Gynaecological Problems

Question 1

What is the prevalence of PCOS when defined by the Rotterdam Criteria compared with the National Institutes of Health criteria?

a. Equivalent
b. 2x
c. 3x
d. 4x
e. 5x

Answer 1

B - 2x

PCOS should be diagnosed in UK practice according to the Rotterdam criteria which requires the presence of any 2 of the following 3 criteria:

• Polycystic appearance of the ovaries on scan, either:
o Total ovarian volume >10cm3
o 12 or more follicles
• Clinical and/or biochemical evidence of hyperandrogenism
• Oligo- or an-ovulation

Unsurprisingly, this leads to more diagnoses (roughly twice as many) than the previously used American National Institutes of Health (NIH) criteria which did not include consideration of ultrasound appearances, relying on clinical and biochemical findings alone. Even with such diagnostic criteria, the exact prevalence of PCOS is uncertain with estimates ranging from 2-26%.

Question 2

The recommended baseline test for hyperandrogenism is the free androgen index, how is this calculated?

a. LH/FSH x 100
b. Free Testosterone/Total Testosterone ratio
c. Free Testosterone/SHBG ratio
d. LH/SHBG ratio
e. Total testosterone/SHBG x 100

Answer 2

E - Total testosterone/SHBG x 100

Older texts may reference the LH:FSH ratio as an important investigation in diagnosing PCOS (>2:1 being considered significant) although the ‘gold standard’ in modern practice is the free-androgen index. This is expressed as a ratio of total testosterone to SHBG multiplied by 100.

Question 3

2 of the 3 Rotterdam criteria are required for diagnosis of PCOS, once component of which is a polycystic appearance of the ovaries on USS. This may be defined by follicle count or volume. What are the diagnostic parameters for each?

Follicle Count Ovarian Volume

a. 8 or more >12cm3
b. 8 or more >10cm3
c. 10 or more >10cm3
d. 12 or more >10cm3
e. 12 or more >12cm3

Answer 3

D - 12 or more follicles; >10cm3 total volume

While pelvic ultrasound reports may commonly include a vague comment regarding a ‘polycystic appearance’ to the ovaries, there are infact firm criteria for such a diagnosis in the context of PCOS – either >12 follicles or a total ovarian volume of >10cm3

Question 4

A 19 year old patient is referred to the gynaecology outpatient clinic with suspected PCOS with a history of highly irregular menstrual cycles since menarche aged 14. On examination you note severe facial and bodily hirsuitism, under-developed breast tissue and cliteromegaly. The patient’s voice is also noted to be rather deep for a women of this age. Bloods are requested in order to calculate the free-androgen index and total testosterone levels are noted to be markedly elevated at 6.8. What test is indicated here?

a. SHBG during luteal phase
b. ACTH stimulation test
c. Free testosterone during luteal phase
d. 17-hydroxyprogesterone during follicular phase
e. LH levels on day 2

Answer 4

D - 17 hydroxyprogesterone during the follicular phase

The patient in the scenario has numerous clinical and biochemical features which may indicate an underlying adrenal tumour or late-onset congenital adrenal hyperplasia. PCOS may well be the underlying diagnosis though these conditions carry considerably greater implications and thus warrant exclusion as a priority. The next logical test here would be 17-hydroxyprogesterone levels taken during the follicular phase of the menstrual cycle. While an ACTH stimulation test may similarly be used, this is usually reserved for borderline results.

Question 5

Which of the following has not been proven to be directly associated with PCOS:

a. Weight gain
b. Acne
c. Hirsuitism
d. Anovulatory infertility
e. Oligomenorrhoea

Answer 5

E - Weight gain

There is often an association made between PCOS and increased BMI (>50% of patients with PCOS are thought to be overweight/obese) however there is no firm evidence that PCOS in itself causes weight gain or indeed makes weight loss any more difficult. Lifestyle modifications, including weight loss, form a cornerstone of PCOS and should be considered first line.

Question 6

What percentage of women with PCOS display biochemical evidence of insulin resistance?

a. 8-12%
b. 15-20%
c. 25-40%
d. 45-60%
e. 65-80%

Answer 6

E - 65-80%

Insulin resistance is present in around 65–80% of women with PCOS, independent of obesity, and is further exacerbated by excess weight. Insulin resistance has been shown to worsen reproductive and metabolic features, type II diabetes and cardiovascular disease (CVD) risk in PCOS. The highest incidence of metabolic abnormalities is seen in women with marked hyperandrogenism and anovulation.

Question 7

Women with PCOS who fall pregnant are advised to undergo a GTT in the third trimester. What is the prevalence of GDM in a PCOS population compared with the general population?

a. Twice as high
b. Three times as high
c. Four times as high
d. Five times as high
e. Ten times as high

Answer 7

A - Twice as high

Prevalence of gestational diabetes is twice as high in those with PCOS who become pregnant than in general population controls. All patients should undergo a GTT at 24-28 weeks gestation.

Question 8

A 39 year old with a background of PCOS presents to her GP complaining of feeling tired and thirsty all the time. She undergoes a 75g 2 hour oral glucose tolerance test which returns the following result:

Fasting Glucose: 4.1
2 hours post-glucose: 8.1

When, if appropriate, should this test be repeated?

a. No indication to repeat
b. 6-monthly
c. Annually
d. 2-yearly
e. 3-yearly

Answer 8

C - Annually

All patients with PCOS who are overweight (BMI >25) or who are normal weight though with additional risk factors for diabetes (i.e. family history, aged >40, personal history of GDM), should undergo an oral glucose tolerance test, normal values for which are as follows:

Fasting glucose:
o Normal: <6.1
o Impaired: 6.1 – 6.9
o Diabetes: >6.9

2 hours:
o Normal: <7.8
o Impaired: 7.8 – 11.1
o Diabetes: >11.1

The results in the question given are consistent with impaired glucose tolerance (raised 2 hour glucose, normal fasting) and thus the test should be repeat annually as per guidelines. The same applies if fasting glucose is elevated above normal but below the threshold for diagnosis of diabetes.

Question 9

Which of the following conditions is not known to be associated with PCOS?

a. Cardiovascular disease
b. Ovarian cancer
c. Depression
d. Endometrial cancer
e. Diabetes

Answer 9

B - Ovarian cancer

Cardiovascular disease risk is greater in women with PCOS related primarily to insulin resistance and obesity, though high androgens and low SHBG have also been linked. Similarly rates of endometrial hyperplasia and malignancy are increased, secondary to higher numbers of anovulatory cycles. Insulin resistance is found in up to 80% of those with PCOS and both type 2 and gestational diabetes are more prevalent than in the general population. Women with PCOS are at an increased risk of psychological issues including depression and anxiety and these should be routinely screened for. There is no link with PCOS and ovarian or breast cancer.

Question 10

How often is progesterone treatment advised to induce a withdrawal bleed in women with amenorrhoeic PCOS?

a. Monthly
b. Every 3-4 months
c. Every 5-6 months
d. Every 9 months
e. Annually

Answer 10

B - Every 3-4 months

Oligo- and amenorrhoea seen in patients with PCOS, together with pre-menopausal levels of circulating oestrogens, may pre-dispose to endometrial hyperplasia and malignancy. There is no clear guidance on the optimum regimen for reducing this risk, though as a minimum, induction of a withdrawal bleed every 3-4 months with progestogens is advised. Alternatives include use of the COCP to achieve a monthly bleed, or on-going endometrial protection with a Mirena IUS.

Question 11

At what BMI should women with PCOS and concurrent cardiovascular disease be considered for bariatric surgery?

a. 35
b. 40
c. 45
d. 50
e. >50

Answer 11

A - 35

Patients with refractory obesity may be considered for bariatric surgery. This may be considered in those with a BMI >40, or >35 if concurrent high-risk obesity related disease (e.g. hypertension, cardiovascular disease or diabetes)

Question 12

At what size should an ovarian cyst in a post-menopausal women be considered significant?

a. >1cm
b. >3cm
c. >4cm
d. >5cm
e. Any size

Answer 12

A - >1cm

Any ovarian cyst >1cm in a postmenopausal women requires further evaluation to determine the risk of malignancy. Cystic lesions smaller than 1 cm are clinically inconsequential and it is at the discretion of the reporting clinician whether or not to describe them in the imaging report as they do not need follow-up.

Question 13

A 62 year old woman undergoing a CT scan during an acute admission with diverticulitis is noted to have a 4cm right sided ovarian cyst. The scan makes no further comment on the character though notes that there is no obvious evidence of extra-ovarian disease. What is the next step:

a. MRI pelvis and Ca125
b. USS and Ca125
c. Ca125
d. Ca125, CEA, hCG and AFP
e. USS and Ca125, hCG and AFP

Answer 13

B - USS and Ca125

Calculation of RMI is the first step in assessing the malignant potential of a post-menopausal cyst. This requires both measurement of Ca125 and ultrasound assessment. Where the initial imaging modality was a CT scan, unless this clearly indicates ovarian cancer and widespread intra-abdominal disease, ultrasound is indicated.

Question 14

A 56 year old patient attends the gynaecology clinic complaining of bloating and unexplained weight loss. A bimanual examination performed in the clinic is unremarkable. What is the sensitivity of clinical examination in the detection of ovarian masses?

a. No greater than 25%
b. No greater than 33%
c. No greater than 51%
d. No greater that 65%
e. No greater than 83%

Answer 14

C - No greater than 51%

Although clinical examination has poor sensitivity in the detection of ovarian masses (15–51%), its importance lies in the evaluation of any palpable mass for tenderness and mobility.

Question 15

In what percentage of epithelial ovarian tumours will Ca125 be elevated?

a. 50%
b. 60%
c. 75%
d. 80%
e. 90%

Answer 15

D - 80%

Ca125 is primary a marker of epithelial cancer and is elevated in around 80% of such tumours and infact is seldom elevated in most primary mucinous tumours. Numerous non-gynaecological and benign conditions are also known to elevate Ca125. The upper limit of normal (35) represents the 99th centile in a study of almost 900 healthy individuals.

Question 16

A 4cm unilateral simple ovarian cyst is diagnosed in a 56 year postmenopausal patient during investigation for PMB. Ca125 is within normal limits at 26. You explain that surveillance of the cyst is advised though reassure her that the likelihood of malignancy is low. What is the likelihood of the cyst disappearing in that time?

a. ~10%
b. ~25%
c. ~33%
d. ~50%
e. ~75%

Answer 16

D - 50%

95-99% of simple ovarian cysts are benign. When followed up for 2 years, typical behaviour of <5cm simple cysts is as follows:
•	53% disappear completely
•	28% stay the same
•	11% increase in size
•	3% decrease in size though persist
•	6% fluctuate

Question 17

A 4cm unilateral simple ovarian cyst is diagnosed in a 56 year postmenopausal patient during investigation for PMB. Ca125 is within normal limits at 26. You explain that surveillance of the cyst is advised though reassure her that the likelihood of malignancy is low. What is the likelihood of the cyst enlarging in that time?

a. 11%
b. 15%
c. 23%
d. 33%
e. 40%

Answer 17

A - 11%

95-99% of simple ovarian cysts are benign. When followed up for 2 years, typical behaviour of <5cm simple cysts is as follows:
•	53% disappear completely
•	28% stay the same
•	11% increase in size
•	3% decrease in size though persist
•	6% fluctuate

Question 18

What percentage of borderline ovarian masses appear simple on USS?

a. <5%
b. 10%
c. 20%
d. 30%
e. 40%

Answer 18

C - 20%

When undertaking surgery for any ovarian mass, the potential diagnosis of a borderline tumour should be considered. When such a diagnosis is made or suspected, referral to a gynaecology oncology centre is recommended. Radiography and serum markers pre-op are relatively insensitive to such a diagnosis and infact 20% will appear as simple cysts on ultrasound. The majority however will display some suspect features on scan.

Question 19

A 65 year old patient is reviewed in the 2WW clinic with bilateral ovarian masses and a raised Ca-125. Calculation of the RMI returns a score of >200. What is the most appropriate next stage in management?

a. Refer to MDT
b. CT abdomen and pelvis
c. MRI abdomen and pelvis
d. List for open TAH+BSO
e. Arrange other tumour markers – CEA, hCG and AFP

Answer 19

B - CT abdomen and pelvis

All patients with an RMI >200 should undergo a CT scan of the abdomen and pelvis. While referral to MDT is also prudent, knowledge of the CT scan is required to facilitate that discussion and thus should occur first. MRI is useful in the context of equivocal ultrasound findings though has little role here. Ca125 is the only tumour marker indicated in assessment of the post-menopausal woman. While in all likelihood the patient will require a laparotomy (inclusive of TAH and BSO), further workup is required first.

Question 20

A 58 year old patient presents to the clinic with the finding of bilateral, apparently simple ovarian masses on scan measuring 9 and 8cm respectively. Ca125 is normal at 25 and there are no other concerning features on scan. She is understandably in some discomfort however and is keen to discuss management. What is the most appropriate treatment in this case?

a. Conservative – repeat USS in 6 months
b. Aspiration of cysts under USS guidance
c. Laparotomy, TAH and BSO with omental biopsy
d. Laparoscopic BSO
e. Arrange MRI and MDT discussion

Answer 20

D - Laparoscopic BSO

The RMI here is only 75 suggesting a low probability of malignancy (the fact that the cysts are bilateral is the only feature of note). This patient is therefore suitable for laparoscopic management. In postmenopausal women there is no merit in attempting ovarian conservation and a bilateral oophorectomy should be performed.

Question 21

A 67 year old patient with multiple co-morbidities is found to have a persistent 10cm simple cyst on her right ovary which causes some discomfort. Ca125 is normal and RMI <200. She is reviewed by the anaesthetic team and it is felt that she is unfit for surgery. She enquires about aspiration of the cyst. What is the likelihood of recurrence in patients undergoing aspiration of ovarian cysts?

a. 25%
b. 33%
c. 50%
d. 60%
e. 75%

Answer 21

A - 25%

Aspiration of ovarian cysts in postmenopausal women is not recommended except for symptom control in those with advanced malignancy unfit for surgery or other intervention. Diagnostic cytological examination of cyst fluid is infact poor at differentiating between benign and malignant and even where a benign cyst is aspirated, 25% will recur within 1 year.

Question 22

What proportion of the adult female population are affected by chronic pelvic pain?

a. 1 in 6
b. 1 in 8
c. 1 in 10
d. 1 in 12
e. 1 in 20

Answer 22

A - 1 in 6

Chronic pelvic pain is common, affecting perhaps one in six of the adult female population. Much remains unclear about its aetiology, but chronic pelvic pain should be seen as a symptom with a number of contributory factors rather than as a diagnosis in itself.

Question 23

What is the incidence of nerve entrapment occurring after one Pffanenstiel incision?

a. 1.5%
b. 3.7%
c. 7.8%
d. 10.1%
e. 20.4%

Answer 23

B - 3.7%

The incidence of nerve entrapment (defined as highly localised, sharp, stabbing or aching pain, exacerbated by particular movements, and persisting beyond 5 weeks or occurring after a pain-free interval) after one Pfannenstiel incision is 3.7%.

Question 24

What proportion of bowel/bladder injuries at laparoscopy require laparotomy to repair?

a. 1/4
b. 1/3
c. 1/2
d. 2/3
e. 3/4

Answer 24

D - 2/3

Diagnostic laparoscopy is the only test capable of reliably diagnosing peritoneal endometriosis and adhesions. Gynaecologists have therefore seen it as an essential tool in the assessment of women with chronic pelvic pain. However, it carries significant risks: an estimated risk of death of approximately 1 in 10 000, and a risk of injury to bowel, bladder or blood vessel of approximately 2.4 in 1000, of whom two-thirds will require laparotomy.

