Women's Health 1 (Gynae/Breast)

Question 1

What is pelvic organ prolapse?

Answer 1

When pelvic organs descend into the vagina as a result of weakness and lengthening of the ligaments and muscles which surround the uterus, rectum and bladder

Question 2

What is vault prolapse?

Answer 2

occurs in women who have had a hysterectomy and is when the top of the vagina (the vault) descends into the vagina

Question 3

What is a rectocele? What symptom is this commonly associated with?

Answer 3

caused by a defect in the posterior vaginal wall which allows the rectum to prolapse forwards into the vagina

they are particularly associated with constipation as women can develop faecal loading in the part of the rectum which has prolapsed into the vagina

women can use their fingers to press the lump backwards, correcting the anatomical position of the rectum and allowing them to open their bowels

Question 4

What is a cystocele?

Answer 4

where a defect in the anterior vaginal wall allows the bladder to prolapse backwards into the vagina

the urethra can also undergo prolapse (urethrocele) and prolapse of both the bladder and urethra is called a cystourethrocele

Question 5

What are some risk factors for pelvic organ prolapse?

Answer 5

multiple vaginal deliveries
instrumental, prolonged or traumatic delivery
advanced age and postmenopause status
obesity
chronic respiratory disease causing coughing
chronic constipation causing straining

Question 6

What are the typical presenting symptoms of pelvic organ prolapse?

Answer 6

feeling of something coming down in the vagina
dragging or heavy sensation in the pelvis
urinary symptoms e.g. incontinence, urgency, frequency, weak stream and retention
bowel symptoms e.g. constipation, altered sensation, reduced enjoyment
lump or mass in the vagina

Question 7

What are the gradings in the pelvic organ prolapse quantification (POP-Q) system?

Answer 7

Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina

Question 8

What is the management for pelvic organ prolapse? 3 main options

Answer 8

Conservative management
- physio, weight loss, lifestyle changes, treatment of related symptoms, vaginal oestrogen cream

Vaginal pessary (ring, cube, donut, hodge, Shelf and Gellhorn)

Surgery (definitive treatment)
- many potential surgical methods including hysterectomy
- mesh repair used to be an option but NICE recommend avoiding them due to complications

Question 9

What is an overactive bladder?

Answer 9

also known as urge incontinence

caused by overactivity of the detrusor muscle of the bladder

sudden feeling of needing to pass urine and inability to control bladder

Question 10

What is stress incontinence?

Answer 10

when urine leaks at times of increased pressure on the bladder often when laughing, coughing or surprised

caused by weakness of the pelvic floor and sphincter muscles

Question 11

What are some risk factors for urinary incontinence? x8

Answer 11

increased age
postmenopausal status
increased BMI
previous pregnancies and vaginal deliveries
pelvic organ prolapse
pelvic floor surgery
neurological conditions, such as MS
cognitive impairment and dementia

Question 12

What are the investigations used to assess urinary incontinence?

Answer 12

bladder diary recording fluid intake and episodes of urination and incontinence

urine dipstick testing

post-void residual bladder volume

urodynamic testing (catheters inserted into bladder and rectum which assess pressures)

Question 13

What is the management for urge incontinence?

Answer 13

bladder retraining
anticholinergic medication (oxybutynin, tolterodine and solifenacin)
mirabegron
invasive procedures e.g. botox injections, augmentation cystoplasty

Question 14

What is the management for stress incontinence?/

Answer 14

avoiding caffeine, diuretics and overfilling of the bladder
avoid ecessive or restricted fluid intake
weight loss if needed
supervised pelvic floor exercises
surgery e.g. TVT, autologous sling procedures, colposuspension
duloxetine

Question 15

What are the most common types of vaginal fistula?

Answer 15

vesicovaginal fistula = tract connecting the vagina and bladder
rectovaginal fistula = tract connecting the vagina and the rectum
colovaginal fistula = tract connecting the vagina and colon
enterovaginal fistula = tract connecting the vagina and small intestine

Question 16

What are some potential causes of vaginal fistualae? x6

Answer 16

childbirth
abdo surgery (hysterectomy, c-section)
pelvic, cervical or colon cancer
bowel disease e.g. Crohn’s, diverticulitis
infection
traumatic injury

Question 17

Briefly describe the embryological development of the female genital tract/

Answer 17

the paramesonephric ducts (mullerian ducts) are a pair of passageways along the outside of the urogenital region which fuse and mature to become the uterus, fallopian tubes, cervix and upper third of the vagina

in a male foetus anti-mullerian hormone is produced , which suppresses the growth of the mullerian ducts, causing them to disappear

Question 18

What is a bicornate uterus? complications? management?

Answer 18

where there are two horns to the uterus, giving it a heart-shaped appearance

can be associated with adverse pregnancy outcomes like miscarriage, premature birth or malpresentation but usually pregnancies are successful

in most cases, no specific management is required

Question 19

What is an imperforate hymen? treatment? complications?

Answer 19

where the hymen at the entrance of the vagina is fully formed without an opening

often discovered at menarche as the menses are sealed in the vagina causing cyclical pelvic pain and cramping without vaginal bleeding

treatment is with surgical incision to create an opening in the hymen

potential complication is retrograde menstruation leading to endometriosis

Question 20

What is transverse vaginal septae? complications? treatment?

Answer 20

an error in development where a septum forms transversely across the vagina

can either be perforate or imperforate so some girls will still menstruate but have difficulty with intercourse or tampon use whereas those with imperforate septae will present similarly to an imperforate hymen

can lead to infertility and pregnancy-related complications

treatment is with surgical correction

Question 21

What is vaginal hypoplasia and agenesis? management?

Answer 21

vaginal hypoplasia is an abnormally small vagina
vaginal agenesis is an absent vagina

these occur due to failure of the mullerian ducts to properly develop and can be associated with an absent uterus and cervix

management may involve the use of a vaginal dilator to create an adequate vaginal size
in some cases surgical intervention is required

Question 22

What is adenomyosis?

