OB-GYN REVIEWPart III

ByJEAN ANNE B. TORAL, M.D.

June 13, 2009

Question67. A 55 y.o. G5P5 (5005) consulted for fish-wash like

vaginal discharge and on-and-off vaginal bleeding. Pelvic exam showed the cervix to be converted to a 6 x 5 cm nodular, fungating mass extending to the R lateral fornix, the right parametria nodular but free while the left was smooth and pliable. Based on the information given, this patient can be clinically staged as

a. IIBb. IIIAc. IIIBd. IVA

Gyn Onc: Cervical Cancer Staging of cervical cancer is clinical.

Allowable diagnostic procedures to be included in clinical staging are pelvic exam preferably under anesthesia, palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctosigmoidoscopy, chest x-ray and bone xray, intravenous urography. Conization is also included.

Optional examinations: laparoscopy, ultrasound, CT scan, MRI, PET scan.

Cervical Cancer StagingStage 0: carcinoma in situ

Stage 1: confined to the cervix (uterine extension is disregarded)

IA: microscopic only IA1: stromal invasion no greater than 3 mm depth and 7 mm

horizontal spread IA2: stromal invasion depth 3-5 mm, horizontal spread up to

7 mm IB: clinically visible lesion confined to the cervix IB1: 4 cm or less IB2: more than 4 cm

Stage II: tumor invades beyond the uterus but not to the pelvic wall or to the lower third of the vagina

IIA: without parametrial invasion IIB: with parametrial invasion

Cervical Cancer StagingStage III: Tumor extends to the pelvic wall and/or involves

the lower third of the vagina and/or causes hydronephrosis or non-functioning kidney

IIIA: tumor involves the lower third of the vagina with no extension to the pelvic wall

IIIB: tumor extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney

Stage IVA: tumor invades the mucosa of the bladder or rectum and/or extends beyond the true pelvis

Stage IVB: distant metastasis

Answer67. A 55 y.o. G5P5 (5005) consulted for fish-wash like

vaginal discharge and on-and-off vaginal bleeding. Pelvic exam showed the cervix to be converted to a 6 x 5 cm nodular, fungating mass extending to the R lateral fornix, the right parametria nodular but free while the left was smooth and pliable. Based on the information given, this patient can be clinically staged as

a. IIBb. IIIAc. IIIBd. IVA

Question68. A 53 y.o. G1P1 (1001) underwent exploratory

laparotomy for an ovarian new growth. Intraoperative findings showed the right ovary to be converted to a 10 cm predominantly cystic mass with excrescences on its outer capsule and was densely adherent to the fundal portion of theuterus. The left ovary was grossly normal. All other abdominopelvic organs were grossly normal. Based on the information given, the Intraoperative stage of this patient is

a. IAb. IBc. ICd. IIA

Ovarian Cancer Staging

Staging of ovarian cancer is surgicopathologic.

Stage I: tumor confined to the ovariesIA: limited to one ovary, intact capsule, no tumor on ovarian surface, no malignant cells in the peritoneal washing or ascitesIB: limited to both ovaries, intact capsule, no tumor on ovarian surface, no malignant cells in the peritoneal washing or ascitesIC: tumor limited to one or both ovaries with any of the following: capsule ruptured, tumor on ovarian surface, positive malignant cells in the ascites or positive peritoneal washings

Stage II: tumor involves one or both ovaries with pelvic extensionIIA: extension/implants to uterus and/or tubesIIB: extension to other pelvic organs, no malignant cells in ascites or peritoneal washingsIIC: IIA/B with positive malignant cells in the ascites or positive peritoneal washings

Ovarian Cancer Staging

Stage III: Tumor involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis and/or regional lymph node metastasisIIIA: microscopic peritoneal metastasis beyond the pelvisIIIB: macroscopic peritoneal metastasis beyond the pelvis 2 cm or less in greatest dimensionIIIC: peritoneal metastasis beyond the pelvis more than 2 cm in greatest dimension and/or regional lymph nodes

