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31 Cards in this Set

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A 10-year-old girl goes to the doctor’s office for her regular check-up. She is healthy, active in school sports and gets good grades. On examination she is 5 feet tall and weighs 80 pounds. She has Tanner stage II breasts and no pubic hair. She asks you when she might have her first menstrual period. You explain to her that appropriate sexual development occurs in which of the following orders?
A. Thelarche-Menarche-Adrenarche-Growth spurt
B. Thelarche-Adrenarche-Growth spurt-Menarche
C. Thelarche-Growth spurt-Menarche-Adrenarche
D. Thelarche-Growth spurt-Adrenarche-Menarche
Thelarche-Adrenarche-Growth spurt-Menarche. The normal and predictable sequence of sexual maturation proceeds with breast budding, then adrenarche (hair growth), a growth spurt and then menarche.
A 16-year-old girl goes to the doctor to discuss why she has not had a menstrual cycle. She is healthy and plays weekend volleyball. She studies hard and gets good grades in school. She has a good relationship with her parents. On examination she is 5 feet 1 inch tall and weighs 84 pounds. Breast and pubic hair growth are at a Tanner stage II. External genital examination is normal. What is the most likely reason this patient has not had any menses?
A. Inadequate body weight
B. Poor nutrition
C. Inadequate sleep
D. Excessive exercise
E. Familial reasons
Inadequate body weight. There are three known critical elements for secondary sexual characteristics: adequate body weight, sleep and optic exposure to sunlight. These factors especially can delay the onset of menarche. A body weight of 85 to 106 pounds is needed before menses begins. Psychosocial causes of delayed puberty include eating disorders, excessive exercise, and stress or depression.
A mother brings her 16-year-old daughter to the doctor because she has not begun menses. She performs poorly in school because of dyslexia. On physical examination, she is 4 feet 11 inches tall, 100 pounds and has Tanner stage I breast and pubic hair growth. Her forehead is wide and her face tapers to her chin, chest is broad, breast nipples are widely spaced and her neck is thickened. No genital tract abnormalities are noted on exam. Which of the following is the most likely cause of her delayed sexual maturation?
A. Partial deletion of the long arm of the X chromosome
B. Down Syndrome
C. Turner Syndrome
D. Noonan’s Syndrome
E. Rokitansky-Kuster-Hauser Syndrome
Noonan’s Syndrome. Clinically, patients with Noonan’s syndrome may have short stature, webbed neck, heart defects, abnormal faces and delayed puberty. Individuals with Noonan’s syndrome have a normal karyotype. Partial deletions of the long arm of the X chromosome also cause premature ovarian failure. The genetic defect of Turner’s syndrome is the absence of one of the X chromosomes. These females have failure to establish secondary sexual characteristics, short stature and characteristic physical features: pterygium colli, shield chest and cubitus valgus. Rokitansky-Kuster-Hauser Syndrome causes vaginal and uterine agenesis and is not suspected in this case due to the normal pelvic exam findings.
A 16-year-old girl comes to the doctor to discuss contraception. She recently became sexually active and states she has never had a menstrual cycle. She regularly attends school and participates in the band. On physical examination, she is 5 feet 3 inches tall and weighs 130 pounds. She has no secondary sexual characteristics with normal appearing external genitalia. The physician suspects Kallmann syndrome. Which of the following diagnostic tests will help confirm the diagnosis?
A. An MRI of the pituitary
B. Olfactory challenge
C. Measurement of testosterone levels
D. Pelvic ultrasound
E. Cortisol levels
Olfactory challenge
A 7-year-old is undergoing evaluation for vaginal bleeding. On physical examination, she has Tanner stage III breasts, tall stature and an otherwise normal examination. An MRI of the brain and a pelvic ultrasound are normal. LH and FSH levels are in the pre-pubertal levels and she has normal DHEAS and androgen levels. What is the most likely diagnosis in this patient?
