Gynaecology

Question 1

What is the definition of a fibroid

Answer 1

benign tumour of the myometrium - also called leiomyoma

Question 2

State three symptoms and signs of a fibroid

Answer 2

symptoms:
• pain inbetween periods
• pain during sex
• heavy periods

Signs:
anaemia, infertility, Menorrhagia, miscarriage

Question 3

Name the gold standard investigation for fibroids

Answer 3

transvaginal USS

Question 4

Name three investigations for fibroids

Answer 4

transvaginal USS
FBC for anaemia
hysteroscopy

Question 5

name one hormonal, non hormonal and one surgical intervention for fibroids

Answer 5

Non hormonal
•Discuss analgesia e.g. paracetamol and ibuprofen
•Tranexamic acid – antifibrinolytics, inhibits tissue plasminogen activator
•reassurance

Hormonal
•Combined hormonal contraceptive
•Cyclical oral progestogens
•Ulipristal acetate – progesterone receptor modulator with a partial progesterone antagonist effect – risk of rare but serious liver injury 
•Intrauterine system (IUS)

Surgical
•hysterectomy
•Laparoscopic/open/hysteroscopic Myomectomy - first line
•Uterine artery embolization

Question 6

What are the signs and symptoms of an ovarian cyst?

Answer 6

swollen abdomen with or without pelvic mass

pelvic pain, nausea, bloating, compression symptoms from other organs e.g. bladder, UTIs

Question 7

Investigations for ovarian cyst

Answer 7

bimanual examination 
transvaginal USS
pregnancy test
CA 125
FBC

Question 8

management of ovarian cyst

Answer 8

Small (<5cm) - leave alone

Medium to large (5-10cm) - cystectomy to preserve fertility

Question 9

Definition of ovarian torsion

Answer 9

twisting of the ovary and or fallopian tube cutting off the blood supply

Question 10

signs and symptoms of ovarian torsion

Answer 10

• Sharp unilateral waxing and waning pelvic pain following sex/strenuous exercise
• Tender abdomen
• Severe may cause syncope

Question 11

investigations of ovarian torsion

Answer 11

transvaginal/transabdominal ultrasound

Question 12

treatment of ovarian torsion

Answer 12

ABCDE!

salpingo-oophrectomy/ or detorsion

Question 13

Define lichen sclerosis

Answer 13

inflammatory skin condition of the anogenital area

Question 14

signs and symptoms of lichen sclerosis

Answer 14

• Chronic pruritus
• Pain
• Dyspareunia
• Red inflamed skin with atrophic white shiny patches
• Bruises, ulcers or blood blisters can develop after scratching or from minimal friction

Question 15

diagnosis of lichen sclerosis

Answer 15

clinical diagnosis + swabs

Question 16

treatment of lichen sclerosis

Answer 16

Topical corticosteroids e.g. clobetasone or diprosone and referral to secondary care
• Avoiding perfumed sprays, creams or lotions
• Clean with only water or emollient soap

Question 17

complications of lichen sclerosis

Answer 17

vulval cancer

Question 18

Definition of endometriosis

Answer 18

Endometrium type tissue growing outside of the uterus, inducing a chronic inflammatory reaction. on ovaries called a chocolate cyst

Question 19

signs and symptoms of endometriosis

Answer 19

• Pain: cyclic, dysmenorrhoea, dyspareunia
• Infertility – possibly from adhesions and inflammation which alter the anatomy of the pelvis
• Chronic condition
• High risk of recurrence

Question 20

investigations for endometriosis

Answer 20

•	Laparoscopy and biopsy (gold standard) 
•	FBC
•	TVS            
•	Endometrial biopsy if >45yrs and:
o	IMB
o	Unresponsive to treatment
•	Place of hysteroscopy
o	Unresponsive to treatment
o	Abnormal scan
o	Assess suitability for OP ablation

Question 21

treatment and management of endometriosis

Answer 21

Non hormonal
• Reassurance
• Tranexamic acid – antifibrinolytics, inhibits tissue plasminogen activator
• Mefenamic acid – NSAIDs, Inhibits cyclooxygenase & block PGE2 receptors
• Also consider ibuprofen or naproxen or paracetamol if unable to take NSAIDS
Hormonal – if does not want to conceive
• Progestogens - Least effective if used in the luteal phase, Must be used from day 5 – 25, Best for anovulatory and chaotic bleeding
• Danazol – inhibits sex steroid production, blocks receptors, s/e: acne, deep voice, excess hair growth – consider HRT for women taking this long term
• Combined oral contraceptive pill – inhibits ovarian function, high patient satisfaction rate
• LNG IUS (Mirena) – local release of levonorgestrel
Surgical
• Endometrial ablations
• Excision
• Oophorectomy
• Pelvic clearance

Question 22

definition of adenomyosis

Answer 22

Ectopic endometrial tissue within the myometrium

Question 23

signs and symptoms of adenomyosis

Answer 23

• Cyclic pain: Dysmenorrhoea + Dyspareunia
• Heavy painful periods
• Pre-menstrual pelvic pain and feelings of heaviness/discomfort in the pelvis
• Pain relating to bowel movements
• ‘boggy’ uterus

