Clinical Cases on Menopause and Breast Cancer

English Clinical Cases
PUEP - ENARM
Dr. Julio Herrera-Zamora Dr. Julio Herrera-Zamora
Case 1
A 52-year-old woman arrives to your office due to nightly hot flashes, insomnia, vaginal dryness
and decreased libido for the last 8 months. She refers variations in her menstrual cycle (irregular).
To interrogation history of hypertension, type two diabetes with a regular control, P: 2, D: 2, C: 0,
A: 0. Medical record with normal cervical cytology and mastography in March 2019, last menstrual
date 10 months ago, although she refers previous period every 5 months. Hormonal laboratory
and lipid profile with 245 mg/dl hypetriglyceridemia and 34 mg/dl HDL.
Case 1
A 52-year-old woman arrives to your office due to nightly hot flashes, insomnia, vaginal dryness
and decreased libido for the last 8 months. She refers variations in her menstrual cycle (irregular).
To interrogation history of hypertension, type two diabetes with a regular control, P: 2, D: 2, C: 0,
A: 0. Medical record with normal cervical cytology and mastography in March 2019, last menstrual
date 10 months ago, although she refers previous period every 5 months. Hormonal laboratory
and lipid profile with 245 mg/dl hypetriglyceridemia and 34 mg/dl HDL.
Case 1
Nightly : Nocturno
Hot flashes : Bochornos
Dryness : Sequedad
Pregnancy : Embarazo
Delivery : Parto
Caesarean section : Cesárea
Abortion : Aborto
Case 1
Q1. Which is the most likely diagnosis of this patient?
a) Menopause
b) Perimenopause
c) Menopause transition stage
d) Climacteric syndrome
Case 1-Q1. Review
Climacteric phase in the aging process during which a woman passes from the reproductive
stage to the non-reproductive and begins around age 45, and can last up to 70 years.
Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

Revisión Caso 1 – P1
Climaterio: fase en el proceso de envejecimiento durante la cual una mujer pasa de la etapa
reproductiva a la no reproductiva y se inicia alrededor de los 45 años y puede permanecer hasta
los 70 años.
Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

Case 1
Q2. Which is the hormonal profile you expect to find in this patient?
a) High estrogens, low FSH, normal LH

b) Low estrogens, low FSH, low LH
c) Low estrogen, high FSH, low LH
d) Low estrogens, high FSH, normal LH
Case 1-Q2. Review
In the patient in climacteric syndrome it is expected to find low estrogens, high follicle
stimulating hormone, normal luteinizing hormone.

En la paciente en síndrome de climaterio se espera encontrar estrógenos bajos, hormona
folículo estimulante alta, hormona luteinizante normal.

Case 1
Q3. Which is the recommendation for calcium and vitamin D intake?
a) 500 mg of calcium and 500 IU/day of vitamin D

b) 500 mg of calcium and 1000 IU/day of vitamin D
c) 1000 mg of calcium and 500 IU/day of vitamin D
d) 1000 mg of calcium and 1000 IU/day of vitamin D
Case 1-Q3. Review
The intake of 1000 to 1200 mg of calcium and 800 to 1000 IU/day of vitamin D are
recommended in women in the peri and postmenopause

La ingesta de 1000 a1200 mg de calcio y de 800 a 1000 UI/día de vitamina D están
recomendados en mujeres en la peri y postmenopausia.

Case 1
Q4. Which is the most appropriate treatment in this patient?
a) Estrogens / Progestogens orally

b) Transdermal estrogen / progestogens
c) Estrogens
d) Hormone therapy is not recommended because of the risk of endometrial hyperplasia
Case 1-Q4. Review
The treatment for the patient in climacteric is based on transdermal estrogen / progestogens
and thus endometrial hyperplasia is avoided.

El tratamiento para la paciente en climaterio es a base de Estrógenos/Progestágenos
transdérmicos y así se evita la hiperplasia endometrial.

Case 1
Q5. Which of the following is not an advantage of transdermal therapy over the oral route?
a) Decrease in triglycerides.
b) Less effect on C-reactive protein.
c) Less effect on insomnia
d) Less risk of decreased libido.
Case 1-Q5. Review
Among the known advantages of transdermal estrogen over the oral route, are:
- Avoid the first-pass liver effect

- Less increase in triglycerides.
- Less effect on C-reactive protein.
- Perhaps less risk of thrombosis.
- Less risk of decreased libido.
- Less gastrointestinal side effects.

Dentro de las ventajas conocidas del Estrógeno transdérmica sobre la vía oral, se encuentran:
- Evita el efecto hepático de primer paso

- Menos incremento en triglicéridos.
- Menos efecto sobre la proteína C reactiva.
- Tal vez menos riesgo de trombosis.
- Menos riesgo de disminución de la libido.
- Menos efectos colaterales gastrointestinales.

