MCQ answers
1 True: a, b, e. Shifting dullness and a fluid thrill are found with ascites or fluid within the peritoneal cavity.
See Chapter 1, Gynaecology by Ten Teachers, 18th edition.
2 True: a, c, e. The Fallopian tube has a lateral ampulla, middle isthmus and medial ostium. The ovary is
attached to the cornua of the uterus by the ovarian ligament and to the hilum by the broad ligament.
See Chapter 2, Gynaecology by Ten Teachers, 18th edition.
3 True: b, c. The normal bladder capacity is 400 mL. The ureter lies lateral to the ovary passing through the
ovarian fossa. The rectum is covered by peritoneum on the front and sides in its upper third, front in its middle third and not at all in its lower third.
See Chapter 2, Gynaecology by Ten Teachers, 18th edition.
4 True: a, c, d. 5-Alpha-reductase deficiency results in failure of virilization of the cloaca owing to the failure of
conversion of testosterone to dihydrotestosterone. If this enzyme is absent, then the external genitalia will be
female but the internal genitalia will be male. Mullerian ducts will regress as the testes still produce Mullerian
inhibitory factor.
See Chapter 3, Gynaecology by Ten Teachers, 18th edition.
5 True: a, b, e. Failure of development of the paramesonephric ducts causes abnormalities in the uterus, cervix
and is associated with a degree of reproductive failure. In congenital adrenal hyperplasia, 21-hydroxylase deficiency prevents the adrenal gland from producing cortisol. Failure of production of cortisol results via a feedback mechanism to stimulate the hypothalamus to produce increased adrenocorticotrophic hormone
(ACTH), which in turn stimulates the adrenal gland to produce excessive amounts of the steroid precursor
17-hydroxyprogesterone. As a result, the adrenal gland produces excessive androgens, which lead to virilization of the cloaca.
See Chapter 3, Gynaecology by Ten Teachers, 18th edition.
6 True: b, c. The follicular phase varies in duration and this determines the cycle length (28–35 days). During
each cycle, several primordial follicles develop, but only one follicle becomes dominant and continues to grow
to around 20 mm in diameter. This follicle can be measured on ultrasound. It produces more oestrogen, while
other follicles degenerate (undergo atresia). Ovarian cysts can grow up to 50 mm without any intervention necessary other than ultrasound observation. When cysts grow over 50 mm, there is a risk of ovarian torsion and,
therefore, if they are persistent over 6 months observation, drainage or cystectomy are required. Oestrogen
and inhibin have a negative feedback on the production of FSH.
See Chapter 4, Gynaecology by Ten Teachers, 18th edition.
7 True: b. Luteinizing hormone stimulates the thecal cells to produce progesterone. Ovulation occurs 24 hours
after the LH surge. Ovulation is caused by the enzymatic degradation of the follicle membrane by endogenous plasminogen activators and prostaglandins. Fertilization involves the degradation of the zona pellucida
of the oocyte by enzymes released from the acrosome of the sperm. Ovulation can be confirmed by measuring
progesterone in the mid-luteal phase.
See Chapter 4, Gynaecology by Ten Teachers, 18th edition.80 Gynaecology
8 True: a, b. The luteal phase is always 14 days (i.e. progesterone peaks on day 21 of a 28-day cycle and day 28
of a 35-day cycle). If pregnancy occurs, serum beta-human chorionic gonadotrophin (sβ-hCG) is produced
by the trophoblast. This has a similar structure to LH. Both LH and sβ-hCG cause the corpus luteum to
mature (and not degenerate) in early pregnancy until the early placenta can produce progesterone, which is
the predominant hormone of the luteal phase and early pregnancy. The granulosa cells have a yellow pigment called lutein, which is rich in cholesterol. Oestrogen and progesterone levels vary throughout the cycle.
The perimenopause is associated with a high FSH. This blood test should be taken within 5 days of the last
menstrual period, as this is when they should be at their lowest.
See Chapter 4, Gynaecology by Ten Teachers, 18th edition.
9 True: c, d. Polymenorrhoea is defined as menses occurring at a 21-day interval. Oligomenorrhoea is
defined as menses at intervals of 35 days. Menorrhagia is defined as prolonged increased menstrual flow.
