Gynaecology

Question 1

What are the Rotterdam criteria for diagnosing PCOS?

Answer 1

You need 2 of the 3 to diagnose PCOS:

1) Signs of infrequent or absent ovulation -> Oligomenorrhoea (menstrual cycles > 35 days) or Amenorrhea

2) Clinical (acne, hirsutism, male-pattern baldness)
or Biochemical indicators (raised Free Androgen Index [ total testosterone level / sex hormone binding globulin x 100]
of hyperandrogenism

3) USS showing polycystic ovary (>12 follicles in one or both ovaries) or increased ovarian volume (>10mls)

Question 2

What are the recommended baseline investigations if PCOS suspected as per NICE CKS?

Answer 2

LH
FSH
Testosterone
Sex Hormone Binding Globulin
Prolactin
Thyroid Stimulating Hormone
HbA1C / FBG to assess for impaired glucose tolerance

Question 3

What are the classical biochemical changes seen in bloods in PCOS?

Answer 3

The only blood marker that is involved in official diagnosis as per the Rotterdam criteria is the Free Androgen Index (total testosterone / SHBG x 100) - this is raised in PCOS as testosterone is usually normal or high and SHBG is usually normal or low)

Other blood markers that may support the diagnosis though are:
Total testosterone - normal to slightly raised (if markedly elevated consider other diagnosis)
Sex Hormone Binding Globulin (SHBG) - normal to low
Prolactin - normal to slightly raised
LH: FSH ratio - may be elevated - in PCOS LH is elevated more continuously and so you don’t get the same LH surge effect to prompt ovulation

Question 4

What is the normal postmenopausal endometrial thickness?

Answer 4

<4mm

Question 5

Under what circumstances is Anti-D required / not required in ectopic pregnancy in rhesus negative woman?

Answer 5

If medical management - anti- D not required
if surgical management of ectopic - anti-D immunoglobulin required (250 IU)

Do not offer anti-D rhesus prophylaxis to women who:
receive solely medical management for an ectopic pregnancy or miscarriage or
have a threatened miscarriage or
have a complete miscarriage or
have a pregnancy of unknown location.

Question 6

What are the reporting / recording obligations in cases of suspected or confirmed FGM?

Answer 6

ALL cases of known FGM must be recorded with the FGM Enhanced Dataset - details are NOT annonymous but the women should be assured it is secure.

Confirmed/reported FGM in girl <18 - must report to the police within 1 month of disclosure

Suspected or at-risk of FGM in girl < 18 - refer to social services or police depending on severity of risk

Non-pregnant women > 18 - no obligation to report to police / social services UNLESS a child is thought to be at risk

Pregnant women - FGM safeguarding risk assessment tool, if risk to unborn child or other child then refer to social services or police

Question 7

Classic presentation of ovarian torsion?

Answer 7

Severe localised pain in RIF or LIF
Associated N+V
Onset may coincide with exercise
May have low-grade fever if ovarian necrosis set in
May have unilateral tender addnexal mass on examination

Question 8

What are contraindications to expectant management of miscarriage as per NICE guidelines?

Answer 8

1st line miscarriage mx is expectant (Await 7-14 days before then offering medical or surgical)
Exceptions to this are if:
1) Evidence of infection
2) Increased risk of haemorrhage (in late first trimester, coagulopathy or pt unable to have a blood transfusion)
3) prev adverse / traumatic experience in pregnancy (stillbirth etc)

Question 9

What is the most common cause of postcoital bleeding?

Answer 9

Cervical ectropion

Question 10

Which medications are contraindicated in combination with Tamoxifen due to interactions?

Answer 10

The SSRIs fluoxetine and paroxetine
(they inhibit CYP450 which reduces the effectiveness of tamoxifen)

Question 11

What is the general management approach for a lady presenting with menorrhagia?

Answer 11

FBC and Hx/exam in all.
If symptoms/signs suggestive of underlying pathology do further Ix including Pelvic USS
If not:
-> if does NOT require contraception, 1st line = Tranexamic Acid 1g TDS OR Mefanamic Acid 500mg TDS (or other NSAID) both started on first day of period
-> if DOES require contraception, 1st line = Mirena coil (if acceptable to the woman) 2nd line = COCP 3rd line = Depot provera

Question 12

What is the upper limit of termination of pregnancy in the UK?

