Benign gynae Flashcards
Fibroids: All of the following statements are true except:
a - >20% of fibroids have a chromosomal abnormality
b - on cytogenetics a single fibroid comes from one single cell (not pleomorphic)
c - 20% of women develop a fibroid
d - Medroxy progesterone acetate most commonly inhibits fibroid mitotic activity
d - Medroxy progesterone acetate most commonly inhibits fibroid mitotic activity
Studies show progestogens actually increase mitotic activity
Red degeneration of a fibroid:
a - causes an elevation of the ESR
b - causes leukopaenia and lymphocytosis
c - only occurs in pregnancy
d - occurs due to embolisation of the major blood vessels supplying the myoma
a - causes an elevation of the ESR
O
Dermoid cysts
A - are the commonest ovarian neoplasms detected in pregnancy
B - are malignant in 10% of cases
C - are bilateral in 40-60% of cases
D - often have a 46, XY chromosomal composition
A - are the commonest ovarian neoplasms detected in pregnancy
O
A 15 yr old girl presents with pelvic pain and an US shows a 4 cm ovarian cyst. What is the commonest cause?
A - Dermoid cyst B - Follicular cyst C - Corpus luteal cyst D - Serous adenoma E - Endometrioma
B - Follicular cyst
Follicular cysts are most common type in adolescents (UTD).
What is the rate of amenorrhoea in patients with intrauterine synechiae?
A - 10% B - 20% C - 40% D - 60% E - 80%
C - 40%
As per UpToDate
Can be caused by TB
Rx: hysteroscopic resection
What is the most common symptom of benign breast disease?
A - pain B - tender lump C - change in breast size D - discharge E - change in menses
B - tender lump
*CHECK as other answer says A
Advantages of GnRH agonist for the treatment of fibroids include all of the following EXCEPT:
A - allow vaginal hysterectomy
B - allow return of patient Hb towards normal before surgery
C - diagnostic test to distinguish between fibroid and leiomyosarcoma
D - allows hysteroscopic resection of fibroid
E - reduced intraoperative blood loss
C - diagnostic test to distinguish between fibroid and leiomyosarcoma
What percentage of fibroids will shrink with GnRH analogues?
A - 10% B - 25% C - 50% D - 75% E - 90%
C - 50%
Cochrane review states 47% reduction in volume
After 6 months of GnRH analogues, how much reduction in uterine size would you expect?
A - 10% B - 25% C - 50% D - 75% E - 90%
C - 50%
The most frequent cause of dyspareunia is
a - inadequate lubrication b - retroverted uterus c - vaginismus d - endometriosis e - pelvic inflammatory disease
a - inadequate lubrication
O
30 yo para 1 with a 3 yo child presents with menorrhagia and on VE there is a 12 week fibroid uterus palpable. She would like another child in the future. Management:
a - TAH b - Myomectomy abdominally c - GnRH analogue for 6/12 d - Continuous provera for 9/12 e - Hysteroscopic resection
b - Myomectomy abdominally
?
Can’t confirm hysteroscopic resection unless know fibroids are submucosal.
No benefit from progestogen only therapy
Which of the following is correct in regard to premenstrual syndrome?
A - it is due to low progesterone level
B - bromocriptine is more effective than cyclical synthetic progesterone in treating PMS
C - cyclical progesterone showed no advantage over placebo in treating PMS
D - it is due directly to endogenous endorphin withdrawal
E - it is related to HLA B27 typing
C - cyclical progesterone showed no advantage over placebo in treating PMS
A woman had a NVD with an episiotomy and has been BF for 8 weeks. She presented complaining of dyspareunia. O/E the episiotomy is well healed. What is the most likely diagnosis?
A - suture granuloma
B - atrophic vaginitis
C - PND
D - Narrowed introitus
B - atrophic vaginitis
A woman has a regular 24 day cycle and is experiencing midcycle bleeding. Which of the following is correct?
a. Oestrogen breakthrough
b. Oestrogen withdrawal
c. Progesterone breakthrough
d. Progesterone withdrawal
e. Inadequate androgens
b. Oestrogen withdrawal
Physiologic intermenstrual bleeding at the time of expected ovulation is secondary to the brief abrupt decline in estradiol that follows its preovulatory surge.
Milford
A 46 yo lady presented with severe menorrhagia for six months and clinical evidence of a tender enlarged uterus. What is your first investigation?
A - hysteroscopy and D&C B - FBC C - LH and FSH D - Coagulation profile E - Serum progesterone
B - FBC
Milford
A woman presented to you with lack of sexual excitement. What is the most likely reason?
A - fear of pregnancy B - poor coital techniques C - marital discordance D - endometriosis E - pelvic congestion syndrome
C - marital discordance
25 yo. O/E 5 cm simple cystic R adnexal mass confirmed on US. Mx?
