EBCOG P1 High Yield ques – General Gyneacology – 29 April(E.M.Q)

A Combined oral contraceptive pill

B Bilateral salpingo-oophorectomy

C Diagnostic laparoscopy

D GnRH analogue

E GnRH analogue + add-back hormone replacement therapy

F Hysterectomy

G Hysterectomy and bilateral salpingo oophorectomy

H Levonorgestrel intrauterine system (insert or replace)

I None of the above

J Pain team referral

K Pelvic MRI

L Pelvic ultrasound scan

M Progesterone-only pill/depot medroxy progesterone acetate

N Referral to another specialty  

O Tricycling combined oral contraceptive pill

 

For each clinical scenario described below, choose the next most appropriate intervention from the list of options above. Each option may be used once, more than once or not at all.

 

1. A 25-year-old patient with a body mass index of 26 is referred by her general practitioner with a 3-year history of dysmenorrhoea, non-menstrual pelvic pain and dyspareunia. She has been tri-cycling her COCP, which she is reliant upon for contraception, for 9 months. Despite this she reports that her symptoms are worsening. She has no significant past medical or surgical history and her clinical examination is unremarkable other than bilateral adnexal tenderness.

2. A 30-year-old patient with known endometriosis comes to clinic for review. She is using a levonorgestrel intrauterine system for both endometriosis management and contraception. It was inserted 4 years ago. She has on-going problems with non-menstrual pelvic pain associated with abdominal bloating. This tends to be associated with bouts of constipation. She reports no loss of blood or mucus from her back passage.

3.A 45-year-old woman with known endometriosis has been managing her disease with a GnRH analogue and tibolone. She is para 2 and her husband has had a vasectomy. Her symptoms are well controlled but she is fed up with monthly injections and requests a hysterectomy.

4. A 22-year-old woman presents with symptoms suggestive of endometriosis. She uses inhalers for asthma and has no surgical history. She has just started a relationship and is currently using condoms for contraception. At her diagnostic laparoscopy mild endometriosis was noted in the left ovarian fossa and over the right side of the uterovesical fold. This was treated with diathermy.

5.A 28-year-old woman had endometriosis confirmed at diagnostic laparoscopy 2 years ago. She had diathermy treatment and changed from the COCP to POP. Her symptoms were well controlled for about a year but over the last 6 months have worsened considerably. She has pain most days and has had to take a week off work with her period for the last 2 months. She is fed up with her symptoms as they are interfering with her life. She has no immediate plans for a family at this time.

A Combined oral contraceptive pill

B Bilateral salpingo-oophorectomy

C Diagnostic laparoscopy

D GnRH analogue

E GnRH analogue + add-back hormone replacement therapy

F Hysterectomy

G Hysterectomy and bilateral salpingo oophorectomy

H Levonorgestrel intrauterine system (insert or replace)

I Pain team referral

J Pelvic CT/MRI

K Pelvic ultrasound scan

L Progesterone-only pill/depot medroxy progesterone acetate

M Referral to another specialty

N Tricycling combined oral - contraceptive pill

0 None of the above

 

For each clinical scenario described below, choose the single most appropriate next step in managing the patient's disease from the list of options above. Each option may be used once, more than once or not at all.

 

6. A 32-year-old woman with known endometriosis undergoes laparoscopy to assess her disease because she is struggling with significant pelvic pain and dyspareunia despite GnRH analogues and add-back HRT. At surgery a nodule is palpable in the posterior fornix and the pouch of Douglas is seen to be partially obliterated with significant disease over both uterosacral ligaments.

7. A 43-year-old woman with known endometriosis underwent a repeat laparoscopy to re-evaluate her disease. She uses a levonorgestrel intrauterine system for contraception and has been experiencing pelvic pain, dyspareunia, dyschezia and cyclical rectal bleeding. At laparoscopy a large nodule of deep infiltrating endometriosis is seen overlying the rectum and appears to be tethered to the underlying muscularis.

8. A 25-year-old woman with a BMI of 26 is referred by her general practitioner with a 3-year history of dysmenorrhoea, non-menstrual pelvic pain and dyspareunia. She has been tri-cycling her COCP, which she is reliant upon for contraception, for 9 months. Despite this she reports her symptoms are worsening. She has no significant past medical or surgical history. Clinical examination rev left adnexal swelling that is tender and some induration of the left uterosacral ligament.

9.A 25-year-old woman is managing her endometriosis with the progesterone only pill. She is amenorrhoeic and is much happier with her symptoms but still has flares of pelvic pain. There does not seem to be a particular pattern nor are there triggers. She cannot tolerate non-steroidal anti-inflammatory drugs and finds codeine causes constipation.