See Chapter 5, Gynaecology by Ten Teachers, 18th edition.
10 True: a, d. Thyroid function tests are only indicated if there is a clinical suspicion of thyroid disease. Royal
College of Obstetricians and Gynaecologists (RCOG) guidelines suggest a hysteroscopy is indicated in women
over the age of 40. If the cycle is regular, this is sufficient to suggest ovulation.
See Chapter 5, Gynaecology by Ten Teachers, 18th edition.
11 True: a, c, e. The progesterone-only pill has a higher risk of ectopic pregnancy compared with the combined
oral contraceptive pill and has a worse bleeding profile compared to the combined pill. As it does not inhibit
ovulation in all women, it is quicker to resume ovulation after stopping the progesterone-only pill, compared
with the combined oral contraceptive.
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.
12 True: a,b, c. The Implanon involves insertion of a single rod into the upper arm and this lasts for up to 3 years.
The previous Norplant implants were licensed for 5 years and involved five rods into the upper arm but have
since been withdrawn. The return to ovulation after removal of an Implanon implant is usually within 30 days.
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.
13 True: a, e. The levonorgestrel intrauterine system (Mirena) is licensed currently for 5 years. Irregular heavy
bleeding is a side effect associated with the copper coil; however, the Mirena is usually associated with reduction
of menstrual loss. There is no increased risk of pelvic inflammatory disease with coil use; in fact, it is the same as
with other contraceptive methods. The risk of infection is only increased at the time of insertion or removal.
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.
14 True: a, b. The combined pill has a 12-hour window. Acute/severe liver disease is an absolute contraindication to COCP usage. The risk of VTE is 15 per 100 000 for second-generation users, 30 per 100 000 for thirdgeneration users and 60 per 100 000 for pregnancy.
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.
15 True: a, e. Rates of conception rapidly decline after the age of 35. Tubal infertility is the main cause of infertility in Africa; however, in the Western world, male factors or ovulation disorders are the most likely cause of
infertility.A young couple with no adverse infertility factors have a 20 per cent chance of conceiving each cycle.
See Chapter 7, Gynaecology by Ten Teachers, 18th edition.MCQ answers 81
16 True: c. Investigations for infertility are expensive and some of them are invasive. Therefore, investigations
should be directed towards each couple having gained an insight into the possible cause of infertility from
the history. For example, a woman with a regular menstrual cycle need only require a mid-luteal progesterone to suggest ovulation occurs and does not need a full hormone profile. Further investigations are targeted according to the clinical picture. A low mid-luteal progesterone will confirm anovulation. A high
progesterone of 30 nmol/L is certainly suggestive of ovulation but does not confirm ovulation. Ovulation
can only be truly confirmed by serial scanning of ovarian follicles. However, in day to day use, a regular cycle
and a progesterone level of 30 nmol/L is usually seen as indicative of ovulation.
Full investigations for ovulatory disorders and male factor infertility are mandatory prior to embarking
upon laparoscopy and tubal patency testing, as this procedure does have a morbidity associated with it. A
hysterosalpingogram will gain information on tubal patency and uterine cavity outline; however, this does
not give any indication of pelvic disease, such as previous pelvic infection or endometriosis. Laparoscopy allows
both the tubal patency to be assessed as well as staging degree of endometriosis or pelvic inflammatory disease.
A normal semen analysis obtained after 3 days abstention is sufficient to confirm a normal healthy population of sperm; however, a single suboptimal sample needs repeating to confirm oligospermia and further
investigations are necessary until two suboptimal samples have been obtained. If a subsequent sample is
normal, then no further action is necessary.
See Chapter 7, Gynaecology by Ten Teachers, 18th edition.
17 True: d. If the cervical os is open, it is an inevitable miscarriage. If an ultrasound scan shows products of
50 mm. in diameter, one would consider evacuation of retained products of conception. If products are
between 30 and 50 mm, one would consider either medical or surgical evacuation of the uterus, and if
30 mm conservative treatment would be appropriate. Serum β-hCG is not useful in dating the pregnancy
and levels vary considerably between patients at the same gestation. The snowstorm appearance on ultrasound scan is suggestive of hydatidiform mole pregnancy.
See Chapter 8, Gynaecology by Ten Teachers, 18th edition.
