Questions (Gyne)

Question 1

Which ages do cervical smears occur if they are being repeated every 3 or 5 years? [2]

Answer 1

Every 3 years: 25-49

Every 5 years: 50-69

Question 2

You dx a patient with PMS.

She smokes 35 cigarettes a day.

You encourage excercise and weight loss but this hasn’t helped.

You want to prescribe a medication. What could you give and when should you tell the patient to take this medication? [1]

Answer 2

Newer combined oral contraceptive pills (COCPs) can be considered in PMS but this is CI as she smokes.

Sertraline during the LAST 14 days of her cycle

Question 3

A patient has CIN 2 found and treated.

Describe how cytology is performed after this [1]

Answer 3

After cervical intraepithelial neoplasia (CIN) 2 has been treated, patient will be referred back to colposcopy if HPV smear is positive on re-screening after 6 months, regardless of cytology.

NB: Re-screening in 12 months is indicated after CIN 1 is indicated on colposcopy/biopsy, or following a positive initial HPV smear screening and negative cytology result. This is not appropriate in this case as the patient’s results are from a re-screening after an excision of CIN 2.

Question 4

A 48-year-old woman presents with perimenopausal symptoms. Apart from suffering from migraines with aura, she does not have any relevant medical history. She has a family history of deep vein thrombosis (DVT). The patient’s last menstrual periods are irregular, the last one being 3 months ago. She is not currently on any contraception

Which option for HRT would be the most suitable? [1]

Answer 4

Topical cyclical combined HRT
- Migraine with aura is NOT a contraindication for HRT, unlike with the combined oral contraceptive pill, however, topical preparations are preferred rather than oral
HRT contraindicated
The correct answer is: Topical cyclical combined HRT 26%

Migraine with aura is not a contraindication for HRT, unlike with the combined oral contraceptive pill, however, topical preparations are preferred rather than oral.

This patient has a uterus, so combined oestrogen and progesterone treatment is required. The oestrogen replaces the oestrogen deficiency that occurs during menopause but also causes endometrial hyperplasia. Using progesterone with the oestrogen protects against this.

As the patient has a family history of DVT, topical HRT is preferred here as there is no increased DVT risk compared to oral preparations.

Menopause is defined as amenorrhea for >1 year, where a continuous regime can be used (oestrogen and progesterone daily).
This patient has not yet achieved her menopause, so a cyclical regime should be used (oestrogen daily, but progesterone used for a few weeks in the cycle).

Question 5

Describe the pathophysiology of androgen insensitivty syndrome [1]

How do they present? [4]

Answer 5

Androgen-insensitivity syndrome occurs when an individual has XY chromosomes (male sex), but their body does not respond to the androgen hormones that drive the development of the male body

Present with externally female characteristics but no female reproductive organs:
* primary amenorrhoea
* lack of secondary sexual characteristics (except for breast development),
* absence of female reproductive organs
* short vagina (sometimes described as ‘blind ending’).

Question 6

A 55-year-old woman presents with mood swings and night sweats for the last few years which she has managed herself. She reports her last period was over 1 year ago but reports some vaginal bleeding a few days ago. She is not on any contraception.

What is the most suitable HRT option? [1]

Answer 6

HRT contraindicated
- Undiagnosed vaginal bleeding is a contraindication. This woman has achieved her menopause as she has been amenorrheic for over 1 year, but per vaginal bleeding post menopause warrants further urgent investigation.

Question 7

Why can breast development still occur in androgen-insensitivity syndrome? [1]

Answer 7

Breast development still occurs because testosterone can be converted to oestrogen in the periphery to drive breast development, but it is not present in the reproductive system.

Question 8

A 49-year-old patient presents with hot flushes and mood swings. She has no previous medical history or family history. She has been amenorrheic since her Mirena (levonorgestrel) coil was placed 2 years ago. She would like to consider HRT with the least side effects.

What is the best option for HRT? [1]

Answer 8

Oestrogen patch

The patient requires combined HRT as she has a uterus, so requires progesterone for protection of the endometrial lining against estrogen. However, the patient has a Mirena coil in situ, which is the only form of contraception licensed to be used as the progesterone component in HRT. It is licensed for 4 years if used as HRT.

Therefore the patient only requires oestrogen preparation only.

Transdermal oestrogen such as patches and gels do not have an increased risk of deep vein thrombosis, compared to oral oestrogen preparations.

Question 10

Which of the following is a well-recognised possible outcome of tubal ligation?

Sexually transmitted infections (STIs)
Weight gain
Depression
Ectopic pregnancy
Increased abdominal cramps during menstruation

Answer 10

Question 11

A 24-year-old female presents with high fever, headache, vomiting, and diffuse erythroderma. She has high fever (temperature 39.5 °C), hypotension (blood pressure 80/50 mmHg), tachycardia (heart rate 120 bpm) and a diffuse erythematous rash. She had been using a menstrual cup for the first time in the past two days. Blood cultures grew methicillin-sensitive Staphylococcus aureus.

What is the most appropriate treatment?

Answer 11

Clindamycin + vancomycin
- This patient has toxic shock syndrome secondary to menstrual cup use
- The causative agent is methicillin-sensitive S. aureus. As such, the combination of clindamycin plus vancomycin is indicate

Question 12

A 32-year-old female presents to the Emergency Department with fever, headache, muscle pain and increased shortness of breath. Two weeks before, she had given birth to her first child, with an uncomplicated delivery. On assessment, she looks unwell. Her blood pressure is 90/44 mmHg, her heart rate is 112 bpm, and her oxygen saturation is 91% on room air. Her abdomen is slightly tender, and a diffuse, erythematous rash is observed over her extremities. Her neurological examination is normal. Her chest is clear on auscultation.

What is the most likely diagnosis? [1]

Answer 12

Toxic shock syndrome
- There is an established association between surgical procedures (for which vaginal delivery is considered) and toxic shock syndrome
- While the presenting symptoms can be vague and non-specific, toxicity is an early feature, making rapid diagnosis and treatment essential. Toxic shock syndrome can occur at any site and in patient groups outside the typical ‘menstruating females using tampons’ group.

