Gyneco(301-350)

A 24-year-old nulligravida woman comes to your office with an 18-month history of cyclic, debilitating pelvic pain related to menses. Her menses is regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normalsized, immobile, retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments.Which of the following studies would establish a diagnosis in this condition?

A 24-year-old nulligravida woman comes to your office with an 18-month history of cyclic, debilitating pelvic pain related to menses. Her menses is regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normalsized, immobile, retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments.Which of the following is not an appropriate medical therapy for this condition?

A 24-year-old nulligravida woman comes to your office with an 18-month history of cyclic, debilitating pelvic pain related to menses. Her menses is regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normalsized, immobile, retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments.Which of the following is least consistent with secondary dysmenorrhea?

A 24-year-old nulligravida woman comes to your office with an 18-month history of cyclic, debilitating pelvic pain related to menses. Her menses is regular and heavy, requiring 10 to 15 thick pads on the days of heaviest flow. She denies ever being diagnosed with a sexually transmitted infection (STI). She and her husband have been engaging in regular intercourse without contraception for 1 year in an attempt to conceive. On pelvic examination, you find a normalsized, immobile, retroverted uterus with nodularity and tenderness on palpation of the uterosacral ligaments.Other causes of secondary dysmenorrhea include all of the following except

A 35-year-old female presents to your office with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip 2 months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse. She denies any vaginal discharge or any other symptoms. She is a nonsmoker. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of sexually transmitted infections (STIs). On physical examination, her blood pressure is 120/80 mmHg and her body mass index (BMI) is 32. Her physical examination is normal, including pelvic exam.The patient’s bleeding pattern is best described as

A 35-year-old female presents to your office with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip 2 months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse. She denies any vaginal discharge or any other symptoms. She is a nonsmoker. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of sexually transmitted infections (STIs). On physical examination, her blood pressure is 120/80 mmHg and her body mass index (BMI) is 32. Her physical examination is normal, including pelvic exam.Which of the following should initially be considered in the differential diagnosis of this patient’s problem?

A 35-year-old female presents to your office with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip 2 months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse. She denies any vaginal discharge or any other symptoms. She is a nonsmoker. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of sexually transmitted infections (STIs). On physical examination, her blood pressure is 120/80 mmHg and her body mass index (BMI) is 32. Her physical examination is normal, including pelvic exam.Which of the following tests is not appropriate for the initial workup of this patient?

A 35-year-old female presents to your office with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip 2 months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse. She denies any vaginal discharge or any other symptoms. She is a nonsmoker. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of sexually transmitted infections (STIs). On physical examination, her blood pressure is 120/80 mmHg and her body mass index (BMI) is 32. Her physical examination is normal, including pelvic exam.The most likely diagnosis is

A 35-year-old female presents to your office with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip 2 months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse. She denies any vaginal discharge or any other symptoms. She is a nonsmoker. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of sexually transmitted infections (STIs). On physical examination, her blood pressure is 120/80 mmHg and her body mass index (BMI) is 32. Her physical examination is normal, including pelvic exam.What is the most likely underlying mechanism for this patient’s abnormal bleeding?

A 35-year-old female presents to your office with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip 2 months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse. She denies any vaginal discharge or any other symptoms. She is a nonsmoker. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of sexually transmitted infections (STIs). On physical examination, her blood pressure is 120/80 mmHg and her body mass index (BMI) is 32. Her physical examination is normal, including pelvic exam.Your patient returns to discuss test results. Her hemoglobin is 10.8 g/dL. She does not desire future fertility and has no method of birth control at this time. Which of the following therapies would not be an appropriate medical management option for this patient?

A 25-year-old female (gravida 0, para 0) presents to your office complaining of not having her period for the past 6 months. She previously had regular cycles since menarche at age 13 years. Her blood pressure is 100/70 mmHg, and her BMI is 19. Her physical exam is unremarkable, including pelvic exam. She has normal secondary sexual development. Upon further questioning, she reveals that she has been training for a marathon and has lost approximately 10 pounds in the past 2 months. She does not have an eating disorder. She is currently sexually active with one partner and desires contraception.Which of the following best describes this patient’s bleeding pattern?

