UWISE--Gynecology and Breast Pathology

Contraception and Sterilization

Correct! The patient should be reassured since initially after Depo-Provera injection
there may be unpredictable bleeding. This usually resolves in 2-3 months. In general,
after oone year of using Depo-Provera, nearly 50% of users have amenorrhea.
Correct! Emergency contraceptive pills are not an abortifacient, and they have not
been shown to cause any teratogenic effect if inadvertently administered during
pregnancy. They are more effective the sooner they are taken after unprotected
intercourse, and it is recommended that they be started within 72 hours, and no
later than 120 hours. Plan B, the levonorgestrel pills, can be taken in one or two
doses and cause few side effects. Emergency contraceptive pills may be used anytime
during a womans cycle, but may impact the next cycle, which can be earlier or later
with bleeding ranging from light, to normal, to heavy.
Correct! Ideal candidates for progestin-only pills include women who have
contraindications to using combined oral contraceptives (estrogen and progestin
containing). Contraindications to estrogen include a history of thromboembolic
disease, women who are lactating, women over age 35 who smoke or women who
develop severe nausea with combined oral contraceptive pills. Progestins should be
used with caution in women with a history of depression.
Correct! Oral contraceptives will decrease a womans risk of developing ovarian and
endometrial cancer. The earlier, higher dose oral contraceptive pills have been
linked to a slight increase in breast cancer, but not the most recent lower dose pills.
Women who use oral contraceptive pills have a slightly higher risk of developing
cervical intraepithelial neoplasia, but their risk of developing PID, endometriosis,
benign breast changes and ectopic pregnancy are reduced. Both hypertension and
thromboembolic disorders can be a potential side effect from using oral
contraceptive pills. Condoms and intrauterine devices will not lower her risk of
ovarian cancer.
Incorrect! Correct answer is B. Tubal ligation has not been shown to reduce the risk
of breast, cervical, or endometrial cancers, nor is there a decrease in menstrual
blood flow in women who have undergone a tubal ligation. There is a slight
reduction in the risk of ovarian cancer, but the mechanism is not yet fully
understood.
Correct! Approximately 10% of women who have been sterilized regret having had the
procedure with the strongest predictor of regret being undergoing the procedure at a
young age. The percentage expressing regret was 20% for women less than 30 years old at

the time of sterilization. For those under age 25, the rate was as high as 40%. The regret
rate was also high for women who were not married at the time of their tubal ligation,
when tubal ligation was performed less than a year after delivery, and if there was conflict
between the woman and her partner.
Correct! Both vasectomy and tubal ligation are 99.8% effective. Vasectomies are
performed as an outpatient procedure under local anesthesia, while tubal ligations
are typically performed in the operating room under regional or general anesthesia;
therefore carrying slightly more risk to the woman, assuming both are healthy. She
is morbidly obese, so the risk of anesthesia and surgery are increased. In addition,
she has chronic medical problems that put her at increased risk of having
complications from surgery.
Incorrect! Correct answer is E. The levonorgestrel intrauterine device has lower
failure rates within the first year of use than does the copper containing intrauterine
device. It causes more disruption in menstrual bleeding, especially during the first
few months of use, although the overall volume of bleeding is decreased long-term
and many women become amenorrheic. The levonorgestrel intrauterine device is
protective against endometrial cancer due to release of progestin in the endometrial
cavity. She is not a candidate for oral contraceptive pills because of her poorly
controlled chronic hypertension. The progestin only pills have a much higher failure
rate than the progesterone intrauterine device. She is not a candidate for the coppercontaining intrauterine device because of her history of Wilsons disease.
Correct! The patch has comparable efficiency to the pill in comparative clinical trials,
although it has more consistent use. It has a significantly higher failure rate when
used in women who weigh more than 198 pounds. The patch is a transdermal system
that is placed on a womans upper arm or torso (except breasts). The patch (Ortho
Evra) slowly releases ethinyl estradiol and norelgestromin, which establishes steady
serum levels for seven days. A woman should apply one patch in a different area each
week for three weeks, then have a patch-free week, during which time she will have
a withdrawal bleed.
Correct! Long-acting reversible contraceptives (LARC) methods such as
contraceptive implants and intrauterine devices are a good option for this patient.
Despite high up-front costs and the need for office visits for insertion and removal,
LARC methods provide many distinct advantages over other contraceptive methods
as Depo-Provera and oral contraceptives. While Depo-Provera is an effective form of
contraception, it may not be the best choice in this woman with a high BMI. For this
young mother who desires a reversible, but reliable form of contraception, the high
effectiveness, continuation rate and user satisfaction of LARC methods would be of

most benefit. Emerging evidence indicates that increasing the use of LARC methods
also could reduce repeat pregnancy among adolescent mothers and repeat abortions
among women seeking induced abortion. (Increasing Use of Contraceptive Implants
and Intrauterine Devices To Reduce Unintended Pregnancy, ACOG Committee
Opinion, No. 450, 2009). Tubal ligation and Essure are permanent and are not
appropriate for this patient.

Abortion
Correct! The patient has a septic abortion. She has fever and bleeding with a dilated
cervix which are findings seen with septic abortion. Threatened abortions clinically
have vaginal bleeding, a positive pregnancy test and a cervical os closed or
uneffaced, while missed abortions have retention of a nonviable intrauterine
pregnancy for an extended period of time (i.e. dead fetus or blighted ovum). A
normal pregnancy would have a closed cervix. Ectopic pregnancy would likely
present with bleeding, abdominal pain, possibly have an adnexal mass, and the
cervix would typically be closed.
Correct! The management of septic abortion includes broad-spectrum antibiotics
and uterine evacuation. Single agent antimicrobials do not provide adequate
coverage for the array of organisms that may be involved and therefore are not
indicated. A laparoscopy can be indicated if ectopic pregnancy is suspected, but it is
unlikely in this case. Medical termination is not the best option since prompt
evacuation of the uterus is indicated in this case.
Correct! Antiphosphospholipid antibodies are associated with recurrent pregnancy
loss. The workup for antiphospholipid syndrome includes assessment of
anticardiolipin and beta-2 glycoprotein antibody status, PTT, and Russell viper
venom time. There are multiple etiologies for recurrent pregnancy loss, which is
defined as > two consecutive or > three spontaneous losses before 20 weeks
gestation. Etiologies include anatomic causes, endocrine abnormalities such as hyper
or hypothyroidism and luteal phase deficiency, parental chromosomal anomalies,
immune factors such as lupus anticoagulant and idiopathic factors. Her history is not
consistent with cervical insufficiency which is diagnosed typically in the second
trimester by history, physical exam and other diagnostic tests, such as ultrasound.
Serial cervical lengths or placement of a cerclage are not indicated in this patient.
Treatment with 17-hydroxyprogesterone is indicated in patients with a history of
prior preterm birth. Factor V Leiden mutation has not been associated with
recurrent pregnancy loss. It can be associated with thrombotic events.

