Sba 3 Flashcards
(199 cards)
1
Q
You are demonstrating a laparoscopic myomectomy procedure to your minimal
access surgery module trainee.
What is the most serious complication?
A
Severe blood loss
2
Q
You are demonstrating laparoscopic hysterectomy (LH) to one of your trainees.
What is the most common surgical complication with this procedure compared to
abdominal hysterectomy (AH)?
A
Major intraoperative haemorrhage. ( Not minor)
3
Q
You are demonstrating laparoscopic hysterectomy (LH) to one of your trainees.
What is the most common surgical complication with this procedure compared to
vaginal hysterectomy (VH)?
A
There was no difference
4
Q
While reviewing the outpatient cases, your junior colleague wants to discuss the
management of ovarian cyst in a woman who is 35 years old.
What is the cyst size at which laparoscopic management should be a cost-effective
procedure?
A
> 70 mm.
* Asymptomatic simple cysts of 30
–50 mm in diameter do not require follow-up,
cysts of 50–70 mm in diameter require follow-up .
cysts
70 mm in
diameter should be considered for either further imaging (MRI) or surgical
intervention
5
Q
You are performing an outpatient hysteroscopy while investigating postmenopausal
bleeding.
What is the most common cause of failure to obtain a good view of the cavity?
A
Difficult entry
6
Q
A 29-year-old woman comes for her scheduled antenatal care appointment. She is
36 weeks pregnant. She had a hysteroscopic resection of a uterine septum because of
recurrent pregnancy loss. All her antenatal visits have been normal.
What is your plan for her delivery?
A. Allow for continuation of pregnancy and await spontaneous labour.
B. Caesarean section at 39 weeks for fear of rupture of the uterus if allowed vaginal
delivery.
C. Caesarean section at 38 weeks after a course of steroids.
D. Offer a choice of vaginal versus Caesarean section delivery.
E. Induce at 37 weeks.
A
Offer a choice of vaginal versus Caesarean section delivery.
* Vaginal delivery seems safe, but rare serious complications like rupture of the
uterus have to be considered.
7
Q
You are planning a laparoscopic adhesiolysis procedure for a 28-year- old woman
who had secondary infertility, previous pelvic inflammatory disease (PID) and two
Caesarean section procedures.
Which one of the following anti-adhesion agents would you like to use to prevent
adhesion formation?
A
Hyaluronic acid derivatives.
8
Q
A 24–year-old primigravida woman presented for a dating scan, which showed a
6-cm right ovarian cyst. A follow-up scan at 15 weeks confirms an increase in size up
to 14 cm, with radiological and laboratory features suggestive of benign disease. The
pregnancy is otherwise progressing normally.
Which one of the following options is the most appropriate management?
A
Laparoscopic cystectomy.
* If the tumour is >6 cm in diameter, it is better to operate and remove during
pregnancy
9
Q
A 36-year-old Afro-Caribbean woman with a subserosal fibroid (5 x 7 cm) is counselled for a laparoscopic myomectomy using a morcellator. She would like to know
about the associated adverse outcomes.
What is the most common complication?
A
Peritoneal myomatosis ( Disseminated Peritoneal Leiomyomatosis)
10
Q
You are starting your hysteroscopy training module and are shown different diameter
hysteroscopes.
Which one would you recommend for outpatient hysteroscopy?
A
2.7 mm with a 3–3.5 mm sheath.
11
Q
While performing a diagnostic laparoscopy, blood was dripping into the pelvis soon
after inserting the lateral secondary trocar, quickly filling the operative field.
Which blood vessel is more likely to be injured?
A
Deep inferior epigastric artery.
12
Q
A 26-year-old woman is admitted for diagnostic laparoscopy for assessment of
chronic pelvic pain.What is the estimated risk of death associated with this procedure?
A
1/10 000
13
Q
A 42-year-old complains of cyclical cramping with or without menses. She had an
endometrial ablation and tubal sterilization two years previously .
MRI imaging during times of
symptomatic cramping showed blood trapped in the uterine cornua and swollen tubes.
The diagnosis of post-ablation tubal sterilization syndrome was made (PATSS).
What is the risk of PATSS after endometrial ablation? When it’s usually develop ? How to make a diagnosis? What is the treatment?
A
6%–10%
* usually develops two to
three years after endometrial ablation
* MRI imaging
during times of symptomatic cramping may be useful in looking for blood
trapped in the uterine cornua.Ultrasound scanning has not been reliably
sensitive at diagnosing .
* The definitive treatment of PATSS is hysterectomy.
14
Q
A 68-year-old woman presented with vaginal spotting on three occasions. She was
not sexually active before her menopause. She suffers from depressive anxiety disorders. An ultrasound scan shows a thickened irregular endometrium of 10 mm.
What is the most suitable management?
A
Outpatient vaginoscopic hysteroscopy
15
Q
A 46-year-old woman is attending the outpatient hysteroscopy clinic for the removal
of a 2-cm endometrial polyp. You decided to use electrosurgery for removal of
the polyp.
Which distention media should be used?
A
Normal saline.
1- act as both the distension and conducting
medium.
2- allows improved image quality
3- hysteroscopy to be completed more quickly
4- appears to reduce the incidence of vasovagal episodes.
16
Q
A 28-year-old woman presents to the antenatal clinic at 14 weeks pregnant with mild
lower abdominal pain and frequency in micturition. An ultrasound scan notes a solid
adnexal mass. Her serum lactate dehydrogenase (LDH) and human chorionic gonadotropin (hCG) levels are raised.
Which of the following tumours is the most likely cause of her symptoms?
A
Dysgerminoma
elevations in LDH,
17
Q
A 21-year-old woman presents with an abdominal mass and constipation. She also
has lower abdominal pain. At laparotomy, the tumour appeared solid, fleshy and
pink. Unilateral salphingo-oophorectomy was performed. The histology showed Tcell lymphoid infiltration of the fibrous stroma. Which of the following is the most
likely diagnosis?
A
Dysgerminoma
18
Q
What are the characteristics of Dysgerminoma ?
Appearance? Tumer markers ? Histology? Malignancy?
Percentage of ovarian malignancies ? bilateral or unilateral?
The
five-year survival rate ? Recurrence? Chemotherapy ?
A
Appearance: solid, fleshy and
pink
Tumer markers : LDH raised & hCG
Histology: T cell lymphoid infiltration of the fibrous stroma .
Malignancy: 97% are benign proliferations (mature teratomas); the remaining 3% are
malignant.
Percentage of ovarian malignancies : <1%
Unilateral & bilateral in 15%
The
five-year survival rate 95%
15%–20% of tumours will recur
Chemotherapy : platinum is successful in almost all of the tumours .
19
Q
In the Management of ovarian masses in pregnancy :
What is the risk of abortion when preforming Surgery in the first trimester ?
What is the percentage of malignant masses ?
What is the The ideal time for surgical intervention ?
A
1- Surgery in the first trimester carries an abortion risk approaching 30%.
2- 2% of masses presenting in pregnancy are malignant.
3- The ideal time for surgical intervention is 16–18 weeks’ gestation.
20
Q
For dermoid cysts during pregnancy , when to perform surgery?
A
if they grow beyond 6 cm in diameter,
particularly if they are bilateral (10%)
preferably in the second trimester
21
Q
In the Management of ovarian masses in pregnancy
Which adjuvant chemotherapy can be used during pregnancy ?
A
Methotrexate and cisplatin can be used during pregnancy with success in the second and third trimesters .
Chlorambucil has been
used as early as the first trimester.
22
Q
What are the most common tissues found in Struma ovarii ( monodermal teratoma ) tumours ? Possibility of malignancy?
How is the patient present ? What tumour markers are elevated? Management?
What is the Postoperatively adjuvant therapy ?
A
- Thyroid tissue
comprises more than 50% of the overall mass. - The vast majority are
benign . - It may present with abdominal pain, a palpable abdominal mass and/or
abnormal vaginal bleeding or thyroid hyperfunction in 5%–8% of patients. - (CA-125) may be elevated but is not specific .
- management: Surgical resection of the ovary is sufficient to treat benign unilateral disease
- Postoperatively adjuvant therapy : with radioablative iodine-131 .
23
Q
A cyst is sent for histologic investigation and the report shows an insular pattern of
round uniform cells with 80% neurosecretory granules. This patient also has 5-
hydroxyindoleacetic acid (5-HIAA) in her urine sample.
Which of the following cysts is the most likely diagnosis?
A
Ovarian carcinoid.
24
Q
Ovarian carcinoid tumours : incidence? Origin?
malignant potential ? evidence for the diagnosis ?
A
- incidence: uncommon
- Origin: germ cell
origin - malignant potential : low .
- evidence for the diagnosis :
A 24-hour excretion of 5-hydroxyindoleacetic acid (5-HIAA)
>25 mg
25
An 18-year-old girl presents with a large abdominal mass with abdominal pain. She
claims the mass has increased in size within the last three months. A laparotomy and
unilateral salphingo-oophorectomy is performed. The histology report shows a mesodermal core with a central capillary (Schiller–Duval body).
Which ovarian tumour is this most likely to be?
Endodermal sinus tumour ( Yolk sac tumors )
26
Endometrial sinus tumour ( yolk sac tumour (YST) )
origin? malignant potential ?
Treatment? Histology? survival rate ?
* Origin: germ cell .
* malignant potential : usually malignant.
