A 46-year-old woman presents with a 12-month history of heavy menstrual bleeding significantly affecting her quality of life. She has used maximum-dose tranexamic acid and mefenamic acid without adequate improvement. She declined the levonorgestrel intrauterine system. Examination reveals a mobile, non-tender uterus of approximately 10-week size. Transvaginal ultrasound shows a bulky uterus with adenomyosis and endometrial thickness of 8mm. She has completed her family. What is the most appropriate next management step?
Q72
A 29-year-old woman presents to the emergency department with 6 weeks amenorrhoea and right lower abdominal pain. She has a history of pelvic inflammatory disease treated 2 years ago. Examination reveals right iliac fossa tenderness without peritonism. She is haemodynamically stable. Serum beta-hCG is 4,200 IU/L. Transvaginal ultrasound shows an empty uterus with endometrial thickness of 9mm, a 28mm right adnexal mass with a hyperechoic ring, and a small amount of free fluid in the pouch of Douglas. What is the most appropriate management?
Q73
A 38-year-old woman with heavy menstrual bleeding has had a levonorgestrel intrauterine system in situ for 8 months. She returns to clinic reporting persistent irregular bleeding and spotting occurring 15-20 days per month. She is finding this unacceptable and wishes to have the LNG-IUS removed. Prior to LNG-IUS insertion, her ultrasound showed a normal uterus with endometrial thickness of 8mm. What is the most appropriate next step in management?
Q74
A 44-year-old multiparous woman presents with heavy menstrual bleeding that has not responded to tranexamic acid or mefenamic acid. She has completed her family and does not wish to use hormonal treatments. Examination reveals a 16-week-size uterus with multiple palpable irregular masses. Transvaginal ultrasound confirms multiple intramural and subserosal fibroids, the largest measuring 8cm. She has significant dysmenorrhoea and pressure symptoms including urinary frequency. Haemoglobin is 88 g/L. What is the most appropriate definitive management?
Q75
A 35-year-old woman with a body mass index of 34 kg/m² presents with a 14-month history of increasingly irregular and heavy menstrual bleeding. Her cycles vary from 21 to 45 days, and bleeding lasts 7-10 days. She has noticed increased facial hair growth over the past year. Pelvic examination is normal. Transvaginal ultrasound shows a bulky uterus with endometrial thickness of 14mm and multiple small peripheral follicles in both ovaries. What is the most important next investigation?
Q76
A 30-year-old woman presents to the emergency department with 6 weeks amenorrhoea, mild right-sided abdominal pain, and minimal vaginal spotting. She is haemodynamically stable. Transvaginal ultrasound shows an empty uterus with endometrial thickness of 12mm and a 15mm adnexal mass with a hyperechoic ring. There is no free fluid in the pouch of Douglas. Serum beta-hCG is 1,200 IU/L. She has no significant past medical history and takes no regular medications. What is the most appropriate next step in management?
Q77
A 42-year-old woman with heavy menstrual bleeding is assessed in the gynaecology clinic. She reports flooding through night-time protection and passing clots larger than a 50-pence coin. Her menstrual cycle is regular at 28 days, with bleeding lasting 8 days. Abdominal and pelvic examination are unremarkable. Full blood count shows haemoglobin 95 g/L and ferritin 8 μg/L. Transvaginal ultrasound demonstrates a normal uterus with endometrial thickness of 7mm. What is the most appropriate first-line medical treatment?
Q78
A 39-year-old nulliparous woman presents with heavy menstrual bleeding for 14 months. She reports flooding and clots, requiring time off work. Examination reveals a 16-week size irregular uterus. Ultrasound confirms multiple fibroids, with the largest (8cm) being intramural and distorting the endometrial cavity. Endometrial biopsy shows proliferative endometrium with no atypia. She strongly wishes to preserve her fertility. What is the most appropriate management option to discuss?
Q79
A 41-year-old woman presents with increasingly heavy menstrual bleeding over 18 months. Transvaginal ultrasound shows multiple intramural fibroids, the largest measuring 6cm, and a uniformly thickened endometrium of 11mm in the secretory phase. She has dysmenorrhoea and deep dyspareunia. She has completed her family. Examination reveals a bulky, tender uterus. What additional diagnosis should be considered alongside the fibroids?