A - repeat exam in 3/12
B - give OCP and repeat US in 1/12
C - laparotomy
D - laparoscopy and aspiration of cyst
A - repeat exam in 3/12
<50mm diameter - do not require f/u
- Likely physiological and almost always resolved within
50-70mm - yearly USS f/u
25 yo, 1 yr history of acute virilizing symptoms and normal pelvic exam. LH 2 (low) FSH 3 (low-normal) Testosterone 2-3x normal DHEAS normal 17 OHP Normal
A - Cushing’s syndrome B - PCOS with insulin resistance C - Late onset CAH D - Sertoli-Leydig cell tumour E - Adrenal cortical adenoma
D - Sertoli-Leydig cell tumour
O
43 yo rapid onset virilizing symptoms, normal pelvic exam
LH 2 L (4-25) FSH 3 N Test 12.3 H (0.5-2.5) DHEAS 25 H (0.9-11.7) 17 HOP N
A - Cushing syndrome
B - Polycystic ovarian syndrome with insulin resistance
C - Late onset congenital adrenal hyperplasia
D - Sertoli-leydig tumour
E - Adrenal cortical adenoma
E - Adrenal cortical adenoma
O
22 yo, long Hx irregular menses and hirsuitism. Short stature, OE borderline clitoromegaly. LH 12 (N) FSH 6 (N) Test 3 (1.5x normal) DHEAS 21 (1.5x normal) 17 HOP 16.5 (2x normal)
A - PCOS
B - Late onset CAH
C - Androgen secreting tumor of the ovary
D - Androgen secreting tumor of the adrenal
E - Ovarian hyperthecosis
B - Late onset CAH
*Isolated DHEAS would suggest androgen secreting tumor of the adrenals
O
22 yo long Hx irregular menses and hirsuitism LH 1.9 FSH 6 Test 1.5x normal DHEAS 1.5x normal 17 HOP normal
A - Cushing’s syndrome B - PCO C - Late onset CAH D - Sertoli-leydig tumour E - Adrenal cortical adenoma
B - PCO
47 yo has progressive menorrhagia with regular cycles. O/E uterus normal anteverted with no adnexal masses. Hysteroscopy – regular cavity, no pathology.
D&C – secretory normal endometrium.
Management?
A - Cyclic Progesterone
B - OCP
C - NSAIDS
D - Advise endoablation, compared to TAH is more effective and less complications
E - Advise endoablation is adequate contraception
A - Cyclic Progesterone
*CHECK as other answer says C
How long does it take to stop heavy bleeding with GnRH analogues?
A - 12 hrs
B - 18 hrs
C - 1 week
D - 4 weeks
D - 4 weeks
Begins to work after 2 weeks
Which of the following is true concerning uterine fibroids?
A - characteristically cause pain
B - associated with nulliparity
C - 1% undergo sarcomatous change
D - should be removed at caesarean section if larger than 2cm diameter
B - associated with nulliparity
O
0.02-0.3% undergo sarcomatous change
A 35 yo with menorrhagia and a 6 cm intramural fibroid wishes to become pregnant. Should she?
A - ignore fibroid and attempt to conceive
B - 3/12 of GnRH agonist then attempt to conceive
C - undergo myomectomy at laparotomy after GnRH analogue
D - undergo hysteroscopic resection of fibroid
A - ignore fibroid and attempt to conceive
There is insufficient evidence to determine whether myomectomy for IM fibroids improves fertility outcomes
- mainly submucosal or those that distort the cavity
You have been asked to see a 22yo nulligravida who has oligomenorrhoea and idiopathic hyperprolactinemia. She desires pregnancy. Her physician initiated 2.5mg bromocriptine BD, and she is experiencing orthostatic symptoms and moderate nausea. Serum bHCG is negative, TSH normal and MRI normal. The most appropriate next step in her management is to
a. Advise her to continue bromocriptine and she will eventually become tolerant of the medication
b. Discontinue the bromocriptine
c. Reduce the dose to ½ tablet at bedtime until she becomes tolerant of the medication
d. Tell her to take an extra dose at bedtime
c. Reduce the dose to ½ tablet at bedtime until she becomes tolerant of the medication
O
1.25mg nocte for 5 nights, and gradually up titrate to 7.5mg daily in 2-3 divided doses over about 3 weeks
Common adverse effects:
- N/v, headache, postural hypotension, vertigo, GI disturbance
- Minimised by taking at night and then taking tablets with food
A 22yo woman has had severe hirsutism for 7 years and oligomenorrhoea since menarche. Her sister has mild hirsutism and uses the COCP. She is 1.5 metres tall and weighs 50kg. Pelvic examination shows borderline clitoromegaly but is otherwise normal. Hormone profile shows LH 19 [5-25] FSH 6 [4-22] Testosterone 3 [0.5-2.6] DHEAS 21 [0.9-11.7] 17-OH progesterone 16 [0.8-8.0]
The MOST LIKELY diagnosis is:
a. PCOS
b. Ovarian hyperthecosis
c. Late onset CAH
d. Androgen secreting adrenal tumour
e. Androgen secreting ovarian tumour
