Gynae MCQ pool Flashcards by Steph Peterson

While you are dissecting on the medial aspect of the psoas muscle at the level of the pelvic brim, which of
the following structures is most likely to be injured?
a. External iliac vein
b. External iliac artery
c. Ureter
d. Genito-femoral nerve
e. Obturator nerve

Answer: E (probably best answer – C next best)

– the obturator nerve descends
through the psoas major muscle, leaving the MEDIAL border of the muscle at the LEVEL of the PELVIC
BRIM. However, it does say that it is more likely to be damaged in the lower pelvis where it lies in extraperitoneal fat and is liable to damage during operations to remove pelvic lymphatics.

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Which vessel is not contained in ischiorectal fossa?
a. perineal
b. pudendal

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Which of the following is divided in performing an omentectomy?
a. Omental branch of the abdominal aortic artery
b. Middle colic artery
c. Epigastric artery
d. Gastroepiploic artery
e. Median sacral artery

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Pubourethral ligament contains?
a. collagen
b. collagen, elastin
c. collagen, elastin, muscle

C
Histologically the ligaments consist of smooth muscle, elastin, collagen, nerves and, blood vessels

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In anatomical position, the angle of the vagina is upwards and backwards**
a. 90 degrees
b. 135 degrees
c. 260 degrees
d. 310 degrees

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Where does the paravaginal fascia insert?
a. Arcus tendineus
b. Iliopectineal line
c. Urogenital diaphragm
d. Perineal body
e. Sacrospinous ligament

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The structure posterior to the external iliac artery and vein and would dissect medially off the psoas
muscle is:
a. Superior gluteal artery
b. Obturator nerve
c. Ureter
d. Uterine artery

Likely C
Probably ureter as the obturator nerve lies very deep to the external iliac artery, despite the ureter not
being truly posterior to the external iliac artery

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How many oocytes are left by the time a woman reaches puberty?
a. 4000
b. 15,000
c. 30,000
d. 100,000
e. 400,000

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What histological change occurs in the post-menopausal ovary?
a. Increased number of granulosa cells
b. Increased immature oocytes
c. Increased stromal cells
d. Increased theca interna cells

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Cystic glandular hyperplasia associated with?
a. cyclical HRT
b. depot MPA
c. NIDDM
d. COCP

C (unopposed oestrogen)

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Which of the following conditions require urgent surgical treatment?
a. acute appendicitis
b. acute cholecystitis
c. acute pancreatitis
d. acute pyelonephritis
e. acute osteomyelitis

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60 yo with several year history of LIF pain. Temp 38, raised WBC (15,000), few WBC in urine, unwell. Most
likely diagnosis?
a. acute appendicitis
b. acute cholecystitis
c. acute diverticulitis

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Effect of electrosurgical waveform with high current, low voltage and increase tissue temperature rapidly
(>100 degrees to result in vaporization)**
a. Cut
b. Fulguration
c. Coagulation
d. Blend
e. Desiccate

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After a vaginal hysterectomy, the patient is brought back to theatre for primary haemorrhage. In ligating
the internal iliac arteries, which of the following structures is most likely to be injured?
a. external iliac arteries
b. external iliac veins
c. ureters
d. obturator nerve
e. common iliac arteries

Most likely B, possibly C

a. external iliac arteries (lateral and should not come into play)
b. external iliac veins (most likely answer – will sit just infero-lateral to internal iliac and is
bulbous at level of bifurcation)
c. ureters (always in play even with a gynaecologist doing neurosurgery, but crosses internal iliac
from medial to lateral and should be below it at level of internal iliac)
d. obturator nerve (you are going medial to psoas and so are far enough away from the nerve)
e. common iliac arteries (should be below it at level of internal iliac)

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Difficult endometriosis TAH. Sudden profuse bleeding from L paracervical tissue. Mx?
a. large clamp laterally
b. pack and call for help
c. clamp aorta above pelvic brim
d. clamp common iliac
e. finger to occlude common iliac then identify ureter

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Day 1 post TAH for benign pathology, the patient is SOB and has severe central chest pain. O/E – T 36.7,
PR 110, RR 28, BP normal. CXR shows bibasal atelectasis, WCC 11, pO2 66 mmHg. Next step?
a. Antibiotics
b. V/Q
c. Pulmonary angiogram
d. Blood transfusion

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Raised temp 12-24 hrs following TAH?
a. vault cellulitis
b. septicaemia
c. DVT
d. Reaction to transfusion

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A 30 yo with TAH for intraepithelial Ca of the cervix. Flushed, temp 39 C, PR 140/min, RR 24, clear chest.
Most likely diagnosis?**
a. PE
b. Pelvic sepsis secondary to bacteroides fragilis
c. Beta Strep
d. Pelvic vein thrombosis
e. Reaction to blood

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A 100kg woman had a routine TAH for uterine fibroid. On post operative day 5, temp 38, there was profuse watery discharge from the wound. What is your management?
a. return to theatre
b. commence on antibiotics
c. apply pressure dressing
d. perform an IVP
e. no treatment needed

D - intravenous pyelogram

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5 days post TAH, vertical incision, serous ooze, Mx?
a. nothing
b. Steristrip
c. antibiotics
d. probe

D - probe with swab

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A TAH, BSO was performed for extensive endometriosis. The operation took approximately 2 hours. On
day 1 post op review, the patient c/o numbness on the anterior aspect of the right thigh and weakness on
flexion of the right hip. Which of the following is most likely?
a. patient has a psoas haematoma
b. pressure effect of the retractor during the long operation
c. patient has a pelvic haematoma
d. your assistant has been leaning on the thigh
e. Duplex Doppler to exclude DVT

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Difficult hysterectomy with endometriosis, significant blood loss of 2 litres throughout the procedure. At
the end of the procedure is noted to have a haemostatic suture too close to what you thought was the
ureter. Your next options are:
a. Do nothing but closely observe in the next couple of days
b. Remove the suture
c. IV indigo carmine and watch the dye through the ureter
d. Do a cystotomy at the operation and pass some catheters up the bladder to make sure the
ureter is patent

D - but cystoscopy is probably more appropriate

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Difficult TAH for endometriosis, difficulty with haemostasis. Finally haemostasis secured but stitch
uncomfortably close to left ureter at top of vaginal vault.
a. Do nothing, observe closely post-op
b. Ureterotomy at level of pelvic brim and insert ureteric stent
c. Cystotomy and insert stent into left ureter
d. Injection of indigo carmine IV and follow dye flow through ureter
e. Remove suture

C - but cystoscopy likely more appropriate

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At end of TAH there is fluid in pelvis that looks like urine. What do you do?
a. Sterile milk into bladder
b. Dissect out ureters
c. Ask anaesthetist to give IV indigo carmine
d. Redivac drain and close
e. IDC x 10 days and close

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During a TAH for severe endometriosis a 1cm longitudinal laceration is made in the sigmoid colon. Your management would be: a. Anterior resection b. Hemicolectomy c. Repair defect in colon d. Repair defect and form transverse loop colostomy e. Repair defect and form caecostomy

The proven benefits of subtotal hysterectomy include: a. Reduced hospital stay b. Better sexual function c. Reduced risk of vault prolapse d. All of the above e. None of the above

You are performing a laparoscopy for infertility and when inserting the Verres needle get a constant stream of blood coming out of it. You remove the needle and the anaesthetist says her HR/BP etc are stable. Do you? a. Abandon laparoscopy and discharge patient home b. Observe for 48 hrs c. Laparoscopy with Hassan entry d. Laparoscopy with Verres in LUQ e. Do laparotomy

The highest mortality with laparoscopic tubal ligation is due to a. Vascular injuries b. Perforation of abdominal viscus c. General anaesthetic d. Air embolism e. Infection

When would neo-uretero-cystotomy be the most appropriate procedure? a. ureter divided closer to the trigone b. ureter divided at the pelvic brim c. ureter ligated and immediately recognised d. ureter ligated and recognised just prior to peritoneal closure e. ureter clamped for 30 secs

When would re-anastomosis with splint be most appropriate? a. ureter divided closer to the trigone b. ureter divided at the pelvic brim c. ureter ligated and immediately recognised d. ureter ligated and recognised just prior to peritoneal closure e. ureter clamped for 30 secs

B, or possibly D - if divided for prolonged time a splint is needed) a. ureter divided closer to the trigone (close to trigone assume not enough distal ureter for primary anastomosis and would suggest hitch and reimplantation) b. ureter divided at the pelvic brim (most likely answer- but I would prefer a Boari flap at this level) c. ureter ligated and immediately recognised (this dose tell us where injury has occured, so not the most appropriate answer also ligating it would disrupt blood supply so I would resect before anastomosis) d. ureter ligated and recognised just prior to peritoneal closure (presume ligated for a while so woud require resection of likely avascular area prior to anastomosis) e. ureter clamped for 30 secs (crushing injury from clamp--> resect before ansstomosis Reimplantation is treatment of choice due to the high chance of stenosis with reanastomosis but there are limited options with high injuries. D/W Naven: Some people could suggest that uretreoureterostomy in the pelvis should always be accompanied by psoas hitch and reimplantation. But ureteroureterostomy OK in abdo and pelvis above cardinal ligament.

When is uretero-ureteral anastomosis most appropriate? a. ureter divided closer to the trigone b. ureter divided at the pelvic brim c. ureter ligated and immediately recognised d. ureter ligated and recognised just prior to peritoneal closure e. ureter clamped for 30 secs

B Reimplantation is treatment of choice due to the high chance of stenosis with reanastomosis but there are limited options with high injuries. D/W Naven: Some people could suggest that uretreoureterostomy in the pelvis should always be accompanied by psoas hitch and reimplantation. But ureteroureterostomy OK in abdo and pelvis above cardinal ligament.

Ten days after a vag hyst a patient developed a watery vaginal discharge. IVP demonstrated an ureterovaginal fistula 3cm above the ureterovesical junction. What is the appropriate treatment? a. Uretero-ureteral reanastamosis b. Reimplantation of the ureter c. Perform a Boari flap d. End to end reanastomosis e. Insertion of a suprapubic catheter and await spontaneous closure

You are performing an endo-cervical curettage, which of the following is correct? a. Dilate internal os, uterine curettage then endocervical b. Dilate internal, endocervical curette, uterine curette c. Endocervical curette, dilate internal os then uterine d. Uterine curette, dilate internal os, endocervical curette

Suction curettage for missed abortion at 10/40. What size suction catheter should you use? a. 6 b. 8 c. 10 d. 12 e. 14

Perforated uterus at D&C with haemorrhagic shock. Most likely site of perforation? a. fundal b. anterior c. posterior d. cervical e. lateral

Answer: E (location of vessels)

While performing a suction TOP, the uterus is perforated and omentum pulled down to the external os. Management? a. observe b. AXR and observe c. Hysterectomy d. Laparoscopy e. Laparotomy and oversew defect

During TOP, uterus is perforated. Safest option is: a. hysterectomy b. observe c. laparoscopy d. laparotomy

.A woman had a termination of pregnancy at 8/40 gestation at a local clinic under LA. The cervix was difficult to dilate and the uterus appeared to be perforated during this dilation. There was no bleeding or pain. A TVS was performed and showed a viable 8/40 fetus with an intact sac. What is the most appropriate management? a. Continue with the termination b. Transfer to hospital and continue termination under GA c. Insert a cervagem vaginally and wait 4 hrs then attempt the suction termination d. Perform a laparotomy and repair the defect, continue with suction termination with hysterotomy and removal of POC if necessary e. Stop the procedure and wait 1-2 weeks then reconsider

TeLindes and UTD state that if perforation occurred with blunt instrument (sound or dilator) then the procedure can be continued under ultrasound guidance. If concerns exist around bleeding laparoscopy is done and the procedure can be finished under laparoscopic guidance Answer ?E

ND YAG laser hysteroscopy. Which medium? a. CO2 b. Glycine c. Dextrose d. Sorbitol e. N Saline

You are doing a hysteroscopic resection of uterine septum and no complications. Just about to remove gloves when note brisk PV bleeding with no obvious vaginal or cervical lesion. Mx? a. pack vagina and cervix with betadine gauze b. laparotomy c. look with hysteroscope d. foley catheter in uterus e. blood product Tx – packed cells/FFP/ cryoprecipitate

Operative hysteroscopy – when are you most likely to perforate? a. Dividing septum b. Submucous fibroid resection c. Rollerball

Advantages of hysteroscopic scissors tha slipt over scope but in sheath. a. Cost b. Flexible distance between scope and scissors c. Heavier more robust rigid scissors possible d. Scissors only take up 1/4 of view

The patient had a radical hysterectomy and in the immediate post-operative period has difficulty walking and the next day she has paraesthesia over her left thigh as well as an absent patella jerk. Which of the following nerves would be appropriate? a. Obturator b. Femoral c. Internal pudendal d. Sciatic

When you are doing a radical hysterectomy you make a hole in the external iliac vein. What is you immediate management? a. put a finger over the hole b. put a sponge over the hole c. put a Kelly clamp over the hole d. put a Kelly clamp distal to the hole e. put a Kelly clamp proximal and distal to the hole

A (Kelly clamp is similar to an artery clip)

During a radical hysterectomy the uterine artery is divided at which of the following: a. At its origin adjacent to the hypogastric artery b. Adjacent to the ureter c. Where it meets the uterus d. In the wall of the uterus

A 35 yo decided on hysterectomy and bilateral BSO for intractable chronic PID. She has heard that hysterectomy is associated with change in sexual function, decreased energy and loss of a sense of wellbeing. You counsel her that? a. It will not affect her orgasm b. She will experience no changes to sexual function as long as one ovary is left c. Her sexual response will be affected by her and her partner’s response to the operation d. Her energy levels will be unchanged as long as she takes oestrogen

Small cyst found in midline at the fourchette. Most likely a. Bartholin’s cyst b. Epidermal inclusion cyst c. Sebaceous cyst d. Gartner’s duct cyst

A small lump is noted in the vagina in the region of the posterior fourchette. It is most likely to be: a. Epidermoid cyst b. Sebaceous cyst c. Gartner’s duct cyst d. Bartholin’s cyst

Accepted time of resting for a girl who has sustained genital trauma? a. 20 mins b. 6 hrs c. 24 hrs d. 3 days e. 4 days

C (as per UTD)

The amount of time before surgery that clear fluids should be stopped in paediatric patients is? a. 2 h b. 6 h c. 12 h d. 24 h e. Can eat up till time of surgery

Normal menstrual cycle exhibits the following hormonal changes. Which of the following is correct? a. LH surge occurs 12 h before ovulation b. LH surge is due to a positive feedback from relatively high oestrogen levels in the late follicular phase c. Short pulses of GnRH occur during REM sleep d. Maximum rate of oogenesis occurs at the trough of gonadotrophin secretion e. In puberty, there is rise of LH before FSH

B Ovulation occurs 10-12 hours after the LH peak but the surge begins 34-36 hours prior to ovulation; LH surge is due to a positive feedback from relative high levels of oestrogen in the late follicular phase; FSH rises before LH during puberty; GnRH pulses during awake according to Kate. A, E are definitely incorrect, D is probably incorrect. Maximal oogenesis is fetal?

What enables a follicle to become dominant over others? a. Production of progesterone during luteal phase b. Production of inhibin by those follicles destined for atresia c. Production of oestradiol d. Induction of prolactin receptors e. Ooph-hypophyseal reflex

Oestrogen receptor present on all except? a. rectum b. uterosacral ligament c. vagina d. urethra

Blood Assay steroid – Which is direct measure of adrenal androgen activity? a. Androstinedione b. Cortisol c. DHEAS d. Testosterone

What will lower the SHBG? a. Pregnancy b. Weight loss c. Oestrogen d. Hyperinsulinaemia

D Pregnancy, hyperthyroidism and oestrogen increase SHBG whilst corticoids, androgens, progestins, growth hormones, insulin and IGF-I decrease SHBG

Main hormone secreted by the PCO ovary? a. Testosterone b. Androstenedione c. Oestrone d. Oestradiol e. DHEAS

Which steroid has the most effect on serum concentration of lipoproteins: a. Testosterone b. Oestrogen c. Natural progesterone d. Synthetic progesterone e. Glucocorticoids

Subcut oestradiol therapy exhibits the following differences when compared with oral oestrogen: a. A physiological ratio of estradiol to estrone is achieved b. Rarely causes endometrial hyperplasia c. Leads to more abnormal changes in clotting factors d. Is less likely to increase serum level of renin substrate e. Is more effective in the prevention of osteoporosis

A Oral – increases SHBG, TBG, Lipids, Corticosteriod binding globulin Transdermal AS effective in bone preservation & osteroperosis, less effect on lipids Oral – greatest effect on clotting factors Physiological state = 2:1 oestradiol to oestrone. Oral preparations metabolised to oestrone by liver – therefore physiological state not maintained.

In an obese postmenopausal woman the commonest hormone is a. Oestriol b. Oestradiol c. Oestrone d. Androstenedione

Answer: C main postmenopausal E2 = oestrone (from peripheral adipose tissue & aromatisation of androstenedione in ovary – this comes from adrenals).

Time after ovulation for eggs to reach uterine cavity? a. 5 hours b. 36 hours c. 1 day d. 4 days e. 7 days

For how long does an unfertilised ovum remain viable after ovulation?** a. 12-24 hrs b. 24-48 c. 72 hrs d. 4 days

A Most estimates range between 12-24 hours although retrieved eggs can be fertilised up to 36 hours of incubation. (Speroff)

What are the characteristics of beta hCG in early pregnancy? a. enhances placental-fetal adrenal steroidogenesis b. supports the corpus luteum c. enhances the effects of maternal blocking antibodies d. maternal serum level rises to a peak at 14w e. is chemically and functionally similar to ACTH

B HCG is produced by the syncytiotrophoblast to promote progesterone production by the corpus luteum until placental progesterone supply is established (after 6 weeks). HCG also plays a role in spiral artery angiogenesis (UTD). The alpha subunit is identical to that of TSH, LH and FSH. HCG levels peak at 8-11 weeks gestation

Young sexually active female with non-offensive white PV discharge. PH < 4.5. What is the cause? a. Gardeneralla b. Thrush c. Physiological d. Gonorrhoea

Which of the following is the earliest sign of female sexual response? a. Increased HR b. Uterine contraction c. Vaginal transudation d. Vasocongestion of the outer third of the vagina e. Erection of nipples

The first sign of sexual arousal in a woman is? a. Enlargement of the clitoris b. Enlargement of the labia majora c. An increase in vaginal length d. An increase in vaginal moisture e. Skin flushing

The most common cause of inhibition during the excitement phase of arousal in marital sex is? a. Menopause b. Hysterectomy c. Fear of pregnancy d. Marital discord e. Empty nest syndrome

A woman presented to you with lack of sexual excitement. What is the most likely reason? a. Fear of pregnancy b. Poor coital techniques c. Marital discordance d. Endometriosis e. Pelvic congestion syndrome

Match drug with effect in endometriosis a. GnRH agonist b. Danazol c. Both d. Neither Delays return of ovulation after cessation Hot flushes An increase in LDL-cholesterol

Delays return of ovulation after cessation Answer: D Hot flushes Answer: C An increase in LDL-cholesterol Answer: B (Danazol increases LDL and total cholesterol, and decreases HDL)

Which medication is not used in treatment of menorrhagia? a. neostigmine bromide b. oestrogen c. GnRH agonist d. Progesterone e. Methyl testosterone

A (side effect of methyltest = amenorrhoea)

Danazol is associated with all EXCEPT a. Fluid retention b. Acne c. Virilisation d. Exacerbation of fibrocystic disease of breasts

Which action of the following anti androgens is the least accurate? a. Cyproterone acetate acts on the 5 alpha reductase receptor b. Spironolactone acts on the DHT receptor as well as 5AR receptor c. Cimetidine acts as a weak binder to DHT receptor d. Flutamide is a non-steroidal anti-androgen e. Finasteride 5AR blocker

A Cyproterone and spironolactone bind to androgen receptor and exert mixed agonism-antagonism. Flutamide is a pure antiandrogen and blocks receptors with competitive inhibition (Speroff). Spironlactone competitively inhibits DHT and 5AR. Cyproterone competitively inhibits DHT. Flutamide inhibits nuclear binding of androgens but has weaker affinity than cyproterone or spironolactone. Cimetidine has a weak anti-androgenic effect on DHT receptors. Finasteride is a specific inhibitor of 5AR with some activity on DHT (Novak). Testosterone by 5 AR (ketoconazole/spironolactone/finasteride) → DHT by androgen receptor complex (flutamide, cyproterone, spironolactone)

The most effective anti-androgen available is? a. Danazol b. MPA c. Dexamethasone d. Spironolactone e. Cyproterone

Hormones with antiandrogen action include the following, except: a. Spironolactone b. Cyproterone acetate c. Cimetidine d. Flutamide e. Tamoxifen

Tamoxifen has been proven to? a. Reduce hospital admissions with cardiac disease b. Reduce bone fracture c. Be associated with hyperplasia d. All of them e. Lower total and LDL cholesterol

D The effects of tamoxifen are uncertain with prevention of bone loss in postmenopausal women but premenopausal women experienced substantial bone loss; reduces total cholesterol and LDL cholesterol; less coronary heart disease; association with endometrial hyperplasia and cancer

Drugs which cause haemolytic anaemia a. penicillin b. methyldopa c. cefoxitin d. all of the above e. none of the above

All of the following drugs are associated with impotence except? a. cimetidine b. Aldomet c. Salzopyrine

All of the following are associated with impotence except? a. Spinal cord lesion b. Methyldopa c. Salazopyrine d. Hyperprolactinaemia e. Chronic renal disease

What is the most common factor associated with ejaculatory impotence? a. Alcohol b. Diabetes c. Methyldopa d. Marital discordance e. Peyronie’s disease

Which is right? a. medroxyprogesterone acetate and virilisation of female fetus b. Clomid and alopecia

"Answer: A BOTH ARE CORRECT"

Select the correct option regarding side effects of hormone drugs a. Depo Provera is well documented to cause congenital abnormalities in infants b. Medroxyprogesterone acetate causes virilisation of male infants c. Clomid is associated with hair loss d. Bromocriptine is associated with hypertension

C Clomid can rarely cause hair loss, bromocriptine occasionally causes both hypertension and hypotension. Quite difficult to virilise a male infant.

