Gynae

Question 1

Primary amenorrhoea
- 2 syndromes with 46 XX
- 2 syndromes with 46 XY

Answer 1

Ovarian failure and MRKH
Swyer syndrome and AIS
(MRKH and AIS - absent uterus)

Question 2

Syphilis. Diagnosis & Tx

Answer 2

Screen with EIA (enzyme immunoassay). If reactive then
RPR (rapid plasma reagin) &
TPPA (treponema pallidum particle agglutination assay)
Tx with benzathine benzylpenicillin tetrahydrate
Jarisch Herxheimer - occurs 6-12hrs after starting Tx

Question 3

POI investigations

Answer 3

Irregular periods for >3/12
2x high FSH 1 month apart
Check TFT, prolactin
Then need…
Karyotype
FMR1
21OHP?
TVUS
DEXA
?AMH

Question 4

Differentials for ambiguous genitalia
(Disorders of sex development DSD)

Answer 4

CAH
CAIS/ PAIS
5 alpha reductase def

Question 5

Tx for Chlamydia
Tx for Gonorrhoea

Answer 5

Azithromycin 1g PO stat (or Doxy 100mg PO BD for 7/7 if not preg)
Ceftriaxone 500mg IM + Azithromycin 1g PO

Question 6

Menopausal symptoms Tx if MHT contraindicated (e.g. PMHx of Breast Ca)

Answer 6

*Gabapentin 900mg OD
(reduces hot flushes in 50% of pts)
Others:
Pregabalin
Clonidine
*SSRIs - Citalopram
SNRI - Venlafaxine

Other non-hormonal:
CBT, Yoga, acupuncture, plant based diet
Supplements:
*Vit D
*Magnesium
*Melatonin
*Vit E (DO NOT USE WITH TAMOXIFEN)

Question 7

Medical Tx for urge incontinence / OAB - drug type and examples

Answer 7

Anticholinergics: oxybutynin or solifenacin
SE: dry eyes/mouth, constipation, long term risk of
dementia. Aim for short term use only.
B3 adrenoceptor agonist: Mirabegron (betmiga)
SE: HTN, renal and liver impairment

Question 8

Steps of a vaginal hysterectomy

Answer 8

Position in dorsal lithotomy
General anaesthetic, IDC, ABx
Grasp anterior lip of cervix with vulsellum.
Infiltrate cervix with dilute local anaesthetic with adrenaline circumferentially at junction
of vaginal mucosae and cervix. Circumferential incision around cervix, dissect anterior
to reflect bladder and repeat at posterior aspect to enter the para rectal space. Perform an
anterior and posterior colpotomy to enter the uterovesical and POD space.
Clamp, cut and tie off uterosacral ligaments bilateral – leave tie long.
Skeletonise the uterine vessels, clamp, cut and ligate bilateral, and repeat with the ovarian ligaments. Remove specimen. Assess haemostasis.
Secure uterosacrals to posterior aspect of vaginal vault. Consider Modified McCall culdoplasty
(Important to take bites of uterosacral high ‘high up’, not just at level of uterosacral pedicles, or there won’t be sufficient elevation of vagina). The vault is closed.

Question 9

SSF steps

Answer 9

Posterior vaginal wall is opened in the midline as for posterior repair.
Right pararectal space entered to access the ischial spine. Blunt dissection and lateral
sweeping movements used
cardinal ligament containing the ureter retracted anteriorly
Sacrospinous ligament identified and exposed
A permanent or delayed absorbable suture is placed in the mid portion of the sacrospinous
ligament 2-3cm medially from the ischial spine using the Capio needle.
Check strength of stitch.

Question 10

Burch Colposuspension

Answer 10

2-3 permanent sutures each side – para-urethral vaginal to iliopectineal ligament