A 25-year-old female (gravida 0, para 0) presents to your office complaining of not having her period for the past 6 months. She previously had regular cycles since menarche at age 13 years. Her blood pressure is 100/70 mmHg, and her BMI is 19. Her physical exam is unremarkable, including pelvic exam. She has normal secondary sexual development. Upon further questioning, she reveals that she has been training for a marathon and has lost approximately 10 pounds in the past 2 months. She does not have an eating disorder. She is currently sexually active with one partner and desires contraception.Which of the following would be the least likely cause for this patient’s bleeding pattern?

A 25-year-old female (gravida 0, para 0) presents to your office complaining of not having her period for the past 6 months. She previously had regular cycles since menarche at age 13 years. Her blood pressure is 100/70 mmHg, and her BMI is 19. Her physical exam is unremarkable, including pelvic exam. She has normal secondary sexual development. Upon further questioning, she reveals that she has been training for a marathon and has lost approximately 10 pounds in the past 2 months. She does not have an eating disorder. She is currently sexually active with one partner and desires contraception.What is the most appropriate initial step in the evaluation of this patient’s condition?

A 25-year-old female (gravida 0, para 0) presents to your office complaining of not having her period for the past 6 months. She previously had regular cycles since menarche at age 13 years. Her blood pressure is 100/70 mmHg, and her BMI is 19. Her physical exam is unremarkable, including pelvic exam. She has normal secondary sexual development. Upon further questioning, she reveals that she has been training for a marathon and has lost approximately 10 pounds in the past 2 months. She does not have an eating disorder. She is currently sexually active with one partner and desires contraception.The patient’s laboratory studies come back normal. She had a positive response to a progestin challenge. At this time, what would be the most beneficial medical therapy for this patient?

A 55-year-old postmenopausal woman with a history of type II diabetes presents to your office for her annual gynecological exam. She experienced menopause approximately 3 years ago. She mentions to you that she has had recurrent episodes of irregular “menstrual-like” vaginal bleeding, occurring every 4 to 8 weeks, for the past 6 months. She describes the bleeding as lasting from 1 to 7 days, requiring one to five pads a day. The patient has never been on hormone therapy (HT). She complains of some fatigue but is otherwise feeling well. Her Pap smears have always been normal. Sexual history is significant for a new sexual partner for the past 6 months. Her blood pressure is 130/80 mmHg and her BMI is 42. The rest of her physical exam, including pelvic, is normal.You perform a Pap smear and a gonorrhea/chlamydia screen. You also check a CBC and TSH. What else do you recommend to the patient at this time?

A 55-year-old postmenopausal woman with a history of type II diabetes presents to your office for her annual gynecological exam. She experienced menopause approximately 3 years ago. She mentions to you that she has had recurrent episodes of irregular “menstrual-like” vaginal bleeding, occurring every 4 to 8 weeks, for the past 6 months. She describes the bleeding as lasting from 1 to 7 days, requiring one to five pads a day. The patient has never been on hormone therapy (HT). She complains of some fatigue but is otherwise feeling well. Her Pap smears have always been normal. Sexual history is significant for a new sexual partner for the past 6 months. Her blood pressure is 130/80 mmHg and her BMI is 42. The rest of her physical exam, including pelvic, is normal.A transvaginal ultrasound is performed and is read as “no structural abnormalities, normal sized uterus and ovaries, 7 mm endometrial stripe noted.” What should be the next step in this patient’s management?

A 27-year-old nulligravida female presents to your office for routine exam. Upon gynecological history, you discover that she has a 5-year history of oligomenorrhea, with only approximately two or three menses a year. She denies intercycle spotting or premenstrual symptoms. Her last menses was 3 months ago. Her blood pressure is 120/75 mmHg and her BMI is 34. Her physical exam reveals a moderate amount of facial hair and facial acne. Her pelvic examination is unremarkable.What condition do you suspect in this patient?

