Atrophic Vaginitis And Serosanguineous Discharge

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271. The answer is d. (DiSaia, 5/e, pp 55-62.) The main routes of spread of cervical cancer include vaginal mucosa, myometrium, paracervical lymphatics, and direct extension into the parametrium. The prevalence of lymph node disease correlates with the stage of malignancy. Primary node groups involved in the spread of cervical cancer include the paracervical, parametrial, obturator, hypogastric, external iliac, and sacral nodes, essentially in that order. Less commonly, there is involvement in the common iliac, inguinal, and paraaortic nodes. In stage I, the pelvic nodes are positive in approximately 15% of cases and the paraaortic nodes in 6%. In stage II, pelvic nodes are positive in 28% of cases and paraaortic nodes in 16%. In stage III, pelvic nodes are positive in 47% of cases and paraaortic nodes in 28%.

272. The answer is c. (Hoskins, 2/e, p 987.) Benign cystic teratomas (der-moids) are the most common germ cell tumors and account for about 20 to 25% of all ovarian neoplasms. They occur primarily during the reproductive years, but may also occur in postmenopausal women and in children. Dermoids are usually unilateral, but 10 to 15% are bilateral. Usually the tumors are asymptomatic, but they can cause severe pain if there is torsion or if the sebaceous material perforates, spills, and creates a reactive peritonitis.

273. The answer is e. (Hoskins, 2/e, pp 940-944.) The survival of women who have ovarian carcinoma varies inversely with the amount of residual tumor left after the initial surgery. At the time of laparotomy, a maximum effort should be made to determine the sites of tumor spread and to excise all resectable tumor. Although the uterus and ovaries may appear grossly normal, there is a relatively high incidence of occult metastases to these organs; for this reason, they should be removed during the initial surgery.

Ovarian cancer metastasizes outside the peritoneum via the pelvic or paraaortic lymphatics, and from there into the thorax and the remainder of the body.

274. The answer is c. (Hoskins, 2/e, p 728.) Although rare, adenocarci-noma of the Bartholin's gland must be excluded in women over 40 years of age who present with a cystic or solid mass in this area. The appropriate treatment in these cases is surgical excision of the Bartholin's gland to allow for a careful pathologic examination. In cases of abscess formation, both marsupialization of the sac and incision with drainage as well as appropriate antibiotics are accepted modes of therapy. In the case of the asymptomatic Bartholin's cyst, no treatment is necessary.

275. The answer is a. (Hoskins, 2/e, pp 827-828.) Cervical cancer is still staged clinically. Physical examination, routine x-rays, barium enema, col-poscopy, cystoscopy, proctosigmoidoscopy, and IVP are used to stage the disease. CT scan results, while clinically useful, are not used to stage the disease. Stage I disease is limited to the cervix. Stage Ia disease is preclinical (i.e., microscopic), while stage Ib denotes macroscopic disease. Stage II involves the vagina, but not the lower one-third, or infiltrates the parametrium but not out to the pelvic side wall. IIa denotes vaginal but not parametrial extension, while IIb denotes parametrial extension. Stage III involves the lower one-third of the vagina or extends to the pelvic side wall; there is no cancer-free area between the tumor and the pelvic wall. Stage IIIa lesions have not extended to the pelvic wall, but involve the lower one-third of the vagina. Stage IIIb tumors have extension to the pelvic wall, and/or are associated with hydronephrosis or a nonfunctioning kidney caused by tumor. Stage IV is outside the reproductive tract.

276-277. The answers are 276-b, 277-c. (Hoskins, 2/e, pp 793-794, 802-803.) Microinvasive carcinoma of the cervix includes lesions within 3 mm of the base of the epithelium, with no confluent tongues or lymphatic or vascular invasion. The overall incidence of metastases in 751 reported cases is 1.2%. Simple hysterectomy is accepted therapy.

278. The answer is e. (DiSaia, 5/e, pp 153-160.) Women who have invasive vulvar carcinoma usually are treated surgically. If the lesion is unilateral, is not associated with fixed or ulcerated inguinal lymph nodes, and does not involve the urethra, vagina, anus, or rectum, then treatment usually consists of radical vulvectomy and bilateral inguinal lymphadenec-tomy. If inguinal lymph nodes show evidence of metastatic disease, bilateral pelvic lymphadenectomy is usually performed. Radiation therapy, though not a routine part of the management of women who have early vulvar carcinoma, is employed (as an alternative to pelvic exenteration with radical vulvectomy) in the treatment of women who have local, advanced carcinoma.