Q80
A 28-year-old woman is being monitored for a pregnancy of unknown location following one dose of intramuscular methotrexate given 6 days ago for a presumed ectopic pregnancy. Her initial beta-hCG was 1,650 IU/L. She now presents to the emergency department with worsening right-sided abdominal pain and shoulder tip pain. She is tachycardic at 110 bpm with blood pressure 100/65 mmHg. What is the most appropriate interpretation and management?
Gynaecology UK Medical PG Practice Questions and MCQs
Question 71: A 46-year-old woman presents with a 12-month history of heavy menstrual bleeding significantly affecting her quality of life. She has used maximum-dose tranexamic acid and mefenamic acid without adequate improvement. She declined the levonorgestrel intrauterine system. Examination reveals a mobile, non-tender uterus of approximately 10-week size. Transvaginal ultrasound shows a bulky uterus with adenomyosis and endometrial thickness of 8mm. She has completed her family. What is the most appropriate next management step?
A. Offer endometrial ablation after appropriate counselling (Correct Answer)
B. Prescribe continuous oral progestogen therapy with norethisterone
C. Refer for GnRH analogue therapy with add-back hormone replacement
D. Arrange hysterectomy without further medical management trials
E. Prescribe combined oral contraceptive pill for three months then review
Explanation: ***Offer endometrial ablation after appropriate counselling***
- In patients with **heavy menstrual bleeding (HMB)** who fail or decline pharmaceutical treatments like **LNG-IUS**, **tranexamic acid**, or **mefenamic acid**, surgical options such as **endometrial ablation** are recommended by NICE guidelines.
- It is a suitable choice for this patient as she has **completed her family** and has a uterus less than **10-week size**, although she must be counselled that **adenomyosis** may reduce its overall success rate.
*Prescribe continuous oral progestogen therapy with norethisterone*
- This is generally not considered a long-term first-line solution due to a significant **side-effect profile** and lower efficacy compared to structural or hormonal interventions.
- It lacks the high patient satisfaction rates and definitive management benefits provided by **ablation** or **hysterectomy** in cases of failed medical therapy.
*Refer for GnRH analogue therapy with add-back hormone replacement*
- **GnRH analogues** are typically used as a **temporary measure** to thin the endometrium before surgery or to manage symptoms short-term, rather than as a primary management step.
- Their use is limited by concerns over **bone mineral density loss** and the recurrence of symptoms once the medication is discontinued.
*Arrange hysterectomy without further medical management trials*
- While **hysterectomy** is a definitive option and effective for **adenomyosis**, it is a major surgical procedure with a longer **recovery time** and higher complication risk than ablation.
- Guidelines suggest offering **endometrial ablation** as a less invasive alternative before proceeding to major abdominal surgery, unless the patient specifically requests it or ablation is contraindicated.
*Prescribe combined oral contraceptive pill for three months then review*
- The **combined oral contraceptive pill** is likely to be less effective in a 46-year-old with a **bulky, adenomyotic uterus** and already established failed medical management.
- Given her age and clinical history, moving toward a **surgical management** option is more appropriate than continuing to trial oral pharmaceutical agents.
Question 72: A 29-year-old woman presents to the emergency department with 6 weeks amenorrhoea and right lower abdominal pain. She has a history of pelvic inflammatory disease treated 2 years ago. Examination reveals right iliac fossa tenderness without peritonism. She is haemodynamically stable. Serum beta-hCG is 4,200 IU/L. Transvaginal ultrasound shows an empty uterus with endometrial thickness of 9mm, a 28mm right adnexal mass with a hyperechoic ring, and a small amount of free fluid in the pouch of Douglas. What is the most appropriate management?
A. Intramuscular methotrexate with beta-hCG monitoring
B. Emergency laparoscopic salpingectomy (Correct Answer)
C. Expectant management with weekly beta-hCG measurements
D. Laparoscopic salpingotomy with preservation of the tube
E. Diagnostic laparoscopy followed by shared decision-making regarding surgical approach
Explanation: ***Emergency laparoscopic salpingectomy***
- **Surgical intervention** is the gold standard for ectopic pregnancy when **beta-hCG levels exceed 3,000-3,500 IU/L** or when medical management criteria are not met.
- **Laparoscopic salpingectomy** is preferred over salpingotomy if the contralateral tube is healthy, as it prevents **persistent trophoblast** and removes a tube likely damaged by prior **pelvic inflammatory disease**.
*Intramuscular methotrexate with beta-hCG monitoring*
- Medical management is generally reserved for patients with a **beta-hCG <1,500-3,000 IU/L** and no visible fetal heartbeat or significant pain.
