Uterine Fibroids and Adenomyosis Test Questions

CPT Laurie Kwolek
Uterine Fibroids and Adenomysosis

The key difference between uterine fibroids and adenomyosis is

Uterine fibroids seldom exceed 5lbs whereas adenomyosis tumors can exceed the size of a watermelon.
Uterine fibroids can vary grossly in size and occur as one or clusters of abnormal tissue whereas in adenomyosis, endometrial tissue discretely penetrates into fibrous tissue of the myometrium causing either a focal or diffuse inflammatory-like process particularly during menses.
Uterine fibroid proliferation is largely moderated by immunologic responses of TNF alpha whereas adenomyosis is more affected by circulating levels of IL6.
Uterine fibroids can only be truly cured via a hysterectomy whereas adenomyosis can only be truly cured by removal of affected area of the myometrium.

The correct answer is b. Uterine fibroids to vary in extremes of size so much that some can only be seen under a microscope and others can grow up to 50lbs (largest recorded 140lbs!!! Adenomyosis, on the other hand, is resultant of endometrial tissue that finds its way into the muscular layer of the myometrium thus exposing the muscle tissue to the cyclic endometrial changes which leads to swelling, bleeding, and discomfort. Answer a. is incorrect because there is no report to date that states the typical size of fibroids and adenomyosis is not a tumor. Answer c. is incorrect because there is no evidence that either of these immunologic factors influence either uterine disorder. Answer d. is also incorrect because there are many therapeutic agents available that mediate the severity of these uterine abnormalities however with uterine fibroids, to “cure” a particular fibroid means to remove the fibroid (myomectomy) but removal of the uterus is often not necessary. However, because adenomyosis is not tumor like/or encapsulated, in order to remove the involved tissue requires removal of the uterus. Recall, too that there are new procedures, ultrasound and laser, which are improving each day and getting closer to this “cure” like state for both abnormalities so hysterectomies may become a thing of the past for women who suffer from fibroids and adenomyosis.

Most clients with either uterine fibroids and or adenomyosis will present with

Predictable monthly uterine colic, malaise, excessive bleeding and back pain.
No symptoms
A classic triad of increased uterine size, menometrorrhagea, pelvic fullness
Infertility, urinary frequency, irregular uterine bleeding and abdominal pain.

The correct answer is b. MOST women with either uterine fibroids or adenomyosis are asymptomatic. Answer a. is incorrect because symptoms are not always predictable-symptoms care vary largely depending on the growth of the fibroid or uterine tissue. Answer c. is incorrect because while this is the classic triad for adenomyosis, it is not for uterine fibroids and still MOST women are asymptomatic for both. Answer d. is incorrect because these are additional symptoms not the MOST common.

Special points to consider when preparing a female active duty service member for deployment include

Ensuring that the female has a current profile to limit her duties to CONUS operations only just in case her status changes.
Ensuring that the female has a current profile to limit her physical activities to walking at own pace, no stair climbing, no swimming, no heavy lifting to prevent any undue stress to her pelvic anatomy.
Complete a thorough obstetric and gynecological exam, obtain a CBC, urine hCG, and provide an updated physical profile limiting her physical activities to swimming, biking, no road march, no heavy lifting.
Complete a thorough gynecologic exam, obtain serum labs, correct any existing anemia, hCG to rule out pregnancy (may need to do ultrasound to rule out ectopic), ensure her condition is stable and that an adequate treatment plan is in place prior to her departure.

The correct answer is d. This is not all you can do but definitely should be done to ensure optimal health of the deploying female. Answer a. b. and c. are all incorrect specifically because the administration of a physical profile is seldom necessary; if the female’s condition is so fragile that normal activities are limited to walking at own pace, swimming, or biking, due to fibroids, this might be the point that surgical intervention is a consideration in order to make her return to deployable status. Answer c is also incorrect because if you are doing an OB exam on this female, she is pregnant and will not be deploying until after the birth of her child and a urine hCG is only quantitative for positive or negative; it would behoove you to obtain a more sensitive serum level and if hCG>0 continue with the algorithm of pregnancy we’ve previously reviewed.

Of the options listed below, what is the number one teaching point for all patients with uterine fibroids or adenomyois?