Select the incorrect option regarding the side effects of hormonal agents: a. Depo-provera is well documented to cause congenital abnormalities b. Medroxyprogesterone acetate causes fetal virilisation c. Clomiphene is associated with hair loss d. Bromocriptine is associated with hypertension e. Venous thrombosis is associated with oestradiol implants

Severe acne, before Rx with retinoic acid needs? a. HCG b. FSH c. Oestrogen

What is the recognised clinical action of the antiprogestins? a. Endometriosis b. Post coital contraception c. Hot flushes d. Endometrial hypoplasia

B Mifepristone can be used for emergency contraception and to a lesser extent endometriosis

The most common side effect that causes discontinuation of selective serotonin reuptake inhibitors is? a. Cardiac dysfunction b. Sexual dysfunction c. Pulmonary hypertension d. Anticholinergic effects including dry mouth and constipation e. Sedation and lethargy

Starting dose of bromocriptine? a. 1.25 mg nocte increasing to 2.5 mg BD with food over 2/52 b. 1.25 mg nocte increasing to 10mg /day over 2/52 c. 1.25 mg tds initially and increase

Reason for failure of bromocriptine treatment? a. Under dosage b. Non-compliance c. Intolerance of symptoms

What is the most common symptom of benign breast disease? a. Pain b. Tender lump c. Change in breast size d. Discharge e. Change in menses

Answer: A Cyclical, non cyclical or mammary

Woman with chronic pelvic pain. All Ix normal. She finally says she does not know if she can cope with her husband’s physical abuse of her for much longer. Is this form of abuse a. Easy to treat with counselling once recognised b. Usually first picked up by physicians c. Gets better in pregnancy d. Women/the victims fear being left alone

You are seeing a 20 yo in ED who presents within 3 hrs of a sexual assault. In giving her psychological counselling as to what she can expect you explain that she is likely to experience? a. Anger and aggression followed by a rapid return to normal function b. Anger and aggression followed by a long period before full recovery c. Fear and somatic symptoms followed by a rapid return to normal function d. Fear and somatic symptoms followed by a long period before full recovery

Answer: D Anger / Fear / Anxiety & Physical pain then somatic symptoms Second stage = somatic symptoms

You are asked to assess a woman who was raped 6 hrs ago. Which of the following is least likely? a. She will develop fear and anxiety with restlessness b. Somatic symptoms of headaches, fatigue and sleep disturbance c. Emotional reactions of anger, self-blame and humiliation d. Those with severe somatic symptoms tend to recover faster

.ou examine a woman who has been raped. 24 hrs afterwards her attorney phones to say there was no sperm or acid phosphatase on the specimens collected. Your reply? a. You did not want to make a statement anyway b. Both tests were probably showing false negatives c. About 1 in 3 rapists have some form of sexual dysfunction d. The man probably had a vasectomy

B or possibly C

Which of the following scenarios constitutes aggravated criminal sexual assault? a. Sexual assault where the woman is not the wife b. Where the penis penetrates the vagina c. Where consent is not given d. Where the victim has been coerced by the display or use of a weapon e. Where force is used

The most common cause of injury in women is? a. Automobile accidents b. Domestic violence c. Muggings d. Rape e. Athletic injuries

The pearl index a. % become pregnant using a particular contraceptive b. % do not get pregnant c. Number of pregnancies / 100 woman years d. Number of pregnancies / 1000 woman years

The most effective post coital contraception is: a. Ethinyloestrodiol 50mg for 5 days b. Ethinylestradiol 100mcg and norethisterone 500mcg repeat in 12 hours c. Provera 10mg for 5 days d. Danazol 200mg for 5 days

B Current recommendations are levonorgestrel 0.75mg 12/24 apart or 1.5mg as a single dose (89% of pregnancies prevented). Other options include Yuzpe regime (E+P) as above (75-80% of pregnancies prevented, more side effects). Copper IUD within 120 hours of intercourse (90%) and mifepristone 600mg (100%) were other options. The Cochrane review on the topic discussed Danazol and the five day E approach and said that they didn’t hold any advantage over Yuzpe. Speroff says danazol is not effective. Additionally the 5mg E dose is 5mg not 50mg.

You are seeing a rape victim 12 hrs after the event. She is on day 13 of a 28-30 day cycle and wants the best advice re contraception. The options are: a. Nothing b. 10 mg of progesterone for 5 days c. Oral contraceptive pill for five days d. Vaginal douching e. Intrauterine saline wash out

Sex 24 hrs ago but condom broke. Which is true? a. Ethynyl oestradiol plus norgestrel should be given within 96 hrs after unprotected sex b. Ethynyl oestradiol 5mg/day for 5 days within 96 hrs c. After 1 unprotected midcycle intercourse, pregnancy rate about 15% can be expected d. Pregnancy rate after postcoital contraception is about 5% e. 90% of women after postcoital hormone treatment get withdrawal bleed within 14 days

C and E Emergency contraception should be used within 72 hours of unprotected intercourse; unprotected midcycle intercourse is about 20%, although Speroff says 8% after single act of intercourse; pregnancy rate following emergency contraception is less than 5%; 90% get a period on time or early

What is the concern about the pregnancy after failed morning after pill? a. Multiple pregnancy b. Abnormal fetus c. Increased risk of ectopic d. Increased risk of miscarriage e. Higher risk of premature labour

C Ectopic pregnancies have been reported anecdotally following emergency oral contraception. In theory progestational agents may inhibit tubal mobility and predispose to ectopic implantation, but none of the emergency oral contraceptive regimens in use increase the risk. (Speroff).

All effective post-coital contraception except? a. Yuzpe regime b. levonorgestrel c. IUCD d. RU 486 e. Single dose danazol

What is the least correct statement regarding contraception or MAP (they weren’t sure which) a. RU486 plus misoprostol 400mg oral 48/24 later b. RU 486 plus misoprostol 800 mg PV 48/24 later c. Mifepristone had been approved for the use in the USA as contraception (or maybe TOP)

All are correct if the question refers to TOP. If using mifepristone as a morning after pill a single dose of 600mg is effective. It is not licensed as contraception or MAP; only licensed for TOP Answer: C

Which is most effective contraception? a. OCP b. Depot Provera c. Condoms

B OCP – 0.1/7.6; depot – 0.3/0.3; condoms – 3.0/13.9; minipill – 0.5/3.0

Failure rate in users of which contraceptive is 1% a. COCP b. Depo Provera c. POP d. Condoms

B a. COCP – 8% b. Depo Provera c. POP – 8% d. Condoms – 15%

In typical users, which has a pregnancy rate below 1%? a. Depot MPA b. Condoms c. POP d. COCP

Largest drop out rate in first year of use? a. Micronor (POP) b. Norplant c. Progesterone coated IUD d. Depo Provera e. No difference

D a. Micronor (POP) – 72% continue (same for OCP) b. Norplant – 85% continue c. Progesterone coated IUD – 81% d. Depo Provera – 70% continue

The contraceptive with greatest continuation at one year is: a. Progesterone only pill b. Mirena IUCD c. Depo Provera d. Norplant / implanon

D POP – 72% continue (same for OCP) Norplant – 85% continue Progesterone coated IUD – 81% Depo Provera – 70% continue

Regarding contraception. Which is true? a. Principle action of POP is to suppress ovulation b. More females using IUD have ectopics than females using no contraception c. More females with Cu IUD have ectopics than inert IUD d. Epileptics can’t use OCP e. Mucus method has Pearl index < or equal to 5 preg/100 years if couple abstain 2 days prior to ovulation f. Unilateral tuboovarian abscess is associated with IUD

37 yo woman expresses concern about developing ovarian cancer. She took OCP for 1 yr at age 25 and asks whether the use of OCP’s has increased her risk of ovarian cancer. You explain that? a. OCP use as described by the patient does not alter the risk of ovarian ca b. OCP use as described decreased the risk of ovarian cancer c. OCP use as described offer a protective effect for 5-7 yrs d. OCP use decreased the risk but only if taken for 3 yrs or longer continuously e. OCP use does not protect against epithelial tumours

B The protective effect increases with duration of use and continues for 20 years after stopping the medication. The protection is seen in women who use it for as little as 3-6 months although use for at least 3 years is required for a noticeable impact. (Speroff)

Benefits of OCP are all except: a. Reduce menorrhagia b. Reduce PID c. Reduce benign breast disease d. Reduce ovarian cancer e. Reduce cervical cancer

In regard to the OCP a. Older women (>35yo) are at increased risk of arterial thromboembolism regardless of whether they smoke b. The principle action of the POP is to inhibit ovulation c. Diane 35 is likely to take over as the most frequently used OCP in well asymptomatic young women d. OCP containing the new progesterones gestodene and desogesteral have been shown to be more effective at preventing pregnancy than the older formulations e. Phenytoin does not affect the efficacy of 30-35 microgram OCP formulations

A d. OCP containing the new progesterones gestodene and desogesteral have been shown to be more effective at preventing pregnancy than the older formulations **side effect profile better only**

An 18 yo epileptic comes to you requesting OCP. She is on phenytoin. You would prescribe: a. 30 ug OCP formulation b. 50 ug OCP formulation c. POP d. IUCD e. Barrier methods

17 yo presents with vaginal spotting. She is sexually active and has been on OCP for 1 yr without trouble. What do you do? a. Increase E dosage of OCP b. Increase P dosage of OCP c. Ask her to come in to do a swab for Chlamydia d. Give her a 1 week course of ?E with the OCP too

Woman who constantly forgets to take oral contraceptive pill. You should: a. Consider she has dementia praecox…(it would improve on oestrogen Rx) b. Consider she has covert intentions c. Change her from the 28 days pill d. Consider she secretly desire pregnancy e. Consider she has hidden guilt regarding contraception as a bad thing

Progesterone only pills work by all except? a. thickens cervical mucus b. sperm toxicity c. inhibits ovum transport d. inhibits ovulation e. endometrial atrophy

After Depo Provera usage number of women who conceive after 15 months? a. 90% b. 75% c. 50% d. 25%

A 90% by 18 months (Speroff) 12/12 = 78% ( FPA) 18/12 = all

Depo Provera is noted for all except: a. Useful for those on phenytoin b. No increased risk of VTE c. No change in menstrual pattern

Which of the following is not true of depo provera a. Has no significant effect on lactation b. Is safe during lactation c. Does not cause troublesome PV bleeding d. Is effective contraception for a patient with epilepsy

LEAST TRUE depot a. Causes bone loss b. Amenorrhoea 50% at 12 months c. Amenorrhoea 95% at 24 months d. CI in breastfeeding

What is the cumulative pregnancy rate of a woman using norplant for 5 yrs? a. <1% b. 1% c. 3% d. 5% e. 8%

0.2% per year (Speroff) Answer: B

Who is most likely to have an ectopic pregnancy. One who conceives while using? a. condoms b. diaphragm c. minipill d. OCP e. No contraception

?C Absolute rate without contraception would be higher

Risk of ectopic highest with? a. COCP b. Condoms c. No contraception d. POP e. Diaphragm

A 25yo P2 has an IUCD for contraception. She developed increasing dysmenorrhoea and heavier menstrual periods. Management: a. commence NSAIDS b. removal of IUCD c. removal of IUCD and start antibiotics d. removal of IUCD and perform laparoscopy e. removal of IUCD and perform hysteroscopy

IUCD (copper)? a. increased PID with increased use b. increased PID in multiparas c. increased unilateral tuboovarian infection d. copper virtually eliminates actinomycoses e. treat uncomplicated actinomycoses

C Increased risk of PID around time of use; rate of actinomyces is much lower with copper IUD (less than 1%) but still higher than LNG IUD.

Regarding contraception? a. The risk of PID increases with the duration of use of an IUD b. Unilateral tubo-ovarian abscess is more common when an IUD is insitu c. A copper containing IUD rapidly loses efficacy after 2 yrs as the copper is degraded d. An IUD should not be removed in the event of a pregnancy as removing it may cause miscarriage e. The natural family planning method in which ovulation is predicted by the presence of cervical and vaginal fluid has a Pearl index of < 5 pregnancies per year providing abstinence commences at least 2 days prior to ovulation

B A pearl index of <5 is unlikely for natural methods

Actinomycosis on routine Pap with IUCD in situ. Management? a. Remove the IUCD b. Give antibiotics c. Remove the IUCD and give penicillin d. Repeat the smear

D UTD suggests that if the patient is asymptomatic the finding may reflect colonisation rather than infection and in this situation there is no evidence for ABx or removal.

A patient presents after a Pap smear showing Actinomycoses on Gram stain. Your immediate management plan would include. a. Treat with antibiotics with the IUCD in situ b. Remove the IUCD and resmear in 3 months c. Repeat the Pap smear d. Remove the IUCD and treat with antibiotics e. Reassure the patient

Patient has IUCD for 2 yrs and now actinomycosis detected on routine pap smear. Pelvic exam was normal. What is the next most appropriate treatment? a. Leave IUCD in, treat with penicillin b. Remove IUCD, treat with penicillin for 2 weeks and then reinsert another IUCD c. Remove IUCD, treat with oral penicillin for 2 weeks. IUCD contraindicated in future d. Remove IUCD, treat and no further treatment required e. No treatment needed if asymptomatic

Pelvic actinomycosis infection a. Should be treated with streptomycin b. Is a Gram negative fungus c. Is usually R sided d. May occur secondary to uterine colonisation which occurs with 5% of plastic IUD users

A Actinomyces is found in up to 30% of plastic IUD users; is a gram positive bacilli and should be treated with oral penicillin although tetracycline can be used.

In a woman who is 8 weeks pregnant with an IUD in situ the correct management is? a. Immediate removal of the IUD b. Advise termination of pregnancy c. Remove the IUD only if there is evidence of infection d. If the strings are visible cut them as high up in the cervical canal as possible e. Immediate laparoscopy to exclude ectopic pregnancy

In a woman who conceives with an IUD inset, all of the following are associated EXCEPT: a. Miscarriage b. Prematurity c. Low birth weight d. Fetal abnormalities e. Chorioamnionitis

Tubal sterilisation (diathermy) risk of failure per 1000? a. 0.1 b. 0.7 c. 3 d. 7

D (Speroff – 0.75% 10 year cumulative failure rate) 7.5/1000 unipolar 24.8/1000 Bipolar 10 yr cumulative (NOVAKS)

G3P3 had TL. Presents with ectopic in one tube. Mx? a. bilateral salpingectomy b. salpingostomy c. reclip tubes after removing ectopic

The most common emotional response after a termination is a. severe depression b. shame c. relief d. anxiety e. psychosis

After which procedure is the decay rate of BHCG the fastest? a. Vacuum curette for termination of pregnancy b. Vacuum curette for spontaneous abortion c. Resection of ectopic pregnancy d. Linear salpingotomy for ectopic pregnancy e. BHCG decays at the same rate for all procedures

What is the smallest fetal pole that a competent ultrasonologist would confidently diagnose as nonviable due to absence of cardiac activity? a. 5 mm b. 9mm c. 13mm d. 17mm e. 21mm

What is the smallest fetal sac size that a competent ultrasonologist would confidently diagnose as a blighted ovum because of lack of fetal pole? a. 11mm b. 15mm c. 19mm d. 23mm e. 27mm

D When no live fetus is visible in a gestation sac and the mean sac diameter is 2.0cm or greater (ASUM)

Patient presents 6 weeks pregnant. PVB and pain. US live IU pregnancy. Normal FH. Chance of ongoing pregnancy? a. 90% b. 70% c. 50% d. 30% e. 10%

A 90-96% with FHB at 7-11/40 do not miscarry

Threatened miscarriage at 6 weeks shows cardiac activity and appropriate for dates. Risk of miscarriage? a. <10% b. 50% c. 25% d. 90%

Least valuable predictor of missed abortion a. 5mm sac with no heart beat b. 15 mm sac with no fetal pole c. 20 mm sac and no fetal heart beat

A patient is 16 days late for her period and BHCG is 140,000. The most likely diagnosis is? a. Multiple pregnancy b. Molar pregnancy c. Miscarriage d. Ectopic pregnancy e. Gestational trophoblastic disease

UTD states that HCG > 100 000 in early pregnancy is strongly suggestive of molar pregnancy Answer: A – twins are more common

A woman is 6 weeks late for her period and her BHCG was noted to be 140,000 mIU/ml. The most likely diagnosis is: a. Single IU pregnancy b. Tubal ectopic pregnancy c. IU pregnancy anddysgerminoma d. Multiple pregnancy e. Ovarian pregnancy

Percentage of chromosomal abnormalities in 1st trimester spontaneous miscarriage? a. 20% b. 30% c. 40% d. 50% e. 60%

D 50% of all 1st trimester losses, 30% of 2nd trimester losses and 3% of stillbirths are karyotypically abnormal. (Speroff

Spontaneous ab, correct option: a. Increased in women > 40 b. DES associated with many pregnancy problems but not with spontaneous miscarriage c. Most common chromosomal abnormality is triploidy d. Genetic abnormality in aborted fetuses are similar to those occurring in term fetuses

A 28 yo has had 2 miscarriages 8w and 10w and presents for advice: a. She should be labelled recurrent miscarriage b. She does not warrant pre-conception counselling c. If one more miscarriage then chance of livebirth <6% d. Chance of another miscarriage = 40% e. 50-60 % spontaneous abortuses are chromosomally abnormal

E After one miscarriage – 14-21% chance; two – 24-29%; three – 31-33% (UTD)

Miscarriage at 18/40 but 12/40 size, best Rx? a. nothing b. suction curettage c. prostaglandins d. intra amniotic saline/PG

A woman had 3 consecutive first trimester miscarriages. What is the likelihood of miscarriage in the next pregnancy? a. 5% b. 10% c. 30% d. 50% e. 70%

C If one previous liveborn infant – 32%; if no previous liveborn infants – 40-45%

What is the percentage of patients with recurrent miscarriage that have chromosome abnormality? a. 1% b. 3% c. 10% d. 30% e. 50%

B The incidence of chromosomal abnormalities in this group is 2.9% (UTD). 50% balanced reciprocal translocation, 25% Robertsonian translocation and 10% sex chromosome mosaicism in females

One partner of a couple with recurrent miscarriage has a balanced reciprocal translocation – the most correct is: a. Phenotypically normal offspring in 50% of conceptions b. Major anomalies with trisomy in 25% c. Phenotypically normal in 10% if husband has translocation d. Phenotypically normal in 70% if mother has translocation e. All offspring will have a balanced translocation

A Theoretically - 25% of gametes should be normal, 25% abnormal but balanced; this yields 50% chance of a normal pregnancy (normal or balanced) and 50% chance of abnormal (miscarriage or anomalous fetus). If Robertsonian (questions above is reciprocal) – 1/6 normal, 1/6 abnormal but balanced, 2/3 abnormal and unbalanced; this yields 33% chance of normal pregnancy and 67% of abnormal pregnancy. (Speroff) There is a parental sex influence with the risk for unbalanced progeny higher if the female parent carries the gene (C&R). If diagnosed after the birth of an abnormal child they have a 5-30% chance of having a liveborn offspring with unbalanced chromosomes as compared to 5% risk is carriers identified for other reasons. (Williams)

