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 35-year-old woman at 32 weeks gestation presents with severe headache, visual changes, and RUQ pain. BP is 175/110 mmHg. Blood tests show AST 200 U/L, platelets 70,000/μL. What is the most appropriate management?

• A. Antihypertensive treatment
• B. Magnesium sulfate
• C. Immediate delivery (Correct Answer)
• D. Corticosteroids
• E. Observation

Gynaecology Explanation: ***Immediate delivery*** - The patient's symptoms (severe headache, visual changes, RUQ pain, BP 175/110 mmHg) and lab results (**AST 200 U/L**, **platelets 70,000/μL**) meet the criteria for **HELLP syndrome**, a severe manifestation of preeclampsia. - **Immediate delivery** is the definitive management for **HELLP syndrome**, as removing the placenta resolves the underlying pathology and prevents life-threatening maternal complications like stroke, DIC, and liver rupture, especially given the severe presentation at 32 weeks gestation. *Antihypertensive treatment* - While crucial for preventing **hemorrhagic stroke** by managing the severe hypertension (BP 175/110 mmHg), antihypertensive treatment (e.g., **labetalol**, **hydralazine**) only addresses a symptom. - It is a supportive measure and not the definitive treatment for the underlying pathophysiology of **HELLP syndrome**, which requires removal of the placenta. *Magnesium sulfate* - **Magnesium sulfate** is essential for **seizure prophylaxis** to prevent **eclampsia** in patients with severe preeclampsia and HELLP syndrome, addressing a critical maternal complication. - However, it does not resolve the underlying liver dysfunction or hematological abnormalities of **HELLP syndrome**; therefore, it is an important stabilizing measure but not the primary definitive management. *Corticosteroids* - Corticosteroids like **betamethasone** are primarily administered before 34 weeks for **fetal lung maturity**, but they require 24-48 hours to be effective. - In severe maternal conditions like **HELLP syndrome**, delaying delivery for corticosteroid administration can pose significant risks to the mother and is often contraindicated when immediate delivery is indicated. *Observation* - **Observation** is dangerous and contraindicated in cases of severe preeclampsia with **HELLP syndrome** due to the imminent risk of life-threatening maternal complications, including **eclampsia**, **placental abruption**, and **maternal stroke**. - This clinical scenario requires **active management**, which includes stabilization and **definitive delivery**, rather than passive monitoring.

Gynaecology UK Medical PG Question 3: A 37-year-old woman at 28 weeks gestation presents with sudden onset dyspnea and chest pain. She has a history of previous DVT. D-dimer is elevated. What is the most appropriate anticoagulant if PE is confirmed?

• A. Warfarin
• B. Dabigatran
• C. Rivaroxaban
• D. Low molecular weight heparin (Correct Answer)
• E. Unfractionated heparin

Gynaecology Explanation: ***Low molecular weight heparin*** - **Low molecular weight heparin (LMWH)** is the preferred anticoagulant for treating **pulmonary embolism (PE)** during pregnancy because it **does not cross the placenta**, minimizing risk to the fetus. - It is effective, has a predictable dose-response, and requires less monitoring than unfractionated heparin. *Warfarin* - **Warfarin** is a **teratogen** (Category X) and is strictly contraindicated during the first trimester due to the risk of **fetal warfarin syndrome**. - It carries a risk of fetal hemorrhage and central nervous system abnormalities even in later trimesters, making it generally avoided in pregnancy. *Dabigatran* - **Dabigatran** is a direct thrombin inhibitor (DOAC) with limited data on safety during pregnancy, and its molecular weight suggests some placental transfer is possible. - Due to lack of robust safety data, **DOACs** are generally not recommended for use in pregnant women for treating VTE. *Rivaroxaban* - **Rivaroxaban** is a Factor Xa inhibitor (DOAC) also generally avoided in pregnancy due to insufficient data on fetal safety and potential placental transfer. - There is a theoretical risk of fetal bleeding, and **LMWH** remains the standard of care. *Unfractionated heparin* - **Unfractionated heparin (UFH)** is safe in pregnancy as it does not cross the placenta, similar to LMWH. - However, **LMWH** is preferred due to its greater bioavailability, longer half-life, and lower risk of **heparin-induced thrombocytopenia (HIT)** and **osteoporosis** with long-term use.

Gynaecology UK Medical PG Question 4: 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 5: 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 6: 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 7: 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 8: 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 9: 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 10: A 29-year-old woman is being monitored for a right tubal ectopic pregnancy with expectant management. Her initial serum beta-hCG was 680 IU/L. She remains clinically stable with minimal pain. Repeat beta-hCG 48 hours later is 890 IU/L. What is the most appropriate next step in management?

• A. Continue expectant management with repeat beta-hCG in 48 hours
• B. Administer intramuscular methotrexate (Correct Answer)
• C. Arrange urgent laparoscopy
• D. Repeat transvaginal ultrasound to assess for intrauterine pregnancy
• E. Commence oral misoprostol

Gynaecology Explanation: ***Administer intramuscular methotrexate***- The **rising beta-hCG** (from 680 to 890 IU/L) indicates that **expectant management has failed**, as successful expectant management requires decreasing hCG levels.- **Methotrexate** is the treatment of choice in this stable patient because the hCG is below **1500–3000 IU/L** and there are no clinical signs of tubal rupture.*Continue expectant management with repeat beta-hCG in 48 hours*- This approach is only appropriate if **beta-hCG levels are declining**; a rise indicates the ectopic pregnancy is still actively developing.- Delaying intervention in the presence of rising levels increases the risk of **tubal rupture** and emergency surgery.*Arrange urgent laparoscopy*- Surgical intervention is generally reserved for patients who are **hemodynamically unstable**, have signs of rupture, or have very high beta-hCG levels.- As this patient is **clinically stable** and currently meets criteria for medical management, invasive surgery is not the primary next step.*Repeat transvaginal ultrasound to assess for intrauterine pregnancy*- The diagnosis of **ectopic pregnancy** has already been established; repeating the scan is unnecessary and delays definitive treatment.- Suboptimal hCG rises (less than 35% in 48 hours) are more consistent with an **extrauterine pregnancy** than a viable intrauterine one.*Commence oral misoprostol*- **Misoprostol** is used for the management of miscarriages (intrauterine pregnancies) to induce uterine contractions, but it has no role in treating an **ectopic pregnancy**.- Using misoprostol in this context would be ineffective and dangerous, as it would not resolve the **adnexal mass**.

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