General Gynaecology Extra Questions

1. Which of the following is a selective progesterone receptor modulator?

2. Medical management of fibroids is best indicated when

3. The incidence of chronic pelvic pain in women of reproductive age group is:

4. The commonest pathology identified at diagnostic laparoscopy in patients with chronic pelvic pain is:

5. The incidence of adnexal pathology detected for the first time in pregnancy is:

6. The preferred period for intervention for an ovarian mass in pregnancy is:

7. Pick the correct statement regarding management of ovarian cysts in pregnancy.

8. A 45-year-old woman presents with right-sided nipple discharge. Clinical examina- tion and mammography showed no abnormalities. Which one of the following is the next most appropriate action?

9. Which one of the following is correct in relation to polycystic ovarian syndrome, PCOS?

10. Obstetric outcomes in pregnancy after uterine artery embolisation—which of the following is not true?

11. A 14-year-old girl presents in the gynaecology OPD with a history of irregular bleeding per vaginam for the last 4–5 months. She has been rather stressed out with her school and theatre group activities which is adversely affecting her routine life and cannot recollect her dates or menstrual pattern well.She was on the pill for the past year. Of late she has loss of appetite with nausea and vomiting and fullness of the lower abdomen. She has lost weight in the last 3 months due to poor food intake. On examination vesicles are seen in the vagina close to the external cervical os. What is the most likely clinical diagnosis?

12. Ms. XY is 64 years old and is postmenopausal. She has recently been diagnosed with a 4 cm ovarian cyst on a transabdominal scan. The scan could not identify the other ovary as the bowel obscured it.The scan was being undertaken for suspected gallstones with the cyst being an incidental finding. Ms. XY is very anxious that this may represent ovarian cancer. Which of the following investigations are best suited to her to further investigate the ovarian cyst?

13. Ms. XY is 32 years old, otherwise fit and well and using the progesterone-only pill for contraception. She has recently been diagnosed (incidentally) with a 55 mm simple right ovarian cyst with anechoic fluid.Her CA-125 results are 5 u/ml. She is very anxious about the prospect of surgery. She has been risk assessed for VTE and is at low risk for using the COCP.

Which of the following treatment options are best suited to her?

14. XY, 22 years old, has recently been diagnosed with PCOS. Her BMI is 23. Her modified GTT was normal. She has very irregular oligomenorrheic cycles. She is extremely anxious about her general health and the risk of cancer. She is not plan- ning a pregnancy in the near future. She suffers from migraines. Which of the fol- lowing treatment options are best suited to her?

15. XY is 35 years old with a Mirena IUD in situ. She presents to the colposcopy clinic with her latest smear showing Actinomyces-like organisms (ALO). She com- plains of pelvic pain, deep dyspareunia and vaginal discharge for a week. She is not sexually active presently.

Which of the following treatment options are best suited to her?

16. Which of the following statements is true about endometrial polyps?

17. A 45-year-old woman with a BMI of 48 is requesting for a hysterectomy in order to have a permanent solution to her menorrhagia. She has been having heavy bleeding since the last 5–6 months and her haemoglobin is 100 g/L. Her colleague at work had a hysterectomy 6 months back for long-standing menorrhagia, and she is relieved after the surgery, so she also wants to have the operation as soon as possi- ble. You are reluctant to plan a surgery right away as there are serious risks associ- ated with surgery in obese women. Which of the following approach is not recommended?

18. A 26-year-old woman presents to her OPD with complaints of dyspareunia. She has been having a painful period for the past 1 year, and the pain has increased lately. She has some vaginal discharge which is not foul smelling or associated with pruri- tus. She also complains of becoming irritable during her periods in the past few months. Speculum examination reveals the presence of blue nodules in the vagina. What is the most likely diagnosis?

19. During embryological development of the normal female reproductive system in humans, which of the following does not occur

20. Some procedures are recommended while conducting a routine gynaecological examination. Which of the following is not appropriate?

