Gynaecology

Question 1

A 47-year-old woman who smokes 20 cigarettes per day has complained of menorrhagia for one year. You have investigated her and the endometrium was normal on sampling. Treatment with cyclical progesterone therapy was unsuccessful.
She does not want any surgery.

Which of the following is the most appropriate option for her?

a. Transvaginal ultrasound of the endometrium
b. Depo medroxy-progesterone acetate
c. Progesterone releasing intrauterine device
d. Continuous oral progesterone
e. Combined oral contraceptive pill

Answer 1

b. Depo medroxy-progesterone acetate

Question 2

A patient, aged 45, gravida 3 para 3, presents to you complaining that she missed her period for 3 months and this was followed by very heavy vaginal bleeding that persisted for 3 weeks.
Which of the following is the most likely cause of her symptoms?

a. Pelvic inflammatory disease
b. Anovulatory bleed
c. Cervical cancer
d. Endometrial cancer
e. Multifibroid uterus

Answer 2

b. Anovulatory bleed

Question 3

A 51 year old woman suffering from menopausal symptoms consults you about hormonal replacement therapy. She has previously taken progesterone but she felt it made her depressed and asks if she can take oestrogens only for her symptoms of hot flushes.
Which of the following options do you think is the most important reason why she should not receive oestrogen-only treatment?

a. Failure of cardiovascular protection
b. Danger of endometrial hyperplasia/cancer
c. Danger of breast cancer
d. Failure of skeletal protection
e. Deep vein thrombosis

Answer 3

b. Danger of endometrial hyperplasia/cancer

Question 4

A 52 year old woman presents to you complaining of symptoms of the menopause; hot flushes, vaginal dryness, irritability and insomnia. She reports that her symptoms are interfering with her quality of life and causing difficulties in her relationship with her husband.
What would be the most appropriate approach to the care of this patient?

a. Blood tests for oestrogen levels
b. Blood tests for FSH and LH
c. Start hormonal replacement therapy immediately
d. Order an osteodensitometry
e. Discuss with her the risks and benefits of hormone replacement therapy

Answer 4

e. Discuss with her the risks and benefits of hormone replacement therapy

Question 5

A 23 year old woman presents to you complaining of 8 weeks of amenorrhoea. She is sexually active and not using any contraception. She is also complaining of increasingly severe abdominal pain, associated with nausea but no vomiting.
On examination you find that she is apyrexial and on palpation of the lower abdomen, there is guarding and rebound tenderness. This is confirmed on vaginal examination, which reveals cervical excitation tenderness.

Which investigation would you consider to be the most appropriate?

a. Blood glucose
b. White blood count
c. Thyroid stimulating hormone
d. Ultrasound
e. Full blood count

Answer 5

d. Ultrasound

Question 6

A 23 year old woman presents to you complaining of 8 weeks of amenorrhoea. She is sexually active and not using any contraception. She is also complaining of increasingly severe abdominal pain, associated with nausea but no vomiting.

On examination you find that she is apyrexial and on palpation of the lower abdomen, there is guarding and rebound tenderness. This is confirmed on vaginal examination, which reveals cervical excitation tenderness.

Which of the following conditions would you consider to be the most likely cause of her symptoms?

a. Acute appendicitis
b. Pelvic inflammatory disease
c. Ectopic pregnancy
d. Threatened miscarriage
e. Septic retained products of conception

Answer 6

c. Ectopic pregnancy

Question 7

A 23 year old woman presents to you complaining of 8 weeks of amenorrhoea. She is sexually active and not using any contraception. She is also complaining of increasingly severe abdominal pain, associated with nausea but no vomiting.

On examination you find that she is apyrexial and on palpation of the lower abdomen, there is guarding and rebound tenderness. This is confirmed on vaginal examination, which reveals cervical excitation tenderness.

What would you consider to be the most appropriate further management of this patient?

a. CT scan of the abdomen
b. Referral for a surgical opinion
c. Admit to hospital, give analgesia and antibiotic trial
d. Dilatation and curettage
e. Laparoscopy or Laparotomy

Answer 7

d. Dilatation and curettage

Question 8

A 24 year old woman, gravida 1 para 1, presents to you complaining of a foul smelling discharge associated with increasingly severe abdominal pain. She is using intramuscular medroxyprogestone for contraception. On examination you fund that she is pyrexial, with evidence of lower abdominal peritonitis.
What would be the most appropriate management of this patient?

a. Admit to hospital and start intravenous antibiotics and analgesia
b. Ask for a surgical opinion
c. Oral antibiotics
d. Laparoscopy
e. Pelvic ultrasound

Answer 8

a. Admit to hospital and start intravenous antibiotics and analgesia

Question 9

A 24 year old woman, gravida 1 para 1, presents to you complaining of a foul smelling discharge associated with increasingly severe abdominal pain. She is using intramuscular medroxyprogestone for contraception. On examination you fund that she is pyrexial, with evidence of lower abdominal peritonitis.