Answer 22

endometrial tissue inside the myometrium (muscle layer of the uterus)

Question 23

What is the typical presentation of adenomyosis

Answer 23

dysmenorrhoea
menorrhagia
dyspareunia

enlarged, boggy uterus

infertility or pregnancy-related complications
1/3 of patients are asymptomatic

Question 24

How is adenomyosis diagnosed?

Answer 24

1st line - transvaginal USS
MRI and transabdominal USS can also be used

GS = histological examination of the uterus after a hysterectomy (not usually appropriate)

Question 25

What is the management for adenomyosis?

Answer 25

same as the treatment for heavy menstrual bleeding

for women who do not want contraception:
- tranexamic acid (if no associated pain) = antifibrinolytic
- mefenamic acid (with associated pain) = NSAID

for women who want or are happy to have contraceptives:
- mirena coil (1st line)
- COCP
- cyclical oral progestogens

Question 26

What are some potential pregnancy complications caused by adenomyosis? x8

Answer 26

Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage

Question 27

What is Asherman’s syndrome?

Answer 27

where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus

these adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages

Question 28

What causes Asherman’s syndrome?

Answer 28

it usually occurs after a pregnancy-related dilatation and curettage (scraping) procedure, e.g. in the treatment of retained products of conception (removing placental tissue left behind after birth)

can also occur after uterine surgery or several pelvic infections

the adhesions can bind the uterine walls together, or within the endocervix, sealing it shut

Question 29

What are the presentations of Asherman’s syndrome? x4

Answer 29

secondary amenorrhoea
significantly lighter periods
dysmenorrhoea
infertility

Question 30

How is a diagnosis of Asherman’s syndrome confirmed? what is the treatment?

Answer 30

hysteroscopy (GS) also the treatment as adhesions can be dissected during this procedure
hysterosalpingography (XR imaging of the uterus with contrast)
sonohysterography (uterus is filled with fluid before pelvic USS)
MRI scan

Question 31

What is lichen sclerosis? what does lichen refer to?

Answer 31

a chronic inflammatory skin condition which presents with patches of shiny, ‘porcelain-white’ skin and commonly affects the labia, perineum and perianal skin in women

lichen refers to a flat eruption that spreads

Question 32

What are the symptoms of lichen sclerosus?

Answer 32

itching
soreness and pain (possibly worse at night)
skin tightness
superficial dyspareunia
erosions
fissures

Question 33

What is the Koebner phenomenon?

Answer 33

occurs in lichen sclerosus when the signs and symptoms are made worse by friction to the skin

Question 34

What is the appearance of the skin in lichen sclerosus?

Answer 34

porcelain-white colour
shiny
tight
thin
slightly raised
may be papules or plaques

Question 35

What is the management for lichen sclerosus?

Answer 35

cannot be cured but symptoms can be effectively managed

long term strong topical steroids like clobetasol propionate

emollients

Question 36

What are the potential complications of lichen sclerosus?

Answer 36

5% risk of squamous cell carcinoma of the vulva

sexual dysfunction
narrowing of the vaginal or urethral openings
bleeding, pain, discomfort

Question 37

What is endometriosis? what is an endometrioma?

Answer 37

a condition where there is ectopic endometrial tissue outside the uterus

endometrioma = a lump of endometrial tissue outside the uterus

Question 38

What causes endometriosis? what are the theories for the growth of ectopic endometrial tissue?

Answer 38

no clear cause
seems to be a genetic element

• retrograde menstruation where the endometrial lining flows backwards through the fallopian tubes during menstruation, into the pelvis and peritoneum where it seeds itself
• embryonic cells destined to become endometrial tissue remain in areas outside the uterus during foetal development and then develop into ectopic endometrial tissue
• spread of endometrial cells through the lymphatic system (similar to cancer spread)
• metaplasia of cells outside the uterus into endometrial cells

Question 39

What are the symptoms of endometriosis?

Answer 39

can be asymptomatic

cyclical abdominal or pelvic pain
deep dypareunia
dysmenorrhoea
infertility
cyclical bleeding from other site e.g. haematuria

Question 40

What investigations are used to diagnose endometriosis?

Answer 40

pelvic USS - may reveal endometriomas and chocolate cysts but more commonly unremarkable
laparoscopic surgery (GS) with biopsy and potential to removed deposits for symptom relief

Question 41

What are the management options for endometriosis?

Answer 41

important parts of initial management are education, analgesia and partnership with patient to establish their ICEs

hormonal management: COCP, progesterone pill, depo injection, nexplanon implant, mirena coil, GnRH agonists

Surgical management: laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions, hysterectomy

Question 42

What are some differential diagnoses for endometriosis? x8

Answer 42

pelvic inflammatory disease
ectopic pregnancy
torsion of an ovarian cyst
appendicitis
primary dymenorrhoea
IBS
uterine fibroids
UTI

Question 43

What is a vulval intraepithelial neoplasia? what are some types of VIN?

Answer 43

a premalignant condition affecting the squamous epithelium of the skin which can precede vulval cancer

High grade squamous intraepithelial lesions are a type of VIN associated with HPV infection which typically occur in younger women aged 35-50

Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (50-60 yrs)

Question 44

What are some risk factors for vulval cancer

Answer 44

lichen sclerosus (5% get vulval cancer)
advanced age (75+)
immunosuppression
HPV infection

Question 45

What are the treatment options for VIN? x4

Answer 45

watch and wait
wide local excision to remove the lesion
imiquimod cream
laser ablation

Question 46

What are the symptoms of vulval cancer? x6

Answer 46

vulval lump
ulceration
bleeding
pain
itching
lymphadenopathy of the groin

Question 47

What are some features of vulval tumours? what part of the vulva is usually affected?

