SBA Flashcards
2.A 30-year-old woman is referred to the colposcopy clinic with borderline dyskaryosis, high risk HPV positive. Her colposcopy directed biopsy is reported as CIN1. What should she be advised?
To repeat smear with GP in 6 months
To repeat smear with GP in 1 year
To repeat smear with GP in 3 years
To repeat smear and colposcopy in 6 months time
To repeat smear and colposcopy in 1 year
The correct answer is to repeat smear with GP in 1 year. If the colposcopy had included treatment for CIN then it would not be correct to repeat the smear in 6 months. If the colposcopy had been normal with no CIN on biopsy then it would be correct to repeat the smear in 3 years. Colposcopy is not indicated other than for follow up for CGIN and, even then, it is optional. See NHS Cervical screening Programme. Screening protocol algorithm for HPV triage and test of cure. 2014 accessed online November 2014.
3.You are asked to review a 55-year-old woman with overactive bladder symptoms. She has responded poorly to bladder training and is on oxybutynin therapy. Her main complaint is nocturia, which is badly affecting her quality of life. What is the best treatment for her continuing symptoms? Darifenacin Desmopressin Mirabegrone Tolterodine Transdermal oxybutynin
The correct answer is Desmopressin. The use of desmopressin may be considered specifically to reduce nocturia in women with UI or OAB who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension. See National Institute of Health and Clinical Excellence.Urinary incontinence in women.CG 171. London: NICE. 2013.
4.A 55-year-old woman is due to come in for total abdominal hysterectomy and bilateral salpingo-oophorectomy for a large mucinous ovarian cyst. She takes sequential HRT for menopausal symptoms. What is the approximate overall risk of serious complications from abdominal hysterectomy? 1 operation in every 100 2 operations in every 100 3 operations in every 100 4 operations in every 100 5 operations in every 100
The correct answer is 4 operations in every 100. The overall risk of serious complications from abdominal hysterectomy is approximately four women in every 100 (common). See National Institute of Health and Clinical Excellence. Venous thromboembolism: reducing the risk. Clinical Guideline 92. London: NICE. 2010 and Royal College of Obstetricians and Gynaecologists.Abdominal hysterectomy for benign conditions. Consent Advice 4. London: RCOG. 2009.
5.A 46-year-old para 2 woman is referred to your gynaecology clinic complaining of regular but heavy menstrual bleeding which is affecting her quality of life. Which of the following associated features indicates the need for endometrial biopsy? BMI greater than 30 Dysmenorrhoea Failure of previous medical therapy Iron deficiency anaemia Uterus enlarged on vaginal examination
The correct answer is failure of previous medical therapy. An endometrial biopsy should be taken if there is persistent intermenstrual bleeding or if treatment is ineffective in women over 45. An ultrasound is the first line diagnostic tool for identifying structural abnormalities and should be performed if the uterus is palpable abdominally, vaginal examination reveals a pelvic mass or if drug treatment fails. See National Institute of Health and Clinical Excellence.Heavy menstrual bleeding. London: NICE. 2013.
6.A woman has been recommended to undergo hysterectomy and bilateral salpingo-oophorectomy for benign disease. You discuss the risks and benefits of an open versus a laparoscopic procedure. Which sort of injury is more common at laparoscopic hysterectomy compared to an open procedure? Bowel Nerve Ovary Urinary tract Vascular
The correct asnwer is urinary tract injury. Laparoscopic surgery involves risks to bowel, urinary tract and major blood vessels. These risks are higher in women who are obese or significantly underweight, however the risks of laparotomy are significantly greater in the morbidly obese. Urinary tract injury and vaginal cuff dehiscence are more common in the laparoscopic approach with an odds ratio of 2.61 for urinary tract injury. Royal College of Obstetricians and Gynaecologists.Preventing entry-related gynaecological laparoscopic injuries. Green-top Guideline 49. London: RCOG. 2008.
