Chapter 18 Gynecology: Common Lesions Of The Vulva, Vagina, Cervix, And Uterus; Gynecologic Pain Syndromes; Imaging In O

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  • 1/35 Questions

    A 19-year-old woman is seen in the emergency department with a history of amenorrhea for 8 weeks, 1 week of unilateral adnexal pain. On physical examination, she is found to have an acute abdomen with tenderness and absent bowel sounds. Laboratory evaluations reveal a hematocrit that is 23%, and a positive pregnancy test. Which of the following is the most likely diagnosis?

    • Ectopic pregnancy
    • Pelvic inflammatory disease (PID)
    • Endometriosis
    • Appendicitis
    • Ruptured corpus luteum cyst of the ovary
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About This Quiz

This educational quiz explores common gynecological conditions affecting the vulva, vagina, cervix, and uterus, and addresses gynecologic pain syndromes. It is designed to test knowledge on diagnosis and management of these conditions, enhancing skills crucial for medical practitioners.

Chapter 18 Gynecology: Common Lesions Of The Vulva, Vagina, Cervix, And Uterus; Gynecologic Pain Syndromes; Imaging In O - Quiz

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  • 2. 

    A 63-year-old patient is seen for routine examination. An excoriated 2-cm lesion is found on her left labium majus, which, she states, has been present for at least 3 months. What is the next best step in the management of this patient?

    • Prescribe hydrocortisone cream

    • Schedule colposcopy

    • Perform excisional biopsy

    • Prescribe Burow’s solution soaks

    • Paint the area with toluidine blue stain

    Correct Answer
    A. Perform excisional biopsy
    Explanation
    Performing an excisional biopsy is the next best step in the management of this patient. The presence of an excoriated lesion on the labium majus that has been present for at least 3 months raises concern for possible malignancy. An excisional biopsy would allow for a definitive diagnosis and guide further management. Prescribing hydrocortisone cream, scheduling colposcopy, prescribing Burow's solution soaks, or painting the area with toluidine blue stain would not provide a definitive diagnosis or address the potential malignancy.

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  • 3. 

    A patient has secondary dysmenorrheal and a fixed pelvis. At laparoscopy, lesions are biopsied that are thought to represent endometriosis. The diagnosis of endometriosis is confirmed histologically by identifying extragenital implants containing which of the following?

    • Endometrial glands and stroma

    • Hypertrophic smooth muscle

    • Hemorrhage and iron pigment deposits

    • Fibrosis

    • Stromal decidualization

    Correct Answer
    A. Endometrial glands and stroma
    Explanation
    The correct answer is endometrial glands and stroma. Endometriosis is a condition where the endometrial tissue, which normally lines the inside of the uterus, grows outside of the uterus. During laparoscopy, biopsies are taken to confirm the diagnosis. Histologically, endometriosis is confirmed by identifying extragenital implants that contain endometrial glands and stroma, which are characteristic features of this condition. The presence of these structures in the biopsy samples confirms the diagnosis of endometriosis.

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  • 4. 

    A 53-year-old woman is diagnosed with anovulatory dysfunctional bleeding. Which of the following is the most appropriate medical therapy?

    • Orally administered estrogen for the first 25 days of each month

    • Vaginal estrogen cream two to three times per week

    • Orally administered progesterone 5 to 10 mg daily for 10 days each month

    • Testosterone tablets 10 mg/d

    • Estrogen 20 mg administered intravenously

    Correct Answer
    A. Orally administered progesterone 5 to 10 mg daily for 10 days each month
    Explanation
    The most appropriate medical therapy for a 53-year-old woman with anovulatory dysfunctional bleeding is orally administered progesterone 5 to 10 mg daily for 10 days each month. Progesterone helps regulate the menstrual cycle and can help control abnormal bleeding. This treatment option is commonly used for women with anovulatory dysfunctional bleeding to promote regular menstrual cycles and reduce excessive bleeding.

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  • 5. 

    A 63-year-old patient presents with symptoms of vaginal itching, vaginal dryness, and dys-pareunia. Which of the following is the most appropriate medical therapy?