A. Pituitary adenoma
B. Congenital adrenal hyperplasia
C. True precocious puberty
D. McCune Albright Syndrome
E. Ovarian neoplasm
True precocious puberty
An 8-year-old has been diagnosed with precocious puberty due to presence of menarche, Tanner stage III breasts and otherwise normal work-up for brain, adrenal and ovarian abnormalities. What is the most appropriate next step in the management of this patient?
A. Depo-Provera
B. GnRH agonist
C. Danazol
D. Estradiol
E. Observation
GnRH agonist. True precocious puberty is manifested by premature secretion of GnRH hormone in a pulsatile manner. Once other causes of hormone production are ruled out, treatment would include GnRH agonist to suppress pituitary production of follicular-stimulating hormone and luteinizing hormone. Observation is acceptable if the precocious puberty is within a few months of the routinely expected puberty. The process should be treated if the bone age or puberty is advanced by several years.
A 4-year-old girl is being evaluated for premature hair growth in the pubic area. She has no breast development and has not had any menstrual bleeding. Laboratory evaluation revealed high DHEA and DHEAS levels and low levels of LH and FSH. Which of the following is the most likely cause of this girl’s premature adrenarche?
A. Idiopathic isosexual precocious puberty
B. Congenital adrenal hyperplasia
C. Hypothalamic dysfunction
D. Pituitary adenoma
E. Polycystic ovarian syndrome
Congenital adrenal hyperplasia. Congenital adrenal hyperplasia of the 21-hydroxylase type results in the adrenal being unable to produce adequate cortisol as a result of a partial block in the conversion of 17-hydroxyprogesterone to desoxycorticosterone, with the accumulation of adrenal androgens. This leads to precocious adrenarche. Treatment includes steroid replacement.
A 15-year-old adolescent discusses with her doctor that she has never had a menstrual cycle. She is healthy, active in school activities and eats a normal diet. She denies ever being sexually active. On physical examination, she has Tanner stage II breast and pubic hair growth, and average weight and height. Vaginal opening is present and appears normal. What is the most appropriate next step in her management?
A. Pelvic ultrasound
B. Oral contraceptive pills
C. Reassurance
D. MRI of sella turcica
E. Cortisol challenge test
Reassurance. Normal age for menarche is between nine and 17
A 17-year-old is brought to the physician because she has never had a menstrual cycle. She has normal breast and pubic hair development. Physical examination reveals a small vaginal opening with a blind pouch. Pelvic ultrasound reveals normal ovaries, but absence of uterus and cervix. Which of the following is the most appropriate next study in this patient?
A. Renal ultrasound
B. FSH and LH determination
C. Karyotype
D. Cortisol level
E. Testosterone level
Renal ultrasound. Renal anomalies occur in 25-35% of females with Mullerian agenesis. The uterus and cervix are absent, but the ovaries function normally and, therefore, secondary sexual characteristics are present. You would expect the karyotype in this patient to be 46,XX and testosterone levels in the female range.
A 13-year-old girl is brought to the physician for increasingly severe abdominal pain. The pain is now a constant low discomfort, but every month she has a week when it is more severe. She has Tanner stage II breasts and pubic hair development. On genital examination, there is a bluish mass pushing the labia open. What is the most likely cause of this patient’s abdominal pain?
A. Turner’s syndrome
B. Transverse vaginal septum
C. Isolated atresia of the cervix
D. Imperforate hymen
E. Synechiae of the uterine cavity
Imperforate hymen. Lower genital tract malformations occur in 1 in 10,000 females and are most commonly an imperforate hymen where the genital plate canalization is incomplete. Amenorrhea and abdominal pain are also associated with isolated atresia of the vagina or cervix. The menstrual blood will collect in the vagina and uterus causing pain. Treatment involves surgical correction. When a transverse vaginal septum is present, a normal vaginal opening with a short blind vagina and pelvic mass may be located above the level of the obstruction found on exam. Asherman’s syndrome is associated with secondary amenorrhea resulting from intrauterine scarring/synechiae.
