Sba 2 Gynecology

Question 1

A22-year-old woman was seen in the GUM clinic with Chlamydia trachomatis infection.
What would be regarded as the most suitable treatment for this patient?

Answer 1

Appropriate antimicrobial therapy such as a single dose of oral azithromycin 1g, partner
notification, advice to abstain from sex (including oral) until both index case and current
partner have been treated and for 1 week thereafter even when treated at the same time
and relevant health education
* no need for re-testing

Question 2

A23-year-old woman presents with acute onset of
lower abdominal pains of 5days duration. These symptoms started 5days after unprotected sexual intercourse. Shealso complained of a vaginal discharge and right upper abdominal pain. Shehas a temperature but does notsuffer from rigors. You examine and find lower abdominal tenderness and cervical motion tenderness. You suspect that she has Chlamydia salpingitis and perihepatitis and have sent swabs for testing. What firstline treatment should she be prescribed?

Answer 2

Doxycycline 100mg bd and metronidazole 400mg four times a day for 14days
* An alternative
to this regimen is combining metronidazole with ofloxacin (400mg twice daily)

Question 3

You have seen a 23-year-old woman presenting to the Gynaecology Emergency Unit
of your hospital with dysuria and a urethral discharge. You suspect that she may have
Chlamydia trachomatis genital infection. What would be the most appropriate action to
take in her management?
A. Give her 1g azithromycin as a single dose after obtaining specimens for NAAT and culture
B. Obtain endocervical swabs for NAAT and culture and sensitivity and then give 1 g
azithromycin as a single dose but review with sensitivity result
C. Obtain urethral swabs for diagnosis with NAAT and then give 1g azithromycin as a single
dose
D. Obtain urine sample for NAAT and await rapid result and then give 1g azithromycin as a
single dose
E. Obtain vaginal swab for diagnosis with NAAT and then give 1g azithromycin as a single dose

Answer 3

Give her 1g azithromycin as a single dose after obtaining specimens for NAAT and culture
* Itis recommended that treatment is initiated without waiting for laboratory confirmation of infection in patients with symptoms and signs of chlamydia infection and their sexual partners.

Question 4

What is the risk of laparotomy following a laparoscopic tubal occlusion procedure?
A. Up to 1in 1000
B. Up to 2in 1000
C. Up to 3in 1000
D. Up to 4in 1000
E. Up to 5in 1000

Answer 4

Up to 3in 1000

Question 5

What is the definition of UKMEC Category 2?

Answer 5

Acondition where the advantage of using the method generally outweighs the theoretical
or proven risks

Question 6

What is the definition of UKMEC Category 4?

Answer 6

A condition in which the risks of using the contraceptive method are minimal
but acceptable to the woman provided she understands the risks involved.)

Question 7

A45-year-old mother of three had a copper intrauterine device (Cu-IUD) inserted 4 months
ago for contraceptive purposes. Since then, she has suffered from spotting and sometimes
heavier and longer bleeding periods. Shehas attended because she is frustrated and wants
to have the device removed. What would be the most appropriate step to take in this woman?

Answer 7

Reassure her and reassess in 2months if the bleeding continues

Question 8

A51-year-old woman who is on the combined oral contraceptive pill (COCP) is seen for
follow-up. Shehas been on the combined pill for the past 7years. What advice will you
give her?
A. To change to another method such as the Mirena®, POP or implant
B. To change to a barrier method
C. To continue with this for another 2years if she is using a low-dose COCP
D. To stop and check her estradiol levels
E. To stop and check her FSH levels

Answer 8

To change to a barrier method
* women over 50years should be advised to switch to an alternative method such as POP, LNG-IUS or barrier method until the age of 55years or until menopause can be confirmed

Question 9

A 48-year-old woman was seen in the Gynaecology Clinic with severe menopausal
symptoms. Shehad been amenorrhoeic for 6months. Following counselling she opted
for HRT in the form of estrogens only tablets but chose the LNG-IUS for endometrial
protection. How long is this device licensed for use in endometrial protection in this
woman?

Answer 9

4years
* but may be used off license for up to 5years.

Question 10

A 48-year-old woman was seen in the Gynaecology Clinic with severe menopausal
symptoms. Shehad been amenorrhoeic for 6months. Following counselling she opted
for HRT in the form of estrogens only tablets but chose the LNG-IUS for endometrial
protection. How long is this device licensed for use in endometrial protection in this
woman?

Answer 10

4years
* but may be used off license for up to 5years.

Question 11

What percentage of those presenting to Early Pregnancy Units have ectopic
pregnancies?

Answer 11

2-3%
* the incidence of ectopic pregnancy is approximately 11/1000 pregnancies

Question 12

A30-year-old woman presents with symptoms highly suggestive of an ectopic pregnancy.
Atransvaginal ultrasound scan is performed. What is the most common ultrasound finding in those with an ectopic pregnancy?

Answer 12

An inhomogeneous or non-cystic adnexal mass ( 50-60%)
* An empty extrauterine gestational sac will be present in around 20%–40% of cases

Question 13

Adiagnosis of a cervical pregnancy has been made in a 36-year-old woman who had two
previous normal deliveries. Serum β-hCG has been quantified to help plan for her management. Atwhat β-hCG level will there be a decreased chance of successful treatment
with methotrexate?

Answer 13

Greater than 10000IU/L

Question 14

Alaparoscopic salpingotomy was performed on a 32-year-old woman who has a fertilityreducing factor (previous ectopic pregnancy treated by salpingotomy). What follow-up
monitoring will you recommend for this woman?

Answer 14

Serum β-hCG on days 7 after surgery and then weekly until negative
* No day 4 testing

Question 15

A24-year-old woman diagnosed with an ectopic pregnancy has elected to have treatment
with methotrexate. Shehas been given 50mg/m2 of the cytotoxic drug. What would be the
estimated success rate of a single-dose injection of methotrexate in this woman?

Answer 15

65%–95%
* with 3%–27% of women requiring a second dose

Question 16

What is the most common gynaecological cancer in the UK?
A. Cervical
B. Choriocarcinoma
C. Endometrial
D. Ovarian
E. Vaginal

Answer 16

Endometrial

Question 17

You performed an endometrial biopsy on a 60-year-old postmenopausal woman who was
referred to the Gynaecology Clinic by her GP with a 1 week history of vaginal bleeding. Thehistology report is negative for pathology. Inapproximately what percentage of
women like her will the diagnosis of endometrial hyperplasia be missed with outpatient
endometrial biopsy?

Answer 17

2%
* Outpatient endometrial biopsy is convenient and has a high overall accuracy for diagnosing endometrial cancer. Theaccuracy for hyperplasia is more modest

Question 18

A38-year-old woman who is known to have polycystic ovary syndrome is seen in the
clinic with 9months amenorrhoea. Atransvaginal ultrasound scan shows a 6-mm-thick
but regular endometrium. What recommendation would you offer this patient?
A. Commence on progestogens
B. Commence on the combined oral contraceptive pill
C. Hysteroscopy and biopsy
D. Outpatient endometrial biopsy
E. Reassure and rescan in 6months

Answer 18

Commence on progestogens
* Studies have failed to identify pathology in women with endometrial thickness of less than 7mm

Question 19

You saw a 63-year-old woman with postmenopausal bleeding of 1 week duration in the
gynaecology clinic. Apipelle endometrial biopsy was performed and reported as hyperplasia without atypia. An ultrasound was ordered, and the report is as follows: ‘normal
size uterus with a thickened endometrium, which measures 5mm in its widest diameter.
Thereis a right ovarian cyst, which measures 6×7 cm. Thereis no increased vascularity
around the cyst wall on colour Doppler’. What will be the next step in her management?
A. Arrange a diagnostic laparoscopy
B. Arrange insertion of the levonorgestrel intrauterine system
C. Commence her on progestogens– oral
D. Discuss a hysterectomy and bilateral salpingo-oophorectomy
E. Obtain blood for ovarian tumour markers test

Answer 19

Obtain blood for ovarian tumour markers test
* possibility of an oestrogen secreting granulosa tumour of the ovary.
If an ovarian cyst is detected on pelvic USS, then blood for tumour markers should be obtained.

Question 20

What will you recommend as the first-line treatment for a 55-year-old woman diagnosed with endometrial hyperplasia without atypia following a pipelle endometrial
biopsy?
A. Dihydrogesterone 10–20mg daily
B. Medroxyprogesterone acetate 10–20mg daily continuously
C. Norethisterone acetate 10–15mg daily
D. Sequential medroxyprogesterone acetate 10mg
E. Thelevonorgestrel intrauterine system (Mirena)

Answer 20

Thelevonorgestrel intrauterine system (Mirena)

Question 21

A48-year-old woman presents with irregular and heavy bleeding of 6months duration.
Her BM is 32kg/m2. An endometrial biopsy is performed and this has been reported as
hyperplasia with atypia. What will be the first treatment option you will recommend for
this patient?
A. Hysterectomy and bilateral salpingectomy
B. Thelevonorgestrel intrauterine system
C. Thelevonorgestrel intrauterine system and sixmonthly endometrial biopsies
D. Total hysterectomy
E. Total hysterectomy and bilateral salpingo-oophorectomy

Answer 21

Total hysterectomy and bilateral salpingo-oophorectomy

Question 22

You are running a routine Gynaecology Clinic when a couple attend with fertility problems. Approximately what proportion of heterosexual couples in the UK present with
infertility?

