EMQ answers
1 Embryology
1 D 2 H 3 F 4 G
The sinovaginal bulbs develop as outgrowths that canalize and form the lower portion of the vagina below the
level of the hymen. The ovary is derived from three components: the genital ridge, underlying mesoderm and
the primitive germ cells. The genital tubercle forms the clitoris, the genital folds the labia minora and genital
swellings the labia majora.
See Chapter 2, Gynaecology by Ten Teachers, 18th edition.
2 Anatomy and physiology
1 G 2 E 3 F 4 C
Lymphatic drainage of the ovary is via a plexus of vessels lying in the infundibulopelvic folds to the para-aortic
node on both sides of the midline. The lymphatic drainage of the lower third of the vagina follows that of the
vulva to the superficial inguinal and femoral nodes, whilst the upper portion of the vagina follows that of the
cervix to the obturator, internal and external iliac nodes. The venous drainage of the ovary is to the renal vein on
the left and inferior vena cava on the right.
See Chapter 2, Gynaecology by Ten Teachers, 18th edition.
3 Normal and abnormal sexual development and puberty
1 G 2 H 3 F 4 D
The SRY gene lies on the short arm of the Y chromosome and is responsible for determination of testicular
development as it produces TDF (testicular development factor). TDF stimulates the undifferentiated gonad to
produce Mullerian inhibitor. The Leydig cells produce testosterone, which promotes development of the
Wolffian ducts into the vas deferens, epididymis and seminal vesicles.
See Chapter 3, Gynaecology by Ten Teachers, 18th edition.
4 Disorders of the menstrual cycle
1 C 2 D 3 G 4 A
Abnormal bleeding outside the normal menstrual cycle should always be investigated. Intermenstrual bleeding
is commonly associated with an endometrial polyp or luteal phase insufficiency. Postcoital bleeding should
always be investigated by visualization of the cervix to exclude a cervical malignancy. Postmenopausal bleeding
should be considered to be endometrial carcinoma until this has been excluded by either ultrasound and endometrial sampling, or hysteroscopy and curettage. Adenomyosis causes painful periods and is typified by a tender,
bulky uterus.
See Chapter 4, Gynaecology by Ten Teachers, 18th edition.
5 Disorders of the menstrual cycle
Surgical treatments
1 D 2 C 3 F 4 BEMQ answers 65
An endometrial curettage is useful to gain histology of the endometrium and is often performed at the time of
hysteroscopy. The endometrium can be either resected (transcervical resection of the endometrium; TCRE) or
ablated using microwaves, hot water or a balloon filled with heated solutions. Any of these methods can result in
reduced menstrual loss or amenorrhoea to various degrees. Myomectomy can be performed to remove large
fibroids to allow symptomatic relief without removal of the uterus, thus retaining a woman’s fertility. Pregnancy
is contraindicated after (TCRE) or ablation. Hysterectomy is the definitive treatment for menorrhagia. The route
is determined by the size of the uterus, the degree of uterine descent and the necessity for oopherectomy.
See Chapter 5, Gynaecology by Ten Teachers, 18th edition.
Medical treatments
1 C 2 E 3 A 4 D
The levonorgestrel intrauterine system (LNG-IUS) is an intrauterine device with a sleeve inpregnanted with
slow-release levonorgestrel (progesterone). Prolonged exposure of the endometrium to progesterone causes thinning of the endometrium and reduces menstrual loss. Cyclical progesterone causes the endometrium to remain
secretory until withdrawal of the progesterone, which results in menstruation.Antiprostaglandins, such as mefenamic
acid, are non-steroidal anti-inflammatory drug (NSAID) derivatives and inhibit prostaglandin formation, whereas
antifibrinolytics, such as tranexamic acid, inhibit lysis of formed clots. Both are useful in reducing loss in the regular cycle.
See Chapter 5, Gynaecology by Ten Teachers, 18th edition.