279. The answer is b. (DiSaia, 5/e, pp 619-622.) Different tissues tolerate different doses of radiation, but the ovaries are by far the most radiosensitive. They tolerate up to 2,500 rads, while the other tissues listed tolerate between 5,000 and 20,000 rads. Acute evidence of excessive radiation exposure includes tissue necrosis and inflammation, resulting in enteritis, cystitis, vulvitis, proctosigmoiditis, and possible bone marrow suppression. Chronic effects of excessive radiation exposure are manifest months to years after therapy, and include vasculitis, fibrosis, and deficient cellular regrowth; these can result in proctitis, cystitis, fistulas, scarring, and stenosis.

Successful radiation depends on (1) the greater sensitivity of the cancer cell compared with normal tissue and (2) the greater ability of normal tissue to repair itself after irradiation. The maximal resistance to ionizing radiation depends on an intact circulation and adequate cellular oxygenation. Resistance also depends on total dose, number of portions, and time intervals. The relative resistance of normal tissue (cervix and vagina) in cervical cancer allows high surface doses approaching 15,000 to 20,000 rads to be delivered to the tumor with intracavitary devices, and, because of the inverse square law, significantly lower doses of radiation reach the bladder and rectum. The greater the fractionalization (number of portions the total dose is broken into), the better the normal tissue tolerance of that radiation dose; hence 5,000 rads of pelvic radiation is usually given in daily fractions over 5 weeks, with approximately 200 rads being administered each day.

280. The answer is c. (Hoskins, 2/e, pp 790-791.) By definition, a positive IVP would mean extension to the pelvic side wall and thus a stage III carcinoma, specifically stage IIIb. Such staging applies even if there is no palpable tumor beyond the cervix. In addition to examination, IVP, cys-toscopy, and proctosigmoidoscopy are the diagnostic tests used to stage cervical cancer. However, it is important to understand that while the results of only certain tests are used to stage the cancer, this does not limit the physician from performing any other diagnostic tests (such as CT scans of the abdomen, pelvis, or chest) that in his or her judgment are required for appropriate medical care and decision making.

281. The answer is a. (DiSaia, 5/e, pp 1-16.) Cervical cancer is a more common gynecologic malignancy in pregnancy than ovarian or breast cancer due to the fact that it is a disease of younger women. Management of cervical intraepithelial lesions is complicated in pregnancy because of increased vascularity of the cervix and because of the concern that manipulation of and trauma to the cervix can compromise continuation of the pregnancy. A traditional cone biopsy is only indicated in the presence of apparent microinvasive disease on a colposcopically directed cervical biopsy. Otherwise, more limited procedures such as shallow coin biopsies are more appropriate. If invasive cancer is diagnosed, the decision to treat immediately or wait until fetal viability depends in part on the gestational age at which the diagnosis is made and the severity of the disorder. Survival is decreased for malignancies discovered later in pregnancy. Radiation therapy almost always results in spontaneous abortion, in part because the fetus is particularly radiosensitive. Chemotherapy is associated with higher than expected rates of fetal malformations consistent with the antimetabo-lite effects of agents used. Specific malformations depend on the agent used and the time in pregnancy at which the exposure occurs.

282. The answer is d. (DiSaia, 5/e, pp 69-71.) Radical hysterectomy was popularized by Meigs in the 1940s and has become a very safe procedure in skilled hands. It is most often used as primary treatment for early cervical cancer (stage Ib and IIa), and occasionally as primary treatment for uterine cancer. In either case, there must be no evidence of spread beyond the operative field, as suggested by negative intraoperative frozen section biopsies. The procedure involves excision of the uterus, the upper third of the vagina, the uterosacral and uterovesical ligaments, and all of the para-metrium, and pelvic node dissection including the ureteral, obturator, hypogastric, and iliac nodes. Radical hysterectomy thus attempts to preserve the bladder, rectum, and ureters while excising as much as possible of the remaining tissue around the cervix that might be involved in microscopic spread of the disease. Ovarian metastases from cervical cancer are extremely rare. Preservation of the ovaries is generally acceptable, particularly in younger women, unless there is some other reason to consider oophorectomy.

283. The answer is c. (DiSaia, 5/e, pp 282-300.) Approximately 20% of ovarian neoplasms are considered malignant on pathologic examination. However, all must be considered as placing the patient at risk. Given that most ovarian tumors are not found until significant spread has occurred, it is not unreasonable to attempt to operate on such patients as soon as there is a suspicion of tumor. Papillary vegetation, size greater than 10 cm, ascites, possible torsion, or solid lesions are automatic indications for exploratory laparotomy. In a younger woman, a cyst can be followed past one menstrual cycle to determine if it is a follicular cyst, since a follicular cyst should regress after onset of the next menstrual period. If regression does not occur, then surgery is appropriate. Doppler ultrasound imaging allows visualization of arterial and venous flow patterns superimposed on the image of the structure being examined; arterial and venous flow are expected in a normal ovary.

