Gynaecology

Gynaecology UK Medical PG Question 1: A 43-year-old woman presents with fatigue, weight gain, and cold intolerance. TSH is 22 mU/L, free T4 is low. Anti-TPO antibodies are positive. She is trying to conceive. What is the TSH target?

• A. $< 1.0 \mathrm{mU} / \mathrm{L}$
• B. $< 2.5 \mathrm{mU} / \mathrm{L}$ (Correct Answer)
• C. $< 4.0 \mathrm{mU} / \mathrm{L}$
• D. $< 6.0 \mathrm{mU} / \mathrm{L}$
• E. $< 10.0 \mathrm{mU} / \mathrm{L}$

Gynaecology Explanation: ***< 2.5 \mathrm{mU} / \mathrm{L}$*** - For women with **hypothyroidism** who are trying to conceive or are in the first trimester of pregnancy, the recommended TSH target is generally **< 2.5 mU/L** to ensure optimal maternal and fetal outcomes. - Achieving this target helps to reduce the risk of **infertility**, **miscarriage**, and adverse pregnancy complications such as **preterm birth** and **gestational hypertension**, while also supporting proper fetal neurodevelopment. *$< 1.0 \mathrm{mU} / \mathrm{L}$* - This target is generally considered **too stringent** and may lead to **over-treatment** with levothyroxine, potentially inducing iatrogenic hyperthyroidism symptoms. - While very low TSH can be observed, it is not the standard recommendation for preconception in hypothyroidism and could be unnecessarily aggressive. *$< 4.0 \mathrm{mU} / \mathrm{L}$* - While a TSH of < 4.0 mU/L might be acceptable for non-pregnant adults with hypothyroidism, it is **insufficient** for women trying to conceive or in early pregnancy. - Higher TSH levels during the preconception period and early pregnancy are associated with increased risks for both the mother and the fetus, necessitating a tighter TSH control. *$< 6.0 \mathrm{mU} / \mathrm{L}$* - This TSH target is significantly **too high** for a woman attempting to conceive and is typically considered for adults with **subclinical hypothyroidism** (TSH 4-10 mU/L) who are **not pregnant**. - Maintaining TSH at this level during pregnancy substantially increases the risk of **adverse obstetric outcomes** and potential cognitive deficits in the offspring. *$< 10.0 \mathrm{mU} / \mathrm{L}$* - A TSH target of < 10.0 mU/L is far **too liberal** and would mean the patient remains **frankly hypothyroid** in the context of trying to conceive or during pregnancy. - This target would not adequately address the patient's severe hypothyroid symptoms nor mitigate the significant risks to successful conception and healthy pregnancy progression.

Gynaecology UK Medical PG Question 2: A 30-year-old woman presents with amenorrhea, hirsutism, and acne. She has gained 10kg over the past year. Ultrasound shows multiple ovarian cysts. Testosterone and LH are elevated, FSH is normal. What is the most likely diagnosis?

• A. Congenital adrenal hyperplasia
• B. Polycystic ovary syndrome (Correct Answer)
• C. Ovarian tumor
• D. Cushing's syndrome
• E. Hypothyroidism

Gynaecology Explanation: ***Polycystic ovary syndrome***- Amenorrhea, hirsutism, acne, and weight gain are classic signs of **hyperandrogenism** and **anovulation** characteristic of PCOS.- The presence of **multiple ovarian cysts** on ultrasound combined with **elevated testosterone** and an **elevated LH** with normal FSH strongly points to PCOS. *Congenital adrenal hyperplasia*- Typically involves an enzyme deficiency (e.g., **21-hydroxylase deficiency**) leading to elevated adrenal androgens and often **abnormal cortisol precursors**.- While it can cause virilization, the hormonal profile would differ, usually showing very high **17-hydroxyprogesterone** and not primarily an elevated LH:FSH ratio characteristic of PCOS. *Ovarian tumor*- An **androgen-secreting ovarian tumor** would cause rapid onset and more severe virilization, often with significantly **higher testosterone levels**.- The ultrasound findings of **multiple small cysts** and the specific hormonal imbalance (elevated LH) are more consistent with PCOS than a single tumor. *Cushing's syndrome*- Caused by **excess cortisol**, leading to central obesity, striae, moon facies, and hyperglycemia.- While it can cause weight gain and menstrual irregularity, **hirsutism** and **acne** are less prominent, and the hormonal pattern (e.g., elevated cortisol, suppressed ACTH or pituitary adenoma) is different. *Hypothyroidism*- Symptoms include **fatigue**, **weight gain**, **cold intolerance**, and **bradycardia**, with menstrual irregularities often manifesting as menorrhagia or oligomenorrhea.- It does not cause **hirsutism** or **acne**, and the hormonal profile would show elevated TSH and low free T4, not elevated androgens or LH.

