Day 4 Gynaecology Flashcards
A 31-year-old woman presents to her GP with severe dysmenorrhoea and deep dyspareunia. She has a regular menstrual cycle.
She has no other medical or gynaecological history of note.
On examination she has a fixed, retroverted uterus.
What is the most likely diagnosis?
(5)
Endometriosis
The classic symptoms of endometriosis are
- pelvic pain
- dysmenorrhoea
- dyspareunia
- subfertility
- fixed, retroverted uterus
The classic symptoms of endometriosis are
(5)
pelvic pain
dysmenorrhoea
dyspareunia
subfertility
fixed, retroverted uterus
A 70-year-old woman is seen in the acute medical unit with shortness of breath and abdominal distension. A chest x-ray shows a right pleural effusion. An ovarian mass is removed but it is found to be benign on histology.
What is this syndrome called?
The three features of Meig’s syndrome are:
a benign ovarian tumour
ascites
pleural effusion
What is the triad of Meig’s syndrome?
(3)
a benign ovarian tumour
ascites
pleural effusion
The 4 main types of ovarian tumours:
Surface derived tumours: These account for around 65% of ovarian tumours, including the greatest number of malignant tumours.
Germ cell tumours: These are more common in adolescent girls and are account for 15-20% of tumours. Similar cancer types to those seen in the testicle.
Sex cord-stromal tumours: Represent around 3-5% of ovarian tumours. Often produce hormones.
Metastasis: Account for around 5% of tumours.
Jenny, a 55-year-old woman presents to your GP surgery with menopausal symptoms. Her last period was 14 months ago and she describes mood changes, irritability, hot flushes, night sweats and a reduced libido. These symptoms are getting on top of her and disrupting her work.
Jenny has 3 children and has had no previous surgery. Her friend has suggested oestrogen hormone replacement therapy (HRT) and Jenny would like to give it a go.
What is the major risk of prescribing oestrogen-only HRT instead of combined HRT for Jenny?
Unopposed oestrogen increases her risk of endometrial cancer
Unopposed oestrogen increases her risk of endometrial cancer is the correct answer. Combined oestrogen and progesterone HRT reduces the risk of endometrial cancer in patients with a uterus. Patients without a uterus should be prescribed oestrogen only HRT as combined HRT is less well tolerated.
A 29-year-old woman visits her GP. She is currently 10 weeks pregnant. After discussion with her partner, she has decided to have the pregnancy terminated. The GP makes the appropriate referral and the termination is conducted.
Two weeks later, she phones the GP, sounding concerned. She has performed a urine pregnancy test and it is still showing as positive.
For what maximum period following termination is this considered normal?
(4)
Termination of pregnancy: Urine pregnancy test often remains positive for up to 4 weeks following termination.
A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
The current law surrounding abortion
based on the 1967 Abortion Act
In 1990 the act was amended
reducing the upper limit to 24 weeks
Which methods of abortion are performed at how many weeks
less than 9 weeks:
less than 13 weeks:
more than 15 weeks:
less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
A 38-year-old woman attends the gynaecology outpatient clinic. She complains of a 5-month history of pelvic pain and intermenstrual bleeding. The pain is worse around the time of her periods and during sexual intercourse. Her periods have also become heavier. The patient is not experiencing any urinary or bowel symptoms.
You arrange a transvaginal ultrasound (TVUS), which shows several masses in the uterine wall.
The patient is keen to have the masses surgically removed.
However, the waiting time for the operation is five months.
She asks if there is a medication that will help reduce the size of the masses in the meantime.
What is the most appropriate management option whilst this patient awaits surgery?
Triptorelin
For patients with uterine fibroids, GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
Tranexamic acid
What is it used for? (1)
What is its mechanism of action? (2)
What is it used for?
Tranexamic acid is used to treat menorrhagia and excessive blood loss.
What is its mechanism of action?
Tranexamic acid is a synthetic derivative of the lysine and binds to the lysine binding sites on plasminogen.
