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What cancer does polycystic ovarian syndrome (PCOS) increase the long term risk of? - Correct Answer endometrial cancer What conditions complicate PCOS? - Correct Answer -chronic an ovulation -hyperandrogenism What are the long term complications of PCOS? - Correct Answer -Subfertility -diabetes mellitus -stroke and TIA -Coronary artery disease -obstructive sleep apnoea -endometrial cancer These complications are further increased in patients who are obese What is the reason for increased endometrial hyperplasia and carcinoma in women with PCOS - Correct Answer it is due to oligo/amenorrhea in the presence of pre- menopausal levels of oestrogen this risk is greatest in women with menstrual cycle lengths of >3months How can the risk of endometrial cancer be reduced in women with PCOS? - Correct Answer by inducing a withdrawal bleed every 1-3 months (using a combined contraceptive pill or cyclical medroxyprogestrone or with insertion of a Mirena coil Optimising BMI in overweight patients will help to regulate menstrual cycles thereby reducing the risk of endometrial hyperplasia Is there increased risk of osteoporosis in PCOS? - Correct Answer No because there is no oestrogen deficiency
What is PCOS? - Correct Answer It is a complex condition of ovarian dysfunction thought to affect 5-20% of women of reproductive age the aetiology is not fully understood both hyperinsulinaemia and high levels of LH are seen in PCOS and there appears to be some overlap with the metabolic syndrome What are the features of PCOS - Correct Answer -subfertility and infertility -menstrual disturbances: oligomenorrhea and amenorrhea -hirsuitism, acne (due to hyperandrogegism) -obesity -acanthosis nigricans (due to insulin resistance) What investigations will you do for PCOS? - Correct Answer -pelvic ultrasound: multiple cysts on the ovaries -FSH, LH , prolactin, TSH and testosterone are useful investigations: raised LH:FSH ratio are a 'classical' feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes -check impaired glucose tolerance A 19-year-old primigravida at 9 weeks presents with vaginal bleeding and suprapubic pain. Tissue has passed through her vagina. The cervix is closed and blood is pooled in the vagina. Ultrasound shows an empty uterine cavity. What is the diagnosis? a. inevitable miscarriage b. incomplete miscarriage c. threatened miscarriage d. complete miscarriage e. ectopic pregnancy - Correct Answer complete miscarriage What is a complete miscarriage - Correct Answer it is a spontaneous abortion with expulsion of the entire foetus through the cervix pain and uterine contractions stop after foetus has been expelled diagnosis: ultrasound shows empty uterus
What is the management of cervical cancer - Correct Answer simple hysterectomy is the preferred treatment choice for early stage disease in postmenopausal women What is Wertheim's hysterectomy - Correct Answer it involves pelvic node clearance, hysterectomy, removal of parametric and upper third of vagina What is a subtotal hysterecomty - Correct Answer removal of the uterus but not the cervix What is the epidemiology of cervical cancer - Correct Answer around 50% of cases of cervical cancer occur in women under the age of 45 years with incidence rates for cervical cancer in the UK are highest in people aged 25-29 years according to Cancer Research UK What types can cervical cancer be divided into - Correct Answer -squamous cell cancer (80%) -adenocarcinoma (20%) What are the features of cervical cancer - Correct Answer -may be detected during routine cervical cancer screening -abnormal vaginal bleeding: post-coital, inter menstrual or postmenopausal bleeding -vaginal discharge What are the risk factors for cervical cancer - Correct Answer -HPV particularly serotypes 16, 18 and 33 is by far the most important factor in the development of cervical cancer -smoking -HIV -early first intercourse, many sexual partners -high parity -lower socioeconomic status -combined oral contraceptive pill What is the mechanism for HPV causing cervical cancer? - Correct Answer HPV 16 and 18 produces the oncogenes E6 and E7 genes respectively E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene A 37-year-old female presents to her GP complaining of dyspareunia, irregular menstrual cycles for 6 months until she recently missed 3 periods. She also complains of sudden hot flushes for the past 3 months. Her only history of note includes previous breast cancer for which she was on chemotherapy and radiation. Examination reveals no abnormalities and her pregnancy test is negative. What is the most likely diagnosis? - Correct Answer premature ovarian failure Premature ovarian failure (POM) is defined as the cessation of menses for 1 year before the age of 40. It can, however, be preceded by irregular menstrual cycles. Common symptoms include hot flushes, vaginal dryness, vaginal atrophy, sleep disturbance, and irritability. What are the risk factors for premature ovarian failure - Correct Answer Strong risk factors for POM include a positive family history, exposure to chemotherapy/radiation and autoimmune disease. What is premature ovarian failure - Correct Answer it is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years it occurs in around 1 in 100 women What are the causes of premature ovarian failure - Correct Answer -idiopathic - the most common -chemotherapy -autoimmune -radiation What are the features of premature ovarian failure - Correct Answer Features are similar to those of the normal climacteric but the actual presenting problem may differ; -climacteric symptoms: hot flushes, night sweats -infertility