Correct! The prolonged dilute Russell viper venom time leads one to suspect that the
etiology of recurrent pregnancy loss is due to antiphospholipid antibody syndrome. The
treatment is aspirin plus heparin. There is roughly a 75% success rate with combination
therapy versus aspirin alone. There is conflicting evidence regarding steroid use for
treatment. 17-OH progesterone is used for the prevention of preterm delivery and not
recurrent pregnancy loss.
Correct! Medical abortion is associated with higher blood loss than surgical abortion. Early
in pregnancy (less than 49 days) both medical and surgical procedures can be offered.
Mifepristone (an antiprogestin) can be administered, followed by misoprostol (a
prostaglandin) to induce uterine contractions to expel the products of conception.
This approach has proven to be effective (96%) and safe. A surgical termination is
required in the event of failure or excessive blood loss. Medical termination seems to
be more desirable by some patients since they do not have to undergo a surgical
procedure. It does not affect future fertility. Any termination of pregnancy, whether
medical or surgical, can have psychological sequelae.
Correct! Manual vacuum aspiration is more than 99% effective in early pregnancy
(less than eight weeks). Age, parity and medical illnesses are not contraindications
for manual vacuum aspiration. Although the risk of Ashermans syndrome increases
with each subsequent pregnancy termination, this patient may still undergo surgical
termination as long as she understands risks and benefits. Complications of
pregnancy termination increase with increasing gestational age.
Incorrect! Correct answer is E. Both medical and surgical abortions are options for
this patient, depending on her personal preferences. However, if she desires an
autopsy, she must undergo a medical abortion in order to have an intact fetus.
Abortion is legal until viability is achieved (24 weeks gestation) unless a fetal
anomaly inconsistent with extrauterine life is identified. A dilation and curettage is
performed if the fetus is less than 16 weeks, while dilation and evacuation can be
performed after 16 weeks by those trained in the procedure. Induction with oxytocin
at this early gestational age has a high failure rate.
Incorrect! Correct answer is E. This patient is having heavy bleeding as a
complication of medical termination of pregnancy. This is managed best by
performing a dilation and curettage. It is not appropriate to wait six hours before
making a decision regarding next step in management, or to just admit her for
observation. Since the patient is not symptomatic from her anemia, it is not
necessary to transfuse her at this time.

Correct! Even though the patient reports being pregnant, she is asymptomatic with
no gestational sac in the uterus. First step in her management is to establish
pregnancy by obtaining a Beta-hCG level. One should not assume she has an
intrauterine pregnancy and perform a dilation and curettage or assume that she has
an ectopic pregnancy and treat her with methotrexate or surgery until the pregnancy
is confirmed.
Correct! This patient has postoperative endometritis that could be due to
introduction of bacteria into the uterine cavity at the time of dilation and curettage.
It is important to begin antibiotics immediately. After starting antibiotics, an
ultrasound should be obtained to look for products of conception. If found, the
patient would then require a repeat dilation and curettage. A Beta-hCG level would
not be helpful 2 days after the termination. Hysterosonogram is contraindicated
when infection is present. There are no indications for laparoscopy in this patient.
Vulvar and Vaginal Disease
Correct! Bacterial vaginosis is the most common cause of vaginitis. The infection
arises from a shift in the vaginal flora from hydrogen peroxide-producing lactobacilli
to non-hydrogen peroxide-producing lactobacilli, which allows proliferation of
anaerobic bacteria. The majority of women are asymptomatic; however, patients
may experience a thin, gray discharge with a characteristic fishy odor that is often
worse following menses and intercourse. Modified Amsel criteria for diagnosis
include three out of four of the following: 1) thin, gray homogenous vaginal
discharge; 2) positive whiff test (addition of potassium hydroxide releases
characteristic amine odor); 3) presence of clue cells on saline microscopy; and 4)
elevated vaginal pH >4.5. Treatment consists of Metronidazole 500 mg orally BID for
seven days, or vaginal Metronidazole 0.75% gel QHS for five days.
Correct! Lichen sclerosus is a chronic inflammatory skin condition that most
commonly affects Caucasian premenarchal girls and postmenopausal women. The
exact etiology is unknown, but is most likely multifactorial. Patients typically
present with extreme vulvar pruritus and may also present with vulvar burning,
pain and introital dyspareunia. Early skin changes include polygonal ivory papules
involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris,
and hypopigmentation. The vagina is not involved. More advanced skin changes may
include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema
and surface vascular changes. Ultimately, scarring with loss of normal architecture,
such as introital stenosis and resorption of the clitoris (phimosis) and labia minora,

may occur. Treatment involves use of high-potency topical steroids. There is less
than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus.
Incorrect! Correct answer is C. This patient has signs and symptoms of
trichomoniasis, which is caused by the protozoan, T. vaginalis. Many infected women
have symptoms characterized by a diffuse, malodorous, yellow-green discharge with
vulvar irritation. However, some women have minimal or no symptoms. Diagnosis of
vaginal trichomoniasis is performed by saline microscopy of vaginal secretions, but
this method has a sensitivity of only 60% to 70%. The CDC recommended treatment
is metronidazole 2 grams orally in a single dose. An alternate regimen is
metronidazole 500mg orally twice daily for seven days. The patients sexual partner
also should undergo treatment prior to resuming sexual relations.
Correct! Vulvovaginal candidiasis (VVC) usually is caused by C. albicans, but is
occasionally caused by other Candida species or yeasts. Typical symptoms include
pruritus and vaginal discharge. Other symptoms include vaginal soreness, vulvar
burning, dyspareunia and external dysuria. None of these symptoms are specific for
VVC. The diagnosis is suggested clinically by vulvovaginal pruritus and erythema
with or without associated vaginal discharge. The diagnosis can be made in a woman
who has signs and symptoms of vaginitis when either: a) a wet preparation (saline or
10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae;
or b) a vaginal culture or other test yields a positive result for a yeast species.
Microscopy may be negative in up to fifty percent of confirmed cases. Treatment for
uncomplicated VVC consists of short-course topical Azole formulations (1-3 days),
which results in relief of symptoms and negative cultures in 80%-90% of patients
who complete therapy.
Incorrect! Correct answer is C. Lichen planus is a chronic dermatologic disorder
involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva.
This disease manifests as inflammatory mucocutaneous eruptions characterized by
remissions and flares. The exact etiology is unknown, but is thought to be
multifactorial. Vulvar symptoms include irritation, burning, pruritus, contact
bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern
of the labia and perineum, with or without scarring and erosions as well. With
progressive adhesion formation and loss of normal architecture, the vagina can
become obliterated. Patients may also experience oral lesions, alopecia and
extragenital rashes. Treatment is challenging, since no single agent is universally
effective and consists of multiple supportive therapies and topical superpotent
corticosteroids.

