Gynaecology and Breast

Question 1

2ww referral criteria for breast cancer?

Answer 1

-aged 30 and over with unexplained breast lump with/without pain
-aged 50 and over with any 1 of the following sx in 1 nipple only:
discharge
retraction
other changes of concern

consider 2ww referral if 30 and over with unexplained lump in axilla or any age with skin changes that suggest breast cancer

consider non-urgent referral if age under 30 with unexplained breast lump

Question 2

When to measure CA-125 in primary care?

Answer 2

sx that suggest ovarian cancer-women that report any of the below sx on a persistent or frequent basis, especially more than 12 times per month and if age 50 and over:
persistent abdo bloating
early satiety and/or reduced appetite
increased urinary urgency and/or frequency
pelvic or abdo pain

consider if woman reports unexplained weight loss, change in bowel habit or fatigue.

also if woman 50 and over with new sx suggesting IBS in the last 1 year

Question 3

Level of CA-125 that necessitates US scan of abdo and pelvis?

Answer 3

35 and above (IU/ml)

if US findings suggestive of ovarian cancer make urgent referral to gynae

Question 4

2ww referral for suspected endometrial Ca?

Answer 4

if age 55 and over with post-menopausal bleeding

consider if post-menopausal bleeding under age of 55

Question 5

When should direct access US scan be offered to women to assess for endometrial cancer?

Answer 5

if age 55 and over with:

• unexplained sx of vaginal d/c who are presenting with these sx for first time OR raised PLT OR report haematuria
• visible haematuria and low Hb OR raised PLT OR high blood glucose levels.

Question 6

How often should women with a gene mutation for breast cancer receive breast cancer screening?

Answer 6

if TP53 gene mutation women should have annual MRI scans from the age of 20.
if BRCA 1 or 2 mutation women should have annual MRI from age of 30.

Question 7

NICE guidance on referral of patients with cyclical breast pain to secondary care?

Answer 7

if persistent cyclical breast pain for more than 3 months which is affecting QOL or sleep and which has not responded to 1st line treatment e.g. topical NSAIDs-diclofenac, piroxicam. Also dopamine agonists e.g. bromocriptine.

Question 8

In the presentation of menorrhagia, which women should be examined?

Answer 8

if any abnormal features in hx e.g. abnormal pattern to the bleeding or hx of pelvic pain or pressure e.g. frequent urination, pt should then have abdo exam, speculum and bimanual

Question 9

If a woman with menorrhagia is at risk of endometrial pathology based on the hx e.g. persistent intermenstrual bleeding, or RFs e.g. PCOS, what is the 1st line investigation?

Answer 9

hysteroscopy +/- endometrial biopsy

she should also have FBC- investigation recommended for all women with menorrhagia

Question 10

Biggest modifiable risk factor for endometrial cancer?

Answer 10

obesity

Question 11

When would a hysterectomy usually be advised for a women with endometrial hyperplasia?

Answer 11

if hyperplasia with atypia

Question 12

Which type of fibroids are most likely to cause abnormal uterine bleeding?

Answer 12

submucosal (affect the endometrium)

if <3cm diameter may be controlled using LNG-IUS or other medical management

Question 13

Most common cause of infertility in young women?

Answer 13

PCOS

Question 14

Management of oligomenorrhoea or amenorrhoea in women with PCOS?

Answer 14

cyclical progesterone e.g. medroxyprogesterone 10mg daily for 14/7, to induce a WD bleed, then r/f for TV US to assess for endometrial thickness-if normal, need to ensure tx given to prevent endometrial hyperplasia:
cyclical progesterone for 14/7 every 1-3 months
COCP
mirena

Question 15

1st line tx of acne in PCOS?

Answer 15

COCP

Question 16

How should bladder diaries be used in the assessment of urinary incontinence in women?

Answer 16

used for initial assessment in incontinence or overactive bladder
should be kept for minimum of 3 days covering variations in usual activities

Question 17

1st line tx for stress or mixed urinary incontinence?

Answer 17

supervised pelvic floor muscle training for at least 3 months

at least 8 contractions performed 3 times a day

Question 18

1st line tx for women with urgency or mixed urinary incontinence?

Answer 18

bladder training lasting at least 6 weeks

if satisfactory result not achieved and frequency is a troublesome sx consider combining training with an overactive bladder medicine

Question 19

Next step if women taking medication for overactive bladder have not found it successful/tolerated?

Answer 19

refer to secondary care

Question 20

1st line tx of women with symptomatic pelvic organ prolapse stage 1 or 2?

Answer 20

supervised pelvic floor muscle training for at least 16 weeks

Question 21

When to refer couples for earlier assessment of infertility (prior to 1 yr of unsuccessful conception)?