Patient with a history of recurrent abortion now 6-7 weeks pregnant. Investigation performed in past could reveal no cause for recurrent Abs. Management: a. Progesterone until 28 weeks b. Anti-prostaglandins c. Serial hCG measurements d. Pelvic USS e. Reassurance

A woman with 4 previous 1st trimester miscarriages has been fully investigated and no cause found. Management in next pregnancy? a. Progesterone supplement empirically or test serum progesterone levels b. Aspirin and heparin c. Serial BhCG d. US at 6/40

37 yo with recurrent miscarriage. Most likely diagnosis is a. Obstetric Lupus b. Luteal phase deficiency c. Uterine anomaly d. Idiopathic

D Acquired and congenital uterine abnormalities are responsible for 10-50% of RPL. Congenital uterine abnormalities are present in 10-15% of women with RPL. Luteal phase defects are present in up to 25%, APLS in 5-15%. No cause is found in 50%

Recurrent miscarriage x 4. Most likely cause? a. lupus b. idiopathic c. chromosomal abnormalities in parents

Patient has had 3rd miscarriage and karyotype on products was abnormal. What is the most likely abnormality?** a. Autosomal trisomy b. Triploidy c. Chromosomal translocation d. Sex chromosome abnormality

A Autosomal trisomies > monsomy X > polyploidies. In women with recurrent pregnancy loss the karyotype is more likely to be normal, especially under the age of 35. If the karyotype is abnormal it follows the same pattern as seen in the general population. (Speroff)

A woman who is G3P0 with 3 previous miscarriages all requiring D&C. After the last D&C she developed 6 months of irregular light menstrual periods. Hysterosalpinogram was performed. Which of the following likely to be? (4 HSG’s were shown) a. T-shaped uterus after DES exposure b. Bicornuate uterus c. Single IU filling defect – endometrial polyp/fibroid d. Multiple IU synechiae

What is the most common chromosomal abnormality found in abortuses? a. Trisomy 16 b. Trisomy 21 c. 45, X d. Trisomy 18 e. XXXX

?C Chromosomal abnormalities account for approximately 50% of miscarriages; increased at earlier gestations. Breakdown is – autosomal trisomies 52%, monosomy X 19%, polyploides 22% and others 7%. Trisomy 16 is the most common autosomal trisomy (UTD). Does XO have > than trisomy 16? - No

.A woman has LNMP 7w ago, pv bleeding. bhCG positive and TVUS 7w viable fetus and left adnexal mass. Laparoscopy revealed a haemorrhagic CL. Which of the following is correct? a. oral oestrogen b. oral progesterone c. IM depot progesterone d. IM hCG e. No hormone needed

At 12 weeks gestation the corpus luteum is removed for bleeding, the most appropriate pregnancy support with the least fetal risk is: a. Duphaston b. Depo Provera c. Norethisterone d. Progesterone and oestrogen e. No hormones

What is of proven value as treatment for recurrent 2nd trimester miscarriages associated with uterine contractions? a. Erythromycin b. Transfusing wife with husbands WBC c. Strassmann operations d. McDonald cerclage

TOP at 6w. One week later, no bleeding or pain but BHCG remains positive. There is a 6-7 week size uterus. The path showed scanty decidual tissue, no fetal parts. Next? a. Qualitative BHCG b. Ultrasound c. Repeat curette d. Laparotomy

.At 7 weeks gestation, which of the following findings is most likely to be consistent with a tubal ectopic pregnancy? a. Abdo US empty uterus + BHCG <600 b. Abdo US empty uterus + BHCG <1000 c. Abdo US empty uterus + BHCG >7000 d. Abdo pain and negative culdocentesis

A woman presents with abdominal pain and vaginal spotting at 6 weeks amenorrhoea, βhCG is 6000, US empty uterus. O/E tender adnexa. Best next step: a. Serial BCHG b. Rpt US in 1 week c. Laparoscopy d. Laparotomy

6/52 pregnant, 3 days of abdo pain and 2 days of PV bleeding. Bilateral adnexal tenderness. US – complex adnexal mass and free fluid in POD. Next? a. Culdocentesis b. Laparotomy c. Quantitative BHCG d. Laparoscopy

Regarding ectopic pregnancy: a. Continuing US and BHCG delays intervention and leads to greater risk of rupture b. Recurrence risk about 10% c. Better chance of subsequent live birth with salpingostomy vs salpingectomy

B Recurrence risk 10-27% (Speroff)

Ectopic pregnancy a. Increased after legal TOP b. Increased on progesterone only pill more than without contraception c. Rate is higher with copper IUD’s than plastic ones d. Increased with IUD more than normal population e. None of the above

Woman at 6/52 amenorrhoea with PV bleeding and lower abdominal pain. HCG 3000 and US empty uterus. Options? a. Do nothing b. Serial HCG c. Laparoscopy

A G1 P0 woman with an ectopic pregnancy. At laparotomy, the right tube is found to be bound down with adhesions. There is a 1 cm bluish fimbrial mass on the left tube. Best option. a. Salpingectomy and repair of the other tube. b. Fimriectomy c. Milk the lesion from the tube. d. Methotrexate

?D Ideal management would be salpingostomy and later laparoscopy and dye studies +/- dye studies. Is finbriectomy an appropriate substitute, or milking lesion or MTX?

A lady 12 weeks pregnant with a bicornuate uterus presents to A&E with pain and bleeding. US shows an empty uterus and 8 cm adnexal mass. Obs BP 90/60, PR 110: a. Get A&E to organise laparoscopy with probable salpingostomy b. Get A&E to organise laparoscopy with probable laparotomy c. Do nothing until you arrive in 30 mins d. Have a culdotomy tray ready for you

12 weeks pregnant. HCG positive at 6 weeks. No other antenatal care. Feels pregnant. One-week history of PCB without cramping. Speculum reveals bright red 3 cm mass on the ectocervix. Which test will give a definite diagnosis? a. Real time US b. Tissue biopsy c. Colposcopy and biopsy d. Stain with Lugold’s iodine

A routine obstetric ultrasound showed a viable singleton fetus outside the uterine cavity with measurements consistent with 18/40. No fetal abnormality detected. What is appropriate Mx? i. Expectant management ii. Wait until fetal viability, deliver electively and remove the placenta iii. Wait until fetal viability, deliver electively iv. Immediate delivery of fetus only v. Immediate delivery of fetus and placenta

iv If T1 – operative scope is an option. Even if advanced gestation – do IMMEDIATE interruption. Leave placenta behind

Do CS and find an unanticipated abdominal pregnancy with placenta involving left broad ligament and sigmoid. Management: a. Attempt to remove all placenta doing colostomy b. Remove as much of the placenta as you can c. Leave placenta behind

A patient presented to casualty: 8 weeks of amenorrhoea with vaginal bleeding. Pelvic US by LMO showed numerous small, cystic and fluid containing spaces in the uterus with characteristic “snowstorm” appearance and no fetus detected. Histology showed hydropic degeneration, swelling of the villous stroma and abundant avascular villi. Which of the following is correct? a. it is not associated with choriocarcinoma b. karyotypically is either 69XXY and 69XYY c. chromosomal composition completely of paternal origin d. it has a chromosomal pattern of 69XXX or 46XX

C These histological findings are consistent with a complete molar pregnancy. Choriocarcinoma usually doesn’t have villi (Robbins) but the findings above can be associated with choriocarcinoma. It has a normal karyotype (46 XX) but both chromosomes are derived from paternal origin. Partial moles are usually triploid.

The most common presenting symptom of molar pregnancy is: a. Abnormal bleeding b. Hyperemesis c. Larger than expected fundus d. Thyrotoxicosis e. Pre-eclampsia

Concerning partial moles, all true except: a. Fetus may be alive b. Mostly triploidy c. Same follow up as complete moles d. More often go on to choriocarcinoma than complete moles e. Preeclampsia occurs most commonly with partial moles

Answer: D (most incorrect although C and D aren’t correct either)

Hydatidiform mole – which is correct? a. Choriocarcinoma can be associated with hyperthyroidism b. Incidence decreases after age 40 c. Rhesus blood group is prognostic indicator d. Persistent in <5%

A Choriocoarcinoma can be associated with hyperthyroidism, incidence increases with increasing maternal age, Rh is not a prognostic factor and persistence occurs in 15%

Regarding hydatidiform mole, which statement is correct: a. <3 % progress to choriocarcinoma b. Choriocarcinoma can be associated with thyrotoxicosis c. Commonest karyotype is 45 XO d. Association between prognosis and rhesus blood group e. Less common in older women

B Choriocarcinoma occurs following 2.5% of molar pregnancies; usually 46XX karyotype, not association with blood group, commoner in older women

A 30yo lady, diagnosed to have hydatidiform mole at 14 weeks amenorrhoea, which of the following is the management of choice? a. suction curette b. sharp curette c. hysterectomy d. methotrexate e. hysterectomy

32 yo G2P2 with molar pregnancy. Fundal height 28 weeks. Best method of evacuation? a. IOL b. abdominal hysterotomy c. Suction curettage d. D&C e. TAH

Treatment of non metastatic gestational trophoblastic tumour in a 21yo who had D&C 8 weeks earlier is: a. single agent chemotherapy b. multi agent chemotherapy c. radiotherapy d. hysterectomy e. D&C

Patient presents 4 months after a term delivery with daily pv bleeding. Serum bhCG 104,000IU. CXR shows multiple opacities. CT head and abdo normal. LFTs normal. Management: a. methotrexate b. hysterectomy to debulk disease c. suction curette d. combined chemotherapy e. lumbar puncture

Patients with hyperthyroidism with trophoblastic tumours have? a. High total T4 +T3 b. High free T4 + T3 c. Decrease TSH d. All of the above

Who is less likely to have high concentrations of lactobacillus in vaginal flora?** a. Neonate b. Premenopausal c. Postmenopausal d. Pregnant e. Non-pregnant reproductive age

The percentage of woman who experience at least one episode of vaginal candidiasis in their reproductive years: a. 20% b. 35% c. 50% d. 70% e. 90%

D 75% by menopause (UTD), and 45% have > 2 episodes

Regarding candida? a. ketoconazole is safe in pregnancy b. typical thrush spots seen in 20% candida vaginitis c. antifungal treatment to vulva reliably eradicates candida vulvitis d. low oestrogen favours candida e. diabetics are prone to candida and often present with it prior to diagnosis of DM

E Occurs in increased oestrogen states; ketoconazole is contra-indicated in pregnancy

Which of the following is not an acceptable treatment for Candida vulvovaginitis? a. Ketoconazole b. Fluconazole c. Itraconazole d. Terazole

The most common sexually transmitted disease in Australia? a. Gonorrhoea b. Chlamydia c. Syphilis d. HSV 1 e. HSV 2

Herpes –which is wrong? a. HSV1 confers some protection against HSV2 b. HSV2 generally affects genitals c. Most have recurrence within 6 months of primary attack d. Acyclovir with primary infection reduces no & severity of recurrences

HSV, all true except: a. HSV1 offers some protection against HSV 2 b. HSV 2 > genital infection than HSV 1 c. Acyclovir for acute attack decreases recurrences d. HSV 2 most recur in 6 months e. Women with cervical cancer have increased incidence of HSV

What is the most common organism to cause septic shock in gynaecology? a. E. coli b. Bacteroides c. Beta haemolytic Streptococci d. Staphylococcus e. Clostridium

12 hrs after a TAH + BSO a patient developed a temperature of 39.4 degrees, tachycardia and BP 90/50. A diagnosis of septic shock was made. The most likely organism is: a. E.coli b. Clostridium c. Bacteroides d. GBS e. S. Aureus

Necrotising fasciitis caused by all except a. Staph b. Proteus c. Bacteroides d. E. Coli e. Clostridium

All of the following are the characteristics of toxic shock syndrome except? a. temp > 39C b. multi-system involvement c. S aureus in blood culture d. Diffuse erythematous rash e. S aureus on vaginal swab

C 80-90% of patients have S.Aureus isolated from wound or mucosal sites whilst only 5% will have S.Aureus isolated on blood cultures

For Bacteroides fragilis the least effective antibiotic is a. Cefotaxime b. Clindamycin c. Chloramphenicol d. Gentamicin e. Metronidazole

D An anaerobic, gram-negative bacillus that is sensitive to metronidazole and clindamycin. Gentamicin offers gram-negative cover. Chloramphenicol and cefotaxime cover bacteroides fragilis.

What organism will metronidazole and gentamicin not cover? a. Gram positive aerobe b. Gram positive anaerobe c. Gram negative aerobe d. Gram negative anaerobe e. Trichomonas

Of following antibiotics the one not recommended as a first line agent of choice for UTI in young children is? a. Sulfonamide b. Nitrofurantoin c. Trimethoprim d. Amoxicillin e. Cephalosporins

A 38yo woman with ph of chronic PID presents to you with increasing pelvic pain, unwell, rigors. Temp 40 degrees, HR 100. VE: 8cm tender mass protruding onto upper half of rectovaginal septum in midline. WCC 24,000. Diagnosis of pelvic abscess made. Which is correct? a. colpotomy and drainage of abscess and antibiotics b. TAH, BSO and ABx c. Abdominal drainage of abscess and ABx d. Conservative treatment with iv ABx

A Now laparoscopic drainage may be the appropriate answer. Either colpotomy or laparotomy are reasonable. Colpotomy if access is easy

Regarding tubo-ovarian abscess? a. Can be visualised by US b. Causes eosinophilia c. Positive Chlamydia on cervical swab d. Associated with leucopenia

The organism most likely to be grown from culture of a tubo-ovarian complex is: a. Group D enterococci b. Mixed anaerobes c. Neisseria gonorrhoea d. Chlamydia trachomatis e. Escherichia coli

PID with temp. 39 degrees and bilateral pelvic tenderness. Chlamydia on swabs. Best therapy: a. IM Cephalothin and PO doxy b. PO doxy alone c. IV cefoxitin and PO doxy d. IV clindamycin e. IV penicillin + erythromycin

A 27 yr old lady with a diagnosis of PID. She was treated with oral doxycycline. After 3 days there was no improvement. A 8cm swelling was found on ultrasound in POD. What is the appropriate management? a. Laparoscopy b. Laparotomy c. Culdotomy d. Change to IV cefotaxime plus oral doxycycline e. Transvaginal ultrasound guided aspiration

D Probably OK to trial medical management first but probably will need surgical drainage, definitely if signs of rupture or if systemically unwell.

A woman at 8w is diagnosed with Chlamydia on endocervical swab. The appropriate management would be: a. no treatment needed b. oral doxycycline c. oral erythromycin d. oral penicillin e. no treatment needed now but repeat swabs at 28w

C The optimal treatment for chlamydia is azithromycin 1gm orally once or doxycycline 100mg BD for 7 days. Given that the patient is pregnant the treatment would be erythromycin although a Cochrane review suggests that amoxycillin is better tolerated and just as effective.

26 yo at 26 weeks gestation with PV discharge and Chlamydia on swab? a. penicillin b. cephalosporin c. doxycycline d. erythromycin e. metronidazole

D The optimal treatment for chlamydia is azithromycin 1gm orally once or doxycycline 100mg BD for 7 days. Given that the patient is pregnant the treatment would be erythromycin although a Cochrane review suggests that amoxycillin is better tolerated and just as effective.

Which of the following is most likely to be associated with offensive post coital discharge? a. Chlamydia b. Gonorrhoea c. Gardnerella d. Candidiasis e. HPV

Chlamydia: a. Cervix usually looks irritated or inflamed b. Incidence <1% in antenatal, family planning or general gynae population c. If low incidence population, Microtrac false +ve ~ 50% d. Cefoxitin/metronidazole is adequate treatment e. At first infection 50% of women have symptomatic salpingitis

Chlamydia: a. Is in <1% of O&G and FPA clinics b. Diagnosis is by posterior vaginal fornix swab c. Cervix usually looks abnormal d. In a low risk population has a 50% PPV on ELISA e. Treatment is with cefoxitin and Flagyl f. 50% will clinically develop PID D

D Although the S&S of testing for chlamydia is 95% inhigh risk populations it falls significantly in lower risk populations (less than 75%)

16 yo woman presents asking for an STD check. Partner recently diagnosed with NGU, most appropriate management? a. Cervical swabs and review b. Doxycycline bd for 10/7 c. Cervical swabs and oral doxycycline for 10 days d. Counsel and test for HIV

A 24 yo not sexually active woman presents with a history of an intermittent white vaginal discharge, is not pruritic, the pH is less than 0.45. a. Candidiasis b. Trichomonas c. Gardnerella d. Physiological vaginal discharge

A woman with known Gardnerella vaginal infection is to have a vaginal hysterectomy. Which antibiotic would be most cost effective for pre-op prophylaxis? a. Ceftriaxone b. Piperacillin c. Cephazolin d. Chloramphenicol e. Clindamycin and gentamicin

E Best options would be metronidazole, tinidazole or clindamycin

Sexually active 27 yo has 2/52 history of urgency and dysuria. Came to casualty, MSU collected and commence on Keflex. There was no growth on the MSU. Her symptoms persist. Next? a. Repeat MSU b. Quantitative analysis of urine WBC’s c. Uretheroscopy d. Chlamydia swabs of urethra and cervix

A 37 yo woman, previous TAH for micro-invasive Ca cervix. Thinks the man she slept with 2 weeks ago has developed gonorrhoea. Best way to establish the diagnosis? a. Culture urethra b. Culture vaginal vault c. Culture rectum d. Gram stain of vaginal secretions e. Gonozyme assay

With respect to Actinomyces, which is incorrect a. Causes toxic shock syndrome b. Can be detected on Pap smear c. Is associated with IUD d. Can be treated with IM penicillin

A Somali woman presents for a routine pelvic exam. While doing the pap smear you notice a cluster of small vesicles of her right buttock. She says she has had this problem on and off over several years. the likely diagnosis is:** a. Condyloma lata b. Herpes (HSV2) c. Eczema

Which of the following combinations is correct? a. Syphilis is satisfactorily treated with erythromycin b. Ampicillin to treat PID c. Lindane to treat molluscum contagiosum d. Tetracycline to treat LGV (Lymphogranulosum venereum) patient newly migrated to Australia e. Sulphonamide to treat granuloma inguinale

D Syphilis is treated with penicillin, PID is treated with multiple antibiotics, molluscum contagiosum resolves spontaneously, granuloma inguinale (Donovanosis) is treated with azithromycin

Which combination is correct? a. erythromycin – syphilis in pregnancy b. penicillin/ampicillin for teenager with PID c. tetracycline for recent migrant with LGV d. lindane for molluscum contagiosum

Which viral class does Molluscum Contagiosum belong to a. Pox virus b. Herpes virus c. Adenovirus d. Papilloma virus

What organism causes Donavanosis? a. Gardenerella vaginalis b. Chlamydia trachomatis c. Corynebactium donavoneias d. Haemophilus ducreyi e. Calymmatobacterium granulomatis

E Gardenerella vaginalis causes bacterial vaginosus, chlamydia trachomatis causes lymphogranuloma venereum, corynebacterium donavoneias (made up), haemophylis ducreyii causes chancroid and calymmatobacterium granulomatis (Klebsiella granulomatis / granuloma inguinale) causes donovanosis. Treat with azithromycin.

What organism causes Chancroid a. Gardenerella vaginalis b. Chlamydia trachomatis c. Corynebacterium donavoneias d. Haemophilus ducreyi e. Calymmatobacterium granlumatis

D Gardenerella vaginalis causes bacterial vaginosus, chlamydia trachomatis causes lymphogranuloma venereum, corynebacterium donavoneias (made up), haemophylis ducreyii causes chancroid and calymmatobacterium granulomatis (Klebsiella granulomatis / granuloma inguinale) causes donovanosis. Treat with azithromycin.

Which organism causes Lymphogranuloma venereum? a. Calymmatobacterium granulomatis b. Haemophilus ducreyi c. Gardnerella vaginalis d. Chlamydia trachomatis e. Calymmatobacterium donovae

D Calymmatobacterium granulomatis - donovanosis; Haemophilus ducreyi – chancre; gardnerella vaginalis – BV; chlamydia trachomatis – lymphogranuloma venereum; calymmatobacterium donovae – made up. Treat with doxycycline or azithromycin.