Which of the following conditions is the most common long-term complication of the condition described above?

a. Hepatitis
b. Infertility
c. Renal failure
d. Endocarditis
e. Arthritis

Answer 9

b. Infertility

Highlighted answer was renal failure?

Question 10

A 36 year old woman presents complaining of chronic vulval itch. She has used a variety of creams given to her by her pharmacist but with no improvement. She is a known diabetic using oral medication. She is obese and on examination of the vulva the skin is noted to be red and inflamed, with evidence of scratch marks and involvement of the groins.
What is the most likely cause of her vulval pruritus?

a. Candidiasis
b. Bacterial vaginosis
c. Trichomonas vaginalis
d. Cancer of the vulva
e. Psoriasis

Answer 10

a. Candidiasis

Question 11

After unprotected sexual intercourse emergency contraceptive pills work best it taken:

a. Within 72 hours
b. Within first 24 hours
c. After the next period
d. With an anti-emetic
e. With combined oral contraceptive pills

Answer 11

a. Within 72 hours

Question 12

A woman should immediately stop the combined oral contraceptive pill and never restart if she experiences:

a. Break through bleeding
b. Severe headaches
c. Weight gain
d. Pulmonary embolism
e. Nausea and vomiting

Answer 12

d. Pulmonary embolism

Question 13

A 32 year old G2P2 with a history of menorrhagia currently controlled with combined pills complains that she is tired of pill taking.
What would the most appropriate contraceptive option would be from the options below?

a. Levonorgesterol intra-uterine releasing system
b. Hysterectomy
c. Copper intra-uterine device
d. Tubal ligation
e. Vasectomy for her partner

Answer 13

c. Copper intra-uterine device

Question 14

A 24 year old woman presents after a single episode of unprotected coitus 24 hours earlier. She requests emergency contraception.
Of the following options, which offers her the best protection against conception?

a. Yuzpe method (Ovral 28, 2 tablets, 12 hours apart)
b. Immediate commencement of the combined oral contraceptive pill
c. GnRH analogues
d. Danazol
e. High dose progestagens (Given in 2 doses, 12 hours apart)

Answer 14

e. High dose progestagens (Given in 2 doses, 12 hours apart)

Question 15

A 32 year old woman, gravida 2 para 1, comes to you complaining of severe secondary dysmenorrhoea and deep dyspareunia. She is not using any contraception and has no medical history of note.
Clinical examination is normal except for a fixed retroverted uterus and some tenderness in the pouch of Douglas.

Which of the following conditions would you consider to be the most likely cause of her symptoms?

a. Spastic colon
b. Uterine fibroids
c. Ectopic pregnancy
d. Pelvic inflammatory disease
e. Endometriosis

Answer 15

e. Endometriosis

Question 16

Which investigation would you consider most appropriate for identifying whether a woman with infertility is ovulating?

a. Ultrasonography
b. Laparoscopy
c. Mid luteal phase serum progesterone
d. Hysterosalpingography
e. Mid-cycle follicular stimulating hormone

Answer 16

e. Mid-cycle follicular stimulating hormone

Question 17

A 25 year old HIV positive woman who has tuberculosis and is socio-economically compromised comes to you requesting a termination of pregnancy. You do not agree with performing termination of pregnancy
What would your next step be?

a. Instruct her about a healthy diet
b. Refer her to the antenatal clinic
c. Refer her to a colleague who does terminations of pregnancy and give her information as to her rights under the Choice of Termination of Pregnancy Act
d. Start antiretroviral therapy
e. Tell her you object to performing termination of pregnancy and ask her to leave

Answer 17

c. Refer her to a colleague who does terminations of pregnancy and give her information as to her rights under the Choice of Termination of Pregnancy Act

Question 18

You see a 36 year old patient at your clinic. She complains of sudden onset of amenorrhoea and on systematic enquiry has a history of galactorrhoea. She has had 2 uneventful pregnancies and subsequently had a tubal ligation 2 years ago. She is not on any medication.
Which investigation would you choose to do first?

a. X-ray skull
b. Serum prolactin
c. Pregnancy test
d. Serum progesterone on day 21
e. Full blood count

Answer 18

b. Serum prolactin

Question 19

What method of termination of pregnancy would you use preferentially in the second trimester?