Case 2
A 57-year-old woman arrives to your office due to a 14x12x 9-cm mass in her left breast. Her
grandmother has breast cancer and her father has prostate cancer. On physical examination shows
that the mass is firm, nontender and immobile, and it is not attached to the overlying skin or the
chest wall. There is a palpable stony axillary nodes, erythematous breast without ulceration.
Case 2
A 57-year-old woman arrives to your office due to a 14x12x 9-cm mass in her left breast. Her
grandmother has breast cancer and her father has prostate cancer. On physical examination shows
that the mass is firm, nontender and immobile, and it is not attached to the overlying skin or the
chest wall. There is a palpable stony axillary nodes, erythematous breast without ulceration.
Case 2
Breast : Mama
Nontender : No dolorosa
Not attached : No adherido
Overlying : Superpuesto
Stony : pétreo
Case 2
Q1. Which is the possible diagnosis of this patient?
a) Skin cancer
b) Breast cancer
c) Fibrocystic mastopathy
d) Breast Fibroadenoma
Case 2-Q1. Review
Breast cancer: Accelerated and uncontrolled proliferation of glandular epithelial cells. They are
cells that have greatly increased their reproductive capacity. Breast cancer cells can spread
through the blood or lymph vessels and reach other parts of the body, adhere to the tissues and
grow into metastases.
Literature: Guía de Práctica Clínica: Tratamiento del cáncer de mama en segundo y tercer nivel de atención.
Cáncer de mama: Proliferación acelerada e incontrolada de células del epitelio glandular. Son
células que han aumentado enormemente su capacidad reproductiva. Las células del cáncer de
mama pueden diseminarse a través de la sangre o de los vasos linfáticos y llegar a otras partes
del cuerpo, adherirse a los tejidos y crecer formando metástasis.
Bibliografía: Guía de Práctica Clínica: Tratamiento del cáncer de mama en segundo y tercer nivel de atención.
Case 2
Q2. Which is the most frequent histological variety in this type of cancer?
a) Lobular in situ
b) Ductal Insitu
c) Infiltrating lobular
d) Infiltrating ductal
Case 2-Q2. Review
The most common histological type of breast cancer is infiltrating ductal.
El tipo histológico más común de cáncer de mama es ductal infiltrante.
Case 2
Q3. Which percentage of the population will have an invasive carcinoma?
a) 10
b) 20
c) 25
d) 30
Case 2-Q3. Review
Approximately 10% to 15% of patients will have an invasive carcinoma during their lifetime. The
risk of occurrence is 0.5% per year of follow-up and when linked to first-degree genetic load
increases to 1% per year
Aproximadamente 10% a 15% de las pacientes presentará durante su vida un carcinoma invasor.
El riesgo de aparición es de 0.5% por año de seguimiento y cuando se vincula con carga genética
de primer grado aumenta a 1% por año.
Case 2
Q4. Which is the treatment of this patient if she has a Van Nuys index of 7?
a) Wide local split

b) Wide local excision plus radiation therapy
c) Total mastectomy without sentinel node biopsy
d) Total mastectomy with Sentinel Node Biopsy
Case 2-Q4. Review
The Van Nuys index contemplates a numerical range of 4 to 12 with the following
recommendations for treatment:
- 4, 5 and 6 points: Wide local excision (lumpectomy).

- 7, 8 and 9 points: Wide local excision plus radiotherapy
- 10.11 and 12 points: Total mastectomy with or without sentinel node biopsy and with or
without breast reconstruction.
El índice de Van Nuys contempla un rango numérico de 4 a 12 con las siguientes
recomendaciones para el tratamiento:
- 4, 5 y 6 puntos: Escisión local amplia (lumpectomia).
- 7,8 y 9 puntos: Escisión local amplia más radioterapia
- 10,11 y 12 puntos: Mastectomía total con o sin biopsia de ganglio centinela y con o sin
reconstrucción mamaria.
Case 2
Q5. Which of the following genetic factors favor this disease?
a) BCRA1 and 2
b) PTEN
c) P53
d) Ca 15-3
Case 2-Q5. Review
The expression of BCRA1 and BCRA2 are related to breast cancer.
La expresión de BCRA1 y BCRA2 están relacionados con el cáncer de mama.
Case 3
A 33-year-old woman arrives to your office due to history of one week with heat and swelling of
the left breast. She refers to breastfeeding her 1 month old baby. On physical examination: HR: 78
bpm, RR: 16 rpm, TA: 100/70 mmHg, T: 37.8 oC. On physical examination: painful left breast, with
palpation of a fluctuating, crackling mass accompanied by erythematous changes.
Case 3
A 33-year-old woman arrives to your office due to history of one week with heat and swelling of
the left breast. She refers to breastfeeding her 1 month old baby. On physical examination: HR: 78
bpm, RR: 16 rpm, TA: 100/70 mmHg, T: 37.8 oC. On physical examination: painful left breast, with
palpation of a fluctuating, crackling mass accompanied by erythematous changes.
Case 3
Heat : Calor
Swelling : Tumefacción
Breastfeeding : Alimentación a seno materno
Painful : Doloroso
Crackling : Crepitante
Case 3
Q1. Which is the most common causative agent in infectious mastitis?
a) Streptococcus pneumoniae
b) Staphylococcus aureus
c) Staphylococcus epidermis
d) Streptococcus agalactiae
Case 3-Q1. Review
The most common etiologic agent of infectious mastitis is Staphylococcus aureus.
Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Patología Mamaria Benigna en Primer y
Segundo Nivel de Atención.
El agente etiológico más común de la mastitis infecciosa es el Staphylococcus aureus.
Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Patología Mamaria Benigna en Primer y
Case 3
Q2. Which is the most appropriate management for this patient?
a) Cephalexin and paracetamol