A 27-year-old nulligravida female presents to your office for routine exam. Upon gynecological history, you discover that she has a 5-year history of oligomenorrhea, with only approximately two or three menses a year. She denies intercycle spotting or premenstrual symptoms. Her last menses was 3 months ago. Her blood pressure is 120/75 mmHg and her BMI is 34. Her physical exam reveals a moderate amount of facial hair and facial acne. Her pelvic examination is unremarkable.All of the following laboratory studies are appropriate for initial evaluation except

A 27-year-old nulligravida female presents to your office for routine exam. Upon gynecological history, you discover that she has a 5-year history of oligomenorrhea, with only approximately two or three menses a year. She denies intercycle spotting or premenstrual symptoms. Her last menses was 3 months ago. Her blood pressure is 120/75 mmHg and her BMI is 34. Her physical exam reveals a moderate amount of facial hair and facial acne. Her pelvic examination is unremarkable.The patient returns after 2 weeks to discuss her blood test results. Her pregnancy test is negative and her prolactin, TSH, and 17-hydroxyprogesterone levels are normal. Her LH: FSH ratio is 4:1, and her testosterone level is mildly elevated. Which of the following treatment options has (have) been found to be beneficial in the treatment of PCOS?

A 37-year-old G1P1001 female comes to your office with a 3-day history of progressive pelvic pain. She notes some vaginal spotting but no frank bleeding. She denies any fevers, chills, diarrhea, vaginal discharge, or urinary symptoms. Her last menstrual period was 6 weeks ago. She is married and has been trying to conceive for the past 6 months. She and her husband have one child already, a result of in vitro fertilization (IVF). She is afebrile, and her pulse and blood pressure are normal. On speculum examination, her os appears closed and there is a small amount of dark brownish-red blood pooled in the fornix. There is no mucopurulent discharge or cervical motion tenderness. On bimanual examination, her uterus feels slightly enlarged and boggy, and the left adnexa is tender without any obvious mass. A wet prep is normal except for many red blood cells.Which of the following is the most likely diagnosis?

A 37-year-old G1P1001 female comes to your office with a 3-day history of progressive pelvic pain. She notes some vaginal spotting but no frank bleeding. She denies any fevers, chills, diarrhea, vaginal discharge, or urinary symptoms. Her last menstrual period was 6 weeks ago. She is married and has been trying to conceive for the past 6 months. She and her husband have one child already, a result of in vitro fertilization (IVF). She is afebrile, and her pulse and blood pressure are normal. On speculum examination, her os appears closed and there is a small amount of dark brownish-red blood pooled in the fornix. There is no mucopurulent discharge or cervical motion tenderness. On bimanual examination, her uterus feels slightly enlarged and boggy, and the left adnexa is tender without any obvious mass. A wet prep is normal except for many red blood cells.What is the most appropriate initial test that should be performed to support your diagnosis?

A 37-year-old G1P1001 female comes to your office with a 3-day history of progressive pelvic pain. She notes some vaginal spotting but no frank bleeding. She denies any fevers, chills, diarrhea, vaginal discharge, or urinary symptoms. Her last menstrual period was 6 weeks ago. She is married and has been trying to conceive for the past 6 months. She and her husband have one child already, a result of in vitro fertilization (IVF). She is afebrile, and her pulse and blood pressure are normal. On speculum examination, her os appears closed and there is a small amount of dark brownish-red blood pooled in the fornix. There is no mucopurulent discharge or cervical motion tenderness. On bimanual examination, her uterus feels slightly enlarged and boggy, and the left adnexa is tender without any obvious mass. A wet prep is normal except for many red blood cells.A Serum-hCG is ordered and is reported soon thereafter to be 5000 mIU/mL. Based on this level of serum -hCG, you would expect which of the following?

A 37-year-old G1P1001 female comes to your office with a 3-day history of progressive pelvic pain. She notes some vaginal spotting but no frank bleeding. She denies any fevers, chills, diarrhea, vaginal discharge, or urinary symptoms. Her last menstrual period was 6 weeks ago. She is married and has been trying to conceive for the past 6 months. She and her husband have one child already, a result of in vitro fertilization (IVF). She is afebrile, and her pulse and blood pressure are normal. On speculum examination, her os appears closed and there is a small amount of dark brownish-red blood pooled in the fornix. There is no mucopurulent discharge or cervical motion tenderness. On bimanual examination, her uterus feels slightly enlarged and boggy, and the left adnexa is tender without any obvious mass. A wet prep is normal except for many red blood cells.In which anatomic site do most ectopic pregnancies occur?

