1.

A 29-year-old G0 comes to your office complaining of a vaginal discharge for the

past 2 weeks. The patient describes the discharge as thin in consistency and of a
grayish white color. She has also noticed a slight fishy vaginal odor that seems to
have started with the appearance of the discharge. She denies any vaginal or vulvar
pruritus or burning. She admits to being sexually active in the past, but has not had
intercourse during the past year. She denies a history of any sexually transmitted
diseases. She is currently on no medications. Last month she took a course of
amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears
normal. There is a discharge present at the introitus. A copious, thin, whitish
discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is
5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the
discharge indicates the presence of clue cells.

2. Mrs B, 28 years old, comes to a gynecologist complaining of secondary amenorrhea

for the last 4 years. Menarche at 12 years with regular menstrual cycles. She has first
intercourse at 19 years, when started taking OCs. After stopping administration of
OCs, Mrs B has amenorrhea (for 4 years) and persistent headache during the last year.
Physical exam reveals: height 165 cm, weight 60 kg, without signs of hirsutism. The
breast examination determine bilateral galactorrhea. The patient doesn’t take any
medications now.

3. Ms 45 years, G3, P3, admitted to gynecological ward with heavy vaginal bleeding that
lasts 3 weeks. The history: last menstrual bleeding was abundant, with clots, 6 weeks
ago and lasted 9 days. Gynecological history: cryotherapy for cervical moderate
dysplasia 10 years ago, a leiomyoma diagnosed 3 years ago. Obstetrical history: 3
caesarian sections and tubal ligature. No medical and surgical specific history, doesn’t
take any medication, doesn’t smoke, doesn’t use alcohol and recreational drugs.
Physical exam: blood pressure 110/70 mmHg, T – 36,7. Speculum examination:
healthy clean uterine cervix, bleeding from cervical os. On pelvic examination, an
enlarged, non-tender, mobile uterus is determined, with an irregular contour; no
adnexal pathology.

4. Mrs 42 years, admitted to the gynecological ward on November 28, 2018 with a 6
weeks pregnancy and heavy uterine bleeding that became more abundant after
speculum exam, without any abdominal painful cramps. Because of none specific
vaginal bleeding, the patient was consulted by a gynecologist 5 days earlier,
appreciated serum β - HCG - 8824 UI/ml, after 48 h – 9127 UI/ml. On clinical exam:
BP 110/90 mmHg, Ps 100 bpm. Vaginal exam appreciates an enlarged cervix, with a
barrel appearance, a uterus of a normal size, no adnexal pathology, and free fornixes.
5. Mrs B., 29 years old, admitted to the gynecologic department with acute abdominal
pain, localized in the right iliac region and abnormal uterine bleeding. The history: a
delay of menstruation, clinical signs of pregnancy - nausea, vomiting. Clinical exam:
Mrs B, is pale, her heart rate is 106 bit/min, BP - 90/60 mm Hg, T 37,2 C. Abdominal
palpation determines hypo-gastric pain with signs of acute abdomen. Gynecologic
exam: uterus of normal size, painful during mobilization, painful Douglas paunch. In
the region of right adnexa a mobile, painful formation 30x40mm is determined.
Positive pregnancy test. On ultrasound exam - intra-abdominal fluid and enlarged
right adnexa.

6. An 18-year-old Gravida 2 Para 1 presents to the emergency department with non-

severe abdominal pain and vaginal spotting for the past day. Her last menstrual period
was 7 weeks ago. On examination she is afebrile with normal blood pressure and
pulse. Her abdomen is tender in the left lower quadrant with voluntary guarding. On
pelvic examination, she has a small anteverted uterus, no adnexal masses, mild left
adnexal tenderness, and mild cervical motion tenderness. Labs reveal a normal white
count, hemoglobin of 10.5, and a quantitative β-hCG of 2300. Ultrasound reveals a 10
× 5 × 6 cm uterus with a normal-appearing 1-cm stripe and no gestation sac or fetal
pole. A 2.8-cm complex adnexal mass is noted on the left.

7. A 20-year-old Gravida 2 Para 0 with an LMP 5 days ago presents to the emergency
room complaining of a 24-hour history of increasing pelvic pain. This morning she
experienced chills and a fever, although she did not take her temperature. She reports
no changes in her urine or bowel habits. She has had no nausea or vomiting. Her only
surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports
regular menses and denies dysmenorrhea. She is currently sexually active. She has a
new sexual partner and had sexual intercourse with him just prior to her last menstrual
period. She denies a history of any abnormal Pap smears or sexually transmitted
diseases. Urine pregnancy test is negative. Urinalysis is completely normal. WBC is
18,000. Temperature is 38.8°C (102°F). On physical examination, her abdomen is
diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel
sounds are present but diminished. The bimanual examination reveals tender uterus
and adnexa and cervical motion tenderness.