21. The reported incidence of psychosexual disorders in women attending gynaecology clinics is around:

22. Women with premature ovarian insufficiency are not at increased risk of:

23. A 26-year-old woman presents to her GP complaining of new onset vaginal discharge. She is sexually active and uses condoms for protection against STIs although she has been regularly using the pill for the last 6 months. She has had 2 partners in the last 6 months. She is particularly worried because she has had spotting per vaginam after sexual intercourse in the last few weeks. Her Pap smear done last year was normal. Speculum examination reveals the presence of an erythematous raw-looking cervix.What is the most likely diagnosis?

24. From an outflow tract perspective, the only uterine anomaly that may cause a prob- lem is:

25. A worried mother gets her 16-year-old girl to her GP. She is concerned that her daughter has not as yet commenced her periods. On examination there is poor development of secondary sexual characters, cubitus valgus, evidence of webbed neck and short stature. Which of the following investigations will help you confirm the diagnosis?

26. In the use of SSRI/SNRIs for treatment of severe PMS, all of the following statements are true except:

27. A 43-year-old woman is having a diagnostic hysterolaparoscopy as part of the investigations for abnormal uterine bleeding. During laparoscopy, you see an ovarian cyst in the left ovary which is possible for an endometrioma.

You have taken consent only for diagnostic hysterolaparoscopy. What is the most appropriate course of action?

28. Of the following complementary therapy options, choose the one with evidence of effect in the treatment of premenstrual syndrome:

29. A 34-year-old nullipara is undergoing treatment for primary infertility. She has irregular periods with a cycle length varying from 45 to 60 days. Her last menstrual period was about 7 weeks back. She was posted for diagnostic hysterolaparoscopy, and during laparoscopy you find an unexpected ectopic pregnancy in the left fallo- pian tube. She is hemodynamically stable and the right fallopian tube appears healthy.You have taken consent only for diagnostic hysterolaparoscopy. What is the most appropriate course of action?

30. A 53-year-old woman who is amenorrheic for the past 1 year complains of vaginal dryness, superficial dyspareunia and urinary urgency. She has been treated for uri- nary infection 2 months back, and there is no active urinary infection now although symptoms persist. She has been on HRT for the past 6 months due to severe palpita- tions, hot flushes and night sweats, and she is relieved of those symptoms.

Which of the following statements is appropriate for her?

31. Following a spontaneous miscarriage at 8/40 gestation, a woman is referred to the gynaecology clinic with persistent irregular vaginal bleeding.

What initial investigation should be performed?

32. A 40-year-old woman with BMI 32 kg/m2 is referred to the gynae- cology clinic with secondary amenorrhoea. She has two children and her partner had a vasectomy 5 years ago.

An ultrasound scan is performed, which shows a normal uterus with endometrial thickness 6 mm.
Both ovaries have a typical polycystic appearance. What would be the recommended management?

33. A 55-year-old woman attends the gynaecology clinic. She is suffer- ing with terrible menopausal symptoms and cannot sleep because of the frequency of hot flushes. She is requesting hormone replacement therapy (HRT) for symp- tom relief. She is currently healthy but has a history of a deep venous thrombosis in her calf following a fractured femur as a result of an accident 10 years ago.

Her last menstrual period was 2 years ago and her uterus is intact. What would you recommend?

34. A woman opts to take oral continuous combined HRT for 5 years after the menopause.

In which year of HRT use will her risk of venous thromboembolism (VTE) be greatest?

35. What is the karyotype of a woman with Mayer–Rokitansky– Kuster–Hauser (MRKH) syndrome (mullerian agenesis)?

36. A 20-year-old girl attends the gynaecology clinic with her mother. She presents with primary amenorrhoea. On examination she is tall with a BMI of 19 kg/m . She has normal breast development, but a short blind-ending vagina. There is no axillary or pubic hair.

What is the most likely diagnosis?

37. A 48-year-old woman attends the gynaecology clinic complaining of heavy menstrual bleeding (HMB) and occasional intermenstrual bleeding. Her haemoglobin level is 112 g/l.

An ultrasound scan demonstrated no obvious abnormality. What other investigation is required?

38. A 42-year-old woman with oligomenorrhoea and hirsutism presents to the gynaecology clinic. She recently had a prolonged episode of vaginal bleeding, but an ultrasound scan and endome- trial biopsy performed in primary care both reported normal results. She is obese with a BMI of 40kg/m . She has mild hypertension but does not require antihypertensive therapy. She has no other medical problems. Her father suffered from Type 2 Diabetes mellitus. What further investigation is required?

