general gynae

Question 1

1. 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

Answer 1

d) women/the victims fear being left alone

Question 2

2. A lady presents to you for investigation of metromenorrhagia 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 d/c
e) Pelvic US

Answer 2

d. Office hysteroscopy d/c

Question 3

3. A quality assurance program should include all the following features EXCEPT:

a) identify who is your customer (patient)
b) identify what services are required by the customer (patient)
c) identify how services are provided to the customer (patient)
d) identify the cost of the services to the customer (patient) compared to other institutions
e) identify processes by which services to the customer (patient) may be improved

Answer 3

d) identify the cost of the services to the customer (patient) compared to other institutions

Question 4

4. Fibroids: All of the following statements are true except:

a) >20% of fibroids have a chromosomal abnormality
b) on cytogenetics a single fibroid comes form one single cell(not pleomorphic)
c) 20% of women develop a fibroid
d) MPA decreased mitotic activity in fibroids

Answer 4

c) 20% of women develop a fibroid
d) MPA decreased mitotic activity in fibroids

They are benign monoclonal tumors arising from the smooth muscle cells of the myometrium
A hysterectomy study found myomas in 77 percent of uterine specimens
patients using a progestin-only preparation have a significantly higher mitotic activity in fibromyomas

Question 5

5. A woman in her 30’s with postcoital and IMB attends her LMO. She is referred to you with a Pap smear showing CIN2 and many inflammatory cells. On speculum examination she has an exophytic lesion on the posterior lip; the reminder of the examination is unremarkable. Your next step in managements is:

a) colposcopy
b) punch biopsy
c) cone biopsy
d) antibiotics

Answer 5

a) colposcopy

Question 6

6. Which of the following pairs are appropriate:
   a) erythromycin for syphilis in pregnancy
   b) ampicillin for PID in a 16 yo
   c) tetracycline for LGV
   d) lindane for molluscum contagiosum

Answer 6

c) tetracycline for LGV

LGV - Lymphogranuloma venereum a gential ulcer disease caused by serotypes L1, L2, and L3 of the bacteria Chlamydia trachomatis. differ from the chlamydial serotypes that cause trachoma, inclusion conjunctivitis, urethritis, and cervicitis because they can invade and reproduce in regional lymph nodes.
Lindane pharmaceutical treatment for lice and scabies
Syphilis – treated with long acting Bicillin (benzathine penicillin) – as short acting formulations provide insufficient treatment duration
Molluscum contagiosum, a poxvirus, causes a chronic localized infection, flesh-colored, dome-shaped papules on the skin. The self-limited nature of molluscum contagiosum and the paucity of evidence that definitively supports therapeutic intervention has led to debate over the need for treatment

Question 7

7. Which is least likely to have a high concentration of lactobacillus in vaginal flora?

a) neonate
b) premenopausal
c) postmenopausal
d) pregnant
e) nonpregnant reproductive age

Answer 7

c) postmenopausal

oestrogen – stratified sqaumaous epithelium is thick and risk in glycogen. Glycogen from sloughed cells is the substrate for lactobacilli which convert it to lactic acid. Vgainal pH 3.5-5.0
menopause, decrease oestrogen, thining of layer of epithelial cells, loss of elasticity of vaginal epithelium, loss of rugae, reduction in vaginal secretions, low gyclogen content so less lactic acid production leads to increase in vaginal pH >5
disappearance of lactobacillus and overgrowth of coliforms.

Question 8

8. Small cyst found in midline at the fourchette. Most likely to be?

a) Bartholins cyst
b) Epidermal inclusion cyst
c) Sebaceous cyst
d) Gartners duct cyst

Answer 8

b) Epidermal inclusion cyst

Gartners cyst- typically simple cystic lesions arising from the anterolateral aspect of the superior vagina – remnant of wollfian duct.
Anterior wall masses may be vaginal wall cysts, but urethral diverticula are more common at this location
Epidermal cysts - occur on the labia majora, but not in the vulvar vestibule

Question 9

9. A 47 y.o. woman with irregular heavy bleeding has a curette. Pathology shows atypical adenomatous hyperplasia. What is the best treatment?

a) MPA 100mg IM monthly
b) TAH
c) NSAIDs
d) Hysteroscopy to rule out cancer, then rollerball diathermy
e) Nd-YAG laser endometrial ablation

Answer 9

b) TAH

Question 10

10. Regarding thecoma, which is incorrect?

a) usually benign
b) commonly unilateral
c) associated with virilisation
d) may be associated with endometrial hyperplasia
e) usually occurs in prepubertal girls

Answer 10

e) usually occurs in prepubertal girls – mainly postmenopausal women

a) usually benign T
b) commonly unilateral T 90%
c) associated with virilisation T
d) may be associated with endometrial hyperplasia T

thecoma tumours - may be hormonally active – oestrogen, androgenic if steroid cells present
up to 20% of patients present with a endometrial cancer -
most common symptom is abnormal uterine bleeding
so all women with a thecoma should have endometrial sampling
treatment – TAH BSO if peri or post menopause. Unilateral oophorectomy if preservation of fertility

sex cord stromal tumour: granulosa cell, fibroma, thecoma, fibrothecoma, Luteinized thecomas associated with sclerosing peritonitis, sertoli-leydig.

