Gynaecology Flashcards by Maia Cunningham

Lady who’s been on depo provera for 5y and wishes to continue but it’s been 91d since her last depo and she had unprotected sex last night
Give the “morning after“ pill immediately
Insert a copper IUD immediately
Give her the depo today, no further management

Give her the depo today, no further management

Safe for 14 weeks

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Chica with whitish vaginal discharge, smelled fishy, not itchy or painful.
Bacterial vaginosis
Candida
Trich
Chlamydia
Gonorrhoea

Bacterial vaginosis

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Young woman with RIF pain, bit of a temp. Also had nausea/pelvic pain for 2 weeks. Vag exam showed pain in both fornices R>L. Rebound tenderness. IUCD in place for 6 months no problems. No discharge. What’s she got now?
Appendicitis
Acute salpingitis
Tubal abscess
Haemorrhagic cyst

Salpingitis/a type of PID essentially, IUD predisposes to this.

Tuboovarian - more likely to have mass, more +++ peritonism symptoms

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Old lady with dementia and heaps of comorbidities who has vaginal prolapse, what is best management?
Ring pessary
Hysterectomy
Oestrogen cream

Ring pessary

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Lady in 50s with abdominal discomfort and fullness, palpable mass, CA-125 within normal limits, U/S shows cystic mass
Cystadenoma
Carcinoma
Urachal cyst

Cystadenoma

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Girl had unprotected sex on day 14 of 28 day cycle with a bicornate uterus, what do you give her as emergency contraception
IUD
Levonogestrel (Postinor- ECP) stat single dose

Lovenogestrel

Structural abnormalities - absolute contraindication

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4m of amenorrhoea with PCOS sx (increasing hirsutism + acne). First investigation?
Urine B-HCG
TV U/S
FSH/LH assays

Urine B-HCG

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Was there a vulval cyst? Yes! (Otherwise called Bartholins cyst) Previously had similar painful lump on the other side, settled with antibiotics. This time still febrile and very uncomfortable despite ABx. What is the best management?
Aspiration
Marsupialisation
Excision
Different antibiotics

Marsupialisation

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Lady with RLQ pain. Regular 28-30 day cycle, last period 2 weeks ago. Had small amount of fluid in Pouch of Douglas, cyst seen in left ovary. Beta HCG negative.
- Endometriosis
- Ectopic pregnancy
- Dermoid cyst
- Haemorrhagic corpus luteum

Haemorrhagic corpus luteum

?typo re: left/right

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Women having lots of unprotected sex x3 last night. What do you give her for ECP

Levenorgesterol
Implanon
- GNRH antagonist analogue
- Depot injection

Levenorgesterol

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49 year old lady who smokes 20 ciggys a day and has a BMI of 35 has irregular bleeding. Management
- Cyclical progesterone + continuous estrogen
- Both continuous
- COCP

Continuous estrogen + cyclical progestogen

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Lady going through menopause, period has become irregular over last 6 months and infrequent but she’s getting flushing and night sweats. Treatment?
Oestrogen and cyclical progesterone
Oestrogen only
Continuous oestrogen and progesterone
COC

Oestrogen and cyclical progesterone

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Male presents with scant watery yellow penile discharge. What should we treat him with empirically before receiving swab results?
Azithromycin PO
Cef IM

Azithromycin PO

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16 yr old girl. Menarche at 13. Painful periods. Already tried mefenamic acid/other NSAIDs etc with no relief. Not sexually active
What you do?
● Explorative laparotomy
● Fluoxetine hydrochloride
● COCP
● Tranexamic acid

COCP

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Woman with both urinary stress incontinence and detrusor instability. Mild cystocele. Tried pelvic floor exercises but no success. Treatment?
a. TFVT
b. Oxybutinin
c. Pelvic floor exercise
d. Anterior vaginal wall repair

TFVT

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GYN 1. Girl with irregular periods, treated for acne as a teenager. BMI 29, facial hair. What investigations do you do for diagnosis?
a) BHCG
b) Transvaginal USS

TUSS
Sounds like PCOS

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Lady presents with a few years of deep dyspareunia and congestive dysmenorrhoea, has been trying to conceive unsuccessfully for maybe 3 years. Periods are otherwise regular, every 28d and 5d long, (?normal volume?). Pain on palpation in the posterior fornix and nodules felt on uterosacral ligaments. USS showed beaded appearance of uterosacral ligaments
A) Endometriosis
B) Adenomyosis
C) PID
D) PCOD

