Gynaecology

Question 1

HEAVY MENSTRUAL BLEEDING
i) what is avg blood loss during menstruation? what counts as excessive?
ii) name five potential causes? what examination should be performed? (2) what is it used to assess?
iii) what bloods should be done? name three indications of outpatients hysteroscopy?
iv) give three indications for pelvic and TV US?
v) name three other tests that may be done

Answer 1

i) normally lose 40ml, excessive is 80ml+
ii) dysfunctional uterine bleeding (idiopathic), extremes of repro age, fibroids, endometriosis, PID, contraceptives (copper coil), bleeding disorders (VWF), endometrial hyperplasia/ancer, PCOS
do a pelvic exam with a speculum and bimanual > for fibroids, ascites and cancer
iii) FBC to look for iron defic anaemia
hysteroscopy - suspected submucosal fibroids, suspected endometrial pathol (hyperplasia/cancer), persistent intermenstrual bleeding
iv) US - possible large fibroids (pelvic mass), poss adenomyosis, exam difficult to interpret eg obesity
v) may swab to look for infection, coag screen, ferritin, TFT (hypothyroid)

Question 2

HEAVY MENSTRUAL BLEEDING MANAGEMENT
i) name two treatments for symptomatic relief? which is used when there is pain and which when there is no pain?
ii) name three contraceptives that can be used to mx?
iii) when is a patient referred to secondary care for mx?
iv) what can be done with medical mx has failed? (2) what do these involve?

Answer 2

i) tranexamic acid when no pain (anti fibrinolytic)
mefanamic acid when paain (NSAID - reduces bleed and pain)
ii) mirena coil is first line, COCP amd cyclical oral progestogens eg norethisterone 5mg TDS (assoc with VTE)
iii) refer if tx unsucessful, severe symptoms or large fibroids
iv) failure of medical mx - endometrial ablation (destroys endometrium) or hysterectomy

Question 3

FIBROIDS
i) what are they? what are they aka? what hormone are they sensitive to?
ii) what are the four types?
iii) name five ways they can present? which is most common? what may be felt on abdo and bimanual exam?
iv) name three investigations

Answer 3

i) benign tumours of smooth muscle of uterus - aka uterine leiomyomaa
sensitive to oestrogen - grow in response
ii) intramural - within myometrium
subserosal - below outer layer, grow outwards
submucosal - below endometrium
pedunculated - on a stalk
iii) can be asymp
heavy mens bleeding is most common
prolonged menstruation >7d, bloating, urinary symp eg pelvic pressure/fullness, deep dysparunia, reduced fertility
abdo exam - palp pelvic mass, enlarged firm tender uterus
iv) ix - hysteroscopy (for submucosal fibroids px wih heavy mens bleeding), pelvic US for large fibroids, MRI scanning

Question 4

FIBROIDS MX
i) what are fibroids <3m managed the saame as? name four ways
ii) name three surgical options for larger fibroids
iii) what drug may be given to reduce fibroid size pre op?
iv) name four complications
v) what is red degeneration? when is it likely to occur? how can it px? how is it managed

Answer 4

i) <3cm mx the same as heavy mens bleeding
mirena coil is 1st line, symptomatic (NSAID/TXA), COCP or cyclical oral progres
ii) endometrial ablation, resection if submucosal, hysterectomy
iii) GnRH agonists eg goserelin or leuprorelin - reduce oestrogen
iv) heavy bleeding (fe defic anaemia), reduced fertility, preg complications, constipation, red degeneration, torsion, malignant change
v) red degen = ischaemia, infarction and necrosis due to disrupted blood supply
more likely to occ if larger than 5cm durimg second trimester of preg
px with severe abdo pain, low grade fever, vomiting
mx with rest, fluid, analgesia

Question 5

ENDOMETRIOSIS
i) what is it? what is adenomyosis?
ii) what is the main symptom? what causes this? what may be found due to local bleeding/inflamm? what type of pain do these lead to?
iii) name four symptoms it may present with?
iv) what may be seen on speculum exam? what may be found on bimanual exam? where may there be tenderness?
v) what imaaging is used? what type of cyst may be seen? what is gold standard for dx?