b) Dicloxacillin and ibuprofen
c) Amoxicillin and ibuprofen
d) Only drainage and warm builds
Case 3-Q2. Review
The treatment of infectious mastitis is dicloxacillin and ibuprofen.
El tratamiento de la de la mastitis infecciosa es dicloxacilina e ibuprofeno.
Case 3
Q3. Which is the serious and most frequent complication in infectious mastitis?
a) Breast cyst
b) Puerperal sepsis
c) Breast abscess
d) Residual mastalgia
Case 3-Q3. Review
La complicación más grave de la mastitis infecciosa es el absceso mamario.
The most serious complication of infectious mastitis is breast abscess.
Case 3
Q4. Which of the following is not an adverse effect of dicloxacillin?
a) Nausea
b) Vomit
c) Pseudomembranous colitis
d) Cholestatic jaundice
Case 3-Q4. Review
The following are adverse effects of dicloxacillin: Nausea, vomiting, diarrhea,
pseudomembranous colitis. Mild allergic reactions (rash, pruritus, etc.). Serious allergic
reactions (anaphylaxis, serum sickness), interstitial nephritis, neutropenia.
Los siguientes son efectos adversos de la dicloxacilina: Náusea, vómito, diarrea, colitis
pseudomembranosa. Reacciones alérgicas leves (erupción cutánea, prurito, etc.). Reacciones
alérgicas graves (anafilaxia, enfermedad del suero), nefritis intersticial, neutropenia.
Case 3
Q5. Which of the following is not an adverse effect of danazol?
a) Acne
b) Hirsutism
c) Arterial hypotension
d) Clitoral hypertrophy
Case 3-Q5. Review
The following are adverse effects of danazol: Acne, edema, mild hirsutism, oily skin or hair,
weight gain, clitoral hypertrophy, manifestations of hypoestrogenism
(Climacteric syndrome), rash, vertigo, nausea, headache, sleep disorders, irritability, elevated
blood pressure.
Los siguientes son efectos adversos del danazol: Acné, edema, hirsutismo leve, piel o cabello
graso, aumento de peso, hipertrofia del clítoris, manifestaciones de hipoestrogenismo
(Síndrome climatérico), erupción cutánea, vértigo, náusea, cefalea, trastornos del sueños,
irritabilidad, elevación de la presión arterial.
Case 4
A 50-year-old nun arrive to your office due to the diagnosis of uterine fibroids of a size equivalent
to a 12-week gestation, presenting hyperpolymenorrhea and with hemoglobin of 9 g/dl in the
blood count. No associated pathologies are referred. The patient is waiting to practice her
definitive treatment in 4 months.
Case 4
A 50-year-old nun arrive to your office due to the diagnosis of uterine fibroids of a size equivalent
to a 12-week gestation, presenting hyperpolymenorrhea and with hemoglobin of 9 g/dl in the
blood count. No associated pathologies are referred. The patient is waiting to practice her
definitive treatment in 4 months.
Case 4
Nun : Monja
Case 4
Q1. Which is preoperative treatment indicated in this patient?
a) Estrogen
b) Fibrinolysis inhibitors
c) GnRH analogues
d) Intrauterine device with progestogen
Case 4-Q1. Review
The use of GnRh analogues is suggested in patients who are going to undergo myomectomy, but
not for more than 6 months, due to their side effects.
Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Se sugiere el uso de los análogos de GnRh en las pacientes que van a ser sometidas a
miomectomía, pero no por más de 6 meses, debido sus efectos secundarios.
Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Case 4
Q2. Which is the definitive treatment in this patient?
a) Myomectomy
b) Total hysterectomy keeping annexes
c) Vaginal hysterectomy
d) Radical hysterectomy
Case 4-Q2. Review
Hysterectomy should be offered as a definitive treatment in women with symptomatic uterine
myomatosis and satisfied parity, referring to alternatives and risks.

Debe ofrecerse como tratamiento definitivo la histerectomía , en mujeres con miomatosis
uterina sintomática y paridad satisfecha, refiriendo alternativas y riesgos.

Case 4
Q3. Which would be the appropriate follow-up for the patient?
Ultrasound every year

Cervical cytology every 6 months
Clinical only
Ultrasound + cervical cytology every 2 years
Case 4-Q3. Review
Reviews should be performed every 6 to 12 months according to the characteristics of the
patient with first-level control ultrasound.

Se deberán realizar revisiones cada 6 a 12 meses de acuerdo con las características propias de la
paciente con ultrasonido de control en primer nivel de atención.

Case 4
Q4. Which of the following is not an indication of reference to the second level of attention?
a) Abnormal uterine hemorrhage

b) Leukocytosis
c) Chronic pelvic pain
d) Hydronephrosis
Case 4-Q4. Review
They must be referred to second level of care patients with:
- Abnormal uterine hemorrhage

- Anemia
- Chronic pelvic pain (dysmenorrhea, dyspareunia)
- Abdominal compression
- Acute torsion pain of pedicle myoma prolapse myoma
submucous
- Urinary symptomatology (hydronephrosis) myoma growth
- Infertility without more findings than the myoma

Deben ser referidos a un segundo nivel de atención con los pacientes:
- Hemorragia uterina anormal

- anemia
- Dolor pélvico crónico (dismenorrea, dispareunia)
- Compresión abdominal.
- Dolor agudo por torsión de mioma pediculado prolapso de mioma
submucoso
- Sintomatología urinaria (hidronefrosis) crecimiento de mioma
- Infertilidad sin más hallazgos que el mioma

Case 4
Q5. Which of the following is not an adverse effect of indomethacin?
a) Local irritation
b) Colitis
c) Decrease in platelet aggregation
d) Vomit
Case 4-Q5. Review
The adverse effects of indomethacin are: Local irritation, colitis, decreased platelet aggregation,
hyperkalemia, hypoglycemia, headache, anemia, pruritus.

