obg: Pediatric and Adolescent Gynecology (share)

What is the effect that counts for the differentiation of the gonads?

A) testosterone

B) estrogen

C) sex chromosome

D) hypophyseal hormones

C) sex chromosome

EXPLANATION

Differentiation of the gonads occurs after the 7^th pregnancy week from the „indifferent” gonads determined by the sex chromosomal complex. The differentiation toward testis is initiated by a material encoded by the short arm of the Y-chromosome (TDF: testis determining factor). In the absence of a functional Y-chromosome the gonad will develop to ovary.

In case of primary amenorrhea the first step after general gynecological examination should be:

A) clomiphene test

B) genetical screening

C) estrogen-progesterone test

D) gonadotropin stimulation test

C) estrogen-progesterone test

EXPLANATION

The coordinated operation of the hypothalamus-pituitary-ovary-endometrial axis is essential for regular menstruation. Checking the function of the peripheral target organ should start with clarifying the disturbances in the system. In case of primary amenorrhea the first step to do after general gynecological examination is to induce "withdrawal bleeding" by performing the estrogen-progesterone test. With a responsive endometrial layer, menstruation should appear after the exogenous hormone effect finishes.

Which of the followings is not progesterone effect?

A) endometrial proliferation

B) increase of basal body temperature

C) development of breast acinars

D) endometrial secretion

A) endometrial proliferation

EXPLANATION

Cyclic genital function in women is fundamentally influenced by estrogen and progesterone. Typical progesterone effects are basal body temperature elevation and endometrial secretion, whereas endometrial proliferation occurs in the first half of the cycle due to estrogen action.

In adolescents, secondary amenorrhea is defined as missing the menstrual period for at least:

A) 2 months

B) 4 months

C) 6 months

D) 12 months

C) 6 months

EXPLANATION

In adolescence, regular menstrual cycles develop gradually with the hypothalamic-pituitary-ovary-endometrial axis. Delicate disturbances may still occur in the system at this age, but most of these cases gradually disappear spontaneously. The specificity of this period is also reflected in the definition that in adolescents we are talking about secondary amenorrhea when the period is missing for at least 6 months, in contrast with adulthood, where this time-interval is only 3 months.

The estimated amount of an average menstruation is about:

A) 10-15 ml

B) 25-50 ml

C) 75-100 ml

D) 100-120 ml

B) 25-50 ml

EXPLANATION

The amount of menstrual bleeding can be estimated based on the number of bleeding days, the presence of larger blood clots and the number of used pads/tampons. The average amount is approximately 25-50 ml. Women using oral contraceptives usually have less menstrual bleeding than women with non-hormonal intrauterine devices.

The origin of lutein cells:

A) theca externa

B) theca interna

C) granulosa cells

D) corona radiata

C) granulosa cells

EXPLANATION

Stromal cells outside the basal lamina create the theca externa and interna. Lutein cells form from the granulocyte cells within the basal membrane.

The most frequent malignant tumor in adolescents is:

A) cervical cancer

B) clear cell adenocarcinoma of the vagina

C) ovarian cancer

D) rhabdomyosarcoma

C) ovarian cancer

EXPLANATION

Malignant tumors of female genital organs in adolescence are rarely seen. Endometrial cancer does not occur at all, cervical cancer is extremely rare at this age group, although the early start of sexual activity allows early HPV exposure in the latter group. Malignant ovarian tumors are the most common, but these are age-specific tumors (granulosa cell tumor, dysgerminomas, etc.), not characteristic for adults. The clear-cell adenocarcinoma of the vagina may occur where diethylstilbestrol treatment has been routinely used in cases of threatening abortion. Fortunately, in Hungary this therapy was not used.

A 17-year-old girl underwent transabdominal ultrasound scan due to the reason of cystopyelitis. A simple ovarian cyst measuring 4,5 x 3,5 cm was detected. The next step in the management should be:

A) start to use combined oral contraceptive pill

B) repeat the ultrasound scan after 1 month

C) ultrasound guided transvaginal/transabdominal punction

D) laparoscopy

B) repeat the ultrasound scan after 1 month

EXPLANATION

Most of the ovarian cysts seen in adolescents are simplex functional retention cysts. Vast majority of them are absorbed within 1 to 2 months, and generally no intervention is needed within a diameter of 5 cm. Larger cysts can be also observed without any risk in the patient does not have any complain. Ultrasound evaluation should be repeated one month later and further steps should be decided afterwards. Ovarian cysts occur less frequently when taking oral contraceptive pills, but in case of an existing cyst the onset of the tablet has not been proven effective. Ultrasound guided transvaginal/transabdominal puncture is an easy-to-perform, less invasive procedure for treating persistent or growing cysts, but recurrence is very common, so laparoscopic cystectomy can be suggested as a definitive solution.

