Gynecology

Question 1

Name the causes of primary amenorrhea.

Answer 1

Hypergonadotrophic hypogonadism (lack of response to LH & FSH by the gonads)
Hypogonadotrophic hypogonadism (deficiency of LH & FSH)
Imperforate hymen or other structural pathology

Question 2

Name the causes of secondary amenorrhea.

Answer 2

Pregnancy
Menopause
PCOS
Birth control
Physiological stress: excessive exercise, low body weight, nutrition, psychosocial factors
Premature ovarian insufficiency
Hypo/hyperthyroidism
Excessive prolactin from a prolactinoma
Cushing’s syndrome

Question 3

List the causes of menorrhagia.
(Treatment: tranexamic acid for no more than 5 days)

Answer 3

Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome

Question 4

Identify treatment for the following:
Bacterial vaginosis
Candidiasis
Genital Herpes

STIs:
N. gonorrhea
Chlamydia
Syphilis
T. vaginalis

Answer 4

BV (not an STI): mild itching, fishy odour, painful urination; metronidazole
Candidiasis: fluconazole 150 po x1 OR clotrimazole 10% cream 5g intravag hs x1
Genital Herpes: acyclovir, famciclovir, valacyclovir
STIs:
N. gonorrhea: screen using NAAT on vaginal/cervical swab or first-void urine; ceftriaxone 250 mg IM x 1 + azithro 1 g po once; treat all sexual partners with 60 days; reswab in 3 months
Chlamydia: doxycycline 100 mg po bid x 7 days OR azithro 1g po once
Syphilis: diagnosed using serology; long-acting Pen G
T. vaginalis: caused by trichomoniasis; metronidazole 500 mg po bid x 7 days

Question 5

Describe congenital adrenal hyperplasia (CAH).

Answer 5

Caused by a congenital deficiency of the 21-hydroxylase enzyme.
Causes underproduction of cortisol and aldosterone and overproduction of androgens from birth.

Question 6

Primary amenorrhea assessment.

Answer 6

Initial investigations assess for underlying medical conditions:
Full blood count and ferritin for anaemia
U&E for chronic kidney disease
Anti-TTG or anti-EMA antibodies for coeliac disease

Hormonal blood tests assess for hormonal abnormalities:
FSH and LH
Thyroid function tests
Insulin-like growth factor I is used as a screening test for GH deficiency
Prolactin is raised in hyperprolactinaemia
Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia

Question 7

Secondary amenorrhea assessment.

Answer 7

BetaHCG

LH & FSH:
High FSH suggests primary ovarian failure
High LH, or LH:FSH ratio, suggests polycystic ovarian syndrome
Prolactin can be measured to assess for hyperprolactinaemia, followed by an MRI to identify a pituitary tumour.

TSH. This is followed by T3 and T4 when the TSH is abnormal.
Raise TSH and low T3 and T4 indicate hypothyroidism
Low TSH and raised T3 and T4 indicate hyperthyroidism

Raise testosterone indicates polycystic ovarian syndrome, androgen insensitivity syndrome or congenital adrenal hyperplasia.

Question 8

Explain the relationship between PCOS and birth control.

Answer 8

It is worth remembering that women with polycystic ovarian syndrome require a withdrawal bleed every 3 – 4 months to reduce the risk of endometrial hyperplasia and endometrial cancer. Medroxyprogesterone for 14 days, or regular use of the combined oral contraceptive pill, can be used to stimulate a withdrawal bleed.

Question 9

During which phase of the menstrual cycle do PMS symptoms occur?

Answer 9

Luteal phase

Question 10

How is premenstrual dysphoric disorder diagnosed and what is the treatment?

Answer 10

Diagnosed based on symptom diary for 2 cycles.
SSRIs - continuous or taken during period

Question 11

Management of uterine fibroids

Answer 11

For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding:
Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
Symptomatic management with NSAIDs and tranexamic acid
Combined oral contraceptive
Cyclical oral progestogens

For > 3 cm, refer to gynecology.

Question 12

What is the space between the uterus and the rectum called?

Answer 12

Pouch of Douglas

Question 13

What is the Rotterdam criteria for PCOS?

Answer 13

Polycystic ovaries on U/S
Anovulation or oligoovulation (presents as amenorrhea or oligomenorrhea)
Hyperandrogenism (presents as hirsutism & acne)

Question 14

What are the symptoms of endometriosis?

Answer 14

Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria

Question 15

What is adenomyosis?

Answer 15

Endometrial tissue inside the myometrium.

Question 16

What is the blood test used to diagnose menopause?

Answer 16

FSH

Question 17

Side effects of depot (Depo-Provera)?

Answer 17

Weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.

Question 18

What is the management of perimenopausal symptoms?

Answer 18

CBT
HRT
SSRIs
Testosterone
Vaginal estrogen
Vaginal moisturizers

Question 19

Premature ovarian insufficiency bloodwork

Answer 19

FSH > 25 IU on 2 samples over 4 weeks

Question 20

What is the treatment for premature ovarian insufficiency?

Answer 20

HRT
- Not considered to increase risk of breast cancer in women <50 y.o.
- May increase risk of VTE (risk can be reduced by using transdermal patches)
COC

Question 21

Ovarian cysts

Answer 21

Premenopausal women with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations.

Question 22

Tumour marker for ovarian cancer.

Answer 22

CA125 - can also be raised d/t endometriosis, adenomyosis, fibroids, pregnancy, liver dx, pelvic infection
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)

Question 23

What is the management of ovarian cysts in premenopausal and postmenopausal women?

Answer 23

Simple ovarian cysts in premenopausal women can be managed based on their size:

Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.

5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.

More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.

Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral.

Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.

Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).

Question 24

What is cervical ectropion?

Answer 24

Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix which has stratified squamous epithelium). The lining of the endocervix becomes visible on examination of the cervix using a speculum. This lining has a different appearance to the normal endocervix.

Ectocervix = more prone to bleeding (postcoital bleeding)

Question 25

Gynecological treatments for cervical ectropion and Nabothian cysts?

Answer 25

Colposcopy

Question 26

Medication used in the management of stress incontinence.

Answer 26

Duloxetine

Question 27

Medication used in the management of urge incontinence.

Answer 27

Caused by overactivity of the detrusor muscle
Med: Oxybutynin

Question 28

What bloodwork is used to diagnose PCOS?

Answer 28

The NICE clinical knowledge summaries recommend the following blood tests to diagnose PCOS and exclude other pathology that may have a similar presentation:

Testosterone
Sex hormone-binding globulin
Luteinizing hormone
Follicle-stimulating hormone
Prolactin (may be mildly elevated in PCOS)
Thyroid-stimulating hormone

Hormonal blood tests typically show:

Raised luteinising hormone
Raised LH to FSH ratio (high LH compared with FSH)
Raised testosterone
Raised insulin
Normal or raised oestrogen levels

Question 29

Which strains of HPV cause cervical cancer and which ones cause genital warts?

Answer 29

Strains 6 and 11 cause genital warts
Strains 16 and 18 cause cervical cancer

Question 30

What are the risk factors for endometrial cancer?

Answer 30

Any woman presenting with postmenopausal bleeding has endometrial cancer until proven otherwise. The key risk factors to remember are obesity and diabetes.