OB-GYN REVIEW

Part III
By
JEAN ANNE B. TORAL, M.D.
June 13, 2009

Question
67. A 55 y.o. G5P5 (5005) consulted for fish-wash like
vaginal discharge and on-and-off vaginal bleeding. Pelvic
exam showed the cervix to be converted to a 6 x 5 cm
nodular, fungating mass extending to the R lateral fornix,
the right parametria nodular but free while the left was
smooth and pliable. Based on the information given, this
patient can be clinically staged as
a. IIB
b. IIIA
c. IIIB
d. IVA

Gyn Onc: Cervical Cancer

Staging of cervical cancer is clinical.
Allowable diagnostic procedures to be included in
clinical staging are pelvic exam preferably under
anesthesia, palpation, inspection, colposcopy,
endocervical curettage, hysteroscopy, cystoscopy,
proctosigmoidoscopy, chest x-ray and bone xray,
intravenous urography. Conization is also included.
Optional examinations: laparoscopy, ultrasound, CT
scan, MRI, PET scan.

Cervical Cancer Staging

Stage 0: carcinoma in situ
Stage 1: confined to the cervix (uterine extension is
disregarded)
IA: microscopic only
IA1: stromal invasion no greater than 3 mm depth and 7 mm
horizontal spread
IA2: stromal invasion depth 3-5 mm, horizontal spread up to
7 mm

IB: clinically visible lesion confined to the cervix

IB1: 4 cm or less
IB2: more than 4 cm

Stage II: tumor invades beyond the uterus but not to the
pelvic wall or to the lower third of the vagina
IIA: without parametrial invasion
IIB: with parametrial invasion

Cervical Cancer Staging

Stage III: Tumor extends to the pelvic wall and/or involves
the lower third of the vagina and/or causes
hydronephrosis or non-functioning kidney
IIIA: tumor involves the lower third of the vagina with
no extension to the pelvic wall
IIIB: tumor extends to the pelvic wall and/or causes
hydronephrosis or non-functioning kidney
Stage IVA: tumor invades the mucosa of the bladder or
rectum and/or extends beyond the true pelvis
Stage IVB: distant metastasis

Answer
67. A 55 y.o. G5P5 (5005) consulted for fish-wash like
vaginal discharge and on-and-off vaginal bleeding. Pelvic
exam showed the cervix to be converted to a 6 x 5 cm
nodular, fungating mass extending to the R lateral fornix,
the right parametria nodular but free while the left was
smooth and pliable. Based on the information given, this
patient can be clinically staged as
a. IIB
b. IIIA
c. IIIB
d. IVA

Question
68. A 53 y.o. G1P1 (1001) underwent exploratory
laparotomy for an ovarian new growth. Intraoperative
findings showed the right ovary to be converted to a 10
cm predominantly cystic mass with excrescences on its
outer capsule and was densely adherent to the fundal
portion of theuterus. The left ovary was grossly normal.
All other abdominopelvic organs were grossly normal.
Based on the information given, the Intraoperative stage
of this patient is
a. IA
b. IB
c. IC
d. IIA

Ovarian Cancer Staging

Staging of ovarian cancer is surgicopathologic.
Stage I: tumor confined to the ovaries
IA: limited to one ovary, intact capsule, no tumor on ovarian surface,
no malignant cells in the peritoneal washing or ascites
IB: limited to both ovaries, intact capsule, no tumor on ovarian
surface, no malignant cells in the peritoneal washing or ascites
IC: tumor limited to one or both ovaries with any of the following:
capsule ruptured, tumor on ovarian surface, positive malignant cells
in the ascites or positive peritoneal washings
Stage II: tumor involves one or both ovaries with pelvic extension
IIA: extension/implants to uterus and/or tubes
IIB: extension to other pelvic organs, no malignant cells in ascites or
peritoneal washings
IIC: IIA/B with positive malignant cells in the ascites or positive
peritoneal washings

Ovarian Cancer Staging

Stage III: Tumor involves one or both ovaries with
microscopically confirmed peritoneal metastasis outside
the pelvis and/or regional lymph node metastasis
IIIA: microscopic peritoneal metastasis beyond the pelvis
IIIB: macroscopic peritoneal metastasis beyond the
pelvis 2 cm or less in greatest dimension
IIIC: peritoneal metastasis beyond the pelvis more than 2
cm in greatest dimension and/or regional lymph nodes
Stage IV: Distant metastasis beyond the peritoneal cavity

