EBCOG Part1 – General Gynaecology – Day 6(E.M.Q)

A  Cervical biopsy

B  Cervical smear

C  Computed tomography (CT) scan

D  Hysteroscopy and endometrial biopsy

E  Diagnostic laparoscopy and proceed

F  Magnetic resonance imaging scan (MRI)

G  No further tests required

H Transvaginal scan (TVS) for endometrial thickness

I Thyroid function tests

J Pregnancy test

K Pelvic examination

L  Rectal examination

M Renal function tests

N Saline hysterosonography

O Speculum examination of cervix

Instructions: For each case described below, choose the single most appropriate investigation in women with postmenopausal bleeding (PMB) from the above list of options. Each option may be used once, more than once, or not at all.

1. A 48-year-old Caucasian woman is referred to the rapid access gynaecology oncology clinic with PMB. Speculum examination reveals stenosed cervical os and two failed attempts at endometrial pipelle biopsy. A transvaginal ultrasound shows an endometrial thickness of 6 mm. She claims to be fit and well.

2. A 48-year-old Asian woman presents to her general practitioner with PMB. She had a left mastectomy and axillary node dissection for breast cancer 4 years ago. She is currently on two medications: tamoxifen and anastrozole. She has been up to date with her smears and all her previous smears including the current one are normal. A TVS performed in the clinic reveals 5 mm endometrial thickness and normal ovaries. A recent breast appointment shows no clinical evidence of recurrence of breast cancer.

3. A 48-year-old Caucasian woman visits the UK to see her daughter-in-law and her grandson. She is newly registered with a general practitioner and presents with PMB for the last 2 weeks. She is up to date with her smears and has never had any abnormal smears. Pelvic examination is normal.

4. A 48-year-old Asian woman is referred to the gynaecology oncology clinic for PMB which occurred 2 weeks ago. She did not have any further bleeding following that one episode. She is up to date with her smears which are normal, and a TVS reveals 3 mm endometrial thickness. Clinical examination reveals an atrophic cervix and vagina.

5. A 48-year-old Caucasian woman is referred to the gynaecology oncology clinic for ongoing PMB for the last 3 weeks. So far all her previous smears have been normal and her endometrial thickness measures 4 mm on recent TVS. Clinical examination is normal.

A Discharge from follow-up
B Follow-up endometrial biopsy after 3 months
C Follow-up endometrial biopsy after 6 months
D Follow-up endometrial biopsy after 12 months
E Follow-up endometrial biopsy at 3 and 6 months and then yearly
F Follow-up endometrial biopsy at 3 and 6 months and then yearly for 2 years
G Follow-up endometrial biopsy at 3 and 6 months and then yearly for 3 years
H Follow-up endometrial biopsy at 3 and 6 months and then yearly for 4 years
I Three-monthly biopsies until 2 consecutive negative histologies and then annual histology until surgery
J Three-monthly biopsies until 2 consecutive negative histologies and then 6-12 monthly histologies until surgery
K Three-month biopsies until 2 consecutive negative histologies and then 6-12 monthly for 5 years
L Three-month biopsies until 2 consecutive negative histologies and then 6-12 monthly histologies for 10 years
M Two consecutive negative 3 monthly biopsies and then yearly
N Two consecutive negative 3 monthly biopsies and then yearly for 5 years
0 Two consecutive negative 6 monthly biopsies
P Two consecutive negative 6 monthly biopsies and then yearly
Q Two consecutive negative 6 monthly biopsies and then yearly for 5 years
R Two consecutive negative 6-12 monthly biopsies until hysterectomy
S Yearly follow-up endometrial biopsy for 3 years
T Yearly follow-up endometrial biopsy


Instructions: Each patient presented below has been diagnosed with endometrial hyperplasia and is either being treated or scheduled for treatment. Choose from the above option list the single best follow-up you will recommend for the patient. Each option may be chosen once, more than once or not at all.

6. A 38-year-old woman presents with irregular periods for the past 3 years. She also complains of increase in her weight and acne. Her last period was 6 months ago. A pregnancy test is negative, and a transvaginal ultrasound scan reveals a thickened endometrium at 8 mm. A biopsy is performed, and the result shows hyperplasia with atypia. She wishes to preserve her fertility and hence opted for insertion of the levonorgestrel intrauterine system.

7. A 43-year-old woman presents with irregular vaginal bleeding and following investigations she is found to have endometrial hyperplasia with atypia. Her BMI is 35 kg/m2. She does not wish to have a hysterectomy but elects to have medical treatment.

8. A 58-year-old woman presents with postmenopausal bleeding of 3 weeks duration. Her BMI is 36 kg/m2. An ultrasound scan is performed, and the endometrium is found to be 8 mm thick. A biopsy is performed, and the result is hyperplasia without atypia. Following counselling, she is commenced on oral progestogen.

9. A 55-year-old woman was diagnosed with endometrial hyperplasia with atypia and had the levonorgestrel intrauterine system inserted as she was not ready for surgery.