* Treatment: combination of surgery and chemotherapy ( cisplatin-based )
* Histology : Schiller–Duvall bodies are present in only 50%–75% of these tumours
*
survival rate : >90%
27
An 8-year-old girl presents with symptoms and signs of precocious puberty. Which of
the following tumours should not be included in the differential diagnosis?
Endodermal sinus tumour
* secrete alpha-fetoprotein and not oestrogen .
28
An 8-year-old girl presents with symptoms and signs of precocious puberty. Which of
the following tumours should be included in the differential diagnosis?
1- Choriocarcinoma of the ovary
2- Embryonal carcinoma : secretes (hCG)
3- Granulosa cell tumour :
(GCT) secrete oestrogen
4- Polyembryoma : Mixed germ cell tumor with predominant embryoid bodies (central core of embryonal carcinoma cells)
29
In Granulosa cell tumours
(GCT) :
Tumour markers ? Management?
Tumour markers : oestradiol,
inhibin : Inhibin levels are undetectable in the postmenopausal woman,but are elevated even in postmenopausal women with GCT
anti-Müllerian hormone.
Cancer antigen 125 (CA-125) is not
correlated to the tumour progression
* Management: surgical removal and adjuvant chemotherapy .
30
What are the 4 types of ovarian tumors?
1- Germ cell :
* Dysgerminoma
* Yolk sac ( Endodermal sinus tumour )
* Choriocarcinoma
* Teratoma
* Embryonal
2 - Sex cord :
* Granulosa cell
* Sertoli leydig cell
3- Epithelial:
* Serous
* Mucinous
* Brenner
* Endometroid
4- metastatic:
* Krukenberg
31
What is the ligament that contains the vessels going to the ovary?
The suspensory ligament of the ovary
( Infundibulopelvic ligament)
32
Serous cystadenocarcinoma & mucinous cystadenocarcinoma of the ovary :
Who gets these tumers?
Postmenopausal women
Or BRCA 1 & Lynch syndrome
🚫 Protective: multipara & OCP
33
Serous cystadenocarcinoma & mucinous cystadenocarcinoma of the ovary :
Histology?
Cysts : Epithelium ( gland - like structures ) secreting clear or mucinous fluid.
* Benign: ( cystadenoma) simple layer
* Malignant: ( adenocarcinoma) papillary projections - shaggy appearance
❄️ Serous 👉 psammoma bodies
34
What are psammoma bodies?
Histological appearance exists in serous cystadenocarcinoma
Described as : dystrophic calcifications OR calcific spherules
35
Serous cystadenocarcinoma & mucinous cystadenocarcinoma of the ovary :
Tumer markers?
Ca 125 : not diagnostic
36
In Brenner tumour of the ovary: histology?
Transient epithelium like seen in bladder
37
The germ cell tumors of the ovary: the 4 histologic features?
Dysgerminoma: fried egg appearance
Yolk sac: Schiller duval bodies
Teratoma: multiple cell types
Choriocarcinoma: cyto-syncytiotrophoblast
38
Dysgerminoma: who ? Histology? Tumour markers?
Who : premenopausal women
Histology: fried egg ( large cells with clear cytoplasm & large nucleus
Tumour markers: PLAP ( placental like alkaline phosphatase) + bHCG + LDH
39
Yolk sac ( endodermal sinus) : who ? Histology? Tumour markers?
Who : children
Histology: Schiller duval bodies - resemble primitive glomeruli
Tumour markers: afp
40
Malignant transformation can occur in mature teratomas most commonly to ...?
Squamous cell carcinomas
41
In Granulosa cell tumours
(GCT) :
Histology? Appearance? Physiology?
Histology: call exner bodies ( cuboidal cells in multifollicular patterns ) around eosinophilic material
Appearance: yellow gross
Physiology: precocious puberty or postmenopausal bleeding
42
Sertoli leydig cell tumour of the ovary: histology? Appearance? Tumour markers? Physiology?
Histology: solid tubes surrounding by Sertoli cells ( reinke crystals)
Appearance: gross , yellow.
Tumour markers: androgen
Physiology: virilization
43
Krukenberg tumor : definition? Histology?
GI adenocarcinoma most commonly diffuse gastric ( thickening & leathery stomach wall)
Histology: signet ring cells: mucin droplets displacing the nucleus
44
You are reading the histology report of a patient who had a laparotomy for an
abdominal mass. A biopsy was taken as the mass was deemed to be inoperable.
The histology report showed a tumour with an appearance of mucin-filled epithelial
glandular cells (‘signet-ring’ cells).
Which of the following organs is the most likely origin of the primary cancer?
Stomach
45
Your ST1 asks you about a 42-year-old patient with a 5-cm right-sided ovarian cyst.
The patient has occasional right iliac fossa pain. She would like to know the overall
chance of a symptomatic ovarian cyst in a premenopausal female being malignant.
Which of the following statements is most accurate?
1:1000
increasing to 3:1000 at the
age of 50 years
46
You are reading an ultrasound scan report concerning a patient with left-sided
pelvic pain. The report reads ‘a 6 x 5 x 5-cm left adnexal mass possibly ovarian in
origin’.
In adnexal masses, what is the incidence of a non-ovarian origin?
10%
47
A 38-year-old woman presents with an ultrasound scan report showing a unilocular
anechoic left ovarian cyst measuring 5.6 x 5.2 x 5 cm. The CA-125 is 25.
What is the risk of malignancy index?
0
RMI = U × M × Ca125
* U = 0 for an ultrasound score of 0
* The menopausal status is scored as 1 = premenopausal and 3 =
postmenopausa
48
What is The risk of malignancy index (RMI) indicate?
RMI 25
–250 indicates risk of 20%; RMI >250 indicates risk of 75%.
49
A 67-year-old patient developed a recurrence of ovarian cancer two months after
completing her last dose of platinum chemotherapy.
How would you define her response to platinum chemotherapy?
Platinum-resistant disease.
* Platinum-resistant disease: recurrent disease within six
months of completing their last dose of platinum.
* Platinum-refractory disease:
patients who develop resistance while receiving chemotherapy
*
Platinum-sensitive disease: patients who develop recurrence beyond six
months after completing their last dose of platinum.
50
A 54-year-old patient is found to have advanced stage III ovarian cancer
What is the best management?
Neo-adjuvant chemotherapy and interval debulking surgery
( Carboplatin and paclitaxel )
51
What is
The standard-of-care for patients with advanced ovarian cancer ?
primary maximal debulking surgery and platinum-based chemotherapy
52
What is the survival rate for ovarian Cancer?
early stage cancer is 90%, dropping to
<30% for stages III
and IV.
53
A 64-year-old woman developed resistance to platinum chemotherapy after undergoing surgery for grade III ovarian cancer.
What are her chances of responding to second-line chemotherapy in this case?
<10 %
54
A 51-year-old woman had a total hysterectomy, bilateral salpingo-oophorectomy and
surgical staging for stage IC ovarian cancer. The pathologist’s report confirmed clear
cell histology.
What is your care plan for her?
Adjuvant chemotherapy.( Carboplatin and paclitaxel)
*
55
A 38-year-old woman attends for her cervical screening appointment. You have
tried to do the smear but you failed because of severe cervical stenosis resulting
from traumatic surgery six years previously. In her notes, it was documented that
the same thing happened in her last two appointments. Her first two smear results
were normal.
What will you do next?
Offer cervical dilatation and retry to take the smear.
( Not colposcopy)
56
A 30-year-old woman has had her cervical screening result reported as borderline.
What will be your plan of management?
Offer human papilloma virus (HPV) test.
* Those with a
positive reflex test showing a high-risk HPV type should be referred for
colposcopy. If the reflex test is negative, they are returned to the routine call–
recall system
57
A 30-year-old woman has had her cervical screening result reported as Moderate or high-grade dyskaryosis
What will be your plan of management?
colposcopy without a high-risk HPV test
58
A woman has had her cervical smear. It shows moderate dyskaryosis. She subsequently had a colposcopy and a loop excision of transformation zone (LETZ) procedure. The histopathology shows negative margins.
What will be your further plan of management?
Cervical smear with or without test-of-cure in six months.
💯 The absence of high-risk HPV DNA has a 100% negative predictive value for
cure after treatment of CIN2+. and is more accurate
than cytology ( early valid prognostic evidence of failure or cure )
59
Using high-risk HPV as the primary screening test is an attractive option for countries
with existing cervical screening programmes.
Compared to liquid-based cytology for detection of borderline changes or worse,
HPV primary screening is:
25% more sensitive and 6% less specific.
60
A 43-year-old woman has had her cervical smear taken on day 14 of her menstrual
period. The result shows no abnormality but there were normal endometrial cells in
the sample. She has a history of bilateral tubal ligation.
What will be your further management?
Transvaginal scan and endometrial sampling.
* In women aged over 40 years, who are beyond the 12th day of the menstrual
cycle, the finding of normal endometrial cells in a cervical sample may indicate
endometrial pathology ranging from benign polyps to carcinoma. Hence,
endometrial biopsy is indicated
🚫 in a sample from a woman <40 years do not indicate significant endometrial
pathology
61
A 32-year-old woman attends the colposcopy clinic after a high-grade smear result.
After discussion, the woman accepts the LETZ procedure.
What is the minimum depth of excision that is accepted in the LETZ procedure?
7 mm
🪷
Type I cervical transformation zone
: depth of excision should be >7 mm and
<10 mm.