a. Misoprostol
b. Buccal oxytocin
c. Dilatation and evacuation
d. Intravenous oxytocin
e. Ergometrine

Answer 19

c. Dilatation and evacuation

Question 20

What aspect of a national cervical cancer prevention programme would you consider the most valuable in terms of reducing the incidence of cervical cancer?

a. Screening women who have multiple partners
b. Starting screening women at a young age
c. Screening women every year
d. Screening women who have access to identification documents
e. Maximum coverage of the target population

Answer 20

e. Maximum coverage of the target population

Question 21

A 42 year old, gravida 6 para 6, presents to you complaining of irregular vaginal bleeding associated with an offensive vaginal discharge. On general examination she is well, but she has a fungating mass which has nearly replaced the cervix. Her haemoglobin is 9 gm/dl.
Which investigation would be the most appropriate?

a. Human papilloma virus test
b. Punch biopsy of the mass
c. Chest X-Ray
d. Liver and renal functions
e. Pap smear

Answer 21

b. Punch biopsy of the mass

Question 22

A 34-year-old woman has just started taking the combined oral contraceptive pill. She forgets to take a pill and phones you for advice. It is 12 hours after the time she should have taken the pill.
Which of the following is the most appropriate advice for her?

a. Take the missed pill immediately
b. Start the placebo pills immediately
c. Take two pills straight away
d. Take emergency contraception
e. Have an intrauterine device fitted

Answer 22

a. Take the missed pill immediately

Question 23

A 42 year old, gravida 6 para 6, presents to you complaining of irregular vaginal bleeding associated with an offensive vaginal discharge. On general examination she is well, but she has a fungating mass which has nearly replaced the cervix. Her haemoglobin is 9 gm/dl.
You assume this patient has a cervical cancer, what is the most appropriate treatment?

a. Chemoradiation
b. Local ablative therapy, eg cryotherapy
c. Chemotherapy
d. Radical hysterectomy
e. Oral antibiotics
f. Cone biopsy

Answer 23

f. Cone biopsy

Question 24

A 56 year old woman, gravida 1 para 0, presents to you complaining of dyspepsia, abdominal distension and fatigue. On examination you find that she has signs of wasting, pallor with a mass arising from the pelvis and ascites.
What information or advice would you give the patient during your consultation at this initial visit?

a. Her condition was caused by her infertility
b. You would like to give her antacids and review her condition in 2 months time
c. You suspect that she may have cancer
d. She will be dead in three months
e. It is important she has an HIV test
f. Surgery is unlikely

Answer 24

c. You suspect that she may have cancer

Question 25

A 70 year old woman complains of 2 days of post menopausal bleeding. She had her menopause at age 50. She is only occasionally sexually active with her partner. She is otherwise healthy and the gynaecological examination is completely normal.
The most appropriate approach to this patient would be:

a. You would like to give her antacids and review her condition in 2 months time
b. High vaginal swab
c. Cystoscopy
d. Test her urine for glucose
e. Endometrial sampling
f. Reassure her and ask her to return if the bleeding persists

Answer 25

e. Endometrial sampling

Question 26

A 35-year-old woman is referred to you with a diagnosis of menorrhagia.

Which of the following would most accurately fit her bleeding pattern?
A. Bleeding abnormal in duration and amount at any time in her cycle
B. Cyclical excessive menstrual loss
C. Bleeding abnormal in duration at any time in her cycle
D. Bleeding outside of normal menstruation

Answer 26

B. Cyclical excessive menstrual loss

Question 27

A patient, aged 47 with 3 children, presents to you complaining that she missed her period for 3 months and this was followed by very heavy vaginal bleeding that persisted for 3 weeks.

Which of the following is the most likely cause of her symptoms?
	A. Anovulatory bleed 	
	B. Endometrial cancer 	
	C. Miscarriage 	
	D. Multifibroid uterus

Answer 27

C. Miscarriage

Question 28

A 47-year-old woman who smokes 20 cigarettes per day has complained of menorrhagia for one year. You have investigated her and treated her with cyclical progesterone therapy without improvement. She does not want any surgery.

Which of the following is the most appropriate option for her?
A. Depo medroxy-progesterone acetate
B. Continuous oral progesterone
C. Combined oral contraceptive pill
D. Progesterone-releasing intra-uterine device

Answer 28

A. Depo medroxy-progesterone acetate

Question 29

A 25 year old patient who has never been pregnant complains of heavy cyclical bleeding and primary dysmenorrhoea. Clinical examination is normal.

