Repro Quiz Flashcards
A 30 year old woman is referred to the Gynaecology clinic due to heavy cyclical vaginal bleeding. She is using double protection and reports passage of clots, predominantly on the first two days of her period. Her menstrual cycles are regular with 7 days of bleeding for every 28 days (7/28). Her family is complete and her husband has had a vasectomy.
Pelvic examination findings are normal.
What would be the first line investigations for this patient?
A. FBC
B. FSH
C. Group and save
D. Platelet function test
E. TFT
A. FBC
First line investigation is to determine haemoglobin level and platelet count, particularly in a low risk patient with regular periods without IMB.
A 42 year old woman attends the Gynaecology clinic because of some bleeding between her periods. She has regular menstrual cycles 5/28 with normal blood loss, that are not painful. She is not sexually active and is not using any contraception. She had a normal cervical smear last year.
What is the likely cause of her intermenstrual bleeding?
A. Asherman syndrome
B. Endometrial cancer
C. Endometrial polyp
D. Pelvic inflammatory disease
E. Submucousfibroid
Endometrial polyp
Most common cause of abnormal uterine bleeding.
Endometrial cancer could also cause abnormal uterine bleeding, but benign causes are more common.
A 35 year old woman attends the Gynaecology clinic because of heavy periods. She is nulliparous and has been actively trying to conceive for the last 9 months. Her cervical smears have been normal. Her mother had hysterectomy at 42 years of age due to fibroids.
She undergoes a pelvic ultrasound scan which shows a 5 cm intramural fibroid at the uterine fundus.
What would be the appropriate treatment option for her?
A. Combined oral contraceptive pill
B. Mirena IUS
C. Progestogen implant
D. Progestogen only pill
E. Tranexamic acid
Tranexamic acid
A 16 year old girl attends a Gynaecology clinic with her mother, because of a history of very heavy periods. Her menarche was at age 14, and she reports regular but very heavy periods from the outset. Her cycles are 8/28. She has to change soaked pads every two hours for first three days of her period.
On further questioning she mentions she can bruise very easily and may bleed for a long time from small cuts.
She has never been sexually active and is not using any contraception. She had her HPV vaccination at school.
Initial investigations via her GP include a normal trans-abdominal pelvic ultrasound scan, and mild anaemia on FBC.
What is the likely cause of her heavy periods?
A. Endometritis
B. PCOS
C. Pelvic inflammatory disease
D. Thrombocytopenia
E. Von-Willebrand disease
Von-Willebrand disease
VWD is the most common congenital human bleeding disorder which is detected most commonly in younger women when investigating for idiopathic menorrhagia. It is manifested as a quantitative deficiency in Von Willebrand factor (VWF) or dysfunction of this factor.
A 21 year old university student is referred to the Gynaecology clinic because of problems with her periods. Her cycles used to be 5/30, but over the last two years have become 7/38-58.
She is on medication for asthma and acne.
She also reports that she is undergoing laser treatment for excessive facial hair.
Her abdominal and pelvic examination is normal.
Which blood test is most likely to confirm the suspected diagnosis?
A. Free androgen index B. FSH/LH
C. Insulin
D. Progesterone
E. Thyroidfunctiontest
A. FAI
Raised free androgen index is the diagnostic test for PCOS, and is the result of suppressed SHBG levels, resulting in higher concentration of circulating free testosterone.
FSH/LH and TFT would help exclude other conditions.
A 62 year old patient is attending a 2-Week-Wait Postmenopausal Bleeding clinic because of recurrent episodes of PMB over the past 2 months.
Her smears have always been normal.
She has a history of Type 2 Diabetes and Hypertension. Her BMI is 42.
Abdominal, speculum and pelvic examination is normal.
What investigation would be diagnostic?
A. Endometrial biopsy
B. Pelvic ultrasound scan
C. Platelet function test
D. Serum Ca125
E. Thyroid function test
Endometrial biopsy
to rule out endometrial hyperplasia or cancer. Normal appearance at hysteroscopy does not rule out hyperplasia or cancer, a tissue biopsy is needed.
A 43 year old woman is undergoing an outpatient hysteroscopy and endometrial biopsy for menorrhagia, as she failed to respond to first line treatment with Tranexamic acid. Her cervical smears are up to date and normal.
Her family is complete, having had three children by normal vaginal delivery. She and her partner use condoms for contraception.
At hysteroscopy, the uterine cavity is normal. Result of endometrial biopsy is awaited.
What is the most appropriate treatment to offer her at the hysteroscopy appointment?