Stage IV: Distant metastasis beyond the peritoneal cavity

Question68. A 53 y.o. G1P1 (1001) underwent exploratory

laparotomy for an ovarian new growth. Intraoperative findings showed the right ovary to be converted to a 10 cm predominantly cystic mass with excrescences on its outer capsule and was densely adherent to the fundal portion of theuterus. The left ovary was grossly normal. All other abdominopelvic organs were grossly normal. Based on the information given, the Intraoperative stage of this patient is

a. IAb. IBc. ICd. IIA

Question69. Histopath of a a 47 y.o. nulligravid who underwent PFC, THBSO,

BLND was read as follows:Endometrial adenocarcinoma, endometrioid type, well-differentiated with less than 50 % myometrial invasion.Chronic endocervicitis with squamous metaplasiaNegative for tumor: peritoneal fluid, all harvested lymph nodes.Positive lymphovascular space invasion.No diagnostic abnormality recognized, both ovaries and fallopian tubes

What is the stage of the patient?a. Stage IBb. Stage ICc. Stage IIBd. Stage IIIC

Endometrial Cancer Staging Staging of endometrial carcinoma is surgicopathologic. Only in

instances where radiation is the first treatment given is clinical staging used.

Stage I: Tumor confined to the corpusIA: limited to the endometriumIB: invades up to less than half of the myometriumIC: invades to more than half of the myometrium

Stage II: tumor invades the cervix but does not extend beyond the uterusIIA: endocervical glandular involvement onlyIIB: cervical stromal invasion

Endometrial Cancer StagingStage III: local and/or regional spread

IIIA: tumor involves uterine Serosa and/or adnexae and/or cancer cells in peritoneal washings or ascitesIIIB: vaginal involvementIIIC: metastasis to the pelvic and/or para-aortic nodes

Stage IVA: tumor invades the bladder and/or bowel mucosaStage IVB: distant metastasis including intra-abdominal

metastasis other than para-aortic and/or inguinal nodes

Answer69. Histopath of a a 47 y.o. nulligravid who underwent PFC, THBSO,

BLND was read as follows:Endometrial adenocarcinoma, endometrioid type, well-differentiated with less than 50 % myometrial invasion.Chronic endocervicitis with squamous metaplasiaNegative for tumor: peritoneal fluid, all harvested lymph nodes.Positive lymphovascular space invasion.No diagnostic abnormality recognized, both ovaries and fallopian tubes

What is the stage of the patient?a. Stage IBb. Stage ICc. Stage IIBd. Stage IIIC

Question

70. This woman is at high risk to develop endometrial carcinoma:a. 52 y.o. breast cancer patient on tamoxifenb. 35 y.o. nulligravid with PCOSc. 37 y.o. with BMI of 35 kg/m2

d. all of the above

Endometrial Cancer: Risk FactorsRisk factors for endometrial cancer (histogenic Type I) are related to

hyperestrogenic states including: obesity Nulliparity (history of infertility) late menopause (beyond 52 y.o.), polycystic ovary syndrome (common in endometrial cancer in young

patients), intake of tamoxifen (with estrogenic effect on the uterus), intake of unopposed estrogen replacement therapy.

There is also a genetic risk for endometrial cancer, the most common being the one associated with Hereditary Non-Polyposis Colorectal Cancer Syndrome (HNPCC). Endometrial cancer is the syndromes most common extracolonic manifestation with a lifetime risk of up to 60 %.

Answer

70. This woman is at high risk to develop endometrial carcinoma:a. 52 y.o. breast cancer patient on tamoxifenb. 35 y.o. nulligravid with PCOSc. 37 y.o. with BMI of 35 kg/m2

d. all of the above

Question

71. In an epithelial carcinoma of the ovary, the tumor marker that is most likely to be elevated is:a. alpha fetoproteinb. lactic dehydrogenasec. CA 125d. B-hcg

Ovarian Cancer Tumor Markers CA-125: epithelial ovarian cancer

CA-19-9: used for mucinous epithelial tumors

Alpha fetoprotein: germ cell tumor endodermal sinus tumor (EST) or also known as yolk sac tumor

Lactic dehydrogenase (LDH): germ cell tumor dysgerminoma

B-hcg: choriocarcinoma

Answer

71. In an epithelial carcinoma of the ovary, the tumor marker that is most likely to be elevated is:a. alpha fetoproteinb. lactic dehydrogenasec. CA 125d. B-hcg

