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WOMENS HEALTH EOR|GYNECOLOGY|
SCIENCE| 2026 FINAL EXAM
Failure of menses to occur by 15 yo in the PRESENCE of normal growth of secondary sex characteristics - ANSWER-Primary amenorrhea 24-year-old nulligravid woman comes to your office with an 18-month history of painful intercourse, difficulty defecating, and dysmenorrhea. These symptoms are cyclical and come and go with her menses. Her menses are regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normal-sized, immobile, retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments. - ANSWER-Endometriosis Ectopic endometrial tissue outside of uterus (MC ovaries, fallopian tubes, cul-de-sac 3 D's of endometriosis - ANSWER-Dyspareunia, Dyschezia (diff defacting), dysmenorrhea XO karotype, webbed neck, broad chest, high fsh - ANSWER-Turners Syndrome 46XY, high testosterone, breast development only - ANSWER-Androgen insensitivity 46XX diagnosed on PE (pt with cyclic pelvic pain), observed on speculum exam - ANSWER-Imperforate hymen Secondary sex characteristics, no uterus - ANSWER-Mullerian agenesis When to use a progesterone challenge test - ANSWER-If pt with secondary amemorrhea, give medroxyprogesterone 5-10mg PO once a day or another progestogen for 7-10days = if bleeding occurs think anovulatory cycles 15yo who missed last 3 menstrual periods, but had regular periods started at 12 yo. She runs cross country. Very sexually active, uses condoms most times. Normal tanner stage 5 development. What is the most likely cause of amenorrhea - ANSWER- Intrauterine pregnancy is MC cause of secondary amenorrhea Dx menopause - ANSWER-One year of no periods after 40 yo with no pathologic cause; FSH (>30) and dec estradiol levels Tx for hotflashes - ANSWER-Estrogens + Progesterone if uterus intact (need prog, d/t inc risk of endometrial cancer but prog has a risk of breast CA)
No uterus = estrogen only CI for HRT - ANSWER-↑ triglycerides Undiagnosed vaginal bleeding Endometrial cancer History of breast CA or estrogen-sensitive cancers CVD History DVT or PE history Days of highest chance of fertilization - ANSWER-Day 11- Physiology of Follicular phase - ANSWER-Days 0- GnRH stimulate FSH and LH (from ant pituitary) Follicle grows and secrets estrogen (which gives - feedback) once estrogen levels are high enough from follicle secretion give + feedback on FSH and LH causing a surge. LH spike triggers ovulation Physiology of Luteal Phase - ANSWER-Day15- After ovulation, follicle becomes the corpus luteum secrete progesterone acting as a (-) feedback to FSH and LH. If preg does not occur, corpus albicans is formed no longer secreting Es and Pro. Dec in hormones causes endometrial sloughing (menses) 26-year-old patient is complaining of depression and anxiety just prior to her menses. The symptoms have been going on for more than 1 year, but are now starting to interfere with her relationships and her productivity at work. One week prior to menses each month she experiences a depressed mood, a feeling of being on edge, increased irritability, difficulty sleeping, a feeling of being overwhelmed, and is easily fatigued. She charted her symptoms daily in a log and returned to the office two cycles later. The log is consistent with the history. Her physical examination and general laboratory profile showed no abnormalities. - ANSWER-Premenstrual Dysphoric d/o Dx: req 5 symp (4 PSM symp + 1 depression symp) in the final week before the onset of menses and become minimal post-menses Tx: SSRIs, BC Tx for chlamydia or gonorrhea - ANSWER-C: Doxycycline x7 d (alt: Azithromycin 1g PO single dose) G: Critriaxone IM one dose 22-year-old patient presents with a complaint of painful blisters on the vulva and vaginal introitus. She admits to a prodrome of burning, tingling, and pruritus before the appearance of lesions. Upon examination, you note vesicles on an erythematous base.