Answer 22

1:7

Question 23

You have seen a 28-year-old woman with her 30-year-old partner in the clinic complaining of difficulties in achieving a pregnancy despite 2years of unprotected sexual intercourse. Inwhat proportion of such couples will the infertility be unexplained?
A. 10%
B. 20%
C. 25%
D. 30%
E. 40%

Answer 23

25%

Question 24

. A30-year-old woman is seen in the clinic having tried for 12months to become pregnancy unsuccessfully. Sheand her partner are investigated and no obvious cause for the
infertility is found. What would the recommendation for this couplebe?
A. Consider inducing ovulation and artificial insemination with husband’s semen
B. Consider inducing ovulation with clomifene citrate
C. Consider inducing ovulation with gonadotrophins
D. Refer for IVF
E. To continue trying for another 12months after which they will be referred for IVF

Answer 24

To continue trying for another 12months after which they will be referred for IVF
* 2 years before referral to IVF

Question 25

Acouple visited the Infertility Clinic for counselling and management. Theman is unable
to have penetrative sexual intercourse and it was decided that they would best be managed by artificial insemination. Which type of insemination will give the best outcome (in
terms of pregnancy) for the couple?
A. Intracervical insemination with fresh sperm
B. Intracervical insemination with frozen-thawed sperm
C. Intrauterine insemination with fresh sperm
D. Intrauterine insemination with frozen-thawed sperm
E. Intravaginal insemination with either fresh or frozen-thawed sperm

Answer 25

Intrauterine insemination with fresh sperm

Question 26

A38-year-old woman presents with suprapubic pain related to her bladder and associated with urgency and nocturia. Thepain is described as burning in nature. Aurine
sample is obtained for dipstick test and the result is positive for protein and leucocytes.
Asample of the urine is sent for culture and this yields sterile pyuria. What would be the
next investigation for this woman?
A. Biopsy of the bladder for histology
B. Cystoscopy
C. Repeat urine culture
D. Ultrasound scan of the kidneys and bladder
E. Urine culture for acid-fast bacilli

Answer 26

Urine culture for acid-fast bacilli
* To confirm adiagnosisof TB or other mycobacterial infection. But it takes 6-8 weeks to grow enough bacteria

Question 27

A40-year-old woman is referred by her GP to the urogynaecology unit with what is most
likely bladder pain syndrome. What factor at her first consultation is likely to have the
greatest impact on her chances of complete recovery at follow-up?
A. Afavourable rating of the initial consultation
B. Counselling on the course of the condition
C. Effectiveness of the treatment offered and accepted
D. Theduration of her symptoms
E. Thethoroughness of the history and investigations

Answer 27

. Afavourable rating of the initial consultation

Question 28

A37-year-old woman was diagnosed with bladder pain syndrome (BPS) 9months ago
and started on conservative measures. Shehas had various combinations of these measures including paracetamol for her pain but remains refractory to treatment. What
would be the next approach to her management?
A. Intravesical injection of botulinum toxin A(Botox)
B. Intravesical lidocaine
C. Neuromodulation
D. Oral cimetidine
E. Oral amitriptyline

Answer 28

Oral amitriptyline
Also cimetidine is considered to be a first line treatment but is not licenced

Question 29

What is the estimated proportion of women in the reproductive age who suffer from premenstrual syndrome (PMS)?

Answer 29

40% (2in 5)

Question 30

A30-year-old woman has been suffering from depression and mood swings which she
feels are related to her periods for the past few years. These issues have a significant
impact on the quality of her life. TheGP has referred her to the Gynaecology Clinic for
assessment and treatment. What is required to help make the diagnosis of PMS in this
patient?
A. Adetailed history demonstrating the relationship of the symptoms with the luteal phase
of the menstrual cycle and how these impact on her daily activity
B. Completing the premenstrual Symptoms Screening Tool (PSST) over a 2-month period
C. Prospective recording of symptoms in a diary such as the Daily Record of Severity of
Problems (DRSP) over two cycles
D. Retrospective diary of her symptoms at the clinic visit
E. Thorough history to exclude other causes of her symptoms prior to making a diagnosis,
which is based on exclusion

Answer 30

Prospective recording of symptoms in a diary such as the Daily Record of Severity of
Problems (DRSP) over two cycles

Question 31

Ayoung Librarian has been referred to the clinic with symptoms suspicious of PMS.
Areview of her 2 months prospectively completed symptom diary is notconclusive with
respect to the diagnosis of PMS. What should be the next step in her evaluation?
A. Commence her on the combined oral contraceptive pill (if there are no contraindications)
for 3 months and then reassess her symptoms
B. Commence her on Danazol 200mg daily for 3 months and then reassess her symptoms
C. Commence her on a GnRH agonist for 2 months and then reassess her symptoms
D. Commence her on a GnRH agonist for 3 months and then reassess her symptoms
E. Give a diagnostic trial of an SSRI for 3 months and review her response to the
treatment

Answer 31

Commence her on a GnRH agonist for 3 months and then reassess her symptoms
* Symptom diaries can sometimes be confusing and inconclusive
* These should be used for 3 months to establish a definite diagnosis. This is to allow a month for agonist to generate a complete hormonal suppressive effect as well as providing a 2months’ worth of symptom diaries

Question 32

What is the estimated incidence of ovarian cysts in postmenopausal women?

Answer 32

5% -17%

Question 33

A60-year-old woman presents with a sudden onset lower abdominal pain for the past
24h. Shehas otherwise been well. Shehas had two normal vaginal deliveries, the last of
which was 20years ago. Shewas examined and suspected to have a right ovarian cyst.
What would be the initial assessment of this woman?

Answer 33

Pelvic ultrasound scan and CA125 (T)
* No need to other Tumer markers

Question 34

GP sees a 59-year-old postmenopausal woman in the surgery with lower abdominal
pain of sudden onset. Sheexamines her and suspects a pelvic mass. When should she
refer this woman urgently to specialist services?
A. An adnexal mass is palpated to be approximately 6cm in diameter
B. An adnexal mass is palpated to measure approximately 10cm in diameter
C. Sheis confirmed on clinical examination to have an abdominal mass
D. Sheis confirmed on clinical examination to have a pelvic mass
E. Sheis confirmed on clinical examination to have a mass with fixed nodularity

Answer 34

Sheis confirmed on clinical examination to have a mass with fixed nodularity

Question 35

What is the estimated percentage of the calculated typical blood volume lost in the acute
phase of severe OHSS in a 30-year-old woman who has undergone ovarian hyperstimulation and egg retrieval?

Answer 35

20 %

Question 36

A32-year-old woman underwent superovulation with a gonadotrophin and developed
OHSS. When will this OHSS be classified as early onset?

Answer 36

Onset within 7days of hCG trigger
* ( Not 24h)

Question 37

You are operating with your consultant and a Foundation Year 1 doctor on a difficult
abdominal hysterectomy for endometriosis. Theuterus has been removed but you stick
the needle accidentally into the finger of the Foundation Year doctor. PEP has been prescribed for him. How long should he or she take PEP for?

Answer 37

post exposure prophylaxis should be continued for 28 days
* within 72 hours (3 days) after a possible exposure to HIV to prevent HIV

Question 38

You have seen a 19-year-old girl with a history highly suspicious of a pelvic inflammatory
disease. What is the most common organism for PID in such young girls?

Answer 38

Chlamydia trachomatis
* Neisseria gonorrhoea and Chlamydia trachomatis have been identified as causative agents

Question 39

A26-year-old woman presents with bilateral lower abdominal pain and a vaginal discharge of 3 days duration. She also has a temperature of 37.8°C. She had a copper
intrauterine device inserted 2 years ago for contraception. You have taken swabs for
microbiology and provisionally think she has acute PID. What would be the advice with
respect to the IUD?

Answer 39

Removal of the IUD should be considered as it may be associated with better short-term
clinical outcomes

Question 40

A37-year-old woman presents with urinary incontinence associated with coughing and
when she is doing her aerobic exercises. Following examination, what will be the next
stage in her management?
A. Assess pelvic floor muscle contractions
B. Categorize her urinary incontinence
C. Refer for urodynamics
D. Request for a 3-day voiding diary
E. Send a mid-urine sample for microscopy, culture and sensitivity

Answer 40

Categorize her urinary incontinence

Question 41

A40-year-old woman has been diagnosed with an overactive bladder and you decide to
commence her on drug treatment. What discussion should take place prior to starting
the treatment?
A. That failure to respond by 6–8weeks indicates failure of medical treatment
B. That the adverse side effects such as dry mouth and constipation may indicate that the
treatment will notbe effective
C. That the full benefits may not be seen until they have been taking the treatment for
4weeks
D. That treatment is only effective for 6–9months
E. That urodynamics is essential to assess the response to treatment

Answer 41

That the full benefits may not be seen until they have been taking the treatment for
4weeks
* Thefact that they have notresponded by 6–8weeks is notindicative of failure of treatment and
treatment can be maintained as long as possible

Question 42

51-year-old woman, with a BMI of 30 kg/m2, presents with severe vasomotor symptoms for the past 12months. These symptoms have been gradually getting worse.
How will you manage her vasomotor symptoms?

Answer 42

Combined oestrogen-progesterone HRT for 5years
* Selective serotonin reuptake inhibitors (SSRIs), serotonin
and norepinephrine reuptake inhibitors (SNRIs) and clonidine should notbe used as the first-line
treatment for vasomotor symptoms .

Question 43

What treatment should be offered to a 55-year-old woman who attained menopausal
4years ago and is nowpresenting with a dry vagina, loss of libido and irritation? Shehas
nothad any surgery and has no medical problems.
A. Cognitive behavioural therapy and moisturizers for as long as needed to relieve symptoms
B. Combined oestrogen and progestogen hormone replacement therapy
C. Combined oestrogen and progestogen and moisturizers hormone replacement therapy for
as long as needed to relieve symptoms
D. Vaginal oestrogen and moisturizers for as long as needed to relieve symptoms
E. Vaginal oestrogen for 6months

Answer 43

Vaginal oestrogen and moisturizers for as long as needed to relieve symptoms

Question 44

A27-year-old woman presents in primary care with heavy menstrual bleeding (HMB)
for 3years. Her periods are regular. Shehas had two normal vaginal deliveries and was sterilized 3 years ago. Sheis otherwise healthy. What investigation should be carried out in
primary care prior to commencing her on pharmacological treatment?
A. Afull blood count
B. Measurement of endometrial thickness
C. Physical examination
D. Thyroid function test
E. Transabdominal ultrasound scan

Answer 44

Afull blood count
* pharmacological treatment can be started without carrying out a physical
examination or other investigations at the initial consultation in primary care unless the treatment
chosen is the levonorgestrel-releasing intrauterine system (LNG-IUS).

Question 45

Which symptom will be suggestive of a histological abnormality in a 36-year-old woman
presenting with heavy menstrual bleeding of 2years duration?
A. Bleeding associated with intermenstrual bleeding
B. Bleeding associated with pain
C. Bleeding associated with superficial dyspareunia/loss of libido
D. Bleeding associated with symptoms of anaemia
E. Bleeding associated with the passage of clots

Answer 45

Bleeding associated with intermenstrual bleeding

Question 46

A 38-year-old woman presents to her primary care physician with heavy menstrual
bleeding of 2years duration. When should performing a physical examination prior to
commencing medical treatment be considered?
A. Shegives a family history of uterine fibroids
B. Thebleeding is heavy enough to affect the quality of life
C. Thelevonorgestrel intrauterine system is being considered as a treatment option
D. Thepatient has had two mid-trimester miscarriages
E. Thereare associated premenstrual symptoms severe enough to warrant treatment

Answer 46

Thelevonorgestrel intrauterine system is being considered as a treatment option

Question 47

What is the most effective method of emergency contraception (EC)?

Answer 47

Thecopper intrauterine device (Cu-IUD)

Question 48

Forabout how long are viable sperms present in the upper genital tract after unprotected
sexual intercourse?

Answer 48

5days (120h)

Question 49

What proportion of uterine malignancies are due to sarcomas?

Answer 49

2%–7%

Question 50

A47-year-old woman presents with an abdominal mass that has been increasing in size
associated with pressure symptoms and heavy menstrual bleeding. You examine her and
suspect a uterine fibroid; however, the increasing size suggests the need to exclude a leiomyosarcoma. What first investigation will you offer this woman?
A. Computed tomographic scan (CT scan)
B. Magnetic resonance imagining (MRI)
C. MRI spectroscopy and dynamic contrast-enhanced MRI
D. Positron emission tomography (PET/CT) with fluorodeoxyglucose (FGD)
E. Ultrasound scan with colour Doppler

Answer 50

Ultrasound scan with colour Doppler ( first)

Question 51

What is the estimated number of lives per year that the cervical cancer screening programme saves in England?