Question 11

11. What does random allocation achieve?

a) equal numbers in each arm of the trial
b) equal distribution of confounding factors
c) increased readership of your article
d) equal distribution of possible unknown factors

Answer 11

d) equal distribution of possible unknown factors

Question 12

12. What organism causes chancroid?

a) Calymmatobacterium granulomatis - deep purulent ulcers on or near the genital organs
b) Haemophilus Ducreyi
c) Gardnerella vaginalis
d) Chlamydia trachomatis
e) Calymmatobacterium donovae - results in nodular lesions that evolve into ulcers, assoc w othr STI’s

Answer 12

b) Haemophilus Ducreyi

Question 13

13. What organism causes Donovanosis?

a) Calymmatobacterium granulomatosis
b) Haemophilus Ducreyi
c) Gardnerella vaginalis
d) Chlamydia trachomatis
e) Calymmatobacterium donovae

Answer 13

a) Calymmatobacterium granulomatosis

Question 14

14. What causes LGV (lymphogranuloma venereum) ?

a) Calymmatobacterium granulomatis
b) Haemophilus Ducreyi
c) Gardnerella vaginalis
d) Chlamydia trachomatis
e) Calymmatobacterium donovae

Answer 14

d) Chlamydia trachomatis

Question 15

15. PID with temp. 39 degrees and bilateral pelvic tenderness. Chlamydia on swabs. Best therapy:

a) IM Cephalothin and PO doxy
b) PO doxy alone
c) IV cefoxitin and PO doxy
d) IV clindamycin
e) IV penicillin + erythromycin

Answer 15

c) IV cefoxitin and PO doxy

Question 16

16. All of the following statements about HSV II are true except:
    * **
    a) infection with HSV I confers some immunity from HSV II
    b) treatment with acyclovir significantly reduces recurrence
    c) genital herpes is mostly HSV II
    d) recurrence occurs in the first 6 months

Answer 16

b) treatment with acyclovir significantly reduces recurrence

Question 17

17. Chlamydia:

a) is in <1% of O&G and FPA clinics
b) diagnosis is by posterior vaginal fornix swab
c) cervix usually looks abnormal
d) in a low risk population has a 50% PPV on ELISA
e) treatment is with cefoxitin and Flagyl
f) 50% will clinically develop PID

Answer 17

d) in a low risk population has a 50% PPV on ELISA

Question 18

18. In an acute tubo-ovarian mass, most common culture

a) group b strep
b) gonococcus
c) Chlamydia
d) Anaerobes
e) E.coli

Answer 18

e) E.coli

Question 19

19. Regarding dermoid cysts/ Mature cystic teratomas

a) the most common ovarian mass in pregnancy
b) 10% are malignant
c) 40-50% are bilateral
d) oophorectomy required for adequate removal

Answer 19

a) the most common ovarian mass in pregnancy

Almost invariably benign
They are bilateral in 10 to 17 percent of cases
Contain mature tissue of ectodermal, mesodermal and endodermal origin
Possibly by failure of meiosis II or from a premeiotic cell in which meiosis I has failed
Dermoid cysts may be removed via either laparoscopy or laparotomy. With either approach, the abdomen should be copiously irrigated to avoid a chemical peritonitis from spillage of the sebaceous cyst fluid.

Question 20

20. The most common ovarian tumour in the postmenopausal period is:

a) fibroma
b) serous cystadenoma
c) mucinous cystadenoma
d) teratoma

Answer 20

b) serous cystadenoma

Question 21

21. What degree of cervical dyplasia must be treated in pregnancy?

a) HPV
b) CIN2
c) CIN3
d) All of the above
e) None of the above

Answer 21

e) None of the above

Question 22

22. When is the least sensible time to remove a 45 yo woman’s ovaries?

a) during operation for a fibroid uterus with a family history of ovarian cancer
b) during operation for endometriosis with bowel involvement

Answer 22

a) during operation for a fibroid uterus with a family history of ovarian cancer

Question 23

24. Lichen planus, incorrect option
    * **
    a) purple scaly patches
    b) white mucosal lesions
    c) flexor surfaces
    d) erosive vaginitis
    e) saw tooth rete pegs
    f) corticosteroids effective

Answer 23

b) white mucosal lesions

Affect skin, mucosal membranes. Scalp, nails and genitalia
Can have fine white lines = wickhams striae