Answer 5

i) ectopic endometrial tissue is found outside of the uterus = endometrioma (chocolate cyst in the ovaries)
adenomyosis - endometrial tissue within the myometrium of uterus
ii) main symptom is pelvic pain caused by cyclical inflam and bleeding
may also get adhesions = chronic non cyclical pain
iii) cycliccal abdo or pelvic pain, deep dysparunia, painful periods, infertility, urine symp
iv) speculum - endometrial tissue in vagina
bimanual - fixed cervix
tenderness in vagina, cervix, adnexa
v) pelvic US - may see endometriomas or chocolate cysts but may be unremarkable
gold standard is laparoscopic surgery with biopsy

Question 6

ENDOMETRIOSIS MX
i) what does initial mx involve? (4)
ii) name four methods of hormonal mx? when may this be used?
iii) what are the surgical mx options?
iv) which option may improve fertility?

Answer 6

i) establish dx, explain, listen to patient concerns, analgesia
iii) COCP, POP, injection, nexplanon implant, mirena coil, GnRH agonists
used before a definitive dx is estab by laparoscopy
iii) laparoscopy to excise or ablate
hysterectomy
iv) lap may improve fertility
hormonal maay improve symptoms but not fertility

Question 7

PREMATURE OVARIAN INSUFFICIENCY
i) what is it defined as? what type of hypogonadism is it?
ii) what LH and FSH levels are seen? what oestradiol levels are seen?
iii) name five causes
iv) name four ways it may present? how is it diagnosed? (2) FSH level

Answer 7

i) menopause before the age of 40
hypergonadotrophic hypogonad - lack of negative feedback on pit gland therefore excess gonadotrophins are produced
ii) high LH and FSH and low oestradiol
iii) idiopathic, iatrogenic, autoimmune (coeloac, adrenal insuff, T1DM), genetic, infections (TB, CMV, mumps)
iv) irregular perioods, lack of periods, low oes levels - hot flush, night sweats and vaginal dryness
dx in women younger than 40 with typical menopausal symptoms aand an elevated FSH (>25 on two seperate ocassions)

Question 8

POI MX
i) how is it managed? (2) why is it managed in this way?
ii) is there still a possibility of pregnancy?
ii) what may there be increased risk of with this mx

Answer 8

i) mx with HRT until at least the age of normal menopause to reduce CV, osteoporosis, psych risks
HRT - traditional or COCP
ii) yes still small chance of pregnancy
iii) inc risk of VTE

Question 9

PCOS
i) name five characteristic features
ii) what criteria is used to make a dx? name thre three key features? how many are needed for a dx?
iii) name four things a patient may px with? name three other features/complications
iv) how may insulin resistance leaad to PCOS/anovulation?

Answer 9

i) multiple ovarian cysts, infertility, oligomenorea, hyperandrogenism, insulin resistance
ii) rotterdam criteria
1) oligo-ovulation or anovulation - irregular or absent menstrual periods
2) hyperandrogenism - hirsutism and acne
3) PCO on ultrasound or ovarian volme more than 10cm3
iii) oligo/amennorea, infertility, obesity, hirsutism, acne, male pattern hair loss
may also have - insulin resis/diabetes, acanthosis nigracans, CV disease, OSA
iv) insulin resis > panc makes more > insulin promotes androgen release from ovaries
insulin supresses SHBG which binds androgens

Question 10

PCOS IX
i) name five bloods that may be done to exclude other pathology
ii) what levels of LH will be seen? what LH:FSH ratio will be seen? what levels of testos, insulin and oestrogen may be seen?
iii) what is the gold standard imaging to confirm’? what appearance may be seen? who is this not reliable in?
iv) what ovarian volume can indicate PCOS even with the absence of cysts?
v) what screening test is done for diabetes?

Answer 10

i) testosterone, SHBG, LH, FSH, PRL, TSH
ii) high LH, raised LH:FSH ratio
raised testos, insulin, oes
iii) transvaginal US is gold standard
follicles arranged around periphery of ovary = string of pearls appearance
not reliable in adolescence
iv) ovariam vol >10cm3 can be dx
v) oral glucose tolerance test - fast then give 75g glucose drink then measure plasma glucose 2 hours later

Question 11

PCOS MX
i) what four things need to be risk reduced? naeme four complications of PCOS
ii) what is a significant part of mx? what can be given to helpo this
iii) which cancer at patients more at risk of?

