to her symptoms; limiting water intake to 2 L (0.53 gal) daily will likely improve both urinary frequency and SUI symptoms. Patients who do not improve with conservative measures are candidates for surgical management, typically a mid-urethral sling procedure. (Choice A) Overflow urinary incontinence can be caused by bladder outlet obstruction and presents with constant urinary dribbling, a weak urinary stream, and incomplete bladder emptying. However, bladder outlet obstruction typically occurs in men with benign prostatic hypertrophy or in women as a complication of a mid-urethral sling procedure. (Choice B) Detrusor muscle overactivity is a cause of urgency urinary incontinence (ie, overactive bladder), which typically presents with a sudden, overwhelming urge to void followed by an involuntary loss of urine. (Choice C) Intrinsic sphincteric deficiency, a urethral sphincter weakness that prevents the urethra from closing completely, is the result of neuromuscular damage that typically occurs during pelvic surgery or vaginal delivery. This diagnosis is unlikely in this patient who has had only cesarean deliveries. (Choice D) Primary polydipsia is a compulsive, excessive fluid intake typically seen in patients with a concomitant psychiatric illness. Patients with polydipsia have dilute urine (eg, low specific gravity) and polyuria; however, they also have hyponatremia, not seen in this patient. Educational objective: Stress urinary incontinence is the involuntary leakage of urine with increased intraabdominal pressure. It occurs when pelvic trauma, loss of pelvic connective tissue, or high-impact activity causes inadequate urethral support and urethral hypermobility. References: Clinical management of urinary incontinence in women. (http://www.ncbi.nlm.nih.gov/pubmed/23668526) Diagnosis of urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/23668444)

Question 17

A 23-year-old nulligravid woman comes to the office for evaluation of dyspareunia. The patient reports a year-long history of increasing dyspareunia and has not been sexually active for the last 3 months due to pain on penetration. The pain is deep in the pelvis and becomes intolerable, causing her to become tense during intercourse. The pain is not relieved with water-based lubricants. The patient became sexually active at age 19 and has had 4 lifetime partners. She had gonococcal cervicitis at age 20. She has no chronic medical conditions and has never had surgery. Menarche was at age 14 and menstrual periods are regular. The patient has painful cramping with menses that requires nonsteroidal anti-inflammatory drugs for the first 3 days of her menstrual period as well as the day prior. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 76/min. BMI is 22 kg/m². Pelvic examination reveals normal external genitalia with no tenderness to palpation. The cervix has no lesions and no discharge. There is mild tenderness on bimanual examination of the uterus; no adnexal masses are palpated. Transvaginal ultrasound reveals a small, anteverted uterus with no adnexal masses. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bef7_bded_8f63_efb167caf288_MD0005_00 Endometriosis is a progressive disease typically diagnosed in women age 25-35 and is thought to affect 5%-10% of all women. It is characterized by the presence of endometrial tissue outside the uterus (eg, ovaries, fallopian tubes, cul-de-sac, uterosacral ligaments). Symptoms include dysmenorrhea, chronic pelvic pain, deep dyspareunia, dyschezia, and infertility. Clinical presentation varies and is dependent on the specific location of the endometrial implants in the pelvis. Pelvic examination findings include pain on lateral movement of the cervix; a fixed, immobile uterus; uterosacral nodularity; and adnexal masses, although examination is often normal. endometrial tissue Endometriosis can be treated medically or surgically. Tissue diagnosis with biopsy is not required to initiate treatment. First-line treatment for endometriosis is with nonsteroidal anti-inflammatory drugs and combined oral contraceptives as these are typically well tolerated. Combined oral contraceptives decrease the amount of endometrial implant shedding in the pelvis, thereby reducing pain and inflammation. Other pharmacotherapy includes progestin-only therapy (eg, medroxyprogesterone acetate), gonadotropin-releasing hormone analogs (eg, leuprolide), and danazol (a synthetic androgen). Surgical treatment involves excision of lesions, and definitive treatment is with hysterectomy and bilateral salpingo-oophorectomy. (Choice A) Azithromycin plus ceftriaxone is used to treat acute cervicitis, which classically presents with intermenstrual or postcoital spotting and a friable cervix with mucopurulent discharge on examination; these are not seen in this patient. acute cervicitis (Choice C) Pelvic floor physical therapy is a treatment for genitopelvic pain/penetration disorder (eg, vaginismus), which typically presents with superficial introital pain rather than deep dyspareunia. (Choice D) Progressive vaginal dilation may be used to alleviate symptoms of introital pain rather than deep dyspareunia. Introital dyspareunia is typically associated with genitourinary syndrome of menopause (eg, vulvovaginal atrophy) and genitopelvic pain/penetration disorder (eg, vaginismus). (Choice E) Topical lidocaine ointment is used to treat vulvodynia, which presents with superficial dyspareunia rather than dysmenorrhea and deep dyspareunia. In addition, patients with vulvodynia report tenderness on external pelvic examination, which is not seen in this patient. Educational objective: Endometriosis, characterized by endometrial tissue outside the uterus, presents with dysmenorrhea and deep dyspareunia as well as chronic pelvic pain, dyschezia, and infertility. First-line treatment is with nonsteroidal anti-inflammatory drugs and combined oral contraceptives. References: When love hurts. A systematic review on the effects of endometriosis surgical and pharmacological treatments on female sexual functioning. (http://www.ncbi.nlm.nih.gov/pubmed/27687240) Safety of medical treatments for endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/26576479) Advances in pharmacotherapy for treating endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/26569155)