Question 25

Which of the following therapies is of no proven benefit in treating chronic pelvic pain? a. Combined Oral Contraceptives b. Laparoscopic utero-sacral Nerve Ablation c. GnRH analogues d. Anti-spasmodics for symptoms of IBS e. Progesterones

Answer 25

B - LUNA Laparoscopic utero-sacral nerve ablation is of no proven benefit in the treatment of chronic pelvic pain

Question 26

Which of the following is the best description of ‘trapped ovary syndrome’? a. Small functional pieces of ovary left behind following oophorectomy b. Herniation of the ovary through a laparoscopic port defect in anterior abdominal wall c. A retained ovary buried in dense adhesions post-hysterectomy d. Necrotic ovary, leading to infection and subsequent adhesions, inadvertently left in the abdominal cavity following oophorectomy e. Ovaries adherent together either anterior or posterior to the uterus, leading to a distinct pattern of pain

Answer 26

C - A retained ovary buried in dense adhesions post-hysterectomy Two distinct phenomena of ovarian derived chronic pelvic pain are described: * Retained ovary syndrome – small pieces of functional ovary inadvertently left behind post-oophorectomy * Trapped ovary syndrome – where a purposely left ovary becomes trapped in dense adhesions post-hysterectomy

Question 27

What proportion of women experience premenstrual symptoms of any kind? a. 15% b. 40% c. 65% d. 80% e. >90%

Answer 27

B - 40% Four in ten women experience symptoms of PMS, of which 5-8% suffer from ‘severe’ PMS. The exact aetiology of the condition is unclear though believed to revolve around the hormone cycle – re-enforced by its absence pre-pubertally, during pregnancy and post-menopausally. The two main theories which predominate are either 1) an over-sensitivity to progesterone in affected women (as levels are the same in women with and without PMS) or 2) driven by serotonin and GABA (as SSRIs can be used to beneficial effect while GABA levels are modulated by levels of progesterone metabolite allopregnanolone which is reduced in women with PMS)

Question 28

Amongst women who report premenstrual symptoms, what proportion would be considered ‘severe’? a. < 5% b. Up to 8% c. Up to 15% d. Up to 25% e. Up to 33%

Answer 28

B - Up to 8% Four in ten women experience symptoms of PMS, of which 5-8% suffer from ‘severe’ PMS. The exact aetiology of the condition is unclear though believed to revolve around the hormone cycle – re-enforced by its absence pre-pubertally, during pregnancy and post-menopausally. The two main theories which predominate are either 1) an over-sensitivity to progesterone in affected women (as levels are the same in women with and without PMS) or 2) driven by serotonin and GABA (as SSRIs can be used to beneficial effect while GABA levels are modulated by levels of progesterone metabolite allopregnanolone which is reduced in women with PMS)

Question 29

How should the diagnosis of pre-menstrual syndrome be made? a. Retrospective recall of symptoms b. Prospective completion of a symptom diary of 3 random cycles within 12 months c. Prospective completion of a symptom diary over 2 consecutive months d. Serum progesterone and oestrogen levels during the luteal phase e. Serum FSH/LH levels during luteal phase

Answer 29

C - Prospective completion of a symptom diary over 2 consecutive months In reviewing women with suspected PMS, symptoms should be recorded prospectively over two menstrual cycles using a symptom diary – retrospective recall of symptoms is generally unreliable. Levels of sex hormone are unchanged in women with PMS thus there is little merit in measuring these. Gonadotrophins are not implication in the pathophysiology of PMS and also do not warrant formal quantification. Where diagnostic uncertainty remains (usually in patients with variant-type PMS), a 3 month trial of GnRH analogues may be employed to induce ovarian quiescence.

Question 30

Which of the following patient questionnaires is the most reliable and reproducible in assessing patients with suspected PMS? a. Premenstrual symptoms screening tool b. National association of PMS survey c. Ovulatory dysfunction and premenstrual syndrome screening tool d. Daily record of severity of problems e. Women’s menstrual health symptom tracker

Answer 30

D - Daily record of severity of problems There are numerous patient questionnaires available for assessment of PMS however the Daily Record of Severity of Problems is the most widely used and is simple for patients – it has been consistently shown to be provide a reliable and reproducible record of symptoms. The PSST is another though is retrospective and used for screening but not diagnosis. The other tests mentioned are fictitious.

Question 31

You review a patient in the gynaecology clinic who is taking St. John’s Wort for treatment of pre-menstrual syndrome. Alongside which drugs should St John’s Wort not be used? a. Tricyclic Antidepressants b. Proton pump inhibitors c. SSRIs d. H2 receptor antagonists e. Metformin

Answer 31

C - SSRIs There are a number of holistic therapies with which patients may be self medicating for the symptoms of PMS. Of particular note to clinicians is St. John’s Wort owing to its significant interaction potential with other prescribed medications. Of relevance to this setting is the interaction with SSRI anti-depressants, also used in PMS, which can lead to the serotonin syndrome (toxicity) characterised by neuromuscular hyperactivity (tremor, clonus, rigidity), autonomic dysfunction (tachycardia, blood pressure change, hyperthermia, diaphoresis, shivering) and altered mental state. Administered together, St John’s Wort can also render low-dose combined oral contraceptive ineffective.

Question 32

Alongside which contraceptive preparation should St John’s Wort be used with caution? a. Combined pill b. Depo-provera c. Implanon d. LNG-IUS e. Progesterone only pill

Answer 32

A - Combined Pill There are a number of holistic therapies with which patients may be self medicating for the symptoms of PMS. Of particular note to clinicians is St. John’s Wort owing to its significant interaction potential with other prescribed medications. Of relevance to this setting is the interaction with SSRI anti-depressants, also used in PMS, which can lead to the serotonin syndrome (toxicity) characterised by neuromuscular hyperactivity (tremor, clonus, rigidity), autonomic dysfunction (tachycardia, blood pressure change, hyperthermia, diaphoresis, shivering) and altered mental state. Administered together, St John’s Wort can also render low-dose combined oral contraceptive ineffective.

Question 33

Combined oral contractive containing which progesterone should be considered first line in management of PMS? a. Drosperinone b. Levonorgesterol c. Norethisterone d. Medroxyprogesterone Acetate e. Pregnenolone

Answer 33

A - Drosperinone Combined oral contraceptives containing drosperinone should be considered first line pharmaceutical management in the treatment of PMS. Emerging data suggests this is most efficacious when administered continuously rather than the traditional 21:7 regimen.

Question 34

Danazol is described as an alternative therapy for treatment of premenstrual synrome. Which of the following is NOT side effect of danazol therapy? a. Virilisation of a female fetus b. Acne c. Weight gain d. Hirsuitism e. Impaired glucose tolerance

Answer 34

E - Impaired glucose tolerance Danazol, an androgenic steroid, appears to be of some benefit in treating the breast symptoms of PMS when administered in the luteal phase. It is not without considerable side effects however including acne, weight gain, hirsuitism and voice changes. Users require robust contraception as virilisation of a female fetus (cliteromegaly, labial fusion and urogenital sinus abnormalities) is also reported should pregnancy occur on treatment.

Question 35

Which of the following is not a recommended treatment for premenstrual syndrome? a. Spironolactone b. SSRI c. GnRH analogues d. Progesterone monotherapy e. Oestrogen patch with oral progesterone

Answer 35

D - Progesterone monotherapy There is good evidence to suggest that treating PMS with progesterone in isolation is not appropriate

Question 36

A 42 year old patient is referred by her GP to the gynaecology clinic with symptoms of severe PMS. She has already had a trial of both a suitable combined pill taken continuously for 6 months and low-dose SSRI during the luteal phase, without benefit. On review of the history you feel there is no diagnostic uncertainty. Which of the following is the most appropriate next step in the management of this patient? a. 3 month trial of GnRH analogues b. 6 month trial of GnRH analogues c. Estradiol patch with micronized progesterone during the luteal phase d. LNG-IUS e. Laparoscopic BSO

Answer 36

C - Estradiol patch with micronized progesterone during the luteal phase This patient has tried both recommended first line pharmacological management strategies (drosperinone containing combined pill and low-dose SSRI) both taken in line with recommended dosing regimens. Second line pharmacological management therefore is either a high-dose trial of an SSRI which is not one of the options given or estradiol patches with micronized or intrauterine progesterone. GnRH analogues are third line and would be next on the treatment ladder if second line therapy fails. The LNG-IUS in isolation is not recommended for treatment of PMS. Surgical treatment is considered fourth line when all other therapy has failed.

Question 37

The exact aetiology of pre-menstrual syndrome remains uncertain though appears to be related to the effect of cyclical ovarian activity on neurotransmitters. Which neurotransmitters in particular are implicated in this process? a. Adrenaline and dopamine b. Adrenaline and noradrenaline c. GABA and noradrenaline d. GABA and serotonin e. Serotonin and dopamine

Answer 37

D - GABA and Serotonin Both serotonin and GABA (as SSRIs can be used to beneficial effect while GABA levels are modulated by levels of progesterone metabolite allopregnanolone which is reduced in women with PMS) are implicated in the aetiology of PMS.

Question 38

A patient is issued with an appointment for the outpatient hysteroscopy clinic after being seen in the clinic with post-menopausal bleeding. What pain relief would you advise pre-appointment to help minimise post-procedural pain? a. Paracetamol 1 gram (30 minutes prior) b. Oramorph 10mg (15 minutes prior) c. Ibuprofen 400mg (1 hour prior) d. Codeine 8-16mg (30 minutes prior) e. Tramadol 100mg (30 minutes prior)

Answer 38

C - Ibuprofen 400mg 1 hour prior Women without contraindications should be advised to take standard doses of an NSAID around 1 hour prior to the scheduled outpatient hysteroscopy appointment with the aim of reducing pain in the immediate post-operative period. Opiate analgesia should be avoided as it may cause adverse effects.

Question 39

2. Which of the following is NOT a recognised risk factor for perforation at the time of outpatient hysteroscopy? a. Blind dilatation of the cervix b. Tortuous cervical canal c. Cervical stenosis d. Abnormal uterine anatomy e. Previous endometrial ablation

Answer 39

E - Previous endometrial ablation Uterine trauma – cervical lacerations or uterine perforation – is a recognised complication of blind or endoscopic instrumentation of the uterus. Factors associated with increased risk include need for blind dilatation, cervical stenosis (atrophy, surgery, previous section, nulliparity), a tortuous canal and a deviated cavity (acute flexion, pelvic adhesions, fibroids)

Question 40

Which of the following is advised where mechanical dilatation of the cervix is anticipated at outpatient hysteroscopy? a. Opiate analgesia pre-procedure b. Injection of local anaesthetic intra-cervically c. Misoprostol d. Topical local-anaesthetic (e.g. Instilagel) e. Pudendal block

Answer 40

B - Injection of local anaesthetic intra-cervically Routine cervical dilatation is associated with pain, vasovagal reactions and uterine trauma and should be avoided. Where necessary, mechanical cervical dilatation generally requires administration of local cervical anaesthesia. Instillation of local anaesthetic into the canal does not reduce pain during diagnostic outpatient hysteroscopy but may reduce incidence of vasovagal reactions. Topical application to the ectocervix should be considered where use of a tenaculum is deemed necessary.

Question 41

What is the recommended maximum diameter of a hysteroscope used in outpatient procedures (i.e. scope and sheath combined)? a. 2.7mm b. 3.5mm c. 4.2mm d. 5mm e. 5.6mm

Answer 41

B - 3.5mm Miniature sized hysteroscopes – that is 2.7mm scopes with a 3.5mm sheath – should be used as standard for diagnostic outpatient hysteroscopy. This is associated with considerably improved pain scores. There is insufficient evidence to recommend 0, 12, 25 or 30 degree scopes – this should be left to the discretion of the operator.

Question 42

What angle of scope is recommended for use in outpatient hysteroscopy? a. 0 ° b. 12° c. 25° d. 30° e. Any of the above

Answer 42

E - Any of the above Miniature sized hysteroscopes – that is 2.7mm scopes with a 3.5mm sheath – should be used as standard for diagnostic outpatient hysteroscopy. This is associated with considerably improved pain scores. There is insufficient evidence to recommend 0, 12, 25 or 30 degree scopes – this should be left to the discretion of the operator.

Question 43

Which of the following is NOT a recognised benefit of NaCl over CO2 as the distension medium at outpatient hysteroscopy? a. Better pain scores b. Less vaso-vagal episodes c. Improved images d. Reduced operating time e. Enables use of bipolar diathermy

Answer 43

A - Better pain scores Pain scores for both saline and CO2 hysteroscopy are equivalent. The incidence of vaso-vagal episodes, image quality and operating time are all improved with saline however. Any OPH requiring the use of bipolar electro-surgery must use saline to act as both the distension and conducting medium.

Question 44

A 35 year old woman is referred to gynaecology after undergoing a CT scan to investigate left iliac fossa pain. This highlights the presence of a 7cm complex left-ovarian cyst. What tumours marker(s) are recommended to aid in evaluating complex ovarian masses in women <40 years? a. Ca-125, CEA, hCG b. Ca-125, CEA, AFP, hCG c. CEA, AFP, hCG d. CEA, hCG and LDH e. Ca-125, hCG, AFP, LDH

Answer 44

E - Ca125, hCG, AFP, LDH All women under 40 with a complex ovarian mass should have LDH, AFP and hCG measured owing to the possibility of germ cell tumours. Ca-125 – primarily a marker for epithelial ovarian cancer and raised in only 50% of cases – does not need to be undertaken routinely in all premenopausal women in whom a diagnosis of a simple cyst has been made.

Question 45

A 24 year old patient is reviewed in a general gynaecology clinic with a unilateral ovarian mass, described as an ‘irregular solid tumour with prominent blood flow on colour doppler, measuring 45mm in widest diameter’. Her tumour markers are all within normal limits. She is asymptomatic and the mass was detected only on account of an ultrasound performed to investigate missing coil threads. What is the next step in management? a. Arrange an MRI to evaluate further b. Arrange CT to evaluate further c. Plan laparoscopic unilateral ovarian cystectomy +/- oophorectomy d. Repeat USS in 3-6 months e. Referral to gynaecological oncologist

Answer 45

E - Refer to a gynae-oncologist Using the IOTA rules, any of the following features (‘M-Rules’) on ultrasound should prompt review by a gynaecological oncologist: • Irregular solid tumour • Ascites • At least 4 papillary structures • Irregular multi-locular solid tumour with largest diameter >100mm • Very strong blood flow

Question 46

A patient is referred to the gynaecological assessment unit with bleeding in early pregnancy. Sadly a missed miscarriage is diagnosed on scan and the patient opts for medical management. On the scan report you note that a ‘65mm right-sided simple cyst is noted’. The patient is otherwise well and has no symptoms. What follow up, if any, is required here? a. No further follow up indicated b. Repeat scan in 6 months c. Repeat scan in 12 months d. Arrange laparoscopic cystectomy e. Arrange oncology clinic review

Answer 46

C - Repeat scan in 12 months Patients with small (i.e. <50mm simple ovarian cysts) do not generally require follow up as these are invariably physiological and likely to resolve within 3 menstrual cycles. Where cysts are between 50 and 70mm, such as in this case, yearly ultrasound follow up is appropriate. If any larger, consideration should be given to surgical intervention of further imaging with MRI.

Question 47

A 19 year old patient is referred to the gynaecology clinic with irregular menses. An ultrasound scan of the pelvis is arranged which is reported as showing a ‘48mm left-sided apparently simple ovarian cyst’. The patient is otherwise well and reports no pain which could be attributed to this findings. What management do you suggest? a. No further follow up indicated b. Repeat scan in 6 months c. Repeat scan in 12 months d. Tumour markers e. Laparoscopic cystectomy

Answer 47

A - No further follow up indicated Patients with small (i.e. <50mm simple ovarian cysts) do not generally require follow up as these are invariably physiological and likely to resolve within 3 menstrual cycles. Where cysts are between 50 and 70mm, such as in this case, yearly ultrasound follow up is appropriate. If any larger, consideration should be given to surgical intervention of further imaging with MRI.

Question 48

A 47 year old patient presents to the 2-week wait clinic with intermenstrual bleeding. A pipelle biopsy is taken of the endometrium which confirms endometrial hyperplasia. When compared with normal, proliferative endometrium, what is the principal histological abnormality seen in endometrial hyperplasia? a. Increase in nucleus : cytoplasm ratio b. Increase in gland : stroma ratio c. Squamous metaplasia of endometrial stroma d. Columnar metaplasia e. Dysplasia of basal endometrial layer

Answer 48

B - Increase in gland : stroma ratio Endometrial hyperplasia is defined as an irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio when compared with normal proliferative endometrium.

Question 49

What percentage of appropriately tested women will have a negative endometrial pipelle biopsy in the presence of endometrial hyperplasia? a. 2% b. 5% c. 12% d. 15% e. 23%

Answer 49

A - 2% TV USS may be useful in triaging women presenting with PMB who require a biopsy of their endometrium. Systematic reviews have suggested 3-4mm as the cut-off for ruling out cancer. Outpatient endometrial biopsy is convenient and has high accuracy for making a diagnosis of cancer. Its accuracy for hyperplasia is a little more modest – despite a negative test result, 2% of appropriately biopsied women will still have endometrial hyperplasia.

