1. A 28 year married, nulliparous woman, a school teacher by profession comes to you for routine gynaecological referral from a general practitioner for complaints of vague back ache. She has not had any OBG referrals before. There is nothing remarkable in the clinical examination. You have taken a pap smear. Few days later, results arrive with the information that specimen shows no abnormality. Your best advice to the patient would be,

1. ‘You are perfectly fine and need not come for a pap smear again.’

2.  ‘you are just fine but will have to come for another smear in 3 months time’

3. ‘you are perfectly fine but its better we repeat the pap smear same time next year’

4. ‘you cant be declared disease free until we take two more smears, the first of which can be taken next week’

5. ‘ you need not have a pap smear taken again, unless you have symptoms’

The correct answer is C – the screening for cervical cancer should begin in women at the onset of sexual activity or at 18 years, which ever occurs first and should end at 65 years. During this period, two specimens are taken at each visit, yearly. If all of them are negative for 3 consecutive years, then the schedule is one visit once in every 3 years. Since the woman in question has had no previous referrals and this is probably the first visit, she has to have smears taken every year for 3 years.

Choice A is incorrect – the routine screening schedule is not kept up if she doesn’t return for another smear next year

Choice B is incorrect – 3 months is not the right interval for the next visit

Choice D is incorrect – the patient can definitely be declared disease free if pap smears are normal. Moreover the scheduling of the visits is inappropriate

Choice E is incorrect – whether or not symptoms intervene, she has to visit next year for a smear. However, if symptoms occur within a year, she can make a visit and smear can be taken.

2. A 40 year old woman comes for routine gynaecological visit during which two pap smears are taken. One of the samples turns out to be class II and the other class III. You want to confirm the diagnosis before proceeding to definitive management. The next most appropriate step would be

1. perform an ultrasound scan of the abdomen and pelvis

2. perform colposcopic directed biopsy and endocervical curettage

3. reassure that these findings are common and don’t need further intervention

4. perform a cone biopsy

5. repeat the pap smear after 3 months 

Choice B is correct – once an abnormal pap smear is obtained, the next best step is to do a colposcopy and stain the cervix with acetic acid and look for abnormal patterns like mosaicism, punctation, etc. This is called ectocervical biopsy. This is often accompanied by endocervical curettage. The results thus obtained are compared with the Pap smear results and accordingly decisions are taken.

Choice A is incorrect – An USG is often performed in a variety of gynaecological conditions but in the above case a biopsy would be more informative

Choice C is incorrect – Though class II is inflammatory pattern often needs no treatment, class III refers to mild to moderate dysplasia which represents a higher risk to progression to cervical carcinoma when compared to normal histology. Hence, further investigation is warranted

 Choice D is incorrect – a cone biopsy is performed only under certain definitive indications. In this case there is no such indication. However, if the results are worse when compared to the biopsy results, it indicates that the abnormal site indiacted by the smear was not biopsied.

Choice E is incorrect – there is no necessity to wait for 3 months and take another pap smear as dysplasia warrants further treatment as soon as possible

3. A 28 year old comes with her husband with the complaint that she is unsuccessful in conceiving. She had been married for 3 years during which they have had unprotected frequent sexual intercourse. The woman says she attained menarche at the age of 16 and since then her periods had been regular, each cycle lasting for 28 to 30 days. There is nothing significant in the history and clinical examination is unremarkable for both partners. The first investigation to be done in this case would be,

A. CXR for the woman

B. CXR for the man

C. Semen analysis

D. USG abdomen and pelvis for the woman

E. Thyroid and prolactin assays for the woman

Choice C is correct – the first most appropriate investigation in a case of infertility would be semen analysis as male factors for infertility are said to be equally frequent as female factors. Since semen analysis is non-invasive, easy, quick, inexpensive and non-elaborate, this is often considered first before going for more-expensive, elaborate and invasive investigations in the woman

Choice A, B are incorrect – A CXR is often taken as a part of routine investigation and can yield a lot of data concerning the heart and lungs, especially for tuberculosis, yet would not be a preliminary test in an infertility clinic  

Choice D is incorrect – USG abdomen and pelvis are very significant in investigation the female reproductive system but are done after semen analysis

Choice E is incorrect – thyroid and prolactin abnormalities can cause infertility problems but they are more important in investigating amenorrhoea and menstrual disturbances. Since the woman here reports regular cycles, semen analysis would be more appropriate.