Answer 47

irregular mass
fungating lesion
ulceration
bleeding

most commonly affect the labia majora

Question 48

How is a diagnosis of vulval cancer established?

Answer 48

Biopsy of the lesion
Sentinel node biopsy to demonstrate lymph node spread
Further imaging for staging (e.g. CT abdomen and pelvis)

Question 49

What are the management options for vulval cancer?

Answer 49

Wide local excision to remove the cancer
Groin lymph node dissection
Chemotherapy
Radiotherapy

Question 50

What is HPV? What are the important strains and associations? How does it increase the likelihood of cancer?

Answer 50

a viral STI associated with anal, vulval, penis, mouth and throat cancers

important strains are type 16 and 18 which are responsible for around 70% of cervical cancers and also the strains targeted with the HPV vaccine

HPV produces two proteins (E6 and E7) which inhibit the tumour suppressor genes, P53 and pRb respectively, promoting cancer development as a result

Question 51

What are some of the risk factors for cervical cancer?

Answer 51

HPV - early sexual activity, multiple sexual partners, not using condoms

not having cervical screening
smoking
HIV
COCP for 5+ years
family history
exposure to diethylstilbestrol during foetal development

Question 52

What are some symptoms of cervical cancer?

Answer 52

abnormal vaginal bleeding
vaginal discharge
pelvic pain
dyspareunia

Question 53

What is cervical intraepithelial neoplasia? what are the grades?

Answer 53

a grading system for the level of dysplasia in the cells of the cervix

CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated

Question 54

How is cervical cancer staged?

Answer 54

Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis

Question 55

What is the management for cervical cancer?

Answer 55

Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care

Question 56

What is colposcopy?

Answer 56

a procedure where the epithelial lining of the cervix is examined in detail and stains such as acetic acid and iodine solution are used to identify abnormal areas

Question 57

What is large loop excision of the transformation zone (LLETZ)?

Answer 57

also known as a loop biopsy and can be performed with local anaesthetic during a colposcopy procedure

uses a loop of wire with electrical current to remove abnormal epithelial tissue on the cervix

Question 58

What is a cone biopsy? what are the potential risks?

Answer 58

a treatment for CIN and very early-stage cervical cancer

an operation performed under general anaesthetic where the surgeon removes a cone-shaped piece of the cervix using a scalpel which is then sent for histology to assess for malignancy

risks:
- pain
- bleeding
- infection
- scar formation with stenosis of the cervix
- increased risk of miscarriage and premature labour

Question 59

What is pelvic exenteration

Answer 59

an operation which can be used in advanced cervical cancer and involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum

Question 60

What is bevacizumab ?

Answer 60

a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer

targets vascular endothelial growth factor A which is responsible for the development of new blood vessels

also used to treat wet age-related macular degeneration

Question 61

What are the most common types of cervical cancer?

Answer 61

80% are squamous cell carcinomas
adenocarcinoma
rarely small cell cancer

Question 62

What is the screening programme for cervical cancer in the UK?

Answer 62

A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)

Question 63

What are the potential cytology results of cervical screening?

Answer 63

inadequate
normal
borderline changes
low-grade dyskaryosis
high-grade dyskaryosis (moderate/severe)
possible invasive squamous cell carcinoma
possible glandular neoplasia

can also identify bacterial vaginosis, cadididasis and trichomoniasis

Question 64

What are the management options for smear results?

Answer 64

Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy

Question 65

What is endometrial hyperplasia? prognosis? types?

Answer 65

a precancerous condition involving thickening of the endometrium

most cases return to normal over time
less than 5% will progress to endometrial cancer

2 types:
hyperplasia without atypia and atypical hyperplasia

Question 66

What is the treatment for endometrial hyperplasia?

Answer 66

intrauterine system e.g. mirena coil
continuous oral progestogens e.g. medroxyprogesterone

Question 67

What are some risk factors for endometrial cancer? x8

Answer 67

Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity (adipose tissue is a source of oestrogen)
Polycystic ovarian syndrome
Tamoxifen (oestrogenic effect on the endometrium)

Question 68

Why is PCOS a risk factor for endometrial cancer?

Answer 68

it lead to increased exposure to unopposed oestrogen due to a lack of ovulation

when ovulation occurs a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg and its the corpus luteum which produces progesterone and provide endometrial protection during the luteal phase of the menstrual cycle

women with PCOS are less likely to ovulate and form a corpus luteum so progesterone is not produced and the endometrial lining has more exposure to unopposed oestrogen

Question 69

What is used for endometrial protection in women with PCOS? x3

Answer 69

COCP
intrauterine system like mirena coil
cyclical progestogens to induce a withdrawal bleed

Question 70

What are some protective factors against endometrial cancer?

Answer 70

COCP
mirena coil
increased pregnancies
cigarette smoking (due to anti-oestrogenic effect)

Question 71

What are the symptoms of endometrial cancer? x7

Answer 71

Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count

Question 72

What is the referral criteria for a 2 week-wait urgent cancer referral for endometrial cancer?

Answer 72

postmenopausal bleeding (12+ months after last menstrual period)

Question 73

What potential symptoms of endometrial cancer trigger referral for a transvaginal USS in women over 55?

Answer 73

unexplained vaginal discharge
visible haematuria (with raised platelets, anaemia or raised blood glucose)

Question 74

What are the 3 main investigations for diagnosing endometrial canceR?

Answer 74

Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy

Question 75

What are the stages of endometrial cancer?

Answer 75

Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis

Question 76

What is the management for endometrial cancer?