284. The answer is b. (Hoskins, 2/e, p 720.) An important feature of the lymphatic drainage of the vulva is the existence of drainage across the mid-line. The vulva drains first into the superficial inguinal lymph nodes, then into the deep femoral nodes, and finally into the external iliac lymph nodes. The clinical significance of this sequence for patients with carcinoma of the vulva is that the iliac nodes are probably free of the disease if the deep femoral nodes are not involved. Unlike the lymphatic drainage from the rest of the vulva, the drainage from the clitoral region bypasses the superficial inguinal nodes and passes directly to the deep femoral nodes. Thus, while the superficial nodes usually also have metastases when the deep femoral nodes are implicated, it is possible for only the deep nodes to be involved if the carcinoma is in the midline near the clitoris.

285. The answer is a. (DiSaia, 5/e, p 285.) The most common ovarian neoplasms in children are of germ cell origin, and about half of these tumors are malignant. Functioning ovarian tumors have been reported to produce precocious puberty in about 2% of affected patients. Epithelial tumors of the ovary, which are quite rare in prepubertal girls, are benign in approximately 90% of all cases; papillary serous cystadenocarcinoma is an example of such a malignant epithelial tumor. Stromal tumors (such as fibrosarcoma) and Brenner tumors are not seen in this age group. Sarcoma botryoides, a tumor seen in children, is a malignancy associated with Mullerian structures such as the vagina and uterus, including the uterine cervix.

286. The answer is c. (Hoskins, 2le, pp 928-930.) Serous carcinoma is the most common epithelial tumor of the ovary. On histologic examination, psammoma bodies can be seen in approximately 30% of these tumors. Bilateral involvement characterizes about one-third of all serous carcinomas. Although mesonephroid carcinomas tend to be associated with pelvic endometriosis, a similar association has not been demonstrated for serous carcinomas.

287. The answer is a. (DiSaia, 5le, pp 41-42.) Lichen sclerosus was formerly termed lichen sclerosus et atrophicus, but recent studies have concluded that atrophy does not exist. Patients with lichen sclerosus of the vulva tend to be older; they typically present with pruritus, and the lesions are usually white with crinkled skin and well-defined borders. The histo-logic appearance of lichen sclerosus includes loss of the rete pegs within the dermis, chronic inflammatory infiltrate below the dermis, the development of a homogenous subepithelial layer in the dermis, a decrease in the number of cellular layers, and a decrease in the number of melanocytes. Mechanical trauma produces bullous areas of lymphedema and lacunae, which are then filled with erythrocytes. Ulcerations and ecchymoses may be seen in these traumatized areas as well. Mitotic figures are rare in lichen sclerosus, and hyperkeratosis is not a feature. While a significant cause of symptoms, lichen sclerosus is not a premalignant lesion. Its importance lies in the fact that it must be distinguished from vulvar squamous cancer.

288-289. The answers are 288-b,c,e, 289-a. (Hoskins, 2le, pp 78-79, 182, 197.) Human papillomavirus (HPV), in particular types 16, 18, and 31, has been linked to cervical neoplasia. HPV types 6 and 11 are associated with benign condyloma. Two types of vulvar dystrophies exist: lichen sclerosus and hyperplastic dystrophy. When hyperplastic dystrophy is found to have atypical features, the lesion is thought to be premalignant. Lichen sclerosus is a benign condition that does not develop cellular atypia.

290-295. The answers are 290-b, 291-a, 292-a, 293-d, 294-c, 295-e.

(Griffiths, p 188.) Sertoli-Leydig cell tumors, which represent less than 1% of ovarian tumors, may produce symptoms of virilization. Histologically, they resemble fetal testes; clinically, they must be distinguished from other functioning ovarian neoplasms as well as from tumors of the adrenal glands, since both adrenal tumors and Sertoli-Leydig tumors produce androgens. The androgen production can result in seborrhea, acne, menstrual irregularity, hirsutism, breast atrophy, alopecia, deepening of the voice, and cli-toromegaly. Recurrences of Sertoli-Leydig cell tumors, which seem to have a low malignant potential, usually appear within 3 years of the original diagnosis. Granulosa and theca cell tumors are often associated with excessive estrogen production, which may cause pseudoprecocious puberty, post-menopausal bleeding, or menorrhagia. These tumors are associated with endometrial carcinoma in 15% of patients. Because these tumors are quite friable, affected women frequently present with symptoms caused by tumor rupture and intraperitoneal bleeding. Granulosa tumors are low-grade malignancies that tend to recur more than 5 years after the initial diagnosis. Because their malignant potential is impossible to predict histologically, long-term follow-up is mandatory. Recurrences have been reported as late as 33 years after the original diagnosis. Gonadoblastomas frequently contain calcifications that can be detected by plain radiography of the pelvis. Women who have gonadoblastomas often have ambiguous genitalia. The tumors are usually small, and are bilateral in one-third of affected women. The malignant potential of immature teratomas correlates with the degree of immature or embryonic tissue present. The presence of choriocarcinoma can be determined histologically as well as by human chorionic gonadotropin (hCG) assays. The presence of choriocarcinoma in an immature teratoma worsens the prognosis. Krukenberg tumors are typically bilateral, solid masses of the ovary that nearly always represent metastases from another organ, usually the stomach or large intestine. They contain large numbers of signet ring adeno-carcinoma cells within a cellular hyperplastic but nonneoplastic ovarian stroma.