Regarding pelvic tuberculosis: a. Its origin is usually bovine b. First line treatment is streptomycin c. It affects the tubes more often than the uterus

C Fallopian tube and endometrium are the two commonest sites of infection

Female with painless vulval ulcer, 1 cm, indurated base. Definitive/first Ix? a. TPHA b. Dark field illumination c. VDRL d. Herpes immuno fluorescence

A vs B VDRL has poor sensitivity in primary syphilis (60-87%), dark field microscopy is better (70-95%) but is operator dependent, TPHA is probably the best. These days PCR swap for treponema would be ideal

A 20 yo Aboriginal woman presents with 3/52 of a labial ulcer – painless, firm, indurated: also has inguinal lymphadenopathy. RPR 1/64, TPHA – pos, FTA-Abs – pos, Darkfield microscopy – neg. What is the most likely diagnosis? a. Primary syphilis b. Secondary syphilis c. Chancroid d. Donovanosis

A Syphilitic ulcers last up to six weeks and are associated with lymphadenopathy. Chancroid is painful; donovanosis essentially requires biopsy.

Which true about syphilis? a. VDRL is a specific Ab for syphilis b. Condyloma of secondary syphilis is not sexually transmitted c. Tertiary syphilis require weeks of penicillin

Condyloma lata are caused by: a. HSV 1 b. HPV c. Treponema pallidum d. Haemophilus ducreyii e. Chlamydia

C Condyloma lata are caused by syphilis (treponema pallidum). HSV 1 causes cold sores, HPV causes genital warts (condyloma accuminata), haemophilus dureyii causes chancroid.

Appropriate treatment for secondary syphilis? a. Benzathine penicillin IM x1 b. Procaine penicillin IV x1 c. Cefoxitin d. Doxycycline

The most effective management strategy in the treatment of somatization disorders is? a. Strict limits on the duration and number of early appointments b. Mandatory psychiatric referral c. An exhaustive battery of complex, expensive and invasive investigations to rule out organic disease d. Treatment of the somatic symptoms including any analgesia required e. Negotiate to reduce the symptoms without promising a cure

The best treatment for premature ejaculation is? a. Sensate focus b. Kegel exercises c. Squeeze technique d. Bridge manoeuvre e. Tranquillisers

21 yo G0P0 comes for contraceptives. Had in utero DES exposure. VE -> small cervix, flush with vaginal fornices, and anterior cervicovaginal ridge. Best Mx of DES exposed patient? a. Patients with adenosis should be treated with CO2 laser b. Need a pap smear every 6/12 c. The CO2 laser is the most appropriate Rx of high grade CIN in DES exposed patients d. DES patients are increased risk of infertility

D – Every 12/12 with COLP (cervix and vagina), continue indefinitely. Manage by Gynae Onc

60 yo who took DES in 2 pregnancies for 4 months. What to advise her – all except? a. She has increased risk of breast cancer b. Her daughter age 30 has 1% chance of clear cell cancer and risk increased with age c. Her son might have abnormalities of the reproductive tract d. Her daughter may have fertility problems related to abnormal uterus

B Small increased risk of breast cancer in women who took DES; 1:1000-2000 risk of clear cell cancer in women exposed in utero; fertility problems due to uterine malformations occur; males to have increased risk of genitourinary abnormalities if exposed.

A 55 year-old woman seeks your advice regarding exposure to DES. She used DES during both of her pregnancies. All of the following statements are true except: a. Her daughter has an increased risk of infertility b. Her daughter has an increased risk of developing clear cell CA of the vagina c. Her daughter has an increased risk of cervical dysplasia d. Her son has an increased risk of genital tract abnormalities e. She has an increased risk of breast cancer

Answer: C (although technically all are true)

A 55yr old woman seeks advice regarding exposure to DES. She used DES during both her pregnancies. She has a 30year old daughter and a 25year old son. All of the following are correct except a. Her daughter has an increased risk of infertility b. Her daughter has an 1% risk of developing clear cell Ca of vagina c. Her daughter has increased risk of CIN and VAIN d. Her son has increased risk of genital tract abnormalities e. She has an increased risk of breast Ca

B Two fold increase risk of CIN

Progesterone in premenstrual tension? a. Rx corpus luteal defect b. Placebo effect

B Speroff states the progesterone is no better than placebo

Which is not required for a diagnosis of PMS a. Symptoms consistent with the diagnosis b. There is a luteal phase pattern c. Symptoms cause a disruption to her life d. There are objective findings to support the diagnosis

Least common symptom of PMS a. Bloating b. Breast tenderness c. Headache d. Increased appetite e. Urinary frequency

Which of the following is correct in regard to premenstrual syndrome? a. It is due to low progesterone level b. Bromocriptine is more effective than cyclical synthetic progesterone in treating PMS c. Cyclical progesterone showed no advantage over placebo in treating PMS d. It is due directly to endogenous endorphin withdrawal e. It is related to HLA B27 typing

Which of the following have been proven more effective than placebo in treatment of premenstrual dysphoria? a. Combined oral contraceptive b. Progesterone pessaries c. Synthetic oestrogens d. Micronised oral progesterone e. Serotonergic antidepressants

The most common sexual dysfunction in women is? a. Stress b. Depression c. Guilt d. Lack of knowledge e. Gender identity

What is the most common cause of dyspareunia? a. Endometriosis b. Lack of lubrication c. Adenomyosis d. Vulvovaginitis e. PID

B The leading cause in women under the age of 50 is localized vulvodynia. In women over the age of 50, urogenital atrophy is the leading cause of sexual dysfunction.

Introital dyspareunia. Common cause a. Thrush b. Inadequate arousal c. Psychosexual issues

A 27 yo woman presents with increasing dyspareunia. She has a past history of ‘woman’s infections” but cannot remember if these were treated with topical or systemic therapy. The situation is becoming an increasing source of frustration to her and her husband, but both are mutually supportive. Pelvic examination reveals only mild unilateral adnexal tenderness. Next step? a. Diagnostic laparoscopy b. Relaxation therapy to reduce the anxiety component of the problem c. Reassure the findings are normal d. Marital therapy to relieve the frustration e. Trial of antibiotics

Most common cause of deep dyspareunia? a. ‘oestrogen’ b. retroversion of uterus c. uterine prolapse

The most likely cause of dyspareunia after vaginal delivery is? a. Uncomfortable stitches b. Lack of sleep c. Having intercourse too soon after delivery d. Atrophic vaginitis

With regard to pelvic pain a. 25% of women will experience it 5 days/month or one full day/month b. It will have significant impact on work or home life in 2-5% of women c. It is the reason for 10% of laparoscopies d. It is the reason for 5% of hysterectomies e. A full history and examination is rarely helpful in identifying the cause

B Pelvic pain is the indicated reason for 40% of laparoscopies and 20% of hysterectomies. It will impact on the work life of 4% of women.

Mild symptomatic endometriosis in young married woman. Rx a. Danazol 12/12 b. GnRH 3/12 c. Nothing d. Laparoscopic ablation

Endometriosis? a. Most severe disease have worst symptoms b. Affected peritoneum almost always seen with naked eye at laparoscopy c. Most have immunological defect which explains their infertility d. Medical treatment OK for endometriomas provided they are < 3cm

B Severe disease does not necessarily correlate with symptoms; ‘Naked eye’ laparoscopy is the gold standard for diagnosis; there is no immunological defect that describes infertility; medical treatment is only effective for endometriomas < 1cm

With endometriosis a. Peritoneal implants are usually visible to the naked eye at laparoscopy b. Many women with endometriosis have an associated autoimmune condition which may contribute to the associated infertility c. Danazol and GnRH derivatives are curative so long as the biggest endometrioma is < 3cm d. Commonest finding is an ovarian endometrioma

A woman has a regular 24 day cycle and is experiencing midcycle bleeding. Which of the following is correct? a. oestrogen breakthrough b. oestrogen withdrawal c. progesterone breakthrough d. progesterone withdrawal e. inadequate androgens

B Physiologic intermenstrual bleeding at the time of expected ovulation is secondary to the brief abrupt decline in estradiol that follows its preovulatory surge.

A woman has a regular period every 28 days. She has spotting around day 14 of her cycle. Which of the following is correct? a. Oestrogen BTB b. Progesterone BTB c. Oestrogen withdrawal bleeding d. Progesterone withdrawal bleed

Treat DUB with all except? a. aminocaproic acid b. mefanamic acid c. transexamic acid d. clomiphene e. neostigmine

A 40yo with premenstrual spotting, menorrhagia and dyspareunia with mid-cycle pain. What is the most likely diagnosis? a. adenomyosis b. endometriosis c. luteal phase deficiency d. fibroids e. endometrial polyp

A Endometrial polyps and fibroids may cause the bleeding symptoms but are unlikely to cause pain. Endometriosis may cause pain but will not cause the bleeding symptoms. Adenomyosis is the most likely culprit although luteal phase deficiency is hard to quantify (discussed in association with infertility, may cause premenstrual spotting)

Fibroids. Which is true? a. Generally cause pain b. Increased in nulliparous women c. 1% become sarcomatous

B Incidence of sacromatous change = 0.23%

Fibroids? a. Arise from single clone b. Has capsule c. Made from fibrous tissue

A Fibroids are monoclonal tumours arising from smooth muscle and are largely composed of extracellular matrix (collagen, proteoglycan and fibronectin) and are surrounded by a thin pseudo-capsule of areolar tissue and compressed muscle fibres.

Uterine fibroids. MOST TRUE: a. Are usually painful b. Should be removed in pregnancy c. Associated with nulliparity d. 1% undergo sarcomatous change

Fibroids: All of the following statements are true except: a. >20% of fibroids have a chromosomal abnormality b. On cytogenetics a single fibroid comes from one single cell (not pleomorphic) c. 20% of women develop a fibroid d. MPA decreased mitotic activity in fibroids

C and D are incorrect - go with D Fibroids are clinically apparent in 25% of women and 80% on pathological examination of uteri. Monoclonal as above; 60% have an abnormal karyotype; progesterone increases mitotic activity.

Regarding red degeneration of a fibroid, all are false except: a. Causes an elevation of the ESR b. Causes leucopaenia c. Only occurs in pregnancy d. Occurs due to embolisation of the feeding vessels

A Causes leucocytosis

A 6 month course of GnRH analogues used to treat fibroids will reduce uterine size by: a. 10% b. 20% c. 33% d. 50% e. 66%

D 30-64% after 3-6 months of treatment (Speroff); 40-60% (Novak);

What percentage of fibroids will shrink with GnRH analogues? a. 10% b. 25% c. 50% d. 75% e. 90%

E 24% will decrease by <25%, 50% will decrease by 25-50%, 21% will decrease by >50% = 90%

Advantages of GnRH agonist for the treatment of fibroids include all of the following EXCEPT: a. Allow vaginal hysterectomy b. Allow return of patient HB towards normal before surgery c. Diagnostic test to distinguish between fibroid and leiomyosarcoma d. Allows hysteroscopic resection of fibroid e. Reduced intraoperative blood loss

A 24yo primigravid woman was treated by LMO for pelvic pain with OCP 4 years ago. Now she presents with dysmenorrhoea. Which of the following is correct? a. Incorrect initial treatment and diagnosis b. Change to a monophasic pill will cure her symptoms c. Laparoscopy will show evidence of PID d. Cyclical progesterone is the preferred treatment

?A Probable initial diagnosis of primary dysmenorrhoea → correct treatment; cyclical progesterones thin the endometrium and reduce the amount of arachidonic acid released. May have new PID but probably should examine and swab rather than scope.

After removal of an ovarian endometrioma, once haemostasis achieved and ovarian cortex edges are opposed, best way to minimise adhesions is? a. catgut b. interrupted dexon c. continuous dexon d. surgical glue e. leave alone

25 yo. O/E 5 cm simple cystic R adnexal mass confirmed on US. Mx? a. Repeat exam in 3/12 b. Give OCP and repeat US in 1/12 c. Laparotomy d. Laparoscopy and aspiration of cyst

A 14 yo girl presents with pelvic pain and US shows a 4cm ovarian cyst. What is the commonest cause? i. Dermoid cyst ii. Follicular cyst iii. CL cyst iv. Serous adenoma v. Endometrioma

.You are performing a laparotomy for a ruptured right ectopic pregnancy in a 17 yo. A 10cm right ovarian cyst is noted. Left ovary appears normal. Optimal management is: a. RSO b. Aspiration of cyst c. Cystectomy d. Cystectomy and biopsy of other ovary e. R oopherectomy

27 yo female at 7/40 pregnant with 8 cm unilocular cyst presents with LIF pain. Mx? a. Operative laparoscopy b. Cystectomy via Pfannensteil c. Oophorectomy via midline incision and washings d. Laparoscopy and aspiration of cyst e. Repeat US in 6 weeks

E - best time to operate is in T2

37 yo at 20/40 on routine anomaly US is found to have 11cm complex left ovarian cyst. Mx? a. Operative laparoscopy b. Cystectomy via Pfannenstiel c. Oophorectomy via midline incision and washings d. Laparoscopy and aspiration of cyst e. Repeat US in 6 weeks

Regarding dermoid cysts, which is true? a. Most common ovarian tumour in pregnancy b. 10% risk of malignancy c. 40-50% bilateral

A 10-17% are bilateral and almost all are benign.

Previous normal BP in a 42 year old woman, Diastolic BP 95mmHg, most appropriate next step a. Recheck in two weeks b. Recheck in 1 year c. Begin thiazide d. Begin ACE inhibitor

A lady presents to you for investigation of metromenorrhagia with regular cycles. She is 45 years old and G4P4. Which investigation would give you most information regarding her diagnosis? a. FBE b. Dilation and curettage c. Hysterosalpingogram d. Office hysteroscopy e. Pelvic US

B In the absence of irregular bleeding the most likely diagnoses are going to be structural causes such as polyps and fibroids. Therefore hysteroscopy is most useful. If it was the real world it would be FBE, USS and H, D&C

A 46 yo lady presented with severe menorrhagia for six months and clinical evidence of a tender enlarged uterus. What is your first investigation? a. Hysteroscopy and D&C b. FBE c. LH and FSH d. Coagulation profile e. Serum progesterone

48 yo woman experienced increasing menorrhagia and cramping pelvic pain in the last 3 months. On spec, a 2cm red beefy lesion was found in the cervical os. What is the most likely cause? a. endocervical polyp b. prolapsed endometrial polyp c. submucous fibroid d. prolapsed pedunculated fibroid e. clear cell adenocarcinoma

D The lesion is in the cervical os and 2cm in size making a submucous fibroid and endocervical polyp unlikely. Endometrial polyps are not usually large enough to prolapse. Clear cell carcinoma is unlikely in this age group with no history of DES exposure.

50yo G4P4. LMP 12 months ago. PV spotting for 2 weeks. D&C shows atrophic endometrium. Next step in management? a. progesterone b. oestrogen c. hysteroscopy d. hysterectomy e. HRT (combined)

E (or nothing)

Perimenopausal patient with endometrial hyperplasia a. HPV b. Fibroids c. Diabetes d. PCOS

D Most likely association with endometrial hyperplasia is PCOS (RR 3) although diabetes (RR 2) is also a risk factor.

A 48 yo lady presented with 6 months of increasing menorrhagia and dysmenorrhoea. On examination the uterus was anteverted, bulky, tender and consistent with a 10-week size. Office hysteroscopy revealed a secretory endometrium and no evidence of submucous fibroids. Pelvic US showed an enlarged uterus but no evidence of adnexal mass. Which of the following is correct about her condition? a. Requires the presence of endometrial glands two high powered fields below the basement membrane b. Responds to cyclical progesterone c. Responds to OCP d. NSAIDS reduce the symptoms e. Often successfully treated by endometrial ablation

D The diagnosis is adenomyosis. The pathognomonic feature is the presence of endometrial tissue within the myometrium at a distance of at least one low power field (some say two) from the endo-myometrial junction. It does respond to progestins whilst the effect of OCP is not clear. Ablation can be helpful. NSAIDs, OCP and LNG-IUD are effective.

A 47 year-old woman has progressive menorrhagia with regular cycles. On examination, normal anteverted uterus, no adnexal masses. At hysteroscopy, regular cavity, no pathology found. Secretory endometrium. What is the best management? a. Cyclic progesterone b. OCP c. NSAIDS d. Advise endometrial ablation cf TAH is more effective and less cancer e. Advise endometrial ablation is adequate contraception

C UTD states that low dose OCP are as effective as NSAIDs and that both are more effective than cyclic progesterone. Speroff says that OCP is best and Novak agrees. However OCPs have risks and need to be taken all the time. Speroff also states that NSAIDs are first line treatment in ovulatory women with no demonstrable pathology

45 yo regular periods, G4 P3 T1. Increasing menorrhagia, no IMB or PCB. Normal pelvic exam, hysteroscopy and endometrial biopsy normal. To reduce the blood loss? a. Aspirin with menses b. OCP c. Cyclic progestins d. Ponstan with periods

You have just made the diagnosis of atypical endometrial hyperplasia in a 32 year-old woman with PCO who wants to retain her fertility. She is concerned about developing carcinoma. Which of the following is true about this patient’s condition? a. Her risk of developing cancer approaches 50% b. If cancer occurs it is likely to be grade 2 or 3 c. If cancer occurs it is likely to be deeply invasive d. Her risk of cancer will be reduced if she becomes ovulatory

D Risk of cancer = 29%

A 47 yo woman with irregular heavy bleeding has a curette. Pathology shows atypical adenomatous hyperplasia. Best treatment? a. Medroxyprogesterone acetate 100mg IM monthly b. TAH c. NSAIDS d. Hysteroscopy to rule out cancer then rollerball diathermy e. YAG laser endometrial ablation

46 yo woman with 5 months of menorrhagia referred to you following D&C by LMO where inadequate sample was collected. ? further Mx a. Commence progesterone b. Commence oestrogen c. Coagulation profile d. Hysteroscopy D&C e. Endometrial ablation

Endometrial cystic hyperplasia most likely to be associated with? a. Maturity onset diabetes b. Adenomyosis c. Biphasic OCP d. Combined HRT e. Tamoxifen

Treatment of menorrhagia with GnRH. How long does it take to work? a. 24/24 b. 48/24 c. 1/52 d. 3/52 e. 7/52

D Produce a hypogonadtropic hypogonadal state in 1-3 weeks. Three cycles for amenorrhoea (30% of patients)

Most common clinical indication for GnRH agonist in Australia at present: a. Prostatic cancer b. Fibroids c. IVF d. Endometriosis e. Abnormal uterine bleeding

PMB x 3 3/12 ago EUA, hysteroscopy D&C NAD, next Mx? a. rpt D&C ideally with a Ca125 for tubal ca b. TAH c. Nothing

B Up to 20% may have endometrial cancer or hyperplasia, even with negative biopsy. (UTD)

A 40 yr old woman has been taking the OCP for the last 5 yrs with no notable problems. How much longer can she continue with the pill? a. 5 yrs b. 10 yrs c. Till menopause d. Should cease now

With regards to the cOCP, a woman of 35 years who is a non smoker and has a serum cholesterol of 5.8 should: a. Cease and use alternative contraceptive methods b. Continue to 38yo then cease c. Continue to 40 yo d. Continue to 45 yo e. Continue to menopause

A post-menopausal woman presents with several episodes of PV bleeding over 9 months. Negative pap smear, hysteroscopy NAD curettage. Next Rx? a. repeat curette b. TAH / BSO

Risk of cardiac disease in a patient aged 35 who undergoes surgical castration compared to a normal woman of the same age a. Less than control b. Equal to control c. 2 x control d. 3 x control e. 4 x control

C Hazard ratio of 1.34 if BSO occurs at age less than 45

45 yo with 2 family members with ovarian cancer who is booked for elective TAH for menorrhagia. Best option? a. Oophrectomy b. HRT

Severity of menopausal hot flushes altered by all except? a. Younger age of menopause b. Thin female c. High oestrogen d. Low oestrogen bound to Non SHBG e. Low GnRH

Probably A Hot flushes are worst in women who are obese or smoke. (UTD and Speroff). – hot flushes relate to thermoregulatory dysfunction in the low oestrogen environment

A postmenopausal woman should be told that HRT may benefit the following areas of her health except a. Cardiovascular b. Osteoporosis c. Wrinkles d. Hot flushes e. Vaginal dryness

Beneficial effects of oestrogen replacement in elderly women is LEAST proven in the literature for prevention of: a. Osteoporosis b. Skin wrinkling c. Urge incontinence d. Recurrent UTI

Vasomotor irritability found in post-menopausal women is due to: a. The level of oestrogen b. Alternation in temperature regulation c. LH surge d. Elevated FSH e. The level of progesterone

Least likely to help hot flushes a. Fluoxetine b. Phytoestrogens c. Venlafaxine d. Clonidine