Answer 76

For stage 1 and 2 usually a total abdominal hysterectomy with bilateral salpingo-oopherectomy (TAH and BSO) where the uterus, cervix and adnexa are removed

A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer

Question 77

What are the types of ovarian cancers

Answer 77

epithelial cell tumours (serous tumours (MC), endometrioid carcinomas, clear cell, mucinous tumours, undifferentiated tumours)

dermoid cysts/ germ cell tumours - teratomas (can contain other tissue types e.g. skin, teeth, hair and bone), particularly associated with ovarian torsion

sex cord-stromal tumours - rare and can be benign or malignant, arise from the stroma or sex cords, include sertoli-leydig cell tumours, granulosa cell tumours

metastasis - krukenberg tumour is a common type of metastasis in the ovary usually from the GI tract and these have characteristic signet ring cells on histology

Question 78

What are some risk factors for ovarian cancer?

Answer 78

age (peak age 60)
BRCA1 and BRCA2 genes
increased number of ovulations
obesity
smoking
recurrent use of clomifene

Question 79

What are 3 protective factors for ovarian cancer?

Answer 79

COCP
breastfeeding
pregnancy

Question 80

What are the symptoms of ovarian cancer? x8

Answer 80

abdo bloating
early satiety
loss of appetite
pelvic pain
urinary symptoms
weight loss
abdo pain or pelvic mass
ascites

Question 81

What examination findings trigger a 2 week-wait referral for ovarian cancer?

Answer 81

ascites
pelvic mass
abdo mass

Question 82

What are the investigations for ovarian cancer?

Answer 82

CA1245 blood test
pelvic USS

CT scan
histology using a CT guided biopsy, laparoscopy or laparotomy
paracentesis

Question 83

What are the factors considered in the risk of malignancy index (RMI) for an ovarian mass?

Answer 83

menopausal status
USS findings
CA125 level

Question 84

Which tumour markers could indicate a possible germ cell tumour?

Answer 84

Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)

Question 85

What are some non-malignant caused of a raised CA125? x6

Answer 85

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

Question 86

What is the staging for ovarian cancer?

Answer 86

Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)

Question 87

What is vaginal cancer? how does it usually present ?

Answer 87

a squamous cell carcinoma involving the posterior wall of the upper third of the vagina. It may directly invade the bladder or rectum. Lesions may be ulcerative or exophytic.

80% of vaginal cancers are metastatic spread i.e. from the urethra, bladder, rectum etc.

vaginal bleeding/bloody discharge

Question 88

What are the investigations for vaginal cancer?

Answer 88

colposcopy
biopsy, cervical cytology, endometrial biopsy
CT scan
fluorodeoxyglucose-positron emission tomography
CXR
cytoscopy, sigmoidoscopy

Question 89

What is the staging for vaginal cancer?

Answer 89

Stage 0 - squamous cell carcinoma in situ; this disease is usually multifocal and commonly occurs at the vaginal vault.

Stage I - the disease is limited to the vaginal wall mucosa.

Stage II - the disease involves the subvaginal tissue, but not the pelvic wall.

Stage III - the disease extends to pelvic wall.

Stage IV - the disease either extends beyond the true pelvis or involves the bladder or rectal mucosa:

Stage IVA - the disease has spread to adjacent organs.

Stage IVB - the disease has spread to distant organs.

Question 90

What are the management options for vaginal cancer?

Answer 90

dependent on tumour stage

surgery and radiotherapy are very effective in early-stage disease

radiation therapy is the treatment of choice in most patient with vaginal cancer, particularly in later-stage disease
chemoradiation therapy (cisplatin, 5-fluorouracil)

Question 91

What is a hydatidiform mole? complete vs partial?

Answer 91

also known as a molar pregnancy where a mass of tissue grows inside the womb which will not develop into a baby

a complete mole occurs when two sperm cells fertilise an ovum which contains no genetic material and so the genetic material of the sperm combine and divide

a partial mole is when 2 sperm cells fertilise a normal ovum at the same time so that it has 3 sets of chromosomes and then divides and multiplies into a tumour called a partial mole (some foetal material may develop)

Question 92

What are some indicators for a molar pregnancy which differ from a normal pregnancy?

Answer 92

molar pregnancies generally behave like a normal pregnancy

• more severe morning sickness
• vaginal bleeding
• increased enlargement of the uterus
• abnormally high hCG
• thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3/T4)`

Question 93

What is the characteristic sign of a molar pregnancy on USS?

Answer 93

snowstorm appearance (created by the presence of many hydropic villi which give the appearance of a central heterogenous mass filling the entire uterine cavity)

Question 94

What is the management for molar pregnancies?

Answer 94

evacuation of the uterus to remove the mole

the products of conception need to be sent for histological examination to confirm a molar pregnancy

patients should be referred to the gestational trophoblastic disease centre for management and follow up

hCG levels should be monitored until they return to normal

occasionally the mole can metastasise and the patient may need systemic chemotherapy

Question 95

What is gestational trophoblastic disease?

Answer 95

a group of pregnancy-related tumours which develop from the cells which surround the fertilised egg or embryo e.g. hydatidiform mole, choriocarcinoma, placental site trophoblastic tumour, epithelioid trophoblastic tumours

Question 96

What are the potential causes of primary amenorrhoea? x3

Answer 96

primary amenorrhoea = when the patient has never developed periods

abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)

abnormal functioning of the gonads (hypergonadotropic hypogonadism)

imperforate hymen or other structural pathology

Question 97

What are some potential causes of secondary amenorrhoea? x9

Answer 97

pregnancy (MC)
menopause
physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
polycystic ovarian syndrome
medications, such as hormonal contraceptives
premature ovarian insufficiency (menopause before 40yrs)
thyroid hormone abnormalities (hypo or hyperthyroid)
excessive prolactin e.g. from a prolactinoma
Cushing’s disease

Question 98

What is an endometrial polyp?

Answer 98

also known as uterine polyps

a fleshy tag of tissue which can appear on the neck or in the cavity of the uterus

usually benign but some can be cancerous or precancerous

Question 99

What are some of the symptoms associated with endometrial polyps?