    • Orally administered estrogen for the first 25 days of each month

    • Vaginal estrogen cream daily

    • Orally administered progesterone 5 to 10 mg daily for 10 days each month

    • Testosterone tablets 10 mg/d

    • estrogen 20 mg administered intravenously

    Correct Answer
    A. Vaginal estrogen cream daily
    Explanation
    The most appropriate medical therapy for a 63-year-old patient presenting with symptoms of vaginal itching, vaginal dryness, and dyspareunia is vaginal estrogen cream daily. Vaginal estrogen cream is a commonly prescribed treatment for menopausal symptoms such as vaginal dryness and itching. It helps to restore the natural levels of estrogen in the vaginal tissues, improving symptoms and promoting vaginal health. This localized treatment option is often preferred over systemic estrogen therapy, which carries a higher risk of side effects.

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  • 6. 

    An 18-year-old woman consults you for a painful swelling of her left labium that has progressively worsened over the past 3 days. She has been treating the discomfort with over-the-counter analgesics and warm sitz baths. On examination, a 6-cm swollen, red, tender, tense cystic mass is present in the base of the left labium majus. What is the most appropriate next step in the care of this patient?

    • Excision of the mass

    • Dry heat

    • Oral antibiotics

    • Ntramuscular or intravenous (IV) antibiotics

    • Incision and drainage of the mass

    Correct Answer
    A. Incision and drainage of the mass
    Explanation
    The most appropriate next step in the care of this patient is incision and drainage of the mass. The patient's symptoms, including the progressively worsening painful swelling and the presence of a tense cystic mass, indicate the need for immediate intervention. Incision and drainage will help relieve the pain and discomfort, as well as prevent the formation of an abscess. The other options, such as excision of the mass, dry heat, and oral or intravenous antibiotics, may not be as effective in addressing the immediate concern of relieving the patient's symptoms.

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  • 7. 

    Which of the following is the most common benign neoplasm of the cervix and endocervix?

    • Polyp

    • Leiomyoma

    • Nabothian cyst

    • Endometriosis

    • Gartner’s dust cyst

    Correct Answer
    A. Polyp
    Explanation
    Polyps are the most common benign neoplasm of the cervix and endocervix. They are abnormal tissue growths that can occur in various parts of the body, including the cervix. They usually develop from the lining of the cervix and can cause abnormal bleeding or discharge. Polyps are typically non-cancerous and can be easily removed if necessary. Leiomyoma, nabothian cysts, endometriosis, and Gartner's duct cysts are all conditions that can affect the cervix, but they are not as commonly seen as polyps.

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  • 8. 

    28. A 23-year-old G1P1 patient is using barrier contraception and is 1 week past onset of her last mense. She is found to have bilaterally equal adnexal pain; cervical motion tenderness; direct abdominal tenderness; temperature, 101.3°F; and WBC, 12,000/mL. Which of the following is the most likely diagnosis?

    • Ectopic pregnancy

    • PID

    • Endometriosis

    • Urinary tract infection (UTI)

    • Ruptured corpus luteum cyst of the ovary

    Correct Answer
    A. PID
    Explanation
    The most likely diagnosis in this scenario is PID (pelvic inflammatory disease). The patient presents with symptoms such as adnexal pain, cervical motion tenderness, direct abdominal tenderness, elevated temperature, and elevated white blood cell count, which are all consistent with PID. Ectopic pregnancy may also present with similar symptoms, but the use of barrier contraception makes it less likely. Endometriosis typically presents with dysmenorrhea and chronic pelvic pain, while a UTI would not typically cause adnexal pain. A ruptured corpus luteum cyst would not typically present with cervical motion tenderness or direct abdominal tenderness.

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  • 9. 

    A 58-year-old G2P2 patient presents with complaints of severe vulvar pruritus. She is 10 years postmenopausal. Her examination is consistent with atrophic vulvitis. Which of the following is the most effective treatment of vulvar pruritus associated with atrophic vulvitis?

    • Antihistamines

    • Hydrocortisone

    • Alcohol injections

    • Tranquilizers

    • Topical estrogen therapy

    Correct Answer
    A. Topical estrogen therapy
    Explanation
    Topical estrogen therapy is the most effective treatment for vulvar pruritus associated with atrophic vulvitis. Atrophic vulvitis is a common condition in postmenopausal women due to decreased estrogen levels. Topical estrogen helps to restore the thickness and elasticity of the vaginal and vulvar tissues, reducing symptoms such as itching and dryness. Antihistamines may provide temporary relief but do not address the underlying cause. Hydrocortisone may help with inflammation but does not address the underlying estrogen deficiency. Alcohol injections and tranquilizers are not appropriate treatments for this condition.

