Gynaecological Problems Flashcards
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
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%.
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
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.
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
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
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
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.
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
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.
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%
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.
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
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.
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
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.
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
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.
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
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.
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
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)
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
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.
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
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.
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%
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.
In what percentage of epithelial ovarian tumours will Ca125 be elevated?
a. 50%
b. 60%
c. 75%
d. 80%
e. 90%
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.
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%
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
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%
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
What percentage of borderline ovarian masses appear simple on USS?
a. <5%
b. 10%
c. 20%
d. 30%
e. 40%
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.
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
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.
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
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.
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%
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.
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
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.
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%
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%.
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
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.
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
B - LUNA
Laparoscopic utero-sacral nerve ablation is of no proven benefit in the treatment of chronic pelvic pain
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
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
What proportion of women experience premenstrual symptoms of any kind?
a. 15%
b. 40%
c. 65%
d. 80%
e. >90%
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)
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%
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)
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
D - Progesterone monotherapy
There is good evidence to suggest that treating PMS with progesterone in isolation is not appropriate
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
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.
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
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.
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)
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.
- 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
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)
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
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.
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
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.
What angle of scope is recommended for use in outpatient hysteroscopy?
a. 0 °
b. 12°
c. 25°
d. 30°
e. Any of the above
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.
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
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.
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
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.
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
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
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
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.
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
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.
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
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.
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%
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.
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%
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.
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
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.
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
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.
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
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
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
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
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
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
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
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.
What percentage of endometrial hyperplasia with atypia will progress to cancer in 4 years?
a. 4%
b. 8%
c. 12%
d. 25%
e. 35%
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
B - 1 in 20
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
C - FBC
What size of hysteroscope is recommended for use in the outpatient setting?
a. 2mm
b. 3.5mm
c. 4mm
d. 5mm
e. 7mm
B - 3.5mm
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
C - 6 months
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
A - Tranexamic acid
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
A - Paracetamol
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
A - Combined pill
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
C - 3 month trial of GnRH
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
E - Sciatic
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
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
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
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.
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
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.
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
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.
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
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.
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
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.
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
D – LNG-IUS
LNG-IUS is first line in women complaining of HMB and NICE recommend it is used prior to tranexamic acid.
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 37.8C 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 17.6x109 (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
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.
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
A – Endometrial biopsy
Woman over 45 with failure of first line medical treatment need endometrial sampling
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
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
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
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.
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
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.
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
C – Progestogen antagonist
Ullipristal acetate acts on fibroids by inducing apoptosis in the cells.
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
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
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%
B – 1.2%
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
B - Induction of 3 monthly withdrawal bleeds with gestogens
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
E - Transdermal continuous combined HRT
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
D - >/= -1
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%
B - 50%
What is the estimated prevalence of endometriosis in women of reproductive age?
a. <1%
b. 2-10%
c. 10-20%
d. 25%
e. 50%
B - 2-10%
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
D - Idiopathic
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
E - Tricyclic antidepressants
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
E - Topical tacrolimus
- 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
A - Hysteroscopic resection
What progesterone has been shown to be effective in treating PMS?
a. Desogestrel
b. Drosperinone
c. Levonorgestrel
d. Medroxyprogesterone acetate
e. Norethisterone
B - Drosperinone
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
A - Granulosa cells
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
D - Inhibition of LH pulsatility
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
B - Free androgen index
What proportion of women with PCOS are overweight/obese?
a. 10-20%
b. 40-50%
c. 60-70%
d. 80-85%
e. >90%
B - 40-50%
What is the estimated prevalence of endometriosis in infertile women?
a. 10%
b. 20%
c. 30%
d. 40%
e. 50%
E - 50%
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
B - 2/10,000 per year
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
D - Rape