Answer 11

i) obesity, T2DM, high choles, CVD
complications - endometrial cancer, infertility, hirsutism, acne, OSA, depression
ii) weight loss > orlistat (lipase inhibitor)
iii) endometrial

Question 12

OVARIAN CYSTS
i) what is it a cyst? what is a functional cyst? who are they common in? at what point in life are cysts more concerning?
ii) two of which three things are required for PCOS dx?
iii) name four vague symptoms that may be seen? name three things that may have happened if they px with acute pelvic pain?
iv) what are the most common type? how do they look on US? which type are often seen in early pregnancy? what sympptom may they cause?

Answer 12

i) fluid filled sac
functional - related to fluctuating hormones of the menstrual cycle - common in pre meno women
more concerning in post meno women for malignancy
ii) anovulation, hyperandrogenism, PCOS on US
iii) pelvic pain, bloating, fullness in abdo, palpable pelvic mass
acute pelvic pain - torsion, haemmorhage or rupture of cyst
iv) follicular are most common - fail to rupture and release egg sp persist - have thin walls and no internal structure on US
corpus luteum cysts are seen in early preg - can cause pelvic discomfort, pain, delayed menstruation

Question 13

OVARIAN CYSTS IX
i) name five features that may suggest malignancy? name four RF for ovarian malignancy? what does risk of ovarian ca correlate with?
ii) which woman does not need further investigation after US? what tumour marker is used for ovarian ca detection? name three markers for a GCT
iii) name thre causes of a raised tumour marker used in ovarian ca
iv) which three things are included n the risk of malignancy index?

Answer 13

i) abdo bloating, reduced appetite, early satiety, weight loss, urine symptoms, pain, ascites, lympohadenopathy
RF - age, post meno, increased number ovulations, HRT, smoking, breastfeeding is protective
inc risk correlates with inc number of ovulations
ii) pre meno women with simple ovarian cyst <5cm on US
CA125 marker for detection
GCT - AFP, LDH, HCG
iii) raised ca125 - very non specific - also raised in endometriosis, fibroids, adenomyosis, PID, liver disease, pregnancy
iv) risk of malig index - meno status, US findings, CA125 level

Question 14

OVARIAN CYSTS MX
i) which two things warrant 2WW referral?
ii) how is a simple cyst in pre meno woman managed if <5cm, 5-7cm, >7cm,?
iii) what marker must be done for cysts in post meno women?
iv) name three complications of cysts?
v) what is meig syndrome?

Answer 14

i) complex cyst or raised ca125
ii) <5cm - usually resolve in three cycles
5-7cm - routine refer to gynae and yearly monitor
>7 - MRI or surgical intervention
iii) CA125
iv) torsion, haemmorhage into cust or rupture with bleeding into peritoneum
v) meig syndrome is a triad of ovarian fibroma (benign ovarian tumour), pleural effusion and ascites (remove tumour usually resolves all three)

Question 15

OVARIAN TORSION
i) what happens? what is it usually caused by? when is it more likely to occur? (2)
ii) what does torsion cause and what can it lead to if it persists? how quickly does it need to be tx?
iii) what is the main presenting symptom? what is this associated with?
iv) what is found on examination? what may be palpable?
v) what is the first line investigation? what sign may be seen? what causes this? how is a definitive dx made?

Answer 15

i) ovary twists in relation to surrounding connective tissue, fallopian tube and blood sup
usually caused by an ovarian mass >5cm
more likely to occur in pregnancy and in young girls befor menarche where ligaments can twist easier
ii) causes twisting leading to ischaemia and necrosis if it persists > ovarian function will be lost
emergency tx
iii) px with sudden onset severe unilateral pelvic pain that gets progressively worse and is assoc with N+V
iv) OE - localised tenderness and may be a palpable mass
v) pelvic US is first line (TV is ideal)
see whirlpool sign due to free fluid in pelvis and oedema in ovary
defintiive dx by lap surgery

Question 16

OVARIAN TORSION MX
i) what needs t happen immediately? what can be done surgically? (2)
ii) what type of sx may be done if large mass or malignancy is suspected?
iii) what can delay in tx lead to?
iv) what can happen if a necrotic ovary is niot removed? name two other things that can happen as a complication

Answer 16

i) urgent refer to gynae
lap surgery to untwist and fix in place (detrsion) or remove affected ovary
ii) laparotomy
iii) delay can lead to loss of function of ovary
iv) necrotic > infected > abscess > sepsis
may also rupture > peritonitis and adhesions

Question 17

ADENOMYOSIS
i) what is it? who is it more common in? what two things can it occur alongside?
ii) what does it depend on? when does it usually resolve?
iii) name three things it typically px with? what can examination demonstrate?
iv) what is first line investigation? what is the gold standard investigation?

