What differentiates pelvic pain from abdominal pain?
1. Pain below the umbilicus is pelvic pain
2. Duration of pain
3. Gender specific
4. Age of the patient
1. Pain below the umbilicus is pelvic pain
Primary amenorrhea may be diagnosed by age 15 years. What should be
present for this diagnosis? Select all that apply.
1. Normal growth
2. Presence of secondary sexual characteristics
3. Elevated testosterone level
4. Hyperprolactinemia
1. Normal growth
2. Presence of secondary sexual characteristics
Primary Amenorrhea
Absence of menses by age 15 years (could consider earlier if abnormalities
present)
� Often secondary to dysfunction in the hypothalamus, pituitary, ovaries, uterus,
or vagina
� Many causes
� Refer for dx, tx
DYSMENORRHEA
Painful cramping associated with menstruation secondary to excessive
uterine muscle contraction
� Most common GYN problem in adolescents and many adult females
� Get a good HISTORY!!!
� Primary vs. Secondary
Primary Dysmenorrhea
Absence of pelvic pathology but likely have a lot of prostaglandins being
produced
� Usually starts in adolescence
� Pain starts 1-2 days prior to onset of menses, then resolves over the next 12-
72 hours
� May present with nausea, diarrhea, fatigue, dizz
Secondary Dysmenorrhea
Get a good history (medical and menstrual)
� Physical exam
Purpose: Rule out a secondary cause (pelvic pathology-endometriosis,
adhesions, fibroids, PID)
� Pelvic exam (consider deferral for young, non-sexually active adolescents
with mild symptoms)
� Con
Once Primary Dysmenorrhea is established...
Non-Pharm Management
� Exercise improves symptoms
� Heat to the lower abdomen is as effective as oral analgesics for relief
Pharm Management
NSAIDs: 80-86% response rate
(Start at onset of menses for 1-2 days or for
duration of pain)
�Hormonal contraceptive therapy (OK for first line tx)
�If treatment with NSAIDs or hormonal contraceptives fails, try the other
�Consider treatment with both
�Co
Polycystic Ovarian Syndrome (PCOS)
Chronic, complex endocrine disorder associated with oligo-ovulation and/or anovulation
�Characterized by formation of cysts in the ovaries (hence, "polycystic")
�Common endocrinopathy; affects 6.5
-8% of females
�Endocrine Society has a diagnostic
algorhy
Polycystic Ovarian Syndrome (PCOS)
Cutaneous symptoms:
acne, hirsutism, alopecia, acanthosis nigricans
�Anovulatory symptoms:
amenorrhea, oligomenorrhea, dysfunctional uterine
bleeding,and infertility
(typically begins in teenage years)
�Hyperinsulinemia: Increased insulin level increase a
Differential Diagnosis
Pregnancy!
�Congenital adrenal hyperplasia
�Thyroid dysfunction
�Cushing's syndrome
�Androgen secreting tumors
� Others
Diagnostic Studies
Testosterone:
increased
(but < 150 ng/dL), most sensitive measure of
hyperandrogenemia
�Pregnancy test
�Lipid studies
(decreased HDL
s;elevated trigs, LDLs)
�OGTT (oral glucose tolerance test) (more sensitive
/specific
than FBG/A1C)
�Doppler ultrasound of
Management for PCOS
Weight loss(may restore ovulation)
, exercise, stress management
If pregnancy not desired
To Treat Androgen Exces: Estrogen/progestin contraceptive (first line
treatment) treats acne, hirsutism and protects the endometrium
OR drospirenone (
analogue of spironolactone) OR Both
�Metformin if needed for glucose regulation, reduces insulin secreti
If pregnancy desired
Weight loss should always be attempted initially; this may restore ovulation
�REFER
-Clomiphene first line (Clomid�) OR Letrozole (more effective in obese women)
Possible complications with PCOS
Endometrial cancer
(due to d
eficient progesterone secretion)
�Postmenopausal breast cancer
�Ovarian cancer
�Hyperlipidemia
�Hyperinsulinemia
and insulin resistance
�Diabetes mellitus
; metabolic syndrome
�Cardiovascular
disease
�Infertility
(due to infre
1. A 4 year-old female is brought in to the clinic by her mother who reports that she is constantly scratching "her private part". The patient states that it itches. On exam, the vagina is red and irritated. How should the NP proceed?
