GYNECOLOGY

Lecture notes

1. A25 yrs multigravid woman comes to the

physician for her annual visit. she has no
complaints. She has a history of hepatitis A, but
denies prior surgeries. She has been taking the
oral contraceptive pills for 2 yrs. She has no known
drug allergies. She is sexually active and
occasionally uses condoms. A pap smear shows
perinuclear cytoplasmic vacuolization and nuclear
enlargement, irregularity, and hyperchromasia.The
report states that she has a low- grade squamous
intraepithelial lesion (LGSIL).Which of the
following organism is most likely responsible for
the cellular changes?
A.Donovania granulomatis
B. Haemophilus ducreyi
C. Hepatitis A
D. Hepatitis B
E. Human papilomavirus

The correct answer is E. It is generally

accepted that the human papiloma
virus(HPV) is the most likely etiologic agent
for cervical dysplasia. Epidemiologic
evidence supports the association between
cervical dysplasia and HPV. Infection with
HPV leads to cellular changes ; perinuclear
cytoplasmic vacuolization and nuclear
enlargement, irregularity. And
hyperchromasia. Under the Bethesda system
of papanicolaou smear grading, these HPVassociated changes are considered to be a
low grade squamous intra epithelial
lesion(LGSIL).

2. A 42 yrs old woman comes to the physician

because of irregular vaginal bleeding. She has a
normal menstrual period every 29 days that lasts
3-4 days. Then a few days after the cessation of
her normal menses, she has a second period
that lasts for 1-2 days. Physical examination is
unremarkable; including a normal pelvic
examination .Urine hCG is negative. Endometrial
biopsy suggests the presence of an endometrial
polyp. Pap smear is within normal limits.
Hysteroscopy reveals a 2-3 cm endometrial polyp
at the fundus. Which of the following is most
appropriate next step in management?

A GnRH agonist therapy

B Medroxiprogesterone acetate therapy
C Hysteroscopic polypectomy
D Total vaginal hysterectomy
E Total abdominal hysterectomy

The correct answer is C. The patient has

an endometrial polyp. Endometrial polyps
are localized, hyperplasic overgrowths of
glands and stroma that projects out from
the endometrial surface. The most common
symptoms are irregular bleeding and
postmenopausal spotting, although many
are asymptomatic. Polyps may be
diagnosed on the basis of an endometrial
biopsy. Hysteroscopy or
sonohysterogram(an ultrasound performed
while the endometrial cavity is distended
with saline) may also be used to diagnose
polyps. This patient has a symptomatic
polyp (the polyp is causing irregular
bleeding). The management of a
symptomatic polyp involves removal with a
Hysteroscopic polypectomy. If a dilatation
and curettage is performed without a
hysteroscopy, the polyp could be missed.

ENDOMETRIAL POLYP

3. A 19 yr old woman is brought to the emergency

department because of severe lower abdominal pain.
Over the past 24 hrs, she has had several episodes of
severe abdominal pain lasting for 15-20 minutes and then
resolving. With the episodes of pain, she has nausea,
vomiting and diaphoresis. Her temperature is 37.7C (100
F), blood pressure is 114/78 mm hg, pulse is 110/min, and
respirations are 14/min.Her lower abdomen is bilaterally
tender , more on the left than the right. Pelvic
examination is somewhat limited because of the patients
inability to tolerate it. But there is the suggestion of a left
adnexal mass. Urine HCG and urinalysis are negative.
Which of the following is the most appropriate next step in
diagnosis?

A. Pelvic ultrasound
B. Abdominal x-ray
C. CT scan
D. MRI
E. Culdocentesis

The correct answer is A.

This patients presentation is classic for
ovarian torsion, which occurs when an adnexal
mass (i.e. an ovarian cyst or perovarian cyst)
twists on its pedicle. When this happens, blood
supply to the ovary may be compromised,
causing infarction. The symptoms are lower
abdominal pain, which may wax and wane as
the torsion and detorsion occur. On
examination, patient will have abdominal
tenderness, often with peritoneal signs. Pelvic
examination will demonstrate an adnexal mass
with adnexal tenderness; pelvic ultrasound is
diagnostic modality of choice in the emergency
department, as it rapidly allows for evaluation
and characterization of adnexal masses. If the
pelvic ultrasound shows an adnexal mass, the
patient should be brought to the operating
room for laparoscopy for presumed ovarian
torsion.

OVARIAN TORSION

TORSION

4. A 27 yrs old woman at 12 weeks

gestation presents to the physician for 1st
prenatal visit. She has had nausea but no
other complaints. Pelvic examination
shows a bulky cervix with a mass
involving the cervix and the upper
vagina. A biopsy of the mass reveals
squamous cell carcinoma of the cervix.
Which of the following is the most
appropriate management?

A. Expectant management
B. Pap smear in 3-6 month
C. Colposcopy in 4-6 week
D. Cone biopsy
E. Radical hysterectomy

The correct answer is E. This patient has

cervical cancer in the first trimester of
pregnancy. Prompt therapy is required to treat
invasive cervical cancer during pregnancy
Depending on the stage; cervical cancer may
be treated with surgery or radiation. An
advanced stage cervical cancer in early
pregnancy (as suggested by the findings in
this case) would require radical hysterectomy
or radiation, which would lead to termination
of pregnancy. If cervical cancer is diagnosed
late in pregnancy, one can wait for fetal
maturity prior to delivery and treatment.

CERVICAL CANCER

SQUAMOUS CELL
CARCINOMA OF
CERVIX

5.

An 85 yrs-old lady comes to you because of

pelvic pressure and the feeling that
something is coming out of her vagina. She
has a history of coronary artery disease and
she had coronary artery bypass graft 10 yrs
back. She had a cerebrovascular accident 2
yrs ago that left her with decreased rightsided sensory and motor function. She takes
multiple cardiac medications. Examination
shows morbid obesity. Her uterus is noted to
have mild to moderate prolapse. Which of
the following is most appropriate next step
in managemen

A. Oral contraceptive pills

B. Hormone replacement therapy
C. Trial of pessary
D. Vaginal hysterectomy
E. Abdominal hysterectomy

The correct answer is C.

This patient has uterine prolapse, a result from damage
to pelvicfascia, muscles, and ligaments during child birth.
Management is either with pessary used to support
pelvic organs or with surgery (hysterectomy). This
patient with her numerous medical problems, represents
a significant surgical and anesthesia risk. Therefore a non
surgical approach (the pessary) should be attempted
first.

The oral contraceptive pills (A) or hormone replacement

therapy (B) .would not be appropriate treatment. Uterine
prolapse is essentially a mechanical problem that
requires a mechanical solution. Hormones increase the
risk of thrombosis. This patient with her history of
coronary artery disease and recent stroke is not a good
candidate for hormone therapy.

Vaginal hysterectomy (D) or abdominal

hysterectomy (E) would not be a
choice for treatment.

6.

A 29 yrs old woman comes to you because

of warts on her external genitalia. She first
noted their appearance approximately 9
months ago. Since that time she states that
they have become numerous. She has no
medical problems. Examinations shows
multiple, small, raised lesions and a few
larger cauliflower-like lesions on her vulva
.Rapid plasma reagin (RPR) is negative.
Which of the following is most likely
diagnosis?
A.Condylomata acuminata
B Condylomata lata
C. Herpes genitalis
D.Molluscum contagiosum
E. Syphilis

The correct answer is A.