A 37-year-old G1P1001 female comes to your office with a 3-day history of progressive pelvic pain. She notes some vaginal spotting but no frank bleeding. She denies any fevers, chills, diarrhea, vaginal discharge, or urinary symptoms. Her last menstrual period was 6 weeks ago. She is married and has been trying to conceive for the past 6 months. She and her husband have one child already, a result of in vitro fertilization (IVF). She is afebrile, and her pulse and blood pressure are normal. On speculum examination, her os appears closed and there is a small amount of dark brownish-red blood pooled in the fornix. There is no mucopurulent discharge or cervical motion tenderness. On bimanual examination, her uterus feels slightly enlarged and boggy, and the left adnexa is tender without any obvious mass. A wet prep is normal except for many red blood cells.A transvaginal ultrasound reveals a mass in the adnexal and no evidence of an intrauterine pregnancy. Which of the following medical treatments is appropriate for this condition?

A 37-year-old G1P1001 female comes to your office with a 3-day history of progressive pelvic pain. She notes some vaginal spotting but no frank bleeding. She denies any fevers, chills, diarrhea, vaginal discharge, or urinary symptoms. Her last menstrual period was 6 weeks ago. She is married and has been trying to conceive for the past 6 months. She and her husband have one child already, a result of in vitro fertilization (IVF). She is afebrile, and her pulse and blood pressure are normal. On speculum examination, her os appears closed and there is a small amount of dark brownish-red blood pooled in the fornix. There is no mucopurulent discharge or cervical motion tenderness. On bimanual examination, her uterus feels slightly enlarged and boggy, and the left adnexa is tender without any obvious mass. A wet prep is normal except for many red blood cells.Which of the following situations could explain a s-hCG titer below the “discriminatory threshold” and an absence of an intrauterine gestational sac on ultrasound?

A 37-year-old G1P1001 female comes to your office with a 3-day history of progressive pelvic pain. She notes some vaginal spotting but no frank bleeding. She denies any fevers, chills, diarrhea, vaginal discharge, or urinary symptoms. Her last menstrual period was 6 weeks ago. She is married and has been trying to conceive for the past 6 months. She and her husband have one child already, a result of in vitro fertilization (IVF). She is afebrile, and her pulse and blood pressure are normal. On speculum examination, her os appears closed and there is a small amount of dark brownish-red blood pooled in the fornix. There is no mucopurulent discharge or cervical motion tenderness. On bimanual examination, her uterus feels slightly enlarged and boggy, and the left adnexa is tender without any obvious mass. A wet prep is normal except for many red blood cells.Which of the following statements is true regarding the clinical presentation of ectopic pregnancy?

A 37-year-old G1P1001 female comes to your office with a 3-day history of progressive pelvic pain. She notes some vaginal spotting but no frank bleeding. She denies any fevers, chills, diarrhea, vaginal discharge, or urinary symptoms. Her last menstrual period was 6 weeks ago. She is married and has been trying to conceive for the past 6 months. She and her husband have one child already, a result of in vitro fertilization (IVF). She is afebrile, and her pulse and blood pressure are normal. On speculum examination, her os appears closed and there is a small amount of dark brownish-red blood pooled in the fornix. There is no mucopurulent discharge or cervical motion tenderness. On bimanual examination, her uterus feels slightly enlarged and boggy, and the left adnexa is tender without any obvious mass. A wet prep is normal except for many red blood cells.Major complications of ectopic pregnancy include which of the following?

A 23-year-old healthy, nulliparous female comes to your office for her annual physical and Papanicolaou (Pap) test. Her last menstrual period was 7 days ago. She has been on oral contraceptive pills (OCPs) for several years and tells you that she stopped taking them recently to “give her body a break.” She heard from friends and relatives that using OCPs for a long time increases the risk of future health problems, including infertility. She is currently sexually active with one male partner for the past 6 months. They use condoms and withdrawal inconsistently. The patient reports a history of chlamydia several years ago for which she and her partner were treated. She does not want to be pregnant anytime in the near future. She smokes a pack of cigarettes a day. On examination, her blood pressure is 120/80 mmHg, her weight is 200 pounds, and she is 5 feet 5 inches tall (body mass index is 33). The rest of her examination is unremarkable except for some mild facial acne. You perform a pelvic examination, a Pap test, and gonorrhea and chlamydia cultures.What would you tell your patient regarding the use of the “withdrawal method?”