Gynaecology UK Medical PG Question 3: A 35-year-old woman with a 16-month history of heavy menstrual bleeding reports that her periods last 9 days and she passes large clots. She has tried tranexamic acid and mefenamic acid with minimal improvement. She has two children and does not wish for future pregnancy. Examination is normal and transvaginal ultrasound shows a normal uterus (8 cm length) with no fibroids and endometrial thickness of 6 mm on day 5 of cycle. Full blood count shows haemoglobin 101 g/L. She declines hormonal treatment. What is the most appropriate next management option?

• A. Offer endometrial ablation (Correct Answer)
• B. Prescribe oral norethisterone for cycle regulation
• C. Arrange hysterectomy
• D. Increase dose of tranexamic acid and mefenamic acid
• E. Offer trial of levonorgestrel intrauterine system despite preferences

Gynaecology Explanation: ***Offer endometrial ablation*** - **Endometrial ablation** is the appropriate next step for **heavy menstrual bleeding** when medical treatments have failed, a woman has completed her family, and has **declined hormonal therapy**. - This patient meets all criteria: failed medical treatment, completed family, declined hormones, has a **normal uterus** (8 cm length), and her **anemia** (Hb 101 g/L) necessitates effective management. *Prescribe oral norethisterone for cycle regulation* - The patient has explicitly **declined hormonal treatment**, rendering this option unsuitable based on her preferences. - **Oral norethisterone** is a hormonal agent and may not be sufficiently effective for severe **heavy menstrual bleeding** that has not responded to other medical therapies. *Arrange hysterectomy* - While **hysterectomy** offers a definitive cure for heavy menstrual bleeding, it is a **major surgical procedure** and typically considered a last resort after less invasive options. - For a woman with a **structurally normal uterus** and no contraindications, **endometrial ablation** is generally preferred as a less invasive surgical alternative before considering hysterectomy. *Increase dose of tranexamic acid and mefenamic acid* - The patient has already reported **minimal improvement** with these medications, suggesting that simply increasing their dose is unlikely to achieve adequate control of her **heavy menstrual bleeding**. - Her persistent symptoms and **anemia** indicate a need for a more effective intervention beyond dose adjustment of previously ineffective symptomatic treatments. *Offer trial of levonorgestrel intrauterine system despite preferences* - The **levonorgestrel intrauterine system (IUS)** is a **hormonal treatment**, which the patient has specifically **declined**. - Offering a treatment despite a patient's clear refusal disregards **patient autonomy** and established shared decision-making principles.

Gynaecology UK Medical PG Question 4: A 26-year-old woman presents to the emergency department with sudden onset severe left-sided pelvic pain, nausea, and one episode of syncope 2 hours ago. She has 7 weeks amenorrhoea. On examination, she is alert with heart rate 102 bpm, blood pressure 104/68 mmHg, and temperature 36.8°C. Abdominal examination reveals left iliac fossa tenderness with mild guarding but no rigidity. Transvaginal ultrasound shows an empty uterus, a 35 mm left adnexal mass with a hyperechoic ring, and a small amount of free fluid in the pouch of Douglas. Serum beta-hCG is 5600 IU/L. What is the most appropriate management?