Question
68. A 53 y.o. G1P1 (1001) underwent exploratory
laparotomy for an ovarian new growth. Intraoperative
findings showed the right ovary to be converted to a 10
cm predominantly cystic mass with excrescences on its
outer capsule and was densely adherent to the fundal
portion of theuterus. The left ovary was grossly normal.
All other abdominopelvic organs were grossly normal.
Based on the information given, the Intraoperative stage
of this patient is
a. IA
b. IB
c. IC
d. IIA

Question
69. Histopath of a a 47 y.o. nulligravid who underwent PFC, THBSO,
BLND was read as follows:
Endometrial adenocarcinoma, endometrioid type, well-differentiated
with less than 50 % myometrial invasion.
Chronic endocervicitis with squamous metaplasia
Negative for tumor: peritoneal fluid, all harvested lymph nodes.
Positive lymphovascular space invasion.
No diagnostic abnormality recognized, both ovaries and fallopian
tubes

What is the stage of the patient?

a. Stage IB
b. Stage IC
c. Stage IIB
d. Stage IIIC

Endometrial Cancer Staging

Staging of endometrial carcinoma is surgicopathologic. Only in

instances where radiation is the first treatment given is clinical
staging used.

Stage I: Tumor confined to the corpus

IA: limited to the endometrium
IB: invades up to less than half of the myometrium
IC: invades to more than half of the myometrium
Stage II: tumor invades the cervix but does not extend
beyond the uterus
IIA: endocervical glandular involvement only
IIB: cervical stromal invasion

Endometrial Cancer Staging

Stage III: local and/or regional spread
IIIA: tumor involves uterine Serosa and/or adnexae and/
or cancer cells in peritoneal washings or ascites
IIIB: vaginal involvement
IIIC: metastasis to the pelvic and/or para-aortic nodes
Stage IVA: tumor invades the bladder and/or bowel mucosa
Stage IVB: distant metastasis including intra-abdominal
metastasis other than para-aortic and/or inguinal nodes

Answer
69. Histopath of a a 47 y.o. nulligravid who underwent PFC, THBSO,
BLND was read as follows:
Endometrial adenocarcinoma, endometrioid type, well-differentiated
with less than 50 % myometrial invasion.
Chronic endocervicitis with squamous metaplasia
Negative for tumor: peritoneal fluid, all harvested lymph nodes.
Positive lymphovascular space invasion.
No diagnostic abnormality recognized, both ovaries and fallopian
tubes

What is the stage of the patient?

a. Stage IB
b. Stage IC
c. Stage IIB
d. Stage IIIC

Question
70. This woman is at high risk to develop
endometrial carcinoma:
a. 52 y.o. breast cancer patient on tamoxifen
b. 35 y.o. nulligravid with PCOS
c. 37 y.o. with BMI of 35 kg/m2
d. all of the above

Endometrial Cancer: Risk Factors

Risk factors for endometrial cancer (histogenic Type I) are related to
hyperestrogenic states including:
obesity
Nulliparity (history of infertility)
late menopause (beyond 52 y.o.),
polycystic ovary syndrome (common in endometrial cancer in young
patients),
intake of tamoxifen (with estrogenic effect on the uterus),
intake of unopposed estrogen replacement therapy.
There is also a genetic risk for endometrial cancer, the most common
being the one associated with Hereditary Non-Polyposis Colorectal
Cancer Syndrome (HNPCC). Endometrial cancer is the syndromes
most common extracolonic manifestation with a lifetime risk of up to
60 %.

Answer
70. This woman is at high risk to develop
endometrial carcinoma:
a. 52 y.o. breast cancer patient on tamoxifen
b. 35 y.o. nulligravid with PCOS
c. 37 y.o. with BMI of 35 kg/m2
d. all of the above

Question
71. In an epithelial carcinoma of the ovary,
the tumor marker that is most likely to be
elevated is:
a. alpha fetoprotein
b. lactic dehydrogenase
c. CA 125
d. B-hcg

Ovarian Cancer Tumor Markers

CA-125: epithelial ovarian cancer
CA-19-9: used for mucinous epithelial tumors
Alpha fetoprotein: germ cell tumor endodermal sinus
tumor (EST) or also known as yolk sac tumor
Lactic dehydrogenase (LDH): germ cell tumor
dysgerminoma
B-hcg: choriocarcinoma