Los efectos adversos de la indometacina son: Irritación local, colitis, disminución de la
agregación plaquetaria, hiperpotasemia, hipoglucemia, cefalea, anemia, prurito.

Case 5
A 35-year-old woman arrives to your office due to postcoital hemorrhage in the last month
accompanied by yellowish vaginal discharge that stains her panties, without bad smell or
discomfort. Beginning of active sex life at age 16, SP: 7, P: 0, D: 0, C: 0, A: 0. She refers to taking
oral contraceptives combined for 4 years, positive smoking, last Pap smear at 20 years without
alterations. Refer a mother with a history of cervical cancer.
Case 5
A 35-year-old woman arrives to your office due to postcoital hemorrhage in the last month
accompanied by yellowish vaginal discharge that stains her panties, without bad smell or
discomfort. Beginning of active sex life at age 16, SP: 7, P: 0, D: 0, C: 0, A: 0. She refers to taking
oral contraceptives combined for 4 years, positive smoking, last Pap smear at 20 years without
alterations. Refer a mother with a history of cervical cancer.
Case 5
Yellowish vaginal discharge : Flujo vaginal amarillento
Sexual partners (SP) : parejas sexuales
Case 5
Q1. Which of the following is the first diagnostic step?
a) Abdominal CT
b) Endometrial biopsy
c) Colposcopy with biopsy
d) Diagnostic cone
Case 5-Q1. Review
All patients with suspected cervical cancer should be corroborated by colposcopy and
histopathological study which will be performed by: directed biopsy, endocervical curettage and
/ or diagnostic cone.
Literature: Norma Oficial Mexicana NOM-041-2011.

Toda paciente con sospecha de cáncer cervicouterino deberá ser corroborado mediante
colposcopia y toma de estudio histopatológico el cual se realizará mediante: toma de biopsia
dirigida, curetaje endocervical y/o cono diagnóstico.
Bibliografía: Norma Oficial Mexicana NOM-041-2011.

Case 5
Q2. It is classified in I A1 according to the classification of FIGO. What is the most appropriate
treatment at this stage?
a) Chemotherapy + radiotherapy
b) Conization with free margins
c) Radical hysterectomy
d) Brachytherapy
Case 5-Q2. Review
Patients with stage IA1, the standard treatment consists of conization with free margins and / or
extrafacial hysterectomy.

Las pacientes con estadio IA1, el tratamiento estándar consiste en conización con márgenes
libres y/o histerectomía extrafacial.

Case 5
Q3. Which cause of morbidity and mortality does cervical cancer represents in Mexico?
a) The first cause of morbidity and mortality

b) The second cause of morbidity and mortality
c) The third cause of morbidity and mortality
d) The fourth cause of morbidity and mortality
Case 5-Q3. Review
Cervical cancer is the second leading cause of mortality from malignant neoplasms in women,
resulting in up to 11 deaths per day affecting the age group of 25-69 years and is only surpassed
by breast cancer.

El cáncer cérvicouterino es la segunda causa de mortalidad por neoplasias malignas en la mujer
al producir hasta 11 muertes por día afectando al grupo de edad de 25 – 69 años y solamente es
superado por el cáncer de mama.

Case 5
Q4. Which most common HPV serotype that cause malignancy?
a) 6
b) 11
c) 16
d) 18
Case 5-Q4. Review
Serotypes 16, 18, 31, 33 and 45 of the human papillomavirus are associated with the
development of neoplasms. Serotype 16 being the most aggressive.

Los serotipos 16, 18, 31, 33 y 45 del virus del papiloma humano se asocian al desarrollo de
neoplasias. Siendo el más agresivo el serotipo 16.

Case 5
Q5. Which HPV serotypes cause condylomas?
a) 6 and 11
b) 16 and 18
c) 20 and 45
d) 30 and 32
Case 5-Q5. Review
Serotypes 6 and 11 of the human papillomavirus are associated with the development of warts
or condylomas.

Los serotipos 6 y 11 del virus del papiloma humano se asocian al desarrollo de verrugas o
condilomas.