Answer 99

vaginal bleeding post-menopause
intermenstrual bleeding
frequent, unpredictable periods with varying length/heaviness
infertility

Question 100

What are some risk factors for endometrial polyps? x4

Answer 100

being peri or post menopausal
obesity
tamoxifen (drug therapy for breast cancer)
HRT

Question 101

What investigations would be used to diagnose endometrial polyps?

Answer 101

transvaginal USS
hysterosonography
hysteroscopy
endometrial biopsy

Question 102

What is the treatment for endometrial polyps?

Answer 102

watch and wait
progestins or gonadotropin-releasing hormone agonists to relieve symptoms
polypectomy during hysteroscopy

Question 103

What are uterine fibroids?

Answer 103

benign tumours of the smooth muscle of the uterus

also known as uterine leiomyomas

Question 104

What are the types of uterine fibroids?

Answer 104

intramural (within the myometrium) - they change the shape of the uterus as they grow
subserosal (just below the outer layer of the uterus) - the grow outwards and can be very large
submucosal (just below the lining of the uterus)
pendunculated (on a stalk)

Question 105

What are the symptoms of fibroids? x7

Answer 105

often asymptomatic

heavy menstrual bleeding (menorrhagia)
prolonged menstruation
abdo pain
bloating or feeling full in the abdomen
urinary or bowel symptoms (due to pelvic pressure or fullness)
deep dyspareunia
reduced fertility

Question 106

What are the investigations for fibroids?

Answer 106

hysteroscopy
pelvic USS
MRI scanning

Question 107

What are the management options for fibroids <3cm?

Answer 107

for fibroids less than 3cm (same as management for heavy menstrual bleeding):

mirena coil
symptomatic management
combined oral contraceptive
cyclical oral progestogens e.g. medroxyprogesterone acetate

endometrial ablation
resection of submucosal fibroids during hysterectomy
hysterectomy

Question 108

What are the management options for fibroids >3cm?

Answer 108

for fibroids more than 3cm

referral to gynaecology needed
symptomatic management with NSAIDs and tranexamic acid
mirena coil
combined oral contraceptive
cyclical oral protestogens

uterine artery embolisation
myomectomy
hysterectomy

Question 109

Briefly explain the following terms which are surgical treatments for fibroids:
myomectomy
endometrial ablation
hysterectomy

Answer 109

myomectomy = surgical removal of the fibroid via laparoscopic surgery or laparotomy

endometrial ablation = destruction of the endometrium by inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid which burn the endometrial lining of the uterus

hysterectomy = removal of the uterus and fibroids which can be laparoscopy (keyhole), laparotomy (open) or vaginal approach

Question 110

What are some of the complications of uterine fibroids? x9

Answer 110

menorrhagia (+/- anaemia)
reduced fertility
pregnancy complications e.g. miscarriages, premature labour, and obstructive delivery
constipation
urinary outflow obstruction and UTIs
red degeneration of the fibroid
torsion of the fibroid
malignant change to a leiomyosarcoma (very rare)

Question 111

What is red degeneration of the fibroid? why does it occur?

Answer 111

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply
more likely to occur in larger fibroids (5cm+) in the 2nd or 3rd trimester of pregnancy

may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic
may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy

Question 112

What symptoms indicate red degeneration of fibroids? what is the management?

Answer 112

severe abdo pain
low-grade fever
tachycardia
vomiting

management = supportive - rest, fluids and analgesia

Question 113

What is an ovarian cyst?

Answer 113

a fluid-filled sac in the ovary

majority benign in premenopausal women but more concerning for malignancy in postmenopausal women

Question 114

What is required for a diagnosis of PCOS?

Answer 114

anovulation
hyperandrogenism
polycystic ovaries on USS

Question 115

What are some symptoms of ovarian cysts?

Answer 115

mostly asymptomatic

pelvic pain
bloating
fullness in the abdomen
palpable pelvic mass

Question 116

What are the 2 types of functional ovarian cysts? what causes them?

Answer 116

follicular cysts - occur when the developing follicle fails to rupture and release the egg but a cyst persists

corpus luteum cysts - occur when the corpus luteum fails to break down and instead fills with fluid

Question 117

What is the management for simple ovarian cysts in premenopausal women? size-dependent

Answer 117

less than 5cm - almost always resolve within 3 cycles and do not require a follow up scan

5-7cm - require routine referral to gynaecology and yearly USS monitoring

7+cm - consider an MRI scan or surgical evaluation

persistent or enlarging cysts may require laparoscopy or ovarian cystectomy or oophorectomy

Question 118

What are some potential complications of ovarian cysts?

Answer 118

torsion
haemorrhage into the cyst
rupture with peritoneal bleeding

Question 119

What is Meig’s syndrome

Answer 119

triad of:
ovarian fibroma
pleural effusion
ascites

typically occurs in older women and removal of the tumour results in complete resolution of the effusion and ascites

Question 120

What is ovarian torsion?

Answer 120

where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply

usually due to an ovarian mass >5cm e.g. cyst or tumour

twisting of the adnexa and blood supply to the ovary leads to ischaemia so if the torsion persists, necrosis occurs and the function of the ovary will be lost
therefore ovarian torsion is an emergency requiring prompt diagnosis and management

Question 121

How does ovarian torsion present? what might be found on examination?

Answer 121

sudden onset severe unilateral pelvic pain
the pain is constant, gets progressively worse and is associated with nausea and vomiting

can take a milder and more prolonged course in some cases with less severe pain

occasionally the ovary can twist and untwist intermittently resulting in pain which comes and goes

localised tenderness and potentially a palpable mass in the pelvis on examination

Question 122

How is ovarian torsion diagnosed? management?

