-
Question 1
Correct
-
A 60-year-old female visits the clinic with a complaint of urinary incontinence. She reports experiencing unintentional urine leakage when coughing or laughing. No urinary urgency or nocturia is reported, and a routine pelvic exam reveals no abnormalities. Despite consistent pelvic floor muscle exercises for the past five months, the patient's symptoms have not improved. She expresses a desire to avoid surgical interventions. What is the most suitable treatment option for this patient?
Your Answer: Duloxetine
Explanation:For patients with stress incontinence who do not respond to pelvic floor muscle exercises and decline surgery, duloxetine may be a suitable option. However, if urge incontinence is the main issue, antimuscarinic (oxybutynin) or beta-3 agonist (mirabegron) medications may be more appropriate. In this case, since the patient has not seen improvement with pelvic floor muscle training and has declined surgery, duloxetine would be the best choice.
Understanding Urinary Incontinence: Causes, Classification, and Management
Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.
Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.
In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 2
Incorrect
-
A 30-year-old nulliparous patient presents to the Gynaecology Clinic with complaints of severe menstrual pain and pain during intercourse. She reports that the symptoms have been progressively worsening. An ultrasound of the pelvis reveals a 4-cm cyst in the right ovary. The serum CA-125 level is 225 (0–34 iu/ml). What is the probable diagnosis?
Your Answer: Granulosa cell tumour of the right ovary
Correct Answer: Ectopic endometrial tissue
Explanation:The patient is likely suffering from endometriosis, which is the presence of endometrial tissue outside of the uterus. This condition can cause subfertility, chronic pelvic pain, dysmenorrhoea, and dyspareunia. It may also lead to an increase in serum CA-125 levels and the development of ovarian deposits known as chocolate cysts. Acute appendicitis and ovarian neoplasms are unlikely causes of the patient’s symptoms, while mittelschmerz only causes mid-cycle pain and does not explain the elevated CA-125 levels. Granulosa cell tumors of the ovary typically secrete inhibin and estrogen, making endometriosis a more likely diagnosis. Symptoms of ovarian cancer are often vague and include abdominal discomfort, bloating, back and pelvic pain, irregular menstruation, loss of appetite, fatigue, and weight loss. Risk factors for ovarian cancer include not having children, early first menstruation and last menopause, hormone replacement therapy, endometriosis, and the BRCA genes. In this age group, germ cell tumors are the most likely ovarian carcinoma.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 3
Incorrect
-
A 16-year-old girl visits her nearby pharmacy at 11 am on Tuesday, asking for the morning-after pill. She discloses that she had unprotected sex around 10 pm on the previous Saturday and is not using any birth control method. She specifically asks for levonorgestrel, as her friend had taken it a few weeks ago. Is it possible for her to receive levonorgestrel as an emergency contraception option?
Your Answer: Yes, as it can be taken up to 120 hours later
Correct Answer: Yes, as it can be taken up to 72 hours later
Explanation:Levonorgestrel can still be taken within 72 hours of unprotected sexual intercourse (UPSI) in this case. Ulipristal acetate can also be taken up to 120 hours later, but the efficacy of oral options may have decreased after 61 hours. The copper coil is not a suitable option as the patient has declined any form of birth control. Therefore, the correct answer is that levonorgestrel can still be taken within 72 hours of UPSI.
Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 4
Correct
-
A 28-year-old woman comes to her GP complaining of not having had a period for 7 months. She stopped taking the pill 9 months ago to try to conceive. She reports having always had irregular and heavy periods, which is why she started taking the pill at 16. She admits to gaining around 4 kg recently. She took a pregnancy test yesterday, which was negative. There is no other relevant medical or family history. What is the probable cause of this patient's symptoms?
Your Answer: Polycystic ovary syndrome
Explanation:Women who would otherwise experience symptoms of polycystic ovarian syndrome may not realize they have the condition if they are using the combined oral contraceptive pill.
Polycystic ovary syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.
To diagnose PCOS, a range of investigations may be performed, including pelvic ultrasound to detect multiple cysts on the ovaries. Other useful baseline investigations include FSH, LH, prolactin, TSH, testosterone, and sex hormone-binding globulin (SHBG). While a raised LH:FSH ratio was once considered a classical feature of PCOS, it is no longer thought to be useful in diagnosis. Testosterone may be normal or mildly elevated, but if markedly raised, other causes should be considered. SHBG is typically normal to low in women with PCOS, and impaired glucose tolerance should also be checked.