Question 13

Why do you measure ‘day 21’ progesterone to assess fertility? [1]

Answer 13

Serum progesterone testing must be performed 7 days before the end of the menstrual cycle, as a rise in progesterone indicates that the corpus luteum has formed

Question 14

Describe the treatment options for fibroids to treat

• menorrhagia [4]
• to shrink fibroid size [2]

Answer 14

Menorrhagia:
- levonorgestrel intrauterine system (LNG-IUS)
- NSAIDs - e.g. mefenamic acid
- tranexamic acid
- combined oral contraceptive pill
- oral progestogen

To shrink fibroids medically:
- GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment due to side-effects

To shrink fibroids surgically:
- myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
- hysteroscopic endometrial ablation
- hysterectomy

Question 15

The Mirena coil works via which mechanism? [1]

Answer 15

Release of progesterone only

Question 16

What is the aim of HRT? [1]

Describe how you treat menopausal symptoms in a women with a uterus [2]

Answer 16

The aim of treating symptoms of menopause is to replace oestrogen (hormone replacement therapy).

However, in a woman with a uterus, an additional source of progesterone is needed to counter the action of unopposed oestrogen on the womb, increasing the risk of endometrial hyperplasia and malignancy.

Question 17

When is tranexemic vs mefanamic acid indicated for menorrhagia? [2]

Answer 17

Painless menorrhagia - Tranexamic acid

PainFul menorrhagia - MeFenamic acid

Question 18

Woman aged > 30 years with dysmenorrhoea, menorrhagia, enlarged, boggy uterus → [1]

Answer 18

Woman aged > 30 years with dysmenorrhoea, menorrhagia, enlarged, boggy uterus → ?adenomyosis

Question 19

How do you distinguish endometriosis from adenomyosis on TVUS? [2]

Answer 19

Adenomyosis:
- enlarged, boggy uterus

Endometriosis:
* A transvaginal scan would either show nothing or would show clumps of tissue (endometrial tissue) growing in places away from the endometrium.

Question 20

If an incomplete miscarriage has occured - what do you give for medical management? [1]

Answer 20

Medical management of an incomplete miscarriage involves giving vaginal misoprostol alone

Don’t need mifepristone if the cervical os is open

Question 21

[] is associated with a decreased incidence of hyperemesis gravidarum

Answer 21

Smoking is associated with a decreased incidence of hyperemesis gravidarum

Question 22

What is the most significant risk of prescribing an oestrogen-only preparation rather than a combined oestrogen-progestogen preparation for a women with a uterus?

Increased risk of venous thromboembolism
Increased risk of ovarian cancer
Increased risk of endometrial cancer
Increased risk of breast cancer
Increased risk of colorectal cancer

Answer 22

What is the most significant risk of prescribing an oestrogen-only preparation rather than a combined oestrogen-progestogen preparation for a women with a uterus?

Increased risk of venous thromboembolism
Increased risk of ovarian cancer
Increased risk of endometrial cancer
Increased risk of breast cancer
Increased risk of colorectal cancer

Question 23

Ovarian cancer initially spreads by local invasion to where first? [1]
What are the presenting features? [4=

Answer 23

Para-aortic lymph nodes
- Older women presenting with vague gastrointestinal symptoms like bloating, early satiety, and weight loss raise suspicion of ovarian cancer.
- Nulliparity, early menarche, and late menopause are additional risk factors. A palpable mass in the left adnexa also suggests ovarian malignancy. Ovarian cancer tends to spread locally first to the para-aortic lymph nodes, which drain the ovaries and fallopian tubes.

Question 24

Ectopic pregnancy localised to the [] increases the risk of rupture

Answer 24

Ectopic pregnancy localised to the isthmus increases the risk of rupture

Question 25

In patients with urinary incontinence, make sure to rule out [2]

Answer 25

In patients with urinary incontinence, make sure to rule out a UTI and diabetes mellitus

Question 26

A patient suffers from PMS.

What is the treatment ladder for this patient? (mild; moderate; severe) [+]

Answer 26

mild symptoms
* can be managed with lifestyle advice
* apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates

moderate symptoms
- may benefit from a new-generation combined oral contraceptive pill (COCP) examples include Yasminµ (drospirenone 3 mg and ethinylestradiol 0.030 mg)

severe symptoms
- may benefit from a selective serotonin reuptake inhibitor (SSRI)
- this may be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length)

Question 27

Name a drug that can be used for N&V during pregnancy but has a limited timespan. What is the timespan and why does this occur? [1]

Answer 27

Metoclopramide is an option for nausea and vomiting in pregnancy, but it should not be used for more than 5 days due to the risk of extrapyramidal effects

Question 28

[] is the drug of choice for medical management of ectopic pregnancy

Answer 28

Methotrexate is the drug of choice for medical management of ectopic pregnancy

Question 29

[Drug class] should be offered as first-line treatment for primary dysmenorrhoea, and [drug] specifically is recommended due to its favourable side effect profile and over-the-counter availability.

Answer 29

NSAIDs should be offered as first-line treatment for primary dysmenorrhoea, and ibuprofen specifically is recommended due to its favourable side effect profile and over-the-counter availability.

Question 30

Women who have been admitted with hyperemesis gravidarum are generally given IV []

Answer 30

Women who have been admitted with hyperemesis gravidarum are generally given IV normal saline with added potassium as hypokalaemia is common

Question 31

A mother attends the GP with her 14-year-old daughter. She is concerned as her daughter has not yet started her periods although suffers cyclical pain. On examination the daughter looks well. What is the most likely diagnosis? [1]

Answer 31

the patient appears well but is suffering cyclical pain with no evidence of menstruation:
- imperforate hymen

Question 32

A women who is 5 weeks pregnant presents with PV bleeding.

She has no history of ectopic pregnancy. On examination, her heart rate is 85 beats per minute, blood pressure is 130/80 mmHg and her abdomen is soft, non-tender.

How do you manage her? [1]

Answer 32

Pregnant women who are < 6 weeks gestation and present with vaginal bleeding and no pain can be managed expectantly
- Monitor expectantly and advise to repeat pregnancy test in 7 days. If negative, this confirms miscarriage. If positive, or continued or worsening symptoms, refer to the early pregnancy assessment unit
30%

Question 33

Infertility in PCOS - [] is typically used first-line

Answer 33

Infertility in PCOS - clomifene is typically used first-line

Question 34

A 76-year-old woman presents with post-menopausal bleeding for the past 4 months. She is diagnosed with well-differentiated adenocarcinoma (stage II) on endometrial biopsy. There is no evidence of metastatic disease. Which is the most appropriate treatment?

