REPRODUCTIVE REPRODUCTIVE (FEMALE) REVIEW
1) A 16-year-old female presents with a complaint of pelvic cramps with her menses over the past 2 years. years. She describes her periods periods as heavy, and says says they occur once a month and last for 7 days, with no spotting in between. She has never been sexually active and does not expect this to change in the foreseeable future. An abdominal examination examination is normal. normal. Which one of the following would be the most appropriate next step? A. A pelvic examination B. Ultrasonography C. A TSH level D. Naproxen prior to and during menses 2) A 34-year-old female who delivered a healthy infant 18 months ago complains of a milky discharge discharge from both nipples. nipples. She reports that normal normal periods have resumed resumed since cessation of breastfeeding breastfeeding 6 months months ago. She takes ethinyl estradiol/norgestimate estradiol/norgestimate (Ortho (Ortho Tri-Cyclen) for birth control. control. A complete review of systems is otherwise negative. The most likely cause of the discharge is: A. a medication side effect B. breast cancer C. a hypothalamic tumor D. hypothyroidism hypothyroidism 3) The most common cause of abnormal vaginal discharge discharge in a sexually active 19-year-old female is: A. Candida albicans B. Trichomonas vaginalis C. Staphylococcus Staphylococcus D. Group B Streptococcus E. Bacterial vaginosis 4) A 35-year-old female is planning planning a second pregnancy. pregnancy. Her last pregnancy pregnancy was complicated by placental abruption caused by a large fibroid tumor of the uterus, which is still present. Which one of the following would be the most appropriate treatment for the fibroid tumor? A. Myomectomy B. Myolysis with endometrial ablation C. Uterine artery embolization D. Observation
5) An asymptomatic 24-year-old white female comes to your office for a refill of oral contraceptive pills. A speculum examination is normal with the exception of a slightly friable, well-demarcated, 1.4-cm raised lesion involving a portion of the cervix. All previous Pap tests have been normal and she has no history of abnormal bleeding or leukorrhea. Which one of the following would be most appropriate at this point? A. A Pap test, including a scraping of the erosion, with routine follow-up unless the patient becomes symptomatic B. A Pap test with follow-up in 3 months if results are normal C. A Pap test and a colposcopically-directed biopsy D. A cone biopsy E. Topical antibiotic cream 6) In patients with breast cancer, the most reliable predictor of survival is: A. estrogen receptor status B. cancer stage at the time of diagnosis C. tumor grade D. histologic type E. lymphatic or blood vessel involvement 7) Which one of the following fetal ultrasound measurements gives the most accurate estimate of gestational age in the first trimester (up to 14 weeks)? A. Femur length B. Biparietal diameter C. Abdominal circumference D. Crown-rump length E. Scapulo-sacral length 8) Late decelerations on fetal monitoring are thought to indicate which one of the following? A. Fetal head compression B. Umbilical cord compression C. Fetal sleep D. Uterine hypotonus E. Uteroplacental insufficiency
9) A 20-year-old female long-distance runner presents with a 3-month history of amenorrhea. A pregnancy test is negative, and other blood work is normal. She has no other medical problems and takes no medications. With respect to her amenorrhea, you advise her: A. to increase her caloric intake B. that this is a normal response to training C. to begin an estrogen-containing oral contraceptive D. to stop running 10) A 62-year-old white female comes to see you for her annual pelvic examination. You find a nontender, cystic left adnexal mass. The patient is asymptomatic and otherwise in good health, and has no other pelvic abnormalities. Transvaginal ultrasonography demonstrates a 5-cm septated left ovarian cyst. Her CA-125 level is 120 U/mL (N <35). The best management option is to: A. Repeat the clinical examination in 3 months B. Repeat the ultrasonography and CA-125 level in 3 months C. Repeat the ultrasonography every 3 months for 1 year D. Treat with estrogen plus progestin for 3 months, then repeat the ultrasonography and CA-125 level E. Refer for surgical consultation 11) A 26-year-old white female presents to you 5 weeks after her last menstrual period with the complaint of painless spotting for 2 days. She