A 50yo well woman attends for regular check up. Hysterectomy for fibroids at 35yo. No symptoms. FSH 60. What regime of HRT would you prescribe? a. continuous EE 30mcg and cyclic NE 10mg b. continuous Premarin, cyclic Primolut c. continuous low dose conjugated E, 2.5mg Provera daily d. no clinical need for HRT

Woman had a pelvic clearance for an ovarian cancer at the age of 37. Severe flushes 6/52 post surgery. Mother had a Colle’s fracture. Sister had a mastectomy. BP130/90. Options: a. Clonidine b. Recommence OCP c. Oestrogen alone d. Oestrogen/progesterone

34 yo pelvic clearance for ovarian Ca develops hot flushes at 6 weeks visit. Previously on OCP. Mother has past history of Colles fracture, sister of breast Ca. Normal breast examination. Therapeutic options include: a. Initiate clonidine b. Oestrogen alone c. Oestrogen after bone densitometry d. Oestrogen and progesterone after mammography e. Recommence OCP

A 53 yo multiparous postmenopausal woman has recently begun daily therapy with Premarin 1.25mg to prevent osteoporosis. She is non-obese but hypertensive and has an intact uterus. The patient is concerned about the risk of endometrial carcinoma with ERT and comes to you for a second opinion. You explain that her greatest risk of developing endometrial carcinoma relates to? a. overabundance of endogenous oestrone b. hypertension c. development of and oestrogen secreting tumour d. unopposed ERT

A 50 yo woman with an intact uterus complains of severe vasomotor symptoms. You prescribe Premarin 0.625 mg daily for 25 days and Provera 10 mg daily for the last 13 days of each 25-day cycle. You explain that the combination reduces the risk of endometrial ca but may also result in monthly PMT like symptoms, including withdrawal bleeding. The patient who has been looking forward to cessation of menses, asks about other effects of this combined treatment. You advise her that the benefits of adding P to ERT include? a. cessation of withdrawal bleeding after 2-3 months b. long term beneficial effects on HDL cholesterol c. protection against ovarian carcinoma d. elimination of the need for regular endometrial sampling

A 60 yo has been on cyclic ERT for 10 yrs. Diagnosed with Stage 1A, grade 1 CA endometrium. During hospitalisation she experienced symptoms of oestrogen lack and wants to resume HRT. You advise her that? a. ERT is contraindicated b. She can resume ERT at any time c. She should not resume ERT for 2 yrs d. Non hormonal therapy is indicated

50yo G2P2 smokes 2 packs/day for last 30 years. Last period 6 months ago. Hot flushes. You would advise her: a. HRT is contraindicated in smoking b. Wait for 6 months before commencing HRT c. HRT will reduce risk of osteoporosis related to her cigarette smoking d. HRT causes increased risk in cardiovascular disease e. I reckon this question was a while ago

50 yo whose last menstrual period was 6 months would like some advice. a. Continue contraception for another 5 yrs b. Warn of dangers of possible pregnancy c. Wait for another 6 months before commencing HRT d. Advise hysterectomy

Slim 65 yo, non-smoker, neg Fhx, menopause 6 yrs ago. Has had HRT on/off. Best regimen for continuing use? a. cyclical Premarin& MPA b. continuous Premarin with 2.5 mg MPA

60yo well woman, last period 6 years ago. Wants to start HRT as family history of something relevant, what dose? a. continuous EE 30, NE 10mg b. continuous Premarin, cyclic Primolut 5mg c. continuous low dose conjugated E, 2.5mg Provera daily d. continuous low dose conjugated E

The most common ovarian tumour in the postmenopausal period is: a. Fibroma b. Serous cystadenoma c. Mucinous cystadenoma d. Teratoma

With regards to bone mass the most correct statement is. a. Peaks at 25 years of age b. 65% cortical, 35% trabecular c. 70 year old, not on HRT, lose 2% bone mass per year d. Accelerated loss occurs after menopause

D Bone mass peaks at mid to late 20s in the femur (between 18-30 otherwise); 80% is cortical; accelerated loss after menopause; 1-1.5% bone mass per year is lost after menopause initially, which then slows.

All of the following are associated with osteoporosis except? a. Smoking b. Caucasian race c. Relative with osteoporosis d. Poor calcium intake e. Competitive rowing

Which drug is likely to cause osteoporosis a. Phenytoin b. Warfarin c. Prazosin d. Amitryptiline

A Warfarin – maybe; phenytoin – true; prazosin – false; amitryptaline – false

The risk factors for osteoporosis include all of the following except? a. Caucasian b. Immobile c. Excess alcohol d. Obesity e. Hyperthyroidism

D – Low BMI = risk factor

Pick the most accurate statement a. Supplement of calcium 1500mg will increase the risk of renal stones b. Bone loss associated with menopause occurs mostly in the first 3 years after menopause c. HRT not required after 60 years of age

B Accelerated bone loss occurs in the first five years after menopause (Speroff). Over supplementation with calcium is associated with a small increased risk of nephrolithiasis (RR 1.2). (UTD)

Which of the following will increase pregnancy rates if treated:** a. Anorexia b. Minimal endometriosis c. Hyperprolactinaemia in ovulatory women d. Anti – sperm antibodies in the female e. All of the above

A Some evidence for treatment for minimal – moderate endometriosis now

A patient is amenorrhoeic and hypothyroid on testing. What test is most indicative of multiple endocrine abnormalities? a. Normal GTT b. Antithyroid antibodies c. ANA positive d. 46 XX

Amenorrhoea following chemo for Hodgkins, which would predict whether she can conceive? a. LH b. FSH c. E2 d. Prog

A 21 yo girl presents with 6 months of hot flushes. She had a history of Hodgkin’s lymphoma diagnosed when she was 18. A full course of MOPP was completed. Since then she became amenorrhoeic. What is your management? a. BhCG to rule out pregnancy b. Serum FSH c. Commence on cyclical oestrogen alone d. Commence on cyclical oestrogen and progesterone e. Commence on OCP

A (vs B)

26 yo secondary amenorrhoea. Most likely abnormal test? a. Raised FSH b. Raised LH c. Raised androstenedione d. Decreased progesterone e. Decreased oestrogen

D Low progesterone because ovulation has not occurred and therefore there is no CL

What is the chance of conception with one active intercourse on the day on the LH surge? a. 5% b. 20% c. 10% d. 75% e. 80%

B Reproductive efficiency averages about 20% and would not exceed 35% even with carefully timed coitus. (Speroff)

In minimal endometriosis associated with infertility, which of the following is the most appropriate management a. danazol b. surgery c. observation d. laser laparoscopy

A woman presents with 2 yrs of infertility. On laparoscopy mild endometriosis was seen. Next Mx? a. Laparoscopic diathermy b. Danazol for 6 months c. Progesterone d. Combined OCP e. Conservative management

Laparoscopy performed on a 26 yo with a 12 month history of infertility reveals minimal endometriosis. Management? a. Progestogens for 6/12 b. GnRH analogues for 6/12 c. COCP for 12 months d. Expectant management for 6/12

A patient with known endometriosis presents with a 3 year history of infertility, dyspareunia and pelvic pain. Laparoscopy reveals dense pelvic adhesions with neither ovary visible but both tubes patent. Management: a. GnRH analogues for 6 months b. Laparotomy, adhesiolysis and excision of endometriotic implants c. Laparotomy to free adhesions and suspend ovaries for IVF d. US guided IVF

B Consider the use of GnRH analogues prior to surgery.

35yo menorrhagia and 6cm subserosal fibroid wishes to become pregnant a. ignore the fibroid and attempt to conceive b. 3m GnRH agonist and then attempt to conceive c. undergo myomectomy d. undergo hysteroscopic resection

A Poor evidence for the treatment of subserosal fibroids in the setting of infertility unless large (>5-7cm)

30 yo para 1 with a 3 yo child presents with menorrhagia and on VE there is a 12 week fibroid uterus palpable. She would like another child in the future. Management: a. TAH b. Myomectomy abdominally c. GnRH analogue for 6/12 d. Continuous provera for 9/12 e. Hysteroscopic resection

C (lap myomectomy = best but not an option)

Which of the following is not associated with amenorrhoea and galactorrhoea? a. Metoclopramide use b. Chlorpromazine use c. Chronic renal failure d. Prolactinoma e. Thyrotoxicosis

Hyperprolacinaemia is related to: a. Metoclopramide b. OCP c. Beta blockers d. Herpes simplex e. Diabetes insipidus

Galactorrhoea occurs after a laparoscopic sterilisation. What is your management? a. CT head b. Mammogram c. Bromocriptine d. Reassurance e. OCP

D According to UTD stresses such as surgery and anaesthesia can inhibit dopamine release and cause galactorrhoea and hyperprolactinaemia. CT head will not show a pituitary lesion as a MRI is required. Mammogram should be done if breast discharge is stained with blood to investigate a breast tumour. Bromocriptine or the OCP are not indicated.

G2P2 28 yo with galactorrhoea after lap steri. Investigation? a. CT head b. TFT c. Mammogram d. Prolactin e. Gonadotrophins

G3P3 lady who has had TL has galactorrhoea. PRL 700. Normal pit fossa on CT. Mx? a. Bromocriptine b. Do nothing c. OCP

G2P2, 8 months post partum, galactorrhoea, normal PRL. Mx? a. OCP b. Bromocriptine c. Nil – advise 1/3 settle spontaneously

With microprolactinomas which is correct? a. 75% regress spontaneously b. 10% of postmortems for non-endocrine causes of death revealed unsuspected microadenoma’s

B 10% spontaneously regress

Irregular menses with prolactin ~2000, 6mm pituitary microadenoma. Wants to get pregnant. Advice? a. Too dangerous to get pregnancy b. May go blind c. Start bromocriptine d. Breast feeding contraindicated

How does high prolactin cause infertility? a. Dopamine and GnRH b. Failure of aromatase c. Endometrial effect d. Progesterone suppression of corpus luteum

Woman has completed her family. Long history of high prolactin but no pituitary tumour: a. OCP and yearly prolactin levels b. HRT and condoms and yearly prolactin levels c. Bromocriptine alone and yearly prolactin levels

A Surely depends on symptoms? Assuming no symptoms – needs contraception

A 30 yo woman presented with 6/12 of secondary amenorrhoea and PRL 1500. Which of the following investigations is least useful? a. Serum BHCG b. Pelvic US c. TFT’s d. Karyotype e. 17 hydroxy progesterone

D or E

27 year old with hypothalamic amenorrhoea desires pregnancy. Induction of ovulation with GnRH is effective** a. Administered continuously as a s/c infusion until follicular maturation b. Only if hCG is used to trigger ovulation c. Only if hMG are administered simultaneously d. Hormone administered in pulsatile fashion

A lady presented with oligomenorrhoea, basal body temperature chart showed monophasic patterns. Histology of the endometrial biopsy will most likely be: a. cuboidal endometrial gland with compact stroma b. supranuclear vacuoles c. infranuclear vacuoles d. stromal disorganisation e. glandular disorganisation

E Oligomenorrhoea and monophasic BBT is associated with anovulatory cycles. The classical histology would be glandular disorganisation. Subnulcear intracytoplasmic vacuoles are a sign of ovulation. The cuboidal endometrial gland with compact stroma probably relates to implantation phase. Stromal disorganisation probably happens with menstruation. (Speroff)

Woman with 3 periods a year lasting 10-12 days. Endometrial biopsy approx 10 days after a period shows? a. Subnuclear vacuolisation b. Supranuclear vacuolisation c. Stromal oedema d. Haemorrhagic endometrium e. Lots of straight glands

E Subnuclear vacuoles suggest secretory phase post-ovulation, stromal oedema suggests implantation phase, haemorrhage suggests endometrial breakdown. Therefore straight glands would imply proliferative phase that occurs after menses

A woman with PCO. LMP 25 days ago. Usually has 3 periods a year. Heavy flow day 10-12. Endometrium is likely to show? a. Subnuclear vascuolisation b. Haemorrhagic and necrotic glands c. Crowding of straight glands

26 yo with 3 yrs of infertility and oligomenorroea. Which of the following is most appropriate? a. Karyotype b. Androgen and pelvic ultrasound c. FSH and LH d. Basal temperature chart e. Serum oestrogen and progesterone

What is the rate of multiple pregnancies associated with Clomid? a. 1-2% b. 2-5% c. 5-10% d. 10-15% e. 15-20%

C 5-8% according to Speroff

You are advising a patient to commence on clomiphene for ovulation induction. Which of the following is correct? a. no potential for fetal abnormalities b. 50% side effect rate c. 30% multiple pregnancy rate d. Pregnancy rate is half of the ovulation rate (73% and 36%) e. 80% ovulation rate expected in treating patient with secondary amenorrhoea

D The multiple pregnancy rate 5-8%; doesn’t increase congenital abnormalities but the background rate remains; generally well tolerated with few side effects (<10%); ovulation rate is 80%; cycle fecundability is about 15-22% with cumulative pregnancy rates of 70-75% (Speroff) UTD states ovulation rates of 73% and pregnancy rates of 32% for a mix of indications.

Regarding clomid: a. Twins in 25% b. Can cause ovarian cysts and most probably hyperstimulation c. If gets pregnant will not have increased congenital abnormalities

A 29yo with PCOS had attempted ovulation induction with clomiphene 50mg then 100mg and has been unsuccessful. The next step in management should be: a. 150mg clomiphene b. HMG and hCG c. Mid cycle hCG 10,000 units d. GHT e. POQ

A Treatment with doses up to 150mg is reasonable prior to considering more aggressive therapies. Subsequent options would be extended course treatment, glucocorticoids, hCG, preliminary suppressive therapy and insulin sensitising agents. (Speroff)

Clomid in anovulation, Rx 50mg and 100mg. Still no ovulation, otherwise normal investigations. Next option? a. increase to 150mg b. hMG c. hCG

Ovulation cannot be induced in which of the following conditions? a. Galactosemia b. PCOS c. Hyperprolactinaemia d. Kallman’s syndrome

A Kallman’s syndrome can be treated with exogenous gonadotropins to achieve pregnancy

Use of HMG will not produce ovulation in which of the following? a. Polycystic ovaries b. Hyperprolactinaemia c. Galactosaemia d. Tubal damage

C toxic levels of galactose → ovarian failure

Use of HMG will not produce ovulation in which of the following? a. Polycystic ovaries b. Hyperprolactinaemia c. Galactosaemia d. Failed ovarian follicle syndrome

D Definitely galactosaemia, although if resistant or insensitive ovarian syndrome is meant this is also true

Regarding PCOS, correct option: a. Low SHBG b. Testosterone 4-6 c. Multiple follicles on US d. 1 dominant follicle on US

18 yo girl with 2 yrs of secondary amenorrhoea has been found to have PCOS. Which is true? a. SHBG will be low b. Inborn error of adrenal steroidogenesis is likely the underlying cause c. She will have bilateral enlarged ovaries with 1 dominant follicle d. Her ovaries contain multiple follicles each of 5-10 diameter

A The Rotterdam criteria state - ovaries will containing at least 12 follicles of between 2-9mm

A 24 year-old presents with facial hirsutism requiring depilation not shaving. Has been gradually worsening since menarche age 13. OE NAD else, Ix by LMO shows testosterone 1.3x upper limit of normal. Next most important investigation? a. Androstenedione b. DHEAS c. 17 OH ketosteroids – urinary d. LH e. Pelvic US

A young woman with recent onset of severe hirsutism and clitoromegaly comes for help. Ix testosterone is 17 / DHEAS upper limit of normal. Next Ix? a. Serum androstenedione b. US ovaries c. CT adrenal d. Venous sampling for androgen levels

An 18 yo with 2 yrs of secondary amenorrhoea has been found to have PCO. Which is true? a. SHBG will be low b. Inborn error of adrenal steroidogenesis is likely to be the underlying cause c. She will have bilateral enlarged ovaries with 1 dominant follicle d. Her ovaries will contain multiple follicles of 5-10mm diameter

18 yo girl presented with hirsuitism. She is having regular cycles. Hormonal profile revealed normal testosterone, DHEA & DHEAS levels. Pelvic US normal. What is the most appropriate treatment? a. COCP b. Spironolactone and OCP c. Progesterone d. Oestrogen e. Cyproterone acetate

In PCOS oestrogen is mainly produced by? a. The ovary b. Peripheral conversion of androstenedione

B PCOS is associated with increased levels of oestrogen. The ovaries produce the normal amount but the excess is from peripheral conversion of androstenesione.

On PCOS the follicles are surrounded by? a. Granulosa cells b. Theca interna c. Theca externa

USS findings of PCO a. In 5% of normally ovulating women and 75% of hyperandrogenic anovulatory women b. In20% of normally ovulating women and 75 % of hyperandrogenic anovulatory women c. In 5% of normally ovulating women and 90% of hyperandrogenic anovulatory women d. In 20% of normally ovulating women and 90% of hyperandrogenic anovulatory women

D USS findings in 20% of normal women and 80-100% of hyperandrogenic anovulatory women (UTD)

.Most effective treatment for a woman with hirsutism. Normal testosterone level? a. Electrolysis b. Low dose OCP c. Spironolactone

30 yo woman presents with 12 month history of virilisation. T = 8 (high), DHEAS normal. Best choice for next investigation: a. TV US b. 17 OHP c. Androstenedione

25 yo, 1 yr Hx acute virilizing symptoms. Bloods - LH 2, FSH 3, Testosterone 2-3x normal, DHEAS normal, 17 OHP Normal a. Cushing’s syndrome b. PCO c. Late onset CAH d. Sertoli-leydig tumour e. Adrenal cortical adenoma

43 yo with recent onset virilizing symptoms. Bloods - LH 1, FSH 1, Test 2x normal, DHEAS 1.5x normal, 17 HOP normal a. Cushing’s syndrome b. PCO c. Late onset CAH d. Sertoli-leydig tumour e. Adrenal cortical adenoma

22 yo, long Hx irregular menses and hirsuitism. Bloods - LH 12, FSH 6, Test 1.5x normal, DHEAS 1.5x normal, 17 HOP 2x normal a. Cushing’s syndrome b. PCO c. Late onset CAH d. Sertoli-leydig tumour e. Adrenal cortical adenoma

22 yo long Hx irregular menses and hirsuitism. Bloods - LH 1.9, FSH 6, Test 1.5x normal, DHEAS 1.5x normal, 17 HOP normal a. Cushing’s syndrome b. PCO c. Late onset CAH d. Sertoli-leydig tumour e. Adrenal cortical adenoma

23yo woman, recent onset of virilisation, DHEAS x2.5, testosterone x1.5, LH high normal, cause: a. CAH b. PCOS

DHEAS and testosterone are elevated enough to give concern over an adrenal tumour.