Question 18

A 41-year-old woman, gravida 1 para 1, comes to the office for persistent vaginal spotting and lower abdominal pain following an uncomplicated delivery 4 months ago. Since then, she has had bloody discharge of decreasing volume that has not completely resolved. For the past month, the patient has used a sanitary pad that is stained but not saturated with blood at the end of the day. The abdominal pain has been mild but constant and is minimally relieved by over-the-counter analgesics. The patient's last Pap test, during her initial prenatal visit, was normal. Human papillomavirus testing at that time was negative. She is breastfeeding her infant, who is doing well. The patient is a former smoker who has not used alcohol since prior to pregnancy and does not use illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 68/min, and respirations are 18/min. BMI is 30 kg/m². Abdominal examination reveals mild lower abdominal tenderness to deep palpation but no masses, rebound, or guarding. Pelvic examination reveals an enlarged uterus and no adnexal masses. Speculum examination shows a dark, irregular 2-cm lesion on the posterior fornix that bleeds after contact with an applicator, with scant blood in the vaginal vault. A urine pregnancy test is positive. Which of the following is the most likely diagnosis for this patient?

Accepted Answer

Explanation: 11ec2b69_befb_405e_8f63_2fe525a6bbb0_MD0005_00 After a term vaginal delivery, this patient has abnormal vaginal bleeding, an enlarged uterus, a vascular vaginal lesion, and a positive urine pregnancy test, a presentation consistent with gestational trophoblastic neoplasia (GTN). Choriocarcinoma is the most aggressive form of GTN, and metastasis to the lungs, vagina, central nervous system, or liver often occurs. Abnormal vaginal bleeding is common and can be from either metastatic disease (eg, vaginal lesion) or the primary tumor itself (eg, enlarged uterus). GTN is a type of neoplasm that results from malignant transformation of the chorionic villi or trophoblast. Although GTN is typically a sequela of a hydatidiform mole, it can follow any type of pregnancy, including a normal term delivery, spontaneous abortion, or ectopic pregnancy. Another risk is maternal age >40. In patients with suspected GTN, initial evaluation includes a quantitative β-hCG; thyroid, renal, and hepatic function panels; pelvic ultrasound; and chest x-ray. Treatment options include chemotherapy (typically methotrexate) and hysterectomy. After treatment, β-hCG levels are used as a marker for disease remission or progression. (Choice B) Endometrial polyps can cause abnormal vaginal bleeding; however, they typically present as intermenstrual bleeding. There is no associated abdominal pain or uterine enlargement. Endometrial polyps (Choice C) Patients with an incomplete abortion have vaginal bleeding and a positive pregnancy test. However, there is also associated cervical dilation, and products of conception are frequently visible at the cervical os, neither of which is seen in this patient. incomplete abortion (Choice D) Prolapsing leiomyomas can cause vaginal bleeding and pelvic pain; however, they typically cause heavy menses rather than persistent spotting. Prolapsing leiomyoma appear as round, smooth masses protruding through the cervix. (Choice E) Sarcoma botryoides, a type of vaginal sarcoma, typically presents in infants as a tumor with a "cluster of grapes" appearance. Educational objective: Choriocarcinoma, the most aggressive type of gestational trophoblastic neoplasia, can follow any type of pregnancy and can present with irregular vaginal bleeding. The most common locations for metastasis include the lungs and vagina. References: Gestational choriocarcinoma after term pregnancy: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/25826515) Unusual clinical presentations of choriocarcinoma: a systematic review of case reports. (http://www.ncbi.nlm.nih.gov/pubmed/28254207) Gestational trophoblastic disorders: an update in 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26556906)

