Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

CHAPTER 14
Pediatric Gynecology

14–1. Which of the following statements is FALSE regarding development of the hypothalamic-pituitary-ovarian axis in the female fetus and neonate?

a. The gonadotropin-releasing hormone (GnRH) “pulse generator” remains functionally dormant until shortly after birth.

b. By 5 months’ gestation, 6 to 7 million oocytes have been created from accelerated germ cell division.

c. At birth, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) concentrations rise and remain high during the first 3 months of life.

d. Neonatal breast budding, minor uterine bleeding, and transient ovarian cysts may occur as a normal response to initially high gonadotropin levels.

14–2. Which of the following statements is true regarding pelvic anatomy in the female infant and child?

a. The ovaries have obtained their normal adult size by birth.

b. At birth, the uterus and cervix are approximately equal in size.

c. Presence of an endometrial stripe or fluid within the endometrial cavity of the newborn uterus is a normal finding with sonography.

d. All the above are true statements.

14–3. Which of the following generally occurs first among the major developmental events of female puberty?

a. Menarche

b. Pubarche

c. Thelarche

d. Growth spurt

14–4. Precocious puberty is defined as initial pubertal changes occurring prior to what age?

a. 6.5 years

b. 8 years

c. 9.5 years

d. 10 years

14–5. Delayed puberty is characterized by a lack of initial pubertal changes, usually thelarche, by what age?

a. 13 years

b. 14 years

c. 15 years

d. 16 years

14–6. During the past several decades, the ages at which U.S. girls experience thelarche and menarche have shown which of the following trends?

a. Later than in past

b. Earlier than in past

c. No significant change from past

d. No clear trend has been observed

14–7. Indications for an internal vaginal examination in a child include which of the following?

a. Possible tumor

b. Vaginal bleeding

c. Suspected foreign body

d. All of the above

14–8. Management of labial adhesion or agglutination in a child includes which of the following options?

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Reproduced, with permission, from Ellen Wilson: Pediatric gynecology. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 14-7.

a. Emollients

b. Topical estrogen cream

c. Await spontaneous resolution

d. All of the above

14–9. A 14-year-old female presents with increasingly painful, cyclic menses since menarche 9 months ago. Oral analgesics and nonsteroidal antiinflammatory medications no longer adequately control her dysmenorrhea. Which of the following congenital anomalies is most likely present?

a. Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome

b. Imperforate hymen

c. Müllerian agenesis

d. Complete transverse vaginal septum

14–10. A 13-year-old female presents with increasing abdominal pain. She has begun appropriate pubertal development, although menarche has not occurred. During examination, a central abdominopelvic mass is appreciated and is shown in Figure A. Physical examination findings prompt sonography and then magnetic resonance (MR) imaging with contrast. The MR imaging results are shown in Figure B. Which of the following congenital anomalies is most likely present?

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Figure A: Photograph contributed by Dr. Ellen Wilson. Figure B: Reproduced, with permission, from Wilson EE, Bradshaw KD, Hoffman BL: Case report: imperforate hymen (update) In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. Online. New York, McGraw-Hill, 2008, July 29, Figure 3.

a. Müllerian agenesis

b. Cervical agenesis

c. Imperforate hymen

d. Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome

14–11. A 7-year-old girl has experienced vulvar irritation with external itching and burning with urination for several months. Symptoms have persisted despite attempts to eliminate potential irritants and contact allergens from the bath and laundry products used by the family. Examination shows symmetrical hypopigmentation and a parchment-like thinning of the vulvar and perianal skin. What is the most likely diagnosis?

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Photograph contributed by Dr. Mary Jane Pearson.

a. Eczema

b. Candidiasis

c. Sexual abuse

d. Lichen sclerosus

14–12. What approximate percentage of malignant tumors diagnosed in childhood are of ovarian origin?

a. 1

b. 5

c. 10

d. 15

14–13. What is the preferred imaging modality when a congenital müllerian anomaly is suspected?

a. Computed tomography

b. Transabdominal sonography

c. Magnetic resonance imaging

d. Abdominopelvic x-ray series

14–14. Which of the following is true regarding isolated premature thelarche?

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Reproduced, with permission, from Muram D: Pediatric & adolescent gynecology. In DeCherney AH, Nathan L (eds): CURRENT Diagnosis & Treatment Obstetrics & Gynecology, 10th ed. New York, McGraw-Hill, 2007, Figure 34–25.

a. Bone age is advanced.

b. Gonadotropin levels are elevated.

c. It is most common in girls less than 2 years of age.

d. None of the above.