This inhibits plasmin formation and displaces plasminogen from the fibrin surface.
You are the surgical FY1 talking to a patient about her forthcoming vaginal hysterectomy with antero-posterior repair. Which of the following is a long-term complication of this procedure?
Common long term complications of vaginal hysterectomy with antero-posterior repair include enterocoele and vaginal vault prolapse.
Urinary retention may occur acutely following hysterectomy, but it is not usually a chronic complication.
What is Mestranol?
Mestranol is an estrogen medication which has been used in birth control pills, menopausal hormone therapy, and the treatment of menstrual disorders.
Sarah is a 28-year-old woman who attended for cervical screening 1 week ago. She is well with no past medical history.
Her result is positive for high-risk human papillomavirus (hrHPV). Cervical cytology has returned as inadequate.
What is the most appropriate next step?
Cervical cancer screening: if smear inadequate then repeat within 3 months
NICE guidelines for cervical screening state:
‘If the high-risk human papillomavirus (hrHPV) test result is unavailable or cytology is inadequate at any screening episode in the pathway — the sample is repeated in no less than 3 months.’
A 29-year-old woman who has been suffering with severe dysmenorrhoea for years is seen at the gynaecological clinic.
The consultant believes she may have adenomyosis, but wishes to confirm this diagnosis and rule out any other pathology before commencing treatment.
What is Adenomyosis?
Which is the best imaging technique for diagnosing the suspected condition?
The best imaging technique for diagnosing adenomyosis is MRI
Adenomyosis is the presence of endometrial tissue in the myometrium.
The best imaging technique that is able to confirm this diagnosis is MRI, however ultrasound can also aide diagnosis, but it is not the most effective imaging.
Frankie is a 32-year-old woman who attended for cervical cancer screening 2 years ago. The result was positive for high-risk human papilloma virus (hrHPV) and cervical cytology was normal.
She had repeat testing 12 months later and again tested positive for hrHPV with normal cytology. She was booked in for repeat testing in a further 12 months.
This was carried out 2 weeks ago. The result reveal that Frankie remains hrHPV positive and cytology is normal.
What is the most appropriate next step?
Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy
The NICE guidelines on cervical cancer screening state:
(5)
The NICE guidelines on cervical cancer screening state:
- Individuals who are positive for high-risk human papillomavirus (hrHPV) and receive a negative cytology report as part of routine primary HPV screening should have the HPV test repeated at 12 months.*
- If HPV testing is negative at 12 months, individuals can be safely returned to routine recall.*
- Individuals who remain hrHPV positive, cytology negative at 12 months should have a repeat HPV test in a further 12 months.*
- Individuals who become hrHPV negative at 24 months can be safely returned to routine recall.*
- Individuals who remain hrHPV positive, cytology negative or inadequate at 24 months should be referred to colposcopy.*
A 57-year-old woman is referred to urogynaecology with symptoms of urge incontinence. A trial of bladder retraining is unsuccessful.
It is therefore decided to use a muscarinic antagonist.
Give 3 examples of muscarinic antagonists?
Other examples of muscarinic antagonists used in urinary incontinence include oxybutynin, solifenacin and Tolterodine
What is Tolterodine?
muscarinic agonist used for urge incontinence
A 19-year-old woman presents to your surgery 14 weeks into her second pregnancy. Her pregnancy has been progressing normally so far, including a normal dating scan at 10 weeks.
She visited 24 hours ago due to excessive nausea and vomiting.
What was her first line treatment?
However, she is still unable to tolerate any oral intake, including fluids.
Her urine dip is positive for ketones.
What is the most appropriate next step?
- start on oral cyclizine 50mg TDS.
- Arrange admission to hospital
Failure of oral antiemetics to control symptoms, ketonuria and weight loss (>5% of pre pregnancy body weight) are all reasons to refer a woman to gynaecology for urgent assessment and intravenous fluids.
It is particularly important to keep a low threshold for referral if the woman has a concurrent condition which may be affected by prolonged nausea and vomiting (for example diabetes).