Transcervical endometrial resection
Total abdominal hysterectomy
Provera (medroxyprogesterone acetate)
Wertheim’s radical hysterectomy
Total abdominal hysterectomy with bilateral salpingo-oophorectomy

Answer 34

Total abdominal hysterectomy with bilateral salpingo-oophorectomy

Question 35

Older woman with [] and [] → ?vulval carcinoma

Answer 35

Older woman with labial lump and inguinal lymphadenopathy → ?vulval carcinoma

Question 36

A 20-year-old female presents with a 3-month history of abdominal pain. Abdominal ultrasound shows an 8cm mass in the right ovary. Histopathological analysis reveals Rokitansky’s protuberance. What is the most likely diagnosis? [1]

Answer 36

Teratomas (dermoid cysts)

Question 37

Expectant management of an ectopic pregnancy can only be performed for [5]

Answer 37

1) An unruptured embryo
2) < 35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of < 1,000IU/L and declining

Question 38

A 24-year-old woman attend with her partner having tried to conceive for 2 years. She has a regular 35 day cycle and her last menstrual period was 3 weeks ago. A recent STI screen was unremarkable. As part of the initial investigations for subfertility, she has progesterone checked to confirm ovulation.

On which day of her menstrual cycle should she have the blood test for progesterone?

Day 1-5
Day 14
Day 21
Day 28
Day 35

Answer 38

To confirm ovulation: Take the serum progesterone level 7 days prior to the expected next period
- This woman has a 35 day cycle so 35 - 7 days = day 28. Therefore day 28 is the day that a serum progesterone should be taken.

Question 39

What are the three cardinal symptoms of endometriosis? [3]

Answer 39

Dysmenorrhoea (usually a few days before the onset of menstruation), dyspareunia and pelvic pain

Question 40

A patient has Turner’s syndrome.

Which of the following will they most likely have?

Increased FSH/LH
Imperforate hymen
Increase in prolactin
Increased serum androgen levels
Increased oestrogen

Answer 40

Increased FSH/LH

For FSH & LH
* KALLman = FALL (Low FSH & LH)
* TURNer = TURNed up (High FSH & LH)

Question 41

For FSH & LH - how can you remember which congenital syndromes cause which changes to them? [2]

Answer 41

For FSH & LH
* KALLman = FALL (Low FSH & LH)
* TURNer = TURNed up (High FSH & LH)

Question 42

Patient with menopause.

Out of the following options, which is most likely to increase her risk of breast cancer?

Clonidine
Combined hormone replacement therapy (HRT)
Low dose progesterone
Oestrogen only HRT
Venlafaxine

Answer 42

Patient with menopause.

Out of the following options, which is most likely to increase her risk of breast cancer?

Combined hormone replacement therapy (HRT)
- HRT: adding a progestogen increases the risk of breast cancer
- O x P = increased risk of breast cancer

NB: increased risk of breast cancer: proBREASTerone <3

Question 43

Why might fibroids have pedal oedema as a presenting feature? [1]

Answer 43

Venous congestion as fibroid presses on abdominal veins like IVC

Question 44

What is a Nabothian cyst? [1]

Describe the colour of Nabothian cysts [1]

Answer 44

Nabothian cysts are cysts on the cervix that occur when the squamous-cell epithelium of the cervix slightly covers the columnar epithelium. As the columnar epithelium secretes mucous, the mucous becomes trapped, and cysts form

The cysts contain yellow/amber mucous and are usually located around the os where the epitheliums transition.

Question 45

How do you exactly manage a miscarriage? [2] Include doses and timings

Answer 45

200 mg oral mifepristone and 48 hours later, 800 micrograms oral misoprostol

Question 46

ruptured ectopic pregnancy - which is first line:
- Salpingotomy or Salpingectomy? [1]

Answer 46

Salpingectomy - the removal of the affected fallopian tube, is the preferred surgical treatment, especially in cases where the patient is haemodynamically unstable or there is a high risk of rupture.

NB: salpingotomy (removal of the ectopic pregnancy while preserving the fallopian tube) is an option in some cases, it is generally considered when the patient has only one functioning fallopian tube or fertility preservation is a priority

Question 47

A diagnosis of premature ovarian insufficiency is suspected.
Which of the following is most likely to be found?

Low LH level

Low FSH level

Raised oestradiol level

Raised testosterone level

Raised FSH level

Answer 47

A diagnosis of premature ovarian insufficiency is suspected.
Which of the following is most likely to be found?

Raised FSH level:
- The history described above is most consistent with a diagnosis of premature ovarian insufficiency. It is characterised by the onset of menopausal symptoms before the age of 40 years with raised gonadotrophin levels including FSH and LH.
- A repeat sample should be taken 4-6 weeks apart to confirm the elevated FSH levels

Question 48

Which of the following strains is most likely associated with anal cancer?

HPV 31

HPV 16

HPV 18

HPV 6

HPV 8

Answer 48

HPV 16

Question 49

There are three criteria for use of lactational amenorrhoea as an effective contraceptive choice for women in the post partum period [3]

Answer 49

The woman has complete amenorrhoea.
The woman must be exclusively breast feeding day and night.
It has been six months or less since the birth of the baby

Question 50

Which one of the following medications is an example of a muscarinic antagonist?

Tolterodine
Teriparatide
Toremifene
Finasteride
Tamsulosin

Answer 50

1. Tolterodine = muscarinic receptor antagonist [urinary frequency, urinary urgency, urinary incontinence]
2. Teriparatide = parathyroid hormone analogue [osteoporosis]
3. Toremifene = selective oestrogen receptor modulator [hormone-dependent breast cancer] (same drug class as Tamoxifen)
4. Finasteride = 5a-reductase inhibitor [benign prostatic hyperplasia]
5. Tamsulosin = alpha adrenoceptor blocker [benign prostatic hyperplasia]

Question 51

She is found to have stage 2 ovarian cancer. What is the primary treatment?