- This patient’s **beta-hCG of 4,200 IU/L** significantly increases the risk of treatment failure and subsequent **tubal rupture** with methotrexate.
*Expectant management with weekly beta-hCG measurements*
- This approach is only appropriate for clinically stable patients with very low, **declining beta-hCG levels** (typically <1,000-1,500 IU/L).
- High baseline **beta-hCG levels** and the presence of **adnexal pain** make expectant management unsafe and inappropriate.
*Laparoscopic salpingotomy with preservation of the tube*
- Salpingotomy carries a higher risk of **persistent trophoblastic tissue**, requiring post-operative beta-hCG monitoring and potential methotrexate treatment.
- It is usually reserved for patients with a **damaged contralateral tube** who wish to maintain future fertility, which is not indicated as the primary concern here.
*Diagnostic laparoscopy followed by shared decision-making regarding surgical approach*
- While shared decision-making is important, the definitive diagnosis of **ectopic pregnancy** is already established by the high **beta-hCG and ultrasound findings**.
- Delaying the specific procedure for further discussion during surgery is inefficient when **salpingectomy** is the clinically recommended definitive treatment for a damaged tube.
Question 73: A 38-year-old woman with heavy menstrual bleeding has had a levonorgestrel intrauterine system in situ for 8 months. She returns to clinic reporting persistent irregular bleeding and spotting occurring 15-20 days per month. She is finding this unacceptable and wishes to have the LNG-IUS removed. Prior to LNG-IUS insertion, her ultrasound showed a normal uterus with endometrial thickness of 8mm. What is the most appropriate next step in management?
A. Remove LNG-IUS and prescribe tranexamic acid and mefenamic acid (Correct Answer)
B. Reassure that irregular bleeding settles by 6 months and continue for another 4 months
C. Remove LNG-IUS and commence combined oral contraceptive pill
D. Arrange hysteroscopy to exclude endometrial pathology before removing LNG-IUS
E. Remove LNG-IUS and arrange endometrial ablation
Explanation: ***Remove LNG-IUS and prescribe tranexamic acid and mefenamic acid***
- The patient has had the LNG-IUS for **8 months**, which is beyond the typical 3-6 month adaptation period for irregular bleeding. Her reporting of **persistent irregular bleeding** (15-20 days per month) that she finds **unacceptable** necessitates honoring her request for removal due to **patient autonomy**.
- After removal, for persistent heavy menstrual bleeding, **tranexamic acid** (an antifibrinolytic) and **mefenamic acid** (an NSAID) are effective **non-hormonal medical treatments** that can be offered as first-line options.
*Reassure that irregular bleeding settles by 6 months and continue for another 4 months*
- The patient is already at **8 months** of LNG-IUS use, past the typical 3-6 month period where irregular bleeding is expected to settle, making further reassurance without action inappropriate.
- The patient explicitly states the bleeding is **unacceptable** and wishes for removal, therefore continued use against her will disregards **patient preference** and quality of life.
*Remove LNG-IUS and commence combined oral contraceptive pill*
- While the **combined oral contraceptive pill (COCP)** is a valid treatment for heavy menstrual bleeding, the patient's dissatisfaction stems from **hormonal irregular bleeding** with the LNG-IUS, so switching immediately to another hormonal method may not be her preferred choice without exploring non-hormonal options.
- A 38-year-old would require a full assessment for **COCP contraindications** (e.g., smoking, migraines with aura, BMI) before initiation.
*Arrange hysteroscopy to exclude endometrial pathology before removing LNG-IUS*
- The patient had a **normal ultrasound** and a normal **endometrial thickness of 8mm** prior to LNG-IUS insertion, which makes significant underlying endometrial pathology less likely to be the cause of the current irregular bleeding.
- **Hysteroscopy** is an invasive procedure generally reserved for cases with abnormal findings on ultrasound, failure of medical management, or new **red flag symptoms**, not as a routine step before removing a device at patient request.
*Remove LNG-IUS and arrange endometrial ablation*
- **Endometrial ablation** is a **surgical procedure** that is typically considered a **second-line treatment** for heavy menstrual bleeding, offered after medical management has failed or is contraindicated.
- It is a permanent procedure requiring **permanent contraception** and extensive counseling, making it an overly aggressive and premature step before trying simpler, less invasive medical options following LNG-IUS removal.