Answer 17

i) endometrial tissue inside the myometrium
more common in later reproductive years and those that have had several pregnancies
can occ alongside endometriosis or fibroids
ii) depends on hormones and symptoms tend to resolve after the menopause
iii) px with painful and heavy periods and pain during intercourse
examination - enlarged tender uterus
iv) first line is TV US (can also do MRI or trans abdo US)
gold standard is histolgical exam of uterus after hysterectomy

Question 18

ADENOMYOSIS MX
i) what is it treated the same as? name two tx that dont involve contraception
ii) what is first line contraceptive mx? name two others?
iii) name three other ways to mx
iv) name four complications adenomyosis is assoc with in pregnancy

Answer 18

i) same as heavy menstrual bleeding
TXA or mefanemic acid
ii) mirena coil is first line, then COCP and cyclical oral progestogens
iii) mx with GnRH analogues, endometrial ablation, uterine artery embolisation, hysterectomy
iv) infertility, miscarraige, preterm birth, SGA< PROM, CS, post partum haemmorhage

Question 19

URINARY INCONTINENCE
i) what are the two main types? what happens in each?
ii) when does overflow incontinence occur? name threet hings that can cause it?
iii) name five RF for UI
iv) which type can be triggered by cough/sneeze? which gives a sudden urge to pass urine?

Answer 19

i) urge incontinence - overactivity of detrusor muscle (overactive bladder)
stress incont - pelvic floor muscles are weak > lax and urethra/vagina/rectal canals are poorly supported > uine leaks at times of inc pressure on bladder eg cough
ii) overflow when there is chronic retention due to an obstructuin to outflow
can occ with anti cholinergic medication, fibroids, pelvic tumours, neuro conds eg MS
rare in women > refer for urodynamic testing
iii) RF inc age, post meno, inc BMI, preg/vaginal delivery, pelvic organ prolapse, pelvic floor sx
iv) cough sneeze - stress
sudden urge - urge

Question 20

URINARY INCONTINENCE IX
i) name three modifiable RF that can contribute?
ii) what should examination assess? name three things that should be examined for?
how can strength of pelvic muscles be tested?
iii) name three things that can be done to investigate
iv) what is urodynamic testing? what medicaton must be stopped five days before

Answer 20

i) caffiene consumption, ETOH, medications, BMI
ii) assess pelvic tone and examine for pelvic organ prolapse, atrophic vaginitis, urethral diverticulum, pelvic massess
strength assess by bimanual exam and ask women to squeeze against examining fingers - grade with modified oxford grading system
iii) bladder diary, urine dip, post void residual bladder vol, urodynamic testing
iv) urodynamic - assess prescence and severity of urinary symptoms
thin catheter into bladder and rectum > measures pressures in each and compare
also take measurements after filling bladder with liquid

Question 21

URINARY INCONTINENCE MX
i) what needs to be done first? where are most patients managed?
ii) name four mx for stress incont? what exercises can ebd one? which drug can be given? name three surg
iii) name three ways urge incontinence can be managed? name three invasive options

Answer 21

i) distinguish between urge and stress - most mx in primary are
ii) stress - avoid caffiene, diuretics, excess fluid intake, weight loss,
pelvic floor exercises for 3m before considering sx
duloextine can be given if surgery isnt suitable
surgical - tension free vaginal tape (supports urethra), sling procedure, colposuspension, intramural uretheral bulking
iii) bladder retaining is first line (gradually increase time between wee for 6 weeks)
anti cholinergics eg oxybutinin
mirabegron (less anti cholinergic burden)
invasive - botox, perc sarcral nerve stim, urinary diversion (urostomy)

Question 22

ATROPHIC VAGINITIS
i) what is it? what causes it? who does it occur in?
ii) name four symptoms women may px with? name three things that may px in an older woman where AV should be considered?
iii) name five things that may be seen on exam of labia and vagina
iv) what can be used to help with dryness? which treatment can make a big difference to symtoms? name four options for this
v) name three contraindications of this tx