- ANSWER-Herpes simplex Dx: viral culture (gold standard), PCR or tzanck prep from skin scrapings Tx: valcyclovir; can take daily for suppressive therapy
Risk for breast CA - ANSWER-(Inc estrogen exposure) Menarche before 12, old age of first pregnancy or no pregnancy, menopause after 52 MC type of breast CA - ANSWER-infiltrating ductal carcinoma Chronic eczematous itchy, scaling rash on the nipples - ANSWER-Pagets dz of the nipple Red swollen, warm and itchy breast with nipple retraction and pea d'orange - ANSWER- Inflammatory Breast CA Screening rules for Breast CA - ANSWER-Q2years from age 50-74. Start at age 40 if inc risk and 10y prior to first degree relative dx Self breast exam monthly on days 5-7 of cycle Tx for ER + breast CA - ANSWER-Tamoxifen (binds and blocks the estrogen receptor in breast tissue) Aromatase inhibitors if Post-menopausal ER + (reduces production of estrogen) Tx for HER2 + breast CA - ANSWER-Monoclonal AB What clinical triad is indicative of cervical CA extension into pelvic wall - ANSWER- Unilateral leg edema, sciatic pain, ureteral obstruction MC type of cervical CA - ANSWER-Squamous cell (arise from transformational zone) Caused by HPV (16/18) assoc with cigarette smoking Dx: friable bleeding cervical lesion —> bx of lesion and colposcopically directed biopsy Tx: resect, chemotherapy and radiation, if stage one conservative, simple or radical hysterectomy Age when everyone should recieve their first pap regardless of sexual activity - ANSWER-21 then q3yrs HPV testing begins at 30yo (q5years) No paps after hysterectomy or >65 yo with non concerning prev tests Tx if - cytology and + HPV - ANSWER-Follow up testing in 12 mo If pt pap shows ASC-US what is the treatment plan - ANSWER-ORDER HPV testing if - repeat in 12 mo, if + send for colposcopy When to start HPV vaccination - ANSWER-11-12yo two dose series (6mo apart) >15 yo 3 dose series (0, 2 mo, 6mo)
Cardinal symptom for Endometrial CA; whats the MC type - ANSWER-Postmenopausal vaginal bleeding (Bleeding in postmenopausal women is CA until proven otherwise) MC adenocarcinoma Dx: need to order endometrial bx Risk for endometrial CA: - ANSWER-Obesity, nulliparity, early menarche, late menopause, unopposed estrogen, HTN, gallbladder dz, DM 49 yo pt with ascites, abdominal pain - ANSWER-Ovarian CA ascities = ovarian tumor (usually epithelial tumors) Protective and risk for ovarian CA - ANSWER-Protective: multiparty, OCP use and Breast feeding Risk: nullpartity/infertility, late menopause, endometriosis Dx: transvag US then bx Tumor markers assoc with Ovarian CA - ANSWER-CA125* Some BRCA1 gene Risk for vulvar/vaginal carcinoma - ANSWER-HPV infection, smoking MC location of vaginal CA - ANSWER-Upper 1/3 of posterior vaginal wall MC squamous (adeno if DES exposure) 2 MC types of vulvar CA and how to dx - ANSWER-Squamous cell and melanoma Dx: acetic acid or staining toluidine blue 32-year-old lactating female with breast pain, swelling, fever, chills, and a fluctuant mass of her left breast. The area directly above the lesion is warm, erythematous and tender to touch. Tx? - ANSWER-breast abscess MC caused by Staph aureus from mastitis Tx: I/D and Nafcillin/oxacillin IV or cefazolin + metronidazole
- cont breast feeding 27-year-old female with a painless mass in the left breast. She discovered this mass three months ago while showering and reports it has been unchanged since that time. Her last menstrual period was 10 days ago. There is no family history of breast cancer. On physical exam, you palpate a 3 cm, firm, non-tender mass in the upper lateral quadrant of the left breast. The mass is smooth, well-circumscribed, and mobile. There are no skin changes, nipple discharge, or axillary lymphadenopathy. - ANSWER-Breast Fibroadenoma