What action should be taken with regards to these semen analysis findings?
If a semen sample is abnormal, a repeat test should be arranged,
ideally 3 months later
This man has mild oligozoospermia/oligospermia based on World Health Organisation criteria (sperm concentration of 10 to 15 million per ml).
Normal semen results*
volume
pH
sperm concentration
morphology
motility
vitality
Normal semen results*
volume > 1.5 ml
pH > 7.2
sperm concentration > 15 million / ml
morphology > 4% normal forms
motility > 32% progressive motility
vitality > 58% live spermatozoa
A 24-year-old woman presents with mild, crampy suprapubic pain and light vaginal bleeding.
Her last period was 10 weeks ago.
Vaginal examination shows a small amount of blood around the cervix but is otherwise unremarkable.
What is the most likely diagnosis?
Threatened miscarriage
The mild suprapubic pain at 10 weeks gestation is more characteristic of a miscarriage than an ectopic pregnancy.
In clinical practice this patient would be referred the same day for an ultrasound scan.
A 67-year-old woman presents with a heavy, dragging sensation in the suprapubic region. She also has frequency and urgency.
What is the most likely diagnosis?
Urogenital prolapse
Women who have a urogenital prolapse typically describe a ‘bearing down’, ‘heaviness’ or ‘dragging’ sensation.
A 29-year-old woman presents with suprapubic pain, irregular periods, dysuria and pain during intercourse.
There is cervical excitation on examination.
What is the most likely diagnosis?
Pelvic Inflammatory Disease
Cervical excitation is found in both pelvic inflammatory disease and ectopic pregnancy.
A 53-year-old woman presents to her general practitioner for a routine smear test, the results of which show she is HPV positive.
A subsequent cytology swab is taken which shows normal cells.
1. How long should the patient take to be recalled?
The results of her next swab are negative.
2. What is the most appropriate next stage in the management of this patient?
- The patient is recalled 12 months later for a second HPV swab, the results of which are negative.
- Cervical cancer screening: if 2nd repeat smear at 24 months is now hrHPV -ve → return to routine recall
As this patient is now HPV negative, they may return to routine recall. As this patient is over the age of 50, routine recall requires a smear test be taken every 5 years.
How is CIN treated?
(3)
Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia.
LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic.
Alternative techniques include cryotherapy.
What is CIN?
What is the treatment pathway?
A classification for cervical cancer changes
A 31-year-old woman is invited for routine cervical smear.
She is subsequently telephoned by the practice, informing her that the laboratory reported the sample as ‘inadequate’, and is invited back for a repeat smear.
Once again, she is telephoned to inform her that this sample was also reported as ‘inadequate’ by the laboratory.
What should the next step be?
Cervical cancer screening: if two consecutive inadequate samples then → colposcopy
The correct answer is to refer for colposcopy - this should be done if two consecutive samples are ‘inadequate’.
Which cancer does CA-125 implicate?
Which gene mutation confers the highest risk for the pathology indicated by high levels of CA-125?
This patient’s presentation along with an elevated level of the tumour marker CA-125 is most consistent with a diagnosis of ovarian cancer and breast cancer.
BRCA1 is a tumour suppressor gene which confers a higher risk of ovarian cancer and breast cancer in individuals who have inherited a mutated copy.
Which cancer does Rb implicate?
Rb for retinoblastoma
Which cancer does WT1 mark indicate?
WT1 for Wilm’s tumour
Which tumour marker does c-Myc test for?
c-Myc for Burkitt lymphoma
Clinical features of ovarian cancer:
(6)
Clinical features are notoriously vague
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea
no pain
A 32-year-old nulliparous woman presents to the emergency department with a 6-hour history of diarrhoea, mild abdominal discomfort, and a positive home pregnancy test.
Her last menstrual period was 8 weeks ago and she takes no regular contraception. She has a past medical history of pelvic inflammatory disease.
Transvaginal ultrasound reveals a 40mm foetal sac at the ampulla of the fallopian tube with no visible heartbeat, and serum B-HCG is 1200IU/L.