Condylomata acuminata is caused by human papillomavirus.It is a
sexually transmitted disease that is transmitted when viral particles
comes into contact with the female genitalia or surrounding skin.
Smaller lesions appear to be warts; whereas larger lesions are
cauliflower-like .Diagnosis is based on the appearance of the lesions
or biopsy. Treatment is through local destruction with laser,
cryotherapy, trichloroacetic acid, podophyllin, excision, or
immunomodulators, such as imiquimod

Condylomata lata(B) is a manifestation of secondary syphilis .these

lesions are elevated area and moist grayish patches that
occasionally cause ulceration. This patient has a negative RPR;
therefore her lesions do not represent Condylomata lata.

Herpes genitalis (C) is characterized by painful vesicles and ulcers.

Moll scum contagiosum (D) is characterized by numerous small

dome-shaped papules with smooth surface and sometimes an
umbilicated centre. These lesions are sometimes pruritic. It occours
in patients who are immunosuppressed secondary to HIV or taking
immunosuppressive medications.

Syphilis (E) can present with many different manifestations. Primary

Syphilis is characterized by a chancre, which is painless ulcer.
Secondary syphilis may be characterized by Condylomata lata.

7. A 21 yrs-old lady comes to you because of painful

menstrual periods. Menarche was at age 13.During
her first several cycles, her cramping was bearable,
but since then it has grown increasingly worse. Her
episodes are now characterized by lower abdominal
pain that starts several hours prior to the onset of
menses, lasts about 2 days, and then resolves
completely. She has diarrhea and fatigue during this
time. A year ago, a physician had tried her ibuprofen,
which helped significantly. Physical examination is
unremarkable, and pelvic examination is normal. This
patients painful menstrual periods are related to
which of the followings?
A. Endotoxin
B. Nonsteroidal anti-inflammatory drugs (NSAIDs)
C. Prolactine
D. Prostaglandins
E. Thyroid stimulating hormone(TSH)

The correct answer is D. This patient has primary

dysmennorrhea, which is painful menstruation
without any demonstrable pelvic disease.
Prostaglandins releases from the endometrial cells,
as these cells undergo lyses during menstruation.
Prostaglandin causes smooth muscle contraction
that causes the cramping pain. Prostaglandins
causes contractions of other smooth muscle toowhich causes diarrhea. Treatment of primary
dysmennorrhea is with NSAIDs or OCP.
Endotoxin (A) is a lipopolysaccharide that is released
when the cell wall of gram negative bacteria is
lysed.It is associated with septic shock.

NSAIDs (B) are first line treatment for primary

dysmenorrhea.
NSAIDs block the formation of
prostaglandins and therefore relieves the pain.

Prolactine(C ) AND TSH (E ) has no demonstrable

relation with p.dysmenorrhea.

8. A 39 yrs-old lady comes to the emergency

dept. because of right lower quadrant
abdominal pain and vaginal spotting.
Examination is remarkable for a diffusely
tender abdomen with rebound and guarding.
Halfway through the examination, the patient
begins to complain of shoulder pain. Urine hCG
is positive. Serum hCG is 5500 mlU/dl.
Trunsvaginal ultrasound shows nothing in the
uterus and significant free fluid in the
abdomen and pelvis. Which of the following is
the most likely cause of this patients shoulder
pain?

A. Diaphragmatic ectopic pregnancy

B. Diaphragmatic irritation
C. Malingering
D. Rotator cuff tear

The correct answer is B. When an ectopic

pregnancy ruptures, there is often
significant amount of bleeding in the
peritoneal cavity when hemoperitonium
occours blood can track upward and irritate
the diaphragm. This irritation is perceived by
the patient as shoulder pain.
A diaphragmatic ectopic pregnancy is rare.
(A).
Malingering (C) should never be assumed
until all other possibilities have been
explored.
A rotator cuff tear (D) can certainly cause
shoulder pain .But its unlikely that this
patient suddenly tore her rotator cuff muscle
halfway through the examination.

9. A29 yrs-old lady comes to you complaining of

persistent dysmenorrhea and dyspareunia.Both began
about 4 yrs ago. The patient has tried non-steroidal
anti-inflammatory drug (NSAIDs) and has been on the
oral contraceptive pill for a few yrs without relief. The
patient is brought to the operating room for
laparoscopy, during which multiple lesions along her
anterior and posterior cul-de-sac are noted. Many of
these lesions appear like gun-powder burns, where
as others are reddish or bluish. The patient also has
thickening of her uterosacral ligaments with
nodularity.In addition to dysmenorrhea and
dyspareunia. , which of the following conditions does
this patient most likely have?
A. Basal cell carcinoma
B. Infertility
C. Lengthy menstrual cycle
D. Lung cancer
E. Menorrhagia

The correct answer is B.

This patient has a presentation

that is classic for endometriosis.
Endometriosis is a condition in which
implants of endometrial glands and
stroma are found outside of their normal
location within the endometrial lining of
the uterine cavity, in endometriosis,
these implants are found along several
sites in the pelvis, including the anterior
and posterior cul-de-sac, the tube and
ovaries and the pelvic side walls.
Definitive diagnosis is made with
laparoscopy and biopsy of the lesion.
There is strong association between
endometriosis and infertility.

10.A 24 yrs-old primigravid patient comes to you because

of vaginal bleeding. Her last menstrual period was 8
weeks ago. Since then, she has had no problems with
the early pregnancy except for some nausea and
vomiting. She is afebrile, and her vital signs are stable
.Pelvic examination shows a small amount of brown
blood in the vagina. The cervical os closed. The uterus
is 8 weeks size and non-tender. There are no adnexal
masses or tenderness. Pelvic ultrasound shows an 8week fetus with a heart rate of 158 /min and no
abnormalities. The patient wants to know what the
prognosis is for her pregnancy. Which of the following
is the correct response?
A. There is no risk for miscarriage
B. There is approximately a 10%risk of miscarriage.
C. There is an approximately 50%risk of miscarriage
D. There is an approximately 75%risk of miscarriage
E. Miscarriage is almost certain

The correct answer is B.20% to 25%of

woman will have first trimester bleeding
,and the chief concern is with ectopic
pregnancy and spontaneous abortion .Of
those women,appx.50% will go to have a
spontaneous abortion. However ,once
fetal cardiac activity is seen, the risk of
spontaneous abortion is 10%.This
patient has fetal cardiac activity and a
normal examination and ultrasound .
She should be counseled that her risk of
miscarriage is appx. 10%.
No risk of miscarriage (A) is not correct.
Because in any pregnancy there is a
risk of miscarriage, no matter how
normal or healthy the pregnancy is .