hours. She has nausea but denies diarrhea, urinary symptoms, or vaginal discharge. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 24/min, and blood pressure is 140/90 mmHg. Pulse oximetry in room air shows an oxygen saturation of 98%. Physical examination shows left lower quadrant tenderness with guarding. Pelvic examination shows left adnexal tenderness without cervical motion tenderness or discharge. A urine pregnancy test is negative. Doppler ultrasound of the left lower quadrant is obtained. - ANSWER-Ovarian Torsion (rotation of ovary at Pedicle to occlude ovarian aa. Or vein Dx: ab US with doppler but gold standard is laparoscopy Tx: laparoscopic sx to uncoil the ovary 63-year-old, G5P5, Hispanic woman with a three-day history of increased pelvic pressure and a "bulge" that is felt in her vagina when she coughs. Additionally, she complains of incomplete emptying of her bladder, constipation and has noticed a recent worsening of lower back pain. - ANSWER-Uterine Prolapse s/s: vaginal fullness and ab pain worse in the day Dx: speculum or bimanual pelvic exam How do OCPs prevent ovulation - ANSWER-Inhibit mid-cycle surge, thicken cervical mucus, and thin endometrium For instructions: goal is to start on day one. If started after day 5 - may not supress and can req back up for one month dx for endometriosis and tx - ANSWER-Definative is laparscopy and confirmed bx Uterus will be retroflexed on PE Tx: NSAIDs, OCPs (for ovarian suppression), Danazole (steroid that inhibits cycle surge), GnRH agonists (dec estrogen), progesterone analogs (inhibit growth of Endometrium). MC cause of infertility in women - ANSWER-Anovulation Steps in working up infertility - ANSWER-Start with info about Coitus Ovulation tracking (get progesterone level on day 21- if <3ng/ml then pt did not ovulate) Male factor is dx by semen analysis Labs: TSH, prolactin, LH and FSH in women over 35 Tx options for infertility - ANSWER-Clomid to hyperstimulate ovulation Possibly Metformin if PCOS (inc ovulation) urge incontenence, tx? - ANSWER-Detrusor overactivity, frequent small amount of urine MC in elderly and nursing home pt
Tx: bladder-training; Oxybutin (anticholinergic) and TCA (imipramine) Stress incontinence, tx? - ANSWER-Weakness of pelvic floor; urine leakage d/t inc in abdominal pressure NS (cough,sneeze); common if multiple deliveries; will have NO urine loss at night Tx: Kegels exercise (vaginal estrogens, pessary, sx) Overflow Incontinence and tx - ANSWER-Urinary retention; common in DM from neuro problems Dx: elevated postvoid residual volume Tx: self-cath; cholinergic agents (Bethanechol) or a-blockers (terazosin, doxazosin) to dec sphincter resistance Functional incontinence - ANSWER-Occurs in pt who have normal voiding systems, who have diff reaching the toliet d/t physical or mental disabilities Tx: scheduled voiding times What does APGAR measure and when to take it - ANSWER-Take at 1 and 5 mins after birth Activity, Pulse, Grimace, Appearance, Respiration >6 good (7-10 is normal) =4 needs resuscitiation fetal attitude - ANSWER-Relationship of fetal parts to one another Full flexion (normal= body tucked) Fetal Lie - ANSWER-relationship of the long axis (cephalocaudal-spine) of the fetus to the long axis of the mother Longitudinal: (upside down-ideal) fetal spine lies along mothers Transverse: fetal spine perpendicular to maternal Oblique: fetus at angle Fetal presentation - ANSWER-What part of the baby is entering the pelvis first
- cephalic/vertex- head
- breech-bum