Answer 122

pelvic USS which may show a whirlpool sign, free fluid in pelvis and oedema of the ovary

laparoscopic surgery is used to make a definitive diagnosis and treat it

detorsion or oophorectomy may be performed during laparoscopic surgery

Question 123

What are the rotterdam criteria for PCIS?

Answer 123

oligoovulation or anovulation (irregular or absent menstrual periods)
hyperandrogenism (characterised by hirsutism and acne)
polycystic ovaries on USS

diagnosis requires 2 or 3 of these features

Question 124

What are some key features of PCOS? x6

Answer 124

oligomenorrhoea or amenorrhoea
infertility
obesity (~70% patients)
hirsutism
acne
hair loss in a male pattern

Question 125

What are some other conditions/symptoms linked with PCOS? x8

Answer 125

insulin resistance and diabetes
acanthosis nigricans (due to insulin resistance)
cardiovascular disease
hypercholesterolaemia
endometrial hyperplasia and cancer
obstructive sleep apnoea
depression and anxiety
sexual problems

Question 126

What are some differential diagnoses for hirsutism? x5

Answer 126

PCOS
medications e.g. phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
ovarian or adrenal tumours secreting androgens
Cushing’s syndrome
congenital adrenal hyperplasia

Question 127

What are the blood tests recommended in PCOS diagnosis? x6 which are usually raised?

Answer 127

testosterone
sex hormone-binding globulin
luteinizing hormone
follicle-stimulating hormone
prolactin
thyroid-stimulating hormone

LH, LH:FSH ratio, testosterone, insulin and sometimes oestrogen are all typically raised in PCOS

Question 128

What is seen on USS in PCOS?

Answer 128

string of pearls appearance where the follicles are arranged around the periphery of the ovary
ovarian volume of >10cm3

Question 129

What are the general management steps for PCOS?

Answer 129

weight reduction if appropriate
risk management for risks associated with diabetes, cardiovascular disease, endometrial cancer e.g. smoking cessation, antihypertensive medications, COCP, mirena coil (continuous endometrial protection)

Question 130

What are some treatments for hirsutism and acne associated with PCOS?

Answer 130

COCP (1st line for acne)
topical adapalene (retinoid), antibiotics (clindamycin with benzoyl peroxide) or azelaic acid for acne

topical elflornithine (for facial hirsutism)
spironolactone (mineralocorticoid antagonist with anti-androgen effects), flutamide (non-steroidal anti-androgen) and finasteride (5a-reductase inhibitor which decreases testosterone production)

Question 131

WHat are some treatments for infertility associated with PCOS?

Answer 131

weight reduction if applicable
metformin, clomifene or a combination to stimulate ovulation (ongoing efficacy debate)
gonadotrophins
ovarian drilling (puncturing holes into the ovaries to improve the woman’s hormonal profile and result in regular ovulation and fertility)

Question 132

What is a prolactinoma? how can they be classified?

Answer 132

a type of pituitary adenoma

size classification: microprolactinoma = <1cm and macroprolactinoma = >1cm

hormonal status classification: secretory/functioning adenoma produces an excess of a particular hormone and a non-secretory/functioning adenoma does not produce excess hormone

Question 133

What are some features of excess prolactin in women? x4

Answer 133

amenorrhoea
infertility
galactorrhoea
osteoporosis

Question 134

What are some features of excess prolactin in men? x4

Answer 134

impotence
loss of libido
galactorrhoea
gynaecomastia

Question 135

What are some symptoms of pituitary macroadenomas?

Answer 135

headache
visual disturbances e.g. bitemporal hemianopia or upper temporal quadrantanopia
symptoms and signs of hypopituitarism (lethargy, anorexia, decreased muscle strength and bone density, impotency)

Question 136

How are prolactinomas diagnosed and managed>

Answer 136

diagnosis = MRI

management:
- dopamine agonists e.g. cabergoline, bromocriptine which inhibit the release of prolactin from the pituitary gland
- trans-sphenoidal surgery to remove the tumour (when medical therapy failed)
- radiation therapy

Question 137

What are the minimum investigations for a palpable breast mass for women:
- under 25 years
- 25-40 years
- over 40 years

Answer 137

<25 yrs - histology or cytology only. No imaging if clinically feels benign. USS if clinically indeterminate or suspicious. Risk of malignancy negligible in this age group.

25-40 years: breast USS plus histology or cytology. Triple assessment

over 40 yrs: mammography and USS and either histology or cytology: Triple assessment

Question 138

Why is USS favoured over mammography in women under 40?

Answer 138

In younger women the breast tissue is dense and predominately glandular. With age it becomes less dense and dominated by fatty tissue.
Mammograms struggle to differentiate between fluid-filled cysts and solid masses in dense breasts so are less useful diagnostically in younger women

Question 139

What are breast cysts and what are they like on examination?

Answer 139

benign, individual, fluid-filled lumps
most common cause of breast lumps

on examination:
smooth
well-circumscribed
mobile
possibly fluctuant

Question 140

What are the clinical assessment gradings of breast lumps?

Answer 140

P1 - Normal
P2 - Benign
P3 - Indeterminate
P4 - Suspicious
P5 - malignant

Question 141

What is the most common cause of a breast lump?

Answer 141

breast cyst

Question 142

What is fat necrosis in the breast? how does it present on examination? what are the common triggers? how is it diagnosed/managed?

Answer 142

localised degeneration and scarring of fat tissue in the breast which causes a benign lump

O/E:
painless
firm
irregular
fixed in local structures
may be skin dimpling or nipple inversion

may be associated with an oil cyst containing liquid fat

commonly triggered by localised trauma, radiotherapy or surgery –> an inflammatory reaction resulting in fibrosis and necrosis of the fat tissue

can appear similar to breast cancer on mammogram so biopsy may be required to rule this out

conservative management as can resolve spontaneously over time
surgical excision may be used if required for symptoms

Question 143

What is a lipoma? how does it present on examination? management?

