Ob-gyn Review Part 3

OB-GYN REVIEW Part III By JEAN ANNE B. TORAL, M.D. June 13, 2009

Question 67. 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. IIB b. IIIA c. IIIB d. 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 Staging Stage 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 Staging Stage 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

Answer 67. 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. IIB b. IIIA c. IIIB d. IVA

Question 68. 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. IA b. IB c. IC d. IIA

Ovarian Cancer Staging Staging of ovarian cancer is surgicopathologic. Stage I: tumor confined to the ovaries IA: limited to one ovary, intact capsule, no tumor on ovarian surface, no malignant cells in the peritoneal washing or ascites IB: limited to both ovaries, intact capsule, no tumor on ovarian surface, no malignant cells in the peritoneal washing or ascites IC: 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 extension IIA: extension/implants to uterus and/or tubes IIB: extension to other pelvic organs, no malignant cells in ascites or peritoneal washings IIC: 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 metastasis IIIA: microscopic peritoneal metastasis beyond the pelvis IIIB: macroscopic peritoneal metastasis beyond the pelvis 2 cm or less in greatest dimension IIIC: 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

Question 68. 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. IA b. IB c. IC d. IIA

Question 69. 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 metaplasia Negative 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 IB b. Stage IC c. Stage IIB d. 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 corpus IA: limited to the endometrium IB: invades up to less than half of the myometrium IC: invades to more than half of the myometrium Stage II: tumor invades the cervix but does not extend beyond the uterus IIA: endocervical glandular involvement only IIB: cervical stromal invasion

Endometrial Cancer Staging Stage III: local and/or regional spread IIIA: tumor involves uterine Serosa and/or adnexae and/ or cancer cells in peritoneal washings or ascites IIIB: vaginal involvement IIIC: metastasis to the pelvic and/or para-aortic nodes Stage IVA: tumor invades the bladder and/or bowel mucosa Stage IVB: distant metastasis including intra-abdominal metastasis other than para-aortic and/or inguinal nodes

Answer 69. 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 metaplasia Negative 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 IB b. Stage IC c. Stage IIB d. Stage IIIC

Question 70. This woman is at high risk to develop endometrial carcinoma: a. 52 y.o. breast cancer patient on tamoxifen b. 35 y.o. nulligravid with PCOS c. 37 y.o. with BMI of 35 kg/m2 d. all of the above

Endometrial Cancer: Risk Factors Risk 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 syndrome’s 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 tamoxifen b. 35 y.o. nulligravid with PCOS c. 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 fetoprotein b. lactic dehydrogenase c. CA 125 d. 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 fetoprotein b. lactic dehydrogenase c. CA 125 d. 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 cancer b. cervical cancer c. endometrial cancer d. ovarian cancer

Answer 72. The most common genital tract malignancy in Filipino women based on the 2005 Philippine Cancer Facts and Estimates is: a. vulvar cancer b. cervical cancer c. endometrial cancer d. 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.

Question 73. 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 tumor b. germ cell tumor c. sex-cord stromal tumor d. metastatic tumor

Answer 73. 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 tumor b. germ cell tumor c. sex-cord stromal tumor d. 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.

Question 74. 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 hysterectomy b. total hysterectomy c. suction curettage d. dilatation and curettage

Answer 74. 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 hysterectomy b. total hysterectomy c. suction curettage d. 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 12 b. age 18 c. age 21 d. once the woman is sexually active

Answer 75. According to the American Cancer Society Guidelines for Cervical Cancer Screening, screening using Pap smear should be started a. age 12 b. age 18 c. age 21 d. 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. Schiller’s test b. Toluidine blue test c. 4-quadrant cervical biopsy d. 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. • Schiller’s test is the use of Lugol’s 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 Lugol’s 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. Schiller’s test b. Toluidine blue test c. 4-quadrant cervical biopsy d. visual inspection with acetic acid

Question 77. Staging of ovarian cancer is: a. clinical b. surgicopathologic c. clinicopathologic d. histopathologic

Answer 77. Staging of ovarian cancer is: a. clinical b. surgicopathologic c. clinicopathologic d. histopathologic