7.A 65-year-old had a hysterectomy for endometrial cancer. She recovered well but complained of dribbling urine 2 days later and was given a course of antibiotics for a presumed UTI. On review at 4 weeks she complains of continued urinary incontinence. She has no dysuria, no sensation of urgency, needs to wear a pad at night, and intermittently voids good volumes of urine with normal flow. Urinalysis is negative. What the most likely diagnosis? Fistula Occult underlying stress incontinence Overactive bladder syndrome Overflow incontinence Urinary tract infection
The correct answer is fistula. In the developed world the majority of urinary tract fistulae occur following hysterectomy (both vaginal and abdominal) and caesarean section. This is usually due to failure to dissect the bladder free of the cervix and upper vagina. Leakage starting in the immediate postoperative period suggests direct damage. Leakage that starts 1-2 weeks postoperatively is due to avascular necrosis. See Monaghan JM, Lopes T, Naik R. Bonney’s gynaecological surgery. Wiley-Blackwell. 2004.
8.A 47-year-old woman seeks advice about continuing the combined oral contraceptive pill (COCP). She is normotensive and a non-smoker with a BMI of 25. She has no other medical history and no significant family history. She is concerned that the COCP may give her additional health risks. Which of the following malignancies would you advise she may have a small additional risk of developing due to taking the COCP? Breast cancer Colorectal cancer Endometrial cancer Lung cancer Ovarian cancer
The correct answer is breast cancer. COCP use provides a protective effect against ovarian and endometrial cancer that continues for 15 years or more after stopping the pill. Women can be advised that there may be a small additional risk of developing breast cancer if they use COCP, which reduces to no risk 10 years after stopping the pill. See Faculty of Sexual & Reproductive Healthcare. Contraception for women aged over 40 years. Clinical Guidance. London: FSRH. 2010.
You have been reviewing the NICE guidelines on urinary incontinence. You have been asked to perform an audit on management of urinary incontinence in your department. What is the main purpose of audit? Changing practice Collecting data Providing patient feedback Improving quality Reducing costs
The correct answer is improving quality. Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in healthcare delivery. See Royal College of Obstetricians and Gynaecologists.Understanding audit.Clinical Governance Advice 5. London: RCOG. 2003.
A 35-year-old woman undergoes extensive laparoscopic surgery in the lithotomy position. She presents after 3 days with unresolved weakness of right hip extension and right knee flexion. There is associated sensory impairment below the right knee. Damage to which nerve is the most likely cause? Femoral Ilio-inguinal Lateral cutaneous of the thigh Obturator Sciatic
The correct answer is the sciatic nerve. See Kuponiyi O, Alleemudder DI, Latunde-Dada A, Eedarapalli P. Nerve injuries associated with gynaecological surgery. The Obstetrician & Gynaecologist 2014;16:29–36.
You see a 45-year-old nulliparous woman at your gynaecology clinic who is a carrier for the BRCA2 mutation. She wishes to discuss surgery to reduce her cancer risk. What is the approximate average cumulative risk of her developing ovarian-type cancer by the age of 70? 10% 25% 40% 55% 70%
The correct answer is 10%. BRCA1 and BRCA2 are highly penetrant genes that account for 95% of families with both breast and ovarian cancer. The cumulative risk of ovarian cancer is lower in women with BRCA2 at 11%, compared with BRCA1 where the risk is 39%. See Devlin LA, Morrison PJ. Inherited gynaecological cancer syndromes. The Obstetrician & Gynaecologist 2008;10:9–15 and Antoniou A, Pharoah PD, Narod S, Risch HA, Eyfjord JE, Hopper JL et al. Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case Series unselected for family history: a combined analysis of 22 studies. Am J Hum Genet 2003;72:1117–30.
You prescribe hormone replacement therapy (HRT) for vasomotor instability in a healthy 51-year-old woman who has no significant past medical or family history. During her appointment you counsel her regarding the risks of estrogen and progestogen HRT. How many estimated additional cases of breast cancer are there per 1000 women using HRT for five years? 3 cases per 1000 women 6 cases per 1000 women 9 cases per 1000 women 12 cases per 1000 women 14 cases per 1000 women
The correct answer is 6 additional cases per 1000 women. Combined (estrogen and progesterone) HRT is associated with a higher risk of breast cancer than estrogen-only HRT or tibolone. There are some discrepancies between the Million Women Study (MWS) and Women’s Health Initiative (WHI) study. Many of the discrepencies can be explained by the populations studies. The WHI study group was 16 000 women aged 50-79, 45% of whom had a BMI of 30 or more. The MWS looked at 1 084 110 women aged 50-64, only 18% of whom had a BMI of 30 or more See the British National Formulary. Hormone replacement therapy.Accessed online November 2014.