An 18-year-old consults you for evaluation of disabling pain with her menstrual
periods. The pain has been present since menarche and is accompanied by nausea and
headache. She is sexually active for one year, and her partner use condoms as
 contraceptive method. History is otherwise unremarkable. On pelvic examination,
she has a small anteverted uterus, no adnexal masses, no pathological vaginal
discharge.

8. A mother brings her daughter in to see you for consultation. The daughter is 17 years
old and has not started her period. She is 152 cm in tall. She has no breast budding.
On examination, she has no pubic hair. By digital examination, the patient has a
cervix and uterus. The ovaries are not palpable. As part of the workup, serum FSH
and LH levels are drawn and both are high.

9. A 22-year-old S. presents to the emergency center with right-side pelvic pain, a 2-day
history of non-significant vaginal bleeding (spotting) and a 15-day menstrual delay.
She does not use any contraceptive method. She has a history of appendectomy and
recurrent genital infections. The patient has nausea without other intestinal tract
disturbances. Bimanual pelvic examination reveal a uterus that is smaller than the
assumed term of gestation and painful right side adnexal mass. The Douglas space
(the posterior vaginal fornix) is painless. The vital signs are stabile: BP 115/65 mm
Hg, Ps 85 bpm, body temperature – 37.2 ° C. The rest of the clinical examination is
considered normal.

10. A 21-year-old woman presents to the emergency gynecological department with acute
abdominal pain. She reports a 6-week menstrual delay, the presence of sympathetic
signs of pregnancy (morning sickness, vomiting, unexplained asthenia) and the
presence of moderate vaginal bleeding. Clinical examination: body temperature 37.5 °
C, BP 90/60 mmHg, Ps 100 bpm. On physical examination, her abdomen is tender in
the right lower quadrant with rebound and voluntary guarding. Bimanual exam: a
normal, not enlarged uterus, the mobilization of which is painful, with a right side
adnexal mass. Palpation of posterior fornix (Duglas space) is very painful. The β-hCG
level in the blood is 6258 IU/l. The transvaginal ultrasound demonstrates a significant
quantity of intraabdominal fluid and an adnexal mass to the right side of the uterus.

11. Mrs C., a 20-year-old woman comes to a gynecological consultation for absence of
her periods for 6 months. You determine that breast development and growth of pubic
heat started when C. was 11.5 years old. The age of menarche was 13.5. Between
13,5 and 16,5 years, her periods were very unpredictable, usually coming every 3 to 4
months. At the age of 16 she started taking combined oral contraceptive pills (Diane
35). The pills were discontinued 6 months ago, and she had no menstruation after
stopping the pills. Clinical examination reveals: the patient weighs 67 kg, height 169
cm, BP 130/70 mm Hg, a moderate hirsutism, greasy hair and skin.
 Vaginal exam reveals no congenital anomalies, normal-appearing clitoris, normal
appearance and quantity of cervical mucus. Lab results:
FSH 2.4 U/l (1.0-6.5)
LH 10.0 U/l (1.5-9.0)
Testosterone 2.8 nmol/l (0.6-2.3)
Androstenedione 18 nmol/l (3-10)
SHBG 5.0 nmol/l (15-90)

12. A 20-year-old G1 woman presents to the emergency department with a history of 3

days pelvic pain that increase in time and become more severe in the last 2 hours,
accompanied by nausea and vomiting. The patient has no significant past medical or
surgical history. She denies any urinary symptoms. Clinical examination reveals: BP
114/60 mmHg, Ps 100 bpm, T° = 37,4 °C. On physical examination, her abdomen is
diffusely tender in the left lower quadrant with rebound and voluntary guarding.
Bowel sounds are present. There is a normal-appearing cervix on speculum
examination. Bimanual vaginal exam: ante-verted, not enlarged uterus; on the left side
of the uterus there is a tender, firm-elastic 7-8 cm mass with limited mobility. Vaginal
fornixes are deep, and painless. Full blood count test: Hb = 130 g/l, Erythrocytes 3.2 x
10 2/l, Leucocytes 11.5 x 10 3/mcl, of which 10% non-segmented neutrophils, 47%
segmented neutrophils, 33% lymphocytes, basophils 1%, eosinophils 0%.
Erythrocytes Sedimentation Rate - 46 mm/h. The ultrasound exam determine a 7-8 cm
adnexal mass left from the uterus, with a granular, homogeneous, but hyper-echogenic
appearance, without a shadow cone and no collections of intraabdominal liquid
(figure 1, and 2). Doppler ultrasound does not detect intra-tumoral vascularization.