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  • 10. 

    A 47-year-old woman complains of postcoital bleeding, nearly as heavy as menses. Which of the following is the most likely origin of her bleeding?

    • Cervical polyps

    • Cervical ectropion

    • Cervical carcinoma

    • Cervical nabothian cysts

    • Cervical infection

    Correct Answer
    A. Cervical carcinoma
    Explanation
    Cervical carcinoma is the most likely origin of the woman's postcoital bleeding. Cervical carcinoma refers to cancer of the cervix, which can cause abnormal bleeding. Postcoital bleeding, particularly if it is heavy and similar to menses, can be a symptom of cervical carcinoma. It is important to further evaluate the woman to confirm the diagnosis and determine the appropriate treatment.

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  • 11. 

    A patient complains of heavy but regular menstrual periods. An anatomic cause of the magnitude of her flow has been ruled out. Which of the following has been shown to be most effective in reducing rather than eliminating her menstrual flow?

    • Tranexamic acid

    • Dilation and curettage

    • Depot medroxyprogesterone acetate (DMPA)

    • Misoprostol

    • Ergonovine maleate

    Correct Answer
    A. Tranexamic acid
    Explanation
    Tranexamic acid has been shown to be most effective in reducing, rather than eliminating, menstrual flow. This medication works by preventing the breakdown of blood clots, which can help to decrease the amount of blood loss during menstruation. It is often used as a treatment for heavy menstrual bleeding and has been found to be effective in reducing the severity of symptoms in many patients. Dilation and curettage, depot medroxyprogesterone acetate (DMPA), misoprostol, and ergonovine maleate are not specifically indicated for reducing menstrual flow.

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  • 12. 

    A 21-year-old patient is seen for a physical examination prior to her return to college. She has been healthy and is using OCs for the past 3 years. On physical examination, you note a 2-mm pigmented flat lesion with irregular margins on the left labia. What is the most appropriate next step in the management of this lesion?

    • follow up in 6–12 months

    • Discontinue OCs

    • Excisional biopsy of the lesion

    • Wide local excision of lesion with 5 mm margins

    • Electrodessication of the lesion

    Correct Answer
    A. Excisional biopsy of the lesion
    Explanation
    The most appropriate next step in the management of a 2-mm pigmented flat lesion with irregular margins on the left labia is to perform an excisional biopsy of the lesion. This is necessary to obtain a tissue sample for histopathological examination to determine if the lesion is benign or malignant. Follow-up in 6-12 months would not be appropriate as it does not provide a definitive diagnosis. Discontinuing OCs, wide local excision with 5 mm margins, or electrodessication are not indicated without a confirmed diagnosis.

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  • 13. 

    Which of the following is the most common indication for treatment of uterine leiomyomata in a 42- year-old woman?

    • Interference with reproductive function

    • Rapid enlargement

    • Pain

    • Excessive uterine bleeding

    • Impingement on another organ

    Correct Answer
    A. Excessive uterine bleeding
    Explanation
    Excessive uterine bleeding is the most common indication for treatment of uterine leiomyomata in a 42-year-old woman. Uterine leiomyomata, also known as uterine fibroids, are benign tumors that commonly cause heavy or prolonged menstrual bleeding. This can lead to anemia and significantly impact a woman's quality of life. Therefore, treating excessive uterine bleeding is often the primary concern when managing uterine leiomyomata in this age group. Other symptoms such as pain, rapid enlargement, interference with reproductive function, or impingement on another organ may also warrant treatment but are not as common as excessive uterine bleeding.

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  • 14. 

    An obese 63-year-old woman presents with a 3-month history of continuous scanty vaginal bleeding. She denies the use of hormone replacement therapy. Adequate history and physical examination in the office reveal no other abnormalities. A Pap smear is negative. Which of the following is the next most appropriate step in her management?