c. Late onset CAH
Which of the following drugs is NOT associated with non-androgen dependent hair growth (hypertrichosis)
a. Phenytoin
b. Cyclosporin A
c. Ranitidine
d. Diazoxide
c. Ranitidine
All are characteristic behavioural components of the Chronic pelvic pain syndrome EXCEPT
a. Pain is refractory to medical management
b. Signs of depression have begun
c. The patients role in the family has changed
d. A history of sexual abuse is usually present
d. A history of sexual abuse is usually present
In the HAIR-AN syndrome, the mechanism of insulin resistance is
a. Abnormalities in the insulin receptor
b. Obesity related changes in ovarian function
c. Underlying diabetes mellitus
d. Alterations in adrenal steroid synthesis pathways
e. Alterations in ovarian steroidogenic enzymes
a. Abnormalities in the insulin receptor
O
Hyperandrogenism
Insulin resistance
Acanthosis nigricans
The most common cause of introital dyspareunia is:
a. Monoilial vulvovaginitis
b. Herpes genitalis
c. Inadequate arousal
d. Vaginismus
c. Inadequate arousal
O
A blood assay of which of the following is the most direct measure of adrenal androgen activity
a. Androstenedione
b. Cortisol
c. DHEAS
d. Testosterone
c. DHEAS
O
A 25yo presents with virilisation over the past year. Her menstrual cycles are irregular and infrequent. On examination she is obese, has marked facial hair growth and clitoromegaly. Uterus is slightly enlarged, ovaries not easily palpated. Hormone profile shows testosterone of 8 [normal 1-4], and DHEAS of 8 [normal 1-10]. The MOST APPROPRIATE next step in diagnosis is:
a. Vaginal ultrasound of the ovaries
b. Dexamethasone suppression test
c. Measurement of serum 17-OH progesterone
d. Measurement of serum androstenedione
e. Laparoscopy or laparotomy
a. Vaginal ultrasound of the ovaries
O
Concern for ?SL tumor
Regarding therapy for mild to moderate endometriosis, which of the statements below is LEAST CORRECT
a. Monthly fecundity over the first 36 weeks is significantly increased after laparoscopic treatment of mild or moderate endometriosis
b. There is a tendency for fertility to plateau at the same level with either surgery or expectant management
c. Danazol reduces both pain and disease progression
d. After a course of GnRH analogue therapy, fecundity is transiently improved in comparison to expectant management
d. After a course of GnRH analogue therapy, fecundity is transiently improved in comparison to expectant management
RANZCOG 2011 answer
Medical treatment does not affect the fertility rate
The principle secretory product of polycystic ovaries is
a. Androstenedione
b. Testosterone
c. DHEAS
d. Oestrone
e. Oestradiol
a. Androstenedione
O
Cholesterol converted to androstenedione by insulin. Further converted to testosterone.
In patients with hyperandrogenic chronic anovulation, all of the following are described EXCEPT
a. Raised LH:FSH ratio in serum
b. Hyperoestrogenism
c. Raised serum triglyceride, reduced HDL cholesterol
d. Increased SHBG
d. Increased SHBG
O
Insulin resistance –> increased insulin –> increased androgen production by ovarian theca cells and reduced hepatic synthesis of sex hormone-binding globulin
Low SHBG –> high levels of free testosterone
In patients with hyperandrogenic chronic anovulation, which is LEAST CORRECT?
a. Insulin inhibits granulosa cell production of IGF-1 binding protein
b. Insulin inhibits hepatic production of SHBG
c. Insulin, through homology with IGF-1, binds to the IGF-1 receptor
d. Metformin increases circulating androgen levels by reducing serum insulin
d. Metformin increases circulating androgen levels by reducing serum insulin
O
Amenorrhoea and galactorrhoea is LEAST likely to be caused by
a. Pituitary tumour
b. Chlorpomazine
c. Thyrotoxicosis
d. Metoclopramide
e. Chronic renal failure
c. Thyrotoxicosis
O
Hypothyroidism more common to cause galactorrhea and amenorrhoea
Hyperthyroid rarely can
Which of the following statements regarding the mechanism of anti-androgen effects is LEAST correct
a. Cyproterone acetate inhibits 5-alpha reductase
b. Spironolactone competitively inhibits binding to the dihydrotestosterone receptor and inhibits 5-alpha reductase
c. Finasteride inhibits 5-alpha reductase
d. Cimetidine weakly binds to the dihydrotestosterone receptor
a. Cyproterone acetate inhibits 5-alpha reductase
O
Cyproterone and spironolactone bind to androgen receptor and exert mixed agonism-antagonism.