13. Patient L., 26 years old, presents to the gynecology clinic because of the inability to
become pregnant for 2 years, despite regular and unprotected intercourse during this
period of time. The gynecological history: Menarche occurred at the age of 12,
menses were regular, every 28-30 days. For the last two years the character of the
menstruations changed: they last for 1-2 days, are reduced in flow and painless. The
patient had three surgical abortions (D&C) without complications. The patient do not
have any chronic pathologies or allergies. The woman says that her husband is
healthy. The clinical and paraclinical examination revealed: normostenic
constitutional type, normally developed secondary sexual characteristics, no
pathology of internal organs. Gynecological exam: External genitalia without
pathologies. Vagina without visible pathologies, vaginal fornixes are painless. Cervix
is hard-elastic, mobile, painless at palpation. Uterus is of normal size, mobile,
painless. There are no adnexal masses and no pathological discharge from genital
tract. The basal body temperature chart is biphasic, with raise of the t 0 by 0.50 on day
14. Hysteroscopy - uterine cavity deformities with multiple fibrous adhesions. The
endometrium is thin and pale with avascular surfaces.
14. Ms. J, 24, was admitted to emergency gynecological service for hypogastric pain and
fever 38.6 ° C. During examination, the patient reports regular menstrual cycles
without dysmenorrhea. Last menstruation: 2 weeks ago. She uses oral contraceptives
 for 2 years. Lower abdominal pain started 4 days ago, with gradual intensification.
The patient does not complaint of gastrointestinal disturbances or constipation. She
has taken Paracetamol for fever. She is married, non-smoker, without a history of
sexually transmitted diseases. The physical exam reveals: BP 110/75 mmHg, Pulse 84
bpm, temperature 38.6 ° C. On the abdominal examination, the patient reports
tenderness in the lower quadrants at superficial palpation. External genitalia are intact,
without lesions. Speculum exam reveals a mucopurulent discharge from the cervix in
a moderate amount. The bimanual examination reveals tender uterus and adnexa and
cervical motion tenderness. Anteverted uterus, of normal size, firm-elastic, with
smooth surface. Non tender renal palpation.
15. Patient S., 48 years old, presented to the gynecology clinic with intermenstrual
bleeding during the last 2 months, heavy menstrual bleeding over the last 4 months,
fatigue. Menstrual bleeding may last 8-10 days, with an abundant blood flow,
sometimes with clots. There is no associated pain or episodes of warmth and
sweating. The patient is sexually active, has 3 children. As contraception, she uses
barrier methods. The last Papanicolaou test was performed 2 years ago, revealing
normal features. She does not take any medication and has no other relevant medical
history.Physical Examination: The abdomen is soft at palpation, without any
particularities.The speculum exam did not reveal cervical lesions or current bleeding.
Bimanual gynecological exam: the uterus is painless, has normal dimensions and
regular surface, no adnexal masses are detected. Mucosal discharge from the genital
tract. Blood tests: Hemoglobin 8.7 g / l; White cell count - 4.5x10 9 / L; Platelets
401x109 / L.The result of the ultrasound exam is presented below:
16. Patient S, 26 years old, presents to the gynecology clinic with complains on
amenorrhea for 8 months, galactorrhea for 6 months, and inability to conceive for 2
years. Gynecological history: the first menstruation occurred at 15 years, menstrual
cycles have been rare and irregular until now. The secondary sexual characteristics
are normal. Sexual life from 22 years. She and her husband used spermicides and
condoms for contraception. Last two 2 years they have regular, unprotected
intercourses. The woman never took any hormonal contraception.Physical
examination reveals: weight 90 kg, height 165cm, without signs of hirsutism. The
gynecological exam does not determined any pathologies, the breast examination
reveals a bilateral galactorrhea without other pathologies at the palpation. The patient
didn't received any treatment.