A. COCP (Microgynon)
B. GnRH analogues (Decapeptyl)
C. Levonorgestrel IUS (Mirena)
D. Progestogen only pill (Cerazette)
E. Ulipristal (Esmya)
Mirena
A 39 year old Para 3 with a long standing history of menorrhagia is attending the Gynaecology clinic for follow up. She has an enlarged uterus with a cavity length of 13cm (normal ≤10 cm) and multiple large intramural and sub serous uterine fibroids, with the largest around 8 cm diameter, diagnosed by ultrasound and hysteroscopy.
She was managed with Tranexamic and Mefenamic acid, with no success. She has been sterilised and is not keen for hormonal treatment of her condition.
What would be the most appropriate and least invasive long-term treatment option for her?
A. Endometrial ablation
B. Fibroid embolisation
C. Laparotomy and Myomectomy
D. Total Abdominal Hysterectomy & Bilateral Salpingo-oophorectomy
E. Total Abdominal Hysterectomy with conservation of ovaries
fibroid embolisation
Least invasive management is fibroid embolisation via interventional radiology. Almost 90 percent of women experience either significant or complete resolution of their fibroid-related symptoms following embolisation.
A 14 year old girl is brought to the Emergency Department by her mother because severe abdominal pain. The mother reports that over the past year the girl has had recurrent abdominal pain, occurring every few weeks.
She has not started her period yet. Her older sister had menarche at 12 years of age.
On examination she has normally developed secondary sexual characteristic. On genital inspection there is a bulging bluish membrane is visible at the vaginal introitus.
Select the most likely diagnosis
A. Cervical stenosis
B. Gonadaldysgenesis
C. Imperforate hymen
D. Mullerian agenesis
E. Vaginalcancer
Imperforate hymen
A 14 year old girl is brought to the Emergency Department by her mother because severe abdominal pain. The mother reports that over the past year the girl has had recurrent abdominal pain, occurring every few weeks.
She has not started her period yet. Her older sister had menarche at 12 years of age.
On examination she has normally developed secondary sexual characteristic. On genital inspection there is a bulging bluish membrane is visible at the vaginal introitus.
Select the most likely diagnosis
A. Cervical stenosis
B. Gonadaldysgenesis
C. Imperforate hymen
D. Mullerian agenesis
E. Vaginalcancer
Imperforate hymen
A 35 year old nulliparous woman has been trying for pregnancy for the past 2 years. She attends her GP surgery worried about ovarian cancer. She has recently found out that her grandmother has ovarian cancer at the age of 79, and one of her aunts has been recently diagnosed aged 60.
She recently had a normal pelvic ultrasound scan in the Infertility clinic.
Which one of the following may increase her risk of ovarian cancer?
A. Clomiphene citrate (Clomid)
B. Combined oral contraceptive pill (Microgynon)
C. GnRH analogues (Decapeptyl)
D. Levonorgestrel IUS (Mirena)
E. Progesterone(Cyclogest)
A. Clomid (for Ovulation induction)
Fertility drugs may be related to an increase in ovarian cancer risk, particularly when used over many cycles, because they cause an increase in LH and FSH levels, and increased ovarian stimulation.
COCP is rather protective of ovarian cancer.
A 21 year old woman presents to her GP following an episode of post coital bleeding. She is using Combined oral contraceptive pill for contraception for the past 2 years.
She is worried about risk of cervical cancer and requests a cervical smear test. From what age can she be offered cervical screening in England?
A. 20 years B. 21years C. 23years D. 25 years E. 28years
25
A 35 year old woman undergoes cervical screening. The results is positive for High Risk HPV, and cytology shows moderate dyskaryosis.
The patient is very anxious as her mother had chemoradiotherapy for stage 1b cervical cancer at 45 years of age.
What would be most appropriate next step in her management?
A. Cold Knife Cervical Cone biopsy
B. Colposcopy and Cervical Cryotherapy
C. Colposcopy and LLETZ
D. Radical Hysterectomy
E. Total Laparoscopic Hysterectomy
Colposcopy and LLETZ
LLETZ is the most common procedure done in the outpatient setting for CIN and some of very early carcinoma of cervix cases.
A 65 year old parous woman is referred to the Gynaecological Oncology clinic with a two month history of bloating and abdominal discomfort.
She had one vaginal delivery in the past. She underwent a Total Abdominal Hysterectomy at 45 years of age for heavy periods and fibroids.
Her pelvic ultrasound scan shows a 10 cm unilateral, simple unilocular cyst and her serum CA 125 level is 23 u/ml (≤ 35 u/ml).
What is her Risk of Malignancy index (RMI)?