has not been using contraception and is trying to conceive. She had regular menses until her last menstrual period, and a home pregnancy test was positive 5 days ago. Her only previous pregnancy, 4 years ago, was electively terminated at 8 weeks' gestation. Her past history is significant for an episode of presumed salpingitis treated with intravenous antibiotics 2 years ago. Physical Findings: Abdomen – nontender; Vagina - small amount of dark blood in the posterior fornix; Cervix - no active bleeding; Bimanual - uterus slightly enlarged, adnexa nontender, no masses. Laboratory Findings: Urine pregnancy test positive Beta-hCG 1400 mIU/mL; vaginal ultrasonography 3mm sac with no definite fetal contents, adnexa negative. The most appropriate action at this point is to: A. Refer the patient for laparoscopy because of the possibility of ectopic pregnancy B. Perform dilatation and curettage C. Instruct the patient to return in 4 weeks D. Instruct the patient to call if she develops pain or increased bleeding; otherwise repeat the beta-hCG in 2–3 days
E. Administer progesterone, 100 mg intramuscularly, and repeat the betahCG in 2–3 days
12) You are attending the delivery of a 34-year-old gravida 2 para 1 with no prenatal complications who entered spontaneous labor at full term several hours ago. All fetal heart tones have been reassuring. The head delivers in the occiput anterior position over a posterior midline episiotomy without problems. However, the delivery stalls with the infant’s chin pressing against the perineum. When there is a contraction or the mother attempts to push, the head descends slightly and then returns to the same position. After you call for additional assistance, which one of the following should you do first to facilitate delivery? A. Apply gradually increasing amounts of traction on the infant’s head B. Ask an assistant to apply strong fundal pressure on the mother’s abdomen C. Deliberately fracture the infant’s anterior clavicle to free it from behind the mother’s pubis D. Place the mother’s knees and hips into extreme flexion onto the abdomen (McRoberts maneuver) E. Replace the infant’s head back inside the birth canal and prepare for immediate cesarean section (Zavanelli maneuver) 13) A 25-year-old married white female comes to your office for a routine examination. She expresses some concern because she has not had a menstrual period in 6 months. She has been trying to get pregnant for over 2 years without success. Examination shows an obese woman with a central pattern to her obesity. She has a mild increase in facial hair, but the examination is otherwise normal, although the pelvic examination is difficult to perform because of her obesity. Her blood pressure is 138/90 mm Hg. A CBC, metabolic panel, and thyroid studies are all normal. Other laboratory findings include the following: Fasting glucose 120 mg/dL (N 70–110), LDL cholesterol 136 mg/dL, HDL cholesterol 33 mg/dL, Triglycerides 220 mg/dL, FSH 3.0 mU/mL (N 2.5–10.2), and LH 15.0 mU/mL (N 1.9–12.5). In addition to weight loss and exercise, which one of the following would improve her chances for conception? A. Medroxyprogesterone (Provera), 10 mg/day for 14 days each month B. Conjugated equine estrogens (Premarin) on days 1 through 10 each month C. Metformin (Glucophage) D. Niacin E. Ginseng
14) An 18-year-old white nulliparous student comes to your office. She had unprotected intercourse within the past 24 hours and does not want to become pregnant. You explain all options, including nonintervention. She decides she does not want to be pregnant and requests emergency contraception. Of the following, which one would be the most appropriate, effective, and best tolerated for this patient? A. Diethylstilbestrol, 50 mg twice a day for 5 days B. High-dose combination oral contraceptives, 2 pills now and 2 pills in 12 hours C. Immediate insertion of an intrauterine device D. Endometrial aspiration 15) A 23-year-old female is informed by one of her sexual partners that he was recently treated for gonorrhea. They have had unprotected intercourse on many occasions in the past few months. Her last menstrual period was 6 weeks ago. Testing for chlamydial infection is negative, but her gonococcal culture is positive and a pregnancy test is positive. According to CDC guidelines, the best treatment plan for the gonococcal infection is: A. Ofloxacin (Floxin), 400 mg orally B. Ceftriaxone (Rocephin), 