Type II cervical transformation zone
: the depth of excision should be >10 mm
and <15 mm.
Type III cervical transformation zone
: the depth of excision should be
>15 mm and <25 mm.
62
A 45-year-old woman has had the LETZ procedure for high-grade dyskaryosis. The
histopathology result shows CIN3 with positive margins.
What will be your further management?
Cervical smear with or without test-of-cure in six months.
🚫 the case does not justify routine
re-excision, provided there is no evidence of glandular abnormality or invasive
disease and the woman is under 50 years of age
63
A 45-year-old woman has had the LETZ procedure for high-grade dyskaryosis. The
histopathology result shows CIN3 with positive margins.
six months after treatment the
cytology sample is reported as high-grade dyskaryosis
What will be your further management?
must be referred for colposcopy without
test-of-cure
64
A 42-year-old woman has had the LETZ procedure for high-grade dyskaryosis. The
histopathology result shows Cervical glandular intraepithelial neoplasia (CGIN) with positive margins.
What will be your further management?
re-excision should
be done. ( has a risk of recurrence;
if excision is not complete)
Then repeat test-of-cure should be done after six months and 12
months. If both are negative, the woman should be recalled in three years.
65
36-year-old woman has had a LETZ procedure for cervical glandular intraepithelial
neoplasia (CGIN). The histopathology result showed negative margins. Six months
later the repeat cervical smear is negative but the HPV test-of-cure is positive.
What will be your next management?
Colposcopy.
no abnormality is detected at colposcopic 👉 should have a second test-of-cure sample 12 months later
66
45-year-old woman has had a total hysterectomy for abnormal uterine bleeding.
The histopathology result shows positive margins for CIN1.
What will be your further management?
Vault cytology and HPV test-of-cure at six, 12 and 24 months
🦄 CIN 1: vault cytology at six, 12 and 24 month
CIN 2/3: vault cytology at six and 12 months, followed by nine annual vault cytology samples
* follow up for incompletely excised CIN continues to 65 years or until 10 years after surgery (whichever is later)
67
A woman was found to be 10 weeks pregnant when she attended for her colposcopy
appointment for high-grade dyskaryosis. The colposcopy examination suspected
CIN1.
What will be your further management?
Repeat colposcopy at 12 weeks postpartum
* The incidence of invasive cervical cancer in pregnancy is low, and pregnancy
itself does not have an adverse effect on the prognosis.
68
Cervical cancer according to Figo ?
* Stage IA1 : a microscopic , stromal invasion< 3 mm in depth < 7 mm width
Stage IA2 : a microscopic , stromal invasion 3 - 5 mm in depth
* Stage IB1 : The tumor is 2 centimeters or smaller
Stage IB2: The tumor is larger than 2 centimeters but not larger than 4 centimeters.
Stage IB3: The tumor is larger than 4 centimeters.
* Stage IIA: Cancer has spread from the cervix to the upper two-thirds of the vagina
Stage IIA1: < 4 cm
Stage IIA2: > 4 cm
Stage IIB: Cancer has spread from the cervix to the tissue around the uterus.
* Stage IIIA: Cancer has spread to the lower third of the vagina
Stage IIIB: Cancer has spread to the pelvic wall; and/or hydronephrosis
Stage IIIC: is divided into stages IIIC1 and IIIC2, based on the spread of cancer to the lymph nodes.
IIIC1 : pelvic lymph nodes
IIIC2 : aortic lymph nodes
* Stage IVA: pelvic organs, such as the bladder or rectum.
Stage IVB: Cancer has spread outside the pelvis
69
Cervical Cancer Treatment by Stage ?
🌸stage IA1 : conization or total hysterectomy
🌸stage IA2 : modified radical hysterectomy and removal of lymph nodes
radical trachelectomy, and removal of lymph node
Internal radiation therapy, for patients who cannot have surgery
🌸stage IB and stage IIA :1- Chemoradiation
2- radical hysterectomy and removal of pelvic lymph nodes with or without radiation therapy to the pelvis, plus chemotherapy .
3- radical trachelectomy
4- radiation therapy alone
🌸stage IIB, stage III, and stage IVA : Chemoradiation
surgery to remove pelvic lymph nodes followed by radiation therapy with or without chemotherapy
🌸stage IVB : Radiation therapy as palliative therapy, to stop bleeding
Chemotherapy
70
32-year-old nulliparous woman has suffered post-coital and intermenstrual bleeding for 10 weeks before being diagnosed with stage IB2 cervical cancer.
What is the most appropriate management?
Chemoradiation ( stages IB2 or more )
* For women diagnosed with cervical cancer stages IA1
–IB1, the procedures are:
surgery
71
Above which stage Removal of pelvic lymph nodes is recommended during treatment ?
FIGO IA2
72
When to consider adding adjuvant treatment ( platinum-based chemotherapy ) to Chemoradiation in the management of cervical cancer?
Patients who have undergone surgery for cervical carcinoma and have positive
nodes
73
When to offer fertility conservation management to women with cervical cancer ( radical trachelectomy and pelvic lymph node dissection) ?
If the tumour diameter is less
than 2 cm and there is no lymphatic-vascular space invasion
( IB1 or less)
74
A 35-year-old woman is found to be 15 weeks pregnant when she is diagnosed with
stage IB1 cervical cancer.
What will be the most appropriate management?
Immediate radical hysterectomy and bilateral pelvic lymphadenectomy.
( If after 16 weeks of gestation + IA1, IA2, IB1 treatment may be delayed to allow fetal maturity
to occur )
* If gestational age is
<20 weeks + 1B2 or greater 👉 immediate termination
75
In the UK, HPV) vaccination of girls aged 12–13 years started in September,
2008. Almost 90% of girls eligible for the vaccine in 2010/2011 received all three
doses.What is the predicted impact that HPV vaccination may have, based on the current
high uptake?
50% decrease in high-grade CIN and 70% reduction in cervical cancer.
76
A 32-year-old nulliparous woman is diagnosed with a cancer lesion at the anterior lip
of the cervix with extension of 6 mm and stromal invasion of 8 mm. There is no
parametrial invasion, neither is there any lesion elsewhere. Cystoscopy and sigmoidoscopy are normal. She asks for fertility sparing treatment.
What is the most appropriate treatment in her case?
Radical trachelectomy and pelvic lymph node dissection
( She is Stage IB1 (clinically visible lesions limited to the cervix uteri) )
77
A 32-year-old woman is referred to the colposcopy clinic because of a suspicious
looking cervix on speculum examination done because of heavy menstrual bleeding.
She is diagnosed with cervical adenocarcinoma with depth of invasion of 2 mm and
horizontal spread of 6 mm.
What is the risk of lymph node invasion in her case?
1%
* FIGO
IA1 👉 1%
* FIGO IA2 👉 3 - 6 %
78
The incidence of endometrial cancer is rising in postmenopausal women, but in the
same time the five-year survival rates have improved.
In terms of order, currently, endometrial cancer is:
A. The most common female cancer.
B. The second most common female cancer.
C. The third most common female cancer.
D. The fourth most common female cancer.
E. The fifth most common female cancer.
The fourth most common female cancer.
79
Obesity is now affecting 25% of adults in the UK and predisposes women to endometrial as well as other cancers.
What type of endometrial cancer is obesity predominantly associated with?
Type 1 (endometroid) endometrial cancer rather than type 2 (non-endometroid).
(both subtypes are increased with obesity)
* Risk of endometrial cancer is increased in women with a BMI
>30 kg/m2 and
the risk increases linearly with increasing BMI
80
What percentage of endometrial cancers are attributable to
obesity ?
50 %
81
A 55-year-old woman, with a BMI of 34, attends the gynaecology clinic as an urgent
two-week referral with postmenopausal bleeding. She has had a transvaginal
scan, which shows a thin endometrium apart from a focal area with a thickness of
8 mm.
What will be the most appropriate further management?
Offer hysteroscopy and biopsy
82
A 51-year-old woman has had hysteroscopy and biopsy for postmenopausal
bleeding. The biopsy result shows endometrial hyperplasia without atypia.
What is the risk that she may progress to have endometrial cancer?
<5% in 20 years
< 2% in 10 years
83
A 49-year-old woman has had a Pipelle biopsy done for abnormal heavy uterine
bleeding. The result shows endometrial hyperplasia without atypia.
What is the most appropriate management for her condition?
A. Expectant management.
B. Levonorgestrel intrauterine system.
C. Hysterectomy.
D. Medroxyprogesterone 10–20 mg per day.
E. Northisterone 10–15 mg per day.
Levonorgestrel intrauterine system.
( it has a higher disease regression rate with a more
favourable bleeding profile and it is associated with fewer adverse effects.)
84
In patients with endometrial hyperplasia in the absence of cytological atypia
treated
conservatively.
what is the chance of success by this management?
2/3
85
A 46-year-old woman attends the gynaecology clinic six months after being diagnosed with endometrial hyperplasia without atypia; she is on northisterone 15 mg
daily. She has had a surveillance Pipelle biopsy. The result shows a persistence of the
same endometrial pathology.
What will be your further management?
Continue treatment for a further six months and then biopsy
( Hysterectomy is indicated if no histological regression of hyperplasia despite 12 months of
treatment )
86
A 55-year-old woman attends the gynaecology clinic with postmenopausal bleeding.
She had a transvaginal scan, which showed an endometrial thickness of 8 mm. She
had a successful Pipelle biopsy in the clinic. The result shows endometrial hyperplasia
with atypia.