Case 6
A 67 years old woman arrives to your office due to palpation of a mass in the left iliac fossa, which
is slightly painful. The patient comments that she had 1 pregnancy, used oral contraceptives for 5
years and that her last menstruationwas 4 years ago. In another hospital she underwent to a
transvaginal ultrasound with a 6 cm hypervascular left occipital ovarian lesion, with some solid
areas, no free liquid is observed.
Case 6
A 67 years old woman arrives to your office due to palpation of a mass in the left iliac fossa, which
is slightly painful. The patient comments that she had 1 pregnancy, used oral contraceptives for 5
years and that her last menstruation was 4 years ago. In another hospital she underwent to a
transvaginal ultrasound with a 6 cm hypervascular left occipital ovarian lesion, with some solid
areas, no free liquid is observed.
Case 6
Slightly painful : Un poco doloroso
Case 6
Q1. Which is the most likely diagnostic suspicion?
a) Ovarian cancer
b) Pelvic inflammatory disease
c) Endometriosis
d) Tube-ovarian abscess
Case 6-Q1. Review
Ovarian cancer is the leading cause of death from gynecological cancer. The fundamental clinical
feature is the absence of symptoms and slow growth, so diagnosis usually occurs in advanced
stages or as a casual finding. The most frequent initial symptom is an increase in the abdominal
perimeter produced by the growth of the tumor as in this case, followed by variable pain.
Literature: Guía de Práctica Clínica: Tratamiento Quirúrgico-Médico del Cáncer Epitelial de ovario.
El cáncer de ovario es la primer causa de muerte por cáncer ginecológico. Las característica
clínica fundamental es la ausencia de sintomatología y crecimiento lento, por lo que le
diagnóstico suele ocurrir en etapas avanzadas o como hallazgo casual. El síntoma inicial más
frecuente es aumento en el perímetro abdominal producido por el crecimiento del tumor como
en este caso, seguido de dolor variable.
Bibliografía: Guía de Práctica Clínica: Tratamiento Quirúrgico-Médico del Cáncer Epitelial de ovario.
Case 6
Q2. Which studies can help you to corroborate your diagnostic suspicion?
a) Therapeutic test with oral contraceptives

b) Cultivation of cervicovaginal secretion
c) Biopsy and determination of Ca125
d) Therapeutic test with antibiotics
Case 6-Q2. Review
The definitive diagnosis of ovarian cancer is histological, so a biopsy needs to be done, although
it is possible to rely on the clinical history, imaging techniques and serum markers (Ca 125). This
glycoprotein is expressed primarily by epithelial ovarian tumors.
El diagnóstico definitivo de cáncer de ovario es histológico por lo que se necesita hacer una
biopsia, aunque es posible apoyarse en la historia clínica, en las técnicas de imagen y en los
marcadores séricos (Ca 125). Esta glicoproteína se expresa principalmente por los tumores
epiteliales de ovario.
Case 6
Q3. Which is the best treatment for this disease?
a) Drainage of the abscess

b) Only removing suspicious lesión
c) Optimal cytoreduction
d) Antibiotic treatment
Case 6-Q3. Review
The treatment of ovarian cancer is surgical and has a double utility: diagnostic, allowing patients
to be properly staged, and therapeutic, removing the greatest amount of tumor mass. In the
search for cytoreduction, a hysterectomy, bilateral salpingoophorectomy, omentectomy,
peritoneal biopsy, peritoneal lavage are performed.
El tratamiento del cáncer de ovario es quirúrgico y tiene una doble utilidad: diagnóstica, al
permitir estadificar adecuadamente a los pacientes, y terapéutica, extirpando la mayor cantidad
de masa tumoral. En la búsqueda de citoreducción se realiza una histerectomía,
salpingooforectomía bilateral, omentectomía, biopsia de peritoneo, lavado peritoneal.
Case 6
Q4. Which is the most common ovarian cancer?
a) Mucinous
b) Serous
c) Clear cells
d) Endometrioid
Case 6-Q4. Review
The most common histological type of ovarian cancer is the epithelial type and of these the
serous represents 60-80%.
El tipo histológico más común del cáncer de ovario es el tipo epitelial y de ellos el seroso
representa el 60-80%.
Case 6
Q5. Which of the following is not an adverse effect of Paclitaxel?
a) Myelosuppression
b) Hypersensitivity
c) Hematuria
d) Hypotension
Case 6-Q5. Review
The main adverse effects of paclitaxel are:
- Myelosuppression
- Hypersensitivity
- Hypotension
- Mucositis
- Nausea, vomiting and diarrhea
- Arthralgias and myalgias
- Fever
- Fatigue
- Peripheral neuropathy
- It is genotoxic
Los principales efectos adversos del paclitaxel son:
- Mielosupresión.
- Hipersensibilidad.
- Hipotensión.
- Mucositis
- Náuseas, vómito y diarrea.
- Artralgias y mialgias.
- Fiebre
- Fatiga
- Neuropatía periférica
- Es genotóxico.
Case 7
A 26-year-old woman with 25 gestation weeks arrives to your office due to nausea, constipation,
frequent urination and burning when urinating. Cervical examination with closed cervix, without
the presence of contractions or secretions, rest without alterations. A positive urine culture is
reported.
Case 7
A 26-year-old woman with 25 gestation weeks arrives to your office due to nausea, constipation,
frequent urination and burning when urinating. Cervical examination with closed cervix, without
the presence of contractions or secretions, rest without alterations. A positive urine culture is
reported.
Case 7
Burning : Ardor
Case 7
Q1. Which is the diagnosis of this patient?
a) Asymptomatic bacteriuria
b) Pyelonephritis
c) Hyperemesis gravidarum
d) Urinary tract infection
Case 7-Q1. Review
Urinary tract infection is one of the most frequent medical complications of pregnancy, which if
not diagnosed and treated in a timely manner, leads to a significant increase in morbidity in
both the mother and the fetus.
Literature: Guía de Práctica Clínica Prevención, Diagnóstico y Tratamiento de la Infección del Tracto Urinario Bajo
Durante el Embarazo del Primer Nivel de Atención.
La infección urinaria es una de las complicaciones médicas más frecuentes del embarazo, la cual
si no es diagnosticada y tratada de manera oportuna, conlleva a un incremento significativo en
la morbilidad tanto en la madre como en el feto
Bibliografía: Guía de Práctica Clínica Prevención, Diagnóstico y Tratamiento de la Infección del Tracto Urinario Bajo
Case 7
Q2. If the patient had no symptoms, how is a positive urine culture considered?
a) The presence of 3 or more leucos per field in 2 samples