    • Begin estrogen replacement therapy

    • Sample the endometrium

    • Perform colposcopic evaluation of the cervix

    • Obtain random biopsies of the cervix

    • Obtain serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and prolactin levels

    Correct Answer
    A. Sample the endometrium
    Explanation
    The patient is a postmenopausal woman with continuous vaginal bleeding, which is concerning for endometrial pathology. Since the Pap smear is negative, it does not rule out endometrial abnormalities. The next most appropriate step in her management would be to sample the endometrium to evaluate for endometrial pathology such as endometrial hyperplasia or endometrial cancer. This can be done using endometrial biopsy or dilation and curettage (D&C). Hormone replacement therapy would not be appropriate without further evaluation, and colposcopy and random biopsies of the cervix are not indicated in this case. Obtaining serum FSH, LH, estradiol, and prolactin levels may be helpful in assessing hormonal status but would not provide direct information about the endometrium.

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  • 15. 

    A 32-year-old G0P0 patient presents complaining of secondary dysmenorrhea that is increasing in severity. The pain is triggered by deep thrusting with coitus. Which of the following is the most common cause of deep-thrust dyspare-unia?

    • Endometriosis

    • Depression

    • Vaginismus

    • Vestibulitis

    • Atrophic change

    Correct Answer
    A. Endometriosis
    Explanation
    Endometriosis is the most common cause of deep-thrust dyspareunia. Endometriosis is a condition where the tissue that normally lines the inside of the uterus grows outside of it. This abnormal tissue can cause pain during sexual intercourse, especially with deep thrusting. The symptoms of endometriosis can vary, but deep dyspareunia is a common complaint. Other symptoms may include pelvic pain, heavy menstrual bleeding, and infertility.

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  • 16. 

    A 17-year-old girl is seen at a local clinic desiring contraception because she thinks she will soon become sexually active. During her examination, an ulcerative lesion is seen in the vaginal fornix. It has a rolled, irregular edge with a reddish-appearing granular base. The lesion is mildly tender to palpation. This lesion is most likely which of the following?

    • Vaginal intraepithelial neoplasia

    • Vulvar carcinoma

    • Syphilis

    • An ulcer caused by the use of tampons

    • Genital herpes

    Correct Answer
    A. An ulcer caused by the use of tampons
    Explanation
    The correct answer is "an ulcer caused by the use of tampons." This is indicated by the description of the lesion having a rolled, irregular edge with a reddish-appearing granular base, which is consistent with a tampon-induced ulcer. The tenderness to palpation further supports this diagnosis. The other options, such as vaginal intraepithelial neoplasia, vulvar carcinoma, syphilis, and genital herpes, do not match the given description of the lesion.

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  • 17. 

    A patient in her forties presents with dysfunctional bleeding. You want to do an endometrial biopsy. Because she has no insurance, she would prefer not to have the procedure unless it is likely to show important pathology. An endometrial sampling is likely to be reported as showing endometrial hyperplasia in a patient who is which of the following?

    • Obese

    • Postmenopausal

    • Using cyclic combination OCs

    • Using DMPA

    • using a copper intrauterine contraceptive device (IUCD)

    Correct Answer
    A. Obese
    Explanation
    Obesity is associated with an increased risk of endometrial hyperplasia, which is the abnormal thickening of the lining of the uterus. This condition can lead to dysfunctional bleeding, which is the patient's presenting symptom. Therefore, in a patient who is obese, an endometrial sampling is more likely to show endometrial hyperplasia compared to the other options.

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  • 18. 

    A 33-year-old patient has been diagnosed as having adenomyosis. Which of the following symptoms is most consistent with this diagnosis?

    • Dyspareunia

    • Mood swings

    • Painful defecation

    • Secondary dysmenorrhea

    • Infertility

    Correct Answer
    A. Secondary dysmenorrhea
    Explanation
    Secondary dysmenorrhea is the most consistent symptom with a diagnosis of adenomyosis. Adenomyosis is a condition where the tissue that lines the uterus grows into the muscular wall of the uterus. This can cause heavy and painful periods, which is known as secondary dysmenorrhea. The other symptoms listed, such as dyspareunia (pain during intercourse), mood swings, painful defecation, and infertility, can also be associated with adenomyosis, but secondary dysmenorrhea is the most specific symptom.

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  • 19. 

    A 21-year-old G0P0 healthy college student presents to Student Health Center, complaining of severe vulvar puritius. She has a BMI of 24, uses condoms with coitus, and finished her last menses 4 days prior. Last month she was diagnosed with and successfully treated for manila vaginitis. She denies any other symptoms including vaginal discharge. What is the most likely diagnosis?