A) Call child protec
C) Collect a vaginal swab of the external vagina for microscopic evaluation
Explanation:
This child has a vaginitis. There are many diagnoses in the differential including pinworms, yeast, contact irritants from soap or bubble bath, etc. Since the diagnos
Which form of birth control presents the highest risk to a female patient if she is exposed to a sexually transmitted disease (STD)?
A) Intrauterine device
B) Progestin only pill
C) Diaphragm
D) Oral contraceptives
A) Intrauterine device
Explanation:
Exposure to an STD always increases the likelihood of contracting an STD. However, the patient is at very high risk of developing pelvic inflammatory disease when there is an implanted foreign body. An example of this i
What choice below has no precautions for oral contraceptive pill use?
A) Gallbladder disease
B) 5 months post-partum and lactating
C) Blood pressure 160/100
D) Varicose veins
D) Varicose veins
Explanation:
One of the major components of gallstones is estrogen. A patient with underlying gallbladder disease should not receive oral contraceptives (OC) since they will increase estrogen exposure and theoretically, formation of gall
Three of the following interventions are appropriately used to prevent osteoporosis after menopause. Which one is not?
A) Limited alcohol intake
B) Performance of weight-bearing activities for 40 mins. at least 5 days/week
C) Estrogen replacement therapy
C) Estrogen replacement therapy
Explanation:
Prevention of osteoporosis may be optimized by elimination of risk factors and engaging in interventions that maximize bone density. Good nutrition from infancy throughout adulthood is a major component of good
A 50 year-old female believes that she is "menopausal". She complains of "hot flashes" and has not had menses in 12 months. Which of the following test results may be helpful for confirmation of menopause?
A) Increased thyroid stimulating hormone
B) Decre
D) Increased follicle stimulating hormone
Explanation:
Follicle stimulating hormone (FSH) begins to rise during menopausal transition. This stage of menopause begins with variation in menstrual cycle length and ends 12 months after the final menses. If th
An initial pharmacologic approach to a patient who is diagnosed with primary dysmenorrhea could be:
A) acetaminophen.
B) NSAIDs at the time symptoms begin or onset of menses.
C) NSAIDs prior to the onset of menses.
D) combination acetaminophen and NSAIDs
B) NSAIDs at the time symptoms begin or onset of menses.
Explanation:
Pain associated with dysmenorrhea is likely due to prostaglandins which can cause prolonged contraction of the uterus. This produces uterine ischemia, sometimes termed "uterine angina".
Clue cells are found in patients with:
A) leukemia.
B) bacterial vaginosis.
C) epidermal fungal infections.
D) pneumonia.
B) bacterial vaginosis
Explanation:
The hallmark finding in a patient with bacterial vaginosis (BV) is clue cells on microscopic exam. Clue cells are epithelial cells with adherent bacteria. The most common clinical feature is an unpleasant, "fishy" smell
An 84 year-old female patient is a resident in an assisted living facility. She has early dementia. She walks daily and has had urinary incontinence for years. Her urinary incontinence is likely to be:
A) urge.
B) stress.
C) mixed.
D) unable to be determi
C) mixed.
Explanation:
The most common type of urinary incontinence in women is mixed incontinence. This refers to at least two simultaneous mechanisms. Usually detrusor overactivity and impaired urethral sphincter function are present, giving mixed incon
A woman who is 65 years old presents to your clinic with a breast lump. She has had only normal annual mammograms and her last one was 6 months ago. What is true about this lump?
A) It is probably breast cancer.
B) It may not be a lump at all.