b) Positive nitrites in 2 or more samples
c) > 100,000 CFU per ml in 2 sample
d) Fetidity and urinary pH <6.5
Case 7-Q2. Review
Urine culture is considered positive above 100,000 CFU if there are no symptoms.
El urocultivo se considera positivo arriba de 100,000 UFC si no hay síntomas.
Case 7
Q3. Which is the most likely etiologic agent?
a) Impaired bowel movements due to increased intra-abdominal pressure

b) Klebsiella pneumoniae
c) E. Coli
d) Smooth muscle relaxation by progesterone
Case 7-Q3. Review
The most likely etiologic agent is E. Coli
El agente etiológico más probable es E. Coli.
Case 7
Q4. Which of the following is not an adverse effect of nitrofurantoin?
a) Hemolytic anemia
b) Peripheral neuropathy
c) Hepatitis
d) Anorexy
Case 7-Q4. Review
The adverse effects of nitrofurantoin are: anorexia, nausea, vomiting, abdominal pain, hemolytic
anemia and peripheral neuropathy.
Los efectos adversos de la nitrofurantoína son: anorexia, náusea, vómito, dolor abdominal,
anemia hemolítica y neuropatía periférica.
Case 7
Q5. With which drug does nitrofurantoin decrease its therapeutic effect?
a) Quinolones
b) Cephalosporins
c) Beta-lactams
d) Aminoglycosides
Case 7-Q5. Review
With quinolones its therapeutic effect decreases.
Con quinolonas disminuye su efecto terapéutico.
Case 8
A 23-year-old woman arrives to the prenatal consultation in her second trimester of pregnancy
due to dysuria, bladder tenesmus, urgency and frequent urination. A closed cervical examination
without the presence of contractions or secretions, the rest without alterations. GUT is reported
with leukocytosis and positive urine culture.
Case 8
A 23-year-old woman arrives to the prenatal consultation in her second trimester of pregnancy
due to dysuria, bladder tenesmus, urgency and frequent urination. A closed cervical examination
without the presence of contractions or secretions, the rest without alterations. GUT is reported
with leukocytosis and positive urine culture.
Case 8
Bladder : Vegija
General urine test (GUT) : Examen general de orina
Case 8
Q1. Which of the following is the is the main complication of the patient's clinical picture?
a) Chorioamnioitis
b) Cardiac malformations
c) Oligohydramnios
d) Threat of preterm birth
Case 8-Q1. Review
The bacteria cause the destruction of fetal fibronectin, which causes a threat of preterm birth.
Las bacterias provocan la destrucción de la fibronectina fetal, lo que ocasiona amenaza de parto
pretérmino.
Case 8
Q2. Which is the best treatment for this patient?
a) Amoxicillin with clavulanate 500 mg every 6 hours for 7 days

b) TMP-SMX 500 mg every 8 hours for 10 days
c) Nitrofurantoin 100 mg every 6 hours for 7 days
d) Ciprofloxacin 200 mg every 8 hours for 7 days
Case 8-Q2. Review
The indication in this patient is nitrofurantoin.
La indicación en esta paciente es nitrofurantoina.
Case 8
Q3. Which of the following is a recommendation for this patient?
a) Cranberry juice intake

b) Avoid sexual intercourse during pregnancy
c) Water restriction
d) Regular vaginal showers.
Case 8-Q3. Review
Cranberry juice intake acidifies urine.
La ingesta de jugo de arándano acidifica la orina.
Case 8
Q4. Which of the following are not symptoms of acute cystourethritis?
a) Dysuria
b) Frequency
c) Abdominal pain
d) Bladder tenesmus
Case 8-Q4. Review
Acute cystourethritis is a urinary tract infection that is characterized by dysuria, polaquiuria and
occasionally bladder tenesmus.
La cistouretritis agudas es una infección del tracto urinario que se caracteriza por disuria,
polaquiuria y en ocasiones tenesmo vesical.
Case 8
Q5. Which is the contraceptive of choice during breastfeeding?
a) Abstinence
b) Estrogens
c) Progestagens
d) Estradiol
Case 8-Q5. Review
Progestogens are the contraceptives of choice during breastfeeding.
Los progestágenos son los anticonceptivos de elección durante la lactancia.
Case 9
A 28 year old arrive sto your office due to nausea and one week history of headache. On
interrogation P: 2, D:0, C:0, A1. Currently in pregnancy with 16 gestation weeks. On physical
examination HR: 88 bpm, RR: 18 rpm, TA: 142/94 mmHg, T: 37 oC, 24 cm uterine fundus.
Abdominal ultrasound is performed which shows mixed echogenic pattern, image in "snowflakes",
absence of fetal heart rate and presence of fetal parts.
Case 9
A 28 year old arrive sto your office due to nausea and one week history of headache. On
interrogation P: 2, D:0, C:0, A1. Currently in pregnancy with 16 gestation weeks. On physical
examination HR: 88 bpm, RR: 18 rpm, TA: 142/94 mmHg, T: 37 oC, 24 cm uterine fundus.
Abdominal ultrasound is performed which shows mixed echogenic pattern, image in "snowflakes",
absence of fetal heart rate and presence of fetal parts.
Case 9
snowflakes : Copos de nieve
Case 9
Q1. According to these findings and the clinical picture described, the most likely diagnosis is?
a) Abortion in evolution
b) Incomplete abortion
c) Partial mole
d) Complete mole
Case 9-Q1. Review
It is considered partial mola due to the presence of fetal parts and its karyotype is 46 XXY.
Literature: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Se considera mola parcial debido a la presencia de partes fetales y su cariotipo es 46 XXY.
Bibliografía: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Case 9
Q2. Which of the following represents the most important risk factor for the development of
this disease?
a) Previous abortion
b) Mole history
c) Previous Ectopic Pregnancy
d) Pre-term pregnancy
Case 9-Q2. Review
The history of mola is an important risk factor, it represents 40%.

