A 23-year-old Caucasian G2P1 presents for a routine prenatal care visit at 25 weeks gestation. She has no complaints and the pregnancy has been uncomplicated thus far. The previous pregnancy was complicated by pre-eclampsia and she delivered a small-for-gestational-age girl at 36 weeks gestation. The pre-pregnancy weight was 73 kg (161 lb), and she now weighs 78 kg (172 lb). Her height is 155 cm. The blood pressure is 120/80 mm Hg, the heart rate is 91/min, the respiratory rate is 14/min, and the temperature is 36.7℃ (98℉). Her physical examination is normal and the gynecologic examination corresponds to 25 weeks gestation. An oral glucose tolerance test (OGTT) with a 75-g glucose load was abnormal with a 1-h glucose level of 189 mg/dL. Which of the following is a risk factor for the patient’s condition?
Q242
A 30-year-old woman, gravida 2, para 1, comes for a prenatal visit at 33 weeks' gestation. She delivered her first child spontaneously at 38 weeks' gestation; pregnancy was complicated by oligohydramnios. She has no other history of serious illness. Her blood pressure is 100/70 mm Hg. On pelvic examination, uterine size is found to be smaller than expected for dates. The fetus is in a longitudinal lie, with vertex presentation. The fetal heart rate is 144/min. Ultrasonography shows an estimated fetal weight below the 10th percentile, and decreased amniotic fluid volume. Which of the following is the most appropriate next step in this patient?
Q243
A 28-year-old woman G1P0 presents at 38 weeks of gestation for a standard prenatal visit. She endorses occasional mild lower back pain but otherwise remains asymptomatic. Her past medical history is significant for HIV for which she is treated with azidothymidine (AZT). Her vital signs and physical exam are unremarkable. Her current HIV viral titer level is 1,400 copies. If she were to go into labor today, what would be the next and most important step for the prevention of vertical HIV transmission to the newborn?
Q244
A 17-year-old female presents to her pediatrician due to lack of menstruation. She states that she developed breasts 4 years ago but has not experienced menses yet. The patient denies abdominal pain and has no past medical history. Her mother underwent menarche at age 13. The patient is a volleyball player at school, is single, and has never attempted intercourse. At this visit, her temperature is 98.3°F (36.8°C), blood pressure is 110/76 mmHg, pulse is 72/min, and respirations are 14/min. She is 5 feet 7 inches tall and weighs 116 pounds (BMI 18.2 kg/m²). Exam shows Tanner IV breasts, Tanner I pubic hair, and minimal axillary hair. External genitalia are normal, but the vagina is a 5-centimeter blind pouch. Which of the following is the most appropriate initial diagnostic test?
Q245
A 26-year-old Caucasian G1 presents at 35 weeks gestation with mild vaginal bleeding. She reports no abdominal pain or uterine contractions. She received no prenatal care after 20 weeks gestation because she was traveling. Prior to the current pregnancy, she used oral contraception. At 22 years of age she underwent a cervical polypectomy. She has a 5 pack-year smoking history. The blood pressure is 115/70 mmHg, the heart rate is 88/min, the respiratory rate is 14/min, and the temperature is 36.7℃ (98℉). Abdominal palpation reveals no uterine tenderness or contractions. The fundus is palpable between the umbilicus and the xiphoid process. An ultrasound exam shows placental extension over the internal cervical os. Which of the following factors present in this patient is the risk factor for her condition?
Q246
A 55-year-old woman comes to your office because she noticed the growth of unwanted hair on her upper lip, chin, and chest. She has also noticed an increase in blackheads and pimples on her skin. Her female partner has also recently brought to her attention the deepening of her voice, weight gain, and changes in her external genitalia that generated some personal relationship issues. The patient is frustrated as these changes have appeared over the course of the last 8 months. She claims that she was feeling completely normal before all of these physical changes started. Physical examination shows dark coarse stubbles distributed along her upper lip, chin, chest, back, oily skin, and moderately inflamed acne. Pelvic examination reveals a clitoris measuring 12 mm long, a normal sized mobile retroverted uterus, and a firm, enlarged left ovary. What is the most likely diagnosis of this patient?