11. A 16-year-old nulligravid woman comes to the emergency

department because of heavy vaginal bleeding. She states
that she normally has heavy periods every month but missed
a period last month and this period has been unusually heavy
with the passage of large clots. She has no medical problems,
has no history of bleeding difficulties, and takes no
medications. Her temperature is 37 C (98.6 F), blood pressure
is 110/70 mm Hg, pulse is 96/minute and respirations are
12/minute. Pelvic examination shows a moderate amount of
blood in the vagina, a closed cervix, and a normal uterus and
adnexae. Hematocrit is 30%. Urine hCG is negative. Which of
the following is the most appropriate management?
A. Expectant management
B. Hysteroscopy
C. Oral contraceptive pills
D. Laparoscopy
E. Laparotomy

The correct answer is C

This patient has Menorrhagia, likely due to an anovulatory cycle. During the
first few years after menarche, it is common for women to have some
anovulatory cycles and irregular menses. During an anovulatory cycle, because
no egg is released and no corpus luteum is formed, there is no progesterone
production. This lack of progesterone means that the endometrium is
stimulated by unopposed estrogen. This leads to a buildup of the endometrial
lining and often, when the period does come, Menorrhagia. The treatment for
this type of bleeding is with oral contraceptive pills. The pills, by providing
estrogen and progesterone, can help to stabilize the endometrium and halt the
bleeding. Because this patient is bleeding heavily and now has a significant
hematocrit drop (30%), it is reasonable to provide high doses of hormones. A
common method of doing this is to have the patient take three pills per day for
three days, followed by 2 pills per day for three days, followed by one pill per
day until the pack is finished. It is important in this case to note that
pregnancy was ruled out with a negative urine hCG test. It is essential to rule
out pregnancy in a young woman who presents with bleeding from the vagina.

Expectant management (choice A) would not be appropriate. This patient is

losing enough blood to have dropped her hematocrit to 30%. If one does not
intervene, there is the risk that the patient will continue to bleed and to drop
her hematocrit even further. Patients with dysfunctional uterine bleeding such
as this can lose enough blood to require a blood transfusion with the
corresponding risks (e.g. infection and transfusion reaction.)
Hysteroscopy (choice B)
would not be the most appropriate option. With such severe vaginal bleeding,
hysteroscopy will likely not provide sufficient visualization of the
endometrium. Also, hysteroscopy exposes the patient to the risks of surgery
(e.g. perforation of the uterus, damage to internal organs) for a problem that
can be managed effectively medically.
Laparoscopy (choice D) and laparotomy (choice E) would not be
appropriate.

12. A 19-year-old nulligravid woman comes to the

emergency department because of severe left
lower quadrant pain. She has been noticing this
pain intermittently for the past 3 days, but this
afternoon it became persistent and severe and
was accompanied by nausea and vomiting.
Examination shows left lower quadrant tenderness
and a tender left adnexal mass. Urine hCG is
negative. Pelvic ultrasound shows a 7 cm left
ovarian complex mass. Which of the following is
the most appropriate next step in management?
A. Expectant management
B. Follow-up ultrasound in 6 weeks
C. Intravenous antibiotics
D. Laparoscopy
E. Oophorectomy

The correct answer is D.

Ovarian torsion is a surgical emergency. Ovarian torsion occurs when the ovary completely
twists and thus, occludes its blood supply. Patients often present with intermittent pain as
the ovary twists and untwists and then constant, severe pain when the torsion becomes
complete and the ovary becomes ischemic. Time is of the essence and can mean the
difference between saving, versus losing, an ovary. This is important for any patient, but is
particularly important for a young female of childbearing age, especially one who is
nulligravid. The reason that time is so essential is that the longer the ovary stays torsed,
the more likely it is to become necrotic. Most surgeons would perform laparoscopy on this
patient if they felt it was safe to do so. The pelvis can be fully evaluated through the
laparoscope and torsion can often be untwisted using laparoscopic instruments. However,
with large cysts, some surgeons prefer to perform a laparotomy.

Expectant management (choice A) would not be appropriate for this patient. When ovarian
torsion is considered to be likely in a patient, that patient must have surgery. To expectantly
manage these patients is to risk further damage to, and possible loss of, the ovary.

A
follow-up ultrasound in 6 weeks (choice B) is appropriate management for some ovarian
cysts. For example, if this patient were asymptomatic and the cyst did not have features
suspicious for malignancy, one could follow-up with an ultrasound in 6 weeks, as long as the
patient was given strict instructions and precautions regarding the risk of torsion. However,
this patient has severe pain and may be infarcting her ovary and therefore needs surgery.

Intravenous antibiotics (choice C) would be appropriate if the patient had pelvic

inflammatory disease or another infectious process, however, the likely diagnosis is torsion,
and surgery, rather than intravenous antibiotics, is needed.

13. A 53-year-old woman comes to the physician

because of concerns regarding menopause.
She has a period almost every month, but her
cycle is lengthening. She is worried because
her mother, her two older sisters, and
practically all her aunts have osteoporosis. She
does not want to be on estrogen because she
is concerned about cancer and thrombosis.
Physical examination is within normal limits.
The patient is started on raloxifene. On this
medication, which of the following is this
patient most likely to develop?
A. Breast cancer
B. Elevated cholesterol
C. Endometrial hyperplasia
D. Hot flashes
E. Osteoporosis

correct answer is D.
Raloxifene is a medication that belongs to the class of
drugs called selective estrogen receptor modulators (SERMs).
These drugs, of which the most widely known are raloxifene and
tamoxifen, have pro-estrogenic effects in some tissues and antiestrogenic effects in other tissues. Raloxifene has been
approved for the prevention of osteoporosis. This patient, with
her strong family history of osteoporosis, is a good candidate for
prevention. Raloxifene acts as an estrogen agonist in the bone,
it appears to have no effect on hot flashes or to actually cause
hot flashes. Therefore, this perimenopausal patient is most likely
to develop hot flashes while on raloxifene.

It appears that raloxifene acts as an estrogen

antagonist in the breast. Therefore, this patient would not be
most likely to develop breast cancer (choice A) while on
raloxifene. She would be more likely to develop hot flashes.
Raloxifene appears to lower cholesterol, especially LDL
cholesterol, in patients. Therefore, elevated cholesterol (choice
B) would be less likely while on this medication. Raloxifene
appears to act as an estrogen antagonist at the level of the
endometrium. Endometrial hyperplasia (choice C) would be less
likely than hot flashes.

The Raloxifene is used in the prevention of

osteoporosis (choice E).