18 True: a, b, c. Miscarriage is much more likely after the age of 40 (30–40 per cent) compared to under the age of
40 (6–10 per cent). The most common cause of spontaneous miscarriage is a spontaneous chromosomal defect.
See Chapter 8, Gynaecology by Ten Teachers, 18th edition.
19 True: a, b, d. Ultrasound is very useful in assessing molar pregnancy. There is a typical ‘snowstorm’ appearance but with partial molar pregnancies, one can also see a fetus. Histology is used to confirm the diagnosis.
Partial molar pregnancies are usually triploid, having two sets of chromosomes from the paternal origin and
one from maternal origin. Most have a 69XXX or 69XXY gene type.
See Chapter 8, Gynaecology by Ten Teachers, 18th edition.
20 True: c, d. The incidence of ectopic pregnancy is 22 per 1000 live births and 16 per 1000 pregnancies. Ectopic
pregnancy is associated with chlamydial infection and methotrexate is contraindicated if the mass is 2 cm
in diameter.
See Chapter 8, Gynaecology by Ten Teachers, 18th edition.82 Gynaecology
21 True: a, b. The outpouching of columnar epithelium on to the ectocervix is termed as cervical ectropion or
ectopy. An erosion is a common misnomer, which should be avoided, as it conveys the impression of eroded
tissue on the surface of the cervix which is incorrect. Columnar epithelium undergoes metaplasia to a normal squamous epithelium. The change of one normal cell type to another cell type is termed metaplasia,
whereas dysplasia describes transformation from a normal cell type to an abnormal cell type (e.g. cervical
intraepithelium neoplasia).
Vaginal discharge and postcoital bleeding should always be seen as pathological until proven otherwise.
Other causes of vaginal discharge need to be excluded prior to treatment with cold coagulation. High vaginal
swabs for bacterial vaginosis and endocervical swabs for chlamydia and gonorrhoea need to be taken and
colposcopy needs to be undertaken if the patient does not have normal cytology on smear. A physiological
vaginal discharge and postcoital bleeding are often seen with an ectopy, but a cervical malignancy or infective lesion need to be excluded prior to treatment with cold coagulation or, occasionally, some clinicians will
use a gel to alter the vaginal pH which can shrink an ectropion.
See Chapter 9, Gynaecology by Ten Teachers, 18th edition.
22 True: a, d, e. Dermoid cysts are lined by either ectodermal tissue, such as skin, sebum or hair, or by endodermal tissue, such as bone or teeth. Typically, only 10 per cent of dermoids are bilateral.
See Chapter 11, Gynaecology by Ten Teachers, 18th edition.
23 True: a, c, d, e. Call–Exner bodies are pathognomonic of granulosa cell tumours.
See Chapter 11, Gynaecology by Ten Teachers, 18th edition.
24 True: c, d. Single cysts with no suspicious features tend not to be malignant. Multiple cysts located round the
periphery with a dense stroma are pathognomonic of polycystic ovary syndrome. Calcification and fat are
often suggestive of a dermoid cyst, which is benign.
See Chapter 11, Gynaecology by Ten Teachers, 18th edition.
25 True: b. Cervical cancer is the second commonest cancer in women worldwide; breast cancer being the commonest. There are approximately 1500 deaths in England and Wales from carcinoma of the cervix; however,
the rate has fallen steeply in recent years owing to the introduction of the cervical cytology screening programme. HPV type 16 and 18 are the most commonly associated with cervical cancer. Cervical cancer is
associated with previous HPV infection.
See Chapter 12, Gynaecology by Ten Teachers, 18th edition.
26 True: a, b, e. Cervical cytology is inaccurate in pregnancy and should be deferred until 12 weeks postpartum.
The cervical screening programme only screens for squamous cervical intraepithelial neoplasia. Occasionally, abnormalities of the glandular epithelia are detected (cervical glandular intraepithelial neoplasia;
CGIN) but can also be missed if they occur high up the cervical canal.
See Chapter 12, Gynaecology by Ten Teachers, 18th edition.
27 True: b, d.
See Chapter 12, Gynaecology by Ten Teachers, 18th edition.
28 True: a, b, e. Nulliparity and late menopause are risk factors for endometrial cancer along with ovarian
tumour, previous pelvic irradiation and a family history of breast, ovary or colon cancer.