Q247
A 16-year-old girl is brought to the physician by her mother because she has not had her menstrual period yet. At birth, she was found to have partial labial fusion and clitoromegaly. The mother reports that during the pregnancy she had noticed abnormal hair growth on her chin. The girl has severe acne. Three years ago, she broke her wrist after a minor trauma. Last year, she sustained a spinal compression fracture after lifting a box during a move. She currently takes oral isotretinoin and an oral contraceptive. The patient is at the 97th percentile for height and 50th percentile for weight. Physical examination shows numerous inflamed pustules on her face and upper back. Breast development is at Tanner stage I. The patient refuses to have a pelvic examination. A pelvic ultrasound shows ovaries with multiple cysts and a normal uterus. Which of the following is the most likely diagnosis?
Q248
A 15-year-old girl comes to the physician because of a 2-year history of irregular menstrual bleeding. Menses have occurred at irregular 45- to 60-day intervals since menarche at the age of 13 years. Her last menstrual period was 5 weeks ago and lasted for 7 days with heavy flow and no cramping. She is not sexually active. She is 171 cm (5 ft 7 in) tall and weighs 58 kg (128 lb); BMI is 20 kg/m2. Her temperature is 36.6°C (97.8°F), pulse is 80/min, and blood pressure is 110/60 mm Hg. Pelvic examination shows a normal-appearing vagina and cervix. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses. The remainder of the physical examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most likely explanation for this patient's symptoms?
Q249
A 41-year-old nulliparous woman comes to the physician for an annual pelvic examination and Pap smear. Over the past year she has been feeling healthy. She is sexually active and uses an intrauterine device with copper for contraception. She has smoked one pack of cigarettes daily for 20 years. She is 160 cm (5 ft 3 in) tall and weighs 88 kg (194 lb); BMI is 34.4 kg/m2. Bimanual pelvic examination shows an irregularly enlarged uterus. A transvaginal ultrasound reveals a singular 4 cm, hypoechoic mass inside the myometrial wall. Which of the following is the most likely cause of this finding?
Q250
A 43-year-old woman presents to her primary care physician for a general wellness appointment. The patient states that sometimes she has headaches and is ashamed of her body habitus. Otherwise, the patient has no complaints. The patient's 90-year-old mother recently died of breast cancer. The patient smokes 1 pack of cigarettes per day. She drinks 2-3 glasses of red wine per day with dinner. She has been considering having a child as she has just been promoted to a position that gives her more time off and a greater income. The patient's current medications include lisinopril, metformin, and a progesterone intrauterine device (IUD). On physical exam, you note a normal S1 and S2 heart sound. Pulmonary exam is clear to auscultation bilaterally. The patient's abdominal, musculoskeletal, and neurological exams are within normal limits. The patient is concerned about her risk for breast cancer and asks what she can do to reduce her chance of getting this disease. Which of the following is the best recommendation for this patient?
High-risk pregnancies US Medical PG Practice Questions and MCQs
Question 241: A 23-year-old Caucasian G2P1 presents for a routine prenatal care visit at 25 weeks gestation. She has no complaints and the pregnancy has been uncomplicated thus far. The previous pregnancy was complicated by pre-eclampsia and she delivered a small-for-gestational-age girl at 36 weeks gestation. The pre-pregnancy weight was 73 kg (161 lb), and she now weighs 78 kg (172 lb). Her height is 155 cm. The blood pressure is 120/80 mm Hg, the heart rate is 91/min, the respiratory rate is 14/min, and the temperature is 36.7℃ (98℉). Her physical examination is normal and the gynecologic examination corresponds to 25 weeks gestation. An oral glucose tolerance test (OGTT) with a 75-g glucose load was abnormal with a 1-h glucose level of 189 mg/dL. Which of the following is a risk factor for the patient’s condition?
A. Patient age
B. Patient ethnicity
C. History of pre-eclampsia
D. Pre-pregnancy BMI (Correct Answer)
E. History of birth of a small-for-gestational-age baby
Explanation: ***Pre-pregnancy BMI***
- The patient's pre-pregnancy BMI is 30.4 kg/m² (73 kg / (1.55 m)²), which is classified as **obese**.
