A married 41-year-old G5P3114 presents to your office for a routine examination. She reports being healthy except for a history of migraine headaches. All her Pap smears have been normal. She developed gestational diabetes in her last pregnancy. She drinks alcohol socially, and admits to smoking occasionally. Her grandmother was diagnosed with ovarian cancer when she was in her fifties. Her blood pressure is 140/90 mm Hg, height is 5 ft 5 in, and weight is 150 lb.
Which of the following is the most common cause of death in women of this patient’s age?
The leading causes of death in women aged 35 to 44 years, in order of decreasing incidence, are as follows: cancer, accidents, heart disease, suicide, chronic liver disease, stroke, diabetes mellitus, homicide, HIV, influenza, and pneumonia.
A 44-year-old G2P2 presents for her well-women examination. She reports no prior medical problems or surgeries. She does not use tobacco, but reports that she drinks two glasses of wine on the weekends and occasionally smokes marijuana. She works as a secretary. She is recently divorced and has become sexually active with a new partner. She has not had STD testing since her divorce.
She asks whether she should be tested for HIV. How should you counsel her?
The CDC and ACOG recommend that females aged 13 to 64 years be tested at least once during their lifetime, and annually thereafter based on risk factors. This patient has a new partner, and therefore should be offered testing. Repeat HIV testing should be offered annually to women who use IV drugs, are sex partners of a person who uses IV drugs, exchanges sex for drugs or money, are sex partners of HIV infected individuals, have sex with men who have sex with men, or have had more than one sex partner since their last HIV test.
A 40-year-old G3P2012 presents for her well-woman examination. Her last Pap smear and visit to a doctor was 5 years ago. She has had two vaginal deliveries and her largest baby weighed 4000 g. She has no current medical problems, but had a history of gestational diabetes in her last pregnancy. She had a postpartum bilateral tubal ligation. Her menstrual cycles occur every 28 days and last 5 days. She is sexually active in a monogamous relationship with her husband of 16 years. She reports that she occasionally leaks urine when she coughs; otherwise she has no complaints. On physical examination, she weighs 198 lbs and her blood pressure is 132/81 mm Hg. Her breast and pelvic examinations are normal.
What are the most appropriate screening tests for this patient?
Pap smear is indicated since it has been over 5 years since her last Pap smear. Given her history of gestational diabetes and the large birth weight of her child, diabetes screening is indicated. Also a lipid profile is indicated every 5 years after the age of 20 years. Her symptoms of urinary incontinence require that urinary tract infection be ruled out as a cause. Most national agencies recommend screening with mammogram for breast cancer beginning at the age of 40 years.
A 36-year-old G2P2 presents for her well-woman examination. She has had two spontaneous vaginal deliveries without complications. Her largest child weighed 3500 g at birth. She uses oral contraceptive pills and has never had an abnormal Pap smear. She does not smoke, but drinks about four times per week. Her weight is 70 kg. Her vital signs are normal. After placement of the speculum, you note a clear cyst approximately 2.5 cm in size on the lateral wall of the vagina on the right side. The cyst is nontender and does not cause the patient any dyspareunia or discomfort.
Which of the following is the most likely diagnosis of this mass?
Gartner duct cysts arise from embryonic remnants of the mesonephric duct that course along the lateral vaginal wall. These are usually small and asymptomatic and are found incidentally during a pelvic examination. They can be followed conservatively unless the patient becomes symptomatic, at which time excision is recommended. Inclusion cysts are usually seen on the posterior lower vaginal surface. Inclusion cysts are the most common vaginal cysts and result from birth trauma or previous gynecologic surgery. Bartholin duct cysts are the most common large cysts of the vulva. Bartholin ducts open into a groove between the hymen and labia minora on the posterior lateral vaginal opening. Lipomas are benign, encapsulated tumors of fat cells; they are most commonly discovered in the labia majora and are superficial in location. Hematomas of the vulva usually occur as a result of blunt trauma or straddle injury. Spontaneous hematomas can occur as a result of rupture of a varicose vein in pregnancy or the postpartum period.
A 50-year-old G4P4 presents for her well-woman examination. She had one cesarean delivery followed by three vaginal deliveries. Her menses stopped 1 year ago and she occasionally still has a hot flash. She tells you that about 10 years ago she was treated with a loop electro-excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) III. Since that time, all of her Pap tests have been normal.
What recommendation should you make regarding how frequently she should undergo Pap smear testing?
Cervical cancer screening should begin at 21 years of age. Cervical cytology screening is recommended every 3 years for women aged 21 to 29 years. Women aged 30 to 65 years may have cytology and co-testing every 5 years, or cytology alone every 3 years. Women with a history of CIN 2, CIN 3, or adenocarcinoma in situ should continue routine age-based screening for at least 20 years following treatment. Hysterectomy is not indicated. Certain risk factors have been associated with CIN in observational studies; women with any of the following risk factors may require more frequent cervical cytology screening: HIV infection, immunosuppression (such as transplant patients), or women with in-utero diethylstilbestrol exposure. Women older than 65 years may discontinue screening after adequate negative prior screening results. This is defined as three consecutive negative cytology results or two consecutive negative HPV co-test tests results within the past 10 years, with the most recent test performed within the past 5 years.