What would be your first choice of treatment from the list of options below?
A. Progesterone-releasing intra-uterine device
B. Danazol
C. Combined oral contraceptive pill
D. Oral progesterone

Answer 29

C. Combined oral contraceptive pill

Question 30

A 32 year old with 2 healthy children has a history of menorrhagia which is currently somewhat controlled with combined oral contraceptive pills. She complains that she is tired of pill taking.

What would the most appropriate contraceptive choice be for her?
A. Progesterone-releasing intra-uterine device
B. Tubal ligation
C. Hysterectomy
D. Copper intra-uterine device

Answer 30

A. Progesterone-releasing intra-uterine device

Question 31

A 36 year old woman presents complaining of chronic vulval itch. She has used a variety of creams given to her by her pharmacist but with no improvement. She is a known diabetic using oral medication. She is obese and on examination of the vulva the skin is noted to be red and inflamed, with evidence of scratch marks and involvement of the groins.
What is the most likely cause of her vulval pruritus?
A. Lichen sclerosus et atrophicus
B. Psoriasis
C. Trichomonas vaginalis
D. Candidiasis

Answer 31

D. Candidiasis

Question 32

A woman should immediately stop the combined oral contraceptive pill and never restart if she experiences which of the following conditions:
	A. Break-through bleeding 	
	B. Nausea and vomiting 	
	C. Severe headaches 	
	D. Pulmonary embolism

Answer 32

D. Pulmonary embolism

Question 33

A woman complains of excessive nausea and vomiting at 10 weeks gestation by dates. On ultrasound she is found to have a molar pregnancy.

What method of treatment would you recommend from the list below?
A. Misoprostol
B. Suction evacuation under ultrasound guidance
C. Intravenous oxytocin
D. Dilatation and evacuation

Answer 33

B. Suction evacuation under ultrasound guidance

Question 34

You are asked to address a girls’ school about cancer of the cervix. You decide to address the issue of preventative cytology and advise them to attend for screening.

When would you encourage the girls to have their first Pap smear?
	A. Aged 18 years 	
	B. Before she becomes sexually active 	
	C. Once she becomes sexually active 	
	D. Aged 21 years

Answer 34

C. Once she becomes sexually active

Question 35

A 45 year old woman presents to you with a foul smelling discharge and intermittent vaginal spotting. She has a firm, fungating lesion on vaginal examination.

What would you consider to be the most likely diagnosis?
	A. Cervical carcinoma 	
	B. Foreign body 	
	C. Pelvic inflammatory disease 	
	D. Endometrial cancer

Answer 35

A. Cervical carcinoma

Question 36

A 23 year old woman presents to you complaining of 8 weeks of amenorrhoea. She is sexually active and not using any contraception. She is also complaining of increasingly severe abdominal pain, associated with nausea but no vomiting.

On examination you find that she is apyrexial and, on palpation of the lower abdomen, there is guarding and rebound tenderness. This is confirmed on vaginal examination, which reveals cervical excitation tenderness.

Which of the following conditions would you consider to be the most likely cause of her symptoms?
	A. Pelvic inflammatory disease 	
	B. Ectopic pregnancy 	
	C. Acute appendicitis 	
	D. Threatened miscarriage

Answer 36

B. Ectopic pregnancy

Question 37

A 23 year old woman presents to you complaining of 8 weeks of amenorrhoea. She is sexually active and not using any contraception. She is also complaining of increasingly severe abdominal pain, associated with nausea but no vomiting.

On examination you find that she is apyrexial and, on palpation of the lower abdomen, there is guarding and rebound tenderness. This is confirmed on vaginal examination, which reveals cervical excitation tenderness.

What would you consider to be the most appropriate further management of this patient?
	A. Laparoscopy or laparotomy 	
	B. CT scan of the abdomen 	
	C. Dilatation and curettage 	
	D. Referral for a surgical opinion

Answer 37

A. Laparoscopy or laparotomy

Question 38

Which investigation would you consider most appropriate for identifying whether a woman with infertility is ovulating?
A. Mid-cycle follicular stimulating hormone
B. Ultrasonography
C. Mid luteal phase serum progesterone
D. Laparoscopy

Answer 38

C. Mid luteal phase serum progesterone

Question 39

A 32-year-old woman is referred to you with a diagnosis of infertility.
You take a history from her to try to establish if she is ovulating.

Which factor from the options below would be the best evidence that she is ovulating?
	A. Premenstrual tension 	
	B. Premenstrual dysphoria 	
	C. Dysmenorrhoea 	
	D. A regular menstrual cycle

Answer 39

D. A regular menstrual cycle

Question 40

A 51 year old woman suffering from menopausal symptoms consults you about hormonal replacement therapy. She has previously taken progesterone but she felt it made her depressed and asks if she can take oestrogens only for her symptoms of hot flushes.