Question 19

A 32-year-old woman comes to the office due to heavy vaginal bleeding. For the past 6 months, the patient has had regular menses every 30 days, with 7 days of painful cramping, heavy vaginal bleeding, and passage of large clots. She uses both a tampon and a sanitary napkin simultaneously to prevent blood from staining her underwear and soaking through her clothes. The patient has had no intermenstrual bleeding or abnormal vaginal discharge. Her last menstrual period ended a week ago. Her menses previously consisted of 5 days of mild cramping with moderate bleeding. Past medical history is significant for recurrent migraines with aura, for which she takes daily prophylaxis. The patient is sexually active and uses condoms and spermicide for contraception. She would like to attempt to conceive in the next few years. Blood pressure is 100/70 mm Hg and pulse is 84/min. BMI is 23 kg/m². Pelvic examination reveals a 14-week-sized, irregularly shaped uterus with no cervical motion tenderness or adnexal masses. Hemoglobin is 9.8 g/dL. A urine pregnancy test is negative. Pelvic ultrasound shows a large uterus with several intramural leiomyomas and a normal endometrial stripe. The patient asks what can be done to treat her condition. Which of the following is the most appropriate management at this time?

Accepted Answer

Explanation: 11ec2b69_bf17_04cd_8f63_9d1f28193caf_MD0005_00 Leiomyomas (fibroids) are benign, smooth muscle tumors of the uterus that can present with heavy, regular vaginal bleeding; painful menses; and an enlarged, irregularly shaped uterus. Depending on their size and location, symptomatic leiomyomas can also cause pelvic pressure, urinary symptoms, and constipation. leiomyomas Treatment is tailored to the patient's symptoms and desire for future fertility, as well as the size, number, and location of the leiomyomas. The initial treatment of symptomatic leiomyomas is typically with medical management. Options include combined estrogen/progestin contraceptives (eg, pill, patch, vaginal ring), progestin-only contraceptives (eg, progestin-only pills, progestin-releasing intrauterine device [IUD]), and GnRH agonists. The progestin-releasing IUD decreases uterine bleeding by inducing endometrial atrophy and reducing leiomyoma size. An IUD may be less efficacious in patients with intracavitary and submucosal leiomyomas due to distortion of the endometrial cavity. However, this patient's ultrasound shows a normal endometrial stripe and an intramural leiomyoma. When this patient is ready to conceive, the IUD can be removed with no long-term effects on fertility. submucosal leiomyomas (Choice A) Combined estrogen/progestin contraceptives are effective in decreasing menstrual bleeding. However, because of an increased risk for ischemic stroke, they are contraindicated in patients who have migraines with aura. (Choices B and E) Surgical management of fibroids via hysterectomy or uterine artery embolization is indicated for patients who have leiomyomas unresponsive to medical management and who do not desire future fertility. Pregnancy after uterine artery embolization is not recommended because it is associated with an increased risk for spontaneous abortion, cesarean delivery, and postpartum hemorrhage. (Choice C) In patients with symptomatic leiomyomas, GnRH agonists temporarily induce amenorrhea and shrink leiomyoma size. However, their usefulness is limited due to decreased bone mineral density with prolonged use and symptom recurrence after treatment completion. Therefore, GnRH agonists are used primarily for preoperative management. Educational objective: First-line management for patients with symptomatic leiomyomas who wish to preserve fertility includes combined estrogen/progestin contraceptives and progestin-releasing intrauterine devices. Migraine with aura is a contraindication to estrogen-containing contraceptives. References: The role of levonorgestrel intrauterine systems in the treatment of symptomatic fibroids. (http://www.ncbi.nlm.nih.gov/pubmed/29483855)

