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TitleUwise Gynecology and Breast
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UWISE--Gynecology and Breast Pathology

Contraception and Sterilization

Correct! The patient should be reassured since initially after Depo-Provera injection

there may be unpredictable bleeding. This usually resolves in 2-3 months. In general,

after oone year of using Depo-Provera, nearly 50% of users have amenorrhea.

Correct! Emergency contraceptive pills are not an abortifacient, and they have not

been shown to cause any teratogenic effect if inadvertently administered during

pregnancy. They are more effective the sooner they are taken after unprotected

intercourse, and it is recommended that they be started within 72 hours, and no

later than 120 hours. Plan B, the levonorgestrel pills, can be taken in one or two

doses and cause few side effects. Emergency contraceptive pills may be used anytime

during a woman’s cycle, but may impact the next cycle, which can be earlier or later

with bleeding ranging from light, to normal, to heavy.

Correct! Ideal candidates for progestin-only pills include women who have

contraindications to using combined oral contraceptives (estrogen and progestin

containing). Contraindications to estrogen include a history of thromboembolic

disease, women who are lactating, women over age 35 who smoke or women who

develop severe nausea with combined oral contraceptive pills. Progestins should be

used with caution in women with a history of depression.

Correct! Oral contraceptives will decrease a woman’s risk of developing ovarian and

endometrial cancer. The earlier, higher dose oral contraceptive pills have been

linked to a slight increase in breast cancer, but not the most recent lower dose pills.

Women who use oral contraceptive pills have a slightly higher risk of developing

cervical intraepithelial neoplasia, but their risk of developing PID, endometriosis,

benign breast changes and ectopic pregnancy are reduced. Both hypertension and

thromboembolic disorders can be a potential side effect from using oral

contraceptive pills. Condoms and intrauterine devices will not lower her risk of

ovarian cancer.

Incorrect! Correct answer is B. Tubal ligation has not been shown to reduce the risk

of breast, cervical, or endometrial cancers, nor is there a decrease in menstrual

blood flow in women who have undergone a tubal ligation. There is a slight

reduction in the risk of ovarian cancer, but the mechanism is not yet fully


Correct! Approximately 10% of women who have been sterilized regret having had the
procedure with the strongest predictor of regret being undergoing the procedure at a
young age. The percentage expressing regret was 20% for women less than 30 years old at

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Correct! Central and lateral cystoceles are repaired by fixing defects in the pubocervical

fascia or reattaching it to the sidewall, if separated from the white line. Defects in the

rectovaginal fascia are repaired in rectoceles. Uterine prolapse is surgically treated by a

vaginal hysterectomy, but this patient already had a hysterectomy. Enteroceles are

repaired by either vaginal or abdominal enterocele repairs. Vaginal vault prolapse is

treated either by supporting the vaginal cuff to the uterosacral ligaments, sacrospinous

ligament or sacrocolpopexy. Urethral diverticulum does not present with severe pelvic


Incorrect! Correct answer is C. This patient has urge incontinence, which is caused by

overactivity of the detrusor muscle resulting in uninhibited contractions, which cause an

increase in the bladder pressure over urethral pressure resulting in urine leakage. Stress

incontinence is caused by an increase in intra-abdominal pressure (coughing, sneezing)

when the patient is in the upright position. This increase in pressure is transmitted to the

bladder that then rises above the intra-urethral pressure causing urine loss. Associated

structural defects are cystocele or urethrocele. Overflow incontinence is associated with

symptoms of pressure, fullness, and frequency, and is usually a small amount of continuous

leaking. It is not associated with any positional changes or associated events. Mixed

incontinence occurs when increased intra-abdominal pressure causes the urethral-vesical

junction to descend causing the detrusor muscle to contract. A vesicovaginal fistula

typically results in continuous loss of urine.

Correct! This patient is asymptomatic from her prolapse; therefore, no intervention is

necessary at this point. Cystocele repairs and hysterectomies are invasive procedures

which are not indicated in this asymptomatic patient. It is not necessary to obtain a pelvic

ultrasound, as her uterus is normal in size and she has no adnexal masses. Topical estrogen

would not help improve the prolapse, although it might help with her vaginal dryness. She

seems to be doing well with the lubricants and it is not necessary to expose her to the

estrogen, especially since she still has her uterus, and estrogen treatment alone may

increase her risk of endometrial cancer.

Correct! Because of the hydronephrosis due to obstruction, intervention is required.
Colpocleisis is a procedure where the vagina is surgically obliterated and can be performed
quickly without the need for general anesthesia. Anterior and posterior repairs provide no
apical support of the vagina. She will be at high risk of recurrent prolapse. The
sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or sacrocolpopexy (cuff to
sacral promontory using interposed mesh) require regional or general anesthesia and is
not the best option for this patient with high surgical morbidity.

Correct! Pessary fitting is the least invasive intervention for this patient’s symptomatic
prolapse. Although a sacrospinous ligament suspension would be an appropriate

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cancer (classify the depth of invasion if biopsy shows invasion). It is unusual to manage low

grade lesions by CKC. Indications for LEEP are similar to CKC.

Correct! A vulvar lesion unresponsive to treatment needs a biopsy. In addition to testing for
invasive cancer, the biopsy can also ensure that your diagnosis and treatment are correct. If
the initial diagnosis of condyloma is unsure, a biopsy should be performed prior to
initiating therapy. Imiquimod would not be recommended, as this patient previously had a
full treatment without total response. Prior to initiating treatment again, a tissue diagnosis
is recommended. A repeat Pap is not indicated for a vulvar lesion, and, prior to using laser
vaporization to destroy the lesion, a biopsy should be done to ensure that the lesion is not
cancer. Interferon is not effective in the treatment of HPV.

Incorrect! Correct answer is E. A hysteroscopy would be easily performed either in the

office or in the operating room, and the IUD could then be removed under direct

visualization. This would be the best choice for this patient. In vitro fertilization requires a

normal endometrial cavity so that the embryo may implant in the uterus. A retained IUD is

not an indication for this procedure. Having an ultrasound showing the retained IUD in the

uterine cavity, it would not be visible upon laparoscopy. If the IUD had been seen outside

the uterus, laparoscopy could be offered for removal of the IUD. Hysterosonogram would

not offer additional information since the pelvic ultrasound showed an intrauterine IUD. A

pelvic MRI will not give any additional information what would be helpful in the

management of this patient.

Incorrect! Correct answer is A. Needle aspiration of a palpable breast mass or lymph node

allows for pathologic diagnosis of the mass with minimal discomfort to the patient. Results

correlate well with excisional biopsy results. Observation or waiting for the patient to

decrease caffeine intake would not be recommended for a patient with a new finding of a

palpable breast mass, especially in a patient with a family history of breast cancer. A

mammogram does not need to be repeated since one was performed three months ago.

Excisional biopsy is not necessary at this point although she might ultimately require it.

Correct! A hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment

for a patient with pelvic pain due to endometriosis. In 60% of cases, when a patient with

endometriosis undergoes a simple hysterectomy without bilateral salpingo-oophorectomy

for pelvic pain, re-operation for continued pain will be necessary. Even if the patient

requires hormone replacement therapy postoperatively, her pain is unlikely to return. A

laparoscopy is indicated in the workup of pelvic pain in order to determine the etiology of

the pain. If endometriosis is noted, it may be excised, fulgurated or burned by laser. This

may offer some relief of the patient’s pain; however, relief is usually temporary in a pre-

menopausal female. In addition, this patient had a previous laparoscopy with only

temporary relief. A radical hysterectomy, usually used to treat cervical cancer, is too

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