Answer
71. In an epithelial carcinoma of the ovary,
the tumor marker that is most likely to be
elevated is:
a. alpha fetoprotein
b. lactic dehydrogenase
c. CA 125
d. B-hcg

Question
72. The most common genital tract
malignancy in Filipino women based on
the 2005 Philippine Cancer Facts and
Estimates is:
a. vulvar cancer
b. cervical cancer
c. endometrial cancer
d. ovarian cancer

Answer
72. The most common genital tract malignancy in Filipino women
based on the 2005 Philippine Cancer Facts and Estimates is:
a. vulvar cancer
b. cervical cancer
c. endometrial cancer
d. ovarian cancer

The most common gynecologic malignancy among Filipino

women is cervical cancer, followed by ovarian cancer,
then endometrial cancer.
The trend is the reverse in developed countries because
their cervical cancer rate is low because of effective
screening programs.

Question
73. A 17 y.o. nulligravid consulted for an
abdominopelvic mass. On physical examination,
there were virilizing signs and symptoms. Even
before a pelvic exam is done, the primary
consideration if this were an ovarian pathology
is:
a. epithelial tumor
b. germ cell tumor
c. sex-cord stromal tumor
d. metastatic tumor

Answer
73. A 17 y.o. nulligravid consulted for an abdominopelvic mass. On
physical examination, there were virilizing signs and symptoms.
Even before a pelvic exam is done, the primary consideration if this
were an ovarian pathology is:
a. epithelial tumor
b. germ cell tumor
c. sex-cord stromal tumor
d. metastatic tumor

Hormonally active tumors of the ovary are usually the sex

cord stromal type (those arising from granulosa cells and
theca cells.
Hormonal effect could either be estrogenic (can present as
bleeding or precocious puberty) or virilizing.

Question
74. A 27 y.o. primigravid consults at the ER for vaginal
spotting of one week duration. She has an amenorrhea
of 10 weeks. On pelvic exam, you note the uterus to be
boggy and enlarged to 20 weeks age of gestation.
Ultrasound showed an endometrial mass with snowstorm
pattern. Best management for this case would be:

a. subtotal hysterectomy
b. total hysterectomy
c. suction curettage
d. dilatation and curettage

Answer
74. A 27 y.o. primigravid consults at the ER for vaginal spotting of one
week duration. She has an amenorrhea of 10 weeks. On pelvic
exam, you note the uterus to be boggy and enlarged to 20 weeks
age of gestation. Ultrasound showed an endometrial mass with
snowstorm pattern. Best management for this case would be:
a. subtotal hysterectomy
b. total hysterectomy
c. suction curettage
d. dilatation and curettage

Hydatidiform mole is usually diagnosed bu ultrasound.

Pathognomonic is the snowstorm pattern. Treatment
consists of suction curettage (conservative). Those no
longer desirous of pregnancy can have total
hysterectomy with mole-in-situ.

Question
75. According to the American Cancer
Society Guidelines for Cervical Cancer
Screening, screening using Pap smear
should be started
a. age 12
b. age 18
c. age 21
d. once the woman is sexually active

Answer
75. According to the American Cancer Society Guidelines
for Cervical Cancer Screening, screening using Pap
smear should be started
a. age 12
b. age 18
c. age 21
d. once the woman is sexually active
Based on the 2003 American Cancer Society guidelines,
screening should start 3 years after onset of vaginal
intercourse or no later than 21 years old.
Discontinuation is recommended at age 70 after 3 normal
smears in the preceding 10 years.

Question
76. In low resource settings like the
Philippines, this has become an
acceptable method of cervical cancer
screening:
a. Schillers test
b. Toluidine blue test
c. 4-quadrant cervical biopsy
d. visual inspection with acetic acid

Cervical Cancer Screening

Visual inspection with acetic acid has become the
alternative screening method in low resource settings.
The DOH has made a policy formulation making this
as the screening method of choice for the Filipino
woman based on validity and economic studies.
Schillers test is the use of Lugols iodine in the cervix.
In glycogen-rich areas, the cervix will turn brown which is
the normal result (reaction of glycogen and the
iodine).No or partial uptake of Lugols is a positive result.
Toluidine blue test is for the vulva.
Four quadrant biopsy is no longer done.
When there is already a gross lesion in the cervix, there
is no need to do Pap smear or a screening method,
biopsy should be done.

