NMS Q&A Family Medicine

136 NMS Q&A Family MedicineIf the patient has been taking estrogen replacement or inthe past without progesterone and has an intact uterus,the chances of endometrial carcinoma are heightenedbeyond those inherent in having an intact uterus withouthormonal influence. Each of the other questions is relevantbut only at a secondary level, after an opinion isformed as to what causes the bleeding. Postural lightheadednessin the present setting is possibly a symptomof relative hypovolemia and therefore anemia caused byblood loss. In the present vignette that is unlikely, giventhe history of only recent and modest blood loss. Therefore,also unlikely is the relevance of number of padsrequired. Having associated cramps generally is related tothe volume of flow of vaginal bleeding. Bleeding withintercourse is a nonspecific symptom that could relate tovulvar or uterine causes, including cervicitis.14. The answer is B. Unless this patient is successfullytreated, she will have significantly increased risk of spontaneousabortion and infertility. Women who developedactive chlamydial infections during pregnancy are atincreased risk for premature rupture of membranes, pretermlabor with smaller newborns, spontaneous abortion,and intrauterine deaths. C. trachomatis may cause severePID, urethritis, and cervicitis, although both women andmen with chlamydial infection may be asymptomatic.The infection responds to doxycycline and azithramycinbut to none of the penicillins or cephalosporins. Theincubation period is between 5 and 21 days.15. The answer is B, anovulatory cycle. If the patient hasno obstruction to the outflow of menstrual blood and ifthe endometrium has been sufficiently primed with estrogen,the exposure to and withdrawal of progesterone willinduce uterine bleeding. This will not occur in primary orsecondary ovarian failure that is due to lack of estrogenpriming or if there is an obstruction to uterine outflowsuch as in Asherman syndrome (uterine obstruction secondaryto endometrial scarring, as occurs sometimes afterdilatation and curettage). Likewise, gonadal agenesisresults in a barren, unprimed endometrium that cannotrespond to progesterone withdrawal.16. The answer is C, premature ovarian failure. The failureto respond to the progestin challenge suggests a problemwith estrogen stimulation of the endometrium (fromeither a pituitary or an ovarian problem), or outflowobstruction in the uterus. Because the patient did bleedafter reproduction of the estrogen–progestin cycle, outflowobstruction cannot be responsible and the causemust lie in the ovarian or pituitary axis regulating estrogen,with the result being inadequate serum estrogen level.The increase in FSH and LH shows an appropriate pituitaryresponse to these low estrogen levels, and thus thedifficulty must be ovarian failure.17. The answer is B, osteoporosis. This patient exhibitsthe criteria to diagnose anorexia nervosa: inappropriatevoluntary weight loss, distorted body image, and at least 3months of amenorrhea in a woman not in the perimenopausalage group. The menstrual abnormality is a form ofhypothalamic amenorrhea. It is often a response to physicalor psychological stress or to excessive exercise or weightloss. It is associated with osteoporosis. Serum estrogenand LH and FSH levels are decreased or normal in hypothalamicamenorrhea. Many anorectics are also bulimicand compensate by purging or inducing vomiting. Thelatter activity causes severe dental deterioration.18. The answer is B. Medical management of missed abortionis highly successful when the situation is uncomplicatedand ectopic pregnancy is ruled out. Intravaginal misoprostol,a prostaglandin E analog, allows successful evacuationof the uterine contents. Dilatation and curettage is necessarywhen there is evidence of infection, bleeding is severe, or ifthe patient is extremely anxious or presses for such intervention.If the uterus is empty on ultrasonic study andexpelled products of conception are confirmed and if noneof the aforementioned complications are present, expectantobservation only is needed. Symptomatic treatment ofcramps is inappropriate, as is initiation of contraception atthis time. Naproxen, as an NSAID, is a protaglandin inhibitor,would delay evacuation of the uterus.ReferencesBauman KA , Brown DR . Gynecology in primary care . In: RudyDR , Kurowski K , eds. Family Medicine: House Officer Series .Baltimore, MD : Williams & Wilkins ; 1997 : 297 – 328 .Family Medicine Board Review 2009. Kansas City, Missouri; May3–10 , 2009.French L . Dysmenorrhea . Am Fam Physician . 2005 ; 71 : 285 – 291 ,302.Griebel CP , Halvorsen J , Goleman TB , et al. Management of spontaneousabortion . Am Fam Physician . 2005 ; 72 :1243–1250.Johnson BA . Insertion and removal of intrauterine devices . AmFam Physician . 2005 ; 71 : 95 – 101 .Lozeau A-M . Diagnosis and management of ectopic pregnancy .Am Fam Physician . 2005 ; 72 : 1707 – 1714 , 1719 – 1720 .McKay HT . Gynecology . In: Tierney LM , McPhee SJ , PapadakisMA , eds. Current Medical Diagnosis and Treatment , 45th ed .New York : McGraw-Hill/Appleton & Lange ; 2006 : 728 – 762 .Owen MK , Clenney TL . Management of vaginitis . Am Fam Physician. 2004 ; 70 : 2125 – 2132, 2139–2140 .Sherif K . Polycystic ovary syndrome in primary care . Female Patient. 2005 ; 70 : 24 – 28 .Shrager S , Potter BE . Diethylstilbestrol exposure . Am Fam Physician. 2004 ; 69 : 2395 – 2400, 2401–2402 .