14.A 54-year-old woman comes to the physician because of hot

flashes. She states that her hot flashes have been steadily
worsening over the past year since she had a total abdominal
hysterectomy and bilateral salpingo-oophorectomy for
menometrorrhagia. Pathology from the surgery showed low
grade endometrial hyperplasia. She has no medical problems
and takes no medications. Her family history is unremarkable
except for a strong family history of osteoporosis. She states
that the hot flashes have become absolutely debilitating for her
and she wants to take something that will give her the best
chance of stopping them. Which of the following is the most
appropriate pharmacotherapy?
A. Alprazolam
B. Clonidine
C. Estrogen
D. Oral contraceptive pill
E. Raloxifene

The correct answer is C. Menopause can bring about a

number of symptoms for patients. These include anxiety,
fatigue, depression, headaches, insomnia, and dyspareunia.
Perhaps the most common symptom is the hot flash, which is an
uncomfortable sensation of heat, especially in the face and
chest. These flashes can occur once in a while or several times
each day. There are many therapies available for hot flashes, but
the most effective appears to be estrogen. Numerous studies
have shown estrogen replacement to be highly effective in
reducing central nervous system symptoms such as hot flushes,
insomnia, irritability, anxiety, and headaches. This patient may
also benefit from estrogen given her strong family history of
osteoporosis, as estrogen replacement has been shown to be
beneficial in reducing bone loss in postmenopausal women. The
fact that this patient had endometrial hyperplasia does not
prevent her from taking estrogen replacement therapy. She had
hyperplasia, not endometrial cancer. And, even in some cases of
endometrial cancer, some gynecologic oncologists would argue
that once therapy has been given (i.e., hysterectomy and
bilateral oophorectomy) and there is no evidence of residual
disease, then estrogen replacement may be given. This patient,
with only low grade endometrial hyperplasia on pathologic
evaluation, has no contraindication to estrogen and would likely
benefit significantly from estrogen replacement therapy.

15. A 38-year-old woman comes to the

physician because of burning with urination.
She states that the burning started about 2
days ago and has been growing worse since.
She has no frequency or urgency. She had
one episode of pyelonephritis in the past but
no other medical problems. On examination
there is no costovertebral angle or abdominal
tenderness. The examination is significant for
a thick, white vaginal discharge with
erythema and excoriations of the labia.
Urinalysis is negative. KOH/Normal saline
smear demonstrates pseudohyphae. Which of
the following is the most likely diagnosis?
A. Candida vaginitis
B. Hemorrhagic ovarian cyst
C. Pelvic inflammatory disease
D. Pyelonephritis
E. Urinary tract infection

The correct answer is A. A patient with candidiasis

classically presents with complaints of a thick, white, "cottage
cheese-like" discharge. Such patient may also complain of
vulvar pruritus and burning. Dysuria is often seen in cases of
candidiasis because there is pain when the acidic urine comes
in contact with the inflamed vaginal mucosa. This dysuria is
often confused for a urinary tract infection. The keys to
distinguishing between the two are the examination and
laboratory studies. Examination on a patient with candidiasis
often shows a thick, white, discharge as well as erythema of
the vagina and vulva, as this patient has. The excoriations
that this patient has are likely present because the patient has
been scratching the area. In a urinary tract infection,
examination of the vagina and vulva will most often be
unremarkable. The KOH preparation will demonstrate pseudohyphae in cases of candidiasis. The urinalysis should be
negative in cases of candidiasis, although if there is
contamination of the sample, abnormalities may be seen.

16.A 42 yrs-old lady comes to you because of

vaginal itch and discharge, dysuria, and
dyspareunia. These symptoms have been
steadily worsening over the past 3 days. Pelvic
examination reveals an erythematous vagina
and a thin, green, frothy vaginal discharge with
ph of 6. Microscopic examination of the
discharge demonstrates the presence of a pearshaped, motile organism. Which of the following
is the most likely pathogen?
A. Candida albicans
B. Gardnerella vaginalis
C. Herpes simplex virus
D. Treponema pallidum
E. Trichomona vaginalis

The correct answer is E. This patient

has symptoms and signs most
consistent with T. vaginalis
infection. Those patients typically
experience vaginal itch, discharge,
dysuria, frequency and urgency of
urination, and dyspareunia. However
a significant (20%)number of
patients may be asymptomatic .The
key findings to diagnosis is the
presence of motile, pear-shaped,
flagellated organisms on the normal
saline, wet-mount smear
preparation.

17.A 33 yrs-old lady comes to you because she

doesnt have a menstrual period for 6 months. Prior
to this she had a normal period every 29 days that
lasted for 4 days. She has some weight gain in the
past few months. She has a history of hepatitis A
infection 6 yrs ago and had an appendectomy at
age 12 .She takes no medications and has no
allergies to medications. Her father died of acute
pancreatitis 3 yrs ago. Her mother is alive and well
with no medical problems. Which of the following is
the most appropriate next step in diagnosis?
A. Amylase
B. FSH
C. B-hCG
D. Liver function test
E. TSH

The correct answer is C. The first step in the

diagnosis of secondary amenorrhea is a
pregnancy test. This patient has normal periods
up until the last 6 months. The most common
cause of secondary amenorrhea in 33 yrs old
with previous normal cycle is pregnancy.
Therefore B-Hcg is indicated as the first step.
FSH (B) is useful test in women with secondary
amenorrhea after a pregnancy test, TSH, and
prolactin have been checked, and after the
patients estrogen status is assessed with a
progesterone withdrawal test.
TSH (E ) is an excellent test in the workup with
secondary amenorrhea after pregnancy has
been ruled out. Woman with abnormal thyroid
function can have menstrual irregularities, so a
TSH is a good test for any woman with abnormal
menses. However a pregnancy test should still
be done first in the evaluation of secondary
amenorrhea.

18. A 24-yrs-old woman, gravida 2, Para 2, comes to you for

yearly physical and birth control counseling. She is currently
using the rhythm method of birth control, but has heard that
this method has a high failure rate and would like to try a
different method. Several of her friends use intrauterine
device (IUD), and she is wondering whether she could also use
this method. Past medical history is significant for eczema.
Past surgical history is significant for a right ovarian
cystectomy 2 yrs ago. Past gynecologic history is significant
for multiple episodes of Chlamydia cervicities and two
episodes of pelvic inflammatory disease. The most recent
episode occurring 1 yr ago. She takes acetaminophen for
occasional tension headaches. She is allergic to penicillin . She
smokes one-half pack of cigarettes per day. Physical
examination is unremarkable. Which of the following would be
the best recommendation for this patient regarding her birth
control method?
A. The IUD is absolutely contraindicated
B. The IUD is recommended
C. The IUD is recommended if cervical cultures are negative
D. The oral contraceptive pill is absolutely contraindicated
E. The rhythm method is recommended

The correct answer is A. Active,

recent, or recurrent sexually
transmitted diseases (STD ) are
absolutely contraindicated for
IUD. She has multiple episodes
of Chlamydia cervicitis and two
episodes of pelvic inflammatory
disease. In a patient with an
IUD in place, PID has an
increase chance of causing
significant morbidity and
mortality.

19. A 22-year-old woman comes to the physician for an

annual examination. She has been sexually active since
the age of 15 and has not had regular Pap smears or
examinations. She is currently sexually active with
multiple partners and intermittently uses condoms. She
has no medical problems and takes no medications. Her
examination is unremarkable. Her Pap smear is
described as satisfactory but limited by the absence of
endocervical cells. It is otherwise within normal limits.
Which of the following is the most appropriate next step
in management?
A. Repeat the Pap smear in 1 year
B. Repeat the endocervical portion of the Pap test as
soon as possible
C. Perform colposcopy with colposcopically directed
biopsies
D. Perform laparoscopy with laparoscopically directed
biopsies
E. Perform exploratory laparotomy

The correct answer is B.