To formally diagnose PCOS, other conditions must first be excluded. The Rotterdam criteria state that a diagnosis of PCOS can be made if at least two of the following three criteria are present: infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound scan. Polycystic ovaries are defined as the presence of at least 12 follicles measuring 2-9 mm in diameter in one or both ovaries, and/or an increased ovarian volume of over 10 cm³.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 5
Correct
-
A 70-year-old smoker presents to the Gynaecology clinic following a general practitioner’s referral. Her presenting complaint is long-standing vulval irritation and itching. She has a past medical history of lichen sclerosus. On examination, there is an obvious growth in the vulval area. A biopsy is taken and sent for pathological analysis.
What is the most common cause of vulval carcinoma?Your Answer: Squamous cell carcinoma
Explanation:Types of Vulval Cancer: Symptoms, Diagnosis, and Treatment
Vulval cancer is a rare type of cancer that affects the external female genitalia. There are different types of vulval cancer, each with its own set of symptoms, risk factors, and treatment options. Here are some of the most common types of vulval cancer:
Squamous cell carcinoma: This is the most common type of vulval cancer, accounting for about 85% of cases. It usually affects women over 60 who smoke or have a weakened immune system. Symptoms include vulval irritation or itching, and as the disease progresses, pain and discharge. Squamous cell carcinoma can be cured if caught early, and treatment usually involves surgical excision.
Basal cell carcinoma: This type of vulval cancer is rare and usually occurs in sun-exposed areas of the skin. It is often treated with surgery.
Sarcoma: Sarcoma is a rare type of vulval cancer that can occur at any age, including childhood. Treatment usually involves surgery and radiation therapy.
Bartholin’s gland carcinoma: This is a rare cause of vulval cancer that affects the Bartholin glands, which are two small mucous-producing glands on either side of the vaginal opening. Risk factors include HPV infection and Paget’s disease of the vulva. It is often diagnosed late, as it is often confused with Bartholin gland cyst, which is a benign condition.
Malignant melanoma: This is a rare type of vulval cancer that accounts for about 5% of cases. Symptoms include itching, bleeding, and an irregular border. Treatment usually involves surgery and chemotherapy.
If you experience any symptoms of vulval cancer, such as itching, pain, or bleeding, it is important to see a doctor as soon as possible. Early diagnosis and treatment can improve your chances of a full recovery.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 6
Correct
-
Sophie is a 32-year-old mother of two, who is uncertain if she wants to have more children. She comes to you with a history of not having a period for the past 9 months. Sophie had regular menstrual cycles for 28 months after giving birth to her last child. She has never used any hormonal birth control or undergone any surgeries. Upon examination, her abdomen and gynecological areas appear normal, and there are no signs of hyperandrogenism. A pregnancy test confirms that she is not pregnant.
Lab results show a decrease in follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol levels, while prolactin, thyroid-stimulating hormone (TSH), and T4 levels are normal. A 10-day progestin challenge fails to induce a withdrawal bleed.
What is the underlying cause of Sophie's amenorrhea?Your Answer: Hypothalamic dysfunction
Explanation:Caroline’s case of secondary amenorrhoea suggests a hypothalamic cause, as indicated by low levels of gonadotrophins (FSH and LH) and oestradiol. This is different from pituitary adenoma, which often presents with panhypopituitarism and normal prolactin levels, and premature ovarian failure, which is diagnosed in women under 40 with increased FSH levels and menopausal-like symptoms. PCOS is also unlikely as there is no hyperandrogenism or other symptoms present. Hypothalamic dysfunction can be caused by excessive exercise, stress, or dieting, which should be explored in the patient’s history.
Understanding Amenorrhoea: Causes, Investigations, and Management
Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls without secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.
There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.
The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 7
Correct
-
A 65-year-old woman presents to your clinic with a complaint of spotting in the past month, despite having gone through menopause 8 years ago. She had taken hormone replacement therapy for 3 years. On examination, her abdomen appears normal, but she has vaginal dryness. What initial investigation would you perform?
Your Answer: Trans-vaginal ultrasound scan
Explanation:Postmenopausal women are at risk of developing endometrial cancer, making it crucial to rule out this possibility in cases of postmenopausal bleeding. Hormone replacement therapy, nulliparity, late menopause, early menses, obesity, diabetes, polycystic ovarian syndrome, and family history are all risk factors for this type of cancer. The first step in investigating endometrial cancer is to conduct a trans-vaginal ultrasound scan to measure the thickness of the endometrial lining. Different hospitals have varying cut-offs for endometrial thickness and further investigation. If the endometrial lining is thickened, a hysteroscopy will be performed, and an endometrial biopsy will be taken. Treatment for endometrial cancer typically involves laparoscopic hysterectomy with bilateral salpingo-oophorectomy, with or without radiotherapy.
Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.