Incorrect! Correct answer is C. Vulvar vestibulitis syndrome consists of a

constellation of symptoms and findings limited to the vulvar vestibule, which include
severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure
and erythema of various degrees. Symptoms often have an abrupt onset and are
described as a sharp, burning and rawness sensation. Women may experience pain
with tampon insertion, biking or wearing tight pants, and avoid intercourse because
of marked introital dyspareunia. Vestibular findings include exquisite tenderness to
light touch of variable intensity with or without focal or diffuse erythematous
macules. Often, a primary or inciting event cannot be determined. Treatment
includes use of tricyclic antidepressants to block sympathetic afferent pain loops,
pelvic floor rehabilitation, biofeedback, and topical anesthetics. Surgery with
vestibulectomy is recommended for patients who do not respond to standard
therapies and are unable to tolerate intercourse.
Correct! Lichen simplex chronicus, a common vulvar non-neoplastic disorder, results
from chronic scratching and rubbing, which damages the skin and leads to loss of its
protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the
result is susceptibility to infection, ease of irritation and more itching. Symptoms
consist of severe vulvar pruritus, which can be worse at night. Clinical findings
include thick, lichenified, enlarged and rugose labia, with or without edema. The
skin changes can be localized or generalized. Diagnosis is based on clinical history
and findings, as well as vulvar biopsy. Treatment involves a short-course of highpotency topical corticosteroids and antihistamines to control pruritus.
Correct! Mucopurulent cervicitis (MPC) is characterized by a mucopurulent exudate
visible in the endocervical canal or in an endocervical swab specimen. MPC is
typically asymptomatic, but some women have an abnormal discharge or abnormal
vaginal bleeding. MPC can be caused by Chlamydia trachomatis or Neisseria
gonorrhoeae; however, in most cases neither organism can be isolated. Patients with
MPC should be tested for both of these organisms. The results of sensitive tests for C.
trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid amplification tests)
should determine the need for treatment, unless the likelihood of infection with
either organism is high or the patient is unlikely to return for treatment.
Antimicrobial therapy should include coverage for both organisms, such as
azithromycin or doxycycline for chlamydia and a cephalosporin or quinolone for
gonorrhea. Uncomplicated cervicitis, as in this patient, would require only 125 mg of
Ceftriaxone in a single dose. Ceftriaxone 250 mg is necessary for the treatment of
upper genital tract infection or pelvic inflammatory disease (PID).
Incorrect! Correct answer is C. Two serotypes of HSV have been identified: HSV-1 and
HSV-2. Most cases of recurrent genital herpes are caused by HSV-2. Up to 30% of

first-episode cases of genital herpes are caused by HSV-1, but recurrences are much
less frequent for genital HSV-1 infection than genital HSV-2 infection. Genital HSV
infections are classified as initial primary, initial nonprimary, recurrent and
asymptomatic. Initial, or first-episode primary genital herpes is a true primary
infection (i.e. no history of previous genital herpetic lesions, and seronegative for
HSV antibodies). Systemic symptoms of a primary infection include fever, headache,
malaise and myalgias, and usually precede the onset of genital lesions. Vulvar lesions
begin as tender grouped vesicles that progress into exquisitely tender, superficial,
small ulcerations on an erythematous base. Initial, nonprimary genital herpes is the
first recognized episode of genital herpes in individuals who are seropositive for HSV
antibodies. Prior HSV-1 infection confers partial immunity to HSV-2 infection and
thereby lessens the severity of type 2 infection. The severity and duration of
symptoms are intermediate between primary and recurrent disease, with
individuals experiencing less pain, fewer lesions, more rapid resolution of clinical
lesions and shorter duration of viral shedding. Systemic symptoms are rare.
Recurrent episodes involve reactivation of latent genital infection, most commonly
with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of
lesions at varying intervals and of variable severity. Clinical diagnosis of genital
herpes should be confirmed by viral culture, antigen detection or serologic tests.
Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.
Correct! Pessary fitting is the least invasive intervention for this patients
symptomatic prolapse. Although a sacrospinous ligament suspension would be an
appropriate procedure for this patient, it is invasive and not an appropriate first
step. Transvaginal tape is used for urinary incontinence and has no role in the
management of this patient. An anterior repair can potentially help with her
symptoms, depending on what is contributing most to her prolapse but, again, it is
invasive. Topical estrogen is unlikely to properly treat her prolapse and related
symptoms.
Sexually Transmitted Infections and Urinary Tract Infections
Correct! The patient is most likely infected with herpes. Herpes simplex virus is a
highly contagious DNA virus. Initial infection is characterized by viral-like symptoms
preceding the appearance of vesicular genital lesions. A prodrome of burning or
irritation may occur before the lesions appear. With primary infection, dysuria due
to vulvar lesions can cause significant urinary retention requiring catheter drainage.
Pain can be a very significant finding as well. Treatment is centered on care of the
local lesions and the symptoms. Sitz baths, perineal care and topical Xylocaine jellies

or creams may be helpful. Anti-viral medications, such as acyclovir, can decrease

viral shedding and shorten the course of the outbreak somewhat.
These medications can be administered topically or orally. Syphilis is a chronic
infection caused by the Treponema pallidum bacterium. Transmission is usually by
direct contact with an infectious lesion. Early syphilis includes the primary,
secondary, and early latent stages during the first year after infection, while latent
syphilis occurs after that and the patient usually has a normal physical exam with
positive serology. In primary syphilis, a painless papule usually appears at the site of
inoculation. This then ulcerates and forms the chancre, which is a classic sign of the
disease. Left untreated, 25% of patients will develop the systemic symptoms of
secondary syphilis, which include low-grade fever, malaise, headache, generalized
lymphadenopathy, rash, anorexia, weight loss, and myalgias. This patients
symptoms are less consistent with syphilis, but she should still be tested for it.
Human immunodeficiency virus is an RNA retrovirus transmitted via sexual contact
or sharing intravenous needles. Vulvar burning, irritation or lesions are not typically
noted with this disease, although generalized malaise can be. HIV can present with
many different signs and symptoms, therefore risk factors should be considered, and
testing offered. Trichomonas is a protozoan and is transmitted via sexual contact. It
typically presents with a non-specific vaginal discharge. It does not have a systemic
manifestation.

The patient is most likely has candida vaginalis. Clinically women have itching and
thick white cottage cheese like discharge. They may also have burning with urination
and pain during intercourse. Herpes simplex viral infections are characterized by
viral like symptoms preceding the appearance of vesicular genital lesions. A
prodrome of burning or irritation may occur before the lesions appear. With
primary infection, dysuria due to vulvar lesions can cause significant urinary
retention requiring catheter drainage. Pain can be a very significant finding as well.
Treatment is centered on care of the local lesions and the symptoms. Sitz baths,
perineal care and topical Xylocaine jellies or creams may be helpful. Anti-viral
medications, such as acyclovir, can decrease viral shedding and shorten the course of
the outbreak somewhat. These medications can be administered topically or orally.
Syphilis is a chronic infection caused by the Treponema pallidum bacterium.
Transmission is usually by direct contact with an infectious lesion. Early syphilis includes
the primary, secondary, and early latent stages during the first year after infection, while
latent syphilis occurs after that and the patient usually has a normal physical exam with
positive serology. In primary syphilis, a painless papule usually appears at the site of
inoculation. This then ulcerates and forms the chancre, which is a classic sign of the
disease. Left untreated, 25% of patients will develop the systemic symptoms of secondary
syphilis, which include low-grade fever, malaise, headache, generalized lymphadenopathy,
rash, anorexia, weight loss, and myalgias. Bacterial vaginosis is due to an overgrowth of
anaerobic bacteria and characterized by a grayish / opaque foul-smelling discharge.

Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents with
a non-specific vaginal discharge. It does not have a systemic manifestation.
Correct! It is estimated that 38% of hepatitis B cases worldwide are acquired from sexual
transmission. Post-exposure prophlaxis should be inititated as soon as possible but not
later than 7 days after blood contact and within 14 days after sexual exposure. In
individuals who are unvaccinated but exposed to persons who are HBsAG positive,
recommendations are to receive a dose of HBIG (Hepatitis B Immune Globulin) and the
HBV (Hepatitis B Vaccine Series). If the source is HBsAG negative or unknown status, then
only the HBV series is used. If the exposed individual has been vaccinated and is a
responder then no further treatment is necessary. If the exposed individual is vaccinated
and a non-responder, then HBIG plus HBV or HBIG times two doses is used. Because the
incubation period for the virus is six weeks to six months, checking liver function and
immunologic status at this time is not indicated.
Incorrect! Correct answer is E. The most likely cause of the symptoms and signs in this
patient is infection with a sexually transmitted organism. The most likely organisms are
both N. gonorrhoeae and chlamydia, and the patient should be treated empirically for both
after appropriate blood and cervical cultures are obtained. Since the patient also has a high
fever, inpatient admission is recommended for aggressive intravenous antibiotic therapy in
an effort to prevent scarring of her fallopian tubes and possible future infertility.
Incorrect! Correct answer is D. Although salpingitis is most often caused by sexually
transmitted agents such as gonorrhea and chlamydia, any ascending infection from the
genitourinary tract or gastrointestinal tract can be causative. The infection is polymicrobial
consisting of aerobic and anaerobic organisms such as E. coli, Klebsiella, G. vaginalis,
Prevotella, Group B streptococcus and/or enterococcus. Although diverticulitis and
gastroenteritis should be part of the differential diagnosis initially, the specific findings on
examination and ultrasound are more suggestive of bilateral tubo-ovarian abscesses. Even
though this patient does not have the typical risk factors for salpingitis, the diagnosis
should be considered and explained to the patient in a sensitive and respectful manner. The
patient should also be questioned separate from her partner regarding the possibility of
other sexual contacts.
Correct! The signs and symptoms of acute salpingitis can vary and be very subtle
with mild pain and tenderness, or the patient can present in much more dramatic
fashion with high fever, mucopurulent cervical discharge and severe pain. Important
diagnostic criteria include lower abdominal tenderness, uterine/adnexal tenderness
and mucopurulent cervicitis.
Incorrect! Correct answer is D. Although some patients can be treated with an outpatient
regimen, this patient should be hospitalized for IV treatment, as she has nausea and
vomiting so she might not be able to tolerate oral medications. She is also at risk for noncompliance with an outpatient treatment regimen. It is important to treat aggressively in
order to prevent the long-term sequelae of acute salpingitis. You would not wait for culture
results before initiating treatment. Her recent sexual contacts should also be informed (by

her and/or with her consent) and treated. According to the 2010 CDC treatment guidelines,
there are two options for parenteral antibiotics covering both gonorrhea and chlamydia.
Cefotetan or cefoxitin PLUS doxycycline or clindamycin PLUS gentamicin. For outpatient
treatment, the 2010 CDC guidelines recommend ceftriaxone, cefoxitin, or other thirdgeneration cephalosporin (such as ceftizoxime or cefotaxime) PLUS doxycycline WITH or
WITHOUT metronidazole. There are alternative oral regimens as well.
http://www.cdc.gov/std/treatment/2010/pid.htm
Correct! The rate of tubal infertility has been reported as 12% after one episode of
PID, 25% after 2 episodes and 50% after three episodes. Salpingitis can develop in
15-30% of women with inadequately treated gonococcal or chlamydial infections
and can result in significant long-term sequelae, such as chronic pelvic pain,
hydrosalpinx, tubal scarring and ectopic pregnancy. Given this patients history, her
inability to conceive is most likely due to the long-term sequelae of a sexually
transmitted infection. Although the patient had a LEEP, risk for cervical stenosis is
low. She is having regular cycles; therefore, anovulation and luteal phase defect is
less likely. This case emphasizes the importance of aggressive screening and
treatment protocols for sexually transmitted infections, as well as counseling
regarding abstinence and safer sex practices. While endometriosis can cause tubal
occlusion, her clinical presentation is not consistent with endometriosis.
Correct! Acute cystitis in a healthy, non-pregnant woman is considered
uncomplicated and is very common. Escherichia coli causes 80 to 85 percent of cases.
The other major pathogens are Staphylococcus saprophyticus, Klebsiella
pneumoniae, Enterococcus faecalis and Proteus mirabilis. The physician must
consider antibiotic resistance when determining treatment.
Incorrect! Correct answer is D. Mildly symptomatic or asymptomatic urinary tract
infections are common in female patients. Urinary tract infection must be considered
in patients who present with low pelvic pain, urinary frequency, urinary urgency,
hematuria or new issues with incontinence. In addition, routine screening of
pregnant patients for asymptomatic urinary tract infections at each prenatal visit is
recommended in order to prevent urinary tract infection, which can cause preterm
labor. A pelvic ultrasound is not indicated at this point.
Pelvic Relaxation and Urinary Incontinence
Correct! Overflow incontinence is characterized by failure to empty the bladder adequately.
This is due to an underactive detrusor muscle (neurologic disorders, diabetes or multiple
sclerosis) or obstruction (postoperative or severe prolapse). A normal post-void residual
(PVR) is 50-60 cc. An elevated PVR, usually >300 cc, is found in overflow incontinence.
Stress incontinence occurs when the bladder pressure is greater than the intraurethral
pressure. Overactive detrusor contractions can override the urethral pressure resulting in
urine leakage. The mixed variety includes symptoms related to stress incontinence and
urge incontinence.

Correct! Urge incontinence is due to detrusor instability. Though the testing may be simple
(using a Foley catheter and attached large syringe without the plunger, filling with 50-60 cc
of water at a time) or complex (using computers and electronic catheters), the uninhibited
contraction of the bladder with filling makes the diagnosis. Genuine stress incontinence
(GSI) is the loss of urine due to increased abdominal pressure in the absence of a detrusor
contraction. The majority of GSI is due to urethral hypermobility (straining Q-tip angle >30
degrees from horizon). Some (<10%) of GSI is due to intrinsic sphincteric deficiency (ISD)
of the urethra. Overflow incontinence is associated with symptoms of pressure, fullness,
and frequency, and is usually a small amount of continuous leaking. It is not associated with
any positional changes or associated events. Mixed incontinence occurs when increased
intra-abdominal pressure causes the urethral-vesical junction to descend causing the
detrusor muscle to contract.
Correct! Genuine stress incontinence (GSI) is the loss of urine due to increased abdominal
pressure in the absence of a detrusor contraction. The majority of GSI is due to urethral
hypermobility (straining Q-tip angle >30 degrees from horizon). Some (<10%) of GSI is due
to intrinsic sphincteric deficiency (ISD) of the urethra. Patients can have both
hypermobility and ISD. Retropubic urethropexy such as tension-free vaginal tape and other
sling procedures have the best five-year success rates for patients with GSI due to
hypermobility. Needle suspensions and anterior repairs have lower five-year success rates
for GSI. Urethral bulking procedures are best for patients with ISD, but with little to no
mobility of the urethra. Colpocleisis is one option to treat uterine prolapse, and is not
indicated for urinary incontinence.
Correct! This is a classic example of intrinsic sphincteric deficiency. Urethral bulking
procedures are minimally invasive and have a success rate of 80% in these specific
patients. The success rates for retropubic urethropexies, needle suspension and slings are
less than 50%. An obstructive or tight sling can be performed to increase the success rate,
but the voiding difficulties are significant, even requiring prolonged or lifelong selfcatheterization. Artificial sphincters should be used in patients as a last resort.
Correct! The patient has the diagnosis of detrusor instability. The parasympathetic system
is involved in bladder emptying and acetylcholine is the transmitter that stimulates the
bladder to contract through muscarinic receptors. Thus, anticholinergics are the mainstay
of pharmacologic treatment. Oxybutynin is one example. Although the tricyclic
antidepressant, amitriptyline, has anticholinergic properties, its side effects do not make it
an ideal choice. Vaginal estrogen has been shown to help with urgency, but not urge
incontinence. Pseudoephedrine has been shown to have alpha-adrenergic properties and
may improve urethral tone in the treatment of stress incontinence. Kegel exercises or
pelvic muscle training are used to strengthen the pelvic floor and decrease urethral
hypermobility for the treatment of stress urinary incontinence.