Chemotherapy
Radiotherapy
Surgical excision of the tumour
Hormone therapy
Biological therapy

Answer 51

Surgical excision of the tumour
- Ovarian cancers which are stage 2-4, are treated primarily by surgical excision of the tumour. This may be accompanied by chemotherapy. NICE CG122

Question 52

What is the best way to detect ovulation? [1]

Answer 52

Day 21 progesterone test is the most reliable test to confirm ovulation
- In simple terms, measure serum progesterone 7 days prior to expected next period (for 28-day cycle: 28 - 7 = 21. For 35-day cycle: 35 - 7= 28)

Question 53

In terms of her VTE risk, which of the following HRT options is safest? [1]

Answer 53

Transdermal HRT does not appear to increase the risk of VTE (vs. oral)

Question 54

Name two risk factors that can cause an ovarian cyst to rupture [2]

Answer 54

Sex
Strenous exercise

Question 55

[] is the most common cause of postmenopausal bleeding

Answer 55

Vaginal atrophy is the most common cause of postmenopausal bleeding

Question 56

Treatment for mild, moderate and severe PMS? [3]

Answer 56

mild symptoms can be managed with lifestyle advice:
- apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates

moderate symptoms
- may benefit from a new-generation combined oral contraceptive pill (COCP)
- examples include Yasminµ (drospirenone 3 mg and ethinylestradiol 0.030 mg)

severe symptoms
- may benefit from a selective serotonin reuptake inhibitor (SSRI)
- this may be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length)

Question 57

How do you treat a women with 1a cervical cancer if they want to maintain fertility? [1]
What would be if she didn’t care about fertility? [1]

Answer 57

Women with stage IA cervical cancer may be considered for a cone biopsy with negative margins if they wish to maintain their fertility
- Hysterectomy without lymph node clearance is an option to consider for IA1 tumours, but this would not preserve her fertility.

Question 58

In which situations would you admit a patient with HG? [2]

Answer 58

Nausea and vomiting in pregnancy: admission should be considered in cases of ketonuria and/or weight loss despite use of oral anitemetics

Question 59

Urinary incontinence - first-line treatment:
urge incontinence: []
stress incontinence: []

Answer 59

Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training

Question 60

Ovarian torsion may be associated with a [] sign on ultrasound imaging

Answer 60

Ovarian torsion may be associated with a whirlpool sign on ultrasound imaging

Question 61

How would you council a patient about need for contraception if they have a menopause? [2]

Answer 61

12 months after the last period in women > 50 years
24 months after the last period in women < 50 years

Question 62

[] is the gold-standard investigation for patients with suspected endometriosis

Answer 62

Laparoscopy is the gold-standard investigation for patients with suspected endometriosis

Question 63

A pregnancy test should be performed at [] weeks following medical management of a miscarriage

Answer 63

A pregnancy test should be performed at 3 weeks following medical management of a miscarriage

Question 64

What would be a contraindication for LNG-IUS being used as treatment for menorrhagia for fibroids? [1]

Answer 64

cannot be used if there is distortion of the uterine cavity

Question 65

How does LNG-IUS work to treat fibroids? [2]

Answer 65

Releases progesterone locally, thinning the uterine lining and reducing bleeding

Question 66

Name two side effects of using GnRH agonists for fibroid treatment? [2]

Answer 66

menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density

Question 67

Stereotypical PCOS results:
* [] LH:FSH ratio
* testosterone may be [] or []
* SHBG is []

Answer 67

Stereotypical PCOS results:
* raised LH:FSH ratio
* testosterone may be normal or mildly elevated
* SHBG is normal to low

Question 68

If a patient has a clotting disorder causing menorrhagia - which is it most likely to be? [1]

Answer 68

Von Willebrand’s disease is an inherited disorder of coagulation that leads to either a deficiency or a malfunction of von Willebrand factor. It is a recognised cause of menorrhagia (heavy periods). People affected may have a history of easy bruising, bleeding from minor wounds and in females menorrhagia from the onset of menarche such as in this patient. To confirm the diagnosis, blood can be sent for von Willebrand antigen testing and von Willebrand factor function assay. Typically patients with von Willebrand’s disease have prolonged activated partial prothrombin time (APTT) as seen in this patient, which is required to stabilise factor 8. Bleeding time is also prolonged because von Willebrand Factor is required for platelet function.

Question 69

Abdominal pain. Recent menstruation (2/7 ago)

TVUS given. A cyst is seen - what is the most likely type? [1]

Answer 69

Corpus luteal cyst:
- During ovulation, the dominant follicle ruptures to release an egg. This process may itself be accompanied by pain. The follicle then becomes the corpus luteum, which acts to secrete hormones in preparation of pregnancy. If pregnancy does not occur, the corpus luteum involutes and regresses. Failure of the corpus luteum to regress may result in a corpus luteal cyst, which can rupture and cause pain. These are considered physiological and almost always resolve spontaneously.
Provided there is no evidence of torsion, and pain is controlled, conservative management is usually first line

Question 70

The risks of developing breast and [] cancer are markedly increased in people who inherit a harmful change in BRCA1 or BRCA2.

Answer 70

19 Jul 2024 — The risks of developing breast and ovarian cancer are markedly increased in people who inherit a harmful change in BRCA1 or BRCA2.

Question 71

A patient presents with ?PID.

What is the most likely organism that has caused this? [1]

Answer 71

Chlaymdia trachomatis

Question 72

[] is the gold standard diagnostic tool for confirming ovarian torsion and facilitating immediate intervention.

Answer 72

Laparoscopy is the gold standard diagnostic tool for confirming ovarian torsion and facilitating immediate intervention.

Question 73

How do you distinguish between PMS and primary dysmenorrhia? [1]

Answer 73

PMS is before the luteal phase which is at least 10 days

symptoms 4-12 hours prior to menstruation and no mention of emotional symptoms makes primary dysmenorrhia more likely

E.g.: PMS The week before her period she has noticed a significant change in her mood. She feels incredibly low and anxious, with poor concentration.

Question 74

Name three typical risk factors that occur in questions that would indicate endometrial cancer? [3]

Answer 74

60-year-old obese, nulliparous woman presenting with vaginal bleeding

This malignancy is characteristic of women who are older than 60 years old, and obese patients are at particular risk, as increased levels of peripheral fat increase aromatase activity, which leads to the conversion of androgens to oestrogens, which directly promotes endometrial proliferation. Additionally, the fact that the bleeding is worse following sexual intercourse but the intercourse itself is not painful, points away from the other likely diagnosis of vaginal atrophy, making a diagnosis of endometrial cancer the most likely.

Question 75

How can you distinguish if PV bleeding is atrophic vaginitis vs endometrial cancer based off their history? [1]

Answer 75

If bleeding is worse following sexual intercourse but the intercourse itself is not painful, points away from the diagnosis of vaginal atrophy, making a diagnosis of endometrial cancer the most likely.