Question 20

A 76-year-old woman, gravida 4 para 4, comes to the office with pelvic pressure and heaviness, lower back pain, and constipation. Her constipation has not improved with daily laxative use. She has no melena, hematochezia, or changes in stool caliber. The patient has hypertension and peptic ulcer disease controlled with oral medications. Surgical history is significant only for an appendectomy. A screening colonoscopy performed 2 years ago was negative. Her mother had coronary artery disease and died from a myocardial infarction. The patient has a 52-pack-year smoking history and occasionally drinks hard liquor. Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, and pulse is 72/min. Pulse oximetry is 98% on room air. BMI is 35 kg/m². Cardiac examination reveals a normal rate and rhythm; there are no rubs, murmurs, or gallops. Pulmonary examination reveals decreased breath sounds in bilateral lung bases. On pelvic examination, a protrusion of the posterior vaginal wall expands with increased intraabdominal pressure and with standing. The patient is bothered by these symptoms. Which of the following is the most accurate statement regarding this patient's condition?

Accepted Answer

Explanation: 11ec2b69_bf09_e564_8f63_39c16732fffd_MD0005_00 Rectocele, a type of pelvic organ prolapse (POP), is the result of herniation of the rectum through a defect in the posterior vaginal wall. POP develops due to an injury of the pelvic floor muscles (eg, herniation) typically incurred during vaginal delivery. Herniation and POP are further exacerbated by increased intraabdominal pressure (eg, Valsalva maneuver) and the effect of gravity. Risk factors include multiparity, increasing age, and obesity. Symptoms of a rectocele include pelvic pressure, lower back pain, constipation, and fecal incontinence. Typical physical examination findings include a posterior vaginal mass that increases with the Valsalva maneuver. Treatment options include pelvic floor muscle exercise and either surgical repair or conservative management (eg, pessary placement), which are equally efficacious in symptom improvement. Rectocele pessary placement (Choice B) Patients with rectocele often have concomitant constipation, incomplete emptying, and obstruction symptoms (eg, splinting). However, improved treatment of the constipation does not fix the underlying vaginal wall defect and does not resolve this patient's symptoms of pelvic pressure. (Choice C) POP is a progressive process until menopause, after which symptoms can either improve or worsen. In addition, there is no association between POP and cessation of tobacco use. (Choice D) Systemic hormone replacement therapy is indicated in the treatment of menopausal vasomotor symptoms (eg, hot flashes); it is not used in the management of POP. In addition, it is not recommended in this patient; candidates are women age <60 who have undergone menopause within the past 10 years. Topical estrogen can be used with other treatments to improve vaginal atrophy but does not improve prolapse symptoms. (Choice E) Although obesity increases the risk of developing POP, weight loss may or may not improve it and therefore is not the most effective treatment. Educational objective: Rectocele, herniation of the rectum through a defect in the posterior vaginal wall, typically presents with constipation, pelvic pressure, lower back pain, fecal incontinence, and a pelvic mass that increases with the Valsalva maneuver. Management options include pessary placement and surgical repair. References: Posterior wall prolapse and repair. (http://www.ncbi.nlm.nih.gov/pubmed/20142644)

Exam 1: Advanced Clinical Medicine