Question

72. The most common genital tract malignancy in Filipino women based on the 2005 Philippine Cancer Facts and Estimates is:

a. vulvar cancerb. cervical cancerc. endometrial cancerd. ovarian cancer

Answer72. The most common genital tract malignancy in Filipino women

based on the 2005 Philippine Cancer Facts and Estimates is:a. vulvar cancerb. cervical cancerc. endometrial cancerd. ovarian cancer

The most common gynecologic malignancy among Filipino women is cervical cancer, followed by ovarian cancer, then endometrial cancer.

The trend is the reverse in developed countries because their cervical cancer rate is low because of effective screening programs.

Question73. A 17 y.o. nulligravid consulted for an

abdominopelvic mass. On physical examination, there were virilizing signs and symptoms. Even before a pelvic exam is done, the primary consideration if this were an ovarian pathology is:

a. epithelial tumorb. germ cell tumorc. sex-cord stromal tumord. metastatic tumor

Answer73. A 17 y.o. nulligravid consulted for an abdominopelvic mass. On

physical examination, there were virilizing signs and symptoms. Even before a pelvic exam is done, the primary consideration if this were an ovarian pathology is:

a. epithelial tumorb. germ cell tumorc. sex-cord stromal tumord. metastatic tumor

Hormonally active tumors of the ovary are usually the sex cord stromal type (those arising from granulosa cells and theca cells.

Hormonal effect could either be estrogenic (can present as bleeding or precocious puberty) or virilizing.

Question74. A 27 y.o. primigravid consults at the ER for vaginal

spotting of one week duration. She has an amenorrhea of 10 weeks. On pelvic exam, you note the uterus to be boggy and enlarged to 20 weeks age of gestation. Ultrasound showed an endometrial mass with snowstorm pattern. Best management for this case would be:

a. subtotal hysterectomyb. total hysterectomyc. suction curettaged. dilatation and curettage

Answer74. A 27 y.o. primigravid consults at the ER for vaginal spotting of one

week duration. She has an amenorrhea of 10 weeks. On pelvic exam, you note the uterus to be boggy and enlarged to 20 weeks age of gestation. Ultrasound showed an endometrial mass with snowstorm pattern. Best management for this case would be:

a. subtotal hysterectomyb. total hysterectomyc. suction curettaged. dilatation and curettage

Hydatidiform mole is usually diagnosed bu ultrasound. Pathognomonic is the snowstorm pattern. Treatment consists of suction curettage (conservative). Those no longer desirous of pregnancy can have total hysterectomy with mole-in-situ.

Question

75. According to the American Cancer Society Guidelines for Cervical Cancer Screening, screening using Pap smear should be started

a. age 12b. age 18c. age 21d. once the woman is sexually active

Answer75. According to the American Cancer Society Guidelines

for Cervical Cancer Screening, screening using Pap smear should be started

a. age 12b. age 18c. age 21d. once the woman is sexually active

Based on the 2003 American Cancer Society guidelines, screening should start 3 years after onset of vaginal intercourse or no later than 21 years old.

Discontinuation is recommended at age 70 after 3 normal smears in the preceding 10 years.

Question

76. In low resource settings like the Philippines, this has become an acceptable method of cervical cancer screening:

a. Schillers testb. Toluidine blue testc. 4-quadrant cervical biopsyd. visual inspection with acetic acid

Cervical Cancer Screening Visual inspection with acetic acid has become the

alternative screening method in low resource settings. The DOH has made a policy formulation making this as the screening method of choice for the Filipino woman based on validity and economic studies.

Schillers test is the use of Lugols iodine in the cervix. In glycogen-rich areas, the cervix will turn brown which is the normal result (reaction of glycogen and the iodine).No or partial uptake of Lugols is a positive result.

Toluidine blue test is for the vulva. Four quadrant biopsy is no longer done. When there is already a gross lesion in the cervix, there

is no need to do Pap smear or a screening method, biopsy should be done.

