A 32-year-old woman visits her family physician for a routine health check-up. During the consult, she complains about recent-onset constipation, painful defecation, and occasional pain with micturition for the past few months. Her menstrual cycles have always been regular with moderate pelvic pain during menses, which is relieved with pain medication. However, in the last 6 months, she has noticed that her menses are “heavier” with severe lower abdominal cramps that linger for 4–5 days after the last day of menstruation. She and her husband are trying to conceive a second child, but lately, she has been unable to have sexual intercourse due to pain during sexual intercourse. During the physical examination, she has tenderness in the lower abdomen with no palpable mass. Pelvic examination reveals a left-deviated tender cervix, a tender retroverted uterus, and a left adnexal mass. During the rectovaginal examination, nodules are noted. What is the most likely diagnosis for this patient?
AEndometriosis
BOvarian cyst
CPelvic inflammatory disease (PID)
DDiverticulitis
EIrritable bowel syndrome (IBS)
A 31-year-old female presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to the three months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are currently trying to have children. What is the next best step?
AStart progestin-only therapy
BPartial, cervix-sparing hysterectomy
CObservation with annual endometrial biopsies
DStart combination estrogen and progestin therapy
ETotal abdominal hysterectomy with bilateral salpingo-oophorectomy
A 19-year-old woman presents to her gynecologist for evaluation of amenorrhea and occasional dull right-sided lower abdominal pain that radiates to the rectum. She had menarche at 11 years of age and had regular 28-day cycles by 13 years of age. She developed menstrual cycle irregularity approximately 2 years ago and has not had a menses for 6 months. She is not sexually active. She does not take any medications. Her weight is 94 kg (207.2 lb) and her height is 166 cm (5.4 ft). Her vital signs are within normal limits. The physical examination shows a normal hair growth pattern. No hair loss or acne are noted. There is black discoloration of the skin in the axillae and posterior neck. Palpation of the abdomen reveals slight tenderness in the right lower quadrant, but no masses are appreciated. The gynecologic examination reveals no abnormalities. The hymen is intact. The rectal examination reveals a non-tender, mobile, right-sided adnexal mass. Which of the following management plans would be best for this patient?
APelvic MRI should be the first-line imaging since both transvaginal and transabdominal ultrasound are inappropriate for this virginal, obese patient
BClinical examination is sufficient for diagnosis since the adnexal mass was clearly palpable on rectal examination, making imaging unnecessary
CTransabdominal ultrasound is the appropriate first-line imaging for this virginal patient, despite reduced sensitivity due to her obesity, as transvaginal ultrasound would be inappropriate given her intact hymen
DThe patient's obesity will not significantly affect transabdominal ultrasound quality, so transvaginal ultrasound is unnecessary even though she is virginal
ETransvaginal ultrasound should be performed first as it provides superior resolution for adnexal masses, regardless of the patient's sexual history or hymenal status
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