450 SBAs in Clinical Specialties - General Gynaecology Flashcards
- Dyspareunia
A 59-year-old woman attends the gynaecology clinic complaining of worsening pain during penetrative sexual intercourse. She went through the menopause 9 years before, with very few problems, and did not require hormone replacement therapy (HRT). She has been with the same partner for 4 years since the death of her husband with whom she had four children. What is the most likely diagnosis?
A. Ovarian malignancy
B. Chlamydia trachomatis infection
C. Discoid lupus erythematosus
D. Atrophic vaginitis
E. Bacterial vaginosis
D. Atrophic vaginitis
1 DDyspareunia is the sensation of pain before, during or after penetrative sexual contact with the vagina. It is most commonly associated with pain during penetration. It should not be confused with vaginismus which is the inability to engage in penetrative sex due to involuntary spasm of the pubococcygeus muscle. In younger (although not exclusively young) patients for whom there is new dyspareunia it is important to exclude sexually transmitted infections and acute intrapelvic conditions (such as ovarian cysts or appendicitis) and to ensure there is no cervical pathology (for example, cervical carcinoma in situ). The vaginal lining of women who have gone through the menopause progressively atrophies with age as the residual level of circulating estrogens decreases. Estrogens ensure the vaginal lining remains moist and expansile, comfortably permitting sexual penetration. Without exposure to these estrogens, the lining can become atrophied. Friction to an unlubricated atrophic vagina (D) can cause extreme discomfort. Sexually transmitted infections (B), although increasingly common in older couples, are rare in those beyond the menopause. Bacterial vaginosis (E) is uncommon in post-menopausal women also. Although these two diagnoses would be unlikely, it is still important to exclude them by careful vaginal examination and swabs. Ovarian malignancy (A) is not suggested by this clinical presentation here. In addition, she has no risk factors for ovarian cancer (including HRT) and has the protective factor of having had four pregnancies. Discoid lupus erythematous (C) is a complex atrophying lesion of the skin similar in aetiology to systemic lupus erythematosus but without the systemic features. Although it may result in dyspareunia, through atrophy of the vaginal lining, there are no other features here to suggest an autoantibody-mediated disease, and the usual age of onset for discoid lupus is 30 years.
- Lower abdominal pain
A 19-year-old woman is referred to accident and emergency with a fluctuant lower right abdominal pain which started over the course of the morning, associated with vomiting. There is rebound tenderness on examination. She is afebrile. Serum beta human chorionic genadotrophin (hCG) is negative. An ultrasound shows free fluid in the peritoneal cavity but no other pathology to account for the pain. White cells are 14 × 109/L and the C-reative protein (CRP) is 184 mg/L. What is the most likely diagnosis?
A. Acute appendicitis
B. Early ectopic pregnancy
C. Pelvic inflammatory disease (PID)
D. Tubo-ovarian abscess
E. Ovarian torsion
A. Acute appendicitis
2 ADifferentiating between pain caused by gynaecological or by surgical pathology is a difficult but important and common problem. Knowing the natural history of the diseases can help. Ovarian torsion (E) classically presents with a sudden onset pain on one side which does not improve and is constantly there. It often requires opiate analgesia. Ovarian torsion is an important diagnosis as the risk of compromising the ovarian blood supply is high, with ovarian compromise and possible infarction. In this case the pain is fluctuant not constant, and although torsion may cause an inflammatory response accounting for the raised CRP, it would not cause a leukocytosis which is present here. Tubo-ovarian abscess (D) and PID (C) would normally lead to a fever, with a high white cell count. Tubo-ovarian abscesses can be a sequel of untreated PID and their early courses may be similar. However, a woman with a frank abscess in the pelvis (D) would likely be much more seriously ill than the patient here (or a patient with PID) and the fever would usually be swinging. Serum beta hCG can detect the earliest of pregnancies, so an ectopic pregnancy (B) is highly unlikely here given the negative serum hCG. A normal ultrasound unfortunately cannot completely rule out adnexal or gastrointestinal pathology, not least because transabdominal ultrasound often cannot visualize the appendix.
- Polycystic ovaries
A 39-year-old woman is seen in the gynaecology clinic having been diagnosed with polycystic ovarian syndrome (PCOS). She has lots of questions in particular about the associated long-term risks. Which of the following is not a risk of PCOS?
A. Endometrial hyperplasia
B. Sleep apnoea
C. Diabetes
D. Breast cancer
E. Acne
D. Breast cancer
3 DPCOS is a condition diagnosed by the presence of two out of three of oligo/amennhorea, polycystic ovaries and clinical and/or biochemical signs of hyperandrogenism. Long-term risks include the development of endometrial hyperplasia (A), sleep apnoea (B) and diabetes (C). Diet, exercise and weight control are key to preventing long-term complications. Acne (E) is often present and is a clinical sign of hyperandrogenism. Endometrial hyperplasia should be treated with progestogens, and a withdrawal bleed should be induced every 3–4 months. There is no evidence of an increase in breast (D) or ovarian cancer in PCOS.