296-301. The answers are 296-a, 297-b, 298-j, 299-e, 300-h, 301-i.

(Hoskins, 2/e, pp 385-386, 393-394, 628-630.) Cyclophosphamide is an alkylating agent that cross-links DNA and also inhibits DNA synthesis. Hemorrhagic cystitis and alopecia are common side effects. Cisplatin causes renal damage and neural toxicity. Patients must be well hydrated. Its mode of action does not fit a specific category Taxol can produce allergic reactions and bone marrow depression. Bleomycin and doxorubicin are antibiotics whose side effects are pulmonary fibrosis and cardiac toxicity, respectively Vincristine arrests cells in metaphase by binding microtubular proteins and preventing the formation of mitotic spindles. Peripheral neuropathy is a common side effect.

302-308. The answers are 302-f, 303-a, 304-g, 305-e, 306-c, 307-b, 308-d. (Hoskins, 2/e, pp 4-9, 607-610.) The tumor in question 302 is an opened mature cystic teratoma (dermoid tumor) in which hair is visible.

The microscopic section in question 303 is a classical example of well-differentiated adenocarcinoma of the endometrium, showing cellular pleo-morphism, nuclear atypia with mitoses, and back-to-back crowding of glands with obliteration of intervening stroma; the glandular architecture of the tissue is maintained, however. Endometrial cancer is categorized by both stage and grade. The differentiation of a carcinoma is expressed as its grade. Grade I lesions are well differentiated; grade II lesions are moderately well differentiated; grade III lesions are poorly differentiated. An increasing grade—i.e., a decreasing degree of differentiation—implies worsening prognosis. Tumors may be of a mixed cell type—for example, squamous and adenocarcinoma—or may be mucinous, serous, or clear.

Question 304 shows clear cell adenocarcinoma with large, pale staining cells. Clear cell carcinoma of the endometrium is similar to that arising in the cervix, vagina, and ovary, and the histologic appearance is similar in each of these organs. Diethylstilbestrol exposure has been associated with an increased incidence of vaginal and cervical clear cell carcinomas. The tumor's origins are suggested to be mesonephric duct remnants. The microscopic appearance of clear cell carcinoma is related to deposits of periodic acid-Schiff (PAS) stain-positive glycogen. These tumors characteristically occur in older women and are very aggressive.

The section in question 305 shows mixed Mullerian endometrial cancer. Mixed Mullerian tumors refer to the combination of heterologous elements—that is, tissue of different sources (cartilage in this picture).

Question 306 is an example of choriocarcinoma, showing sheets of malignant trophoblast. Malignant choriocarcinoma is a transformation of molar tissue or a de novo lesion arising from the placenta. There are significant degrees of cellular pleomorphism and anaplasia. Choriocarcinoma can be differentiated from invasive mole by the fact that the latter has chori-onic villi and the former does not.

Questions 307 and 308 show early- to mid-proliferative endometrium and late secretory endometrium, respectively. Proliferative and late secretory endometrium can be differentiated by the development of glandular tissue and secretory patterns. In question 307, the glands are just beginning to proliferate, and the section cuts through several coils as they course toward the surface epithelium on the left. In question 308, the glands are dilated and filled with amorphous (glycogen) material.

309. The answer is c. (Hoskins, 2/e, pp 1094-1095.) Recognition of the high risk associated with axillary metastases for early death and poor 5-year survival has led to the use of postsurgical adjuvant chemotherapy in these patients. Patients who have estrogen- or progesterone-receptive tumors (i.e., receptor present or receptor-positive) are particular candidates for this adjuvant therapy, as 60% of estrogen-positive tumors will respond to hormonal therapy. Age and size of the tumor are certainly factors of importance, but they are secondary to the presence or absence of axillary metastases.