Question 76

How do you manage patients with symptoms of an ectopic based of their length of gestation [2]

Answer 76

< 6 weeks gestation:
- women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly

>= 6 weeks gestation:
- and the woman has bleeding she should be referred to an early pregnancy assessment service for a transvaginal ultrasound scan to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.

Question 77

Describe the dietary advice you would give for someone who suffering from PMS? [1]

Answer 77

Regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates

Question 78

[] is the most common identifiable cause of postcoital bleeding

Answer 78

Cervical ectropion is the most common identifiable cause of postcoital bleeding

Question 79

A patient presents with ?stress incontinence.

What do you have to investigate / rule out before making a stress incontinence dx? [2]

What tests would reveal stress incontinence after these prior tests have been performed?

Answer 79

urinalysis should be performed in order to exclude diabetes or a urinary tract infection before diagnosing stress incontinence

uroflometry to diagnose stress incontinence and cystmetrography to diagnose urge incontinence

Question 80

4 stages of ovarian cancer? [4]

Answer 80

Stage 1 Tumour confined to ovary
Stage 2 Tumour outside ovary but within pelvis
Stage 3 Tumour outside pelvic but within abdomen
Stage 4 Distant metastasis

NB:
Stage 1 (1 word) = ovary
Stage 2 (2 words) = ovary + pelvis
Stage 3 (3 words) = ovary + pelvis + abdomen

Question 81

Urge incontinence, often due to detrusor overactivity, may require [] treatment when first-line anticholinergics are contraindicated.

Why might they be contraindicated? [1]

Answer 81

Anticholinergics are contraindicated in myasthaenia gravis as they can precipitate a crisis OR if elderly

Instead - give botox

Question 82

Which is the most likely cell type if ovarian cancer is diagnosed?

Stromal-cell tumours

Ductal-cell carcinoma in situ (DCIS)

Germ-cell tumour

Epithelial-cell tumour

Answer 82

Which is the most likely cell type if ovarian cancer is diagnosed?

Epithelial-cell tumour
- The most likely diagnosis here is ovarian cancer. Around 90% of ovarian tumours are epithelial-cell tumours. Epithelial-cell tumours are thought to arise from the lining of the fimbriae in the fallopian tubes.
- Serous cystadenocarcinoma is the most common subtype of epithelial ovarian cancer and is characterised by the presence of Psammoma bodies on histology.

Question 83

BRCA1 gene mutation in the context of raised [] and pelvic mass is a risk factor for [] cancer.

Answer 83

BRCA1 gene mutation in the context of raised CA125 and pelvic mass is a risk factor for ovarian cancer.

Question 84

What is the most common type of uterine fibroid?

Extrauterine fibroid

Subserosal fibroid

Pedunculated subserosal fibroid

Intramural fibroid

Submucosal fibroid

Answer 84

What is the most common type of uterine fibroid?

Intramural fibroid
- Intramural fibroids are the most common form of fibroid and are located within the myometrium. If they enlarge, they can distort the uterus and can cause issues with intrauterine system insertion and future pregnancies.

Question 85

How do you manage / how does screening occur for high risk HPV but negative cytological smears? [2]

Answer 85

High risk HPV and negative cytology - repeat in a year

If same result again - refer for colposcopy

Question 86

Lynch syndrome refers to which group of cancers associated togther?

Answer 86

People affected by LS have a higher risk of developing:
* colon cancer
* rectal cancer
* endometrial cancer
* ovarian cancer

And they have a slightly higher risk of developing:
* stomach cancer
* pancreatic cancer
* small bowel cancer
* ureter and renal pelvis cancer.

Question 87

complex papillary architecture, nuclear atypia and the presence of Psammoma bodies’.
Which of the following is the best description of the patient’s ovarian lesion?

Serous cystadenocarcinoma

Mucinous cystadenocarcinoma

Dysgerminoma

Krukunberg tumour

Mature teratoma

Answer 87

Serous cystadenocarcinoma
- Epithelial ovarian cancer is the most common type of ovarian cancer comprising approximately 90% of all ovarian tumours. Serous cystadenocarcinoma is the most common subtype of epithelial ovarian cancer and is characterised by the presence of Psammoma bodies on histology.

Question 88

Psammoma bodies on histology indicate which type of ovarian cancer? [1]

Answer 88

Serous cystadenocarcinoma (the most common type of epithelial ovarian cancer)

Question 89

What is a key differential for PCOS? [1]

Answer 89

hypothyroidism

Question 90

A Bartholin’s cyst becomes infected.

What is the most likely causative organism? [1]

Answer 90

E. coli

Question 91

Premature Ovarian Insufficiency - how do you treat? (include age treated to) [1]
Why do you give this medication? [2]

Answer 91

HRT until 51
- prevent osteoporosis, as well as to protect against symptoms of oestrogen deficiency and possible cardiovascular complications

Question 92

How do you manage a women with repeat high-risk HPV but negative cytology? [1]

Answer 92

Women with repeat high-risk HPV but negative cytology require repeat cervical screening in 12 months.

Question 93

What’s a way of remembering first line treatment for surgical management of ectopic? [1]

Answer 93

Ectopic pregnancy requiring surgical management: salpingectomy is first-line (rather than salpingotomy) for women with no other risk factors for infertility
- salpingEctomy is before salpingOtomy in alphabet

Question 94

Describe the risks of HRT and which hormones specifically cause them [4]

Answer 94

Breast cancer has increased risk from combined HRT - specifically the progesterone component

Unopposed oestrogen causes in an increased risk of endometrial cancer (which is why it’s never given in women with a uterus)

Increased risk of VTE from systemic HRT - reduced by giving as transdermal patch due to progesterone

HRT for 10+ years after menopause increases the risk of stroke

Question 95

The whirl pool sign refers to an ovarian [cyst or torsion]?