Hyperkeratosis without parakeratosis
●Vacuolization of the basal layer
●Civatte bodies (apoptotic keratinocytes) in the lower epidermis
●Wedge-shaped hypergranulosis, “saw-tooth” shaped rete ridges
●Small clefts at the dermal-epidermal junction (Max-Joseph spaces)
●Band-like lymphocytic infiltrate at the dermal-epidermal junction
●Eosinophilic colloid bodies (apoptotic keratinocytes) in the papillary dermis
●Pigment incontinence (most prominent in dark-skinned individuals)

Question 24

If test for Chlamydia has sensitivity 95% and specificity 95% and prevalence is 30% then positive predictive value is approx 90%. If prevalence is now 5% then PPV is:

a) 10%
b) 30%
c) 50%
d) 70%?
e) 90%

Answer 24

c) 50%

Question 25

26. If the sensitivity and specificity of a test stay the same with increasing prevalence the positive predictive value will:

a) increase
b) decrease
c) stay the same

Answer 25

a) increase

Positive and negative predictive values are influenced by the prevalence of disease in the population that is being tested. If we test in a high prevalence setting, it is more likely that persons who test positive truly have disease than if the test is performed in a population with low prevalence.. for eg blood in stool in older population likely to be predictive of bowel cancer compared to younger population.

Question 26

To increase the power of a study you should:

a) employ a statistician
b) test for a high frequency outcome
c) test for a low frequency outcome
d) increase your sample size

Answer 26

d) increase your sample size

Question 27

An infant with pure gonadal dysgenesis with karyotype 46 XY will have as a phenotype:

a) ambiguous genitalia
b) infantile female
c) atrophic testis in inguinal canal

Answer 27

b) infantile female

swyers syndrome

Question 28

29. Chlamydia:
    a) cervix usually looks irritated or inflamed
    b) incidence <1% in antenatal, family planning, general gynae population
    c) if low incidence population, PPV 50%
    d) cefoxitin and metronidazole is adequate treatment
    e) at 1st infection 50% women will have symptomatic salpingitis

Answer 28

c)

Types of testing for chlamydia
NAAT ( nucleic acid amplification test – gold standard ) – vaginal swab or first pass 10mls of urine ( no Pu 2 hrs earlier or vaginal cleaning prior ),
- Urine and invasive swabs comparable ( systematic review )
- Sens 83 vs 86%
- Spec 99.5 vs 99.6%
Chlamydia rapid test ( use of monoclonal ab to chlamydia liposaccaride )
Culture ( not used now – need ecs, antigen testing sensitivity 85-90%, labour intensive ,
Serology and genetic probe ( no amplification sens 80% )

NAAT on rectal specimen more sensitive than pv specimen

Question 29

31. Most common STD pathogen?
    a) gonorrhoea
    b) Chlamydia
    c) Syphilis
    d) HSV 1
    e) HSV 2

Answer 29

e) HSV 2

Question 30

32. Following rape the most likely reaction is?

a) anger, aggression then period of short resolution
b) anger, aggression then period of long resolution
c) fear, somatic symptoms then period of short resolution
d) fear, somatic symptoms then period of long resolution

Answer 30

d) fear, somatic symptoms then period of long resolution

Question 31

33. A patient presents after a pap smear showing actinomycoses on gram stain. Your immediate management plan would include.

a) treat with antibiotics with the IUCD in situ
b) remove the IUCD and resmear in 3 months
c) repeat the pap smear
d) remove the IUCD and treat with antibiotics
e) reassure the patient

Answer 31

e) reassure the patient

Actinomyces on cervical cytology Gram positive anaerobic bacillus, part of the normal flora of the gastrointestinal tract and is commonly present in normal vaginal flora
Although there are several case reports of endometritis, pelvic inflammatory disease, pelvic abscess associated with actinomyces in IUD users, actinomyces in the vagina or cervix is not diagnostic of disease and is not predictive of development of disease.

Approx 7 % of women using an IUD have actinomyces-like organisms on a smear test
If the cervical cytology show actinomyces-like organisms, then we suggest that the woman be notified of the finding and examined. If she is asymptomatic - probably represents colonization.
NO evidence to support antibiotic treatment and NO evidence to support IUD removal in asymptomatic women
Contact her health care provider if she develops signs of PID

Question 32

34. Most common clinical indication for GnRH agonist in Australia at present

a) prostatic cancer
b) fibroids
c) IVF
d) Endometriosis
e) Abnormal uterine bleeding

Answer 32

c) IVF ( 1 in 25 babies in Aust is IVF)

vs a) prostate cancer

Question 33

35. 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

Answer 33

a) Pain
b) tender lump

Fibrocystic changes (FCCs) constitute the most frequent benign disorder of the breast.
The most common presenting symptoms are breast pain and tender nodularities in breasts.
The most common nonproliferative breast lesions are breast cysts, cysts are common in women 35 -50 years old
Acute enlargement of cysts may cause severe, localized pain of sudden onset