Correct! Central and lateral cystoceles are repaired by fixing defects in the pubocervical
fascia or reattaching it to the sidewall, if separated from the white line. Defects in the
rectovaginal fascia are repaired in rectoceles. Uterine prolapse is surgically treated by a
vaginal hysterectomy, but this patient already had a hysterectomy. Enteroceles are
repaired by either vaginal or abdominal enterocele repairs. Vaginal vault prolapse is
treated either by supporting the vaginal cuff to the uterosacral ligaments, sacrospinous
ligament or sacrocolpopexy. Urethral diverticulum does not present with severe pelvic
protrusion.
Incorrect! Correct answer is C. This patient has urge incontinence, which is caused by
overactivity of the detrusor muscle resulting in uninhibited contractions, which cause an
increase in the bladder pressure over urethral pressure resulting in urine leakage. Stress
incontinence is caused by an increase in intra-abdominal pressure (coughing, sneezing)
when the patient is in the upright position. This increase in pressure is transmitted to the
bladder that then rises above the intra-urethral pressure causing urine loss. Associated
structural defects are cystocele or urethrocele. Overflow incontinence is associated with
symptoms of pressure, fullness, and frequency, and is usually a small amount of continuous
leaking. It is not associated with any positional changes or associated events. Mixed
incontinence occurs when increased intra-abdominal pressure causes the urethral-vesical
junction to descend causing the detrusor muscle to contract. A vesicovaginal fistula
typically results in continuous loss of urine.
Correct! This patient is asymptomatic from her prolapse; therefore, no intervention is
necessary at this point. Cystocele repairs and hysterectomies are invasive procedures
which are not indicated in this asymptomatic patient. It is not necessary to obtain a pelvic
ultrasound, as her uterus is normal in size and she has no adnexal masses. Topical estrogen
would not help improve the prolapse, although it might help with her vaginal dryness. She
seems to be doing well with the lubricants and it is not necessary to expose her to the
estrogen, especially since she still has her uterus, and estrogen treatment alone may
increase her risk of endometrial cancer.
Correct! Because of the hydronephrosis due to obstruction, intervention is required.
Colpocleisis is a procedure where the vagina is surgically obliterated and can be performed
quickly without the need for general anesthesia. Anterior and posterior repairs provide no
apical support of the vagina. She will be at high risk of recurrent prolapse. The
sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or sacrocolpopexy (cuff to
sacral promontory using interposed mesh) require regional or general anesthesia and is
not the best option for this patient with high surgical morbidity.
Correct! Pessary fitting is the least invasive intervention for this patients symptomatic
prolapse. Although a sacrospinous ligament suspension would be an appropriate

procedure for this patient, it is invasive and not an appropriate first step. Transvaginal tape
is used for urinary incontinence and has no role in the management of this patient. An
anterior repair can potentially help with her symptoms, depending on what is contributing
most to her prolapse but, again, it is invasive. Topical estrogen is unlikely to properly treat
her prolapse and related symptoms.

Endometriosis

Incorrect! Correct answer is C. This patient has typical symptoms of endometriosis,

including dysmenorrhea and dyspareunia. In addition, the nodularity on the back of
the uterus is suggestive of endometriosis. Chronic pelvic inflammatory disease
would not present this far out from a known infection. Adenomyosis is endometrial
glands embedded in the wall of the uterus. Endometritis is an infection of the
endometrium. Premenstrual dysphoric disorder (PMDD) is a condition in which a
woman has severe depressive symptoms, irritability, and tension before
menstruation.

Correct! The patient has typical signs of endometriosis which is characterized by the
presence of endometrial glands and stroma outside of the uterus. Endometriosis is
present in about 30% of infertile woman. She does not have the signs and symptoms
of chronic pelvic inflammatory disease. She also does not have the signs and
symptoms of polycystic ovarian syndrome, which typically presents with
oligomenorrhea in overweight patients. The complex ovarian cyst is most likely an
endometrioma. The duration of her symptoms makes functional hemorrhagic cyst a
less likely option.

Correct! A complex ovarian mass in a postmenopausal patient needs to be surgically

explored. Although this could be an old endometrioma which never resolved, this cannot be
assumed. If this is ovarian cancer, waiting three months can change this patients
prognosis. This complex cyst most likely will not resolve, since this is not a physiological
cyst. A CT scan or MRI will not add more information and ultrasounds are typically the best
imaging studies for the uterus and adnexa.
orrect! Oral contraceptives will be the next best choice for this patient. They provide
negative feedback to the pituitary-hypothalamic axis which stops stimulation of the

ovary to produce sex hormones, such as estrogen, which stimulates endometrial

tissue located outside of the endometrium and uterus. GnRH agonists also exert
negative feedback, but can be used short term only and have more side effects.
Danazol is a synthetic androgen used to treat endometriosis, but due to its
androgenic side effects (weight gain, increased body hair and acne, and adverse
affect on blood lipid levels) it is not usually the first choice of treatment. Laparoscopy
is indicated in the patient who fails medical treatment and/or is planning pregnancy
in the near future. A progesterone intrauterine device might potentially help
alleviate some of her symptoms but is not the best management for endometriosis.
Correct! Definitive diagnosis is based on exploratory surgery and biopsies, although
endometriosis is usually initially treated based on the clinical presentation. In
addition, this patient can benefit from laparoscopy, since she has failed the two most
common treatments for endometriosis, NSAIDs and OCPs. There is no imaging study
or blood test that can confirm the diagnosis of endometriosis.
Correct! This patient most likely has a hemorrhagic cyst, considering her history and where
she is in her menstrual cycle. Her mothers history of endometriosis does increase her risk;
however, it is unlikely since she has never had any symptoms herself. Ovarian carcinoma
would need to be ruled out, but it is unlikely in an otherwise asymptomatic premenopausal
patient. A mature teratoma would have more pathognomonic findings on ultrasound. This
patient does not have typical symptoms, body habitus or ultrasound findings for patients
with polycystic ovaries.
Correct! A repeat ultrasound is the most appropriate next step, as this is most likely a
hemorrhagic cyst which will resolve on its own. Oral contraceptives are contraindicated in
this patient, as she is older than 35 and smokes. A CT scan of the pelvis will not add any
more information. Needle aspiration is not the standard of care in this asymptomatic
premenopausal patient. There is no indication to proceed with a TAH/BSO.
Correct! The sudden onset of pain and nausea, as well as the presence of a cyst on
ultrasound suggest ovarian torsion. Although appendicitis is on the differential diagnosis
list, it is unlikely to have such a sudden onset of pain and a normal white count. Her
endometriosis can get worse but it would be unlikely to be of such sudden onset. Although
she has an adnexal mass, the Beta-hCG is negative, which rules out pregnancy.
Correct! This patient most likely has ovarian torsion and needs to be surgically explored.
Further imaging studies will not help beyond the information obtained on the ultrasound. A
Doppler ultrasound to check the blood flow to the ovaries is controversial, as normal flow
does not rule out ovarian torsion. Although oral contraceptives can help decrease the
development of further cyst formation and control the pain associated with endometriosis,
this patient needs immediate surgical attention due to suspected ovarian torsion.