A 23-year-old healthy, nulliparous female comes to your office for her annual physical and Papanicolaou (Pap) test. Her last menstrual period was 7 days ago. She has been on oral contraceptive pills (OCPs) for several years and tells you that she stopped taking them recently to “give her body a break.” She heard from friends and relatives that using OCPs for a long time increases the risk of future health problems, including infertility. She is currently sexually active with one male partner for the past 6 months. They use condoms and withdrawal inconsistently. The patient reports a history of chlamydia several years ago for which she and her partner were treated. She does not want to be pregnant anytime in the near future. She smokes a pack of cigarettes a day. On examination, her blood pressure is 120/80 mmHg, her weight is 200 pounds, and she is 5 feet 5 inches tall (body mass index is 33). The rest of her examination is unremarkable except for some mild facial acne. You perform a pelvic examination, a Pap test, and gonorrhea and chlamydia cultures.Which of the following statements is true regarding the use of any estrogen-containing hormonal contraceptive method for this patient?

A 23-year-old healthy, nulliparous female comes to your office for her annual physical and Papanicolaou (Pap) test. Her last menstrual period was 7 days ago. She has been on oral contraceptive pills (OCPs) for several years and tells you that she stopped taking them recently to “give her body a break.” She heard from friends and relatives that using OCPs for a long time increases the risk of future health problems, including infertility. She is currently sexually active with one male partner for the past 6 months. They use condoms and withdrawal inconsistently. The patient reports a history of chlamydia several years ago for which she and her partner were treated. She does not want to be pregnant anytime in the near future. She smokes a pack of cigarettes a day. On examination, her blood pressure is 120/80 mmHg, her weight is 200 pounds, and she is 5 feet 5 inches tall (body mass index is 33). The rest of her examination is unremarkable except for some mild facial acne. You perform a pelvic examination, a Pap test, and gonorrhea and chlamydia cultures.You counsel the patient about her contraceptive options. All of the following are true except

A 23-year-old healthy, nulliparous female comes to your office for her annual physical and Papanicolaou (Pap) test. Her last menstrual period was 7 days ago. She has been on oral contraceptive pills (OCPs) for several years and tells you that she stopped taking them recently to “give her body a break.” She heard from friends and relatives that using OCPs for a long time increases the risk of future health problems, including infertility. She is currently sexually active with one male partner for the past 6 months. They use condoms and withdrawal inconsistently. The patient reports a history of chlamydia several years ago for which she and her partner were treated. She does not want to be pregnant anytime in the near future. She smokes a pack of cigarettes a day. On examination, her blood pressure is 120/80 mmHg, her weight is 200 pounds, and she is 5 feet 5 inches tall (body mass index is 33). The rest of her examination is unremarkable except for some mild facial acne. You perform a pelvic examination, a Pap test, and gonorrhea and chlamydia cultures.Your patient decides that she wants to restart combined oral contraceptives (COCs) since she has used the pills in the past and would like to have regular and predictable menstrual cycles. Which option would not be ideal for this patient?

A 23-year-old healthy, nulliparous female comes to your office for her annual physical and Papanicolaou (Pap) test. Her last menstrual period was 7 days ago. She has been on oral contraceptive pills (OCPs) for several years and tells you that she stopped taking them recently to “give her body a break.” She heard from friends and relatives that using OCPs for a long time increases the risk of future health problems, including infertility. She is currently sexually active with one male partner for the past 6 months. They use condoms and withdrawal inconsistently. The patient reports a history of chlamydia several years ago for which she and her partner were treated. She does not want to be pregnant anytime in the near future. She smokes a pack of cigarettes a day. On examination, her blood pressure is 120/80 mmHg, her weight is 200 pounds, and she is 5 feet 5 inches tall (body mass index is 33). The rest of her examination is unremarkable except for some mild facial acne. You perform a pelvic examination, a Pap test, and gonorrhea and chlamydia cultures.You counsel your patient about starting COCs. Which of the following statements regarding COC initiation in this patient is true?