Eat a diet high in Vitamins A, D, E, and K to help decrease the growth of uterine fibroids.
Abstain from sexual intercourse during your menstrual cycle to prevent potential rupture of swollen uterine fibroids and adenomyotic tissue.
Avoid pregnancy due to the high risk of uterine rupture or preterm delivery.
Ensure you have, at a minimum, your annual gynecologic exam and notify your provider promptly when you experience changes in your typical symptoms.

The correct answer is d. It is very important for women with established diagnosis of uterine fibroids or adenomyosis to get regular annual gynecologic exams to maintain accurate surveillance of uterine anatomical changes. It is imperative that the woman notify her provider when she experiences changes in the typical presentation of symptoms associated with fibroids or adenomyosis because changes in symptoms could imply involvement of other pelvic or abdominal organs or progression of tissue histology to a malignant status whereby a change in therapeutic management is might be required. As a key point mentioned by Dr. Seibert, keep your radar out for older women presenting with uterine bleeding…it is CA until proven otherwise! Answer a. is incorrect because while these vitamins in normal dosing might be a nice supplement, in high doses for anyone can become toxic (they are the fat soluble vitamins) and they have no proven influence on uterine abnormalities. Answer b. is incorrect because there is no evidence that women should abstain from sexual intercourse, regardless of menses or not, however she will likely prefer not to engage in these activities due to the pain associated with edematous tissue and fibroid growth. Answer c. is incorrect because fertility is often a specific goal for women with these conditions and providers often strive to facilitate a successful pregnancy. Rarely will a fibroid grow so large during a pregnancy that is results in uterine rupture, and it is not the fibroid itself that does, it is the forces of labor that often stretches the uterus beyond the point of tolerance, so women with large fibroids should be monitored closely throughout their pregnancy and consideration for c-section might be the only option for some to prevent complications associated with the passage of the fetus during the birthing process; and possibly to avoid uterine rupture. The risk for preterm labor and delivery exist for many reasons and is not a reason to encourage women with these uterine conditions to not become pregnant.

Which of the following classifications of uterine fibroids is THE MOST likely to the greatest impact on a woman’s fertility?

Subserous (outer wall of uterus)
Intramural (within the uterine wall)
Submucous
Pedunculated (subserous fibroid that grows on a stalk)

The correct answer is c. The submucous fibroid has been identified as the most likely type of fibroid that effects a woman’s fertility because of its potential to prevent implantation. The other options are incorrect because they don’t share the same direct potential to impact fertility however depending on size and displacement of normal uterine anatomy they can have an untoward effect on success of a term pregnancy.

Due to the technical difficulties of this blog taking my original script I have also sent this bb and gw! Thanks

Von Willebrand Disease Test Questions

1. A 24-year-old woman presents with severe menorrhagia. A pregnancy test is negative. The most common coagulopathy associated with menorrhagia is?

a. Hemophilia A (FALSE) Hemophilia A is the most common type of hemophilia not the most common hereditary bleeding disorder)

b. Hemophilia B (FALSE) Hemophilia B is the 2^nd most common type of hemophilia also known as the Christmas Disease

c. von Willebrand's disease (TRUE) vWD is the most common hereditary bleeding (Coagulation) disorder. It is also the leading coagulapthy associated with adolescent menorrhagia.

d. Factor V Leiden (FALSE) Factor V is the most common hereditary hypercoagulability disorder.

2. As a Family Nurse Practitioner, you have a 25-year old female patient that presents to you with Type II von Willebrand’s Disease and you are deciding what treatment is needed for this patient. Which of the following is the most recommended birth control method for patients who have vWD?

a. Morphone (FALSE) Narcotics were not even discussed in this paper.

b. Aspirin (FALSE) Aspirin aggravates bleeding and interferes with platelet function.

c. Combined Contraceptives (TRUE) Combined oral contraceptives are the most recommended birth control for patients who have vWD.

d. Heparin (FALSE) Since bleeding and hemorrhages are a characteristic of this condition, Heparin should not be given since it aggravates bleeding

3. A patient presents to your clinic requesting more information on vWD. She is trying to get pregnant and is worried that she will pass it on to her child. Your best response should be:

a. You have a 50% chance of passing it on only if you have a son. (FALSE) vWD affects males/females equally.