Question 50

A 48 year old patient is seen for follow up in the gynae clinic after a diagnosis is made of endometrial hyperplasia without atypia on hysteroscopy to investigate irregular menstrual bleeding. She is anxious as she has been reading online that the condition may pre-dispose to cancer. What is the risk of malignant transformation in women with endometrial hyperplasia without atypia over 20 years? a. <5% b. 8-10% c. 12-15% d. 17-20% e. 25-30%

Answer 50

A - <5% The risk of endometrial hyperplasia without atypia progressing to endometrial cancer is low – less than 5% over 20 years – and the vast majority of cases will regress spontaneously even without treatment during follow up. Observation alone with follow up biopsies to ensure regression may be considered, especially in women with reversible risk factors, however women should be informed that treatment with progestogens carries a higher regression rate (89-96%) than observation alone (74-81%). Progestogen treatment is definitively indicated in women who fail to regress following observation alone or in symptomatic women with abnormal bleeding.

Question 51

What is the fist line treatment in patients diagnosed with endometrial hyperplasia without atypia who have troublesome bleeding? a. Oral high-dose progesterones b. Combined oral contraceptive pill c. Depo-provera d. Levonorgestrel IUS e. Endometrial ablation

Answer 51

D - LNG-IUS Both oral and intra-uterine progestogens are suitable for the management of hyperplasia without atypia though intra-uterine (LNG-IUS) should be considered first line owing to its higher regression rate and more favourable bleeding and side-effect profile when compared with oral preparations.

Question 52

What is the minimum treatment duration advised in patients with endometrial hyperplasia without atypia? a. 6 months b. 12 months c. 3 years d. 5 years e. 10 years

Answer 52

A - 6 months Treatment with oral or intrauterine progestogens should be continued for a minimum of 6 months in order to induce local histological regression in hyperplasia without atypia.

Question 53

A 52 year old nulliparous patient with a BMI of 46 is referred to the 2-week wait clinic with irregular menstrual bleeding which has become heavier in nature over the last 12 months. An endometrial pipelle biopsy is taken in clinic after a TVUSS reveals the ETT to be elevated at 12mm. This confirms endometrial hyperplasia without atypia and appropriate treatment to induce regression is commenced. What is optimum follow up in this case? a. 6-monthly biopsies until at least 2 consecutive negative results b. 6-monthly biopsies until at least 4 consecutive negative results c. 12 monthly biopsies until at least 2 consecutive negative results d. 6 monthly biopsies until 2 negatives, annual follow up thereafter e. 6 monthly biopsies for first year, annual follow up thereafter

Answer 53

D - 6 monthly biopsies until 2 negatives, annual follow up thereafter This is a slight trick question – for the majority of women, follow up until 2 negative biopsies are obtained is sufficient and they can then be discharged. The women in the scenario described has a significantly raise BMI (46) however – for obese women (BMI >35) the RCOG guideline suggests long term follow up with annual biopsies

Question 54

A 53 year old patient has been under surveillance after being diagnosed with endometrial hyperplasia without atypia 1 year ago. At the time of diagnosis she was fitted with a LNG-IUS and has thus far undergone one further biopsy, at 6 months, which demonstrated persistent hyperplasia. She returns for a further biopsy today which is similarly reported as hyperplasia without atypia. The threads of the LNG-IUS are visualised on examination. What do you advise? a. Repeat biopsy in 6 months b. Consider supplementary oral Norethistone 5mg BD c. Replace LNG-IUS d. Hysterectomy e. Hysteroscopy and endometrial biopsy

Answer 54

D - Hysterectomy In women not wishing to preserve their fertility, failure of regression after 12 months of treatment should prompt counselling towards hysterectomy. Small studies suggest the risk of cancer may be considerably higher in such women. Counselling around hysterectomy should also occur in women who: • Progress to atypical hyperplasia during treatment • Relapse after completing treatment • Continue to experience persistent troublesome bleeding • Decline surveillance or treatment

Question 55

A 46 year old patient with a BMI of 36 is diagnosed with endometrial hyperplasia without atypia. The natural history of the condition is explained, including the need for surveillance and she is advised to commence progesterone therapy. She refuses as she does not wish to take ‘artificial hormones’ and explains she is unwilling to re-attend every 6 months for repeat biopsies. What alternative management should be offered here? a. Discharge with reassurance that the risk of progression to cancer is low, though should report any further unscheduled bleeding b. Offer non-hormonal alternative therapy, explaining that efficacy of such treatment is unknown c. Hysterectomy d. Endometrial ablation e. TCRE

Answer 55

C - Hysterectomy In women not wishing to preserve their fertility, failure of regression after 12 months of treatment should prompt counselling towards hysterectomy. Small studies suggest the risk of cancer may be considerably higher in such women. Counselling around hysterectomy should also occur in women who: • Progress to atypical hyperplasia during treatment • Relapse after completing treatment • Continue to experience persistent troublesome bleeding • Decline surveillance or treatment

Question 56

A 53 year old patient presents to the gynaecology clinic with post-menopausal bleeding. A pipelle biopsy is collected after a TVUSS demonstrates and endometrial thickness of 13mm. This is reported as ‘atypical endometrial hyperplasia’. What do you recommend as first line management? a. Levonorgestrel IUS b. High dose oral progesterone c. Hysteroscopy and endometrial biopsy to confirm d. Trans-cervical resection of the endometrium e. Hysterectomy and BSO

Answer 56

E - Hysterectomy and BSO The risk of progression to cancer with atypical endometrial hyperplasia is higher than in those without atypia (8% in 4 years compared with 5% in 20). As such, the advice to these women should be that they undergo total hysterectomy owing to this increased risk. A laparoscopic approach is preferable to open owing to the benefits of such a route. Post-menopausal women should be offered bilateral salpinoophrectomy at the same time; in premenopausal women this should be an individualised decision. Endometrial ablation is not advised as a treatment because complete and persistent endometrial destruction cannot be guaranteed and intrauterine adhesion formation may well preclude further histological surveillance.

Question 57

What percentage of endometrial hyperplasia with atypia will progress to cancer in 4 years? a. 4% b. 8% c. 12% d. 25% e. 35%

Answer 57

B - 8% The risk of progression to cancer with atypical endometrial hyperplasia is higher than in those without atypia (8% in 4 years compared with 5% in 20). As such, the advice to these women should be that they undergo total hysterectomy owing to this increased risk. A laparoscopic approach is preferable to open owing to the benefits of such a route. Post-menopausal women should be offered bilateral salpinoophrectomy at the same time; in premenopausal women this should be an individualised decision. Endometrial ablation is not advised as a treatment because complete and persistent endometrial destruction cannot be guaranteed and intrauterine adhesion formation may well preclude further histological surveillance.

Question 58

A 39 year old nulipara presents with unscheduled vaginal bleeding undergoes a pipelle biopsy which shows endometrial hyperplasia with atypia. She is unwilling to undergo definitive treatment as she and her partner are hoping to try for a family in the near future. What is the first step in her management? a. Place on waiting list for hysterectomy +/- BSO b. Commence high dose oral progesterones c. Insert LNG-IUS d. Hysteroscopy and endometrial curettage e. Refer to fertility clinic

Answer 58

E - Referral to a fertility clinic Any woman with endometrial hyperplasia who wishes to conceive should be promptly referred to a fertility specialist to discuss options for attempting conception, further assessment and appropriate treatment – ART may be considered in such women as the live birth rate is higher and may prevent relapse compared with women who attempt natural conception. Prior to achieving any conception however, disease regression (at least one sample) is recommended as this is associated with higher implantation and clinical pregnancy rates.

Question 59

In otherwise healthy women refusing definitive management for hyperplasia with atypia, what is the recommended follow up? a. 6 monthly until 2 successive negative biopsies obtained b. 6 monthly until 2 successive negative biopsies obtained, 12 monthly thereafter c. 3 monthly until 2 negative biopsies obtained; 6 monthly thereafter d. 3 monthly for first year; 6 monthly thereafter irrespective of findings on 12 month sample e. 12 monthly

Answer 59

C - 3 monthly until 2 negative biopsies obtains' 6 monthly thereafter The optimum follow up schedule of women who decline hysterectomy for atypical hyperplasia is unknown though the guideline refers to the fact that ‘most clinicians would recommend’ endometrial sampling every 3 months initially until 2 negative biopsies are obtained followed by long term follow up every 6-12 months until a hysterectomy is performed.

Question 60

What regimen of oral progestogens is appropriate for women who decline the LNG-IUS for initial management of endometrial hyperplasia without atypia? a. Progesterone only pill at normal dose, taken continuously b. Progesterone only pill – double dose, taken continuously c. Norethisterone 5mg OD d. Medroxyprogesterone 10mg BD e. Desogestrel 20mg BD

Answer 60

D - Medroxyprogesterone 10mg BD Women who decline the LNG-IUS may find oral progestogens more acceptable though should be informed of the lower regression rates and greater side effect profile with this route. The recommended regimen in the guideline is either medroxyprogesterone 10-20mg/day or norethisterone 10-15mg/day.

Question 61

A 53 year old attends the gynaecology clinic with unscheduled bleeding whilst on a sequential HRT regimen to manage vasomotor symptoms of menopause. A pipelle biopsy confirmed endometrial hyperplasia without atypia. What management should be initiated? a. Hysterectomy b. Stop all HRT, repeat biopsy in 6 months c. Stop all HRT, insert LNG-IUS, repeat biopsy in 6 months d. Switch to an HRT regimen with continuous progesterone or continuous combined e. Switch to tamoxifen

Answer 61

D - Switch to an HRT regime with continuous progesterone or continuous combined Women with endometrial hyperplasia taking sequential HRT who wish to continue with HRT should be advised to change to continuous progesterone using either the LNG-IUS or a continuous combined preparation. Women already on a continuous combined preparation should have a review of their need to continue with HRT. Consideration should be given to using the LNG-IUS as the progesterone component.

Question 62

A 47 year old patient with a history of breast cancer is diagnosed with endometrial hyperplasia while taking tamoxifen. What is the most appropriate first line management? a. Discuss on-going need for tamoxifen with oncologist b. Continue tamoxifen, insert LNG-IUS c. Stop tamoxifen, repeat biopsy in 6 months d. Hysterectomy e. Stop tamoxifen, insert LNG-IUS

Answer 62

A - Discuss on-going need for tamoxifen with oncologist Tamoxifen is a selective oestrogen receptor modulator which inhibits proliferation of breast tissue via competitive antagonism at oestrogen receptors. It has a proliferative effect on other tissues however including the vagina and uterus which may promote the development of fibroids, polyps and hyperplasia as well as increasing the risk of endometrial cancer. While there is evidence the LNG-IUS prevents polyp formation and reduces the risk of endometrial hyperplasia in women on tamoxifen, its effect on breast-cancer recurrence is uncertain thus routine use cannot be recommended. In such patients, the first step should be to discuss the on-going need for tamoxifen with the woman’s oncologist – generally management according to the histological classification of endometrial hyperplasia is advisable.

Question 63

What proportion of women between the ages of 30-49, consult their GP every year because of heavy menstrual bleeding? a. 1 in 10 b. 1 in 20 c. 1 in 30 d. 1 in 50 e. 1 in 100

Answer 63

B - 1 in 20

Question 64

A 42 year old patient presents to the gynaecology clinic with a history of heavy menstrual bleeding which has been on-going for 12 months. She is otherwise well and has no associated symptoms. What is the most appropriate first line investigation in this patient? a. Pelvic examination b. US pelvis c. FBC d. FSH/LH e. Endometrial biopsy

Answer 64

C - FBC

Question 65

What size of hysteroscope is recommended for use in the outpatient setting? a. 2mm b. 3.5mm c. 4mm d. 5mm e. 7mm

Answer 65

B - 3.5mm

Question 66

A patient has LNG-IUS fitted for HMB though returns to the clinic 2 weeks later unhappy that she is continuing to experience irregular bleeding. How long should patients expect before the full effect of a LNG-IUS is felt? a. 1 month b. 3 months c. 6 months d. 12 months e. 18 months

Answer 66

C - 6 months

Question 67

A 38 year old Para 4 attends the outpatient clinic complaining of heavy menstrual bleeding. Her GP has organised an ultrasound scan which is reported as follows: “the uterus is normal in size though a few small intramural fibroids are identified, the largest of which measures 21x19x25mm”. She is not currently on any treatment. On questioning, she insists her family is complete. What do you recommend first line? a. Tranexamic acid b. Cyclical oral progesterone c. Endometrial ablation d. Mirena IUS e. Hysterectomy with ovarian conservation

Answer 67

A - Tranexamic acid

Question 68

A 19 year old patient undergoes a diagnostic laparoscopy for chronic pelvic pain and if found to have mild endometriosis with a few superficial focal lesions around the ovarian fossae and pouch of Douglas. She is not currently taking any medication and has no known allergies. What would you recommend first line for pain control in this patient? a. Paracetamol b. Codeine c. Tranexamic Acid d. Mirena IUS e. GnRH analogues

Answer 68

A - Paracetamol

Question 69

A patient attends the gynaecology clinic for review with a history of cyclical pelvic pain on-going for several months. She has tried simple analgesia which has offered no relief. A recent pelvic ultrasound scan was reported as normal. She is suing condoms only for contraception though has not been sexually active recently on account of dyspareunia. You clinically suspected endometriosis and propose a trial of treatment. What treatment do you suggest? a. Combined pill b. GnRH analogues c. Tranexamic acid d. Opiate analgesia e. Laparoscopy

Answer 69

A - Combined pill

Question 70

A patient with known deep endometriosis invading the bladder and bowel is planned for surgery. What adjuvant hormonal therapy prior to surgery may be useful here? a. 6 month trial of COCP b. 6 month trial of Mirena IUS c. 3 month trial of GnRH d. 6 month trial of GnRH e. 6 month trial of Depo-Provera

Answer 70

C - 3 month trial of GnRH

Question 71

A 35 year old woman undergoes extensive laparoscopic surgery in the lithotomy position. She presents after 3 days with unresolved weakness of right hip extension and right knee flexion. There is associated sensory impairment below the right knee. Damage to which nerve is the most likely cause? a. Femoral b. Ilio-inguinal c. Lateral cutaneous nerve of the thigh d. Obturator e. Sciatic

Answer 71

E - Sciatic

Question 72

A 46 year old Para 2 woman is referred to your gynaecology clinic complaining of regular, but heavy menstrual bleeding which is affecting her quality of life. Which of the following associated features indicates the need for endometrial biopsy? a. BMI >30 b. Dysmenorrhoea c. Failure of previous medical therapy d. Iron deficiency anaemia e. Uterus enlarged on vaginal examination

Answer 72

C - Failure of previous medical therapy An endometrial biopsy should be taken if there is persistent intermenstrual bleeding or if treatment is ineffective in women over 45. An ultrasound is the first line diagnostic tool for structural abnormalities and should be performed if the uterus is palpable abdominally, vaginal examination detects a pelvic mass or drug treatment fails

Question 73

A 16 year old girl presents to the gynaecology outpatient clinic with primary amenorrhoea. She is 148cm tall and weighs 54kg (BMI 24.7). Breast development is assessed as Tanner Stage 2 and pubic hair is noted to be sparse. Further examination identifies cubitus valgus. She has no other dysmorphic features. What is the most likely diagnosis? a. Congenital adrenal hyperplasia b. Down syndrome c. Mayer-Rokitansky-Hauser syndrome d. Testicular feminisation e. Turner syndrome

Answer 73

E - Turner Syndrome Turner syndrome (45XO) is the most common cause of gonadal dysgenesis. These patients often have additional renal and cardiac anomalies. Some women do menstruate due to mosaicism but premature ovarian failure is more common.

Question 74

You prescribe HRT for vasomotor instability in a healthy 51 year old woman who has no significant past medical nor family history. During her appointment you counsel her regarding the risks of oestrogen and progesterone HRT. How many additional cases of breast cancer are there per 1000 women using HRT for 5 years? a. 3 cases per 1000 women b. 6 cases per 1000 women c. 9 cases per 1000 women d. 12 cases per 1000 women e. 14 cases per 1000 women

Answer 74

B - 6 cases per 1000 women Combined HRT is associated with a higher risk of breast cancer than oestrogen only or tibolone. There are some discrepancies between the ‘Million Women Study’ (MWS) and the ‘Women’s Health Initiative’ (WHI) study many of which can be explained by population discrepancies – WHI looked at 16,000 women aged 50-79 45% of whom had a BMI >30 while the MWS looked at >1,000,000 women aged 50-64, 18% of whom had a BMI of >30.