they are thought to occur in around 20% of white and around 50% of black women in the later reproductive year What are the associations with uterine fibroids - Correct Answer -more common in Afro-Carribean women -rare before puberty, develop in response to oestrogen, don't tend to progress following menopause What are the features of uterine fibroids - Correct Answer -may be asymptomatic -menorrhagia -lower abdominal pain: cramping pains, often during menstruation -bloating -urinary symptoms e.g frequency, may occur with larger fibroids -subfertility How is the diagnosis of fibroids made - Correct Answer transvaginal ultrasound What is the management of fibroids - Correct Answer -symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line -other options include tranexamic acid, combined oral contraceptive pill etc GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment -surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy -uterine artery embolization What are the complications of fibroids - Correct Answer red degeneration - haemorrhage into tumour: commonly occurs during pregnancy Which women are offered cervical screening - Correct Answer all women between the ages of 25 and 64 years How often should women get screened for cervical cancer - Correct Answer age 25: first invitation age 25-49yrs: screening every 3 years
age 50-64yrs: screening every 5 years women 65 years of age or older if they have not had a cervcial screening test since 50 years of age or a recent cervical cytology sample is abnormal Women who are virgins may choose not to have cervical screening as their risk of cervical cancer is low - Correct Answer true What should happen to women with cervical stenosis - Correct Answer they should be referred to the colposcopy clinic for consideration of cervical dilatation Women with a cervix that cannot be visualised should be referred for colposcopy - Correct Answer true transgender men who have retained their cervix should be included in the national cervical screening programme unless they have made an informed decision to opt out - Correct Answer true unscheduled cervical screening is not recommended unless the woman is immunosuppressed, where more frequent screening may be required - Correct Answer true Which cervical cancers are not detected by screening - Correct Answer it should be noted that cervical adenocarcinomas which account for around 15% of cases are frequently undetected by screening Who is screened for cervical cancer and how often - Correct Answer A smear test is offered to all women between the ages of 25-64 years 25-49 years: 3-yearly screening 50-64 years: 5-yearly screening How is smear performed - Correct Answer There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid. Advantages of LBC includes -reduced rate of inadequate smears -increased sensitivity and specificity When is the best time to take a cervical smear - Correct Answer It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS.
A 25-year-old woman is investigated for acute pelvic pain and is diagnosed as having pelvic inflammatory disease. What is the most common cause of pelvic inflammatory disease in the UK? - Correct Answer chlamydia trachomatis What is pelvic inflammatory disease - Correct Answer it is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and surrounding peritoneum it is usually the result of ascending infection from the endocervix What are the causative organisms in pelvic inflammatory disease - Correct Answer - chlamydia trachomatis- the most common cause -Neisseria gonorrhoea -mycoplasma genitalium -mycoplasma hominis What are the features of pelvic inflammatory disease - Correct Answer -lower abdominal pain -fever -deep dyspareunia -dysuria and menstrual irregularities may occur -vaginal or cervical discharge -cervical excitation What investigations will you do for pelvic inflammatory disease - Correct Answer screen for Chlamydia and Gonorrhoea What is the management of pelvic inflammatory disease - Correct Answer due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ' Removal of the IUD should be considered and may be associated with better short term clinical outcomes'
What are the complications of pelvic inflammatory disease - Correct Answer - infertility: the risk may be as high as 1020% after a single episode -chronic pelvic pain -ectopic pregnancy A 38-year-old woman with a 4.5cm fibroid has been listed for a myomectomy following a 5 month history of heavy menstrual bleeding, What drug should be prescribed to be taken whilst awaiting surgery? - Correct Answer Gonadotrophin-releasing hormone analogue Use of a gonadotrophin-releasing hormone analogue could be considered prior to surgery which helps to reduce the size of the fibroids. A 34-year-old, G2P1, is referred to the obstetrics assessment unit by her general practitioner for mild abdominal pain and vaginal bleed. She is 15 weeks pregnant. Ultrasound scan results are consistent with a 2nd-trimester miscarriage. Which one of the following is a risk factor for 2nd-trimester miscarriage? a. exercise b. primigravid c. previous Caesarian section d. large cervical cone biopsy - Correct Answer large cervical cone biopsy What are the risk factors for miscarriages - Correct Answer -age:Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35, you have about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it's about 80 percent. -previous miscarriages:Women who have had two or more consecutive miscarriages are at higher risk of miscarriage. -chronic conditions:Women who have a chronic condition, such as uncontrolled diabetes, have a higher risk of miscarriage. -uterine or cervical problems:Certain uterine abnormalities or weak cervical tissues (incompetent cervix) might increase the risk of miscarriage. -smoking, alcohol and illicit drugs:Women who smoke during pregnancy have a greater risk of miscarriage than do nonsmokers. Heavy alcohol use and illicit drug use also increase the risk of miscarriage.