C) It is li
D) It is probably a benign lesion.
Explanation:
The vast majority of breast lumps, even in older women are benign. However, because of the risk of breast cancer in any female patient, especially an older patient, she must be evaluated for breast cancer. F
What recommendation should be made to a 70 year-old female regarding mammograms?
A) She should continue to have them annually.
B) She should have them annually until age 75 years.
C) She should have them every three years.
D) She should have them annually
D) She should have them annually as long as she has a reasonable life expectancy.
Explanation:
Breast cancer is more prevalent in older women. In fact, 85% of breast cancer occurs in women after age 50 years. Older women profit from screening with mammogr
A nurse practitioner identifies filamentous structures and many uniform, oval shaped structures during a microscopic exam of vaginal discharge. These are probably:
A) bacteria.
B) sperm.
C) Hyphae and Yeast
D) Candida albicans.
C) Hyphae and Yeast
Explanation:
Filamentous structures likely describe hyphae. Typically, hyphae are the mechanism that allows fungal growth. The uniform oval shaped structures are likely yeast. These can range in size but are usually large and unicellul
A 51 year-old female patient presents with a 2 cm palpable breast mass. How should this be evaluated to determine whether it is solid or cystic in nature?
A) Mammogram
B) Ultrasound
C) MRI
D) Clinical breast exam
B) Ultrasound
Explanation:
The diagnostic test of choice to differentiate a solid from a fluid filled breast mass is ultrasound. More than 90% of breast masses in women in the 20s to early 50s are benign. However, they must be evaluated. Clinical breast e
Athletic amenorrhea increases the risk of:
A) osteoporosis.
B) an eating disorder.
C) covert hypothyroidism.
D) breast cancer.
A) osteoporosis.
Explanation:
Athletic amenorrhea creates states of prolonged hypoestrogenemia. This results in an increased risk of osteoporosis.
A patient who is scheduled for pelvic exam with PAP smear should be advised to avoid douching, sexual intercourse, and tampon use before her exam. For how long should she be advised to avoid these activities for optimal evaluation?
A) 24 hours
B) 48 hours
B) 48hours
Explanation:
The general recommendation is to avoid these activities and any vaginal medication for 48 hours prior to PAP smear. Douching and tampon use can remove superficial cells which are the ones collected and used as representative sample
A 54 year-old female presents with a small to moderate amount of vaginal bleeding of recent onset. She has been postmenopausal for approximately 2 years. What diagnosis is least likely?
A) Endometrial carcinoma
B) Ovarian cancer
C) Endometrial hyperplasia
B) Ovarian cancer
Explanation:
Ovarian cancer may present as an adnexal mass, pelvic or abdominal symptoms and a variety of others. Postmenopausal bleeding (PMB) is a very uncommon presentation of ovarian cancer, but can present this way. In women with PM
The clinical syndrome resulting from replacement of normal vaginal flora with anaerobic bacteria is:
A) candidal vaginitis.
B) bacterial vaginosis.
C) pelvic inflammatory disease.
D) herpes simplex.
B) bacterial vaginosis.
xplanation:
Bacterial vaginosis (BV), results when normal vaginal flora such as Lactobacillus sp. are replaced with anaerobic bacteria like Prevotella, Mobiluncus and Gardnerella. This is usually, but not always associated with sex
A patient asks the NP's advice about an herb to help with her hot flashes. The NP knows these:
A) are safe to use in all patients.
B) may be contraindicated in patients with history of breast cancer.
C) substances have a mild estrogenic effect and will ha
B) may be contraindicated in patients with history of breast cancer.
Explanation:
The herb that the patient is asking about is probably black cohosh, Actaea racemosa. It is a phytoestrogen. This means that it provides estrogen from a plant source. If estr
After a vaginal exam, a patient received a prescription for metronidazole. What was her likely diagnosis?