125 mg intramuscularly in a single dose C. Azithromycin (Zithromax), 1 g orally in a single dose D. Doxycycline (Vibramycin), 100 mg orally twice a day for 7 days 16) Which one of the following single-dose regimens is effective for treatment of uncomplicated urethral or cervical infection caused by Chlamydia trachomatis? A. Azithromycin (Zithromax), 1 g orally B. Doxycycline (Vibramycin), 200 mg orally C. Amoxicillin, 2 g orally D. Cefixime (Suprax), 400 mg orally E. Metronidazole (Flagyl), 2 g orally 17) You diagnose varicella in the two preschool children of a 28-year-old patient. She has no history of having had the disease, and serology done in your office confirms her lack of immunity. A pregnancy test is also negative and you tell her to return for a varicella vaccination, which she does the following week. She returns after 5 weeks because a home pregnancy test is now positive, and a pregnancy test in your office is also positive. She is concerned about the effect of varicella vaccine on the fetus. Which one of the following would be the most accurate advice?
A. There is little likelihood of a problem B. She should receive varicella zoster immune globulin (VZIG) to protect the fetus C. She has a high likelihood of having a spontaneous abortion D. Women receiving varicella vaccine during the first trimester are likely to have children with congenital varicella E. Her risk of problems would be much higher in the second or third trimester 18) A 24-year-old primiparous female delivered a 4200-g (9 lb 4 oz) male infant after a prolonged 18-hour labor requiring oxytocin (Pitocin) augmentation. A vacuum-assisted delivery was performed because of maternal exhaustion, and the mother required repair of a third degree perineal laceration. Thirty minutes after you leave the delivery room, the delivery nurse calls you urgently to report that the mother’s blood pressure is 80 mm Hg systolic and that the bed is soaked with blood. The most likely cause of this problem is: A. Occult cervical lacerations B. Uterine atony C. Uterine rupture D. Disseminated intravascular coagulopathy 19) Which one of the following is true regarding routine prenatal screening ultrasonography before 24 weeks' gestation? A. It has been shown to reduce maternal mortality B. It has been shown to reduce perinatal mortality C. It has been associated with increased hearing abnormalities in infants D. It has been associated with better Apgar scores in infants at 1 minute of life E. It has not been proven to have any significant benefits 20) A 28-year-old gravida 2 para 2 notes bilateral milky discharge from her breasts. She delivered her last child 2 years ago, and breastfed exclusively for 8 months and at night for a few more months. She totally stopped breastfeeding several months ago, but she can still express milk from both breasts daily. She takes no medications, and uses a diaphragm for contraception. The physical examination is unremarkable except that a milky discharge is easily expressible from both nipples. The most likely diagnosis is:
A. Intraductal papillomatosis B. Mammary duct ectasia C. Empty sella syndrome D. Illicit drug ingestion E. Physiologic galactorrhea 21) A 28-year-old white female consults you with a complaint of irregular heavy menstrual periods. Her general physical examination, pelvic examination, and Papanicolaou test are normal and she has a negative pregnancy test. A CBC and chemistry profile are also normal. The next step in her workup should be: A. Endometrial aspiration B. Dilatation and curettage C. LH and FSH assays D. Administration of estrogen E. Cyclic administration of progesterone for 3 months 22) A 42-year-old white female has a 2-month history of vaginal itching. Another physician prescribed three courses of antifungal therapy, but the condition persists. The patient says there has been no discharge, and there are no skin lesions anywhere else. The physical examination is remarkable only for a lacy white rash on the labia minora. Which one of the following is the most likely diagnosis? A. Atrophic vaginitis B. Lichen planus C. Contact dermatitis D. Chronic candidiasis E. Vaginal adenosis 23) A 32-year-old white female comes to see you because of moderately severe pelvic pain that has been present for several years and is worse with menses. She describes the pain as bilateral, deep in the pelvis, and intermittently cramping and steady. She has never been pregnant, although she has not been using any contraception during the 6 years she has been married. She is not interested in fertility at this time. She has no history of previous sexually transmitted disease, IUD use, or abdominal or pelvic surgery. She currently uses ibuprofen, 600 mg 3–4 times a day as needed, with moderate pain relief. She is a nonsmoker. Physical examination reveals a blood pressure of 120/70 mm Hg and normal findings on examination of the heart, lungs, and abdomen. The vagina and cervix are normal in appearance. Bimanual examination reveals a normal-sized uterus and adnexa with no