Answer 95

The whirl pool sign in this case refers to an ovarian torsion - its caused by the blood vessels being twisted

Whirpool = spinning = torsion

Question 96

Which triad is used to dx HG? [3]

Answer 96

• 5% pre-pregnancy weight loss
• dehydration
• electrolyte imbalance

Question 97

[] are first-line in the management of nausea & vomiting in pregnancy/hyperemesis gravidarum

Answer 97

Antihistamines are first-line in the management of nausea & vomiting in pregnancy/hyperemesis gravidarum

AntiHistamines for HG

Question 98

Risk malignancy index (RMI) prognosis in ovarian cancer is based on which three components? [3]

Answer 98

Risk malignancy index (RMI) prognosis in ovarian cancer is based on US findings, menopausal status and CA125 levels

Question 99

A patient presents with the following:
* mid-cycle ovulatory pain (4/10)
* pain can vary from being right-sided to left-sided
* Duration of pain can vary from minutes up to a few days

What is the most likely diagnosis? [1]
How can you manage this? [1]

Answer 99

Mittelschmerz is mid-cycle ovulatory pain and it is common.
* The pain is due to rupture of the Graafian (dominant) follicle, each month, which results in the release of an ovum into the fallopian tube.
* The pain can vary from being right-sided to left-sided depending on which ovary is ovulating that month.
* Duration of pain can vary from minutes up to a few days and it can be controlled using simple analgesics such as paracetamol and NSAIDs

Question 100

How do you treat CIN1 cytology? [1]

Answer 100

50-60% of CIN 1 will spontaneously regress within 2 year and the malignant potential is low, so conservative management with repeat cytology in 6 months is usually recommended if there are no other risk factors

Question 101

What is the most common cause of pruritus vulvae?

Lichen sclerosus
Psoriasis
Pubic lice
Contact dermatitis
Lichen simplex

Answer 101

What is the most common cause of pruritus vulvae?

Contact dermatitis
- This is either a delayed allergic reaction to allergens like medication, contraceptive creams/gel, latex, etc. or an irritant reaction to chemical or physical triggers like humidity, detergents, solvents or friction/scratching etc.

Question 102

How do you manage the risk of cervical cancer in patients with HIV? [1]

Answer 102

Annual cytology

Question 103

Which is the most important consideration when prescribing this medication to the patient?

Avoid use for more than 5 days due to risk of acute dystonia
Prolonged use leads to a small increased risk of the baby having a cleft lip
Prolonged use may lead to hyperprolactinaemia and associated complications
She will require additional IV vitamin supplementation
The drug can cause diarrhoea

Answer 103

Which is the most important consideration when prescribing this medication to the patient?

Avoid use for more than 5 days due to risk of acute dystonia
Prolonged use leads to a small increased risk of the baby having a cleft lip
Prolonged use may lead to hyperprolactinaemia and associated complications
She will require additional IV vitamin supplementation
The drug can cause diarrhoea

Question 104

Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → [?]

Answer 104

Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy

Question 105

Which of the following ovarian tumours is associated with the development of endometrial hyperplasia?

Thecomas
Sertoli cell tumours
Fibromas
Teratomas
Granulosa cell tumours

Answer 105

Which of the following ovarian tumours is associated with the development of endometrial hyperplasia?

Granulosa cell tumours
- Atyplical hyperplasia of the endometrium is classified as a premalignant condition
- granulosa cells make oestrogen which causes endometrial hyperplasia

Question 106

Lynch syndrome causes which cancers? [3]

Answer 106

Lynch Syndrome is the CEO of cancers
* Colon
* Endometrial
* Ovarian

Question 107

Around 1 in 5 women who undergo a salpingotomy for an ectopic pregnancy require further treatment. What is this treatment? [1]

Answer 107

Around 1 in 5 women who undergo a salpingotomy for an ectopic pregnancy require further treatment: methotrexate and/or a salpingectomy

Question 108

What is the most appropriate investigation to diagnose premature ovarian failure?

Progesterone level
Ovarian ultrasound
Follicle stimulating hormone level
Serial measurement of basal body temperature
Oestrogen level

Answer 108

Follicle stimulating hormone level

Question 109

A 50-year-old lady is commenced on tamoxifen for the treatment of an oestrogen receptor positive breast cancer. Which of the following malignancies are associated with tamoxifen use?

Adenocarcinoma of the colon
Hodgkins lymphoma
Adenocarcinoma of the lung
Ovarian cancer
Endometrial cancer

Answer 109

Endometrial cancer

Question 110

How should you counsel this woman on the risks of ondansetron use in pregnancy?

There are no recognised risks for her, the pregnancy or the newborns
There is a small but significant risk of spontaneous miscarriage in twin pregnancies
There is a small increased risk of cleft lip/palate in the newborn if used in the first trimester
There is an established risk of severe congenital heart defects in the newborn and it should be stopped
There is some evidence of an increased rate of developing HELLP syndrome in the 3rd trimester

Answer 110

There is a small increased risk of cleft lip/palate in the newborn if used in the first trimester

Ondansetron - Orofacial malformation - Trimester One

Question 111

Polycystic ovarian syndrome (PCOS) increases the long-term risk of which of the following conditions?

Cervical cancer
Osteoporosis
Endometrial cancer
Endometriosis
Vulval intra-epithelial neoplasia

Answer 111

Polycystic ovarian syndrome (PCOS) increases the long-term risk of which of the following conditions?

Endometrial cancer
- The polycystic ovaries develop and secrete oestrogen (like any developing follicle), but as there’s no corpus luteum (because the follicles don’t fully mature, and rupture), theres no progesterone to protect against the high oestrogen

Question 112

What is functional incontinence? [1]
What is overflow incontinence? [1]

Answer 112

functional incontinence - physical disability prevent from urinate (eg.wheelchair/bedridden)

overflow incontinence - poor stream/incomplete emptying

Question 113

How do you differentiate between androgen insensitivity syndrome and congenital adrenal hyperplasia? [3]

Answer 113

Androgen insensitivity syndrome (AIS)
- This patient has presented with primary amenorrhoea as she has failed to establish menstruation by 15 years of age.
- The blood tests show increased testosterone and her examination shows little to no axillary or pubic hair and bilateral lower pelvic masses.
- These findings all point in the direction of AIS, which is an X-linked recessive condition characterised by end-organ resistance to testosterone, causing genetically male children (46XY) to have a female phenotype.
- The bilateral lower pelvic swellings are likely to be undescended testes and testosterone is elevated due to tissues being unresponsive to it.

Congenital adrenal hyperplasia (CAH)
- Although this can also cause primary amenorrhoea, this is associated with the development of male secondary sexual characteristics in females (such as deep voice and hirsutism)
- This is because of impaired cortisol synthesis leading to surplus progesterone which is converted to extra testosterone to reduce the levels of progesterone.
- Unlike AIS, the body is still responsive to testosterone, therefore, this would mean that this patient would have hirsutism and excess male-pattern hair growth, including axillary and pubic hair.