Change in breast size relative to menstrual cycle

Question 34

36. 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

Answer 34

c) diagnostic test to distinguish between fibroid and leiomyosarcoma

Question 35

37. The percentage of woman who experience at least one episode of vaginal candidiasis in their reproductive years:

a) 20%
b) 35%
c) 50%
d) 70%
e) 90%

Answer 35

c) 50%

Question 36

39. After 6 months of GnRH analogues, how much reduction in uterine size would you expect?

a) 10%
b) 20%
c) 50%
d) 75%
e) 90%

Answer 36

c) 50%

Question 37

40. A 20 yo Aboriginal woman presents with 3/52 of a labial ulcer – painless, firm, indurated: also has inguinal lymphadenopathy. RPR 1/64, TPHA – pos, FTA-Abs – pos, Darkfield microscopy – neg. What is the most likely diagnosis?

a) primary syphilis
b) secondary syphilis
c) chancroid
d) donovanosis

Answer 37

a) primary syphilis

Not:
secondary syphilis – no other systemic sx discussed.
chancroid – Cant be because TPHA +ve

chronic infection caused by the bacterium Treponema pallidum. Transmitted – direct contact wthin lesion during sex
Incubation ~21 days
Primary – painless papule appears on skin, then forms an ulcer/chancre assoc with moderate regional lymphadenopathy often bilateral. They heal spontaneously 3-6 weeks. Widespread dissemination of the spirochete also occurs early during primary stage of infection.
Chancre of a primary symphilis is best diagnosed by darkfield microscopy or direct fluorescent antibody
Secondary – weeks to months later, systemic illness, may not have had preceeding chancre (lesion may go unnoticed). Rash (of ay form e.g. diffuse macular or popular trunk and extremeties), fever, LN, alopecia moth eaten, GI ulcers, MSK abnormalities, renal, neuro, ocular
Secondnay syphilis best diagnosed by serologic testing
Latent - evaluate clinically for evidence of tertiary disease (eg, aortitis and neurologic signs) and ocular disease (iritis and uveitis)
Treatment – IM Benzathine penicillin G (IV assoc with Mi and death)

Diff Dx of a gential ulcer - syphilis, genital herpes, chancroid, drug eruptions, Behçet’s disease

Pregnancy
Screening is recommended to prevent in utero transmission of asymptomatic infection, which can lead to congenital syphilis.

Diagnosis
T.pallidum cannot be cultured – so either identify it by direct microscopy or by serology
First → nonspecific nontrponemal ab test: VDRL, RPR, TRUST +ve tests are reported as a titre
Then → more specific treponemal for dx confirmation: TP-EIA, TP-PA, MHA-TP, FTA-ABS

Question 38

41. 46 yo woman with 5 months of menorrhagia referred to you following D&C by LMO where inadequate sample was collected. ? further Mx

a) commence progesterone
b) commence oestrogen
c) coagulation profile
d) hysteroscopy D&C
e) endometrial ablation

Answer 38

d) hysteroscopy D&C

Question 39

42. Patient has IUCD for 2 yrs and now actinomycosis detected on routine pap smear. Pelvic exam was normal. What is the next most appropriate treatment?

a. leave IUCD in, treat with penicillin
b. remove IUCD, treat with penicillin for 2 weeks and then reinsert another IUCD
c. remove IUCD, treat with oral penicillin for 2 weeks. IUCD contraindicated in future
d. remove IUCD, treat and no further treatment required
e. no treatment needed if asymptomatic

Answer 39

e. no treatment needed if asymptomatic

Question 40

43. Bias is
    a) reduced by increasing sample size
    b) systematic error
    c) not affected by blinding

Answer 40

b) systematic error

Question 41

45. You are asked to assess a woman who was raped 6 hrs ago. Which of the following is least likely?

a) she will develop fear and anxiety with restlessness
b) somatic symptoms of headaches, fatigue and sleep disturbance
c) emotional reactions of anger, self-blame and humiliation
d) those with severe somatic symptoms tend to recover faster

Answer 41

d) those with severe somatic symptoms tend to recover faster

Question 42

46. 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

Answer 42

c) cyclical progesterone showed no advantage over placebo in treating PMS

At least one symptom associated with “economic or social dysfunction” that occurs during the 5 days before the onset of menses and is present in at least 3 consecutive menstrual cycles
Sx’s may be affective (depression, anger) or physical (breast pain, bloating)
Premenstrual dysphoric disorder (PMDD) is the most severe
Greentop guidelines: All the trials of progesterone (by both routes of administration) showed no clinically significant difference between progesterone and placebo

Question 43

47. How does high prolactin cause infertility?

a) dopamine and GnRH
b) failure of aromatase
c) endometrial effect
d) progesterone suppression of corpus luteum