17. Patient C., 15 year old presents at gynecology clinic complaining of five months of
amenorrhea. She underwent normal pubertal development and had menarche at the
age 12 with regular cycles for three years. She is intensively practicing gymnastics.
 Clinical examination: vital parameters (heart rate, blood pressure, t ℃) are normal;
the abdomen on palpation is soft, painless over the entire surface. She has Tanner
stage 4 breast development, axillary and pubic hair growth. There was no bleeding
following progesterone challenge test. Lab tests results are:

B-HCG Negative

Estradiol 110 pmol/l (200-1500)

Prolactin 20.0 ug/l (< 30)

TSH 1.6 U/l (0.5-4.0)

FSH 0.4 U/l (1.0-6.5)

LH 1.2 U/l (1.5-9.0)

18. Patient V., 17 year old presents at gynecology clinic with primary amenorrhea. She is
of normal weight, has normal breasts, but no sexual hair. Gynecological examination
reveals normally looking female external genitalia, but no uterus and upper vagina.
Lab tests results are:Estradiol 150 pmol/l (200-1500), FSH 2.3 U/l
(1.0-6.5, LH 3.0 U/l (1.5-9.0), Testosterone 4.8 nmol/l
(0.6-2.3), Prolactin 17.0 ug/l (< 30), TSH 2.6 U/l (0.5-4.0)

19. Patient R. 15 years old, presents at gynecology clinic with primary amenorrhea.
Physical exam reveals no secondary sexual characteristics, short stature, webbed
neck, cubitus valgus. Gynecological examination reveals normally looking female
external genitalia, no clitoromegaly, cervix uteri and a small uterus. Lab tests results:

B-HCG Negative

Prolactin 10 ug/l (< 30)

Estradiol 120 pmol/l (200-1500)

FSH 9.3 U/l (1.0-6.5)

LH 13.0 U/l (1.5-9.0)

TSH 1.6 U/l (0.5-4.0)

Testosterone 0.8 nmol/l (0.6-2.3)

20. Patient F. 39 year old, Gravida 3 Para 3 presents at gynecology clinic with 5 months
amenorrhea and hot flashes. She is of normal weight; do not have any chronic
somatic disorders. Lab tests results: B-HCG Negative, Prolactin 10 ug/l (<
30), Estradiol 120 pmol/l (200-1500), FSH 9.3 U/l (1.0-6.5), LH
13.0 U/l (1.5-9.0), TSH 1.6 U/l (0.5-4.0), Testosterone
0.8 nmol/l (0.6-2.3)
21. A 16 yeas old presents to gynecology clinic because she never had menstruation. She
do not have any chronic illness and no known drug allergies. She is in a high school
with excellent academic performance, and practice sports (basketball and
gymnastics). She is 178 cm tall and weighs 73 kg. Clinical examination: vital
parameters (heart rate, blood pressure, t ℃) are normal; the abdomen on palpation is
soft, painless over the entire surface. She has Tanner stage 4 breast development,
axillary and pubic hair growth. On speculum examination a short vagina is
discovered, that ends blindly, there is no cervix and uterus. Ultrasound reveals
normally sized ovaries. Lab tests results:

B-HCG Negative

Prolactin 10 ug/l (< 30)

Estradiol 320 pmol/l (200-1500)

FSH 5.3 U/l (1.0-6.5)

LH 8.0 U/l (1.5-9.0)

TSH 1.6 U/l (0.5-4.0)

Testosterone 0.8 nmol/l (0.6-2.3)

22. A 15 yeas old presents to gynecology clinic because she never had menstruation. She
do not have any chronic illness and no known drug allergies. She is in a high school
with excellent academic performance, and practice sports (basketball and
gymnastics), did not start a sexual life. She is 168 cm tall and weighs 63 kg. Clinical
examination: vital parameters (heart rate, blood pressure, t ℃) are normal; the
abdomen on palpation is soft, painless over the entire surface. Physical exam reveals
no secondary sexual characteristics: she has Tanner stage 0 breast development, and
no pubic hair growth. On speculum examination a normal vagina and cervix are
discovered. Lab tests results:

B-HCG Negative

Prolactin 10 ug/l (< 30)

Estradiol 110 pmol/l (200-1500)

FSH 15.3 U/l (1.0-6.5)

LH 18.0 U/l (1.5-9.0)

TSH 1.6 U/l (0.5-4.0)

Her karyotype is 46 XY.