Answer

76. In low resource settings like the Philippines, this has become an acceptable method of cervical cancer screening:

a. Schillers testb. Toluidine blue testc. 4-quadrant cervical biopsyd. visual inspection with acetic acid

Question

77. Staging of ovarian cancer is:a. clinical b. surgicopathologicc. clinicopathologicd. histopathologic

Answer

77. Staging of ovarian cancer is:a. clinical b. surgicopathologicc. clinicopathologicd. histopathologic

Gynecologic InfectionsQuestion

78. Speculum exam of a 27 y.o. complaining of leucorrhea showed copious frothy greenish vaginal discharge with strawberry-like mucosa. This is most likely due to:

a. candidiasisb. trichomoniasisc. gonococcal infectiond. bacterial vaginosis

Gynecologic Infections: Candidiasis caused by ubiquitous, airborne, gram positive fungus.

Most common is Candida albicans. Candida species are part of the normal flora of 25 % of women.

When the ecosystem of the vagina is disturbed, C. albicans becomes an opportunistic pathogen (e.g. when lactobacilli concentration declines).

NOT usually associated with other STDs and is itself not considered an STD.

predominant symptom is pruritus. Vaginal discharge is white or whitish gray, granular or

floccular (like curd milk or cottage-cheese type discharge).

Ph is usually below 4.5. Treatment: oral or topical azoles

Gynecologic Infections:Trichomoniasis

an STD with the protozoa isolated also in male partners. Incubation is 4 to 28 days. It is a hardy organism and can survive for hours on towels and moist surfaces.

A basic pH promotes the infection. Primary symptom is profuse vaginal discharge making

patients feel wet. Discharge is color white, gray, yellow or green. Classic

description is frothy (with bubbles) and with unpleasant odor.There is also erythema even of the vulva. The classic strawberry appearance of the upper vagina and the cervix is rare.

Treatment: oral metronidazole including partner.

Gynecologic Infections: Bacterial Vaginosis

high concentrations of anaerobic bacteria predominate in the vaginal flora by replacing the normal lactobacillus.

Associated organism is Gardnerella vaginalis. is not invariably an STD but may be sexually

transmitted. Discharge is thin and gray-white. Patients

describe a musty or fishy smell. Clue cells are the findings on wet smear are

epithelial cells with clusters of bacteria. Treatment: oral metronidazole

Gynecologic Infections: Gonoccoccal

Gonoccoccal infection in the majority of women are asymptomatic.

Some would present with mucopurulent cervicitis.

Thayer-Martin culture media is the diagnostic standard.

Treatment: ceftriaxone 125 mg IM including the partner

Answer

78. Speculum exam of a 27 y.o. complaining of leucorrhea showed copious frothy greenish vaginal discharge with strawberry-like mucosa. This is most likely due to:

a. candidiasisb. trichomoniasisc. gonococcal infectiond. bacterial vaginosis

Question

79. In a patient with mucopurulent cervicitis, the patient is also given doxycycline to take care of:

a. Neisseria gonorrheab. Ureaplasma urealyticumc. Chlamydia trachomatisd. Gardnerella vaginalis

Answer79. In a patient with mucopurulent cervicitis, the patient is

also given doxycycline to take care of:a. Neisseria gonorrheab. Ureaplasma urealyticumc. Chlamydia trachomatisd. Gardnerella vaginalis

In 50 % of cases, gonococcal infection is accompanied by Chlamydia trachomatis which is an indolent infection. Doxycyline is the drug of choice for Chlamydia trachomatis.

Question

80. Which of the following is not considered a sexually transmitted disease?

a. Candidiasisb. Trichomoniasisc. Syphilisd. Genital warts

Answer

80. Which of the following is not considered a sexually transmitted disease?

a. Candidiasisb. Trichomoniasisc. Syphilisd. Genital warts

Trichomoniasis, Syphylis, and genital warts caused by human papilloma virus are all considered STDs.

Question

81. A 20 y.o. commercial sex worker came to you because of multiple, pruritic warty masses at the vulva. The largest measured 2 x 3 cm. Causative agent of these warts:

a. pox virusb. bacterialc. treponemesd. human papilloma virus

Answer81. A 20 y.o. commercial sex worker came to you because of multiple,

pruritic warty masses at the vulva. The largest measured 2 x 3 cm. Causative agent of these warts:

a. pox virusb. bacterialc. treponemesd. human papilloma virus

Genital warts are caused by the low risk types of human papillomavirus (HPV). Most common are types 6 and 11.