-cervical incompetence What factors have NOT been associated with an increased risk of miscarriage - Correct Answer -heavy lifting -bumping your tummy -having sex -air travel -being stressed A 26-year-old woman is referred to the gynaecology clinic with severe dysmenorrhoea and a clinical history suggestive of endometriosis. She has tried paracetamol and ibuprofen with little benefit. She is not planning to start a family for the next couple of years. What is the recommended first-line management, providing that there are no contraindications? - Correct Answer combined oral contraceptive pill (COCP) The COCP is the first line option and can be used back-to-back with no pill-free interval. Second line treatments include progesterone only methods, such as POP, implant or injection (again they work by inhibiting ovulation). In addition, the Mirena coil can be used as it will reduce bleeding, resulting in less retrograde menstruation. The copper intrauterine device can make menstrual cycles longer and more painful and would not be a suitable option. If the above methods fail to improve a patient's symptoms, then GnRH analogues may be used. What is endometriosis - Correct Answer Endometriosis is a common disorder, characterised by the deposits of endometrial-like tissue outside the uterus. It is an oestrogen dependent condition, that starts after menarche and regresses following the menopause. In patients with endometriosis who wish to conceive what should you do - Correct Answer make a referral to fertility services if they have not conceived after 6 months of regular unprotected vaginal sexual intercourse surgical options such as laparoscopic adheiolysis may improve fertility rates in patients with mild-moderate disease What are the clinical features of endometriosis - Correct Answer -chronic pelvic pain -dysmenorrhoea- pain often starts days before bleeding -deep dyspareunia
-subfertility -non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. dyschezia (painful bowel movements) -on pelvic examination reduced organ mobility, tender modularity in the posterior vaginal fornix and visible vaginal emdometriortic lesions may be seen What investigations will you do for endometriosis - Correct Answer -laparoscopy is the gold-standard investigation -there is little role for investigation in primary care (e.g ultrasound) - if the symptoms are significant the patient should be referred for a definitive diagnosis What is the management for endometriosis - Correct Answer management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE in 2017 recommends; -NSAIDs and/or paracetamol are recommended first line treatment for symptomatic relief -if analgesia does help then hormonal treatment such as the combined oral contraceptive pill or progestogens e.g medroxyprogesterone acetate should be tried If analgesia/hormonal treatment does not improve symptoms in endometriosis or if fertility is a priority what should happen - Correct Answer the patient should be referred to secondary care secondary treatments include; -gonadotrophin-releasing hormone (GnRH) analogues - said to induce a 'pseudo menopause' due to the low oestrogen levels -drug therapy unfortunately does not seem to have a significant impact on fertility rates -surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cyst may improve fertility A 52-year-old journalist presents with a 6/12 history of hot flushes and vaginal dryness. Her last menstrual period was 13 months ago and she has no significant medical or surgical history. After discussing all of her menopause treatment options, she opts for an oestrogen only preparation. Which additional treatment (if any) would she be recommended to combine this with? - Correct Answer Mirena intrauterine system The Mirena intrauterine system is licensed for use as the progesterone component of HRT for 5 years
What is the management of menorrhagia that does not need contraception - Correct Answer -either mefenamic acid 500mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1g tds. Both are started on the first day of the period -if no improvement then try other drug whilst awaiting referral What is the management of menorrhagia that requires contraception - Correct Answer -intrauterine system (Mirena) should also be considered first-line -combined oral contraceptive pill -long-acting progestogens Norethiserone 5mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding - Correct Answer true A 76-year-old woman presents with post-menopausal bleeding for the past 4 months. She is diagnosed with well-differentiated adenocarcinoma (stage II) on endometrial biopsy. There is no evidence of metastatic disease. Which is the most appropriate treatment? a. transcervical endometrial resection b. total abdominal hysterectomy c. provera (medroxyprogesterone acetate) d. Wertheim's radical hysterectomy e. total abdominal hysterectomy with bilateral saplingo-oophorectomy - Correct Answer otal abdominal hysterectomy with bilateral saplingo-oophorectomy Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the