 23. An 19 years old gravida 0 presents to gynecology clinic because she has not had a
period for the last 10 months. She is in a high school now, actively practice sports,
and she is sexually active.She had the menarche at age 14, had irregular menses
during one year that became regular after that. She is 168 cm tall and weighs 43 kg.
Her vital signs are as follow: BP 105/60 mmHg, Ps 54 bpm, T 35.7°C. On
examination, she has a normally developed vulva and vagina without any lesions,
unremarkable cervix and uterus. There are no adnexal masses or tenderness. Physical
examination also unremarkable, except her teeth, on which there many erosions of the
incisors. Also, she has many small scars on the back of her hands.

Lab tests results:

B-HCG Negative

Prolactin 10 ug/l (< 30)

Estradiol 110 pmol/l (200-1500)

FSH 0.3 U/l (1.0-6.5)

LH 1.0 U/l (1.5-9.0)

TSH 1.6 U/l (0.5-4.0)

24. A 17 year old girl was brought by ambulance to the emergency department because
she collapsed at home and all her clothes are in the blood. She has irregular
menstruations, without dysmenorrhea, and, periodically, she is bleeding abundantly
during her periods. Last menstrual period was 45 days ago. She do not have any
chronic illness, no known drug allergies, and do not use any contraceptive
method.She is conscious now, but very pale. Her vital signs are as follow: BP 88/52
mm Hg, Ps 125 bpm, T 36.7°C. Speculum examination reveals red bright blood
coming from cervical os. Vagina and cervix are intact. Bimanual examination
determine a normally sized, non tender, regular uterus, no adnexal masses. Pelvic
ultrasound is also unremarkable. Pregnancy test is negative. Blood tests: Hemoglobin
6.7 g / l; Red blood cells – 2, 5x10 9 / L; White cell count - 4.5x109 / L; Platelets
301x109 / L.
25. A 15 year old girl was brought by ambulance to the emergency department because
she started to bleed heavily from vagina two hours ago. She had the menarche at age
14. She had regular menstruations, at 30-32 days intervals, without dysmenorrhea, but
she has been bleeding abundantly during all her periods. Last menstrual period was
one month ago. She do not have any chronic illness, no known drug allergies, and do
not use any contraceptive method. From anamnesis, the patient reported that she
frequently has bruises on the skin and is bleeding for a long period of time after any
skin laceration or a teeth extraction. She is conscious now, but very pale. Her vital
signs are as follow: BP 88/52 mm Hg, Ps 125 bpm, T 36.7°C. Speculum examination
 reveals red bright blood coming from cervical os. Vagina and cervix are intact.
Bimanual examination determine a normally sized, non tender, regular uterus, no
adnexal masses. Pelvic ultrasound is also unremarkable. Pregnancy test is negative.
Blood tests: Hemoglobin 6.7 g / l; Red blood cells – 2, 5x10 9 / L; White cell count -
4.5x109 / L; Platelets 301x109 / L.
26. A 23 year old woman, presents to gynecology office complaining on increased
vaginal discharge, associated with pruritus. She had one pregnancy that ended with
full term delivery. She is not using contraceptives. One week ago she got antibiotics
for treatment of sinusitis. Gynecological examination reveals hyperemia of vulva and
vagina and whitish-gray and clumpy vaginal discharge. pH of vaginal secretions is
4.5. Vaginal smear confirm presence of many pseudohyphae and absence of clue
cells.
27. Patient M., 21 year old, presents to the emergency gynecological service with
progressive hypogastric pain accompanied by nausea, vomiting and fever 38.8 °
C.Gynecological history: the patient reports regular menstrual cycles without
dysmenorrhea. Last menstruation: 2 weeks ago. Lower abdominal pain began 4 days
ago, with progressive intensification and accompanied by bloating and flatulence. She
is sexually active, not married, non-smoker, with a recurrent history of sexually
transmitted diseases and several episodes of salpingitis treated in ambulatory
conditions.The physical exam reveals: BP 110/65 mm Hg, Ps 100 bpm, temperature
39.4 ° C. On physical examination, her abdomen is diffusely tender in the lower
quadrants. Bowel sounds are present, but diminished. Speculum exam: an abundant
muco-purulent discharge from cervical os. The bimanual examination reveals tender
uterus and adnexa and cervical motion tenderness. Laterally, on the left side of uterus
there is a very painful adnexal formation, of elastic consistency, 6x7 cm in size, and
with reduced mobility. Non tender renal palpation.The endo-vaginal ultrasound
reveals a complex solid, unilateral, hypo-ecogenic mass.
28.