Answer 51

4500

Question 52

A56-year-old woman had a routine cervical cytology that was reported as high-grade
squamous dyskaryosis. She was offered colposcopy and treatment for CIN 3. At her
6months follow-up cytology, she was found to have low-grade squamous dyskaryosis. An
HPV test of cure was therefore performed and reported as negative. What would be the
plan for this woman’s follow-up?

Answer 52

Follow-up cytology at 3years and then every 5years
* after 6 months: Asample is reported as negative, borderline change (of squamous or endocervical type) or lowgrade dyskaryosis is offered an HR-HPV test.
* Those who are HR-HPV positive are referred back to colposcopy
* Women whose cytology is reported as high-grade dyskaryosis or worse are referred straight to colposcopy without an HR-HPV test.

Question 53

A43-year-old woman attended for her 6-month follow-up cytology and test of cure following the treatment for CIN 2. Theresult is borderline changes (squamous) and HPV
positive. What should be offered to this woman?

Answer 53

Colposcopy and follow-up cytology and test of cure at 6months

Question 54

What would be a reliable means of assessing current ovarian function and therefore prediction of fertility in a childhood survivor of cancer treatment?

Answer 54

Anti-Müllerian hormone (AMH)
* can be used in the assessment of ovarian function in both pre-pubertal and post-pubertal girls

Question 55

A17-year-old childhood survivor of cancer is seen with primary amenorrhoea. Various
investigations are performed, and she is then offered what is considered adequate cyclical
hormone replacement. She, however, fails to have a withdrawal bleed. What is the implication of this response?

Answer 55

That her uterine function has been compromised by the treatment

Question 56

You see a 55-year-old woman with symptoms of bladder storage consisting of urgency
with urge incontinence, frequency and nocturia. You suspect that she has an overactive
bladder. Shedoes nothave any signs of prolapse, and her BMI is 26kg/m2. What would
be the first-line treatment for this patient’s symptoms?
A. Antimuscarinic drugs
B. Bladder retraining
C. Pelvic floor exercises
D. Vaginal oestrogen
E. Weight loss

Answer 56

Bladder retraining
* lifestyle changes and behavioural therapies should be the first-line treatment for an overactive bladder
* include reduction in caffeine intake, modification of fluid intake, bladder retraining and weight loss in those with a BMI greater than 30kg/m2

Question 57

A65-year-old woman has been assessed and offered botulinum toxin for the treatment of
her refractory overactive bladder. What must she be trained to do before this treatment
can be started?

Answer 57

To undertake intermittent self-catheterization
* only 10%–15% of women on this treatment will actually need to perform intermittent self-catheterization.

Question 58

A68-year-old woman with refractory overactive bladder was seen and assessed to be
suitable for Botulinum toxin. What important investigation must be performed before
she is commenced on this treatment?
A. Cystoscopy
B. Culture of urine
C. Examination under anaesthesia
D. Frequency and volume chart (voiding diary)
E. Urodynamics

Answer 58

Urodynamics
* must be performed in all cases prior to treatment with Botulinum toxin

Question 59

What is the main advantage of robotic surgery over laparoscopic surgery?
A. Better precision and microsurgical dissection
B. Decreased hospital stay
C. Improved cosmesis
D. Less pain after surgery
E. Quicker recovery for the patient

Answer 59

Better precision and microsurgical dissection

Question 60

A46-year-old woman underwent a subtotal hysterectomy as a treatment for heavy menstrual bleeding. Inapproximately what percentage of women who have had a subtotal
hysterectomy will persistent cyclical bleeding be a symptom?

Answer 60

5 %
Will have continuing cyclical light bleeding.

Question 61

You see a 40-year-old woman with heavy menstrual bleeding and uterine fibroids to discuss treatment options. Which is the most cost-effective treatment option that will guarantee amenorrhoea in this woman?
A. Endometrial ablation
B. GnRH agonist
C. Hysterectomy
D. Thelevonorgestrel intrauterine system (Mirena)
E. Uterine artery embolization

Answer 61

Hysterectomy

Question 62

Ahysterectomy was offered to a 37-year-old woman with heavy menstrual bleeding that
was refractory to medical treatment. What would be the main advantage of a subtotal
hysterectomy over a total hysterectomy?
A. Better sexual/orgasmic satisfaction
B. Lower morbidity
C. Reduced impact on ovarian function
D. Reduced incidence of bladder dysfunction
E. Thesurgical expertise required to perform it is less than that for a total hysterectomy

Answer 62

Lower morbidity
* Randomized trials have failed to demonstrate any difference in sexual satisfaction

Question 63

What is the commonest cause of vulval itching in children?

Answer 63

Atopic vulvitis

Question 64

What is the definition of recurrent vulvovaginal candidiasis?

Answer 64

Recurrent candidiasis infection of more than six attacks per year

Question 65

What is the British Association of Dermatologists recommended treatment regimen for
lichen sclerosus?

Answer 65

Clobetasol propionate (0.05%) over 3 months
* ( Not topical steroid/ not with baths/ not 6 months)

Question 66

Approximately what proportion of women affected by tubo-ovarian abscess are
nulliparous?

Answer 66

60 %

Question 67

What is the most common cause of tubo-ovarian abscess (TOA) in women of reproductive
age ?

Answer 67

Ascending pelvic inflammatory disease

Question 68

A 25-year-old woman is admitted with lower abdominal pain associated with a fever
and diarrhoea. Shealso had a history of painful micturition and a purulent urethral
discharge a week before. When she is examined, there is localized tenderness to the left
lower abdomen with a suspicious mass. Adiagnosis of a tubo-ovarian abscess (TOA) is
suspected, and an ultrasound scan is ordered. What finding from blood investigations is
the most sensitive predictor of TOA?
A. High blood lactate
B. High C-reactive protein
C. High erythrocyte sedimentation rate (ESR)
D. Raised interleukin 6
E. Raised white blood cell count

Answer 68

High C-reactive protein

Question 69

What proportion of patients admitted into an acute medical ward in hospitals in the UK
may lack mental capacity to make a decision relevant to the episode of admission?

Answer 69

30 %

Question 70

A30-year-old woman with learning disability is seen in the gynaecology clinic with significant menstrual disturbances. What will be useful in determining mental capacity in
this woman?
A. Theability of the assessor (clinician) to determine whether there is any disturbance in the
functioning of her mind
B. Theability of the assessor (clinician) to determine whether there is any impairment in the
functioning of her mind
C. Theability of the assessor to determine whether the patient is able to comprehend
D. Theprinciple of the two-stage test of capacity (diagnostic and functional components)
E. The rationality of patient to make a decision considered logical by the clinician
(assessors)

Answer 70

Theprinciple of the two-stage test of capacity (diagnostic and functional components)

Question 71

37-year-old woman had treatment for cervical cancer by trachelectomy 2years ago.
She presents with active bleeding after 8 weeks amenorrhoea. An ultrasound scan is
performed, and there is an irregular gestational sac measuring 30mm in diameter and a
10-mm fetal pole with no obvious fetal heart activity. Adiagnosis of a missed miscarriage
is made. What would be the recommended treatment?
A. Expectant management
B. Hysterotomy
C. Medical management
D. Removal of the cervical cerclage and evacuation
E. Surgical evacuation

Answer 71

Medical management
* without having to remove the cerclage. Surgical management can be performed through the isthmic cerclage with neo-cervical dilation to Hegar size of 7 if required,

Question 72

A 35-year-old woman has had trachelectomy as a treatment for cervical cancer stage
1A2. What advice should she be given with regard to contraception and the timing of
trying to conceive?

Answer 72

Sheshould commence contraception and continue for at least 6months before shestarts
trying for a baby
* conceiving within 2–3months of the conization procedure is associated with a high risk of
preterm

Question 73

Approximately what proportion of women who conceive after trachelectomy do so after
assisted reproduction?

Answer 73

60 %

Question 74

A 33-year-old woman has been diagnosed with carcinoma of the cervix stage 1A2.
Shehas been offered fertility-sparing surgery in the form of trachelectomy. What does
this procedure entail?

Answer 74

Removal of the cervix, upper vagina and parametrium
* Without lymph nodes 🚫

Question 75

What is the difference in action between Levonelle (levonorgestrel) and EllaOne (ulipristal acetate– UPA) as emergency contraceptives?

Answer 75

UPAworks only up to the LH peak, while Levonelle works up to the pre-ovulatory surge
* Levonorgestrel (LNG) is a progestogen derived from nortestosterone, while ulipristal acetate (UPA) is a progesterone receptor modulator.

Question 76

What is the failure rate of female sterilization?

Answer 76

1:200

Question 77

A 45-year-old woman is on the progesterone-only pill containing desogestrel. What
would be considered a missed pill in this woman?

Answer 77

Delay in taking the pill by more than 12h ( containing desogestrel )
* Other progesterone-only pill : Delay in taking the pill by more than 3h

Question 78

A45-year-old woman whose periods are regular has been referred by her GP for counselling on effective contraception. What basic examination and investigations should be
performed prior to commencing her on the combined hormonal contraception?

Answer 78

Check cervical smear history, measure BP and BMI and offer STI screening and then
perform a pregnancy test
* no need for : examine breast or serum cholesterol levels
or Pelvic examination .

Question 79

A 24-year-old woman has attended the clinic following a serious sexual assault.
Which type of sexual intercourse poses the greatest risk for HIV transmission in this
woman?
A. Penetrative anal intercourse where there is interruption of ejaculation
B. Penetrative unprotected anal intercourse
C. Penetrative unprotected vaginal intercourse
D. Penetrative vaginal intercourse where there is interruption of ejaculation
E. Unprotected oral intercourse

Answer 79

Penetrative unprotected anal intercourse

Question 80

You have seen a 21-year-old student who was a victim of rape. What recommendation will you offer with respect to HIV post-exposure prophylaxis post-sexual assault
(PEPSE)?

Answer 80

Thismust be commenced as soon as possible but within 72h and for 4weeks

Question 81

You have just seen a 19-year-old girl in the Accident and Emergency who reports a sexual
assault. Sheis found to have minor injuries that do notrequire suturing. What would be
the most appropriate step to take in her management?

Answer 81

Not to clean until samples have been taken for DNAevidence

Question 82

A20-year-old girl has been seen with a report of sexual assault. Sheis considering a
forensic medical examination. What advice should she be given prior to evidence being
collected?

Answer 82

Not to wash or wipe herself and notto drink or pass urine

Question 83

What is the average age at menopause in the UK?

Answer 83

50–51years

Question 84

What will you consider postmenopausal bleeding in a woman who has been referred to
the gynaecology clinic for investigations?

Answer 84

Vaginal bleeding that occurs 1 year after the menopause regardless of the cause but
excluding bleeding that occurs with sequential hormone replacement therapy
* Not 6 months

Question 85

Approximately what percentage of women who go through physiological menopause
experience hot flushes?