Answer
76. In low resource settings like the Philippines,
this has become an acceptable method of
cervical cancer screening:
a. Schillers test
b. Toluidine blue test
c. 4-quadrant cervical biopsy
d. visual inspection with acetic acid

Question
77. Staging of ovarian cancer is:
a. clinical
b. surgicopathologic
c. clinicopathologic
d. histopathologic

Answer
77. Staging of ovarian cancer is:
a. clinical
b. surgicopathologic
c. clinicopathologic
d. histopathologic

Gynecologic Infections
Question
78. Speculum exam of a 27 y.o. complaining
of leucorrhea showed copious frothy
greenish vaginal discharge with
strawberry-like mucosa. This is most likely
due to:
a. candidiasis
b. trichomoniasis
c. gonococcal infection
d. bacterial vaginosis

Gynecologic Infections: Candidiasis

caused by ubiquitous, airborne, gram positive fungus.

Most common is Candida albicans. Candida species are
part of the normal flora of 25 % of women.
When the ecosystem of the vagina is disturbed, C.
albicans becomes an opportunistic pathogen (e.g. when
lactobacilli concentration declines).
NOT usually associated with other STDs and is itself
not considered an STD.
predominant symptom is pruritus.
Vaginal discharge is white or whitish gray, granular or
floccular (like curd milk or cottage-cheese type
discharge).
Ph is usually below 4.5.
Treatment: oral or topical azoles

Gynecologic Infections:Trichomoniasis
an STD with the protozoa isolated also in male partners.
Incubation is 4 to 28 days. It is a hardy organism and
can survive for hours on towels and moist surfaces.
A basic pH promotes the infection.
Primary symptom is profuse vaginal discharge making
patients feel wet.
Discharge is color white, gray, yellow or green. Classic
description is frothy (with bubbles) and with unpleasant
odor.There is also erythema even of the vulva. The
classic strawberry appearance of the upper vagina and
the cervix is rare.
Treatment: oral metronidazole including partner.

Gynecologic Infections: Bacterial Vaginosis

high concentrations of anaerobic bacteria
predominate in the vaginal flora by replacing the
normal lactobacillus.
Associated organism is Gardnerella vaginalis.
is not invariably an STD but may be sexually
transmitted.
Discharge is thin and gray-white. Patients
describe a musty or fishy smell.
Clue cells are the findings on wet smear are
epithelial cells with clusters of bacteria.
Treatment: oral metronidazole

Gynecologic Infections: Gonoccoccal

Gonoccoccal infection in the majority of
women are asymptomatic.
Some would present with mucopurulent
cervicitis.
Thayer-Martin culture media is the
diagnostic standard.
Treatment: ceftriaxone 125 mg IM including
the partner

Answer
78. Speculum exam of a 27 y.o. complaining
of leucorrhea showed copious frothy
greenish vaginal discharge with
strawberry-like mucosa. This is most likely
due to:
a. candidiasis
b. trichomoniasis
c. gonococcal infection
d. bacterial vaginosis

Question
79. In a patient with mucopurulent cervicitis,
the patient is also given doxycycline to
take care of:
a. Neisseria gonorrhea
b. Ureaplasma urealyticum
c. Chlamydia trachomatis
d. Gardnerella vaginalis

Answer
79. In a patient with mucopurulent cervicitis, the patient is
also given doxycycline to take care of:
a. Neisseria gonorrhea
b. Ureaplasma urealyticum
c. Chlamydia trachomatis
d. Gardnerella vaginalis
In 50 % of cases, gonococcal infection is accompanied by
Chlamydia trachomatis which is an indolent infection.
Doxycyline is the drug of choice for Chlamydia
trachomatis.

Question
80. Which of the following is not considered
a sexually transmitted disease?
a. Candidiasis
b. Trichomoniasis
c. Syphilis
d. Genital warts

Answer
80. Which of the following is not considered a
sexually transmitted disease?
a. Candidiasis
b. Trichomoniasis
c. Syphilis
d. Genital warts
Trichomoniasis, Syphylis, and genital warts caused by
human papilloma virus are all considered STDs.

Question
81. A 20 y.o. commercial sex worker came
to you because of multiple, pruritic warty
masses at the vulva. The largest
measured 2 x 3 cm. Causative agent of
these warts:
a. pox virus
b. bacterial
c. treponemes
d. human papilloma virus

Answer
81. A 20 y.o. commercial sex worker came to you because of multiple,
pruritic warty masses at the vulva. The largest measured 2 x 3 cm.
Causative agent of these warts:
a. pox virus
b. bacterial
c. treponemes
d. human papilloma virus
Genital warts are caused by the low risk types of human papillomavirus
(HPV). Most common are types 6 and 11.
HPV types 16 and 18 are the two most common high risk oncogenic types
leading to cervical cancer.