Answer 143

benign tumour of adipose tissue which commonly occurs in the breast

O/E:
soft
painless
mobile
do not cause skin changes

typically treated conservatively with reassurance, in some cases can be surgically removed

Question 144

What is a galactocele? how do they present on examination? management?

Answer 144

breast milk filled cysts which occur when the lactiferous duct is blocked, preventing the gland from draining milk

O/E:
firm
mobile
painless
usually beneath the areola

usually resolve without treatment
is possible to drain them with a needle
small risk of infection

Question 145

What is a phyllodes tumour? how are they managed?

Answer 145

rare tumour of the connective tissue of the breast which occur most often in 40-50yr old women

large and fast growing

can be benign (50%) or malignant (25%)

treatment involves surgical removal of the tumour and the surrounding tissue (wide excision)

can reoccur after removal

chemotherapy may be used in malignant or metastatic tumours

Question 146

What are fibroadenomas? How do they present on examination? how are they managed?

Answer 146

common benign tumours of stromal/epithelial breast duct tissue

typically small and mobile within the breast tissue

more common in younger women between 20-40yrs

O/E:
painless
smooth
round
well circumscribed (well-defined borders)
firm
mobile
usually up to 3cm diameter

usually not treated, in some cases surgical removal is indicated

Question 147

What are some risk factors for breast cancer? x7

Answer 147

female
increased oestrogen exposure (earlier onset of periods and later menopause)
more dense breast tissue (more glandular tissue)
obesity
smoking
family history (1st deg relative)
HRT (particularly combined)

*COCP –> small increase in breast cancer risk but it returns to normal ten years after stopping the pill

Question 148

Which genes are assocaited with breast cancer? what chromosomes are they associated with?

Answer 148

BRCA1 on chromosome 17

BRCA2 on chromosome 13

Question 149

What are some of the common types of breast cancer? x6

Answer 149

Invasive ductal carcinoma (MC) also known as ‘No Special Type’ while other rarer types are known as ‘Special type’
Invasive lobular carcinoma
Ductal carcinoma-in-situ
Lobular carcinoma-in-situ
Inflammatory Breast Cancer
Paget’s disease of the nipple

Question 150

What are some rarer types of breast cancer?

Answer 150

medullary breast cancer
mucinous breast cancer
tubular breast cancer
multiple others

Question 151

What is Paget’s disease of the nipple?

Answer 151

an eczematoid change of the nipple associated with an underlying breast malignancy and is present in 1-2% of patients with breast cancer

Question 152

What is inflammatory breast cancer?

Answer 152

where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast

accounts for around 1 in 10,000 cases of breast cancer

Question 153

What is the NHS screening program for breast cancer? how is this modified for high risk patients?

Answer 153

to offer a mammogram every 3 years to women aged 47-73yrs old

annual mammogram screening is offered to women with increased risk between specific age ranges, depending on their level of risk

Question 154

What are some potential downsides to screening for breast cancer?

Answer 154

anxiety and stress
exposure to radiation, with a very small risk of causing breast cancer
missing cancer, leading to false reassurance
unnecessary further tests or treatment where findings would not have otherwise caused harm

Question 155

What are the options for chemoprevention in patients at high risk of breast cancer?

Answer 155

tamoxifen if premenopausal
anastrozole if postmenopausal (except with severe osteoporosis)

Question 156

What are some clinical features which may suggest breast cancer?

Answer 156

hard, irregular, painless or fixed lumps
lumps tethered to the skin or chest wall
nipple retraction
skin dimpling or oedema
lymphadenopathy (especially in the axilla)

Question 157

What are the referral criteria according to NICE guidelines for suspected breast cancer?

Answer 157

an unexplained breast lump in patients aged 30 or above
unilateral nipple changes in patients aged 50 or above (discharge, retraction, other changes)

consider 2 week wait referral for:

an unexplained lump in the axilla in patients aged 30 or above
skin changes suggestive of breast cancer

Question 158

What is included in the triple diagnostic assessment for suspected breast cancer? Why is it important?

Answer 158

clinical assessment
imaging (USS or mammography)
biopsy (fine needle aspiration or core biopsy)

Important to ensure concordance i.e. a clinically suspicious mass should
have suspicious imaging and cytology before a decision is made to remove a woman’s
breast. If there is discordance it may mean that the biopsy has missed the lesions and that further biopsies should be taken

Question 159

What imaging is used in breast cancer assessment and why?

Answer 159

USS typically used to assess lumps in younger women (breasts are more dense and glandular), helpful in distinguishing solid lumps from cystic lumps

Mammograms are generally more effective in older women and can pick up calcifications not seen on USS

MRI scans can be used in women at higher risk of developing breast cancer, also to assess size and features of a tumour in more detail

Question 160

What is a sentinel lymph node biopsy and when is it performed?

Answer 160

performed during breast surgery for cancer

an isotope contrast and a blue dye are injected into the tumour area and travel through the lymphatics to the first lymph node (the sentinel node)

this will show up blue on the isotope scanner and a biopsy can be performed to assess if cancer cells are present

Question 161

What breast cancer receptors can be targeted with breast cancer treatments?

Answer 161

oestrogen receptors
progesterone receptors
human epidermal growth factor (HER2)

Question 162

What is triple-negative breast cancer?

Answer 162

where the breast cancer cells do not express any of the breast cancer receptors resulting a worse prognosis due to limited treatment options

Question 163

What are the main sites that breast cancer metastasises to?

Answer 163

Lungs
Liver
Bones
Brain

Can spread to anywhere though!

Question 164

What are the management options for breast cancer? x5

Answer 164

surgery (mastectomy or wide local excision)
radiotherapy
hormone therapy
biological therapy
chemotherapy

Question 165

What are some indications for mastectomy to treat a breast tumour? x4

Answer 165

multifocal tumour
central tumour
large lesion in small breast
DCIS >4cm

Question 166

What are some indications for wide local excision of a breast tumour?