Answer 22

i) dryness and atrophy of vaginal mucosa due to lack of oestrogen
occurs in women entering the menopause
ii) itchy, dry, dysparuniea, bleeding due to loc inflam
older woman with recurrent UTIs, stress incont or pelvic organ prolapse
iii) exam = pale mucosa, thin skin, reduced skin folds, erythema/inflamm, dryness, sparse public hair
iv) vaginal lubricant to help with dryness
topical oestrogen can help = estriol cream before bed, estriol pessaties at bedtime, estradiol tablets, estradiol ring replaced every 3 m
v) CI to oestrogen tx = breast cancer, angina, VTE (same as HRT)
monitor women at least annually

Question 23

INFERTILITY
i) when should referral be made for couples struggling to concieve? what if the woman is older than 35?
ii) what is the most common cause? name three other causes? is timed intercourse reccomended?
iii) name three ix that can be done in primary care? which five female hormones can be tested?
iv) what does high FSH indicate? what may high LH indicate?
v) what is a hyerterosalpingogram? what can it help with?

Answer 23

i) refer after 12 months
if over 35 then refer after 6 months
ii) sperm problems most common then ovulation problems, tubul problems, uterine problems, unexplained
dont reccom timed intercourse
iii) BMI, chlamidya screen, semen analysis, remale hormone testing, rubella immunity
hormones - LH and FSH d 2-5
progesterone on d21
AMG, TFTs, prolactin
iv) high FSH may indicate low ovarian reserve
high LG can suggest PCOS
v) HSG - scan to assess shape of uterus and patency of the fallopian tubes - can be dx and have therapeutic benefit by opening up the tubes

Question 24

MX OF INFERTILITY
i) name four ways to manage anovulation? what drug can be given to stim ovulation? how does it work?
ii) name three ways tubal abnormalities can be mx?
iii) name three ways sperm problems can be mx?

Answer 24

i) weight loss if overweight, ovarian drilling, metformin
clomifene can stim ovulation (anti oes) given on day 2 and 6 of cycle > inc GnRH rel and FSH/LH
can also give letrozole or gonadotrophins instead of clomifene
ii) tubal cannulation during hysterosalpingogram, laparoscopy to remove adhesions/endo, IVF
iii) sperm - surgical sperm retrieval direct from epididymis, IUI of sperm direct to uterus, intracytoplasmic sperm injection (sperm inject to cyto of egg), donor insemintation

Question 25

PELVIC ORGAN PROLAPSE
i) what is it a result of? what is a vault prolapse?
ii) what is a rectocele? what caauses it? what is it associated with? what is a cystocele?
iii) name four risk factors? name three presenting symptoms?
iv) what type of speculum is used on examination? how can the full extent of the prolapse be assesed?
v) what grading system is used for severity?

Answer 25

i) result of weakness and lengthening of ligaments and muscles surrounding uterus, rectum and bladder
vault = top of the vagina - when a women hsa had a hysterectomy and top of vagina descends down
ii) rectocele = defect in posterior vaginal wall allowing rectum to prolapse forward into vaagina
assoc with constiption and palpable lump in vagina
cystocele is a defect in anterior vaginal wall and bladder prolapses backwards into vagina
iii) RF - multiple vaginal deliveries, instrumental/prolonged delivery, adv age, obesity, chronic resp disease causing coughing, chronic constipation
px = something coming down vaginaa, dragging/heavy sensation, urinary symptoms, bowel symptoms, sexual dysfunction
iv) sims speculum U shaped - support ant/post vaginal wall while other is examined
cough or bear down to aassess full extent
v) grading - POP Q

Question 26

PELVIC ORGAN PROLAPSE MX
i) what are the three mx options?
ii) who is conservative mx for? name three things that can be done
iii) what do vaginal pessaries used for? name three types? how can irritation be protected against?
iv) what is the definitive option? name three possible complications?

Answer 26

i) conservative, vaginal pessary and surgery
ii) conservative if mild symptoms, dont tol pessaries or surgery
physio, weight loss, lifestyle change, vaginal oes cream
iii) pessaries insert into vagina to provide extra support - irritation reduced by oestrogen cream
iv) definitive - sx
complicat - pain, bleed, DVT, damage bladder/bowel, recurrence, change in sex sensation