- **Obesity** is a significant risk factor for developing gestational diabetes mellitus (GDM) due to increased insulin resistance.
*Patient age*
- The patient is 23 years old, which is generally considered a **low-risk age group** for gestational diabetes.
- The risk of GDM typically increases with maternal age, particularly after 25 or 30 years old.
*Patient ethnicity*
- The patient is Caucasian, and while certain ethnicities (e.g., Hispanic, African American, Asian) have a higher prevalence of GDM, **Caucasian ethnicity** itself is not typically considered a primary risk factor when compared to other ethnicities.
- The patient's specific background would need to be evaluated in a broader epidemiological context.
*History of pre-eclampsia*
- A history of pre-eclampsia can be associated with an **increased risk of cardiovascular disease and type 2 diabetes** later in life for the mother.
- However, **pre-eclampsia itself is not a direct risk factor for *developing* gestational diabetes** in a subsequent pregnancy; rather, both conditions share some underlying risk factors like obesity and insulin resistance.
*History of birth of a small-for-gestational-age baby*
- A history of a **small-for-gestational-age (SGA)** baby is more commonly associated with maternal conditions like uncontrolled **hypertension, pre-eclampsia, or placental insufficiency**.
- Gestational diabetes is more typically associated with the birth of a **large-for-gestational-age (LGA)** baby due to fetal hyperinsulinemia and increased growth.
Question 242: A 30-year-old woman, gravida 2, para 1, comes for a prenatal visit at 33 weeks' gestation. She delivered her first child spontaneously at 38 weeks' gestation; pregnancy was complicated by oligohydramnios. She has no other history of serious illness. Her blood pressure is 100/70 mm Hg. On pelvic examination, uterine size is found to be smaller than expected for dates. The fetus is in a longitudinal lie, with vertex presentation. The fetal heart rate is 144/min. Ultrasonography shows an estimated fetal weight below the 10th percentile, and decreased amniotic fluid volume. Which of the following is the most appropriate next step in this patient?
A. Serial nonstress tests (Correct Answer)
B. Emergent cesarean delivery
C. Amnioinfusion
D. Reassurance only
E. Weekly fetal weight estimation
Explanation: ***Serial nonstress tests***
- This patient presents with **intrauterine growth restriction (IUGR)** and **oligohydramnios**, placing her fetus at high risk for fetal compromise and stillbirth.
- **Serial nonstress tests (NSTs)** are essential for monitoring fetal well-being in such high-risk pregnancies, as they assess fetal heart rate accelerations in response to fetal movement, indicating a healthy central nervous system and adequate oxygenation.
*Emergent cesarean delivery*
- While the fetus has IUGR and oligohydramnios, there is no immediate evidence of **fetal distress** (e.g., severe decelerations or persistent bradycardia) that would warrant an **emergent** delivery at 33 weeks.
- Delivery at 33 weeks increases the risk of **neonatal complications** associated with prematurity, so conservative management with close monitoring is preferred if the fetus is not in acute distress.
*Amnioinfusion*
- **Amnioinfusion** involves introducing saline into the amniotic cavity and is primarily used to alleviate **umbilical cord compression** during labor by increasing amniotic fluid volume.
- It is **not indicated** for chronic oligohydramnios in the antepartum period as a primary treatment and does not address the underlying pathology of IUGR.
*Reassurance only*
- Given the findings of **IUGR** (estimated fetal weight below 10th percentile) and **oligohydramnios**, the situation is not benign and requires active management and monitoring.
- **Reassurance only** would be inappropriate and potentially harmful, as these conditions significantly increase the risk of adverse perinatal outcomes.
*Weekly fetal weight estimation*
- While **fetal weight estimation** is important for diagnosing and tracking IUGR, performing it **weekly** is unnecessarily frequent and not the primary method for ongoing surveillance of fetal well-being.
- **Biophysical profiles (BPPs)** or **nonstress tests (NSTs)** combined with amniotic fluid index measurements are more appropriate for regular surveillance of fetal compromise in IUGR.