14–15. A 13-year-old adolescent is brought in for examination due to her left breast being noticeably larger than her right when she is undressed. Thelarche occurred at age 11.5 years. She is left handed and plays softball, tennis, and lacrosse. She cannot think of any specific trauma to the right breast. The breasts are otherwise normal upon examination. Cosmetically, the difference is not obvious when she is clothed. Which of the following is the most common cause of asymmetric breast growth in a female adolescent?

a. Physical trauma

b. Surgical trauma

c. No identifiable cause

d. Strong right- or left-handedness

14–16. What is the best approach to remedy the case of the breast asymmetry described in Question 14–15?

a. Initiate combination oral contraceptive pills

b. Refer now for plastic surgery before asymmetry progresses

c. Temporarily discourage sports requiring dominant use of one arm or one side of the torso

d. Reassure that most cases of breast asymmetry resolve by completion of breast development

14–17. Abnormal breast development may be due to either fascial adherence to the underlying muscle layer or high-dose exogenous hormone exposure. In such cases, there is excessive forward and limited lateral development of the breasts, causing an abnormal shape. This condition is referred to as which of the following?

a. Polythelia

b. Tuberous breasts

c. Breast hypertrophy

d. Asymmetric lactiferous hyperplasia

14–18. A breast mass that is noted in a young adolescent female prompts you to order breast sonography. What is the most likely outcome of the lesion found and shown below?

Image

Reproduced, with permission, from Freimanis RI, Ayoub JS: Radiology of the breast. In Chen MYM, Pope TL, Ott DJ (eds): Basic Radiology, 2nd ed. New York, McGraw-Hill, 2011, Figure 5–7.

a. Spontaneous regression over time

b. Persistence with little change in size

c. Gradual increase in size with hormonal stimulation

d. Development of more generalized fibrocystic changes

14–19. A smooth, firm, mobile, nontender right breast mass is palpable on examination of a 12-year-old girl. It is 1 cm in its greatest dimension and appears solid by sonography. She has had no major health problems to date. What is the most likely diagnosis?

a. Malignancy

b. Fibroadenoma

c. Ductal ectasia

d. Asymmetric breast budding

14–20. Mastitis is unusual in children and adolescents. What is the most common pathogen isolated from breast abscesses in the pediatric population?

a. Escherichia coli

b. Staphylococcus aureus

c. Streptococcus pyogenes

d. Staphylococcus epidermidis

14–21. An 8-year-old girl is brought in for evaluation of 4 days of intermittent vaginal bleeding. She shows no signs of pubertal development. The cause of the bleeding is not apparent during physical examination, and the decision is made to proceed with examination under anesthesia and saline vaginoscopy. What is the most likely finding?

a. Foreign object

b. Atrophic vaginitis

c. Endocervical polyp

d. Sarcoma botryoides

14–22. Which of the following is the most common cause of central precocious puberty?

a. Idiopathic

b. Head trauma

c. Hydrocephalus secondary to surgery

d. Congenital central nervous system anomaly

14–23. Primary therapy for central (gonadotropin dependent) precocious puberty consists of which of the following?

a. Bromocriptine

b. Depot medroxyprogesterone acetate

c. Combination oral contraceptive pills

d. Gonadotropin-releasing hormone (GnRH) agonist

14–24. A primary goal of therapy for central precocious puberty includes prevention of which of the following consequences?

a. Short stature

b. Excessive breast size

c. Learning disabilities

d. None of the above

14–25. A 5-year-old girl suffers from precocious puberty. Gonadotropin levels are low, even following gonadotropin-releasing hormone (GnRH) infusion stimulation testing. However, estrogen levels are elevated. Which of the following could be a cause of her disorder?

a. Primary hypothyroidism

b. Ovarian granulosa cell tumor

c. Congenital adrenal hyperplasia

d. All of the above

14–26. Pubarche, with development of axillary and pubic hair, is stimulated by the androgens derived from which of the following?

a. Adrenal glands

b. Ovarian stroma

c. Peripheral aromatization of estrogens

d. All of the above

14–27. Delayed puberty in females is defined as lack of secondary sexual characteristics by age 13 or lack of menarche by what age?

Image

Reproduced, with permission, from Styne D: Puberty. In Gardner DG, Shoback D (eds): Greenspan’s Basic & Clinical Endocrinology, 8th ed. New York, McGraw-Hill, 2007, Figure 16–6A.

a. 14

b. 15

c. 16

d. 18

14–28. Sexually active adolescents are particularly vulnerable to partner violence. In a study by Abma and associates (2010), what percentage of adolescent females who experienced coitarche prior to age 20 years described their first sexual intercourse as nonvoluntary?

a. 1

b. 3

c. 5

d. 7

14–29. Which of the following contraceptive methods is generally contraindicated in adolescents (age less than 21 years)?

a. Vaginal ring

b. Intrauterine devices

c. Extended-use oral contraceptive pills

d. None of the above

14–30. Which of the following is required when initiating a contraceptive method for a healthy, sexually active adolescent?

a. Pap screening

b. Pelvic examination

c. Human papillomavirus (HPV) vaccination

d. None of the above

14–31. In the United States, adolescents can obtain medical care without parental knowledge or consent for which of the following?

a. Pregnancy

b. Contraception

c. Substance abuse

d. All of the above

References:

Abma JC, Martinez GM, Copen CE: Teenagers in the United States: sexual activity, contraceptive use, and child-bearing, National Survey of Family Growth 2006–2008. National Center for Health Statistics. Vital Health Stat 23:30, 2010

Chapter 14 ANSWER KEY

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