Answer 12

23+6 weeks (ie <24 weeks

(legal beyond 24 weeks only if mother’s life is at risk or child at risk of severe disability)

Question 13

Beyond which gestation do rhesus negative women require anti D?

Answer 13

Rhesus neg women need anti D during TOP from 10+0 weeks onwards

Question 14

What criteria are stipulated for expectant management of an ectopic pregnancy?

Answer 14

Size < 35mm
Beta HCG < 1,000 and declining
Asymptomatic
Nil heartbeat
Unruptured

Question 15

How should cervical bleeding during cervical smear procedure be managed?

Answer 15

Contact bleeding in otherwise healthy-looking cervix - reassure, explain sample may be insufficient -> if repeated problem of contact bleeding, refer to gynae

Contact bleeding + suspicion of malignancy - DO NOT send off the smear -> refer with 2WW to gynae

Question 16

Under what circumstances should the cervical smear be delayed?

Answer 16

Pregnant
<12 weeks postpartum or post-miscarriage or TOP
Currently menstruating
Active infection / abnormal discharge

Question 17

Which other QTc prolonging medications should be avoided being given in combination wih fluconazole?

Answer 17

Erythromycin
Quinodine
Pimozide
Cisapride

Question 18

Which route of taking Misoprostol (2nd step) in medical TOP is better tolerated?

Answer 18

Vaginal misoprostol carries a lower risk of side-effects (N+V) than buccal or sublingual

Question 19

What is the typical presentation of partial v complete molar pregnancy?

Answer 19

Partial molar pregnancy -> may mimic a miscarriage [may have intrauterine sac +/- fetal pole] but with a disproportionally high beta HCG

Complete mole - snowstorm appearance on USS, large-for-dates uterus, symptoms of thyrotoxicosis (hcg has common alpha unit as TSH so in large amounts can stimulate thyroid gland), hyperemesis

Question 20

What is Nageles Rule to predict EDD?

Answer 20

LMP + 9 months + 7 days

Question 21

What is the only intervention which is shown to reduce the rate of further miscarriage in couples with recurrent unexplained miscarriage?

Answer 21

Psychological support & regular scans

Question 22

What is the recurrence risk of a further ectopic pregnancy after a previous ectopic?

Answer 22

Recurrence = ~ 10%

Question 23

How long after management of a hydatiform mole should the woman wait until TTC again?

Answer 23

If had chemo (with MTX) -> wait 1 year

If surgical evacuation, wait for 6 months post-evacuation or post-HCG levels normalising whichever is later

Question 24

Which investigation is now considered the most accurate / gold-standard investigation for diagnosing ectopic pregnancy?

Answer 24

Transvaginal USS

• laparoscopy is no longer considered gold standard as false negative rate may be upto 5% if undertaken too early in the pregnancy*

Question 25

What is the classical USS finding in ovarian torsion?

Answer 25

Enlarged ovary in the midline with free pelvic fluid & WHIRLPOOL SIGN = as a result of the ovary twisting on itself

Question 26

Risk factors for ovarian torsion?

Answer 26

Ovarian Mass Reproductive Age Pregnancy (^ ligament laxity & corpus luteum cyst) Ovarian stimulation for fertility tx High-intensity exercise R cyst more likely to tort than left cyst as ligament longer and L cyst held in place more by sigmoid colon

Question 27

Potential causes of paralytic ileus post-operatively?

Answer 27

HYPOkalaemia - important to check U&Es as replacing the potassium helps resolve the ileus Urine in the abdomen 2ndary to ureteric or bladder injury can also cause ileus.

Question 28

What is the rate of progression to endometrial cancer in women found to have endometrial hyperplasia WITHOUT atypia?

Answer 28

< 5% over 20 years Most cases of endometrial hyperplasia without atypia resolve spontaneously

Question 29

Differentials for post-hysterectomy PV bleeding?