b. You have a 75% chance of passing the gene on to his/her child. (FALSE) A man or woman with vWD has a 50% chance of passing the gene on to his/her child.

c. vWD primarily affects African Americans which puts you at low risk for passing it on to your child. (FALSE ) There is no racial or ethnic associations associated with the vWD

d. vWD is a genetic disease that affects males and females equally, thus giving you a 50% chance of passing on the gene to your child. (TRUE)

4. Which of the following risks are greater in pregnant women who have vWD?

a. Post Partum Hemorrhage and excessive bleeding in the mother after delivery (TRUE)

b. Gestational diabetes (FALSE) women with vWD are less likely to develop gestational diabetes.

c. Pre-eclampsia (FALSE) Women with vWD were no more likely to develop this pregnancy complication than those without it.

d. Intrauterine (fetal) growth restriction. (FALSE) Women with vWD were no more likely to develop this pregnancy complications than those without it.

5. A 28-year old patient has recently been treated with oral contraceptives for vWD and wants to know the benefits of this type of method. Which of the following is the best explanation that can be given for this patient?

a. Combined Oral Contraceptives are used to suppress ovulation and thought to reflect an estrogen-induced increase in vWF and Factor VIII levels. (TRUE)

b. Combined Oral Contraceptives are used to suppress ovulation and thought to decrease risk of atherosclerotic events. (FALSE) While, COC are used to suppress ovulation and increase vWF and factor VIII, they are not beneficial for decreasing atherosclerotic events. This is a disadvantage/con of combined oral contraceptives).

c. Combined Oral Contraceptives are used to suppress ovulation, increase vWF and factor VIII levels while decreasing a patient’s risk for a stroke. (FALSE) While, COC are used to suppress ovulation and increase vWF and factor VIII, they are not beneficial for decreasing a stroke. This is a disadvantage/con of combined oral contraceptives).

d. Combined Oral Contraceptives are used to suppress ovulation, increase vWF and factor VIII levels while decreasing a patient’s risk for a Myocardial Infarction (MI). (FALSE) While, COC are used to suppress ovulation and increase vWF and factor VIII, they are not beneficial for decreasing a MI. This is a disadvantage/con of combined oral contraceptives)

Multiple Sclerosis Test Questions

Test Questions

1. Mrs. Smith comes in to see you and is concerned that her Multiple Sclerosis will be passed on to her baby if she gets pregnant. So you tell her:
A. Your baby will get the disease as this is inheritable and you are the carrier
B. There is no way your child can get the disease since it is not inheritable
C. You will not be able to get pregnant since you have MS so it isn’t a concern
D. There is a 15% chance that a relative of yours will have this disease, but it isn’t directly inheritable
(A isn’t correct because MS is not directly inheritable, B isn’t correct because there is a 15% chance a relative will get MS, C isn’t correct as the disease doesn’t affect fertility)

2) Mrs Smith wants to know what are risks to her from pregnancy regarding her life expectancy.
A. There is an increase of 5-10 years in life expectancy from pregnancy
B. There is no decrease in life expectancy from pregnancy
C. There is 5-10 year decrease in life expectancy from pregnancy
D. There is 10-20 year decrease in life expectancy from pregnancy
(A,C & D are incorrect as there is no change to life expectancy r/t pregnancy in MS pts)

3.) Mr. Jones wants to know if having MS will lower his chances for getting his wife pregnant.
A. He is infertile from the MS and will not be able to have children
B. MS will not effect his fertility
C. There is a 50% decrease in his fertility
D. He can have his sperm frozen for the future as he will slowly become infertile
(A,C & D are incorrect as MS does not effect fertility directly)


4) Mr. Jones understand his fertility will not be effected but wants to know how it will effect his sex life
A. There can be no effect on sexual function related to MS
B. He will never be able to have sex due to the MS side effects
C. There can be side effects as the disease progresses that can interfere with sexual function.
D. His spouse can contract the disease from him so he should not have sex
(A,B & D are incorrect as the patient gets lesions they can interfere with sexual function and so can the medications. Also his spouse cannot contract the disease from him as it is not sexually transmitted)

5) Mrs. Smith wants to know if she should use contraceptives and if so what type.
A. She does not need to use contraceptives as she can not get pregnant
B. She should use contraceptives, but only condoms as she does not want to upset her hormone levels
C. She should use contraceptives, but only estrogen only pills as they will lower her risk of MS overall
D. She should use contraceptives and can use any type that she feels will work for her based upon the rest of her risk factors and ability to use the contraceptive.
(A,B & C are incorrect as there is no effect on fertility. Hormone levels do not effect her MS and the estrogen only pills do not lower MS risk overall.)