39. A 35-year-old woman attends the gynaecology clinic complaining of worsening HMB. Investigations have been performed in primary care. Her haemoglobin level is 123 g/l and a pelvic ultrasound scan showed no obvious abnormality. What is the most appropriate first-line pharmacological treatment?

40. What percentage of women experience severe premenstrual symptoms?

41. The aetiology of premenstrual syndrome (PMS) remains unclear but appears to be related to the effect of cyclical ovarian activity on neurotransmitters. Which neurotransmitters are considered to have a key role?

42. A 70-year-old woman undergoes a dual-energy X-ray absorptiom- etry (DXA) scan to assess her bone mineral density.

What T score is diagnostic of osteoporosis?

43. What is the mode of action of bisphosphonates?

44. What is the most common side effect of bisphosphonates?

45. Raloxifene is a selective oestrogen receptor modulator.

What kind of action does this drug have on the endometrium, breast and bone?

46. A 29-year-old woman presents with a constant ongoing pain in the pelvis.

The pain does not occur exclusively with menstruation or inter- course and the woman is not pregnant.For what minimum duration should the pain occur before it is deemed chronic?

47. An 18-year-old girl presents with chronic lower abdominal pain. In what percentage of patients attending a gynaecology outpatient clinic with lower abdominal/pelvic pain would you expect to find irritable bowel syndrome (IBS)?

48. A 24-year-old girl attends the gynaecology clinic with persistent pain over her Pfannenstiel scar that has not settled since her caesarean section of 6 months. What is the incidence of nerve entrapment (defined as highly localised, sharp, stabbing or aching pain, exacerbated by particular movements and persisting beyond 5 weeks or occurring after a pain free interval) after one Pfannenstiel incision?

49. A 22-year-old girl presents with lower abdominal pain, which is cyclical in nature.Which modality is the only way to reliably diagnose peritoneal endometriosis?

50. An 18-year-old girl with pelvic pain presents to the gynaecology outpatient clinic. An ultrasound scan is arranged, which demonstrates a normal pelvis. Hormonal treatment is discussed with the girl. How long should she persist with this therapy before contemplating a laparoscopy?

51. What proportion of the female adult population will complain of chronic pelvic pain?

52. A 19 year old has been seen in the gynaecology clinic with abdom- inal pain, which improves with defecation. It is associated with change in frequency of stool and change in form, for at least 3 days per month in the past 3 months. What are the criteria used to define IBS?

53. A 21 year old presents to the gynaecology outpatient clinic with pelvic pain. The general practitioner referral suggests possible endometriosis. What is the estimated prevalence of endometriosis in women of reproductive age?

54. A 15-year-old girl is seen in the paediatric gynaecology clinic due to persistent vaginal discharge. Examination reveals the following: Partial removal of the clitoris and the prepuce is noted. The hymen is intact. The possibility of female genital mutilation (FGM) is raised. What type of FGM is this?

55. A 21 year old who complains of superficial dyspareunia is seen in the gynaecology clinic. She has just started her first ever sexual relationship. On examination, the following features are noted: Normal vulva and vagina. Clitoris is intact. A piercing is noted in the right labium minorum. What type of FGM is this?

56. A 33-year-old woman is newly arrived in the United Kingdom from Africa and is complaining of dyspareunia. How many women undergo FGM each year according to WHO estimates?

57. A 24 year old has been seen in the antenatal clinic and is known to have undergone FGM. The lead midwife and health visitor are aware that any female offspring will be at risk of undergoing FGM. What is the estimated number of children in the United Kingdom that are considered to be at risk of this each year?

58. 13 year old attends the Accident & Emergency department with bleeding, pain and urinary retention following a recent FGM. Which vaccine would you advise the patient to receive?

59. What is the most common cause of central precocious puberty (CPP) in girls?

60. A 47-year-old Para 3 who has had three previous vaginal deliv- eries presents with a history of HMB that has not responded to medical treatment or the levonorgestrel-containing intrauterine system (LNG-IUS). The patient was offered endometrial ablation but declined. On examination, the uterus is bulky, no masses palpable in the adnexa and the cervix descends to about 2 cm above the hymenal ring. An ultrasound confirms the physical examination findings. What is the most appropriate treatment option?

