Day 12 OBGYN Flashcards
1
Q
A 28 year old female attends her GP with her husband, who is 29.
They have been trying to become pregnant for six months.
They are both fit and healthy, are not using any contraception, and are having intercourse three to four times per week.
She is concerned she is infertile and is wondering what investigations are available to her.
What is the most appropriate initial management for this couple?
A
No specific medical investigations are warranted at this time
As a healthy young couple, they have a high (80%) chance of conception within one year of regular unprotected intercourse.
It is sensible to provide this couple with lifestyle advice related to conception e.g. alcohol and caffeine intake, folic acid supplementation, drug use, smoking and body weight.
A woman of reproductive age that has not conceived after one year of regular unprotected intercourse should be offered further clinical assessment and investigation, along with her partner.
2
Q
A 23 year old para 1 (previous vaginal delivery) woman is brought into maternity by ambulance at 28+3 weeks with heavy vaginal bleeding and intense abdominal pain.
She reports a sudden onset of abdominal pain this morning ‘like a contraction but continuous’, unrelieved by Paracetamol.
40 minutes later she noted heavy vaginal bleeding, soaking through three sanitary pads in the last hour.
Her observations are: pulse 110, blood pressure 132/96, respiratory rate 24, SpO2 99%, temperature 37.4
She is otherwise well and has had an uncomplicated pregnancy so far.
On examination her abdomen is hard and tender and you are unable to feel foetal movements.
Dark red vaginal bleeding is ongoing.
What is the most likely diagnosis?
A
Placental abruption occurs when the placental prematurely separates from the wall of the uterus. This can cause profuse bleeding as the uterine vessels are sheared.
Immediate investigations in this case would involve evaluation of the foetus via either dopplar or CTG and ultrasound scan to view the uterus and look for evidence of placental abruption. Ongoing management would depend on the status of the patient, viability of the foetus and the degree of placental abruption suspected. In this case, bleeding continues to be heavy, and therefore urgent caesarean section would be considered.
3
Q
A 30 year old primiparous woman who is now 41 weeks pregnant is seen in the antenatal clinic by the midwife.
She has had an uncomplicated pregnancy so far and all bloods and scans have been normal.
There has been no rupture of membranes.
On examination the symphysis-fundal height is 40cm, the fetus is cephalic presentation and the head is 2/5 palpable.
The mother explains that she is “fed up” and hopes that she goes into labour soon.
Which is the next most appropriate step in her management?
A
She should be offered a cervical membrane sweep to try and stimulate spontaneous labour
A cervical membrane sweep increases the likelihood of spontaneous labour initiating as it causes release of prostaglandins.
4
Q
A 31 year old woman attends her booking visit at 10 weeks gestation.
This is her first pregnancy and other than some morning sickness she has had no vaginal bleeding or other problems so far.
The results of her booking bloods come back which show no abnormalities, but her Rhesus status is found to be negative.
She is worried that she will need injections.
Which of the following is the most appropriate management?
A
Give anti-D immunoglobulin at 28 weeks.
National guidelines advise one 1500IU dose of anti-D immunoglobulin at 28 weeks gestation, with further doses if sensitising events occur (such as heavy vaginal bleeding, amniocentesis, delivery and external cephalic version).
5
Q
Facts about placenta praevia
(4)
A
A digital vaginal examination should not be performed with known placenta praevia as it can cause massive haemorrhage.
Bleeding from placenta praevia is usually painless and rarely fatal. It presents after 20 weeks of gestation.
Multiparity is considered a risk factor for placenta praevia.
Increasing maternal age is a risk factor placenta praevia.
6
Q
An ultrasonography of a 25 year old female at 24 weeks gestation reveals twin pregnancy.
Both foetuses are female and it appears to be a diamniotic, monochorionic twin pregnancy.
Twin A appears much smaller than Twin B.
Which of the following is a concern for Twin B?
What is the cause?
A
Hypervolaemia
The recipient twin would develop hypervolemia as a result of receiving transfusion from the donor twin (which would develop oligohydramnios and growth retardation).
7
Q
You meet a 37-year-old woman on labour ward who is 40+5 weeks gestation and has elected to be induced.
You return shortly after induction to find the patient is barely responsive and visibly dyspnoeic.
Your colleage takes some observations which show the patient is hypoxic and hypotensive.
You suspect an amniotic fluid embolism.
Which of the following is the most appropriate next step in management?
A
Give the patient 15l oxygen via a non-rebreathe mask and call an anaesthetist
In amniotic fluid embolism, patients can quickly deteriorate and develop acute respiratory distress syndrome.
As such, the first step in management should be treating the maternal hypoxia in an effort to prevent any neurological sequelae
8
Q
What is a sign of placental separation during the third stage of labour? (3)
A
Signs of placental separation and imminent placental delivery:
- Gush of blood
- Lengthening of the umbilical cord
- Ascension of the uterus in the abdomen
9
Q
A 34 year women G3P2 is undergoing labour at 41 weeks gestation.
She has a history of two previous uncomplicated vaginal deliveries.
After 20 minutes of pushing, the midwife notices a visible umbilical cord in the vagina.
The patient is prepared for an emergency caesarean section.
What should the patient be instructed to do in the mean time?
A
Ask the patient to go on all fours, on knees and elbows
This is cord prolapse, which is an emergency as if left untreated because cord compression or spasm can lead to foetal hypoxia, irreversible damage, or death. As the patient is being prepared for an emergency caesarean section, they should be asked to on all fours on knees and elbows, while someone else pushes the presenting part of the foetus up to prevent cord compression.
10
Q
You see a 25-year-old nulliparous patient in clinic who has recently had a singleton pregnancy confirmed.
She was diagnosed with epilepsy 6 years ago and has been seizure free for 18 months on her current dose of lamotrogine.
She is concerned about how her to manage both her epilepsy and pregnancy and is seeking advice.
She has no other medical history of note.
Which of the following is best advice to give this patient after delivering the baby?
A
It is recommended that she try to breastfeed after delivery
Anticonvulsant medication is present in breast milk in smaller quantities and allows the baby to withdraw slowly
11
Q
A 35 year old primiparous woman attends antenatal clinic at 35 weeks gestation.
The baby has breech throughout the pregnancy and has failed to turn spontaneously.
She is thus offered an elective Caesarean section.
She is worried about the risks of having a Caesarean section, in particular the implications on any future pregnancies.
Regarding future placenta, which of the following statements is true after caesarean?
A
Increased risk of placenta accreta
Following Caesarean section there is increased risk of placental abnormalities for future pregnancies. Placenta accreta is the abnormal implantation of the placenta into the uterine wall, a common site being the old Caesarean scar.
12
Q
A 22 year old woman presents to her GP at 34 weeks gestation with a new thick, white, odourless vaginal discharge.
She also complains her vulva is itchy and becoming red and sore.
She is otherwise well.
She has had no new sexual partners since becoming pregnant.
On examination, her blood pressure is 122/76, pulse 68, her abdomen is soft and non-tender with a fundal height appropriate for 34 weeks.
On external genital examination, the vulval area is red and excoriated.
There are no discrete ulcers or lesions. On speculum, there is copious thick lumpy discharge seen.
The cervix is long and closed. There is no bleeding seen.
What is the most likely diagnosis?
A
Vulvovaginal candidiasis
Vulvovaginal candidiasis (thrush) is common in pregnancy and typically presents with a thick white discharge (often described as ‘like cottage cheese’) which is usually odourless. It is a fungal infection that can cause itching and irritation around the vulva and vagina.
Candidiasis should be treated in pregnancy with an intravaginal antifungal agent such as a Clotrimazole pessary +/- a topical antifungal cream e.g. Clotrimazole. Oral antifungal medication is not recommended for pregnant women
13
Q
A 24 year old woman presents to her GP at 30 weeks gestation suffering with ‘heartburn’.
She describes a retrosternal burning sensation, which commonly occurs following eating, or when lying in bed at night.
Which hormone is responsible for the promotion of smooth muscle relaxation, which contributes to reduced oesophageal tone and reflux oesophagitis?
A
Progesterone
Progesterone is increased throughout pregnancy.
It is produced by the corpus luteum in the first four weeks of pregnancy and by the placenta thereafter.
It promotes smooth muscle relaxation in the digestive system, urinary system and uterus.
14
Q
A 25 year old primiparous woman presents to the day assessment unit at 37 weeks gestation with rupture of membranes.
This occurred 24 hours ago but still no contractions have occurred yet.
She feels generally well with no vaginal bleeding or pain.
A cardiotocograph is normal and the mother reports that the baby has been moving normally.
On examination her temperature is 36.8ºC, symphysis-fundal height is 34cm and the fetus is cephalic presentation with 3/5 palpable.
Which of the following is the next most appropriate step in her management?
A
She should be offered an induction of labour as it has now been 24 hours since the rupture of membranes with no commencement of labour.
This is the most appropriate answer. Following rupture of membranes if spontaneous labour does not occur within 24 hours induction of labour should be offered.
15
Q
A 24-year-old lady attends a pre-conception clinic for advice.
She has a past medical history of epilepsy well controlled with Valproate.
Her doctor advises her that it is important to switch to a safer antiepileptic drug (AED) in pregnancy.
Which of the following is the most common fetal anomaly associated with Valproate?
A
Neural tube defects
This is the correct answer. Valproate exposure in the first trimester is associated with the highest risk of major congenital malformations. These include neural tube defects, cardiovascular anomalies, genital abnormalities, skeletal abnormalities and developmental delay. AEDs such as Valproate, Phenytoin and Carbamazapine are known to be associated with the risk of development of neural tube defects.
