Women s Health 2023 A patient who is 35 years old has identified a small discrete mass in one breast How should this be evaluated correct answerOrder a mammogram and ultrasound to assess the mass Clinical evaluation of a breast mass begins with a good history of the mass and a physical exam of the breasts lymph nodes neck and chest wall While asking about whether the mass changes with menses is a good question in history a mammogram should be the first radiographic assessment in females with breast complaints who are over age 30 This patient is 35 years old An ultrasound is used for evaluation of a focal abnormality in a breast especially if it has been identified on a mammogram In this patient both are prudent since there is a discrete palpable mass Re assessing the mass 3 10 days after next menses may be appropriate for a female younger than age 30 depending on her history and physical exam A diagnosis of osteoporosis can be made when correct answerbone mineral density is 2 5 standard deviations below the mean Osteoporosis can be diagnosed with a bone mineral density test BMD The technique used is a dual energy x ray absorptiometry DXA This is the most common clinical tool used to diagnose osteoporosis Osteoporosis can also be diagnosed when there is a fragility fracture This can be identified on x ray In an absence of trauma a fragility fracture may indicate osteoporosis multiple myeloma or other diseases BMD that is 2 5 or more standard deviations below the young adult mean or T score of 2 5 or less constitutes a diagnosis of osteoporosis The recommended time to initiate screening for cervical cancer in women is correct answerat the age of 21 years Prior to 2009 the recommendation for cervical cancer screening was by age 18 years or 3 years after first sexual intercourse American Cancer Society ACS and American College of Obstetricians and Gynecologists ACOG have updated this The current recommendation for cervical screening is age 21 years Cervical cancer is considered extremely rare in patients younger than 21 years A 16 year old female is diagnosed with primary dysmenorrhea She has taken over the counter ibuprofen in 800 mg increments every 8 hours during menses for the past 3 months with minimal relief of symptoms What intervention will provide greatest relief of dysmenorrhea symptoms correct answerCombined oral contraceptives NSAIDs and hormonal contraceptives represent the mainstay of pharmacologic treatment for dysmenorrhea NSAIDs produce an 80 86 response rate when used for dysmenorrhea The general recommendation is that when one agent NSAIDs or hormonal contraceptives does not produce relief of symptoms the other agent should be tried Hence the best choice is oral contraceptives Both agents should be considered for women who are symptomatic with one agent only Which form of birth control presents the highest risk to a female patient if she is exposed to a sexually transmitted disease STD correct answerIUD Exposure to an STD always increases the likelihood of contracting an STD However the patient is at very high risk of developing pelvic inflammatory disease when there is an implanted foreign body An example of this is an intrauterine device IUD The risk is also increased with a diaphragm but because it is not implanted for long periods at a time the risk is less than with an IUD A female patient who takes oral contraceptives has just completed her morning exercise routine She complains of pain in her right calf Her blood pressure and heart rate are normal She is not short of breath Her calf is red and warm to touch What is NOT part of the differential diagnosis correct answerTrochanteric bursitis Trochanteric bursitis does not produce pain in the calf Pain is concentrated in the affected hip While it is not likely that someone who exercises regularly would have a DVT this patient does take oral contraceptives Therefore DVT should always be part of the differential given the potential risks associated with untreated DVT pulmonary embolism A 54 year old female presents with a small to moderate amount of vaginal bleeding of recent onset She has been postmenopausal for approximately 2 years What diagnosis is least likely correct answerOvarian cancer Ovarian cancer may present as an adnexal mass pelvic or abdominal symptoms and a variety of others Postmenopausal bleeding PMB is a very uncommon presentation of ovarian cancer but can present this way In women with PMB other causes of uterine pathology should be evaluated before considering ovarian pathology In early menopause the most common etiology is atrophy of the endometrium or vaginal mucosa This patient is postmenopausal for approximately 2 years Other common causes of PMB are polyps fibroids and endometrial hyperplasia After a vaginal exam a patient received a prescription for metronidazole What was her likely diagnosis correct answerTrichomonas Trichomonas can be treated with metronidazole orally This is usually effective and is generally well tolerated as long as the patient avoids alcohol Alcohol in the presence of metronidazole can produce a disulfiram reaction Another medication used to treat trichomonas is tinidazole The exact mechanism of tinidazole is unknown but is an antiprotozoal A patient asks the NP s advice about an herb to help with her hot flashes The NP knows these correct answermay be contraindicated in patients with history of breast cancer The herb that the patient is asking about is probably black cohosh Actaea racemosa It is a phytoestrogen This means that it provides estrogen from a plant source If estrogen is contraindicated in a patient then it does not matter whether it comes from plants or is produced synthetically There is a potential safety concern in using black cohosh in women with breast cancer or who are at high risk of breast cancer because of the estrogenic effects that are possible on the breasts A 28 year old female presents with a slightly tender 1 5 cm lump in her right breast She noticed it two days ago She has no associated lymphadenopathy and there is no nipple discharge How should she be managed correct answerRe examination after her next menses Women who are less than age 35 years who have no associated suspicious findings of breast cancer should delay imaging studies until re examination 3 10 days after the last menstrual period to determine whether the lump changes in size or becomes non palpable If there are associated suspicious findings on exam like palpable nodes