A 23-year-old healthy, nulliparous female comes to your office for her annual physical and Papanicolaou (Pap) test. Her last menstrual period was 7 days ago. She has been on oral contraceptive pills (OCPs) for several years and tells you that she stopped taking them recently to “give her body a break.” She heard from friends and relatives that using OCPs for a long time increases the risk of future health problems, including infertility. She is currently sexually active with one male partner for the past 6 months. They use condoms and withdrawal inconsistently. The patient reports a history of chlamydia several years ago for which she and her partner were treated. She does not want to be pregnant anytime in the near future. She smokes a pack of cigarettes a day. On examination, her blood pressure is 120/80 mmHg, her weight is 200 pounds, and she is 5 feet 5 inches tall (body mass index is 33). The rest of her examination is unremarkable except for some mild facial acne. You perform a pelvic examination, a Pap test, and gonorrhea and chlamydia cultures.Which of the following statements regarding long-term COC use is true?

A 23-year-old healthy, nulliparous female comes to your office for her annual physical and Papanicolaou (Pap) test. Her last menstrual period was 7 days ago. She has been on oral contraceptive pills (OCPs) for several years and tells you that she stopped taking them recently to “give her body a break.” She heard from friends and relatives that using OCPs for a long time increases the risk of future health problems, including infertility. She is currently sexually active with one male partner for the past 6 months. They use condoms and withdrawal inconsistently. The patient reports a history of chlamydia several years ago for which she and her partner were treated. She does not want to be pregnant anytime in the near future. She smokes a pack of cigarettes a day. On examination, her blood pressure is 120/80 mmHg, her weight is 200 pounds, and she is 5 feet 5 inches tall (body mass index is 33). The rest of her examination is unremarkable except for some mild facial acne. You perform a pelvic examination, a Pap test, and gonorrhea and chlamydia cultures.All of the following conditions may be improved with the use of estrogen-containing hormonal contraceptives except

A 40-year-old female (gravida 2, para 2) comes to your office for her 6-week postpartum visit. She had an uncomplicated pregnancy, normal spontaneous vaginal delivery, and routine postpartum course. She and her baby are doing well. She has not gotten her period yet. She is breast-feeding and supplementing with formula intermittently. She does not want to get pregnant again, at least not for another few years. The patient has no major medical problems, does not smoke, and has already returned to her aerobics class. She has no history of STDs or abnormal Pap tests. She desires a reliable birth control method that she does not have to remember to take every day or remember to use every time she has sex with her husband. Her examination is completely normal.Of the following choices, which would be the most appropriate contraceptive method for this patient at this time?

A 40-year-old female (gravida 2, para 2) comes to your office for her 6-week postpartum visit. She had an uncomplicated pregnancy, normal spontaneous vaginal delivery, and routine postpartum course. She and her baby are doing well. She has not gotten her period yet. She is breast-feeding and supplementing with formula intermittently. She does not want to get pregnant again, at least not for another few years. The patient has no major medical problems, does not smoke, and has already returned to her aerobics class. She has no history of STDs or abnormal Pap tests. She desires a reliable birth control method that she does not have to remember to take every day or remember to use every time she has sex with her husband. Her examination is completely normal.All of the following would be appropriate management strategies except

A 40-year-old female (gravida 2, para 2) comes to your office for her 6-week postpartum visit. She had an uncomplicated pregnancy, normal spontaneous vaginal delivery, and routine postpartum course. She and her baby are doing well. She has not gotten her period yet. She is breast-feeding and supplementing with formula intermittently. She does not want to get pregnant again, at least not for another few years. The patient has no major medical problems, does not smoke, and has already returned to her aerobics class. She has no history of STDs or abnormal Pap tests. She desires a reliable birth control method that she does not have to remember to take every day or remember to use every time she has sex with her husband. Her examination is completely normal.Which of the following statements is true regarding the use of estrogen-containing hormonal contraceptives in this patient?

A 40-year-old female (gravida 2, para 2) comes to your office for her 6-week postpartum visit. She had an uncomplicated pregnancy, normal spontaneous vaginal delivery, and routine postpartum course. She and her baby are doing well. She has not gotten her period yet. She is breast-feeding and supplementing with formula intermittently. She does not want to get pregnant again, at least not for another few years. The patient has no major medical problems, does not smoke, and has already returned to her aerobics class. She has no history of STDs or abnormal Pap tests. She desires a reliable birth control method that she does not have to remember to take every day or remember to use every time she has sex with her husband. Her examination is completely normal.Which of the following statements is true regarding the use of Depo-Provera in this patient?