Endometriosis - dysmenorrhea but regular is hallmark

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15 year old having sex with 14 year old boyfriend and only using condoms, they met 2 weeks ago. Wants the pill. What do you do?
a. Tell her parents on her, and don’t give her the pill without their permission
b. Tell the police on her, and don’t give her the pill
c. Counsel and then give her the pill
d. Advice to wait until relationship is more secure
e. Advice abstinence is best.

c. Counsel and then give her the pill

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Girl with bad acne and wants treatment has been using face washes etc. currently uses condoms for contraception and wants to start the pill. Acne all over her face, back etc. what do you do?
a) Refer to dermatologist for retinioids
b) Doxycycline
c) Isotretinoin
d) Prescribe OCP

Prescribe OCP

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19 year old girl. Never sexually active. Regular 28 day cycle. 3 weeks of increasing pelvic pain (relation to period unknown yay). US shows 5cm mixed cystic/solid mass.
a) Serous cystadenoma
b) Dermoid cyst
c) Corpus luteum cyst
d) Ectopic Pregnancy

Dermoid cyst - large, mixed mass

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GYN 80. 20-something lady comes in for ovarian cancer test, no symptoms, no FHx, otherwise well, co-worker had recent diagnosis
Screen from age 40
Order USS?
Order CA-125
Advise testing not indicated
Perform Bimanual examination

Advise testing not indicated

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Middle aged lady with heavy bleeding, small clots. Anaemic. Gets migraines with aura. Does not want to become pregnant.
a) OCP
b) Depo-progesteron
c) Progesterone in luteal phase
d) Other stuff
e) Mirena®

e) Mirena®

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A guy who had noticed some vesicular lesions and shallow ulcers on his penis. His girlfriend gets recurrent cold sores. What investigation would you choose?
a. Swab base of ulcer for bacterial culture
b. Swab base of ulcer for HSV then PCR
c. Serology of HSV
d. Take biopsy
e. Girlfriend’s HSV serology

b. Swab base of ulcer for HSV PCR

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Lady with reasonable incontinence worse with exercise, question confirmed it was stress incontinence. 3 children. Had tried pelvic floor exercises not helped. O/E Grade 1 prolapse, Grade 1 cystocoele, Grade 1 rectocoele. Next step in treatment? Anterior repair TVT Bladder retraining Doxazosin Pelvic floor exercises

TVT 'tape sling' thingie

Which one is not an absolute contraindication of OCP? 36 yo woman Mum was diagnosed with breast cancer at age 50 Smoking 20 cigs a day Cholestasis at the end of every pregnancy Migraine with transient loss of vision Positive anticardiolipin antibodies (Increased risk of DVT)

Cholestasis at the end of every pregnancy

Women with abdo pain for the last 2 days, had sterilisation 15 years ago. First day LMP 3 weeks ago. A 10cm unilocular epithelial ovarian mass seen on US. She also had some symptoms too ? pain or heaviness? Most likely diagnosis? serous cystadenoma Kroekenberg tumour Mucinous cystadenocarcinoma Corpus luteum cyst Dermoid cyst Teratoma

serous cystadenoma

50 year-old lady presents with an abdominopelvic mass which can be palpated just below the xiphisternum (!) Unilocular cyst is seen on the USS. Ca125 is within normal limits. What is the most likely diagnosis? - ovarian cystadeoma - mucinous carcinoma - serous adenocarcinoma - secondary colon cancer

ovarian cystadeoma

37 year-old woman has recently come off the OCP. LIF pain with periods, initial spotting for 2-3 days before heavier flow, but everything else normal (regular 5/28 cycle). No dyspareunia or pain on defecation. Also gets right-sided pain mid-cycle. Proven male factor fertility. Most likely cause of infertility? Endometriosis Endometrial hyperplasia Abnormal cervical mucus

Endometriosis

Middle age woman with stress incontinence, 3 kids, pelvic muscle exercise not helpful, on examination, mild cyctocoele and rectocoele and uterus prolapse, what further treatment: · Surgery for stress incontinence · Anterior vaginal repair · Estrogen cream · Pelvic floor training · Bladder retraining

Surgery for stress incontinence

14 year old started her periods 1 year ago, they are irregular and bleeding is heavy and last 2 weeks sometimes with clots. //Now cycle very irregular, when has periods they are heavy with clots and last a week. Feels tired all the time. What is going on?