Question 75

A 42 year old para 2 woman is referred to your gynaecological clinic complaining of regular but heavy menstrual bleeding that is affected by her quality of life. Which of the following investigations is most appropriate for the first clinic visit? a. FBC b. Gonadotrophin assay c. TFTs d. LFTs e. TVUSS

Answer 75

A – FBC All woman presenting with HMB should have a FBC performed. An ultrasound scan is not indicated unless the uterus is palpable abdominally, an adnexal mass is palpable or medical treatment fails.

Question 76

A 16 year old girl attends the gynaecology clinic for heavy periods and confides that she is being forced to undergo female genital mutilation (FGM). What is the estimated number of children at risk of FGM in the UK? a. 500 b. 5000 c. 10,000 d. 20,000 e. 50,000

Answer 76

D – 20,000 It is estimated that 20,000 girls in the UK are at risk of FGM, usually through foreign travel to facilitate the procedure. The safeguarding team should be informed when a woman who has undergone FGM herself delivers a female child.

Question 77

A 65 year old postmenopausal woman attends the clinic having been found to have a 4.9cm simple cyst arising from the right ovary. There is no other abnormality on scan. Her Ca125 is 29. She is asymptomatic and the cyst was picked up on investigation for haematuria. What is the most appropriate management? a. Aspiration of the cyst under ultrasound guidance b. Laparoscopic aspiration of the cyst c. Repeat scan and Ca125 in 4 months d. Right oophorectomy e. Right ovarian cystectomy

Answer 77

C – Repeat scan and Ca125 in 4 months | RMI is zero since the cyst is simple and measures <5cm therefore 12 months of monitoring is all that is required.

Question 78

A 40 year old woman has regular, heavy menstrual bleeding. The history and investigations indicate that pharmacological treatment is appropriate. Her GP has tried tranexamic acid without success. What is the most appropriate next pharmaceutical treatment? a. Etamsylate b. GnRH analogues c. Injected long acting progesterones d. LNG-IUS e. Norethisterone 15mg daily from day 5 to day 26 of cycle

Answer 78

D – LNG-IUS LNG-IUS is first line in women complaining of HMB and NICE recommend it is used prior to tranexamic acid.

Question 79

A 17 year old girl presents with a 12 hour history of lower abdominal pain. She had unprotected sex a week ago which was 6 days after her last period. Her pulse is 110 beats per minute, her blood pressure is 110/70mmHg, her temperature is 37.8*C and she is tender over her lower abdomen especially in the right iliac fossa where there is rebound tenderness. There is cervical excitation. Her Hb is 137g/L (115-165) and her white cell count 17.6x10*9 (normal 7-11). What is the most likely diagnosis? a. Acute appendicitis b. Acute pelvic inflammatory disease c. Ectopic pregnancy d. Pelvic endometriosis e. Rupture corpus luteum

Answer 79

A – Acute appendicitis The raised WCC and mild pyrexia suggest infection and the localisation to the right iliac fossa makes this more likely to be appendicitis.

Question 80

A 46 year old nulliparous woman has been referred by her GP having been treated for heavy menstrual bleeding with cyclical progestogens for a period of 6 months. The treatment has failed to improve her symptoms. What is the most appropriate next line of management? a. Endometrial biopsy b. LNG-IUS c. NSAIDs d. Pelvic ultrasound e. Tranexamic acid

Answer 80

A – Endometrial biopsy Woman over 45 with failure of first line medical treatment need endometrial sampling

Question 81

A 36 year old parous woman was diagnosed with stage 3 endometriosis. She was on GnRH analogues for 12 months. Subsequently, she underwent laparoscopic excision of recto-vaginal endometriosis. She continues to be in pain despite medical and surgical management. What is the next most appropriate treatment for her? a. Aromatase inhibitors b. Danazol c. Long term GnRH d. Progesterone only pills e. Tibolone

Answer 81

A – Aromatase inhibitors Aromatase inhibitors are recommended in women with rectovaginal endometriosis which is refractory to medical or surgical treatment. It can be prescribed in combination with hormones or GnRH analogues

Question 82

A 51 year old woman attends your clinic with a family history of severe vasomotor symptoms (hot flushes, night sweats). She has a family history of breast cancer and would like to avoid hormone replacement therapy (HRT). Which non-hormonal method is most likely to control her symptoms? a. Citalopram b. Metaprolol c. Nifedipine d. Phentolamine e. Venlafaxine

Answer 82

E – Venlafaxine Selective serotonin and noradrenaline re-uptake inhibitors are the drugs most commonly employed to alleviate vasomotor symptoms. The most convincing data relates to venlafaxine though this was a short study.

Question 83

A 24 year old woman in her first pregnancy attends the antenatal clinic. Her community midwife has referred her to a consultant clinic as she disclosed having had female genital mutilation (FGM) at 8 years of age. Which one of the following countries is this woman LEAST likely to originate from? a. Egypt b. Eritrea c. Nigeria d. Somalia e. Sudan

Answer 83

C – Nigeria The prevalence of FGM varies by country. The type of FGM also varies and the more severe types are most common in Somalia. Somalia has the highest incidence overall with 98-100% of girls affected – usually type 3.

Question 84

Your consultant asks you to prescribe a 3 month course of Ullipristal acetate to a woman with fibroids prior to having a hysterectomy. To what class of drugs does Ullipristal acetate belong? a. Aromatase inhibitor b. GnRH analogue c. Progestogen antagonist d. Prostaglandin e. Selective estrogen receptor modulator

Answer 84

C – Progestogen antagonist Ullipristal acetate acts on fibroids by inducing apoptosis in the cells.

Question 85

A 52 year old woman wants to discuss the option of hormone replacement therapy (HRT). She is particularly concerned about the risk of breast cancer. What study focuses mainly on the risk of breast cancer associated with HRT? a. The Cochrane Collaboration Systematic Review 2012 b. The Heart and Estrogen/Progestin Replacement Study (HERS) I and II c. The Million Women Study d. The Women’s Health Institute Study e. The Women’s Hormone Intervention Secondary Prevention Study

Answer 85

C – The Million Women Study Women aged 50-64 years attending the NHS breast screening programme were invited to take part in this study which was subsequently followed by the completion of a questionnaire. A significant increased risk of breast cancer was seen in the women on combined HRT compared with oestrogen alone or tibolone

Question 86

A 57 year old post-menopausal woman is referred by her GP following the incidental finding of an endometrial polyp on a transvaginal scan during the investigation of lower abdominal pain. She is otherwise asymptomatic. What is the incidence of atypical hyperplasia in this case? a. 0.6% b. 1.2% c. 2% d. 3.1% e. 4.3%

Answer 86

B – 1.2%

Question 87

A 40 year old woman with a BMI of 32 is referred to the gynaecology clinic with secondary amenorrhoea. She has 2 children and her partner had a vasectomy 5 years ago. An ultrasound is performed which shows a normal uterus with an endometrial thickness of 6mm. Both ovaries appear typically polycystic. What would recommended management be? a. Endometrial biopsy b. Induction of 3 monthly withdrawal bleeds with gestogens c. Metformin twice daily d. Ovulation induction with clomiphene citrate e. Reassure and discharge

Answer 87

B - Induction of 3 monthly withdrawal bleeds with gestogens

Question 88

A patient with a history of DVT following a femoral fracture after an accident 10 years ago presents requesting hormone replacement therapy for severe vasomotor symptoms of menopause which she is now struggling to live with. Her uterus is intact. What would you recommend? a. All HRT is contraindicated here b. Oestrogen and testosterone implants c. Oral continuous combined HRT d. Raloxifene e. Transdermal continuous combined HRT

Answer 88

E - Transdermal continuous combined HRT

Question 89

A 70 year old woman undergoes a DEXA scan to assess her bone mineral density. What is considered a normal T score? a. >/= +2.5 b. >/= +1.0 c. >/= 0 d. >/= -1 e. >/= 2.5

Answer 89

D - >/= -1

Question 90

In what percentage of patients attending gynaecology outpatient’s clinic with lower abdominal/pelvic pain would you expect to find irritable bowel syndrome? a. 66% b. 50% c. 33% d. 25% e. 10%

Answer 90

B - 50%

Question 91

What is the estimated prevalence of endometriosis in women of reproductive age? a. <1% b. 2-10% c. 10-20% d. 25% e. 50%

Answer 91

B - 2-10%

Question 92

What is the most common cause of central precocious puberty in girls? a. Craniopahryngioma b. Hydrocephalus c. Hypoththalamic hamartoma d. Idiopathic e. McCune-Albright syndrome

Answer 92

D - Idiopathic

Question 93

A woman with localised unprovoked vulvodynia has had no relief of her symptoms despite good vulval care, topical Lidocaine and gabapentin. What is the next line of management? a. Anti-convulsant therapy b. Laser ablation of the vulva c. Modified vestibulectomy d. Transcutaneous electrical nerve stimulation e. Tri-cyclic antidepressant drugs

Answer 93

E - Tricyclic antidepressants

Question 94

A woman with biopsy proven lichen sclerosis is not responding to ultra-potent steroids. What is second line treatment? a. CO2 laser vaporisation b. Local surgical excision c. Topical emoillent d. Topical imiquimod e. Topical tacrolimus

Answer 94

E - Topical tacrolimus

Question 95

57. During investigation for HMB, a 42 year old woman is found to have a 3cm submucous fibroid. She is otherwise fit and well. Her husband has had a vasectomy. She does not wish to try pharmacological treatments. What would you recommend? a. Hysteroscopic resection of the fibroid and endometrium b. Novasure endometrial ablation c. Open myomectomy d. Total abdominal hysterectomy e. Uterine artery embolisation

Answer 95

A - Hysteroscopic resection

Question 96

What progesterone has been shown to be effective in treating PMS? a. Desogestrel b. Drosperinone c. Levonorgestrel d. Medroxyprogesterone acetate e. Norethisterone

Answer 96

B - Drosperinone

Question 97

In the female, what type of cells produce Anti-Müllerian Hormone? a. Granulosa cells b. Leydig cells c. Primary oocytes d. Secondary oocytes e. Sertoli cells

Answer 97

A - Granulosa cells

Question 98

A 32 year old woman presents to the gynaecology clinic with galactorrhoea and secondary amenorrhoea. A serum prolactin level is measured and found to be elevated. What is the main mechanism by which prolactin causes secondary amenorrhoea? a. Disruption of granulosa cell development b. Induction of atrophic changes in the endometrium c. Inhibition of FSH pulsatility d. Inhibition of LH pulsatility e. Inhibition of meiosis in the developing oocyte

Answer 98

D - Inhibition of LH pulsatility

Question 99

What test is recommended for the biochemical detection of hyperandrogenism? a. 17-hydroxyprogesterone b. Free-androgen index c. Free testosterone d. Sex hormone binding globulin e. Total testosterone

Answer 99

B - Free androgen index

Question 100

What proportion of women with PCOS are overweight/obese? a. 10-20% b. 40-50% c. 60-70% d. 80-85% e. >90%

Answer 100

B - 40-50%

Question 101

What is the estimated prevalence of endometriosis in infertile women? a. 10% b. 20% c. 30% d. 40% e. 50%

Answer 101

E - 50%

Question 102

What is the background rate of venous thromboembolism in women of reproductive age? a. 1/10,000 per year b. 2/10,000 per year c. 5/10,000 per year d. 10/10,000 per year e. 20/10,000 per year

Answer 102

B - 2/10,000 per year

Question 103

A 26 year old man had vaginal intercourse with a 21 year old woman who was heavily intoxicated at the time of the act. She was seen flirting and kissing the man at a party earlier in the evening. She has no memory of going to the man’s home and engaging in any sexual activity. In regards to the Sexual Offences Act 2003, what is the most likely allegation or charge here? a. Assault by penetration b. Consensual sex c. Drug facilitated sexual assault d. Rape e. None of the above

Answer 103

D - Rape

Question 104

A 48 year old woman vaginally and anally penetrated a 32 year old woman with her fingers and an object without the consent of the 32 year old woman. In regards to the Sexual Offences Act 2003, what is the most likely allegation or charge here? a. Assault by penetration b. Not chargeable under the Sexual Offence Act 2003 c. Rape d. Sexual assault e. None of the above

Answer 104

A - Assault by penetration

Question 105

A 19 year old man had consensual vaginal intercourse with a 16 year old girl. He believed she was 18 as they met in the student union bar. In regards to the Sexual Offences Act 2003, what is the most likely allegation or charge here? a. Assault by penetration b. Sexual activity with a child c. Sexual assault d. Rape of a child e. None of the above

Answer 105

E - None of the above

Question 106

How should ovarian torsion by best managed? a. Conservatively with antibiotics, fluids and analgesia b. Untwisting and fixation to the pelvic side wall c. Untwisting d. Open oophorectomy e. Laparoscopic oophorectomy

Answer 106

C - Untwisting

Question 107

In which of the following situations is laparoscopy indicated for suspected PID? a. When right upper quadrant pain is present b. Six weeks following successful completion of treatment c. If symptoms do not resolve significantly within 24 hours of commencing IV antibiotics d. Where CRP is >100 e. Where ultrasound suggests a pelvic collection

Answer 107

C - If symptoms do not resolve significantly within 24 hours of commencing IV antibiotics

Question 108

Which of the following statements, concerning appendicitis, is true? a. The ‘bagel sign’ at transvaginal ultrasound is pathognomic b. It has not been proven to affect future fertility c. Appendiceal abscess is usually best managed by formal surgical drainage d. All patients should receive a CT prior to laparoscopy e. Ultrasound is a reliable diagnostic tool

Answer 108

B - It has not been proven to affect future fertility

Question 109

Which of the following statements, concerning Bartholin’s abscess, is true? a. It is an infection of the greater vestibular glands b. N. Gonorrhoea is isolated in 1% of cases c. Has a recurrence rate of 20-30% d. Incision, drainage and marsupialisation is the only evaluated treatment option e. IV antibiotic therapy is always indicated

Answer 109

A - It is an infection of the greater vestibular glands

Question 110

Which of the following statements, concerning pelvic inflammatory disease, is true? a. Most commonly affects multiparous women b. Laparoscopy is a reliable tool for confirming the diagnosis c. May present with an acute abdomen d. Is associated with an infertility rate of >30% after one episode e. Chlamydia is the most commonly isolated organism

Answer 110

C - May present with an acute abdomen

Question 111

Regarding a non-pregnant 45-year old women presenting with acute, heavy vaginal bleeding, which of the following statements is true? a. Thyroid function should always be checked b. IV tranexamic acid may be given to arrest the bleeding c. A haemoglobin of 12g/dL may be associated with significant haemodynamic compromise d. A pipelle biopsy should form first line investigation in all cases e. Vaginal packing is unlikely to be effective where bleeding is due to an endometrial carcinoma

Answer 111

C - A haemoglobin of 12g/dL may be associated with significant haemodynamic compromise

Question 112

In acute retention of urine: a. Pain is always a feature b. Infection is the cause in over 75% of cases c. The incidence if up to 10% following TVT insertion d. An in/out catheter is usually appropriate management e. Herpes simplex infection is a cause only where there is associated neuropathy

Answer 112

C - The incidence is up to 10% following TVT insertion

Question 113

Which of the following statements is true with respect to gynaecological sepsis? a. Uterine perforation and endometritis are easy to distinguish clinically b. In the case of RPOC, evacuation of the uterus should always be delayed 24 hours to permit antibiotics to take effect c. Is usually always accompanied by vaginal discharge d. A sunburn-type rash is associated with toxic shock syndrome e. Has an increased frequency over the last 40 years owing to the increased rate of termination of pregnancy

Answer 113

D - A sunburn-type rash is associated with toxic shock syndrome

Question 114

With regards the resuscitation of a young women who has collapsed, which of the following statements is correct? a. A ruptured corpus luteal cyst may cause life threatening haemoperitoneum b. Fluid resuscitation should be commence prior to transfer to theatre if an ectopic pregnancy is suspected c. Metabolic acidosis is demonstrated by normal or low pH and raised bicarbonate d. Serum hCG should be requested if she is unconscious and thus unable to pass urine e. A patient with a systolic blood pressure of 80mmHg is not suitable for laparoscopic salpingectomy