Question 74: A 44-year-old multiparous woman presents with heavy menstrual bleeding that has not responded to tranexamic acid or mefenamic acid. She has completed her family and does not wish to use hormonal treatments. Examination reveals a 16-week-size uterus with multiple palpable irregular masses. Transvaginal ultrasound confirms multiple intramural and subserosal fibroids, the largest measuring 8cm. She has significant dysmenorrhoea and pressure symptoms including urinary frequency. Haemoglobin is 88 g/L. What is the most appropriate definitive management?
A. Total abdominal hysterectomy (Correct Answer)
B. Uterine artery embolisation
C. Laparoscopic myomectomy
D. Levonorgestrel intrauterine system insertion
E. GnRH analogue therapy for 6 months
Explanation: ***Total abdominal hysterectomy***
- This is the **definitive management** for symptomatic fibroids in a woman who has **completed her family**, has failed medical therapy, and specifically **declines hormonal treatments**.
- The **16-week-size uterus** and multiple large fibroids make an **abdominal approach** the most appropriate surgical route to ensure complete removal and address **pressure symptoms** and **anaemia**.
*Uterine artery embolisation*
- While it is a uterine-sparing option, it is less effective for **very large and multiple fibroids** and has a higher risk of requiring **secondary interventions** compared to hysterectomy.
- It may not resolve **pressure symptoms** as effectively as a hysterectomy when the uterine volume is significantly increased, and the patient seeks definitive management.
*Laparoscopic myomectomy*
- This procedure is primarily considered for women who wish to **preserve fertility** or their uterus, which is not a priority for this patient who has completed her family.
- Given the **multiple intramural fibroids** and large uterine size, complete resection would be complex with a high risk of **recurrence** and significant intraoperative bleeding, not offering a definitive solution.
*Levonorgestrel intrauterine system insertion*
- The patient has specifically stated she **does not wish to use hormonal treatments**, making this an inappropriate choice despite its efficacy in some cases of HMB.
- **Cavity distortion** from large intramural fibroids often leads to a high **expulsion rate** of the device and reduced efficacy in controlling bleeding and dysmenorrhoea.
*GnRH analogue therapy for 6 months*
- These are **temporary measures** often used to shrink fibroids and improve **anaemia** pre-operatively rather than serving as a **definitive treatment**.
- Symptoms and fibroid size typically **rebound** rapidly once the medication is discontinued, and long-term use is limited by side effects like **bone mineral density loss**.
Question 75: A 35-year-old woman with a body mass index of 34 kg/m² presents with a 14-month history of increasingly irregular and heavy menstrual bleeding. Her cycles vary from 21 to 45 days, and bleeding lasts 7-10 days. She has noticed increased facial hair growth over the past year. Pelvic examination is normal. Transvaginal ultrasound shows a bulky uterus with endometrial thickness of 14mm and multiple small peripheral follicles in both ovaries. What is the most important next investigation?
A. Endometrial biopsy (Correct Answer)
B. Serum follicle-stimulating hormone and luteinising hormone levels
C. Hysteroscopy with directed biopsies
D. Serum testosterone and sex hormone-binding globulin
E. MRI pelvis to assess uterine pathology
Explanation: ***Endometrial biopsy***
- This patient presents with significant risk factors for **endometrial hyperplasia or carcinoma**, including **obesity**, **irregular heavy menstrual bleeding** (suggesting chronic anovulation and unopposed estrogen), and clinical features of **PCOS** (hirsutism, ovarian morphology on ultrasound).
- An **endometrial thickness of 14mm** in a symptomatic premenopausal woman with these risk factors mandates an immediate **histological assessment** to rule out malignancy, making it the most critical next step.
*Serum follicle-stimulating hormone and luteinising hormone levels*
- These tests can aid in the diagnostic workup for **PCOS** by evaluating the **LH:FSH ratio**, which is often elevated in this condition.
- However, while useful for confirming PCOS, hormonal assessment is secondary to ruling out urgent pathology like **endometrial cancer** in a patient with a significantly thickened endometrium and irregular bleeding.
*Hysteroscopy with directed biopsies*
- **Hysteroscopy** allows for direct visualization of the uterine cavity and targeted biopsies, which is valuable for focal lesions or failed blind biopsies.
- However, a less invasive **blind endometrial biopsy** (e.g., pipelle biopsy) is generally the appropriate initial investigation for diffuse endometrial assessment in the outpatient setting to assess global risk.