A
Papanicolaou smear should ideally be a sampling of the transformation zone.
An adequate sample should show endocervical cells. When endocervical cells
are not present, there is some question as to whether the transformation
zone was fully sampled. If a woman has no risk factors for cervical dysplasia,
has had three normal annual Pap smears in a row, and has a current Pap that
shows no abnormality other than the absence of endocervical cells, then the
Pap smear can be repeated in 1 year. This patient, however, has significant
risk factors for cervical dysplasia, including early initiation of sexual activity,
multiple partners, and unprotected intercourse. Therefore, this patient needs
the endocervical portion of the Pap test to be repeated as soon as possible.
To repeat the Pap smear in 1 year (choice A) would be incorrect management.
As noted above, repeating the Pap smear in 1 year is correct only in patients
who have no risk factors for cervical dysplasia, three normal annual Pap
smears, and a present Pap that is normal except for the lack of endocervical
cells.

To perform a colposcopy with colposcopically directed biopsies (choice C)

would not be correct. This patient has a normal Pap smear overall. The lack of
endocervical cells makes the smear incomplete but not abnormal.
To perform laparoscopy with laparoscopically directed biopsies
(choice D) would not be correct. Laparoscopy does not allow evaluation of the
cervix and is not indicated for abnormal or incomplete Pap smears.
To perform an exploratory laparotomy (choice E) is not indicated.
Again, this patient has a normal but incomplete Pap smear, and major
surgery would not be correct management.

20. A 24-year-old woman comes to the physician

because of right lower quadrant abdominal pain.
She has had the pain off and on for the past
month, but it is now increasing. She has no other
symptoms and no medical problems. Examination
reveals a mildly tender, right adnexal mass. Pelvic
ultrasound shows a 7 cm right adnexal complex
cyst. Urine hCG is negative. The patient is taken
to the operating room for laparotomy and right
ovarian cystectomy. Microscopically the cyst has
cartilage, adipose tissue, intestinal glands, hair,
and a calcification that appears to be a tooth.
There is also a large amount of thyroid tissue.
Which of the following is the most likely
diagnosis?
A. Corpus luteum
B. Ectopic pregnancy
C. Gastric carcinoma
D. Struma ovarii
E. Thyroid carcinoma

The correct answer is D.

Cystic teratomas, also known as dermoid cysts, are the most common
benign ovarian neoplasm. They account for approximately 1/3 of all ovarian
neoplasms. They may be composed of a variety of cell types and have a
mixture of tissues, as this patient has. When thyroid tissue makes up more
than 50% of the teratoma, the dermoid is then referred to as struma ovarii.
Approximately 3% of ovarian teratomas fall into this category and there is an
association of struma ovarii with carcinoid tumor. Struma ovarii is unilateral
in approximately 90% of patients and most (80%) are benign. Rarely struma
ovarii is a cause of hyperthyroidism and patients with this manifestation may
have symptoms of hyperthyroidism, as well as elevated levels of thyroid
hormones and decreased levels of thyroid stimulating hormone (TSH).
Treatment of struma ovarii is by surgical removal of the tumor.
A corpus luteum (choice A) is a common cause of complex
cysts in young women. However, a corpus luteum does not contain thyroid
tissue, hair, teeth, and other such tissues.
Ectopic pregnancy (choice B) can cause an adnexal
mass, and a live ectopic may have various tissues in it when examined
microscopically. However, this patient has a negative hCG, which effectively
rules out ectopic pregnancy unless there is a laboratory error. Also, this cyst
has tissues that are found in struma ovarii.
Gastric carcinoma (choice C) can metastasize to the ovary. In fact, 5% of all
ovarian malignancies are metastases from other sites. The cancers that most
frequently metastasize to the ovary are colon, breast, stomach, and
pancreas. When a gastric carcinoma metastasizes to the ovary, it is termed a
Krukenberg tumor and has the pathognomonic "signet-ring" cells.
Thyroid carcinoma (choice E)
rarely metastasizes to the ovary and rarely would be found in combination
with the other tissue elements that this patient's cyst has.

21. A 32-year-old woman comes to the physician because

of amenorrhea. She had menarche at age 13 and has had
normal periods since then. However, her last menstrual
period was 8 months ago. She also complains of an
occasional milky nipple discharge. She has no medical
problems and takes no medications. She is particularly
concerned because she would like to become pregnant as
soon as possible. Examination shows a whitish nipple
discharge bilaterally, but the rest of the examination is
unremarkable. Urine human chorionic gonadotropin (hCG) is
negative. Thyroid stimulating hormone (TSH) is normal.
Prolactin is elevated. Head MRI scan is unremarkable.
Which of the following is the most appropriate
pharmacotherapy?
A. Bromocriptine
B. Dicloxacillin
C. Magnesium sulfate
D. Oral contraceptive pill (OCP)
E. Thyroxine

The correct answer is A

Hyperprolactinemia is the cause in approximately 10 to 20% of cases of

amenorrhea. It is known that elevated prolactin levels alter the hypothalamicpituitary-ovarian axis such that ovulation is suppressed and menses do not occur.
This patient has amenorrhea, galactorrhea (i.e., a milky discharge from the
breasts), and an elevated prolactin level. All of these findings are consistent with
hyperprolactinemia, likely coming from a pituitary microadenoma. The fact that no
mass is seen on the head MRI is also consistent with a pituitary microadenoma, as
small microadenomas may not be visualized. The treatment of choice for this
patient is with bromocriptine. Bromocriptine is a dopamine agonist that has been
shown to decrease prolactin levels and bring about a return of ovulation and
menses. The re-establishment of ovulation is especially important for this patient
who wishes to conceive.
Dicloxacillin (choice B) is often used to treat a breast infection, which can occur in
a nursing mother. This patient, however, does not have findings consistent with
breast infection. Rather, the nipple discharge is secondary to the patient's elevated
prolactin levels.
Magnesium
sulfate (choice C) is used in obstetrics to prevent seizures in patients with preeclampsia and to stop the uterus from contracting in patients with preterm labor. It
is not indicated for the treatment of hyperprolactinemia.
The oral contraceptive pill (choice D) would not be appropriate as this is a young
woman who wishes to become pregnant. If she did not desire pregnancy, the oral
contraceptive pill would be appropriate therapy. One of the major concerns in
young women with microadenomas is that decreased levels of estrogen will lead to
bone loss and the eventual development of osteoporosis. The oral contraceptive
pill, by providing daily estrogen and progestin, will help to prevent bone loss.
Thyroxine (choice E) is used in patients with hypothyroidism. This patient has a
normal TSH and no evidence of hypothyroidism, and would, therefore, not need
thyroxine.

22. A 62-year-old woman comes to the

physician because of bleeding from the
vagina. She states that her last menstrual
period came 11 years ago and that she has
had no bleeding since that time. She has
hypertension and type 2 diabetes mellitus.
Examination shows a mildly obese woman in
no apparent distress. Pelvic examination is
unremarkable. An endometrial biopsy is
performed that shows grade I endometrial
adenocarcinoma. Which of the following is the
most appropriate next step in management?
A. Chemotherapy
B. Cone biopsy
C. Dilation and curettage
D. Hysteroscopy
E. Hysterectomy

The correct answer is E.