Answer 114

A - A ruptured corpus luteal cyst may cause life threatening haemoperitoneum

Question 115

A 28 year old is admitted via A&E to the gynaecology ward with on-going pyrexia, lower abdominal pain, negative pregnancy test and offensive vaginal discharge. What is most suitable management for her? a. Stat IM Ceftriaxone 500mg followed by 14 days of oral Doxycycline 100mg BD and 400mg oral Metronidazole 400mg BD b. 14 days of oral Ofloxacin 400mg BD and oral Metronidazole 400mg BD c. 14 days of oral Moxifloxacin 400mg BD d. IV Ceftriaxone 2mg OD plus IV doxycycline 100mg BD followed by 14 days of oral Doxycycline 100mg BD and oral Metronidazole 400mg BD e. Stat IM Ceftriaxone 500mg followed by 2 weeks of 1 gram/week Azithromycin

Answer 115

D - IV Ceftriaxone 2mg OD plus IV doxycycline 100mg BD followed by 14 days of oral Doxycycline 100mg BD and oral Metronidazole 400mg BD

Question 116

A 32 year old woman presents to A&E feeling unwell. Her temperature is 38.9C, pulse 140/min and RR 38/min. She had a termination of pregnancy 3 days ago. What is the immediate next step of management? a. Blood cultures, WCC, lactate and broad spectrum antibiotics b. Immediate surgical management to remove retained products c. Paracetamol d. Pelvic ultrasound to check for retained products e. Transfer to HDU

Answer 116

A - Blood cultures, WCC, lactate and broad spectrum antibiotics

Question 117

A 17 year old girl presents to A&E with sudden onset acute pelvic and abdominal pain, fluctuating in intensity, radiating to the thigh and associated with nausea and vomiting. On abdominal examination, there is generalised tenderness, localised guarding and rebound. Vaginal examination elicits cervical excitation and adnexal tenderness. Which criteria is NOT included in the scoring system for the identification of women with adnexal torsion? a. Absence of leucorrhoea/metorrhagia b. Pain lasting >8 hours c. Scan feature of septation d. Unilateral lumbar or abdominal pain e. Vomiting

Answer 117

C - Scan feature of septation The diagnostic criteria for ovarian torsion are as follows: i. Unilateral lumbar or abdominal pain ii. Pain lasting >8 hours iii. Vomiting iv. Absence of leucorrhoea or metorrhagia v. Ovarian cyst >5cm on USS

Question 118

A 24 year old nulliparous woman presents to the emergency department with a tender swelling on the right-side of her vulva at the 8 o’clock position. You diagnose a Bartholin’s abscess which is incised and drained. A microbiology swab taken at the time of drainage subsequently shows growth of a single organism. What is this organism most likely to be? a. Chlamydia Trachomitis b. Eschieria Coli c. Neisseria Gonorrhoea d. Staphlococcus Aureus e. Streptococcus Faecalis

Answer 118

C - N. Gonorrhoea In 20% of cases, N Gonorrhoea is isolated and should prompt a STI screen. The other causes usually form part of mixed organism growth (the scenario says ‘a single organism’)

Question 119

A 26 year old woman comes complaining of left iliac fossa pain which is sharp, radiates across her whole abdomen and is sudden in onset. She states her periods are currently irregular and last occurred 3 weeks ago. She has no other symptoms and is otherwise well. Urine pregnancy test is negative and a negative ultrasound scan showed a normal uterus, tube and ovaries with a small amount of free fluid in the pouch of Douglas. What is the most likely diagnosis? a. Appendicitis b. Ectopic pregnancy c. Endometriosis d. Functional cyst rupture e. Ovarian torsion

Answer 119

D - Functional cyst rupture

Question 120

A 25 year old Para 1 is referred to the acute gynaecology assessment unit with suspected ovarian torsion. She is taken to theatre and diagnostic laparoscopy confirms torsion of the right ovary with a 2cm follicle. What is the most appropriate operative management of ovarian torsion? a. No further action – conservative management only b. Laparoscopic oophorectomy c. Laparoscopic salpingectomy d. Laparoscopic salpingo-oophorectomy e. Laparoscopic detorsion of the ovary

Answer 120

E - Laparoscopic detorsion of the ovary

Question 121

An 18 year old nulliparous woman presents with lower abdominal pain. She feels nauseous and has vomited 3 times. She also complains of a fever and a heavy, yellow, vaginal discharge. Around 2 weeks ago she had an episode of post-coital bleeding. Triple swabs are taken during examination. What is the most common result found on micriobiology? a. C. Trachomitis b. G. Vaginalis c. N. Gonorrhoea d. No organism isolated e. Staph. Aurues

Answer 121

A - C. Trachomitis Clinically this case represents a common presentation of pelvic inflammatory disease. Although N. gonorrhoea and Chlamydia are the most commonly isolated organisms (14% and 10% respectively) in PID, around 20% of swabs are negative. Chlamydia trachomatis is the most commonly identified organism in PID, accounting for 14–35% of cases.

Question 122

You are called to review a 28 year old woman admitted 48 hours earlier with suspected PID. She has a LNG-IUS in situ and is being treated with IV ceftriaxone and doxycycline. Swabs taken on admission have been reviewed and are negative. She has not responded to treatment and remains pyrexial. How long after initiation of treatment without response should you consider removing her LNG-IUS? a. Immediately when starting IV antibiotics b. 24 hours c. 48 hours d. 72 hours e. 96 hours

Answer 122

D - 72 hours Coils should be removed when: • Requested by the woman • There is no response to treatment in 72 hours • The woman has Actinomyces-like organisms on her smear AND pelvic pain

Question 123

A 30 year old with no risk factors wishes to start the combined pill. She has read about it causing bleeding in between periods and wishes to know the risk of this happening to her. What do you advise? a. Less than 10% b. 10-20% c. 20-30% d. 30-40% e. 40-50%

Answer 123

D - 30-40% IMB occurs in 30-40% of COCP users in the first 3 months

Question 124

A 22 year old presents with a prolonged and painful period which occurred 1 week after her normal period was due. A home pregnancy test was negative. What is the most likely diagnosis? a. Anovulatory cycle b. Cervical cancer c. Fibroids d. Missed miscarriage e. STI

Answer 124

A - Anovulatory cycle Anovulatory cycles are common and have a typical presentation of delayed menstruation followed by a prolonged bleed. Most women will return to normal cycles within 4-6 weeks.

Question 125

An obese 47 year old is referred to the gynaecology outpatients with HMB. She has a history of type 2 diabetes. She was initially trialled on a progesterone only conception by her GP which has failed. What would be your first line investigation in clinic? a. CT pelvis b. MRI pelvis c. Outpatient hysteroscopy d. Pelvic USS e. Pipelle

Answer 125

E - Pipelle NICE guidelines state that any woman 45 or over with HMB should have a pipelle taken to exclude hyperplasia or malignancy when initial treatment fails. This is especially important where there are concurrent risk factors – in this case obesity and type 2 diabetes

Question 126

A 56 year old woman is seen in the emergency clinic with a painful vulval swelling. She has general malaise and on examination, a painful 3cm swelling in the anterior lower vagina, very close to the urethral meatus which is red and inflamed. What is the most likely diagnosis? a. Bartholin’s (greater vestibular gland) abscess b. Urethral diverticulum c. Skene’s (less vestibular gland) abscess d. Vulval carcinoma e. Vulval lipoma

Answer 126

C - Skene's abscess

Question 127

A 58 year old woman had a Mirena IUS fitted 2 years ago for heavy menstrual periods. She was initially amenorrhoeic but has now developed heavy menstrual bleeding again. Endometrial biopsy shows complex endometrial hyperplasia with atypia. What is the best treatment option? a. Oral contraceptive pill in addition to Mirena in situ b. Reinsert a Mirena coil c. TAH + BSO d. TAH e. Tranexamic acid in addition to Mirena

Answer 127

C - TAH + BSO

Question 128

A 55-year-old woman has been referred to the postmenopausal bleeding clinic following an ultrasound organised by her GP for abdominal bloating. This showed the presence of cystic spaces in the endometrium and an endometrial thickness of 15 mm. She has previously used tamoxifen for 5 years for breast cancer. What is the best management option? a. High dose oral progesterones b. Do nothing as she did not have bleeding c. Hysteroscopy and endometrial biopsy d. Mirena IUS insertion e. MRI

Answer 128

C - Hysteroscopy and endometrial biopsy Tamoxifen is a selective estrogen receptor modulator (SERM). It has both estrogenic and antiestrogenic properties. In standard doses, tamoxifen is associated with endometrial proliferation, hyperplasia, polyp formation, invasive carcinoma and uterine sarcoma. Most studies show a two to three times increased risk of endometrial cancer in women on tamoxifen compared with an age matched population not on tamoxifen

Question 129

You review a 48-year-old woman in the menstrual disorders clinic who complains of a 3-year history of heavy menstrual bleeding. She is a mother of four children, all born by normal vaginal deliveries. Her menstrual cycle is every 29 days and the bleeding lasts for 6 days. However, recently it has become associated with clots. Cervical smears are up-to-date and her BMI is 39. You perform a transvaginal scan which reveals a bulky uterus of 8 mm endometrial thickness and three intramural fibroids of 2, 4 and 5 cm size respectively. On vaginal examination you find stage I cystocele, stage II rectocele and stage II uterine descent. The current waiting list for benign gynaecological surgery in your hospital is 4 months. What is the next most appropriate step in her management? a. Add to the waiting list for LAVH b. Arrange for pre-operative assessment for TAH c. Counsel regarding NovaSure endometrial ablation d. Insert Mirena IUS and follow up in 6 months e. Perform endometrial sampling

Answer 129

E - Perform endometrial sampling The correct answer is perform endometrial sampling. This woman has three risk factors for endometrial hyperplasia: her age, the increased endometrial thickness and the high BMI. Although vaginal hysterectomy might seem necessary, endometrial sampling is essential at this stage

Question 130

You are performing an outpatient hysteroscopy on a 62-year old woman who presents with postmenopausal bleeding. Her menstrual cycles ceased at the age of 50. She used combined HRT for 2 years afterwards. A transvaginal scan reveals an endometrial thickness of 8 mm with a hyper-echoic intracavitary shadow suggestive of an endometrial polyp. The size of the polyp was 16 mm in diameter. What finding on hysteroscopy would make you consider the polyp as a malignant lesion? a. Broad based avascular lesion b. Haemorrhagic lesion with pus-like discharge c. Multiple projections with mucous like content d. Smooth surface pedunculated polyp e. Vascular surface

Answer 130

E - Vascular surface The correct answer is vascular surface. In most cases, a vascular surface of any endometrial lesion means neovascularisation, a typical feature of malignant tissue transformation. Hence, endometrial malignancy must be ruled out in this case.

Question 131

A 46-year-old para 2 who has completed her family presents with a history of painful heavy menstrual bleeding in association with infrequent cycles (every 2–3 months) for 1 year. Her BMI is 44. She is currently on iron supplements for anaemia and is prescribed proton pump inhibitors for GORD. She is otherwise fit and well. Abdominopelvic examination is unremarkable. Pelvic ultrasound shows an endometrial thickness of 12 mm with a bulky uterus and normal ovaries with no pelvic pathology. A pipelle biopsy suggests a proliferative endometrium. What treatment is most suited to her? a. COCP b. GnRH analogues c. Mefenamic acid d. Mirena IUS e. Tranexamic acid

Answer 131

D - Mirena IUS The answer is Mirena® IUS. The possible diagnoses in this patient could be anovulation (given her BMI) with resultant infrequent cycles. Given the findings of bulky uterus and painful heavy periods in a parous woman in the 4–5th decade of life, adenomyosis is a likely diagnosis as well. Mefenamic acid is not suited as NSAIDS are associated with gastric irritation. Plus it is often only a short-term solution. In addition it will not protect the endometrium. Tranexemic acid again may be a short term solution for the bleeding, but will not regulate the cycle or protect the endometrium. There is some link between high doses of tranexemic acid and blood clots; given her BMI this may not be the best choice. Also it is unlikely to improve pain. Mirena® IUS provides a long term solution (5 years), when she is likely to attain menopause. It will also protect the endometrium from high levels of oestrogen exposure. It will also improve pain.

Question 132

A woman who has recently had a uterine artery embolisation performed for a fibroid uterus (18 weeks size – intramural and submucous fibroids) presents to the emergency department with fever, nausea, vomiting, and foul smelling vaginal discharge. What investigation is best suited to guide further management? a. CT abdomen and pelvic b. Hysteroscopy c. MRI abdomen and pelvic d. TA ultrasound e. TV ultrasound

Answer 132

C - MRI abdomen and pelvis The answer is MRI of the abdomen and pelvis. MRI with contrast is best suited to identify a partially infarcted/necrosed fibroid with may be secondarily infected. This would also help differentiate postembolisation syndrome

Question 133

Ms XY is a 27-year-old para 0 with a BMI of 22. She presents with a history of post-coital bleeding for 6 months. She feels this is often unpredictable and is affecting her relationship. She is otherwise fit and well. She is using a COCP over the last year for contraception. Gynaecological examination is within normal limits with the exception of a cervical ectropion. Swabs for Chlamydia and an HVS are negative. Pelvic USS shows an endometrial thickness of 10 mm with a normal uterus, rest of the pelvic anatomy being normal. What treatment is most suited to her? a. Change of contraception b. Colposcopy +/- biopsy c. Local silver nitrate application d. Repeat cervical smear with HPV testing e. Repeat cervical smear without HPV testing

Answer 133

C - Local silver nitrate application The answer is MRI of the abdomen and pelvis. MRI with contrast is best suited to identify a partially infarcted/necrosed fibroid with may be secondarily infected. This would also help differentiate postembolisation syndrome.

Question 134

A 67 year old woman presents with lichen sclerosis and has been using her steroid cream regularly. At her consultation she was advised to ensure she did not use the cream across ‘Hart’s line’. Though it was explained to her at the time, she is seeking clarification as to exactly its location. How would you describe this boundary to her? a. The anal and perinala region b. The labia majora and labia minora c. The mons pubis and clitoral hood d. The vaginal fourchette and lower third of the vagina e. The vestibule and labia minora

Answer 134

E - The vestibule and labia minora

Question 135

A 45 year old woman presents with a history of superficial dyspareunia. Her GP has queried the possibility of a cyst of Skene’s duct. You arrange for her to have an ultrasound scan. What anatomical area do you specify on your request that should be particularly addressed? a. Distal urethral area b. In the labia minora c. In the labia majora d. Medial to Bartholin’s gland e. In the posterior fourchette

Answer 135

A - Distal urethral area

Question 136

A 70-year-old woman presents to the gynaecology clinic complaining of vulval pruritus. On examination the vulva has lesions which are sharply bordered with a red and velvety texture and islands of hyperkeratosis. A biopsy was done and histology shows large round atypical cells with oval nuclei and pale cytoplasm within clusters among the basal cells of the epidermis. What is the most likely diagnosis? a. Basal cell carcinoma b. Lichen sclerosis c. Lichen planus d. Paget’s disease of the vulva e. Plasma cell vulvitis

Answer 136

D - Paget's disease of the vulva

Question 137

A 28-year-old woman presents with dyspareunia. On examination, the vulva has lesions which are red and raw with features of erosion extending into vagina with scarring stenosis and adhesions. There are purple nodules with overlying white lacy patterned appearance on inner surface of wrists and lower legs. There is a small lesion in the mouth. What is the most likely diagnosis? a. Behcet’s disease b. Lichen planus c. Lichen sclerosis d. Paget’s disease e. Sjorgen’s syndrome

Answer 137

B - Lichen planus

Question 138

A 70-year-old woman presented with pruritus vulvae. Examination showed a lesion on the vulva with florid eczematous appearance. Biopsy was done and histology showed Pagets disease of the vulva. Excissional surgery was done and histology suggested clear excision margins. What will you tell her regarding her risk of recurrence? a. Risk of recurrence is 10% b. Risk of recurrence is 15-20% c. Risk of recurrence is 30-40% d. Risk of recurrence is 50% or more e. There is no risk of recurrence

Answer 138

D - Risk of recurrence is 50% or more

Question 139

A 40-year-old woman is referred by her GP with pruritus in the vulval area. She has tried emollients and local steroid creams with no relief. On examination, you notice redness and excoriation on the vulva. Microscopy of a vulval biopsy reveals "areas of spongiosis with acanthosis and parakeratosis". What is the most likely diagnosis? a. Bullous pemphigoid b. Eczema c. Lichen sclerosis d. Lichen simplex e. Psoriasis