A 24-year-old nulliparous woman comes into the office because she has not had her menses for six months. She is in good health and not taking any medications. She is not sexually active. She does well in graduate school, despite her demanding new program. Her height is 5 feet 6 inches and her weight is 104 pounds. Her vital signs are normal. Her physical examination, including a pelvic examination, is completely normal. What is the most likely reason for her amenorrhea?
A. Ovarian dysfunction
B. Thyroid disease
C. Premature ovarian failure
D. Hypothalamic-pituitary dysfunction
E. Pregnancy
. Hypothalamic-pituitary dysfunction. Anorexia nervosa or significant weight loss may cause hypothalamic-pituitary dysfunction that can result in amenorrhea. A lack of the normal pulsatile secretion of gonadotropin releasing hormone (GnRH) leads to a decreased stimulation of the pituitary gland to produce follicle stimulating hormone (FSH) and luteinizing hormone (LH). This leads to anovulation and amenorrhea
A 23-year-old nulliparous woman presents to the office because she has not had any menses for four months. She has a long history of irregular menstrual cycles since menarche at age 14. She is otherwise in good health and is not taking any medications. She is thin and has chronic anxiety. Her Beta-hCG is < 5 mIU/mL, and her prolactin and TSH levels are normal. What would be the next best diagnostic test to order?
A. Estrogen level
B. Progesterone level
C. Gonadotropin releasing hormone level (GnRH)
D. Follicle stimulating hormone and luteinizing hormone levels (FSH and LH)
E. Dehydroepiandrosterone sulfate (DHEAS)
Follicle stimulating hormone and luteinizing hormone levels (FSH and LH)
A 23-year-old nulliparous woman presents to the office because she has not had any menses for four months. She has a long history of irregular menstrual cycles since menarche at age 14. She is in good health and is not taking any medications. She is sexually active with her partner of six months, and uses condoms for contraception. She is 5 feet 4 inches tall and weighs 170 pounds. On exam, she has noticeable hair growth on her upper lip and chin. The rest of her examination including a pelvic exam is normal. Her Beta-hCG is < 5 mIU/mL, and her prolactin and TSH levels are normal. In addition to recommending weight loss, what is the most appropriate next step in the management of this patient?
A. Treatment with gonadotropin releasing hormone level (GnRH) agonist
B. Treatment with clomiphene citrate
C. Treatment with oral contraceptives
D. Check progesterone levels
E. Check cortisol levels
Treatment with oral contraceptives
A 32-year-old nulliparous woman presents with amenorrhea for the last three months. She has a long history of irregular cycles, 26 to 45 days apart, for the last two years. She is otherwise in good health and is not taking any medications. She is sexually active with her husband and uses condoms for contraception. She is 5 feet 4 inches tall and weighs 140 pounds. On exam, she has a slightly enlarged, non-tender uterus. There are no adnexal masses. Which of the following is the most appropriate test to obtain in this patient?
A. Thyroid stimulating hormone (TSH)
B. Progesterone and estrogen
C. Follicle stimulating hormone and luteinizing hormone levels (FSH and LH)
D. Urine pregnancy test
E. Pelvic ultrasound
Pregnancy is the most common cause of amenorrhea. It is important to consider it early in the workup to avoid unnecessary tests, procedures and treatments that may be contraindicated during pregnancy. Although the patient has a history of irregular cycles and is using condoms for contraception, it is important to first rule out pregnancy before initiating further work-up.
A 33-year-old nulliparous woman presents with amenorrhea for the past 12 months. She also reports a recent onset of dyspareunia, causing her to feel anxious about having intercourse. She had menarche at age 15. Her cycles were normal until two years ago when she began skipping menses. She is otherwise in good health. She is 5 feet 4 inches tall and weighs 130 pounds. Her physical examination is completely normal. TSH and prolactin levels are normal. Urine pregnancy test is negative. What is the most likely cause of this patient’s amenorrhea?