The Human Papilloma Virus

99.7 % of women with cervical cancer
are positive for HPV.
Wallboomers JM et al, J Pathol 1999; 189:12-19Bosch FX et
al J Clin Pathol 2002; 55: 244-265

HPV is the NECESSARY CAUSE of

cervical cancer.
Persistent infection with the oncogenic or
high risk HPV types can lead to cervical
cancer.

The HPV
HPV is a very common infection, though
most infected individuals eliminate
evidence of the virus without ever
developing clinically recognized
manifestations.
Thus, very few HPV-infected individuals
progress to invasive cervical cancer.

Estimated World Burden of HPVRelated Disease

and Diagnoses
Cervical cancer: 0.493 million in 2002
1

typ
es
HP
V

on
on
co
ge
nic

to
n
uta
ble

Low-grade cervical lesions:

30 million2
Genital warts: 30 million3

HPV infection
without detectable
abnormalities:
300 million2

At
trib

At
trib
uta
ble

to
on
co
ge
nic

HP
V

typ
es

High-grade precancerous lesions:

10 million2

1. Parkin DM, Bray F, Ferlay J, Pisani P. CA Cancer J Clin. 2005;55:74108. 2. World Health Organization. Geneva,
Switzerland: World Health Organization; 1999:122. 3. World Health Organization. WHO Office of Information. WHO
Features. 1990;152:16.

Prevention

Primary and secondary prevention

Primary prevention
measures used in people
with no clinical evidence
of disease to prevent
disease developing e.g.
vaccines
Human
papillomavirus
(HPV) infection

Normal

Vaccines
Screening

Secondary prevention
treatments used in
people with evidence of a
disease action to slow
or stop the progress of a
disease during its early
stages

Persistence

Vaccines

Pre-cancerous
lesions

Invasive
cancer

Prevention
Vaccination has great potential
Vaccination should be a primary prevention
tool, integrated with any existing screening
programmes for early detection of cervical
cancer

HPV Types in Cervical Cancer

Worldwide
HPV genotype
16
18
45
31
33
52
58
35
59
56
51
39
68
73
82
Other
X

53.5
17.2
6.7
2.9
2.6
2.3
2.2
1.4
1.3
1.2
1.0
0.7
0.6
0.5
0.3
1.2

53.5%
70.7%
77.4%
80.3%

Vaccine
types

4.4
0

10

20

30

40

50

60

70

80

90

100

Cancer cases attributed to the most frequent HPV genotypes (%)

Munoz N et al. Int J Cancer 2004;111:27885.

Vaccine profiles

Cervarix
HPV 16/18 vaccine

Gardasil
HPV 6/11/16/18 vaccine

GlaxoSmithKline

MSD

Per dose

0.5 mL Per dose

0.5 mL

Females
Target: 1055 years
Studies 1055 years
5.5 years follow-up for HPV
16/18

Females and males

Target: 926 years
Studies 1045 years

Cancer focus
Pure cervical cancer vaccine

Cancer and STD

Dual cervical cancer and genital
warts vaccine

L1 HPV 16
L1 HPV 18
Intramuscular

L1 HPV 6
L1 HPV 11
20 g L1 HPV 16
20 g L1 HPV 18
0, 1, 6 mths Intramuscular

20 g
40 g
40 g
20 g
0, 2, 6 mths

Expected Benefits of HPV Vaccines

HPV 6/11/16/18 Vaccine (Gardasil)
Reduce infection with HPV types associated with over
90% of condyloma acuminata
Reduce/eliminate Recurrent Respiratory Papillomatosis
in young children
Reduce/eliminate the psycho-social-financial burden of
external genital warts

Reduce infection with HPV types associated with

about 65-70% of cervical cancers.

Expected Benefits of HPV Vaccines

GSK HPV 16/18 Candidate Vaccine
The same benefits, except those derived from
protection against HPV 6 or 11.
Preliminary evidence of cross-protection against other
HPV types (Types 45 and 31).