• A. Emergency laparoscopy
• B. Intramuscular methotrexate
• C. Admit for observation with 4-hourly observations and repeat ultrasound in 24 hours
• D. Diagnostic laparoscopy with decision for salpingectomy or salpingotomy at surgery (Correct Answer)
• E. Arrange urgent MRI pelvis to better characterise the adnexal mass

Gynaecology Explanation: ***Diagnostic laparoscopy with decision for salpingectomy or salpingotomy at surgery***- The patient's symptoms including **syncope**, severe left-sided pelvic pain, tachycardia (HR 102 bpm), and ultrasound findings of an **empty uterus**, **35 mm adnexal mass**, and **free fluid** in the pouch of Douglas are highly indicative of a ruptured or actively bleeding ectopic pregnancy, requiring immediate surgical intervention.- Surgical management via **laparoscopy** is the most appropriate approach, allowing for direct confirmation of the ectopic, assessment of blood loss, and definitive treatment, either **salpingectomy** for extensive damage or **salpingotomy** for tubal preservation where feasible, considering the high beta-hCG of 5600 IU/L which also contraindicates medical management.*Emergency laparoscopy*- While surgery is urgently indicated,

Gynaecology UK Medical PG Question 5: A 41-year-old woman with a 10-month history of heavy menstrual bleeding undergoes hysteroscopy which reveals a 3 cm type 2 submucosal fibroid partially extending into the myometrium (>50% intramural component). She wishes to preserve her fertility. Transvaginal ultrasound confirms no other significant fibroids and normal endometrial cavity. What is the most appropriate initial management?

• A. Hysteroscopic myomectomy
• B. Trial of levonorgestrel intrauterine system
• C. Uterine artery embolisation
• D. Abdominal myomectomy (Correct Answer)
• E. GnRH agonist therapy for 6 months

Gynaecology Explanation: ***Abdominal myomectomy***- A **type 2 submucosal fibroid** with **>50% intramural component** makes hysteroscopic removal technically challenging, increasing the risk of **incomplete resection** or **uterine perforation**.- Given the patient's desire for **fertility preservation**, an open or laparoscopic **abdominal myomectomy** allows for complete removal of the fibroid and meticulous **myometrial reconstruction**, which is crucial for subsequent pregnancies.*Hysteroscopic myomectomy*- This technique is primarily suitable for **type 0 and 1 fibroids**, which are largely or entirely within the uterine cavity.- For a **type 2 fibroid** with a substantial intramural component, hysteroscopic removal is often difficult, risks **uterine injury**, and may require multiple procedures for complete resection.*Trial of levonorgestrel intrauterine system*- The **levonorgestrel intrauterine system (LNG-IUS)** has reduced efficacy and higher rates of **expulsion** in the presence of **submucosal fibroids**.- It does not address the underlying anatomical distortion of the **endometrial cavity** caused by a 3 cm fibroid, which can hinder fertility.*Uterine artery embolisation*- **Uterine artery embolisation (UAE)** is generally not recommended for women who desire **future fertility** due to potential risks to **ovarian reserve** and increased complications like **placental abnormalities** in subsequent pregnancies.- **Myomectomy** remains the preferred surgical option for fertility preservation.*GnRH agonist therapy for 6 months*- **GnRH agonists** are typically used as a short-term **pre-operative adjunct** to reduce fibroid size and improve anemia, making surgery easier, rather than as a definitive treatment.- Fibroids commonly **regrow** after cessation of therapy, and long-term use is limited by side effects such as **bone mineral density loss** and vasomotor symptoms.

Gynaecology UK Medical PG Question 6: A 31-year-old woman presents to the emergency department with left-sided pelvic pain and 7 weeks amenorrhoea. Transvaginal ultrasound demonstrates an empty uterus and a 20 mm left adnexal mass. Initial serum beta-hCG is 1450 IU/L. She is clinically stable. Repeat beta-hCG 48 hours later is 1380 IU/L. What is the most appropriate management?