Question 243: A 28-year-old woman G1P0 presents at 38 weeks of gestation for a standard prenatal visit. She endorses occasional mild lower back pain but otherwise remains asymptomatic. Her past medical history is significant for HIV for which she is treated with azidothymidine (AZT). Her vital signs and physical exam are unremarkable. Her current HIV viral titer level is 1,400 copies. If she were to go into labor today, what would be the next and most important step for the prevention of vertical HIV transmission to the newborn?
A. Urge the patient to have a cesarean section delivery (Correct Answer)
B. Add nevirapine to the patient’s AZT
C. Treat the newborn with AZT following delivery
D. Increase AZT dose
E. Avoid breastfeeding
Explanation: ***Urge the patient to have a cesarean section delivery***
- A **high viral load** (>1000 copies/mL) at 38 weeks gestation is an indication for a **scheduled cesarean section** to reduce the risk of vertical HIV transmission.
- This approach minimizes the infant's exposure to maternal blood and genital secretions during vaginal delivery.
*Add nevirapine to the patient’s AZT*
- While adding a second antiretroviral (ARV) medication is generally beneficial in HIV treatment, a single dose of **nevirapine** given to the mother in labor is typically used when **highly active antiretroviral therapy (HAART)** has not been given prenatally or with unknown viral load status.
- The primary intervention for a known high viral load near term is delivery mode modification.
*Treat the newborn with AZT following delivery*
- This is a standard and essential component of **post-exposure prophylaxis (PEP)** for all infants born to HIV-positive mothers, regardless of maternal viral load or delivery route.
- However, it is a post-delivery intervention and not the **next and most important step** for prevention *at the time of labor* with a high viral load.
*Increase AZT dose*
- Increasing the dose of a single ARV medication like **AZT** alone is unlikely to rapidly suppress a viral load of 1,400 copies/mL sufficiently to mitigate transmission risks during labor, and could lead to toxicity.
- Achieving viral suppression before labor is crucial, and if not achieved, a C-section is indicated.
*Avoid breastfeeding*
- **Avoiding breastfeeding** is a critical recommendation for HIV-positive mothers in developed countries to prevent **postnatal vertical transmission**.
- While important for overall prevention, it addresses transmission after birth and is not the immediate and most important step to prevent transmission *at the onset of labor* when a high viral load is present.
Question 244: A 17-year-old female presents to her pediatrician due to lack of menstruation. She states that she developed breasts 4 years ago but has not experienced menses yet. The patient denies abdominal pain and has no past medical history. Her mother underwent menarche at age 13. The patient is a volleyball player at school, is single, and has never attempted intercourse. At this visit, her temperature is 98.3°F (36.8°C), blood pressure is 110/76 mmHg, pulse is 72/min, and respirations are 14/min. She is 5 feet 7 inches tall and weighs 116 pounds (BMI 18.2 kg/m²). Exam shows Tanner IV breasts, Tanner I pubic hair, and minimal axillary hair. External genitalia are normal, but the vagina is a 5-centimeter blind pouch. Which of the following is the most appropriate initial diagnostic test?
A. Obtain FSH and estrogen levels (Correct Answer)
B. Vaginoplasty
C. ACTH stimulation test
D. Gonadectomy
E. Estrogen replacement therapy
Explanation: ***Obtain FSH and estrogen levels***
- The patient presents with **primary amenorrhea**, breast development (Tanner IV), but absent pubic/axillary hair (Tanner I) and a blind pouch vagina. These findings are highly suspicious for **Androgen Insensitivity Syndrome (AIS)**.
- Measuring **Follicle-Stimulating Hormone (FSH)** and **estrogen levels** will help differentiate between causes of primary amenorrhea, particularly in cases of suspected gonadal dysfunction or end-organ unresponsiveness. Elevated FSH would suggest gonadal failure, while normal to high estrogen despite absent menses points towards hormonal unresponsiveness.
*Vaginoplasty*
- This is a surgical procedure to create or lengthen the vagina and is a **definitive treatment** for conditions like Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome or severe vaginal agenesis, but it is not an initial diagnostic step.
- Performing surgery without a clear diagnosis is inappropriate and premature, as the underlying cause of the blind vaginal pouch needs to be identified first.
