Gynaecology 1

Question 1

Adenomyosis

1. What is it?
2. When is it most common?
3. What clinical features are seen?
4. How is it managed?

Answer 1

1. presence of endometrial tissue in the myometrium
2. multiparous women at end of reproductive years
3. • dysmenorrhoea
   • menorrhagia
   • enlarged, boggy uterus
4. • GnRH analogues
   • hysterectomy

Question 2

Amenorrhea Causes

1. What is meant by
   a) primary amenorrhoea
   b) secondary
2. What should you do before searching for a cause of secondary amenorrhoea?
3. What can cause
   a) primary amenorrhoea
   b) secondary

Answer 2

1. a)
   - 15 year old with secondary sexual characteristics or 13 year old with no secondary sexual characteristics yet to have have a period

b) cessation of menstruation for:
- 3-6 months in women with previous regular menses
- 6-12 months in women with previous oligomenorrhoea

2. exclude pregnancy
3. a)
   - hypothalamic (stress, excessive exercise, anorexia)
   - congenital adrenal hyperplasia
   - congenital gonadal dysgenesis (e.g. turner’s syndrome)
   - imperforate hymen (think likely if women experiencing cyclical pain / changes but no period)

mnemonic: point in order and if stuck think what could go wrong in repro system

b)
- hypothalamic
- hyperprolactinaemia
- thyrotoxicosis / hypothyroid
- Sheehan’s syndrome
- Asherman’s syndrome (uterine adhesions)
- premature ovarian failure
- PCOS

mnemonic: lots of hypothalamic pituitary causes, Hs for brain, Ps for ovarian causes

Question 3

Amenorrhoea Investigation and Management

1. What investigations should be done?
2. What management should be considered in gonadal dysgenesis?

NOTE: management mainly find and treatment underlying cause

Answer 3

1. • exclude pregnancy with urinary or serum bHCG
   • full blood count, urea & electrolytes, coeliac screen, thyroid function tests
   • gonadotrophins: low levels indicate a hypothalamic cause, raised levels suggest an ovarian problem (e.g. Premature ovarian failure, gonadal dysgenesis)
   • prolactin
   • androgen levels: raised levels may be seen in PCOS
   • oestradiol
2. hormone replacement to prevent osteoporosis

Question 4

Androgen Insensitivity Syndrome

1. What is it?
2. What clinical features can be seen?
3. How is it managed?

Answer 4

1. testosterone resistance causing female phenotype in male genotype
2. • ‘primary amenorrhoea’
   • groin swellings (undescended testes)

+/- breast development as testosterone can be converted to estradiol

3. • oestrogen
   • counselling: raise as female
   • bilateral orchidectomy
   • > as undescended testes RF for testicular cancer

Question 5

Atrophic Vaginitis

1. What is it?
2. How does vagina appear on examination?
3. How is it treated?

NOTE: this is diagnosis of exclusion must look for other causes first

Answer 5

1. postmenopausal vaginal dryness leading to dyspareunia and spotting
2. pale + dry
3. vaginal lubricants / moisturiser

if this doesn’t work then try topical oestrogen

Question 6

What symptoms suggest an ectopic pregnancy and hence immediate referral for assessment?

Answer 6

• abdominal pain + tenderness
• pelvis tenderness
• cervical motion tenderness

mnemonic: basically just tenderness

Question 7

How should bleeding in pregnancy be managed if:

1. > 6 weeks or unsure
2. <6 weeks gestation

Answer 7

1. referral to early pregnancy assessment service
2. if also no pain or risk factors for ectopic pregnancy, then patient should be managed expectantly:
   take pregnancy test again in 7-10 days
   return if positive, council that if negative pregnancy has miscarried

Question 8

Cervical Cancer

1. What clinical features are seen?
2. a) What is the most important risk factor?
   b) What other risk factors are there?
3. What ages can cervical cancer present?

Answer 8

1. abnormal bleeding:
   - intermenstrual, post coital, postmenopausal
2. a) HPV 16, 18, 33

b)
- early first intercourse
- high number of sexual partners
- high parity
- smoking

NOTE: think RFs someone who has had a lot of sex and not careful

3. 50% cases <50 with highest incidence at 25-29

Question 9

Cervical cancer screening

1. What screening is offered
   a) 25-49 years old
   b) 50-64 years old
2. What should be done in pregnancy?

Answer 9

1. a) every 3 years
   b) every 5 years
2. delay until 3 months postpartum
   UNLESS:
   - missed smear
   - previous abnormal smear

Question 10

Cervical cancer screening: interpretation of results

1. a) What is performed first?
   b) What is done if this is
   i) negative
   ii) positive
2. What happens if cytology is
   a) normal
   b) abnormal
3. How is CIN treated?
4. What is done if the sample is ‘inadequate’?

Answer 10

1. a) HPV test

b)
i) return to normal screening programme

UNLESS:

• patient has had diagnosed/treatment for CIN or neoplasia / incompletely excised neoplasia
• follow up for borderline changes

ii) samples are examined cytologically

2. a) HPV test repeated at 12 months
   - if HPV -ve return to normal screening
   - if HPV +ve repeat again at 24 months: if -ve again return to normal, if +ve colposcopy

b) colposcopy
3. most commonly large loop excision of transformation zone (LLETZ)

THEN follow up cervical screening 6 months later

mnemonic: lets get rid of the neoplasia

4. repeat again within 3 months,
   if 2 in a row inadequate then colposcopy

Question 11

Cervical ectropion

1. What is it?
2. What clinical features are seen?

Answer 11

1. larger number of columnar epithelium present on the ectocervix
2. • vaginal discharge
   • post-coital bleeding

Question 12

Complete hydatidiform mole

1. What clinical features are seen?
2. What is seen on investigation?
3. What is the genetic make up of
   a) complete
   b) partial

Answer 12

1. • vaginal bleeding
   • uterus size larger than for gestational age
2. • abnormally high hCG
   • snowstorm appearance on US
3. a) two sperm fertilise empty egg meaning all DNA is from father

b) two sperm fertilise viable egg giving 69 chromosomes

Question 13

What is the differential for

1. delayed puberty short stature
2. delayed puberty normal stature

Answer 13

1.

• turner’s syndrome
• noonan’s syndrome
• Prader-Willi

2. • PCOS
   • Androgen insensitivity syndrome
   • Klinefelter’s syndrome
   • Kallman’s syndrome

Question 14

Dysmenorrhoea

1. Primary dysmenorrhea
   a) What clinical features are seen?
   b) How is it managed?
2. Secondary dysmenorrhoea
   a) What can cause it?
   b) How should it be managed?

Answer 14

1. a) within 1-2 years of menarche suprapubic cramps which start just before / within a few hours of start of period

b) NSAIDs e.g. mefenamic acid or ibuprofen

if still troublesome COCP second line

2. a)
   - endometriosis
   - adenomyosis
   - fibroids
   - pelvic inflammatory disease
   - IUD (NOT the IUS)

b) refer to gynaecology for investigation