61. An asymptomatic postmenopausal woman is diagnosed with a simple unilateral unilocular cyst with a diameter of 4.5 cm. Her serum CA125 is 10 iu/l. What is the most appropriate first line of management?

62. Theprevalenceofovariancystsinpremenopausalwomanishigher than that in postmenopausal women; 35% versus 17% respectively.A premenopausal woman presents with an asymptomatic 4.5 cm simple cyst in the left ovary with a serum CA125 of 18 iu/l.

What would be the recommended management plan?

63. A 40-year-old woman complains of burning and stinging in the vulva. There is no clinically identifiable neurological condition and there are no relevant visible findings. What is the most likely clinical diagnosis?

64. A women diagnosed with localised unprovoked vulvodynia has had no relief from her symptoms despite practising good vulval care and using topical treatments which included lidocaine ointment and gabapentin. What is the next line of management?

65. Community-based surveys indicate that about one-fifth of women have significant vulval symptoms. Symptoms and signs of vulval skin disorders are common and include pruritus, pain and changes in skin colour and texture. What is the most common vulval disorder seen in a hospital setting?

66. Lichen sclerosus accounts for at least 25% of the women seen in dedicated vulval clinics, with estimates of incidence quoted as 1 in 300 to 1 in 1000 of all patients referred to dermatology departments. What is the pathognomonic histologic feature of lichen sclerosus?

67. A 60-year-old woman presents with vulval itching with no relief with scratching. On examination the skin appears fragile, with well demarcated white plaques. There is no involvement of the vagina or the oral mucosa What is the most likely diagnosis?

68. A woman with biopsy-proven lichen sclerosus is not responding to topical ultra-potent steroids. What is the second line of treatment?

69. A 25-year-old smoker is diagnosed to have mild dyskariosis in her index smear at the GP surgery. The smear is HPV negative. What is the ideal management?

70. A 40-year-old woman attends for a consultation in primary care complaining of HMB. She is otherwise fit and well and examina- tion is unremarkable. What investigation should be undertaken?

71. Following referral to secondary care for HMB, a 38-year old woman undergoes pelvic examination, which confirms that the uterus is palpable abdominally What is the first line diagnostic test to identify structural abnormalities in this situation?

72. A 39-year-old woman presents to the gynaecology clinic with HMB and dysmenorrhoea. She is otherwise fit and well. Pelvic examination is unremarkable. She is not keen on hormonal methods of treatment. What treatment would you initially recommend?

73. A 38-year-old woman is seen in the gynaecology clinic. She pre-sented with HMB. History and examination are unremarkable and she is commenced on tranexamic acid, to be taken during menstruation only. Should this treatment ultimately prove to be ineffective, for how many cycles should she have tried it to come to this conclusion?

74. During investigation for HMB, a 42-year-old woman is found to have a 3 cm submucus fibroid. She is otherwise fit and well. Her husband has had a vasectomy. She does not wish to try pharmaceutical treatments. What would you recommend?

75. A 55-year-old woman attends the general practitioner surgery with abdominal distension, low abdominal pain and urinary urgency. Abdominal examination is unremarkable and urine dipstick is negative. What investigation should be performed?

76. What screening test should be offered to all sexually active women who present to the gynaecology clinic with chronic pelvic pain?

77. After a year of 4-monthly follow-up, a healthy 75-year-old woman with a 5 cm simple unilocular ovarian cyst and a normal serum CA-125 level decides that she would prefer to have surgical treatment. What treatment would you recommend?

78. Following a diagnosis of anogenital lichen sclerosus, a 70-year-old woman returns to clinic as topical potent steroids have not been effective in controlling her symptoms. The recommended second-line treatment is Tacrolimus. Which cell type of the immune system has its response suppressed by this drug?

79. Which progestogen has been shown to be effective in cases of PMS?

80. A 58-year-old postmenopausal woman presents for HRT counselling. While questioning her about her health, you ask her about the risk factors for osteoporosis from the fracture risk assessment (FRAX) tool, which is used to determine which individuals warrant further evaluation for osteoporosis by bone mineral density testing. Which of the following is not part of the FRAX tool?