16
Q
A 30 year old primiparous woman is inactive labour at 37 weeks gestation.
She is having a vaginal delivery and is currently in the second stage of labour.
She has been pushing regularly with contractions and the fetal head has now extended fully out of the vaginal introitus.
The fetal head is in an occipito-anterior position.
What is the next step in this labour?
A
Restitution
Following delivery of the fetal head, the fetus externally rotates (restitution) to bring the shoulders into an antero-posterior position. This facilitates delivery of the anterior shoulder and expulsion of the fetus.
17
Q
What is restitution?
A
Restitution
Following delivery of the fetal head, the fetus externally rotates (restitution) to bring the shoulders into an antero-posterior position. This facilitates delivery of the anterior shoulder and expulsion of the fetus.
18
Q
A 17-year-old woman presents to her GP.
She states that her menstrual period has been several weeks later than expected, which is unusual as her menstrual cycle is normally very regular.
She also explains that her period was accompanied by some “grey bits” and a few blood clots.
She had unprotected sexual intercourse with someone at a party 5 weeks ago.
Which of the following is the most likely diagnosis?
A
Miscarriage
If the woman had become pregnant because of her unprotected sexual intercourse this would explain why her period did not occur when she was expecting it.
Passage of fetal and placental tissue during a miscarriage can appear as greyish tissue and be accompanied by blood clots.
19
Q
Indications for Category 1 Caesarean sections?
(2)
A
Category 1 (immediate) Caesarean section should be performed where there is evidence or clinical suspicion of acute foetal compromise:
- cord prolapse
- Scalp pH <7.2 is an indication for category 1 Caesarean section
20
Q
A 14 year old female presents to her GP with a positive pregnancy test, nausea and slight vaginal bleeding.
She does not know when her last menstrual period was.
She is referred to the antenatal clinic where a a transvaginal ultrasound is performed.
The transvaginal ultrasound shows a ‘cloud like’ appearance and she is diagnosed with a molar pregnancy.
Which of the following is true regarding management of a molar pregnancy? (2)
A
The molar pregnancy requires removal as it is not viable. This is usually achieved surgically using a dilatation and curettage
Correct. A molar pregnancy (or hydatidform mole) occurs when there is an abnormality in the usual fusion of sperm and egg, resulting in a rapidly dividing tissue mass which is not compatible with a normal pregnancy.
Molar pregnancies can be subdivided into:
- Complete mole = Occurs when one or two sperm fertilise an egg that contains no chromosomal material. Therefore there is no maternal chromosomal material. A placenta is formed but there is no embryo.
- Partial mole = Occurs when two sperm fertilise a normal egg and instead of forming twins, there is an abnormal proliferation of tissue. There is embryonic tissue, but this is not a viable pregnancy.
A molar pregnancy is not a viable pregnancy and requires removal as there is a risk it may progress to invasive or malignant disease.
21
Q
A 28 year old G2P2 is nearing term and has planned to breastfeed her baby after delivery.
She is wondering which of her medications is safe to continue during breastfeeding.
Which asthmatic drug is permitted during breastfeeding?
Which drugs are absolutely contra-indicated?
A
Salbutamol
The absolute contraindications to breastfeeding are:
- Infants of mothers with TB infection
- Infants of mothers with uncontrolled/unmonitored HIV
- Infants of mothers who are taking medications which may be harmful e.g. amiodarone
22
Q
A 30-year-old, 41 week pregnant woman with gestational diabetes has failed to progress in the second stage of labour and is becoming distressed.
You suspect shoulder dystocia and call for additional help.
An episiotomy has been performed.
What of the following is the most appropriate next step in management?
A
McRoberts’ manoeuvre
After an episiotiomy has been performed, the patient should be placed in McRoberts’ position.
This involves hyperflexion at the hips with the thighs abducted and externally rotated
23
Q
Gaskin manoeuvre
A
Gaskin manoeuvre
The Gaskin manoeuvre involves the patient rolling over to an ‘all fours’ position. The change in pelvic dimensions may assist with delivery
24
Q
Rubin II manoeuvre
A
Rubin II manoeuvre
This is an internal manoeuvre used in shoulder dystocia involving applying external pressure to the posterior aspect of the anterior shoulder.
If successful, it allows the shoulders to be adducted and rotated to the larger oblique diameter
25
**Woods' screw manoeuvre**
**Reverse Woods' screw manoeuvre**
**Woods' screw manoeuvre**
This is another internal manoeuvre that follows a failed Rubin II manoeuvre. It combines the Rubin II manoeuvre with pressure on the anterior aspect of the posterior shoulder
**Reverse Woods' screw manoeuvre**
This is another internal manoeuvre that can be conducted if the abovementioned manoeuvres fail. It involves applying pressure on the anterior aspect of the anterior shoulder and posterior aspect of the posterior shoulder
26
A 22 year old male has attended the GUM clinic with itching and tingling in his genital region.
On questioning, he states that he had a genital herpes infection 4 months ago.
He has also been successfully treated for Chlamydia in the past.
At present he is not using any form of contraception
**What is the most appropriate advice for this patient?**
Abstain from all sexual activity until asymptomatic
The patient is experiencing the prodromal phase that precedes a recurrent herpes infection.
This occurs in 50% of patients who experience a recurrence of herpes infection.
The current guidance states that the patient should abstain from all sexual activity until symptoms from the prodromal phase and the clinical recurrence have passed.
27
A 22 year old woman visits the GUM clinic.
She is asking about types of contraception.
On questioning it is determined that she suffers from migraines that are associated with a preceding change in smell.
She also comments that she is against having an intra uterine device fitted and is currently using no contraception.
**Given the clinical picture and patient preferences, what is the most appropriate contraceptive method to use?**
**POP**
The current guidance stipulates that patients who suffer from migraines with aura should be offered the progesterone only pill is a suitable alternative.
28
A 42 year old female visits A&E with exertional shortness of breath.
A chest X-ray is requested and demonstrates bilateral bihilar interstitial infiltrates.
She has a past history of using intravenous drugs.
**Give the most likely diagnosis. (2)**
**What is the most appropriate initial treatment? (1)**
**What is the second line treatment? (1)**
She has (Pneumocystis pneumonia) infection, common in patients with HIV.
**First line = Co-Trimoxazole**
This is the appropriate first line treatment for PCP. The presentation confers adequate evidence of PCP infection, thus treatment can be prescribed in this case
**Second line = Clindamycin-primaquine**
Clindamycin-primaquine are used as second line agents in severe PCP refractory to Co-trimoxazole treatment.
29
What is cART?
| (3)
The introduction of **combined antiretroviral therapy (cART)** in 1996 ushered in a new era for HIV-infected individuals in countries where this therapy was available.
* cART increases CD4 count
* decreases HIV RNA level
* extends AIDS-free survival
30
**What is Liposomal Amphotericin?**
**(3)**
**This would be the appropriate treatment for Histoplasmosis infection.**
**Histoplasmosis is an infection caused by a fungus called Histoplasma.**
This would present:
* disseminated infection
* weight loss
* fever
* dyspnoea
31
A 24 year old pregnant patient visits the antenatal clinic for her booking appointment.
She has had a cough for the last two days and is experiencing general coryzal symptoms.
**When is the booking appointment?**
**Which of the following is the next most appropriate investigation?**
**between 8-12 weeks**
**HIV antigen and HIV antibody**
The point of this question is to remind you that every patient who presents for a booking appointment should be tested for HIV. Given the absence of other features, this is most likely to be a common cold.
32
A 47 year old HIV positive man presents to A & E with a non-productive cough and shortness of breath.
He notes that he has become more breathless recently as he walks.
**Which is the most likely causative organism? (3)**
**Pneumocystis Jiroveci**
* The classic sign of PCP is a lowering of oxygen saturations on exercise.
* This would manifest as newfound breathlessness in patients recently infected.
* commonly found in patients with HIV
33
A 70 year old male presents to his GP with a red, hot and painful scrotal swelling that has worsened over the past 2 days.
He also reports pain on urination.
Examination reveals a red, hot swollen left testicle that is tender on palpation.
There is no regional lymphadenopathy.
**What is the diagnosis?**
**Which is the most likely cause of his presentation?**
**E. coli**
This is the most common cause of **epididymoorchitis** in older males, which is often associated with urinary tract infections.
34
An 18 year old woman visits the GP clinic asking about different types of contraception.
Previously she has been using barrier protection, but would like hormonal contraception.
She has a past medical history of **epilepsy**.
**Of the following, what is the most appropriate contraceptive method to prescribe?**
Contraceptive injection
The injection is the contraceptive of choice amongst the epileptic population. The injection does not interact with liver enzymes.
35
A 32 year old pregnant lady presents to the GP with vaginal discharge and an associated fishy odour.
She reports this is the first time this has happened and she has been successfully treated for a chlamydia infection in the past.
**What is the appropriate next stage in management?**
**What is the diagnosis?**
**Oral Metronidazole**
This is the correct treatment option for women who are pregnant and displaying classic symptoms of **Bacterial** **Vaginosis**, notably an uncomfortable vaginal discharge associated with a fishy odour.