What is the most appropriate management?
Laparoscopy, total hysterectomy and bilateral salpingo-oophorectomy
87
A 60-year-old woman, BMI 40, attends the outpatient hysteroscopy clinic as part of
the investigation for her third episode of heavy postmenopausal bleeding. The endometrium looks suspicious and copious curettings are obtained. The result shows
endometrial cancer. Stage I endometrial cancer is suspected after magnetic resonant
imaging.
What is the most appropriate management?
Laparoscopy, total hysterectomy and bilateral salpingo-oophorectomy
88
What is surgical technique of choice for women with endometrial cancer for each stage ?
🩷For stage I disease: simple hysterectomy and bilateral salpingo-oophorectomy.
🩷
For stage II disease: laparotomy/laparoscopy, bilateral salpingooophorectomy and lymphadenectomy.
🩷Stage III disease: laparotomy/laparoscopy, bilateral salpingo-oophorectomy
and adjuvant radiotherapy.
🩷 Stage IV disease: radiotherapy
89
A 65-year-old woman is diagnosed with stage IB endometrial cancer. She declines any
surgical intervention and requests radiotherapy as an alternative.
What will be the risk of recurrence if she is treated using radiotherapy?
18 %
Hence, it should be
considered only in exceptional cases
90
A 65-year-old woman is referred to the two-week-wait general gynaecology clinic
because her general practitioner observed an irregular vulval ulcer with raised edges
while he was performing a rectal examination for suspected haemorrhoids.
What will you do next?
Urgent referral to cancer centre
* where a vulval cancer is strongly suspicious on examination, urgent
referral to a cancer centre should not await biopsy
91
Vulval cancer spreads by direct extension to adjacent structures, by embolization to
the regional inguinal and femoral lymph nodes, or by haematogenous spread.
What proportion of the women with vulval cancer who are operable have nodal
spread?
30 %
92
A 70-year-old woman is diagnosed with vulval cancer. The tumour involves the
vagina and the urethra. The pelvic nodes are negative.
What is the most likely stage of her disease?
Stage II.
93
vulval cancer figo staging ?
🌸Stage 1 : IA, the tumor measures ≤ 2 cm in size and invades stroma ≤ 1 mm
IB the tumor > 2 cm size and >1 mm stromal invasion
🌸Stage II : any sized tumor extending to the lower one-third of the urethra, vagina, or anus without metastases to lymph nodes
🌸Stage III : IIIA contains tumors of any size with extension to the upper two-thirds of the urethra, bladder mucosa, upper two-thirds of the vagina, rectal mucosa, or regional inguinofemoral lymph node metastases ≤ 5 mm.
IIIB is tumor metastasis > 5 mm to regional lymph nodes.
IIIC contains tumors with regional lymph node metastases with extracapsular spread.
🌸Stage IV : IVA metastases fixed or ulcerated lymph nodes or tumors fixed to the pelvic bone ( bilateral regional lymph nodes )
IVB signifies distant metastases , including pelvic lymph nodes .
94
A 68-year-old woman is diagnosed with vulval cancer. The lesion is 2 cm and lateral.
The pathologist has phoned and informed you that the frozen section for the sentinel
lymph node biopsies is positive.
How will you proceed with the surgery?
Proceed with bilateral lymphadenectomy
* If the sentinel lymph node biopsy (SLNB) is negative then no further surgery is
necessary.
*
If the SLNB is positive then consideration should be given to complete lymphadenectomy of both groins
95
In vulval cancer: The
five-year survival in cases with no lymph node involvement is ...
the inguinal nodes are involved is ...
with iliac or other
pelvic nodes involved ...
The
five-year survival in cases with no lymph node involvement is ...80%
the inguinal nodes are involved is ...< 50 %
with iliac or other
pelvic nodes involved ...10 -15 %
96
A 72-year-old woman is diagnosed with verrucous vulval cancer. The lesion is 3 cm in
diameter and 2 cm lateral to the left labia majora.
What is the most appropriate management?
Wide local excision
(Without lymphadenectomy or biopsy)
97
A 60-year-old woman is diagnosed with vulval basal cell carcinoma. The lesion is
3 cm in diameter and less than 10 mm above and lateral to the anus
What is the most appropriate management?
Radiotherapy
* should be the preferred
treatment if resection would compromise function of adjacent organs, e.g. anal
orifice.
* Basal cell carcinoma is rarely associated with lymph node metastases
can
be managed by wide local excision
98
A 54-year-old woman presents to you in the gynaecology outpatient clinic with vulval
soreness and itching. On examination you find suspicious vulval lesions and you take
a biopsy. Two weeks later you review her and the histology report shows irregular
saw-toothed acanthosis, increased granular layer and basal cell liquefaction and a
band-like dermal infiltrate that is mainly lymphocytic.
Which of the following conditions does this woman have?
Lichen planus
99
54-year-old woman presents to you in the gynaecology outpatient clinic with vulval
soreness and itching. On examination you find suspicious vulval lesions and you take
a biopsy. Two weeks later you review her and the histology report shows thinned
epidermis with subepidermal hyalinization and deeper inflammatory infiltrate.
Which of the following conditions does this woman have?
Lichen sclerosis
100
Your ST1 feels confused about vulval intraepethial neoplasia (VIN) and wishes to
know which of these has the highest malignant potential.
Which of the following VINs has the highest risk to change into squamous cell
carcinoma of the vulva?
VIN associated with lichen sclerosis.
101
Your ST1 feels confused about vulval intraepethial neoplasia (VIN)
Which is The most common aetiology ?
The most common aetiology is HPV type 16
102
A 36-year-old woman is complaining of having had heavy menstrual bleeding (HMB)
for two years. Abdominal examination reveals a 20-week sized uterus and her pelvic
scan shows multiple interstitial fibroids. Her haemoglobin level is 9 gm/dL. She is
nulliparous and wishes to preserve her fertility.
What management option would you recommend?
Gonadotropin-releasing hormone (GnRH) analogue for six months followed by
myomectomy.
* The hypo-oestrogenic side effects could be minimized by adding low-dose
oestrogen and progestin(.E2 1 mg coupled with NETA 0.5 mg ) or tibolone after the initial phase of down regulation.
103
A 24-year-old woman is counselled regarding surgical treatment of a 7-cm symptomatic fibroid. She is keen to know all the facts and particularly wants to hear about new
techniques. She wants to know the effect of the procedures on her future fertility.
What information can you give her?
Laparoscopic myomectomy is her best option.
(longer operating times but less blood loss, less postoperative pain and fewer complications)
* No difference in pregnancy rate after the procedure
104
A 48-year-old woman is complaining of abnormal uterine bleeding, which has
lasted for two years. She has tried the combined oral contraceptive, oral progestogens, tranexamic acid and mefenamic acid but without any improvement.
She has three children and has been sterilized. Her last cervical smear was two
years previously and was normal. She had surgery for breast cancer four years
before. Her pelvic scan shows no uterine abnormalities. Her endometrial sampling
is normal.
What would you offer her as a further step of treatment?
Endometrial ablation : with a uterus no bigger than a 10-week pregnancy, endometrial
ablation should be considered preferable to hysterectomy
* Mirena intrauterine device is category 3
105
A 50-year-old woman has had two previous episodes of abnormal uterine bleeding.
She had a cervical smear a year previously, which was normal. Pelvic ultrasound
scanning shows an endometrial thickness of 15 mm. She is on anticoagulation for
recurrent thromboembolic events.
What is your next step in management?
A. Book for inpatient dilatation and curettage.
B. Inpatient hysteroscopy and biopsy.
C. LNG-IUS.
D. Outpatient office hysteroscopy and biopsy.
E. Pipelle biopsy in the clinic and offer LNG-IUS
Outpatient office hysteroscopy and biopsy.
(hysteroscopy is the gold standard
for evaluating the endometrial cavity. Historic dilation and curettage alone is
no longer acceptable )
* Pipelle endometrial samples is not sensitive in detecting
endometrial polyps
106
An 18-year-old woman is referred to you because of her concerns about the irregularity of her menstrual cycle. She thinks she has very frequent cycles, which come every
25 days but may increase to every 38 days. She also thinks that she loses a lot of blood.
Her general practitioner says she is not anaemic and a 2D ultrasound scan was
normal. He tried to reassure her but she insists on referral.
How best can you handle the situation
Reassure her and explain that the average cycle length is between 24 days and
38 days
107
A 45-year-old woman complains of HMB. She has tried medical treatment without
any improvement. All her investigations came back as normal. She is frustrated and
keen to have an explanation for her problem.
What information should you give her to reassure her?
Between 40% and 60% of women with HMB have no uterine, endocrine, haematological or infective pathology on investigation
*
Pathological causes of HMB include :
uterine
fibroids (20%–30%),
uterine polyps
(5%–10%),
adenomyosis (5%).
Endometriosis is associated with 5% of cases.
* The most common age : late thirties
* HMB affects around 10 % -30 % of premenopausal women
108
20-year-old woman with learning difficulties comes with her caregiver who states
that she has frequent irregular menstruation, which is also causing her problems with
her hygienic care. Her pelvic scan is normal and her BMI is 22.
What will you advise when prescribing medical treatment for her?
A three-month continuous use of combined oral contraceptive pills (COCP) and
restart a new three-cycle after the end of the withdrawal bleed.