6 Infertility
1 E 2 F 3 D 4 A
Polycystic ovary syndrome is a condition associated with insulin resistance. Women are typically overweight,
hirsute and have acne. The hormone profile of these women typically shows elevated androgens and a low sex
hormone-binding globulin. Chlamydial infection is the commonest cause of pelvic inflammatory disease and
tubal factor infertility in the West. Men suffering from azoospermia have no sperm to be harvested and hence can
only have children either by adoption or donor insemination. Anovulation can be treated orally with Clomid or
by intramuscular gonadotrophins (e.g. Puregon).
See Chapter 7, Gynaecology by Ten Teachers, 18th edition.
7 Disorders of early pregnancy
1 E 2 C 3 A 4 D
Molar pregnancies can be either partial or complete depending on whether embryonic tissue also develops.
Incomplete miscarriage is associated with retained products of conception on ultrasound, whereas the uterus is
empty after a complete miscarriage. If a viable pregnancy is confirmed on ultrasound after bleeding, it is defined
as a threatened miscarriage. Ectopic pregnancies are typified by unilateral pain, blood in the pelvis, which causes
diaphragmatic irritation and pain referred to the shoulder tip.
See Chapter 8, Gynaecology by Ten Teachers, 18th edition.
8 Benign diseases of the cervix
1 F 2 C 3 D 4 G
Dyskaryosis is a cytological diagnosis made on a cervical smear. Cervical intraepithelial neoplasia (CIN) is a histological diagnosis made on biopsy of cervical tissue. Mild dyskaryosis is analogous to CIN1, moderate dyskayosis66 Gynaecology
to CIN2 and severe dyskaryosis to CIN3. Glandular atypia occurs in the columnar cells of the endocervical canal
and is associated with Cervical glandular intra-epithelial neoplasia (CGIN) and adenocarcinoma.
See Chapter 9, Gynaecology by Ten Teachers, 18th edition.
9 Benign diseases of the uterus
1 E 2 C 3 H 4 A
Fibroids can undergo various forms of change. A sudden loss of blood supply causes pain and red degeneration
typically seen in pregnancy. Slow outgrowth of its blood supply causes necrosis and cyst formation. After the
menopause, fibroids may calcify. Rarely, leiomyosarcoma can develop from fibroids.
See Chapter 9, Gynaecology by Ten Teachers, 18th edition.
10 Endometriosis and adenomyosis
1 B 2 D 3 G 4 E
Endometriosis is a benign condition that has various treatments depending on the clinical situation. Asymptomatic
endometriosis requires no treatment at all. The exogenous endometrial tissue is susceptible to endogenous oestrogen and the menstrual cycle. Mild to moderate endometriosis can be treated by administration of exogenous
hormones, such as the combined oral contraceptive pill or GnRH agonists to downregulate the hypothalamic–
pituitary–ovarian axis. Laser ablation to mild endometriosis has been shown to improve symptoms and improve
chances of conception in women with subfertility. Once a woman’s family is complete and there is extensive symptomatic disease, definitive treatment is necessary along with bilateral oophorectomy.
See Chapter 10, Gynaecology by Ten Teachers, 18th edition.
11 Benign diseases of the ovary
1 B 2 H 3 D 4 G
Ultrasound can be helpful in differentiating benign tumours. More often, histological classification is necessary
to determine the origin and nature of the tumour.
See Chapter 11, Gynaecology by Ten Teachers, 18th edition.
12 Malignant disease of the uterus and cervix
1 D 2 B 3 C 4 H
Cervical ectopy is not a pre-malignant condition. It can be left alone, if it is asymptomatic in the presence of a
normal smear and colposcopy. If it is symptomatic, then coagulation can be used. Preclinical disease that invades
to a depth less than 3 mm and width of 7 mm can be safely treated with local excision (LLETZ). Treatment of
clinical disease is usually with surgery, radiotherapy or both. If the disease is confined to the cervix, then surgery
or radiotherapy can be used. Once it has spread outside the cervix, radiotherapy is the main treatment modality.
See Chapter 12, Gynaecology by Ten Teachers, 18th edition.