Anovulatory cycles

19 y/o woman regular periods, mixed solid, cartilage and cystic lesion on USS of ladies ovary?

= dermoid cyst

Woman with assisted delivery 7 days ago, had prolonged rupture of membranes, now has smelly lochia, temp 39 Endometritis Retained products Mastitis Respiratory infection UTI

Endometritis

Another chlamydia woman, contact traced from chlamydia positive partner, what is the best way to prevent her from spreading chlamydia in the community?

Treat with azithro. This question has variants e.g. stop HER from spreading versus stop community spread have diff answers.

A young woman who has really heavy periods, and also migraines, wants to stop bleeding so much. She doesn’t want kids. Treatment? (Repeat q) a. Mirena® +34 b. COC c. Mini-pillx d. Depot Provera e. Something else

Mirena

A 44y multiparous woman with heavy periods and low Hb of 80, you’ve tried a bunch of stuff including drugs and a previous dilatation and curettage with no benefit. Biopsy had found secretory endometrium. She’s had kids and doesn’t want any more. + lots of small Fibroids but also the fibroids were not submucosal? / were not the cause of the bleeding. a. Hysterectomy b. Repeat D+C c. Drugs d. Some myomectomy thing e. Tranexamic acid f. A couple of other options

Hysterectomy

Pretty sure another question about a lady whos come in with heavy bleeding, normally regular periods 28-29 days, last period 6 weeks ago. What is the initial investigation? (repeat q) a. Urine pregnancy test b. USS c. Serum b hcg

Urine pregnancy test (re: initial)

88 y/o woman with advanced dementia with a lump in her introitus. Vaginal wall partially keratinised? Walls collapsing with vaginal eversion.

Ring Pessary

Uterine prolapse due to which ligament not working? a. Uterosacral b. Broad c. Round d. Cervico-sacral e. Trans-cervical

Uterosacral

20 y.o. Girl started COCP (30 micrograms levonorgestrel) 3-6 months ago, developed hypertension (160/110 or something), was previously normotensive a. swap to lower oestrogen dose b. swap to progesterone only c. stop pill and give anti-HTN d. Continue pill & give antiHTNs e. use non-hormonal contraception and reassess BP in 3 months

e Combined hormonal contraceptives should be stopped (pending investigation and treatment) if any of the following occur:

14 year old gymnast with heavy irregular bleeding since menarche aged 13. 5-6 weekly cycles. What is the cause? (Similar repeat q in 2017/16) a. Hypothalamic dysfunction b. Anorexia nervosa c. Inherited bleeding disorder

Hypothalamic dysfunction

Woman with dysmenorrhoea, some spotting before heavier days during period. No dyspareunia. Never had STIs. Partner has had previous kids? Why are they struggling to conceive a. Endometriosis b. PID c. PCOS d. Altered cervical mucus

Endometriosis

Oestrogen – which is false Oestrogen therapy decreases risk of breast cancer, oestrogen therapy decreases risk of bowel cancer, oestrogen therapy should be used in post menopausal women, oestrogen therapy increases risk of vertebral fracture

Oestrogen therapy decreases risk of breast cancer

Female with infertility, anovulatory cycles. & acne. Wants baby. Treatment?

Clomiphene

Picture of ovarian endometrioma in lady with dyspareunia.

?teratoma thingie

Case of endometriosis spread through entire pelvis

Grade IV

Young girl comes with her mum reporting sore 'bottom' area, no signs of abuse

non-specific vulvovaginitis

Case of urge incontinence. Cause?

Detrusor ?instability, overactivity

girl with (+) pelvic pain, knees tucked into tummy

4 weeks preconception and carry on through 1st trimester (up to 12 weeks)

Cardinal + uterosacral ligaments

Lady with reasonable stress incontinence worse with exercise. 3 children. Had tried pelvic floor exercises not helped. On exam: Grade 1 uterus prolapse, Grade 1 cystocoele, Grade 1 rectocele. Next step in treatment? a) Anterior vaginal repair b) Tension free vaginal tape c) Bladder retraining d) Estrogen cream e) Duloxetine f) Doxazosin g) Pelvic floor exercises