Answer 85

70%–80%

Question 86

What is the current recommendation for the use of vaginal meshes in pelvic organ prolapse?
A. Anterior repair
B. Apical repairs
C. Enterocele repair
D. Posterior repair
E. Recurrent prolapse where other procedures have failed

Answer 86

Recurrent prolapse where other procedures have failed

Question 87

A58-year-old woman has been diagnosed with endometrial cancer following investigations that included histology on an endometrial biopsy. Shehad surgery and has returned
for review 2 weeks after the surgery. What will be the most important factor in providing
a guide to prognosis?
A. Depth of myometrial invasion
B. Histological type of the malignancy
C. Lymphovascular space invasion
D. Stage of the disease
E. Volume of the tumour

Answer 87

Lymphovascular space invasion

Question 88

A55-year-old woman has been diagnosed with cervical cancer. Shewas offered surgery
as this was staged as IIA. What would be an indication for adjuvant radiation with or
without chemotherapy?
A. Grade 3disease and lymph node involvement
B. Lymphovascular space invasion
C. Parametrial extension
D. Stromal invasion of 50%
E. Tumour size of 2cm

Answer 88

Grade 3disease and lymph node involvement

Question 89

A45-year-old woman presents with irregular vaginal bleeding, a foul-smelling vaginal
discharge and coital bleeding. Atpelvic examination, she was suspected to have cervical
cancer, which has been confirmed on biopsy. What will be the modality of choice for local
staging of the cervical cancer?

Answer 89

Magnetic resonance imaging

Question 90

Awoman who underwent treatment for a gynaecological cancer is admitted with bowel
obstruction. What type of gynaecological cancer is most commonly associated with bowel
obstruction?
A. Cervical cancer post-radiotherapy
B. Epithelial ovarian cancer
C. Endometrial cancer post-radiotherapy
D. Germ cell ovarian cancer
E. Stroma ovarian cancer

Answer 90

Epithelial ovarian cancer

Question 91

What is the 5-year survival of ovarian cancer in the UK?

Answer 91

20%–30%

Question 92

What is the main cause of death in women with epithelial ovarian cancer?

Answer 92

Bowel obstruction and its complications

Question 93

What is the best investigation to identify extrapelvic disease in patients beingconsidered
for exenterative surgery for recurrent gynaecological cancer?

Answer 93

Positron emission tomography (PET)– CT scan

Question 94

A60-year-old had a vaginal hysterectomy 3years ago and nowpresents with vault prolapse that is having a significant impact on her quality of life. What is the best approach
to treat this patient?

Answer 94

Sacrocolpopexy
* involves suspending the vaginal apex to the anterior longitudinal ligaments of
the sacrum. Itis considered the best surgical treatment for apical prolapse with a success rate of
78%–100%

Question 95

Sexual exploitation is defined as the exploitation sexually of children and young people
involving exploitative situations, contexts and relationships where the young people
(or a third person or persons) receive something (e.g. food, accommodation, drugs,
alcohol, cigarettes, affection, gifts, money) as a result of them performing and/or
another or others performing on them sexual activities. What is the age limit within
this definition?

Answer 95

Less than 18years

Question 96

Who does the GMC consider responsible for protecting children from sexual exploitation?
A. All doctors
B. All general practitioners
C. All general practitioners and paediatricians
D. All paediatricians
E. All paediatricians, general practitioners and emergency physicians

Answer 96

All doctors

Question 97

What is the estimated prevalence of child sexual exploitation in children under the age of
16years in the UK?

Answer 97

5%–15%

Question 98

A17-year-old girl has been referred by her GP for labioplasty as she is unhappy with its
appearance and complaints of feeling depressed about it. TheGP says that she is Fraser
competent. What would be your approach to her management following the consultation?
A. As she is under the age of 18years, female genital cosmetic surgery is notallowed
B. Ask for an assessment by a psychiatrist prior to offering surgery if her mental state is
indeed thought to be affected by the appearance of the vulva
C. Confirm that she is Fraser competent and place on the list for this procedure if it is thought
to be appropriate
D. Proceed to perform the procedure as this is in the interest of her mental health
E. Refer her for the assessment to ensure that her physical or mental state is safeguarded
before considering surgery

Answer 98

As she is under the age of 18years, female genital cosmetic surgery is notallowed

Question 99

Acouple has been diagnosed with unexplained infertility of 2years duration. Thewoman
is a smoker. What may be the effect of the smoking as a contributor to their infertility?

Answer 99

Alteration of tubal function

Question 100

Acouple has been diagnosed with unexplained infertility of 2years duration. Thewoman
is a smoker. What may be the effect of the smoking as a contributor to their infertility?

Answer 100

Alteration of tubal function

Question 101

Acouple has been diagnosed with unexplained infertility of 2years duration. Theman is
a smoker. What may be the effect of the smoking as a contributor to their infertility?

Answer 101

Increases DNAdamage in sperms

Question 102

What age group in women in the UK has the highest prevalence of Chlamydia trachomatis infection?

Answer 102

15 - 19 years

Question 103

A 25-year-old student was seen in the GUM clinic with a urethral discharge and following investigations, was diagnosed with Chlamydia trachomatis infection. What is the
ideal treatment you will recommend for this patient?

Answer 103

Asingle dose of 1g of azithromycin ( considering compliance with therapy )
* doxycycline 100mg twice daily for 7 days

Question 104

You are counselling a 35-year-old who has requested for tubal occlusion. What would you
tell her about the additional benefit of the procedure with regard to prevention/reduction
of risk of disease?

Answer 104

Itis associated with a reduction in the incidence of ovarian cancer

Question 105

A 42-year-old whose periods remain regular wishes to start the oral combined hormonal contraception (CHC). Shesmokes 6cigarettes per day. What is the UK Medical
Eligibility Criteria (UKMEC) category for this woman with respect to prescribing the
combined oral contraceptive pill?

Answer 105

UKMEC 3
* Forwomen over the age of 35years and who smoke less than 15cigarettes per day, use of the CHC is a UKMEC 3
* for those who smoke at least 15cigarettes per day, use of the CHC is UKMEC 4.
* former smoker over the age of 35years, the use of CHC becomes less restrictive a year after stopping (UKMEC 2).

Question 106

A42-year-old woman who smoked approximately 20cigarettes per day but stopped 2 years
ago wishes to start the combined oral contraceptive pill. What advice would you give her?

Answer 106

Advise that she can go on the pill as has been off smoking for at least 1 year

Question 107

A20-year-old woman is seen in the Emergency Department complaining of vague lower
abdominal pain. Shehas never been pregnant, though having unprotected sexual intercourse. Apregnancy test is performed and is positive. Sheis examined and found to be
clinically stable with a BP of 115/70mmHg and a pulse of 76bpm. Theabdomen is mildly
tender, but there is no guarding. Theonly positive finding on bimanual examination is
mild adnexal tenderness. An ultrasound is performed and shows the presence of echogenic fluid in the pouch of Douglas. What is the most likely explanation for this fluid in
this patient?

Answer 107

Slowly leaking tubal ectopic (leakage of blood from the fimbrial end)
* ( Not 🚫 Ruptured ectopic pregnancy)

Question 108

A 33-year-old woman has been admitted through the Gynaecology Assessment Unit
(GAU) with mild lower abdominal pain. What on ultrasound scan will make you diagnose a cervical pregnancy?

Answer 108

An empty uterus with ballooning of the cervix with a gestational sac and a negative sliding sign
* + and blood flow around the gestational sac using colour Doppler

Question 109

An ultrasound is performed on a 30-year-old woman who presented with lower abdominal pain and a dark brown vaginal discharge. Thisshows an intrauterine gestational sac
with no obvious fetal pole but with a yolk sac and an inhomogeneous left adnexal mass
measuring 40mm in diameter and a small echoic fluid in the pouch of Douglas. Adiagnosis of a heterotopic pregnancy is made from these findings. What would be the best
approach to the management of this patient who is haemodynamically stable?

Answer 109

Laparoscopic surgical removal

Question 110

A33-year-old woman nursing assistant has been diagnosed with an ectopic pregnancy on
the basis of an ultrasound scan finding of an inhomogeneous mass measuring 25mm in
the right adnexum with no fluid in the POD and a β-hCG level of 1200IU/L 48h after an
initial reading of 1500IU/L. What would be the recommended management option for
this woman who is asymptomatic?
A. Expectant management
B. laparoscopic salpingectomy
C. laparoscopic salpingostomy
D. Local methotrexate injection and aspiration of the sac
E. Methotrexate injection at a dose of 50mg/m2

Answer 110

Expectant management
* 1- clinically stable
2- no evidence of haemoperitoneum on ultrasound scan
3- ectopic pregnancy measuring less than 30mm in diameter with no evidence of embryonic cardiac activity
4- serum β-hCG of less than 1500IU/L.

Question 111

Adiagnosis of endometrial hyperplasia was made on a biopsy taken from a 48-year-old
patient who presented to the Gynaecology clinic. What is the most common symptom she
is likely to have presented with?
A. Abnormal uterine bleeding
B. Heavy menstrual bleeding
C. Intermenstrual bleeding
D. Irregular vaginal bleeding
E. Unscheduled bleeding on hormone therapy

Answer 111

Abnormal uterine bleeding

Question 112

You have seen a 59-year-old P2, all normal vaginal deliveries in the Gynaecology clinic
with a 2-month history of irregular postmenopausal bleeding. What will be the indication for performing a diagnostic hysteroscopy and biopsy in this patient?
A. Apolypectomy is being contemplated for the same procedure
B. Asuspicion of endometrial cancer
C. Athickened endometrium (>5mm on transvaginal ultrasound scan)
D. Thereis a suspicion of an intrauterine structural abnormality
E. You are considering starting her on progestogens or inserting the levonorgestrel intrauterine system (Mirena)

Answer 112

Thereis a suspicion of an intrauterine structural abnormality
* C is also correct

Question 113

Awoman is referred to the outpatient clinic with postmenopausal bleeding. Atransvaginal ultrasound scan is performed, and the endometrial thickness is found to be 4mm.
Thisis described as having an irregular profile at the fundus and a double layer in the
body. No polyps are present. What would be the next step in the management of this
woman?
A. Arrange an endometrial biopsy
B. Commence on progestogens and arrange follow-up at 3months
C. Discharge with the advice to report back if any further bleeding
D. Offer a follow-up ultrasound scan at 6months or earlier if persistent bleeding
E. Reassure and rescan at 3months

Answer 113

Arrange an endometrial biopsy
* A TVU : that detects an irregularity of the endometrial profile or an abnormal
double-layer endometrial thickness measurement would further give reason to perform an endometrial biopsy in women with postmenopausal bleeding

Question 114

Acouple has been referred for pre-pregnancy counselling. Theman is 36years old and
the woman is 30years old. You have spoken to them and feel that there are no obvious
issues that they should be concerned about. What will be their approximate chances of
achieving a pregnancy in the next 12months if they have regular unprotected sexual
intercourse?