- shoulder (breech) Tx for breech babies - ANSWER-Prevalence dec with increasing gestational age (rarer to be breech at full term) Tx: external cephalic version at or near term, followed by a trial of vaginal delivery 24-year-old G2P1 comes for her 13-week office visit she has a fundal height and an alpha-fetoprotein which are greater than expected for her due date. - ANSWER-multiple gestations
Timing for glucose tolerance test - ANSWER-At 26-28 wks Give 75g 2-hours GBS screen - ANSWER-35-37 weeks When to give Rhogam - ANSWER-28 weeks gestation and within 72 hours of delivery A 25-year-old female, G2 P1001, presents to your office at 11-weeks gestation with vaginal bleeding, mild lower abdominal cramping, and bilateral lower pelvic discomfort. On examination, blood is noted at the dilated cervical os. No tissue is protruding from the cervical os. The uterus by palpation is 8-9 weeks gestation. No other abnormalities are found. - ANSWER-Spontaneous abortion (Expulsion of all or part of the products of conception before 20wks gestation)
- Smoking or BMI <18.5 or >25 is higher risk Tx for spontaneous abortion - ANSWER--Expectant management (<13 wk) -If >13 wks may need Mifepristone or Misprostol -D/C -Dilation and evacuation -Sx req if ineffective or excessive blood loss Expulsion of all or part of the POC before 20 wks of gestation - ANSWER-Spontaneous Abortion Bloody vaginal d/c before 20 wks of gestation with or w/o uterine contractions in the presence of close cervix - ANSWER-Threatened abortions Dilated cervical os with passage of some but not all POC before 20wks gestation - ANSWER-Incomplete abortion Dilated Cervical Os w/o passage of tissue before 20wks gestation - ANSWER-Inevitable abortion Death of fetus before 20wks of gestation with POC remaining intrauterine - ANSWER- Missed abortions 32-year-old female who presents with sudden onset of left lower abdominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was five weeks ago. She has a history of PID and unprotected intercourse. - ANSWER-Ectopic pregnancy
- 95% in fallopian tubes (ampulla) triad for ectopic pregnancy and MC cause - ANSWER-Abdominal pain, bleeding, and adenexal mass
MC cause: occlusion of tube secondary to adhesion (can be from PID) Pt with severe abdominal pain, peritonitis, tachycardia, syncope or orthostatic HTN - ANSWER-Ruptured ectopic pregnancy How to dx Ectopic pregnancy and treatment - ANSWER-bHCG >1500 but no fetus in utero US: ring of fire (vascularity) Tx: MTX if bHCG <5000, ectopic mass 3.5cm, no fetal heart tones, hemodynamically stable, no blood d/o OR Sx treatment (Salpingostomy-if emergent like a rupture) MC complication of gestational DM - ANSWER-Macrosomia
- gtt results? - ANSWER-Nonfasting 50g gluc followed by serum glucose level 1hr later. If the 1-hr serum gluc >130 a 3-hr gtt is performed (100g fasted pt + is 180 at 1 hr, 155 at 2hr, 140 at 3hr If pt has fasting BG >105 may need insulin or Glyburide Only gestational PO DM medication safe in pregnancy - ANSWER-Gylburide - but higher risk of eclampsia 31-year-old who had her LMP 6 weeks ago and has a beta HCG level of 100,000. Ultrasound shows a "snowstorm pattern" - ANSWER-Gestational trophoblastic dz (Molar Pregnancy) Can also appear like a grape-like mass Pt with LARGE amounts of HCG, missed periods, + pregnancy, vaginal bleeding, s/s of hyperthyroidism, large utuerus with snow storm OR grape-like mass appearance - ANSWER-Complete mole Pt who has higher HCG than normal, uterus not enlarged - ANSWER-Incomplete mole (usually causes spont abortions) Malignant/Invasive Moles - ANSWER-Dervive from benign moles and choriocarnioma (placental CA) Develop after molar pregnancy Tx for complete and incomplete moles - ANSWER-Uterine evacuation via suction curettage