Given this information, what is the definitive indication for surgical management in this patient?
(2)
All ectopic pregnancies >35 mm
in size
or with a serum B-hCG >5,000IU/L
should be managed surgically
A 67-year-old woman attends your GP surgery complaining of three episodes of postmenopausal bleeding in the past month, which she describes as spotting.
She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first?
Expectant vs Medical vs Surgical Mangement
of ectopic pregnancy
(7)
A 67-year-old woman attends your GP surgery complaining of three episodes of postmenopausal bleeding in the past month, which she describes as spotting.
She went through the menopause 10 years ago and has had no bleeding until this episode.
She took hormone replacement therapy for five years.
You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first?
Which diagnosis is implicated?
Trans-vaginal ultrasound scan
Endometrial cancer
The risk factors for endometrial cancer:
(7)
- obesity
- many ovulations*: early menarche, late menopause, nulliparity
- unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
- diabetes mellitus
- tamoxifen
- polycystic ovarian syndrome
- hereditary non-polyposis colorectal carcinoma
Risk factor for ovarian cancer
(2)
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
A 26-year-old female presents to her GP complaining of post-coital bleeding.
This has happened on three occasions, but there is no pain, no discharge and no inter-menstrual bleeding.
She is taking the combined contraceptive pill and only has sex with a regular partner.
She has never been pregnant. She is worried as her grandmother has had endometrial cancer.
On examination, there is a small area of redness around the cervical os.
What is most likely to be responsible for her presentation?
Cervical ectropion is more common in those on the COCP due to higher oestrogen levels
This may result in the following features
- vaginal discharge
- post-coital bleeding
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
What is an anterior colporrhaphy?
What is a cystocele?
Anterior colporrhaphy is when the vaginal wall is repaired following a cystocele.
A cystocele is when the wall between the bladder and the vagina weakens.
This can cause the bladder to drop or sag into the vagina.
Signs of Sheenan’s syndrome
(4)
Signs include:
- amenorrhoea
- problems with milk production
- hypothyroidism
- pituitary dysfunction.
What is the most appropriate management?
Repeat smear again in 12 months
Cervical cancer screening: if 1st repeat smear at 12 months is still hrHPV +ve → repeat smear 12 months later (i.e. at 24 months)
Which conditions are associated with hypermemesis gravidarum?
(5)
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
Gestational trophoblastic disease
(2)
Gestational trophoblastic disease (GTD) is a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception.
In gestational trophoblastic disease (GTD), a tumor develops inside the uterus from tissue that forms after conception (the joining of sperm and egg).
Scoring system for hyperemesis gravidarum
Validated scoring systems such as the
Pregnancy-Unique Quantification of Emesis (PUQE) score
can be used to classify the severity of NVP.
A 30-year-old woman presents with an offensive ‘fishy’, thin, grey vaginal discharge. Testing the discharge shows the pH to be > 4.5.
What is the diagnosis?
What is the most appropriate treatment?
Oral metronidazole
bacterial vaginosis
Amsel’s criteria requires 3 of the following 4 points should be present:
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
A 27-year-old woman complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation.
What is the diagnosis?
What is the most appropriate treatment?
The ‘strawberry cervix’ is actually quite rare outside of examinations - some studies suggest only 2% of patients with Trichomonas vaginalis have this finding.
Oral metronidazole
Amsel’s criteria for BV
(4)
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge.
She also complains of dysuria, intermenstrual bleeding and dyspareunia.
A swab shows a Gram-negative diplococcus.
What is the diagnosis?
What is the treatment?
IM ceftriaxone
For gonorrhoea, there was a change in the 2019 British Society for Sexual Health and HIV (BASHH) guidelines.
If sensitivities are known (and the organism is sensitive to ciprofloxacin) then a single dose of oral ciprofloxacin 500mg should be given
A 27-year-old woman has been referred to Early Pregnancy Unit, with pregnancy of unknown gestation and with some per vaginal bleeding.