Which of the following is not characteristic for Turner’s-syndrome?

A) pigmented nevus

B) hypoplastic fingernails and toenails

C) incidence is increasing in newborns with maternal age

D) high-arched roof of mouth

C) incidence is increasing in newborns with maternal age

EXPLANATION

In addition to the typical symptoms described by Turner in 1938, several other minor features can be found in the syndrome, such as pigmented nevus, hypoplastic nails and arcuated palate, but X-monosomy is the consequence of an abnormality in spermatogenesis, so the frequency with maternal age does not increase significantly.

Which of the followings is not characteristic for polycystic ovarian syndrome?

A) increased GnRH pulsatoric frequency

B) increased LH/FSH ratio

C) increased estradiol/estron ratio

D) increased DHEAS level (dehydroepiandrosterone-suphate)

C) increased estradiol/estron ratio

EXPLANATION

LH-hypersecretion is a diagnostic criteria in polycystic ovarian syndrome, while hyperandrogenism is responsible for hirsutism. Recent data have demonstrated increased GnRH pulsation frequency. Estradiol level is decreased in polycystic ovarian syndrome.

With a short history of existing acute abdominal complaints, a 16-year virgin girl was admitted. Based on the complaints and the physical examination, diagnostic laparoscopy was performed and the torsion of the right adnexa was detected with blue-colored ovaries. The best solution during surgery:

A) salpingo-oophorectomy

B) detorsion of the ovary and wait until normal color returns

C) converting to laparotomy, detorsion and resection of the ovary

D) converting to laparotomy, salpingo-oophorectomy

B) detorsion of the ovary and wait until normal color returns

EXPLANATION

Possible complications of ovarian cysts are: rupture, bleeding and adnexal torsion. The torsion of the adnexa may also occur in case of a healthy ovary, but most often the cystic ovary (and the Fallopian-tube) are torquated. Due to anatomical conditions, young people are at increased risk. In case of suspected adnexal torsion, surgical intervention is indicated, as its persistence may cause irreversible damage to the adnexa. First, venous flow decreases, the adnexa swells and then arterial blood supply is damaged. Early surgery and resolving the torquation is the only way to save the ovary. According to the principles of minimally invasive surgery, laparoscopy is the optimal solution. Based on the available data, resection of smaller cysts is not necessarily recommended; recurrent torsion practically does not occur. Of course, larger cysts can be removed, and if the technical conditions are not met, laparotomy is the solution to be chosen. However, we must always strive for the conservation of the ovary.

Which of the followings is frequently related to hematometra?

A) polycystic ovarian syndrome

B) hirsutism

C) endometriosis

D) adnexal torsion

C) endometriosis

EXPLANATION

During adolescence those developmental disorders where the menstrual fluid pathway is blocked can result hematometra. In older age, closure of the cervix after cervical surgeries can cause similar problems. In these cases, the menstrual secretion appears in the abdominal cavity through the Fallopian tube. Endometrial parts here can be implanted and may lead to the development of endometriosis.

Which organs are formed from the Müllerian-tube?

1) the fallopian tubes

2) lower third of the vagina

3) uterus

4) ovaries

A) 1st, 2nd and 3rd answers are correct

B) 1st and 3rd answers are correct

C) 2nd and 4th answers are correct

D) only 4th answer is correct

E) all of the answers are correct

B) 1st and 3rd answers are correct

1) the fallopian tubes

3) uterus

EXPLANATION

The Müllerian-tube is formed in the sixth embryonic week. It is bypassing the Wolffian-tube medially and the lower part of it is united with the contralateral Müllerian-tube. This union will form the uterovaginal canal, of which the uterus, the upper two-third of the vagina and the two Fallopian tubes will develop.