.Markedly raised testosterone and DHEAS, which is least helpful? a. CT adrenals b. US ovaries c. 17 OH prog d. LH e. FSH

22 yo 87kg female with irregular menses and 1 yr history of hirsuitism and a deepening voice. Ix include raised testosterone (80) and normal DHEAS 8 (N<10). Obese, ovaries difficult to feel, uterus normal. Next? a. 17 keto-steroids b. androstenedione c. TV US of ovaries and adnexa

Unexplained infertility in a couple with the female aged 30 for 2 yrs. Management? a. GIFT b. IVF c. AIH d. Clomid

A or B UTD: Expectant → lifestyle changes → has IUI → Clomid 1st (Data for unexplained – IUI is strong, clomid less clear)

.26 yo couple with a 3y history of infertility and very irregular menses. Examination of the woman is normal and her partner has a normal semen analysis. There is abundant clear cervical mucous. The next most appropriate management is a. Serum prolactin, progesterone challenge, Clomid after menses b. Serum androgens and pelvic US c. Serum progesterone today d. Endometrial biopsy today e. BBT and review 3 months

B Mucous reflects that the woman is mid-cycle

All of the following are indicators of the appropriate time for a post-coital test except: a. Profuse clear mucus b. Ferning pattern of the mucus on a slide c. Leucocytic infiltration of the mucus d. External os open e. Spinnbarkeit of 10 cm

A couple with infertility have a post-coital test performed on day 10 of the cycle. Scant mucous is present on the cervix. Best option is? a. Give oestrogen for day 10-15 of the cycle b. Use clomiphene in the next cycle c. Repeat the test in 2-3 days d. Advise AIH next cycle e. Advise IVF next cycle

C Most common explanation for poor results is improper timing. (Speroff)

On day 14, the cervical mucus is noted to be clear with Spinbarkeit. Which of the following is correct? a. Ovulation occurs in 36 hrs b. She had produced sufficient amount of oestrogen c. She will get her period in 2 weeks if she doesn’t fall pregnant d. She is producing sufficient amount of progesterone

Unexplained infertility: absence of definable cause after 12/12 attempting pregnancy: ovulation, tubal patency, adequate oocyte resevere, normal cavity, semen analysis a. Never offer IVF or GIFT unless infertility is > 3 yrs duration b. Can be diagnosed if SA normal, normal HSG, ovulatory and normal PCT c. Explanation that everything normal is as effective as any other treatment except GIFT d. Clomiphene can double chance of conception

B As a minimum unexplained fertility is a normal SA, evidence of ovulation, normal cavity and bilateral tubal patency. Other treatments are effective with clomiphene has a small effect (Speroff) – not double

Couple with 2 years infertility. She has a normal pelvis & tubes and appears to be ovulating. Normal SFA. Which option gives the highest chance of conceiving? a. IVF b. GIFT c. Clomiphene d. AIH e. Do nothing

A Expectant management – pregnancy rate of 1.3-4.1% per month; IUI 3.8%; clomiphene 5.6%+ IUI 8.3%; IVF 20.7%; GIFT 27% (Speroff). These numbers are old with IVF being more effective than GIFT

Which has a significant effect from extravasation? a. Oil based HSG b. H2O based HSG c. Both d. Neither

D H2O based HSG – lower cost, better imaging, less intravasation reaction

Which is contraindicated if allergic to iodine? a. Oil based HSG b. H2O based HSG c. Both d. Neither

Which has the risk of salpingitis? a. Oil based HSG b. H2O based HSG c. Both d. Neither

Which require delayed films of 12-24 hrs to complete series? a. Oil based HSG b. H2O based HSG c. Both d. Neither

D Late film = 20 mins

Which of the following tubal conditions treated by microsurgical techniques has a better pregnancy rate than current ART? a. reversal of tubal sterilisation using clips b. reversal of tubal sterilisation using diathermy c. hydrosalpinx d. cornual blockage e. salpingitis isthmic nodosa

A The pregnancy rate for IVF is about 27% per cycle. Tubo-cornual anastomosis results in pregnancy rates of 16-50%. Tubal re-anastomosis results in pregnancy rates > 46% (clips > diathermy). Salpingostomy for hydrosalpinx results in rates of approximately 30%. (UTD)

.A couple presented to you for investigation of primary infertility. SA normal. HSG showed bilateral proximal tubal blockage. What is the next appropriate choice of management? a. Rubin test test of tubal patency using CO2 gas b. IVF c. GIFT d. Laparoscopy and hydrotubation e. Microsurgical removal of proximal blockage

Offer IVF to? a. Couple with mildly abnormal SA and 1 year of infertility b. 1 failed GIFT cycle c. PID with bilateral tubal disease d. Mild endometriosis

IVF should be discussed when a. Unexplained infertility for 1 yr b. Mild semen abnormality in a male – 2 yrs infertility c. Bilateral tubal disease d. One cycle of GIFT unsuccessful

28yo woman with bilateral hydrosalpinges, 2-3cm diameter, with minor adhesions to the ovaries. HSG reveals the proximal portion of the tubes to be patent. Which of the following is true? a. IVF eliminates the risk of an ectopic pregnancy b. Surgery offers a similar chance of pregnancy to a single cycle of IVF c. Laser laparoscopy offers a better chance of successful pregnancy than microsurgery

A patient had ovulation induction for anovulation and on day 13 noted to have 5 follicles on US each measuring 16mm in diameter. Her oestrogen was 1000 pg/mL. What is the management? a. expectant management b. selective puncture of 3 follicles c. convert to an IVF cycle d. give hCG e. give GnRH agonist

B HCG is given on the day that at least one follicle appears to be mature. The criteria for follicle maturity are a follicle diameter of 18 mm and/or a serum oestrodiol concentration of 200 pg/mL (734 pmol/L) per dominant follicle. If three or more follicles larger than 15 mm are present, stimulation should be stopped, hCG withheld, and use of a barrier contraceptive advised in order to prevent multiple pregnancies and ovarian hyperstimulation (UTD). Viable options other than cancelling the cycle include aspiration of follicles, conversion to IVF or using a GnRH agonist to trigger an endogenous LH surge (may still increase risk of multiple pregnancy).

.A patient on ovulation induction with HMG has 5 follicles > 16 mm on US and an oestradiol level of 6 nmol/l. The most appropriate management is? a. Give HCG and counsel of risk of multiple pregnancy b. Give HCG and advise barrier contraception c. Convert to IVF cycle d. Advise ooctye pickup and freezing of the embryos e. Do nothing

.A lady has a GIFT procedure and developed abdominal distension, N&V on day 2. Which of the following is correct? a. prolonged effects of anaesthesia b. paralytic ileus c. OHSS d. Perforation of bowel e. Should improve with hCG

C OHSS is most likely given that GIFT occurs a couple of days after egg pick-up, which is when OHSS is likely.

Female undergoing IVF with Phx of PID/tubal blockage 5 days post T/V egg pick up has low abdo pain and vomiting? a. OHSS b. Vaginal haematoma c. PID d. Appendicitis e. Torsion of ovary

.Best lubricant for an infertile couple to conceive and complaining of vaginal dryness? a. KY jelly b. Saliva c. Glycerine d. Skin cream e. Alpha keri lotion

C UTD states mineral oil, canola oil

A couple presented with 2 yr history of primary infertility. Investigations of the female were normal. SFA showed oligospermia and his FSH was higher than normal. What is your management? a. Give the husband testosterone b. Give the husband clomiphene c. Consider obstruction d. IVF e. Adoption

.A couple with 3 yrs of infertility. Woman is ovulating and has patent tubes on laparoscopy. Husband’s semen analysis showed 1,000,000 sperms/ml, 10% motility. Mx a. IVF b. AIH c. GIFT d. DI e. Await spontaneous conception

28 year-old G0. Infertile 2 years. Regular menses, HSG showing no evidence of tubal disease, and Day 21 progesterone normal. SFA shows volume of 1 million, 10% motility. Best option. a. GIFT b. IVF c. AIH d. DI e. IUI husbands sperm

Semen analysis – 3ml; 30 x 106 sperm; normal vicosity; 30% forward motility; 40% normal forms. Which statement is wrong? a. 2 parameters are abnormal b. Suitable for IVF c. If smokes and drinks should stop d. Could be explained by a recent nasty infection e. Could be explained by delay in getting sample to lab

A Normal values are – volume: 1.5-5ml; viscosity < 3; total sperm count >20 x 106 / ejaculate; >50% motility; >30% normal morphology.

.Triple defect on semen analysis (density 12 million/ml, morph 20%, motility 30%) a. FSH > 12 on 3 occasions correlates with a poor prognosis b. Rx with Clomid is effective c. Excision of a moderate sized varicoele will improve the defect

.SA – 8 million/ml, decreased motility, 30% normal forms a. Raised FSH generally means no treatment available b. Treatment of small varicocele will improve SA c. Treatment of husband with danazol, GnRH agonist & something else d. If wife has never been pregnant she has an 80% chance of conception with 6 cycles frozen donor sperm

A 50% pregnancy rates after six cycles with donor sperm

.Infertile couple, SFA vol 3ml, count 8x10`6/ml, motility 30%, morphology 30% (triple defect), small testes. a. Varicocoele repair will improve parameters b. Repeated values of FSH of 12 (<8 normal) indicates that improvement is unlikely c. Frozen donor insemination for 6 months will yield a pregnancy rate of 80% if the woman has had no previous pregnancies d. HCG or clomiphene is of value e. Obstruction is likely

The most useful investigation in a man with azoospermia is? a. FSH b. LH c. Prolactin d. Testosterone e. TFT’s

A (vs D) – the key is to distinguish between obstructive (normal T) and gonadal dysfunction (low T). LH/FSH can be checked after you know the T is low

A man has azoospermia, normal testicular size and normal male secondary sex characteristics. Which of the following tests is most predictive of outcome? a. Karyotype b. Testosterone level c. FSH d. DHEAS e. Seminal fructose

.The next best test for azoospermia is: a. FSH b. Examination c. Antibody d. Post-coital test

Semen analysis in a 33 year old = Azoospermia. The lab test most likely to be of value in determining cause. a. Serum Prolactin b. Serum FSH c. Karyotype d. CF gene studies

Which result is independently diagnostic of the cause of secondary amenorrhoea? a. Increase FSH b. Increase LH c. Decrease progesterone d. Decrease oestrogen

Recognised causes of ovarian failure. All except? a. mumps b. galactosaemia c. alkylating agents d. radiotherapy e. turners mosaics f. none of the above

A 35 yo infertile woman with resistant ovary syndrome and hypergonadotrophic hypogonadism. Rx? a. high dose HMG b. HMG and HCG c. GnRH and HMG d. FSH e. O & P HRT

E Ovarian follicles are unresponsive to stimulation maybe due to absent or defective gonadotrophin receptors. Therefore further stimulation will not work and so the hypogonadism should be treated

35 yo woman with prem ovarian failure diagnosed on biopsy. Taking 1.3 mg Premarin for 25 days and 10 mg Provera days 16-25. Complaining of dysmenorrhoea and menorrhagia. Biopsy reveals secretory endometrium. Best option? a. stop HRT b. reduce oestrogen to 0.3 mg daily c. stop progesterone d. continuous O and P

Answer: B or decrease dose of insulin – over fertilising her lawn. Standard dose = 0.625mg Continuous O&P makes the most sense as none of the other options seem to be viable alternatives. UTD states that the dose of O should mimic normal ovarian range (2mg/day)

Septate uterus with 4 midtrimester pregnancy losses. Management: a. Strassman’s procedure b. Jones metroplasty c. Expectant management d. Transcervical resection of the septum

D Hysteroscopic resection of septum is the treatment of choice. Jones metroplasty and Strassman’s procedure are performed for uterine didelphys or arcuate uterus

.Most common time for subseptate uterus to abort? a. 8-14 weeks b. 12-16 weeks c. 14-18 weeks d. 18-22 weeks

Patient presents with recurrent miscarriage. HSG picture is shown (either broad septum or bicornuate uterus). Management: a. transcervical resection of septum b. Hysteroscopy and laparoscopy c. Strassman procedure d. Jones procedure

B Hysteroscopy and laparoscopy to further define abnormality

.23 year old lady has premature labour at 23 weeks after a 10 hr labour. Later it is discovered the she has a vertical uterine septum. You recommend before her next pregnancy: a. Reassurance. No intervention recommended b. Cervical suture required for next pregnancy c. Recommend metroplasty before next pregnancy d. Elective LUSCS next pregnancy

C Metroplasty refers to the correction of uterine abnormalities regardless of route

A woman has two 23-week pregnancy losses due to a uterine septum. Which of the following is most appropriate advice? a. Metroplasty b. Expectant management c. She will carry the next pregnancy longer d. Against pregnancy e. Hysteroscopic removal of septum

The patient has had 2 mid-trimester miscarriages. She then has a hysteroscopic resection of her septum in the uterus. What is her chance of having a term pregnancy next time? a. 10% b. 20% c. 50% d. 90%

What is the rate of full term pregnancy rate after hysteroscopic resection of an endometrial septum? a. 20% b. 30% c. 40% d. 50% e. 70%

Answer: E rate of term preg after excision of septum is 85 – 90%

.What is the rate of amenorrhoea in patients with intrauterine synechiae a. 10% b. 20% c. 40% d. 60% e. 80%

40% have no menstrual symptoms – 60% have menstrual irregularity

Regarding transverse vaginal septum choose the correct option. a. Occurs at the junction of lower 2/3 and upper 1/3 of vagina b. Occurs commonly with abnormalities of upper Mullerian system c. Associated with in utero DES exposure d. Autosomal recessive inheritance e. Treated with Tompkin’s procedure

Both option B and C are true but C is probably true-er. Answer: C

Androgen insensitivity: a. Absent uterus, no breasts b. Absent uterus, breast present c. Uterus present, breast absent d. Uterus present, breast present

Mullerian agenesis:** a. Absent uterus, no breasts b. Absent uterus, breast present c. Uterus present, breast absent d. Uterus present, breast present

Turners syndrome:** a. Absent uterus, no breasts b. Absent uterus, breast present c. Uterus present, breast absent d. Uterus present, breast present

Swyers syndrome a. Absent uterus, no breasts b. Absent uterus, breast present c. Uterus present, breast absent d. Uterus present, breast present

.A man with normal male sexual characteristics, normal testicular size and azoospermia. Which of the following is the most useful investigation? a. chromosome study b. testosterone level c. FSH d. Consider obstruction e. DHEAS

Azoospermic man poorly masculinised with small testes. Next step in management should be a. donor insemination b. PROST c. Karyotype d. Serum prolactin

C Karyotype for Klinefelter’s syndrome

Man with small testes and azoospermia. FSH normal range. Next step in management? a. refer for DI b. check prolactin level c. check for vas obstruction d. check chromosomes

Regarding Kleinfelters, which is not a feature? a. gynecomastia b. female fat distribution c. serious mental retardation d. infertility e. tall eunuchoid status

.Kleinfelters characteristics all except: a. elevated FSH b. azoospermia c. hypogonadism d. normal or low testosterone e. impotence

A normal looking 10 yr old girl (normal size and height) found to have a dimple introitus, short vagina and absent uterus on exam and ultrasound. Most helpful Ix? a. Karyotype b. Testosterone c. 17 OH progesterone

A - differential = MRKH, Swyers (XY, decreased T), AIS (XY increased T)

14 yo, 145 cm tall, no breast, chromosomes - XO. The main advantage in treatment with oestrogen in Turners syndrome is to: a. Oocyte formation b. Increase her height c. Promote breast development d. Prevent hot flushes

15 yo girl with primary amenorrhoea. 160 cm tall, muscular and taller than peers when younger. Shaving since 8 yo (now 3 times/day), pubic hair at 6 yo, tanner stage 2 breasts, normal cervix and vagina with no adnexal masses, but partial fusion of the labioscrotal folds. The most likely chromosomes are? a. 46XX b. 47 XXY c. Mosaic Xo/XY d. Mosaic XX/XY e. 46 XY

A Given that she is virilised 46XY, 47XXY and gonadal dysgenesis are unlikely.

.A 15 yo girl comes to see you with primary amenorrhoea and virilisation, shaving now, taller than colleagues, scant axillary and pubic hair, small breasts, clitoris enlarged and posterior labial fusion has been a problem for at least 10 yrs. Cervix seen at top of vagina. Chromosomes most likely to be? a. XX b. XY c. XY/XO d. XY/XX e. XXXY

.A 160 cm normotensive 15 yo girl has been progressively virilized since age 7. Now shaving face regularly. OE clitoromegaly, posterior scrotal fusion, cervix present, no adnexal masses, tanner 2 breast, amenorrhoeic. Karyotype most likely to be: a. XX b. XX/XY c. XO d. XXY e. XY

.A 20year old presents with amenorrhoea and hirsutism. Her investigations show 17OHP +, LH 2, FSH 3, Testosterone N. Which of the following is the least helpful in definitive diagnosis? a. CT adrenal glands b. TV USS of ovaries c. Dexamethasone suppression test d. ?

A 25 year old presents with rapid virilisation. Her results show Testosterone 25, DHEAS 15, 17OHP normal, FSH and LH normal. What is the most likely diagnosis? a. Adrenal adenoma b. Cushings syndrome c. Late onset CAH

A Normal values – T – 0.7-2.8nmol/L; DHEAS – 2.2-9.5mcmol/L

An 18 yr old girl presents with primary amenorrhoea, no breast development and scant pubic hair. Examination shows normal vagina and vulva with a hypoplastic cervix and uterus. The karyotype is 46 XY. The most likely diagnosis is: a. Pure gonadal dysgenesis b. Androgen insensitivity c. Noonan’s syndrome d. CAH e. True hermaphrotidism

A tall eunachoid 18 yo girl is found to have 46 XY karyotype. OE sparse pubic and axillary hair, tanner stage 2 breasts, normal vagina and vulva, hypoplastic cervix and uterus. Likely cause of intersex disorder: a. True gonadal dysgenesis b. True hermaphrodite c. Testicular feminisation / AIS

14 yo bought by mother because of lack of periods. Which will be most helpful in establishing diagnosis? a. Tanner stage 3 breast development b. Mild obesity c. Waist:hip ratio 0.6 d. Acanthosis nigricans

A Most helpful information is the presence of oestrogen and therefore a functional HPOA. With appropriate breast development this suggests an anatomical cause, although at fourteen it may just be an extreme of normal.

18 yo with normal breast development and pubic hair. Primary amenorrhoea. Least helpful investigation? a. PR and PV examination b. US c. Gonadotrophins d. Oestradiol e. Testosterone

D Normal breast development (normal oestradiol) and pubic hair (normal androgens) means adequate testosterone, gonadotropins and oestradiol. The most useful investigation would be an examination or USS. Testoterone may help differentiate AI or PCOS.

17 year old: Tall at 170cm, primary amenorrhoea, has sparse pubic hair. US shows small uterus. Chromosomes are 46, XY. Management: a. laparoscopic biopsy of gonads b. bilateral gonadectomy c. TAH, BSO d. TAH, BSO, irradiation e. Hysterectomy alone

B Likely 17 alpha hydroxylase deficiency, vanishing testes syndrome or absent testes determining factor (Ullrich – Turner syndrome). Gonadectomy required due to high risk (30%) chance of developing a gonadal tumour.

What cause of primary amenorrhoea has spontaneous ovulation? a. Uterovaginal agenesis b. Kallman’s syndrome c. Turners syndrome d. Testicular feminisation

.Which of the following causes of primary amenorrhoea have spontaneous ovulation? a. Androgen Insensitivity Syndrome b. Turners syndrome c. Swyer syndrome d. Uterovaginal agenesis e. Congenital adrenal hyperplasia

Gonadoblastoma assoc with? a. 47 XXY b. 46 XY

Mechanism of testicular feminisation? a. increased testosterone b. reduction in oestrogen c. chromosomal abnormality d. decreased production of androgen e. decreased sensitivity of the androgen receptor

E Testicular feminisation is otherwise known as complete androgen insensitivity. The mechanism is due to insensitivity to androgens due to a recessive X-linked gene responsible for the androgen receptor. (Speroff)

What is true of testicular feminisation? a. Testosterone is lower than normal range b. Inheritance is X-linked c. Risk of dysgerminoma is highest up to age 20 d. Gonads should be removed immediately diagnosis is made e. Puberty is delayed because of reduced androgen production

.A 15 yr old with known AIS comes requesting more information: a. Breast development is normal due to peripheral conversion of peripheral testosterone to oestrogen b. Axillary and pubic hair development is normal due to peripheral conversion of testosterone to oestrogen c. She will menstruate 1-2 times per year d. She will have normal development of vulva, vagina and ovaries

A is not strictly true but close enough

A 16yr old girl with known androgen insensitivity wants to know more information about it. Which is correct a. She will develop normal breasts b. She will get 1-2 menses a years c. She will develop normal pubic and axillary hair

Which of the following investigations is most urgent in a neonate with indeterminate sex? a. Radiological dye examination of the urogenital sinus b. Karyotype c. Serum FSH measurement d. Serum electrolytes e. Serum 17OH progesterone

D Electrolyte imbalance due to inadequate aldosterone production occurs in 75% of patients with virilising adrenal hyperplasia. (Speroff)

A previously healthy 4 day-old infant becomes hypotensive and dehydrated, low Na and high K. Which definitive Ix likely to be positive next? a. Raised 17-OH progesterone (>200)

17-hydroxylase deficiency will be associated with? a. HT b. Hirsutism c. Salt losing d. Absent vagina e. Regular menstrual cycle

A 17-hydroxylase deficiency results in primary amenorrhoea, female phenotype, hypertension and hypokalaemia due to deficiencies in corticoids and overproduction of mineralocorticoids

.21 hydroxylase deficiency, incorrect option a. Gene on chromosome 6 b. Causes 5% of hirsutism c. Raised DHEAS d. Dexamethasone suppression test to definitively diagnose condition

D Occurs on chromosome 6; does have raised DHEAS; needs ACTH stimulation test for diagnosis; causes 1- 15% of hirsutism; dexamethasone suppression test is used to diagnose Cushing’s syndrome

.If defective primordial germ-cell migration, the patient would present with a. Pubertal delay b. Pubertal failure

.XY gonadal dysgenesis – which is correct? a. Look like prepubertal female b. Undescended testes c. Ambiguous genitalia

.Most consistent with 46XY gonadal dysgenesis (Swyer’s syndrome) a. Ambiguous external genitalia (typically mild) b. Normal infantile female phenotype c. Circulating testosterone in male range d. Small atrophic testes in inguinal canal

.A baby with pure gonadal dysgenesis will have as a phenotype? a. Ambiguous genitalia (but only mild) b. Infantile female c. Atrophic testes in inguinal canals

Cause of testicular feminisation? a. Absent testosterone b. Absent androgen receptors

.Amnio revealed 46 XY but baby born with female external genitalia. What is the most likely cause? a. Lab error b. Androgen insensitivity syndrome c. Mullerian agenesis

Day 4 of life, female developed vaginal bleeding, what is the most appropriate management? a. check for UTI b. investigate for blood in the stool c. US for uterine tumour d. EUA for diagnosing vaginal tumour e. Reassure the mother withdrawal bleeding only.