4. A 53 year old lady comes with her husband with the complaints of discomfort and pain during sexual intercourse for the past six months. She complains of a foul – smelling discharge per vaginum, along with a mild itch. She has been having frequency and nocturia also. She reports having normal cycles as far as she can recollect though she says her cycles have been irregular for past several months. Her last period was about 45 days back, she says. Her husband reports that she has become very irritable of late. There is no history of post coital bleeding. Clinical examination is unremarkable. You have obtained vaginal and urine specimens for investigations and started empirical antibiotics. What would be the most appropriate clinical diagnosis at this point?

1. Menopausal symptoms

2. Premenstrual dysphoric disorder

3. Complicated genital/ vaginal tract infection

4. Suspected cervical carcinoma

5. Sexual dysfunction

Choice A is correct – the conglomeration of symptoms that occur during the time when the ovaries gradually lose their function is term as menopause. It is said to have been attained by a woman if there is history of 12 months of amenorrhoea along with raised serum LH and FSH. The mean age is 51 years and it is genetically determined. The common symptoms include vaginal dryness, dyspareunia, frequency, urgency, nocturia; urge incontinence, common occurrence of vaginal infections, hot flushes, mood swings, irritability, sleep disturbances and depression. Osteoporosis is another major post menopausal symptom.

Choice B is incorrect – Premenstrual dysphoric disorder (PDD), previously called as Premenstrual syndrome (PMS) commonly occurs in women of reproductive age of a comparatively younger cohort. It consists of physical symptoms like edema, bloating, breast engorgement and tenderness together with psychic features like depression, anxiety, mood swings, and irritability. The most important characteristic is the monthly recurrence, onset being in the last two weeks, i.e, after ovulation and resolving with the onset of menses. SSRIs are treatment of choice.

Choice C is incorrect – though vaginal infections are common in menopause, they are not the major diagnosis here. Moreover the case described above is an uncomplicated vaginal infection and does not describe any complication

Choice D is incorrect – Though cervical carcinoma can be considered, menopause is more likely due to the diversity in features mentioned. Moreover, there is no history of post – coital bleed, weight loss, anorexia or mass on examination. However, a pap smear should be taken, if she is not been undergoing regular screening before.

Choice E is incorrect – There is no complaint of decreased libido, decreased arousal, or inability to achieve orgasm. Though sexual dysfunction can occur due to menopause, this would constitute a primary diagnosis, in the presence of the other symptoms of the patient

5. A 60 year old woman comes to you with the history of back pain for the past 1 year. It is diffuse in nature and has no specific aggravating or relieving factors. She attained menopause 5 years ago. Since then, she has been having no problems. Her past history is insignificant. However she says that her mother had history of vaginal bleeding and eventually died of a genital tract cancer. Clinical examination is unremarkable and a pap smear is normal. Her X – ray showed decreased bone density and a DEXA was done, when the diagnosis of osteoporosis was confirmed. The best treatment for this patient would be,

1. Weight bearing exercises and milk

2. Calcium and fluoride supplements

3. Vitamin D

4. Estrogen replacement therapy (ERT)

5. Raloxifene

Choice E is correct – Raloxifene is a selective estrogen receptor modulator (SERM). It has estrogen agonist activity on bone, benefiting osteoporosis and does not have agonist action in the endometrium thereby eliminating the risk of endometrial carcinoma which occurs with estrogen replacement therapy. The woman in question seems to have a history of endometrial carcinoma in the mother thereby displaying the same risk in her. This makes estrogen therapy comparatively unsafe.

Choice A is incorrect – Conservative measures like increased calcium, milk intake and weight bearing exercises have been recommended but studies show that they are useful as adjuvant therapy and do not benefit osteoporotic patients as much as estrogen replacement

Choice B is incorrect – Ca and Fluoride have been used but are not the best treatment option.

Choice C is incorrect – Vitamin D has been advocated as a treatment option in osteoporosis but not as beneficial as ERT

Choice D is incorrect – ERT is considered to be the gold standard in the treatment of postmenopausal osteoporosis, when it is not contraindicated as in known history of endometrial cancer or breast cancer, active liver disease, thromboembolism or unexplained vaginal bleeding