Final O&G III

Question 1

Which methods of contraception are safe for breastfeeding? [3]

When can you put in the copper or IUS coils after birth? [2]

Answer 1

The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.

The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks).

A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).

TOM TIP: Remember that the combined pill should not be started before six weeks after childbirth in women that are breastfeeding. The progesterone-only pill or implant can be started any time after birth.

Question 2

How do you dx post-partum endometritis? [2]

Answer 2

• Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
• Urine culture and sensitivities
• Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).

Question 3

A patient wants to start contraception after birth - what advise what you give them?

Answer 3

‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
- after day 21 additional contraception should be used for the first 2 days

Combined oral contraceptive pill (COCP)
* absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
* UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum
* the COCP may reduce breast milk production in lactating mothers
* after day 21 additional contraception should be used for the first 7 days

The intrauterine device or intrauterine system
- can be inserted within 48 hours of childbirth or after 4 weeks.

Question 4

How do you dx retained products of conception? [1]

How do you manage? [2]

Answer 4

Investigation:
* Ultrasound is the investigation of choice for confirming the diagnosis.

Management:
Evacuation of retained products of conception (ERPC) - surgery under general anaethestic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). The procedure may be referred to as “dilatation and curettage”

Question 5

Postpartum anaemia is defined as a haemoglobin of less than [] g/l in the postpartum period. Anaemia is common after delivery due to acute blood loss.

Answer 5

Postpartum anaemia is defined as a haemoglobin of less than 100 g/l in the postpartum period. Anaemia is common after delivery due to acute blood loss.

Question 6

Which systemic condition might cause low milk supply? [1]

Answer 6

Hypothyroidism

Question 7

What is the management for post-partum thyroiditis? [2]

Answer 7

Thyrotoxicosis:
- symptomatic control, such as propranolol (a non-selective beta-blocker)

Hypothyroidism:
- levothyroxine

Question 8

Lecture

What are two risks of SSRI use in pregnancy [2]

Answer 8

neonatal adaptation syndrome
persistent pulmonary hypertension of the newborn

Question 9

What is the mx of anaemia in pregnancy? [1]

Answer 9

oral ferrous sulfate or ferrous fumarate
* treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished

Question 10

Urinary tract infections in pregnant women increase the risk of []. They may also increase the risk of other adverse pregnancy outcomes, such as [2]

Answer 10

Urinary tract infections in pregnant women increase the risk of preterm delivery. They may also increase the risk of other adverse pregnancy outcomes, such as low birth weight and pre-eclampsia.

Question 11

What are the features, invetigations and management of acute fatty liver of pregnancy?

Answer 11

Features
* abdominal pain
* nausea & vomiting
* headache
* jaundice
* hypoglycaemia
* severe disease may result in pre-eclampsia
* ascties

Investigations
* ALT is typically elevated e.g. 500 u/l

Question 12

Why does acute fatty live of pregnancy occur? [2]

Answer 12

Acute fatty liver of pregnancy results from impaired processing of fatty acids in the placenta

The most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, which is an autosomal recessive condition.

Th LCHAD enzyme is important in **fatty acid oxidation, **breaking down fatty acids to be used as fuel. The fetus and placenta are unable to break down fatty acids. These fatty acids enter the maternal circulation, and accumulate in the liver.

Question 13

What is the management of acute fatty liver of pregnancy? [2]

Answer 13

Acute fatty liver of pregnancy is an obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery.

Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.

Question 14

What is the definition of puerperal pyrexia/Infection? [1]

Answer 14

Presence of fever >38°C in a woman in the first 14 days after giving birth

Question 15

What is the management for post-partum infection for sepsis with undefined source? [3]

Answer 15

1. Cefuroxime and Metrondizole (add amakacin if w septic shock)

Question 16

What is the management for post-partum abdominal-pelvic infection (including endometritis)?

Answer 16

1. Co-amoxclav
2. Cefuroxime and Metrondizole (add amakacin if w septic shock)

Question 17

What is the management for Caesarean Wound Infection and Perineal Wound Infection?
- If mild / superficial cellulitis [1]
- If moderate to severe [1]

Answer 17

If mild / superficial cellulitis:
- Flucoxacillin

If moderate to severe:
- co-amox

Question 18

What causes high grade [1] and differentiated [1] VIN?