A. 23
B. 46
C. 69
D. 92
E. 115
69
RMI is calculated using the formula, RMI = U x M x s-CA 125
The RMI score (malignancy risk index) is calculated based on the s-CA 125 value, menopausal status (M), and evaluation of ultrasound (U).
* Score 0–1: U=1
* Score 2–5: U=3
* s-CA 125 (u/ml) (the actual value is used)
RMI of < 200 is low risk of malignancy and could be managed with surgery not needed to be done in cancer centre, or conservatively if ovarian cyst is less than 5 cm in size. RMI >200 is high risk for ovarian cancer and patient should be referred to gynaeoncology team or cancer centre for the management.
A 70 year old woman presents with a one year history of vulval pruritus. Her GP prescribed various antifungal treatments with no benefit, and she recently started a topical steroid treatment.
She has no significant past medical history, but has had limited access to health care prior to moving to the UK from North Africa two years ago.
On clinical examination her vulva has an atrophic appearance, with loss of architecture and fusion of the labia over the clitoris.
What is the most likely diagnosis?
A. Female Genital Mutilation
B. Lichen sclerosus et atrophicus
C. Vulvalcancer
D. Vulval Intraepithelial Neoplasia
E. Vulval warts
LSA is an autoimmune chronic inflammatory skin disorder that most commonly affects women before puberty or after menopause. The most common distribution is a figure of 8 involving the vulva and perianal area.
The presence of LSA is associated with an increased risk of vulval cancer.
A 35 year old parous woman is referred to secondary care due to an ultrasound finding of an 8 cm right ovarian mass. The mass appears complex and there are sonographic features of posterior acoustic attenuation due to presence of hair and teeth within the cyst, consistent with the diagnosis of a dermoid.
Which combination of tumour markers should be performed in this patient?
A. CEA, Ca125 and HCG
B. AFP, LDH and HCG
C. Ca125, Ca19-9 and CEA
D. Ca19-9, CEA and LDH
E. Ca125,Ca19-9,CEA and LDH
AFP, LDH and HCG
A 30 year old woman is attending the infertility clinic as she has been actively trying for a pregnancy for the last 12 months. Her menstrual cycles are 7/28 days. She has no significant medical or gynaecological history.
Her partner is 35 years old with no medical history of note.
What would be her chances of natural conception, with regular unprotected intercourse, after one year of trying?
A. 50%
B. 60%
C. 70%
D. 80%
E. 90%
80%
A couple attends infertility clinic as they have been trying for a pregnancy for 14 months. The woman’s menstrual cycles are regular at 5/28 days, except for the last cycle when her period was delayed by a week.
Her partner gives a childhood history of surgery for left undescended testis.
Her pregnancy test is negative. Physical examination is normal in both.
What is the most likely cause of infertility in this couple?
A. Male factor
B. Ovulation defects
C. Tubal disease
D. Unexplained infertility
E. Uterine defects
male factor
According to NICE guidance on infertility management, male factor is responsible for 30% of infertility in the UK, followed by anovulation 25 %, tubal factor 20 % and unexplained infertility 25%.
A 35 year old woman is referred to the infertility service by her GP. She has been trying for a pregnancy for over a year, with no success.
She had 1 vaginal delivery from a previous relationship seven years ago.
Her cycles have changed somewhat over the past two years and she now has periods at 7/40, with heavy blood loss. Her partner is fit and healthy with no medical problem.
Her BMI is 35.
Mid luteal phase progesterone level was low when tested last cycle. What would be the first line management of her infertility?
A. Clomiphene citrate
B. Dopamine agonist
C. Egg donation
D. GnRH analogues
E. Weight loss
weight loss
A 32 year old nulliparous woman attends the Gynaecology Clinic with an 18 months history of worsening pelvic pain. She has regular menstrual cycles at 7/28, with heavy blood loss in the first 3 days of her period. Her pain starts two days before her period and lasts for up to 6 days. She reports pain on intercourse, and sometimes on defecation.
She takes co-codamol which gives little relief to her pain.
On transvaginal ultrasound scan her pelvis is normal, with the exception of a unilocular cyst
in her
right ovary, measuring 2.9 cm.
What is the most likely cause of her pelvic pain?
a. Adenomyosis
b. Endometriosis
c. Fibroid uterus
d. Ovarian cyst accident
e. Pelvic inflammatory disease
Endometriosis
A 32 year old woman is attending the Chronic Pain clinic for her ongoing pain at the site of her Caesarean section scar since delivery of her first baby by emergency Caesarean section six months ago.
How common is pain at Caesarean section scar site due to nerve entrapment?