*ACTH stimulation test*
- An **ACTH stimulation test** is used to diagnose **adrenal insufficiency** or **congenital adrenal hyperplasia (CAH)**.
- While CAH can cause ambiguous genitalia and primary amenorrhea in some forms, this patient has normal female external genitalia and breast development, making CAH less likely, and this test isn't the primary diagnostic step for her presentation.
*Gonadectomy*
- **Gonadectomy** is the surgical removal of gonads and is typically performed in individuals with certain **Disorders of Sex Development (DSDs)**, such as AIS with intra-abdominal testes, to prevent **gonadal malignancy**.
- This is a **treatment** measure, not a diagnostic test, and is only considered after a definitive diagnosis of the underlying condition.
*Estrogen replacement therapy*
- **Estrogen replacement therapy** might be considered as a treatment for **hypogonadism** or to induce secondary sexual characteristics in certain types of primary amenorrhea (e.g., gonadal dysgenesis).
- However, in a patient with breast development (Tanner IV), estrogen production is likely occurring, making it an inappropriate initial diagnostic choice or treatment, especially before determining the cause of amenorrhea.
Question 245: A 26-year-old Caucasian G1 presents at 35 weeks gestation with mild vaginal bleeding. She reports no abdominal pain or uterine contractions. She received no prenatal care after 20 weeks gestation because she was traveling. Prior to the current pregnancy, she used oral contraception. At 22 years of age she underwent a cervical polypectomy. She has a 5 pack-year smoking history. The blood pressure is 115/70 mmHg, the heart rate is 88/min, the respiratory rate is 14/min, and the temperature is 36.7℃ (98℉). Abdominal palpation reveals no uterine tenderness or contractions. The fundus is palpable between the umbilicus and the xiphoid process. An ultrasound exam shows placental extension over the internal cervical os. Which of the following factors present in this patient is the risk factor for her condition?
A. White race
B. Smoking (Correct Answer)
C. History of cervical polyp
D. Intake of oral contraceptives
E. Nulliparity
Explanation: **Smoking**
- **Smoking** is a well-established risk factor for **placenta previa**, as it impairs placental development and increases the likelihood of abnormal implantation.
- Nicotine and other toxins in cigarette smoke can cause **vasoconstriction** and **ischemia**, leading to placental abnormalities, including a lower implantation site.
*White race*
- While certain ethnicities may have varying rates of obstetrical complications, **white race** is generally not considered an independent or significant risk factor for placenta previa.
- Risk factors for placenta previa are primarily related to uterine health, placental development, and obstetric history.
*History of cervical polyp*
- A history of **cervical polyps** is not a known or significant risk factor for **placenta previa**.
- Cervical polyps are benign growths of the cervix and do not inherently affect the site of placental implantation.
*Intake of oral contraceptives*
- The use of **oral contraceptives** prior to pregnancy is not a risk factor for **placenta previa**.
- Oral contraceptives primarily affect ovarian function and have no direct impact on the subsequent placental implantation site.
*Nulliparity*
- **Nulliparity** (never having given birth) is actually associated with a *lower* risk of placenta previa compared to multiparity.
- The risk of placenta previa generally **increases with the number of previous pregnancies** and deliveries due to changes in the uterine lining.
Question 246: A 55-year-old woman comes to your office because she noticed the growth of unwanted hair on her upper lip, chin, and chest. She has also noticed an increase in blackheads and pimples on her skin. Her female partner has also recently brought to her attention the deepening of her voice, weight gain, and changes in her external genitalia that generated some personal relationship issues. The patient is frustrated as these changes have appeared over the course of the last 8 months. She claims that she was feeling completely normal before all of these physical changes started. Physical examination shows dark coarse stubbles distributed along her upper lip, chin, chest, back, oily skin, and moderately inflamed acne. Pelvic examination reveals a clitoris measuring 12 mm long, a normal sized mobile retroverted uterus, and a firm, enlarged left ovary. What is the most likely diagnosis of this patient?