- Venous thromboembolism
A 54-year-old menopausal woman comes to your clinic desperate for hormone replacement therapy (HRT) as her vasomotor symptoms are very troubling. Her next door neighbour recently developed a deep vein thrombosis while on HRT. She is concerned about the risks of venous thromboembolism (VTE) and wants your advice. Which of the following would you not advise?
A. The risk of VTE is highest in the first year of taking HRT
B. She should have a thrombophilia screen prior to starting HRT
C. There is no evidence of a continuing VTE risk after stopping HRT
D. Personal history of VTE is a contraindication to oral HRT
E. If she develops any VTE while on HRT it should be stopped immediately
B. She should have a thrombophilia screen prior to starting HRT
4 B HRT can be very beneficial to ladies who are going through the menopause. Vasomotor symptoms can be debilitating and can seriously affect quality of life. The risk of developing a VTE is highest in the first year (A). It is not routine to offer thrombophilia screening to all patients (B) as it is not cost effective. If there was a suggestion of a family history of VTE this might however be sensible. There is no evidence of a continuing VTE risk after stopping HRT (C). If a woman has had a VTE she should not have oral HRT (D). HRT should be stopped immediately if the woman has a VTE (E) as the risk of further VTE is significantly increased if she continues taking replacement therapy.
- Heavy menstrual bleeding
A 34-year-old woman with long-standing menorrhagia attends accident and emergency having fainted at home. She is on the third day of her period, which has been unusually heavy this month. She insists she cannot be pregnant as she has not had sexual intercourse for a year. She is haemodynamically stable. A point-of-care test venous full blood count in the emergency department shows:
Hb 5.2 g/dL
WCC 8.9 × 109/L
Hct 0.41% L
MCV 80 fL
What should the initial management be?
A. Establish large-bore venous access, commence fluid resuscitation and cross-match four units of packed red cells
B. Call for senior help, establish large-bore venous access and prepare the patient for urgent laparotomy
C. Call for senior help, establish large-bore venous access and give group O rhesus negative blood
D. Establish large-bore venous access and begin transfusing group-specific blood as soon as it is available
E. Await the result of a beta hCG test before deciding further management
A. Establish large-bore venous access, commence fluid resuscitation and cross-match four units of packed red cells
5 AThis woman has a significant normocytic anaemia as a result of blood loss, sufficient to cause a faint earlier in the day. The most likely cause is her menorrhagia. Initially she should be appropriately resuscitated (A). Although she is haemodynamically stable, with continuing blood loss she may decompensate rapidly. Therefore, large-bore venous access is warranted. Fully cross-matched blood is the safest option of the three transfusion options presented and will usually take around 45 minutes to prepare compared to 20 minutes for group-specific blood. As this patient is currently stable, one cannot justify the potential complications* associated with giving group-specific (D) or even ungrouped (O-negative, or universal donor) blood (C). A laparotomy (B) is not indicated here as the patient is haemodynamically stable and has a medically treatable cause for the (albeit severe) anaemia.
- Ovarian cysts
A 66-year-old post-menopausal woman is referred to you urgently by her general practioner (GP). She had been complaining of some lower abdominal pain. An ultrasound arranged by the GP shows a 4 cm simple left ovarian cyst. A CA 125 comes back as 29 U/ml (normal 0-35 U/ml). What is the most appropriate management?
A. Referral to a specialist cancer unit
B. Laparoscopic ovarian cystectomy
C. Laparotomy and oophrectomy
D. Conservative management
E. Total laparoscopic hysterectomy and bilateral salpingo-oophorectomy
D. Conservative management
6 D Ovarian cysts in post-menopausal ladies can be managed conservatively if they meet certain criteria. A risk of malignancy index (RMI) can be calculated using the CA 125 value, the characteristics of the cyst on ultrasound and the menopausal status. The features of concern on ultrasound are bilateral cysts, multiloculated cysts, solid components, ascites and metastases. RMI 250 has a 75 per cent chance of cancer. If the cyst is simple and less than 5 cm in diameter with a CA 125
- Atrophic vaginitis
A 79-year-old woman attends your clinic with some vaginal bleeding. Her last period was 16 years ago. She has had two children both via caesarean section, has a normal smear history and is currently sexually active. On examination the vagina appears mildly atrophic with some raw areas near the cervix. What is the most important next step in her management?
