Medical Gynaecology

Question 1

First line treatment of lichen sclerosus is

Answer 1

typically with ultra potent topical steroids

such as clobetasol proprionate

Question 2

What is Lichen sclerosus (LS) and what are it’s associations?

Answer 2

an inflammatory dermatosis of unknown aetiology

Associations:
Increased frequency of autoimmune disorders

Question 3

Signs & Symptoms of lichen sclerosus

Answer 3

Pale white atrophic areas.
Purpura are common
Fissuring
Erosions
Hyperkeratosis
Narrowed Introitus
Pruritus
Soreness/dyspareunia

Question 4

Histological features of lichen sclerosus

Answer 4

Histological features:
Epidermal atrophy (or thinning)
Hydropic degeneration of the basal layer (sub-epidermal hyalinisation)
Dermal inflammation

Question 5

Complications of lichen sclerosus

Answer 5

Complications of LS

Risk of developing squamous cell carcinoma (<5%)
Clitoral pseudo cyst
Sexual dysfunction
Dysaesthesia

Question 6

Possible causes of PCB

Answer 6

Cervical polyps
Ectopion
Cervical cancer
STIs
Vaginal atrophy

Question 7

Possible causes of deep desparunia

Answer 7

PID / STI
Endometriosis 
Ectopic pregnancy
Ovarian cyst / cancer
Chronic pelvic
Pain

Question 8

Incidence of turners syndrome

Answer 8

1 in 2000 births

Question 9

Causes of haemolytic anaemia

Answer 9

Autoimmune haemolytic anaemia

Haemolysis associated with mechanical heart valves

G6PD deficiency

Hereditary spherocytosis

Question 10

Steps in managing a patient with PCB

Answer 10

History - sexual, contraceptive, menstrual & LMP
Speculum and Pelvic Examination
Any suspicion of cervical cancer - refer to colposcopy
Treat any local cause - cervical polyp, ectropion, cervicitis, warts
Test for STIs

Question 11

Steps in managing a patient with IMB

Answer 11

History - sexual, contraceptive, menstrual & LMP
If suspected contraceptive problem consider modifying contraception and review in 6-8 weeks
If ongoing IMB
Speculum and Pelvic Examination
Any suspicion of cervical cancer - refer to colposcopy
Treat any local cause - cervical polyp, ectropion, cervicitis, warts
Test for STIs

Question 12

what is metrorrhagia

Answer 12

bleeding at irregular intervals, particularly between expected menstrual periods.

Question 13

what is menometrorrhagia

Answer 13

combination of metrorrhagia and menorrhagia.
prolonged or excessive uterine bleeding
occurs irregularly and more frequently than normal

Question 14

What is polymenorrhoea

Answer 14

Polymenorrhea is a term used to describe a menstrual cycle that is shorter than 21 days

Question 15

Symptoms of endometriosis

Answer 15

Cyclical pelvic pain, 
dysmenorrhea 
dyspareunia 
chronic pelvic pain,
cyclical intestinal complaints (bloating, diarrhoea or constipation) 
fatigue/weariness 
infertility

Question 16

Empirical treatment options for suspected endometriosis

Answer 16

Analgesia - NSAIDs
and/or hormonal treatment - COCP / desogestrel / DMPA / IUS
or oral Medroxyprogesterone / norethisterone.
support such as Endometriosis UK

Question 17

treatment options for confirmed endometriosis

Answer 17

laparoscopic ablation or resection
+/ - Hormonal suppression

Specialist fertility referral if required

GnRH analogues- short term - or with addback HRT
Radical surgery - TAH BSO

Question 18

most common cause pruritus vulvae?

Answer 18

Contact dermatitis
inflammatory reaction
Lichenification + hyperpigmentation when dermatitis chronic.
can be caused by:
creams (esp containing LA), Topical antibiotics,
Barrier contraception, lubricants, Perfume, soaps, bubble baths, wet wipes, Detergents, fabric conditioners, bleaches, dyes.

Question 19

possible causes of pruritus vulvae?

Answer 19

Contact dermatitis 
Candida / BV / TV / HSV
Pediculus pubis / Scabies (Sarcoptes scabiei) 
Psoriasis
Lichen simplex
Lichen planus 
Lichen sclerosus 
SCC / VIN / pagets
Seborrhoeic dermatitis (rare)

Question 20

features of vulval psoriasis

Answer 20

Due to the moisture and friction, the classic psoriatic lesion is replaced with a poorly demarcated, erythematous plaque
minimal scale
shiny texture
Typical psoriasis lesions occur elsewhere on the body
Genital skin affected in 29–46% of people with psoriasis.

Question 21

features of vulval Lichen sclerosus

Answer 21

Inflammatory skin condition
often >50 yo
Any area from clitoral hood to perianal area affected - classically figure eight pattern
vagina not affected.

Lesions hypopigmented-to-white,
crinkled, fragile plaques
Bruises / blood blisters / ulcers appear after scratching / minimal friction.
Scarring + loss of vulvar architecture / resorption of labia minora, fusing in midline + burying of clitoris.
small risk SCC developing = (less than 5%).

Question 22

features of vulval Lichen simplex

Answer 22

localized plaque - chronic eczematous inflammation
created by repeated rubbing / scratching
Can affect entire vulva /perianal area

skin leathery or lichenified or pale and wrinkled.
May be labial swelling + erythema / hair loss due to scratching

Question 23

features of vulval Seborrhoeic dermatitis

Answer 23

ill-defined border
some scaling,
with or without involvement of other sites,
Rarely affects the vulva.

Question 24

features of vulval Lichen planus

Answer 24

chronic inflammatory condition
affects skin / mucosal surfaces
may appear erosive, glazed or glossy erythematous plaques;
or bluish-purple, shiny, flat-topped papules + small white dots or lines (Wickham’s striae);
or uniformly white hyperkeratotic plaques.

May be loss of vulvar architecture.
small risk SCC developing of <3%