Paralysis: Pregnancy, Fertility & Contraception

1. Signs and symptoms of autonomic dysreflexia that should be monitored for and treated immediately in pregnant females with spinal cord injury/paralysis include all of the following, EXCEPT:

A. loss of deep tendon reflexes

B. paroxysmal hypertension (more than 200/100)

C. piloerection and cold/clammy skin below the level of the SCI

D. flushed and sweaty skin above the level of the SCI

Answer is A, which could occur with a lesion in the reflex arc due to peripheral neuropathy caused by diabetes, alcoholism, amylodosis, uremia, vitamin deficiencies such as pellegra, beriberi, pernicious anemia, remote cancer or toxins including lead, arsenic, isniazid, vincristine and diphenylhydantoin. The other 3 answers (B, C, and D) are typical signs and symptoms of autonomic dysreflexia which if not recognized, treated and the cause corrected rapidly can lead to negative maternal and fetal outcomes, including death.

2. Which of the following is NOT an assisted reproductive method that can improve the fertility outcomes for SCI males:

A. vibratory stimulation

B. electroejaculation

C. vacuum tumescence device

D. prostate massage

Answer is C, which is an intervention for male erectile dysfunction that can be helpful with intercourse after SCI. The other 3 answers are methods to assist in sperm harvesting for fertilization procedures.

3. Which of the following contraceptive methods might be a better choice for a paraplegic woman but not for a quadriplegic woman:

A. oral contraceptives

B. condom or diaphragm

C. IUD

D. sterilization

Answer is B, depending on the increased manual dexterity level of the paraplegic vs. the quadriplegic. Answer A should not be used in either woman due to the increased risk for both for inflammation and blood vessel clots with SCI patients. Answer C would not be a good choice for either woman due to the absence of pelvic sensation that might lead to missing the signs or symptoms of complication(s) from the IUD. Answer D could be used equally as a choice by either woman who had no desire to ever get pregnant.

4. Which of the following is the main reason for decreased fertility in SCI males:

A. erectile dysfunction

B. decline in sperm motility

C. ejaculatory dysfunction

D. prolonged priapism

Answer is B, semen quality deteriorates with decreased sperm motility occurring after SCI due to changes in semen factors. Answers A and C, erectile and ejaculatory dysfunction occur in para- and quadraplegic men, however neither is the main reason for decreased fertility-both can be aided by various assistive methods so that the SCI male can have intercourse and/or release semen. Answer D is a painful, persistent erection unaccompained by sexual desire or excitement that can be caused by dysfunction of the spinal cord as in SCI.

5. All of the following are possible triggers for autonomic dysreflexia in quadraplegic females and should be monitored for and avoided, eliminated or minimized EXCEPT:

a. Perineal manipulation and pressure

b. bowel or bladder distention

c. UTI's

D. Use of stool softeners

ANSWER: is D. Use of stool softeners is advised as part of strict bowel regimen to prevent constipation/impaction or over distention and irritation of the bowel which could trigger AD as could the other 3 answers: A, B & C....all of which should be monitored for and avoided, eliminated or minimized as much as possible to prevent triggering AD and resultant harm to mother and fetus.

CHRONIC LIVER DISEASE-MAJ Frisbie

Chronic Liver Disease-MAJ Susan Frisbie
1. Which of the following statements is true about Hepatitis B?
a) It has a high maternal mortality rate in pregnancy
b) Women usually do well during pregnancy if on prophylactic medication
c) All medication for active Hepatitis B is postponed during pregnancy
d) Pregnancy risks include gestational diabetes and preterm labor

- a) HBV status usually has no affect on pregnancy (Palmer, 2004)
- b) no prophylaxis med indicated(Gambarin-Gelwan, 2007)
- c)Telbivudine, FDA approved, Category B classification(Gambarin-Gelwan, 2007)
- d) CORRECT