    • Vaginal trichomoniasis

    • Leukemia

    • Personal hygiene products

    • Secondary syphilis

    • Hidradenitis suppurativa

    Correct Answer
    A. Personal hygiene products
    Explanation
    Based on the given information, the most likely diagnosis for the 21-year-old college student's severe vulvar pruritus is personal hygiene products. This is because she denies any other symptoms including vaginal discharge, and she had previously been diagnosed with and treated for vaginal vaginitis. The use of personal hygiene products, such as soaps, lotions, or wipes, can cause irritation and itching in the genital area. It is important to consider the possibility of allergic reactions or irritation from these products when evaluating a patient with vulvar pruritus.

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  • 20. 

    A 16-year-old G0P0 patient reports delayed onset of menses, the sudden onset of severe pain, and syncope. A serum pregnancy test is negative. Her CBC reveals an Hct of 42% and a WBC of 8,000. Which of the following is the most likely diagnosis?

    • Ectopic pregnancy

    • PID

    • Endometriosis

    • Appendicitis

    • Ruptured corpus luteum cyst of the ovary

    Correct Answer
    A. Ruptured corpus luteum cyst of the ovary
    Explanation
    The most likely diagnosis in this case is a ruptured corpus luteum cyst of the ovary. This is supported by the patient's symptoms of delayed onset of menses, sudden onset of severe pain, and syncope. A negative serum pregnancy test rules out ectopic pregnancy. PID and endometriosis are less likely as they typically present with different symptoms. Appendicitis is also less likely as it does not explain the delayed onset of menses. The CBC results are within normal range, which further supports the diagnosis of a ruptured corpus luteum cyst.

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  • 21. 

    A 25-year-old patient with her last menstrual period (LMP) 3 weeks ago is being followed for a 5 cm x 4 cm x 4 cm right ovarian cystic mass. She comes to the emergency department complaining of sudden right-sided low abdominal pain and nausea that has been constant for 2 hours. She had intermittent spasms of pain for a week preceding this episode (when you first felt the cyst). All these pain episodes resolved within minutes. The patient denies fever or recent coitus (none in 6 months). Examination demonstrates a 10 cm x 8 cm x 6 cm right pelvic mass that is very tender. White blood cell (WBC) count is 12,500/mL and temperature is 100.2°F. She has had no prior surgery. The patient undergoes diagnostic laparoscopy, and a black mass is seen replacing the entire right ovary. Which of the following is the most appropriate management of this patient?

    • Removal of the ovary

    • Antibiotic therapy

    • Clostridium antitoxin

    • Reverse torsion and oophoropexy

    • Anticoagulation

    Correct Answer
    A. Removal of the ovary
    Explanation
    The most appropriate management for this patient is the removal of the ovary. The patient's symptoms, including sudden onset of severe pain, a large tender pelvic mass, and the presence of a black mass replacing the entire right ovary seen during laparoscopy, are consistent with ovarian torsion. Ovarian torsion is a surgical emergency that requires immediate intervention. The affected ovary is at risk of necrosis and infection, and therefore, removal of the ovary is the most appropriate management in this case.

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  • 22. 

    A patient being treated for prothrombin deficiency develops abnormal uterine bleeding. An anatomic lesion has been ruled out. Further management to control the bleeding should begin with which of the following?

    • Gonadotropin-releasing hormone (GnRH) antagonists

    • medroxyprogesterone acetate

    • Conjugated equine estrogens

    • OC pills

    • Transdermal estradiol

    Correct Answer
    A. OC pills
    Explanation
    Oral contraceptive (OC) pills are a common treatment option for abnormal uterine bleeding. They contain synthetic hormones that help regulate the menstrual cycle and reduce bleeding. OC pills can help stabilize the endometrium and prevent excessive growth, which can be beneficial for patients with prothrombin deficiency. Other options like GnRH antagonists, medroxyprogesterone acetate, conjugated equine estrogens, and transdermal estradiol may not be the first-line treatment for this specific condition.

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  • 23. 

    A patient consults you with complaints of recurrent, painful, draining vulvar lesions. Examination shows multiple abscesses and deep scars in the labia. A foul-smelling discharge from the lesions is noted. During the review of systems, the patient reports the occasional appearance of similar lesions in the axilla. Which of the following is the most likely diagnosis?