HPV types 16 and 18 are the two most common high risk oncogenic types leading to cervical cancer.

The Human Papilloma Virus

99.7 % of women with cervical cancer are positive for HPV.

Wallboomers JM et al, J Pathol 1999; 189:12-19Bosch FX et al J Clin Pathol 2002; 55: 244-265

HPV is the NECESSARY CAUSE of cervical cancer.Persistent infection with the oncogenic or high risk HPV types can lead to cervical cancer.

The HPV

HPV is a very common infection, though most infected individuals eliminate evidence of the virus without ever developing clinically recognized manifestations.

Thus, very few HPV-infected individuals progress to invasive cervical cancer.

Estimated World Burden of HPV-Related Disease and DiagnosesCervical cancer: 0.493 million in 20021

High-grade precancerous lesions: 10 million2

Low-grade cervical lesions: 30 million2

Genital warts: 30 million3

Attri

buta

ble

to o

ncog

enic

HPV

type

s

HPV infection without detectable abnormalities: 300 million2

1. Parkin DM, Bray F, Ferlay J, Pisani P. CA Cancer J Clin. 2005;55:74108. 2. World Health Organization. Geneva, Switzerland: World Health Organization; 1999:122. 3. World Health Organization. WHO Office of Information. WHO Features. 1990;152:16.

Attri

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ble

to n

onon

coge

nic

HPV

type

s

Primary and secondary prevention Primary prevention

measures used in people with no clinical evidence of disease to prevent disease developing e.g. vaccines

Secondary prevention treatments used in people with evidence of a disease action to slow or stop the progress of a disease during its early stages

Prevention

Screening

VaccinesVaccines

Invasive cancer

Pre-cancerous lesionsPersistence

Human papillomavirus (HPV) infection

Normal

Prevention

Vaccination has great potential

Vaccination should be a primary prevention tool, integrated with any existing screening programmes for early detection of cervical cancer

HPV Types in Cervical Cancer Worldwide

Cancer cases attributed to the most frequent HPV genotypes (%)

HPV genotype

Vaccine types

2.32.21.41.31.21.00.70.60.50.31.2

4.4

53.5

2.6

17.26.7

2.9

0 10 20 30 40 50 60 70 80 90 100

XOther

827368395156593558523331451816 53.5%

70.7%77.4%80.3%

Munoz N et al. Int J Cancer 2004;111:27885.

Vaccine profiles

Cancer and STDDual cervical cancer and genital

warts vaccine

Cancer focusPure cervical cancer vaccine

0, 2, 6 mthsIntramuscular0, 1, 6 mthsIntramuscular

20 g40 g40 g20 g

L1 HPV 6L1 HPV 11L1 HPV 16L1 HPV 18

20 g20 g

L1 HPV 16L1 HPV 18

Females and malesTarget: 926 years

Studies 1045 years

FemalesTarget: 1055 yearsStudies 1055 years

5.5 years follow-up for HPV 16/18

0.5 mLPer dose0.5 mLPer dose

MSDGlaxoSmithKline

GardasilHPV 6/11/16/18 vaccine

CervarixHPV 16/18 vaccine

Expected Benefits of HPV Vaccines

HPV 6/11/16/18 Vaccine (Gardasil) Reduce infection with HPV types associated with over

90% of condyloma acuminata Reduce/eliminate Recurrent Respiratory Papillomatosis

in young children Reduce/eliminate the psycho-social-financial burden of

external genital warts Reduce infection with HPV types associated with

about 65-70% of cervical cancers.

Expected Benefits of HPV Vaccines

GSK HPV 16/18 Candidate Vaccine The same benefits, except those derived from

protection against HPV 6 or 11. Preliminary evidence of cross-protection against other

HPV types (Types 45 and 31).