81. A 56-year-old woman with a BMI of 38 and type 2 diabetes mellitus presents with daily dark brown staining on her underwear for the past week. She underwent menopause at age 53 and has had no further bleeding or discharge since that time. ere has been no vaginal or vulval trauma, and her cervical smear test 6 months previously was normal. On examination her cervix appears normal and there is no evidence of external haemorrhoids. A urine dipstick test is negative for blood.

What is the next best step in the management of this patient?

82. A 39-year-old para 2 presents with a 3-year history of heavy painful periods in a 7/28 cycle. e onset of the heavy bleeding started are her laparoscopic tubal occlusion. She has a BMI of 39 and currently smokes 10 per day. She is also known to have type 2 diabetes and is hypertensive on beta blockers. What is the most appropriate management option?

83. A 35-year-old para 3 underwent a TAH+BSO for severe pelvic endometriosis that had not responded to medical and conservative surgical treatment. She attends for her follow-up appointment complaining of hot ushes and sweating. Which HRT regime should you consider?

84. A 17-year-old girl presents with crampy lower abdominal pain which radiates to her legs. For the past year the pain has coincided with the rst 3 days of her menses. She is not sexually active. Her history and general examination are unremarkable What is the optimum management approach?

85. A 25-year-old patient presents with sudden-onset LIF pain associated with nausea and vomiting. She is sexually active, uses the Mirena intrauterine contraceptive device for contraception and is otherwise healthy. On examination she is tachycardic, and abdominal examination demonstrates tenderness over LIF with no rebound. Pelvic examination shows a normal cervix with no abnormal discharge, bu fullness and tenderness on the le urine pregnancy test is negative. What is the most likely diagnosis?

86. A 28-year-old para 3 presents with vulval pruritus and burning. She reports dyspareunia and copious foul-smelling green vaginal discharge. On examination there is erythema of the vulva as well as petechiae of the upper vagina and cervix. What is the most likely diagnosis?

87. A 25-year-old para 0, who has recently become sexually active, is complaining of new onset vulval pain. She describes pain with light touch, particularly on intercourse and when using tampons, and she localizes it to around the vulva. e pain is not present at other times. She does not report any itching, soreness or unusual discharge. What is the most likely diagnosis?

88. You are seeing a 62-year-old patient for a follow-up visit. You evaluated her for fracture risk 2 weeks ago and, given that she has high risk for fracture, you sent her for a DEXA scan. Her T score for bone mineral density in the hip was less than −2.5 and the thoracic spine less than −2.0. She has no secondary causes of osteoporosis, has not been on glucocorticoids recently, is a nonsmoker, and does not drink alcohol. Tere is no dysphagia, and she is able to sit upright for 1 hour a er taking medications. It is determined that she should be placed on a bisphosphonate for treatment of her osteoporosis of the hip. Whichofthefollowingdoesnota ecttheriskoffractureofthehip?

89. A 24-year-old para 1 presents with a 6-hour history of right lower quadrant (RLQ) pain described as intermittent, severe in nature and associated with nausea and vomiting. She denies a change in bowel habits, and she is currently menstruating. On examination she is mildly tachycardic and has tenderness in the RLQ. Her urine pregnancy test is negative, and urine dipstick is negative for both blood and white cells. On pelvic examination she has a normal looking cervix, normal-sized and nontender uterus and no cervical motion tenderness. Tere is a palpable mass in the right adnexa which is tender to palpation and somewhat reproduces her pain. Atransvaginal ultrasounds hows an ormaluterusandle ovary, butthe right ovary measures 7 × 5 cm with cystic and solid components as well as with calci cation. Colour ow Doppler is inconclusive. What is the next best step in the management of this patient?

90. Which of the following has been shown to contribute to surgical patients’ enhanced recovery?

91. Considering prophylactic oophorectomy at the time of hysterectomy for benign disease: At what age is there no signi cantdi erenceinsurvivalin women at low/ average risk for ovarian cancer?

92. A 25-year-old patient su ers with headaches, mood swings, irritability, depression and feeling out of control just before, and during, her menses. She also reports physical symptoms including breast tenderness, bloating and headaches. Her physical and psychological symptoms resolve completely a er menstruation ceases. Which of the following would be the best rst-line management?