El antecedente de mola es un factor de riesgo importante ya que representa un 40%.

Case 9
Q3. Which of the following represents the most appropriate follow-up in post evacuation
patients of gestational trophoblastic disease?
a) Determination of hGC levels monthly until negativization and then weekly up to 6 months
after evacuation.
b) Determination of monthly hGC levels until negativization
c) Determination of monthly hGC levels up to 6 months post evacuation.
d) Determination of hGC levels weekly until negativization and then monthly up to 6 months
after evacuation.
Case 9-Q3. Review
The patient should be followed with determination of weekly hGC levels until negativization and
then monthly until 6 months after evacuation.

Se debe seguir a la paciente con determinación de niveles de hGC semanal hasta negativización
y posteriormente mensual hasta 6 meses post evacuación.

Case 9
Q4. Which is the best indication of folinic acid?
a) Administer prior to the negativization of βhCG

b) A cycle after the negativization of βhCG
c) Two cycles after the negativization of βhCG
d) Not indicated
Case 9-Q4. Review
It is recommended 0.1mg / kg / day, IM of folinic acid, on days 2,4,6,8, repeat every two weeks,
giving two cycles after the negativity of the βhCG.

Se recomienda 0.1mg/kg/día ,IM de ácido folínico, los días 2,4,6,8, repetir cada dos semanas,
dando dos ciclos posterior a la negativización de la βhCG.

Case 9
Q5. In which of the following cases should caution be taken in the administration of
metrotexate?
a) Malnutrition
b) Hepatopathy
c) Liver disease
d) Nephropathy
Case 9-Q5. Review
The contraindications of metrotexate are: Hypersensitivity to the drug.
Precautions should be taken in: Assess risk benefit in malnutrition, serious infections, bone
marrow depression, immunodeficiency, kidney disease and pulmonary alveolitis

La contraindicaciones del metrotexate son: Hipersensibilidad al fármaco.
Se debe tener precauciones en: Valorar riesgo beneficio en desnutrición, infecciones graves,
depresión de la médula ósea, inmunodeficiencia, nefropatía y alveolitis pulmonar

Case 10
A 28-years-old female with history P:2, D:1, C:0, A:0 with history of severe preeclampsia in which
magnesium sulfate was administered, with normal labor and macrosomic product of 4500 gr;
When removing complete placenta and doing uterine massage continues bleeding, making a 1,200
ml count and uterus involved.
Case 10
A 28-years-old female with history P:2, D:1, C:0, A:0 with history of severe preeclampsia in which
magnesium sulfate was administered, with normal labor and macrosomic product of 4500 gr;
When removing complete placenta and doing uterine massage continues bleeding, making a 1,200
ml count and uterus involved.
Case 10
Uterus involved : Involución uterina
Case 10
Q1. Which is the first-line medical treatment?
a) Misoprostol 800mcg rectal DU