You see a 48-year-old woman opting for a hysterectomy for management of her heavy menstrual bleeding. While obtaining her consent for the operation you explain to her that haemorrhage requiring transfusion is a 'common' procedural risk. What is the numerical ratio for a complication when it is quoted as 'common'? 1/1 to 1/10 1/10 to 1/100 1/100 to 1/1000 1/1000 to 1/10 000 Less than 1/10 000
The correct answer is 1/10 to 1/100. See Royal College of Obstetricians and Gynaecologists.Obtaining valid consent for complex gynaecological surgery.Clinical Governance Advice 6b. London: RCOG. 2010.
A 36-year old woman undergoes laparoscopic resection of deep infiltrating endometriosis. You advise her regarding the risk of injury to her ureters during the surgery and the fact that this may be a direct injury or a thermal injury related to electrocautery. If she does receive a thermal injury, when would you expect her to present? 1–2 days post surgery 5–7 days post surgery 10–14 days post surgery 3–4 weeks post surgery 5–6 weeks post surgery
The correct answer is 10–14 days after surgery. Thermal injuries to the ureter may result in delayed necrosis and/or fistula formation that will typically present clinically between 10 and 14 days postoperatively. See Minas V, Gul N, Aust T, Doyle M, Rowlands D. Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management. The Obstetrician & Gynaecologist 2014;16:19–28.
A 68-year-old woman with postmenopausal bleeding is attending for a diagnostic hysteroscopy under general anaesthetic. You discuss the complications with her. What is the incidence of serious complications during hysteroscopy? 1 in 50 1 in 100 1 in 500 1 in 1000 1 in 5000
The correct is 1 in 500. Uterine perforation is uncommon, but a small postmenopausal uterus is an independent risk factor, especially if the cervical os is stenosed. The overall risk is reported as 0.76%. See Shakir F, Diab Y. The perforated uterus. The Obstetrician & Gynaecologist 2013;15:256–61 and Rock JA, Jones HW. TeLinde’s Operative Gynaecology. Lippincott Williams and Wilkins. 2011
A 22-year-old medical student presents with a request for contraception. Her menstrual cycle is irregular and she complains of acne and hirsutism. Previous investigation has diagnosed polycystic ovary syndrome (PCOS). She wishes to have a combined oral contraceptive with the best risk profile and most impact on her androgenic symptoms. Which one of the following is the best available option to recommend for her?
Cilest® (ethinyl estradiol/norgestimate)
Loestrin® (ethinyl estradiol/levonorgestrol)
Marvelon® (ethinyl estradiol/desogestrel)
Microgynon® (ethinyl estradiol/norethisterone)
Yasmin® (ethinyl estradiol/drosperinone)
The correct answer is Yasmin® (ethinyl estradiol/drosperinone). From the given list, Yasmin is more beneficial in terms of management of acne and hirsuitism associated with PCOS. Women with PCOS may also be given Marvelon or Mercilon as contraception. Yasmin contains 3 mg of drosperinone, which has some antiandrogenic properties. Dianette is also useful as it contains cyproterone acetate, which is also an antiandrogenic agent. Care must be taken for women with high body mass index. See Swingler R, Awala A, Gordon U. Hirsutism in young women. The Obstetrician & Gynaecologist 2009;11:101–7.
A 16-year-old girl presents to the gynaecology outpatient clinic with primary amenorrhea. She is 148 cm tall and weighs 54 kg (BMI 24.7). Breast development is assessed as Tanner stage 2 and her pubic hair is noted to be sparse. Further examination identifies cubitus valgus. She has no other dysmorphic features. What is the most likely diagnosis? Congenital adrenal hyperplasia Down syndrome Mayer-Rockitansky-Kusterhauser syndrome Testicular feminisation Turner syndrome
The correct answer is Turner syndrome. The karyotype is 45 XO in Turner syndrome. It is the most common cause of gonadal dysgenesis. These patients may have additional renal and cardiac anamolies. Some women may menstruate due to mosaicism, but premature ovarian failure is more common. See Bondy CA, and for The Turner Syndrome Consensus Study Group. Care of girls and women with Turner syndrome: a guideline of the Turner Syndrome Study Group. J ClinEndocrinolMetab 2007;92:10–25.