Answer 29

Early - vault dehiscence (rare) presents w/ haematoma running down vagina Days - weeks - infection - 2ndary haemorrhage Late (several weeks+) granulation tissue - can cause sudden onset bleeding, apply silver nitrate topically locally.

Question 30

Which tumour markers should be performed in women <40 with an ovarian mass?

Answer 30

CA-125 & hCG & alpha fetoprotein (due to risk of germ cell tumours in younger women) & LDH

Question 31

What is the baseline risk of endometrial cancer in a woman presenting with postmenopausal bleeding?

Answer 31

5-10%

Question 32

What is the typical presentation of lichen sclerosus et atrophicus and which complication should you be wary of?

Answer 32

Painful white skin on the vuva with cracks ^ risk of SCC developing in the area so ensure any ulceration / new lesions are biopsied

Question 33

Typical presentation of imperforate hymen?

Answer 33

Primary amenorrhoea Cyclical lower suprapubic pain Palpable mass due to extended vagina filled with bloods (haematocolpos) Surgical intervention pre-pubertal only if symptomatic as pubertal oestrogen normally causes the hymen to open

Question 34

NICE recommendations for endometriosis management?

Answer 34

1st line symptomatic relief: paracetamol + NSAID (ibuprofen or mefenamic acid) for cyclical pain 2nd line; COCP or Depot provera injection 3rd line or if fertility a priority: refer to gynae for consideration of GnRH analogues or laparoscopic excision or ablation + adhesionolysis +/- endometrioma removal Surgical Mx improves fertility outcomes, not drug Tx

Question 35

Cervical screening programme for HIV positive women?

Answer 35

ANNUAL cervical HPV testing AND liquid-based cytology

Question 36

Typical presentation of and risk factors for vulval squamous carcinoma?

Answer 36

Presents as non-healing lump / ulcer on the vulva, may have associated itch or irritation. Risk factors: Age > 65 Lichen sclerosus Immunocompromise HPV infection VIN (vulval intraepithelial neoplasm)

Question 37

What are the main long-term sequelae of PCOS?

Answer 37

^ risk endometrial hyperplasia & cancer (due to amenorrhoea or oligmenorrheoa while being exposed to pre-menopausal oestrogen levels) - highest risk in people not getting periods for > 3 months - can reduce this risk by inducing a bleed every 1-3 months with COCP or Lg-IUS Subfertility diabetes obstructive sleep apnoea Coronary artery disease Stroke / TIA

Question 38

How to diagnose premature ovarian insufficiency

Answer 38

Suspect in women < 40 with menopausal symptoms. Confirm with 2x FSH levels > 30 IU taken 4-6 weeks apart & oligo/amenorrhoea for > 3 months

Question 39

Clinical features of adenomyosis?

Answer 39

= endometrial tissue growing in myometrium Tends to present towards END of reproductive years Dysmenorrhoea, menorrhagia & enlarged boggy uterus of TV USS. Mx: TXA and mefanamic acid COCP or IUS Uterine artery embolisation

Question 40

Why is ullipristal acetate no longer recommended for fibroid drug treatment?

Answer 40

Concerns re risk of it causing severe liver deficiency

Question 41

What endometrial thickness is considered abnormal on TV USS in post-menopausal woman and would merit a referral for hysteroscopy and biopsy?

Answer 41

> 4mm in post menopausal woman = need to refer for hysteroscopy & biopsy If < 4mm endometrial Ca excluded

Question 42

What are the 4x types of FGM?

Answer 42

Type I - clitoridectomy Type 2 - excision of the clitoris & labia minora +/- excision of the labia majora Type 3 - narrowing of the vaginal orifice by apposition of the labia minora/majora Type 4 - other non-medical procedures to the female genitalia eg piercing, cauterisation

Question 43

Stress versus urge incontinence and their recommended management?