A 40-year-old female (gravida 2, para 2) comes to your office for her 6-week postpartum visit. She had an uncomplicated pregnancy, normal spontaneous vaginal delivery, and routine postpartum course. She and her baby are doing well. She has not gotten her period yet. She is breast-feeding and supplementing with formula intermittently. She does not want to get pregnant again, at least not for another few years. The patient has no major medical problems, does not smoke, and has already returned to her aerobics class. She has no history of STDs or abnormal Pap tests. She desires a reliable birth control method that she does not have to remember to take every day or remember to use every time she has sex with her husband. Her examination is completely normal.Which of the following statements is true regarding the use of a copper IUD (ParaGard T 380A) in this patient.

A 40-year-old female (gravida 2, para 2) comes to your office for her 6-week postpartum visit. She had an uncomplicated pregnancy, normal spontaneous vaginal delivery, and routine postpartum course. She and her baby are doing well. She has not gotten her period yet. She is breast-feeding and supplementing with formula intermittently. She does not want to get pregnant again, at least not for another few years. The patient has no major medical problems, does not smoke, and has already returned to her aerobics class. She has no history of STDs or abnormal Pap tests. She desires a reliable birth control method that she does not have to remember to take every day or remember to use every time she has sex with her husband. Her examination is completely normal.Your patient asks you about sterilization options in the future. Which of the following statements about vasectomies and tubal ligations is true?

A 34-year-old female who is a long-term patient of yours presents to the office for a routine blood pressure check. She was recently diagnosed with hypertension and diabetes. Her medications include metformin, hydrochlorothiazide, and a multivitamin. Her blood pressure today is 150/100 mmHg, and her body mass index is 30. She is currently sexually active with her husband, and they use the “rhythm” method only. She reports that her menses have been irregular and vary from 20 to 45 days apart. The patient is worried about the risks of hormonal contraception given her medical conditions. She does not want to be pregnant for several years.You advise her to do all the following except

A 34-year-old female who is a long-term patient of yours presents to the office for a routine blood pressure check. She was recently diagnosed with hypertension and diabetes. Her medications include metformin, hydrochlorothiazide, and a multivitamin. Her blood pressure today is 150/100 mmHg, and her body mass index is 30. She is currently sexually active with her husband, and they use the “rhythm” method only. She reports that her menses have been irregular and vary from 20 to 45 days apart. The patient is worried about the risks of hormonal contraception given her medical conditions. She does not want to be pregnant for several years.Which of the following statements about barrier methods is true?

A very tearful 21-year-old female (gravida 0, para 0) walks into your office on a Tuesday morning. She tells you that she had sexual intercourse with her boyfriend Friday night. They used a condom, but it broke. They previously had intercourse with a condom the week before. Her last menstrual period was approximately 3 weeks ago and was normal in flow and duration. She had been given a sample pack of Ortho-Tri-Cyclen during her initial gynecologic examination 2 weeks ago, but she did not have a chance to start them yet. She would be devastated ifshe got pregnant. She is a heavy smoker (two packs per day) but otherwise has no medical problems, denies bleeding or other symptoms, and her examination is normal. Her most recent Pap smear and gonococcus/chlamydia results were normal.Which of the following statements regarding the use of emergency contraceptive pills (ECPs) in this patient is true?

A very tearful 21-year-old female (gravida 0, para 0) walks into your office on a Tuesday morning. She tells you that she had sexual intercourse with her boyfriend Friday night. They used a condom, but it broke. They previously had intercourse with a condom the week before. Her last menstrual period was approximately 3 weeks ago and was normal in flow and duration. She had been given a sample pack of Ortho-Tri-Cyclen during her initial gynecologic examination 2 weeks ago, but she did not have a chance to start them yet. She would be devastated ifshe got pregnant. She is a heavy smoker (two packs per day) but otherwise has no medical problems, denies bleeding or other symptoms, and her examination is normal. Her most recent Pap smear and gonococcus/chlamydia results were normal.Which of the following best describes the effects of giving women advance supplies of ECPs?