A. 0.7% B. 3.7% C. 9.7% D. 12.7% E. 26.7%
3.7%
Pfannenstiel scar pain
A 38 year old woman attends her GP surgery because of pelvic pain she has been experiencing for the last 9 months. The pain is intermittent, and is relieved by opening of bowels. She also reports that she experiences nausea, bloating, and her stools can be loose before and during her period. She is unsure as to whether the pain relates to food.
What would be the first line medical treatment for her pain?
A. Antispasmodic only
B. Antispasmodic and dietary changes
C. Antispasmodics and Metronidazole
D. Antispasmodic and Mild Opiates such as co-codamol
E. Antispasmodics and NSAIDS such as Mefenamic acid
Antispasmodic and dietary changes
A 37 year old woman, who is a Para 1, is referred to the Gynaecology clinic as she has had no periods for a year. Previously she had LNG-IUS (Mirena IUS) which was removed a year ago as she is keen to have another baby.
What would be the likely diagnosis in her case?
- Anovulation
- Hyperprolactinemia
- Hypothyroidism
- Premature ovarian insufficiency
- Polycystic ovary syndrome
Premature ovarian insufficiency
Amenorrhoea for a year with FSH ≥40 IU/L is diagnostic pf POI and it would be confirmed with repeating FSH test after eight weeks.
A 51 year old woman presents with nine months of amenorrhoea, and worsening hot flushes and night sweats. She is feeling irritable with significant mood changes that are affecting her work and life at home.
Her mother had breast cancer at 80 years of age.
What would be the most appropriate treatment for her symptoms?
a. Acupuncture and Acupressure
b. Continuous combined HRT of Oestrogen and progesterone
c. Evening Primrose Oil and Black Cohosh
d. Sequential combined HRT of oestrogen and progesterone
e. SSRI such as Fluoxetine
Sequential combined HRT of oestrogen and progesterone
A menopausal woman seeking HRT after less than 12 months amenorrhoea should be treated with sequential combined HRT to avoid unscheduled and heavy bleeding. This patient’s symptoms are affecting her quality of life and she should be offered HRT.
A 55 year old woman, who is a Para 2, attends the Urogynaecology clinic with worsening urinary symptoms. She has daytime urinary frequency of about 9 x per day. She has also reported leakage of urine when rushing to the toilet. She reports occasional loss of urine when she does trampolining with her grandchildren.
She has no significant past medical history, but her mother had type 2 diabetes. What would be most appropriate first line investigation or assessment?
A. Bladder diary
B. Cystoscopy
C. Glucose tolerance test
D. Pelvic ultrasound scan
E. Urodynamics test
Bladder diary
A 65 year old woman presents to her GP because of leakage of urine on coughing and sneezing. She describes having to be close to a toilet most of the day so she makes it on time. She also reports that she wakes to go to the toilet three times in the night.
She had three previous vaginal deliveries, with all three babies weighing more than 4000g.
Her BMI is 28. On pelvic examination there is 1st degree uterine decent, and a small cystocele.
What would be the first line treatment option for this patient?
A. Anticholinergic medication
B. Colposuspension
C. Supervised pelvic floor exercises
D. Vaginal hysterectomy and pelvic floor repair
E. Weight loss
Supervised pelvic floor exercises
A 25 year old woman attends her GP surgery as she finds herself pregnant. Her LMP was 6 weeks ago, and a pregnancy test was faintly positive. Her cycle is 3/28 and has always been regular.
She does not wish to continue the pregnancy, as she has just started a new job and her relationship has broken down. She is very anxious and expresses concerns about how she would manage as an unsupported single parent without financial security.
What would be the next step to take in her management?
A. Arrange to see a counsellor within a few days to discuss options, including continuation of pregnancy, and available support, before arranging an appointment with Gynaecology service in the following week.
B. As her request meets exemptions outlined in the framework of the Abortion Act 1967, provide a prescription for Mifepristone and Misoprostol
C. As her request meets exemptions outlined in the framework of the Abortion Act 1967, provide a prescription for Mifepristone alone
D. Refer for an ultrasound scan and arrange a follow up appointment in two weeks to offer counselling about options, including continuation of pregnancy, and available support.
E. Refer to Gynaecology service for surgical termination of pregnancy
Counselling should be offered to the woman to provide her with information that may impact on her decision, but a short timeline should be observed to allow for safe abortion care.
The GP would not be able to provide a prescription for abortifacient drugs, as TOP can only be performed on licensed premises, after two doctors have agreed in good faith that legal exemptions of the Abortion Act are met and the appropriate Forms have been completed.