Question 114

What is a mneuomnic for the causes of endometrial hyperplasia? [7]

Answer 114

Endometrial hyperplasia

MOONTA Street

Menarchy extremes
Obesity
Oestrogen
Nulliparity
Tamoxifen
Age35+
Smoking

Question 115

What effect does Turner’s syndrome have on FSH/LG? [1]

Answer 115

Raised FSH/LH in primary amenorrhoea - consider gonadal dysgenesis (e.g. Turner’s syndrome)

Question 116

Which diseases is ergometrine CI in? [3]

Answer 116

Ergometrine can cause uncontrolled hypertension due to its smooth muscle constriction and cerebral vasospasm properties. It is also contraindicated in people with peripheral vascular disease or heart disease.

Question 117

How do you treat molar pregnancies? [1]

Answer 117

surgically using a dilatation and curettage

Question 118

How do you follow up treatment for molar pregnancies? [2]
How do you particularly manage for partial [1] and complete moles? [1]

Answer 118

Bimonthly serum and urine hCG testing until levels are normal.
* In the case of a partial mole, a repeat hCG test is done 4 weeks later - if normal, the patient is discharged from surveillance.
* In a complete mole, monthly repeat hCG samples are sent for at least 6 months.

Question 119

How do you calculate estimation date for pregnancy? [1]

Answer 119

The calculation is to add one year and seven days to the first day of the LMP and subtract three months.

Question 121

What are the answers for the following:

1. Commonst type of ovarian cyst due to non rupture of follicle?
2. Can present with intraperitoneal bleed?
3. Most common benign ovarian tumour in women under 30 that is associated with ovarian torsion?
4. Ectopic tissue in ovary aka chocolate cyst
5. Become massive and cause pseudomyxoma peritonei
6. Resembles most common ovarian cancer

Answer 121

1. Commonst type of ovarian cyst due to non rupture of follicle? follicular cysts
2. Can present with intraperitoneal bleed? corpus luteum cyst
3. Most common benign ovarian tumour in women under 30 that is associated with ovarian torsion? dermoid cyst
4. Ectopic tissue in ovary aka chocolate cyst endometrioma
5. Become massive and cause pseudomyxoma peritonei mucinous cystadenoma
6. Resembles most common ovarian cancer: serous cystadenoma

Question 122

What is an easy way of remebering which type of ovarian cysts cause a pseudomyxoma and which is most common? [2]

Answer 122

pseudoMyxoma - Mucinous
SErous - Seriously common Epithelial

Question 123

How would you be able to distinguish an ectopic from a miscarriage (apart from imaging and looking at cervix opening)? [1]

Answer 123

In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy

Question 124

Why you not give patients with HG dextrose? [1]

Answer 124

As thiamine deficiency is common in patients with hyperemesis gravidarum; fluids containing dextrose should not be given as dextrose increases the body’s need for thiamine which might precipitate Wernicke encephalopathy.

Question 125

On examination, the gynaecologist notes an enlarged, boggy uterus.

What does this indicate? [1]

Answer 125

adenomyosis

Question 126

[] should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.

Answer 126

Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.

Question 127

Which nerve is the most likely to be damaged during childbirth?

Obturator
Femoral
Sciatic
Lumbrosacral

Answer 127

Which nerve is the most likely to be damaged during childbirth?

Obturator
Femoral
Sciatic
Lumbrosacral

Question 128

Which of the following is most likely to occur because of damage by forceps during childbirth?

• Weakness in knee extension, loss of the patella reflex, numbness of the thigh
• Weakness in ankle dorsiflexion, numbness of the calf and foot
• Weakness in knee flexion and foot movements, pain and numbness from gluteal region to ankle
• Weakness in hip adduction, numbness over the medial thigh

Answer 128

• Weakness in hip adduction, numbness over the medial thigh due to obturator nerve damage

Question 129

A patient presents with severe PMS.

Describe how often you / when you prescribe the SSRIs [1]

Answer 129

SSRIs, either continuously or during the luteal phase, may help premenstrual syndrome

Question 130

HRT: adding a progestogen increases the risk of [] cancer

Answer 130

HRT: adding a progestogen increases the risk of breast cancer

Question 131

[] may develop during pregnancy, presenting with low-grade fever, pain and vomiting.

PMH of heavy periods

Answer 131

Fibroid degeneration may develop during pregnancy, presenting with low-grade fever, pain and vomiting.

Question 132

The [] is the contraceptive of choice amongst the epileptic population. The injection does not interact with liver enzymes

Answer 132

The progesterone injection is the contraceptive of choice amongst the epileptic population. The injection does not interact with liver enzymes

Question 133

What is the overall most common type of ovarian cancer? [1]

What is the most common in younger (< 40) and older populations? [2]

Answer 133

epithelial ovarian cancers are the most common overall, they occur much more commonly in post-menopausal women

Germ cell tumours are around 10% of ovarian cancers, and mainly affect younger women.

Question 134

A 45-year-old woman presents with right hip pain that has been worsening over the past month. On examination, there is no significant hip pathology, but she reports a history of ovarian cysts.

Explain the mechanism causing the referred pain to the hip [1]

Answer 134

Referred pain to the hip from an ovarian mass occurs due to the shared innervation of the ovary and the hip region by the obturator nerve (L2-L4). The ovary is located near the pelvic sidewall, and when an ovarian mass enlarges or irritates surrounding tissues, it can stimulate the obturator nerve, leading to pain referred to the medial thigh, groin, and hip. This reflects the phenomenon of viscerosomatic convergence, where visceral organ pain is perceived as musculoskeletal pain.

Question 135

A 55-year-old postmenopausal woman presents with abdominal bloating, early satiety, and weight loss. On examination, there is a palpable pelvic mass. CA-125 is elevated. What is the most likely type of ovarian tumor?

A) Germ cell tumor
B) Granulosa cell tumor
C) Serous epithelial tumor
D) Dysgerminoma
E) Sertoli-Leydig cell tumor

Answer 135

A 55-year-old postmenopausal woman presents with abdominal bloating, early satiety, and weight loss. On examination, there is a palpable pelvic mass. CA-125 is elevated. What is the most likely type of ovarian tumor?