A 48-year-old woman presents 1 week after a total abdominal hysterectomy. She has persistent weakness of hip flexion and paraesthesia over the anterior and medial aspects of her left thigh. Damage to which nerve is the most likely cause? Lateral femoral nerve Genito-femoral Ilio-inguinal Lateral cutaneous of the thigh ObturatoR
The correct asnwer is the femoral nerve. Gynaecological surgery, especially abdominal hysterectomy, is the most common cause of iatrogenic femoral nerve injury, and injury to the femoral nerve is the most common nerve injury in gynaecological practice. This is usually caused by compression of the nerve against the pelvic sidewall by a retractor blade. See Kuponiyi O, Alleemudder DI, Latunde-Dada A, Eedarapalli P. Nerve injuries associated with gynaecological surgery. The Obstetrician & Gynaecologist 2014;16:29–36.
A 23-year-old woman whose mother died at the age of 56 of cervical cancer comes to see you. She wants to know how to reduce her own risk of cervical cancer. What is the single most important piece of advice you could give her?
To attend regularly for cervical screening
To avoid sexual promiscuity
To stop smoking
To stop smoking
To undergo prophylactic risk-reducing bilateral salpingo-oophorectomy
The correct asnwer is to attend regularly for cervical screening. The incidence of cervical carcinoma has drastically reduced in countries with screening programmes. Only 1% of abnormal smears progress to malignancy over a long period of time. Most women with cervical cancer have not had a smear in the last 5 years and many of then have never had a smear. See Centres for Disease Control and Prevention. Gynecologic cancers.Accessed online December 2014.
A 23-year-old primigravid woman presents at the emergency department at 6 weeks of gestation with threatened miscarriage. On examination, her vital signs were normal and her abdomen was soft with minimal tenderness on deep palpation. On speculum examination, there was a small amount of brown (old) blood in the vagina. A transvaginal ultrasound scan showed an intrauterine gestation sac measuring 18 mm x 15 mm x 12 mm. No yolk sac or fetal pole was visible. What would be the best management plan for her?
Arrange a repeat scan after 7 days
Arrange a dating scan at 12 weeks of gestation
Arrange serial β-HCG levels
Arrange serum progesterone level
Arrange surgical management of miscarriage
The correct answer is arrange a repeat scan after 7 days. For an embryonic pregnancy, if the mean gestational sac diameter is less than 25.0 mm with a transvaginal ultrasound scan and there is no visible fetal pole, a second scan after a minimum of 7 days should be performed before making a diagnosis of miscarriage. Once a gestation sac has been identified, there is no role for testing of serum β-HCG or serum progesterone level. See National Institute of Health and Clinical Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. Clinical guideline 154. London: NICE. 2012
A 65-year-old postmenopausal woman attends the clinic having been found to have a 4.9 cm simple cyst arising from the right ovary. There is no other abnormality on scan. Her Ca 125 is 29. She is asymptomatic and the cyst was picked up on investigation for haematuria. What is the most appropriate management?
Aspiration of the cyst under ultrasound guidance
Laparoscopic aspiration of the cyst
Repeat scan and Ca 125 test in 4 months
Right oophorectomy
Right ovarian cystectomy
The correct answer is repeat scan and Ca 125 test in 4 months. The risk of malignancy index (RMI) is zero since the cyst is simple and it measures less than 5 cm. Therefore, monitoring for 12 months is all that is required. See Royal College of Obstetricians and Gynaecologists.Ovarian cysts in postmenopausal women. Green-top Guideline 34. London: RCOG. 2003.