    • Herpetic vulvitis

    • Hidradenitis suppurativa

    • Lymphogranuloma venereum

    • Granuloma inguinale

    • Secondary syphilis

    Correct Answer
    A. Hidradenitis suppurativa
    Explanation
    The most likely diagnosis in this case is hidradenitis suppurativa. This is supported by the presence of recurrent, painful, draining vulvar lesions with multiple abscesses and deep scars in the labia. The foul-smelling discharge and occasional appearance of similar lesions in the axilla further suggest hidradenitis suppurativa, which is a chronic inflammatory condition affecting the apocrine sweat glands. Herpetic vulvitis, lymphogranuloma venereum, granuloma inguinale, and secondary syphilis are less likely as they do not typically present with the same clinical features as described in the case.

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  • 24. 

    A 20-year-old patient complains of painful vulvar ulcers present for 72 hours. Examination reveals three tender, punched-out lesions with a yellow exudate but no induration. Which of the following is the most likely diagnosis?

    • Chancroid

    • Granuloma inguinale

    • Herpes

    • Lymphogranuloma venereum

    • Syphilis

    Correct Answer
    A. Chancroid
    Explanation
    The most likely diagnosis in this case is chancroid. Chancroid is a sexually transmitted infection caused by the bacteria Haemophilus ducreyi. It typically presents with painful vulvar ulcers that are tender and have a punched-out appearance. The ulcers may also have a yellow exudate. Unlike other similar conditions such as herpes or syphilis, chancroid does not typically cause induration. Granuloma inguinale and lymphogranuloma venereum are less likely diagnoses in this case.

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  • 25. 

    31. A 36-year-old patient presents for evaluation of complaints of chronic vaginal infection. She reports little vaginal discharge, but rather a 1-year history of progressively worsening vulvar discomfort that has escalated to pain sufficient to preclude intercourse and tampon use. Inspection of the vulva demonstrates focal inflammation, punctation, and ulceration of the perineal and vaginal epithelium. An attempt to perform a bimanual examination of the pelvic organs reveals intense pain and tenderness at the posterior introitus and vestibule. Which of the following is the most appropriate next step in the management of this lesion?

    • Topical anesthetics and antidepressant treatment

    • Reduction of dietary oxylates

    • excisional biopsy of the lesions

    • Interferon injections of the vaginal introitus

    • Electrodessication of the lesions

    Correct Answer
    A. Topical anesthetics and antidepressant treatment
    Explanation
    The patient's symptoms, including vulvar discomfort, pain during intercourse, and tenderness at the posterior introitus and vestibule, are consistent with a diagnosis of vulvodynia. Vulvodynia is a chronic condition characterized by vulvar pain or discomfort without an identifiable cause. The management of vulvodynia typically involves a multidisciplinary approach, including topical anesthetics to provide symptomatic relief and antidepressant treatment to address any underlying psychological factors contributing to the pain. Therefore, the most appropriate next step in the management of this lesion would be topical anesthetics and antidepressant treatment.

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  • 26. 

    A 79-year-old woman presents to your office with a 1-cm fleshy outgrowth from her urethra. It has a slightly infected appearance and bleeds on contact. You perform a biopsy, and the report states “transitional and stratified squamous epithelium with underlying loose connective tissue.” Which of the following is the most likely diagnosis?

    • Urethral leiomyoma

    • Hidradenitis suppurativa

    • Senile urethritis

    • Urethral caruncle

    • Urethral carcinoma

    Correct Answer
    A. Urethral caruncle
    Explanation
    The most likely diagnosis in this case is urethral caruncle. Urethral caruncle is a benign outgrowth of tissue that commonly occurs in postmenopausal women. It is characterized by a fleshy appearance, bleeding on contact, and can have an infected appearance. The biopsy report mentioning transitional and stratified squamous epithelium with underlying loose connective tissue is consistent with the histopathological findings of urethral caruncle. Urethral leiomyoma, hidradenitis suppurativa, senile urethritis, and urethral carcinoma are less likely diagnoses based on the given clinical presentation and biopsy findings.

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  • 27. 

    A 35-year-old accountant complains of episodic bloating, breast tenderness, dyspareunia, irritability, and depression, which leave her with “only 1 good week a month.” She is currently using condoms and foam for birth control because she “felt terrible” on OCs. Pelvic examination is normal. Which of the following is the best diagnostic course?