• A. Expectant management with weekly beta-hCG monitoring (Correct Answer)
• B. Intramuscular methotrexate
• C. Diagnostic laparoscopy
• D. Repeat beta-hCG in 48 hours to confirm declining trend
• E. Arrange MRI pelvis to confirm ectopic location

Gynaecology Explanation: ***Expectant management with weekly beta-hCG monitoring*** - This patient is **clinically stable** with a small **adnexal mass (<35 mm)** and a **declining beta-hCG** (from 1450 to 1380 IU/L), indicating a spontaneously resolving tubal ectopic pregnancy. - **Expectant management** is appropriate when initial beta-hCG levels are low (<2000 IU/L) and declining, requiring weekly monitoring until levels fall below **20 IU/L**. *Intramuscular methotrexate* - **Methotrexate** is a medical management option typically reserved for patients whose beta-hCG levels are **rising or plateauing** rather than declining. - It carries risks of side effects like **hepatotoxicity** and **stomatitis**, which are unnecessary to risk if the ectopic is already resolving on its own. *Diagnostic laparoscopy* - This is an **invasive surgical procedure** indicated for patients who are **hemodynamically unstable**, have severe pain, or have a high risk of rupture. - Given the patient's **clinical stability** and resolving biochemical markers, surgery presents an unnecessary risk of **anesthesia and operative complications**. *Repeat beta-hCG in 48 hours to confirm declining trend* - A 48-hour repeat is used to establish the **initial trend**; once the decline is confirmed (as seen here from 1450 to 1380 IU/L), the protocol shifts to **weekly follow-ups**. - Frequent 48-hour monitoring beyond the initial diagnostic phase is not required for a patient who remains **asymptomatic** and stable. *Arrange MRI pelvis to confirm ectopic location* - **Transvaginal ultrasound (TVUS)** is the gold standard for diagnosing ectopic pregnancy; the presence of an empty uterus and an **adnexal mass** is sufficient for diagnosis. - **MRI** is expensive, time-consuming, and adds no clinical value to the management of a **stable, resolving** ectopic pregnancy.

Gynaecology UK Medical PG Question 7: What is the primary mechanism by which endometrial ablation reduces menstrual bleeding in women with heavy menstrual bleeding?

• A. Destruction of the endometrial basalis layer preventing regeneration (Correct Answer)
• B. Reduction in endometrial blood vessel density through thermal injury
• C. Decreased prostaglandin production from damaged endometrium
• D. Hormonal suppression of endometrial proliferation
• E. Formation of intrauterine adhesions reducing cavity volume

Gynaecology Explanation: ***Destruction of the endometrial basalis layer preventing regeneration*** - Endometrial ablation targets the **basalis layer**, which is the deep regenerative layer responsible for the monthly growth of the functionalis layer. - By destroying this layer through thermal or other energy sources, the **endometrium cannot regrow**, leading to significant reduction or total cessation of menstrual flow. *Reduction in endometrial blood vessel density through thermal injury* - While **thermal injury** does cauterize local vessels, this is a secondary effect rather than the primary goal of the procedure. - Menstrual reduction is achieved primarily by removing the **source tissue** of bleeding rather than just reducing blood supply. *Decreased prostaglandin production from damaged endometrium* - **Prostaglandins** play a role in dysmenorrhea and heavy bleeding, and their levels may decrease after ablation due to tissue loss. - This decrease is a **consequence** of removing the endometrial tissue, not the fundamental mechanism of action of the procedure. *Hormonal suppression of endometrial proliferation* - Endometrial ablation is a **physical/surgical destruction** of tissue and does not involve the use of exogenous hormones. - Unlike medical therapies like the **Levonorgestrel IUS**, it does not alter the underlying **hypothalamic-pituitary-ovarian axis**. *Formation of intrauterine adhesions reducing cavity volume* - While the procedure can lead to **Asherman-like** scarring and reduced cavity volume, this is an anatomical outcome of the healing process. - The intended mechanism is specifically the **prevention of functional layer regrowth** by targeting the basalis layer during the energy application.

Gynaecology UK Medical PG Question 8: A 38-year-old multiparous woman with heavy menstrual bleeding has had a levonorgestrel intrauterine system in situ for 3 years. Initially, her bleeding improved significantly, but over the past 6 months, she has noticed gradually worsening menstrual bleeding returning to pre-treatment levels. She wishes to continue with hormonal management. Pelvic examination is normal. Transvaginal ultrasound shows the IUS in correct position with a normal uterine cavity and no fibroids. What is the most appropriate management?