Answer 43

a) dopamine and GnRH

Question 44

48. Percentage of benign mucinous tumour that are biliateral?
    a) 2-3%

Answer 44

Serous and mucinous cystadenoma - the most common benign ovarian neoplasms
Thin-walled, uni- or multilocular, range in size from 5 > 20 cm
Mucinous cystadenomas occur less frequently, are more likely to be multiloculated, are larger (they can attain an enormous size), and are less often bilateral (< 5%)
Serous cystadenomas bilateral 20-25%

Question 45

51. 25 yo. O/E 5 cm simple cystic R adnexal mass confirmed on USS. Mx?

a) repeat exam in 3/12
b) give OCP and repeat US in 1/12
c) laparotomy
d) laparoscopy and aspiration of cyst

Answer 45

a) repeat exam in 3/12

Question 46

54. Thin white wrinkly vulval skin with absent labia minora?

a) lichen sclerosis
b) psoriasis
c) lichen planus

Answer 46

a) lichen sclerosis

Question 47

55. Regarding pelvic tuberculosis

a) its origin us usually bovine
b) first line treatment is streptomycin
c) it affects the tubes more often than the uterus

Answer 47

c) it affects the tubes more often than the uterus

Question 48

56. How long does it take to stop heavy bleeding with GnRH analogues?

a) 12 hrs
b) 18 hrs
c) 1 week
d) 4 weeks

Answer 48

d) 4 weeks

Question 49

58. A 24 yo not sexually active woman presents with a history of an intermittent white vaginal discharge, is not pruritic, the pH is less than 0.45.

a) candidiasis
b) trichomonas
c) Gardnerella
d) Physiological vaginal discharge

Answer 49

d) Physiological vaginal discharge

Question 50

59. The difference between a case-control and a cohort study is:

a) in a case-control study the subjects are allocated by disease status and in a cohort study by exposure status
b) in a case-control study the subjects are allocated by exposure status and in a cohort study by disease status
c) a case-control study is retrospective whereas a cohort study is prospective
d) a case-control study is prospective whereas a cohort study is retrospective

Answer 50

a) in a case-control study the subjects are allocated by disease status and in a cohort study by exposure status

Question 51

A 32 yo with 2 children sees you requesting sterilisation. You decide not to. This decision is an example of a:

a) clinical decision
b) ethical decision
c) moral decision
d) collaborative decision

Answer 51

a) clinical decision
vs
c) moral decision

Question 52

61. The purpose of ethics is to:

a) resolve moral dilemmas
b) provide ultimate judgement
c) guide us in uncertainty
d) replace clinical decisions

Answer 52

? a

Question 53

62. The decision to allocate funds towards the purchase of new laparoscopic equipment for the department of O&G is an example of the ethical priciple of:

a) beneficence
b) non-maleficence
c) paternalism
d) distributive justice

Answer 53

d) distributive justice

Question 54

64. Appropriate treatment for secondary syphilis?

a) benzathine penicillin IM x1
b) procaine penicillin IV x1
c) cefoxitin
d) doxycycline

Answer 54

a) benzathine penicillin IM x1

Question 55

65. Advice re influenza. Which is incorrect?

a) 90% of deaths from influenza occur in over 60’s
b) significant respiratory or cardiac disease is a contraindication to vaccination
c) vaccination – decreased incidence of influenza in immunised persons of x percent
d) vaccination reduces morbidity of an attack by x percent

Answer 55

b) significant respiratory or cardiac disease is a contraindication to vaccination

Question 56

71. What organism will metronidazole and gentamicin not cover?

a) gram positive aerobe
b) gram positive anaerobe
c) gram negative aerobe
d) gram negative anaerobe -
e) trichomonas

Answer 56

a) gram positive aerobe

b) gram positive anaerobe - Metronidazole
c) gram negative aerobe – Gentamicin
d) gram negative anaerobe - Metronidazole
e) trichomonas - Cover

Question 57

72. A woman presents with three white lesions on her vulva. On biopsy each one shows VIN 3. Treatment should be?

a) wide local excision of all lesions
b) skinning vulvectomy
c) radical vulvectomy
d) radical vulvectomy and groin node dissection
e) review in 3/12

Answer 57

a) wide local excision of all lesions

Question 58

84. With endometriosis

a) Peritoneal implants are usually visible to the naked eye at laparoscopy -
b) Many women with endometriosis have an associated autoimmune condition which may contribute to the associated infertility-
c) Danazol and GnRH derivatives are curative so long as the biggest endometrioma is < 3cm -
d) Commonest finding is an ovarian endometrioma –

Answer 58

a) Peritoneal implants are usually visible to the naked eye at laparoscopy - T

Question 59

Endometrial cystic hyperplasia most likely to be associated with?

e) Maturity onset diabetes – associated with hyperplasia but thought to be secondary to raised BMI
f) Adenomyosis –
g) Biphasic OCP –
h) Combined HRT -
i) Tamoxifen –

