BOARD REVIEW The Female Patient

1
BOARD REVIEW The Female Patient

• By
• Dr. Tanya Oberoi Pandya D.O., M.B.A.

2
Most individuals with PCOS have

• A. decreased estrogen levels
• B. decreased androgen levels
• C. elevated FSH
• D. high TSH
• E. insulin resistance

3
Answer

• E INSULIN RESISTANCE
• -PCOS, is most common endocrine disorder and
  associated with insulin resistance
• High androgen, High LH, normal estrogen, normal
  FSH

4
34 y/o female with cc pelvic pain that
intensifies with her menstrual period. H/o pain
during intercourse, which started in her mid-20s
and has gradually become worse. Reports recent
missing some work d/t menstrual pain. Has had 2
uneventful deliveries and pain was absent during
and after each pregnancy, but gradually returned.
She doesnt want anymore kids. CPE is nl except
moderate nonspecific pelvic tenderness on exam.
Uterus is moderately retroverted and decreased
mobility. Which is the most appropriate initial
step in management of this pt?

• A. conjugated estrogens
• B. combo OCPs
• C. depot medroxyprogesterone acetate
• D. danazol
• E. complete hysterectomy c BSO

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B OCPs

• Combo OCPs should be first line tx in women c
  endometriosis who do not want to get pregnant.
• Conjugated estrogens is not tx of endometriosis
• Depot shot and danazol are accepted tx but have
  undesirable S.E.
• TAHBSO drastic and reserved for difficult cases

6
23y/o sexually active female presents with 2wk
h/o vaginal discharge and discomfort with sex. On
PE you see mucopurulent vaginal discharge and
cervical friability. Afebrile and rest of exam
nl. No trich or yeast seen on wet prep. Chlamydia
test is sent and will be available in 2
days.Which one of the following is true
regarding appropriate mgmt

• A. 7-day course of Doxycycline is superior to 1-g
  dose of Zithromax
• B. 2-g dose of Flagyl given now will clear her
  discharge
• C. No tx is indicated until lab comes back
• D. Pt should be instructed to refrain from sex
  until 7 days after initiating tx

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Answer D

• Pt with suspected genital chlamydia and their
  partners should be instructed to refrain from sex
  until until 7 days after a single dose tx or
  after the completion of a 7 day regimen of tx.
• Suspicion of Chlamydia warrants tx w or w/o
  positive lab finding
• Flagyl is not used for chlamydia tx
• No difference in the trials between 7-day Doxy or
  1-g Zithromax

8
The likelihood of postpartum depression is
increased by which of the following

• A. low educational level
• B. bottle feeding
• C. cesarean delivery
• D. unplanned pregnancy
• E. prior h/o depression

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Answer E

• Predictors of major depression are also
  predictors of postpartum depression
• prior depression
• family h/o mood disorders
• stressful life situations

10
An 18y/o female who has never been sexually
active has just begun a serious relationship with
a 19y/o male. Pt wants to start oral
contraception. Her periods are regular. She
started her current menses 2 days ago and would
like to delay her pelvic exam until period has
ended. Her BP is normal. Which of the following
is the most appropriate plan for this visit

• A. prescribe an OCP and have her come back in 2
  wks for a pelvic exam
• B. delay prescribing an OCP until after a pelvic
  exam and STD screening
• C. delay prescribing an OCP until results of a
  PAP smear
• D. delay prescribing an OCP until a pregnancy
  test is negative 2 weeks after onset of her menses

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Answer A

• A history, pregnancy test (if indicated), and BP
  reading constitute an adequate evaluation before
  beginning hormonal contraception. The pelvic exam
  can be deferred until a later visit.
• Start paps when????
• Sexually active women under 25y/o should get what
  with their paps????

12
According to the USPSTF, which of the following
strategies for osteoporosis screening is
supported by current clinical evidence?

• A. begin universal screening 5 years after date
  of last menstrual period
• B. begin universal screening at 55
• C. begin universal screening at 65
• D. screen only those women who are at increased
  risk for hip fracture based on multiple risk
  assessment scale

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Answer C

• No single study has evaluated the effectiveness
  of osteoporosis screening
• USPSTF recommends screening at 65
• None of the multiple risk assessment scales have
  been studied, but no good result so the criteria
  to screen women less than 65 are unclear

14
The only non-sexual behavior that is consistently
and strongly correlated with cervical dysplasia
and cervical cancer is

• A. alcohol consumption
• B. caffeine consumption
• C. cigarette smoking
• D. cocaine use
• E. high fiber diet

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Answer C

• Cigarette Smoking is The only non-sexual behavior
  that is consistently and strongly correlated with
  cervical dysplasia and cervical cancer
• It independently increases the risk TWO TO
  FOURFOLDS!

16
Over the past year, a 27y/o female has had
feelings of anxiety, tension, irritability
during the week preceding her menses along with
extreme fatigue insomnia. She has regularly
missed several days of work d/t the fatigue. She
has no prior h/o mental problems, and within a
few days of the onset of her period she is back
to normal.Which one of the following is true RE
her condition?