Endometrial cancer is the most common gynecologic cancer in women ages
45 and older. The main factor that predisposes a woman to the development
of endometrial cancer is exposure to unopposed estrogen, whether
endogenous or exogenous. Endogenous factors include, early menarche, late
menopause, chronic anovulation, estrogen-secreting ovarian tumors, and
obesity. Exogenous factors include the ingestion of unopposed estrogen (as
with estrogen replacement therapy). Hypertension and diabetes have also
been associated with endometrial cancer, though this relationship may likely
be related to obesity. This patient has endometrial cancer on the basis of her
endometrial biopsy result. The correct management for this patient is with
total abdominal hysterectomy, bilateral adnexectomy, and possible lymph
node biopsy
Chemotherapy (choice
A) would not be the most appropriate next step in management. If the patient
were not a surgical candidate, because of her obesity, for example, then
radiation therapy could be administered.
Cone biopsy (choice B) is used in the diagnosis and management of cervical
cancer. It would not be used for this patient with an endometrial biopsy
showing endometrial cancer.
Dilation and curettage (choice C)
or hysteroscopy (choice D) would not be the most appropriate next step in
management. The diagnosis of endometrial cancer has been made on the
basis of the endometrial biopsy. Therefore, the most appropriate next step in
management is to treat the patient through hysterectomy or, if hysterectomy
is not possible because of obesity or medical disease, radiation.

23. A 52-year-old woman comes to the physician

because of hot flashes. Her last menstrual period was
1 year ago. Over the past year, she has noted a
persistence of her hot flashes, which come several
times each day and are associated with a feeling of
heat and flushing. They also awaken her at night and
interfere with her sleep. She has no medical problems,
takes no medications, and has no known drug
allergies. She has a family history of cardiovascular
disease and she does not smoke. Physical examination
is unremarkable. She is started on estrogen and
medroxyprogesterone acetate (Provera). The addition
of a progestin is most likely to decrease her risk of
which of the following?
A. Breast cancer
B. Breast pain
C. Endometrial cancer
D. Mood changes
E. Weight gain

The correct answer is C. Unopposed estrogen is known to

cause endometrial hyperplasia and cancer. Estrogen has
direct effects on the growth and development of the
endometrium. Studies have shown that the addition of a
progestin can protect a woman from the development of
endometrial hyperplasia and that the addition of a
progestin to women with endometrial hyperplasia can lead
the endometrium to revert to normal. Thus, any woman
with a uterus who is on estrogen therapy should also be on
a progestin to protect her endometrium. This is usually
done by placing the patient on daily estrogen and
progesterone or on cyclic progesterone. Progestins do not
protect against the development of breast cancer (choice
A). In fact, there is evidence that progestins may stimulate
the growth of breast tumors. Breast pain (choice B) is often
a result of progestin therapy. Mood changes (choice D) and
weight gain (choice E) are well-known side effects of
progestins.

24. A 21-year-old woman comes to the

physician because of "bumps" on her vulva that
she has just recently noticed. These bumps do
not cause her symptoms, but she wants to know
what they are and wants them removed. She
has no medical problems, takes no medications,
and has no allergies to medications. She smokes
one-half pack of cigarettes per day. She is
sexually active with 3 partners. Examination
shows 3 cauliflower-like lesions on the right
labia majora. Which of the following is the most
appropriate next step in management?
A. Acyclovir
B. Penicillin
C. Cone biopsy
D. Cryotherapy
E. Vulvectomy

The correct answer is

D. This patient has findings that are most consistent with condyloma
acuminata, or genital warts. Condyloma acuminata is caused by the
human papillomavirus. This virus, of which there are many different
subtypes, infects epidermal cells and can cause warty growths.
When the virus affects skin cells on the hands, the result is the
common warts that are often seen in children. When the virus affects
cells on the perineum, the result is condyloma acuminata. Diagnosis
is made on the basis of the classic, verrucous (cauliflower-like)
appearance of the lesions. Treatment is with local destruction. This
local destruction can be achieved in a variety of ways including with
cryotherapy (i.e. freezing of the skin), laser therapy, trichloroacetic
acid (i.e. chemical destruction of the skin), or imiquimod. However,
while the lesions themselves are often successfully treated with
these locally destructive agents, the virus is not usually completely
eradicated and recurrences of the lesions may occur Acyclovir
(choice A) is used to treat herpes viruses. Condyloma acuminata is
caused by the human papillomavirus and, therefore, acyclovir is not
used. Penicillin (choice B) is an antibiotic effective against bacteria,
and not the human papillomavirus. Cone biopsy (choice C) is
performed on the cervix when a patient has high-grade dysplasia or
cancer. While there is an association between human papillomavirus
infection and cervical dysplasia, cone biopsy would not be indicated
for a patient on the basis of the presence of condyloma. Vulvectomy
(choice E) is performed on patients for vulvar dysplasia or cancer. It
is not indicated for patients with condyloma.

25. A 14-year-old girl comes to the physician

for an annual examination. She has no
complaints. She became sexually active
during the past year and uses condoms
occasionally for contraception. She has
asthma, for which she occasionally takes an
albuterol inhaler. She had an appendectomy
at age 9. Physical examination is
unremarkable including a normal pelvic
examination. When should this patient begin
having Pap testing?
A. Immediately
B. Age 16
C. Age 18
D. Age 20
E. Age 21

The correct answer is

A. Pap testing is used to screen women for cervical cancer. The
development of cervical cancer is believed to be a gradual process in
which the cervical cells gradually progress from dysplasia to carcinoma
in situ to invasive cancer. Cervical cancer is certainly linked to sexual
activity, as the human papillomavirus, which is transmitted through
sexual contact, is believed to play a causative role. Sexual intercourse
also allows exposure to other infectious diseases and carcinogens that
may play a role in the process. Therefore, a patient should begin
having Pap testing once she begins to engage in sexual intercourse. If
a patient has not had sexual intercourse by the age of 18, Pap testing
should begin then. Pap testing should be performed yearly, primarily
because a single Pap test has a high false-negative rate (i.e., the Pap
test has a low sensitivity). The sensitivity of Pap testing is often
quoted as 80%. Therefore, 2 of 10 women with abnormal cervical cells
will be missed with Pap testing. However, if the examination is
repeated every year, as it should be, then the likelihood of missing the
lesion over time is much lower. To start at age 16 (choice B), 18 (choice
C), 20 (choice D), or 21 (choice E) is too late for this patient. Although
the progression to cervical cancer is believed to be a gradual one,
there are more aggressive forms that are more rapidly progressive.
Also, if one waits until age 16, 18, 20, or 21, and the patient misses
that next appointment or has a false negative on the Pap test, then
the disease will be given even further time to progress. Also, to wait
until later to do Pap testing with this patient is to miss an opportunity
for cervical cancer screening. The patient may not return for follow-up.
Therefore, screening should be performed now.

26. An 18-year-old woman comes to the

physician for advice regarding birth control.
She has been sexually active since the age of
15 and has had numerous sexual partners
since that time. She has tried the oral
contraceptive pill twice, for approximately two
cycles each time, but stopped because of
irregular bleeding. She has had gonorrhea
once and Chlamydia twice. She does not
smoke. Physical examination is unremarkable.
Which of the following forms of birth control
should be recommended for this patient?
A. Condoms
B. Diaphragm
C. Intrauterine device
D. Oral contraceptive pill
E. Tubal ligation

The correct answer is A.