2. Pregnancy risk/s for chronic Hepatitis B include:
a) gestational diabetes and preterm labor
b) low birth weight
c) fetal liver failure
d) preterm delivery

- a) CORRECT
- b) has not been found statistically significant (Gambarin-Gelwan, 2007)
- c) viral hepatitis does not acutely affect the fetus (Gambarin-Gelwan, 2007)
- d) has not been found statistically significant (Gambarin-Gelwan, 2007)

3. Ms. Hepavirus is requesting combined oral contraceptives (COC). She tested positive for Hepatitis C 6 months ago on a routine employment physical, has had no complications, normal liver function tests and is asymptomatic. As the Advanced Practice Nurse you explain to her:
a) A copper IUD is a safe method
b) COC’s are an absolute contraindication
c) COC’s with a synthetic estrogen is more easily metabolized
d) Twenty percent of Hepatitis C positive patients experience acute liver failure after 5 years of COC’s

- a) CORRECT
- b) Women with mild disease can safely use hormonal contraception (WHO, 2009)
- c) Synthetic estrogen, Ethinylestradiol, is more potent and remains in the blood longer and has a greater effect on the liver (WHO, 2009)
- d) Limited data from studies suggest that COC use does not affect the rate of progression (Kapp, Tilley, & Curtis, 2009)


4. Chronic liver disease affects female and male fertility by:
a) Interfering with estrogen and androgen metabolism
b) Producing auto antibodies against gametes
c) Decreasing SHBG in cirrhosis
d) Causing hepatocytes to produce excess androgens

- a) CORRECT
- b) auto antibodies are produced in liver failure associated with an autoimmune component and the anti bodies destroy the liver, not the gametes
- c) SHBG is increased in severe liver disease (Sussman, Chudnovsky, & Niederberger, 2008)
- d) hepatocytes do not produce androgens, the adrenal glands and gonads produce androgens

5. Women during pregnancy with Wilson’s disease are at risk for recurrent miscarriages r/t:
a) Increased copper deposition in the uterus
b) Inhibition of SHBG production r/t auto antibodies
c) Thickening of the placenta r/t increased zinc deposition
d) Ectopic tumor production of oxytocin

- a) CORRECT
- b) People with Wilson’s disease cannot release copper from the liver at a normal rate r/t mutation it the gene ATP7B and the excess copper is released in the bloodstream and travels to other organs ( Theodoridis, 2009)
- c) Wilson’s disease is not related to zinc and Wilson’s disease affects the uterus not the placenta. People with Wilson’s disease cannot release copper from the liver at a normal rate r/t mutation it the gene ATP7B and the excess copper is released in the bloodstream and travels to other organs ( Theodoridis, 2009)
- d) Wilson’s disease is not an ectopic tumor. People with Wilson’s disease cannot release copper from the liver at a normal rate r/t mutation it the gene ATP7B and the excess copper is released in the bloodstream and travels to other organs ( Theodoridis, 2009)












1) d 2) a 3) a 4) a 5) a

Pregnancy with an Ostomy Questions

1. Constipation needs to be taken seriously since it can lead to a bowel obstruction. If not treated, a bowel obstruction can lead to:

a. Maternal death (correct)
b. Appendicitis
c. Urinary tract infection
d. Strained periformis

Answers b, c, and d are not caused by a bowel obstruction. Maternal death is a potential complication of a bowel obstruction because it is often confused with preterm labor and goes untreated by providers unfamiliar with ostomies.

2. Which of the following stomal complications requires immediate surgical evaluation?

a. Lacerations
b. Severe stenosis (correct)
c. Hernia
d. Retraction

Answers a, c, and d are usually corrected without medical intervention with changes to stoma care or they usually resolve after birth.

3. Nausea and vomiting can lead to all of the following complications except:

a. Fluid and electrolyte imbalances
b. Constipation
c. Endometriosis (correct)
d. Dehydration

Answers a, b, and d can all be caused by nausea and vomiting.

4. Which of the following methods of birth control would not be effective for a woman with an ileostomy?

a. Diaphragm
b. Intrauterine device
c. Oral contraceptives (correct)
d. Condoms

Answers a, b, and d are effective if appropriate for the individual. Depending on the amount of intestines that remain, the absorption of oral contraceptives may be unreliable and therefore not effective for a woman with an ileostomy.