Answer 139

B - Eczema

Question 140

A 45 year old lady presents with vulval symptoms. The diagnosis is not clear-cut on examination. Which of the following features makes lichen planus more likely than lichen sclerosis? a. Asymptomatic b. Dyspareunia c. Oral symptoms d. Urinary symptoms e. Vulval itching

Answer 140

C - Oral symptoms

Question 141

A 52 year old woman has a vulval burning sensation. On examination you find symmetrical fissuring and scaling. What is the most likely diagnosis? a. Lichen sclerosis b. Lichen simplex c. Paget’s disease d. VIN e. Vulval psoriasis

Answer 141

E - Vulval psoriasis

Question 142

A 64 year old woman who is HIV positive has vulval itching and soreness. You prescribed a three month course of clobetasol and there is some improvement at the follow up. Which of the following features would prompt you to take a vulval biopsy? a. Erosions on the vulva b. Erythematous lesion c. Fissuring d. Raised lesions e. White patches

Answer 142

D - Raised lesions

Question 143

A 17 year old girl attends the adolescent gynaecology clinic with a history of primary amenorrhoea. She has normal secondary sexual characteristics and is of average height and normal BMI. Further investigations show a normal FSH, LH and oestrogen levels. What is the most likely diagnosis? a. Androgen insensitivity syndrome b. Congenital adrenal hyperplasia c. Kleinfelter syndrome d. Rokitansky syndrome e. Turner syndrome

Answer 143

D - Rokitansky Syndrome

Question 144

A 17 year old girl is brought to the gynaecology clinic by her mother as she has not yet started menstruation. She is of short stature. Blood tests show high-FSH and LH. Secondary sexual characteristics have not yet developed. What is the most likely diagnosis? a. Anorexia b. Craniopharyngioma c. Male karyotype d. Rokitansky syndrome e. Turner syndrome

Answer 144

E - Turner syndrome

Question 145

A 16 year old girl presents with primary amenorrhoea. She has normal external genitalia and normal secondary sexual characteristics appropriate for her age. An ultrasound scan, FSH and LH are normal and karyotyping shows 46XX. Her BMI is 22. What is the most likely reason for primary amenorrhoea? a. Androgen insensitivity syndrome b. Familial delayed puberty c. PCOS d. Premature ovarian failure e. Turner syndrome

Answer 145

B - Familial delayed puberty

Question 146

A 16-year-old girl attends the gynaecology clinic accompanied by her mother. The mother is concerned that her daughters periods have not commenced yet. The girl is short. On examination both pubic hair and breast development are consistent with Tanner stage 3. What investigation will help obtain a diagnosis? a. Prolactin levels b. US pelvis c. MRI pelvis d. Karyotyping e. FSH/LH levels

Answer 146

D - Karyotyping

Question 147

A 35 year old woman with a BMI of 24 has been referred to the infertility clinic with a history of 3 years primary infertility. Her menstrual cycle Is irregular and she has been diagnosed with polycystic ovaries. Semen analysis is normal for her partner. She has tried clomiphene citrate without success. What would be the best initial management option amongst the following? a. IVF b. Intra-uterine insemination c. Oocyte donation d. Laparoscopic ovarian drilling e. Metformin

Answer 147

D - Laparoscopic ovarian drilling

Question 148

A 35 year old woman with a normal BMI presents with a history of secondary amenorrhoea. She had regular periods 2 years back. Abdomino-pelvic examination is normal. Blood tests reveal LH 10iu/L (1-20); FSH 8iU/L (1-20), prolactin 3000Mu/L (50-500). A CT head demonstrates a hypoattenuating round tumour embedded in the parenchyma of the pituitary gland. What is the most appropriate management in this case? a. Cabergoline b. Ethinyl estradiol c. Northisterone d. Spironolactone e. Finasteride

Answer 148

A - Cabergoline

Question 149

An 18 year old woman presents with primary amenorrhoea. She has normal thelarche and pubarche. On examination, external genitalia are normal. Ultrasound shows ovaries but the uterus is not visualised. What is the most likely cause? a. Incomplete fusion of the sinovaginal bulb with the Muellerian system b. Mullerian hypoplasia c. Agenesis of the Wolffian ducts d. Mullerian agenesis e. Turner syndrome

Answer 149

D - Muellerian agenesis

Question 150

A 16 year old girl presents with recurrent abdominal pain and primary amenorrhoea. On examination both breast development and pubic hair distribution are noted to be Tanner stage V. An abdominal mass is detected on palpation. Speculum examination shows a bluish colour at the end of the speculum. What is the most likely cause? a. Gonadal tumour b. Ovarian dysgermioma c. Imperforate hymen d. Fibroid uterus e. Agenesis of the Muellerian ducts

Answer 150

C - Imperforate hymen

Question 151

An 18 year old tall girl with a BMI of 19 presents to the gynaecology clinic with primary amenorrhoea. On examination, breast development is Tanner 5, pubic and axillary hair development is Tanner 2 and her external genitalia appears normal. A small inguinal swelling is noted on the right groin. What is the most likely diagnosis? a. Androgen insensitivity syndrome b. Congenital adrenal hyperplasia c. Kallman’s syndrome d. Rokitanksy syndrome e. Turner syndrome

Answer 151

A - Androgen insensitivity syndrome The correct answer is androgen insensitivity syndrome – these patients have XY karyotype though present with normal female genitalia, a blind ending vaginal pouch and testes which may be palpated within the inguinal canal. In CAH, the external genitalia would appear abnormal. Kallman’s syndrome is associated with poor breast development (hypogonadotrophic hypogonadism). Short stature, widely spaced nipples, neck webbing and an increased carrying angle of the elbows are typical of Turner’s syndrome (XO). Patients with Rokitansky syndrome (congenital absence of the uterus et al.) has normal secondary sexual development – the presence of sparse hair and an inguinal swelling does not support this.

Question 152

A 45 year old woman is referred to the gynaecology clinic with large fibroids. She is counselled regarding her options are states a preference for uterine artery embolisation. Which of the following is a contraindication to uterine artery embolisation? a. Adenomyosis b. Mennorhagia c. Asymptomatic fibroids d. Presence of an IUCD e. Jehovah's Witness

Answer 152

C - Asymptomatic fibroids The absolute contraindications to uterine artery embolisation are as follows: - Asymptomatic - Recent or current genital tract infection - Pregnancy - Uncertain diagnosis - Declines hysterectomy under any circumstances ) a small proportion of patients require a hysterectomy following UAE)

Question 153

A 40 year old woman with urinary frequency and pelvic pressure is consented prior to undergoing a uterine artery embolisation. Which of the following statements, regarding UAE is false? a. 1-2% will have premature ovarian failure b. 3% of women will require further treatment in the form of a hysterectomy c. 40-70% reduction in fibroid volume can be expected d. Risk of post-embolisation syndrome e. 98% will be symptom free following the procedure

Answer 153

E - 98% of patients with be symptom free following the procedure 80-90% of patients can expect to be symptom-free or significantly reduced symptoms 1 year following the procedure

Question 154

A 30 year old woman presents to her GP with increase in growth of male-pattern body hair for the last 3 months. She also reports a deepening of the voice and cliteromegaly. Which of the following blood tests can differentiate androgen-secreting adrenal tumours from ovarian tumours? a. Free testosterone b. DHEA c. DHEA-sulphate d. SHBG e. 17-hydroxyprogesterone

Answer 154

C - DHEA-sulphate (DHEAS) Androgen secreting tumours tend to cause rapidly progressive hirsutism and virilisation. A normal DHEAS with increased testosterone is suggestive of an ovarian androgen-secreting tumour while both will be increased in an adrenal tumour (DHEAS is exclusively produced by the adrenal gland) 95% of hirsutism is due to PCOS, the remaining 5% is made up of (all <1%): - Androgen secreting tumours (adrenal/ovary) - Luteoma of pregnancy - CAH - Cushing's syndrome - Iatrogenic hirsutism - includes drugs with androgenic effect

Question 155

With what specific tumour subtype of the ovary is Meig's syndrome typically associated? a. Epithelial carcinoma b. Germ-cell c. Sex-cord stromal d. Fibroma e. Immature teratoma

Answer 155

D - Fibroma Meig's syndrome is characterised by the presence of: - Benign ovarian tumour - Ascites - Right-sided pleural effusion It is most commonly associated with fibroma though also thecoma or fibro-thecoma. Removal of the tumour is alone usually sufficient to resolve symptoms. Pseudo-Meigs: ascites, effusion and other benign tumours aside from the above Atypical Meigs: tumour and effusion without ascites

Question 156

Which of the following is required for the diagnosis of premature ovarian failure? a. Single elevated FSH level b. Elevated AMH and Inhibin A levels c. Elevated Inhibin A levels d. Elevated FSH on two occasions 4-6 weeks apart e. Single elevated FSH and low AMH levels

Answer 156

D - Elevated FSH on 2 occasions 4-6 weeks apart

Question 157

A patient with biopsy proven lichen sclerosis finds her symptoms are insufficiently controlled by high-potency topical steroids. She is commenced on Tacrolimus which is second line therapy. What immune cell is suppressed by tacrolimus? a. B-lymphocytes b. Natural killer cells c. Phagocytes d. Plasma cells e. T-lymphocytes

Answer 157

E - T-lymphocytes

Question 158

What is the lifetime risk of vulval cancer amongst patients with lichen sclerosis? a. 0.1-0.2% b. 0.5-0.8% c. 1.1-1.6% d. 2-4% e. 8-10%

Answer 158

D - 2-4%

Question 159

What is the background risk of venous thromboembolism per year amongst healthy non-pregnant, non-contraceptive using women in the UK? a. 1 in 20,000 b. 1 in 10,000 c. 1 in 5000 d. 1 in 2000 e. 1 in 1000

Answer 159

C - 1 in 5000

Question 160

What is the risk of venous thromboembolism (per year) in the post-partum period? a. 6 per 1000 b. 15 per 1000 c. 35 per 1000 d. 80 per 1000 e. 100 per 1000

Answer 160

C - 35 per 1000

Question 161

Up to what size of uterus can endometrial ablation be considered for heavy menstrual bleeding according to NICE guidelines? a. 8/40 b. 10/40 c. 12/40 d. 14/40 e. 16/40

Answer 161

B - 10/40 TOG 2017

Question 162

Which of the following is NOT a recognised advantage of second generation ablative techniques for heavy menstrual bleeding when compared with first generation? a. Safer b. Simpler to learn c. Equivalent outcomes in menstrual effect d. Performed under direct vision e. Shorter operating time

Answer 162

D - Performed under direct vision TOG 2017

Question 163

How much of myometrium is intended to be removed during a first generation ablative procedure? a. <1mm b. Up to 2mm c. Up to 3mm d. Up to 4mm e. Up to 5mm

Answer 163

E - Up to 5mm TOG 2017

Question 164

Submucous fibroids encroaching on the uterine cavity may prove a barrier to effective endometrial ablation procedures. Above what size of submucous fibroid may second generation techniques be considered contraindicated? a. Any submucous fibroid b. 5mm c. 1cm d. 3cm e. 5cm

Answer 164

D - 3cm TOG 2017

Question 165

Novasure is the most popular endometrial ablation technology used in the UK. What is the mechanism of action of Novasure? a. Microwave ablation b. Thermal balloon ablation c. Bipolar radio-frequency ablation d. Hydrothermal ablation e. Laser ablation

Answer 165

C - Bipolar radio-frequency ablation TOG 2017

Question 166

Which of the following is a recognised benefit of endometrial preparation pre- ablation with GnRH analogues? a. Facilitates endometrial biopsy b. Improved operator vision c. Reduces relapse risk d. Lower risk of uterine perforation e. Lower risk of cervical trauma

Answer 166

B - Improves operator vision TOG 2017

Question 167

A 46 year old patient attends for an endometrial ablation procedure for heavy menstrual bleeding. On reviewing the notes, the surgeon notes that the patient has not had an endometrial biopsy performed prior to the procedure. A hysteroscopy is performed prior to the planned ablation and the endometrial cavity appearances are unremarkable. What is the most appropriate course of management here? a. Take endometrial biopsy via curettage now and re-book for ablation when result known b. Take endometrial biopsy via curettage now and proceed with ablation c. Take endometrial biopsy via pipelle now and proceed with ablation d. Proceed with ablation, no need for endometrial biopsy e. Cancel ablation and re-book for endometrial biopsy in outpatient clinic following counselling

Answer 167

C - Take endometrial biopsy via pipelle now and proceed with ablation TOG 2017

Question 168

What proportion of patients can be expected to experience complete amenorrhoea following second generation endometrial ablation? a. 50% b. 60% c. 70% d. 80% e. >90%

Answer 168

A - 50% TOG 2017

Question 169

What proportion of women undergoing endometrial ablation will subsequently undergo hysterectomy in the following 5 years? a. Up to 5% b. Up to 10% c. Up to 20% d. Up to 30% e. Up to 40%

Answer 169

C - Up to 20% TOG 2017

Question 170

Transurethral resection syndrome is a well recognised complication of first-generation endometrial ablation techniques and at fluid deficit levels of greater than 1.5L can lead to hyponatraemia, hyperammonaemia, congestive heart failure, haemolysis and even death. What distension medium is responsible for transurethral resection syndrome? a. Glycine b. Normal saline c. Hypertonic saline d. Dextrose e. Carbon dioxide

Answer 170

A - Glycine TOG 2017

Question 171

A patient with a history of 2 previous caesarean sections requests endometrial ablation for heavy menstrual bleeding. What is the most appropriate ablative technique? a. Rollerball b. Novasure c. TCRE d. Thermal balloon e. None of the above

Answer 171

A - Rollerball TOG 2017

Question 172

A 45-year-old woman with heavy menstrual bleeding has been referred for secondary care. She is examined and the uterus is found to be equivalent to about the size of a 10 weeks of pregnancy. An ultrasound scan suggests the presence of small intramural fibroids. What surgical treatment option should be recommended for this woman, who has completed her family? a. Endometrial ablation b. Myomectomy – laparoscopic c. Sub-total abdominal hysterectomy d. Total abdominal hysterectomy e. Uterine artery embolisation

Answer 172

A - Endometrial ablation TOG 2017

Question 173

It has been estimated that the risk of having a hysterectomy for persistent menstrual symptoms is of the order of 14−20% following endometrial ablation. When after surgery is the risk of hysterectomy greatest? a. Between 6 and 12 months b. Between the 2nd and 3rd years c. Between the 4th and 5th years d. In the first 6 months e. In the first 2 years

Answer 173

E - In the first 2 years TOG 2017

Question 174

What is the lifetime risk of fibroids amongst Caucasian women? a. 20% b. 30% c. 50% d. 60% e. 70%

Answer 174

E - 70% TOG 2017

Question 175

Which of the following is a recognised benefit to subtotal hysterectomy when compared with total hysterectomy? a. Improved recovery time b. Reduced likelihood of subsequent pelvic organ prolapse c. Reduced likelihood of urinary incontinence and voiding difficulty d. Improved sexual function e. Reduced post-operative pyrexia and blood loss

Answer 175

E - Reduced post-operative pyrexia and blood loss TOG 2017

Question 176

What is the upper limit of uterine size at which vaginal hysterectomy may be considered? a. 8/10 b. 10/40 c. 12/10 d. 14/40 e. 16/40

Answer 176

D - 14/40 TOG 2017

Question 177

What is the overall risk of complication at hysterectomy according to the RCOG? a. 1 in 1000 b. 1 in 500 c. 1 in 250 d. 1 in 100 e. 1 in 25

Answer 177

E - 1 in 25 TOG 2017

Question 178

What is the risk of vaginal cuff dehiscience following hysterectomy? a. 0.4% b. 0.75% c. 1.2% d. 2% e. 2.5%

Answer 178

A - 0.4% TOG 2017

Question 179

Which route of hysterectomy is associated with the greatest risk of ureteric or bladder injury? a. Total abdominal b. Subtotal abdominal c. Total laparoscopic d. Laparoscopic assisted vaginal e. Vaginal

Answer 179

C - Total laparoscopic TOG 2017

Question 180

What is the prevalence of PCOS in the female population? a. <1% b. 2-3% c. 5-8% d. 10-15% e. 20-23%