Answer 114

80%
If the woman is under 40 y

Question 115

Alesbian couple attend for counselling about pre-pregnancy. Theyare both 28years old
and would like to use artificial insemination. Assuming that there are no factors in their
history to negatively affect fertility, what would be their approximate chance of achieving
a pregnancy after 6cycles of intrauterine insemination?

Answer 115

> 50%
* And about half will do so within a further sixcycles for a cumulative pregnancy rate of over 75%

Question 116

A41-year-old woman is seen by her GP complaining of a burning sensation with voiding
associated with urgency and nocturia. Shealso suffers from severe dyspareunia and as
such is averse to sexual approaches from her husband. On examination, there is significant tenderness over the urethra. What is the first investigation her GP should request
for assuming that bladder pain syndrome (BPS) is a suspected diagnosis?
A. Bladder diary for 3days
B. Food diary for 3days to identify possible trigger factors
C. Post-void bladder scan
D. Urinalysis
E. Urine culture and sensitivity

Answer 116

Urinalysis : to rule out UTI
* Investigations for urinary Ureaplasma and Chlamydia can be considered in symptomatic patients with negative urine cultures and pyuria

Question 117

What are the criteria that have been adopted by several expert panels for a symptombased diagnosis of bladder pain syndrome (BPS)?
A. Pain related to the bladder and nocturia
B. Pain related to the bladder and nocturia of between 6weeks and 6months
C. Pain related to the bladder and at least one other urinary symptom of minimum duration
of 6weeks to 6months
D. Pain related to the bladder, at least one other urinary symptom, absence of identifiable
causes and minimum duration of symptoms of 6weeks to 6months
E. Pain related to the bladder, nocturia and frequency, absence of identifiable causes and
minimum duration of symptoms of 6weeks

Answer 117

Pain related to the bladder, at least one other urinary symptom, absence of identifiable
causes and minimum duration of symptoms of 6weeks to 6months

Question 118

What initial assessment should be undertaken on a 30-year-old who is diagnosed with
bladder pain syndrome in the gynaecology clinic? She has been screened for urinary
tract infection, and the result is negative.
A. Bladder diary
B. Cystoscopy
C. Mid-stream urine for Ureaplasma and Chlamydia
D. Mid-urine for tuberculosis
E. Urodynamics

Answer 118

Bladder diary
* A3-day fluid diary with input and output is useful for initial assessment of patients BPS.
Patients with BPS classically void small volumes

Question 119

TheGP has been treating a 30-year-old colleague with suspected PMS. When should
referral to a Gynaecologist be considered?
A. If cognitive behavioural therapy has failed
B. PMS is confirmed and treatment with SSRIs has yielded variable results
C. When the diagnosis is confirmed
D. When treatment with simple numerous measures has failed
E. When the symptoms are non-cyclical and an underlying psychiatric disorder has been
excluded

Answer 119

When treatment with simple numerous measures has failed

Question 120

A 35-year-old woman has been referred to the Gynaecologist following diagnosis of
severe PMS by her GP. What team should be involved in her care?

Answer 120

Multidisciplinary team of GP, mental health professional, gynaecologist and nutritionist
* Not 🚫 clinical psychologist

Question 121

What is the placebo response rate in the treatment of PMS?
A. 10%–15%
B. 16%–25%
C. 26%–35%
D. 36%–45%
E. 46%–55%

Answer 121

36%–45%

Question 122

In approximately over what proportion of women with epithelial ovarian cancers is
CA125increased above 30IU/mL?
A. 65%
B. 70%
C. 75%
D. 80%
E. 85%

Answer 122

80% ( but notin most primary mucinous ovarian cancers)
* If a cut-off value of 30IU/mL is used, the test has a sensitivity of 81% and a specificity of 75% for the detection of ovarian cancer in a postmenopausal woman.

Question 123

A65-year-old woman is referred to the Gynaecology Clinic with a suspicious abdominal
mass that is thought to be of ovarian origin. Themass is clinically examined to measure
120×120mm in diameter. What would be single most effective way of evaluating the
ovarian cyst?
A. Acombined transvaginal and transabdominal ultrasound scan
B. Atransabdominal ultrasound scan
C. CA125 and transvaginal ultrasound scan
D. MRI of the abdomen and pelvis
E. PET scan

Answer 123

Acombined transvaginal and transabdominal ultrasound scan

Question 124

A 60-year-old woman had an ultrasound scan for mild lower abdominal discomfort.
Thefindings were as follows ‘multicystic loculated mass on the right measuring 6×7cm
with a small solid intracystic area and areas of papillary projections into the largest of
the cyst. Theuterus is atrophic with a thin endometrium that measures 1mm. Thecontralateral ovary was notseen, and there is no fluid in the abdomen or pelvis’. Aquantified
CA125 was reported as 50IU/mL. What is the risk of malignancy index (RMI) in this

Answer 124

450
* Therisk of malignancy index (RMI) is calculated as the product of UxMxCA125; where U is the ultrasound scan score (U=1 for an ultrasound scan score of 1; 3for ultrasound score of 2–5– where each of these parameters scores 1– multilocular, solid areas, metastases, ascites and bilateral lesions),
and Mis the menopausal status– 1for premenopausal and 3for postmenopausal.
Inthis patient, her USS score is 2; hence, the RMI is 3×3×50=450.

Question 125

What is the estimated incidence of mild ovarian hyperstimulation syndrome (OHSS) in
conventional IVF cycles?
A. 1:2
B. 1:3
C. 1:4
D. 1:5
E. 1:6

Answer 125

1:3
* while the combined incidence of moderate-to-severe OHSS varies from 3.1% to 8%

Question 126

A30-year-old woman is undergoing controlled ovarian hyperstimulation for invitro fertilization. What factor will be associated with a decreased risk of ovarian hyperstimulation syndrome (OHSS) in this woman?
A. Her age
B. High antral follicle count
C. Low AMH
D. Known case of PCOS
E. Previous OHSS

Answer 126

Low AMH

Question 127

When is ovarian hyperstimulation syndrome (OHSS) likely to occur in an assisted reproduction programme involving a 30-year-old woman?
A. Agonists have been used in the ovulation regimen
B. Antagonists have been used in the ovulation regimen
C. Embryo replacement was performed on day 5 (i.e. blastocyst replacement)
D. Pregnancy has occurred
E. Progesterone was used for luteal phase support

Answer 127

Pregnancy has occurred ( as well as in those resulting in multiple pregnancies )
* reduced risk of OHSS in IVF cycles using gonadotrophin-releasing hormone (GnRH) antagonist compared with cycles where GnRH agonist

Question 128

Inthe investigation of a 20-year-old woman with suspected acute pelvic inflammatory
disease (PID), which test result has the best negative predictive value?
A. Anormal C-reactive protein
B. Anegative endocervical swab culture
C. Anormal ESR
D. Absence of endocervical or vaginal pus cells
E. Anegative anal swab

Answer 128

Absence of endocervical or vaginal pus cells ( has a good negative predictive value (95%) for
a diagnosis of PID, but their presence is non-specific (poor positive predictive value– 17%)
* Theabsence of infection at this site (endocervical) does notexclude PID

Question 129

You have seen a 23-year-old woman with features of acute pelvic inflammatory disease.
She has been commenced on antibiotics. What advice will you give her about sexual
intercourse?
A. Avoid sexual intercourse for 7days
B. Avoid sexual intercourse until she and her partner have completed treatment and follow-up
C. Avoid sexual intercourse until she has completed treatment and follow-up
D. Avoid unprotected sexual intercourse until treatment is completed
E. Avoid unprotected sexual intercourse until treatment and follow-up of her and her
partner(s) are completed

Answer 129

Avoid unprotected sexual intercourse until treatment and follow-up of her and her
partner(s) are completed

Question 130

You see a 55-year-old woman with urinary incontinence (UI). Following your initial
assessment, you feel that she would benefit from referral to supervised pelvic floor muscle
training. What assessment should be made prior to this referral?
A. A3-day bladder diary
B. Digital assessment to confirm pelvic floor muscle contractions
C. Thedegree of prolapse if any
D. Theimpact of the UI on her daily activities
E. Urethral mobility

Answer 130

Digital assessment to confirm pelvic floor muscle contractions
* as the absence of this will suggest a poor response to the training

Question 131

A48-year-old woman presents with urgency, urgency urinary incontinence (UUI) and
stress urinary incontinence (SUI). You have assessed and found that the predominant
symptom is stress urinary incontinence (SUI). What approach will you take in her
management?
A. Commence her on overactive bladder (OAB) drugs
B. Discuss the benefits of conservative management including OAB drugs before offering
surgery
C. Offer surgery for SUI and then OAB treatment
D. Refer for pelvic floor muscle contraction exercises prior to offering surgery forSUI
E. Treat her SUI first and see whether the symptoms of OAB improve and if not, then commence her on OAB drug treatment

Answer 131

Discuss the benefits of conservative management including OAB drugs before offering
surgery

Question 132

When will you consider screening a 26-year-old woman presenting with heavy menstrual
bleeding for coagulation disorders?
A. Pharmacological treatment with the LNG-IUS has notbeen effective
B. Shehas a family history of heavy menstrual bleeding in her sister and mother
C. TheHMB is associated with flooding
D. TheHMB started since menarche and her sister suffers from a coagulation disorder
E. TheHMB is associated with the passage of clots

Answer 132

TheHMB started since menarche and her sister suffers from a coagulation disorder

Question 133

What would be the indication for histological biopsy in a 45-year-old woman presenting
with regular heavy menstrual bleeding (HMB) to secondary care?
A. Persistent heavy bleeding after 3months on the combined contraceptive pill
B. Physical examination has shown a multiple fibroid uterus
C. Theendometrium is 7mm thick on ultrasound scan
D. TheHMB started with menarche
E. Thereis associated persistent intermenstrual bleeding

Answer 133

Thereis associated persistent intermenstrual bleeding
* Persistent heavy bleeding after 3months on the combined contraceptive pill : is not considered ineffective ( short period of time)

Question 134

A25-year-old woman who has never been pregnant and is notsexually active is seen in
the Gynaecology Clinic having been referred with severe dysmenorrhoea and heavy periods of 2years duration. Sheis notkeen to go on hormonal treatment. What would be the
treatment of choice for this patient?
A. Danazol
B. Etamysylate
C. Non-steroidal anti-inflammatory drugs (NSAIDs)
D. Tranexamic acid
E. Ulipristal acetate

Answer 134

Non-steroidal anti-inflammatory drugs (NSAIDs)

Question 135

What treatment will you recommend for a 33-year-old woman who presents with heavy
menstrual bleeding and on examination, is found to have a uterus that is approximately
8weeks in size. An ultrasound scan shows two fibroids– one measuring 5cm in diameter
and causing a mild distortion of the endometrial cavity and the other a 3cm intramural
fibroid? Her Hb is102g/L.
A. Combined oral contraceptive pill
B. Gonadotrophin-releasing hormonal agonist (GnRHa)
C. Thelevonorgestrel intrauterine system (LNG-IUS)
D. Tranexamic acid
E. Ulipristal acetate 5mg up to 4courses