Cyproterone acetate blocks binding to dihydrotesterone to receptors
5-alpha-reductase
- converts testosterone to dihydrotestosterone
Anti-androgen progesterone
Ginet
Finasteride used for male pattern baldness - specific 5-alpha reductase inhibitor
A 62yo woman has pain in left lower quadrant of the abdomen. She had similar episodes on three previous occasions. Exmaination shows tenderness in the left lower quadrant with rebound tenderness. She has a Hb 136 and WCC 15.4 with 82% neutrophils. Urinalysis 5-6 leuks in high power field. The MOST likely diagnosis is
a. acute cholecystitis
b. acute diverticulitis
c. acute pyelonephritis
d. appendicitis
e. spontaneous bacterial peritonitis
b. acute diverticulitis
O
In obese postmenopausal women, peripheral conversion of oestrogen precursors results primarily in the formation of:
a. Oestrone
b. Oestradiol
c. Oestriol
d. Androstenedione
e. Dehydroepiandrosterone
a. Oestrone
O
Aromtasae converts androstenedione to oestrone
A previously normotensive 42yo woman is found to have a diastolic BP of 95mmHg at her annual examination. You should
a. Recheck BP in 2 weeks
b. Recheck BP in one year
c. Commence a thiazide diuretic
d. Commence an ACE inhibitor
a. Recheck BP in 2 weeks
O
A 30yo has received conflicting advice about HRT. Which would be the CORRECT information to give this patient
a. Bone loss is most rapid in the first 3 years after menopause
b. Ingestion of 1500mg elemental calcium daily will lead to an increased incidence of kidney stones
c. HRT is not indicated above age 60
d. HRT increases the incidence of coronary heart disease
e. HRT increases the incidence of colorectal cancer
a. Bone loss is most rapid in the first 3 years after menopause
Average woman loses up to 10% of her bone mass in the first 5y after menopause
Which is LEAST CORRECT of simple ovarian cysts in postmenopausal women
a. Aspiration is associated with a recurrence of 25% at 3 months
b. Approximately 20% resolve over the next 2-3 months
c. Laparoscopic BSO is the usual procedure of choice if surgery is to be undertaken
d. Less than 1% of such cysts are malignant
c. Laparoscopic BSO is the usual procedure of choice if surgery is to be undertaken
O
- Unilateral salpingo-oophorectomy recommended if cyst is simple
The most common benign tumour of the ovary in a postmenopausal woman is
a. Cystic teratoma
b. Serous cystadenoma
c. Mucinous tumour
d. Endometrioid tumour
b. Serous cystadenoma
In recommending influenza vaccine to your patients, all of the following are correct statements EXCEPT
a. 90% of influenza deaths occur in individuals over age 60
b. The incidence of clinical and serologic influenza is reduced by 50% with immunisation
c. Advanced cardiac or pulmonary disease is a contraindication to vaccination
d. The pulmonary complications of influenza are reduced by 70% in immunised populations.
c. Advanced cardiac or pulmonary disease is a contraindication to vaccination
O
Which of the following is LEAST CORRECT with regard to the Womens Health Initiative trial of HRT
a. Fractures are decreased with HRT
b. The trial included a substantial proportion of women with risk factors for arteriosclerosis, including hypertension, age > 70, and diabetes
c. Total cancer incidence is similar in HRT and no HRT groups
d. HRT increased the incidence of myocardial infarctions and CVA, even after adjusting for risk factors for arteriosclerosis.
d. HRT increased the incidence of myocardial infarctions and CVA, even after adjusting for risk factors for arteriosclerosis.
Which is FALSE regarding raloxifene
a. It has been shown to increase bone mineral density in spine and hip
b. It reduces fracture rates in osteoporosis
c. It does not produce endometrial hyperplasia
d. Oestrogen but not raloxifene has been shown to reduce atherosclerosis in primate studies
d. Oestrogen but not raloxifene has been shown to reduce atherosclerosis in primate studies
O
EVISTA is indicated for the prevention and treatment of osteoporosis in post-menopausal women
A 25 year old woman has developed hirsuitism, weight gain, and deepening of the voice over the last year. Her menstrual cycles are irregular and infrequent. Examination reveals severe facial hair growth and clitoromegaly. The uterus is slightly enlarged. The patient is obese and the ovaries are very difficult to palpate. Investigation shows a testosterone concentration of 17.3 nmol/L (normal range 0.5 - 2.8) and a DHEAS concentration of 9.8 umol/L (normal range 0.9 - 11.7). The MOST APPROPRIATE next step in this patient’s evaluation is:
A. measurement of serum androstenedione. B. measurement of serum 17-hydroxyprogesterone. C. CT scan of the adrenals. D. vaginal ultrasound of the ovaries. E. selective venous catheterisation.