Answer 59

i) Tamoxifen – E receptor stimulation of endometrium

Question 60

85. Granulomatous lesion of vulva?

a) Behcet’s disease
b) Lichen sclerosis
c) Syphilitic gumma
d) Paget’s disease
e) Bowen’s disease

Answer 60

c) Syphilitic gumma

Behcet’s disease - Ulcer
Pagets in vulva: eczema like, raised edges, red background. Multifocal – vulva, mons, perineum, perianal. 
Bowens disease ( Squamous carcinoma insitu ) – scaly patch and well demarcated

Question 61

86. Female with painless vulval ulcer, 1 cm, indurated base. Definitive/first Ix?

a) TPHA
b) Dark field illumination/Microscopy
c) VDRL
d) Herpes immunofluoresence

Answer 61

b) Dark field illumination/Microscopy

Question 62

89. 70 yr old with pap smear showing mild sq atypia. Colp benign sq epi epithelium TZ not seen. Normal endocervical curettings. Mx?

a) Resmear 2/12 after topical oestrogen
b) Resmear 6/12
c) Tell her not to worry
d) Fractional curettage
e) Cone biopsy

Answer 62

a) Resmear 2/12 after topical oestrogen

Question 63

90. Regarding tubo-ovarian abscess?

a) Can be visualised by US
b) Causes eosinophilia
c) Positive Chlamydia on cervical swab
d) Associated with leucopenia

Answer 63

a) Can be visualised by US

Question 64

91. The ability of a test to detect persons with a condition?

a) sensitivity
b) specificity
c) odds ratio
d) PPV

Answer 64

a) sensitivity

Question 65

92. Woman with 3 periods a year lasting 10-12 days. Endometrial biopsy approx 10 days after a period shows?

a) Subnuclear vacuolidation
b) Supranuclear vacuolidation
c) Stromal oedema
d) Haemorrhagic endometrium
e) Lots of straight glands

Answer 65

e) Lots of straight glands

Question 66

93. Cystic glandular hyperplasia associated with?

a) Cyclical HRT
b) Depot MPA
c) NIDDM
d) COCP

Answer 66

c) NIDDM

Question 67

94. Endometriosis?

a) Most severe disease have worst symptoms
b) Affected peritoneum almost always seen with naked eye at laparoscopy
c) Most have immunlogical defect which explains their infertility
d) Medical treatment OK for endometriomas provided they are < 3cm

Answer 67

b) Affected peritoneum almost always seen with naked eye at laparoscopy

Question 68

96. Number of women who will live to their 90’s if alive at 50?

a) 75%
b) 50%
c) 10%
d) 5%

Answer 68

c) 10%

NZ life expectancy 84 yr

Question 69

97. Lesion least likely to be associated with pigmentation?

a) Lentigo – small and pigmented
b) Seborrhoic keratosis -
c) Some sort of naevus

Answer 69

b) Seborrhoic keratosis -

Question 70

98. Treatment for lichen sclerosis?

a) Topical testosterone
b) Topical corticosteroids
c) Topical 5FU

Answer 70

b) Topical corticosteroids

Question 71

99. Treat DUB with all except?

a) Aminocaproic acid
b) Mefanamic acid
c) Transexamic acid
d) Clomiphene
e) Neostigmine

Answer 71

e) Neostigmine

Question 72

102. HPV on cervix. All except?

a) Sometimes associated with carcinoma
b) Intracytoplasmic reproduction is associated with koilocytosis
c) HPV dysplasia not a true pre-malignant condition
d) Fragments of HPV have been isolated on DNA testing in cervical carcinoma
e) HPV 6 causes benign cervical condylomata

Answer 72

c) HPV dysplasia not a true pre-malignant condition - F

a) Sometimes associated with carcinoma - T ( True benign or premalignant or malignant –HPV 16, 18 high oncogenic potential.)
b) Intracytoplasmic reproduction is associated with koilocytosis -
d) Fragments of HPV have been isolated on DNA testing in cervical carcinoma – T ( In cervical ca, continued expression of viral oncogene E6 and E7 necessary to maintain malignant phenotype. )
e) HPV 6 causes benign cervical condylomata – T ( 6 &11)

Question 73

103. All of the following are the characteristics of toxic shock syndrome except?

a) Temp > 39C -
b) Multi-system involvement
c) S aureus in blood culture
d) Diffuse erythematous rash
e) S aureus on vaginal swab

Answer 73

e) S aureus on vaginal swab

Criteria:
Fever T > 38.9
Hypotension – SBP < 90
Skin – Diffuse macular erythroerma
Desquamative rash
- 1-2 wks after onset of illness involves palms and soles
Blood culture –
BC +ve for S aureus but negative for all else ( inc CSF, or throat )
Sero tests neg for leptospirosis or measles
Multisystem involvement ( need 3 of the following )
CNS – disorientation, altered level of consciousness in absence of neuro deficit
Haematological – platelet < 100
Hepatic – transaminases > 2x normal
Renal – Urea nitrogen and Cr > 2x normal, pyuria >
GI tract – vomiting or diarrhoea
Muscular – severe myalgia or creatinine phosphokinase elevation > 2x normal
Mucous membranes – vaginal, oropharyngeal or conjunctival hyperemia