She denies pain and is haemodynamically stable. This is her first pregnancy.
Ultrasound demonstrates a tubal pregnancy, with a visible foetal heartbeat and an unruptured adnexal mass of 40mm. beta-hCG is 5,200 IU/L.
What management would be first-line for this patient?
All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically
Surgical - laparoscopic salpingectomy. Surgical management is indicated if an ectopic pregnancy is confirmed on ultrasound with an adnexal mass of 35mm or larger. In this case, the adnexal mass is 40mm. The beta-hCG is also >5,000 IU/L here. In most cases, surgery is done via laparoscopy.
What are the stages of OHSS?
Mild
- Abdominal pain
- Abdominal bloating
Moderate
- Nausea and vomiting
- Ultrasound evidence of ascites
Severe
- Oliguria
- Haematocrit > 45%
- Hypoproteinaemia
Critical
- Thromboembolism
- Acute respiratory distress syndrome
- Anuria
- Tense ascites
A 34-year-old woman from Zimbabwe presents with continuous dribbling incontinence after having her 2nd child.
Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well.
What is the diagnosis?
What is the best management?
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services.
A dye stains the urine and hence identifies the presence of a fistula.
Urinary dye studies
A 53-year-old lady complains of involuntary passage of urine when she coughs or sneezes. She is multiparous G2, P2 with a forceps delivery of her second child.
What is the diagnosis?
What is the best management?
stress urinary incontinence
Pelvic floor exercises 3 months
The first line management of stress urinary incontinence, in this case arising for pelvic floor trauma is pelvic floor exercises. These will help a proportion of patients. Non responders should have urodynamics performed to confirm the diagnosis.
A 56-year-old lady reports incontinence mainly when walking the dog. A bladder diary is inconclusive.
What is the most appropriate investigation?
Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.
A 22-year-old pregnant lady of Sudanese origin attends the GP anxious about her impending vaginal delivery.
She is currently 30 weeks pregnant and has type 3 female genital mutilation.
She advises that she would prefer for her vagina to be reinfibulated (to be sewn back up to infibulated status) post-delivery as this is what she is used to.
What would be the recommended management?
Advise her that reinfibulation is illegal and cannot be done under any circumstances
Classification of FGM
A 28-year-old female presents to the emergency department with lower abdominal pain. A pregnancy test and ultrasound confirms a tubal ectopic pregnancy measuring 32mm and associated with a foetal heartbeat. The patient has no past medical history of note.
Her observations show:
- Respiratory rate of 15 breaths/min
- Pulse of 93 beats/min
- Temperature of 36.7ºC
- Blood pressure of 126/78 mmHg
- Oxygen saturations of 96% on room air
What is the most appropriate management of this patient?
Presence of a foetal heartbeat on ultrasound in the context of an ectopic pregnancy is an indication for surgical management
What is the most common type of ovarian pathology associated with Meigs’ syndrome?
(3)
Fibroma
Meigs’ syndrome is a benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
What is the most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst (teratoma)
What is the most common cause of ovarian enlargement in women of a reproductive age
Follicular cyst
A 33-year-old female attends your gynaecology clinic.
This is a follow up appointment following diagnosis of a symptomatic 6mm intramural fibroid.
This problem has been troubling her for a number of months and as such she is being considered for surgery.
As she has not yet completed her family, it has been decided that the most appropriate surgical approach would be an open myomectomy.
Which of the following is a common complication following this operation?
Adhesions are the most common complication of this operation. Bladder injury and uterine perforation are complications but they are less common. Cyst formation and surgical menopause are not complications.
Treatment to shrink/remove fibroids
(5)
Medical
- GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
Surgical
- myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
- hysteroscopic endometrial ablation
- hysterectomy
Uterine artery embolization
What is the diagnosis? (1)
What is the most appropriate management? (2)
Miscarriage
Manual vacuum aspiration under local anaesthetic
Methotrexate is used in the medical management of ectopic pregnancy.