A. Psychogenic
B. Genital tract outflow obstruction
C. Asherman’s syndrome
D. Premature ovarian failure
E. Pituitary adenoma
Premature ovarian failure. The patient’s symptom of dyspareunia is likely caused by vaginal dryness, which is associated with estrogen deficiency. Hypergonadotropic amenorrhea is the result of ovarian failure or follicular resistance to gonadotropin stimulation. The history, physical exam and labs make the other possibilities less likely: psychogenic disorder (no chronic anxiety or anorexia nervosa), outflow obstruction (previously had periods), Asherman’s syndrome (no history of pregnancy or intrauterine procedures), or a pituitary tumor (normal labs).
A 17-year-old nulliparous female is brought in by her mother because she has not yet had any menses. She is otherwise in good health, but recently has been experiencing cyclical lower abdominal cramping. She has never had sexual intercourse. She is 5 feet 6 inches tall and weighs 120 pounds. On examination, her breasts are Tanner Stage IV. She has some suprapubic tenderness on abdominal exam. Her pelvic exam reveals normal external genitalia, but there was difficulty inserting a speculum due to patient’s discomfort. Beta-hCG < 5 mIU/mL. What is the most likely diagnosis in this patient?

A. Genital tract outflow obstruction
B. Müllerian agenesis
C. Hypothalamic-pituitary dysfunction
D. Psychogenic amenorrhea
E. Constitutional delay in menarche
Genital tract outflow obstruction. This patient’s primary amenorrhea, with normal secondary sexual characteristics, development and cyclical abdominal pain, points to an anatomical cause of amenorrhea, which is preventing menstrual bleeding. An imperforate hymen commonly causes this and the treatment is surgical
A 31-year-old G3P0 presents with amenorrhea for six months. She is otherwise in good health and is not taking any medications. She had a miscarriage seven months ago, which was complicated by an infection and required antibiotics and a dilation and curettage procedure. Her examination is normal. Her laboratory results show a Beta-hCG <5 mIU/mL, and normal TSH and prolactin levels. What is the most likely underlying cause of this patient’s amenorrhea?
A. Chronic endometritis
B. Recurrent miscarriages
C. Hypothalamic-pituitary amenorrhea
D. Asherman’s syndrome
E. Sheehan’s syndrome
Asherman’s syndrome
A 23-year-old female college student presents with amenorrhea for 10 months. She had menarche at age 14 and normal regular menses every 28 days until this year. She is in good health and not taking any medications. She is 5 feet 4 inches tall and weighs 130 pounds. Her examination, including a pelvic exam, is normal. Beta-hCG is < 5 mIU/mL, and TSH is 5.0 mU/L (normal 0.35-6.7 mU/L). What is the most appropriate next diagnostic test to help determine the cause of amenorrhea in this patient?
A. Serum 17-hydroxyprogesterone level
B. Serum prolactin level
C. Pelvic ultrasound
D. Serum LH and FSH levels
E. Brain MRI
Serum prolactin level. Measurement of serum prolactin level is part of the initial laboratory assessment for a patient with amenorrhea and no other symptoms or findings on physical exam. A prolactinoma is the most common pituitary tumor causing amenorrhea. Galactorrhea may be present when hyperprolactinemia is the cause of anovulation and amenorrhea.
A 22-year-old nulliparous woman presents with five months of amenorrhea since discontinuing her oral contraceptive pills. She had been on the pill for the last six years and had normal menses every 28 days while taking them. She is in good health and not taking any medications. She is 5 feet 4 inches tall and weighs 140 pounds. Her examination, including a pelvic examination, is normal. Which of the following historical elements would be most useful in determining the cause of amenorrhea in this patient?
A. Age at first intercourse
B. History of sexually transmitted infections
C. Parity
D. History of oligo-ovulatory cycles
E. Recent history of weight loss
History of oligo-ovulatory cycles. Since most women resume normal menstrual cycles after discontinuing oral contraceptive pills (OCPs), they are not usually considered the cause of the amenorrhea. A history of irregular cycles prior to pill use may increase the risk of amenorrhea upon discontinuation. This is sometimes referred to as “post pill amenorrhea.