A. Polycystic ovarian syndrome (PCOS)
B. Granulosa cell tumour
C. Sertoli-Leydig cell tumour (Correct Answer)
D. Adrenocortical carcinoma
E. Thecoma
Explanation: ***Sertoli-Leydig cell tumour***
- The rapid onset (8 months) of **virilizing symptoms** (hirsutism, acne, voice deepening, clitoromegaly) in a 55-year-old woman, along with a **palpable, enlarged, firm left ovary**, is highly suggestive of an androgen-producing ovarian tumor, with Sertoli-Leydig cell tumor being a classic cause.
- These tumors are known for producing significant amounts of **androgens**, leading to prominent and relatively rapid signs of **virilization and defeminization**.
*Polycystic ovarian syndrome (PCOS)*
- While PCOS causes hirsutism and acne, it typically presents in **younger women** (reproductive age) and symptoms develop **gradually** rather than rapidly.
- PCOS is associated with **bilateral polycystic ovaries** and hormonal imbalances, but usually does not cause such marked **virilization** or **clitoromegaly** as seen here, nor a firm enlarged ovary.
*Granulosa cell tumour*
- Granulosa cell tumors are **estrogen-producing** ovarian tumors, which would cause **feminizing effects** (e.g., endometrial hyperplasia, breast tenderness) rather than virilizing symptoms.
- They are typically associated with **postmenopausal bleeding** due to estrogenic stimulation.
*Adrenocortical carcinoma*
- An adrenocortical carcinoma could cause virilization, but the physical exam points to an **ovarian mass (firm, enlarged left ovary)**.
- While necessary to rule out, the primary presentation with a palpable ovarian mass makes an ovarian source more likely initially.
*Thecoma*
- Thecomas are primarily **estrogen-producing** ovarian tumors, similar to granulosa cell tumors, leading to **feminizing symptoms**.
- They do not typically cause the **virilization** and **clitoromegaly** described in this patient.
Question 247: A 16-year-old girl is brought to the physician by her mother because she has not had her menstrual period yet. At birth, she was found to have partial labial fusion and clitoromegaly. The mother reports that during the pregnancy she had noticed abnormal hair growth on her chin. The girl has severe acne. Three years ago, she broke her wrist after a minor trauma. Last year, she sustained a spinal compression fracture after lifting a box during a move. She currently takes oral isotretinoin and an oral contraceptive. The patient is at the 97th percentile for height and 50th percentile for weight. Physical examination shows numerous inflamed pustules on her face and upper back. Breast development is at Tanner stage I. The patient refuses to have a pelvic examination. A pelvic ultrasound shows ovaries with multiple cysts and a normal uterus. Which of the following is the most likely diagnosis?
A. Polycystic ovary syndrome
B. Turner syndrome
C. Congenital adrenal hyperplasia
D. Aromatase deficiency (Correct Answer)
E. Hyperprolactinemia
Explanation: ***Aromatase deficiency***
- Aromatase deficiency presents with **undervirilized female external genitalia** at birth due to impaired estrogen synthesis, leading to **ambiguous genitalia** (partial labial fusion and clitoromegaly) in 46,XX individuals, which describes the patient's birth findings.
- The patient's **primary amenorrhea**, **acne**, advanced bone age (suggested by fractures from minor trauma), **high height percentile**, and **low or absent breast development (Tanner stage I)** are all consistent with a lack of estrogenization and excess androgen effects due to impaired conversion of androgens to estrogens.
*Polycystic ovary syndrome*
- While **PCOS** can cause hirsutism, acne, and menstrual irregularities, it typically presents after puberty with **normal external genitalia at birth** and often **obesity**, which contrasts with this patient's birth findings and current high height percentile with only average weight.
- PCOS is associated with **insulin resistance** and usually presents with secondary amenorrhea or oligomenorrhea, not primary amenorrhea in a patient with severe virilization signs from birth.
*Turner syndrome*
- **Turner syndrome** (45,XO) is characterized by **gonadal dysgenesis**, leading to **primary amenorrhea** and **lack of breast development**, but it presents with a distinctive phenotype including short stature, webbed neck, and **normal female external genitalia** at birth, and does not involve virilization or clitoromegaly.