310. The answer is d. (Hoskins, 2/e, p 937.) Transvaginal ultrasound aided by Doppler color flow techniques is improving the ability to detect ovarian tumors at early stages. The neovascularity of tumor tissue is the basis on which diagnosis can be made by observing ectopic blood flow patterns. There are no characteristic vascular patterns found in early tumors, nor is there a temperature difference. Differences of blood flow from one side to the other are very unreliable and certainly not generally useful. The sensitivity and specificity of screening by transvaginal ultrasound is not yet proven.

311. The answer is e. (Ransom 1997, p 53.) The lesions are condyloma acuminatum, also known as venereal warts. This is a squamous lesion caused by a human papillomavirus (HPV). The lesion reveals a treelike growth microscopically with a mantle that shows marked acanthosis and parakeratosis. Treatment options include local excision, cryosurgery, application of podophyllum or trichloroacetic acid, and laser therapy, although podophyllum is not recommended for extensive disease because of toxicity (peripheral neuropathy). For intractable condyloma of the vagina, 5-fluorouracil can be employed. Vulvectomy is rarely indicated. A strong relationship between condyloma and intraepithelial neoplasia and carcinoma of the cervix has recently been demonstrated.

312. The answer is d. (Ransom 1997, p 52.) Syphilis is a chronic disease produced by the spirochete Treponema pallidum. Because of the spirochete's extreme thinness, it is difficult to detect by light microscopy; therefore, spirochetes are diagnosed by use of a specially adapted technique known as dark-field microscopy. Clinically, syphilis is divided into primary, secondary, and tertiary (or late) stages. In primary syphilis a hard chancre develops. This is a painless ulcer with an indurated base that is usually found on the vulva, vagina, or cervix. Secondary syphilis is the result of hematogenous dissemination of the spirochetes and thus is a systemic disease. There are a number of systemic symptoms depending on the major organs involved. The classic rash of secondary syphilis is red macules and papules over the palms of the hands and the soles of the feet. The manifestations of late syphilis include optic atrophy, tabes dorsalis, generalized paresis, aortic aneurysm, and gummas of the skin and bones.

313. The answer is b. (Ransom 1997, p 53.) Lymphogranuloma venereum (LGV) is a chronic infection produced by C. trachomatis. The primary infection begins as a painless ulcer on the labia or vaginal vestibule; the patient usually consults the physician several weeks after the development of painful adenopathy in the inguinal and perirectal areas. Diagnosis can be established by culture or by demonstrating the presence of antibodies to C. trachomatis. The Frei skin test is no longer used because of its low sensitivity The differential diagnosis includes syphilis, chancroid, granuloma inguinale, carcinoma, and herpes. Chancroid is a sexually transmitted disease caused by H. ducreyi that produces a painful, tender ulceration of the vulva. Donovan bodies are present in patients with granuloma inguinale, which is caused by C. granulomatis. Therapy for both granuloma inguinale and LGV is administration of tetracycline. Chancroid is successfully treated with either azithromycin or ceftriaxone.

314. The answer is c. (Mishell, 3/e, pp 637-643.) Persons at high risk for infection by human immunodeficiency virus (HIV) include homosexuals, bisexual males, women having sex with a bisexual or homosexual partner, intravenous drug users, and hemophiliacs. The virus can be transmitted through sexual contact, use of contaminated needles or blood products, and perinatal transmission from mother to child. The antibody titer usually becomes positive 6 to 12 weeks after exposure, and the presence of the antibody provides no protection against acquired immunodeficiency syndrome (AIDS). Because of occasional delayed appearance of the antibody after initial exposure, it is important to follow up patients for 1 year after exposure.

315. The answer is d. (Droegemueller, 3/e, pp 803-811.) The occurrence of cervical squamous dysplasia/carcinoma is thought to be related to infec tion with the human papillomavirus (HPV), which is sexually transmitted. Therefore women who begin sexual activity at a young age, have multiple sexual partners, do not use condoms, and have a history of sexually transmitted diseases are at an increased risk for cervical neoplasia. Alterations in immune function (such as in patients with HIV or on immunosuppressive therapy) place a patient at an increased risk of infection with HPV and therefore of cervical neoplasia. Women who smoke tobacco have an increased risk of developing cervical neoplasia. There is no known increased risk of cervical dysplasia due to use of Depo-Provera. However, some studies support an association of increased risk of cervical adenocarcinoma with oral contraceptive use. The literature does not support an increased risk of squamous cell carcinoma of the cervix in women who smoke.