A 35-year-old Asian woman presents with irregular menses and hirsutism of three months duration. The patient has no family history of hirsutism. On exam, the patient was noted to have terminal hair growth on her chest and recently had laser treatment to remove similar hair on her chin. Her total testosterone is 76 ng/dl (normal) and her DHEAS is 1500µg/dl (elevated). Which of the following is the most likely diagnosis in this patient?
A. Pituitary adenoma
B. Ovarian tumor
C. Cushing’s syndrome
D. Adrenal tumor
E. Idiopathic
Adrenal tumor. The short duration of symptoms and the significantly elevated DHEAS support the diagnosis of an adrenal tumor as the etiology of the patient’s symptoms. In addition, the patient is Asian and is less likely to have a predisposition to idiopathic hirsutism. Asians with polycystic ovarian syndrome are less likely to present with overt hirsutism than other ethnic groups.
An 18-year-old G0 presents with a one-year history of hirsutism and acne. She had menarche at age 14 and her menses have been irregular every 26-60 days. Her sister has a similar pattern of hair growth. The patient is 5 feet 4 inches tall and weighs 180 pounds. On exam, a few terminal hairs were identified on her chin and upper lip. TSH, prolactin, total testosterone, and DHEAS levels are normal. Which of the following is the most appropriate next test to evaluate this patient’s condition?
A. Estradiol levels
B. Serum cortisol levels
C. Urinary cortisol levels
D. Random blood glucose
E. 17-hydroxyprogesterone
17-hydroxyprogesterone. Checking 17-hydroxyprogesterone would rule out late onset 21-hydroxylase deficiency. Normal TSH, Prolactin, total testosterone and DHEAS levels rule out pituitary or adrenal tumors. The patient could have polycystic ovarian syndrome; however, normal serum testosterone levels make it less likely.
A 22-year-old G0 presents with hirsutism which has been present since menarche. She states that she has laser treatments done to remove the hair on her chin every couple of months, and was wondering if there are additional treatments which might help her. She is otherwise in good health. She has normal menstrual cycles every 28 days. She is sexually active and uses birth control pills for contraception. The patient is adopted and has no information about family history. She is 5 feet 4 inches tall and weighs 125 pounds. On examination, the patient was noted to have terminal hair growth on her chest. Her TSH, Prolactin, total testosterone, DHEAS, 17-Hydorxyprogesterone levels are normal. Which of the following is the most likely underlying etiology for the hirsutism in this patient?
A. Polycystic ovarian syndrome
B. Side effects of the oral contraceptives
C. Cushing’s syndrome
D. Adrenal tumor
E. Idiopathic hirsutism
Idiopathic hirsutism. This patient most likely has idiopathic hirsutism. She has no other clinical signs of polycystic ovaries, such as irregular cycles or obesity. Normal laboratory values rule out other pathogenic causes of hirsutism, such as Cushing’s syndrome or adrenal tumor. Oral contraceptives are actually used for the treatment of hirsutism because they establish regular menses and lower ovarian androgen production. Additionally, they cause an increase in SHBG which allows more testosterone to be bound and unavailable at the hair follicle.
A 17-year-old patient presents with hirsutism, irregular menses and obesity. Her mother is moderately obese with mild hirsutism. Recently, the patient’s hirsutism has worsened and she has been depressed. She has also gained 20 pounds in the past two months and has noticed stretch marks on her abdomen. At the time of your examination, you note that she has terminal hair growth on her chin and hair growth on the back of her hands. Her cheeks appear flushed. Her stretch marks are purplish in color. The rest of her exam is normal. Which of the following is the most appropriate first test to order for this patient?
A. Overnight dexamethasone suppression test
B. 17-hydroxyprogesterone
C. Fasting insulin
D. TSH
E. Pelvic ultrasound
Overnight dexamethasone suppression test. Since Cushing's syndrome is suspected, either a dexamethasone suppression test or a 24-hour urinary measurement for cortisol can be performed. Elevated cortisol would be indicative of Cushing's syndrome. The other tests listed would be reasonable, but only after Cushing’s syndrome had been excluded.