Answer 18

High grade:
HPV infection - younger women

Differentiated:
- Lichen sclerosis - older women

Question 19

What are the 4 stage of endometrial cancer? [4]

Answer 19

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

Question 20

How do you treat stage 1 and 2 endometrial cancers?

Answer 20

Treatment for stage 1 and 2 endometrial canceri:
- a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).
- if a younger patient wishes to retain fertility, can be counselled on alternative therapy like using progestin (not common use)

Radiotherapy may be used for stage 1B+
- Vaginal brachytherapy and pelvic external beam radiotherapy (EBRT)
- Also for palliative care

Chemotherapy

Question 21

Describe the two types of endometrial tumours [2]

Answer 21

Type 1 tumours (adenocarcinomas) account for the majority of endometrial cancers, and are directly linked to long term exposure to increased oestrogen levels.
- Endometrial adenocarcinoma results from the abnormal proliferation of the endometrial glands due to chronic oestrogen stimulation of the endometrium

Type 2 tumours are rarer and have non-endometrioid histology.
* They are made up of serous and clear cell carcinomas.
* 90% of type 2 tumours are associated with p53 mutations.

Question 22

Describe the difference in referral for endometrial thickness and PV bleeding/not for ?endometrial cancer [2]

Answer 22

If PV bleeding and endometrial thickness >4mm - refer

If no PV bleeding and endometrial thickness >11mm - refer

Question 23

Which are the most common type of endometrial cancer? [1]

Answer 23

Adenocarcinomas:
- more than 75% are endometrioid
- also clear cell, uterine serous carcinomas

Question 24

How do you treat stage 3-4 endometrial cancers? [4]

Answer 24

Stage 3-4 disease:
- Individualised treatment depending on symptoms
- Consideration of hysterectomy – can be minimal access
- Lymphadenectomy – removal of bulky lymph nodes versus full lymphadenectomy (less benefit)
- Removal of all visible disease – likely to improve survival but evidence not as strong as in ovarian cancer

Question 25

A patient wants fertility sparing treatment for their endometrial cancer What is the treatment that can be given [1] What stage of cancer would they need to have for this? [1]

Answer 25

Hormonal treatment: **Grade 1A** - **Mirena Coil +/- oral progesterones** ## Footnote NB: also if unfit for surgical management

Question 26

An endometrial cancer is dx as being a sarcoma. What is the most common type? [1]

Answer 26

**Leiomyosarcoma** Endometrial stromal sarcoma, low grade or high grade Undifferentiated sarcoma

Question 27

What is important to note about carcinosarcoma endometrial cancers? [1]

Answer 27

**carcinosarcoma** are aggressive tumours with a poor prognosis - they are adenocarcinoma but behave like both types of cancer (adeno and sarcoma)

Question 28

Radiotherapy is an adjuvant treatment for endometrial cancer. Which stages are indicated for it? [2] What are the modalities? [3]

Answer 28

**Radiotherapy**: - improves local control but not survival **Indications** * ?stage 1b grade 3 * Stage II-III **Modalities**: * Brachytherapy * External beam pelvic RT * Extended field

Question 29

Where is the most common place for endometrial cancer to reoccur? [1] How do you treat? [+]

Answer 29

Vault

Question 30

# Lecture: Describe the bimodal development of vulval cancers and how this is clinically significant [+] ## Footnote *Important to note - he said in lecture*

Answer 30

**Bimodal developmental pathway: HPV dependent and HPV independent** **HPV dependent**: - **younger** **age** group and **radiosensitive**, better prognosis - **HPV dependent associated with anal, vaginal and cervical tumours** - **Associated** with **VIN** **HPV Independent** - Older women; from lichen sclerosus - Worse prognosis

Question 31

Describe how you investigate for endometriosis [3]

Answer 31

**1st line: Transvaginal ultrasound** Identification of: - **Endometriomas** (endometrial cysts on the ovary) - **Superficial peritoneal lesions** - **Deep endometrial lesions** involving the bowel, bladder or ureters - However: picks up deep lesions, but not superficial. **Abdominal US** - If TVUS refued **Pelvic MRI** * Not used as primary investigation but may be considered to assess the extent of deep endometriosis involving the bowel, bladder or ureters **Laparoscopic surgery** - **gold standard way** to diagnose abdominal and pelvic endometriosis. - A **definitive diagnosis** can be established with a **biopsy** of the lesions during laparoscopy. - Laparoscopy has the added benefit of allowing the surgeon to **remove deposits of endometriosis and potentially improve symptoms.** ## Footnote **NB**: - Diagnostic laparoscopy traditionally gold standard but we are moving away from this - **Presumptive diagnosis** based on symptoms and signs