316. The answer is e. (Droegemueller, 3/e, pp 818-820, 822-823.) Any patient with a Pap smear result that comes back suggesting dysplasia of the cervix should undergo a colposcopy with subsequent biopsy of any abnormal-appearing areas and an endocervical curettage. High-grade results include possible moderate dysplasia, severe dysplasia, or carcinoma in situ. The colposcope is a type of microscope that allows the physician to examine the cervix at a magnification of 10 to 16x. Three percent acetic acid is applied to the cervix to help visualize any abnormal blood vessels or acetowhite areas that could represent areas of dysplasia. Abnormal areas are then biopsied for histologic analysis. In patients with an HGSIL Pap, there is no indication for repeating the smear or ordering HPV testing, because you need to immediately rule out a pathologic process. Repeating a Pap can produce a false-negative result, which can lead to a delay in treating the patient. Random cervical biopsies are not indicated because you can miss the abnormal areas. The indications for a cone biopsy would be (1) unsatisfactory colposcopic exam (i.e., the entire transformation zone cannot be seen); (2) a colposcopically directed cervical biopsy that indicates the possibility of invasive disease; (3) neoplasm in the endocervix; or (4) cells seen on cervical biopsy that do not adequately explain the cells seen on cytologic examination (i.e., the Pap).

317. The answer is c. (Beckmann, 4/e, pp 558-561.) As discussed above, one of the indications for a cone biopsy is when the results of the cervical biopsy do not adequately explain the severity of the Pap smear. In about 10% of colposcopically directed cervical biopsies, there will be a substan tial discrepancy between the Pap smear and the biopsy results (i.e., the biopsy is normal but the Pap indicates severely abnormal cells). A coniza-tion is required to rule out lesions higher in the endocervical canal. Merely repeating the Pap smear is incorrect, because you may be delaying treatment of a serious problem. Once cervical dysplasia has been established, cryotherapy and laser ablation are viable treatment options. There is no indication for a hysterectomy in this patient.

318. The answer is e. (Beckmann, 4/e, pp 356-358.) Approximately 0.5% of Pap smears come back with glandular cell abnormalities. These abnormalities can be associated with squamous lesions, adenocarcinoma in situ, or invasive adenocarcinoma. Therefore any patient with AGUS should undergo immediate colposcopy and ECC. In addition, postmenopausal women should have endometrial sampling. Hysterectomy or conization might be indicated based on results of the colposcopy; however, col-poscopy must be performed initially.

319-320. The answers are 319-a, 320-e. (Postgraduate Obstetrics and Gynecology. Droegemueller, 3/e, pp 474-475, 947-948,1163-1164. Beckmann, 4/e, p 538-539.) Vulvar vestibulitis is syndrome of unknown etiology. To make the diagnosis of this disorder, the following three findings must be present: (1) severe pain on vestibular touch or attempted vaginal entry, (2) tenderness to pressure localized within the vulvar vestibule, and (3) visible findings confined to vulvar erythema of various degrees. To treat vulvar vestibulitis, the first step is to avoid tight clothing, tampons, hot tubs, and soaps, which can all act as vulvar irritants. Topical treatments include lido-caine, estrogen, and steroids. Tricyclic antidepressants and intralesional interferon injections have also been used. For women refractory to medical therapy, surgical excision of the vestibular mucosa may be helpful. Valtrex (valacyclovir) is an antiviral medication used in the treatment of genital herpes and is not indicated for vulvar vestibulitis. Contact dermatitis is an inflammation and irritation of the vulvar skin due to a chemical irritant. The vulvar skin is usually red, swollen, and inflamed and may become weeping and eczemoid. Women with a contact dermatitis usually experience chronic vulvar tenderness, burning, and itching that can occur even when they are not engaging in intercourse. Atrophic vaginitis is a thinning and ulceration of the vaginal mucosa that occurs as a result of hypoestro-genism; thus this condition is usually seen in postmenopausal women not on any hormone replacement therapy. Lichen sclerosus is another atrophic condition of the vulva. It is characterized by diffuse, thin whitish epithelial areas on the labia majora, minora, clitoris, and perineum. In severe cases, it may be difficult to identify normal anatomic landmarks. The most common symptom of lichen sclerosus is chronic vulvar pruritus. Vulvar intraepithelial neoplasia (VIN) are precancerous lesions of the vulva that have a tendency to progress to frank cancer. Women with VIN complain of vulvar pruritus, chronic irritation, and raised lesions. These lesions are most commonly located along the posterior vulva and in the perineal body and have a whitish cast and rough texture.