Answer 135

Ulipristal acetate 5mg up to 4courses ( Esmya) { each course 3 months}
should be offered to women with heavy menstrual bleeding and fibroids of 3cm or more in diameter and a haemoglobin level above 102g/L or below

Question 136

A50-year-old woman has been on the combined hormone replacement therapy since the
age of 47years. How will you diagnose menopause in this woman?
A. Amenorrhoea of at least 24months from stopping the HRT
B. Amenorrhea for 3 months with discontinuation of the HRT
C. Presence of menopausal symptoms involving the vasomotor system, mood changes, musculoskeletal and sexual difficulties
D. Serum FSH on two occasions 6weeks apart
E. Serum FSH values of >30IU/L

Answer 136

Amenorrhoea of at least 24months from stopping the HRT
* For women under the age of 50 years, a period of 24 months of amenorrhoea and for those over 50years 12months should lead to the diagnosis of menopause
* Otherwise, serum FSH of more than 35IU/L on two occasions 6weeks apart should be considered

Question 137

A 42-year-old presents with severe vasomotor symptoms highly suggestive of perimenopause. You have examined and found nothing abnormal. Her family and personal history are
notsignificant. You suspect premature ovarian failure and have confirmed the diagnoses by
FSH performed on two occasions 6weeks apart. What treatment will you offer this woman?
A. Black cohosh for 5–8 years
B. Combined estrogen-progesterone HRT for approximately 8years
C. Clonidine for 5–8 years
D. Estrogen only HRT for 5years
E. Non-pharmaceutical treatment such as cognitive behaviour therapy (CBT) for 8years

Answer 137

Combined estrogen-progesterone HRT for approximately 8years

Question 138

A45-year-old woman has been placed on the waiting list for a hysterectomy for abnormal
uterine bleeding. What lifetime risk of pelvic organ prolapse after a hysterectomy will
you quote for this woman during counselling?
A. <1%
B. 1%–2%
C. 3%–4%
D. 5%–6%
E. 7%–8%

Answer 138

1%–2% ( for benign diseases)
* And 11.6% of hysterectomies performed for prolapse

Question 139

A40-year-old woman who presented with vague intermittent lower abdominal pain of
3 months duration has been diagnosed with a simple ovarian cyst on ultrasound scan.
What is the approximately risk of this cyst being malignant?

Answer 139

1:1000

Question 140

. A50-year-old woman whose BMI is 26kg/m2 and has been on HRT underwent a total
abdominal hysterectomy for heavy menstrual bleeding. What is the recommended duration of thromboprophylaxis for this woman after surgery?
A. Asingle dose of dalteparin at the time of surgery
B. Dalteparin for 24h after surgery
C. Dalteparin for 5–7days after surgery
D. Dalteparin for 10days after surgery
E. Dalteparin for 14days after surgery

Answer 140

Dalteparin for 5–7days after surgery
* Thiswoman is low risk as there are no other factors that will increase her risk of VTE. Insuch
patients, the recommendation is to continue with thromboprophylaxis until she is fully mobilized.
Thiscould take between 5and 7 days

Question 141

A57-year-old woman who suffers from multiple sclerosis (MS) is referred to the clinic
with voiding difficulties. How will you manage this patient?

Answer 141

Intermittent self-catheterization

Question 142

You have seen a 56-year-old woman with symptoms of urinary incontinence. You take a
history and examine her. Shehad kept a voiding diary prior to the visit to the clinic. You
suspect that she has an overactive bladder syndrome (OAB). What would be the first line
of management for this woman?
A. Bladder training
B. Mid-stream urine for microscopy culture and sensitivity
C. OAB drugs such as anticholinergic drugs
D. Pelvic floor muscle training
E. Urodynamics

Answer 142

Bladder training
* should be offered for a minimum of 6weeks as the firstline treatment to women with urgency or mixed urinary incontinence
* the combination of OAB drugs with bladder training should be considered if frequency is a troublesome symptom

Question 143

A50-year-old woman presents with symptoms of voiding difficulties. Aurine dipstick
test is negative. What will be the first investigation to perform on this woman?
A. Assessment of residual urine by ultrasound scan of the bladder
B. Urinalysis
C. Urine for microscopy culture and sensitivity
D. Urodynamics
E. Voiding diary– 3days

Answer 143

Assessment of residual urine by ultrasound scan of the bladder
* it is recommended Inwomen presenting with symptoms suggestive of voiding dysfunction or recurrent UTI

Question 144

What is the most common site for uterine perforation at evacuation of the uterus for
retained products of conception?

Answer 144

Anterior wall
* followed by the cervical canal with the fundus being the least

Question 145

During a diagnostic laparoscopy you inadvertently injure the inferior epigastric artery
requiring a figure-of-8stitch to stop the bleeding. What is the origin of this vessel?

Answer 145

External iliac artery

Question 146

You are counselling a 46-year-old woman who wishes to have uterine artery embolization
for her fibroids. What is the risk of early ovarian failure following the procedure in this
woman?

Answer 146

1%–2%
* Around 80%–90% of patients will be asymptomatic or have significantly improved symptoms at 1 year with an associated 40%–70% reduction in fibroid volume

Question 147

An obese woman aged 53years and who smokes 20cigarettes per day complaints of mild
hot flushes and night sweats associated with sleep disturbance. What would be the best
treatment option for this woman?
A. Behavioural modification
B. Combined hormonal contraception with estradiol
C. Estrogen and the levonorgestrel intrauterine system
D. Estrogen only
E. Transdermal patch

Answer 147

Behavioural modification

Question 148

Atotal hysterectomy is performed on a 39-year-old woman for heavy menstrual bleeding
that failed to respond to medical treatment. Thehistology report reveals CIN 1 with fully
excised margins. What would be the recommended management for this woman?

Answer 148

Follow-up smear at 6 and 18months after the hysterectomy
* incompletely excised CIN (or uncertain excision), follow up should be as if their cervix remained
insitu :
- CIN 1: vault cytology at 6 , 12 and 24months:
- CIN 2/3– vault cytology at 6 and 12months,
followed by nine annual vault cytology samples. Follow up for incompletely excised CIN continues to 65years or until 10years after surgery (whichever is later)

Question 149

What is the most common type of ureteric injury at laparoscopic surgery?

Answer 149

Thermal (Diathermy) { 1 - 2 %}

Question 150

What is the most common and lethal subtype of epithelial ovarian cancer?

Answer 150

Serous ( 68% of the ovarian cancers )
* 90% of ovarian cancers are epithelial

Question 151

What proportion of woman with ovarian cancer have a positive family history?

Answer 151

10 %

Question 152

What is Thelifetime risk of developing ovarian cancer is in those with BRCA1mutation ? And with BRCA2mutation ?

Answer 152

BRCA1mutation: 25%–50%
with BRCA2mutation : 10%- 20%

Question 153

A25-year-old woman has been referred for genetic counselling and screening for the
mutations associated with ovarian cancer. Her mother and sister both had ovarian cancer at the ages of 45 and 55years, respectively. Shehas been screened and has BRCA1
mutation. What will be the effect of prophylactic salpingo-oophorectomy on her cancer
risk?

Answer 153

. An approximately 80% reduction in the risk of ovarian, fallopian and peritoneal cancer
* in BRCA1 and BRCA2 carriers

Question 154

couple has been trying for a baby for two and a half years. Following referral to the
hospital, they are investigated thoroughly and apart from minimal peritoneal endometriosis, nothing else is found. What would be the best approach to managing this couple’s
infertility?

Answer 154

Invitro fertilization and embryo transfer (IVF-ET)
* unexplained infertility of 2 years or more 👉 IVF
* in this case has minimal endometriosis, she would be classified as unexplained.

Question 155

A53-year-old woman presents with urgency, frequency and haematuria. On examination, she is found to have an anterior hard 3 mm bulge, which is approximately 2cm from
the inside of the introitus. What single investigation will you undertake to confirm the
diagnosis of urethral diverticulum?
A. Examination under anaesthesia
B. Ninety (90)-degree endoscopy
C. Sixty (60)-degree endoscopy
D. Thirty (30)-degree endoscopy
E. Zero-degree endoscopy

Answer 155

Zero-degree endoscopy
( urethroscopy )
* Also : urodynamics , CT , MRI , US , micturating cystogram and double balloon urethrogram are useful investigations.

Question 156

A70-year-old woman diagnosed with urethral diverticulum is being counselled for surgery. What investigation should she have that will help identify if she is likely to have the
complication of post excision incontinence?
A. Conventional enhanced CT scan
B. Cystometry
C. T2-weighted MRI
D. Transvaginal ultrasound
E. Video urodynamics

Answer 156

Video urodynamics
* to differentiate between stress incontinence and an overactive bladder and post micturition dribbling.

Question 157

What is the main disadvantage of transvaginal ultrasound scan in the assessment of suspected urethral diverticulum?
A. Ithas a false negative rate of more than 20%
B. Ithas a false positive rate of more than 20%
C. Itis invasive and poorly tolerated by the patients
D. Poor sensitivity where the diverticulum is less than 30mm
E. Therisk of the probe directly compressing the urethra

Answer 157

Therisk of the probe directly compressing the urethra
* Otherwise: TVU has an excellent sensitivity

Question 158

A38-year-old woman has been offered a total abdominal hysterectomy with preservation
of the ovaries as treatment of her endometriosis-associated chronic pelvic pain. What is
the main disadvantage of leaving her ovaries behind?
A. Shehas a greater risk of developing an endometrioma
B. Shehas a six-fold greater risk of developing recurrent pain
C. Shehas a fourtimes risk of ovarian endometroid cancer
D. Shehas a fourtimes greater risk of re-operation
E. Sheis at an increased risk of trapped ovary syndrome

Answer 158

Shehas a six-fold (6) greater risk of developing recurrent pain
* Shehas a 8 times greater risk of re-operation

Question 159

When and how should HRT be started on a 45-year-old woman who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis-associated pain?
A. Commence her on combined HRT as soon as possible
B. Commence her on continuous combined HRT approximately 6months after surgery
C. Commence her on estrogen-only HRT as soon as possible
D. Commence her on estrogen-only HRT approximately 6months after surgery
E. Commence HRT in the form of tibolone 3months after surgery

Answer 159

Commence her on combined HRT as soon as possible
* or tibolone for treating menopausal symptoms in women with surgically induced
menopause because of endometriosis, at least up to the age of natural menopause

Question 160

What is the main advantage of drainage over ovarian cystectomy for an ovarian endometrioma that measures 40×40mm and is associated with dysmenorrhea and dyspareunia?
A. Ovarian reserve is less likely to be compromised
B. Recurrence is less
C. Theprocedure has less complications
D. Therisk of adhesion formation is less
E. Therisk of compromising future fertility is greater with drainage

Answer 160

Ovarian reserve is less likely to be compromised

Question 161

An endometrioma has been diagnosed in a 28-year-old woman with chronic unilateral
cyclical lower abdominal pain and dyspareunia. When will you consider performing surgery on this patient?
A. Shehas notresponded to medical options for the pain
B. Theendometrioma is at least 3 cm
C. Thereis associated dyspareunia
D. Thereis associated infertility
E. Thereis associated minimal endometriosis in the pelvis

Answer 161

Theendometrioma is at least 3 cm
* Laparoscopy is the recommended treatment for
endometriomas associated with dysmenorhoea, dyspareunia and non-menstrual pain if the cyst is
at least 3cm in diameter

Question 162

What is the mean interval from presentation to their GP to the diagnosis of endometriosis in the UK?