Question 32

Describe the different management options for endometriosis [+]

Answer 32

**Analgesia**: - A short trial (3 months) of **paracetamol or an NSAID** alone or in combination should be considered for first-line management of endometriosis-related pain - Endometriosis specialists can prescribe **amitrypline or pregabalin** **Hormonal management** - works by suppressing ovarian function and oestrogen release - **COCP** - **POP** - **Mirena coil (IUS)** - **Medroxyprogesterone acetate injection** (e.g. Depo-Provera) - **GnRH agonists** - for more severe / if don't respond. **Hypogonadotropic hypogonadal state** **Surgical management options:** * **Laparoscopic surgery** to excise or ablate the endometrial tissue and remove adhesions - **GOLD STANDARD** - **Abdominal hysterectomy** **with or without bilateral salpingo-oophorectomy** is considered to be the most effective and last-line treatment available for treating the symptoms of endometriosis

Question 33

Describe how you would dx adenomyosis? [3]

Answer 33

**Transvaginal ultrasound** of the pelvis is the first-line investigation for suspected adenomyosis. **MRI** and **transabdominal ultrasound** are alternative investigations where transvaginal ultrasound is not suitable. The **gold standard is to perform a histological** **examination** of the **uterus** after a **hysterectomy**. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.

Question 34

How do you manage adenomyosis if: - the patient does not want contraception [2] - the patient accepts mx with contraception [3] - other (surgical) options [3]

Answer 34

**When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with**: * **Tranexamic acid** when there is **no associated pain** (antifibrinolytic – reduces bleeding) * **Mefenamic acid when there is associated pain** (NSAID – reduces bleeding and pain) **Management when contraception is wanted or acceptable:** * **Mirena coil** (first line) * **Combined oral contraceptive pill** * **Cyclical oral progestogens** **Other & Surgical** * **GnRH agonists** - to induce a menopause-like state * **uterine artery embolisation** * **hysterectomy** - considered the 'definitive' treatment

Question 35

How does the endometriosis lecturer describe how to take COCP? [1]

Answer 35

I tend to recommend ‘**flexible extended use**’, where the woman takes the **pill continuously** until she **experiences bleeding.** She can then **stop the pill for 4 days** to have a short period and then restart continuously again. **This limits the length of period and the number of periods per year and gives greater control**.

Question 36

Describe what is meant by Dienogest? [+] - Main side effect [1] - Other advise [1]

Answer 36

Recently licenced **POP** in the UK after a long delay – only for women with **endometriosis** AKA Zalkya®/Visanne® **Less androgenic** than other progestogens - so less side effects **Main side effect is vaginal spotting** **Manufacturer advises** **additional** **contraception**

Question 37

What are the main benefits of Dienogest? [3]

Answer 37

**Less androgenic** than other progestogens - **so less side effects** Particularly useful for: - **Volume reduction of endometriomas** - **Reduction of size of deep endometriotic nodule**

Question 38

**GnRH agonists** can be used for endometriosis. What might you give alongside this [2] What management would you also need to do

Answer 38

Give **HRT** as induces menopausal like state **Encourage excersise and good diet** Give **bisphosphinates** as GnRH analogues can cause osteoporosis - Start **DEXA** scan at **time of treatment and repeat after two years**

Question 39

What advise would you give about endometriosis and subfertility to a patient? [4]

Answer 39

Most women with endometriosis will conceive spontaneously, however, endometriosis is a leading cause of subfertility Laparoscopic treatment of SPE improves spontaneous fertility rates Laparoscopic treatment of DPE is more controversial and MDT input is advisable Ovarian endometriomas result in reduced monthly fecundity rates

Question 40

**Hypergonadotropic hypogonadism** is the result of abnormal functioning of the gonads. This could be due to [3]

Answer 40

**Previous** **damage** to the **gonads** (e.g. torsion, cancer or infections such as mumps) **Congenital absence of the ovaries** **Turner’s syndrome (XO)**

Question 41

Describe what is meant by **congenital adrenal hyperplasia** [1] How does it present in mild [4] and severe cases [1]

Answer 41

**congenital** **deficiency** of the **21-hydroxylase enzyme**: - **underproduction** of **cortisol** and **aldosterone**, and **overproduction** of **androgens** from **birth**. **Mild cases** - typically present at childhood or puberty: - Tall for age - Facial hair * Absent periods (primary amenorrhoea) * Deep voice * Early puberty **Severe**: * unwell shortly after birth, with electrolyte disturbances and hypoglycaemia. ## Footnote **NB**: In a small number of cases, it involves a **deficiency of 11-beta-hydroxylase rather than 21-hydroxylase**.

