Gynaecology

Question 1

What are the benefits of HRT?

Answer 1

Reduction in vasomotor symptoms, improvement in urogenital symptoms, improvement in sexual function, reduced risk of osteoporosis, reduced risk of colorectal cancer

Question 2

What are the risks of HRT?

Answer 2

Increased risk of breast cancer (especially combined HRT), increased risk of endometrial cancer in unopposed oestrogens, increased risk of VTE, increased risk of gallstones

Question 3

When should cyclical HRT be used over continuous HRT?

Answer 3

Women still having or < 12 months since LMP

Question 4

What are the risk factors for cervical cancer?

Answer 4

Persistent diagnosed high risk HPV, multiple sexual partners, smoking, HIV, post-transplant, oral contraceptives (possibly due to reduced use of barrier contraception)

Question 5

How should CIN be treated?

Answer 5

CIN I - 6 monthly colposcopy, CIN II or III - LLETZ with 6 months follow up smear

Question 6

What are the signs and symptoms of cervical cancer?

Answer 6

Post coital bleeding, post-menopausal bleeding, watery discharge, weight loss, ureteric obstruction, vesicovaginal fistula.
Exam - irregular cervical surface, abnormal vessels and dense uptake of acetic acid. Rough, fixed cervix with contact bleeding.

Question 7

What are the risk factors for endometrial cancer?

Answer 7

Obesity, nulliparity, anovulatary cycles, early late manopause, HNPCC, HRT, tamoxifen

Question 8

What are the symptoms of ovarian cysts?

Answer 8

Chronic pain, dyspareunia, acute pain (tortion or bleeding), irregular bleeding, sudden androgenism, ascites

Question 9

How should ovarian cysts be investigated?

Answer 9

FBC, CA125, AFP, LDH, hCG and CEA

TVUS then MRI if complex

Question 10

How should ovarian cysts be managed in a premenopausal woman?

Answer 10

If small, asymptomatic and no risk of malignancy - observe. Otherwise - laparoscopic cystectomy

Question 11

How should ovarian cysts be managed in a postmenopausal woman?

Answer 11

Calculate RMI - if low risk repeat CA125 and TVS every 4 months until clear for 1 year. Moderate risk = bilateral oopherectomy If high risk = referral to cancer centre for staging laparoscopy

Question 12

What are the risk factors for ovarian cancer?

Answer 12

Nulliparity, eary menarche ad late menopause, BRCA genes especially BRCA1, HNPCC,

Question 13

How does ovarian cancer present?

Answer 13

Presumed IBS, bloating, unexplained weight loss, loss of appetite, feeling full early, increased urinary frequency, change in bowel habit, abdominal or pelvic pain, veinal bleeding, fixed pelvic mass on VE, pleural effusion, ascites and lymphadenopathy

Question 14

How should ovarian cancer be investigated?

Answer 14

Similar to cyst work up bloods. TVUS, CXR, CT abdo pelvis, MEI, ascitic/pleural tap,

Question 15

How should ovarian cancer be managed?

Answer 15

Full staging laparotomy (midline laparotomy with hysterectomy, bilateral salpingo-oopherectomy, omentectomy, para-aortic and pelvic lymph node sampling and peritoneal washings.
Chemotherapy

Question 16

Explain the pathogenesis of endometriosis.

Answer 16

Retrograde menstruation leading to adherance and growth of endometrial tissue, metaplasia, imapired immunity to retrograde menstruation

Question 17

How does endometriosis present?

Answer 17

Pain: cyclical, constant if adhesions, severe dysmenorrhoea, deep dyspareunia, dysuria, dyschezia
Subfertility
Speculum may show lesions on the cervix
Fixed, retroverted uterus of VE

Question 18

How should suspected endometriosis be investigated?

Answer 18

TVUS to look for cysts, MRI for bowel involvement, Laparoscopy and biopsy 3 months after hormonal therapy stops
CA125 may be raised

Question 19

How should mild endometriosis be managed in women who do not currently wish to conceive?

Answer 19

NSAIDs or COCP

Question 20

How should moderate endometriosis be managed in women who do not wish to conceive?

Answer 20

Mirena IUS

Question 21

What medical management options are available to women who wish to conceive?

Answer 21

GnRH analogues short term along with IVF

Question 22

What surgical management options are available for women with endometriosis?

Answer 22

Laparoscopic ablation, excision and coagulation of endometriomas.
Hysterectomy may be the last resort for women who do not wish to conceive or accept this as a trade-off.

Question 23

What is the definition of heavy menstrual bleeding?

Answer 23

Menstruation which the woman feels to be excessive

Question 24

What are the causes of heavy menstrual bleeding?

Answer 24

Endometriosis, adenomyosis, PID, IUD, anticoagulants, Von Willebrand’s disease, diabetes, hypothyroidism, endometrial hyperplasia, PCOS

Question 25

What are the medical management options for dysfunctional uterine bleeding?

Answer 25

If contraception is desired - IUS/COCP or cyclical progesterone Tranexamic acid if painless, mefenamic acid if painful.

Question 26

What is the definition of primary amenorrhoea?

Answer 26

No menstruation at age 13 without any other pubertal changes, or at age 15 with other signs of puberty

Question 27

What are the causes of hypogonadotropic hypogonadism?

Answer 27

Hypopituaritrism, chronic illness (cystic fibrosis, IBD), anorexia nervosa, constitutional delay, hypothyroid, Cushing's syndrome, Kallman's syndrome

Question 28

What are the causes of hypogonadotropic hypogonadism?

Answer 28

Damage to gonads, congenital absence of gonads, Turner's syndrome

Question 29

What is the definition of secondary amenorrhoea?

Answer 29

No menstruation for more than three months after previous regular menstrual periods

Question 30

What are the causes of secondary amenorrhoea?

Answer 30

``` Pregnancy is the most common cause Menopause and premature ovarian failure Hormonal contraception (e.g. IUS or POP) Hypothalamic or pituitary pathology Ovarian causes such as polycystic ovarian syndrome Uterine pathology such as Asherman’s syndrome Thyroid pathology Hyperprolactinaemia ```

Question 31

What is the pathological term for fibroids?

Answer 31

Uterine leiomyoma

Question 32

How do fibroids typically present?

Answer 32

Heavy menstrual bleeding Prolonged menstruation, lasting more than 7 days Abdominal pain, worse during menstruation Bloating or feeling full in the abdomen Urinary or bowel symptoms due to pelvic pressure or fullness Deep dyspareunia (pain during intercourse) Reduced fertility

Question 33

How should fibroids be investigated?

Answer 33

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. Pelvic ultrasound is the investigation of choice for larger fibroids. MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Question 34

How should small fibroids (<3cm) be managed?

Answer 34

Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus Symptomatic management with NSAIDs and tranexamic acid Combined oral contraceptive Cyclical oral progestogens Surgery - Endometrial ablation Resection of submucosal fibroids during a hysteroscopy Hysterectomy

Question 35

How should large fibroids (>3cm) be managed?

Answer 35

Should be referred to gynaecology Can be managed medically with NSAIDs, and contraceptives GnRH agonists may be used pre-op to shrink fibroids Uterine artery embolisation Myomectomy - improves fertility Hysterectomy

Question 36

What are the complications associated with fibroids?

Answer 36

Heavy menstrual bleeding Reduced fertility Miscarriages, premature labour and obstructive delivery Constipation Urinary outflow obstruction and infection Red degeneration of the fibroid Torsion of the fibroid Malignant change to a leiomyosarcoma is very rare (<1%)

Question 37

What is red degeneration of the fibroid?

Answer 37

Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy. Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.