TFVT

Previous hx of PE after surgery

Vitamin B12 - folate

Pre-eclampsia

26 year old woman presented one week post lower segment caesarean section- had delayed 1st stage, underwent augmentation due to PROM. Currently unwell, had a fever of 39.0 degrees and O/E had suprapubic and uterine tenderness and an offensive discharge coming from the cervical os. Diagnosis? a) Wound infection b) Cystitis c) Endometritis/genital tract infection d) Pyelonephritis e) Retained products of conception

Endometritis/genital tract infection

MSS1 screening at 16 weeks showing 1:100 chance of Down syndrome. a) Amniocentesis b) Chorionic villus sample c) Offer abortion d) Continue as normal

Amniocentesis

Pregnant lady with gestational diabetes which she had been controlling with diet. Had a consistently high polycose test (8). What to do next? a) Insulin b) Some drug c) Stricter diet d) Increase exercise

Actually do OGTT test then metformin would be the management

Ring pessary

Progesterone only

Beth + abx No toxolytic unless active contractions

Loop excision

Oxytocin infusion

Woman in labour severe preeclampsia and proteinuria needs an epidural. What test do you need to do beforehand? a) Liver tests b) Platelets c) Serum calcium d) Glucose e) Uric acid

Platelets

16 week pregnant lady, just had first trimester screening. AFP was elevated showing high likelihood of NTD. What do you recommend doing next? a) Fetal morphology scan b) Offer termination of pregnancy c) Repeat AFP d) Amniocentesis e) CVS

Fetal morphology scan AFP --> neural tube

Recurrent introitus blocking Bartholin cyst. Previously had similar painful lump on the other side, settled with antibiotics. This time febrile, painful and not responding to antibiotics. What is the best management? a) Aspiration b) Marsupialisation c) Excision d) More antibiotics e) Undulation

Marsupialisation On same side - could. doexcision if >40 years

Repeat hcg to see if miscarriage

31 year old G1P0 lady with cramping and vaginal bleeding. bHCG 8500, empty uterus on USS. Tender in RIF with rebound tenderness. No adnexal masses, but some free fluid. She has tenderness in the L>R fornix. Management? FBC Reassure and follow up Refer to gynaecology for a laparoscopy Refer to surgery for appendectomy IM methotrexate IV fluids Repeat HCG in 48 hours

IM methotrexate

Teenager with history of migraines has heavy, painful periods, not sleeping due to worrying about exams. Not sexually active. What is first line of treatment? a) NSAIDs b) COCP c) Cyclical progesterone d) Mirena e) Tranexemic acid

Id recommend mirena tbh

Woman with painless vaginal bleeding of 50ml, baby oblique and not engaged. Diagnosis? a) Placenta previa b) Rupture of vaginal varicosities c) Bloody show

Placenta previa

PID in pregnancy (third trimester) caused by chlamydia. Treatment? a) Azithromycin b) Ceftriaxone c) Metronidazole d) Amoxicillin

Azithromycin (it would be doxy if. she was not preggers)

PPH 15 minutes post forceps delivery. Cause? a) Uterine hypotonia/atony b) Cervical tear c) Perineal haematoma

Atony I think would be immediate if torn

Abortion at 7 weeks, small amount of tissue taken but then a week later she is still pregnant. What do you do? a) TVUS b) B-HCG c) Reassure

TVUS

Treatment for Gardnerella vaginalis (bacterial vaginosis)? a) Metronidazole b) Amoxicillin c) Ceftriaxone

Metronidazole

First smear with low grade squamous intraepithelial lesion (LSIL). Follow up? a) 1 year b) 3 years

1 year

Female with infertility, anovulatory cycles and acne. Treatment? a) Letrozole b) Clomiphene citrate

Letrozole is better than clom because less likely to cause multiple pregnancy

Exploratory surgery for endometriosis. Large chocolate cysts in ovaries, deep implants, severe adhesions. Which grade? a) I b) II c) III d) IV

Large chocolate cyst = grade 4

Pregnant lady at 34/40. SFH only 29 cm. Smoker. Dx? a) IUGR b) Oligohydramnios

IUGR

Girl with 4 months amenorrhea, treated for acne as a teenager, increased facial hair. BMI 29. What investigations do you do for diagnosis? a) Urine B-HCG b) Transvaginal USS c) Pelvic USS d) FSH/LH assay

Exclude preg first