Answer 162

8 years

Question 163

Polycystic ovary syndrome is considered the most common endocrine condition affecting
women of the reproductive age group. What is the estimated prevalence of this condition
in this age group?

Answer 163

10%–15%

Question 164

What is the best predictor of cardiovascular risk in a 37-year-old who has been diagnosed
with PCOS?

Answer 164

Her waist circumference

Question 165

What proportion of anovulatory infertility is accounted for by PCOS?
A. 50%–60%
B. 60%–70%
C. 70%–80%
D. 80%–90%
E. >90%

Answer 165

80%–90%

Question 166

You have seen a 28-year-old woman with a BMI of 30kg/m2 in the clinic with primary
infertility. Following investigations, you find that she has anovulatory infertility secondary to PCOS. What would be the first approach to her management?
A. Commence her on folic acid 400µg daily
B. Induce ovulation with clomifene citrate
C. Offer metformin
D. Optimize health before commencing therapy
E. Perform a diagnostic laparoscopy to assess the pelvis and test for tubal patency

Answer 166

Optimize health before commencing therapy
* Then induce regular unifollicular ovulation .
* Asemen analysis + an assessment of tubal patency should be performed before ovulation induction therapy is commenced.

Question 167

Awoman on clomifene citrate (CC) for induction of ovulation has been undergoing follicular tracking. Ovulation has been confirmed. What proportion of women who are on
CC that ovulate will become pregnant by the sixth ovulatory cycle?

Answer 167

60%–70%
* ( >50% for artificial insemination)

Question 168

Approximately what proportion of gynaecological outpatient referrals are for chronic
pelvic pain?
A. 10% (1in 10)
B. 15% (1in 6)
C. 20% (1in 5)
D. 25% (1in 4)
E. 30% (1in 3)

Answer 168

20% (1in 5)

Question 169

A26-year-old woman is seen in the Emergency Gynaecology Unit with symptoms and
signs of an ectopic pregnancy. Sheis investigated and found to have a caesarean scar
pregnancy (CSP). Shehas been counselled and wishes to have medical treatment with
methotrexate as she is haemodynamically stable. When is this treatment most likely to be
successful?

Answer 169

Pregnancy is less than 8weeks and hCG<5000IU/L

Question 170

A30-year-old woman has been referred for an early ultrasound scan, and she books for
antenatal care on account of a previous emergency CS complicated by massive haemorrhage and blood transfusion. Sheis 7weeks pregnant according to her last menstrual
period (LMP). An ultrasound scan is performed and suggests a caesarean scar pregnancy (CSP). Assuming that this diagnosis is correct, what would be the most appropriate initial treatment?

Answer 170

Systemic methotrexate ( Pregnancy is less than 8weeks)

Question 171

A50-year-old woman has had debulking surgery for ovarian cancer. What will be the
standard adjuvant treatment that would be recommended for this patient?

Answer 171

Paclitaxel and carboplatin for 6cycles
* Without radiotherapy

Question 172

A 60-year-old who has been suffering from vague abdominal symptoms was diagnosed with ovarian cancer following various investigations. Itis suspected that she had
advanced disease that cannot be optimally resected. Inaddition, she has liver metastases.
What would be the best approach to managing this patient?

Answer 172

Neoadjuvant chemotherapy followed by delayed primary surgery

Question 173

A60-year-old attends the Gynaecology Clinic with a 9-month history of a dragging sensation in the vagina. You examine and find that she has uterine-vaginal prolapse. You
have discussed all the treatment options and she opts for pelvic floor muscle training.
What information should she be given about the value of this treatment option in remedying her symptoms and the anatomical problems causing the prolapse?

Answer 173

Theexercises have been shown from a randomized trial to significantly improve symptoms but notthe anatomy of the prolapse

Question 174

What is the recommended management of a 64-year-old who has just had a vaginal
hysterectomy and the vaginal vault prolapse is at the introitus at the end of the surgery?
A. Closure of the peritoneum of the cul-de-sac
B. McCall culdoplasty
C. Moschcowitz procedure
D. Sacrocolpopexy
E. Sacrospinous fixation

Answer 174

Sacrospinous fixation
* should be performed if at the time of a vaginal hysterectomy for prolapse, the vaginal vault is at the introitus at the end of the vaginal hysterectomy

Question 175

A70-year-old, frail and diabetic obese woman presents with troublesome procidentia.
Sheis notsexually active and has been assessed to be fit to withstand prolonged surgery.
Acolpocleisis is therefore offered as the treatment of choice. What is the main disadvantage of this procedure?
A. Ahigh recurrent rare
B. Less patient satisfaction than with corrective surgery
C. Loss of access to the cervix and uterus
D. Loss of sexual function
E. Theneed to have drainage channels for the passage of vaginal and cervical secretions

Answer 175

Loss of access to the cervix and uterus
* Satisfaction rates that have been reported are much better than those of reconstructive surgery

Question 176

A40-year-old Ghanaian woman who presents with difficulties in conceiving and heavy periods is found on examination to have uterine fibroids of approximately 16weeks size. An
ultrasound scan has shown these to be multiple, the largest measuring 10×8cm and located
on the right body and extending to the corneum. Sheis notkeen to have surgery and therefore has been offered either a GnRHa for 6months or ulipristal acetate for 13weeks. What
advantage other than side effects does GnRHa have over ulipristal acetate?
A. Ithas less impact on fertility
B. Itis more effective
C. Its duration of action is much longer after discontinuation
D. Thereduction in blood loss at menstruation is greater
E. Thereduction in uterine volume is greater

Answer 176

1- Thereduction in uterine volume is greater
2- no difference in the control of menstrual bleeding
3- Thereduction with is shorter lasting
4- myomectomy could be more difficult following GnRHa

Question 177

A39-year-old woman has been diagnosed with multiple uterine fibroids and heavy menstrual periods. Shehas been offered various treatment options including surgery and medical treatment. Shewishes to have uterine artery embolization (UAE) as she has completed
her family but would like to know the major difference between this and a hysterectomy?
A. Long-term ovarian failure is greater with UAE than with hysterectomy
B. Patient satisfaction is greater with hysterectomy than with UAE
C. UAE is associated with a five-fold increase in the likelihood of further intervention within
2–5years
D. UAE is associated with a similar risk of major complications compared with hysterectomy
E. UAE is associated with fewer minor complications than hysterectomy

Answer 177

UAE is associated with a five-fold increase in the likelihood of further intervention within
2–5years
* satisfaction is similar .
* UAE was associated with more minor complications
* there is no difference in ovarian failure rates.

Question 178

A40-year-old woman is on the waiting list for hysteroscopic resection of Grade 2submucous fibroids. What is the most important factor in determining safety of this resection?

Answer 178

Thethickness between the fibroid and the serosa

Question 179

What are the grades of submucous fibroids ?

Answer 179

1- G0 is a pedunculated intrauterine myoma.
2- G1 has its largest part (>50%) in the uterine cavity.
3- G2 has its largest part (>50%) in the myometrium.
* Grade 0 and 1 fibroid can easily be removed hysteroscopically, but difficulties are likely to be encountered with Grade 2 fibroids

Question 180

What proportion of heterosexual couples in the UK experience delayed conception
despite regular unprotected sexual intercourse for 1 year?

Answer 180

1:7 (14%)
* Not 20%

Question 181

What is the advantage of pituitary downregulation in an assisted reproductive technology (ART) regimen?
A. Ensures a better planning of oocyte retrieval
B. Minimizes the risk of multiple follicular maturation
C. Suppression of endogenous gonadotrophin release, thus decreasing the rate of OHSS
D. Suppression of endogenous gonadotrophin release ensuring that oocytes are available for
retrieval
E. Suppression of endogenous gonadotrophin release, thus preventing recruitment of multiple antral follicles

Answer 181

Suppression of endogenous gonadotrophin release ensuring that oocytes are available for
retrieval . ( premature ovulation ).

Question 182

What is the main difference between ART cycles where GnRH-agonist are used and
those where GnRH-antagonist are used?
A. GnRH-agonist cycles are associated with a lower OHSS
B. InGnRH-agonist cycles, follicular recruitment is as a result of endogenous gonadotrophins
C. InGnRH antagonist cycles, follicular recruitment is as a result of endogenous gonadotrophins
D. Pregnancy rates are higher with the agonist protocol
E. Pregnancy rates are higher with the antagonist protocol

Answer 182

InGnRH antagonist cycles, follicular recruitment is as a result of endogenous gonadotrophins
* incidence of OHSS is significantly less with antagonist protocols
* pregnancy and live birth rates are notsignificantly different
* in GnRH-antagonist treatment cycles, the initial recruitment and selection of follicles occur as a result of endogenous gonadotropins, but their development is augmented by exogenous gonadotrophins

Question 183

What is the best step to take in reducing the risk of OHSS in a woman undergoing GnRH
antagonist-controlled ovarian stimulation for IVF with intact hypothalamic-pituitarygonadal axis?

Answer 183

Administer GnRH agonist for maturation trigger
( ensures more physiological release of endogenous gonadotrophins)
* Instead of recombinant hCG

Question 184

When should an ultrasound scan be performed on a 30-year-old woman who has never
been pregnant before and has had IVF-ET?