Question 74

104. An offensive postcoital discharge is most likely associated with?
     a) Chlamydia
     b) Gonorrhoea
     c) Candida
     d) Gardnerella

Answer 74

d) Gardnerella

Question 75

A 47 yo woman has progressive menorrhagia with regular cycles. On examination, normal anteverted uterus, no adnexal masses. At hysteroscopy, regular cavity, no pathology found. Secretory endometrium. Best management?

e) Cyclic progesterone -
f) OCP
g) NSAIDS
h) Advise endometrial ablation cf TAH is more effective and less cancer
i) Advise endometrial ablation if adequate contraception

Answer 75

i) Advise endometrial ablation if adequate contraception

Question 76

105. Regarding candida?

a) Ketoconazole is safe in pregnancy
b) Typical thrush spots seen in 20% candida vaginitis -
c) Antifungal treatment to vulva reliably eradicates candida vulvitis
d) Low oestrogen favours candida
e) Diabetics are prone to candida and often present with it prior to diagnosis of DM

Answer 76

e.

a) Ketoconazole is safe in pregnancy – F ((Risk of hepatotoxicity , teratogenic in rats (syndactyly (≥ 2 digits fused together )and oligodactyly < 5 digits ))
b) Typical thrush spots seen in 20% candida vaginitis -
c) Antifungal treatment to vulva reliably eradicates candida vulvitis – F ( severe disease - need oral antifungal and topical steroids
d) Low oestrogen favours candida – F ( uncommon in PM women – associated with increased estrogen ie COC use and pregnancy)
e) Diabetics are prone to candida and often present with it prior to diagnosis of DM – T
( more common in type 2, esp non candida )

Question 77

106. Vulval vestibulitis ( vulvodynia ). Cause?

a) Staph
b) Chlamydia
c) Trichomonas
d) Candida – severe by atypical candida species
e) None of the above

Answer 77

e) None of the above

Question 78

107. Which medication is not used in treatment of menorrhagia?

a) Neostigmine bromide
b) Oestrogen
c) GnRH agonist
d) Progesterone
e) Methyl testosterone

Answer 78

a) Neostigmine bromide – Acetylcholinerase inhibitor, treatment of Myasthenia gravis, renal and intestinal
e) Methyl testosterone – androgen, treatment of hypogonadotrophic hypogonadism

Question 79

109. Most common cause of deep dyspareunia?

a) ‘oestrogen’ – hypoestrogemia
b) retroversion of uterus
c) uterine prolapse – can cause if there is marked descent

Answer 79

a) ‘oestrogen’ – hypoestrogemia

b) retroversion of uterus – 20% of patients, pain esp if associated with endometriosis

Question 80

111. Mild symptomatic endometriosis in young married woman. Rx

a) Danazol 12/12
b) GnRH 3/12
c) Nothing
d) Laparoscopic ablation

Answer 80

d) Laparoscopic ablation

Question 81

112. 47 yo, PV bleeding, atypical hyperplasia, Rx?

a) TAH
b) Ablation
c) Ablation after micro-hysterosalpingogram
d) Provera
e) Recurette in 6/52

Answer 81

a. TAH

Question 82

114. PMB x 3 3/12 ago EUA, hysteroscopy D&C NAD, next Mx?

a) Repeat D&C
b) TAH
c) Nothing

Answer 82

c.

Question 83

115. For Bacteroides fragilis the least effective antibiotic is

a) Cefotaxime
b) Clindamycin
c) Chloramphenicol
d) Gentamicin
e) Metronidazole

Answer 83

d) Gentamicin - bacteroides and clostridium has shown resistance

a) Cefotaxime ( 3rd generation cephalosporin )
b) Clindamycin - Effective
c) Chloramphenicol – broad spectrum. Wide range G-ve and G+ve organisms.
d) Gentamicin - bacteroides and clostridium has shown resistance
e) Metronidazole –Effective ( including clindamycin, tinidazole )
Cephalosporin - Blactam – inhibition of bacterial cell wall synthesis. Good for G+ve.
• 1st Generation
o Cefazolin – G+ve less G-ve
• 2nd Generation ( two types )
o Cefuroxime – more Hinfluenza cover,
o Cephamycin subgrp ( inc anaerobes ) Cefoxitin – more anaerobic cover compared to cefuroxime. More active against E.Coli, proteus mirabilis and klebsiella.
• 3rd Generation
o Ceftriaxone and cefotaxime - More active against gram negative bacilli.

Gentamicin – aminoglycoside. Gram negative rod and gram positive coccus. Anaerobes bacteroides and clostridium has resistence.
Metronidazole – for obligate anaerobe ( G-ve bacilli )and protozoa.
Probiotics – RCT not effective.