D. vaginal ultrasound of the ovaries.
O
Need to exclude androgen secreting tumor of the ovary
A 22-year-old woman has infrequent (three times yearly) heavy menses which last 10 to 12 days and increased facial hair growth. She is normotensive and moderately obese. Her last menstrual period started 25 days ago and ended 12 days later. A biopsy specimen from the endometrium would MOST LIKELY show:
A. subnuclear vacuoles.
B. supranuclear vacuoles.
C. stromal oedema with perivascular decidualisation.
D. haemorrhagic stroma and collapsed endometrial glands.
E. crowding of straight tubular glands.
D. crowding of straight tubular glands.
O
Subnuclear vacuoles suggest secretory phase post - ovulation
Stromal oedema suggests implantation phase
Haemorrhage suggests endometrial breakdown
Straight glands would imply proliferative phase that occurs after menses
Crowding is seen in endometrial hyperplasia
In Syndrome X, the mechanism by which insulin resistance occurs is through:
A. abnormalities associated with the insulin receptor.
B. obesity-related changes in ovarian function.
C. alterations in ovarian steroidogenic enzymes.
D. underlying diabetes mellitus
A. abnormalities associated with the insulin receptor.
The significance of an ultrasound finding of polycystic ovaries in the prepubertal sister of a woman with PCOS is that:
A. it means that she will develop PCOS.
B. it is a marker for insulin resistance.
C. it suggests that there is partial 21 hydroxylase deficiency in the family.
D. it indicates that she is using oocytes at an increased rate and will have an earlier menopause.
B. it is a marker for insulin resistance.
O
A 25-year-old lactating woman has vulvovaginal irritation and a burning sensation with intercourse four weeks postpartum. Examination shows a well healed episiotomy, no discharge and an erythematous, thin vaginal mucosa. Findings on bimanual examination are normal. Potassium hydroxide and saline preparation of vaginal secretions are negative. The MOST LIKELY diagnosis is:
A. Mycoplasma hominis vaginitis.
B. Candida vulvovaginitis.
C. Bacterial vaginosis.
D. Atrophic vaginitis.
D. Atrophic vaginitis.
O
Which of the following is LEAST true concerning the healthy vagina of a woman of reproductive age?
a) The pH would be in the range 3.5-4.5
b) Lactobacilli metabolise glycogen to lactic acid
c) The major source of glycogen is from desquamated vaginal epithelial cells
d) Oestrogen increases the ratio of superficial to parabasal cells
e) Parabasal cells have a small pyknotic nucleus
e) Parabasal cells have a small pyknotic nucleus
O
They have a large nucleus as opposed to superficial cells which have small, dark (pyknotic) nuclei
The LEAST COMMON symptom associated with the premenstrual syndrome (PMS) is:
A. bloating. B. breast tenderness. C. headache. D. increased appetite. E. urinary frequency.
E. urinary frequency.
O
Which of the following statements regarding hyperandrogenic chronic anovulation and polycystic ovarian syndrome is MOST CORRECT?
a. Approximately 5% of normal ovulatory women have an ultrasound appearance of polycystic ovaries and approximately 75% of women with hyperandrogenic chronic anovulation have an ultrasound appearance of polycystic ovaries.
b. Approximately 20% of normal ovulatory women have an ultrasound appearance of polycystic ovaries and approximately 75% of women with hyperandrogenic chronic anovulation have an ultrasound appearance of polycystic ovaries.
c. Approximately 5% of normal ovulatory women have an ultrasound appearance of polycystic ovaries and approximately 90% of women with hyperandrogenic chronic anovulation have an ultrasound appearance of polycystic ovaries.
d. Approximately 20% of normal ovulatory women have an ultrasound appearance of polycystic ovaries and approximately 90% of women with hyperandrogenic chronic anovulation have an ultrasound appearance of polycystic ovaries.
b. Approximately 20% of normal ovulatory women have an ultrasound appearance of polycystic ovaries and approximately 75% of women with hyperandrogenic chronic anovulation have an ultrasound appearance of polycystic ovaries.
O
Woman with chronic pelvic pain. All Ix normal. She finally says she does not know if she can cope with her husbands physical abuse of her for much longer. Is this form of abuse
a) easy to treat with counselling once recognised
b) usually first picked up by physicians
c) gets better in pregnancy
d) women/the victims fear being left alone
d) women/the victims fear being left alone
A lady presents to you for investigation of menometrorrhagia with regular cycles. She is 45 years old and G4P4. Which investigation would give you most information regarding her diagnosis?
a) FBE
b) Dilation and curettage
c) Hysterosalpingogram
d) Office hysteroscopy
e) Pelvic US
d) Office hysteroscopy
Most common clinical indication for GnRH agonist in Australia at present:
a) Prostatic cancer
b) Fibroids
c) IVF
d) Endometriosis
e) Abnormal uterine bleeding
a) Prostatic cancer
Milford
A 46-year-old woman presents with a feeling of a lesion inside her vagina. She is an asylum seeker and has a 10-12 year history of episodes of amenorrhoea and dysfunctional bleeding. She is concerned about going to a hospital and also the cost involved. Her GP has supplied a report of a pelvic ultrasound scan and it shows a moderate cystic change in the uterine cavity and endometrium thickness of 27mm. When you examine her you find a pedunculated cervical polyp which is not compromising her, but is bothering her.