WHO position on HPV vaccines

Recommends routine HPV vaccination be
included in national immunization programs
provided that
-prevention of cervical cancer and other HPVrelated diseases is a public health priority in the
country,
-vaccine introduction is programmatically feasible,
-sustainable financing can be secured, and
-cost-effectiveness of vaccine strategies in the
country is considered

WHO position on HPV vaccines

HPV vaccines are most efficacious in
females nave to vaccine-related HPV
types, therefore, the primary target
population should be selected based on
the age of initiation of sexual activity and
the feasibility of reaching young
adolescent girls through schools and
communities
Likely 9-10 through 13 years old

WHO position on HPV vaccines

Vaccination of secondary target population of
older adolescent women and older age group
is recommended only if this is feasible,
affordable, cost-effective, and with big portion of
these secondary target population as nave to
HPV
Male vaccination is not recommended because
of low cost-effectiveness.
Limited information on use of the vaccine on
pregnant women and immunocompromised

Question
82. The most accurate method of diagnosing
acute PID is:
a. history
b. pelvic examination
c. ultrasound
d. diagnostic laparoscopy

Answer
82. The most accurate method of diagnosing acute
PID is:
a. history
b. pelvic examination
c. ultrasound
d. diagnostic laparoscopy
The diagnostic standard for PID is laparoscopy.

Question
83. A 48 y.o. G3P3 (3003) consulted at the Out
Patient Clinic for menometrorrhagia since 5
months ago. Pelvic exam showed a corpus
irregularly enlarged to 16 weeks size. Ultrasound
showed multiple myoma uteri. Best treatment
option for this patient would be:
a. THBSO
b. myomectomy
c. GnRH agonist
d. progestin supplementation

Benign Gyn Lesion: Myoma

In a patient with completed family size and with
advancing age (some use 45 as cut off), myomas are
managed by doing THBSO.
If this same patient were 35 y.o. and nulligravid,
myomectomy is the better treatment option because you
want to be conservative and preserve her uterus for
possible future reproduction.
GnRH agonists may be given prior to myomectomy to
shrink the masses and make the planes more
discernible, thus, helping in doing a successful
myomectomy.
Progestins are not used to treat myomas.
Small myomas (not causing bleeding, obstruction or
uterine enlargement) may be observed.

Answer
83. A 48 y.o. G3P3 (3003) consulted at the Out
Patient Clinic for menometrorrhagia since 5
months ago. Pelvic exam showed a corpus
irregularly enlarged to 16 weeks size. Ultrasound
showed multiple myoma uteri. Best treatment
option for this patient would be:
a. THBSO
b. myomectomy
c. GnRH agonist
d. progestin supplementation

Question
84. A 35 y.o. G3P3 (3003) consults at the Emergency
Room for severe abdominal pain. Pelvic examination
reveals a vague mass at the left adnexal area. But a
thorough examination is difficult due to guarding. On
exploratory laparotomy, the left ovary is converted to a 6
x 8 cm cystic mass with a 1 cm point of rupture extruding
brownish fluid. Best management for this case would be:
a. left oophorocystectomy
b. left salpingo-oophorectomy
c. TH, LSO
d. THBSO

Benign Gyn Lesion: Endometriosis

Chocolate or brownish fluid from the ovary is a
characteristic of endometiosis/endometriotic cyst.
In young patients far from menopause, cystectomy can
be done for endometriotic cysts. The same is true for
dermoid cysts and mature cystic teratomas.
In patients with severe endometriosis, completion
surgery with THBSO may have to be done even if with
younger age (case to case).
Epithelial, germ cell except dermoid, and sex-cord
stromal tumors would warrant a salpingo-oophorectomy.

Answer
84. A 35 y.o. G3P3 (3003) consults at the Emergency
Room for severe abdominal pain. Pelvic examination
reveals a vague mass at the left adnexal area. But a
thorough examination is difficult due to guarding. On
exploratory laparotomy, the left ovary is converted to a 6
x 8 cm cystic mass with a 1 cm point of rupture extruding
brownish fluid. Best management for this case would be:
a. left oophorocystectomy
b. left salpingo-oophorectomy
c. TH, LSO
d. THBSO

Question
85. A 36 y.o. G1P1 (1001) consulted for menorrhagia of
one year duration. Internal examination showed a
globular uterus symmetrically enlarged to 14 weeks size.
Sonographic impression was consistent with
adenomyosis. Definitive management consists of:
a. continuous low-dose oral contraceptive pills
b. GnRH agonists
c. DMPA injections
d. total hysterectomy

Answer
85. A 36 y.o. G1P1 (1001) consulted for menorrhagia of
one year duration. Internal examination showed a
globular uterus symmetrically enlarged to 14 weeks size.
Sonographic impression was consistent with
adenomyosis. Definitive management consists of:
a. continuous low-dose oral contraceptive pills
b. GnRH agonists
c. DMPA injections
d. total hysterectomy
There is no effective medical management for
adenomyosis. Definitive treatment is total hysterectomy.