36
A 55 year old male presents to the Emergency Department with a 2 month history of a persistent dry cough and breathlessness that worsens when going up the stairs. This has progressed to shortness of breath at rest over the past few days. Past medical history is relevant for a road traffic accident in rural Kenya, for which he had a splenectomy and blood transfusion. He has no recent history of illness apart from an episode of flu-like symptoms and a widespread rash 6 months ago, which has since spontaneously resolved.
Observations show a temperature of 37.9 degrees Celsius, respiratory rate of 30, oxygen saturations of 86% on room air, heart rate of 77 beats per minute and blood pressure of 125/80. Arterial blood gas (ABG) showed pH 7.37, PaO2 7.1 kPa, PCO2 5.5 kPa, HCO3 25 mmol/L.
**What is the diagnosis?**
**What is the most appropriate initial treatment?**
**This man likely has PCP secondary to HIV**
**Co-trimoxazole and steroids**
This is the best treatment for Pneumocystis pneumonia (PCP). This is the most likely diagnosis given the progressive shortness of breath, exertional dyspnoea, and desaturation on ABG. He is likely to have contracted HIV from a contaminated blood transfusion in rural Kenya, which explains the seroconversion illness he experienced 6 months ago. Adjunctive steroids should be administered to patients with PaO2 ≤8 kPa and/or evidence of hypoxaemia e.g. oxygen saturations \<92%. This is to reduce mortality and risk of respiratory failure.
37
An 18 year old woman presents to the GUM clinic after having a coryzal illness for three days.
She then describes having some vulval tingling and is now complaining of three painful lesions that have appeared on her vulva.
What is the best advice to give the patient regarding ongoing sexual activity?
**Sexual activity should be avoided until lesions are gone.**
This is a classical description of a herpes simplex virus infection which manifests as genital ulcers. Typically, there is a viral prodrome which is followed by the appearance of painful ulcers on the genitals. The key piece of advice that needs to be given is that sex should be avoided when there is a prodrome and or genital lesions are present. Condoms and daily antivirals reduce transmission but cannot guarantee it. The only way to prevent transmission is to avoid all sexual contact until the lesions have disappeared.
38
A 27 year old female presents to her GP complaining of a one week history of unusual vaginal discharge. She describes this as grey-white, thin and watery. This is especially bad after sex and she is conscious of a fishy smell. There is no soreness or itching. She is in a stable relationship with her husband, both of whom have only had sex with each other. She is not pregnant. **What is the treatment of choice?**
**Metronidazole**
Bacterial vaginosis is a common cause of excessive vaginal discharge that can increase the chances of getting chlamydia. A key sign for BV is an odour, which resembles that of fish. It can or cannot present with soreness and itching. Oral or vaginal Metronidazole is the treatment of choice.
39
A 33 year old female presents to A+E with a 2-week history of worsening shortness of breath on exertion and a dry cough.
Her past medical history is notable for HIV infection, for which she has not been compliant with medication.
On examination, she is hemodynamically stable, alert and orientated. Chest and cardiovascular examinations are unremarkable, but the patient's saturations while walking are 85%. Chest X-ray is clear.
**Given the most likely cause for her symptoms, what treatment should be offered?**
**Co-trimoxazole**
This is the first line treatment for Pneumocystis pneumonia. Side effects include Stevens-Johnson syndrome/TEN, drug-induced lupus and agranulocytosis
40
A 16 year old girl visits the GUM clinic asking about suitable types of contraception. She comments that she is often forgetful.
She has no other relevant medical history.
**Which is the most appropriate contraceptive method to consider?**
**Contraceptive Implant**
This is the contraceptive of choice in a 16 year old girl. It affords the patient the ability to not worry about their contraceptive, as the implant remains active without intervention for 3 years. This also aligns with the patient’s personal preferences.
41
A 24 year old gentleman visits the GUM clinic.
Upon genital examination, he has a painless lesion on his penis.
There is also evidence of a swollen inguinal ligament.
**What is the most likely causative organism for this condition?**
**Chlamydia Trachomatis**
The presentation in this instance is Lymphogranuloma Venereum (LGV).
This is a tropical disease, rare in the UK.
It classically presents with a non indurated lesion on his penis, and due to lymphatic destruction, **it can cause a swollen inguinal ligament.**
This is known as the Groove sign, with a groove visible above and below the inguinal ligament.
LGV is caused by Chlamydia, specifically serovars L1/L2/L3.
42
A 24 year old woman presents to the GUM clinic with vaginal discharge.
A sample of discharge is taken for microscopy.
Upon microscopy, the causative organism is noted to be flagellated and unicellular.
**What is the most appropriate management?**
**What is the causative organism?**
Prescribe **Metronidazole**
This is the appropriate treatment for **Trichomoniasis**. On microscopy,
**Trichomonas** bacteria are classically flagellated unicellular organisms. This is sufficient diagnostic evidence to begin treatment.
43
A 27-year old female presents with right upper quadrant (RUQ) pain and fever.
Her last menstrual period was 2 weeks ago, and she was last sexually active 10 weeks ago.
They did not use a condom, but she is on the oral contraceptive pill.
Her past medical history includes an appendectomy only.
She is febrile but other observations are stable.
On abdominal examination she is tender in the right upper quadrant.
Bimanual vaginal exam reveals cervical excitation.
Urine dip shows leucocytes but is negative on a pregnancy test.
Bloods show a leucocytosis but are otherwise entirely normal.
**What is the most likely diagnosis?**
**What is the treatment?**
**(3)**
**Fitz-Hugh Curtis syndrome**
* Fitz-Hugh Curtis syndrome is when pelvic inflammatory disease (PID) causes perihepatic inflammation, leading to RUQ pain and/or referred shoulder tip pain.
**Chlamydia is the most common culprit.**
This lady had sexual intercourse with contraceptive cover but no condom, and so may have contracted a sexually transmitted infection which has gone unchecked.
**PID is indicated here by the presence of cervical excitation.**
High vaginal swabs can confirm the diagnosis.
Perihepatic fine adhesions may develop as a later complication.
Treatment is with antibiotics, commonly **doxycycline** or **azithromycin**.
44
A 19 year old woman attends her GP 22 weeks into her first pregnancy.
She complains she has developed painful lesions on her vulva. She is otherwise well.
She has no history of previous sexually transmitted infections and is currently sexually active.
On examination, her observations are normal.
There are multiple wet ulcer-like vesicles on her vulva and perineum which are painful to touch, with surrounding erythema.
There is palpable inguinal lymphadenopathy.
**What is the causative agent?**
**What is the most appropriate treatment?**
**Oral Aciclovir 400mg three times a day**
This woman has a primary herpes simplex virus (HSV) genital infection.
A higher dose of 400mg three times a day is required due to the higher circulating blood volume found in pregnancy.
Acquisition of primary genital herpes simplex in the first or second trimester does not preclude vaginal delivery, however suppressive therapy with oral Aciclovir may be given from week 36 to reduce the risk of HSV lesions at term.
If this woman has HSV lesions at term, delivery via caesarean section is recommended to reduce the risk of vertical transmission to the newborn.
45
A 61-year-old woman is referred to gynaecology as she is suspected of having ovarian cancer.
**She has a high Ca-125.**
The pelvic ultrasound is abnormal and so a chest-abdomen-pelvis CT is requested.
The CT shows that the cancer has seeded in the peritoneum and the liver.
**What of the following is the most appropriate next step? (4)**
**Surgery**
* If early disease surgery can include removal of the uterus, ovaries, Fallopian tubes and infracolic omentectomy.
* In advanced disease debulking surgery can be performed.
**Chemotherapy**
* Adjuvant chemotherapy should be given to the patient in an ideal world.
* Intraperitoneal chemotherapy may be performed at the time of operation
46
A 32-year-old lady presents to her General Practitioner (GP) complaining that she has not had a period in the last 6 months.
She also reports reduced libido and white colour, milky discharge from both of her breasts.
Notably, she denies any headache or visual disturbance.
She says she takes an antipsychotic.
**Which medication is most likely to be responsible for the set of symptoms described by the patient?**
**Risperidone**
The symptoms of reduced libido, galactorrhoea (bilateral milky discharge from the breasts that is not associated with pregnancy or lactation) and amenorrhoea are highly suggestive of hyperprolactinaemia.
The release of prolactin from the anterior lobe of the pituitary gland is under dominant-negative control through the release of dopamine from the hypothalamus.
Hence, a reduction in the activity of dopamine in the pituitary will lead to **excess release of prolactin**.
Risperidone is a second-generation (atypical) **antipsychotic and it is a dopamine antagonist.**
Out of the second-generation agents, the highest prevalence of hyperprolactinaemia is associated with risperidone.
47
A 25-year-old woman who has oligomenorrhoea and acne is referred for ultrasound of her ovaries.
The ultrasound reveals multiple cysts on the ovaries and she is diagnosed with polycystic ovary syndrome.
She is prescribed a 12-day course of medroxyprogesterone 10mg daily which induces a withdrawal bleed and she is sent for an ultrasound to assess the endometrial thickness.
The endometrium is found to be normal thickness.
**What is the most appropriate next step in her management?**
Combined oral contraceptive pill
It will both prevent endometrial hyperplasia and may improve the acne.
48
A 55-year-old lady presents to her General Practitioner (GP) complaining of hot flushes, night sweats, difficulty sleeping, poor concentration and reduced libido. Her last period was 18 months ago and she has no significant past medical or family history.
The GP believes that her symptoms are due to the menopause and suggests hormone replacement therapy (HRT).