    • Begin a prospective diary of symptoms for the next 2 months

    • Obtain a serum progesterone level during the last half of her menstrual cycle

    • Obtain a serum estrogen level during the first half of her menstrual cycle

    • Perform a transvaginal ultrasound examination of the posterior cul-de-sac

    • Begin basal body temperature (BBT) recording

    Correct Answer
    A. Begin a prospective diary of symptoms for the next 2 months
    Explanation
    The best diagnostic course in this case would be to begin a prospective diary of symptoms for the next 2 months. This would allow the patient to track her symptoms and identify any patterns or correlations with her menstrual cycle. It can help in determining if her symptoms are related to hormonal changes and if further testing or treatment is necessary. Other options such as obtaining hormone levels or performing ultrasound may not provide as much information in this case. BBT recording may also be helpful, but the prospective diary would provide a more comprehensive assessment of her symptoms.

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  • 28. 

    A 20-year-old woman at 12 weeks’ gestation is involved in a serious automobile accident and is brought to the emergency department with multiple traumas. The emergency department physician believes that imaging studies of the abdomen are needed to assess the patient’s acute injuries. Regarding this imaging, what should you counsel the managing team?

    • Imaging at this stage of pregnancy should not be carried out.

    • Imaging should be limited to no more than two views of the abdomen.

    • Imaging can only be done if the uterus is shielded during the procedure.

    • Only imaging above the level of the uterine fundus should be carried out.

    • There are no contraindications to the needed tests.

    Correct Answer
    A. There are no contraindications to the needed tests.
    Explanation
    Imaging studies can be done during pregnancy if necessary, as long as the benefits outweigh the potential risks to the fetus. In this case, the woman is involved in a serious automobile accident and has multiple traumas, making it important to assess her acute injuries. Therefore, there are no contraindications to performing the needed imaging tests in this situation.

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  • 29. 

    A 26-year-old patient is found to have an 8-week size, irregular uterus. She does not complain of pain or excessive menstrual bleeding. Her Pap smear is normal, and a pregnancy test is negative. Which of the following is the best step in the management of this patient?

    • Continued observation

    • Endometrial biopsy

    • Cervical conization

    • Hysterectomy

    • Pelvic ultrasonography

    Correct Answer
    A. Continued observation
    Explanation
    In this case, the patient has an 8-week size irregular uterus but does not have any symptoms like pain or excessive menstrual bleeding. Her Pap smear is normal and a pregnancy test is negative. Given these findings, the best step in the management of this patient would be continued observation. This means that the patient should be monitored over time to see if any symptoms develop or if the size of the uterus changes. This approach allows for a conservative and non-invasive approach, as there is currently no indication for more invasive procedures like endometrial biopsy, cervical conization, or hysterectomy. Pelvic ultrasonography may be considered to further evaluate the size and characteristics of the uterus.

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  • 30. 

    On pelvic examination of a 28-year-old mul-tiparous patient, several 3–5 mm yellowish translucent or opaque, raised cystic structures are seen on the surface of the cervix. The patient is asymptomatic. What is the most appropriate next step in the management of these findings?

    • Excisional biopsy

    • Incision and drainage of cysts

    • oral antibiotic therapy

    • Topical estrogen therapy

    • Counseling and reassurance

    Correct Answer
    A. Counseling and reassurance
    Explanation
    The most appropriate next step in the management of these findings is counseling and reassurance. The patient is asymptomatic, and the cystic structures on the cervix are likely benign Nabothian cysts. These cysts are common and do not require any intervention. Counseling and reassurance would be sufficient to address any concerns the patient may have. Excisional biopsy, incision and drainage of cysts, oral antibiotic therapy, and topical estrogen therapy are not necessary in this case as the patient is asymptomatic and the cysts are benign.

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  • 31. 

    A 23-year-old woman complains of heavy, painful menstrual periods every 2 weeks. On further questioning, you find that every other episode of bleeding is actually very brief, consisting of only 2 days of spotting. At these times, the pain is also only an occasional twinge. During the heavy bleeding, the pain is crampy, nearly constant, located centrally in the pelvis, and lasts 3 days. She reports that this has been her pattern of menstrual pain since her early teens. A BBT curve is biphasic, compatible with normal ovulatory cycles 28 days in length. Her physical examination is normal. In addition to primary dysmenorrhea, which of the following is the most likely diagnosis?