A 36-year-old woman comes to the office due to hair loss. She delivered a healthy infant girl three months ago. She is currently on a progestin-only oral contraceptive pill since she is breastfeeding. In the last month, she has noticed a large amount of hair on her brush each morning. Her father has male pattern baldness and her mother, who is postmenopausal, has had some thinning of her hair, as well. Testosterone and TSH levels are within the normal range. Which of the following is the most likely underlying cause for alopecia in this patient?
A. Genetic predisposition
B. Progesterone only pills
C. High estrogen levels during pregnancy
D. Stress during pregnancy and delivery
E. Breastfeeding
High estrogen levels during pregnancy. High estrogen levels in pregnancy increase the synchrony of hair growth. Therefore, hair grows in the same phase and is shed at the same time. Occasionally, this can result in significant postpartum hair loss. In the non-pregnant state, asynchronous hair growth occurs such that a portion of hair is in one of the three hair growth cycles at all times.
A 34-year-old G2P2 presents with concerns of hormonal changes. She is worried about facial hair growth, worsening acne, and deepening of her voice. She also realized that she has missed her period for two months, and has been sexually active and had tubal ligation. On examination, she is moderately obese and noted to have severe acne, upper lip and chin terminal hair. Her abdomen is obese with moderate hair growth. Pelvic examination is most notable for an enlarged clitoris, and pelvic exam reveals an enlarged right-sided adnexal mass. Which of the following is the most likely diagnosis in this patient?
A. Sertoli-Leydig cell tumors
B. Granulosa cell tumor
C. Benign cystic teratoma
D. Thecoma
E. Cystadenoma
Sertoli-Leydig cell tumors. Sertoli-Leydig cell tumors are commonly diagnosed in women between the ages of 20-40, and are most often unilateral. Rapid onset of hirsutism and virilizing signs are hallmarks of this disease, and include many of the findings in this patient including acne, hirsutism, amenorrhea, clitoral hypertrophy, and deepening of the voice. Abnormal laboratory findings include suppression of FSH and LH, marked elevation of testosterone, and presence of an ovarian mass. The constellation of findings is most consistent with a testosterone-secreting tumor, and a pelvic ultrasound will confirm the presence of an ovarian mass. The other tumors do not cause virilization. Granulosa cell tumors and thecomas are estrogen secreting tumors.
A 26-year-old woman comes to the office due to irregular menses since menarche, worsening for the last six months. The patient has noted increasing hair growth on her chin and most recently hair growth on her chest, requiring that she shave periodically. No one in her family has hirsutism. On exam, you also notice acne on her chin, acanthosis nigricans and temporal balding. Her serum testosterone is elevated. You suspect hyperthecosis. Which of the following might also be associated with this condition?
A. Hyperthyroidism
B. Hyperprolactinemia
C. Atrophic changes of external genitalia
D. Deepening of the voice
E. Hyperparathyroidism
Deepening of the voice. Hyperthecosis is a more severe form of polycystic ovarian syndrome (PCOS). It is associated with virilization due to the high androstenedione production and testosterone levels. In addition to temporal balding, other signs of virilization include clitoral enlargement and deepening of the voice. Hyperthecosis is more difficult to treat with oral contraceptive therapy. It is also more challenging to achieve successful ovulation induction
A 21-year-old woman comes to the office because of acne, irregular menses and hirsutism. She initially was evaluated six months ago, at which time she was diagnosed with idiopathic hirsutism. She was started on oral contraceptive pills to improve her symptoms. Menstrual periods now occur every month, but her hirsutism has not significantly improved. In addition to the oral contraceptives, which of the following would be an appropriate treatment for hirsutism?
A. Spironolactone
B. Lupron
C. Danazol
D. Depo-Provera
E. Steroids
Spironolactone. an aldosterone antagonist diuretic, can also be used in addition to the oral contraceptives for hirsutism. Danazol is primarily used for the treatment of endometriosis and may actually worsen hirsutism and acne. Lupron and Depo-Provera are also reasonable as second-line treatments of hirsutism, had the patient not already been on oral contraceptives. Steroids will not help.
