Gynaecology clinic

Question 1

How are HPV results reported?

Answer 1

HPV 16/18 detected
Oncogenic HPV (not 16/18) detected
Oncogenic HPV not detected.

Question 2

HPV strains 16 and 18 cause what % of cx cancer?

Answer 2

70%

Ranzcog guideline.

Question 3

How many oncogenic types of HPV can the CST detect?

Answer 3

14

Question 4

If a women has a negative CST test, when should she return for CST screening?

Answer 4

5 years

Question 5

Which is the most common type of cx ca? squamous vs adenocarcinoma?

Answer 5

squamous 80%

adenocarcinoma 20%

Question 6

What ages do we screen for Cx ca?

Answer 6

25-74, who has ever been sexually active, including same-sex relationships, even if they have received HPV vaccination.

Question 7

What are the three outcomes of HPV screening?

Answer 7

There are three risk categories:
• Women who are classified as Low risk will be re-invited to re-screen in five years.
• Women who are classified as Intermediate risk will be invited to have another HPV test in 12 months. This is to check that the infection has cleared.
• Women classified at Higher risk will be referred directly to colposcopy for further investigation

Question 8

What happens if a women’s HPV screening turns up an unsatisfactory result?

Answer 8

Invited to retest for HPV in 6 months.

Question 9

A HPV test demonstrates a non-16/18 HPV strain. What happens next?

Answer 9

LBC -> if neg - > 5 yearly screening
LBC ->pLSIL/LSIL -> repeat screen in 12 months
LBC -> pHSIL/HSIL - > colposcopy

Question 10

A serial HPV screening in 12 months from a previous screen that detected HPV non-18/16 demonsrated persisting HPV infection. What happens next?

Answer 10

LBC + colposcopy.

Question 11

Define PID?

Answer 11

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract and may involve the uterus, fallopian tubes, ovaries and, occasionally, adjacent pelvic structures. Pelvic inflammatory disease includes endometritis, salpingitis, tubo-ovarian abscess, pelvic cellulitis and pelvic peritonitis.

Question 12

Describe the microbiological origins of PID?

Answer 12

usually polymicrobial
Chlamydia trachomatis is the most commonly identified sexually transmitted pathogen, followed by Neisseria gonorrhoeae and Mycoplasma genitalium

Question 13

How does PID differ from post-procedural pelvic infection in terms of micro?

Answer 13

PPPI is usally caused by vaginal flora (c.f. STIs with PID)

Question 14

You suspect a women has PID and decide to undertake endocervical swab. What tests do you request?

Answer 14

nucleic acid amplification testing (NAAT) (eg polymerase chain reaction [PCR]) for C. trachomatis, N. gonorrhoeae, and M. genitalium
Gram stain and culture of N. gonorrhoeae for susceptibility testing.

Question 15

When would you consider IV ABX for a women with PID? (7)

Answer 15

pregnancy
    inability to tolerate oral therapy
    severe pain
    fever (38°C or higher)
    systemic features (eg tachycardia, vomiting)
    sepsis or septic shock
    suspicion of tubo-ovarian abscess.

Question 16

Prompt treatment of pelvic inflammatory disease (PID) reduces the risk of …?

Answer 16

tubal damage and, consequently, infertility, ectopic pregnancy and chronic pelvic pain.

Question 17

Empirical therapy for non-severe PID?

Answer 17

ceftriaxone 500 mg in 2 mL of 1% lidocaine intramuscularly, or 500 mg intravenously, as a single dose [Note 1]

PLUS

metronidazole 400 mg orally, 12-hourly for 14 days

PLUS EITHER
1. doxycycline 100 mg orally, 12-hourly for 14 days

OR for patients who are pregnant, breastfeeding [Note 2] or likely to be nonadherent to doxycycline
2 azithromycin 1 g orally, as a single dose, repeated 1 week later.

Question 18

Describe empirical therapy for severe PID?

Answer 18

1) ceftriaxone 2 g intravenously, daily; for adults with septic shock or requiring intensive care support, use 1 g intravenously, 12-hourly. See Modification and duration of therapy for severe PID

OR
1) cefotaxime 2 g intravenously, 8-hourly; for adults with septic shock or requiring intensive care support, use 2 g intravenously, 6-hourly. See Modification and duration of therapy for severe PID

PLUS (with either of the above drugs)

azithromycin 500 mg intravenously, daily; see Modification and duration of therapy for severe PID

PLUS

metronidazole 500 mg intravenously, 12-hourly; see Modification and duration of therapy for severe PID.

Question 19

How is endometrial hyperplasia classified?

Answer 19

Hyperplasia without atypia

Atypical hyperplasia.

Question 20

What diagnostic and surveillance methods are available for endometrial hyperplasia?