*Serum testosterone and sex hormone-binding globulin*
- These levels are essential for biochemically confirming **hyperandrogenism**, which explains the patient's **hirsutism** and supports the diagnosis of PCOS.
- While important for managing the patient's underlying PCOS, these tests do not directly address the immediate and more pressing concern of **endometrial pathology** or the cause of the abnormal bleeding.
*MRI pelvis to assess uterine pathology*
- **MRI** is not a first-line investigation for evaluating abnormal uterine bleeding or thickened endometrium, especially after a **transvaginal ultrasound** has been performed.
- It cannot provide a **histological diagnosis**, which is paramount for differentiating benign endometrial changes from **hyperplasia** or **malignancy**, making it unsuitable as the most important next step.
Question 76: A 30-year-old woman presents to the emergency department with 6 weeks amenorrhoea, mild right-sided abdominal pain, and minimal vaginal spotting. She is haemodynamically stable. Transvaginal ultrasound shows an empty uterus with endometrial thickness of 12mm and a 15mm adnexal mass with a hyperechoic ring. There is no free fluid in the pouch of Douglas. Serum beta-hCG is 1,200 IU/L. She has no significant past medical history and takes no regular medications. What is the most appropriate next step in management?
A. Repeat beta-hCG in 48 hours to assess rate of change (Correct Answer)
B. Administer intramuscular methotrexate 50mg/m² immediately
C. Arrange emergency laparoscopy for salpingectomy
D. Commence expectant management with weekly beta-hCG monitoring
E. Perform diagnostic uterine curettage to exclude miscarriage
Explanation: ***Repeat beta-hCG in 48 hours to assess rate of change***
- Since the serum **beta-hCG is 1,200 IU/L** (below the typical **discriminatory zone** of 1,500–2,000 IU/L), an intrauterine pregnancy (IUP) may not yet be visible on ultrasound.
- Monitoring the **rate of change** helps differentiate between a viable IUP (expected rise >63%), an **ectopic pregnancy** (plateau or suboptimal rise), or a failing pregnancy.
*Administer intramuscular methotrexate 50mg/m² immediately*
- **Methotrexate** is contraindicated until a viable IUP has been definitively excluded, as it is highly **teratogenic**.
- The patient is currently **clinically stable**, allowing time to confirm the diagnosis through serial biochemical monitoring.
*Arrange emergency laparoscopy for salpingectomy*
- Surgical intervention is reserved for patients who are **haemodynamically unstable**, have signs of **peritoneal irritation**, or have a large adnexal mass (>35mm).
- This patient is stable with no **free fluid** in the pouch of Douglas, making immediate surgery unnecessary and potentially premature.
*Commence expectant management with weekly beta-hCG monitoring*
- **Expectant management** for a confirmed ectopic pregnancy typically requires the beta-hCG to be **initially falling** and often <1,000 IU/L.
- Weekly monitoring is inappropriate at this stage because the diagnosis of a **pregnancy of unknown location (PUL)** has not yet been resolved.
*Perform diagnostic uterine curettage to exclude miscarriage*
- **Uterine curettage** is an invasive procedure that carries the risk of terminating a **viable early intrauterine pregnancy**.
- It is only considered in cases of PUL where the pregnancy is confirmed to be **non-viable** (via serial hCG) and the location remains uncertain.
Question 77: A 42-year-old woman with heavy menstrual bleeding is assessed in the gynaecology clinic. She reports flooding through night-time protection and passing clots larger than a 50-pence coin. Her menstrual cycle is regular at 28 days, with bleeding lasting 8 days. Abdominal and pelvic examination are unremarkable. Full blood count shows haemoglobin 95 g/L and ferritin 8 μg/L. Transvaginal ultrasound demonstrates a normal uterus with endometrial thickness of 7mm. What is the most appropriate first-line medical treatment?