321-322. The answers are 321-b, 322-d. (Droegemueller, 3le, pp 625-635. Beckmann, 4le, pp 370-371.) Bacterial vaginosis is a condition is which there is an overgrowth of anaerobic bacteria in the vagina that replaces the normal lactobacillus. Women with this type of vaginitis complain of an unpleasant vaginal odor that is described as musty or fishy and a thin, gray-white vaginal discharge that is adherent to the vaginal walls. Vulvar irritation and pruritus are rarely present. To confirm the diagnosis of bacterial vaginosis, a wet smear is done. To perform a wet smear, saline is mixed with the vaginal discharge and clumps of bacteria and clue cells are identified. Clue cells are vaginal epithelial cells with clusters of bacteria adherent to their surfaces. In addition, a whiff test can be performed by mixing potassium hydroxide with the vaginal discharge. In cases of bacterial vaginosis, an amine-like odor will be detected. The treatment of choice for bacterial vaginosis is metronidazole (Flagyl) 500 mg given twice daily for 7 days. In cases of a normal or physiologic discharge, vaginal secretions are white, curdy, and odorless. In addition, normal vaginal secretions do not adhere to the vaginal side walls. In cases of candidiasis, patients commonly complain of vulvar burning, pain, pruritus, and erythema. The vaginal discharge tends to be white, highly viscous, granular, and adherent to the vaginal walls. A wet smear with potassium hydroxide can confirm the diagnosis by the identification of hyphae. Treatment of candidiasis can achieved with the administration of topical imidazoles or triazoles or the oral medication Diflucan. Trichomonas vaginitis is the most common nonviral, nonchla-mydial sexually transmitted disease of women. It is caused by the anaerobic, flagellated protozoan T. vaginalis. Women with Trichomonas vaginitis commonly complain of a copious vaginal discharge that may be white, yellow, green, or gray and that has an unpleasant odor. Some women complain of vulvar pruritus, which is primarily confined to the vestibule and labia minora. On physical exam, the vulva and vagina frequently appear red and swollen. Only a small percentage of women possess the classically described strawberry cervix. Diagnosis of trichomoniasis is confirmed with a wet saline smear. Under the microscope, the Trichomonas organisms can be visualized under high power; these organisms are unicellular protozoans that are spherical in shape with three to five flagella extending from one end. The recommended treatment for trichomoniasis is a one-time dose of 2 g metronidazole. Chlamydia trachomatis is an intracellular parasite that can cause an infection that may be manifested as cervicitis, urethritis, or salpingitis. Patients with mild cases may be asymptomatic. On physical exam, women with chlamydial infections may demonstrate a mucopurulent cer-vicitis. The diagnosis of chlamydia is suspected on clinical exam and confirmed with cervical cultures. Treatment for a chlamydial cervicitis is with oral azithromycin, 1 g, or doxycycline 100 mg twice daily for 7 days.

323-325. The answers are 323-d, 324-b, 325-b. (Droegemueller, 3/e, pp 671, 677-680.) Ovarian torsion, appendicitis, acute salpingitis, and ruptured ovarian cyst are all commonly associated with fever, abdominal pain, and elevated white blood cell count. In cases of kidney stone, urinalysis usually indicates the presence of blood. In addition, the pain is usually in the flank areas. Any patient with PID and a tuboovarian abscess should be hospitalized and given intravenous antibiotics. Any patient with TOAs who does not get better on broad-spectrum antibiotics should undergo surgical drainage of the abscesses via laparotomy, laparoscopy, or percutaneously under CT guidance. The Centers for Disease Control's recommendation for inpatient management of PID includes the following:

1. Cefoxitin 2 g IV every 6 h or cefotetan 2 g IV every 12 h plus doxycycline 100 mg PO or IV twice daily or

2. Clindamycin 900 mg IV every 8 h plus gentamicin loading dose IV or

IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 h

The Centers for Disease Control's recommendation for the outpatient management of PID includes the following:

1. Cefoxitin 2 g IM plus probenecid 1 g PO in a single dose concurrently or ceftriaxone 250 mg IM plus doxycycline 100 mg PO twice daily for 14 days or

2. Ofloxacin 400 mg PO two times a day for 14 days plus either clin-damycin 450 mg PO four times a day or metronidazole 500 mg PO two times a day for 14 days.

326. The answer is e. (Droegemueller, 3/e, pp 358-361.) Nipple discharge can occur in women with either benign or malignant breast conditions. Approximately 10 to 15% of women with benign breast disease complain of nipple discharge. However, nipple discharge is only present in about 3% of women with breast malignancies. The most worrisome nipple discharges tend to be spontaneous, unilateral, and persistent. The color of nipple discharge does not differentiate benign from malignant breast conditions. The most common breast disorder associated with a bloody nipple discharge is an intraductal papilloma. However, breast carcinoma must always be ruled out in any patient complaining of a bloody nipple discharge. Sanguineous or serosanguineous nipple discharges can also be seen in women with duct ectasia and fibrocystic breast disease. Women with hyperprolactinemia due to a pituitary adenoma experience bilateral milky white nipple discharges.