See Chapter 12, Gynaecology by Ten Teachers, 18th edition.MCQ answers 83
29 True: b, d. Preclinical invasive disease of a depth of 3 mm and a width of 7 mm can be treated with a
LLETZ.With any greater depth, there is a risk of lymph nodal involvement and local spread; therefore, a radical hysterectomy should be performed. A Wertheim’s hysterectomy involves removal of the uterus, cervix,
paracervical tissue and lymph nodes, and the upper third of the vagina. Poor bladder emptying may be a
consequence of a Wertheim’s hysterectomy owing to division of the parasympathetic nerve supply to the
bladder, which runs in the uterosacral ligaments.
See Chapter 12, Gynaecology by Ten Teachers, 18th edition.
30 True: d. Carcinoma of the ovary is common in wealthy countries. It does have a similar incidence to carcinoma of the endometrium but has a much greater mortality. The peak age is 50–60 and is rare at an age of
35. The mainstay of treatment is surgery and chemotherapy with cisplatin and paclitaxol or carboplatin.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
31 True: b, c.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
32 True: a, d. Late menopause is associated with ovarian cancer and the combined pill is protective against
ovarian cancer with a lifetime instance of 4 times less than those not using the pill. Implanon has no effect
on the development of ovarian carcinoma.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
33 True: b, e. In the normal population, there is a lifetime risk of developing ovarian cancer of 1 per cent. If a
patient has one relative with ovarian cancer, their risk remains at 1–2 per cent. If a patient has two first-order
affected relatives, their risk increases to 10 per cent.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
34 All are true.Computerized tomography (CT) allows visualization of local invasion and spread to lymph nodes.
Barium enema and IVP evaluate tumour invasion into the rectum and descending colon and ureteric obstruction (although these are less commonly required). Ultrasound assesses the nature, size and location of the cyst
along with CT. CA 125 is a non-specific tumour marker used to monitor treatment of ovarian cancer.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
35 True: a, c, d. Cisplatin has a number of well-documented side effects, which include renal damage. However,
the nephrotoxicity can be prevented by the use of vigorous diuresis. Cumulative dose-related neurotoxicity
manifests as paraesthesia and ototoxicity.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
36 True: a, d. Theca cell tumours and androblastomas are both sex-cord stroma tumours. Teratoma is a germ
cell tumour.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
37 True: c, d. The peak age of instance is 30 years old. CA 125 is elevated in epithelial cell tumours, not dysgerminomas. Immature teratoma is malignant and the benign form is a mature teratoma, which is called a dermoid.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.84 Gynaecology
38 True: a, c, e. Although some systemic diseases such as diabetes are associated with pruritis vulvae, nephrotic
syndrome is not. Vaginal discharge may be concurrent but is not a cause of pruritis vulvae.
See Chapter 14, Gynaecology by Ten Teachers, 18th edition.
39 True: b, c, d. Lichen sclerosis commonly affects the labia minora and the perianal region. Dark red and
brown pigmentation is more suggestive of vulval intraepithelial neoplasia.
See Chapter 14, Gynaecology by Ten Teachers, 18th edition.
40 True: b, c. Primary syphilis causes vulval ulcers but tertiary syphilis causes neurosyphilis. HPV is not associated with vulval ulcers, but is associated with cervical intraepithelial neoplasia and cervical cancer. Ulcerative
colitis does not cause benign vulval ulcers, however, Crohn’s disease does.
See Chapter 14, Gynaecology by Ten Teachers, 18th edition.
41 True: c, d. The lower genital tract is lined by simple cuboidal epithelium in the pre-pubertal state and
changes to stratified squamous under the influence of oestrogen. Oestrogen causes the vaginal pH to be
reduced to around 3.5–4.5. Bacterial vaginosis is the commonest cause of abnormal vaginal discharge in
women of childbearing age.
See Chapter 15, Gynaecology by Ten Teachers, 18th edition.
42 True: b. Diagnosis of herpes simplex is made after collection of serum from vesicles. This is then analysed by
electron microscopy or monolayer tissue culture. Reactivation does arise in the dorsal root ganglia. Secondary
infection in pregnancy does not require delivery by lower segment Caesarean section as vertical transmission
cannot occur. The fetus develops passive immunity from maternal antibodies that cross the placenta. If there
is a primary infection near term, then delivery of the infant would be by Caesarean section. Antiviral treatment is not useful in established disease, as secondary infection usually resolves in the same time as viral
treatment would work.