A 32-year-old G0 presents with irregular menses occurring every six to eight weeks for the past eight months. The bleeding alternates between light and heavy. Her irregular menses were treated successfully with Medroxyprogesterone Acetate (MPA), 10 mg every day, taken for 10 days each month. By which mechanism does the MPA control her periods?
A. Stimulates rapid endometrial growth and regeneration of glandular stumps
B. Converts endometrium from proliferative to secretory
C. Promotes release of Prostaglandin F2α
D. Regenerates functional layer of the endometrium
E. Decreases luteal phase inhibin production
Converts endometrium from proliferative to secretory. Patients with anovulatory bleeding have predominantly proliferative endometrium from unopposed stimulation by estrogen. Progestins inhibit further endometrial growth, converting the proliferative to secretory endometrium. Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium. Stimulation of rapid endometrial growth, conversion of proliferative to secretory endometrium, and regeneration of the functional layer describe effects of estrogen on the endometrium. Inhibin is increased in the luteal phase.
A 41-year-old G3P3 reports heavy menstrual periods occurring every 26 days lasting eight days. The periods have been increasingly heavy over the last three months. She reports soaking through pads and tampons every two hours. She has a history of three uncomplicated spontaneous vaginal deliveries and a tubal ligation following the birth of her last child. On pelvic examination, the cervix appears normal and the uterus is normal in size. Which of the following tests or procedures would be most useful in further evaluation of this patient’s complaint?
A. Follicle stimulating hormone level
B. Prolactin level
C. Coagulation studies
D. Pelvic ultrasound
E. Hysteroscopy
Pelvic ultrasound. A pelvic ultrasound would image the endometrium and assess for endometrial pathology such as polyps or submucosal fibroids. In the absence of menopausal symptoms, FSH is unlikely to be helpful. The patient is unlikely to have a coagulation disorder, as she has had three spontaneous vaginal deliveries without postpartum hemorrhage. Hysteroscopy would not be helpful if the cause of abnormal bleeding is myometrial pathology such as intramural and subserosal fibroids or adenomyosis. Hyperprolactinemia is found with prolactin-secreting adenomas associated with amenorrhea.
A 14-year-old G0 adolescent reports menarche six months ago, with increasingly heavy menstrual flow causing her to miss several days of school. Three months ago, her pediatrician started her on oral contraceptives to control her menstrual periods, but she continues to bleed heavily. Her previous medical history is unremarkable. The patient has a normal body habitus for her age. Appropriate breast and pubic hair development is present. Her hemoglobin is 9.1 mg/dl, hematocrit 27.8%, urine pregnancy test negative. Which of the following etiologies for menorrhagia is most likely the cause of her symptoms?
A. Uterine leiomyoma
B. Thyroid disorder
C. Coagulation disorder
D. Endometrial hyperplasia
E. Chronic endometritis
Coagulation disorder. Disorders of clotting may present with menstrual symptoms in young women, with Von Willeberand disease being most common. Leiomyomas typically present in women in their 30s and 40s. Endometrial hyperplasia can occur in younger anovulatory patients, but the short duration of this patient’s symptoms makes this less likely. She does not have any signs of infection or thyroid disease.
A 35-year-old G0 comes to the office because of six months of spotting between her periods and a desire for a pregnancy. She reports using 30 pads/cycle the last two months and has blood clots and cramping pain. Prior menses were light and required 15 pads/cycle. She has been trying to conceive for six months. Her work-up included a transvaginal ultrasound which revealed a 2 cm endometrial polyp. What is the next best step in the management of this patient?
A. Hysteroscopic polypectomy
B. Observation
C. Combination birth control pills
D. Endometrial ablation
E. Hysterectomy
Hysteroscopic polypectomy. Management of an endometrial polyp includes the following: observation, medical management with progestin, curettage, surgical removal (polypectomy) via hysteroscopy, and hysterectomy. Observation is not recommended if the polyp is > 1.5 cm. In women with infertility polypectomy is the treatment of choice. Hysterectomy is reserved for women with polyps and premalignant or malignant changes.