Gynecologic Infections Question 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. candidiasis b. trichomoniasis c. gonococcal infection d. 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. candidiasis b. trichomoniasis c. gonococcal infection d. bacterial vaginosis

Question 79. In a patient with mucopurulent cervicitis, the patient is also given doxycycline to take care of: a. Neisseria gonorrhea b. Ureaplasma urealyticum c. Chlamydia trachomatis d. Gardnerella vaginalis

Answer 79. In a patient with mucopurulent cervicitis, the patient is also given doxycycline to take care of: a. Neisseria gonorrhea b. Ureaplasma urealyticum c. Chlamydia trachomatis d. 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. Candidiasis b. Trichomoniasis c. Syphilis d. Genital warts

Answer 80. Which of the following is not considered a sexually transmitted disease? a. Candidiasis b. Trichomoniasis c. Syphilis d. 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 virus b. bacterial c. treponemes d. human papilloma virus

Answer 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 virus b. bacterial c. treponemes d. 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 HPVRelated Disease and Diagnoses Cervical cancer: 0.493 million in 2002 1

typ es HP V

on on co ge nic

to n uta ble

Low-grade cervical lesions: 30 million2 Genital warts: 30 million3

HPV infection without detectable abnormalities: 300 million2

At trib

At trib uta ble

to on co ge nic

HP V

typ es

High-grade precancerous lesions: 10 million2

1. Parkin DM, Bray F, Ferlay J, Pisani P. CA Cancer J Clin. 2005;55:74–108. 2. World Health Organization. Geneva, Switzerland: World Health Organization; 1999:1–22. 3. World Health Organization. WHO Office of Information. WHO Features. 1990;152:1–6.

Prevention

Primary and secondary prevention • Primary prevention – measures used in people with no clinical evidence of disease to prevent disease developing e.g. vaccines Human papillomavirus (HPV) infection

Normal

Vaccines Screening

• 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

Persistence

Vaccines

Pre-cancerous lesions

Invasive cancer

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 HPV genotype 16 18 45 31 33 52 58 35 59 56 51 39 68 73 82 Other X

53.5 17.2 6.7 2.9 2.6 2.3 2.2 1.4 1.3 1.2 1.0 0.7 0.6 0.5 0.3 1.2

53.5% 70.7% 77.4% 80.3%

Vaccine types

4.4 0

10

20

30

40

50

60

70

80

90

100

Cancer cases attributed to the most frequent HPV genotypes (%) Munoz N et al. Int J Cancer 2004;111:278–85.

Vaccine profiles

Cervarix HPV 16/18 vaccine

Gardasil HPV 6/11/16/18 vaccine

GlaxoSmithKline

MSD

Per dose

0.5 mL Per dose

0.5 mL

Females Target: 10−55 years Studies 10−55 years 5.5 years follow-up for HPV 16/18

Females and males Target: 9−26 years Studies 10−45 years

Cancer focus Pure cervical cancer vaccine

Cancer and STD Dual cervical cancer and genital warts vaccine

L1 HPV 16 L1 HPV 18 Intramuscular

L1 HPV 6 L1 HPV 11 20 µg L1 HPV 16 20 µg L1 HPV 18 0, 1, 6 mths Intramuscular

20 µg 40 µg 40 µg 20 µg 0, 2, 6 mths

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 HPVrelated 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 naïve 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 naïve 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. history b. pelvic examination c. ultrasound d. diagnostic laparoscopy

Answer 82. The most accurate method of diagnosing acute PID is: a. history b. pelvic examination c. ultrasound d. diagnostic laparoscopy The diagnostic standard for PID is laparoscopy.

Question 83. 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. THBSO b. myomectomy c. GnRH agonist d. 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.

Answer 83. 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. THBSO b. myomectomy c. GnRH agonist d. progestin supplementation

Question 84. 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 oophorocystectomy b. left salpingo-oophorectomy c. TH, LSO d. 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.