WHO position on HPV vaccines Recommends routine HPV vaccination be

included in national immunization programs provided that

-prevention of cervical cancer and other HPV-related diseases is a public health priority in the country,

-vaccine introduction is programmatically feasible,-sustainable financing can be secured, and -cost-effectiveness of vaccine strategies in the

country is considered

WHO position on HPV vaccines HPV vaccines are most efficacious in

females nave to vaccine-related HPV types, therefore, the primary target population should be selected based on the age of initiation of sexual activity and the feasibility of reaching young adolescent girls through schools and communities

Likely 9-10 through 13 years old

WHO position on HPV vaccines Vaccination of secondary target population of

older adolescent women and older age group is recommended only if this is feasible, affordable, cost-effective, and with big portion of these secondary target population as nave to HPV

Male vaccination is not recommended because of low cost-effectiveness.

Limited information on use of the vaccine on pregnant women and immunocompromised

Question

82. The most accurate method of diagnosing acute PID is:a. historyb. pelvic examinationc. ultrasoundd. diagnostic laparoscopy

Answer

82. The most accurate method of diagnosing acute PID is:a. historyb. pelvic examinationc. ultrasoundd. diagnostic laparoscopy

The diagnostic standard for PID is laparoscopy.

Question83. A 48 y.o. G3P3 (3003) consulted at the Out

Patient Clinic for menometrorrhagia since 5 months ago. Pelvic exam showed a corpus irregularly enlarged to 16 weeks size. Ultrasound showed multiple myoma uteri. Best treatment option for this patient would be:

a. THBSOb. myomectomyc. GnRH agonistd. progestin supplementation

Benign Gyn Lesion: Myoma In a patient with completed family size and with

advancing age (some use 45 as cut off), myomas are managed by doing THBSO.

If this same patient were 35 y.o. and nulligravid, myomectomy is the better treatment option because you want to be conservative and preserve her uterus for possible future reproduction.

GnRH agonists may be given prior to myomectomy to shrink the masses and make the planes more discernible, thus, helping in doing a successful myomectomy.

Progestins are not used to treat myomas. Small myomas (not causing bleeding, obstruction or

uterine enlargement) may be observed.

Answer83. A 48 y.o. G3P3 (3003) consulted at the Out

Patient Clinic for menometrorrhagia since 5 months ago. Pelvic exam showed a corpus irregularly enlarged to 16 weeks size. Ultrasound showed multiple myoma uteri. Best treatment option for this patient would be:

a. THBSOb. myomectomyc. GnRH agonistd. progestin supplementation

Question84. A 35 y.o. G3P3 (3003) consults at the Emergency

Room for severe abdominal pain. Pelvic examination reveals a vague mass at the left adnexal area. But a thorough examination is difficult due to guarding. On exploratory laparotomy, the left ovary is converted to a 6 x 8 cm cystic mass with a 1 cm point of rupture extruding brownish fluid. Best management for this case would be:

a. left oophorocystectomyb. left salpingo-oophorectomyc. TH, LSOd. THBSO

Benign Gyn Lesion: Endometriosis

Chocolate or brownish fluid from the ovary is a characteristic of endometiosis/endometriotic cyst.

In young patients far from menopause, cystectomy can be done for endometriotic cysts. The same is true for dermoid cysts and mature cystic teratomas.

In patients with severe endometriosis, completion surgery with THBSO may have to be done even if with younger age (case to case).

Epithelial, germ cell except dermoid, and sex-cord stromal tumors would warrant a salpingo-oophorectomy.

Answer84. A 35 y.o. G3P3 (3003) consults at the Emergency

Room for severe abdominal pain. Pelvic examination reveals a vague mass at the left adnexal area. But a thorough examination is difficult due to guarding. On exploratory laparotomy, the left ovary is converted to a 6 x 8 cm cystic mass with a 1 cm point of rupture extruding brownish fluid. Best management for this case would be:

a. left oophorocystectomyb. left salpingo-oophorectomyc. TH, LSOd. THBSO

Question85. A 36 y.o. G1P1 (1001) consulted for menorrhagia of

one year duration. Internal examination showed a globular uterus symmetrically enlarged to 14 weeks size. Sonographic impression was consistent with adenomyosis. Definitive management consists of:

a. continuous low-dose oral contraceptive pillsb. GnRH agonistsc. DMPA injectionsd. total hysterectomy

Answer85. A 36 y.o. G1P1 (1001) consulted for menorrhagia of

one year duration. Internal examination showed a globular uterus symmetrically enlarged to 14 weeks size. Sonographic impression was consistent with adenomyosis. Definitive management consists of:

a. continuous low-dose oral contraceptive pillsb. GnRH agonistsc. DMPA injectionsd. total hysterectomy

There is no effective medical management for adenomyosis. Definitive treatment is total hysterectomy.