A) Germ cell tumor
B) Granulosa cell tumor
C) Serous epithelial tumor
D) Dysgerminoma
E) Sertoli-Leydig cell tumor

Question 136

A 50-year-old woman presents with unexplained weight loss, abdominal pain, and a pelvic mass. Imaging reveals bilateral ovarian masses. Histology confirms signet-ring cells. What is the most likely diagnosis, and what is the origin of this condition? [1]

Answer 136

The most likely diagnosis is a Krukenberg tumor, which is a metastatic ovarian tumor, typically originating from a gastrointestinal primary, most commonly gastric adenocarcinoma.

Key Features:

Krukenberg tumors are characterized histologically by signet-ring cells.
They often present bilaterally and can cause abdominal or pelvic pain, bloating, or ascites.

Question 137

A 42-year-old woman with a long-standing history of endometriosis presents with pelvic pain and a complex ovarian mass on ultrasound. According to NICE guidelines, what is the most likely type of ovarian tumor associated with endometriosis?

A) Dysgerminoma
B) Mucinous cystadenoma
C) Clear cell carcinoma
D) Sertoli-Leydig cell tumor
E) Serous cystadenocarcinoma

Answer 137

C) Clear cell carcinoma

Question 138

A woman with ovarian cancer presents with pelvic pain and bloating. Imaging reveals spread of the tumor to the fallopian tubes and the peritoneum within the pelvis. There is no involvement of lymph nodes or distant metastasis. What is the most likely stage of her ovarian cancer?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Answer 138

A woman with ovarian cancer presents with pelvic pain and bloating. Imaging reveals spread of the tumor to the fallopian tubes and the peritoneum within the pelvis. There is no involvement of lymph nodes or distant metastasis. What is the most likely stage of her ovarian cancer?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Question 139

A 65-year-old woman with ovarian cancer is found to have omental deposits and involvement of para-aortic lymph nodes on CT. No distant metastases are detected. What is the most appropriate FIGO stage?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Answer 139

C) Stage III

Question 140

PCOS causes an increased risk of which cancer? [1]
Why? [1]

Answer 140

Endometrial
- This is primarily due to the hormonal imbalances associated with PCOS, particularly the prolonged exposure to unopposed estrogen.
- In PCOS, women often have irregular ovulation or anovulation (lack of ovulation), leading to infrequent or absent menstrual cycles.

Question 141

What would indicate upon a speculum exam that PROM has occured? [1]

Answer 141

Liquid in posterior vaginal vault

Question 142

Describe the effects of ages of menarche and menopause on both endometrial and ovarian cancers [2]

Answer 142

Both have increased risk of prolonged oestrogen exposure - so both increased by early menarche and late menopause!

Question 143

A 24-year-old woman presents with heavy menstrual bleeding that lasts longer than 7 days, with clots and has been worsening over the past several months. She reports no significant past medical history, although, does mention she had quite frequent and long-lasting nose bleeds as a child. On her medical notes, the practice nurse has documented she bleeds excessively following venepuncture.

What treatment could be given to manage the underlying cause of her symptoms? [1]

Answer 143

This patient’s clinical presentation suggests the possibility of Von Willebrand’s disease. This is the most common inherited bleeding disorder that affects platelet function and coagulation. The disease is characterised by excessive menstrual bleeding and prolonged bleeding after minor trauma. Desmopressin is the first line treatment of Von Willebrand’s disease. The medication works by temporarily increasing FVIII and Von Willebrand factor levels by releasing endothelial stores.

Question 144

Describe what the main risk factors for endometrial cancer are [5]

Answer 144

The main risk factor for endometrial cancer is exposure to unopposed oestrogen. This includes:
* Nulliparity
* Obesity
* DM
* Early menarche
* Late menopause
* Polycystic ovary syndrome
* Oestrogen-only hormone replacement therapy

Question 145

A patient who is 15 presents with amenorrhoea.

They have a wide spaced nipples and short stature.

What is the associated heart condition seen with this condition? [1]

Answer 145

bicuspid aortic valve.

Question 146

A 44-year-old female, who has previously undergone a hysterectomy procedure for the treatment of fibroids, presents to the Preoperative Gynaecology Clinic before sacrospinous fixation for treatment of a vault prolapse. The risks and complications of the surgery are outlined before consent is obtained.

Which of the following nerves is at risk of damage during sacrospinous fixation?

Common peroneal nerve
Femoral
Sciatic
Inguinal
Posterior cutaneous nerve of the thigh
#18155

Answer 146

Sciatic

Question 147

A 54-year-old female presented with pruritus in the perineal area, associated with pain on micturition and dyspareunia. She had thin, hypopigmented skin with white, polygonal patches, which, in areas, formed patches. She returns for review after a three-month trial of clobetasol proprionate, which has failed to improve symptoms. There is no evidence of infection, and her observations are stable.

Which of the following is the next most appropriate step in this patient’s management? [1]

Answer 147

Lichen sclerosus:
* Diagnosis is typically clinical, with first-line treatment being high-potency steroids like clobetasol propionate. A non-responsive patient may benefit from topical calcineurin inhibitors like tacrolimus

Question 148

A female aged 76 years presents with a 2-cm unilateral, invasive vulvar carcinoma with no evidence of lymph node involvement.

What is the recommended management?

Simple vulvectomy and bilateral inguinal lymphadenectomy
Radiation therapy
Simple vulvectomy
Chemotherapy
Wide local excision

Answer 148

Simple vulvectomy and bilateral inguinal lymphadenectomy

Question 149

The differential diagnosis of right iliac fossa pain in a young woman includes [5]

Answer 149

The differential diagnosis of right iliac fossa pain in a young woman includes
* appendicitis
* urinary tract infection (UTI)
* ovarian or tubal pathology
* pelvic inflammatory disease (PID)
* ruptured ectopic pregnancy
* mesenteric adenitis
* and other less common pathologies such as Crohn’s disease.

Question 150

A 36-year-old female is a candidate for artificial insemination.

Which blood hormone can be used as a reliable marker of imminent ovulation?

Luteinising hormone (LH)
Follicle-stimulating hormone (FSH)
Oestrogen
Progesterone
Human chorionic gonadotropin (hCG)

Answer 150

A 36-year-old female is a candidate for artificial insemination.

Which blood hormone can be used as a reliable marker of imminent ovulation?

Luteinising hormone (LH)
- An LH surge, which occurs prior to ovulation, triggers ovulation. There is also a smaller surge in FSH that occurs at the same time. Ovulation occurs about 12 h after the peak in LH.