**Which of the following is an advantage of HRT given through a skin patch compared to HRT given in the form of tablets?**
**Reduced risk of venous thromboembolism (VTE)**
A major advantage of transdermal HRT (e.g. patches, gels, creams) is that it is not associated with an increased risk of VTE compared to the baseline population that do not take any HRT. HRT in the form of tablets is associated with a 2-3 fold increased risk of VTE.
49
A 35-year-old lady presents to her General Practitioner (GP) complaining that her periods have not returned since she stopped taking the combined oral contraceptive pill (COCP) 14 months ago.
She had been using the COCP for 6 years previously.
In addition, she notes episodic vaginal dryness and difficulty sleeping at night due to feeling 'hot and sweaty'.
On examination, there are atrophic changes around the vagina but nothing else of significance.
A pregnancy test is negative and two sets of hormone profiles, repeated 4 weeks apart, reveal raised levels of FSH and LH.
**Which of the following is the most likely explanation for the patient's symptoms?**
**Premature ovarian insufficiency**
Premature ovarian insufficiency (POI) refers to a loss of ovarian function leading to the cessation of periods for more than one year before the age of 40.
It affects about 1 in 100 women and causes include surgery, chemotherapy, radiotherapy, autoimmune disease and genetic disorders (e.g., Turner's syndrome).
Often POI is idiopathic.
Patients usually present with symptoms of the menopause including irregular or absent periods; hot flushes; vaginal dryness; dyspareunia as well as poor sleep and concentration.
Lack of oestrogen release from the ovaries leads to increased release of FSH and LH from the pituitary gland through negative feedback.
To make a diagnosis, the hormones need to be elevated when tested twice, four weeks apart.
50
A 36-year-old woman presents to her GP complaining that her periods have become more painful in the last 4 months.
The pain tends to start the day before her period, and improves as the period continues.
There are no other symptoms and prior to this she has had no other gynaecological problems.
Her menarche was at 13 years.
Pelvic examination and pelvic ultrasound scan are normal.
**Which of the following is the most likely diagnosis?**
**Endometriosis**
* It typically presents with pelvic pain where previously periods were painless. The pain may be chronic or cyclical.
* **Pelvic** **examination is often normal**, but in extensive cases of endometriosis there may be tenderness or palpable nodules.
* **Pelvic** **ultrasound** **is often normal**; however in some cases it may identify an ovarian endometrioma.
51
A 60 year old woman is referred by her GP to the gynaecology clinic.
She has had a 3 week history of a “dragging sensation” down below and problems with leaking urine when coughing or sneezing.
Otherwise, she feels well. She has three children all delivered via natural birth and no history of abdominal or pelvic surgery.
On speculum examination, there is a large anterior wall bulge in the vagina, and the cervix is in a normal position.
**What is the most likely diagnosis?**
Cystocele
The combination of stress incontinence symptoms as well as examination finding of anterior wall prolapse is suggestive of a cystocele.
A cystocele is the herniation of the bladder into the vagina.
There may also be a concurrent urethrocele which is the prolapse of the urethra into the vagina.
52
A 32 year old woman presents to her GP with bloating and mild abdominal discomfort.
She also mentions that she has been getting increased fatigued and is losing weight.
Abdominal examination reveals a mass in the left iliac fossa, which can also be palpated when a bi-manual pelvic examination is done.
**What is the most likely diagnosis?**
**Germ cell ovarian tumour**
* Germ cell tumours are around 10% of ovarian cancer, and mainly affect younger women.
* They may rapidly enlarge, becoming an abdominal mass (which is usually a late sign in ovarian cancer).
* There is a risk of rupture or torsion of the ovary, both leading to severe abdominal pain.
53
A 24 year old female presents to her GP because she has missed her period by one month. She has noticed that she has difficulty in sleeping. She has also been complaining of diarrhoea in the past few days. Which of the following is the next best investigation?
Pregnancy test
Whilst specific thyroid tests will aid in the diagnosis if her symptoms are secondary to thyroid dysfunction, a pregnancy test in a woman of child-bearing age should be the initial test. In fact, a rare cause of thyrotoxicosis is a molar pregnancy.
54
A 39-year-old woman with menorrhagia presents to her GP.
Previously, pelvic examination revealed an enlarged uterus.
A pelvic ultrasound scan identified 2 intramural fibroids and 3 large pedunculated submucosal fibroids.
The patient would like treatment, but wants to avoid surgery.
She smokes 20 cigarettes a day, and has no plans for any more children.
**Which of the following is the most appropriate management option?**
Oral norethisterone
Norethisterone, also known as norethindrone and sold under many brand names, is a progestin medication used in birth control pills
This is the correct answer. It is a 3rd line option when the above treatments are deemed unsuitable, such as in this case.
55
A 32-year woman presents to an infertility clinic after being unable to conceive with her partner for the last year.
Her menstrual cycle is irregular, lasting anywhere from 28 days to 45 days.
Her period usually lasts for 4 days.
She doesn’t have any previous children.
She also complains that her arms and legs are sometimes weak.
On examination, she has a high BMI and there are several linear purple marks, running in a vertical direction on her abdomen.
**What is the most appropriate investigation? (2)**
Dexamethasone suppression test
This is the correct answer. A dexamethasone suppression test is one of the tests to investigate for **Cushing’s** **syndrome**, which is the most likely diagnosis here.
56
A 30-year-old lady presents to the Emergency Gynaecology Unit (EGU) for a repeat β-hCG blood test and transvaginal ultrasound. Two days earlier she presented with vaginal bleeding and a history of 6 weeks since her last period. A pregnancy test showed she was positive but a transvaginal ultrasound scan showed no evidence of pregnancy.
The results of her investigations are shown below:
Initial serum β-hCG level: 1100 mIU/ml (1080-56500 mIU/ml)
Repeat serum β-hCG level (48 hours later): 2050 mIU/ml (1080-56500 mIU/ml)
**Which of the following is the most likely diagnosis?**
**Viable intrauterine pregnancy**
This patient was initially classified as having a pregnancy of unknown location (PUL). This is where a patient has a positive pregnancy test but no evidence of either intrauterine or extrauterine pregnancy on transvaginal ultrasound scan. In this case, the best step is to repeat a serum β-hCG and transvaginal ultrasound scan in 48 hours.
In a viable intrauterine pregnancy, the serum β-hCG level roughly doubles in 48 hours. NICE guidance states that if the level rises by more than 63% after 48 hours, a viable intrauterine pregnancy is most likely. However, an ectopic cannot be ruled out. This should be explained to the patient and she should be asked to come in for a repeat transvaginal ultrasound scan in 7-14 days. By this stage, the foetus is likely to have developed to a stage where it is clearly visible on ultrasound.
57
A 57-year-old woman presents to her GP with abdominal discomfort and says she sometimes feels bloated.
Her menopause was at 54 and she is not taking hormone replacement therapy.
She is a smoker.
The GP performs an abdominal and pelvic examination which are both normal.
**Which is the most appropriate next step?**
Serum Ca-125
When the examinations are normal, the next step should be to perform a Ca-125.
This is a useful intermediate step used to determine who needs ultrasound and who does not.
If the Ca-125 is low/normal then ovarian cancer is highly unlikely.
If Ca-125 is raised then there is an increased chance of ovarian cancer and so ultrasound is necessary.
58
A 35 year old woman is seen in gynaecology outpatients complaining of a 6 month history of amenorrhoea.
She has also had some mild abdominal pain occurring for a few days each month but otherwise feels well. Prior to this, her periods were regular and has no past medical history. She has no children but had a missed miscarriage 7 years ago for which she had a Dilatation and Curettage (D&C) procedure.
Investigation results are as follows:
* Day 3 FSH: 8.1IU/L (1-11)
* Day 3 LH: 7.6IU/L (2-8)
* Day 21 progesterone: 60nmol/L (17-92)
* Day 5 oestrogen: 220pmol/L (70-500)
* Prolactin: 360mu/L (70-550)
* Testosterone: 1.8nmol/L
* TSH: 3.5mu/L (0.7-3.8)
* Free thyroxine: 19.9pmol/L (9-23)
* Transvaginal ultrasound: No abnormalities of the uterine cavity or ovaries seen
* BMI: 22.3
What is the most likely cause for her secondary amenorrhoea?
**Asherman’s syndrome**
Asherman’s syndrome is characterised by intrauterine adhesions commonly as a result of previous uterine surgery such as dilation and curettage. It can lead to obstruction to the menstrual outflow tract which presents as secondary amenorrhoea. In this case, the cyclical abdominal pain may be a sign that menstruation is occurring. Ultrasound examination is not particularly sensitive for making the diagnosis so an HSG or hysteroscopy might be needed for confirmation.
59
A 56-year-old lady presented with symptoms of abdominal pain, bloating and early satiety.
She was found to have a raised CA125 level and a pelvic ultrasound scan revealed a mass on her left ovary.
A total abdominal hysterectomy was performed and the pathology report for the lesion made reference to 'complex papillary architecture, nuclear atypia and the presence of **Psammoma** **bodies**'.
**Which of the following is the best description of the patient's ovarian lesion?**
**Serous cystadenocarcinoma**
Epithelial ovarian cancer is the most common type of ovarian cancer comprising approximately 90% of all ovarian tumours.
Serous cystadenocarcinoma is the most common subtype of epithelial ovarian cancer and is characterised by the presence of Psammoma bodies on histology.
These are round collections of microscopic calcification.
Other important cancers associated with Psammoma bodies are papillary thyroid cancer, meningioma and mesothelioma.