A 17-year-old girl presents with a 12 hour history of lower abdominal pain. She had unprotected intercourse a week ago, which was 6 days after her last period. Her pulse is 110 beats per minute, her blood pressure is 110/70 mmHg, her temperature 37.8°C and she is tender over her lower abdomen, especially in the right iliac fossa where there is rebound tenderness. There is cervical excitation. Her Hb is 137g/L (normal 115–165) and her white cell count 17.6 x 10*9/L (normal 4–11). What is the most likely diagnosis? Acute appendicitis Acute pelvic inflammatory disease Ectopic pregnancy Pelvic endometriosis Ruptured corpus luteum
The correct answer is acute appendicitis. The white count and mild pyrexia suggest an infection and the localisation to the right iliac fossa makes this more likely to be appendicitis.
A 27-year-old woman has had three successive first trimester miscarriages. Investigations show that she has antiphospholipid syndrome. Which treatment option will improve the chance of a successful pregnancy?
Aspirin and heparin
Corticosteroids and intravenous immunoglobulin
Human chorionic gonadotrophin
Metformin
Progesterone
The correct answer is aspirin and heparin. Antiphospholipid syndrome is present in 15% of women with recurrent miscarriage. Without treatment, the live birth rate has been reported to be as low as 10%. Corticosteroids and intravenous immunoglobulin are associated with significant maternal and fetal morbidity. Despite the association between PCOS and miscarriage that is attributed to insulin resistance and hyperinsulinaemia, a meta-analysis of 117 randomised controlled trials showed no reduction in the rate of miscarriage in those women prescribed metformin. See Royal College of Obstetricians and Gynaecologists.Investigation and treatment of couples with recurrent miscarriage. Green-top Guideline 17. London: RCOG. 2011.
A 26-year-old-woman presents to the emergency gynaecology clinic requesting emergency contraception (EC). She had unprotected sex 6 days ago. She is not currently using any contraception, having not had a partner for a year. She has a regular 28 day menstrual cycle, which can be heavy. The first day of her last period was 15 days ago. What emergency contraception option, if any, would you advise?
A copper bearing intrauterine device
A Mirena® coil
It is too late for emergency contraception
Levonelle®
Ulipristal acetate
The correct answer is a copper bearing intrauterine device. The choice of EC depends on the length of time since unprotected sexual intercourse. All forms are not effective after 6 days except for the copper-bearing intrauterine device, and only in the circumstance that it is within 5 days of the earliest estimated date of ovulation. See Faculty of Sexual and Reproductive Healthcare. Emergency contraception.Clinical Guidance. London: FSRH. 2011.
A 46-year-old fit and healthy woman has urodynamically confirmed stress urinary incontinence. She has undergone pelvic floor muscle training without improvement. On examination she is noted to have a POPQ grade 1 anterior vaginal wall prolapse. In view of the effect of her urinary symptoms on her quality of life she is requesting definitive treatment. What is the most appropriate surgical intervention for her? Anterior colporrhaphy Artificial urinary sphincter Intramural bulking agent Laparoscopic colposuspension Synthetic mid-urethral tape
The correct answer is synthetic mid-urethral tape. All women with stress urinary incontinence should be referred for pelvic floor exercises in the first instance. If conservative management fails, the first line management is a synthetic mid-urethral tape procedure. Anterior colporrhaphy is not indicated since her prolapse is only stage 1 and is therefore asymptomatic, and it does not treat stress incontinence. See National Institute for Health and Clinical Excellence.The management of urinary incontinence in women.Clinical Guideline 171. NICE. 2013.
A 36-year-old woman presents to the early pregnancy assessment unit with a history of mild bleeding for 3 days and lower abdominal pain. She has had two vaginal deliveries in the past. She has factor V Leiden deficiency, which was diagnosed during her first pregnancy. Her last menstrual period was 7 weeks ago and this is an unplanned pregnancy. She has no other significant medical or surgical history. She lives with her husband and children. On ultrasound scan, she was found to have an intrauterine gestational sac with a fetal pole measuring 8 mm. No fetal heart beat was seen and was confirmed by two ultrasonographers. What is the best initial management for this woman?