* not suitable for those in a wheelchair because of an increased risk of deep vein
thrombosis.
109
A 30-year-old woman comes to see you because of her symptomatic fibroid uterus.
She has read about uterine artery embolization. She wants to know how it may
compare to other methods of treatment.
Which is the best statement you can give her regarding the complications of this
procedure?
The most common side effects reported after the procedure are pain and vaginal
discharge.
* more minor complications
* lower rate of major complications
* increased risk of re-intervention
* patient satisfaction with UAE was similar to that with surgery
110
One of your junior colleagues comes to ask you about the pharmacological treatments
for fibroid uterus. He wants to know the mechanism of action for some of these
medications.
What is your best explanation?
🌸UA induces apoptosis in fibroid cells and inhibition of cellular proliferation.
111
What is the mechanism of action for LNG- IUD in the management fibroids ?
* LNG-IUS is successful in reducing menstrual blood loss, increasing
hb and relieving symptoms. There are conflicting results regarding
its effect on fibroids or uterine volume .
112
ulipristal acetate (UA) in the management of fibroids:
* mechanism of action ?
* dosage?
* Effect on Menstrual periods ?
* comparison of UA with a
GnRH analogue ?
* side effects ?
* mechanism of action : induces apoptosis in fibroid cells and inhibition of cellular proliferation.
* Dosage: 5-mg tablet orally once daily for treatment
courses of up to three months each
* Effect on Menstrual periods : significant reduction in menstrual blood loss or
amenorrhea within the first 10 days . Menstrual periods generally return within four weeks after the end of each
treatment course
* comparison of UA with a
GnRH analogue : repeated three-month UA courses effectively
control bleeding and shrink fibroids
* side effects : cramps, vaginal discharge, dizziness
113
GnRH analogue in the management of fibroids:
can be used short term to allow for treatment of anaemia or in the
preparation for surgery.
36% reduction in leiomyoma size and an improvement in
symptoms after 12 weeks.
🚫 After discontinuation of treatment, menstruation
returned in 4-8 weeks and fibroid size returned to pretreatment levels
within 4-6 months.
114
A 26-year-old woman is complaining of HMB and dysmenorrhea for six months. She
has used tranexamic acid and mefenamic acid without any improvement and now she
has a LNG-IUS that was fitted one month previously. She is still having slight
irregular bleeding, although the pain has improved.
How long should she expect to have this irregular bleeding?
This could last up to 24 weeks.
115
A 36-year-old woman is referred to the gynaecology clinic complaining of secondary
amenorrhea for the last eight months since stopping COCP, which she has been
taking for two years. She is a mother of two children. Her BMI is 24. Hormonal
assessment five weeks previously showed her follicular stimulating hormone (FSH) of
26 IU/L and luteinizing hormone (LH) of 20 IU/L.
What will be your next step for diagnosis?
A. Anti-Mullerian hormone assay.
B. Auto-ovarian antibody assay.
C. Diagnostic of ovarian failure; no need for further tests.
D. Progesterone withdrawal test to confirm diagnosis.
E. Repeat FSH and LH.
Repeat FSH and LH.
* diagnostic criteria: oligo-/
amenorrhoea for four months and FSH of >25 IU/L on two occasions more
than 4 weeks apart .
116
An 18-year-old national gymnastic champion is referred to you. She experiences
long periods of secondary amenorrhea and she only has two to three periods each
year. She is training for the coming Olympics but her general practitioner advised
her to visit you because she is worried about her. She suffers from backache. Her
BMI is 16.
What will you offer her?
Cyclic COCP.
* exercise-induced amenorrhea
Menstrual irregularities are common in sportswomen (44%)
117
An 18-year-old woman is referred to you by her general practitioner because of severe
dysmenorrhea. She is experiencing severe pain with her periods such that she skips
her academic classes for three days each month. She has tried mefenamic acid and
other analgesics without improvement. She has also tried oral contraceptive pills but
is still in pain. She is not a smoker and is not sexually active.
What is the most appropriate approach?
Laparoscopy
118
You are reviewing a 36-year-old woman with severe premenstrual tension syndrome
(PMS). She is tearful. She has completed her family. She is
exercising regularly. She has tried cognitive behavioral therapy. Her BMI is 35 and she
is a smoker.
What will offer her as treatment?
Low-dose selective serotonin reuptake inhibitor (SSRI).( continuous or luteal phase low-dose SSRI (e.g.
citalopram/escitalopram, 10 mg)
* the use of combined hormonal contraception is category 3
Other therapies: therapy includes exercise, cognitive behaviour therapy, vitamin B6,
combined new generation pill
119
A 39-year-old Jehovah’s Witness woman attends the gynaecology clinic complaining
of HMB. She has used hormonal and non-hormonal medical treatments with no effect.
Her haemoglobin dropped to 90 g/L during her last period. A transvaginal scan
showed multiple uterine fibroids 3–12 cm in size. She wishes to start a family soon
and wants to avoid surgery.
What is the most appropriate management option?
A. Blood transfusion to treat anaemia.
B. Non-cyclical oral contraception.
C. Mirena coil.
D. GnRH analogues.
E. UAE.
UAE
120
What are the Obstetric risks after UAE for fibroids ?
prematurity, intrauterine growth
restriction, abnormal placentation and increased likelihood of Caesarean
delivery
121
A 26-year-old woman attends the clinic complaining of intermenstrual bleeding. On
direct questioning she explains that her periods are regular and of normal amount and
duration. She has been with her current boyfriend for the last nine months. She has
also experienced post-coital bleeding for the last three weeks. Her last smear report
one year ago was normal with a normal cervix. She was not keen on an internal
speculum examination.
What would you like to offer next?
A. A self-collected vaginal swab.
B. A repeat cervix smear.
C. A transvaginal scan.
D. Referral to the genitourinary clinic.
E. Urgent referral to colposcopy.
. A self-collected vaginal swab.
the nucleic acid amplification test
(NAAT) of a self-collected vaginal swab to be tested for chlamydia
122
A 20-year-old female student attends the gynaecology clinic complaining of HMB and
dysmenorrhoea. She is otherwise healthy and well. Currently, she has no concerns
about her fertility.
What is the first line of management for this patient according to the NICE guidelines?
A. COCP.
B. LNG-IUS.
C. Northisterone.
D. Non-steroidal anti-inflammatory drugs (NSAIDs).
E. Tranexamic acid.
LNG-IUS
🌸 treatments should be considered in the
following order:
1- LNG-IUS provided long-term (at least 12 months) use is
anticipated,
2- tranexamic acid or non-steroidal anti-inflammatory drugs
(NSAIDs) or COCP,
3- norethisterone (15 mg) daily from days 5 to 26 of the
menstrual cycle
4- injected long-acting progestogens
123
A 26-year-old woman has had two previous miscarriages and has a BMI of 24, has
been in a stable relationship for three years and is keen to conceive. She presents with
cyclical lower abdominal pain, menstrual dyschezia, unregulated bowel habits and
bloating of the abdomen. The transvaginal ultrasound scan (TVS) findings are: uterus
measuring 8 x 6 x 3 cm, normal appearance of ovaries.
What is your interpretation of these findings?
Rectal endometriosis
* Deep endometriosis of the rectovaginal septum is associated with the most
severe forms of dyschezia and dyspareunia.
124
A 35-year-old woman is having difficulty in getting pregnant. She also gives a history
of dysmenorrhea and menstrual dyschezia. Her symptoms and examination are
suggestive of rectal endometriosis
What is the recommended investigation to make to exclude such a diagnosis?
Transvaginal ultrasound
Not labroscopy
125
A 38-year-old woman, who is a para 6, has come to the gynaecology clinic with
complaints of dull pain in her lower abdomen and pelvis radiating to the thighs; it
increases on standing and after menses. She also complains of dyspareunia. There are
no bowel or urinary complaints. On clinical examination, there are no signs of infection.
A transvaginal scan of the pelvis was normal. Diagnostic laparoscopy was negative.
What is the appropriate treatment option for her?
Transvenous embolization of the ovarian vein.
* Pelvic congestion syndrome: multiparous - dull pelvic pain that radiates to the upper
thighs and is aggravated by prolonged standing and walking.
* women found to have pelvic vein incompetence
* Transvaginal Doppler and MR venography are useful screening tools but
definitive diagnosis can be made by venography.
126
Is Transvenous embolization of the ovarian vein effective in the management of Pelvic congestion syndrome ? What are the complications?
highly successful.
* There has been subjective improvement in pelvic pain frequency, dysmenorrhoea and dyspareunia lasting for up to five years.
* Re-intervention rates were
low.
* Common complications observed were transient pain after the procedure
and a 2% risk of dye migration.
127
A 32-year-old woman, who is a para 2, has come to the gynaecology clinic with
chronic pelvic pain for the past two years. Pain increases in the squatting position and
is relieved on standing/straightening of legs. It is associated with dyspareunia. She
also gives a history of generalized malaise and tiredness. There are no bowel/urinary
symptoms. On clinical examination, there is a tight ropy band palpable along the
levator ani muscle. The transvaginal ultrasound scan of the pelvis was normal.
What is the appropriate treatment option for her?
Botox injections into the levator ani.