60
A 14 year old postmenarchal female presents to the emergency department with sudden onset left iliac fossa pain.
This is her second presentation with similar symptoms in the past 3 months.
On examination she is apyrexial and very tender to palpation in left lower quadrant.
**What is the best inital imaging modality?**
**Transabdominal ultrasound**
The suspected diagnosis here is an ovarian cyst which has been complicated by rupture, haemorrhage or torsion.
Ultrasound is the preferred first line imaging investigation for assessing ovarian pathology as it is a non-invasive and non-ionising form of imaging.
Ultrasound allows for charecterisation of the cyst wall and internal components e.g. presence of haemorrhage.
The main types of cysts that will be visualised include follicular cysts, corpus luteal cysts or haemorrhagic cysts.
61
A 32-year-old lady presents to the Emergency Gynaecology Unit (EGU) with vaginal bleeding for the last 3 days. She is concerned at the fact that her last menstrual period was 6 weeks ago, as usually they occur regularly every 28 days.
A pregnancy test is positive but a transvaginal ultrasound scan does not show evidence of a pregnancy. Her serum β-hCG level is 1100 mIU/ml (1080-56500 mIU/ml).
Which of the following is the next best step in management?
Repeat β-hCG level in 48 hours
The situation where a patient has a positive pregnancy test but no evidence of either intrauterine or extrauterine pregnancy on a transvaginal ultrasound scan is known as pregnancy of unknown location (PUL). The foetus is only visible on transvaginal ultrasound from around 5 weeks and when the β-hCG level is greater than 1500 mIU/ml. Therefore, it may be the case that this lady has a viable intra-uterine pregnancy that is not yet detectable.
In addition to viable intrauterine pregnancy, the other possible scenarios for PUL are an ectopic pregnancy or a miscarriage. In order to determine which of these is the case, β-hCG levels should be repeated in 48 hours and compared within the initial reading. In a viable intrauterine pregnancy, the β-hCG would be expected to roughly double in 48 hours, whereas in a miscarriage the β-hCG level would be expected to half.
62
A 16 year old girl presents to her GP with post-coital bleeding. She is sexually active, and uses the combined oral contraceptive pill. She also reports some episodes of unprotected sex.
She denies any vaginal discharge or abdominal pain.
On speculum examination there is a ring of red mucosa around the cervical os. A cervical smear is taken and sent for analysis.
Which of the following is the most likely diagnosis?
Cervical ectropion
Cervical ectropion is particularly more common in adolescents, during pregnancy, and in women taking combined hormonal contraception.
The high levels of oestrogen trigger an enlargement of the cervix, causing eversion of the endocervical canal, which appears as a red ring.
63
A 24 year old woman attends A&E. She is complaining of left-sided pelvic pain.
On examination there is localised peritonism.
A urinary pregnancy test is negative, and a urine dipstick test yields no positive findings. CRP is not raised
**Given the likely diagnosis, what is the most appropriate management?**
Perform Transvaginal Ultrasound
This is the correct initial investigation in order to confer a diagnosis of a **ruptured** **ovarian** **cyst**.
64
A 52-year-old woman presents to her GP asking about hormone replacement therapy (HRT).
She explains that her periods stopped about 15 months ago, but she is still experiencing hot flushes.
When asked about other symptoms she says she has had some **vaginal bleeding** over the last few weeks, and occasionally has **night** **sweats**.
**What is the most appropriate next step in management?**
2 week referral to gynaecology
The post-menopausal bleeding is concerning as it may be a sign of endometrial cancer.
Therefore, the most appropriate next step should be a 2 weeks referral to gynaecology.
65
A 27-year-old woman with polycystic ovary syndrome has been trying to become pregnant over the last 2 years and has not been successful.
She has been having regular sexual intercourse and is not using any contraception.
In the past she has tried metformin and clomifene for 6 months with no effect.
**Which of the following is the most appropriate treatment?**
**Laparoscopic ovarian drilling**
This is the correct answer. If clomifene and metformin fail then laparoscopic drilling is a second line treatment.
66
A 34 year old woman was found to have moderate dyskaryosis on her routine cervical screening test.
She is referred for colposcopy where staining and biopsy confirms the presence of cervical cancer with stromal invasion of 4mm and horizontal spread of 6mm.
Sentinel lymph node biopsies are negative.
A CT confirms that at this point the cancer is contained within the cervix.
She has 1 child, and would like to bear another in the future.
**What is the most appropriate management option?**
**Radical trachelectomy**
This is the correct answer. A radical trachelectomy would be treatment options for this stage IA cancer. As the woman would like to remain fertile, a trachelectomy would be the most suitable option.
67
A 27 year old woman, who is 8 weeks pregnant presents to her GP with pain in her left iliac fossa.
She is referred to hospital and undergoes a trans-vaginal ultrasound which reveals a 40mm mass in the left Fallopian tube with a fetal heartbeat present.
Her blood type is O rhesus negative.
**What is the most appropriate management?**
**(2)**
**Salpingectomy** and **anti-D** **immunoglobulin**
**When any of the following are present then surgical management is preferred:**
* The patient is in a large amount of pain
* The mass is greater than 35mm
* Ultrasound identifies a fetal heartbeat
* Serum beta-human chorionic gonadotropin (B-hCG) levels are over 5000 IU/L
Anti-D immunoglobulin should be given to all rhesus negative women who are having surgical management for an ectopic.
68
A 66-year-old woman presents to her GP saying that she has a ‘lump down below’.
It has been there for a few months, but she had been too embarrassed to come to the GP.
On examination, there is a mass in the right labia and **inguinal** **lymphadenopathy**, with no tenderness on palpation.
**What is the most likely diagnosis?**
**Vulvar cancer**
The lump should raise concerns about cancer.
This is made even more likely due to the lymphadenopathy which likely indicates lymphatic spread.
69
Criteria for lactational amenorrheoea.
| (3)
**There are three criteria for use of lactational amenorrhoea as an effective contraceptive choice for women in the post partum period:**
* The woman has complete amenorrhoea.
* The woman is fully, or nearly fully (\>85% of feeds are breast milk) breastfeeding.
* It has been six months or less since the birth of the baby.
**With typical use, 2% of women using lactational amenorrhoea as a contraceptive method will conceive during the first six months after childbirth.**
70
A 26 year old lady comes in to see the GP with postcoital and intermenstrual bleeding for 6 months. She has no associated pain or changes in her vaginal discharge. On speculum examination, the cervix looks abnormal. On bimanual examination the uterus is anteverted, there are no masses and no adnexal tenderness or cervical excitation.
She has no other past medical history. She has never been pregnant and she is yet to have a smear.
**What is the most appropriate course of action?**
**Urgent (2 week wait) referral to gynaecology**
The presence of symptoms and abnormal examination findings mean that cervical cancer must be excluded.
This patient must therefore be referred urgently to the gynaecology team
71
A 19-year-old lady presents to her General Practitioner (GP) with heavy menstrual bleeding.
She reports heavy periods since she can remember; however, the symptoms are now preventing her from going to work during her periods.
An initial panel of blood tests, including a clotting profile, are normal except for a haemoglobin of 95 g/L (115-165 g/L).
A transvaginal ultrasound scan reveals no abnormalities.
**Which of the following is the most likely cause of the patient's symptoms? (2)**
**Dysfunctional uterine bleeding**
Menorrhagia is defined as blood loss during a menstrual period to which a patient's quality of life is affected.
**In about half of cases, there is no underlying pathology and this is referred to as dysfunctional uterine bleeding.**
The patient is likely anaemic due to blood loss but otherwise normal investigations make local and systemic cause of menorrhagia unlikely.
72
A 23-year-old lady presents to the Emergency Department (ED) complaining of sudden onset, right-sided abdominal pain for the last 3 hours. She rates the pain as being constantly 9/10 in severity and says she has vomited twice since its onset.
On examination, the patient is tender in the right iliac fossa. A pregnancy test is negative and blood tests reveal leucocytosis with a raised CRP level. On Doppler ultrasound scan of the right ovary, the 'Whirlpool' sign is visualised.
**What is the most likely diagnosis?**
**Ovarian torsion**
Ovarian torsion is a gynaecological emergency and diagnostic delay can lead to a loss of the ovary due to compromised blood supply.
It usually presents with sudden onset, unilateral pain in the right or left iliac fossa. This is often severe, constant and accompanied with nausea & vomiting.
A raised CRP and white cell count is suggestive of an underlying inflammatory response.
he 'Whirlpool' sign is a characteristic sign of ovarian torsion that can be seen on ultrasound or CT scan.
It demonstrates the twisting of the ovarian pedicle.
73
A 55 year old female patient presents to the general practitioner with a 3 month history of early satiety and abdominal discomfort.
She has also noticed a 4kg weight loss in the last month.
There is no past medical history of note.
The patient is taking hormone replacement therapy for management of menopausal symptoms.
**Given the most likely diagnosis, which of the following is the most appropriate next investigation?**
Serum CA-125
In women over 50 reporting persistent abdominal symptoms a useful initial test is CA-125.
For women with ascites or a pelvic/abdominal mass, urgent referral to secondary care is warranted.
CA-125 will be used as part of the evaluation of this patient, and a level \>35 units/mL would be suggestive of malignancy.
**Serum CA-125 is raised in \>80% of patients with advanced ovarian cancer** however it is neither sensitive nor specific for the diagnosis.