A) Syphilis
B) Trichomonas
C) Chlamydia
D) Gonorrhea
B) Trichomonas
Explanation:
Trichomonas can be treated with metronidazole orally. This is usually effective and is generally well tolerated as long as the patient avoids alcohol. Alcohol in the presence of metronidazole can produce a disulfiram reaction.
The frequency for cervical screening depends on the patient and her age. What is the longest recommended time interval between cervical screens for patients who are 65 years-old or younger?
A) 1 year
B) 2 years
C) 3 years
D) 5 years
D) 5 yearsExplanation:
Cervical screening for women aged 21-29 years should take place every 3 years with cytology only. Women aged > 30 years should be screened every 5 years with cytology and HPV. Generally, women who have been adequately screened do no
A 16 year-old female is diagnosed with primary dysmenorrhea. She has taken over the counter ibuprofen in 800 mg increments every 8 hours during menses for the past 3 months with minimal relief of symptoms. What intervention will provide greatest relief of
B) Combined oral contraceptives
Explanation:
NSAIDs and hormonal contraceptives represent the mainstay of pharmacologic treatment for dysmenorrhea. NSAIDs produce an 80-86% response rate when used for dysmenorrhea. The general recommendation is that when
A patient who is 35 years old has identified a small, discrete mass in one breast. How should this be evaluated?
A) Ask whether the mass changes at the time of menses.
B) Order a mammogram and ultrasound to assess the mass.
C) Have her return 3-10 days af
B) Order a mammogram and ultrasound to assess the mass
Explanation:
Clinical evaluation of a breast mass begins with a good history of the mass and a physical exam of the breasts, lymph nodes, neck, and chest wall. While asking about whether the mass chan
A young female has breast buds bilaterally. This represents Tanner Stage:
A) 1
B) 2
C) 3
D) 4
B) 2
Explanation:
Tanner Stage II is characterized by the formation and presence of breast buds, small areas of surrounding glandular tissue, and widening of the areola.
A female should be told to take her OCP at bedtime if she experiences:
A) weight gain.
B) headaches.
C) nausea.
D) spotting.
C) Nausea
Explanation:
A common side effect of oral contraceptives is nausea. This is probably related to increased hormone levels (estrogen and progesterone). An easy way to combat nausea is to take the pill before going to sleep at night. Most patients
The frequency for cervical screening depends on the patient and her age. What is the longest recommended time interval between cervical screens for patients who are 21-65 years of age?
A) 1 year
B) 2 years
C) 3 years
D) 5 years
D) 5 years
Explanation:
Women ages 21-65 who have a cervix should be screened for cervical cancer. Screening intervals every 3 years should take place for women of average risk who are aged 21-29 years. Women aged 30-65 of average risk should take place e
15 year-old female has never menstruated. She and her mother are concerned. What is most important for the NP to assess?
A) Stature
B) Tanner stage
C) Anemia
D) Family history of amenorrhea
B) Tanner stage
Explanation:
Tanner staging, or sexual maturity ratings are very predictable changes that occur with puberty. These should be assessed. In females, breasts and pubic hair signify specific pubertal changes that constitute maturation. These
A young female adult presents with vaginal discharge and itching. Besides trichomoniasis and yeast, what else should be included in the differential?
A) Bacterial vaginosis
B) Chlamydia
C) Herpes genitalis
D) Syphilis
A) Bacterial vaginosis
Explanation:
The most common cause of vaginal discharge in women of child-bearing age is bacterial vaginosis. The most common presentation is a complaint of vaginal discharge with a fishy odor, most noticeable after sexual intercour
A 20 year old female reports that her grandmother and mother have osteopenia. What should she be encouraged to do to reduce her risk of osteopenia?
A) Aerobic exercise, weight loss, low fat diet
B) Smoking cessation, weight bearing exercise
C) Calcium sup
B) Smoking cessation, weight bearing exercise
Explanation:
Cigarette smoking accelerates skeletal bone loss. The mechanism is unknown, but, it may be due to increased metabolism of estrogen. Therefore, smoking cessation is important in prevention of osteo
A female patient is 35 years old. She has never had an abnormal PAP smear and has had regular screening since age 18. If she has a normal PAP smear with HPV testing today, when should she have the next cervical cancer screening?
