Womens Health

A 36-year-old woman is noted to have a 2-cm palpable breast mass noted on physical examination. A mammogram is performed suggestive of a cyst.

Ultrasound confirms a cystic mass. A fine-needle aspiration is performed with 8 cc of blood-colored fluid obtained. The mass is no longer palpable.

Which of the following is the next best step for this patient?

• Expectant management as the prognosis is excellent

• Send the fluid for cytology

• Lumpectomy and lymph node dissection

• Tamoxifen therapy

Answer explanation

When the fluid obtained from a breast cyst is straw-colored and the mass disappears, then the fluid can be discarded and no further therapy is needed. However, when the fluid is a different color such as bloody, then the fluid

should be sent for cytology. Lumpectomy and lymph node sentinel node biopsy is performed for proven breast cancer for staging. Tamoxifen therapy may be used for postmenopausal women with estrogen receptor positive

breast cancer after surgery.

A 26-year-old woman is referred for genetic counseling because her mother died from breast cancer, and her sister has been diagnosed with breast cancer.The patient is noted to have a BRCA1 mutation. Which of the following best describes the genetic transmission of this disorder?

• Autosomal dominant

• Autosomal recessive

• X-linked dominant

• X-linked recessive

Answer explanation

A mutation to BRCA1 gene is associated with an increased risk of breast

and ovarian cancer. This is an autosomal dominant disorder. Half the offsprings

would be affected, and both sexes would be equally affected.

A 49-year-old woman is noted to have a 1.5-cm mass of the right breast. It is nontender, and there are no skin changes or adenopathy. The mammogram and ultrasound findings are normal. A core needle biopsy reveals an infiltrating

intraductal carcinoma. Which of the following would most significantly impact on the patient’s prognosis?

• Hormone receptor status

• Lymph node status

• Size of the primary cancer

• Presence of skin changes

Answer explanation

The patient’s lymph node status is the most significant impact on the patient’s prognosis. Hormone receptor status does play some role but not as significantly as the lymph node condition. Infiltrating intraductal carcinoma is

the most common histological subtype of breast cancer. The size of the primary tumor likewise does play a role. Optimally, the smaller the tumor, the better the survival.

A 35-year-old G0P0 woman complains of right breast redness and tenderness. The patient denies a family history of breast or ovarian cancer. Whichof the following is the next best step in managing this patient?

• Antibiotic therapy to cover Staphylococcus aureus

• Biopsy of the breast

• Ultrasound of the breast

• Begin combination chemotherapy

Answer explanation

This patient very well could have inflammatory breast cancer since she has redness and warmth of the breast and is not lactating. She is nulliparous. Chemotherapy should not be initiated until a diagnosis is made

A 32-year-old P1 woman presents with an 8-month history of amenorrhea. A pregnancy test is negative. TSH and prolactin levels are normal. The FSH level is elevated at 40 IU/ L. Which of the following is the most likelycomplication for this patient?

• She is at significant risk for endometrial cancer

• She is at increased risk for ovarian cancer.

• She is at increased risk for osteoporosis

• She is at increased risk for multiple gestations

Answer explanation

This patient has secondary amenorrhea. Her pregnancy test is negative. The TSH and prolactin levels are normal. Her serum FSH level is elevated, indicating that she has premature ovarian failure. Due to the low estrogen

levels, she is at risk for osteoporosis. She is not at risk for endometrial cancer. Patients with polycystic ovarian syndrome (PCOS) would be at risk for endometrial cancer due to unopposed estrogen.

A 32-year-old G0P0 woman is noted to have irregular menses and hirsutism.

Which of the following is consistent with polycystic ovarian syndrome?

• Elevated 17-hydroxyprogesterone level

• Finding of a 9-cm right ovarian mass

• Vaginal bleeding after a 5-day course of progesterone oral therapy

• DEXA scan showing osteopenia

Answer explanation

PCOS is characterized by obesity, anovulation, hyperandrogenism due to ovarian secretion of testosterone, after excluding other etiologies such as congenital adrenal hyperplasia (CAH), Sertoli– Leydig cell tumor, hypothyroidism

and hyperprolactinemia. An elevated 17-hydroxyprogesterone level would indicate CAH. A 9-cm ovarian mass would suggest a Sertoli–Leydig cell tumor. With PCOS, the DEXA scan usually shows good bone density due to the excess estrogen environment. Women with PCOS usually will have a positive progestin challenge test; in other words, they have bleeding with a 5- to 10-day course of oral progestin.

A 35-year-old woman has had irregular menstrual cycles since high school. She frequently misses cycles and has never been pregnant. When she has cycles, they are very light and last for only a few days. She has had mild-to moderate comedonal and pustular acne since late adolescence and in recent years has developed some hair growing under her chin. She denies taking any medications or history of other gynecologic or medical problems. Which of the following is the most appropriate evaluation for the initial workup of her problem?