74
A 28-year-old lady is referred to the infertility clinic. She reports that she had painful periods as a teenager and was started on the intra-uterine system (IUS). Two years ago, she stopped using the IUS as she was looking to start a family. Since then, in addition to difficulty conceiving, she has experienced menorrhagia as well as pain on urination and defecation.
The gynaecologist suspects endometriosis and this is confirmed following a diagnostic laparoscopy.
Which of the following additional symptoms would be most in keeping with the diagnosis?
**Secondary dysmenorrhoea**
Secondary dysmenorrhoea is defined as painful menstruation secondary to underlying pelvic pathology such as endometriosis, fibroids or a polyp.
The pain typically occurs before the start of menstruation, whereas in primary dysmenorrhoea the pain starts with the onset of menstruation.
75
A 48-year-old woman presents to her GP with heavy periods over the last 6 months.
She must use both tampons and sanitary towels.
She has some bleeding between her periods but this is easily controlled with sanitary towels.
She hasn’t passed any blood clots, and denies any post-coital bleeding or dyspareunia.
She does not have any children.
Bi-manual pelvic examination reveals a firm, irregular uterus.
**Which of the following is most appropriate next step in her management?**
**What is the likely diagnosis?**
**What has she been highly exposed to?**
**Urgent pelvic ultrasound scan**
The patient has inter-menstrual bleeding.
Factoring this alongside **her age** and her **high oestrogen exposure (no children)**, means that this could potentially be a case of **endometrial** **cancer**, and therefore urgent investigation is needed.
76
A 60-year-old woman presents to her GP complaining that she has been feeling bloated for the last few months.
She has changed her diet but this has not had any effect.
She has also having to urinate more regularly, and sometimes has to rush to the toilet.
She has been taking hormone replacement therapy since menopause at the age of 54.
**What is the most likely cause of her symptoms?**
**(3)**
Ovarian cancer
**Ovarian cancer can cause:**
* bloating
* frequency
* urgency
Unlike the other gynaecological differentials, it is more common with advancing age.
**Hormone replacement therapy, when used for longer than 5 years is thought to increase the risk.**
A history of endometriosis is additionally a high-risk factor.
77
A 45-year-old African-American woman presents to her GP with heavy periods over the last 4 months.
She denies passing any blood clots.
She has become increasingly tired over the last month, and has also had constipation for the last 4 days.
Her menstrual cycle lasts for 28 days, during which she bleeds for 8 days.
On abdominal examination there is a palpable mass in the suprapubic region.
**What is the most likely diagnosis?**
**_Fibroids_**
Fibroids can cause menorrhagia and constipation (due to the mass of the fibroids exerting pressure on the neighbouring bowel), but so can endometriosis.
However, the finding of the palpable abdominal mass makes fibroids most likely.
African-American women are also at a higher risk of fibroids compared to other ethnicities.
78
A 32 year old female presents to the Emergency Department complaining of abnormally heavy menstrual bleeding.
She has associated abdominal pain and pain on urination.
She also has a fever and blood tests show a raised **ESR**, **CRP** and leukocytosis.
**_What is the most likely diagnosis?_**
**Pelvic inflammatory disease**
This is a case of pelvic inflammatory disease, as suggested by dysuria, menorrhagia and objective markers of infection and inflammation.
As most causes of PID are infectious in nature, a high vaginal swab is indicated to identify the organisms responsible.
The common causes are Chlamydia trachomatis or Neisseria gonorrhoeae.
79
A 53-year-old lady is referred urgently to the gynaecology clinic after presenting to her General Practitioner (GP) with unexplained vaginal bleeding.
Her last period was 18 months ago.
**What are the risk factors for the development of endometrial cancer?**
**Exposure to unopposed oestrogen leads to an increased risk of endometrial cancer. This can be in the form of**
* Nulliparity
* Obesity
* Early menarche
* Late menopause
* Polycystic ovary syndrome
80
A 24 year old woman presents to her GP with pain in the right iliac fossa.
She also states she is having her menstrual period, which has come a week later than expected and contains blood clots.
This is unusual for her as her cycle is fairly regular.
She is sexually active, having recently started a relationship with a new partner.
In the past she has been treated several times for sexually transmitted infections and once for pelvic inflammatory disease.
Abdominal examination reveals tenderness in the right iliac fossa. Her urine pregnancy test is positive.
**What is the next most appropriate step in management?**
**Immediately transfer to early pregnancy assessment unit (EPU)**
This patient needs a trans-vaginal ultrasound scan to try to identify whether there is an ectopic.
This needs to be done urgently and so an immediate transfer from your GP practice to the early pregnancy assessment unit is appropriate.
81
A 50-year-old lady presents to her General Practitioner (GP) complaining of hot flushes, night sweats, difficulty sleeping, poor concentration and reduced libido.
The patient continues to have regular periods every month.
She has no significant past medical or family history.
The GP believes that the patient is going through the menopause and offers the patient hormone replacement therapy (HRT).
Which type of HRT is most suitable for this patient?
**Monthly, cyclical (sequential) HRT**
Monthly, cyclical (sequential) HRT is recommended for women with menopausal symptoms who continue to have regular periods. It consists of taking oestrogen throughout the menstrual cycle, with progesterone taken only in the last 14 days. This combination maintains normal monthly periods which is useful because it is then possible to determine when periods naturally stop. When this occurs, it is an indicator of progression to the last stage of the menopause.
82
Who should take each HRT?
## Footnote
**_Monthly, cyclical (sequential) HRT_**
**_3-monthly, cyclical (sequential) HRT_**
**_Continuous combined HRT_**
**_Oestrogen only HRT_**
**_Tibolone_**
**_Monthly, cyclical (sequential) HRT_**
Monthly, cyclical (sequential) HRT is recommended for **women with menopausal symptoms who continue to have regular periods**.
**_3-monthly, cyclical (sequential) HRT_**
Recommended for w**omen with menopausal symptoms who have irregular periods**.
**_Continuous combined HRT_**
It is recommended for post-menopausal women (i.e., 12 months post last menstrual period) or **women who have been on cyclical HRT** for at least a year.
**_Oestrogen only HRT_**
increases the risk of endometrial cancer and is therefore not recommended in **women except for those who have undergone a hysterectomy**.
**_Tibolone_**
Tibolone is a synthetic steroid that has oestrogenic, progestogenic and androgenic properties. **It is an option for women with menopausal symptoms but is unsuitable for peri-menopausal women** (i.e., those within 12 months of their last menstrual period) as it causes irregular bleeding.
83
A 56-year-old lady presents to her General Practitioner (GP) complaining of occasional vaginal bleeding over the last two months.
She is otherwise well and reports that she is no longer sexually active.
Her last period was 18 months ago.
On examination, there are atrophic changes around the vagina; however, bimanual and speculum examination are unremarkable.
**Which of the following is the next best step in management?**
**What is the diagnosis?**
**Urgent referral to gynaecology**
This lady presents with postmenopausal bleeding and the most likely diagnosis is **atrophic vaginitis**.
This is a thinning of the vaginal lining, due to low oestrogens levels during the menopause, that predisposes to bleeding.
However, endometrial cancer is the most serious diagnosis and it must be ruled out.
NICE guidance recommends an urgent referral to gynaecology for all women aged over 55 who present with post-menopausal bleeding.
84
A 38-year-old woman has not had a period in the last 16 months.
On investigation, she had elevated levels of follicle stimulating hormone (FSH).
These bloods were repeated after 5 weeks and the results were the same.
She has no medical or surgical history.
**Which of the following is the most appropriate management?**
**Start combined oestrogen-progesterone hormone replacement therapy until at least 51**
The lack of a period for over 12 months is suggestive of menopause.
Premature ovarian insufficiency is diagnosed when menopause occurs before the age of 40.
The menopause can be confirmed by blood results showing elevated FSH levels.
It is advised that the woman starts hormone replacement therapy (HRT).
As well as symptom control, there are long-term benefits, as replacing oestrogen reduces the risk of osteoporosis and cardiovascular disease.
85
A 44 year old female presents to the Emergency Department complaining of abnormally heavy menstrual bleeding.
She has associated abdominal pain and pain on urination.
She also has a fever and blood tests show a raised ESR, CRP and leukocytosis.
**Given the most likely diagnosis, what investigation will be confirmatory?**
**High vaginal swab**
This is a case of pelvic inflammatory disease, as indexed by dysuria, menorrhagia and objective markers of infection and inflammation. As most causes of PID are infectious in nature, a high vaginal swab is indicated to identify the organisms responsible. The common causes are Chlamydia trachomatis or Neisseria gonorrhoeae.
86
A 15 year old girl is brought to the GP by her mother as she has not started her periods.
So far she has been well and there were no delays in her developmental milestones.
Her mother had menarche at 12 years old.
On examination, there are no abnormal facial features but she has a wide neck and wide spaced nipples.
There is no sign of breast development or axillary hair.
You also notice that she has a short stature.
**What is the likely cause for her primary amenorrhoea?**
Turner’s syndrome
Here, primary amenorrhoea with additional physical features such as wide, webbed neck, wide-spaced nipples and failure to develop secondary sexual characteristics point towards a diagnosis of Turner’s syndrome. This is a genetic condition where the female has only one normal X sex chromosome rather than two.
87
When are Anti-Müllerian (AMH) hormone levels measured?
AMH is hormone that serves as a marker of ovarian reserve. It is decreased in women who have amenorrhoea secondary to premature ovarian insufficiency (POI).
POI leads to high levels of LH and FSH so is unlikely in this case.