A 19 year old woman undergoes surgical termination of pregnancy at 12 weeks gestation, by suction evacuation under GA. The procedure is documented as uncomplicated, and the patient is discharged home later the same day.
She is brought to the Emergency Department by Ambulance 48 hours later, having collapsed with at home severe abdominal pain. She had period like pain immediately post op, which had settled the following morning, but overnight started vomiting and complaining of
severe pain.
On examination she has T 39.3oC, BP 88/44 mmHg, P 125bpm, RR 26 breaths per minute, O2 saturations 94% breathing room air.
Her abdomen is distended, generally tender with guarding and rebound, and bowel sounds are absent.
There is minimal vaginal bleeding.
What is the most likely diagnosis?
A. Appendicitis
B. Cervical injury with broad ligament haematoma
C. Ectopic pregnancy
D. Post-operative endometritis
E. Uterine perforation with bowel injury
Uterine perforation with bowel injury
A 32 year old woman presents to the Emergency Department with shortness of breath, abdominal discomfort and vomiting. She is undergoing IVF treatment and had an embryo transfer one week ago.
What is the most likely diagnosis?
A. Hyperemesis gravidarum
B. Ovarian cyst accident
C. Ovarian hyperstimulation syndrome
D. Pulmonary embolus
E. Urinary tract infection
Ovarian hyperstimulation syndrome which is known complication of assisted reproductive technique . Release of vasoactive substances such as interleukins, tumor necrosis factor-α, endothelin-1, and vascular endothelial growth factor (VEGF) secreted by the ovaries results in increased capillary permeability resulting in ascites, ovarian enlargement and in severe cases pleural effusion.
A 31 year old woman who is a Para 2 presents to her GP to discuss family planning. She plans to go travelling for a few weeks and wants to have reliable contraception. She admits that she is forgetful with pills. Her last pregnancy was unplanned and occurred whilst she was using a coil. Her recent pelvic scan was reported to be normal.
What would be the best contraceptive for her?
A. Cyclical oral progesterone
B. Depo Provera injection
C. Mirena IUS
D. Misoprostol
E. Progestogen only implant
Depo Provera injection which provides effective contraception for 3 months with no increased risk of thrombosis which could easily be administered at her GP surgery.
An 18 year old woman attends the sexual health clinic after an episode of unprotected sexual intercourse 4 days ago. She would like postcoital contraception.
She has no significant medical history.
Clinical examination is normal. Genital swabs are taken and sent.
What would be the appropriate method of post coital contraception in this patient?
A. Depot Provera injection
B. LNG-IUS (Mirena)
C. Nexplanon implant
D. Oral Levonorgestrel
E. Ulipristal acetate
Ulipristal acetate
Ulipristal is effective when taken up to 120 hours after unprotected intercourse, but Levonorgestrel up to 72 hours.
A copper coil would be also a possible option in this case.
A 25 year old woman presents to the Emergency Department because of vaginal bleeding. She is 6 weeks into her first pregnancy.
Whilst she is being admitted, she feels a large gush of blood and starts feeling dizzy and faint.
Her blood pressure 88/49 mmHg and her pulse is 48 bpm.
She is immediately cannulated, and bloods are taken for FBC and G&S.
What is immediate management steps should be taken next?
A. Start intravenous fluids and administer oxytocin
B. Start intravenous fluids and await gynae team review
C. Start intravenous fluids and give tranexamic acid
D. Start intravenous fluids and perform an ECG
E. Start intravenous fluids and remove any clots from cervix
Start intravenous fluids and remove clots from cervix.
Products of conception and clots lodged in the cervical canal induce a vasovagal response, resulting in hypotension and bradycardia (so called cervical shock). Immediate action to remove any clot or tissue from the cervix will result in rapid resolution of the symptoms.D.
A 40 year old primigravida attends EPAU (Early Pregnancy Unit) at 8 weeks gestation, having had some light, painless spotting.
She undergoes a pelvic ultrasound scan. The report reads as follows:
“The uterus is enlarged and cavity is distended with diffusely thickened tissue with cystic appearance. There is no obvious gestational sack. Both ovaries appear normal.”
What is the USS diagnosis of her condition?
A. Anembryonic pregnancy
B. Ectopic pregnancy
C. Missed miscarriage
D. Molar pregnancy
E. Retained products of conception
Molar pregnancy.
In a complete mole, there will not be a fetus, nor amniotic fluid. It occurs when a sperm fertilises an egg where the original maternal nucleus is missing (empty egg). The treatment of choice is surgical evacuation.
In a partial mole, an intact egg is fertilised with two sperm, resulting in a triploid embryo.