13 Carcinoma of the ovary and Fallopian tube
1 C 2 H 3 E 4 AEMQ answers 67
Stage 1b is confined to both ovaries with no ascites, or tumour on the external surface of the ovary and an intact
capsule. In this case, TAH and BSO and omentectomy are sufficient. After Stage 1B, chemotherapy is also required.
Unilateral borderline tumours can be treated by removing the affected ovary and taking peritoneal washings to
check for spread. However, if the patient’s family is complete and there is a suspicion of malignancy, TAH and
BSO and omental biopsy may be more prudent. Endometriosis is a benign condition and can be ablated with a
laser or diathermy.
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
14 Infections in gynaecology
1 E 2 A 3 C 4 H
Primary genital herpes is a sexually transmitted condition that presents with painful ulcers and vesicles, often
with urinary retention due to pain. Candida is not sexually transmitted, and is a common condition presenting
with a white discharge and red sore vagina compared with bacterial vaginosis, which has a typical ‘fishy’ odour
and frothy discharge. Gonorrhoea and chlamydia are often asymptomatic. Chlamydia is the commonest cause of
pelvic inflammatory disease (PID) in the West, but is diagnosed by enzyme-linked immunosorbent assay (ELISA),
whereas gonorrhoea can be diagnosed on microscopy.
See Chapter 15, Gynaecology by Ten Teachers, 18th edition.
15 Urogynaecology
1 G 2 C 3 A 4 F
A rise in detrusor pressure associated with urgency is diagnostic of detrusor overactivity. Urodynamic stress
incontinence is diagnosed in the absence of a detrusor contraction. A flow rate of 5 mL per second is reduced. In
the presence of a high detrusor pressure, this would indicate a urethral obstruction. If the detrusor pressure was
low and the flow rate also low, poor detrusor function would be more likely.
See Chapter 16, Gynaecology by Ten Teachers, 18th edition.
16 Uterovaginal prolapse
1 B 2 H 3 A 4 C
Surgery is unsuitable in frail women who could not tolerate general or regional anaesthesia, and so a pessary would
be more appropriate. The Manchester repair is an operation that used to be performed for prolapse with an
elongated cervix. It involved cervical amputation, anterior and posterior repair, and shortening the cardinal ligaments. Anterior repair is an effective treatment for cystocele but is not effective in treating stress incontinence.
Abdominal surgery for vault prolapse (sacrocolpopexy) should be avoided if the patient is frail or has multiple
previous abdominal procedures (concerns about adhesions). Sacrospinous fixation is a vaginal procedure for vault
prolapse and has less morbidity associated.
See Chapter 17, Gynaecology by Ten Teachers, 18th edition.
17 The menopause
1 E 2 C 3 A 4 B
Hormone replacement therapy can be oestrogen alone in hysterectomized women, or oestrogen and progesterone
in women with a uterus. Oestrogen can be taken orally and pass through the first-pass metabolism, or through
transdermal patches, which will avoid hepatic enzymes. Tibolone has mild androgenic side effects and is useful68 Gynaecology
in women with a low libido. Progesterone in various forms (e.g. medroxyprogesterone acetate) is necessary in
women with a uterus to prevent endometrial hyperplasia.
See Chapter 18, Gynaecology by Ten Teachers, 18th edition.
18 Common gynaecological procedures and medico-legal aspects of gynaecology
1 F 2 G 3 B 4 A
Gas embolism can occur after laparoscopy, although it is rare. Women are usually consented about the risk of
injury to the bowel or aorta from Veress needle insertion, trochar insertion and operative laparoscopy. Endometriosis
can cause tethering of the ureter to the parametrium, thus increasing the risk of ureteric injury at hysterectomy.
Bladder perforation is said to occur in 1–5 per cent of TVTs. Cystoscopy is routinely performed and, if recognized, the trochars can be removed and reinserted correctly and a draining catheter left for several days. Uterine
perforation and even hysterectomy are possible at TCRE. This is reduced if rollerball or endometrial ablation is
performed instead.
See Appendices 1 and 2, Gynaecology by Ten Teachers, 18th edition.
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