A Adenomyosis

B Chronic pelvic pain

C Endometriosis

D Endosalpingiosis

E Inflammatory bowel syndrome

F Hydrosalpinx

G Leiomyoma

H Ovarian cyst

I Pelvic congestion

J Pelvic inflammatory disease

K Primary dysmenorrhoea

L Secondary dysmenorrhoea (70-80% pre-menstrual ache, spasmodic dysmenorrhoea, decreases as bleedis slows)

M None of the above

For each of the following cases, select the single most appropriate diagnosis from the list above. Each option may be used once, more than once or not at all.

 

10. A 18-year-old woman is referred to the hospital with pelvic pain as the general practitioner suspects endometriosis. She started her periods at the age of 12 and they are regular. She has always had some mild dysmenorrhoea but is now getting much more non-menstrual pelvic pain. On questioning she reports deen dyspareunia with her current partner but reports no problems with her previous sexual partners.

11. A 24-year-old patient undergoes a diagnostic laparoscopy for pelvic pain. There are clear nodules noted on the pelvic side wall and these are biopsied. They are reported as originating from the fallopian tube.

12. A 28-year-old patient presents to her general practitioner with primary infertility and intermittent pelvic pain. She has been trying for 2 years but has never conceived. She has no significant past medical history other than being treated for chlamydia 5 years ago. Her partner's semen analysis is normal and her general practitioner arrangs an ultrasound. On ultrasound a large cystic swelling is noted in the left adnexa. The left ovary is seen separate from this and contains a small functional cyst.

13. A 40-year-old patient presents with dysmenorrhoea and menorrhagia. Upon being questioned she reports intermittent dyspareunia that is positional but no real pelvic pain through the rest of her cycle. She is para 2 and has completed her family. On examination the uterus feels diffusely enlarged and is quite tender to palpate.

14. A 22-year-old patient is referred to the general surgeons with suspected appendicitis. She has a 2-month history of right-sided pelvic pain but it has been much worse in the last 48 hours. She is not in a relationship, having split up

A Corpus luteal cyst

B Endometrioma

C Granulosa cell tumour

D Haemorrhagic cyst

E Mature cystic ovarian teratoma

F Ovarian epithelial tumour

G Ovarian fibroma

H Ovarian torsion

I Pelvic inflammatory disease

J Polycystic ovaries

K Ruptured ovarian cyst

L Thecoma

M Tubo-ovarian abscess

 

for the following cases, select the single most likely diagnosis from the list above. Each option may be used once, more than once or not at all.

 

15. A 32 year-old woman presents to the rapid access clinic, referred by her general itioner with pelvic pain and dysmenorrhea. She has had the pain for many are but her general practitioner only recently organised a pelvic scan and blood Cost Her CA-125 is 2230 KU/L and the ultrasound scan reveals bilateral enlarged varies containing diffuse low level echoes and a single thick septation. There is no colour flow and no free fluid.

16. A 28-year-old woman presents with severe abdominal pain and offensive discharge and pyrexia of 38.3°C. She had a coil put in for contraception 3 months ago. A pelvic ultrasound revealed bilateral thick walled multilocular cystic lesions continuous with the fallopian tube. There is moderate free fluid in the pouch of Douglas.

17. A 36-year-old woman has a pelvic scan as part of her fertility work up. She is asymptomatic. The scan reveals bilateral ovarian complex masses that contain both solid and cystic components. The right ovary contains a cystic mass with a solid, highly echogenic 'dermoid plug! Her CA-125 is 15 kU/L.

A Mefenamic acid and tranexamic acid

B A levonorgestrel-releasing intrauterine system

 C Hysteroscopy

D Endometrial biopsy

E Endometrial ablation

F GnRH analogues

G Hysterectomy

H Uterine artery embolisation

I Hysteroscopic fibroid resection

For each case described below, choose the single most likely management option from the list of options. Each option may be used once, more than once or not at all.

18.A 37-year-old parous woman withtwo children is suffering from long-standing menstrual bleeding. She has tried various hormonal and non-hormonal de in the past including a levonorgestrel-releasing intrauterine system. Her Partner had a vasectomy few years ago. She is now seeking a permanent solution to her heavy and painful periods. She is a non-smoker and has recently lost a stone; her current body mass index is 37. Her recent endometrial biopsy is normal and she is up to date with her smears.

19.  A 44-year-old woman is known to have heavy menstrual bleeding and uterine fibroids. She has had regular periods while on the combined oral contraceptive pill and tranexamic acid for the last 2 years, but her periods have recently become erratic. She has a 14-year-old child with special needs and being a single parent she finds it difficult to take care of him. Her general practitioner requests a scan which shows three intramural fibroids, the largest measuring 6 cm. Upon examination her uterine size is 15 weeks of pregnancy.

20.A 19-year-old woman presents to emergency department with acute onset severe lower abdominal pain. A pelvic ultrasound reveals a 7 cm ovarian cyst on the left ovary with a thin wall and reticular pattern, there is no internal blood flow. There is a small amount of free fluid in the pouch of Douglas. The emergency department has requested a CA-125 but the result is not back yet.