Which of the following options do you think is the most important reason why she should not receive oestrogen-only treatment?
A. Danger of endometrial hyperplasia/cancer
B. Irregular bleeding
C. Danger of breast cancer
D. Deep vein thrombosis

Answer 40

A. Danger of endometrial hyperplasia/cancer

Question 41

A 51 year old woman suffering from menopausal symptoms consults you about hormonal replacement therapy. She has previously taken progesterone but she felt it made her depressed and asks if she can take oestrogens only for her symptoms of hot flushes.

Which of the following options do you think is the most important reason why she should not receive oestrogen-only treatment?
A. Danger of endometrial hyperplasia/cancer
B. Irregular bleeding
C. Danger of breast cancer
D. Deep vein thrombosis

Answer 41

A. Danger of endometrial hyperplasia/cancer

Question 42

Combined hormonal replacement therapy is proven to have a protective effect on the development of which one of the following conditions?
	A. Alzheimer’s disease 	
	B. Osteoporosis 	
	C. Ovarian cancer 	
	D. Prolapse

Answer 42

B. Osteoporosis

Question 43

A 52 year old woman presents to you complaining of symptoms of the menopause; hot flushes, vaginal dryness, irritability and insomnia. She reports that her symptoms are interfering with her quality of life and causing difficulties in her relationship with her husband.

What would be the most appropriate approach to the care of this patient?
A. Start hormonal replacement therapy immediately
B. Blood tests for FSH and LH
C. Discuss with her the risks and benefits of hormone replacement therapy
D. Blood tests for oestrogen levels

Answer 43

C. Discuss with her the risks and benefits of hormone replacement therapy

Question 44

A 55 year old woman presents to you with bleeding on and off for the last 3 months. On ultrasound the endometrial thickness is found to be 18 mm.

What from the selection below would be the most appropriate investigation?
A. Cervical biopsy
B. Repeat ultrasound measurement in one month
C. Pap smear
D. Hysteroscopy v

Answer 44

D. Hysteroscopy v

Question 45

A 24 year old woman with one child presents to you complaining of a foul smelling discharge associated with increasingly severe abdominal pain. She is using intramuscular medroxyprogestone for contraception. On examination you fund that she is pyrexial, with evidence of lower abdominal peritonitis.

Which of the following conditions is the most common long-term complication of the situation described above?
	A. Renal failure 	
	B. Arthritis 	
	C. Endocarditis 	
	D. Infertility

Answer 45

D. Infertility

Question 46

A 24 year old woman with one child presents to you complaining of a foul smelling discharge associated with increasingly severe abdominal pain. She is using intramuscular medroxyprogestone for contraception. On examination you fund that she is pyrexial, with evidence of lower abdominal peritonitis.

Which of the following investigations are most likely to be abnormal?
	A. HIV 	
	B. Haemoglobin 	
	C. Pregnancy test 	
	D. White cell count

Answer 46

D. White cell count

Question 47

A 24 year old woman with one child presents to you complaining of a foul smelling discharge associated with increasingly severe abdominal pain. She is using intramuscular medroxyprogestone for contraception. On examination you fund that she is pyrexial, with evidence of lower abdominal peritonitis.

What would be the most appropriate management of this patient?
A. Oral antibiotics
B. Pelvic ultrasound
C. Ask for a surgical opinion
D. Admit to hospital and start intravenous antibiotics and analgesia

Answer 47

D. Admit to hospital and start intravenous antibiotics and analgesia

Question 48

A 32 year old woman with one child comes to see you complaining of severe secondary dysmenorrhoea and deep dyspareunia. She is not using any contraception and has no medical history of note. Clinical examination is normal except for a fixed retroverted uterus and some tenderness in the pouch of Douglas.

Which of the following conditions would you consider to be the most likely cause of her symptoms?
	A. Uterine fibroids 	
	B. Pelvic inflammatory disease 	
	C. Spastic colon 	
	D. Endometriosis

Answer 48

B. Pelvic inflammatory disease

Question 49

You see a 36 year old patient at your clinic. She complains of sudden onset of amenorrhoea and on systematic enquiry has a history of galactorrhoea. She has had 2 uneventful pregnancies and subsequently had a tubal ligation 2 years ago. She is not on any medication.
Which investigation would you choose to do first?
A. Thyroid function tests
B. X-ray skull
C. Serum prolactin
D. Serum progesterone on day 21

Answer 49

C. Serum prolactin