Question
86. A 6 y.o. child underwent exploratory
laparotomy for an ovarian cyst. The most
common finding is:
a. serous cystadenoma
b. dysgerminoma
c. dermoid cyst
d. physiologic ovarian cyst

Answer
86. A 6 y.o. child underwent exploratory
laparotomy for an ovarian cyst. The most
common finding is:
a. serous cystadenoma
b. dysgerminoma
c. dermoid cyst
d. physiologic ovarian cyst

Question
87. Endometriosis in this location suggests
iatrogenic dissemination:
a. spinal column
b. anterior abdominal wall
c. cul de sac
d. ovary

Answer
87. Endometriosis in this location suggests
iatrogenic dissemination:
a. spinal column
b. anterior abdominal wall
c. cul de sac
d. ovary

Question
88. Theca lutein cysts may be found in the
following conditions:
a. gestational trophoblastic diseases and
hyperthyroidism
b. acute renal failure and syphilis infection
c. diabetes mellitus and hypertension
d. multiple gestation and tuberculosis

Answer
88. Theca lutein cysts may be found in the
following conditions:
a. gestational trophoblastic diseases and
hyperthyroidism
b. acute renal failure and syphilis infection
c. diabetes mellitus and hypertension
d. multiple gestation and tuberculosis
Similarities in the structure of the alpha subunit of
hCG with the TSH make this possible.

Question
89. The use of combined oral contraceptives
will protect a woman from
a. ovarian cancer
b. breast cancer
c. cervical cancer
d. liver cancer

Question
89. The use of combined oral contraceptives
will protect a woman from
a. ovarian cancer
b. breast cancer
c. cervical cancer
d. liver cancer

Answer
89. The use of combined oral contraceptives will protect a
woman from
a. ovarian cancer
b. breast cancer
c. cervical cancer
d. liver cancer
The incessant ovulation theory for ovarian cancer is
counteracted by OCPs (mechanism: prevents ovulation
by suppression of the hypothalamic gonadotrophin
releasing hormones).
OCPs are also considered protective for endometrial
cancer.

Question
90. A 21 y.o. G2P2 (2002) is interested to learn the
use of rhythm method. She reports that for the
past year, her longest cycle was 38 days while
the shortest was 24 days. Abstinence should be
observed during the following days of her cycle:
a. day 17 to 23
b. day 8 to 21
c. day 6 to 27
d. day 15 to 20

Answer
90. A 21 y.o. G2P2 (2002) is interested to learn the use of
rhythm method. She reports that for the past year, her
longest cycle was 38 days while the shortest was 24
days. Abstinence should be observed during the
following days of her cycle:
a. day 17 to 23
b. day 8 to 21
c. day 6 to 27
d. day 15 to 20

Rhythm method: Subtract 11 from longest cycle.

Subtract 18 from the shortest cycle. The range
should be the abstinence period.

Question
91. The following are known effects of OCP
except:
a. reduced maternal blood loss and
anemia
b. increased risk of ectopic pregnancy
c. improvement of acne
d. decreased risk of endometrial and
ovarian cancer

Oral Contraceptives Effects

As a result of the antiestrogenic action of the progestin component

of the OCP, the height of the endometrium is less than in an
ovulatory cycle (less proliferation). This results in reduction in the
amount of blood loss at the time of endometrial shedding.

OCPs are also preventive against pelvic inflammatory disease,

thus ectopic pregnancies are also lessened. Likewise, by virtue of
the lower rate of pregnancies, ectopic pregnancy risk is also
reduced.

The less androgenic progestin preparations as seen in third

generation pills have been shown to improve acne.

OCP use because of the anti-estrogenic progestin is protective

against endometrial cancer. It is also protective against ovarian
cancer because of the break in ovulation.

OCP use, however, is a risk factor for cervical cancer (based on

case-control studies).

