A 30-year-old female is being evaluated because of absent menses for the last 6 months. Menarche was at age 12. Her menstrual periods have frequently been irregular, and are accompanied only occasionally by dysmenorrhea. She had her first child 4 years ago, but has not been able to become pregnant since. A physical examination and pelvic examination are unremarkable. A serum pregnancy test is negative, prolactin levels are normal, and LH and FSH levels are both three times normal on two occasions.
These findings are consistent with:
Correct Answer B:
The history and physical findings in this patient are consistent with all of the conditions listed. However, the elevated FSH and LH indicate an ovarian problem, and this case is consistent with ovarian failure or premature menopause. Most pituitary tumors associated with amenorrhea produce hyperprolactinemia.
Polycystic ovary syndrome usually results in normal to slightly elevated LH levels and tonically low FSH levels. Hypothalamic amenorrhea is a diagnosis of exclusion, and can be induced by weight loss, excessive physical exercise (running, ballet), or systemic illness. It is associated with tonically low levels of LH and FSH.
In a 27-year-old white female with irregular menstrual cycles and infertility, which one of the following would be more indicative of Cushing’s syndrome rather than the more common polycystic ovarian syndrome?
Correct Answer A:
Easy bruising, moon facies, buffalo hump, abdominal striae, hypertension, and proximal myopathy suggest Cushing’s syndrome. Because this syndrome is very rare compared to polycystic ovarian syndrome, routine screening is not indicated in women with hyperandrogenic anovulation.
A 24-year-old white female contracts a primary genital herpes virus infection during her 25th week of gestation.
Which one of the following statements is true?
Most women who develop primary herpes virus (HSV) infection during pregnancy will deliver healthy babies. Studies have not shown increased rates of miscarriage, especially after the first trimester. Current guidelines recommend treatment with antiviral agents for primary HSV infection in pregnancy. Caesarean section is not routinely recommended if a woman has had an infection during pregnancy unless active viral lesions are present at the time of delivery. Breastfeeding is unlikely to lead to neonatal infection.
A 28-year-old white female presents with painful genital ulcers. She has not had any previous episodes of similar outbreaks. She is single, but has had several heterosexual relationships. She has been with her current partner for 3 years. A culture confirms a herpes simplex virus (HSV) infection.
Which one of the following is true regarding her situation?
Correct Answer A: Suppressive therapy with acyclovir, valacyclovir, or famiciclovir reduces, but does not eliminate, the risk of transmission of HSV to sexual partners. HSV type 1 and HSV type 2 infections in the genital area are clinically identical. Psychological issues, including anger, guilt, low self-esteem, anxiety, and depression are common after first receiving a diagnosis of genital HSV infection. Initial clinical outbreaks of genital HSV infections are often recurrences of previous infection. Either of the partners may have had an asymptomatic infection acquired in a previous relationship. An experimental HSV type 2 vaccine has been developed, but it is ineffective in men.
A 32-year-old white female comes to your office complaining of dysuria. She denies fever and back pain. She appears to be well otherwise and has a normal abdominal examination. A clean-catch urinalysis shows 15-20 WBC/hpf and a dipstick test for leukocyte esterase is positive. You send a urine sample for culture and start the patient on nitrofurantoin (Macrodantin), as she is allergic to sulfa.
Three days later, the patient returns with persistent dysuria despite taking the medication as prescribed. Her urine culture has returned with no growth. A pelvic examination is normal and the rest of the physical examination is unchanged. A wet prep is normal and tests for sexually transmitted diseases are pending.
Which one of the following antibiotics is most appropriate for this patient now?
Correct Answer D:
Urethral syndrome is characterized by dysuria and pyuria in the presence of a negative culture for uropathogens. The infecting organism is typically Chlamydia trachomatis although other organisms such as Ureaplasma urealyticum and Mycoplasma species may be involved. Effective medication choices include doxycycline, ofloxacin, levofloxacin, and macrolides such as erythromycin and azithromycin.
→ Amoxicillin/clavulanate (choice A) and cephalexin (choice B) are incorrect. These would cover gram-positive bacteria but it would not cover gram-negative bacteria nor bacteria without a cell wall, which are the most common causes of this condition.
→ Metronidazole (choice C) is best for treating anaerobic infections and protozoa such as trichomonas vaginalis, it would not be the best for treating this condition, given the most likely causes.
→ Pyridium (choice E) is a phenazopyridine often used to alleviate the pain, irritation, discomfort, or urgency caused by urinary tract infections. While it would be beneficial for symptomatic relief, it is unlikely to completely resolve this patient's condition, given her recent history.
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