In hereditary haemochromatosis, LH and FSH are low as there is hypothalamic failure leading to less GnRH, which usually promotes the release of FSH and LH in the anterior pituitary gland.
88
A 42-year-old Caucasian lady is referred to the gynaecology clinic as she has not had any periods in 8 months.
She also complains of **joint pains** for the last 2 years as well as lethargy.
Her past medical history is significant for **diabetes** diagnosed 4 months ago and **early-stage liver fibrosis** diagnosed 6 months ago.
She has no other past medical history and has never consumed alcohol.
A hormone profile requested by the gynaecologist reveals low levels of FSH and LH.
Which of the investigation would be the next most useful step in order to reach the diagnosis?
**Iron studies**
**liver fibrosis + diabetes = haemochromatosis**
This patient has secondary amenorrhoea which is the cessation of menstruation for at least 6 months in a patient who had periods before.
The symptoms of lethargy and history of recent diabetes together with liver fibrosis point towards a diagnosis of hereditary haemochromatosis.
This is a primary disorder of iron overload and can cause amenorrhoea due to deposition of iron in the hypothalamus and ovaries. Iron studies would reveal elevated levels of serum iron, raised ferritin and raised transferrin saturation. Transferrin levels and total iron-binding capacity (TIBC) would be reduced.
89
Hormonal investigations in PCOS?
| (4)
* LH may be raised in PCOS
* FSH levels remain normal
* Total testosterone: normal/slightly raised
* Fasting and oral glucose tolerance tests: helps diagnose insulin resistance.
90
A 27 year old woman visits the GP asking about types of contraception.
She comments that she currently uses condoms and is looking for a more permanent option.
Having spoken to her friends, she has decided that her preference is for the intra uterine device.
On questioning, it is found that she has a history of both genital herpes and active pelvic inflammatory disease.
**What is the most appropriate advice for this patient?**
Discuss alternative hormonal methods of contraception
The patient may still be eligible for other hormonal methods of contraception, such as the implant, POP and COCP. These are the most effective contraceptives and should be discussed after it has been
made apparent to the patient that an IUD cannot be fitted
91
A 16-year-old girl is known to suffer from heavy periods.
She has recently been started on mefenamic acid and **ferrous** **sulphate**.
She presents to her GP, saying that her periods are now lighter but she now has dark stool.
She has no family history of note and is otherwise well.
**What is the most appropriate course of action? (2)**
**Reassure**
**A potential side effect of ferrous sulphate is the development of dark stool.**
It is a harmless process and the patient can be reassured.
92
A 31-year-old woman presents to A&E with sudden onset pelvic pain, predominantly on the right side, which came on when she was on a run.
She has nausea and vomiting.
She is sexually active and is using the copper coil.
Shortly after arriving, she collapses.
**What is the most likely diagnosis?**
**Ovarian cyst rupture**
Ovarian cyst rupture often presents with sudden-onset abdominal pain, which typically starts during exercise (such as physical activity or sexual intercourse).
93
A 27 year old woman presents to her GP with infertility and **secondary** **amenorrhoea**.
She has some blood tests which show:
* low oestrogen levels
* elevated FSH
* elevated LH
**Which of the following is the most likely diagnosis?**
**Premature ovarian failure**
This pattern of endocrine results is most consistent with primary ovarian failure - low or negligible oestrogen production in the context of high gonadotrophins due to the lack of negative feedback on the pituitary.
94
A 35-year-old woman presents to her GP with dysmenorrhoea.
She also mentions that she has been trying to conceive for the last 2 years without success.
Transvaginal ultrasound is inconclusive.
She is sent for diagnostic laparoscopy which identifies endometrial tissue on the Fallopian tubes and the uterosacral ligaments.
**Which of the following is the most appropriate next step in management of this patient?**
**Laparoscopic ablation of endometrioid lesions**
This is a treatment option which would aim to treat both problems.
Ablation has been shown to reduce pain related to endometriosis.
In the probable event that the endometrial tissue in the Fallopian tubes are impairing egg transfer, then ablation would also improve the chances of successful conception.
95
What is the medroxyprogesterone acetate used to treat?
Medroxyprogesterone acetate
This is a hormonal treatment which mechanism involves suppressing the ovarian function. It is not suitable for a patient who wishes to become pregnant.
96
A 28 year old lady presents to the gynaecology clinic with a 6 month history of heavy menstrual bleeding, increased urinary frequency and constipation.
A trans-vaginal ultrasound scan reveals a 10cm submucosal fibroid.
The lady has no past medical history and would like to start a family in the near future.
**Which is the most appropriate treatment?**
**Myomectomy**
Symptomatic fibroids that are greater than 3cm are usually treated with surgery.
Myomectomy is a surgery that removes the fibroids from the uterus and is the most appropriate option to preserve fertility.
97
A 19-year-old lady presents to her General Practitioner (GP) with a chronic history of lower abdominal pain.
The pain is rated as 4/10 in severity and described as a dull ache that occurs for about two days during the middle of each menstrual cycle.
She states that the site of the pain can vary between the right and left; however, it is predominately right-sided.
**Which of the following is the most likely diagnosis?**
**Mittelschmerz**
Mittelschmerz is mid-cycle ovulatory pain and it is common.
The pain is due to rupture of the Graafian (dominant) follicle, each month, which results in the release of an ovum into the fallopian tube.
The pain can vary from being right-sided to left-sided depending on which ovary is ovulating that month.
Duration of pain can vary from minutes up to a few days and it can be controlled using simple analgesics such as paracetamol and NSAIDs.
98
A 27 year old female presents to the GP on-call list.
She is concerned as she had unprotected sexual intercourse the night before the appointment.
On questioning, it is found that she only uses barrier contraception.
Her periods are 27 days long and she is currently on day 11 of her cycle.
**What is the most effective method of contraception for this patient?** (2)
**Intra-uterine device (IUD)**
**The UPSI would have occurred on day 10 of her cycle, and she would have ovulated on day 13.**
As sperm lasts up to 5 days, there would be a risk of fertilisation, thus emergency contraception should be offered.
The IUD is the gold standard method for emergency contraception and should be offered to all women who require emergency contraception and have no contraindications to the device
99
A 25-year-old woman presents to her GP as she has only had 3 periods over the last 7 months.
She has trying to become pregnant for the last year and not been successful.
On examination, she has a high BMI and has some hyper-pigmentation and thickening of the skin across the back of her neck and in both axilla.
**What is the most likely diagnosis? (3)**
**Polycystic ovary syndrome**
**The hyperpigmentation and thickening (hyperkeratosis)** in these locations is typically of **acanthosis** **nigricans**, which is related to **insulin** **resistance**.
Oligomenorrhoea and insulin resistance (obesity and acanthosis nigricans) are suggestive of polycystic ovary syndrome (PCOS).
100
A 24-year-old lady presents to her General Practitioner (GP) complaining that she has noted a number of episodes of bleeding, after sexual intercourse, over the last 3 months.
She denies dyspareunia, abnormal vaginal discharge or bleeding at any other point in her menstrual cycle.
Her only regular medication is the combined oral contraceptive pill (COCP).
On examination of the cervix, there is a bright red ring that is visualised around the external os.
**Which of the following is the most likely diagnosis? (3)**
**Inevitable miscarriage**
A miscarriage is the spontaneous loss of a pregnancy before 24 weeks.
In an **inevitable** **miscarriage**, patients present with abdominal pain and vaginal bleeding but without evidence of passing any products of conception.
**Importantly, on examination, the cervical os is open.**
The foetus may be alive, as in this case, but a miscarriage is inevitable.
101
A 38-year-old woman with endometriosis presents to her GP.
She has been suffering from cyclical pelvic pain of severity 2/10.
The pain occurs for a few days prior to the onset of menstruation.
She has a past medical history of a peptic ulcer disease.
She has one daughter, and is trying for another child.
**Which of the following is the best management option?**
**Paracetamol**
It a suitable analgesic for low level pain, but is preferable in a patient with **peptic ulcer disease** compared to an NSAID.
SHE CANNOT HAVE MENFAMIC ACID (first line)
102
A 46 year old woman presents to her GP with irregular menstrual periods for the last few months.
She is also concerned that she has lost some weight over the last few months.
She has a past medical history of breast cancer and is currently taking tamoxifen.
She has never had children.
There is nothing abnormal detected on bi-manual pelvic examination.
**What is the most likely diagnosis?**
**Endometrial cancer**
Weight loss should concern the GP that this could be cancer.
Combined with irregular vaginal bleeding the most likely diagnosis is endometrial cancer.
This woman has risk factors for endometrial cancer which are age, taking tamoxifen, and nulliparity.
103
A 32 year old G1P0 at 26 weeks gestation presents to Accident and Emergency with vaginal bleeding.
On further questioning, she reports that that she saw a clear liquid discharge following which she started to experience vaginal bleeding.
**Which of the following is the most likely diagnosis?**
**Vasa praevia**
In vasa praevia, the foetal vessels lie over the internal os, partially or completely.
There is a high risk of bleeding and foetal distress as a result if there is a premature rupture of membranes.
It presents with rupture of membranes followed immediately by vaginal bleeding.
Foetal bradycardia is classically seen on the cardioectography (CTG).
Caesarean section is recommended as the mode of delivery to prevent foetal and maternal complications arising from uncontrolled haemorrhage.
Rupture of membranes (clear fluid) followed immediately by vaginal bleeding. Fetal bradycardia is classically seen.