A. Vagifem nightly for 2 weeks and then twice a week after that
B. Triple vaginal swabs for sexually transmitted infection
C. Pelvic ultrasonography
D. HRT to help the vaginal raw areas
E. Smear test
C. Pelvic ultrasonography
7 CThis woman is post-menopausal. Whenever you see a woman with post-
menopausal bleeding it is imperative to exclude cancer of the cervix or endometrium. She has had a normal smear history and there is normal cervical appearance on examination so carcinoma of the cervix is unlikely and repeat testing (E) is not required. She is still sexually active and may well have a sexually transmitted infection so triple swabs (B) would be a sensible part of an overall management plan. She has no other menopausal symptoms and is now 79 so starting HRT is not advisable (D). Topical vaginal oestrogen like Vagifem (A) may be appropriate. However, before prescribing oestrogens, an ultrasound of her pelvis (C) should be arranged to make sure that her endometrial thickness is
- Endometriosis
At laparoscopy a 21-year-old woman is found to have severe endometriosis. There are multiple adhesions and both ovaries are adherent to the pelvic side wall. The sigmoid colon is adherent to a large rectovaginal nodule. The nodule is excised and the bowel and ovaries freed. Which of the following medications would be appropriate to help treat her endometriosis?
A. Danazol
B. Triptorelin
C. Microgynon 30
D. Tranexamic acid
E. Medroxyprogesterone acetate
B. Triptorelin
8 B This woman’s disease is severe and it is most likely that the specialist will want to treat her with medication and then perform a second-look laparoscopy to remove any disease that remains. Danazol (A) has anti-oestrogenic and anti-progestogenic effects and is licensed for 3–6 months. Triptorelin (B) is a gonadotrapin-releasing hormone agonist that creates a temporary artificial menopause by reducing the follicle-stimulating hormone and luteinizing hormone levels. This is an excellent option for up to 6 months. After that there is the risk of loss of bone mineral density. Microgynon 30 (C) is a combined oral contraceptive pill. Tranexamic acid (D) is an antifibrinolytic used in the management of mennorhagia. Medroxyprogesterone acetate (E) is a progestogen. The answer to this question depends on the patient but triptorelin followed by another laparoscopy probably gives this woman the best chance of disease clearance.
- Vasomotor symptoms
A 54-year-old woman comes to your clinic complaing of hot flushes and night sweats that are unbearable. Her last mentrual period was 14 months ago. She has had a levonorgestrel releasing intrauterine system (Mirena) in situ for 2 years as treatment for extremely heavy periods. What treatment would you consider for her symptoms?
A. Elleste Solo
B. Elleste Duet
C. Vagifem
D. Oestrogen implants
E. Evorel
A. Elleste Solo
9 AThis woman is menopausal. When considering HRT a full history is important to highlight any important past medical history, including venous thromboembolism or cancer. The next step is to assess for the uterine function. If the woman has not had a hysterectomy you must always make sure she has constant or cyclical progestogens to reduce the risk of endometrial hyperplasia and endometrial cancer. In this case the woman already has a source of progestegens – the Mirena – so prescribing oestrogen alone would be appropriate (A). Elleste Solo contains estradiol alone while Elleste Duet (B) also contains norethisterone (a progestogen, which is not required here). Evorel (E) is another combined oestradiol and norethisterone preparation. Again, the progestogen component is unnecessary here. Vagifem (C) is used as a local treatment for atrophic vaginitis, not for systemic vasomotor symptoms. Oestrogen implants (D) can be very helpful at dealing with symptoms but supraphysiological levels of oestrogen can lead to a rapid recurrence of vasomotor symptoms when levels begin to fall.
- Progestogens
A 19-year-old biochemistry student is seen in your clinic worried about her hormone levels. She has been told by her GP that her progesterone is low. You enter into a long discussion about the effects of progesterone on the body. Progesterone:
A. Enhances endometrial receptivity
B. Stimulates endometrial growth
C. Increases uterine growth
D. Increases fat deposition
E. Increases bone resorption
A. Enhances endometrial receptivity
10 A Progesterone is released by the corpus luteum following ovulation. Its main function is to enhance endometrial receptivity (A) in the event that an embryo should need to implant. If a pregnancy is successful then the developing embryo will release human chorionic gonadotrophin which will maintain the corpus luteum function. Increased uterine growth (C), increased fat deoposition (D), bone resportion (E) and endometrial growth stimulation (B) are all effects of oestrogens. Other progestogenic effects include an increase in respiratory rate, increase in sodium excretion, reduction in bowel motility and an increase in body temperature – some people will monitor their temperature as a measure of ovulation.