All of the above options will provide birth control for this patient.
However, another major factor for this patient is the prevention of
sexually transmitted disease. Other than abstinence, condoms provide
the best protection against the acquisition of sexually transmitted
diseases. This patient, with her early onset of intercourse at the age of 15
and her numerous sexual partners, is at high risk for HIV, hepatitis,
herpes, chlamydia, gonorrhea, syphilis, human papillomavirus, and the
eventual development of cervical cancer. It is absolutely essential that
she be counseled regarding condom use and the importance of her
protecting herself from sexually transmitted diseases as well as
pregnancy. The diaphragm (choice B) is an effective method of birth
control for motivated women who are able to use this method with each
episode of intercourse. Because it covers the cervix, it provides some
protection against disease. However, it does not provide as much
protection against sexually transmitted diseases as condoms do. The
intrauterine device (choice C) is absolutely contraindicated in a woman
with numerous sexual partners and a recent history of sexually
transmitted disease. Furthermore, it is highly suboptimal for young
women, in whom a pelvic infection could lead to reduced or absent future
fertility. The oral contraceptive pill (OCP) (choice D) would provide this
patient with protection against pregnancy; however, it would not protect
her from sexually transmitted diseases. An ideal approach may be to
have her use both the OCP and condoms. However, consistent use of
both can be difficult. Tubal ligation (choice E) would provide this patient
with no protection against sexually transmitted disease. Furthermore,
except in very rare circumstances, it is contraindicated for an 18-year-old.

27. A 65-year-old woman comes to the physician

because of bleeding from the vagina. She states that
her last menstrual period was at age 50 and that she
has had no bleeding since. She has no medical
problems and takes no medications. She is not
sexually active. Examination is unremarkable,
including a normal pelvic examination. After informed
consent is obtained, an endometrial biopsy is
performed. The patient complains of discomfort during
and after the procedure but feels well enough to go
home. Later that night, with her abdominal pain
worsening, the patient comes to the emergency
department. An ultrasound is performed that shows a
normal uterus and adnexae but a complex fluid
collection posterior to the uterus. Which of the
following is the most likely diagnosis?
A. Bowel perforation
B. Endometritis
C. Endometrial cancer
D. Tuboovarian abscess
E. Uterine perforation

The correct answer is E. This patient presents with

postmenopausal bleeding. The majority of patients who
have postmenopausal bleeding will not have endometrial
hyperplasia or cancer. However, because postmenopausal
bleeding is the most common presenting complaint of
women with endometrial cancer, it is important to rule this
out. A common way to evaluate the endometrium is with an
endometrial biopsy. This can be performed with a small
suction cannula that is introduced through the cervical os
and into the uterine cavity to get a sample of the
endometrium. The procedure is standard in the practice of
gynecology but is not without risks. One of the risks of
endometrial biopsy is uterine perforation (i.e. advancing the
cannula too far such that it penetrates and perforates
through the wall of the uterus). This patient has evidence of
uterine perforation. First, she experienced significant pain
during the procedure and continuing afterwards. While
endometrial biopsy can cause considerable discomfort, it is
usually of a crampy nature that should resolve shortly after
the procedure. Second, her pelvic ultrasound now shows a
complex fluid collection posterior to the uterus, which likely
represents a collection of blood in the posterior cul-de-sac.
If the patient has stable vital signs and an acceptable
hematocrit,
uterine
perforation
can
be
managed
expectantly. If, however, the patient has evidence of
hemodynamically significant bleeding, then she will require
operative intervention. .

Bowel perforation (choice A) is a very unlikely complication

with an endometrial biopsy. It's rare for the cannula to be
advanced far enough to damage the uterus (uterine
perforation), let alone damage the bowel. Endometritis
(choice B) can be a complication of an endometrial biopsy.
Patients undergoing endometrial biopsy should be
counseled that infection is one of the risks of the procedure.
However, this patient is afebrile and the pelvic fluid
collection is more suggestive of a perforation than an
endometritis. While it is possible that this patient has
endometrial cancer (choice C), it is not likely that
endometrial cancer is causing her acute problem. Again,
most women with postmenopausal bleeding do not have
endometrial cancer. And, this patient's sudden onset of pain
and pelvic fluid collection after endometrial biopsy is most
suggestive of endometrial cancer. A patient with a
tuboovarian abscess (choice D) usually presents with
abdominal pain and fevers, and ultrasound will reveal a
pelvic mass. In a non-sexually active patient with no
adnexal mass, tuboovarian abscess can be effectively ruled
out.

28. A 23-year-old female comes to the physician

because of a swelling in her vagina. She states
that the swelling started about 3 days ago and has
been growing larger since. The swelling is not
painful, but it is uncomfortable when she jogs. She
has asthma for which she uses an albuterol
inhaler, but no other medical problems.
Examination shows a cystic mass 4 cm in diameter
near the hymen by the patient's left labia minora.
The mass is nontender and there is no associated
erythema. The mass is freely mobile. The rest of
the pelvic examination is unremarkable. Which of
the following is the most likely diagnosis?
A. Bartholin's cyst
B. Condyloma lata
C. Granuloma inguinale
D. Hematocolpos
E. Vulvar cancer

The correct answer is

A. This patient has a presentation and findings that are most
consistent with a Bartholin's cyst. Bartholin's cysts develop when a
Bartholin's gland becomes obstructed. The Bartholin's glands are
bilateral structures that are present near the posterior fourchette of
the vagina at the 5 and 7 o'clock positions. They secrete mucus,
particularly during sexual stimulation, which drains into the
posterior vagina.They undergo rapid growth during the process of
puberty and they shrink after the menopause. When the duct of
the Bartholin's gland becomes obstructed, a Bartholin's cyst
results. If the cyst becomes infected, the result is a Bartholin's
abscess. These abscesses are usually polymicrobial in nature,
although the gonococcus is implicated in about 25% of cases.
Treatment of a symptomatic Bartholin's cyst is with placement of a
Word catheter. This is a small balloon-tipped catheter device that is
placed into a small hole that is punched into the cyst itself. This
catheter allows drainage of the cyst and the formation of an
epithelialized tract that will allow continued drainage once the
catheter is removed. This tract should prevent the cyst from
reforming. If Bartholin's cysts continue to form in spite of the use of
the Word catheter, a marsupialization procedure may be tried. In
this procedure, the cyst walls are sutured open to the surrounding
skin to prevent re-closure and re-formation of the cyst.

29. A 68-year-old woman comes to the

physician because of a painful lump in
her vagina. She states that the lump
has been there for a few months, but
has recently begun to cause her pain.
She has hypertension, for which she
takes a diuretic, but no other medical
problems. Examination shows a 4 cm
cystic mass near the patient's introitus
by the right labia. The mass is mildly
tender. The remainder of the pelvic
examination is normal. Which of the
following is the most appropriate next
step in management?
A. Expectant management
B. Sitz baths
C. Oral antibiotics
D. Biopsy of the mass
E. Word catheter placement

The correct answer is D.