* Myofascial chronic pelvic pain : Pain
is movement related, aggravated by specific movement ,
can cause chronic pelvic pain . Treatment : trigger point injections with local anaesthetic, corticosteroids and botulinum
toxin A
128
A 35-year-old woman, who is a para 1, has come to the gynaecological clinic with
chronic pain in her lower abdomen and pelvis for the past 10 years. The pain is noncyclical, dull-aching and not associated with movement. There are no bowel or
urinary symptoms. The abdominal and pelvic examination was unremarkable. The
TVS of the pelvis is normal. Diagnostic laparoscopy done one year previously was
negative.
What is the appropriate treatment option for her?
Gabapentin 300 mg three times a day.
129
40-year-old female, who is a para 2+1, had firstly a vaginal delivery and secondly a
Caesarean section for fetal distress. She has presented with chronic pelvic pain three
months after her lower uterine segment Caesarian section (LSCS).
What is the incidence of nerve entrapment after LSCS ?
3.7%.
defined as highly localized, sharp pain , exacerbated by particular movements, and persisting beyond
5 weeks or occurring after a pain-free interval
130
Chronic pelvic pain should be seen as a symptom with a number of contributory
factors rather than as a diagnosis in itself. A patient presenting with chronic pelvic
pain wants to know what the incidence is of chronic pelvic pain in the adult female
population.
1 in 6.
131
A 40-year-old woman, who is a para 2+1, presents with secondary amenorrhea for the
past 10 months and complains of weight gain. She has increased two dress sizes over
the last year. The pelvic examination was normal. A TVS shows an increased antral
follicle count (AFC) and increased ovarian volume.
What is the most appropriate next investigation for her?
Oral glucose tolerance test (OGTT)
* Women presenting with PCOS who are overweight (BMI
> 25 kg/m
2
), and
women with PCOS who are not overweight (BMI
<25 kg/m2
) but who have
additional risk factors such as :
advanced age (>40 years), personal history of
gestational diabetes or family history of type 2 diabetes, should have a two hour post-75 g OGTT performed anually.
132
A 35-year-old woman, who is a para 2+1, has presented with secondary amenorrhea
for the past 10 months and complains of weight gain. She has increased two dress
sizes over the last year. The pelvic examination was normal. The TVS shows an
increased AFC and increased ovarian volume.
What is the best treatment option for her?
Withdrawal bleed every three to four months
133
Oligo- or amenorrhoea in women with PCOS may predispose to endometrial
hyperplasia and later carcinoma , how many folds the risk is increased ?
2.89 folds
134
A 28-year-old woman has presented with oligomenorrhoea, hirsutism and weight
gain over the past two years. She has been diagnosed with polycystic ovarian
syndrome (PCOS). Her BMI is 40 kg/m2
. She was advised about lifestyle measures to
lose weight, which failed. She is currently not in a relationship but wishes to have
children later.
What is the next best option that can be considered regarding her weight?
To consider bariatric surgery.
* (BMI of 40 kg/m2 or more, or 35 kg/m2 or more with a high-risk obesity related condition),
135
A young 25-year-old woman is diagnosed with PCOS. Her BMI is 22. Her mother had
type 2 diabetes and her elder sister developed gestational diabetes in her first pregnancy. She is concerned about her risk of developing diabetes. The OGTT fasting
glucose level was 6.5 mmol/L.
What is the recommended next step for her?
Annual OGTT
* impaired fasting glucose (fasting plasma glucose level from
6.1 mmol/L to 6.9 mmol/L) or impaired glucose tolerance (plasma glucose of
7.8 mmol/L or more but less than 11.1 mmol/L after a two-hour OGTT), an
OGTT should be performed annually
136
Hirsutism, characterized by excess facial and body hair and midline hair growth, is a
common clinical presentation of PCOS. Although free and total testosterone is used in
the diagnosis of PCOS, the recommended baseline biochemical test for hyperandrogenism is the free androgen index.
How is the free androgen index calculated?
Total testosterone/sex hormone-binding globulin x 100
137
You review a woman in the urogynaecology outpatient clinic. You decided to start
her on anticholinergic therapy as she has symptoms of overactive bladder that has
failed to respond to lifestyle modification and bladder retraining.
How long will it take before she can expect to see the full benefits of taking this
medication?
Four weeks
138
A 51-year-old woman with two previous vaginal deliveries is seen in the gynaecology
outpatient clinic complaining of leaking urine on coughing and sneezing for the past
three months.
What would you tell her regarding the number of pelvic floor contractions to perform
and the frequency of the exercise programme per day?
Pelvic floor muscle training programme: at least eight contractions, three
times per day
139
A 65-year-old woman is prescribed mirabegron (Betmiga, Astellas Pharma) for detrusor
overactivity.
What type of drug is mirabegron?
B3-adrenoceptor agonist
* oral beta-3-adrenoceptor agonist, which activates beta-3-adrenoceptors
causing the bladder to relax
140
You see a woman in the gynaecology outpatient clinic. She has symptoms of
frequency and urgency of micturition. You asked her to keep a bladder diary.
Over what length of time should a bladder diary be undertaken?
3 days
141
A 36-year-old patient presents to the clinic with a lower abdominal dragging feeling
for the past 10 days. Her urine dipstick shows positive for nitrites but she has no other
symptoms of urinary tract infection (UTI).
What is the management plan?
Send midstream urine.
* Symptoms 👉 midstream urine specimen for culture and antibiotic sensitivity regardless of the strip reagent result .
* do not have symptoms of UTI but their urine tests positive for
both leucocytes and nitrites👉 do not offer antibiotics without the results of a
midstream urine culture.
142
You review a 49-year-old woman in the gynaecology outpatient clinic with symptoms
of frequency and urgency of micturition. She is a para 1, delivered vaginally 15 years
ago. Her BMI is 27 and she smokes 15 cigarettes a day. She drinks four cups of
coffee daily.
Which of the following lifestyle interventions is the most important to improve her
symptoms?
Reduce caffeine intake.
143
A 67-year-old woman is seen in the gynaecology outpatient clinic. She has tried
various medications for detrusor instability and all failed. She is keen to try the least
invasive procedure
Which of the following options would be most appropriate for her?
Percutaneous posterior tibial nerve stimulation.
* Do not offer transcutaneous sacral nerve stimulation to treat OAB in women
144
A 75-year-old woman presents to the gynaecology outpatient clinic complaining of
continuous leaking of urine. She is known to have had multiple sclerosis for the past
10 years. She is chair-bound. On examination, there are pressure ulcers that are
contaminated by the urine.
Which of the following initial management options would be most appropriate?
In-dwelling urethral catheter
( Not suprapubic catheter OR intermittent self-catheterization )
145
An 82-year-old patient presents to the gynaecology outpatient clinic with symptoms
of frequency and urgency. A post-void bladder scan shows 100 mL residual urine.
Conservative management did not help and now you have decided to start her on
medical treatment for overactive bladder (OAB).
Which of the following would you recommend?
A. Desmopressin.
B. Mirabegron.
C. Botulinum toxin.
D. Oxybutynin.
E. Tolterodine.
Tolterodine ( ditrusitol )
* Desmopressin may be considered with caution in women with cystic
fibrosis and avoid in those over
65 years with cardiovascular disease or hypertension.
* Do not offer oxybutynin (immediate-release) to frail older women.
146
A 72-year-old patient presents to the gynaecology outpatient clinic with symptoms of
frequency and urgency. A post-void bladder scan shows 75 mL residual urine.
Conservative management did not help and now you have decided to start her on
medical treatment for OAB.
How soon after commencing medical treatment does she need a review?
4 weeks
147
A 53-year-old para 2 presents with a 12-month history of leaking on sneezing. She
tried pelvic floor exercise for six months with no improvement. On examination, there
was no evidence of uterovaginal prolapse
What is the most appropriate surgical intervention?
Synthetic mid-urethral tape.
148
You review a 61-year-old patient in the gynaecology outpatient clinic, who is complaining of leaking of urine on coughing or sneezing. Pelvic floor exercises have not
helped. You counselled her and booked her for a mid-urethral tape surgery.
The theatre nurse asks you which type of tape do you prefer?
A. Type 1: macroporous polypropylene tape.
B. Type 2: microporous polypropylene tape.
C. Type 3: macroporous, multifilament polypropylene tape.
D. Type 4: submicronic polypropylene tape, coated biomaterials with pores of
<1 mm.
E. Type 5: microporous monofilament polypropylene tape
macroporous polypropylene tape.
149
A 62-year-old woman is referred to the gynaecology outpatient clinic because of
hesitancy of micturition and dribbling of urine after micturition.
Which of the following initial investigations would you recommend?
A. Measure post-void residual urine volume by bladder ultrasound scan.
B. Measure post-void residual urine volume by catheterization.
C. Request urodynamic studies.
D. Send for pelvic ultrasound scan.
E. Send for urethral pressure studies.
Measure post-void residual urine volume by bladder ultrasound scan.
150
A 49-year-old woman who has multiple uterine fibroids is booked for total abdominal
hysterectomy with conservation of the ovaries.
What is her risk of developing post-hysterectomy vault prolapse (PHVP)?
6%–12%.
151
A 63-year-old woman is booked for vaginal hysterectomy for pelvic organ prolapse
stage 2, according to the Pelvic Organ Prolapse Quantification (POP-Q) classification.1
What is the best surgical procedure to perform to prevent vault prolapse in the future?