What is the next step in the management of this patient?
a. Perform an outpatient pipelle aspiration and polypectomy in your room
b. Perform the polypectomy in your rooms
c. Explain your concern and long term risk of cancer and organise for hysteroscopy and curettage under GA after explaining the cost and procedure
d. Refer her to the public system and they will take care of her
a. Perform an outpatient pipelle aspiration and polypectomy in your room
A 21-year-old anxious and distressed nulliparous woman presents requesting a vaginal repair as her boyfriend commented that she had a lax vaginal wall and is putting pressure on her to have a reconstruction/repair. The gynaecological examination was normal.
What is the most appropriate initial option?
a. Provide psychosexual counselling to the couple
b. Explain to the woman that there is no medical indication for surgery
c. Recommend pelvic floor physiotherapy
d. Perform the procedure after explaining risks and consequences
b. Explain to the woman that there is no medical indication for surgery
A 32-year-old woman who has been infertile for four years has just completed the diagnostic phase of her infertility evaluation. Mid-luteal progesterone, semen analysis and hysterosalpingogram are all normal. A recent laparoscopy indicates moderate pelvic endometriosis without adhesions (stage III). Medical therapy for her endometriosis is recommended by another gynaecologist. The patient presents to the clinic with a list of questions concerning the proposed therapy.
You advise her that:
a. the degree of ovarian suppression (hypo-oestrogenism) achieved by treatment with gonadotrophin-releasing hormone (GnRH) agonists is greater than that achieved with danazol.
b. the availability of new medications has made medical therapy for endometriosis superior to operative therapy in terms of post-treatment pregnancy rates.
c. the pregnancy rate after medical therapy is unrelated to the initial stage of the disease.
d. Danazol (Danocrine) is most effective when administered as a single daily dose.
a. the degree of ovarian suppression (hypo-oestrogenism) achieved by treatment with gonadotrophin-releasing hormone (GnRH) agonists is greater than that achieved with danazol
Danazol - don’t use, high burden androgenic side effects (weight gain, acne, hirsutism)
Androgen
In the graafian follicle, the theca and granulosa cells cooperate to synthesize oestradiol (two-cell theory).
The two-cell theory is plausible because:
a. theca lutein cells express receptors for FSH.
b. androstenedione and testosterone are aromatised in theca cells to oestradiol.
c. granulosa cell has p450 aromatase.
d. granulosa cell has 17b hydroxylase.
c. granulosa cell has p450 aromatase.
E agrees
Oestrogen production requires
- LH to stimulate ovarian theca cells to produce androgens from cholesterol (via desmolase)
- FSH stimulates ovarian granulosa cells to convert androgen into oestrogen (via aromatase)
Main hormone secreted by PCOS ovary
a) Testosterone
b) Androstenedione
c) Oestrone
d) Oestradiol
e) DHEAS
b) Androstenedione
A 21 year old anxious and distressed nulliparous woman presents requesting a vaginal repair as her boyfriend commented that she had a lax vaginal wall, and is putting pressure on her to have a reconstruction/repair. On examination, the genitalia
were normal.
What will be the MOST appropriate option?
A.Perform the procedure after explaining risks and consequences
B. Suggest she sees a colleague for a second opinion
C. Decline patient request and refer for psychosexual counselling
D. Perform the procedure as requested
C. Decline patient request and refer for psychosexual counselling
O
Similar Q repeated with slightly differently worded answers
Which of the following is MOST LIKELY to cause galactorrhea
A. Adrenal androgen excess
B. Sertoli-Leydig tumor
C. Cushing syndrome
D. Hypothyroidism
D. Hypothyroidism
O
Causes increased PRL
Loss of collagen and osteoporosis may be associated with all of the following except
A. Anorexia Nervosa
B. Ovarian dysgenesis
C. Late onset adrenal hyperplasia
D. Competitive rowing
C. Late onset adrenal hyperplasia
O
Which of the following decreases Sex Hormone Binding Globulin concentrations?
A. Pregnancy B. Weight loss C. Hyperinsulinaemia D. Hyperthyroidism E. Oestrogen
C. Hyperinsulinaemia
O
Insulin increases androgen secretion (i.e. in PCOS)
Danazol (Danocrine) causes each of the following EXCEPT:
A. Exacerbation of fibrocystic disease of the breasts
B. Clitoral hypertrophy in female fetuses when given to the mother in pregnancy
C. Labial fusion in female fetuses when given to the mother in pregnancy
D. Acne
E. Fluid retention
A. Exacerbation of fibrocystic disease of the breasts
O
Androgenic - significant side effects
Used to treat: fibrocystic breast disease, endometriosis, hereditary angio-oedema
Which of the following statements regarding late onset 21-hydroxylase deficiency is LEAST correct?
A. The 21-hydroxylase gene mutation is on chromosome 6
B. Late onset 21-hydroxylase deficiency accounts for approximately 5% of hirsutism
C. DHEA-S levels are usually elevated
D. 17-hydroxyprogesterone levels are usually elevated
E. Definitive diagnosis is made with a dexamethasone-suppression test
E. Definitive diagnosis is made with a dexamethasone-suppression test
O
ACTH stimulation test may be performed
All of the following elements are require for the diagnosis of PMS EXCEPT:
A. a symptom complex consistent with the diagnosis
B. a luteal phase pattern
C. severity sufficient to disrupt the woman’s life
D. objective physical findings
D. objective physical findings
O
Approximately how many follicles will a woman have when she enters puberty?