Vasa previa: fetal vessel may lie over the cervix What are the S/S of placenta previa? Treatment? - ANSWER-Painless vaginal bleeding —> higher risk for preterm delivery, preterm PROM, Dx placenta previa: Transvaginal US (NO vaginal exam) Tx: pelvic rest (no sex), no vigorous exercise Time period when pre-eclampsia may occur - ANSWER-20wks to 6wks post-partum HTN, Proteinuria, edema after 20 wks gestation - ANSWER-Preeclampsia Tx for preeclampsia - ANSWER-Delivery at 34-36wks Steroids to mature lungs HELLP syndrome - ANSWER-hemolysis, elevated liver enzymes, low platelets Happens with severe preeclampsia (bp >160) Tx: deliver at 34-36wks; start Mg Sulfate to prevent eclampsia BP meds Hydralazine if >180/ HTN, Proteinuria, seizures - ANSWER-Eclampsia Gestational HTN - ANSWER->150/90 after 20wks into pregnancy that resolves in 12 wks
- no proteinuria Chronic HTN: >140/90 prior to 20wks that persist for >6wk post partum
- Mild = no proteinuria
- severe (>150/100)= labetalol or Nifedipine Rh incompatibility - ANSWER-Mother is Rh- and baby is Rh+ the mother develops AB against the babies blood *1st pregnancy is always uneffected Tx: Rhogam at 28wks and within 72hrs of delivery (risk of hydrops fetalis) Tx for breech presentation - ANSWER-External cephalic version at or near term with a trial of vaginal delivery Signs of dystocia - ANSWER-Turtles sign: retraction of delivered head Tx for shoulder dystocia - ANSWER-Non manipulative: Suprapubic pressure McRoberts Manuever (hip flexion) ' Manipulative: Woods corkscrew (rotate shoulders 180 degrees), deliver post arm Or Emergent Csection (push head back into vaginal canal (Zavanelli)
Fetal distress - ANSWER->160bpm for 10 min <120bpm for 10 min Dx with non-stress testing: BAD = no HR accel or <15bpm for <15sec then order contraction stress test. Good reactive NST - ANSWER-> 2 accelerations in 20 minutes defined by increased fetal heart rate of at least 15 bpm from baseline lasting > 15 seconds, indicates fetal well being Contraction stress test - ANSWER-measure fetal response to stress at time of uterine contraction Good: - CST, no late decels in presense of 2 contraction in 10 min Bad: + CST, late decel in the presence of 2 contraction in 10 min, (Bad if nonreactive NST) Rupture of membranes at >37wks gestation prior to the start of uterine contraction - ANSWER-Premature rupture of membranes If <37wks then preterm PROM S/s of PROM and how to dx - ANSWER-Sudden gush of clear or pale yellow fluid from vagina that occurs >37 wk Dx: confirm that it is amniotic fluid (Nitrazine test- blue is positive) or Microscopic exam shows ferning (crystallization of estrogen and amniotic fluid) Tx for PROM - ANSWER->34 wks = induce labor 32-34wks= collect fluid and check for lung maturity-then induce. <32wks stop contractions and start 2 doses of steroids then delivery baby and give abx Definition of preterm delivery - ANSWER-Delivery of infant before 37 wks gestation Contractions q10min or leaking of fluid from vagina Earliest a baby can be delivered with 50% chance survival is ____ - ANSWER-24wks Way to determine if high risk for preterm delivery - ANSWER-Fetal fibronectin in cervical or vaginal secretions Tx for preterm labor - ANSWER-Tocolytics: NSAIDs, CCB (can buy you 2-7d), Betal mimetics and atosiban ; Mg (helps dec risk of cerebral palsy)
Tissue = retained tissues- when separation of placenta from uterine wall or expulsion of placenta is incomplete Thrombin= coag d/o (VWF cant clot, DIC MC w/severe preeclampsia) Tx for uterine atony - ANSWER-fundal massage and meds that help uterus contract (oxytocin or Misoprostol) Tx for retained placental tissues (after birth) - ANSWER-Placenta accreta (causes placenta to grow too deeply into uterine wall)