Question 42

Describe the diagnosis [2] and management [3] of ASS

Answer 42

**Diagnosis** * **buccal smear** or **chromosomal** analysis to reveal **46XY genotype** * after puberty, **testosterone** **concentrations** are in the **high-normal to slightly elevated reference range for postpubertal boys** **Management** * **counselling** - **raise the child as female** * **bilateral** **orchidectomy** (increased risk of testicular cancer due to undescended testes) * **oestrogen therapy**

Question 43

How do you treat Kallmann's syndrome? [2]

Answer 43

**Treatment**: * **pulsatile** **GnRH** can be used to **induce ovulation and menstruation**. This has the potential to induce fertility * Where pregnancy is not wanted, replacement sex hormones in the form of the **combined contraceptive pill** may be used to induce regular menstruation and prevent the symptoms of oestrogen deficiency.

Question 44

Describe the pathophysiology and presentation of Kallmann's syndrome

Answer 44

**Kallmann's syndrome** is thought to be caused by **failure** of **GnRH-secreting neurons** to migrate to the **hypothalamus** - causing **hypogonadotropic hypogonadism** **Presentation**: * 'delayed puberty' * hypogonadism, cryptorchidism * **anosmia** - **clue in many qs** * sex hormone levels are low * LH, FSH levels are inappropriately low/normal * patients are typically of normal or above-average height

Question 45

Describe how hyperprolactinaemia influences the hypothalamus and causes amenorrhea?

Answer 45

* **High** **prolactin** levels act on the **hypothalamus** to **prevent** the **release of GnRH.** * **Without** **GnRH**, there is **no release of LH and FSH**. * This causes **hypogonadotropic** **hypogonadism**.

Question 46

# s Desribe the hormonal tests are used to assess secondary amenorrhoea [5]

Answer 46

**Beta human chorionic gonadotropin (HCG)** urine or blood tests are required to diagnose or rule out **pregnancy**. **Luteinising hormone and follicle-stimulating hormone:** * **High** **FSH** suggests **primary ovarian failure** * **High LH, or LH:FSH ratio,** suggests **polycystic ovarian syndrome** **Prolactin** can be measured to assess for hyperprolactinaemia, followed by an MRI to identify a **pituitary tumour.** **Thyroid stimulating hormone (TSH)** can screen for thyroid pathology. This is followed by T3 and T4 when the TSH is abnormal. **Raised testosterone** indicates polycystic ovarian syndrome, androgen insensitivity syndrome or congenital adrenal hyperplasia.

Question 47

TOM TIP: It is worth remembering that women with polycystic ovarian syndrome require a **withdrawal bleed every 3 – 4 months** to reduce the risk of endometrial hyperplasia and endometrial cancer. What can be used to do this? [2]

Answer 47

**Medroxyprogesterone** for **14 days, or regular use of the combined oral contraceptive pill**, can be used to stimulate a withdrawal bleed.

Question 48

You've been asked to counsel someone about HRT. You have discussed the menopause, types of HRT and their risks / benefits. What else would should you discuss? [2]

Answer 48

**Discuss contraception:** - **HRT is not contraception** - women are potentially still fertile for a year (>50) or two years (< 50) from menopause - Need to use either barrier methods, POP alongside HRT or Mirena coil (can be used as the P part of HRT - but only lasts for 4 years for HRT) **Discuss alternatives:** - **Mood**: CBT & antidepressants - **Vasomotor symptoms**: SSRIS & clonidine - **Vaginal dryness**: Lubricants - **Irregular periods:** Mirena coil

Question 49

Describe the differences in symptoms from perimenopause --> early menopause --> menopause [+]

Answer 49

Question 50

Clonidine is one non-hormonal treatment that can be used for vasomotor symptoms. Explain how another drug can be used

Answer 50

**Fezolinetant** - Neurokinin 3 receptor antagonist - Acts at level of hypothalamus on temp regulation

Question 51

What are three unlicensed drugs that can be used to treat vasomotor symptoms? [3]