A) One year
B) 2-3 years
C
D) 5 years
Explanation:
American College of Obstetricians and Gynecologists recommends screening for women over age 30 years no more frequently than every 5 years if both tests are negative and adequate screening has taken place. If she had been screened
A 28 year-old female presents with a slightly tender 1.5 cm lump in her right breast. She noticed it two days ago. She has no associated lymphadenopathy and there is no nipple discharge. How should she be managed?
A) Mammogram
B) Ultrasound and mammogram
B) Re-examination after her next menses
Explanation:
Women who are less than age 35 years, who have no associated suspicious findings of breast cancer should delay imaging studies until re-examination 3-10 days after the last menstrual period to determine
The primary risk factor for development of breast cancer in women of average risk is:
A) age.
B) smoking history.
C) number of live births.
D) exposure to estrogen.
A) AGE
Explanation:
Age is the most important risk factor for developing breast cancer in women of average risk. Breast cancer is more common in older women and has a higher mortality rate when discovered. Nearly 85% of breast cancer occurs in women who a
Women who use diaphragms for contraception have an increased incidence of:
A) sexually transmitted diseases.
B) pregnancy.
C) urinary tract infection.
D) pelvic inflammatory disease.
C) urinary tract infection. Correct
Explanation:
The exact mechanism for increased urinary tract infections is unknown, but it is believed to be due to nonoxynol-9 induced changes in vaginal flora. Another consideration is the possible contamination that
24 year-old female patient who is sexually active complains of vaginal itching. If she has bacterial vaginosis, she might complain of:
A) a "fishy" vaginal odor after coitus.
B) a truncal rash.
C) copious vaginal discharge.
D) midcycle bleeding.
A) a "fishy" vaginal odor after coitus.
Explanation:
Bacterial vaginosis is a clinical syndrome where high concentrations of anaerobic bacteria replace normal vaginal flora. This produces many symptoms that cause complaints in women. The typical symptoms
A 70 year-old female has been in a mutually monogamous relationship for the past 33 years. She has never had an abnormal Pap smear, what recommendation should be made regarding Pap smears for her?
A) They may be continued annually.
B) They should be perfo
C) can be discontinued now.
xplanation:
Pap smears screen for cervical cancer. Cervical cancer is very uncommon in older women, especially those who have no risk factors. Most learned authorities agree that screening for cervical cancer can be discontinue
In collection of a specimen for a PAP smear, how is the endocervical specimen collected?
A) After the ectocervical specimen with a broom
B) After the ectocervical specimen with a brush
C) Before the ectocervical specimen with a broom
D) Before the ectocer
B) After the ectocervical specimen with a brush
Explanation:
Ectocervical specimens are collected first to minimize any bleeding that can occur from endocervix when it is sampled. The brush is considered a superior tool for collection of endocervical spec
A female patient who takes oral contraceptives has just completed her morning exercise routine. She complains of pain in her right calf. Her blood pressure and heart rate are normal. She is not short of breath. Her calf is red and warm to touch. What is N
D) Trochanteric bursitis
Explanation:
Trochanteric bursitis does not produce pain in the calf. Pain is concentrated in the affected hip. While it is not likely that someone who exercises regularly would have a DVT, this patient does take oral contraceptiv
An adolescent female has had normal menses for almost 2 years. She has not had menses in 3 months. She is diagnosed with polycystic ovarian syndrome (PCOS). What else is a common finding?
A) Obesity
B) Elevated insulin levels
C) Positive pregnancy test
D)
B) Elevated insulin levels
Explanation:
PCOS is a systemic disease characterized by multiple cysts about the ovaries. Overweight states are common but not obesity. Normal weight is also seen in these patients. This patient will not have a positive pregnan