Answer 180

D - 10-15% TOG 2017

Question 181

What is the name given to the criteria used to diagnose PCOS? a. Amsterdam b. Vienna c. Munich d. Rotterdam e. Berlin

Answer 181

D - Rotterdam TOG 2017

Question 182

What is the minimum number of follicles which must be identified on ultrasound scanning of a single ovary in order to diagnose polycystic ovaries? a. 8 b. 10 c. 12 d. 14 e. 16

Answer 182

C - 12 TOG 2017

Question 183

A young woman presents to the gynaecology clinic with hirsuitism, acne and secondary amenorrhoea. Scan suggests a polycystic appearance to the ovaries and a diagnosis of PCOS is made. What is the likelihood that her sister will also suffer from PCOS? a. 10% b. 25% c. 33% d. 50% e. 75%

Answer 183

D - 50% TOG 2017

Question 184

A girl is brought to the gynaecology clinic aged 13 by her mother who is concerned about a possible diagnosis of PCOS as both she and her older daughter, aged 21, are affected by the condition. On questioning you discover that her concerns are grounded in the irregular nature of her periods which first started 6 months earlier as well as acne across the face and upper back. An transabdominal ultrasound demonstrates an ovarian volume of 10cm3 on the left and 11cm3 on the right. How soon after menarche is it appropriate to diagnose PCOS in adolescents who satisfy all 3 components of the Rotterdam criteria? a. Immediately b. 6 months c. 12 months d. 2 years e. 5 years

Answer 184

D - 2 years TOG 2017

Question 185

A 25 year old patient with a diagnosis of PCOS is seen in the gynaecology clinic requesting treatment for facial hirsuitism. She has tried a variety of both commercial cosmetic and non-hormonal topical preparations to little effect. You note from her medical record that she suffered a DVT following a car accident 6 years earlier. Which of the following treatments is most appropriate here? a. Dianette b. Spironolactone c. Finasteride d. Venlafaxine e. Flutamide

Answer 185

B - Spironolactone TOG 2017

Question 186

What is the most common cause of anovulatory infertility? a. Hypogonadotrophic hypogonadism b. Primary ovary failure c. Pituitary adenoma d. Turner’s syndrome e. Polycystic ovarian syndrome

Answer 186

E - PCOS TOG 2017

Question 187

What is the recommended daily starting dose of clomiphene citrate in ovulation induction therapy for anovulatory infertility? a. 25mg b. 50mg c. 100mg d. 150mg e. 200mg

Answer 187

B - 50mg TOG 2017

Question 188

To what class of drugs does clomiphene citrate belong? a. Anti-oestrogen b. Aromatase inhibitor c. Selective progesterone receptor modulator d. Mineralocorticoid e. Gonadotrophin receptor analogue

Answer 188

A - Anti-oestrogen TOG 2017

Question 189

What is the risk of multiple pregnancy associated with ovulation induction therapy with clomiphene citrate? a. 2% b. 5% c. 10% d. 20% e. 25%

Answer 189

C - 10% TOG 2017

Question 190

A couple with anovulatory subfertility undergo 9 cycles of clomiphene citrate therapy. Luteal phase progesterone levels recorded during each cycle suggest a positive ovulatory response. All other investigations including semen analysis and testing of tubal patency were normal. What is the most appropriate next step in management? a. Further 3 cycles of clomiphene citrate b. Aromatase inhibitors c. GnRH analogues d. Laparoscopic ovarian drilling e. IVF

Answer 190

E - IVF TOG 2017

Question 191

What proportion of women in the general population have ‘polycystic ovaries’ on ultrasound? a. 0-5% b. 10-15% c. 25-30% d. 35-40% e. 50-55%

Answer 191

C - 25-30% TOG 2017

Question 192

In what proportion of women of reproductive age is endometriosis found? a. <1% b. 2-5% c. 5-10% d. 15-20% e. 25-30%

Answer 192

C - 5-10% TOG 2017

Question 193

What proportion of total body iron is stored within haemoglobin? a. 1/10 b. 1/5 c. 1/3 d. 1/2 e. 2/3

Answer 193

E - 2/3 TOG 2017

Question 194

What is the normal total body iron weight for a woman of reproductive age? a. 0.5-1g b. 3-4g c. 50-75g d. 100-150g e. 750-1000g

Answer 194

B - 3-4g TOG 2017

Question 195

What is the main hormone involved in the regulation of gut iron absorption and erythrocyte recycling? a. Transferrin b. Ferritin c. Erythropoetin d. Hepcidin e. Ferroportin

Answer 195

D - Hepcidin TOG 2017

Question 196

A primigravida suffers a major PPH following a normal delivery. It is estimated she has lost approximately 1 litre. How much iron will be contains within 1 litre of blood loss? a. 10mg b. 100mg c. 500mg d. 5 grams e. 50 grams

Answer 196

C - 500mg TOG 2017

Question 197

What is the recommended daily intake of iron for women of reproductive age? a. 5mg b. 10mg c. 18mg d. 50mg e. 500mg

Answer 197

C - 18mg TOG 2017

Question 198

31. What is the most reliable indicator of iron deficiency? a. Mean cell haemoglobin b. Transferrin saturation c. Serum iron level d. Ferritin e. Total iron binding capacity

Answer 198

D - Ferritin TOG 2017

Question 199

A patient with iron deficiency anaemia in the third trimester of her second pregnancy is admitted at 37/40 for a course of parenteral iron therapy in advance of a planned caesarean section at 39/40. Assuming her haemoglobin is recorded as 8.5g/dL pre-treatment, by how much would you anticipate it to rise in the next 7 days following the parenteral iron therapy? a. 0.5g/dL b. 1.0g/dL c. 1.5g/dL d. 2.0g/dL e. 2.5g/dL

Answer 199

D - 2.0g/L TOG 2017

Question 200

What is the main advantage of drainage over ovarian cystectomy in the treatment of an ovarian endometrioma that measures 4cm and is associated with dysmenorrhoea and dyspareunia? a. Ovarian reserve is less likely to be compromised b. Recurrence is less c. The procedure has less complications d. The risk of adhesion formation is less e. The risk of compromising future fertility is greater with drainage

Answer 200

A - Ovarian reserve is less likely to be compromised TOG 2017

Question 201

A 38 year old woman has been offered a total abdominal hysterectomy with preservation of the ovaries as treatment of her endometriosis associated chronic pelvic pain. What is the main disadvantages to leaving her ovaries behind? a. Greater risk of developing an endometrioma b. Four fold risk of re-operation c. Four fold risk of ovarian endometroid cancer d. Six fold risk of developing recurrent pain e. Increased risk of trapped ovary syndrome

Answer 201

D - Six-fold risk of developing recurrent pain TOG 2017

Question 202

What is the best predictor of cardiac risk in a 37 year old woman who has been diagnosed with PCOS? a. Abdominal circumference b. Blood pressure c. BMI d. LH levels e. Waist circumference

Answer 202

E - Waist circumference TOG 2017

Question 203

An amenorrhoeic woman with PCOS was given norethisterone acetate (20mg/day for 5 days) to induce a withdrawal bleed, following which she was commenced on clomiphene citrate 50mg/day from D2-6. She comes back saying she has not had a period after 35 days. What would be your next step in her management? a. Pregnancy test and if negative, await bleed and increase clomiphene citrate to 100mg b. Pregnancy test and if negative commence on second dose of clomiphene citrate c. Pregnancy test and if negative induce a withdrawal bleed with progestogen and then initiate clomiphene citrate d. Pregnancy test and if negative, recommend that she waits for a bleed before restarting the clomiphene e. Pregnancy test and if negative, ultrasound scan and then advise to wait for a bleed before commencing the next course of clomiphene

Answer 203

C - Pregnancy test and if negative induce a withdrawal bleed with progestogen and then initiate clomiphene citrate TOG 2017

Question 204

A 46 year old woman underwent a subtotal hysterectomy as treatment for HMB. What approximate percentage of women who have had a subtotal hysterectomy will cyclical bleeding remain a persistent symptom? a. <3% b. 5% c. 10% d. 15% e. 20%

Answer 204

B - 5% TOG 2017

Question 205

A hysterectomy was offered to a 37 year old woman with heavy menstrual bleeding refractory to medical treatment. What would be the main advantage of a subtotal hysterectomy over a total hysterectomy? a. Better sexual satisfaction b. Lower morbidity c. Reduced impact on ovarian function d. Reduced incidence of bladder dysfunction e. Surgical expertise is less

Answer 205

B - Lower morbidity TOG 2017

Question 206

Approximately what percentage of benign hysterectomies in the UK are still performed by laparotomy? a. >20% b. >30% c. >40% d. >50% e. >60%

Answer 206

E - >60% TOG 2017

Question 207

A 25 year old woman attends for her booking visit at 10 weeks of gestation. On questioning you find that she has never had a cervical smear. Why is it not recommended that she undergo a smear at this time? a. The management of an abnormal result would have to be delayed until after pregnancy anyway b. There is an increased risk of a false negative report c. There is an increased risk of a false positive report d. There is an increased risk of having an inadequate report e. There is an increased risk of miscarriage

Answer 207

C - There is an increased risk of a false positive report TOG 2017

Question 208

What proportion of tubo-ovarian abscess in women in the UK are due to C. Trachomitis or N. Gonorrhoea? a. 1/4 b. 1/3 c. 1/2 d. 2/3 e. 3/4

Answer 208

A - 1/4

Question 209

What is the highly sensitive ultrasound sign seen in tubo-ovarian abscess? a. Double-ring sign b. Chain and ball sign c. Wagon wheel sign d. Ring of fire sign e. Cogwheel sign

Answer 209

E - Cogwheel sign

Question 210

What is the most sensitive imaging medium for diagnosis of tubo-ovarian abscess? a. Contrast CT b. Non-contrast CT c. MRI d. Ultrasound e. Hysterosalpingogram

Answer 210

C - MRI

Question 211

From what age are patients in England and Wales subject to the terms of the Mental Capacity Act (2005)? a. From birth b. 14 years c. 16 years d. 18 years e. 21 years

Answer 211

C - 6 years

Question 212

When is ‘substituted judgment’ considered as a guide to decision making for individuals who lack mental capacity? a. The best interest judgement is ambigious b. The individual does not have any advanced directive in place for a particular decision c. The individual has no next of kin to make decisions d. The individual has wilfully delegated the decision to another person e. The individual judgement is such that an LPA is not appropriate

Answer 212

D - The individual has wilfully delegated the decision to another person

Question 213

You request screening for C. Trachomitis and N. Gonorrhoea on a 23 year old admitted with a diagnosis of right tubo-ovarian abscess confirmed on scan. In approximately what proportion of such women will these organisms be isolated? a. 1:10 b. 1:6 c. 1:5 d. 1:4 e. 1:3

Answer 213

D - 1/4

Question 214

A 19 year old student is unwell and presents with a temperature of 38.5C, pulse of 135bpm, lower abdominal pain and vaginal discharge plus an adnexal mass on bimanual. What will be your management plan? a. Blood cultures, IV antibiotics and fluids and monitor urine output b. Blood culture, IV antibiotics and monitor urine output and oral fluid intake c. Blood cultures, IV antibiotics and urine output, serum lactate and monitor oral fluid intake d. Commence on IV antibiotics, IV fluids, blood cultures and measure urine output e. Initiate the sepsis-six protocol

Answer 214

E - Initiate the sepsis 6 protocol

Question 215

A woman undergoes hysteroscopic resection of fibroids and starts fitting shortly after the procedure. What is the most likely cause of the fits? a. Anaesthetic complications b. Intracranial haemorrhage c. Fluid overload and cerebral oedema d. Hyponatraemia from fluid overload e. Hypokalaemia from fluid overload

Answer 215

C - Fluid overload and cerebral oedema

Question 216

How often should the fluid deficit be measured during hysteroscopic resection of a fibroid in a 39 year old woman? a. Min. 3 minute interval b. Min. 5 minute interval c. Min. 10 minute interval d. Min. 15 minute interval e. Min. 20 minute interval

Answer 216

C - Min. 10 minute interval

Question 217

How great is the increase in cervical cancer risk amongst women with concurrent HIV infection compared with women without HIV? a. Equivalent b. 2x c. 4x d. 6x e. 8x

Answer 217

D - 6x

Question 218

What is the most common reason for hysterectomy amongst women from low-resource countries? a. Abnormal uterine bleeding/fibroids b. Prolapse c. Endometrial cancer d. Cervical cancer e. Post-partum haemorrhage

Answer 218

A - Abnormal uterine bleeding/fibroids

Question 219

Globally, how many women die each year as a consequence of unsafe abortion? a. 700 b. 7000 c. 70,000 d. 700,000 e. 7,000,000

Answer 219

C - 70,000

Question 220

What proportion of women with PCOS are affected by metabolic syndrome? a. 3/4 b. 1/2 c. 1/3 d. 1/5 e. 1/10

Answer 220

C - 1/3

Question 221

How many minutes of exercise per week is recommended in women with PCOS? a. 60 b. 120 c. 150 d. 180 e. 240

Answer 221

C - 150

Question 222

What is the mechanism of action of Orlistat used as an adjunct to conventional weight loss techniques? a. Increases gastric leptin secretion b. Inhibitor of gastric lipase c. Increases synthesis of high-density lipoproteins d. Improves peripheral insulin sensitivity e. Increases hepatic biliary production

Answer 222

B - Inhibitor of gastric lipase

Question 223

What proportion of women with fibroids can be expected to develop symptoms as a result? a. 1/10 b. 1/4 c. 1/2 d. 2/3 e. 3/4

Answer 223

B - 1/4

Question 224

A patient is considering surgery to treat the pressure symptoms associated with large subserosal uterine fibroids. How many courses of Ullipristal Acetate therapy are licensed for patients as a pre-surgical adjunctive measure? a. 1 course b. 2 courses c. 3 courses d. 4 courses e. 5 courses

Answer 224

A - 1 course

Question 225

Which of the following is NOT a recognised risk factor for leiomyosarcoma? a. Lynch syndrome b. African ethnic origin c. Previous pelvic radiation d. Extended tamoxifen use e. Nulliparity

Answer 225

E - Nulliparity

Question 226

Which of the following has been shown to reduce operative blood loss at myomectomy? a. Open rather than laparoscopic approach b. Leaving a drain in situ post-op c. Pre-operative optimisation of haemoglobin d. Pre-op treatment with GnRH analogues e. Use of non-dissolvable sutures in repairing myometrial defect

Answer 226

D - Pre-op treatment with GnRH analogues

Question 227

What threshold is advised for formal sheath closure at laparoscopic port sites outwith the midline? a. >5mm b. >7mm c. >10mm d. >10mm if used for specimen collection e. >12mm

Answer 227

B - >7mm

Question 228

Which gynaecological malignancy results in the highest number of deaths worldwide? a. Cervical b. Ovarian c. Endometrial d. Vaginal e. Fallopian tube

Answer 228

A - Cervical

Question 229

One factor which has been shown to increase the risk of developing cervical cancer is HIV infection. What is the impact of HIV on the risk of cervical cancer? a. Increases it two-fold b. Increases it three-fold c. Increases it four-fold d. Increases it five-fold e. Increases it six-fold

Answer 229

E - Increases it six-fold

Question 230

What is the estimated incidence of the metabolic syndrome in women with PCOS? a. 10% b. 15% c. 20% d. 25% e. 33%

Answer 230

E - 33%

Question 231

For a 33 year old woman with PCOS, what is the recommended regular exercise that has been shown to improve cardiometabolic outcomes? a. Regular exercise for 30 minutes per week including 15 minutes of moderate intensity aerobic exercise b. Regular exercise for 60 minutes per week including 30 minutes of moderate intensity aerobic exercise c. Regular exercise for 90 minutes per week including 60 minutes of moderate intensity aerobic exercise d. Regular exercise for 120 minutes per week including 90 minutes of moderate intensity aerobic exercise e. Regular exercise for 150 minutes per week including 90 minutes of moderate intensity aerobic exercise

Answer 231

E - Regular exercise for 150 minutes per week including 90 minutes of moderate intensity aerobic exercise

Question 232

A 36 year old woman wishes to undergo Uterine Artery Embolisation after being diagnosed with fibroids. What would you consider a relative contraindication to this procedure for this woman? a. Multiple uterine fibroids b. Uterine fibroids of >20 week size c. Sub-serous fibroids d. Sub-mucous fibroids e. Cervical fibroids