Question
92. A 25 y.o. primipara is desirous of family
planning. She is 2 months postpartum and
claims to have been partially
breastfeeding. The best method would be:
a. progestin-only pills
b. combined OCP
c. lactation amenorrhea
d. bilateral tubal ligation

Answer
92. A 25 y.o. primipara is desirous of family planning. She
is 2 months postpartum and claims to have been partially
breastfeeding. The best method would be:
a. progestin-only pills
b. combined OCP
c. lactation amenorrhea
d. bilateral tubal ligation

For breastfeeding women, the only allowable OCP is the progestinonly pill (POP). This does not interfere with milk production unlike
the regular OCPs.
Lactation amenorrhea can be considered a family planning
method if the mother breastfeeds fully her baby. This is up to 98 %
effective in the first 6 months post-delivery.

Question
93. How many weeks postpartum is
menstruation expected to return in a nonbreastfeeding woman?
a. 1 to 2 weeks
b. 3 to 4 weeks
c. 6 to 8 weeks
d. 12 to 14 weeks

Answer
93. How many weeks postpartum is
menstruation expected to return in a nonbreastfeeding woman?
a. 1 to 2 weeks
b. 3 to 4 weeks
c. 6 to 8 weeks
d. 12 to 14 weeks

Question
94. Who among the following should be
worked up for amenorrhea?
a. 14 y.o. with no breast budding
b. 15 y.o. with breast Tanner stage 2
c. 12 y.o. with breast Tanner stage 3
d. 16 y.o. who had her menarche 4
months ago but is amenorrheic presently

Pubertal Development
1. appearance of breast budding (mean at
10.8 years old)
2. pubic hair after a few months
3. breast enlargement, pelvic contour
rounder, rapid growth rate
4. menarche (after about 2.3 years from
breast budding)

Answer
94. Who among the following should be
worked up for amenorrhea?
a. 14 y.o. with no breast budding
b. 15 y.o. with breast Tanner stage 2
c. 12 y.o. with breast Tanner stage 3
d. 16 y.o. who had her menarche 4
months ago but is amenorrheic presently

Question
95. The pathognomonic symptom of
menopause:
a. wrinkling of skin
b. osteoporosis
c. hot flush
d. decrease in libido

Answer
95. The pathognomonic symptom of
menopause:
a. wrinkling of skin
b. osteoporosis
c. hot flush
d. decrease in libido

Question
96. During the perimenopausal transition,
there is:
a. increased FSH
b. decreased estradiol
c. increased LH
d. increased inhibin

Answer
96. During the perimenopausal transition,
there is:
a. increased FSH
b. decreased estradiol
c. increased LH
d. increased inhibin

Question
97. Which of the following is most effective
in reducing postmenopausal bone loss?
a. weight-bearing exercise
b. calcium supplementation
c. estrogen therapy
d. vitamin D supplementation

Answer
97. Which of the following is most effective
in reducing postmenopausal bone loss?
a. weight-bearing exercise
b. calcium supplementation
c. estrogen therapy
d. vitamin D supplementation

Question
98. In semenalysis, the normal value of
sperm motility is:
a. at least 20 %
b. at least 30 %
c. at least 40 %
d. at least 50 %

Semen analysis
Recommended standards for semen analysis:
Volume
2 mL
pH
7.2-7.8
sperm density
20 x 106/ml
Total sperm count 40 x 106/ml
Sperm motility
50 % with progressive motility
Vital staining
50 % live (exclude dye)
Sperm morphology 50 % normal
White cell count
< 106/mL

Answer
98. In semen analysis, the normal value of
sperm motility is:
a. at least 20 %
b. at least 30 %
c. at least 40 %
d. at least 50 %

Question
99. Among the different causes of infertility,
the treatment of this has the greatest
success rate:
a. ovulatory dysfunction
b. tubal dysfunction
c. male factor
d. uterine pathology

Answer
99. Among the different causes of infertility,
the treatment of this has the greatest
success rate:
a. ovulatory dysfunction
b. tubal dysfunction
c. male factor
d. uterine pathology

Question
100. Rectocoele and cystocoele are usually
due to:
a. relaxation of musculature of the pelvic
floor
b. injury during childbirth
c. infection of the bladder
d. trauma in repair of an episiotomy

Answer
100. Rectocoele and cystocoele are usually
due to:
a. relaxation of musculature of the
pelvic floor
b. injury during childbirth
c. infection of the bladder
d. trauma in repair of an episiotomy

END
Good luck!