A. Approximating the round ligament and suturing it to the vaginal vault.
B. Closure of the peritoneum as high as possible.
C. McCall culdoplasty.
D. Vaginal Moskowitz operation.
E. Vaginal packing of the vagina for 24 hours postoperatively
McCall culdoplasty.( sutures placed through the uterosacral ligaments and the peritoneum of the cul-de-sac )
152
You have obtained consent from a 67-year-old woman for a vaginal hysterectomy plus
pelvic floor repair and a possible sacrospinous fixation. She is diagnosed with stage
2 uterovaginal prolapse. After you complete the hysterectomy and anterior vaginal
wall repair, you pull on the vault and it comes down to 1 cm above the introitus.
Which of the following options would you perform next?
Perform sacrospinous fixation before closing the posterior vaginal wall
153
A 55-year-old woman is seen in the clinic complaining of feeling a lump in the vagina.
She has a history of vaginal hysterectomy six years previously. On examination, she
has a complete vaginal vault prolapse, stage 4 POPQ.
Which of the following options would you recommend to her?
Laparoscopic sacrocolpopexy.
154
UTI is common in pregnancy and hence the regular check of urine in antenatal clinics.
What is the incidence of UTI during pregnancy?
Up to 8%.
155
Asymptomatic bacteriuria (ASB) is most commonly seen in early pregnancy, which is
the reason why it is standard antenatal practice to send a urine sample for microscopy
and culture at the initial booking.
Which of the following organisms is the most common cause of ASB?
Escherichia coli
156
A 26-year-old primigravida presented to the labour ward at 18 weeks’ gestation
with a fever of 38.6 C, rigors, abdominal and loin pain. She was diagnosed with
pyelonephritis, and received intravenous antibiotics, antipyretics and fluid
hydration
What is the risk of recurrence of pyelonephritis in the current pregnancy?
10%–19%.
* there is an argument for commencing
long-term suppressive antimicrobial prophylaxis for the remainder of the
pregnancy
157
A 32-year-old woman in her first pregnancy was admitted to hospital at 29 weeks’
gestation because of colicky pain in the left loin, vomiting and a fever of 37.8 C.
Investigations showed that she has a left ureteric stone. The patient is counselled and
offered conservative management with pain killers, antibiotics and hydration.
What is the success rate of conservative management?
Up to 80% success rate.
158
A 48-year-old woman presented to the gynaecology outpatient clinic complaining of
hesitancy of and dribbling after micturition. Uroflometry was requested and you have
the result.
What is the normal female maximum flow rate?
>15 mL/s.
159
A 66-year-old woman is booked for a urodynamic study because of frequency,
urgency and leaking of urine. The urodynamic study shows the maximum bladder
capacity of 200 mL. The Pabd remained unchanged. The Pves and Pdet were consistently rising by 2cm H2O for every 30 mL of infused fluid into the bladder. At the end
of the infusion, the Pves and Pdet remained raised. There was no leak on coughing at
the end of the filling phase.
What is the most likely diagnosis?
Low-compliance bladder.
160
You are teaching medical students about urodynamic studies; they are confused
about Pdet.
How is Pdet calculated?
A. Urodynamic equipment calculates Pdet directly.
B. Urodynamic equipment calculates Pdet by subtracting Pabd from Pves.
C. Urodynamic equipment calculates Pdet by subtracting rectal from vesical
pressure.
D. Urodynamic equipment calculates Pdet by subtracting Pves from Pabd.
E. Urodynamic equipment calculates Pdet by subtracting vaginal pressure
from Pves.
Urodynamic equipment calculates Pdet by subtracting Pabd from Pves
161
The renal plasma flow increases in pregnancy, leading to increased glomerular filtration rate, creatinine clearance and protein excretion.
By how much does the renal plasma flow increase in pregnancy?
60%–80%
162
A 32-year-old woman in her first pregnancy was admitted to hospital at 29 weeks’
gestation because of colicky pain in the left loin, vomiting and a fever of 37.8 degrees
centigrade. Investigations showed that she has a left ureteric stone. The patient was
counselled and offered conservative management with pain killers, antibiotics and
hydration. Unfortunately, 48 hours later she was still spiking a temperature with
deteriorating renal function.
Which of the following methods is the most frequently used to treat obstruction
caused by calculi during pregnancy in this situation?
Percutaneous nephrostomy
163
A 51-year-old woman has had urodynamic studies done because of multiple lower
urinary tract symptoms. The result shows the following:
During the filling phase, maximum bladder capacity of 460 mL.
Pves and Pabd increased synchronously when the patient was asked to cough. Pdet
fluctuated between +5 and –5 cm H2O.
During the voiding phase, the patient leaked on coughing and Pdet was +5 cm H2O.
Which of the following options is the most likely diagnosis?
Urodynamic stress incontinence
164
Your consultant examines a 65-year-old patient who presented with symptoms of
pelvic organ prolapse. She had a hysterectomy 10 years previously. The prolapse is
noticed. The most distal portion of the prolapse protrudes more than 1 cm below the
hymen but no farther than 2 cm less than the total vaginal length.
What is the stage of this prolapse?
Stage 3
165
The Pelvic Organ Prolapse Quantification (POP-Q) system ?
Stage 0:
No prolapse.
Stage 1: The most distal portion of the prolapse is more than 1 cm above the
level of the hymen.
Stage 2: The most distal portion of the prolapse is 1 cm or less proximal or
distal to the hymenal plane.
Stage 3: The most distal portion of the prolapse protrudes more than 1 cm
below the hymen but no farther than 2 cm less the total vaginal length (for
example, not all of the vagina has prolapsed).
Stage 4: Vaginal eversion is essentially complete.
166
In urodynamic study : several peaks in A max wave , what does it indicate?
1- obstruction
2- unsustained detrusor activity
167
In urodynamic study : reduced Q max wave, what does it indicate?
Obstruction
Prolapse
168
A 31-year-old woman presents to the accident and emergency department three days
following an oocyte retrieval procedure. The patient is complaining of abdominal pain,
vomiting, dizziness and shortness of breath. You are on your way to assess the patient.
What would you want the emergency attendant to do while waiting for you to arrive?
Attach a pulse oximeter and electrocardiogram, administration of analgesics and
an antiemetic.
169
Severe ovarian hyperstimulation syndrome (OHSS) is a recognized serious complication of fertility treatments.
What is the triggering factor for this condition?
Administration of human chorionic gonadotropins (hCG) for follicle maturation
170
A 28-year-old female diagnosed with polycystic ovarian disease is undergoing an in
vitro fertilization (IVF) cycle. The patient is counselled and informed that all possible
measures will be taken to avoid the complication of OHSS.
Which protocol of ovarian stimulation would be advisable?
Gonadotrophin releasing hormone (GnRH) antagonist protocol with GnRH
agonist used for ovulation induction.
171
A 29-year-old woman with primary infertility due to tubal obstruction has undergone
two trials of IVF with no success. Ovarian response and embryo cleavage had always
been good. Previous ultrasonography and hysteroscopy were normal. Her partner’s
semen analysis is satisfactory. Karyotyping for the couple is normal.
What is the most probable cause of failure of implantation in this patient?
A. Aneuploidy of the embryos.
B. Antiphospholipid antibodies.
C. Toxic fluid, in a hydrosalpinx draining to the uterus.
D. Progesterone deficiency.
E. Thick or hard zona pellucida.
Aneuploidy of the embryos.
* Aneuploidy is recognized as the most common cause behind repeated implantation failure and early pregnancy loss Even in normal euploid couples
172
A couple have been trying to achieve a spontaneous pregnancy for three years. The
female partner is 37 years old and was diagnosed with endometriosis stage III.
Which of the following would be the most appropriate recommendation?
The couple should proceed to IVF as soon as possible
173
A 35-year-old infertile patient is classified as having stage I endometriosis and was
prepared for IVF treatment. After counselling regarding the treatment, she asks you
some questions.
Which of the following statements regarding IVF is correct?
A. Clinical pregnancy rate for IVF is reduced in endometriosis.
B. Miscarriage rate is higher than average in patients with stage I endometriosis.
C. Ovarian stimulation could make the endometriosis condition worse.
D. Stage of endometriosis has no impact on the number of oocytes produced.
E. Studies have shown lower fertilization rates in stage I endometriosis; however,
implantation and clinical pregnancy rates are not affected.
Studies have shown lower fertilization rates in stage I endometriosis; however,
implantation and clinical pregnancy rates are not affected.
174
An HIV-discordant couple desiring children are counselled regarding the risk of viral
transmission.
Which of the following information is correct?
A. Only IVF should be performed if the infected male partner’s sperm is to be used.
B. Semen washing and artificial insemination is a safe option for both female
partner and offspring.
C. The couple should defer pregnancy in order to avoid the risks of viral transmission.
D. The only safe approach is to use the sperm of a healthy matched donor.
E. Viral suppression therapy is instituted prior to the use of the male
partner semen.
Semen washing and artificial insemination is a safe option for both female
partner and offspring.
* Therefore, IVF is not the only possible
175
A 27-year-old woman fails to conceive for four years. She is a heavy smoker with
oligomenorrhea. Her BMI is 37 kg/m2.
What would be the first line of management?
A. Attempt IVF without any further delay.
B. Assessment laparoscopy.
C. Diet control for weight reduction and advice to stop smoking.
D. Induction of ovulation with a combination of insulin sensitizer and clomiphene
citrate.
E. Pelvic ultrasonography and measurement of serum testosterone and prolactin
hormones.
Pelvic ultrasonography and measurement of serum testosterone and prolactin
hormones.