- Heavy menstrual bleeding
A 41-year-old mother of two presents to the GP with long-standing heavy menstrual bleeding which has become worse over the past year. She is otherwise well and has no significant medical history. She requests treatment to alleviate the impact of her heavy bleeding on her social life. Pelvic examination reveals a normal sized uterus. What is the most appropriate first line treatment?
A. Levonorgestrel-releasing intrauterine system
B. Tranexamic acid
C. Mefenamic acid
D. Tranexamic acid and mefenamic acid combined
E. Vaginal hysterectomy
A. Levonorgestrel-releasing intrauterine system
11 A This woman requests symptom relief from heavy menstrual bleeding
(HMB) which is interfering which her life. For women who have no structural uterine abnormality and present for treatment for the first time, NICE guidance recommends the use of levonorgestrel-releasing intrauterine systems (A) (e.g. Mirena coil) which in addition to reducing or stopping menstrual bleeding are contraceptive. Fertility returns soon after removal of the Mirena coil, so it is appropriate for women who have not undergone the menopause. Tranexamic acid (B) and mefanamic acid (D) and their concomitant use (D) are now second line treatments for HMB: tranexamic acid alone is most commonly prescribed (and recommended by NICE) as the principal pharmaceutical agent given the harsher side effects (nausea, vomiting and diarrhoea) of mefanamic acid. Hysterectomy (E) is reserved for those women who have tried other measures without success and have completed their family. Vaginal hysterectomy is the preferred approach in the absence of contraindications.
- Premenstrual syndrome
A 42-year-old woman is seen in the gynaecology clinic. She has been suffering from severe premenstrual symptoms all her life. They have now significantly affected her relationship and her husband is filing for divorce. She comes to your clinic in tears regarding the future of her children. She demands a hysterectomy and bilateral salpingoophrectomy. After taking her history you talk about other less radical treatments. Which management option is inappropriate?
A. Antidepressants
B. Vitamin C
C. Exercise
D. Cognitive behavioural therapy
E. Yasmin – combined oral contraceptive pill
B. Vitamin C
12 B Premenstrual syndrome (PMS) is defined as a condition that is associated with distressing physical, behavioural and psychological symptoms, in the absence of organic or underlying psychiatric disease, which regularly recurs during the luteal phase of each menstrual (ovarian) cycle and which disappears or significantly regresses by the end of menstruation. First line measures for severe PMS include selective serotonin reuptake inhibitors (A), Vitamin B6, improved diet and physical exercise (C), cognitive behavioural therapy (D), and a trial of Yasmin or Cilest combined oral contraceptive pills (E). There is no evidence that Vitamin C (B) has any effect on symptoms. There are many other complementary treatments that many patients use in conjunction with pharmacological treatments. These include St. John’s Wort, Ginkgo Biloba and Evening Primrose Oil.
- Pelvic inflammatory disease
A 22-year-old woman is seen in accident and emergency with lower abdominal pain and some vaginal discharge. She has had PID once in the past and was treated for it. She is otherwise well. Her temperature is 36.9°c, pulse 90, blood pressure 105/66 mmHg. She is passing good volumes of urine. On clinical examination she has diffuse lower abdominal tenderness. There are no signs of peritonism on examing her abdomen. On vaginal examination she has adnexal tenderness and an offensive discharge. Her CRP is 28 mg/L and her white blood count is 12.2 × 109/L. Her pregnancy test is negative. She is reviewed by your senior and is diagnosed with PID. What would be an appropriate antibiotic regime?
A. IV ceftriaxone and IV doxycycline
B. IV ofloxacin and IV metronidazole
C. IM ceftriaxone, oral doxycycline and oral metronidazole
D. IV clindamycin and gentamicin
E. Oral azithromycin and benzylpeniciilin
C. IM ceftriaxone, oral doxycycline and oral metronidazole
13 C Symptoms that suggest a diagnosis of PID include bilateral adnexal tenderness, abnormal vaginal discharge, fever over 38°C, vaginal bleeding, deep dyspareunia, bilateral adnexal tenderness and cervical motion tenderness. In addition there may be microbiological evidence of infection and raised white cells and inflammatory markers. Options (A), (B) and (D) are all intravenous antibiotic options for severe pelvic infection and sepsis. Systemic (intravenous) antibiotics should be used if there is evidence of clinically severe disease or sepsis, evidence of a tubo-ovarian abscess exists, the woman is pregnant* or there is a lack of response to oral therapy. This woman’s case is mild to moderate (abscence of peritonism, fever, systemic infection or abscess) so option (C) would be appropriate. Option (E) is not a recognized treatment regimen for PID in the UK.
- Note that tetracyclines such as doxycycline should be avoided in pregnancy: an alternative intravenous regimen should be offered to these women.