Book a repeat scan in 7–10 days
Counsel her regarding expectant management of miscarriage
Discuss medical management of miscarriage and prescribe oral administration of 600 micrograms of misoprostol
Discuss medical management of miscarriage and prescribe oral administration of 200 mg mifepristone
Prescribe antibiotics for 7 days and discuss expectant management of miscarriage
The correct answer is counsel her regarding expectant management of miscarriage. Expectant management should be offered as first line management for all women with a confirmed diagnosis of miscarriage, taking into account if she is at increased risk of haemorrhage (e.g. late first trimester), has risks associated with haemorrhage (e.g. unable to have a blood transfusion), evidence of infection, or her personal wishes. Mifepristone is not indicated in management of a non viable pregnancy. See National Institute for Health and Clinical Excellence.Ectopic pregnancy and miscarriage.Clinical Guideline 154. NICE. 2012.
A 40-year-old woman presents with severe pelvic pain. She has had a myomectomy in the past through a vertical abdominal incision to the level of the umbilicus. To investigate her pelvic pain, she undergoes a diagnostic laparoscopy using the Palmer point of entry. Where is Palmer’s point?
3 cm below the left costal margin in the midaxillary line
3 cm below the left costal margin in the midclavicular line
3 cm below the right costal margin in the midaxillary line
3 cm below the right costal margin in the midclavicular line
3 cm below xiphisternum in the midline
The correct answer is 3 cm below the left costal margin in the midclavicular line. Palmer’s point should be used if there is a high suspicion of adhesions. Adhesions are found in up to 50% of women following midline laparotomy but are rarely found in the left upper quadrant. The usual trocar and cannulae can be inserted under direct vision or following dissection of any adhesions seen. If there are two failed attempts at insufflation then utilising Palmer’s point or the open Hasson technique should be used. See Royal College of Obstetricians and Gynaecologists. Preventing entry related gynaecological injuries. Green-top Guideline 49. London: RCOG. 2008.
A 16-year-old girl attends the gynaecology clinic for heavy periods and confides that she is being forced to undergo female genital mutilation (FGM) by her parents. What is the estimated number of children at risk of FGM in the UK? 500 5000 10 000 20 000 50 000
The correct answer is 20 000. It is estimated that 20 000 girls in the UK are at risk of FGM, usually through travelling abroad to facilitate the procedure. It is important that the safeguarding team are informed when a woman who has undergone FGM themselves delivers a female child. See Royal College of Obstetricians and Gynaecologists.Female genital mutilation and its management. Green-top Guideline 53. London: RCOG. 2009.
You have informed a 45-year-old that she has stage 3c ovarian cancer. She is keen to know about her prognosis. What is the 5-year survival rate in UK for advanced ovarian cancer? 20–25% 30–35% 40–445% 50–55% 60–65%
The correct answer is 40–45%. As with the majority of cancers, relative survival for ovarian cancer is improving. Much of the increase occurred during the 1980s and 1990s, and appears to be leveling off in the 2000s. The significant increase in 1-year survival is likely to be the result of greater use of platinum-based chemotherapy. One-year relative survival rates for ovarian cancer increased from 42% in England and Wales in 1971–1975 to 72.3% in England in 2005–2009. The 5-year survival rate for advanced ovarian cancer in 2005–2009 was 43%. See Cancer Research UK. Ovarian cancer survival statistics.Accessed online December 2014.
A 42-year-old para 2 woman is referred to your gynaecology clinic complaining of regular but heavy menstrual bleeding that is affecting her quality of life. Which of the following investigations is most appropriate at the first clinic visit? Full blood count (FBC) Gonadotrophin assay Thyroid function tests (TFTs) Thyroid function tests (TFTs) Transvaginal ultrasound (TVS)
The correct answer is a full blood count (FBC). All women presenting with heavy menstrual bleeding should have FBC performed. An ultrasound scan is not indicated unless the uterus is palpable abdominally, an adnexal mass is palpable or medical treatment fails. See National Institute for Health and Clinical Excellence.Heavy menstrual bleeding.CG 44. NICE 2007.