Correct! A patient with a known history of endometriosis who is unable to conceive

and has an otherwise negative workup for infertility, benefits from ovarian
stimulation with clomiphene citrate, with or without intrauterine insemination.
Waiting another six months is not appropriate as she has been trying to conceive for
18 months unsuccessfully. A GnRH agonist is used to control pelvic pain in
endometriosis patients unresponsive to other hormonal treatments. In vitro
fertilization and adoption can be offered if other treatments fail.
Chronic Pelvic Pain

Correct! Chronic pelvic pain is the indication for at least 40% of all gynecologic
laparoscopies. Endometriosis and adhesions account for more than 90% of the
diagnoses in women with discernible laparoscopic abnormalities, and laparoscopy is
indicated in women thought to have either of these conditions. Often, adolescents are
excluded from laparoscopic evaluation on the basis of their age, but several series
show that endometriosis is as common in adolescents with chronic pelvic pain as in
the general population. Therefore, laparoscopic evaluation of chronic pelvic pain in
adolescents should not be deferred based on age. Laparoscopy can be both
diagnostic and therapeutic in this patient in whom you suspect endometriosis. None
of the other imaging modalities listed will help in the further workup of this patient.
Correct! Interstitial cystitis (IC) is a chronic inflammatory condition of the bladder,
which is clinically characterized by recurrent irritative voiding symptoms of urgency
and frequency, in the absence of objective evidence of another disease that could
cause the symptoms. Pelvic pain is reported by up to 70% of women with IC and,
occasionally, it is the presenting symptom or chief complaint. Women may also
experience dyspareunia. The specific etiology is unknown, but IC may have an
autoimmune and even hereditary component.
Correct! Irritable bowel syndrome (IBS) is a common functional bowel disorder of
uncertain etiology. It is characterized by a chronic, relapsing pattern of abdominal and
pelvic pain, and bowel dysfunction with constipation or diarrhea. IBS is one of the most
common disorders associated with chronic pelvic pain. IBS appears to occur more
commonly in women with chronic pelvic pain than in the general population. Diagnosis is
based on the Rome II Criteria for IBS, which includes at least 12 weeks (need not be
consecutive) in the preceding 12 months of abdominal discomfort or pain that has two of
three features: 1) relief with defecation; 2) onset associated with a change in frequency of
stool; or 3) onset associated with a change in stool form or appearance. The patients

history does not support pelvic adhesions, and diverticulosis (although very common)
typically may be asymptomatic unless inflammation/infection develops. In this case, the
symptoms for IBS may be indistinguishable from diverticulitis or severe diverticular
disease. Although severe endometriosis may affect the lower bowel with constricting and
invasive implants, the lack of any gynecologic/menstrual symptoms and the normal pelvic
examination essentially excludes this diagnosis. The lack of recent antibiotic exposure
essentially rules out the diagnosis of C. difficile.
Correct! Gonadotropin-releasing hormone (GnRH) agonists are analogues of
naturally occurring gonadotropin-releasing hormones that down-regulate
hypothalamic-pituitary gland production and the release of luteinizing hormone and
follicle-stimulating hormone leading to dramatic reductions in estradiol level.
Numerous clinical trials show GnRH agonists are more effective than placebo and as
effective as Danazol in relieving endometriosis-associated pelvic pain. Danazol, a 17alpha-ethinyl testosterone derivative, suppresses the mid-cycle surges of LH and
FSH. Combined estrogen and progestin therapy in oral contraceptives produces the
pseudopregnancy state.
Correct! Most published evidence suggests a significant association of physical and
sexual abuse with various chronic pain disorders. The arguments with the new
partner allude to possible abuse. Studies have found that 40-50% of women with
chronic pelvic pain have a history of abuse. Whether abuse (physical or sexual)
specifically causes chronic pelvic pain is not clear, nor is a mechanism established by
which abuse might lead to the development of chronic pelvic pain. Women with a
history of sexual abuse and high somatization scores have been found to be more
likely to have non-somatic pelvic pain, suggesting the link between abuse and
chronic pelvic pain may be psychologic or neurologic. However, studies also suggest
that trauma or abuse may also result in biophysical changes, by literally heightening
a person's physical sensitivity to pain.
Correct! It is estimated that chronic pelvic pain is the principal preoperative
indication for 10-12% of hysterectomies. Since the patient had a tubal ligation and
does not desire any more children, the best option is removal of ovaries with or
without a hysterectomy. Repeat laparoscopy with treatment of endometriosis and
adhesions can be helpful; however, the patient will continue to be at increased risk
of recurrent disease. An endometrial ablation or wedge resection of ovaries alone
would not be very helpful in the setting of non-cyclical pain.
Incorrect! Correct answer is A. Given the patients age, nonspecific abdomino-pelvic
symptoms, recent postmenopausal bleeding episode and family history of ovarian
cancer, a transvaginal ultrasound is the next best step as it is more sensitive than CT

for evaluation of the uterus and adnexa. Colonoscopy is useful for colorectal cancer
screening, as well as evaluation of the patients gastrointestinal symptoms, but
would not provide information regarding pelvic anatomy. Diagnostic laparoscopy
would be a more invasive procedure that could be performed as indicated, after
these other diagnostic studies. Hysteroscopy might be useful based on the
ultrasound results, since it mig be difficult to perform an endometrial biopsy in the
office.
Incorrect! Correct answer is D. Approximately 18-35% of all women with acute
pelvic inflammatory disease (PID) develop chronic pelvic pain. The actual
mechanisms by which chronic pelvic pain results from PID are not known and not all
women with reproductive organ damage secondary to acute PID develop chronic
pelvic pain. Chronic pelvic pain is the indication for at least 40% of all gynecologic
laparoscopies. Endometriosis and adhesions account for more than 90% of the
diagnoses in women with discernible laparoscopic abnormalities. Given this
patients desire for future fertility, conservative surgical intervention is indicated
with lysis of adhesions. Retention of the patients ovaries is appropriate given the
patients age and their normal appearance. Since the patient has a persistent
hydrosalpinx and pelvic pain, the right fallopian tube should be removed. Neither a
salpingostomy (an incision in the tube) nor aspiration of the tubal fluid would be
adequate treatment for this patient.
Correct! Pelvic congestion syndrome is a cause of chronic pelvic pain occurring in the
setting of pelvic varicosities. The unique characteristics of the pelvic veins make
them vulnerable to chronic dilatation with stasis leading to vascular congestion.
These veins are thin walled and unsupported, with relatively weak attachments
between the supporting connective tissue. The cause of pelvic vein congestion is
unknown. Hormonal factors contribute to vasodilatation when pelvic veins are
exposed to high concentration of estradiol, which inhibits reflex vasoconstriction of
vessels, induces uterine enlargement with selective dilatation of ovarian and uterine
veins. This pain may be of variable intensity and duration, is worse premenstrually
and during pregnancy, and is aggravated by standing, fatigue and coitus. The pain is
often described as a pelvic fullness or heaviness, which may extend to the vulvar
area and legs. Associated symptoms include vaginal discharge, backache and urinary
frequency. Menstrual cycle defects and dysmenorrhea are common. No signs of
pelvic floor relaxation were noted on exam.
Incorrect! Correct answer is B. Nerve entrapment syndrome is a commonly
misdiagnosed neuropathy that can complicate pelvic surgical procedures performed
through a low transverse incision. The nerves at risk are the iliohypogastric nerve
(T-12, L-1) and the ilioinguinal (T-12, L-1) nerve. These two nerves exit the spinal