Mild hirsutism is influenced favorably by combined oral contraceptives because:

1) LH-regulated androgen produce is decreased

2) SHBG level elevates

3) free testosterone level decreases

4) androgen produce of the suprarenal gland is decreased

A) 1st, 2nd and 3rd answers are correct

B) 1st and 3rd answers are correct

C) 2nd and 4th answers are correct

D) only 4th answer is correct

E) all of the answers are correct

E) all of the answers are correct

1) LH-regulated androgen produce is decreased

2) SHBG level elevates

3) free testosterone level decreases

4) androgen produce of the suprarenal gland is decreased

EXPLANATION

The main effect of oral contraceptives is blocking ovulation, but they have a lot of beneficial and some unfavorable side effects. One of the preferred side effects is the beneficial effect on mild hirsutism, which is resulted by several pathways: decreasing LH-regulated androgen production, increasing SHBG levels, decreasing free testosterone levels and decreasing androgen production of the adrenal gland.

Diagnostic criteria of bacterial vaginosis:

1) greyish-white adherent vaginal secretion

2) positive KOH-test (amin-test)

3) presence of „clue-cells”

4) vaginal pH is less than 4,5

A) 1st, 2nd and 3rd answers are correct

B) 1st and 3rd answers are correct

C) 2nd and 4th answers are correct

D) only 4th answer is correct

E) all of the answers are correct

A) 1st, 2nd and 3rd answers are correct

1) greyish-white adherent vaginal secretion

2) positive KOH-test (amin-test)

3) presence of „clue-cells”

EXPLANATION

Bacterial vaginosis is a common form of vulvovaginitis. Its essence is a significant increase in the number of anaerobe bacteria due to changes in the endogenous flora of the vagina. To set up the diagnosis the classic four criteria are: greyish-white adhesive vaginal secretion, positive KOH test (amin-test), presence of "clue cells" and vaginal pH above 4.5. Of these, the nature of the secretion and the immediate pH-test can help in quick diagnosis.

Characteristics of Chlamydia trachomatis infection:

1) mucopurulent cervicitis

2) the infection is frequently asymptomatic

3) parallel treatment of the partner is necessary

4) risk of HIV infection is higher

A) 1st, 2nd and 3rd answers are correct

B) 1st and 3rd answers are correct

C) 2nd and 4th answers are correct

D) only 4th answer is correct

E) all of the answers are correct

E) all of the answers are correct

1) mucopurulent cervicitis

2) the infection is frequently asymptomatic

3) parallel treatment of the partner is necessary

4) risk of HIV infection is higher

EXPLANATION

Chlamydia trachomatis infection is the most frequently occurring sexually transmitted infection in developed countries. Beside its frequency the significance of it is pelvic inflammation caused by ascending infection and its late consequences. The diagnosis is greatly complicated by the often-asymptomatic infection. If a clinical symptom is present, it is most commonly mucopurulent cervicitis. Like in all sexually transmitted infections, it is recommended to treat the partner as well, and we must count on the simultaneous presence of other infections.

Most common causes of cervicitis:

1) Neisseria gonorrhoeae

2) Trichomonas vaginalis

3) Chlamydia trachomatis

4) Candida albicans

A) 1st, 2nd and 3rd answers are correct

B) 1st and 3rd answers are correct

C) 2nd and 4th answers are correct

D) only 4th answer is correct

E) all of the answers are correct

B) 1st and 3rd answers are correct

1) Neisseria gonorrhoeae

3) Chlamydia trachomatis

EXPLANATION

The most common cause of cervicitis is Chlamydia trachomatis and Neisseria gonorroeae, more rarely herpes simplex virus, Mycoplasma hominis, Ureaplasma urealyticum and group B streptococci. Their significance is pelvic inflammation that is caused by ascension and its subsequent consequences. In case of vulvovaginitis only local lesions occur, mainly due to changes in the endogenous flora of the vagina, two examples of them are Trichomonas vaginalis and Candida albicans infection.