Answer 20

Endometrial sampling by outpatient endometrial bx

Diagnostic hysteroscopy (considered to facilitate or obtain an endometrial sample, especially where outpatient sampling fails or is non-diagnostic)

Question 21

What is the risk of endometrial hyperplasia without atypia progressing to endometrial ca?

How should endometrial hyperplasia without atypia be managed?

Answer 21

Risk of EHWA progressing to EC = < 5% over 20 years.
- > the majority of the cases of EHWA will regress spontaneously.

Correct reversible causes:
e.g. obesity, HRT

F/U with serial bx
OR
treatment with progestogens has a higher disease regression rate compared with observation alone.

Progestogen treatment is indicated in women who fail to regress following observation alone AND in symptomatic women with abnormal uterine bleeding.

Question 22

What should be first line medical treatment of EHWA?

Answer 22

Both continuous and local intrauterine progestogens are effective in achieving regression.

LNG-IUG = 1st line (b/c compared with PO progestogens it has a higher disease regression rate with a more favourable bleeding profile and it is a/w fewer adverse effects.

Question 23

For women with EHWA who opt for PO progestogens, what medication + doses can you offer?

Answer 23

Medroxyprogesterone 10-20mg/day or norethisterone 10-15mg/day

Question 24

What should the duration of treatment and f/u of EHWA be?

Answer 24

Tx with progestogens for a minimum of 6 months in order to induce histological regresion of EHWA.

If adverse effects are tolerable and fertility is not desired, women should be encouraged to retain teh LNG-IUS for up to 5 years as this reduces relapse.

Offer OPD endometrial surveillance at 6 monthly intervals. At least two consecuitive 6 monthly neg bx should be obtained prior to d/c.

Advise women to seek further referral if abnormal vaginal bleeding recurs after completion of tx as may indicate disease relapse.

Nb: women at higher risk, i.e. high BMI, PO progestogens should be followed up with annual endometrial biopsies following two neg bx results.

Question 25

When do you consider hysterectomy for a woman with EHWA? (5)

Answer 25

Disease progression during tx
No histological regression of hyperplasia despite 12 months of tx.
relapse of EH after completing progestogen tx.
persistence of bleeding symptoms
Woman declines the undergo surveillance or comply with medical treatment.

Question 26

If a women with EHWA requires surgery, what surgery should be offered:

• Postmenopausal
• Premenopausal

Answer 26

• Hysterectomy + bilateral salpingo-oophorectomy + total hysterectomy
• Premenopausal women (the decision to remove the ovaries should individualised): bilateral salpingectomy should bee considered as this may reduce the risk of future ovarian malignancy.

Question 27

How should atypical hyperplasia be managed?

Answer 27

Total hysterectomy.

Because of risk of underlying malignancy or progression to cancer

Question 28

What surgery do you offer to postmenopausal women who have AtEH?

Answer 28

bilateral salpingo-oophorectomy + total hysterectomy

Question 29

How should you manage a women with AtEH who wishes to preserve her fertility?

Answer 29

Invx to exclude invasive endo ca or co-exisitng ovarian cancer.
LNG-IUD (1st line); PO proges (2nd line)
Once fertility no longer required, hysterectomy should be offered in view of high risk of disease relapse.

Question 30

How should women with AtEH NOT undergoing hysterectomy be followed up?

Answer 30

Review with endometrial biopsies Q3 monthly unti two consecuitve neg biopsies obtained.

Question 31

In an asymptomatic woman with AtEH demonstrating histological regression with medical mng, following two neg 3 monthly biopsies, how offten should you follow her up?

Answer 31

every 6-12 months until hysterectomy.

Question 32

How should EH be managed in women wishing to conceive?

Answer 32

disease regression should be achieved on at least one endometrial sample before women attempt to conceive.

They should be referred to a fertility specialist.

Question 33

What advice do you give to a woman taking tamoxifen for breast ca?

Answer 33

can increase risk of developing endometrial cancer so need to report any signs of abnormal vaginal bleeding.

Question 34

How should endometrial hyperplasia confined to a polyp be managed?

Answer 34

complete removal of the polyp(s) is recommended and an endometrial bx should be obtrained to sample the b/g endometrium.

Question 35

Define causes of abnormal uterine bleeding in the non-pregnant, reproductive age female?

Answer 35

PALM-COEIN
Polyps
Adenomyosis
Leiomyoma
Malignancy and hyperplasia

Coagulopathy
Ovulatory dysfunction
endometrial 
Iatrogen 
Non-yet classified.

Question 36

Abnormal uterine bleeding a/w dysparaunia and dysmenorrhoea would be suggestive of..

Answer 36

endometriosis

adenomyosis.