93. A 29-year-old patient is undergoing a laparoscopic ovarian cystectomy for endometriosis. She is 170 cm tall and weighs 70 kg. Which antibiotic regime should be adopted to reduce surgical site infection?

94. A 24-year-old patient presents with vulval itching, soreness, vaginal discharge, and occasional dysuria. She has had thrush treatment at least five times over the previous 12 months for similar symptoms, with genital swabsconrming the diagnosis. A vaginal swab of vaginal discharge collected from the anterior fornix showed spores/pseudohyphae. The recommended management approach is?

95. A 16-year-old girl presents with primary amenorrhoea. She has reached Tanner V breast and pubic hair development and, on pelvic examination, there is a blind ending vagina. e karyotype shows 46XX. What is the most likely diagnosis?

96. A 12-year-old girl presents to the A & E department with lower abdominal pain. On examination there is a large pelvi-abdominal mass. Transabdominal ultrasound scan shows bilateral solid ovarian tumours. What is the most likely diagnosis?

97. In operative hysteroscopy, fluid distension is preferred above gas so that :

98. In operative hysteroscopy, which of the following distension media has a risk of hyperglycaemia in fluid overload?

99. A 70-year-old Caucasian patient was referred with a 2-year history of vulval and vaginal soreness unrelieved by vaginal oestrogen. She also reports recent onset dyspareunia, both superficial and deep. On further questioning she describes constipation, dysuria and both oral inflammation and ulceration. e examination con rmed oral ulceration and a white lacy pattern on the vulva. e vagina was very erythematous with a narrowed introitus and thin lmy adhesions to the mid-third. The examination was extremely painful. What is the most likely diagnosis?

100. A 25-year-old para 2 presents with a 4-year history of progressive facial hirsutism and increasingly irregular periods. She had menarche at the age of 8. On examination she has moderately severe hirsutism on the face and chin and was not Cushingoid in appearance. Her BP was 136/83 mm Hg and her BMI was 23.3 kg/m. She reports that she was a tall child and volunteered that she has always had a small vaginal introitus with clitoromegaly and, since puberty, a high libido. What are you likely to nd in her laboratory blood tests?

101. A 55-year-old patient presents with severely debilitating vasomotor symptoms. She was declined HRT treatment by her general practitioner as her mother had had a PE while taking the combined oral contraceptive pills. She is otherwise t and well with no signi cant previous medical or surgical history and has never had any gynaecologic surgery. Which HRT would give her the lowest risk of VTE?

102. In 2013 the International Ovarian Tumour Analysis Group (IOTA) published the largest study investigating the use of ultrasound to differentiate between benign and malignant ovarian masses. e group developed simple ultrasound rules. Which of the following rules would NOT suggest a malignant process?

103. A 15-year-old girl attended with her mother asking for the HPV vaccine as she missed the school immunization programme. What does she need to do next?

104. A 35-year-old para 2 presents with dysmenorrhoea over the preceding 12 months. She also reports some dyschesia (difficulty defecating) during her periods. A transvaginal ultrasound scan con rmed a 7-cm endometrioma. She undergoes a laparoscopic ovarian cystectomy and excision of pelvic endometriosis.Which is of the following should be your postsurgical management plan?

105. A 60-year-old para 4 on a continuous combined HRT regimen presents with a 2-week history of irregular vaginal bleeding. What is the most appropriate next step in her management?

106. A 35-year-old patient presents 6 months a er a normal vaginal delivery. e pregnancy was uncomplicated but, following delivery, a piece of placenta was apparently retained in the uterus. She was treated with antibiotics and later underwent a dilatation and curettage procedure. Now she presents with amenorrhoea. She is no longer breast feeding and is concerned. What is the most appropriate next step in her management?

107. A 45-year-old patient presents to the A&E department 2 days a er UAE for a 20-weeks’ size fibroid uterus. She has di use abdominal pain, generalized malaise, anorexia, nausea, vomiting, low-grade fever and leucocytosis. What is the most likely diagnosis?

108. The fluid(1.5% glycine) deficit during an operative hysteroscopy using monopolar diathermy is calculated at 1000 ml. What is the most appropriate step of action?