See Chapter 15, Gynaecology by Ten Teachers, 18th edition.
43 True: a, d. The most sensitive and specific test for syphilis is fluorescent treponemal antibody (FTA). This
requires a skilled interpretation and most laboratories perform the Treponema pallidum haemagglutination
assay (TPHA) or Treponema pallidum particle agglutination (TPPA) test instead. A non-specific test, such as
the Venereal Disease Research Laboratory test (VDRL), is often used in addition. Usually primary syphilis
presents as a painless ulcer (chancre) with occasional regional lymph node enlargement. Treatment for
syphilis is with simple penicillin.
See Chapter 15, Gynaecology by Ten Teachers, 18th edition.MCQ answers 85
44 True: b, c. Stress incontinence is a symptom of an involuntary loss of urine when the patient coughs or
sneezes. It is not a diagnosis. Urodynamic stress incontinence (USI) is a diagnosis that is gained on filling
cystometry, if the patient leaks with a rise in intra-abdominal pressure but with no subsequent rise in detrusor pressure. Detrusor overactivity is idiopathic in 85 per cent of cases; however, it may be caused by neuropathy, incontinence surgery or outflow obstruction. Stress urinary incontinence results from poor
suburethral support and descent at the bladder neck and proximal urethra.
A total of 10–15 per cent of women have a poor urinary stream. This can be either due to urethral obstruction, which can be as a result of scarring from previous surgery, or extraurethral compression (e.g. gravid
uterus, ovarian cyst or fibroid). However, poor voiding may also be secondary to a weak detrusor muscle.
The only way to distinguish between the two is to perform pressure flow studies on the patient. Urethral
obstruction will have a high pressure–low flow picture, whereas a poor detrusor muscle will have a low pressure–low flow picture.
See Chapter 16, Gynaecology by Ten Teachers, 18th edition.
45 True: c, e. Pelvic organ prolapse is predominantly found in multiparous women. The risk of prolapse
increases with increasing parity. Pelvic organ prolapse affects around 2 per cent of nulliparous women and
this suggests a congenital predisposition in these women despite them not undergoing childbirth. Epidural
alone is not a risk factor for the development of prolapse; however, forceps macrosomia and malposition of
the baby are all associated with traumatic delivery and subsequent development of prolapse.
See Chapter 17, Gynaecology by Ten Teachers, 18th edition.
46 True: c, d. The follicles are located peripherally around the cortex of the ovary with the central medulla
being heavily vascularized. The central medulla is mesenchymal in origin. In a woman’s lifetime she will only
have around 400 follicles that will ovulate.
See Chapter 18, Gynaecology by Ten Teachers, 18th edition.
47 True: a, d. Androgens are converted to oestrogen by an enzyme called aromatase. The process is known as
aromatization. Granulosa cells are stimulated by FSH in the developing follicle and, once ovulation has
occurred, thecal cells produce oestrogen from androgens under the stimulating effect of LH. Initially, the
levels of inhibin produced by the ovary start to fall around the menopause. This glycoprotein inhibits FSH
production by the pituitary gland and, therefore, plasma FSH starts to rise around the menopause. It is only
in the true postmenopausal state can one measure consistently elevated FSH levels, which helps with the
diagnosis of the menopause.
See Chapter 18, Gynaecology by Ten Teachers, 18th edition.
48 True: b, d. Provided there is a normal-sized uterus, vaginal hysterectomy can often be performed and extensive prolapse is not necessary. Vaginal hysterectomy is associated with a quicker recovery. This is due to the
absence of an abdominal incision which causes much greater pain than a vaginal incision. Vaginal hysterectomy is associated with a high risk of haematoma formation. The risk of ureteric injury is higher with
abdominal surgery.
49 True: c, d. The gestation should not exceed 24 weeks. The request for termination can only be carried out
after two registered medical practitioners independently consider the effects of continuation of the pregnancy and feel that the woman has formed a judgement that termination is in her best interest. It is recommended that termination should be performed after 8 weeks’ gestation, as the chance
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