A. 15,000
B. 40,000
C. 100,000
D. 300,000
D. 300,000
As per RANZCOG MCQs August 2009
1,000,000 at birth
A 16yo girl has acne unresponsive to conventional therapy. Which of the following tests should be done before prescribing isotretinoin?
A. CBC B. LFTs C. Lipid profile D. Serum urea nitrogen (BUN) E. BhCG in urine
E. BhCG in urine
Given severe teratogenicity
O
All of the following have been identified in the vaginal fluids of women with recurrent vulvovaginitis EXCEPT?
A. IgE antibodies to Candida albicans B. IgM antibodies to Chlamydia trachomatis C. Seminal fluid components D. Contraceptive spermicides E. Prostaglandin E2
B. IgM antibodies to Chlamydia trachomatis
As per RANZCOG MCQs Feb 2008
Recall chlamydia is intracellular
Also IgM antibodies are acute, repeated episodes suggest chronic so would more likely be IgG
IgG predominates in vaginal secretions
In the gynaecological examination of a 25 year old woman presenting with dysmenorrhoea dyspareunia and pelvic pain which of the following is most reliable to indicate the presence of endometriosis?
A. Tender nodules in the uterosacral ligaments
B. Tenderness with bimanual compression of the uterus
C. The presence of an adnexal mass
D. Severe vaginismus precluding bimanual exam
A. Tender nodules in the uterosacral ligaments
O
Which of the following conditions require urgent surgical treatment?
a. acute appendicitis
b. acute cholecystitis
c. acute pancreatitis
d. acute pyelonephritis
e. acute osteomyelitis
a. acute appendicitis
Normal menstrual cycle exhibits the following hormonal changes. Which of the following is correct?
a. LH surge occurs 12 h before ovulation
b. LH surge is due to a positive feedback from relatively high oestrogen levels in the late follicular phase
c. Short pulses of GnRH occur during REM sleep
d. Maximum rate of oogenesis occurs at the trough of gonadotrophin secretion
e. In puberty, there is rise of LH before FSH
LH surge begins 34-36 hours prior to ovulation; LH surge is due to a positive feedback from relative high levels of oestrogen in the late follicular phase; FSH rises before LH during puberty; GnRH pulses less during REM sleep.
A, E are definitely incorrect, D is probably incorrect. Maximal oogenesis is fetal?
Answer: B
Milford
An important factor that enables a single follicle to become dominant over the pool of all follicles undergoing recruitment in the normal ovarian cycle is
a. Production of progesterone in the late follicular phase
b. Production of inhibin by those follicles destined for atresia
c. Production of follicular oestradiol
d. The oophoro-hypophyseal reflex
c. Production of follicular oestradiol
O
Oestrogen receptor present on all except?
a. Rectum
b. Uterosacral ligament
c. Vagina
d. Urethra
a. Rectum
Milford
Which steroid has the most effect on serum concentration of lipoproteins:
a. Testosterone
b. Oestrogen
c. Natural progesterone
d. Synthetic progesterone
e. Glucocorticoids
b. Oestrogen
Milford
Young sexually active female with non-offensive white PV discharge. pH < 4.5. What is the cause?
a. Gardenerella
b. Thrush
c. Physiological
d. Gonorrhoea
c. Physiological
Match drug with effect in endometriosis
a. GnRH agonist
b. Danazol
c. Both
d. Neither
Delays return of ovulation after cessation
Hot flushes
An increase in LDL-cholesterol
Delays return of ovulation after cessation
Answer: D
Hot flushes
Answer: C
An increase in LDL-cholesterol
Danazol s LDL and total cholesterol and s HDL (Speroff)
Answer: B
Milford
Which medication is not used in treatment of menorrhagia?
a. Neostigmine bromide
b. Oestrogen
c. GnRH agonist
d. Progesterone
e. Methyl testosterone
a. Neostigmine bromide
Milford
The most effective anti-androgen available is?
a. Danazol
b. MPA
c. Dexamethasone
d. Spironolactone
e. Cyproterone
e. Cyproterone
Milford
NB Danazol is androgenic
Also antiandrogenic = drosperinone (Yaz)
Hormones with anti-androgen action include the following, except:
a. Spironolactone
b. Cyproterone acetate
c. Cimetidine
d. Flutamide
e. Tamoxifen
e. Tamoxifen
Milford
Tamoxifen has been proven to?