• A. Remove and replace the levonorgestrel intrauterine system (Correct Answer)
• B. Add tranexamic acid during menstruation
• C. Switch to combined oral contraceptive pill
• D. Arrange endometrial ablation
• E. Continue current IUS for remaining 2 years of licensed duration

Gynaecology Explanation: ***Remove and replace the levonorgestrel intrauterine system***- The **LNG-IUS** efficacy for managing **heavy menstrual bleeding** can decline before its 5-year expiration due to the gradual reduction in daily **progesterone release**.- Since the device is correctly positioned, previously effective, and the patient wishes to continue hormonal management, **early replacement** is the most appropriate step to restore the local hormonal suppressive effect on the **endometrium**.*Add tranexamic acid during menstruation*- While **tranexamic acid** is an effective non-hormonal treatment for heavy menstrual bleeding, it does not address the underlying issue of **waning hormonal levels** from the IUS.- The patient specifically prefers to continue with **hormonal management**, making replacement of the primary hormonal device more suitable than adding a non-hormonal adjunct.*Switch to combined oral contraceptive pill*- The **combined oral contraceptive pill (COCP)** requires daily compliance and has a higher risk of **systemic side-effects** compared to the localized action of the LNG-IUS.- The LNG-IUS is generally considered more effective than the COCP for reducing menstrual blood loss, and the patient had good control with it initially, indicating it's still the preferred hormonal method.*Arrange endometrial ablation*- **Endometrial ablation** is a surgical intervention for heavy menstrual bleeding, typically reserved for women who have completed childbearing and either do not desire or have failed medical/hormonal management.- This patient explicitly requested to continue with **hormonal management**, making a less invasive and reversible option like IUS replacement more appropriate at this stage.*Continue current IUS for remaining 2 years of licensed duration*- Waiting for the full 5-year licensed duration is inappropriate when the **clinical efficacy has clearly diminished** and the patient's symptoms have returned to **pre-treatment levels**.- Prolonging an ineffective treatment can lead to persistent **heavy menstrual bleeding**, potential **iron-deficiency anemia**, and reduced quality of life.

Gynaecology UK Medical PG Question 9: A 34-year-old woman presents to the emergency department with sudden onset severe right-sided abdominal pain and syncope. She has 6 weeks amenorrhoea. On examination, she is pale with heart rate 118 bpm and blood pressure 88/54 mmHg. Abdominal examination reveals generalised tenderness with guarding. A bedside urine pregnancy test is positive. What is the most appropriate immediate management?

• A. Insert two large-bore intravenous cannulae, cross-match 4 units blood, commence fluid resuscitation, and arrange emergency laparoscopy (Correct Answer)
• B. Perform urgent transvaginal ultrasound to confirm diagnosis before proceeding to theatre
• C. Administer intramuscular methotrexate and commence fluid resuscitation
• D. Request urgent serum beta-hCG and proceed to laparoscopy only if levels are above 1500 IU/L
• E. Arrange CT abdomen and pelvis with contrast to localise the ectopic pregnancy

Gynaecology Explanation: ***Insert two large-bore intravenous cannulae, cross-match 4 units blood, commence fluid resuscitation, and arrange emergency laparoscopy*** - The patient presents with classic signs of a **ruptured ectopic pregnancy** and **haemorrhagic shock** (hypotension, tachycardia, and peritonism), requiring immediate **hemostasis** and **volume replacement**. - Priority management involves the **ABCDE approach**, stabilizing the patient with fluids while simultaneously preparing for **emergency surgical intervention** (laparoscopy or laparotomy). *Perform urgent transvaginal ultrasound to confirm diagnosis before proceeding to theatre* - Clinical diagnosis of a ruptured ectopic is evident; delaying definitive surgery for imaging in an **unstable patient** increases the risk of mortality. - **Transvaginal ultrasound** is useful in stable patients (PUL) but should not postpone life-saving surgery when **haemoperitoneum** is clinically suspected. *Administer intramuscular methotrexate and commence fluid resuscitation* - **Methotrexate** is strictly contraindicated in patients who are **haemodynamically unstable** or have evidence of tubal rupture. - Medical management with methotrexate is only suitable for small, unruptured ectopics in stable patients with lower **beta-hCG** levels. *Request urgent serum beta-hCG and proceed to laparoscopy only if levels are above 1500 IU/L* - Routine monitoring of the **discriminatory zone** (1500-2000 IU/L) is irrelevant in the presence of acute **peritonitis** and shock. - Waiting for laboratory results is a dangerous delay; a **positive urine pregnancy test** combined with clinical instability is sufficient to mandate surgery. *Arrange CT abdomen and pelvis with contrast to localise the ectopic pregnancy* - **CT scanning** is not the standard of care for diagnosing ectopic pregnancy and involves unnecessary **radiation** and time delay. - Diagnosis is primarily clinical and sonographic; in emergency settings, surgery serves as both the **definitive diagnosis** and treatment.