    • Anovulatory bleeding

    • Progressive endometriosis

    • Chronic constipation

    • Mittelschmerz

    • Halban’s disease

    Correct Answer
    A. Mittelschmerz
    Explanation
    The woman's symptoms of brief spotting and occasional twinges of pain during her menstrual cycle, along with a biphasic BBT curve and normal physical examination, suggest that she is experiencing mittelschmerz. Mittelschmerz is a German word meaning "middle pain," and it refers to the pain or twinges that some women experience during ovulation. This pain is usually mild and lasts for a short duration. In contrast, anovulatory bleeding, progressive endometriosis, and chronic constipation do not explain the specific pattern of pain and bleeding described by the patient. Halban's disease is not a recognized medical condition, so it cannot be the correct answer.

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  • 32. 

    Treatments of primary dysmenorrhea are directed toward addressing the cause, which is associated with elevations in which of the following?

    • Estrogen

    • Progesterone

    • FSH

    • Prostaglandin F2alpha

    • Prostaglandin E2

    Correct Answer
    A. Prostaglandin F2alpha
    Explanation
    The correct answer is prostaglandin F2alpha. Primary dysmenorrhea refers to painful menstrual cramps without any underlying medical condition. Elevated levels of prostaglandin F2alpha, a hormone-like substance, are associated with primary dysmenorrhea. Prostaglandin F2alpha is responsible for causing the uterus to contract, leading to menstrual cramps. Therefore, treatments for primary dysmenorrhea aim to reduce the levels of prostaglandin F2alpha in order to alleviate pain and discomfort during menstruation.

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  • 33. 

    A 45-year-old patient with uterine leiomyomata found on pelvic examination complains of excessive uterine bleeding. Which of the following should be the next step in the management of this patient?

    • Myomectomy

    • Hysterectomy

    • Ultrasonography

    • Endometrial biopsy

    • Hysterosalpingography

    Correct Answer
    A. Endometrial biopsy
    Explanation
    The next step in the management of a 45-year-old patient with uterine leiomyomata and excessive uterine bleeding should be an endometrial biopsy. This is because excessive uterine bleeding in a patient with uterine leiomyomata could be due to endometrial hyperplasia or endometrial carcinoma. An endometrial biopsy will help in evaluating the endometrial lining and determining the cause of the bleeding. Myomectomy and hysterectomy are surgical options that may be considered later depending on the biopsy results. Ultrasonography and hysterosalpingography may provide additional information but are not the next step in management.

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  • 34. 

    Uterine leiomyomata are thought to arise from which of the following?

    • Embryonic rests

    • vascular smooth muscle cells

    • Degenerative uterine smooth muscle cells

    • Pluripotent endometrial epithelium

    • Placental remnants

    Correct Answer
    A. Embryonic rests
    Explanation
    Uterine leiomyomata are believed to originate from embryonic rests. These are remnants of embryonic tissue that persist in the uterus and can give rise to abnormal growth of smooth muscle cells, leading to the formation of leiomyomata. This explanation suggests that the development of uterine leiomyomata is associated with the presence of embryonic tissue remnants in the uterus.

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  • 35. 

    A 15-year-old patient has had menstrual bleeding every 2 to 4 weeks since menarche 1 year ago. The bleeding can be both heavy and light. It sometimes lasts as long as 2 weeks. Which of the following is the next best step in the management of her problem?

    • Obtain a pregnancy test

    • Perform an endometrial biopsy

    • Obtain pelvic ultrasonography

    • Initiate oral contraceptives (OCs)

    • Initiate cyclic progestin therapy

    Correct Answer
    A. Initiate cyclic progestin therapy
    Explanation
    The patient's history of irregular and heavy menstrual bleeding suggests a possible hormonal imbalance. Initiating cyclic progestin therapy can help regulate the menstrual cycle and reduce the heavy bleeding. This is a conservative approach that is often used as a first-line treatment for adolescents with irregular menstrual cycles. It is important to rule out pregnancy before initiating any hormonal therapy, but obtaining a pregnancy test is not the next best step in this case as the patient has been experiencing regular bleeding since menarche.

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Quiz Review Timeline (Updated): Mar 20, 2023 +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 20, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Feb 27, 2018
    Quiz Created by
    Abdallah.a.aji
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