NMS Q&A Family Medicine

Gynecology in Mature Adults 1357. The answer is B. Increased physical activity anddecreased calorie ingestion, that is, weight loss alone, willchange the physiology of PCOS in a significant number ofpatients. Decreased fat stores reduce androgen stores andhence conversion of androgen to estrone, allowingresumption of ovulation. Metformin is an excellent pharmacologicchoice as it reduces insulin resistance and aidsin weight loss. Metformin is virtually the first choice fordrug therapy if weight loss and exercise fail. Metforminfacilitates weight loss and may actually result in fertility.Menstrual regulation with cyclic contraceptive hormonaltreatment is another common approach and may lead toresumption of ovulation. Clomiphene should be usedonly in women who are anxious to become pregnant in ashort time. Epilation and electrolysis are secondaryoptions for treating the hirsutism directly without affectingthe underlying pathophysiology at any point.8. The answer is E. Multiparity is not a contraindicationfor insertion of an IUD. Nulliparity certainly is a relativecontraindication because it may be physically difficultand usually is very painful at the time of insertion andoften remains so until it is removed. Having a present orpast STD is a contraindication, unless a matter of 10 ormore years has passed. An intrauterine pregnancy willlikely be aborted by an IUD. Abortions of normal pregnancyconstitute malpractice unless the procedure is donespecifically for elective abortion. In the latter case, insertionof an IUD is not an approved procedure. Other contraindicationsinclude the presence of liver or breastcarcinoma or jaundice specific for hormone-containingIUDs; copper allergy or Wilson disease (specific for copper-containingIUDs); known or suspected pelvic malignancy;and immunodeficiency or immunosuppression.9. The answer is A. Alcohol drinking, though a risk fornumerous other health problems, is not statistically a riskfactor for dysmenorrhea. Each of the other choices isassociated with dysmenorrhea, although none is provento be a cause thereof. Obesity per se is not associated withdysmenorrhea but attempts to lose weight are so associated,perhaps because of the confounding issue of poorself-image, itself a risk factor. Nulliparity is well known tobe associated with primary dysmenorrhea. Primary dysmenorrheausually begins with the onset of ovulation,6 months to 2 years after the menarche, and decreaseswith age after 20 and with parity.10. The answer is D. Pyridoxine/doxylamine (Bendectin)or each one prescribed separately is known to safelyrelieve nausea and vomiting of pregnancy and is approvedfor that usage. In accord with such approval, its Strengthof Recommendation Taxonomy (SORT) classification isA, meaning evidence is case based and adequately studied.Although each of the other drugs mentioned is an antiemeticand utilized for nausea of pregnancy in practice,they are classified as unproven as to safety in pregnancyand not recommended during nursing. Prochlorperizineis classified as SORT C (i.e., usage is based on clinical custom,usual practice, expert opinion, etc.), as are promethazineand trimethobenzamide. Ondansetron is classifiedSORT B, based on case evidence but not such that rises tostatistical significance.11. The answer is A. Squamous cell carcinoma of the cervix,according to current data, is caused by a papillomavirus. All the other abnormalities, including undescendedtesticles, are associated with in utero exposure to DES,which was a common practice to prevent miscarriagebetween 1938 and 1971. In addition to those mentioned inwomen are other conditions including cockscomb cervix,cervical collar, cervical pseudopolyp, and vaginal adenosis.Not as well known among clinicians are the abnormalitiesof male genital development in DES progeny. These include,in addition to undescended testicles, epididymal cysts andsperm and semen abnormalities. There is a resurgence ofattention being paid to DES progeny because the femaleprogeny are now postmenopausal and perimenopausal, anepoch of increased susceptibility to the vagaries of hormonalshifts. Both male and female progeny of DES-treatedwomen should be conscientious regarding routine cancerscreening for breast, vaginal, and testicular neoplasms.12. The answer is E, Bartholin gland abscess. Herpessimplex produces a sharp, superficial pain aggravated bysheer force contact (i.e., skin or mucosa sliding over theinfected area) but not particularly sensitive to pressure.Craurosis vulvae is a premalignant change secondary tolong-standing hormonal deficiency (i.e., the postmenopausalstate). Both Candida and Trichomonas are characterizedby intense pruritus rather than abscess like pain,though in severe cases, each may produce a superficialsoreness not unlike that associated with herpetic pain.Immediate treatment is incision and drainage, whichallows virtually instantaneous relief. To avoid recurrence,definitive treatment requires marsupialization after incisionand drainage. Bartholin gland cysts occur withoutabscess formation and, if asymptomatic, merit no therapeuticmeasures. The organisms involved are usually notsexually transmitted, but culture should be performedand may yield Gonococcus or Chlamydia organisms. Ifthey are present, these should be treated accordingly.13. The answer is C. Postmenopausal bleeding must beassumed to be caused by endometrial carcinoma untilproven otherwise. If a postmenopausal woman has been onhormone replacement therapy (HRT), three possibleanswers each determine different pathways investigation. Ifthe patient has been on estrogen cycled with progesterone(HRT), the combination is relatively (but not absolutely)protective against endometrial carcinoma, and early in thecourse of HRT, there may be mild breakthrough bleeding.