column at the 12th vertebral body and pass laterally through the psoas muscle
before piercing the transversus abdominus muscle to the anterior abdominal wall.
Once at the anterior superior iliac spine, the iliohypogastric nerve courses medially
between the internal and external oblique muscles, becoming cutaneous 1 cm
superior to the superficial inguinal ring. The iliohypogastric nerve provides
cutaneous sensation to the groin and the skin overlying the pubis. The ilioinguinal
nerve follows a similar, although slightly lower, course as the iliohypogastric nerve
where it provides cutaneous sensation to the groin, symphysis, labium and upper
inner thigh. These nerves may become susceptible to injury when a low transverse
incision is extended beyond the lateral border of the rectus abdominus muscle, into
the internal oblique muscle. Symptoms are attributed to suture incorporation of the
nerve during fascial closure, direct nerve trauma with subsequent neuroma
formation, or neural constriction due to normal scarring and healing. Damage to the
obturator nerve, which can occur during lymph node dissection would result in the
inability of the patient to adduct the thigh.

Disorders of the Breast

Correct! Age and gender are the greatest risk factors for developing breast cancer. Having
one first-degree relative with breast cancer does increase the risk. A womens risk of
developing breast cancer before menopause is increased if she is BRCA1 or BRCA2 positive;
however, these genetic mutations occur in a low percentage of the general population.
There is no indication for a mammogram since the patients last mammogram was normal
four months ago. Ultrasound and MRI would not add valuable information especially in the
setting of a normal mammogram and no masses on physical examination. Genetic testing is
not indicated in this case as there is no strong family history and the sister with breast
cancer was postmenopausal at time of diagnosis.
Correct! This is a typical presentation for folliculitis which can occur with shaving the
axillary hair. Pagets disease is a malignant condition of the breast that has the appearance
of eczema and does not typically present in the axillary area. Fibroadenomas are common,
but are usually firm, painless and freely movable. A supernumerary nipple is a congenital
variation and is typically located in the nipple line and not tender. A clogged milk duct can
be present in the axillary region, but it is typically present in a woman who is
breastfeeding.
Correct! Stimulation of the breast during the physical examination may give rise to an
elevated prolactin level. Accurate prolactin levels are best obtained with patients fasting. If
these are still elevated, then a brain MRI would be indicated to rule out a pituitary tumor.

Although pathologic factors such as hypothyroidism, hypothalamic disorders, pituitary

disorders (adenomas, empty sella syndrome), chest lesions (breast implants, thoracotomy
scars, and herpes zoster) and renal failure can elevate prolactin levels, a non-significant
benign elevation needs to be ruled out first. A ductogram is usually indicated in patients
who have bloody discharge from the nipple.
Incorrect! Correct answer is D. Any solid dominant breast mass on exam should be
evaluated cytologically, with a fine needle aspiration (FNA), or histologically, with an
excisional biopsy. In this scenario, an MRI should not be part of the initial work-up for the
patients palpable breast mass. Testing for genetic mutations is indicated for patients with
a strong family history of breast cancer, but diagnosis is the most important next step in the
management of this patient. A normal mammogram does not rule out the presence of
cancer, and there is no reason to repeat the mammogram in two months, especially
considering that the first one was normal.
Correct! Fibrocystic breast changes are the most common type of benign breast conditions
and occur most often during the reproductive years. There is an increased risk of breast
cancer when atypia is present. The changes do not appear distinct histologically (three
stages) or mammographically. Fibrocystic disease is often associated with cyclic mastalgia,
possibly related to a pronounced hormonal response. Caffeine intake can increase the pain
associated with fibrocystic breast changes, so recommending that she decrease her caffeine
intake may be helpful.
Correct! The first noticeable symptom of breast cancer is typically a lump that feels
different from the rest of the breast tissue. More breast cancer cases are discovered when
the woman feels a lump. Breast cancer can also present with a spontaneous bloody nipple
discharge. Even though the mass decreased in size after aspiration, the bloody discharge
obtained obligates an excisional biopsy be performed to rule out breast cancer. If clear
discharge is obtained on aspiration and the mass resolves, reexamination in two months is
appropriate to check that the cyst has not recurred. An MRI is not the appropriate next step
and lumpectomy with lymph node dissection is not yet indicated in this case. A normal
mammogram does not rule out breast cancer, especially in the presence of bloody
discharge.
Correct! Nipple itch is a common symptom of allergies, dry skin, inflammation, or even
physical irritation. The itch is characterized by tingling and/or uneasy sensation near the
skin surface. Perhaps the most common cause is a chemical irritant such as laundry
detergents, soaps, and even perfumes. Itching sensations are not associated with adenomas
or ruptured breast implants. In rare circumstances, nipple itching may signify an
underlying malignancy such as Pagets disease of the breast. Mastitis is most common in
postpartum women and usually presents with pain and fever.

Correct! Mastitis that accompanies pregnancy or nursing is the most common breast
infection. Puerperal mastitis most commonly occurs during the second to fourth week after
delivery. Patients are treated with oral or IV antibiotics, depending on the severity of
infection. Patients may use ibuprofen in addition to acetaminophen for pain relief, and are
encouraged to continue breastfeeding or expressing their milk during treatment. Mastitis is
usually treated as an outpatient. Ice packs and breast binders are used to decrease breast
discomfort in women who do not desire to breastfeed. Cold compresses may reduce
inflammation but are not indicated in the management of mastitis. A breast ultrasound is
not indicated if there is no suspicion of a breast abscess.
Correct! Most postpartum mastitis is caused by staphylococcus aureus, so a penicillin-type
drug is the first line of treatment. Dicloxacillin is used due to the large prevalence of
penicillin resistant staphylococci. Erythromycin may be used in penicillin allergic patients.
Correct! A specimen obtained on fine-needle aspiration is examined both histologically and
cytologically. An excisional biopsy should be performed when the results are negative, due
to the possibility of a false-negative result. It can, however, prevent the need for other
diagnostic testing and is the appropriate next step. Breast ultrasound can be used to
distinguish between a cyst and a solid mass. Fine needle aspiration under ultrasound
guidance can help distinguish a fibroadenoma from a cyst and exclude cancer in certain
situations. A normal mammogram does not rule out breast cancer and there is no need to
repeat it in two months. There are no indications for obtaining an MRI of the chest in the
initial diagnosis of this patient.
Gynecological Procedures
Correct! The most recent consensus guidelines (2006) state that management of LSIL is
initial colposcopic examination (unless the woman is pregnant, postmenopausal or an
adolescent). An excisional procedure, such as cold knife biopsy or LEEP, is not warranted
without a tissue diagnosis of dysplasia. The Pap smear is merely a screening tool and, as
such, cannot formulate a definitive diagnosis. In fact, up to 20% of patients with LSIL on
Pap smear have high-grade squamous intraepithelial lesion (HSIL) on colposcopicallydirected biopsy. In contrast, up to 50% of patients with LSIL on Pap smear have a negative
colposcopy. Antibiotic treatment is not warranted unless there is an infection. If a Pap
smear is repeated prior to six to eight weeks following the last one, reparative changes may
still be happening to the cervix. This reduces the ability of the test to be a good screening
tool. (The false positive and/or false negative rates can be affected). In some instances, LSIL
may be followed with serial Pap smears; however, a tissue diagnosis or a colposcopy
without evidence of HSIL changes must be done initially.
Incorrect! Correct answer is E. The LEEP procedure is usually done in the office under local
intracervical anesthesia. It involves using an electrosurgical unit (similar to the Bovie in the

