A 25-year-old female is concerned about recurrent psychological and physical symptoms that occur during the luteal phase of her menstrual cycle and resolve by the end of menstruation. She wants help managing these symptoms, but does not want to take additional estrogen or progesterone.
Which one of the following management options is supported by the best clinical evidence?
Correct Answer C:
Premenstrual syndrome (PMS) is a recurrent luteal phase condition characterized by physical, psychological, and behavioral changes of sufficient severity to result in deterioration of interpersonal relationships and normal activity. No single treatment is universally effective, and studies with all therapies have not produced consistent results. The selective serotonin reuptake inhibitors (SSRIs) fluoxetine and sertraline are the first-line drugs for severe emotional symptoms.
→ NSAIDs are useful for managing the general aches, pains, and dysmenorrhea associated with PMS. A warning has been issued regarding the increased risk of serious cardiovascular thrombotic events, myocardial infarction, and cerebrovascular events associated with cyclooxygenase-2 selective NSAIDs (eg, celecoxib, valdecoxib, and rofecoxib).
→ Diuretics are used for edema, bloating, weight fluctuations, and mastalgia of PMS.
→ Alprazolam and buspirone have been effective in helping the anxiety-related symptoms of PMS.
→ Research shows that taking some black cohosh products can reduce some symptoms of menopause. But the benefits are only modest. However, there is insufficient evidence for the treatment of premenstrual syndrome.
A 26-year-old gravida 1 para 0 presents for a prenatal examination. She has two cats and expresses concern about toxoplasmosis.
Which one of the following would be most appropriate for this patient?
Correct Answer A:
There is no immunization against toxoplasmosis, and the use of antibiotics is limited to cases in which there is known maternal infection with the protozoa. Screening pregnant women for seroconversion (not with urine antigen testing) is controversial, and recommendations by various professional groups differ. Currently, the guidelines do not recommend routine screening except in patients who are known to be HIV positive. However, because the infection is thought to be passed primarily from undercooked meat or through infected animal feces, it is universally recommended that pregnant women avoid direct contact with cats’ litter boxes. If avoidance is not possible, wearing gloves when handling a litter box is recommended.
Which one of the following screening tests is recommended as part of the routine postpartum visit?
Correct Answer B:
Screening for postpartum depression is recommended as part of the routine postpartum visit. The use of a screening tool for depression is recommended, such as the Edinburgh Postnatal Depression Scale. This scale has been shown to increase the identification of women at high risk for depression.
→ A CBC or urine dipstick is recommended only for patients who have an indication for them, and should not be routinely ordered.
→ Thyroid function tests and glucose tolerance testing are recommended for patients who are either symptomatic or at high risk for disease.
A 39-year-old female presents with lower abdominal/pelvic pain. On examination, with the patient in a supine position, you palpate the tender area of her abdomen. When you have her raise both legs off the table while you palpate the abdomen, her pain intensifies.
Which one of the following is the most likely diagnosis?
If abdominal tenderness is unchanged or increased when abdominal muscles are tensed (positive Carnett's sign), the abdominal wall (choice B) is the likely origin of pain. Tenderness originating from inside the abdominal cavity (choices A, C, D, and E) usually decreases when a supine patient tenses the abdominal wall by lifting head and shoulders off the examining table.
A 19-year-old college freshman consults you at the request of her cross-country coach because she has not had a period in 2 of the last 3 months. She notes that her current training regimen is much more intense than in high school last year. She has an appropriate body image and denies caloric restriction. A pregnancy test at the student health center was negative. On examination she is lean and highly trained. Her examination is otherwise normal.
Which one of the following would be the most appropriate recommendation for this patient?
This patient has exercise-related oligomenorrhea. Menstrual problems in athletes do correlate with bone density loss and impaired recovery from exercise. Additionally, menstrual irregularity of varying severity is extremely common in female distance runners, perhaps affecting as many as 60%. The main issue in well-nourished female athletes seems to be that energy intake is not increased to match energy expenditures at high levels of training.
→ Hormonal manipulation (choice A and choice B) has not been shown to affect bone density, though it may produce withdrawal bleeding.
→ Bisphosphonate (choice D) therapy has been shown to be ineffective, and is not recommended in women of child bearing age.
→ There is little evidence that athletes without eating disorders suffer substantial harm from exercise-induced menstrual problems. Ending an athletic career (choice E) for this reason alone is not justified.
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