- Patients with Turner syndrome typically have **short stature** and a lack of secondary sexual characteristics, which is inconsistent with this patient's 97th percentile for height and signs of androgen excess.
*Congenital adrenal hyperplasia*
- **CAH**, particularly 21-hydroxylase deficiency, causes **virilization** in 46,XX individuals with **clitoromegaly** and labial fusion at birth, and pubertal development issues. However, untreated CAH typically results in **short stature** due to premature epiphyseal fusion from excessive androgens and often presents with salt-wasting crises, neither of which are described here.
- The patient's **tall stature** (97th percentile for height) makes CAH less likely, as CAH typically leads to advanced bone age and short adult stature.
*Hyperprolactinemia*
- **Hyperprolactinemia** causes **amenorrhea** and can lead to absent or delayed puberty, but it does **not cause virilization** (clitoromegaly, acne) or ambiguous genitalia at birth.
- It is often associated with galactorrhea, which is not mentioned in this case, and does not explain the patient's birth findings.
Question 248: A 15-year-old girl comes to the physician because of a 2-year history of irregular menstrual bleeding. Menses have occurred at irregular 45- to 60-day intervals since menarche at the age of 13 years. Her last menstrual period was 5 weeks ago and lasted for 7 days with heavy flow and no cramping. She is not sexually active. She is 171 cm (5 ft 7 in) tall and weighs 58 kg (128 lb); BMI is 20 kg/m2. Her temperature is 36.6°C (97.8°F), pulse is 80/min, and blood pressure is 110/60 mm Hg. Pelvic examination shows a normal-appearing vagina and cervix. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses. The remainder of the physical examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most likely explanation for this patient's symptoms?
A. Endometriosis
B. Polycystic ovary syndrome
C. Pituitary adenoma
D. Anovulation (Correct Answer)
E. Ovarian insufficiency
Explanation: ***Anovulation***
- Irregular menses, especially in the context of adolescence, are commonly due to **immature hypothalamic-pituitary-ovarian axis**, leading to anovulatory cycles.
- In anovulatory bleeding, the **endometrium proliferates unopposed by progesterone**, leading to irregular shedding and heavy flow.
*Endometriosis*
- Characterized by **pelvic pain** and **dysmenorrhea**, which are absent in this patient.
- Endometriosis typically causes dysfunctional uterine bleeding rather than irregular menses starting at menarche.
*Polycystic ovary syndrome*
- Often presents with **hirsutism**, **acne**, and/or **obesity**, none of which are noted in this patient.
- While it causes irregular menses due to anovulation, the absence of other classic symptoms makes it less likely given the age and presentation.
*Pituitary adenoma*
- Can cause irregular menses via **hyperprolactinemia**, but this would typically present with **galactorrhea** or **visual field defects**, which are not mentioned.
- The patient's otherwise normal examination and lack of symptoms of mass effect or hormonal excess make a pituitary adenoma unlikely.
*Ovarian insufficiency*
- Implies premature ovarian failure, which is rare at this age and would typically present with symptoms of **estrogen deficiency**, like hot flashes, and ultimately **amenorrhea**.
- Ovarian insufficiency is characterized by **elevated gonadotropin levels**, which are not indicated by the patient's presentation.
Question 249: A 41-year-old nulliparous woman comes to the physician for an annual pelvic examination and Pap smear. Over the past year she has been feeling healthy. She is sexually active and uses an intrauterine device with copper for contraception. She has smoked one pack of cigarettes daily for 20 years. She is 160 cm (5 ft 3 in) tall and weighs 88 kg (194 lb); BMI is 34.4 kg/m2. Bimanual pelvic examination shows an irregularly enlarged uterus. A transvaginal ultrasound reveals a singular 4 cm, hypoechoic mass inside the myometrial wall. Which of the following is the most likely cause of this finding?
A. Uterine leiomyosarcoma
B. Endometrial hyperplasia
C. Endometrial cancer
D. Leiomyoma (Correct Answer)
E. Endometrial polyp
Explanation: ***Leiomyoma***
- The patient's presentation with an **irregularly enlarged uterus** and a **singular 4 cm, hypoechoic mass within the myometrial wall** is highly characteristic of a leiomyoma (fibroid).