Applicable medications to treat uncomplicated Chlamydia trachomatis infection:

1) doxycycline

2) erythromycin

3) azithromycin

4) clindamycin

A) 1st, 2nd and 3rd answers are correct

B) 1st and 3rd answers are correct

C) 2nd and 4th answers are correct

D) only 4th answer is correct

E) all of the answers are correct

E) all of the answers are correct

1) doxycycline

2) erythromycin

3) azithromycin

4) clindamycin

EXPLANATION

For the treatment of uncomplicated Chlamydia trachomatis infection, doxycycline is usually the first line of therapy, while pregnant women should be treated with erythromycin. In addition to several other antibiotics, azithromycin and clindamycin are also suitable for the treatment.

In case of juvenile vaginal bleeding we should consider the following conditions:

1) foreign body in the vagina

2) botryoid sarcoma

3) isosexual pubertal praecox

4) endometrial cancer

A) 1st, 2nd and 3rd answers are correct

B) 1st and 3rd answers are correct

C) 2nd and 4th answers are correct

D) only 4th answer is correct

E) all of the answers are correct

A) 1st, 2nd and 3rd answers are correct

1) foreign body in the vagina

2) botryoid sarcoma

3) isosexual pubertal praecox

EXPLANATION

The most common causes of vaginal bleeding in childhood include: vaginal foreign body, injury and recurrent vulvovaginitis. Malignant tumors fortunately occur rarely, but at this age we need to consider botryoid sarcoma of the vagina or the cervix. In case of early sexual development regular menstrual periods may also occur, but exogenous hormone intake can cause vaginal bleeding, as well. Endometrial cancer does not occur in childhood.

Malignant ovarian tumors originated from germ cells include:

1) dysgerminoma

2) choriocarcinoma

3) endodermal sinus tumor

4) granulosa-cell tumor

A) 1st, 2nd and 3rd answers are correct

B) 1st and 3rd answers are correct

C) 2nd and 4th answers are correct

D) only 4th answer is correct

E) all of the answers are correct

A) 1st, 2nd and 3rd answers are correct

1) dysgerminoma

2) choriocarcinoma

3) endodermal sinus tumor

EXPLANATION

Malignant epithelial ovarian cancer is rarely present in adolescence; most of the tumors are originated from germ cells. This includes dysgerminoma, choriocarcinoma, endodermal sinus tumor, malignant teratomas and gonadoblastoma. Granulosa cell tumors can be classified as a stromal tumor and is often associated with isosexual pubertal praecox.

The cytology smear below is characteristic for which phase?

A) early follicular phase

B) late follicular phase

C) early luteal phase

D) late luteal phase

OBG - 1.28 - Mainly surface cells are visible; number of cells from the intermedier layer is small.

OBG - 1.29 - Some of the cells of the intermediate layer are located in smaller groups, the edges of the cells curl, the number of cells of the superficial layer decreases.

OBG - 1.30 - Mainly isolated cells of the intermediate layer are seen, with less superficial and parabasal cells.

OBG - 1.31 - Pronounced group formation in the intermediate layer, the number of cells in the superficial layer is low.

OBG - 1.28 - Mainly surface cells are visible; number of cells from the intermedier layer is small. - B) late follicular phase

OBG - 1.29 - Some of the cells of the intermediate layer are located in smaller groups, the edges of the cells curl, the number of cells of the superficial layer decreases. - C) early luteal phase

OBG - 1.30 - Mainly isolated cells of the intermediate layer are seen, with less superficial and parabasal cells. - A) early follicular phase

OBG - 1.31 - Pronounced group formation in the intermediate layer, the number of cells in the superficial layer is low. - D) late luteal phase

Pair intrauterine drug exposure with possible side effects.

A) adenocarcinoma of the vagina

B) disorder in the development of the bones

C) aplasia cutis

D) masculinization of the female fetus

E) deafness

OBG - 1.32 - Progesterone

OBG - 1.33 - Diethylstilbestrol

OBG - 1.34 - Tetracycline

OBG - 1.35 - Streptomycin

OBG - 1.36 - Methimazole

OBG - 1.32 - Progesterone - D) masculinization of the female fetus

OBG - 1.33 - Diethylstilbestrol - A) adenocarcinoma of the vagina

OBG - 1.34 - Tetracycline - B) disorder in the development of the bones

OBG - 1.35 - Streptomycin - E) deafness

OBG - 1.36 - Methimazole - C) aplasia cutis

The following statements are characteristic of which stage of sexual maturation?

A) pubarche

B) thelarche

C) menarche

OBG - 1.37 - It occurs for a low amount of oestrogen.