E Bleeding due to the withdrawal of oestrogen after delivery

3-4/7 old male child has swollen right breast with discharge. You a. Reassure the mother that it is physiological – oestrogen withdrawal b. Consult a surgeon c. Consult the neonatologist d. Refer to the mother an baby unit

Least common neonatal hymenal configuration? a. Annular b. Semilunar c. imperforate d. fimbriated - prepubescent

C Annular – common (circumferential)

Most common cause of vaginal obstruction in neonate is? a. Transverse vaginal septum b. Imperforate hymen c. Longitudinal vaginal septum d. Vaginal agenesis e. Cervical atresia

.Congenital absence of vagina is associated with all except? a. Abnormal ovarian function b. Urinary tract anomalies c. Musculoskeletal anomalies d. Chromosomal anomalies e. Endocrine anomalies

A Urinary tract anomalies 25-50% Musculoskeletal anomalies 15% Chromosomal anomalies – genetics not known ? Autosomal dominant – familial cases reported

.Of the following what is not an indication for laparoscopy in a child? a. Pain from suspected endometriosis b. Intersex problem c. Possible outlet obstruction d. Mayer Rokitansky Kuster Hauser syndrome

.Most appropriate management of labial agglutination in a 3yo is: a. surgical b. refer to paediatrician for investigation of intersex c. topical E2 daily for 2-3 weeks

Appropriate treatment for a 4 yo girl with labial agglutination is? a. Reassurance and no treatment b. Oestrogen cream and gentle pressure c. Sorbolene cream d. Sitz baths e. Investigate sexual abuse

.What is the most likely diagnosis in a 5 year-old female with constant dribbling despite other wise normal voiding pattern? a. UTI b. Urethral prolapse c. Ectopic ureter d. Labial fusion

Young girl with PV discharge. Solitary kidney, 8cm paravaginal mass. It is? a. Gartners duct cyst b. Duplicate vagina c. Kidney d. Obstructed hemivagina

.A 6 yo girl presents with her mother with a several days of a blood stained vaginal discharge. Outline your initial management a. Ask a senior colleague to RV re ? sexual abuse b. Take swabs and commence on antibiotics c. Perform a rectal examination to rule out a foreign body d. Arrange an EUA e. Pelvic US

.The percentage of children who wet the bed at night is? a. 1% b. 7% c. 15% d. 27% e. 45%

C (UTD at age 5)

A 6yo girl presents with a bloody vaginal discharge. Most appropriate management is: a. Reassure and arrange for an EUA b. Take swabs and treat appropriately c. Perform a rectal examination to exclude a foreign body

.Most common cause of a discharge in a 6 year-old girl? a. Vaginitis b. Foreign body c. Clear cell carcinoma of vagina d. Candidiasis

Definitive finding of sexual abuse in female children? a. Unexplained hymenal transection – ‘absent hymen’ b. Healed unexplained injury to post fourchette c. Posterior narrowing or asymmetry of hymen d. Non-midline anal scars or tears of hymen

A According to UTD hymenal transection is highly specific for abuse whilst unexplained injury to the posterior forchette is only moderately specific

Definitive evidence of sexual abuse? a. Thick nodular labial adhesions not associated with diapering b. Unexplained healed injuries to fossa(?) c. Non-midline scars around anus and fourchette d. Absent or transected hymen e. Asymmetrical fourchette or hymen

Who must report suspected sexual abuse? a. Physicians b. School teachers c. Social workers d. All of above e. None of above

.An 8 yo girl is brought to A&E 1 hr after a sexual assault. Her vital signs are stable. Examination reveals penetration has occurred and there is a tear right through the rectovaginal septum. Next step? a. Collect specimens in ER b. Repair trauma in OT c. Abdominal Xrays d. Colposcopic exam in introitus

13 yo girl presents with heavy menstrual bleeding for 6 months. What is the next most appropriate step? a. Combined OCP b. Hysteroscopy, D& C c. Cyclical progesterone d. Coagulation profile e. Expectant management

D (Novak – 20% have a coagulation disorder)

15 yo with unpredictable menses despite tampon use? a. Vaginal agenesis b. Imperforate hymen c. Complete duplication of uterus, cervix and vagina d. Rectovaginal fistula e. Vesicovaginal fistula

14 yo with 3x3 cm breast lump lateral to nipple, no fluid obtained on FNA. Options? a. RV 6 months b. Bilateral mammogram c. Excisional biopsy d. US localised biopsy e. Canalise mammary duct adjacent

Which of the following diseases are typical of primary amenorrhoea? a. Mixed gonadal dysgenesis b. Turner’s syndrome c. Asherman’s syndrome d. Congenital adrenal hyperplasia

.16yo girl has primary amenorrhoea and no secondary sexual characteristics. What is the least useful test? a. FSH and LH b. Height and weight c. Prolactin d. Oestrogen e. Testosterone

D The absence of secondary sexual characteristics highlights a hormonal rather than a structural cause. Thus oestrogen is going to be of limited benefit. FSH/LH will reveal HPOA function whilst testosterone for androgens and prolactin for adenomas

17 year-old, reserved, in a bulky jumper, referred because of 6 months of secondary amenorrhoea. Mother states she is a ‘picky eater’, keen athlete and has lost weight 48-> 32 kg. Mx? a. hospitalise b. counsel to increase eating and be supportive c. OCP d. Ix with FSH, LH, bhCG, Prl, Oestrogen, TFT’s e. Clomiphene

A One indication for admission for AN is body weight less than 75% of ideal weight for age and height

An 18 yo girl accompanied by her mother to see you concerned about recent weight loss from 54 to 32 kg in a period of 6 months. This was associated with secondary amenorrhoea. She is an intelligent girl and doing very well at school. She recently became more lethargic and lost her appetite. On examination there was no obvious cause for her weight loss. What is the next most appropriate management? a. Commence on oral progesterone b. Commence on oral oestrogen c. Hospitalisation for assessment d. Reassurance

A 16yr old presents with irregular bleeding requesting an increased dose of the pill. Her parents are undergoing a divorce. She is depressed, not sleeping, and has lost 4kg in weight. Recently she has taken medication out of mother’s cupboard. What should you do? a. Prescribe the COCP b. Arrange a psychiatric review c. Get her to see the school guidance counsellor d. Prescribe an antidepressant

Anorexia nervosa: a. Associated with high FSH and LH b. May result in osteoporosis if prolonged

The most important feature to diagnose bulimia nervosa is? a. 6 months of continuous dieting b. Depression c. No feeling of loss of control d. Use of laxatives, vomiting or diuretics or fasting and hyperexercise e. Always associated with loss of weight

The percentage of women with eating disorders who will actively seek medical help, get better, and go on to lead normal lives is? a. 10% b. 33% c. 50% d. 66% e. 90%

An 18 yo presents with secondary amenorrheoa and a recent history of 13.6 kg weight loss associated with long distance running. All investigations are likely to be helpful except: a. TFT’s b. Prolactin c. CT head d. Progesterone challenge e. 17-OH progesterone

C or E CT head – Need MRI Progesterone challenge – assess oestrogen status 17-OH progesterone – only helpful in primary amenorrhoea

.What percentage of the population meet the criteria for primary amenorrhoea (no periods by age 15 or aged 13 with no secondary sexual characteristics – do they mean delayed puberty)? a. 0.1% b. 0.25% c. Another option d. 2.5% e. 5%

D Delayed puberty = 5% (2 S.D.’s outside norm)

.6 yo girl with isosexual idiopathic precocious puberty? Most appropriate treatment? a. GnRH agonists b. Progestogens c. Danazol d. Dexamethasone e. HMG

Commonest cause of precocious puberty in girls? a. CAH b. Ovarian c. Adrenals d. Tumours e. Idiopathic

Most common cause of heterosexual precocious puberty: a. Idiopathic b. Adrenal c. Ovarian d. Tumour e. Pituitary

The following are all causes of precocious puberty except: a. Astrocytoma b. Frolich’s syndrome c. Neurofibromatosis

Causes precocious puberty except? a. Astrocytoma b. Frolich’s syndrome c. Neurofibromatosis d. McCune-Albright syndrome

.Which of the following is not a cause of precocious puberty? a. Frolich’s syndrome b. Craniopharyngioma c. Von Recklinghausen’s disease

A Frolich’s syndrome is associated with delayed puberty; Von Recklinghausen’s disease is the same as neurofibromatosis.

What should never be used to treat detrusor instability? a. ileal conduit b. bladder denervation c. Cholinergic agent d. hydrodistension of the bladder e. IDC permanently

C Ileal conduit, permanent IDC and bladder denervation are end-stage options. Anti-cholinergic medication, not cholinergic medication should be used.

What is true of incontinence? a. 25% of nursing home residents are affected b. Incontinence is often the trigger for institutionalisation of elderly folk c. Incontinence is a normal part of aging d. Kegels exercises will obtain an 80% rate of complete cure in older women

B Nursing home residents are affected – 58% Pregnant women 50-60%

.What is true of incontinence? a. 25% of nursing home residents are affected b. Incontinence is often the trigger for institutionalisation of elderly folk c. Incontinence is a normal part of ageing d. Kegel’s exercise will obtain 80% rate of complete cure in older women e. Estrogen has been proven in RCT to improve GSI

Drugs which worsen stress incontinence, correct option: a. Amiodarone b. Phenoxybenzamine c. Phenylephedrine d. Tolbutamide

B Phenoxybenzamine is a alpha blocker and therefore inhibits the alpha mediated closure of the urethra

Which drug exacerbates stress incontinence? a. Hydralazine b. Enalapril c. Propranolol d. Warfarin

Answer: B (cough)

Which of the following is not associated with detrusor instability? a. Interstitial cystitis b. Autonomic neuropathy c. Multiple sclerosis d. GSI e. Dementia

.What is not recognised cause of urinary urge incontinence? a. Secondary to stress incontinence b. Dementia c. Multiple sclerosis

A low urethral closing pressure is associated with? a. Grand multiparity b. External urethral sphincter defect c. Previous incontinence surgery d. Poor bladder neck support

Concerning the investigation of urodynamics. Select the incorrect option: a. GSI does not occur with bladder pressure below 30 cm water b. Urodynamics cannot distinguish between functional and neuropathic detrusor instability c. In order to calculate detrusor pressure it is necessary to measure intravaginal or rectal pressure

A - pressure of 25 can

45 yo lady with 3 month history of urinary incontinence. There is a slight loss 1-3 seconds after coughing, urgency and nocturia. She had enuresis as a child but there is no Hx of UTI. Examination reveals a small cystocoele and a somewhat tender urethra. Next step? a. MSU / UA b. Urethral suspension c. IVP d. Cystometrography

.What is not a cause of urinary retention and overflow incontinence? a. Fibroids b. Pregnancy c. HSV d. Cholinergic agents

.Which of the following is the commonest cause of urinary incontinence? a. GSI b. Detrusor instability c. Detrusor – urethral dysenergia d. Neurogenic bladder e. Drug therapy

A The prevalence of types of urinary incontinence is as follows: stress > mixed > urge. (UTD)

.Post op Burch, pt complains of severe pain in one groin. Cause? a. Space of Retzius haematoma b. Ilioinguinal nerve damage c. Pubic bone trauma d. UTI

What percentage of women will require an operation for prolapse or incontinence in their lifetime? a. 10% b. 30% c. 50% d. 70% e. 90%

A – telindes page 911. Re-operation rate for failure at 29%.

.Number of women who eventually need prolapse repair surgery: a. 5% b. 10% c. 25% d. 40% e. 50%

A 50 yo with stress incontinence and cystourethrocele. Which surgical management is most likely to be effective? a. Retropubic urethropexy b. Anterior repair with Kelly sutures c. Aldridge sling d. Sacrospinous fixation of periurethral ligaments

A 60 yo otherwise well woman with symptomatic uterine prolapse. Current treatment advice should be? a. LAVH b. Vag hyst c. Sacrospinous colpopexy d. HRT e. Ring pessary

.The five-year success rate of anterior repair for stress incontinence is: a. 90% b. 70% c. 50% d. 40%

.The five-year success rate of Burch colposuspension for stress incontinence is: a. 30% b. 50% c. 85% d. 95%

.51 yo presents with enterocele 3 yrs after Burch. Cause of this mainly due to? a. Big babies b. Change in vaginal axis c. Menopause

Which of the following are true about vesico-vaginal fistulas? a. Site can be accurately localised with an IVU b. Characteristically appear by day 3 post hysterectomy c. Are usually situated above the trigone of the bladder d. Are common following appropriately repaired crush injuries of the bladder e. Large fistula causes a large urine leak

Answer: C (depends on primary surgery)

.Commonest cause of vesico-vaginal fistula in modern obstetrics? a. TAH b. Vag hyst c. Radiation d. Obstetric trauma e. Anterior vaginal repair

A The cause of VVF is gynaecological surgery (primarily TAH for benign disease) 82%, obstetric procedures 8%, radiation 6%, trauma 4%.

.Which HPV type is most associated with invasive cancer a. 6 b. 11 c. 18 d. 31 e. 35

Regarding cervical dysplasia, DNA analysis has a limited role. Which is correct? a. only HPV 16 and 18 cause cancer b. Southern blot is most accurate in diagnosing HPV subtypes c. Pap smear is a reliable as a screening test for cervical dysplasia d. Cervicography has high sensitivity and specificity as a screening test e. DNA hybridisation has low sensitivity and specificity rate

C Other HPV types cause cervical cancer (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 82). Hybrid capture essay is most accurate for determining subtype. Cervicography does not have high S&S as a screening test. DNA hybridisation is both sensitive and specific.

Endocervical brush for cervical cytology a. Increases detection rate when compared to cotton swab b. Can be used instead of the spatula c. Effective in getting endocervical cells d. Recommended in pregnancy

Which of the following definitely requires treatment in pregnancy? a. CIN3 b. HPV c. All of the above d. None of the above

.What degree of cervical dysplasia must be treated in pregnancy? a. HPV b. CIN2 c. CIN3 d. All of the above e. None of the above

All of the following constitutes indications for cone biopsy in pregnancy, except: i. Minimally invasive SCC on cervical biopsy ii. Smear result suggestive of adenocarcinoma in-situ iii. Inadequate colposcopy iv. None of the above v. All or the above

iii vs v

All of the following are indications for annual cervical cytology (high risk) except: a. HIV positive b. Radiotherapy for stage IIb Ca cervix 15 years ago c. Prior vaginal hysterectomy for mixed endometrial hyperplasia 5 years ago d. Female with single partner who has had multiple past female partners e. Prior renal transplant

Which situation does not require at least yearly smears? a. Post TAH for cystic endometrial hyperplasia b. Lady with male partner who has multiple partners c. HIV

HPV on cervix. All except? a. Sometimes associated with carcinoma b. Intracytoplasmic reproduction is associated with koilocytosis c. HPV dysplasia not a true pre-malignant condition d. Fragments of HPV have been isolated on DNA testing in cervical carcinoma e. HPV 6 causes benign cervical condylomata

C HPV 6 does cause benign warts; HPV fragments have been isolated in cervical SCC; Koilocytosis is associated with intracytoplasmic reproduction

Regarding HPV which of the following is correct? a. Causes characteristic changes in cytoplasm b. HPV 16 causes harmless genital warts c. All HPV regarded as pre-malignant d. Some cells of Cx and vulval Ca have HPV

A Koilocytosis is perinuclear vacuolisation

.A woman in her 30’s with postcoital and IMB attends her LMO. He performs a smear that shows a HSIL and many inflammatory cells. She is referred to you for further treatment. You perform a speculum exam that shows an exophytic lesion on the posterior lip. The examination is otherwise normal. Next Ix? a. Colposcopy b. Punch biopsy c. Cone biopsy d. Antibiotics

.On routine exam a 70 yo widow is found to have a Pap test showing squamous atypia. Colposcopic exam of cervix reveals only normal squamous epithelium on the ectocervix and TZ not visualised. ECC reveals benign squamous and endocervical glandular epithelium. Next? a. Cone b. Fractional D&C c. Vaginal oestrogen therapy d. Test for HPV

70 yo lady with pap smear showing mild squamous atypia. Colposcopy -> benign squamous epithelium TZ not seen. Normal endocervical curettings. Mx? a. Re smear 2/12 after topical oestrogen b. Re smear 6/12 c. tell her not to worry d. fractional curettage e. cone biopsy

.CO2 laser vaporisation. Energy is derived from vaporisation of? a. Mitochondria b. DNA c. Intracellular water d. Intracellular protein e. Intracellular lipids

What is next management in 40 year-old P3 who has had a cone biopsy showing 1 mm of invasive ca and clear margins? a. Nil further b. Simple TAH c. Radical hysterectomy d. TAH/BSO

What percentage of lymph nodes are involved in microinvasive cancer of the cervix? a. 1% b. 5% c. 10% d. 30% e. 50%

A The risk of LN metastases in 1A1 is < 1%(0.6%) and 1A2 (7%) or 1B1 is 2-8%.

The most common lymph node involved in ca cervix: a. Femoral b. Obturator c. External iliac d. Para-aortic

Previously thought to be obturator but now known to be any of the pelvic lymph node groups Answer: B

.32 yo primigravida presented at 12/40 for 1st antenatal visit. Pap smear showed CIN3. Colposcopy and biopsy revealed query microinvasion. She is currently 16/40. Which of the following is correct? a. Cryotherapy b. Coldknife cone biopsy c. Laser cone d. TAH e. Radical hysterectomy

Patient presents at 16w. Examination revels a 3cm diameter cancer of the cervix. Management: a. EUA, CXR, IVP, cystoscopy b. Suction TOP and XRT c. Rad hyst and PLND

A 28 yo woman in her first pregnancy presents with a threatened miscarriage at 16/40. O/E a 3.3 cm exophytic lesion is seen on her cervix. A punch biopsy confirms adenocarcinoma. Do you? a. Await maturity b. Arrange EUA/cystoscopy/CXR/IVP c. Irradiate d. Perform radical hysterectomy/PLND e. Reassess after TOP

.On a first antenatal visit at 10 weeks a 2 cm Ca cervix confined to cervix is found. SCC on biopsy. What would you advise the patient? a. Radical hysterectomy b. Cone biopsy c. Await fetal maturity d. Radiotherapy

.A 55 yo woman with Ca cervix. At EUA the tumour extends to one pelvic sidewall. Best treatment? a. Radical hysterectomy and nodes b. Exenteration c. Palliative radiotherapy d. Vaginal radiotherapy then extended hysterectomy e. External beam radiotherapy – full dose

.Which of the following is not an indication for abandoning radical hysterectomy for cervical cancer? a. Stage 2a disease b. Involvement of para-aortic nodes c. Parametrial extension to the pelvic side wall on one side d. Involvement of the ovary

.Management of stage 3b cervical cancer a. Palliative radiation b. XRT c. Exenteration

Which of the following is the best treatment option for carcinoma of the cervix stage 3? a. Rad hyst and bilateral inguinal lymphadenectomy b. Rad hyst and bilateral inguinal lymphadenectomy and vault radiotherapy c. External end extended field radiotherapy d. Extended field radiotherapy and chemotherapy e. Intracavity and extended field radiotherapy

What are the benefits of surgery over radiation for the treatment of cervical cancer (no stage given)? a. Patient satisfaction/reassurance that the cancer has been removed b. Improved outcomes c. More accurate surgical staging d. Easier to correct complications e. Ovaries conserved

.Which of the following is true regarding adenocarcinoma of the cervix? a. Adenocarcinoma is just as radiosensitive as SCC b. Ovarian conservation is C/I with adenocarcinoma c. All of the above d. None of the above

A (vs D)

.In adenocarcinoma of the cervix a. Conservation of the ovaries is contraindicated b. Exogenous oestrogen is contraindicated c. Exogenous progesterone is contraindicated d. All of the above e. None of the above

.The following statements about cervical cancer are proven true except? a. Celibacy protects women from Ca cervix b. Having a circumcised male partner is protective for the women c. First intercourse after 27 yrs associated with lower incidence of Ca cx d. Divorced women have a greater incidence of Ca cx than married women e. Prostitutes have a higher incidence than a control population

.60y woman with 8cm pelvic mass on examination. Best investigation to give a differential diagnosis? a. upper GI series b. cholecystogram c. IVP d. Barium enema e. Plain AXR

.What is the commonest mode of death in patients with advanced epithelial ovarian cancer? a. PE b. Bowel obstruction c. Cerebral haemorrhage d. Renal failure e. Cardiac failure

B (vs A)

A 59 yo lady with a 6cm ovarian mass. What is the probability of malignancy? a. 15% b. 30% c. 45% d. 60% e. 80%

B TeLindes says 45%; UTD says 30%

.A 32 yo woman counselling re ovarian cancer. 2 x 2nd degree Ca ovary – grandma and aunt. What would you advise? a. Reassure b. Yearly pelvic examination c. Yearly pelvic examination with Ca 125 d. Yearly pelvic examination with Ca 125 + US with Doppler

Pseudomyxoma peritonei a. Can only occur if a primary cyst rupture b. Associated with pleural effusions c. Classically associated with bowel obstruction d. Responds to radiotherapy e. Responds to chemotherapy

A 14 yo girl diagnosed to have adenocarcinoma of the left ovary stage 1a. What is your management? a. LSO b. TAH and BSO c. TAH/BSO and omentectomy d. TAH/BSO and omentectomy and radiotherapy e. TAH/BSO and omentectomy and chemotherapy

59 yo woman complains of early satiety and distension. Physical exam reveals an irregular pelvicabdominal cystic mass approx 15 cm in greatest diameter. Physical findings are consistent with ascites. In addition to CXR, preliminary evaluation of this patient prior to exploratory laparotomy should include: a. Paracentesis b. Laparoscopy and US examination of the abdomen and pelvis c. CA 125 measurement and CT abdomen and pelvis d. Lymphangiography e. Liver scan

.A patient with stage 3, grade 3, papillary serous ovarian carcinoma was treated with TAH/BSO and omentectomy, followed by 8 courses of cisplatin-based chemotherapy. A second look laparotomy, including pelvic and para-aortic lymph node removal, was negative. 18 months later, an asymptomatic 4 cm pelvic mass at the vaginal apex if found on pelvic exam. The most likely explanation for this finding is? a. Diverticular abscess b. Lymphocyst c. Recurrent ovarian cancer d. Suture granuloma

.A 45 yo woman underwent primary cytoreductive surgery for a stage 3 epithelial ovarian cancer. After 6 courses of cisplatin and cyclophosphamide a second look operation was positive. She developed progressive abdominal disease during second line treatment with intraperitoneal cisplatin and 5FU. Trials of carboplatin and a new drug failed to control her disease. She is admitted in a severely malnourished condition with a small bowel obstruction. The statement that best reflects the patient’s current management is? a. Because of her age, she should be urged to undergo a second trial of investigational chemo b. Home TPN should be instituted as soon as possible c. Discussion of NFR status should be avoided because emotional trauma may result d. Relief of pain and vomiting is likely to be this patient’s foremost concern

.What is the lifetime risk of ovarian cancer with one first degree relative? a. 1% b. 5% c. 25% d. 50% e. 90%

B Lifetime risk is 1 in 70. With one affected first degree relative the risk is 4-5% (UTD).