- Her risk factors, including nulliparity, obesity (BMI 34.4), and age (41 years old), are consistent with leiomyoma development.
*Uterine leiomyosarcoma*
- While leiomyosarcomas can present as a uterine mass, they are generally rare and grow rapidly, often causing symptoms beyond just an irregularly enlarged uterus.
- Ultrasound findings of leiomyosarcomas are typically less well-defined, heterogeneous, and may show signs of rapid growth and necrosis, which are not described here.
*Endometrial hyperplasia*
- This condition involves thickening of the **endometrial lining** and is usually diagnosed due to abnormal uterine bleeding, not as a discrete myometrial mass.
- Ultrasound would show a thickened endometrium, not a singular mass within the myometrial wall.
*Endometrial cancer*
- Endometrial cancer usually presents with **postmenopausal bleeding** or abnormal uterine bleeding and appears as a thickened, heterogeneous endometrium on ultrasound, not a distinct myometrial mass.
- While her obesity is a risk factor, the ultrasound findings specifically point towards a myometrial lesion.
*Endometrial polyp*
- An endometrial polyp is a projection from the **endometrial surface** into the uterine cavity, often causing intermenstrual bleeding or heavier periods.
- It would be seen as an intracavitary lesion, distinct from a mass within the myometrial wall.
Question 250: A 43-year-old woman presents to her primary care physician for a general wellness appointment. The patient states that sometimes she has headaches and is ashamed of her body habitus. Otherwise, the patient has no complaints. The patient's 90-year-old mother recently died of breast cancer. The patient smokes 1 pack of cigarettes per day. She drinks 2-3 glasses of red wine per day with dinner. She has been considering having a child as she has just been promoted to a position that gives her more time off and a greater income. The patient's current medications include lisinopril, metformin, and a progesterone intrauterine device (IUD). On physical exam, you note a normal S1 and S2 heart sound. Pulmonary exam is clear to auscultation bilaterally. The patient's abdominal, musculoskeletal, and neurological exams are within normal limits. The patient is concerned about her risk for breast cancer and asks what she can do to reduce her chance of getting this disease. Which of the following is the best recommendation for this patient?
A. Recommend monthly self breast exams
B. Begin breastfeeding
C. Switch to oral contraceptive pills for contraception
D. Exercise and reduce alcohol intake (Correct Answer)
E. Test for BRCA1 and 2
Explanation: ***Exercise and reduce alcohol intake***
- **Regular exercise** and **reduced alcohol consumption** are modifiable lifestyle factors that can significantly lower the risk of breast cancer. This addresses the patient's concern about risk reduction.
- The patient's current daily alcohol intake of 2-3 glasses of wine is considered a **risk factor** for breast cancer, making reduction a crucial recommendation.
*Recommend monthly self breast exams*
- While awareness is important, **monthly self-breast exams (SBEs)** have not been shown to reduce breast cancer mortality and are generally not recommended as a primary screening tool.
- Current guidelines emphasize **clinical breast exams** and **mammography** for screening, not SBEs alone.
*Begin breastfeeding*
- **Breastfeeding** is known to modestly reduce the risk of breast cancer, but it is not currently an option for this patient as she has not had children yet.
- This recommendation is premature and not directly applicable to her current situation for breast cancer prevention.
*Switch to oral contraceptive pills for contraception*
- Some **oral contraceptive pills (OCPs)**, particularly combined estrogen-progestin OCPs, are associated with a *slightly increased risk* of breast cancer, especially with prolonged use.
- Given her concerns about breast cancer risk and the presence of a progesterone IUD (which has a lower impact on breast cancer risk than OCPs), switching to OCPs would not be a beneficial preventative measure.
*Test for BRCA1 and 2*
- While the patient's mother had breast cancer, the mother was 90 years old, suggesting a later-onset cancer rather than a strong indicator for **hereditary breast cancer syndromes** like BRCA1/2 directly linked to younger-onset or multiple family members.
- Genetic testing for BRCA1/2 is typically recommended for individuals with a stronger family history, such as multiple first-degree relatives with early-onset breast cancer or ovarian cancer, which is not clearly described here.
