Vaginal Bleeding Answers 455408.The answer is b.(Rosen, pp 219-224.)This patient exhibits signs of
hyperandrogenism and anovulation as evidenced by her history of irregular,
heavy periods and being treated with oral contraceptives. Her physical
examination is consistent with hirsutism, which is a result of increased
serum testosterone. Many of these patients are also obese. For these reasons,
polycystic ovarian syndromeis the most probable reason for this patient’s
symptoms.
Intrauterine and ectopic pregnancy (a and c)should always be ruled out
with a β-hCG. Follicular cysts (d)are very common and usually occur within
the first 2 weeks of the menstrual cycle. Pain is secondary to stretching of the
capsule and cyst rupture. Follicular cysts usually resolve within 1 to 3 months
and do not result in bleeding. Corpus luteum cysts (e)occur in the last 2 weeks
of the menstrual cycle and are less common. Bleeding into the capsule may
occur but these cysts usually regress at the end of the menstrual cycle. In
general, cysts are usually asymptomatic unless they are complicated by rupture,
torsion, or hemorrhage. Ultrasound is the preferred mode of imaging.
409.The answer is d.(Rosen, pp 219-224.)Endometriosisis defined by
the presence of endometrial glands and tissue outside the lining of the
uterus. This tissue may be present on the ovaries, fallopian tubes, bladder,
rectum, appendix, or other GI tissue. There are many different hypotheses
as to how this ectopic tissue forms, the most commonly accepted being
“retrograde menstruation.” Pain most commonly occurs before or at the
beginning of menses. Other symptoms that indicate ectopic endometrial
implantation and activation include dyspareunia and problems with defe-
cation. Clinical suspicions can only be confirmed with direct visualization
through laparoscopy.Treatment includes analgesia for acute episodes and
hormonal therapy to suppress the normal menstrual cycle so that purely
the endometrial tissue may be sloughed during menses. Surgical intervention
is taken for those cases that are truly refractory to these treatments.
Ureteral colic (a) is unlikely given the lack of flank tenderness,
dysuria, and prior history of stones. Obtaining a urinalysis will be compli-
cated by the presence of menstrual blood. Again, pregnancy (b)and there-
fore ectopics (c)should always be ruled out with a quick and easy β-hCG.
The probability of appendicitis (e)is low given that this patient’s abdomi-
nal examination is unremarkable.
410.The answer is a.(Rosen, pp 219-224.)The menstrual cycle consists of a
follicular phase and a luteal phase. The follicular, or proliferative, phase begins