5. Changes in the size and shape of a stoma can cause leaks, skin breakdown, and damage to the stoma. Complications with the stoma can be minimized by all of the following except:

a. Using a mirror to locate and observe the stoma during appliance change
b. Changing the type of appliance used and/or using additional adhesive
c. Consult with ostomy associations and support groups for advice and emotional support
d. Using lotion on the peristomal skin before applying a new wafer (correct)

Answers a, b, and c are all appropriate measures to maintain appropriate appliance fit, minimize leaks, and reduce complications. Lotion is not used on peristomal skin because it will prevent proper wafer adhesion. The area should be washed thoroughly with mild soap and warm water. Rinse and dry the skin completely with a dry soft cloth. All stool or wafer residue must be removed and hair around stoma should be shaved or clipped. Soaps that contain baby oil, cold cream, or perfumes should not be used.

Molar Pregnancy/Ectopic Pregnancy Test Questions

1. Which of the following, by itself, is NOT a risk factor of ectopic pregnancy?
a. history of salpingitis (6x more likely)
b. age (ages 35-44 3x more likely)
c. IUD use (by itself is not a risk factor - increased incidence of PID with IUD use is risk factor)
d. previous ectopic pregnancy (10 x more likely)

2. Which of the following is accurate?
a. Complete molar pregnancies are less likely than partial molar pregnancies to be malignant. (false – molar pregnancies have a 15-30 percent malignancy rate, partial is <5)
b. Partial molar pregnancies result from the fertilization of an empty ovum by one or two sperm. (false – partial pregnancies are the result of a normal ovum fertilized by two sperm)
c. It is highly unlikely that a woman that conceives after age of 50 will experience a molar pregnancy and even if conception results in a molar pregnancy, it rarely is malignant. (false – 1 out of 3 pregnancies after the age of 50 are molar and of those molar pregnancies, 50% are malignant)
d. Complete molar pregnancies are more common than partial molar pregnancies. (True – 90% of molar pregnancies are complete)

3. Which of the following symptoms should raise a clinician’s index of suspicion for a complete molar pregnancy?
a. markedly elevated hCG (>100,000), hyperemesis gravidarum, uterus large for gestational age, vaginal bleeding that resembles prune juice, pre-eclampsia in the first trimester. (true - all are s/s of a complete molar pregnancy)
b. moderately elevated hCG for gestational age, hyperemesis gravidarum, uterus small for gestational age, vaginal bleeding that resembles prune juice, hyperthyroidism. (false – moderately elevated hCG and small for gestational age uterus are more indicative of partial)
c. markedly elevated hCG, lower abdominal pain, adenexal mass and expulsion of tissue resembling grape clusters. (false - lower abdominal pain/adnexal mass are s/s of ectopic pregnancy not molar pregnancy).
d. moderately elevated hCG, mild nausea and vomiting, uterus small to normal for gestational age, vaginal bleeding resembling prune juice, and expulsion of tissue resembling grape clusters. (false – complete molar pregnancies typically will have hcg >100,000, hyperemesis gravidarum, and a large for gestational age uterus).

4. Which of the following is true regarding methotrexate treatment for ectopic pregnancy?
a. Ectopic gestations > 5 cm are most effectively treated with methotrexate. (false – methotrexate is used for pregnancies <3.5cm).
b. Methotrexate is the best options for treating AD service women while deployed. (false – methotrexate is not an option in the deployed setting).
c. Monitoring for regression of hCG due to persistant trophoblstic activity is not necessary following administration of methotrexate. (false – monitoring of hCG is necessary and may indicate need for further methotrexate administration or surgery).
d. Methotrexate is an appropriate choice when ectopic gestations show no signs of rupture, no cardiac activity, and are <3.5> (all are appropriate indications for use of methotrexate).

5. Which of the following symptoms is least likely to be associated with ectopic pregnancy?
a. lower abdominal pain (80-90% present with this)
b. acute pelvic pain (75-90%present with this)
c. vaginal bleeding (65-85% present with this)
d. acute nausea and vomiting (not typically a presenting symptom strongly indicative of ectopic pregnancy, nausea present in only 15% of patients)
e. amenorrhea (75-95 present with this)