Answer 21

woman aged 36 or over (r/f at 6 months of UPSI)
predisposing factors to infertility:
oligomenorrhoea
amenorrhoea
PID, previous STI
endometriosis
previous abdo/pelvic surgery

testicular trauma, mumps orchitis or varicocele, previous urogenital surgery, significant systemic illness

approx 25% of couples will have unexplained infertility

Question 22

Initial investigations for infertility in women?

Answer 22

-Note initial investigations should be arranged if a couple has not conceived after 1 year of regular UPSI, Ix may be offered earlier if at risk of infertility.
-Mid-luteal phase progesterone to confirm ovulation (Day 21 of 28 day cycle)->30 consistent with ovulation
Chlamydia screen
-Additional tests:
FSH and LH-in women with irregular menstrual cycles, should be taken D2-5 of cycle
Weekly serum progesterone from day 21 until start of menstruation may be needed if irregular cycles
TFTs if sx of thyroid disease
Prolactin if sx of an ovulatory disorder e.g. PCOS

rubella status should also be checked

Men-semen analysis and chlamydia screen

Question 23

What duration can clomifene citrate be used for to try and achieve ovulation in women with PCOS?

Answer 23

6 months due to theoretical risk of ovarian cancer

Question 24

What are the NICE recommendations on IVF treatment for infertility?

Answer 24

• Unexplained infertility with failure to conceive after 2 years and under age of 40-offer 3 cycles, if age 40-42 offer 1 full cycle
• donor sperm-if failure to conceive after 12 cycles of IUI
• oocyte donation-premature ovarian insufficency
• tubal disease-if failure to conceive after surgical correction or not correctable surgically
• anovulation-failure to conceive with ovulation induction
• male factor-moderate/severe, may be indication for intracytoplasmic sperm injection

Question 25

Management of endometriosis?

Answer 25

• r/f to gynae/US if severe, recurrent or persistent sx, or pelvic signs of endometriosis
• primary care: -analgesia-PO paracetamol and/or NSAIDs, 3 month trial 1st line
• hormonal tx e.g. COCP, POP, mirena, implant, NOT if trying to conceive
• review after 3-6 months

Question 26

Symptoms suggestive of an underlying pathology in presentation of menorrhagia?

Answer 26

dysmenorrhoea
dyspareunia
intermenstrual or post coital bleeding
vaginal discharge
pelvic pain and/or pressure sx e.g. urinary

Question 27

When to offer a pelvic US scan in presentation of menorrhagia?

Answer 27

• uterus palpable abdominally
• Hx or examination suggests a pelvic mass
• examination inconclusive or difficult e.g. due to obesity

Question 28

Preliminary investigations in primary care for secondary amenorrhoea?

Answer 28

serum prolactin-if mildly elevated e.g. 500-1000, should be repeated before referral
FSH and LH
total testosterone
TSH
US scan (if PCOS suspected)

Question 29

Definition of polycystic ovaries on US scan?

Answer 29

presence of 12 or more follicles (2-9mm in diameter) in 1 or both ovaries and/or increased ovarian volume (>10cm^3)

Question 30

What tx does NICE advise can be considered for women with amenorrhoea for more than 1 year to help prevent osteoporosis?

Answer 30

COCP or combined cyclical HRT
tx should be reviewed annually
if amenorrhoea due to reversible causes e.g. low body weight, periodically stop oestrogen tx for 6 months to see if menses resumes

Question 31

When can PCOS be diagnosed in primary care after investigations?

Answer 31

if 2 of following 3 criteria are present:

• infrequent or no ovulation (oligomenorrhoea or amenorrhoea)
• clinical and/or biochemical evidence of hyperandrogenism e.g. hirsutism, acne, raised free or total testosterone
• 12 or more follicles in 1 or both ovaries and/or increased ovarian volume (>10) on US scan.

in adolescent girls both irregular menstrual cycles and hyperandrogenism are required for PCOS diagnosis

Question 32

If suspect bartholins cyst when should a women be referred to gyne for biospy to r/o malignancy?

Answer 32

if age over 40

Question 33

UKMEC for continuing a COCP in patient with an undiagnosed breast mass?

Answer 33

2

initiating in this patient would be UKMEC 3

Question 34

UKMEC for COCP if previous breast cancer?

Answer 34

3
(same for all methods of hormonal contraception, UKMEC 1=copper coil)

if current breast cancer-4

Question 35

Most common ovarian cyst?

Answer 35

follicular cyst

type of physiological cyst

Question 36

Most common benign ovarian tumour in women under age of 30?

Answer 36

dermoid cyst (mature cystic teratoma)

torsion more likely than with other ovarian tumours

Question 37

Most common benign epithelial cell tumour of ovary?

Answer 37

serous cystadenoma

note most common ovarian cancer=serous carcinoma

Question 38

Management of patients under age of 35 where US reports a simple ovarian cyst which is less than 5cm?

Answer 38

rpt ultrasound in 8-12 weeks

any postmenopausal women with an ovarian cyst should be referred to gynae