OBG - 1.38 - In Hungary it occurs at 12,4 years of age.

OBG - 1.39 - It is present also in testicular feminization.

OBG - 1.40 - It is the puberty of the suprarenal gland.

OBG - 1.41 - Usually this is the first somatic change during puberty.

OBG - 1.37 - It occurs for a low amount of oestrogen. - B) thelarche

OBG - 1.38 - In Hungary it occurs at 12,4 years of age. - C) menarche

OBG - 1.39 - It is present also in testicular feminization. - B) thelarche

OBG - 1.40 - It is the puberty of the suprarenal gland. - A) pubarche

OBG - 1.41 - Usually this is the first somatic change during puberty. - B) thelarche

Match the statements with the clinical scenario:

A) female pseudo hermaphroditism

B) male pseudo hermaphroditism

C) testicular feminization

D) ovotesticular intersexuality

OBG - 1.42 - At birth, the genital gender is not clear based on the examination of the external genitalia.

OBG - 1.43 - It is typically the result of endogenous or exogenous hormonal effects during pregnancy.

OBG - 1.44 - It is the rarest intersexual disorder.

OBG - 1.45 - It is the consequence of insufficient testicular secretion or target organ reaction.

OBG - 1.46 - This includes the adrenogenital syndrome.

OBG - 1.47 - It is characterized by regular internal female genitalia

OBG - 1.42 - At birth, the genital gender is not clear based on the examination of the external genitalia. - C) testicular feminization

OBG - 1.43 - It is typically the result of endogenous or exogenous hormonal effects during pregnancy. - A) female pseudo hermaphroditism

OBG - 1.44 - It is the rarest intersexual disorder. - D) ovotesticular intersexuality

OBG - 1.45 - It is the consequence of insufficient testicular secretion or target organ reaction. - B) male pseudo hermaphroditism

OBG - 1.46 - This includes the adrenogenital syndrome. - A) female pseudo hermaphroditism

OBG - 1.47 - It is characterized by regular internal female genitalia - A) female pseudo hermaphroditism

Pair homologous male and female organs.

A) gubernaculum testis

B) prostate

C) scrotum

D) vas deferens

E) penis

OBG - 1.49 - major labia

OBG - 1.50 - round ligament

OBG - 1.51 - Gärtner-duct

OBG - 1.52 - clitoris

OBG - 1.49 - major labia - C) scrotum

OBG - 1.50 - round ligament - A) gubernaculum testis

OBG - 1.51 - Gärtner-duct - D) vas deferens

OBG - 1.52 - clitoris - E) penis

Hypothyroidism may cause premature sexual maturation because increased TSH production can coexist with increased GnRH production.

A) both the statement and the explanation are true and a causal relationship exists between them;

B) both the statement and the explanation are true but there is no causal relationship between them;

C) the statement is true, but the explanation is false;

D) the statement is false, but the explanation itself is true

E) both the statement and the explanation are false

A) both the statement and the explanation are true and a causal relationship exists between them;

EXPLANATION

Hypothyroidism can cause premature sexual maturation because increased TSH production may be associated with increased GnRH production, based on the Jules' parallelism theory. Clinical experience suggests that in case of untreated primary hypothyroidism true pubertal praecox might occur.

At birth, the proliferation of estrogen-target organs of female newborns is observed, because the fetal ovary has a temporarily expressed endocrine activity.

A) both the statement and the explanation are true and a causal relationship exists between them;

B) both the statement and the explanation are true but there is no causal relationship between them;

C) the statement is true, but the explanation is false;

D) the statement is false, but the explanation itself is true

E) both the statement and the explanation are false

C) the statement is true, but the explanation is false;

EXPLANATION

At birth, the proliferation of the estrogen target organs (breast swab, witch milk, vaginal discharge) can be observed in female newborns, but this cannot be explained by the temporary endocrine activity of the fetal ovary, but with the gradual clearance of the maternal hormones.

In testicular feminization breasts are well developed because peripheral estrogen transformation is enhanced.

A) both the statement and the explanation are true and a causal relationship exists between them;

B) both the statement and the explanation are true but there is no causal relationship between them;

C) the statement is true, but the explanation is false;

D) the statement is false, but the explanation itself is true

E) both the statement and the explanation are false

C) the statement is true, but the explanation is false;

EXPLANATION

The essence of testicular feminization is the androgen insensitivity, when androgens cannot exert their effect, and thus, male genital mutilation is associated with female phenotype. Breasts are well developed, but the development of the genital hair falls behind for the above reasons.

