Gynaecology

Question 1

MOA TXA

Answer 1

Plasmin inhibitor

Tranexamic acid is a synthetic analog of lysine which reversibly binds to lysine receptors on plasminogen. This inhibits conversion of plasminogen into plasmin and arrests the breakdown of fibrin.

Question 2

Ovarian dermoid cyst vs ovarian cystic teratoma

Answer 2

These terms are used interchangeably to describe germ cell tumours however they have slightly different tissue origins:

Ovarian dermoid cyst = purely ectodermal in origin, so contains dermal and epidermal elements (hence the name)

Ovarian mature cystic teratoma = tissue can arise from any of the three germ cell layers (mesoderm, endoderm and ectoderm). Normally 2 of the 3 are seen.

Question 3

stratum functionalis: components

Answer 3

stratum compactum
stratum spongiosum

Question 4

When investigating subfertility, it is common to take a ‘mid-luteal’ phase progesterone. For a patient with a regular 28 day cycle, when would you advise a mid-luteal phase progesterone and what level would you be looking for?

Answer 4

A mid-luteal phase progesterone level can be taken to confirm if ovulation has taken place. For patients with a regular menstrual cycle, this is 7 days prior to the first day of expected menstruation.

A serum progesterone >30 nmol/L confirms ovulation has taken place.

Question 5

Which anatomical structure is found within the infundibulopelvic ligament?

Answer 5

Also known as the ‘suspensory ligament’

Connects the ovary laterally to the pelvic wall

Not a true ligament as it is a fold of the peritoneum

Contains the ovarian artery, vein, nerve plexus and lymphatic vessels

Question 5

Risk of malignancy index (RMI)

Answer 5

RMI = U x M x Ca-125

Ultrasound features (1 point for each) - BAMMS
Multilocular cysts
Solid areas
Metastases
Ascites
Bilateral lesions

Ultrasound score:
0 points = Ultrasound score 0
1 point = Ultrasound score 1
2-5 points = Ultrasound score 3

Menopausal status
Pre-menopausal = 1
Post-menopausal = 3

Ca-125 in IU/ml

NICE recommend referral to the specialist MDT for any patients who score 250 or more

Question 6

Which lymphatic groups are most likely to be associated with cervical cancer metastases?

Answer 6

The most common sites of lymph node metastases from cervical cancer are the external iliac, internal iliac and obturator groups.

Question 7

Which lymphatic groups is most likely to be associated with vaginal cancer metastases from the lower third of the vagina?

Answer 7

superficial inguinal group.

Question 8

The Female Pelvic Floor

Answer 8

Funnel shaped muscular floor of the true (lesser) pelvis

Supports the abdominal/pelvic organs, opposes rises in intra-abdominal pressure and provides sphincteric action to the rectum and urethra

Composed of the levator ani and coccygeus

Two openings permit passage of the anal canal (rectal hiatus) and vagina/urethra (urogenital hiatus)

The perineal body connects the pelvic floor to the perineum and is located inferiorly

Question 9

What is the predominant cell type of the luminal epithelium of the fallopian tube?

Answer 9

Secretory cells (most abundant)
Columnar cells
Peg cells (least abundant)

Question 10

USS features of leiomyoma (fibroid)

Answer 10

Solid, round and well defined

Hypoechoic and heterogenous

Distortion of the outer uterine contour

Calcifications appear hyperechoic

Circumferential flow on colour doppler

Acoustic shadowing (large fibroids)

Question 11

Type one and type two uterine cancers

Answer 11

Type 1 cancers are associated with unopposed oestrogen (endometrioid adenocarcinomas, slower growing)

Type 2 cancers are oestrogen independent and often related to genetic mutations (uterine serous carcinomas and clear cell carcinomas, faster growing). Risk factors include being postmenopausal, having a thickened uterine wall lining, and family history of ovarian, uterine, or bowel cancer.

Question 12

True vs false female pelvis

Answer 12

True (lesser) pelvis: Inferior to the pelvic brim, contains the bladder, colon and reproductive organs

False (greater) pelvis: Superior to the pelvic brim, supports organs of the lower abdomen and the gravid uterus

Question 13

Approximately what proportion of women with BRCA 1 mutation will develop ovarian cancer?

Answer 13

40% risk of women with BRCA 1 mutation developing ovarian cancer before the age of 70.

(15% BRCA 2)

Question 14

Ovarian blood supply

Answer 14

Primary source is from the ovarian artery; a direct branch of the abdominal aorta

There is a smaller collateral supply from the uterine artery

The right ovarian vein drains directly into the inferior vena cava

The left ovarian vein drains into the left renal vein (in the majority)

Both the ovarian artery and vein are contained within the infundibulopelvic (IP) ligament

Question 15

Incontinence management

Answer 15

First-line: Lifestyle changes, pelvic floor exercises, and bladder training.

Second-line: Anticholinergics (e.g., solifenacin, tolteridine, oxybutynin - avoid in frail older adults due to cognitive risks) or Beta-3 adrenergic agonist mirabegron or vaginal oestrogen for OAB; duloxetine for SUI.

Third-line: Botulinum toxin or neuromodulation (Percutaneous tibial nerve stimulation or sacral nerve stimulation) for OAB/ UUI; urethral bulking agents or surgery (Mid-urethral sling; colposuspension; fascial sling) for SUI.

Fourth-line: Surgery for refractory cases.

UUI is a symptom of OAB