a. Reduce hospital admissions with cardiac disease
b. Reduce bone fracture
c. Be associated with hyperplasia
d. Lower total and LDL cholesterol
e. All of them
e. All of them
The effects of tamoxifen are uncertain with prevention of bone loss in postmenopausal women but premenopausal women experienced substantial bone loss; reduces total cholesterol and LDL cholesterol; less coronary heart disease; association with endometrial hyperplasia and cancer
Milford
Drugs which cause haemolytic anaemia
a. Penicillin
b. Methyldopa
c. Cefoxitin
d. All of the above
e. None of the above
d. All of the above
All of the following are associated with impotence except?
a. Spinal cord lesion
b. Methyldopa
c. Salazopyrine
d. Hyperprolactinaemia
e. Chronic renal disease
c. Salazopyrine
= sulfasalazine
Milford
What is the most common factor associated with ejaculatory impotence?
a. Alcohol
b. Diabetes
c. Methyldopa
d. Marital discordance
e. Peyronie’s disease
d. Marital discordance
Select the correct option regarding side effects of hormone drugs
a. Depo Provera is well documented to cause congenital abnormalities in infants
b. Medroxyprogesterone acetate causes virilisation of male infants
c. Clomid is associated with hair loss
d. Bromocriptine is associated with hypertension
c. Clomid is associated with hair loss
Clomid can rarely cause hair loss, bromocriptine occasionally causes both hypertension and hypotension. Quite difficult to virilise a male infant.
Depo can cause virilisation of a FEMALE infant.
Milford
For Bacteroides fragilis the least effective antibiotic is:
a. Cefotaxime
b. Clindamycin
c. Chloramphenicol
d. Gentamicin
e. Metronidazole
d. Gentamicin
Which of the following have been proven more effective than placebo in treatment of premenstrual dysphoria?
a. Combined oral contraceptive
b. Progesterone pessaries
c. Synthetic oestrogens
d. Micronised oral progesterone
e. Serotonergic antidepressants
e. Serotonergic antidepressants
Cochrane review - low to moderate evidence
Can take continuous or luteal phase only
With regard to pelvic pain
a. 25% of women will experience it 5 days/month or one full day/month
b. It will have significant impact on work or home life in 2-5% of women
c. It is the reason for 10% of laparoscopies
d. It is the reason for 5% of hysterectomies
e. A full history and examination is rarely helpful in identifying the cause
b. It will have significant impact on work or home life in 2-5% of women
Pelvic pain is the indicated reason for 40% of laparoscopies and 20% of hysterectomies. It will impact on the work life of 4% of women.
Milford
37 yo at 20/40 on routine anomaly USS is found to have 11cm complex left ovarian cyst. Management?
a. Operative laparoscopy
b. Cystectomy via Pfannenstiel
c. Oophorectomy via midline incision and washings
d. Laparoscopy and aspiration of cyst
e. Repeat US in 6 weeks
c. Oophorectomy via midline incision and washings
Milford
27 yo female at 7/40 pregnant with 8 cm unilocular cyst presents with LIF pain. Management?
a. Operative laparoscopy
b. Cystectomy via Pfannensteil
c. Oophorectomy via midline incision and washings
d. Laparoscopy and aspiration of cyst
e. Repeat USS in 6 weeks
e. Repeat USS in 6 weeks
Milford
UTD recommends against operating on possible CL before 8 weeks as risk of miscarriage. Placenta will take over with progesterone production after this point.
46 yo woman with 5 months of menorrhagia referred to you following D&C by LMO where inadequate sample was collected. Further management?
a. Commence progesterone
b. Commence oestrogen
c. Coagulation profile
d. Hysteroscopy D&C
e. Endometrial ablation
d. Hysteroscopy D&C
Milford
Risk of cardiac disease in a patient aged 35 who undergoes surgical castration compared to a normal woman of the same age
a. Less than control
b. Equal to control
c. 2 x control
d. 3 x control
e. 4 x control
c. 2 x control
Hazard ratio 1.34 if occurs in <45yo
Milford
G2P2 28 yo with galactorrhea after laparoscopic sterilisation. Investigation?
a. CT head
b. TFT
c. Mammogram
d. Prolactin
e. Gonadotrophins
d. Prolactin
Milford
18 yo girl presented with hirsuitism. She is having regular cycles. Hormonal profile revealed normal testosterone, DHEA & DHEAS levels. Pelvic USS nor
mal.
What is the most appropriate treatment?
a. COCP
b. Spironolactone and OCP
c. Progesterone
d. Oestrogen
e. Cyproterone acetate
a. COCP
Milford
COCP is recommended first line
A 30 year old woman presented with 6/12 hx secondary amenorrhoea and PRL 1500. Normal 4-23. Which of the following investigations is least useful?
A) Serum bHCG B) Pelvic USS C) TFTs D) Karyotype E) 17-OHP
D) Karyotype
A lady presented with oligomenorrhoea, basal body temperature chart showed monophasic patterns. Histology of the endometrial biopsy will most likely be:
A) Cuboidal endometrial gland with compact stroma B) Supranucelar vacuoles C) Infranuclear vacuoles D) Stromal disorganisation E) Glandular disorganisation
E) Glandular disorganisation
Disordered proliferative endometrium presents in anovulatory cycles