Answer 84. 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 oophorocystectomy b. left salpingo-oophorectomy c. TH, LSO d. THBSO

Question 85. 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 pills b. GnRH agonists c. DMPA injections d. total hysterectomy

Answer 85. 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 pills b. GnRH agonists c. DMPA injections d. 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 cystadenoma b. dysgerminoma c. dermoid cyst d. physiologic ovarian cyst

Answer 86. A 6 y.o. child underwent exploratory laparotomy for an ovarian cyst. The most common finding is: a. serous cystadenoma b. dysgerminoma c. dermoid cyst d. physiologic ovarian cyst

Question 87. Endometriosis in this location suggests iatrogenic dissemination: a. spinal column b. anterior abdominal wall c. cul de sac d. ovary

Answer 87. Endometriosis in this location suggests iatrogenic dissemination: a. spinal column b. anterior abdominal wall c. cul de sac d. ovary

Question 88. Theca lutein cysts may be found in the following conditions: a. gestational trophoblastic diseases and hyperthyroidism b. acute renal failure and syphilis infection c. diabetes mellitus and hypertension d. multiple gestation and tuberculosis

Answer 88. Theca lutein cysts may be found in the following conditions: a. gestational trophoblastic diseases and hyperthyroidism b. acute renal failure and syphilis infection c. diabetes mellitus and hypertension d. 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 cancer b. breast cancer c. cervical cancer d. liver cancer

Question 89. The use of combined oral contraceptives will protect a woman from a. ovarian cancer b. breast cancer c. cervical cancer d. liver cancer

Answer 89. The use of combined oral contraceptives will protect a woman from a. ovarian cancer b. breast cancer c. cervical cancer d. 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 23 b. day 8 to 21 c. day 6 to 27 d. day 15 to 20

Answer 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 23 b. day 8 to 21 c. day 6 to 27 d. 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 anemia b. increased risk of ectopic pregnancy c. improvement of acne d. 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 pills b. combined OCP c. lactation amenorrhea d. bilateral tubal ligation

Answer 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 pills b. combined OCP c. lactation amenorrhea d. bilateral tubal ligation •

For breastfeeding women, the only allowable OCP is the progestinonly 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 nonbreastfeeding woman? a. 1 to 2 weeks b. 3 to 4 weeks c. 6 to 8 weeks d. 12 to 14 weeks

Answer 93. How many weeks postpartum is menstruation expected to return in a nonbreastfeeding woman? a. 1 to 2 weeks b. 3 to 4 weeks c. 6 to 8 weeks d. 12 to 14 weeks

Question 94. Who among the following should be worked up for amenorrhea? a. 14 y.o. with no breast budding b. 15 y.o. with breast Tanner stage 2 c. 12 y.o. with breast Tanner stage 3 d. 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 months 3. breast enlargement, pelvic contour rounder, rapid growth rate 4. 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 budding b. 15 y.o. with breast Tanner stage 2 c. 12 y.o. with breast Tanner stage 3 d. 16 y.o. who had her menarche 4 months ago but is amenorrheic presently

Question 95. The pathognomonic symptom of menopause: a. wrinkling of skin b. osteoporosis c. hot flush d. decrease in libido

Answer 95. The pathognomonic symptom of menopause: a. wrinkling of skin b. osteoporosis c. hot flush d. decrease in libido

Question 96. During the perimenopausal transition, there is: a. increased FSH b. decreased estradiol c. increased LH d. increased inhibin

Answer 96. During the perimenopausal transition, there is: a. increased FSH b. decreased estradiol c. increased LH d. increased inhibin

Question 97. Which of the following is most effective in reducing postmenopausal bone loss? a. weight-bearing exercise b. calcium supplementation c. estrogen therapy d. vitamin D supplementation

Answer 97. Which of the following is most effective in reducing postmenopausal bone loss? a. weight-bearing exercise b. calcium supplementation c. estrogen therapy d. 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 analysis Recommended 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 dysfunction b. tubal dysfunction c. male factor d. uterine pathology

Answer 99. Among the different causes of infertility, the treatment of this has the greatest success rate: a. ovulatory dysfunction b. tubal dysfunction c. male factor d. uterine pathology

Question 100. Rectocoele and cystocoele are usually due to: a. relaxation of musculature of the pelvic floor b. injury during childbirth c. infection of the bladder d. trauma in repair of an episiotomy

Answer 100. Rectocoele and cystocoele are usually due to: a. relaxation of musculature of the pelvic floor b. injury during childbirth c. infection of the bladder d. trauma in repair of an episiotomy

END Good luck!