masses, but mild tenderness on palpation of the posterior uterus and posterior cul-de-sac. Recent screening laboratory work was normal, including a CBC, thyroid function tests, lipid levels, and liver function tests. What is the most appropriate management at this time? A. Referral for hysterosalpingography B. Prescribing a COX-2 inhibitor such as celecoxib (Celebrex) to be used instead of ibuprofen C. Starting her on an oral contraceptive containing both estrogen and progesterone D. Starting her on danazol (Danocrine), 600 mg/day 24) Which one of the following represents an advantage of injectable medroxyprogesterone acetate (Depo-Provera)? A. There is a general lack of menstrual irregularities B. It is not causally linked with thromboembolic events C. There is no weight gain D. There is no measurable effect on blood lipid levels E. The cost is half that of generic combination oral contraceptives
25) Combination oral contraceptives would be contraindicated in which one of the following? A. A 25-year-old female whose body mass index is >30 B. A 26-year-old female with migraine headaches without focal neurologic symptoms C. A 28-year-old smoker D. A 30-year-old female with a previous history of deep venous thrombosis 26) Which one of the following statements about genital human papillomavirus (HPV) infection is true? A. Cervical cancer and genital warts result from the same HPV types B. A single sexual encounter with a person infected with external genital warts carries a low risk of infection C. Direct culture of cervical lesions is the most accurate diagnostic method D. The most important risk factor for acquiring HPV infection is a history of multiple sexual partners
27) A 50-year-old white female comes to you because she has found a breast mass. You feel a firm, fixed, nontender, 2-cm mass during your examination. No axillary nodes are palpable, nor is there any nipple discharge. You send her for a mammogram, and then have one of your partners who is skilled in fine-needle aspiration obtain cells for cytologic examination. The mammogram is read as “suspicious” and the fine-needle cytology report reads, “a few benign ductal epithelioid cells and adipose tissue.” Which one of the following would be the most appropriate next step? A. A repeat mammogram in 3 months B. Repeat fine-needle aspiration in 3 months C. An excisional biopsy of the mass D. Referral for breast irradiation E. Referral to a surgeon for simple mastectomy 28) Which one of the following is true concerning breastfeeding? A. The first feeding should take place a few hours after delivery when the mother is well rested B. Packets containing information about breastfeeding and samples of infant formula should be provided when mothers go home from the hospital C. Ointment containing vitamins A and D should be applied to prevent cracked nipples D. When lactation is becoming established, infants should be weighed before and after a feeding to determine whether they are getting enough milk E. Breastfeeding mothers should be taught that milk supply depends on the amount of suckling 29) A 72-year-old white female has had annual Papanicolaou smears with normal findings for the past 30 years. She now finds it difficult and uncomfortable to undergo pelvic examinations because of severe arthritis in both hips, as well as vaginal atrophy. She has not been sexually active since the death of her husband 10 years ago. What is the most appropriate approach to further screening for cervical neoplasia in this patient? A. She should be screened every 3–5 years B. She should undergo a test for the presence of human papillomavirus; if it is negative, screening can be discontinued C. She should undergo ultrasound examination of the pelvis every 3–5 years D. Screening can be discontinued now 30) Which one of the following best describes vaginismus?