• SerumTSH

• Serum estradiol

• Urine cortisol

• SerumFSH

Answer explanation

Estrogen does not have a role in the initial workup for anovulation.Urine cortisol may help in the diagnosis of Cushing disease, but not generally indicated unless the patient has other stigmata of corticosteroid excess such as abdominal striae, easy brusability, and buffalo hump. TSH is indicated in DUB workup. Both total serum testosterone levels and prolactin are useful.Thus, in general, a pregnancy test, TSH, and prolactin level are the initial tests for the evaluation of menstrual irregularities.

Which of the following statements regarding postmenopausal osteoporosis is true?

• the most rapid loss of bone density occurs within the first 5 years of menopause

• surgical menopause is a lower risk factor for osteoporosis than natural menopause

• the protective effects of estrogen on bone density are maintained after discontinuation

• all women should undergo bone density testing at menopause

Answer explanation

There is a clear causal relationship between estrogen deficiency and osteoporosis. A woman’s bone density tends to peak by the age of 30 to 35 years, although her most rapid loss of bone tends to occur during the first 5 years of menopause. Postmenopausal status, regardless of the etiology (natural or surgically or hormonally induced), or estrogen deficiency at any age significantly increases a patient’s risk for osteoporosis and subsequent fragility fractures. Estrogen appears to inhibit bone resorption by reducing the production of bone-resorbing osteoclasts while promoting the activation of bone-forming osteoblasts. Estrogen deficiency leads to a rapid increase in osteoclast formation and activity, leading to accelerated bone resorption. Studies also suggest that bone loss is accelerated when ET/HT is discontinued. Therefore, ET/HT may simply postpone the rapid bone loss associated with menopause. This is an important point in counseling patients about ET/HT compliance and the long-term prevention of osteoporosis.

A 51-year-old woman has been experiencing progressive symptoms of profuse night sweats and frequent hot flushes occurring both day and night. She finds her emotional state increasingly labile. She is also experiencing sleep disturbances and anxiety. She denies any weight loss or bowel complaints. Her last period was approximately 12 months ago. She has no history of medical problems or affective disorders. Her pulse is 78 beats per minute, and her blood pressure is 122/74 mm Hg. Her pelvic examination reveals dry atrophic external genitalia, a small anteverted uterus, and no adnexal masses. The rest of her examination is completely normal. What is the most effective treatment option for this patient?

• estrogen with progestin therapy (hormone therapy [HT])

• antidepressants

• estrogen alone (estrogen therapy [ET])

• progestin/progesterone alone

Answer explanation

The most effective treatment for this patient’s vasomotor symptoms is HT (estrogen combined with a daily or cyclic progestin/progestogen). A progestin or progestogen alone may alleviate some of this patient’s symptoms, but her symptoms are related primarily to estrogen deficiency and thus respond best to ET. However, this patient still has her uterus, and ET (estrogen alone) is not recommended because of the significantly increased risk of endometrial hyperplasia or cancer with prolonged unopposed estrogen use. Antidepressants might help alleviate some of this patient’s symptoms, especially if she was also clinically depressed. However, HT/ ET alone often alleviates both the affective and the somatic symptoms of menopause.

A 24-year-old woman comes to your office with a 2-day history of dysuria accompanied by painful genital lesions that have coalesced to form ulcers. The patient also has fever, malaise, myalgias, and a headache. There is no previous history of this condition. She has had three sexual partners in the past and inconsistently uses barrier contraceptive methods. The most likely diagnosis is:

• herpes simplex infection

• chancroid

• e. primary syphilis

• c. lymphogranuloma venereum

Answer explanation

The patient’s symptoms are consistent with herpes simplex virus (HSV) type 2 infection. Given her systemic symptoms, it is likely a primary infection. Classic symptoms of genital herpes infection include a prodrome of tingling or itching, followed by eruption of painful vesicular or ulcerative genital lesions. Systemic symptoms such as fever, malaise, and inguinal adenopathy may occur. Most recurrent genital herpes cases are caused by HSV-2, although HSV-1 has been identified in genital lesions in up to 50% of first-episode cases. Viral culture of genital ulcers can confirm diagnosis (gold standard), although the sensitivity of cultures declines as lesions start to heal. False-negative HSV cultures are common. Newer polymerase chain reaction (PCR) techniques to identify viral antigens from the lesions are available now and have high sensitivity and specificity. The genital lesions of chancroid caused by Haemophilus ducreyi are characterized by painful ulcers and tender inguinal adenopathy. The presence of suppurative inguinal adenopathy is almost pathognomonic for H. ducreyi infection. The CDC recommends that diagnosis of chancroid be based on (1) the presence of painful ulcer(s), (2) negative serologic tests for syphilis, and (3) negative HSV testing of ulcer exudates. Genital lesions caused by primary syphilis are usually painless.