Answer 43

Stress Incontinence: coughing/sneezing/laughing 1st line = pelvic floor exercises (8 exercises TDS for min 3 months) -> then consider surgical referal for retropubic mid-urethral taping If declines surgical referral = Duloxetine = increases contractility of urethral sphincter Urge incontinence / Detrusor overactivity: sudden urge to urinate followed by uncontrolled leakage 1st line = bladder retraining for min 6 weeks (^ time between voids) -> Antimuscarinic agent - Oxybutynin IR (caution in elderly), Tolteridone, Darifenacin In elderly consider Mirabegron (beta 3 agonist) instead to avoid anticholinergic side effects

Question 44

What is the single greatest risk factor for ovarian torsion?

Answer 44

Having an ovarian mass

Question 45

Is there an association between presence of cervical ectropion and cervical cancer risk?

Answer 45

NO COCP slightly increases the risk of cervical cancer but the presence of a cervical ectropion even if symptomatic does not increase the risk of cervical Ca.

Question 46

What category of drug is clonidine for the menopause?

Answer 46

Alpha 2 agonist

Question 47

What medication can be prescribed to help delay a period in the short term eg when going on holiday?

Answer 47

Norethisterone 5mg TDS taken 3 days prior next expected period Menses will resume 2-3 days after stopping the tablets Caution in using norethisterone in those with lots of CVD risk factors or VTE risk factors

Question 48

Definition of primary amenorrhoea?

Answer 48

Failure to develop menses by 15 in someone WITH secondary sexual characteristics or by 13 in someone WITH NO secondary sexual characteristics.

Question 49

Definition of secondary amenorrhoea?

Answer 49

Absence of menses for 3-6 months in someone with previous normal regular cycles or 6-12 months in someone with prev irregular cycles

Question 50

Definition of oligmenorrhoea?

Answer 50

Menses occurring less frequently than every 35 days

Question 51

How long after a breast exam must you wait to take a prolactin level?

Answer 51

48 hrs (prolactin may be falsely elevated for 48 hrs post breast exam)

Question 52

What are indications for referral to urologist in context of woman presenting with urinary continence issues?

Answer 52

- Associated faecal incontinence - Palpable bladder on bimanual or abdo exam post-voiding - Suspected neurological disease - Suspected fistula - Prev continence or pelvic cancer surgery - Prev pelvic radiotherapy - Persisting bladder or urethral pain - Symptoms of voiding difficulty

Question 53

What is the only surgical management option for uterine prolapse that protects future fertility?

Answer 53

Vaginal sacro-hysteroplexy with sutures

Question 54

Where is the most common location for an ectopic pregnancy?

Answer 54

AMPULLA (~ 97%) More dangerous if in the isthmus

Question 55

Indications for surgical Mx in ectopic pregnancy?

Answer 55

HCG > 5,000 Visible fetal heartbeat Significant pain Ruptured Size > 35 mm

Question 56

Indications for methotrexate Mx in ectopic pregnancy?

Answer 56

HCG < 1,500 Unruptured No fetal heartbeat Size < 35mm Nil significant pain

Question 57

Indications for expectant Mx in ectopic pregnancy?

Answer 57

HCG < 1,000 Pain-free, unruptured and nil heartbeat Size < 35 mm

Question 58

Management of ovarian mass / cyst in pre-menopausal women?

Answer 58

DO NOT need to do a CA-125 in all premenopausal women if USS shows a simple cyst. Simple cysts < 50mm nil follow-up needed, almost always resolve within 3 cycles, simple cysts 50-70 mm consider annual USS, simple cysts > 70 mm should be referred for further Ix LDH, AFP, HCG should be done in all women < 40 with a COMPLEX ovarian mass: Elevated in the following malignant germ cell tumours - Dysgerminoma (associated w/ Turner's syndrome) - release HCG & LDH - Yolk sac tumour - releases AFP - Choriocarcinoma - release high levels of HCG Ca-125 less reliable in pre-menopausal women (^ fibroids, endometriosis, adenomyosis and pelvic infection) - if < 200 investigate for one of these other differentials and consider serial levels (Static levels unlikely in malignancy), if > 200 then discuss w/ gynae oncology If USS shows any of these red flags ('M rules') refer to gynae oncology: - Strong blood flow - 4+ papillary structures - Irregular multiloculated solic tumour > 100mm - Ascites Calculate RMI I if suspect ovarian malignancy (although will be less reliable in pre-menopausal women): - USS (1x score for bilateral, solid areas, multi-loculated, ascites, metastases U = 0 if 0 points, U = 1 if 1 point U = 3 if 2-5 points) x Pre-menopausal (1 point) Post-menopausal (3 points) x Ca-125 RMI 200+ = high malignancy risk

Question 59

How should ovarian cysts / masses be managed in postmenopausal women?