* The patient has not been diagnosed fully yet
176
A 33-year-old woman is contemplating IVF for the third time. The patient is worried
about the risk of developing ovarian cancer in the future due to the repeated administration of fertility drugs.
Which of the following statements is correct?
Collective evidence denies any correlation between IVF drugs and an increased
risk of ovarian cancer
177
One of your junior colleagues wants to know what is meant by mild male factor
infertility.
What will you tell him regarding the WHO criteria for mild male factor fertility?
When two or more semen analyses have one or more variables below the fifth
centile.
178
Spontaneous primary ovarian insufficiency (POI) affects 1:250 females at the age of
35 years.
What is the incidence of POI?
1 %
179
A couple with a child who has sickle cell anaemia are seeking pregnancy. The female
partner is 39 years old. The couple request pregestational diagnosis in order to avoid a
second affected child.
Which embryos can be transferred?
Both normal haemoglobin genotype (HbAA) and sickle cell trait (HbAS) embryos
can be transferred
180
A couple come for preconceptional counselling. The woman is 29 years old, her
partner is 32 years old. They both work in a pub. They wanted to know the safe limit
of alcohol consumption that will not affect their fertility.
What is your advice?
They should not exceed the equivalent of 14 units of alcohol per week
( one to
two units a day )
181
An overseas couple attends for consultation regarding pregnancy. She is 32 years old
with four previous pregnancies and one living child. Their last pregnancy ended with
an intrauterine fetal demise at 26 weeks due to severe rhesus isoimmunization
What would be your management?
Check the husband’s genotype
* A homozygous male
(DD) will always cause an affected pregnancy. In this case, an Rh-negative
donor sperm option is possible.
*
A heterozygous male (heterozygous (Dd) might be offered IVF and PGD where Rh-negative embryos are
selected for transfer
182
A couple has come to consult you regarding NHS funding for IVF. They have been
trying to conceive for three years. The female partner is 33 years old. The male partner
has an adopted child because of failure to conceive in a previous relationship. They
have not had any funded procedure previously.
What will you tell them?
They cannot be funded because they have a child in the house
183
A general practitioner requests your help. A man has just come back from a business
visit to a region infected with the Zika virus (ZIKV). The man and his wife are wishing
to try for pregnancy. The couple are free of any symptoms.
What would be your recommendation?
The couple is advised to use contraception for a period of eight weeks
184
You had a panel discussion with colleagues from the oncology department about a 29-
year-old patient diagnosed with cervical cancer. The lesion occupied the lower part of
the cervix and appeared to be of 1–2 cm in diameter. The patient is requesting
preservation of her future fertility.
You suggested radical vaginal trachelectomy (RVT) with lymph node dissection.
Which of the following statements is correct?
Recurrences and five-year survival rates are not significantly different between
RAH and RVT
* Radical abdominal hysterectomy (RAH)
185
A boy of 15 years old has Hodgkin’s lymphoma. His parents come to see you
requesting counselling about preservation of fertility
How will you counsel them?
It is possible if he can produce good quality semen before treatment
186
A couple has been booked for IUI. While reviewing their notes, you find they have not
been screened for chlamydia.
How will you proceed?
Carry on with the scheduled procedure but offer prophylactic antibiotics
( Doxycycline )
187
A couple comes to see you, as they want to start a family. They tried unprotected
intercourse for three months but the male partner complains of a lifelong problem
with premature ejaculation.
What is your first-line management?
Advise pharmacotherapy of selective serotonin reuptake inhibitors
* dapoxetine
188
A young 32-year-old woman is diagnosed with cancer of the ovary stage IA, grade
2 mucinous cancer. She does not have a steady partner. She was not keen on oocyte
preservation as she wishes to achieve spontaneous pregnancy, if possible.
Which of the following is the most appropriate management option?
She can have fertility-sparing surgery
* Stage IA
grade 1 and possibly grade 2 tumours of mucinous, endometrioid or serous
types were suitable for fertility-sparing surgery.
189
While counselling a couple about IVF, they voiced worries about the possibility of any
increase in the rate of congenital anomalies if they achieve pregnancy.
What will you tell them?
There is an increased risk of 30%–40%
* include gastrointestinal,
cardiovascular (specifically septal heart defects), musculoskeletal defects and
cleft lip, esophageal atresia and anorectal atresia.
Nevertheless, the absolute risk is low as the background risk is low
190
A couple comes to see you because they want to achieve a pregnancy. They have tried
unprotected intercourse for the last 12 months. On history taking, you find that the
male partner had a short trip abroad four months ago and had a ZIKV infection. He
has been on condom contraception for the last four months.
What is your advice?
He should wait for two more months before they can start fertility treatment
* ( for six months or
until the semen tests negative for ZIKV RNA by nucleic acid testing )
191
A drug company is undergoing a trial for a new medication for the treatment of heavy
menstrual bleeding. One thousand women are recruited; 550 women are given the
new medication and the rest are given a placebo. The mean age is 32 (SD=5) and 36
(SD=7) years for the former and the latter group, respectively. The women’s ages are
normally distributed.
What is the percentage of the women whose ages range between 29 and 43 years in
the placebo group ?
68% -
When data follow a normal (Gaussian) distribution:
* 68% of the variables will be within one standard deviation (SD) from the
mean (M)
* 95% of the variables will be within two SDs from the mean (M
2SD)
* 99.7% of the variables will be within three SDs from the mean (M
3SD).
192
A drug company ran a trial for the effect of a new medication on the prevention of
pregnancy-induced hypertension (PIH). Following the appropriate approval from the
Regional ethics committee and the women’s consent, 1000 pregnant women were
randomly allocated to one of two different groups. The women were considered to be
at low risk for PIH. The treatment group received a regular single low dose of the new
drug and the control group did not. The following table shows the number of women
in each group who did and who did not develop PIH.
Developed PIH / Did not develop PIH
Treatment group 250 / 250
Control group 200 / 300
What is the relative risk for the treatment group?
1.25 = RR ( relative risk )
250 / 500 divided by 200 in 500 or 250/200 = 1.25.
193
A researcher has developed a new prenatal screening test for Down syndrome.
Following the appropriate approval from the Regional ethics committee and the
women’s consent, 2000 pregnant women were randomly allocated to one of two
different groups. The women were considered to be at low risk for pregnancy affected
by Down syndrome. The following table shows the number of women in each group
who did and who did not have babies affected by Down syndrome.
Screen positive Screen negative
Baby affected by Down syndrome 800 200
Baby not affected by Down syndrome 400 600
What is the positive predictive value of this test?
80 %
PPV = TP/(TP + FP)
194
What is meant by the number needed to treat (NNT)?
A. It is the inverse of the absolute risk.
B. It is the inverse of the attributed risk.
C. It is the difference in the relative risk between the exposed and the non-exposed
groups.
D. It is the number of patients needed to be exposed to the risk factor to cause harm
in one patient.
E. It is the number of patients needed to treat during a specific period.
It is the inverse of the absolute risk.
* NNT is the number of patients needed to be treated to prevent one additional
bad outcome.
195
A researcher has done a comparative study between two populations with regard to
the intelligence quotient (IQ). The mean IQ for the first group is 75 and it is 80 for the
second (P<0.1).
What would be the conclusion of this study?
A. Null hypothesis can be accepted.
B. Null hypothesis cannot be accepted.
C. Type I error.
D. Type II error.
E. Significant difference is detected.
Null hypothesis can be accepted.
* there is no difference between the samples being
compared
* critical level of significance (P-value) are equal
to 0.05 (5%), 0.01 (1%) and 0.001 (0.1%).
Where the level of significance (P-value) is more than these critical levels, the
difference between the two compared groups will be insignificant and the null
hypothesis will be accepted.
196
What is the overall conclusion of the study?
A. P-value is most probably <0.001.
B. P-value is most probably <0.05.
C. P-value is most probably <0.1.
D. P-value is most probably <0.1%.
E. P-value is most probably <5%
P-value is most probably <0.1.
* If the diamond shape crosses the line of action, it means the study has not
found any significant difference or association, i.e. P<0.5 or P<0.1
* If the diamond shape
finds a significant difference in favour of any side of the
study, then the diamond shape will be on that side of the line of action, and the
P-value will be significant at <0.05 (5%), <0.01 (1%) or < 0.001 (0.1%).
197
A researcher is studying the relationship between high beta-human chorionic gonadotropin (BhCG), low pregnancy-associated plasma protein A (PAPP-A), increased
nuchal translucency and the risk of Down syndrome.
Which of the following tests can the researcher use to analyze the results?
A. ANOVA test.
B. Chi-squire (X2
) test.
C. Multiple linear regression test.
D. Simple linear regression test.
E. Student (t)-test.
Multiple linear regression test.
198
A researcher is studying the side effects of a new antihypertensive medication in two
groups of pregnant women (100 women in each group) with PIH. The first group
receives the new medication while the other receives a conventional one.
Which type of the epidemiological studies will suit this study?
A. Case-controlled study.
B. Cohort study.
C. Cross-sectional study.
D. Double-blind randomized case-controlled study.
E. Survey
Cohort study.
199
A researcher is studying the side effects of a new antihypertensive medication in two
groups of pregnant women (100 women in each group) with PIH. The first group
receives the new medication while the other receives a conventional one.
Which type of the epidemiological studies will suit this study?
A. Case-controlled study.
B. Cohort study.
C. Cross-sectional study.
D. Double-blind randomized case-controlled study.
E. Survey
Cohort study.