Question

86. A 6 y.o. child underwent exploratory laparotomy for an ovarian cyst. The most common finding is:

a. serous cystadenomab. dysgerminomac. dermoid cystd. physiologic ovarian cyst

Answer

86. A 6 y.o. child underwent exploratory laparotomy for an ovarian cyst. The most common finding is:

a. serous cystadenomab. dysgerminomac. dermoid cystd. physiologic ovarian cyst

Question

87. Endometriosis in this location suggests iatrogenic dissemination:

a. spinal columnb. anterior abdominal wallc. cul de sacd. ovary

Answer

87. Endometriosis in this location suggests iatrogenic dissemination:

a. spinal columnb. anterior abdominal wallc. cul de sacd. ovary

Question

88. Theca lutein cysts may be found in the following conditions:a. gestational trophoblastic diseases and hyperthyroidismb. acute renal failure and syphilis infectionc. diabetes mellitus and hypertensiond. multiple gestation and tuberculosis

Answer88. Theca lutein cysts may be found in the

following conditions:a. gestational trophoblastic diseases and hyperthyroidismb. acute renal failure and syphilis infectionc. diabetes mellitus and hypertensiond. multiple gestation and tuberculosis

Similarities in the structure of the alpha subunit of hCG with the TSH make this possible.

Question

89. The use of combined oral contraceptives will protect a woman from

a. ovarian cancerb. breast cancerc. cervical cancerd. liver cancer

Question

89. The use of combined oral contraceptives will protect a woman from

a. ovarian cancerb. breast cancerc. cervical cancerd. liver cancer

Answer89. The use of combined oral contraceptives will protect a

woman froma. ovarian cancerb. breast cancerc. cervical cancerd. liver cancer

The incessant ovulation theory for ovarian cancer is counteracted by OCPs (mechanism: prevents ovulation by suppression of the hypothalamic gonadotrophin releasing hormones).

OCPs are also considered protective for endometrial cancer.

Question

90. A 21 y.o. G2P2 (2002) is interested to learn the use of rhythm method. She reports that for the past year, her longest cycle was 38 days while the shortest was 24 days. Abstinence should be observed during the following days of her cycle:

a. day 17 to 23b. day 8 to 21c. day 6 to 27d. day 15 to 20

Answer90. A 21 y.o. G2P2 (2002) is interested to learn the use of

rhythm method. She reports that for the past year, her longest cycle was 38 days while the shortest was 24 days. Abstinence should be observed during the following days of her cycle:

a. day 17 to 23b. day 8 to 21c. day 6 to 27d. day 15 to 20

Rhythm method: Subtract 11 from longest cycle. Subtract 18 from the shortest cycle. The range should be the abstinence period.

Question

91. The following are known effects of OCP except:a. reduced maternal blood loss and anemiab. increased risk of ectopic pregnancyc. improvement of acned. decreased risk of endometrial and ovarian cancer

Oral Contraceptives Effects As a result of the antiestrogenic action of the progestin component

of the OCP, the height of the endometrium is less than in an ovulatory cycle (less proliferation). This results in reduction in the amount of blood loss at the time of endometrial shedding.

OCPs are also preventive against pelvic inflammatory disease, thus ectopic pregnancies are also lessened. Likewise, by virtue of the lower rate of pregnancies, ectopic pregnancy risk is also reduced.

The less androgenic progestin preparations as seen in third generation pills have been shown to improve acne.

OCP use because of the anti-estrogenic progestin is protective against endometrial cancer. It is also protective against ovarian cancer because of the break in ovulation.

OCP use, however, is a risk factor for cervical cancer (based on case-control studies).