A 63-year-old woman with a history of postmenopausal bleeding returns to the gynaecology clinic. Recent endometrial biopsy shows complex hyperplasia without atypia. She wants to know what the risk is of these abnormal cells progressing to cancer. What is the risk of her complex hyperplasia progressing to endometrial cancer over 10 years? 4% 8% 12% 16% 20%
The correct answer is 4%. It is important to be able to counsel patients appropriately regarding their risk of malignancy and not to confuse complex hyperplasia with complex atypical hyperplasia. See Palmer JE, Perunovic B, Tidy JA. Endometrial hyperplasia. The Obstetrician & Gynaecologist 2008;10:211–6.
A 30-year-old multiparous woman with a suspected borderline left ovarian tumour is awaiting laparotomy, frozen section and conservative or complete staging surgery. She wants to know the accuracy of frozen section. How many cases diagnosed as borderline ovarian tumours on frozen section would be later reclassified as invasive tumours? One-tenth of cases One-fifth of cases One-quarter of cases One-third of cases One-half of cases
The correct answer is one-third of cases. Approximately one-third of cases reported as borderline tumours on frozen section are later reclassified as invasive tumours. For the older women with no fertility concerns, if frozen section is reported as a borderline tumour then complete staging should be undertaken. See Bagade P, Edmondson R, Nayar A. Management of borderline ovarian tumours. The Obstetrician & Gynaecologist 2012;14:115–20.
A 25-year-old woman with a bicornuate uterus attends the emergency gynaecology unit requesting emergency contraception (EC). Shehas been on holiday and forgot to take her contraceptive pill for 3 days in the first week of the calendar pack and had unprotected sexual intercourse (UPSI) four days ago. She is in good health. Which of the following is the recommended EC? Copper IUCD Mirena IUS Levonorgestrel (LNG) Mifepristone Ulipristal acetate (UA)
The correct asnwer is ulipristal acetate (UA). The Mirena coil is not licensed for EC. LNG is recommended only within 72 hours of UPSI. A copper IUCD can be used within 5 days of first UPSI in a cycle but is not indicated in the presence of a uterine anomaly. Mifepristone is not licensed for EC in the UK. UA is licensed for use within 120 hours of UPSI so is the recommended choice. See Faculty of Sexual and Reproductive Health Care. Emergency contraception. London: FSRH. 2011.
A 46-year-old nulliparous woman has been referred by her GP having been treated for heavy regular menstrual bleeding with cyclical progestogens for a period of 6 months. The treatment has failed to improve her symptoms. What is the most appropriate next line of management? Endometrial biopsy Levonorgestrel intrauterine system Non-steroidal anti-inflammatory drugs Pelvic ultrasound Tranexamic acid
The correct answer is endometrial biopsy. Endometrial biopsy should be performed if a women over 45 years of age fails to respond to first line treatment. See: National Institute for Health and Clinical Excellence. Heavy menstrual bleeding.Clinical Guideline 44. London: NICE. 2007.
A 45-year-old woman is due to have a total abdominal hysterectomy and bilateral salpingo oopherectomy for chronic pelvic pain. You receive a letter from her GP informing you that her recent cervical smear has shown borderline changes in endocervical cells. What arrangement will you make, if any, prior to her admission? Endometrial sampling HPV testing No change in her management Referral to colposcopy Repeat cervical cytology
The correct answer is referral to colposcopy. All women being considered for hysterectomy who have an uninvestigated abnormal test result or symptoms attributable to cervical cancer should have diagnostic colposcopy and an appropriate biopsy. See: NHS Cancer Screening Programmes. Colposcopy and Programme Management.Guidelines for the NHS Cervical Screening Programme.Second edition. Sheffield: NHS Cancer Screening Programmes. 2010.
A 55-year-old woman is seen in the pre-assessment clinic. She is due to undergo full staging surgery for ovarian cancer as recommended by the MDT. Her only current medications are clopidogrel and thyroxine. If the benefits of stopping clopidogrel outweigh the risks, how long should clopidogrelbe stopped prior to surgery? 1 day 3 days 5 days 7 days 14 days
The correct asnwer is 7 days. You should assess the risks and benefits of stopping pre-existing antiplatelet therapy 1 week before surgery. Consider involving the multidisciplinary team in the assessment. See: National Institute for Health and Clinical Excellence. Venous thromboembolism: reducing the risk. Clinical Guideline 92. London: NICE. 2010.