b) Ergometrine 0.2 intramuscular DU
c) Carbetocin 100mcg IV
d) Oxytocin 20 units in 500 ml of glucose solution
Case 10-Q1. Review
It is recommended to administer Oxytocin 20 units in 500 ml of glucose solution as a treatment
for uterine atony.
Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Hemorragia Obstétrica en la Segunda Mitad del
Embarazo y Puerperio Inmediato.
Se recomienda administrar Oxitocina 20 unidades en 500 ml de solución glucosada como
tratamiento de atonía uterina.
Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Hemorragia Obstétrica en la Segunda Mitad
del Embarazo y Puerperio Inmediato.
Case 10
Q2. Which is a contraindication to administer ergometrine?
a) Hypertension
b) Gestational diabetes
c) Previous caesarean section
d) Abdominal pain
Case 10-Q2. Review
Hypertension contraindicates the administration of ergometrine.
La hipertensión contraindica la administrar ergometrina.
Case 10
Q3. In this patient the uterotonics failed, what is the most appropriate management at this
time?
a) Hysterectomy
b) Exploratory laparotomy
c) Laparoscopy
d) Pelvic packing
Case 10-Q3. Review
Exploratory laparotomy is considered the management against therapeutic failure.
La laparotomía exploratoria se considera el manejo frente al fallo terapéutico.
Case 10
Q4. Which is the histopathological finding observed in ectopic pregnancy?
A) Arias Stella
B) Sparkling macrophages
C) Russell's Bodies
D) Uterus of Kuveliere
Case 10-Q4. Review
In ectopic pregnancy, the biopsy or histopathological sample of the endometrium is generally
scarce and is often accompanied by an atypical endometrial proliferation, called Arias Stella,
consisting of a decidua that lacks chorial villi.
Literature: Guía de Práctica Clínica Diagnóstico y tratamiento del embarazo ectópico en mujeres de edad
reproductiva en segundo y tercer nivel de atención.
En el embarazo ectópico la biopsia o muestra histopatológica del endometrio es generalmente
escasa y se acompaña a menudo de una proliferación endometrial atípica, denominada Arias
Stella, constituida por una decidua que carece de vellosidades coriales.
Bibliografía: Guía de Práctica Clínica Diagnóstico y tratamiento del embarazo ectópico en mujeres de edad
reproductiva en segundo y tercer nivel de atención.
Case 10
Q5. Which of the following is used to prevent seizures in preeclampsia?
A) Diacepan
B) Diphenylhydantoin
C) Phenobarbital
D) Magnesium sulphate
Case 10-Q5. Review
ts treatment is always with magnesium sulfate, diphenylhydantoin has not been shown to be
superior to magnesium sulfate as a treatment in seizures secondary to eclampsia and even less
with prophylactic treatment.
Literature: Guía de Práctica Clínica Atención Integral de Preeclapmsia en el Segundo y Tercer Nivel de
Atención.
Su tratamiento es siempre con sulfato de magnesio, la difenilhidantoina no ha mostrado ser
superior al sulfato de magnesio como tratamiento en las crisis convulsivas secundarias a
eclampsia y menos aún con un tratamiento profiláctico.
Bibliografía: Guía de Práctica Clínica Atención Integral de Preeclapmsia en el Segundo y Tercer Nivel de Atención.
Vocabulary Review
L
PUEP - ENARM
Dr. Julio Herrera-Zamora Dr. Julio Herrera-Zamora
Nightly : Nocturno
Hot flashes : Bochornos
Dryness : Sequedad
Pregnancy : Embarazo
Delivery : Parto
Caesarean section : Cesárea
Abortion : Aborto
Breast : Mama
Nontender : No dolorosa
Not attached : No adherido
Overlying : Superpuesto
Stony : pétreo
Heat : Calor
Swelling : Tumefacción
Breastfeeding : Alimentación a seno materno
Painful : Doloroso
Crackling : Crepitante
Nun : Monja
Yellowish vaginal discharge : Flujo vaginal amarillento
Sexual partners (SP) : parejas sexuales
Slightly painful : Un poco doloroso
Burning : Ardor
Bladder : Vegija
General urine test (GUT) : Examen general de orina
snowflakes : Copos de nieve
Uterus involved : Involución uterina

Clinical Cases on Menopause and Breast Cancer

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English Clinical Cases

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

a) High estrogens, low FSH, normal LH

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

a) 500 mg of calcium and 500 IU/day of vitamin D

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

a) Estrogens / Progestogens orally

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

- Avoid the first-pass liver effect

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

- Evita el efecto hepático de primer paso

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de la Perimenopausia y postmenopausia.

a) Wide local split

- 4, 5 and 6 points: Wide local excision (lumpectomy).

a) Cephalexin and paracetamol

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Ultrasound every year

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

a) Abnormal uterine hemorrhage

- Abnormal uterine hemorrhage

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

- Hemorragia uterina anormal

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Literature: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Bibliografía: Guía de Práctica Clínica Diagnóstico y Tratamiento de Miomatosis Uterina.

Literature: Norma Oficial Mexicana NOM-041-2011.

Bibliografía: Norma Oficial Mexicana NOM-041-2011.

Literature: Norma Oficial Mexicana NOM-041-2011.

Bibliografía: Norma Oficial Mexicana NOM-041-2011.

a) The first cause of morbidity and mortality

Literature: Norma Oficial Mexicana NOM-041-2011.

Bibliografía: Norma Oficial Mexicana NOM-041-2011.

Literature: Norma Oficial Mexicana NOM-041-2011.

Bibliografía: Norma Oficial Mexicana NOM-041-2011.

Literature: Norma Oficial Mexicana NOM-041-2011.

Bibliografía: Norma Oficial Mexicana NOM-041-2011.

a) Therapeutic test with oral contraceptives

a) Drainage of the abscess

a) The presence of 3 or more leucos per field in 2 samples

a) Impaired bowel movements due to increased intra-abdominal pressure

a) Amoxicillin with clavulanate 500 mg every 6 hours for 7 days

a) Cranberry juice intake

Literature: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Bibliografía: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Literature: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Bibliografía: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Literature: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Bibliografía: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

a) Administer prior to the negativization of βhCG

Literature: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Bibliografía: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Literature: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

Bibliografía: Guía de Práctica Clínica: Diagnóstico y Tratamiento de la Enfermedad Trofoblástica Gestacional.

a) Misoprostol 800mcg rectal DU