Gynae 1

Question 1

What is endometriosis?
Where does it most commonly affect?
What is adenomyosis?

Answer 1

Growth of endometrial tissue outside the uterine cavity. Chronic, oestrogen dependent condition.
Uterosacral ligaments, pouch of Douglas, rectosigmoid colon, bladder, distal ureter.

Adenomyosis is invasion of endometrial tissue into the myometrium

Question 2

What are the risk factors for endometriosis?

Answer 2

early menarche/late menopause
short menstrual cycles
obstruction to vaginal outflow
family history

Question 3

what are the clinical features of endometriosis?

Answer 3

chronic cyclical pelvic pain
deep dyspareunia 
subfertility
dysuria/urgency/haematuria
dyschezia

posterior fornix/adnexal tenderness
palpable nodules/adnexal masses
chocolate cysts on ovaries
bluish haemorrhagic nodules in posterior fornix

Question 4

what are the investigations for endometriosis?

Answer 4

laparoscopy: gold standard
TVS routine
MRI (pelvis) for deep endometriomas
urinalysis, chlamydia screen, bhCG

Question 5

what is the management for endometriosis?

Answer 5

suppression of ovarian function (COCP, GnRH agonists, IUS)

surgical: uterine artery embolisation, excision/ablation, hysterectomy
pharmacological: NSAIDs/COCP/danazol/GnRH agonists (goserelin)

to improve fertility: endometrial lesion ablation/IVF

Question 6

what cancer does endometriosis predispose to?

Answer 6

ovarian cancer

and increased risk of IBS

Question 7

what is the pathophysiology of PCOS?

Answer 7

increased LH leads to increased androgen production from ovarian thecal cells
androgens&raquo_space;» oestrogens.
due to the persistently high LH levels, there is no LH surge either = no ovulation.

Question 8

what are the symptoms and signs of PCOS?

Answer 8

oligomenorrhoea (but when periods occur they are extremely heavy), subfertility, acne, hirsutism, alopecia, obesity, sleep apnoea

Question 9

what is the Rotterdam criteria for PCOS?

Answer 9

'SHOP'
String of pearls
Hyperandrogenism
Oligomenorrhoea
Prolactin normal

Question 10

what are the investigations for PCOS?

Answer 10

total testosterone: normal or raised
sex hormone binding globulin: normal or low
LH: may be elevated
USS
OGTT
prolactin, T4, TSH (to exclude prolactinoma/hypothyroidism)

Question 11

for women wishing to conceive, what is the management of PCOS?
for women not planning pregnancy, what is the treatment?
what is the general management of PCOS?

Answer 11

1) clomifene citrate, metformin, ovarian drilling
2) COCP/IUS, co-cyprindol, orlistat
3) weight loss, screen for CVD risk factors, annual OGTT

Question 12

what is the treatment of PCOS induced acne?

Answer 12

benzoyl peroxide

Yasmin/Dianette (increased risk of VTE)

Question 13

what is the definition of, and causes of postmenopausal bleeding?

what are the investigations?

Answer 13

vaginal bleeding occurring after 12m of amenorrhoea
causes: vaginal atrophy, endometrial cancer (can be caused by tamoxifen), vulval cancer, vaginal cancer, cervical cancer, HRT use

investigations = TVS (5mm cut off), endometrial biopsy, hysteroscopy and biopsy

Question 14

what are the symptoms of menopause?

what is early menopause?
what is the normal age of menopause?

Answer 14

hot flushes 
vaginal discomfort/dryness
incontinence 
mood changes
sleep disturbance 

early: 40-45 years of age
average age = 51 years

Question 15

what are the CI to HRT?

Answer 15

current/past breast cancer
any oestrogen sensitive cancer
undiagnosed vaginal bleeding
untreated endometrial hyperplasia

Question 16

what are the indications of HRT?

Answer 16

women <60 at risk of osteoporotic fractures
treatment of menopausal symptoms where the risk:benefit ratio is favourable
women with early menopause (continued until they reach 51)

Question 17

what are the benefits and risks of HRT?

Answer 17

benefits: decreased osteoporosis risk, decreased CVD risk, increased quality of life, increased mood

risks: PO increases VTE risk, oestrogen only increases endometrial cancer risk
erratic bleeding can be common in first 3-6m after starting

Question 18

when should women be prescribed sequential combined HRT?

Answer 18

if their last period was LESS THAN 1 year ago and it is indicated

Question 19

when can women be prescribed continuous combined HRT?

Answer 19

if;
they have received sequential combined HRT >1yr
>1yr since last period
>2yrs since last period if their menopause was premature

Question 20

what are the side effects of HRT?

Answer 20

erratic bleeding in first 3-6m

oestrogen: breast tenderness, leg cramps, bloating, nausea
progestogen: premenstrual like symptoms

initial follow up after 3m

Question 21

outline the features, risk factors, investigations and prognosis of vulval cancer?

Answer 21

features: 85% are squamous, labium majorum is the most common site, highest incidence in elderly

risk factors: VIN, lichen sclerosus, HPV, paget’s disease

investigations: biopsy, examination
prognosis: very good

Question 22

outline the cervical screening programme and how smears are taken

Answer 22

ages 25-64
24-49: smear every 3 years
50-64: smear every 5 years

smears are taken from the transformation zone
if HPV is found (16 and 18), a woman should be sent for colposcopy

Question 23

outline the interpretation and subsequent management of cervical smear results?

Answer 23

borderline/mild dyskaryosis: original sample tested for HPV. negative= routine recall. positive = colposcopy

moderate dyskaryosis = CIN II. refer for urgent colposcopy.

severe dyskaryosis = CIN III. refer for urgent colposcopy

suspected invasive cancer = refer for urgent colposcopy

inadequate = repeat smear. 3 times? = colposcopy

those who have had CIN or neoplasia and been treated = invited back after 6m for ‘test of cure’

Question 24

what are the features, risk factors and investigations for cervical cancer?

Answer 24

features: vaginal bleeding, discharge, vaginal discomfort, urinary symptoms

risk factors: heterosexual, many partners, low socio economic class, smoking, HPV 16&18

80% are squamous cell cancers

investigations: chlamydia test, colposcopy, cone biopsy, CT scan, PET scan, pelvic MRI

Question 25

what are the grades of CIN?

Answer 25

CIN I: confined to lower third of epithelium
CIN II: confined to lower and middle thirds of epithelium
CIN III: affects full thickness of epidermis