This patient has findings that initially seem to be consistent with a

Bartholin's gland cyst or abscess. The Bartholin's glands are paired glands
found on the posterolateral aspect of the vagina at the introitus. These
glands normally secrete mucus into the vagina, particularly with sexual
stimulation. They grow rapidly during puberty and shrink after the
menopause. In a young woman it would be reasonable to assume that this
cystic mass represents a Bartholin's cyst or abscess. However, one cannot
make this assumption in a postmenopausal patient. A cystic mass on the
vulva in a postmenopausal woman must be biopsied as there is a higher
likelihood that this lesion represents a Bartholin's gland carcinoma. Primary
carcinoma of the Bartholin's gland accounts for about 5% of vulvar
malignancies. Delay in diagnosis is common because many clinicians and
patients assume the mass is a benign cyst. Any persistent mass in this
region, especially in women greater than 40 years of age, should be
biopsied.
Expectant management (choice A) would not
be appropriate. First, the patient is symptomatic and therefore requires
something for relief. Second, there is the possibility that this mass
represents a malignancy and it, therefore, should be biopsied. Sitz baths
(choice B) can be recommended to patients with certain vulvar lesions.
However, this mass must first be biopsied to rule out malignancy.
Oral antibiotics (choice C) would not be
the most appropriate next step in management. To simply assume that this
mass represents an infectious process without obtaining tissue for
pathologic diagnosis would not be correct. Word catheter placement
(choice E) would be acceptable in a young woman with
this lesion. In a woman older than 40, however, the lesion must be biopsied
first.

30. A 33-year-old woman comes to the physician

because she has not had a menstrual period for 8
months. She had menarche at the age of 12 and,
after a few years of irregular menses, has since had
normal monthly menses. She has no medical
problems and takes no medications. Examination
reveals a normal-appearing female with no
abnormalities noted. Urine human chorionic
gonadotropin (hCG) is negative. Serum thyroid
stimulating hormone (TSH) and prolactin are also
normal. The patient is given a 10-day course of
medroxyprogesterone acetate. Upon completing the
10 days, she has a heavy menstrual period. This
patient's withdrawal bleeding in response to the
progesterone provides good evidence for which of
the following?
A. Asherman syndrome
B. Endogenous estrogen production
C. Endometrial carcinoma
D. Menopause
E. Pregnancy

The correct answer is B.

Primary amenorrhea is
defined as the lack of spontaneous uterine bleeding by the age of 16.
Secondary amenorrhea is defined as the absence of a menstrual period for 6
months or more in a woman who previously had normal periods or the
absence of menses for 12 months or more in women with previously irregular
menstrual periods. This patient, given that she previously had normal
menstrual periods, has secondary amenorrhea. The most common cause of
missed menses in previously cycling women is pregnancy. Therefore, it is
absolutely essential that a pregnancy test be performed on any woman with
this complaint. Hyperprolactinemia is the cause of amenorrhea in 10 to 20%
of cases, so it is also important that a prolactin level be checked. And,
because thyroid dysfunction can also cause a loss of menses, a TSH should
also be checked. This patient, however, is not pregnant and has normal TSH
and prolactin levels. At this point, some physicians would perform a
progesterone withdrawal test. This consists of giving a woman an
intramuscular injection of progesterone or oral progesterone for 5 to 10 days
and then checking to see if the patient has withdrawal menstrual bleeding. If
withdrawal bleeding occurs within 7 days, then patients are assumed to have
adequate levels of endogenous estrogen production.
Asherman syndrome
(choice A) describes the condition in which menstrual periods do not occur
because the uterine cavity has become obliterated with adhesions. These
adhesions result from trauma to the basal level of the endometrium, most
often occurring at the time of dilation and curettage. Patients with this
syndrome would not be expected to have menses in response to
progesterone.
Endometrial carcinoma
(choice C) typically presents with heavy, irregular bleeding or as
postmenopausal bleeding.

31. A 25 yrs old G1P0 is seen in the

emergency department. Her LMP was 8
weeks ago. She is having lower abdominal
pain and heavy vaginal bleeding with clots.
Examination reveals a soft abdomen with
mild lower abdominal tenderness. On pelvic
examination the vagina is filled with blood
and clots. The cervical os is opened and
tissue is protruding. The uterus is enlarged
to a 6 weeks size. Which of the following is
most likely diagnosis?
A. Ectopic pregnancy
B. Threatened abortion
C. Degenerating fibroid
D. Placenta previa
E. Incomplete abortion

T he Correct answer is E.

32. Which of the following

statement about estrogen
therapy in post menopausal
women is correct?
A. It is a major risk factor for
breast cancer
B. It decreases hepatic
triglyceride production
C. It produces hypertension
D. It protects against vertebral
compression fractures

The Correct answer is D.

33. In the treatment of an

ectopic pregnancy with
methotrexate all of the
following are true except
A. The pregnancy must not
have ruptured
B. It must be less than 5 cm in
size
C. Patient should be clinically
stable
D. No fetal heart activity has
been noted

The answer is B

34. Causes of secondary

amenorrhea include
A. Turner syndrome
B. Anorexia
C. Androgen insensitivity
syndrome
D. Gonadal dysgenesis
E. Imperforate hymen

The Correct answer is B.

35. Which of the following statements

regarding malignant cervical lesions
is true?
A. 95% are squamous cell carcinoma
B. CA-125 levels to monitor treatment
effectiveness are indicated
C. The majority of lesions arise outside
the transformation zone of the
cervix.
D. They are not associated with HPV
infection
E. Treatment for stage 4 disease
radical hysterectomy with
chemotherapy

The Correct answer is A.

36.A young female enters your

office wanting to start oral
contraceptive pills. You remind
yourself of the reasons she may
not start the pill which are
A. Impaired liver function
B. Undiagnosed abnormal uterine
bleeding
C. Congenital hyperlipidemia
D. Past history of thrombophelebitis
E. All of the above

The Correct answer is E.

37.Which of the following segments

characterizes uterine leiomyomas
(fibroids)?
A.They arise from connective tissue
cell
B.They are always symptomatic
C.They frequently undergo
sarcomatous degeneration
D.They always cause Menorrhagia
when present
E.They may be associated with
infertility

The Correct answer is E

38. For which condition would

surgical treatment for
incontinence be most
appropriate?
A. Urge incontinence
B. Overflow incontinence
C. Stress incontinence
D. Detrusor areflexia
E. Urethral syndrome

The correct answer is C.

39. A 20 yrs old nulligravid woman who

has a bicornuate uterus should be
told which of the following about her
condition?
A. She is likely to be sterile
B. She should never conceive
C. The risk of spontaneous abortion is
very high
D. Surgical correction will be necessary
E. She has an 80%-90% chance of
having no reproductive difficulty

The correct answer is E

40. Which of the following is the

most common complication of a
radical abdominal hysterectomy
A. Pelvic thrombo phlebitis
B. Metastasis of tumor to distant
organs
C. Damage to obturator nerve
D. Postoperative hemorrhage
E. Temporary paralysis of the
bladder

The correct answer is E

Thank you