A 54-year-old female presents with a 2-month history of intense vulvar itching that has not improved with topical antifungal treatment. On examination you note areas of white, thickened, excoriated skin. Concerned about malignancy you perform punch biopsies, which reveal lichen sclerosus.
The treatment of choice for this condition is topical application of:
Correct Answer B:
Lichen sclerosus is a chronic, progressive, inflammatory skin condition found in the anogenital region. It is characterized by intense vulvar itching. The treatment of choice is high-potency topical corticosteroids.
Testosterone has been found to be no more effective than petrolatum. Fluorouracil is an antineoplastic agent most frequently used to treat actinic skin changes or superficial basal cell carcinomas.
A 34-year-old female with a history of bilateral tubal ligation consults you because of excessive body and facial hair. She has a normal body weight, no other signs of virilization, and regular menses.
Which one of the following is the most appropriate treatment for her mild hirsutism?
Correct Answer A:
Antiandrogens such as spironolactone, along with oral contraceptives, are recommended for treatment of hirsutism in premenopausal women. In addition to having side effects, prednisone is only minimally helpful for reducing hirsutism by suppressing adrenal androgens. Leuprolide, although better than placebo, has many side effects and is expensive. Metformin can be used to treat patients with polycystic ovarian syndrome, but this patient does not meet the criteria for this diagnosis.
A 40-year-old white female lawyer sees you for the first time. When providing a history, she describes several problems, including anxiety, sleep disorders, fatigue, persistent depressed mood, and decreased libido. These symptoms have been present for several years and are worse prior to menses, although they also occur to some degree during menses and throughout the month. Her menstrual periods are regular for the most part.
The most likely diagnosis at this time is:
Psychological disorders, including anxiety, depression, and dysthymia, are frequently confused with premenstrual syndrome (PMS), and must be ruled out before initiating therapy. Symptoms are cyclic in true PMS. The most accurate way to make the diagnosis is to have the patient keep a menstrual calendar for at least two cycles, carefully recording daily symptoms. Dysthymia consists of a pattern of ongoing, mild depressive symptoms that have been present for 2 years or more and are less severe than those of major depression. This diagnosis is consistent with the findings in the patient described here.
A 36-year-old female, who was scheduled to do a routine Pap smear was reported to have atypical glandular cells of undetermined significance.
Which of the following is the best next step in management?
Correct Answer E:
This patient is found to have atypical glandular cells of undetermined significance (AGUS). The Bethesda system classifies AGUS as glandular cells that demonstrate nuclear atypia appearing to exceed reactive or reparative changes but lacking unequivocal features of adenocarcinoma. AGUS occurs in approximately 0.18 to 0.74 percent of all cervical smears. Because AGUS is associated with significant clinical disease, all women found to have AGUS should have colposcopy as the next step in management. For women older than 35 years, endocervical sampling should be done in addition to colposcopy (choice E). This is particularly encouraged in women with any unexplained vaginal bleeding, history of amenorrhea, or use of oral contraceptive pills.
→ Repeat Pap smear at 6 and 12 months (choice A) may be done for atypical squamous cells of undetermined significance or low grade squamous intraepithelial lesions with few risk factors but it is not sufficient for the management of AGUS. Unlike women with atypical squamous cells of undetermined significance, a significant percentage of women with AGUS will have more serious lesions, such as high-grade preinvasive squamous disease, adenocarcinoma in situ, adenocarcinoma or invasive cancers from sites other than the cervix.
→ Human Papilloma Virus (HPV) testing and typing (choice B) along with follow up Pap smear would be appropriate as next step in management in atypical squamous cells of undetermined significance, but this is not the best course of action for AGUS.
→ Loop electrosurgical excision procedure (choice C) and Cold-knife conization of cervix (choice D) are two methods of excision of a cone-shaped or cylindrical wedge from the cervix that includes the transformation zone and all or a portion of the endocervical canal. They may be used for definitive diagnosis or conservative treatment. They should not be done before colposcopy. Conization of cervix may be done after colposcopy results have been obtained depending on sub-classification of AGUS.
Key point:
A 29-year-old woman, who gave birth to her first baby 2 months ago, comes to request injectable contraceptive medication. While her and her husband want to have more children, she wants to avoid pregnancy for the next year. You discuss using medroxyprogesterone injection.
Which of the following is the most important point this patient should be aware of?
Medroxyprogesterone is a progestin that can be given as intramuscular injection for contraception. It may also be used for endometriosis and irregular menstruation. It works to prevent pregnancy by preventing ovulation. Medroxyprogesterone also thins the lining of the uterus. It is a very effective method of birth control and the intramuscular injection is given once every 3 months (12 weeks). Medroxyprogesterone is associated with decreased calcium stores and reduced bone mass density. Patients should be advised to consume plenty of foods rich in calcium and vitamin D (choiceB) to reduce risks of osteoporosis.
→ Medroxyprogesterone injection may be used in breastfeeding women as long as the baby is 6 weeks old by the first injection. While a certain amount of medroxyprogesterone may be passed to the baby through breast milk it has not been shown to be harmful.
→ Risks of permanent infertility even after discontinuation (choiceC) is incorrect. While there’s delayed fertility after discontinuation (sometimes lasting 10 months), permanent infertility is unlikely to be caused by this medication.
→ Liver disease is an absolute contraindication to medroxyprogesterone injection and it should not be given in those patients.
→ Medroxyprogesterone is injected every 3 months, it is not necessary to give monthly injections.
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