operating room), along with a wire loop of varying sizes to remove the entire
transformation zone and the dysplastic area(s) identified during colposcopy. This tissue is
then sent to pathology so that the area of dysplasia can be fully evaluated. A radical
hysterectomy is an option for patients with invasive cervical carcinoma stage Ia2 through
IIa. This patient has only cervical dysplasia (not invasive cancer). A simple hysterectomy is
not needed, as it is more involved than a LEEP. Serial Pap testing for patients with biopsy
proven CIN III or HSIL is generally not recommended. Although spontaneous regression of
dysplasia may occur with a high-grade lesion, the rate of regression is much lower than
with LSIL. On the other hand, the progression rate of HSIL to invasive cancer is much
higher (up to 12%). High risk HPV testing can be recommended as an adjunct to Pap
smears such as with ASCUS Pap smears. It would not offer additional information in this
patients scenario.
Correct! Endometrial biopsy is typically an office procedure which does not cause extreme
discomfort for the patient. It results in information necessary to tailor the patients care,
such as presence of endometritis, endometrial polyps or endometrial carcinoma. In a
patient with significant risk factors for endometrial carcinoma, this should be done prior to
a hysterectomy or ablation, if at all possible. A hysterectomy or endometrial ablation would
be incorrect, as further workup is needed prior to taking the patient for one of these
procedures. In addition, this patient potentially has a treatable condition, such as
endometritis, an endometrial polyp, endometrial hyperplasia or an enlarging submucosal
fibroid, which could all be treated with either medical therapy or a less radical procedure.
With stable vital signs and a hematocrit of 29, erythropoietin and a blood transfusion
would not be indicated for this patient. Her anemia could be corrected using ferrous sulfate
over a period of a few months, along with targeted therapy to decrease her vaginal bleeding
(therapy would be based on the endometrial biopsy result).
Correct! Women should be offered mammograms yearly starting at age 50 and at least
every two years between age 40 and 50 according to American College of Obstetricians and
Gynecologists (ACOG). Ultrasound is not a good screening modality for pelvic pathology. It
may be used along with yearly examination if the patients habitus does not allow full
evaluation of the adnexa; this patient had a normal exam, so it is not indicated. An
endometrial biopsy is indicated if a patient is experiencing irregular bleeding. A DEXA scan
is not indicated in a pre-menopausal patient. A colposcopy is not indicated as she has not
had a recent history of abnormal Pap smears.
Incorrect! Correct answer is D. The patient should be followed with Pap smears at six and
12 months or undergo HPV DNA testing at 12 months. Excisional or ablative procedures
are not indicated for LSIL. Indications for cold knife conization (CKC) include: positive
endocervical curettage, HSIL lesion too large for LEEP, patient not tolerant of examination
in office, lesion extending into the endocervical canal beyond vision, or to rule out invasive

cancer (classify the depth of invasion if biopsy shows invasion). It is unusual to manage low
grade lesions by CKC. Indications for LEEP are similar to CKC.
Correct! A vulvar lesion unresponsive to treatment needs a biopsy. In addition to testing for
invasive cancer, the biopsy can also ensure that your diagnosis and treatment are correct. If
the initial diagnosis of condyloma is unsure, a biopsy should be performed prior to
initiating therapy. Imiquimod would not be recommended, as this patient previously had a
full treatment without total response. Prior to initiating treatment again, a tissue diagnosis
is recommended. A repeat Pap is not indicated for a vulvar lesion, and, prior to using laser
vaporization to destroy the lesion, a biopsy should be done to ensure that the lesion is not
cancer. Interferon is not effective in the treatment of HPV.
Incorrect! Correct answer is E. A hysteroscopy would be easily performed either in the
office or in the operating room, and the IUD could then be removed under direct
visualization. This would be the best choice for this patient. In vitro fertilization requires a
normal endometrial cavity so that the embryo may implant in the uterus. A retained IUD is
not an indication for this procedure. Having an ultrasound showing the retained IUD in the
uterine cavity, it would not be visible upon laparoscopy. If the IUD had been seen outside
the uterus, laparoscopy could be offered for removal of the IUD. Hysterosonogram would
not offer additional information since the pelvic ultrasound showed an intrauterine IUD. A
pelvic MRI will not give any additional information what would be helpful in the
management of this patient.
Incorrect! Correct answer is A. Needle aspiration of a palpable breast mass or lymph node
allows for pathologic diagnosis of the mass with minimal discomfort to the patient. Results
correlate well with excisional biopsy results. Observation or waiting for the patient to
decrease caffeine intake would not be recommended for a patient with a new finding of a
palpable breast mass, especially in a patient with a family history of breast cancer. A
mammogram does not need to be repeated since one was performed three months ago.
Excisional biopsy is not necessary at this point although she might ultimately require it.
Correct! A hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment
for a patient with pelvic pain due to endometriosis. In 60% of cases, when a patient with
endometriosis undergoes a simple hysterectomy without bilateral salpingo-oophorectomy
for pelvic pain, re-operation for continued pain will be necessary. Even if the patient
requires hormone replacement therapy postoperatively, her pain is unlikely to return. A
laparoscopy is indicated in the workup of pelvic pain in order to determine the etiology of
the pain. If endometriosis is noted, it may be excised, fulgurated or burned by laser. This
may offer some relief of the patients pain; however, relief is usually temporary in a premenopausal female. In addition, this patient had a previous laparoscopy with only
temporary relief. A radical hysterectomy, usually used to treat cervical cancer, is too

invasive for the treatment of endometriosis. It is very unlikely in this scenario to decrease
the patients pain simply by changing her oral contraceptive pill. An endometrial ablation is
an acceptable treatment for menorrhagia and will likely not be helpful in this patient.
Although Levonorgestrel IUD may effectively relieve endometriosis, it is unlikely to do so in
this patient who has been on progestins and oral contraceptives without relief.
Correct! A transvaginal ultrasound would be the best way to begin a workup for an
incidental finding of an adnexal mass. Using this modality, one can distinguish an adnexal
mass from other structures, as well as note the characteristics of the mass (simple vs.
complex, solid vs. cystic, thin or thick walled, size, and ancillary structures involved). Using
this information, a management plan may be constructed. In a stable, asymptomatic
patient, laparoscopy or laparotomy would not be indicated for diagnosis until further
imaging studies had been done. A CT-guided drainage would not be a good choice until one
has a better understanding of the characteristics of the mass. If the mass was malignant,
draining it in this manner could not only seed the needle tract, but it could also spill intraabdominally, causing the malignancy to spread. A plain film would not be helpful unless the
mass contains calcium and thus would not give additional data.