Question 84

118. Patient presents with recurrent miscarriage. HSG picture is shown (either broad septum or bicornuate uterus). Management:

a) Transcervical resection of septum
b) Hysteroscopy and laparoscopy
c) Strassman procedure
d) Jones procedure – laparoscopic or abdominal exision wedge excision of intrauterine septum.

Answer 84

a) Transcervical resection of septum ( hysteroscopic metroplasty ) –
Meta analysis showed pregnancy rate of 64% and live birth rate 54% after procedure.
Vaginal delivery is not contraindicated.

c) Strassman procedure – laparoscopic or abdominal exision of intrauterine septum.
d) Jones procedure – laparoscopic or abdominal exision wedge excision of intrauterine septum.

Question 85

120. A 24yo primigravid woman was treated by LMO for pelvic pain with OCP 4 years ago. Now she presents with dysmenorrhoea. Which of the following is correct?
     a) Incorrect initial treatment and diagnosis
     b) Change to a monophasic pill will cure her symptoms
     c) Laparoscopy will show evidence of PID
     d) Cyclical progesterone is the preferred treatment

Answer 85

c) Laparoscopy will show evidence of PID

Question 86

121. A 48 yo lady presented with 6 months of increasing menorrhagia and dysmenorrhoea. On examination the uterus was anteverted, bulky, tender and consistent with a 10 week size Office hysteroscopy revealed a secretory endometrium and no evidence of submucous fibroids. Pelvic US showed an enlarged uterus but no evidence of adnexal mass. Which of the following is correct about her condition? Dx DUB

a) Requires the presence of endometrial glands two high powered fields below the basement membrane – Answer 1 high powered field adenomyosis
b) Responds to cyclical progesterone
c) Responds to OCP
d) NSAIDS reduce the symptoms
e) Often successfully treated by endometrial ablation –

Answer 86

a.

a) Requires the presence of endometrial glands two high powered fields below the basement membrane – Answer 1 high powered field adenomyosis
) Responds to OCP – F ( patients on COC reduces risk of fibroids )

e) Often successfully treated by endometrial ablation – T
• EM tissue appears to induce hypertrophy and hyperplasia of the surrounding myometrium, which results in a diffusely enlarged uterus
• Does not get bigger than 12/40 size
• Incidence not determined, as can only accurately dx with histology
• Assoc with increasing parity, prior uterine surgery may be a RF
• Can be localised or diffuse
• Micro – presence of EM tissue within the myometrium at a distance of least one HPF (some say 2HPF) from the endomyometrial junction
• Rx – only guaranteed one is hysterectomy. Other rxs you can try, but no real hard evidence. Can try symptomatic relief

Question 87

122. A 24yo lady presented with pruritis vulvae for 6 months. Colposcopic punch biopsy of the vulva showed flattening of the rete ridges and a homogenous zone of collagenisation with loss of elastin fibres in the subepithelial layer. Areas of hyperkeratosis were seen. What of the following treatments is the most appropriate?

a) Topical oestrogen
b) Topical 2% testosterone propionate
c) Topical hydrocortisone
d) Topical promethazine
e) No treatment is needed

Answer 87

c) Topical hydrocortisone

Question 88

123. A patient has been treated for vulval warts. Given 6 cycles of podophyllin then tried trichloroacetic acid for 4 weeks without response. Next line of treatment:

a) 5FU
b) CO2 laser
c) Surgical excision
d) Vulvectomy - No
e) Who writes these questions?
f) Cryotherapy -

Answer 88

c) Surgical excision

Question 89

124. 55yo with multiple white patches on her vulva and posterior perineum. What is the best method of making a diagnosis?

a) pap smear
b) colposcopy
c) biopsy
d) wide local excision
e) skinning vulvectomy

Answer 89

c) biopsy

Question 90

125. Vitiligo condylomata lata are caused by

a) HSV 1
b) HPV
c) Treponema pallidum
d) Haemophilus ducreyii
e) Chlamydia

Answer 90

c) Treponema pallidum

Question 91

133. Which of the following is the earliest sign of female sexual response?

a) increased HR
b) uterine contraction
c) vaginal transudation
d) vasocongestion of the outer third of the vagina
e) erection of nipples

Answer 91

a) increased HR – arousal

b) uterine contraction – organsm
c) vaginal transudation - orgasm
d) vasocongestion of the outer third of the vagina – arousal
e) erection of nipples

4 phases

• desire – desire to have sexual activity, thought, images and wishes
• arousal – subjective sense of sexual pleasure accompanied by physiological changes,including genital vasocongestion and increased hr, bp and rr
• orgasm – peaking and release of sexual tension with rhythmic contraction of perineal muscles and reproductive organs
• resolution – muscular relaxation and sense of general well being after sexual activity