The small body-stature characteristic of Turner-syndrome is apparent even in early childhood because no regular ovarian tissue can be detected.

A) both the statement and the explanation are true and a causal relationship exists between them;

B) both the statement and the explanation are true but there is no causal relationship between them;

C) the statement is true, but the explanation is false;

D) the statement is false, but the explanation itself is true

E) both the statement and the explanation are false

D) the statement is false, but the explanation itself is true

EXPLANATION

Regular ovarian tissue cannot be detected in Turner-syndrome and the exact histological structure depends on chromosome type. At birth, classical symptoms are not yet typical, but more specific signs (e.g. dorsal feet edema) may refer to the disease.

Pregnancy may also conceive in real pubertal praecox because the full functional maturation of the hypothalamus-pituitary-ovarian axis occurs.

A) both the statement and the explanation are true and a causal relationship exists between them;

B) both the statement and the explanation are true but there is no causal relationship between them;

C) the statement is true, but the explanation is false;

D) the statement is false, but the explanation itself is true

E) both the statement and the explanation are false

A) both the statement and the explanation are true and a causal relationship exists between them;

EXPLANATION

True pubertal praecox is the early functional maturation of the hypothalamic-pituitary-ovarian axis. In the ovaries, hormone production and ovulation characteristic for the fertile age can be detected, so pregnancy can occur.

In children, a 3.5 MHz abdominal transducer can easily detect ovaries because the typical location of the ovaries is the area between the bifurcation of the iliac artery and the fallopian tubes.

A) both the statement and the explanation are true and a causal relationship exists between them;

B) both the statement and the explanation are true but there is no causal relationship between them;

C) the statement is true, but the explanation is false;

D) the statement is false, but the explanation itself is true

E) both the statement and the explanation are false

B) both the statement and the explanation are true but there is no causal relationship between them;

EXPLANATION

Children are generally thin and the perivisceral fat layer is also thin, so 3.5 MHz abdominal transducer head is well suited. The ovaries are usually situating between the bifurcation of the common iliac artery and the fallopian tube, and they can be easily represented in children in the vast majority of cases.

In case of recurrent vaginal bleeding in childhood vaginoscopy should always be performed because the cause of bleeding is most often cervical cancer.

A) both the statement and the explanation are true and a causal relationship exists between them;

B) both the statement and the explanation are true but there is no causal relationship between them;

C) the statement is true, but the explanation is false;

D) the statement is false, but the explanation itself is true

E) both the statement and the explanation are false

C) the statement is true, but the explanation is false;

EXPLANATION

The most common reasons in recurrent childhood vaginal bleeding are: a) vaginal foreign body, b) injury, c) recurrent vulvovaginitis, d) malignant tumor, which is usually botryoid sarcoma at this age. In the diagnosis and management of the aforementioned diseases (foreign body removal, injury management, biopsy) vaginoscopy is a suitable tool to use. Cervix carcinoma does not occur in childhood.

In nulliparous teenagers we usually do not recommend the use of an intrauterine device because the risk of uterine perforation is higher due to the smaller size of the uterus.

A) both the statement and the explanation are true and a causal relationship exists between them;

B) both the statement and the explanation are true but there is no causal relationship between them;

C) the statement is true, but the explanation is false;

D) the statement is false, but the explanation itself is true

E) both the statement and the explanation are false

C) the statement is true, but the explanation is false;

EXPLANATION

In nulliparous women the use of an intrauterine device (IUD) is usually not primarily recommended because the possibility of ascending pelvic inflammation. Damage of the fallopian tubes can result in infertility, ectopic pregnancy and chronic pelvic pain. However, null parity cannot be considered as an absolute contraindication for IUD insertion, and in selected cases after special considerations (e.g. psychiatric indication), women who have not yet given birth can also get an intrauterine device. At the beginning of the fertile age the mature cervix:corpus ratio is formed, with careful technique there is no danger of perforation even in case of a small uterus. According to the latest international guidelines, hormone-medicated intrauterine devices are clearly recommended in teenagers.