Question

92. A 25 y.o. primipara is desirous of family planning. She is 2 months postpartum and claims to have been partially breastfeeding. The best method would be:

a. progestin-only pillsb. combined OCPc. lactation amenorrhead. bilateral tubal ligation

Answer92. A 25 y.o. primipara is desirous of family planning. She

is 2 months postpartum and claims to have been partially breastfeeding. The best method would be:

a. progestin-only pillsb. combined OCPc. lactation amenorrhead. bilateral tubal ligation

For breastfeeding women, the only allowable OCP is the progestin-only pill (POP). This does not interfere with milk production unlike the regular OCPs.

Lactation amenorrhea can be considered a family planning method if the mother breastfeeds fully her baby. This is up to 98 % effective in the first 6 months post-delivery.

Question

93. How many weeks postpartum is menstruation expected to return in a non-breastfeeding woman?

a. 1 to 2 weeks b. 3 to 4 weeksc. 6 to 8 weeksd. 12 to 14 weeks

Answer

93. How many weeks postpartum is menstruation expected to return in a non-breastfeeding woman?

a. 1 to 2 weeks b. 3 to 4 weeksc. 6 to 8 weeksd. 12 to 14 weeks

Question

94. Who among the following should be worked up for amenorrhea?a. 14 y.o. with no breast buddingb. 15 y.o. with breast Tanner stage 2c. 12 y.o. with breast Tanner stage 3d. 16 y.o. who had her menarche 4 months ago but is amenorrheic presently

Pubertal Development

1. appearance of breast budding (mean at 10.8 years old)

2. pubic hair after a few months3. breast enlargement, pelvic contour

rounder, rapid growth rate4. menarche (after about 2.3 years from

breast budding)

Answer

94. Who among the following should be worked up for amenorrhea?a. 14 y.o. with no breast buddingb. 15 y.o. with breast Tanner stage 2c. 12 y.o. with breast Tanner stage 3d. 16 y.o. who had her menarche 4 months ago but is amenorrheic presently

Question

95. The pathognomonic symptom of menopause:

a. wrinkling of skinb. osteoporosis

c. hot flush d. decrease in libido

Answer

95. The pathognomonic symptom of menopause:

a. wrinkling of skinb. osteoporosis

c. hot flush d. decrease in libido

Question

96. During the perimenopausal transition, there is:a. increased FSHb. decreased estradiolc. increased LHd. increased inhibin

Answer

96. During the perimenopausal transition, there is:a. increased FSHb. decreased estradiolc. increased LHd. increased inhibin

Question

97. Which of the following is most effective in reducing postmenopausal bone loss?a. weight-bearing exerciseb. calcium supplementationc. estrogen therapyd. vitamin D supplementation

Answer

97. Which of the following is most effective in reducing postmenopausal bone loss?a. weight-bearing exerciseb. calcium supplementationc. estrogen therapyd. vitamin D supplementation

Question

98. In semenalysis, the normal value of sperm motility is:

a. at least 20 %b. at least 30 %

c. at least 40 %d. at least 50 %

Semen analysisRecommended standards for semen analysis: Volume 2 mL pH 7.2-7.8 sperm density 20 x 106/ml Total sperm count 40 x 106/ml Sperm motility 50 % with progressive motility Vital staining 50 % live (exclude dye) Sperm morphology 50 % normal White cell count < 106/mL

Answer

98. In semen analysis, the normal value of sperm motility is:

a. at least 20 %b. at least 30 %

c. at least 40 %d. at least 50 %

Question

99. Among the different causes of infertility, the treatment of this has the greatest success rate:

a. ovulatory dysfunctionb. tubal dysfunctionc. male factord. uterine pathology

Answer

99. Among the different causes of infertility, the treatment of this has the greatest success rate:

a. ovulatory dysfunctionb. tubal dysfunctionc. male factord. uterine pathology

Question

100. Rectocoele and cystocoele are usually due to:a. relaxation of musculature of the pelvic floorb. injury during childbirthc. infection of the bladderd. trauma in repair of an episiotomy

Answer

100. Rectocoele and cystocoele are usually due to:a. relaxation of musculature of the pelvic floorb. injury during childbirthc. infection of the bladderd. trauma in repair of an episiotomy

ENDGood luck!