Gynaecology UK Medical PG Question 10: A 52-year-old woman presents with a 6-month history of irregular vaginal bleeding occurring approximately every 2-3 weeks. She also reports a single episode of postcoital bleeding 2 months ago. She has never had an abnormal cervical smear and her last smear 18 months ago was normal. On speculum examination, the cervix appears healthy with no visible lesions. Bimanual examination reveals a bulky uterus. What is the single most important initial investigation?

• A. Cervical smear
• B. Transvaginal ultrasound
• C. Colposcopy (Correct Answer)
• D. Hysteroscopy and endometrial biopsy
• E. Pipelle endometrial sampling

Gynaecology Explanation: ***Colposcopy*** - **Postcoital bleeding** is a red-flag symptom that mandates urgent exclusion of **cervical malignancy**, even if the cervix appears grossly normal on speculum examination. - While the patient has other symptoms, guidelines (such as **NICE**) prioritize direct visualization of the cervix via **colposcopy** to detect subtle lesions that a recent normal smear might have missed. *Cervical smear* - This patient had a normal smear only **18 months ago**, and a repeat smear is not the diagnostic gold standard for evaluating active symptoms like **postcoital bleeding**. - Screening tests have a known **false-negative rate**; therefore, symptomatic patients require diagnostic visualization rather than repeat screening. *Transvaginal ultrasound* - A TVS is excellent for evaluating the **endometrial thickness** and uterine size (addressing the bulky uterus), but it does not adequately assess the **cervix**. - While it might be performed later to investigate the irregular bleeding, it cannot rule out the primary concern of **cervical cancer**. *Hysteroscopy and endometrial biopsy* - This is the gold standard for investigating **endometrial pathology** in women over 45 with irregular bleeding or suspected hyperplasia. - However, it should follow or be secondary to the exclusion of **cervical pathology** when postcoital bleeding is present. *Pipelle endometrial sampling* - This is an office-based procedure used to sample the **endometrium** to rule out malignancy in the setting of irregular or heavy menstrual bleeding. - It does not address the **postcoital bleeding** component of the history, which specifically points toward the need for **cervical assessment**.

Gynaecology Flashcard 1 of 9

Question: It uterine fibroids is less than 3cm in size, not distorting the uterine cavity, medical treatment can be tried e.g. _____

Answer: IUS, tranexamic acid, COCP etc

Gynaecology Flashcard 2 of 9

Question: Atrophic vagnitis is a _____ diagnosis

Answer: clinical

Gynaecology Flashcard 3 of 9

Question: Adenomyosis is typically seen in _____ women towards the end of their reproductive years

Answer: multiparous

Gynaecology Flashcard 4 of 9

Question: Vesicovaginal fistulae should be suspected in patients with: _____ AND From an area with limited obsteric services

Answer: continuous dribbling incotinence after prolonged labour

Gynaecology Flashcard 5 of 9

Question: What is the management option for stage IA cervical tumours for patients wanting to maintain fertility _____

Answer: Cone Biopsy

Gynaecology Flashcard 6 of 9

Question: What is the investigation of choice for a Vesicovaginal fistulae _____

Answer: Urinary Dye studies

Gynaecology Flashcard 7 of 9

Question: The most common complication of a Myomectomy are _____

Answer: Adhesions

Gynaecology Flashcard 8 of 9

Question: What is the most common risk following a TOP? _____

Answer: Infection

Gynaecology Flashcard 9 of 9

Question: The Risk Malignancy Index (RMI) prognosis in ovarian cancer is based on _____

Answer: US findings, Menopausal status, CA125 levels