.Woman with large pelvic mass. Pre op CXR showed no pleural effusion. Operative findings include ascites and bilateral multiloculated 8 cm cystic ovaries. Papillary tumour nodules ranging from 0.5-1.5 cm in diameter were present on pelvic peritoneum, small bowel mesentery and serosa and liver capsule. Microscopic disease in aortic lymph nodes. Cytology of ascites negative. Stage of ovarian cancer? a. 2c b. 3a c. 3b d. 3c e. 4

.Ca of one ovary. One lymph node with tumour between renal vein and IVC. Stage is: a. Ia b. I c. II d. III e. IV

.A 29 yo woman presenting with menometorrhagia was found to have a 6 cm left adnexal mass, and adenomatous hyperplasia was found on endometrial biopsy. She is interested in preserving her fertility. D&C revealed focal adenomatous hyperplasia. At laparotomy LSO was performed with the removal of a 5x7 cm firm mass. Frozen section – granulosa cell tumour. A staging evaluation (cytology, peritoneal patch biopsies and node biopsies) was completed. According to the patient’s wishes, no additional extirpative surgery was performed. The final path confirmed the FS report and the staging biopsies and cytology showed no tumour. In counselling the patient postoperatively about prognosis and future treatment, you advise her that? a. This tumour is likely to recur but not for many years b. She will benefit from adjuvant chemotherapy c. Close clinical follow up without additional surgery is acceptable d. Surgery less extensive than hysterectomy and BSO is incomplete treatment e. This tumour is not radiosensitive

In a patient with ovarian carcinoma and negative 2nd look laparotomy the chances of disease recurrence are? a. 0-20% b. 20-40% c. 40-60% d. 60-80% e. 80-100%

C 30-50% (UTD)

.Which is not a germ cell tumour? a. Granulosa cell tumour b. Dysgerminoma c. Embryonal cell tumour d. Immature teratoma

Not a germ cell neoplasm of the ovary?** a. Gynanadnoblastoma b. Dysgerminoma c. Embryonal cell tumour d. Gonadoblastoma

Which of the following is a type of epithelial tumour of the ovary?** a. Embryonal cancer b. Dysgerminoma c. Endometrioid carcinoma d. Endometrioma e. Endodermal sinus tumour

.Ovarian thecomas are associated with a. Brenner tumour b. Kruckenberg tumour c. Granulosa cell tumour d. Endometrioid tumour e. Mucinous cystadenoma

.Thecoma, which is wrong? a. Usually benign b. Commonly unilateral c. Associated with virilisation d. May be associated with endometrial hyperplasia e. Usually occurs in pre-pubertal girls

E (most wrong)

Regarding thecomata, which is incorrect? a. Predominantly unilateral b. Virilising c. Prepubertal d. Associated with hyperplasia e. Benign

.Ovarian cancer assoc with Peutz-Jegher syndrome? a. papillary serous cancer b. mucinous c. endometrial ca d. clear cell ca e. sex cord stromal

.Regarding Meigs syndrome a. It is associated with fibromas > 10 cm b. Pleural effusions are composed of peritoneal fluid c. Pleural effusions are more common on the left side

.Which of the following combinations is correct? a. Struma Ovari – carcinoid tumour b. Lymphocytic infiltration and large vacuolated cells – dysgerminoma c. Leiomyosarcoma – 7 mitotic figures/10 HPF d. Cystic Endometrial hyperplasia – endometrial cancer e. Sarcoma botryoides – mesonephric duct

B Sturma ovarii is the presence of thyroid tissue as a major component of an ovarian tumour, usually a dermoid; dysgerminoma has large vacuolated cells (fried eggs) and lymphocytic infiltration; leimyosarcoma has >10 mitoses per high powered field; cystic endometrial hyperplasia is from tamoxifen and associated with endometrial hyperplasia; sarcoma botryoides is a soft tissue tumour that occurs in children

.Lady with dermatomyositis on steroids. Big cystic mass in left adnexa. Mx options? a. leave alone b. admit for sigmoidoscopy, FBE, U&E, IVP, US ,CT, cystoscopy c. admit for colonoscopy, Ba enema, cystoscopy, IVP -> laparotomy

C Patients with dermatomyositis have higher risk of malignancies.

.Spindle cells are seen histologically in a. Krukenberg b. Brenner c. Leiomyosarcoma

.Signet cells are associated with a. Brenner tumour b. Kruckenberg tumour c. Granulosa cell tumour d. Endometrioid tumour e. Mucinous cystadenoma

.16 yo girl presents with pelvic discomfort and a complex cystic mass was found on US. At laparotomy, an immature teratoma was found in the right ovary. Most appropriate Mx: a. RSO b. R ovarian cystectomy c. R ovarian cystectomy & wedge biopsy of L ovary d. TAH, BSO omentectomy e. RSO & wedge biopsy of L ovary

A 28 year-old woman with a dysgerminoma was treated with LSO and chemotherapy. She completed the chemotherapy six months ago and is enquiring about trying to fall pregnant. What is your advice? a. Her babies will have chromosomal abnormalities following the chemotherapy b. To wait another 6 months to allow the effects of chemotherapy on remaining ovary to wear off c. The effect of her type of chemotherapy on ovarian function is unpredictable d. She will never fall pregnant e. She will need an amniocentesis with every future pregnancy

.What is tumour marker for ovarian embryonal carcinoma? a. BHCG b. AlphaFP c. CEA d. Ca 125 e. LDH

A Also AFP

.Which is most malignant? a. granulosa cell tumour b. thecoma c. luteoma d. hilus cell tumour e. Sertoli tumour

A Granulosa cell tumours have malignant potential, thecomas are generally beign and sertoli cell tumours can be benign or malignant. Luteomas are benign, Hilus cell tumours are ???

.Secondary ovarian cancer – most common primary? a. breast b. pancreas c. kidney d. lung

.Acute left heart failure is most likely to occur with which antineoplastic agent a. Vincristine b. Cisplatin c. Bleomycin d. Doxorubicin e. Cyclophosphamide

A 28 yo nulliparous woman who smokes one pack of cigarettes per day and whose mother has endometrial cancer asks how she can reduce her own risk of the disease. The most effective way to reduce the risk is to? a. use a barrier contraceptive b. take combination oral contraceptives c. stop smoking d. maintain ideal weight

B 50% reduction with OCP if taken for more than three years and smoking is also protective

.The most appropriate treatment for a patient with poorly differentiated adenocarcinoma of the endometrium is? a. Simple hysterectomy b. TAH/BSO c. Radiotherapy d. Chemotherapy e. TAH/BSO and pelvic LN dissection

.60 yo woman with PMB and D&C revealed poorly differentiated endometrial adenocarcinoma. Mx? a. Pfannenstiel & TAH/BSO b. Vertical incision & TAH/BSO c. Vertical incision & Wertheim’s radical hysterectomy d. Vertical incision, TAH/BSO, PLND

PMB – D&C with undifferentiated adenocarcinoma. Mx? a. TAH & BSO b. Irradiation c. Radical hyst d. TAH/BSO and pelvic nodes

What do you do after rad TAH/BSO/PLA for Ca endometrium with 1 pos pelvic node, invasion to inner 2/3 myometrium, grade 2. a. External beam MVT b. Vault caesium c. Progesterone d. Chemo e. Nil

.Use of vault radiation in endometrial carcinoma. Aim to treat: a. Pelvic node secondaries b. Vaginal vault recurrences c. Para-aortic node secondaries d. Femoral secondaries

.For which of the following reasons is radiotherapy given following surgery for endometrial cancer? a. Prevent recurrence in pelvic lymph nodes b. Prevent recurrence at the vault c. Prevent recurrence in para-aortic lymph nodes

60 yo with scanty PV bleeding and O/E right adnexal mass (not present on exam age 57). Diagnosis? a. Ca endometrium b. Benign ovarian tumour c. Ca ovary d. Endometriosis e. Atrophic vaginitis

A vs C

.Which of the following is the commonest tumour of the round ligament? a. paramesonephric tumour b. mesonephric tumour c. leiomyoma d. Gartner’s duct tumour e. Metastatic carcinoma

Cyst associated with round ligament most likely? a. Mesonephroma b. Gartner’s duct cyst

Uterine sarcoma, risk factors include: a. Family history b. Multiparity c. Previous pelvic irradiation d. Exogenous oestrogen

C The only risk factor for uterine sarcoma seems to be previous pelvic irradiation although tamoxifen is also listed.

.Post-menopausal lady with TAH/BSO for fibroids. On sectioning leiomyosarcomatous change found in one fibroid. Subsequent management? a. Radioactive gold b. Watch carefully c. Pelvic lympadenectomy d. Radiotherapy e. Chemotherapy

.Highest incidence of vaginal malignancy is? a. VAIN b. Metastatic carcinoma of the cervix c. Clear cell adenocarcinoma with exposure to DES d. Primary SCC of the vagina e. Vaginal metastases from adenocarcinoma of the endometrium

B Majority of vaginal cancers are metastatic. 1:1000 for DES exposure.

.Metastatic carcinoma of the vagina account for > 50% of cases. The most common primary is from? a. Ovary b. Cervix c. Kidney d. Endometrium e. Fallopian tube

Least likely pigmented vulval lesion a. Lentigo b. Melanosis c. Acrochordon d. Nevus e. Seborrhoeic keratosis

Which of the following is a vulval granulomatous lesion? a. Behcet’s disease b. Lichen sclerosis c. Hidradenitis suppurativa d. Chancroid e. Chancre

C Behcet’s disease is characterised by vulval ulceration. Lichen sclerosis is usually atrophic and excoriated. Hidrandenitis suppurativa is nodular and pustular but heals and becomes a granulomatous lesion. A chancre is a syphilitic ulcer. Chancroid is most likely to be characterised by painful ulcers

.Granulomatous lesion of vulva? a. Behçet’s disease b. Lichen sclerosis c. Syphilitic gumma d. Paget’s disease e. Bowen’s disease

C syphilitic gumma manifest as granulomatous lesions

A 24yo lady presented with pruritis vulvae for 6 months. Colposcopic punch biopsy of the vulva showed flattening of the rete ridges and a homogenous zone of collagenisation with loss of elastin fibres in the subepithelial layer. Areas of hyperkeratosis were seen. What of the following treatments is the most appropriate? a. topical oestrogen b. topical 2% testosterone propionate c. topical hydrocortisone d. topical promethazine e. no treatment is needed

C Histology is likely to be lichen sclerosis

.Thin white wrinkly vulval skin with absent labia minora? a. Lichen sclerosis b. Psoriasis c. Lichen planus

Regarding lichen planus; incorrect option? a. Purple scaly patches b. White mucosal lesions c. Flexor surfaces d. Erosive vaginitis e. Saw tooth rete pegs f. Corticosteroids effective

Answer: All are correct

Treatment for lichen sclerosis? a. topical testosterone b. topical corticosteroids c. topical 5FU

Vulval vestibulitis. Cause? a. staph b. Chlamydia c. Trichomonas d. Candida e. None of the above

A patient has been treated for vulval warts. Given 6 cycles of podophyllin then tried trichloroacetic acid for 4 weeks without response. Next line of treatment: a. 5FU b. CO2 laser c. Surgical excision d. Vulvectomy e. Who writes these questions? f. Cryotherapy

.A 24 yo G0P0, health worker, using IUCD for contraception. Some vaginal warts. Her only sexual partner of 2 yrs has no obvious penile warts. She wants to know where they came from? a. Secondary to irritation from the strings of the IUCD b. Transferred from other parts of her body by her hands c. Wart virus has been dormant in dorsal root ganglion d. Partner probably has no apparent penile warts e. It does not matter where they came from it will not affect her Mx

.55yo with multiple white patches on her vulva and posterior perineum. What is the best method of making a diagnosis? a. pap smear b. colposcopy c. biopsy d. wide local excision e. skinning vulvectomy

Treatment with wide local excision in all except? a. Paget’s b. Melanoma c. Carcinoma in situ d. Itch

A gynaecologist removes a 2 cm ulcerating lesion with sharp rolled edges from the lateral aspect of the right labium majus in an 80 yo patient. The lesion had been present for 15 yrs. Path shows BCC with one surgical margin involved. The best Mx? a. observation for local recurrence and wide resection if noted b. application of topical chemotherapy c. further excision d. hemi vulvectomy with ipsilateral node dissection

What proportion of VIN occurs in women aged 40 and under a. <1% b. 10% c. 20% d. 30 (or 40%?) e. 40 (or 50%?)

E UTD says that young women account for 75% of the disease

.A woman presents with 3 white lesions on vulva, biopsy all VIN 3? a. WLE of all lesions b. Skinning vulvectomy c. Radical vulvectomy d. Radical vulvectomy and groin node dissection e. Review in 3 months

60 yo woman presented with a 3cm lesion in the posterolateral part of the right labium. Punch biopsy suggested changes consistent with Paget’s disease of the vulva. No inguinal node palpable. What is the most appropriate treatment? a. Local excision with 5mm extra surgical margin b. Local excision with 2cm extra surgical margin c. Skinning vulvectomy d. Simple vulvectomy e. Radical vulvectomy

B Paget’s disease is intraepithelial adenocarcinoma. The optimal management of Paget’s disease of the vulva is WLE with 2cm surgical margins.

What percentage of patients with vulval carcinoma have tumours with a depth of invasion less than 1mm? a. 1% b. 5% c. 10% d. 20% e. 30%

.What percentage of patients with vulval carcinoma with a depth of invasion less than 1mm have nodal disease? a. nearly zero b. 2% c. 5% d. 10% e. 20%

.The second most common vulval malignancy is: a. Sarcoma b. Verrucous carcinoma c. Melanoma d. Adenocarcinoma e. Basal cell carcinoma

.2cm vulval lesion. Wide excision showed invasive Ca to 0.8mm beyond the basement membrane. Therapeutic options include: a. nothing b. Wider excision c. Simple vulvectomy d. Radical vulvectomy e. Option d) plus bilateral groin dissection

Answer: A (assuming adequate margins)

.What is the best management of a 3 cm vulval carcinoma? a. Wide local excision b. Radical vulvectomy c. Radical vulvectomy and ipsilateral LN d. Radical vulvectomy and bilateral LN e. Radiotherapy

D Bilateral LN for stage II disease

Which of the following is correct about carcinoma of the vulva? a. SCC at the clitoris associated with metastasis of both inguinal nodes at an early stage b. Metastasis to the iliac node with negative inguinal nodes c. A 3 cm lesion has a 33% chance of positive lymph nodes d. Stage 3 disease has 40% chance of positive lymph nodes

.Which of the following are correct about vulvar carcinoma except: a. Radical vulvectomy and bilateral lymphadenectomy for stage 2 disease is adequate b. 3cm SCC on the right vulva, radical vulvectomy showed clear surgical margins and bilateral inguinal lymphadenectomy showed one positive node. Additional pelvic and groin irradiation is needed c. Pelvic exenteration combined with radical vulvectomy and bilateral groin dissection performed for stage 3 disease only for a younger and psychologically fit woman d. Chronic leg oedema is found in 60-70% of patients after a bilateral inguinal lymphadenectomy e. Wound breakdown and infection reported in up to 85% of patients having en bloc operation

B Chronic leg oedema occurs in 30% of patients (Novak), 30-70% (UTD). In regards to B - Ipsilateral groin and pelvic irradiation are recommended when there are two or more microscopically positive groin nodes, one or more macroscopically involved lymph nodes, any evidence of extracapsular spread, or if only a small number of lymph nodes were sampled.

Management of stage 2 vulval carcinoma a. wide excision b. radical vulvectomy c. radical vulvectomy and ipsilateral XRT to groin d. radical vulvectomy and deep inguinal and femoral LN dissection e. wide excision and ipsilateral XRT to groin

Answer: D (refers to old staging; if current staging resect if resectable + bilateral nodes

.Where does vulval cancer first spread to? a. Deep inguinal lymph nodes b. Femoral lymph nodes c. External iliac lymph nodes d. Superficial inguinal lymph nodes e. Cloquets node

Most common complication of radical vulvectomy. a. Haemorrhage b. Wound infection

Most common malignancy in young girls? a. Leukaemia b. Hodgkins lymphoma c. Neuroblastoma d. Rhabdomyosarcoma e. Ovarian germ cell tumour

.Number of women diagnosed with breast cancer at 35 years a. 1/3600 b. 1/1400 c. 1/600 d. 1/200

A Australian incidence in women <50 is one per 2500

What is the increased incidence if 1st degree relative has breast cancer? a. 10% b. 30% c. 50% d. 100% e. 200%

If a first-degree relative is diagnosed breast cancer the risk is 1.5 times the population average (up 50%). If relative was less than fifty – 1.5-3 times average (up 50-300%). Familial breast cancer guidelines

What percentage of patients with breast cancer have nipple discharge? a. 3% b. 13% c. 23% d. 33% e. 43%

B 4-10% of nipple discharge is due to carcinoma (Novak); 5-15% (UTD); can’t find rates in patients with breast cacner

The incidence of breast carcinoma in a female with NO first degree relatives with breast carcinoma is? a. 1% b. 2% c. 4% d. 8% e. 15%

Detection rate of FNA in benign and malignant breast tumour? a. 50% b. 70% c. 90% d. 99% e. 100%

C (false negative 10-15%)

.Which of the following organs is most resistant to radiation? a. liver b. kidney c. ovaries d. spleen e. bladder

D Doses of 15-20 Gy will cause ovarian failure; the bladder is fairly sensitive and should be exposed to doses > 75 Gy. The liver is resistant as long as the entirety is not radiated (5% risk of radiation hepatitis 1/3, 2/3 and all being 90 Gy, 47 Gy and 31 Gy respectively.

Gynae MCQ pool Flashcards

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