A. Levonorgestrel intrauterine system (Correct Answer)
B. Combined oral contraceptive pill
C. Oral norethisterone 5mg three times daily from days 5-26 of cycle
D. Tranexamic acid 1g three times daily during menstruation
E. Intramuscular medroxyprogesterone acetate 150mg every 12 weeks
Explanation: ***Levonorgestrel intrauterine system***- According to **NICE guidelines**, the **LNG-IUS** is the first-line treatment for heavy menstrual bleeding (HMB) in women with no identified uterine pathology.- It is highly effective in reducing blood loss, provides **long-term contraception**, and helps in the management of associated **iron-deficiency anemia** by reducing menstrual blood loss.*Combined oral contraceptive pill*- The COCP is an effective treatment for HMB but is usually considered a **second-line option** if the LNG-IUS is declined or unsuitable.- It carries more potential systemic **side effects** and **contraindications** compared to the LNG-IUS, such as an increased risk of venous thromboembolism.*Oral norethisterone 5mg three times daily from days 5-26 of cycle*- **Cyclical oral progestogens** are generally less effective at reducing menstrual blood loss compared to the LNG-IUS.- High-dose norethisterone can be associated with significant **side effects** like mood changes, bloating, and weight gain.*Tranexamic acid 1g three times daily during menstruation*- **Tranexamic acid** is a non-hormonal option and can be used for HMB, but it is typically less effective than the LNG-IUS for substantial, long-term blood loss reduction.- It only reduces bleeding during menstruation and **does not provide contraception** or directly improve iron deficiency beyond reducing blood flow.*Intramuscular medroxyprogesterone acetate 150mg every 12 weeks*- **Injectable progestogens** are not a primary first-line treatment for heavy menstrual bleeding, particularly when other more effective and less impactful options exist.- Long-term use is associated with potential concerns regarding **bone mineral density** and a variable return to fertility after discontinuation.
Question 78: A 39-year-old nulliparous woman presents with heavy menstrual bleeding for 14 months. She reports flooding and clots, requiring time off work. Examination reveals a 16-week size irregular uterus. Ultrasound confirms multiple fibroids, with the largest (8cm) being intramural and distorting the endometrial cavity. Endometrial biopsy shows proliferative endometrium with no atypia. She strongly wishes to preserve her fertility. What is the most appropriate management option to discuss?
A. Levonorgestrel intrauterine system insertion
B. Uterine artery embolization
C. GnRH agonist therapy for 6 months followed by myomectomy (Correct Answer)
D. Hysteroscopic fibroid resection
E. Ulipristal acetate 5mg daily for 3 months
Explanation: ***GnRH agonist therapy for 6 months followed by myomectomy***
- **Myomectomy** is the gold standard surgical approach for women with symptomatic **intramural fibroids** who strongly desire to preserve their **fertility**, particularly when the fibroid distorts the endometrial cavity.
- Pre-operative **GnRH agonists** are used to reduce fibroid size and **vascularity**, which decreases intraoperative blood loss and allows time to correct any associated **anemia** before surgery.
*Levonorgestrel intrauterine system insertion*
- The effectiveness and suitability of a **levonorgestrel intrauterine system** (LNG-IUS) are significantly compromised when there is marked **endometrial cavity distortion** by a large fibroid, like an 8cm intramural fibroid.
- While effective for managing **heavy menstrual bleeding**, it does not address the **mass effect** of the fibroid or its impact on uterine structure, which is crucial for fertility preservation.
*Uterine artery embolization*
- **Uterine artery embolization (UAE)** is generally not recommended for women who desire future **pregnancy** due to potential risks of **ovarian compromise** and adverse obstetric outcomes, including higher rates of miscarriage, preterm birth, and placental complications.
- Although it can reduce fibroid size and symptoms, its long-term impact on **fertility** makes it a less appropriate choice in this clinical scenario.
*Hysteroscopic fibroid resection*
- **Hysteroscopic fibroid resection** is primarily indicated for **submucosal fibroids** (Type 0, 1, or 2) that project into the uterine cavity, and are typically smaller in size.
- An 8cm **intramural fibroid** cannot be safely or completely resected via a **hysteroscopic** approach as it is embedded within the myometrial wall.
*Ulipristal acetate 5mg daily for 3 months*
- The use of **Ulipristal acetate** for fibroid treatment has been largely restricted or withdrawn in many regions due to concerns about a risk of **serious liver injury**.
- While it can reduce bleeding and fibroid volume, its safety profile and the availability of more established and safer preoperative options like **GnRH agonists** make it less favorable.
Question 79: A 41-year-old woman presents with increasingly heavy menstrual bleeding over 18 months. Transvaginal ultrasound shows multiple intramural fibroids, the largest measuring 6cm, and a uniformly thickened endometrium of 11mm in the secretory phase. She has dysmenorrhoea and deep dyspareunia. She has completed her family. Examination reveals a bulky, tender uterus. What additional diagnosis should be considered alongside the fibroids?