Question 24

definition of menopause

Answer 24

cessation of menstruation

Question 25

definition of perimenopause

Answer 25

irregular periods and symptoms leading up to the menopause

Question 26

definition of premature ovarian insufficiency

Answer 26

menopause less than 40

Question 27

clinical features of the menopause

Answer 27

``` SHORT TERM Vasomotor symptoms • experienced by 60-80% women • last on average 2-7 years • Impact on sleep, mood and QoL Generalise symptoms • mood change/irritability • loss of memory/concentration • headaches, dry and itchy skin, joint pains • loss of confidence, lack of energy ``` ``` MEDIUM TERM Urogenital atrophy • Dyspareunia • Recurrent UTIs • PMB • Peak incidence of urinary incontinence and prolapse in 55-65 year olds ``` LONG TERM Osteoporosis • Menopause well established as a significant risk factor • Effects reliably reversible with oestrogens Cardiovascular disease • Adverse changes in lipid • Increased prevalence with early menopause Dementia Increased prevalence with early menopause Risk reduction strategies should start at the time of the menopause

Question 28

diagnosis of the menopause

Answer 28

• Diagnose the following without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms: o Perimenopause — if the woman has vasomotor symptoms and irregular periods. o Menopause — if the women has not had a period for at least 12 months. o Menopause — based on symptoms in women without a uterus. • Consider using the follicle stimulating hormone (FSH) blood test to diagnose menopause

Question 29

diagnosis of premature ovarian insufficiency

Answer 29

Diagnosis FSH >25IU/l – 2 samples >4 weeks apart + 4 months of amenorrhoea. Consider anti-mullerian hormone testing If there is doubt

Question 30

management of menopause

Answer 30

``` • Holistic approach • Lifestyle advice • Reduce modifiable risk factors • Inform about options -Hormonal eg HRT, vaginal estrogens -Non Hormonal eg clonidine -Non pharmaceutical eg CBT ``` hormonal progesterone, mirena, estradiol cream non-hormonal • Alpha adrenergic receptor agonist - Clonidine • SSRI: Fluoxetine, Paroxetine, Citalopram, Sertraline • SSRI-SNRI - Venlafaxine • Anti-epileptics - Gabapentin

Question 31

risks of HRT

Answer 31

VTE, breast cancer, stroke

Question 32

Definition of polycystic ovaries

Answer 32

Transvaginal USS appearance of multiple (12 or more) small (2-8mm) follicles in an enlarged (>10mL volume) ovary

Question 33

Which criteria is used in the diagnosis of polycystic ovaries, and state the components

Answer 33

Rotterdam criteria 1) PCO on USS (12 or more follicles or ovarian volume >10mL on USS) 2) oligo-ovulation and/or anovulation 3) -clinical and/or biochemical signs of hyperandrogenism - acne or hirsutism - raised serum testosterone

Question 34

Investigations for polycystic ovaries

Answer 34

transvaginal USS - FSH = normal - raised LH - raised LH:FSH ratio (about 3:1) - serum testosterone raised

Question 35

Treatment and management of polycystic ovaries

Answer 35

Conservative Mx VERY IMPORTANT • Maintain normal weight/ LOSE WEIGHT • Exercise & Diet advice • Smoking cessation Improving Menstrual Regularity • COCP (also treats hirsutism) • Metformin (improves ovulation rates too) -Insulin-sensitising agent, also reduces androgen levels -No impact on hirsutism Controlling Symptoms (Anti-androgens – do not give during conception or pregnancy) • Cyproterone acetate - Can be combined with COCP • Spironolactone • Vaniqa (Eflornithine) facial cream Subfertility *Weight loss alone may be enough to achieve spontaneous ovulation* Ovulation Induction • Antioestrogens (Clomid – clomifene citrate) -Taken orally, safe, inexpensive -Can develop CC resistance • Gonadotrophins (FSH/LH/pulsatile GnRH analogues) -Incr. risk of multiple pregnancy & OHSS • Laparoscopic ovarian diathermy -Recommended by NICE for those not responding to Clomid • IVF & ART

Question 36

Definition of pelvic inflammatory disease

Answer 36

inflammation of the upper genital tract

Question 37

Clinical features of pelvic inflammatory disease

Answer 37

* Can begin with a acute infection that resolves completely or develop into a chronic course with recurrent episodes * May be asymptomatic * Pelvic pain (usually bilateral) * Deep dyspareunia * Vaginal discharge * Dysmenorrhoea/Oligomenorrhoea * IMB/PCB * Fever * Tachycardia, Fever * Abdominal tenderness, Bilateral adnexal tenderness, Cervical excitation

Question 38

Diagnosis of pelvic inflammatory disease

Answer 38

* History (including sexual Hx) + Examination * FBC (WCC/CRP), consider Blood Cultures * Triple swabs screen for STIs * Urine Pregnancy Test – exclude EP * Pelvic/TVUSS – exclude ovarian tube abscess/ ovarian cyst accident * Laparoscopy – gold standard, only when Dx uncertain

Question 39

Treatment/management of pelvic inflammatory disease

Answer 39

* IM Ceftriaxone 500mg stat + * PO Doxycycline 100mg bd 14d + * PO Metronidazole