Answer 166

solitary lesion
peripheral tumour
small lesion in large breast
DCIS <4cm

Question 167

When is radiotherapy recommended for breast cancer treatment?

Answer 167

whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around 2/3’s

radiotherapy is also offered to women who’ve had a mastectomy for T3-T4 tumours and for those with 4+ positive lymph nodes

Question 168

when is hormonal therapy offered for breast cancer? what are the medications offered and how do they work?

Answer 168

if tumours are positive for hormone receptors

tamoxifen - a selective oestrogen receptor modulator whic either blocks or stimulates oestrogen receptors depending on the site of action (block in breast, stimulates in uterus and bone)

aromatase inhibitors (e.g. letrozole, anastrozole or exemestane) block the creation of oestrogen in fat tissue

Question 169

What are some targeted treatments for HER2 positive breast cancer? x3

Answer 169

trastuzumab = monoclonal antibody which targets the HER2 receptor, may be used in patients with HER2 positive breast cancer

pertuzumab = monoclonal antibody which targets the HER2 receptor

neratinib = tyrosine kinase inhibitor, reducing the growth of breast cancers, may be used in HER2 positive breast cancer

Question 170

What are the criteria for being classed as a high risk patient for breast cancer?

Answer 170

a first-degree relative with breast cancer under 40 yrs

a first-degree male relative with breast cancer

a first-degree relative with bilateral breast cancer, first diagnosed under 50 yrs

two first-degree relatives with breast cancer

Question 171

When is radiotherapy indicated for breast cancer treatment?

Answer 171

• always given to the remaining breast after wide local excision
• after some mastectomies for poor prognosis, high-risk tumours
• as palliation for large or inoperable primary cancers
• to treat symptomatic bone mets
• to treat the axilla in women who cannot have axillary clearance surgery
• to reduce local recurrence rates (usually around 2/3rds)

Question 172

Who is offered hormonal therapy for breast cancer?

Answer 172

all women with oestrogen sensitive breast cancer are offered 5 or more year of anti-oestrogen therapy

Question 173

What are the 1st line hormonal therapies in pre and post menopausal women?

Answer 173

Pre-menopausal women:
- tamoxifen (30% increase in survival rate) (selective oestrogen receptor modulator which acts on oestrogen receptors throughout the body)

Post-menopausal women:
- aromatase inhibitors e.g. exemestane, letrozole, anastrozole (prevent the peripheral conversion of adrenal androgens to oestrogens by the aromatase enzyme in fatty tissues)

Question 174

What is the follow up for a patient who has had breast cancer?

Answer 174

a mammogram every year for 5 years

Question 175

What is the treatment for breast pain?

Answer 175

Reassurance that they do not have breast cancer is sufficient for 85% of women

Cyclical pain
1. simple explanation, reassurance and occasional simple analgesia

2. Danazol - weak androgen and mild inhibitor of gonadal function by inhibition of LH and FSH (significant side effects to breast)
3. Tamoxifen - can’t be given long term due to risk of endometrial cancer
4. Goserelin - agonist of LH and FSH which causes stimulation of these receptors followed by a block

Non-cyclical pain - NSAIDs

Question 176

What is mammary duct ectasia?

Answer 176

a benign condition where there is dilation of the large ducts in the breasts leading to intermittent discharge from the nipple which can be white, grey or green.

occurs most frequently in perimenopausal women

ectasia = dilation

Question 177

What are the signs/symptoms of mammary duct ectasia?

Answer 177

nipple discharge
tenderness of pain
nipple retraction or inversion
a breast lump

Question 178

What are the investigations used to diagnose duct ectasia?

Answer 178

Clinical assessment (history and examination)
Imaging (ultrasound, mammography and MRI)
Histology (fine needle aspiration or core biopsy)

*Microcalcifications are a key finding on mammogram

Ductography
Nipple discharge cytology
Ductoscopy

Question 179

What is the management for duct ectasia?

Answer 179

can resolve without any treatment

symptomatic management of mastalgia (breast pain)
antibiotics if infection is suspected or present
surgical excision of the affected duct in problematic cases

Question 180

What is intraductal papilloma?

Answer 180

a warty lesion which grows within one of the ducts in the breast as a result of epithelial cell proliferation

Question 181

What are the presenting signs/symptoms of intraductal papillomas?

Answer 181

can occur at any age

often asymptomatic

nipple discharge (clear or blood stained)
tenderness or pain
palpable lump

Question 182

How does an intraductal papilloma present on ductography>

Answer 182

in ductography contrast is injected into the abnormal duct and a mammogram is then performed to visualise the duct

the papilloma will be seen as an area that does not fill with contrast

Question 183

What is the management for intraductal papillomas?

Answer 183

they require complete surgical excision

Question 184

What are the options for breast reconstruction following mastectomy?

Answer 184

Implants

Flap reconstruction

The breast can be reconstructed using a portion of the latissimus dorsi and the associated skin and fat tissue.

Transverse Rectus Abdominis Flap (TRAM Flap)

Deep Inferior Epigastric Perforator Flap (DIEP Flap)

The breast can be reconstructed using skin and subcutaneous fat from the abdomen (no muscle) as a free flap. The deep inferior epigastric artery, with the associated fat, skin and veins, is transplanted from the abdomen to the breast.

Question 185

what are the 3 features of physical examination which require 2ww referral for suspected ovarian cancer?

Answer 185

ascites
pelvic mass (unless clearly due to fibroids)
abdominal mass

Question 186

What 3 factors are taken into account in the risk of malignancy index?

Answer 186

menopausal status
USS findings
CA125 level

Question 187

What are some non-malignant causes of raised CA125?>

Answer 187

endometriosis
fibroids
adenomyosis
pelvic infection
liver disease
pregnancy