A. Dyspareunia caused by a structurally small vagina B. A voluntary contraction of the vaginal muscles to prevent penetration C. An involuntary contraction of the vaginal and pelvic floor muscles D. A condition associated with general sexual and orgasmic inhibition 31) Which one of the following is the most reliable clinical symptom of uterine rupture? A. Sudden, tearing uterine pain B. Vaginal bleeding C. Loss of uterine tone D. Fetal distress 32) A 30-year-old African-American female is being evaluated because of absent menses for the last 6 months. Menarche was at age 12; her menstrual periods were frequently irregular and were accompanied only occasionally by dysmenorrhea. She had her first child 4 years ago, but has not been able to become pregnant since. Her physical examination and pelvic examination are unremarkable. A serum pregnancy test is negative, prolactin levels are normal, and LH and FSH levels are both three times normal on two occasions. These findings are consistent with: A. Hypothalamic amenorrhea B. Ovarian failure C. Pituitary microadenoma D. Polycystic ovarian syndrome
33) A 25-year-old healthy female presents with a 1-week history of a thin, mildly odorous vaginal discharge accompanied by mild vaginal itching. Physical examination is normal except for a thin, homogeneous discharge, but no significant cervical or vaginal inflammation. A wet-mount preparation of the discharge reveals numerous epithelial cells coated with small nonmotile organisms. A KOH preparation is negative but has a “fishy” odor. Which one of the following is correct regarding this patient’s condition? A. Failure to treat the male partner may result in urethritis or prostatitis B. Symptomatic relief of the infection frequently requires several courses of treatment in patients taking oral contraceptives C. The infection should be reported to local health authorities for contact
tracking D. This infection can be treated with oral or vaginal clindamycin (Cleocin) 34) A 17-year-old white female has had no menstrual period for the last 6 months. She has no significant previous medical history, but admits to a history of irregular periods since menarche at age 14. A urine pregnancy test is negative and a physical examination is unremarkable. The most appropriate initial workup of this patient would include which one of the following? A. Reassurance and reevaluation in 1 month B. Measurement of serum FSH and LH C. Administration of conjugated estrogens D. Administration of medroxyprogesterone E. A CT scan of the brain 35) Which one of the following is associated with a decreased risk for ovarian cancer? A. Use of fertility drugs B. Use of oral contraceptives C. Nulliparity D. Postmenopausal hormone replacement therapy E. Age >50 36) Compared to forceps, which one of the following is a potential advantage of the vacuum extractor in an assisted vaginal delivery? A. It can be used in patients with incomplete cervical dilatation B. The incidence of cephalohematoma is lower C. It causes less maternal genital trauma D. There is a higher rate of successful vaginal delivery
37) A 26-year-old married nulliparous female consults you after her 44-yearold sister was diagnosed with ovarian cancer. Her mother died in an automobile accident at the age of 59. Her aunt was diagnosed with breast cancer at age 50. The patient is BRCA1 positive. She asks your advice on childbearing and oophorectomy. Which one of the following would be appropriate advice? A. Prophylactic oophorectomy should be performed as soon as possible B. Surgery can be safely delayed until her family is complete
C. Oophorectomy will increase her risk of breast cancer D. Surveillance measures including CA-125 levels and ultrasonography will improve her prognosis E. Oral contraceptives are highly effective for delaying disease 38) Which one of the following is true regarding prenatal risk assessment for trisomy 21? A. The majority of pregnant women with a positive “triple screen” on maternal serum screening have a fetus with trisomy 21 B. Maternal serum screening should be regarded as an alternative to amniocentesis in women over the age of 35 C. Amniocentesis is performed at an earlier gestational age than chorionic villus sampling D. An elevated second-trimester maternal serum