Answer 51

**SSRIs/SNRI (venlafaxine)** * licensed for depression * SEs dry mouth, nausea, constipation, weight gain **Oxybutynin** * licensed for overactive bladder * SEs dry mouth, dry eyes, nausea, diarrhoea **Gabapentin (Controlled drug)** * Licensed for neuropathic pain and epilepsy * SEs dizziness, fatigue, tremor, weight gain

Question 52

Describe the risk of oestrogen only vs oestrogen and progesterone HRT for endometrial cancer [2]

Answer 52

**Endometrial cancer**: * **Oestrogen only**: increased risk * **O & P:** decreased risk

Question 53

How long can you continue taking HRT? [1]

Answer 53

As long as want, no cut off date

Question 54

A diagnosis of PCOS requires at least two of: [3]

Answer 54

Anovulation Hyperandrogenism Polycystic ovaries on ultrasound

Question 55

Describe the difference between follicular and corpus luteums cysts [2]

Answer 55

**Follicular cysts** - represent the developing follicle. - When these **fail to rupture** and release the egg, the **cyst** can **persist**. - Follicular cysts are the **most common ovarian cyst**, they are **harmless** and tend to **disappear** after a **few menstrual cycles**. - Typically they have **thin walls and no internal structures**, giving a reassuring appearance on the ultrasound. **Corpus luteum cysts** - occur when the **corpus luteum fails to break down and instead fills with fluid**. - They may **cause pelvic discomfort, pain or delayed menstruation.** - They are often seen in **early pregnancy.**

Question 56

Describe what theca lutein cysts are [1] and when they occur [2]

Answer 56

Caused by **overstimulation** of **hCG** during **pregnancy** - stimulates growth in **follicular theca cells** - occur in **high** **hCG**: **multiple pregnancy; trophoblastic disease** ## Footnote **NB**: Theca cells are essential for female reproduction being the source of androgens that are precursors for follicular oestrogen synthesis

Question 57

Which investigations would you conduct for ?ovarian cysts [2]

Answer 57

**Blood tests:** - If **premenopausal** w **simple cyst < 5cm on US** - none - **CA125** helps determine if cyst is related to cancer - If under 40 and complex cysts - need tumour markers **(AFP; LDH; HCG)** **Abdominal Ultrasounds**: * **simple**: unilocular, more likely to be physiological or benign * **complex**: multilocular, more likely to be malignant

Question 58

As per RCOG how do you monitor cysts if: o If pre-menopausal + asymptomatic simple cyst < 5 cm [1] o If 5-7 cm --> [1] o If > 7 cm --> [1] o If multilocular, acoustic shadowing, or solid components (i.e., not simple cyst) --> [1] o If post-menopausal --> [2]

Answer 58

o **If pre-menopausal + asymptomatic simple cyst < 5 cm** --> **no follow-up** o **If 5-7 cm**: - **repeat USS in 1 year, and if growing** --> **refer** o **If > 7 cm** --> **refer** o **If multilocular, acoustic shadowing, or solid components (i.e., not simple cyst)** --> **refer** o **If post-menopausal** --> **CA-125, and if normal + asymptomatic simple cyst < 5 cm** --> **repeat USS in 4-6 months**

Question 59

What would be the referral protocol if: - postmenopausal, raised CA125

Answer 59

* Cysts in postmenopausal women generally require correlation with the **CA125 result** and referral to a **gynaecologist**. When there is a **raised CA125, this should be a two-week wait suspected cancer referral**. * **Simple cysts under 5cm with a normal CA125** may be monitored with an **ultrasound every 4 – 6 months.**

Question 60

What are the 4 types of FGM? [4]

Answer 60

**Type 1**: Removal of part or all of the clitoris **Type 2:** Removal of part or all of the clitoris and labia minora. The labia majora may also be removed. **Type 3**: Narrowing or closing the vaginal orifice (**infibulation**). **Type 4**: All other unnecessary procedures to the female genitalia.

Question 61

Pelvic organ prolapse can be classified according to the affected compartments. What are they? [3]

Answer 61

**Anterior** **compartment**: - cystocele (bladder herniation) and urethrocele (urethral herniation) **Middle compartment**: - uterine prolapse (uterus descent) and vaginal vault prolapse (post-hysterectomy) **Posterior compartment**: - rectocele (rectal herniation) and enterocele (small bowel herniation)