A. Endometrial hyperplasia
B. Endometriosis
C. Adenomyosis (Correct Answer)
D. Chronic pelvic inflammatory disease
E. Endometrial polyp
Explanation: ***Adenomyosis***- The presence of a **bulky, tender uterus** on examination is a classic sign of adenomyosis; fibroids typically present as a non-tender enlarged uterus unless undergoing degeneration.- Clinical features such as **heavy menstrual bleeding**, **progressive dysmenorrhea**, and **deep dyspareunia** often occur together when adenomyosis coexists with fibroids.*Endometrial hyperplasia*- While it causes heavy bleeding, an **endometrial thickness of 11mm** is considered within the **normal range** for the secretory phase (7-16mm).- Hyperplasia would not typically explain a **tender, bulky uterus** or significant **deep dyspareunia**.*Endometriosis*- While associated with dysmenorrhea and dyspareunia, it involves ectopic tissue **outside the uterus**, which usually does not cause the uterus itself to be **bulky**.- Uterine tenderness in endometriosis is often related to **fixed retroversion** or pelvic nodules rather than global uterine enlargement.*Chronic pelvic inflammatory disease*- This usually presents with **chronic pelvic pain**, adnexal tenderness, and a history of infection rather than isolated heavy menstrual bleeding and a **bulky uterus**.- Ultrasound would more likely show **hydrosalpinx** or tubo-ovarian complexes rather than intramural fibroids and uniform thickening.*Endometrial polyp*- Polyps are more commonly associated with **intermenstrual bleeding** or postmenopausal bleeding rather than progressive global uterine tenderness.- A polyp would usually appear as a **focal echogenic mass** within the endometrial cavity on ultrasound, rather than a uniformly thickened endometrium.
Question 80: A 28-year-old woman is being monitored for a pregnancy of unknown location following one dose of intramuscular methotrexate given 6 days ago for a presumed ectopic pregnancy. Her initial beta-hCG was 1,650 IU/L. She now presents to the emergency department with worsening right-sided abdominal pain and shoulder tip pain. She is tachycardic at 110 bpm with blood pressure 100/65 mmHg. What is the most appropriate interpretation and management?
A. This represents separation pain; manage with analgesia and reassess in 24 hours
B. Arrange urgent beta-hCG to assess treatment response before deciding on management
C. This suggests methotrexate treatment failure; administer second dose of methotrexate
D. This indicates possible tubal rupture; arrange emergency laparoscopy (Correct Answer)
E. Perform urgent transvaginal ultrasound to visualize ectopic pregnancy location
Explanation: ***This indicates possible tubal rupture; arrange emergency laparoscopy***
- The patient exhibits classic signs of **ruptured ectopic pregnancy**, including **shoulder tip pain** (suggestive of diaphragmatic irritation from blood) and **hemodynamic instability** (tachycardia and hypotension).
- While medical management with **methotrexate** was initiated, its risk of treatment failure and subsequent **tubal rupture** necessitates immediate surgical intervention when clinical deterioration occurs.
*This represents separation pain; manage with analgesia and reassess in 24 hours*
- **Separation pain** (occurring 3-7 days after treatment) is typically milder and not associated with **hemodynamic compromise** or **shoulder tip pain**.
- Dismissing these red-flag symptoms as benign could lead to a life-threatening **hemoperitoneum** and maternal collapse.
*Arrange urgent beta-hCG to assess treatment response before deciding on management*
- While **beta-hCG levels** are monitored on days 4 and 7 post-methotrexate, clinical stability always takes precedence over biochemical trends.
- Waiting for lab results in a patient showing signs of **internal hemorrhage** unnecessarily delays life-saving **operative management**.
*This suggests methotrexate treatment failure; administer second dose of methotrexate*
- A **second dose of methotrexate** is only considered if beta-hCG does not drop by >15% between days 4 and 7, and only if the patient remains **hemodynamically stable**.
- Administering further medical therapy in the face of a suspected **tubal rupture** is strictly contraindicated.
*Perform urgent transvaginal ultrasound to visualize ectopic pregnancy location*
- While **transvaginal ultrasound** could show free fluid, it should not delay the transfer to theater in a patient with clear clinical signs of **peritoneal irritation** and tachycardia.
- **Surgical exploration** via laparoscopy is the definitive diagnostic and therapeutic step for suspected **ruptured ectopic pregnancy**.