327. The answer is b. (Droegemueller, 3/e, pp 357-360. Beckmann, 4/e, pp 420-421.) This patient's breast mass is characteristic of a fibroadenoma. Fibroadenomas are the second most common benign breast disorder, after fibrocystic changes. They are characterized by being firm, solid, nontender, and freely mobile. Fibroadenomas have an average size diameter of 2.5 cm and are well circumscribed. These lesions most commonly occur in adolescents and women in their twenties. Fibrocystic changes occur in about one-third to one-half of reproductive-age women and represent an exaggerated response of the breast tissue to hormones. Patients with fibrocystic changes complain of bilateral mastalgia and breast engorgement preceding menses. On physical exam, diffuse bilateral nodularity is typically encountered. Cys-tosarcoma phyllodes are rare fibroepithelial tumors that constitute 1% of breast malignancies. These rapidly growing tumors are the most frequent breast sarcoma and occur most frequently in women in the fifth decade of life. Trauma to the breast can result in fat necrosis. Women with fat necrosis commonly present to the physician with a firm, tender mass that is sur rounded by ecchymosis. Occasional skin retraction can occur, making this lesion difficult to differentiate from cancer. It is unlikely that this patient who presents in her twenties has breast cancer. Fine-needle aspiration or excisional biopsy must be performed to rule out the rare chance of malignancy, but breast cancer is not the most likely diagnosis based on the patient's age and lack of any other breast changes consistent with carcinoma (such as a fixed mass, skin retraction, or lymphadenopathy).

328. The answer is c. (Beckmann, 4/e, pp 571-574.) Uterine fibroids or myomas are benign smooth-muscle tumors of the uterus. They are present in about 30% of American women; most women with fibroids are asymptomatic and do not require therapy. Uterine myomas are hormonally responsive and grow in response to estrogen exposure. Therefore, during pregnancy a woman with fibroids may have an increase in size of these fibroids to the point where they outgrow their blood supply (carneous degeneration). In pregnancy, uterine fibroids can also be associated with fetal malpresentation due to distortion of the endometrial cavity, postpar-tum atony due to inability of the uterine muscle to contract normally after delivery, and preterm labor. Uterine leiomyosarcomas are smooth muscle malignancies characterized by more than 5 mitoses per 10 hpf. These malignancies are not thought to arise from benign fibroids but occur de novo. Uterine leiomyosarcomas typically occur in postmenopausal women with a rapidly enlarging uterus.

329. The answer is e. (Droegemueller, 3/e, pp 1025, 1028, 1030-1031, 1077.) Menometrorrhagia is prolonged or excessive bleeding occurring at irregular intervals. Such abnormal bleeding can have a hormonal etiology (dysfunctional uterine bleeding) or it can be associated with an anatomic cause (e.g., uterine fibroids/polyps). Hypothyroidism can be associated with menorrhagia and intermenstrual bleeding. Prolactinemia due to either a pituitary adenoma or hypothyroidism can be associated with anovulation and irregular menses and should be checked as well. Since this patient has missed a menses at the time of presentation, a pregnancy test should also be ordered. In a woman this patient's age, endometrial sampling should be performed via either a D and C or office pipelle to rule out the possibility of uterine cancer. A hysteroscopy would give added information regarding the presence of any submucosal fibroids or endometrial polyps. In addition, a pelvic ultrasound would offer information regarding the size and location of any uterine fibroids or polyps. This patient has no indication for a cone biopsy. A Pap smear needs to be done first to screen for any cervical disease.

330. The answer is a. (Beckmann, 4/e, pp 569-572, ACOG, Practice bulletin 16.) Hysterectomy would be a reasonable treatment for this patient who has symptomatic fibroids, does not desire fertility, and wants definitive therapy. Administration of a GnRH analogue, such as Lupron, would be an appropriate medical alternative for this patient because this medication causes pharmacologic inhibition of estrogen secretion and thus will cause shrinkage of the estrogen-dependent leiomyomas. This therapy is ideal for this patient, who is perimenopausal and will reach menopause in the near future. Progestin supplementation may be successful in minimizing uterine bleeding by thinning the endometrial lining. Uterine artery embolization is an innovative radiologic alternative to surgery for fibroids. It involves partial blockage of the uterine arteries, which causes shrinkage of leiomyomas due to decreased blood flow to the uterus. Most reports indicate that patients undergoing this procedure report a significant reduction in bleeding symptoms as well as a reduction in uterine size. This procedure is still considered to be experimental or investigational since it can result in serious complications (infection, massive uterine bleeding, emergency hysterectomy, and uterine necrosis) and no long-term outcome data is available. Myomectomy is not recommended for this patient because she does not desire future fertility and myomectomies (in comparison to hysterectomies) are associated with a potential for severe intraoperative blood loss and the risk of recurrence of fibroids.

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