• A. neither biological nor psychological factors
  play a part in this condition
• B. this condition is a variation of a depressive
  disorder
• C. OCPs are consistently effective in the tx of
  this condition
• D. this problem can effectively be txd with
  serotonergic antidepressants
• E. Xanax is an effective first line agent for tx
  of this condition

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Answer D

• Dx PMDD
• Cluster of sx mood, cognitive, physical that
  recur in the luteal phase of cycle and remit in
  follicular phase
• Multiple trials have shown benefit of SSRI
• B/c many pts do not have depressive sx this
  disorder should not be considered as simply a
  depressive variant
• Some studies show that sx actually worsen with
  OCPs
• Use BZD only as 2nd line when optimal effect not
  reached with SSRI d/t high dependence

18
35y/o female comes with 6 month h/o irregular
menstrual bleeding. Before this, her periods came
q 30d and lasted 5days. Now they occur q 20d and
last 10d and are heavier. P.E. shows no obvious
anatomic source of bleeding, PAP is normal, preg
test is neg, blood workup of organic causes is
neg. she takes no meds. Which is most appropriate
at this time?

• A. pelvic ultrasound
• B. increasing the dosage of OCPs
• C. changing to a progesterone-only contraceptive
• D. reassurance that the problem will resolve on
  its own

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Answer A

• Dx DUB
• But diagnosis is made by excluding other
  pathologies cervical ca, polyps, thyroid
  problems, prolactinemia, coagulopathy, hepatic
  dysfunction, adrenal dysfunction, pregnancy
• If organic causes r/o, need to examine
  endometrium to exclude cancer especially if r.f.
  present
• Ultrasound is needed to r/o other uterine causes
  such as polyps or fibroids

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Risk Factors for Endometrial Cancer

• age over 35
• obesity
• nulliparity
• anovulatory cycles
• h/o tamoxifen use
• diabetes mellitus

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Who needs a mandatory uterine biopsy?

• ANY POSTMENOPAUSAL WOMAN WITH UTERINE BLEEDING

22
Metformin which is normally used for diabetes, is
also shown to be beneficial for

• A. osteoporosis
• B. hyperthyroidism
• C. polycystic ovary syndrome
• D. right ventricular hypertrophy
• E. morbid truncal obesity

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Answer C

• Insulin resistance and Hyperinsulinemia are
  suggested as important in pathogenesis of PCOS
• Tx with drugs that reduce insulin levels such as
  metformin has been shown to correct many
  metabolic abnormalities with PCOS
• Correction of ovulation, improved beta cell
  function, decreased insulin resistance
• Improvement in CV risk factors such as
  dyslipidemia and impaired fibrinolysis

24
After fitting a 30y/o G2P2 for a diaphragm you
advise her not to leave the diaphragm in place
for longer than 24 hours because of risk of which

• A. loss of contraceptive effectiveness
• B. chlamydia infection
• C toxic shock syndrome
• D. HPV infection
• E. adhesions

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Answer C

• Just like tampons, if left in place for gt24 hours
  it is associated with TSS

26
Diaphragm Tips

• The diaphragm can be inserted up to six hours to
  immediately before sexual intercourse.
• The diaphragm must remain in place for at least
  six hours after intercourse, but not for more
  than 24 hours (to reduce the risk of toxic shock
  syndrome).
• Douching should not be performed while the
  diaphragm is in place.
• Should be used with spermicide

27
Diaphragm is associated with increase in what?

• Diaphragm use is associated with an increased
  rate of urinary tract infections.

28
Which one of the following PAP results is most
likely to indicate a cancerous lesion?

• A. atypical squamous cells of undetermined
  significance (ASC-US)
• B. atypical squamous cells cannot exclude high
  grade intraepithelial lesion (ASH-H)
• C. atypical glandular cells not otherwise
  specified (AGC-NOS)
• D. low grade squamous intraepithelial lesion
  (LSIL)
• E. high grade squamous intraepithelial lesion
  (HSIL)

29
Answer C

• AGC-NOS has a benign sound to it, but has a 17
  cancer rate.
• HGSIL only has a 3 associated cancer rate

30
A 32y/o female is concerned about ovarian cancer.
She has no sx at this time, but a close friend
was dx with ovarian cancer at advanced stage.
This friend told her to get a simple test called
CA-125 to detect ovarian ca at a curable stage.
As part of your discussion, you inform the
patient that which of the following is true?

• A. most consensus opinions recommend performing
  this test for average risk women
• B. detecting ovarian cancer at an earlier stage
  using CA125 has not been shown to reduce
  mortality
• C. a high serum ca-125 level is not associated
  with ovarian ca
• D. a screening serum CA125 level will not detect
  ovarian ca at an earlier stage
• E. this test should not be ordered d/t its high
  false negative rate

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Answer B

• Convenient, inexpensive test which does detect
  ovarian ca at earlier stage, but it has not been
  shown to improve chance of a woman surviving this
  condition
• Over 99 of women with high CA125 will NOT have
  ovarian cancer
• Most consensus recommend against measuring this
  for average risk women

32
33y/o female requests combined OCPs for birth
control. Which of the following will be a
contraindication for OCP use

• A. h/o controlled hypertension
• B. family history of ovarian cancer
• C. h/o thromboembolic disease
• D. current h/o smoking
• E. h/o hepatitis C infection with no liver disease

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Answer C

• Previous thrombosis
• Preexisting vascular disease
• CAD
• CHF
• Active liver disease
• Estrogen dependent cancers
• Breast cancer
• Untreated hypertension
• Current smoking (regardless of amount) in a pt
  gt35years old