alpha-fetoprotein level indicates increased risk for trisomy 21 E. Seventy percent of trisomy 21 pregnancies occur in women younger than 35 years of age 39) According to evidence-based guidelines of the American College of Obstetricians and Gynecologists (ACOG), which one of the following is an indication for hysterectomy for leiomyoma? A. Difficulty making a diagnosis of ovarian cancer because of nonpalpable adnexa B. A desire to avoid increased surgical morbidity due to continued uterine enlargement C. Persistent, severe pelvic discomfort caused by myomas D. Prophylaxis for possible future symptoms E. Prophylaxis for malignant leiomyosarcoma 40) The most frequently reported symptom of vulvar cancer is which one of the following? A. Longstanding pruritus B. Bleeding C. Pain D. Discharge E. Dysuria 41) A 29-year-old gravida 0 para 0 presents to your office with a chief complaint of irregular, infrequent menses. Over the past few years, she has noted increasing dark hair growth on her chin and above her upper lip. On
examination, she is normotensive and moderately overweight. Examination of the skin reveals acne and abdominal striae. The remainder of the examination is normal. Laboratory Findings: TSH 2.1 μU/mL (N 0.3–5.0), FSH 8 U/L (N 1–10), LH 38 U/L (N 1–20), Free testosterone 50 ng/dL (N 0.3–1.9), Prolactin 28 ng/mL (N 0–23), 17 hydroxyprogesterone 4 ng/dL (N 0–8), DHEAS (dehydroepi-androsterone sulfate) 2.0 μg/dL (N 0–3.0). In addition, a dexamethasone suppression test and pelvic ultrasonography are normal. Which one of the following is the most likely diagnosis for this patient? A. Cushing’s syndrome B. Polycystic ovarian syndrome C. Virilizing adrenal tumor D. Prolactinoma E. Adult-onset congenital adrenal hyperplasia 42) Which one of the following is associated with galactorrhea? A. Hypothyroidism B. Breast cancer C. Fibrocystic breast disease D. Adrenal insufficiency E. Graves’ disease 43) A 30-year-old white gravida 2 para 2 presents to your office complaining of mild to moderate tenderness in the left groin. She and her husband use condoms and contraceptive foam for birth control. An examination fails to elicit any significant abdominal pain, but on pelvic examination a tender, 4.5cm, freely movable left adnexal mass is felt. A qualitative serum hCG is negative. The most likely diagnosis is: A. Dysgerminoma B. Corpus luteum cyst C. Serous cystadenoma D. Dermoid cyst E. Ovarian fibroma
44) You see a 17-year-old white female who has recently become sexually active. She requests oral contraceptives and you perform a brief evaluation, including blood pressure measurement. A pregnancy test is negative. She is
resistant to further evaluation unless it is necessary. In addition to appropriate counseling, which one of the following should be done before prescribing oral contraceptives? A. No further evaluation at this visit unless indicated by history B. A pelvic examination and Papanicolaou test C. Screening for sexually transmitted diseases D. A breast examination 45) Black cohosh (Cimicifuga racemosa) is an herbal remedy used by patients for: A. Dementia B. Menopausal symptoms C. Nausea and vomiting D. Benign prostatic hypertrophy E. Osteoarthritis 46) Medicare pays for which one of the following? A. Routine dental care B. Custodial nursing-home care C. Hearing aids D. Screening mammography 47) A recently married 29-year-old nulliparous African-American female presents with uncomplicated cystitis. She is otherwise healthy. She reports that she is currently using barrier birth control methods but plans to discontinue this soon, as she would like to become pregnant. Which one of the following supplemental vitamins or minerals would you advise this patient to begin taking? A. Thiamine B. Iron C. Calcium D. Folate E. Iodine
48) A 30-year-old female requests advice about the use of oral contraceptives. In discussing potential risks you explain that:
A. Her risk of anemia will increase B. Her risk of endometrial cancer will increase C. Her risk of exacerbation of her acne will increase D. Her risk of thrombophlebitis will decrease E. Her risk of ovarian cancer will decrease 49) The tumor marker most closely associated with ovarian cancer is: A. CA-125 B. Carcinoembryonic antigen C. CA 19-9 D. CD25 E. Alpha-fetoprotein 50)