104
A 56-year-old woman presents to her GP with vaginal bleeding over the last few weeks.
Previously her periods stopped at the age of 50.
The bleeding also sometimes noticeable after sexual intercourse.
She has no past surgical history.
She has had 6 previous pregnancies, with 2 miscarriages and 4 children.
She smokes 20 cigarettes a day but does not drink alcohol.
**What is the most likely diagnosis?**
**Atrophic vaginitis**
Atrophic vaginitis is the most common cause of bleeding in post-menopausal women as the vaginal mucosa becomes drier and thinner.
This can then bleed, especially when there is contact on the mucosa such as during intercourse, leading to symptoms such as post-coital bleeding and dyspareunia.
Overall, although the other diagnoses should not be disregarded, atrophic vaginitis is the most likely diagnosis in this case.
105
A 33-year-old lady presents to the gynaecology clinic with dysmenorrhoea and menorrhagia.
On questioning, she also reports dyspareunia and an inability to conceive for the last 3 years.
A transvaginal ultrasound scan is normal and she, therefore, undergoes a diagnostic laparoscopy that reveals endometriosis.
**Which of the following treatment options would be most appropriate?**
**Laparoscopic diathermy and adhesiolysis**
This patient has infertility that is likely secondary to endometriosis.
The only treatment option that has been shown to improve fertility in endometriosis is surgery.
Laparoscopic diathermy and adhesiolysis is a procedure that removes the endometrial deposits and adhesions from the pelvic cavity.
106
A 19-year-old lady presents to her General Practitioner (GP) with heavy menstrual bleeding.
She reports heavy periods since she can remember; however, the symptoms are now preventing her from going to work during her periods.
She is not sexually active at present, has no plans to conceive in the near future and takes iron supplements for symptomatic anaemia.
An initial panel of blood tests, including haemoglobin, are normal.
**Which of the following is the most appropriate next step in management?**
**Intra-uterine system (IUS)**
This patient has menorrhagia as the heavy blood loss during her periods is affecting her quality of life.
This is most likely not associated with any underlying pathology (i.e., dysfunctional uterine bleeding).
In this scenario, for women who are not trying to conceive, the first-line treatment is a trial of the IUS.
The IUS reduces menstrual blood flow as it causes a thinning of the endometrial lining, which also means it serves as an effective contraceptive.
107
A 56-year-old woman is referred by her GP to gynaecology under 2 weeks wait review after she presented with a history of vaginal bleeding for the last 4 weeks.
At her gynaecological appointment she had a trans-vaginal ultrasound.
This showed a uterus with thickness of 2mm.
**What is the most appropriate next step? (2)**
**What is the most likely diagnosis? (1)**
**Reassure and discharge from clinic**
## Footnote
**If the endometrial thickness is less than 5mm uniformly then the risk of endometrial cancer is less than 1%.**
Atrophic vaginitis is the most likely diagnosis.
108
A 35-year-old lady is referred to colposcopy after her cervical smear sample tested positive for HPV and revealed severe dyskaryosis.
A biopsy taken at colposcopy reveals Cervical Intraepithelial **Neoplasia (CIN) III**.
**Which of the following is the next best step in management?**
Large loop excision of the transformation zone (LLETZ)
**CIN III indicates that atypical cells occupy the full thickness of the cervical epithelium; however, the cells have not breached the basement membrane.**
**This is also known as carcinoma in situ.**
**In CIN I and CIN III, the atypical cells occupy 1/3rd and 2/3ds of the cervical epithelium respectively.**
CIN I regresses spontaneously whereas CIN II and CIN III often progress to invasive cancer. Hence CIN I is usually monitored whereas CIN II and III are treated with procedures such as a LLETZ, cone biopsy or cryotherapy.
In LLETZ the transformation zone (the area of the cervix from which around 90% of cervical cancers originate) is excised using diathermy.
109
**_Cervical cancer Risk factors (_****_4)_**
**_Risk factors_**
HPV 16 and 18 infection (accounts for 70% of cases)
Multiple sexual partners
Smoking
Immunosuppression (e.g. HIV or organ transplants)
110
A 28-year-old lady presents to the Emergency Gynaecology Unit (EGU) with a 3-day history of dark vaginal bleeding and dull lower abdominal pain. She states that her last period was 7 weeks ago. Her past medical history is significant for a left-sided tubo-ovarian abscess that required surgery.
A pregnancy test is positive and a transvaginal ultrasound shows a foetus implanted in the right fallopian tube.
A foetal heartbeat is detected.
Which of the following is the next best step in management?
Right-sided salpingostomy
This patient has an ectopic pregnancy in her right fallopian tube.
**The only treatment option, in this case, is surgical as a foetal heartbeat has been detected.**
A salpingostomy involves an incision into the fallopian tube and removal of the pregnancy.
It is preferred in this case as the patient has had an infection and surgery to her left fallopian tube.
This may mean that the left tube is no longer functioning and hence it would be important to retain the right tube to preserve fertility.
111
A 26 year old attends her GP surgery with pelvic pain.
She describes the pain as cramping in nature and it is located in the suprapubic region.
It occurs 2 days before her period.
Her periods are quite heavy but normally regular.
She also describes pain when she has intercourse and when she opens her bowels.
She mentions that her and her partner have been trying for a baby for 18months and she has not fallen pregnant.
Her cervical smear last year was negative.
Recent investigations including a FBC, vaginal swabs and a pelvic ultrasound were both normal.
**What is the most likely diagnosis?**
Endometriosis
This patient has the 3 cardinal symptoms of endometriosis (dysmenorrhoea, dyspareunia and pelvic pain) along with extra symptoms such as bowel problems and subfertility.
Endomteriosis is not caused by a vaginal infection and rarely is demonstrated on an ultrasound scan, unlike STIs and PCOS, so this makes it the most likely answer.
112
A primiparous 25 year old woman at 35 weeks gestation presents to the labour ward after rupturing her membranes one hour ago.
Since this episode she has experienced continuous bright red vaginal bleeding.
This is first episode of bleeding during the pregnancy so far.
On speculum examination, there is visible liquor and a moderate amount of blood in the vagina.
The patient reports no abdominal pain and otherwise feels well.
The fetal heart rate is 90 bpm and cardiotocogram is non-reassuring.
**What is the most likely diagnosis?**
**What is the triad? (3)**
**Vasa praevia**
Vasa praevia is a condition where the fetal blood vessels (which are unprotected by the umbilical cord) run close to or across the internal cervical os.
This is dangerous as rupture of membranes can cause rupture of the fetal vessels and subsequent fetal haemorrhage.
The classical triad of clinical features is
* painless vaginal bleeding
* rupture of membranes
* fetal bradycardia (fetal heart rate \<100bpm).
113
A 38 year old lady is referred following 2 years of amenorrhoea, she has been experiencing hot sweats, exhaustion and irritability.
She has a background history of type 1 diabetes and vitiligo. She is keen to get pregnant.
**What is the most likely diagnosis?**
**Premature ovarian failure**
* The early age differentiates this from menopause (\<40 years old)
* The symptoms are consistent with oestrogen deficiency.
* There is a strong association with other autoimmune conditions
114
A 56-year-old woman presents to her GP with an itch in her groin, which is especially worse at night.
Examination of the anogenital area reveals several white thickened plaques.
**Which of the following is the most likely diagnosis?**
Lichen sclerosus
This is the correct answer. Lichen sclerosus is a chronic inflammatory skin condition which affects the anogenital area (specifically the glans penis and prepuce in men).
The lesions are white thickened papules and/or plaques.
Itch can occur, and there may be pain if there are fissures or erosions.
115
A 52-year-old lady presents to her General Practitioner (GP) complaining of widespread abdominal pain for the past 6 months.
The pain usually occurs after meals and is often associated with bloating.
She also reports that she has experienced episodes of diarrhoea and constipation periodically over the last 3 months.
When questioned directly, she denies any weight loss or blood in her stools.
**Which of the following is the next best step in management? (2)**
**Arrange CA125 blood test**
This patient has non-specific symptoms that are often attributed to irritable bowel syndrome (IBS).
**However, IBS is a diagnosis of exclusion and ovarian cancer is an important differential to exclude, especially in women over 50.**
Ovarian cancer can present with changes to bowel habit, bloating, abdominal pain, early satiety, increased urinary frequency and weight loss.
NICE guidelines recommended that the first-line investigation is a CA125 blood test for women who experience suggestive symptoms on a persistent or frequent basis.
116
A 30-year-old African lady presents to the General Practitioner (GP) with a 6-month history of menorrhagia.
This is associated with lower abdominal cramps, increased frequency of urination and **swollen legs**.
The patient denies dysmenorrhoea.
On bimanual examination, the patient has an irregular and enlarged uterus.
**What is the most likely diagnosis?**
**Which additional symptoms is the patient most likely to complain of?**
**Constipation**
This patient most likely has fibroids.
Fibroids are more common in Afro-Caribbean women and can present with menorrhagia, lower abdominal pain, infertility and compressive symptoms.
Compressive symptoms may include increased frequency of urination (compression of the bladder), pedal oedema (compression of veins) and constipation (compression of the rectum).
Fibroids may cause dysmenorrhoea however this is less common and occurs in the context of either: sarcomatous change, torsion of the fibroid or red degeneration (haemorrhage into the fibroid)
117
What is Ebstein's anomaly?
Ebstein's anomaly is a congenital heart defect in which there is an abnormality with the tricuspid valve