Answer 59

Any post-menopausal woman with an ovarian cyst > 10mm should get CA-125 and TV USS & calculate RMI. If RMI < 200: If asymptomatic, unilateral, unilocular, simple AND < 50mm with normal Ca-125 consider conservative Mx - repeat USS & Ca-125 in 4-6 months if unchanged repeat again in 4-6 months. Consider discharging if resolved by 1 year. If any of the following: symptomatic, multi-locular, non-simple, > 50mm, bilateral -> bilateral laparoscopic salpingo-oopherectomy (using laparoscopic retrieval bag) if RMI > 200: Need CT Abdo & Pelvis & Refer to Gynae Oncology MDT review If gynae onc MDT thinks high risk of malignancy = full staging procedure If thinks low risk of malignancy = laparotomy & pelvic clearance (TAH & BSO & omenectomy & peritoneal cytology)

Question 60

NICE Guidelines on ectopic and miscarriage care?

Answer 60

If woman < 6 wks, nil risk factors for ectopic & PAINLESS PV bleeding = conservative mx - advise to return if bleeding continues / worsens, advise UPT 7-10 days and that if negative = miscarriage Refer to early pregnancy assessment unit or out-of-hours gynae if PV bleeding with; - Pain - Gestation > 6 weeks - Pregnancy of uncertain gestation for pregnancy viability scan - If CRL < 7mm & no heartbeat - repeat in 7 days - if CRL > 7mm & no heartbeat - either ask for 2nd opinion to confirm non-viability or repeat in 7 days If no fetal pole, can measure gestational sac; - if gestational sac < 25mm & no HB - repeat in 7 days - if gestational sca > 25 mm & no HB either ask for 2nd opinion to confirm non-viability or repeat in 7 days DO NOT DIAGNOSE COMPLETE MISCARRIAGE BASED ON USS IF NIL PREV USS TO CONFIRM INTRAUTERINE PREGNANCY - TREAT AS PUL AND HAVE F/U HCG OR USS PUL: if stable Measure HCG 48 hrs apart - If ^ > 63% at 48 hrs - inform likely intrauterine pregnancy - offer USS at 7-14 days - If > 50% drop in HCG at 48 hrs, inform likely non-viable pregnancy - urine PT at 14 days - If between 50% drop to 63% increase refer for EPAU assessment within 24 hrs Threatened miscarriage: (Bleeding in woman with confirmed intrauterine pregnancy with fetal HB) - If prev miscarriage - then give 400mg vaginal progesterone BD until 16 wks - if nil prev miscarriage then don't - advise to re-contact if bleeding continues > 14 days Confirmed miscarriage: Expectant management for 7-14 days unless * at risk of haemorrhage eg late first trimester or coagulopathy * signs of infection * prev traumatic experience Medical management: Missed miscarriage - 200mg oral mifepristone then 800 mcg misoprostol oral/sublingual/vaginal 48 hrs later Incomplete miscarriage - 600mcg misoprostol oral/sublingual/vaginal Expectant management ectopic: repeat HCG day 2, 4, 7 then weekly until negative - should get at least 15% drop each time, if not refer for review Fertility and safety outcomes similar between expectant and medical ectopic management Post-MTX HCG day 4 and 7 (should be > 15% drop) then weekly until negative Surgical ectopic mx: Only offer salpingotomy if concern re the contralateral tube health If offer salpingotomy advise 1 in 5 women will need either mTX or further surgical Mx Repeat HCG 7 days post surgery then weekly until negative If have salpingectomy then just need UPT at 3 weeks Only need anti D if SURGICAL mx of ectopic or miscarriage (250IU, nil KH needed)