Answer 184

Five weeks after ER
( at 7weeks of gestation )
* An early ultrasound is offered to women with a previous history of ectopic pregnancy or recurrent miscarriage or who have symptoms of bleeding or pain

Question 185

A27-year-old woman has been admitted with severe OHSS. What monitoring should be
recommended for this woman?
A. Daily fluid intake and output and full blood count and urea and electrolytes
B. Daily fluid intake and output, liver function test, urea and electrolytes and full blood count
C. Daily measurements of weight, abdominal girth and fluid intake and output and blood
tests for full blood count, electrolytes and liver and renal function tests
D. Daily measurement of weight, abdominal girth and fluid intake and output and twicedaily blood tests for full blood count, electrolytes and liver and renal function tests
E. Daily measurements of weight, abdominal girth and fluid intake and alternate day blood
tests for full blood count, electrolytes and liver and renal function tests

Answer 185

Daily measurements of weight, abdominal girth and fluid intake and output and blood
tests for full blood count, electrolytes and liver and renal function tests

Question 186

Compared to natural conception, what is the difference in monochorionic pregnancy
rates with that following ART where elective single embryo transfer (eSET) is performed?
A. Therate in ART conception is up to fourtimes higher than that in natural conception
B. Therate is marginally higher in natural conception than in ART conception
C. Therate in natural conception is double than in ART conception
D. Therate in natural conception is half that in ART conception
E. Therate is the same in both natural and ART conception

Answer 186

Therate in ART conception is up to fourtimes higher than that in natural conception
* increased incidence of monozygotic twin following eSET compared to cleavage stage embryo transfer (ET)

Question 187

A32-year-old woman who has previously been pregnant is on the waiting list for ART.
What in her past reproductive history will be associated with a better outcome of the
ART treatment?
A. Previous pregnancy after ART
B. Previous pregnancy after ART and live birth
C. Previous pregnancy irrespective of whether this was spontaneous or followed ART
D. Previous spontaneous pregnancy
E. Previous spontaneous pregnancy and live birth

Answer 187

Previous pregnancy after ART and live birth

Question 188

What proportion of pregnancies in the UK are unplanned?

Answer 188

1:3

Question 189

27-year-old woman has just had a spontaneous vaginal delivery following an uncomplicated pregnancy at term. Shewishes to breastfeed exclusively for 6months. What would
be the success rate of this form on contraception assuming that she fulfils the criteria for
lactational amenorrhea as a method of contraception?

Answer 189

95%–98%
* there must be amenorrhoea, breastfeeding must be exclusive and last less than 6months

Question 190

A30-year old woman who has had a spontaneous vaginal delivery and is breastfeeding
wishes to start the combined hormonal contraception (CHC). How soon after birth can
she start the CHC?

Answer 190

Six weeks
* the available data do notindicate a harmful effect.

Question 191

What is considered postpartum immediate intrauterine contraception (PPIUC)?
A. Insertion of an intrauterine device within 48h of caesarean delivery
B. Insertion of an intrauterine contraceptive device (copper or levonorgestrel) within 48h of
vaginal delivery
C. Insertion of an intrauterine contraceptive device (copper or levonorgestrel) within 48h of
vaginal or caesarean delivery
D. Insertion of an intrauterine contraceptive device (copper or levonorgestrel) 48 h to 2
weeks after vaginal or caesarean delivery
E. Insertion of an intrauterine contraceptive device (copper or levonorgestrel) 48 h to 2
weeks after vaginal delivery

Answer 191

Insertion of an intrauterine contraceptive device (copper or levonorgestrel) within 48h of
vaginal or caesarean delivery

Question 192

A57-year-old underwent a hysteroscopic resection of grade 2submucous fibroids and
has been admitted because of hypervolaemia (the fluid deficit was over 2500mL), but she
is asymptomatic. Blood sodium level indicates hyponatremia. What will be the recommended first-line management?
A. Restriction of fluid intake and consider starting a diuretic
B. Restriction of fluid intake, diuretics and a small dose of an antihypertensive drug
C. Restriction of fluid intake but commence on hypertonic normal saline at a rate of
1000mL/h
D. Restriction of fluid intake to 1L of Ringer’s lactate every 6–8h
E. Restriction of fluid intake to 1L of dextrose saline with potassium chloride

Answer 192

Restriction of fluid intake and consider starting a diuretic
( Because the patient is asymptomatic / with or without hyponatraemia )
* No need to commence any kind of fluids

Question 193

Ina 40-year-old woman undergoing hysteroscopic resection of a large fibroid, what is the
most important step to take to reduce the risk of fluid overload?
A. Intracervical injection of vasopressin
B. Maintenance of intrauterine pressure to just above the mean arterial pressure level
C. Pre-treatment with a GnRH agonist
D. Use of bipolar as opposed to unipolar electrocautery
E. Use of hypertonic distension medium

Answer 193

Pre-treatment with a GnRH agonist
* Intracervical injection of vasopressin can be considered before dilatation of the cervix.
* Theintrauterine pressure needed for distension should be maintained as low as possible to allow adequate visualization and kept below the mean arterial pressure.

Question 194

A32-year-old woman who has been on the contraceptive patch for the past 12months
presents for advice saying that her patch has been partly detached for the past 36 h.
Shehas had unprotected sexual intercourse for the past two days. What advice would you
offer to this woman?
A. Reassure and discharge from follow-up
B. To have a pregnancy test and emergency contraception with Cu-IUD
C. To have a pregnancy test and emergency contraception with the LNG
D. To have a pregnancy test and emergency contraception with UPA
E. To reattach the patch if still sticky or replace if notand no need for additional or emergency contraception

Answer 194

To reattach the patch if still sticky or replace if notand no need for additional or emergency contraception
* If the patch has been off for less than 48h before its replaced it, it remains effective in protecting against pregnancy as long as the patch wason properly for 7 days before it came off

Question 195

. A30-year-old woman attends for counselling having delayed applying her contraceptive
patch for 3days (i.e. she forgot to take the patch off on time and applied the next patch
after 72h)– 1 week into the cycle. What would be your recommendation for this woman?
A. Apply new patch and offer emergency contraception (EC) in the form of the levonorgestrel emergency contraception (LNG-EC) and continue with patch cycle
B. Apply new patch and consider as Day 1 of patch cycle and use barrier method for 7days
C. Apply new patch and consider as Day 1 of patch cycle and offer LNG-EC and barrier
method for 7days
D. Apply new patch and consider as Day 1 of patch cycle– no additional contraception needed
E. Offer a barrier method for 7days and restart the new patch cycle

Answer 195

Apply new patch and consider as Day 1 of patch cycle and use barrier method for 7days
( More than 48h : not effective)
* If she has had UPSI in
the previous few days, she may need emergency contraception. Inthis scenario, there is no given
information about UPSI

Question 196

A36-year-old housewife forgot to take her patch off after week 3 . Sheattends the clinic
for advice. What would be your recommendation for this woman? Shehas been having
UPSI during the last few days.
A. Take it off as soon as possible, perform a pregnancy test and levonorgestrel emergency
contraception (LNG-EC) and then start a new patch cycle
B. Take it off as soon as possible, start a new patch cycle and no need for additional
contraception
C. Take it off as soon as possible, start a new patch cycle and offer barrier contraception for
the next 7days
D. Take it off as soon as possible, start a new patch cycle but perform pregnancy test and offer
Cu-IUD EC
E. Take it off as soon as possible, start a new patch cycle, perform a pregnancy test and offer
UPA-EC

Answer 196

Take it off as soon as possible, start a new patch cycle and no need for additional
contraception
* Sheshould start a new patch on the usual start day, even if they are bleeding. Thismeans that she will nothave a full week of patch-free days

Question 197

A30-year-old woman who suffers from epilepsy that has been well controlled with carbamazepine and who also has an unknown allergy attends for emergency contraception.
Shehad unprotected sexual intercourse (UPSI) 12days into her regular 28-day cycle.
What treatment option will consider in this woman?
A. Levonelle– 1.5mg
B. Levonelle– 3.0mg
C. Cu-IUD
D. Ulipristal acetate (UPA)– 30mg
E. UPA– 60mg (double dose)

Answer 197

Levonelle– 3.0mg
* UPA-EC is notrecommended with liver enzyme-inducing drugs.
Inthis patient with an unknown allergy unless copper allergy has been excluded, the best option is LNG-EC at a double dose of 3mg.

Question 198

A28-year-old woman reports missing two Micronor® (norethisterone 350µg) tablets and
having had UPSI during this period. Shedoes notwish to conceive. What emergency
contraception (EC) if any will you recommend for her?
A. Cu-IUD
B. LNG– 1.5mg
C. LNG– 3.0mg
D. UPA– 30mg
E. UPA– 60mg

Answer 198

Cu-IUD
* EC is indicated if a progestogen only pill (minipill) is late or missed (>27h for non-desogestrel containing and >36h for desogestrel containing POPs
* Because the POP has been used in the last 7days, the efficacy of UPA-EC could theoretically be reduced
* consideration should be given to the use of the LNG-EC. But CU-IUD is the most effective EC, and in this case, can be used up to 5days after the UPSI

Question 199

A30-year-old woman attended for EC following an episode of UPSI 3days ago. Shewas
counselled and offered the Cu-IUD. What is the primary mechanism by which this
method prevents pregnancy?
A. Inhibition of fertilization
B. Inhibition of fertilization and implantation
C. Inhibition of implantation
D. Inhibition of ovulation and fertilization
E. Inhibition of sperm and ovum transport and implantation

Answer 199

Inhibition of fertilization ( primary )
*If fertilization does occur : Inhibition of implantation

Question 200

A30-year-old who presented with a troublesome vaginal discharge had a cervicalsmear,
which has been reported as inadequate. Shereturned for follow-up. What recommendation will you offer her with respect to the management of her smear result?
A. Offer HPV test to triage subsequent management
B. Reassure and refer for routine recall cytology
C. Refer for colposcopy and treatment
D. Repeat cytology at 3months
E. Repeat cytology at 6months

Answer 200

Repeat cytology at 3months
* Referral for colposcopy is indicated after 3inadequate smears

Question 201

You are seeing a 40-year-old who had a low-grade dyskaryosis on her routine cervical
smear 2weeks ago. HPV testing, was therefore performed and reported as inadequate/
unreliable. What would be your next step in her management?
A. Refer for colposcopy
B. Refer for repeat cytology at 12months
C. Refer for repeat cytology at 3months with HPV testing if indicated
D. Repeat cytology and HPV testing now
E. Repeat cytology and HPV testing at 6months

Answer 201

Refer for colposcopy

Question 202

A 30-year-old woman had CGIN-treated and at follow-up, she was found to have an
abnormal cytology. She was therefore referred for colposcopy where treatment was
offered. What follow-up should be offered to this woman after treatment?
A. 6months for 3 years and then back to routine recall
B. 6month for 3 years and then yearly for 10years
C. 6month follow-up and then yearly for 10years
D. 6 month follow-up and then yearly for three followed by three yearly until the age of
55years
E. 12months follow-up cytology and HPV testing and if negative, yearly for 3years and then
back to routine recall

Answer 202

6month follow-up and then yearly for 10years
* follow-up cytology and {test of cure} should be offered at 6months. If this
comes back as abnormal, cytology referral should be done for colposcopy after which yearly follow-up is recommended to complete 10years of cytology follow-up.

Question 203

42-year-old presents with stress urinary incontinence and features of urinary tract
infections. A pelvic examination is performed and there are no features of prolapse.
Aurinalysis shows the presence of nitrites and leucocytes. What will be your plan for this
patient’s urinalysis findings?
A. Commence her on antibiotics as soon as possible as these findings indicate an infection
B. Refer her for urodynamics and ignore this finding as she is asymptomatic
C. Send a mid-stream urine (MSU) and discuss options with the patient
D. Send an MSU and await results before commencing her on antibiotics
E. Send an MSU sample but commence her on antibiotics

Answer 203

Send an MSU sample but commence her on antibiotics