Answer 232

B - Uterine fibroids >20 week size

Question 233

What would be considered a contraindication to treating uterine fibroids in a 30-year old woman with MR-guided focused ultrasound? a. Fibroids >8cm b. Concomitant adenomyosis c. Intramural fibroids d. Interligametous fibroids e. Sub-serous fibroids

Answer 233

B - Concomitant adenomyosis

Question 234

What proportion of gynaecology outpatient referrals are made for chronic pelvic pain? a. 1 in 20 b. 1 in 10 c. 1 in 5 d. 1 in 3 e. 1 in 2

Answer 234

C - 1 in 5 TOG 2016

Question 235

What is the prevalence of IBS amongst women of reproductive age? a. 1-2% b. 3-4% c. 10-15% d. 25-30% e. 40-50%

Answer 235

C - 10-15% Rates of IBS in the female population are similar to that of endometriosis - around 10-15% TOG 2016

Question 236

Which of the following statements concerning irritable bowel syndrome (IBS), is false? a. It is more common in women than men b. Low grade inflammation is a common finding on gut-mucosal biopsy c. The relative risk is twice as high in those with a biological relative with IBS d. There is an associated small increased risk of bowel cancer e. Diagnosis is made via the ROME III criteria

Answer 236

D - There is an associated small increased risk of bowel cancer There is no known association between IBS and malignancy of any kind. TOG 2016

Question 237

A 24 year old woman with a long history of chronic pelvic pain is booked for a diagnostic laparoscopy in a bid to exclude endometriosis. During consenting she remarks that she is ‘glad she’ll finally know what the problem is’. What is the likelihood of finding endometriosis on a laparoscopy for chronic pelvic pain in reproductive age women? a. 10% b. 33% c. 50% d. 66% e. 75%

Answer 237

B - 33% It is important to counsel patients undergoing laparoscopy for chronic pelvic pain in gynaecology that endometriosis (which in most instances is the diagnosis the procedure seeks to refute or confirm) is found in only 1/3 of cases on average TOG 2016

Question 238

A patient considering surgical myomectomy undergoes GnRH treatment pre-operatively for 6 months. After this period she feels her symptoms have improved such that she no longer wishes to proceed with surgery. How long after stopping GnRH might she expect her fibroids to return to pre-treatment size? a. 3 months b. 6 months c. 1 year d. 2 years e. 5 years

Answer 238

B - 6 months TOG 2016

Question 239

A 25-year-old presents with lower abdominal pain of 12 months duration. The pain is worse around her menses, which are also heavy. Sexual intercourse is painful. She has altered bowel habits especially around menstruation. You suspect that she may have either irritable bowel syndrome or endometriosis or both. What approach will you take to differentiate between the two conditions? a. Assessment of visceral hypersensitivity b. Bowel endoscopy c. Diagnostic laparoscopy d. Three months on the combined oral contraceptive pill e. Ultrasound of the pelvis (transvaginal)

Answer 239

D - Three months of the combined oral contraceptive pill. Approximately 40% of women with endometriosis also have irritable bowel syndrome (IBS). Patients with IBS and endometriosis both have visceral hypersensitivity and endoscopy of the gastrointestinal tract has not been found to be useful in diagnosing IBS but beneficial in excluding bowel pathology that may be a differential. Although a diagnostic laparoscopy will identify most cases of endometriosis, a negative laparoscopy does not exclude the diagnosis. A therapeutic trial of ovarian suppression with the combined oral contraceptive pill or a GnRH agonist is therefore the most useful test to distinguish endometriosis from IBS. TOG StratOG Resource

Question 240

A 30-year-old presents to the clinic with lower abdominal pain, altered bowel habits, dyspareunia and dysmenorrhoea. Clinical examination fails to identify any signs of pathology. You suspect irritable bowel syndrome. What first treatment will you recommend? a. Dietary advice and anticholinergics b. Dietary advice and weight loss c. Pregabalin d. Serotonin receptor antagonist (e.g. ondansetron) e. Tricyclic anti-depressants

Answer 240

A - Dietary advice and anticholinergics.  When irritable bowel syndrome (IBS) is a suspected diagnosis, anticholinergics such as smooth muscle relaxants are the traditional first line pharmacological approaches to controlling abdominal pain although they have little effect on bowel dysfunction; therefore in addition, laxatives and anti-diarrhoeals have to be used as appropriate. Initially advise changes in dietary habits with avoidance of specific types of food such as insoluble fibre, beans, fatty food, caffeine, chocolate, sugar substitutes and alcohol, which can all trigger pain in some patients with IBS. TOG StratOG Resource

Question 241

A 30-year-old woman whose periods have become increasingly heavy over the last 6–9 months was examined and found to have an enlarged irregular uterus. Uterine fibroids were suspected and an ultrasound of the pelvis requested. This has confirmed the presence of multiple intramural fibroids, the largest of which measures 6 x 7 cm. She is not keen to have surgery and wishes to discuss medical treatment. What should she be told about treatment with a GnRH agonist and the size of her fibroids six months after completion of treatment? a. There will be a significant reduction in size, which will be maintained for 6–12 months following treatment b. There will be a significant reduction in size but within 4–6 months of treatment, the fibroids will most likely return to pretreatment sizes c. There will be a significant reduction in size that will be maintained for 6 months only, after which there will be a gradual return to pretreatment sizes by 12–18 months d. There will be a significant reduction in size but within 3 months of stopping treatment, the fibroids will return to their pretreatment sizes e. There will a reduction in size of more than 50% and by 4–6 months of stopping treatment, the fibroids would have returned to half their pretreatment sizes

Answer 241

B - There will be a significant reduction in size but within 4–6 months of treatment, the fibroids will most likely return to pretreatment sizes. GnRH agonist treatment of uterine fibroids induces a menopausal state with low estrogen levels. Treatment for 6 months has been shown to result in a significant reduction in the size of fibroids although this is associated with menopausal side effects especially if Addback therapy is not included in the treatment. After discontinuing treatment, the fibroids return to pretreatment levels within 4–6 months and menstruation tends to return within 4–8 weeks. TOG StratOG Resource

Question 242

You have discussed medical treatment of symptomatic uterine fibroids with a 32-year-old nulligravida who plans to start trying for a baby in 2–3 years’ time. She has opted for the selective progesterone receptor modulator (SPRM) ulipristal acetate. What is the main mechanism of action of this SPRM? a. It acts by inhibiting angiogenesis within the fibroids b. It binds to progesterone receptors and inhibits the action of estrogens mainly c. It induces apoptosis of uterine fibroid cells and inhibits proliferation d. It is an anti-estrogen e. It reduces blood flow to the fibroids and thereby reduce their size

Answer 242

C - It induces apoptosis of uterine fibroid cells and inhibits proliferation Ulipristal acetate causes a reduction in the size of fibroids by inducing apoptosis in fibroid cells and inhibiting proliferation of cells. It has been shown to reduce menstrual loss in over 90% of patients after 13 weeks of treatment with either 5 or 10 mg daily. Following the initiation of treatment, amenorrhoea is achieved within 10 days in three-quarters of patients. The median change in fibroid volume is approximately 40–50% after 13 weeks of treatment and this reduction, unlike that following GnRH agonist treatment, is maintained for at least 6 months after discontinuation. TOG StratOG Resource

Question 243

A 34-year-old presents with uterine prolapse. She has had one normal vaginal delivery and wishes to have more children. Following counselling she is offered ’Oxford hysteropexy’. What advice should she be given about pregnancy after the procedure? a. It encircles the cervix and will be removed prior to a vaginal delivery b. It is associated with an increased risk of miscarriage c. Pregnancy rates are much lower after the procedure d. There is associated compromise of uterine circulation resulting in fetal growth restriction e. Vaginal birth is not possible after the procedure

Answer 243

E - Vaginal birth is not possible after the procedure.  The Oxford hysteropexy is a uterine preserving surgical procedure to correct uterine prolapse in women who wish to retain their fertility (as in this patient). The procedure involves inserting a mesh which encircles the cervix and vaginal birth is therefore not possible. The mesh has been described as acting as a cervical cerclage. Concerns raised about compromised uterine blood flow are theoretical as there is often collateral circulation. TOG StratOG Resource

Question 244

A 70–year-old, frail and diabetic obese woman presents with troublesome procidentia. She is not sexually active and has been assessed as unfit to withstand prolonged surgery. A colpocleisis is therefore offered as the treatment of choice. What is the main disadvantage of this procedure? a. A high rate of recurrence b. Less patient satisfaction than with corrective surgery c. Loss of access to the cervix and uterus d. Loss of sexual function e. The need to have drainage channels for the passage of vaginal and cervical secretions

Answer 244

C - Loss of access to the cervix and uterus The women who are suitable for obliterative procedures are those who are sexually inactive, elderly and in particular those with co-morbidities that may render them unsuitable for longer operating times and more invasive procedures associated with reconstructive surgery. Sexual inactivity both at present and in the future is a criterion for the procedure and cannot therefore be a disadvantage. The main disadvantage is lack of access to the cervix and uterus. Satisfaction rates that have been reported have been approximately 90–95%, which are much better than those of reconstructive surgery. TOG StratOG Resource

Question 245

What is the average age of menopause amongst women in the UK? a. 46 b. 49 c. 51 d. 55 e. 61

Answer 245

C - 51 NICE Guidelines

Question 246

What is the incidence of premature menopause occurring prior to 40 years of age amongst women in the UK? a. 1 in 100 b. 3 in 100 c. 1 in 1000 d. 3 in 1000 e. 5 in 1000

Answer 246

A - 1 in 100 The incidence of premature menopause in the UK is 1% in women <40 NICE Guidelines

Question 247

A patient attends the gynaecology clinic complaining that she is finding the vasomotor symptoms of menopause unbearable and requests treatment. For how long following menopause can most women be advise they are likely to experience symptoms? a. 2 years b. 4 years c. 10 years d. 15-20 years e. 24 years

Answer 247

B - 4 years Most women experience symptoms for up to 4 years following their last menstrual period though ~10% of patients will still be symptomatic at 12 years NICE Guidelines

Question 248

A 54 year old woman attends the gynaecology clinic complaining of hot flushes and night sweats. She is requesting medical treatment as she is finding these symptoms increasingly unbearable. She has no medical history of note and no history of surgery. What therapy should she be offered first line? a. Cognitive behavioural therapy b. Combined oestrogen and progesterone HRT c. Oestrogen only HRT d. Clonidine e. Venlafaxine

Answer 248

B - Combined oestrogen and progesterone HRT Women with vasomotor symptoms of menopause should be offered HRT first line. In women with an intact uterus, this should take the form of combined oestrogen/progesterone therapy, while oestrogen-only preparations are suitable for women who have previously undergone hysterectomy NICE Guidelines

Question 249

A 50 year old woman attends the gynaecology clinic complaining of hot flushes and night sweats. She is requesting treatment as she is finding these symptoms increasingly unbearable though wishes to avoid ‘artificial hormones’ and states a preference for herbal or natural remedies. Which of the following preparations may offer her relief of her symptoms? a. Garlic Extract b. Red Clover c. Ginseng d. Evening Primrose Oil e. Black Cohosh

Answer 249

E - Black Cohosh It is reasonable to explain to women that isoflavones or black cohosh may relieve vasomotor symptoms though exact safety of varying preparations in unknown and interactions with other medications have been reported NICE Guidelines

Question 250

A 55 year old woman attends the gynaecology clinic complaining of hot flushes and night sweats. She is requesting medical treatment as she is finding these symptoms increasingly unbearable. She has no medical history of note though has previously undergone a vaginal hysterectomy for prolapse 3 years earlier. What therapy should she be offered first line? a. Cognitive behavioural therapy b. Combined oestrogen and progesterone HRT c. Oestrogen only HRT d. Clonidine e. Venlafaxine

Answer 250

C - Oestrogen only HRT Women with vasomotor symptoms of menopause should be offered HRT first line. In women with an intact uterus, this should take the form of combined oestrogen/progesterone therapy, while oestrogen-only preparations are suitable for women who have previously undergone hysterectomy NICE Guidelines

Question 251

A 53 year old woman consults her GP with concern regarding her low mood since her periods stopped some 14 months earlier. The GP in turn has referred her for CBT, though has written to you requesting advice on medical management. What medical therapy should be offered first line to such women? a. Trial of low dose SSRI b. Trial of SSRI at normal dose c. Trial of SNRI d. Trial of tricyclic anti-depressant e. Trial of HRT

Answer 251

E - Trial of HRT HRT should be first line in women reporting low mood secondary to the menopause. There is no evidence to support the use of anti-depressant drugs in such women who have not been diagnosed with depression NICE Guidelines

Question 252

A 56 year old woman reports a deterioration in her sexual drive and libido which is placing strain on her relationship with her husband. She has been using continuous combined HRT since her periods stopped 3 years earlier. What management is appropriate here? a. Switch to an alternative HRT preparation b. Trial of Ginseng and Red Clover c. Trial of Isoflavones d. Supplementation with testosterone e. Increase progesterone dose of current HRT regimen

Answer 252

D - Supplementation with Testosterone Testosterone should be offered to women complaining of low libido post-menopausally NICE Guidelines

Question 253

A patient is commenced on continuous combined HRT following 18 months of amenorrhoea. She returns to the clinic 6 weeks after starting, anxious as she has experienced vaginal spotting on a few occasions over the last 2-3 weeks. What is the most appropriate first line management here? a. Ultrasound pelvis b. Pipelle endometrial biopsy c. Outpatient hysteroscopy d. Stop HRT e. Reassure

Answer 253

E - Reassure Unscheduled bleeding on HRT is to be expected in the first 3 months - beyond this investigation would be required NICE Guidelines

Question 254

A woman wishes to start HRT after 15 months of amenorrhoea as she is finding the vasomotor symptoms of menopause unbearable. Her medical history is unremarkable though her body mass index is elevated at 34. Which of the following is most appropriate? a. Continuous combined oral HRT b. Cyclical combined oral HRT c. Transdermal oestrogen with oral or intrauterine progesterones d. Oestrogen only HRT e. None of the above

Answer 254

C - Transdermal oestrogen with oral or intrauterine progesterones Women over 34 or those with other risk factors for VTE should be offered transdermal in preference to oral HRT NICE Guidelines

Question 255

Which of the following statements concerning HRT is true? a. There is an association between HRT use in women under 60 and cardiovascular disease b. There is no increased VTE risk with transdermal preparations at standard dose c. An SSRI may be used in lieu of hormonal preparations first line to treat vasomotor symptoms d. SSRIs should be used first line to treat symptoms of low mood in menopausal women with no history of depression e. Patients have a small increase in their risk of fragility fractures while taking HRT which returns to baseline within 6 months of stopping

Answer 255

B - There is no increased VTE risk with transdermal preparations at standard dose NICE Guidelines

Question 256

Which of the following is required for confirmatory diagnosis of premature ovarian insufficiency in a woman aged <40 years? a. Elevated FSH levels on 2 occasions 4-6 weeks apart b. Single elevated FSH >30 c. AMH <5 on more than one occasion d. >18 months amenorrhoea e. Elevated FSH and LH levels on more than one occasion 6 months apart

Answer 256

A - Elevated FSH levels on 2 occasions 4-6 weeks apart NICE Guidelines

Question 257

A 48 year old woman who has not had a menstrual period in 12 months attends the gynaecology outpatient clinic for review. She states that in addition to her amenorrhoea, she has also been experiencing vaginal dryness and occasional hot flushes. She states that she and her partner use condoms for contraception, though wishes to know if it is now safe to stop doing so. What do you advise her? a. Safe to stop contraception now b. Continue contraception for 12 months c. Continue contraception until age 50 d. Continue contraception until age 55 e. Measure serum FSH and stop contraception if >30

Answer 257

B - Continue contraception for 12 months Advice on stopping contraception for women around menopause is as follows: - Age >55: safe to stop contraception at any time - Age 50-55: a) if using hormonal contraception, after 2 FSH levels >30 6 weeks apart b) after 12 months amenorrhoea - Age <50: after 24 months amenorrhoea

Question 258

A 49 year old women complains of occasional hot flushes and vaginal dryness despite the fact she is still menstrauting most months. She enquires about using HRT and wishes to know if this could be used as a substitute for her current contraceptive pill. In what proportion of women is ovulation NOT reliably inhibited while on HRT? a. 20% b. 40% c. 60% d. 80% e. 90%

Answer 258

B - 40% TOG 2016