When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 8
Incorrect
-
A 22-year-old woman comes in for her dating scan after discovering she was pregnant 6 weeks ago through a urine pregnancy test. However, her ultrasound reveals that the pregnancy is ectopic and located in her left fallopian tube. The size of the pregnancy is 20mm, unruptured, and has no cardiac activity. The patient is not experiencing any symptoms such as bleeding, cramping, vomiting, or systemic symptoms, and her vitals are normal. Her blood test results show that her β-hCG levels have decreased from 940 IU/L at her booking appointment to 740 IU/L today. She has no significant medical history. What is the most appropriate management plan for this patient?
Your Answer: Prescribe oral mifepristone and vaginal misoprostol
Correct Answer: Give safety netting advice and ask to return in 48 hours for serum β-hCG levels
Explanation:Expectant management of an ectopic pregnancy is only suitable for an embryo that is unruptured, <35mm in size, has no heartbeat, is asymptomatic, and has a β-hCG level of <1,000 IU/L and declining. In this case, the woman has a small ectopic pregnancy without cardiac activity and a declining β-hCG level. Therefore, expectant management is appropriate, and the woman should be given safety netting advice and asked to return for a follow-up blood test in 48 hours. Admitting her for 12-hourly β-hCG monitoring is unnecessary, and performing a salpingectomy or salpingostomy is not indicated. Prescribing medical management is also inappropriate in this case. Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test. There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility. Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 9
Correct
-
A 50-year-old woman presents with severe itching in the perineal region, accompanied by pain during urination and painful intercourse. During examination, you observe white, polygonal papules on the labia majora that merge into a patch that affects the labia minora. There is one area of fissuring that bleeds upon contact. The skin appears white, thin, and shiny, with mild scarring. There is no vaginal discharge, and no other skin lesions are present on the body. What is the most probable diagnosis?
Your Answer: Lichen sclerosus
Explanation:Common Genital Skin Conditions: Symptoms and Treatment Options
Lichen sclerosus, candidiasis, contact dermatitis, lichen planus, and psoriasis are some of the most common skin conditions that affect the genital area. Each condition has its own set of symptoms and treatment options.
Lichen Sclerosus: This chronic inflammatory condition can affect any part of the body but is most commonly found in the genital area. It presents with pruritus, skin irritation, hypopigmentation, and atrophy. Treatment involves topical steroids and good hygiene.
Candidiasis: This fungal infection is associated with pruritus, burning sensation, erythema, and oedema of the vestibule. The most common characteristic is a thick, curd-like, white vaginal discharge.
Contact Dermatitis: This condition is often caused by changes to shower gel or washing detergent. It presents with pruritus, erythematosus skin, excoriations, and skin breaks, leading to ulceration and superimposed infection. Chronic contact dermatitis can lead to lichenoid changes.
Lichen Planus: This condition presents with purple, red plaques usually on the labia, with central erosion and overlying lacy, white, striated patch. It can cause scarring and narrowing of the introitus and dyspareunia.
Psoriasis: This condition is rare in the genital area but can appear in the inguinal creases and the labia majora. It presents with erythematous plaques with minimal white scale and is associated with itching and excoriations.
It is important to seek medical attention if you suspect you have any of these conditions. Treatment options may include topical or oral medications, good hygiene practices, and lifestyle changes.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 10
Correct
-
A 28-year-old woman presents to the Surgical Assessment Unit with acute abdominal pain, pain in her right shoulder, and pain during bowel movements. She reports that her last menstrual period was about 8 weeks ago. A pregnancy test is performed and comes back positive. An urgent ultrasound scan is ordered, which confirms an ectopic pregnancy in the Fallopian tube. What is the most frequent location for implantation of an ectopic pregnancy?
Your Answer: The ampullary region of the Fallopian tube
Explanation:Ectopic Pregnancy: Sites and Symptoms
Ectopic pregnancy is a condition where the fertilized egg implants outside the uterine cavity. The most common site for ectopic implantation is the Fallopian tube, particularly the ampullary region, accounting for 97% of cases. Symptoms include 4-8 weeks of amenorrhea, abdominal pain, vaginal bleeding, and signs of shock associated with rupture. Shoulder tip pain may also occur due to irritation of the phrenic nerve. Diagnosis is made through measurement of β-human chorionic gonadotrophin and ultrasound scan of the abdomen, with laparoscopic investigation as the definitive method. Treatment involves removal of the pregnancy and often the affected tube via laparoscopy or laparotomy.
Other sites for ectopic pregnancy include the peritoneum or abdominal cavity, which accounts for 1.4% of cases and may proceed to term. Cervical pregnancy is rare, accounting for less than 1% of cases. Ovarian pregnancy occurs in 1 in 7000 pregnancies and accounts for 0.5-3% of all ectopic pregnancies. The broad ligament is an uncommon site for ectopic pregnancies due to its poor vascularity.
-
This question is part of the following fields:
- Gynaecology
-
00
Correct
00
Incorrect
00
:
00
:
0
00
Session Time
00
:
00
Average Question Time (
Mins)