You receive a call at 3 am from your prenatal patient who is worried about bleeding and cramping that began several hours ago. This is the fourth pregnancy for your patient, which was a planned pregnancy. She has had two uncomplicated, spontaneous vaginal deliveries and one elective abortion in the past. Her prenatal course to date has been uncomplicated. Two weeks ago, you obtained a first trimester ultrasound for dating purposes that revealed a 6-week intrauterine pregnancy. She denies any fever, nausea, vomiting, dizziness, lightheadedness, shortness of breath, or arm or chest pain. Her cramps are becoming more intense, but she is managing to control the pain with a heating pad. She reports using approximately three sanitary pads in the past 6 hours for bleeding, none of which were soaked through. The patient is home with her husband, who is a well-known patient of yours as well. They are very anxious and want to know what to do next.You advise your patient to

You receive a call at 3 am from your prenatal patient who is worried about bleeding and cramping that began several hours ago. This is the fourth pregnancy for your patient, which was a planned pregnancy. She has had two uncomplicated, spontaneous vaginal deliveries and one elective abortion in the past. Her prenatal course to date has been uncomplicated. Two weeks ago, you obtained a first trimester ultrasound for dating purposes that revealed a 6-week intrauterine pregnancy. She denies any fever, nausea, vomiting, dizziness, lightheadedness, shortness of breath, or arm or chest pain. Her cramps are becoming more intense, but she is managing to control the pain with a heating pad. She reports using approximately three sanitary pads in the past 6 hours for bleeding, none of which were soaked through. The patient is home with her husband, who is a well-known patient of yours as well. They are very anxious and want to know what to do next.She follows your advice. The next day you see the patient and her husband in your office. She appears tearful, though calm. Her temperature is 98.4°F, blood pressure is 120/80 mmHg, pulse is 80 beats/minute, and respiratory rate is 16 breaths/minute. She reports that since she spoke to you, she has passed a few dime-sized clots but no obvious tissue. She continues to have lower abdominal cramping. You perform a speculum exam, which reveals some blood in the vaginal vault and a small amount of tissue protruding from an open, dilated cervical os. A bimanual exam reveals a 6-week-size uterus with minimal tenderness but no peritoneal signs. The most likely diagnosis is

A 23-year-old female graduate student presents to the office for a “personal problem” as reported by your nurse. When you enter the room, she is noticeably tearful. She has regular menses, and her last menstrual period was approximately 6 weeks ago. Today, she denies fever, vaginal bleeding, and abdominal pain. You perform a high-sensitivity urine pregnancy test, which is positive. On examination, the uterus is approximately 6 weeks in size with no adnexal tenderness or masses. You tell the patient that she is approximately 6 weeks pregnant. The patient is quiet and will not make eye contact with you.Which the following is the most appropriate next step in management?

A 23-year-old female graduate student presents to the office for a “personal problem” as reported by your nurse. When you enter the room, she is noticeably tearful. She has regular menses, and her last menstrual period was approximately 6 weeks ago. Today, she denies fever, vaginal bleeding, and abdominal pain. You perform a high-sensitivity urine pregnancy test, which is positive. On examination, the uterus is approximately 6 weeks in size with no adnexal tenderness or masses. You tell the patient that she is approximately 6 weeks pregnant. The patient is quiet and will not make eye contact with you.The patient’s pregnancy options could include all the following except

A 24-year-old female comes to the emergency room with a 2-day history of lower abdominal pain, fever, chills, and malaise. The patient also complains of nausea and multiple episodes of vomiting in the past 24 hours. On physical examination, there is bilateral adnexal tenderness, muco-purulent cervical discharge, and cervical motion tenderness. The patient has a temperature of 40°C. Her last menstrual period was 4 weeks ago, and her pregnancy test is negative. She admits to being sexually active but denies a history of any sexually transmitted diseases (STDs). She is currently not using birth control.What is the most likely diagnosis in this patient?

A 24-year-old female comes to the emergency room with a 2-day history of lower abdominal pain, fever, chills, and malaise. The patient also complains of nausea and multiple episodes of vomiting in the past 24 hours. On physical examination, there is bilateral adnexal tenderness, muco-purulent cervical discharge, and cervical motion tenderness. The patient has a temperature of 40°C. Her last menstrual period was 4 weeks ago, and her pregnancy test is negative. She admits to being sexually active but denies a history of any sexually transmitted diseases (STDs). She is currently not using birth control. What is the most appropriate intervention for this patient?