treatment of choice for stage I and II endometrial carcinoma. Provera is a progesterone used as a hormonal treatment for endometrial carcinoma - it acts by slowing the growth of malignant cells in the endometrium. Wertheim's radical hysterectomy includes removal of lymph nodes and is used to treat stage IIB endometrial carcinoma. How is Provera used to treat endometrial cancer - Correct Answer it is a progesterone hormonal treatment and acts by slowing the growth of malignant cells in the endometrium What is Wertheim's radical hysterectomy - Correct Answer it includes removal of lymph nodes and is used to treat stage IIB endometrial carcinoma In which people do we see endometrial cancer - Correct Answer it is classically seen in post-menopausal women but 25% of cases occur before the menopause it usually carries a good prognosis due to early detection
What are the risk factors for endometrial cancer - Correct Answer -obesity -nulliparity -early menarche -late menopause -unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously -diabetes mellitus -tamoxifen -polycystic ovarian syndrome *the oral contraceptive pill is protective What are the features of endometrial cancer - Correct Answer -post-menopausal bleeding is the classic symptom -pre-menopausal women may have a change inter menstrual bleeding -pain and discharge are unusual features What investigations will you do for endometrial cancer - Correct Answer -first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value -hysteroscopy with endometrial biopsy What is the management of endometrial cancer - Correct Answer -localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy -progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery A 37-year-old woman who is 15 weeks pregnant presents with abdominal pain. The pain came on gradually and has been getting progressively worse for 3 days. She is nauseated and has vomited twice this morning. She has a temperature of 38.4ÂșC, blood pressure is 116/82 mmHg and heart rate is 104 beats per minute. The uterus is palpable just above the umbilicus and a fetal heart beat is heard via hand-held Doppler. On speculum examination the cervix is closed and there is no blood. She has a history
What is the law surrounding the termination of pregnancy - Correct Answer The current law surround abortion is based on the 1967 Abortion Act. In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks these limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is risk of serious physical or mental injury to the woman. Who can perform a termination of pregnancy - Correct Answer -two registered medical practitioners must sign a legal document (in an emergency only one is needed) -only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise What method is used to terminate pregnancy - Correct Answer The method used to terminate pregnancy depend upon gestation; -less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions -less than 13 weeks: surgical dilation and suction of uterine contents -more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces 'mini-labour') What is the 1967 Abortion act - Correct Answer Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith -that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or -that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or -that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or -that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped. A 17-year-old girl presents due to painful periods. These have been present for the past three years and are associated with a normal amount of blood loss. Her periods are
regular and there is no abnormal bleeding. She is not yet sexually active. What is the most appropriate first-line treatment? - Correct Answer Ibuprofen NSAIDs are offered first-line as they will inhibit prostaglandin synthesis, one of the main causes of dysmenorrhoea pains. What is dysmenorrhoea - Correct Answer Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea. What is primary dysmenorrhoea - Correct Answer In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible. What are the features of primary dysmenorrhoea - Correct Answer -pain typically starts just before or within a few hours of the period starting -suprapubic cramping pains which may radiate to the back or down the thigh What is the management for primary dysmenorrhoea - Correct Answer -NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production -combined oral contraceptive pills are used second line What is secondary dysmenorrhoea - Correct Answer Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. What are the causes of secondary dysmenorrhea - Correct Answer -endometriosis -adenomyosis -pelvic inflammatory disease intrauterine devices (referring to copper coils. Mirena coil mat help dysmenorrhoea -fibroids A 20-year-old woman presents to her GP complaining of painful periods. She currently uses an implant (Nexplanon) for contraception which she is very happy with. What is the most suitable initial treatment? - Correct Answer Mefanamic acid
