Normal and abnormal sexual development and puberty
1 A 17-year-old girl presents complaining she hasn’t started having periods yet. What are the salient features in the history and examination that would help to determine a diagnosis?
History
Developmental history: reflects sexual hormone production.
Presence/absence of cyclical symptoms: suggests ovarian function normal.
History of chronic illness: inhibits hypothalamic–pituitary–ovarian axis
Excessive weight loss/eating disorder: inhibits hypothalamic–pituitary–ovarian axis.
Excessive exercise: inhibits hypothalamic–pituitary–ovarian axis.
Contraceptive history: menses on exogenous hormones may mask primary amenorrhoea.
Reproductive history: pregnancy is the commonest cause of secondary amenorrhoea.
Menopausal symptoms and family history of premature menopause: may be familial.
Medications: can inhibit hypothalamic–pituitary–ovarian axis, e.g. gonadotrophin-releasing hormone (GnRH)
analogues.
Virilizing signs, galactorrhoea: suggests androgen tumour, congenital adrenal hyperplasia (CAH), prolactinoma.
Hirsutism, acne: may be suggestive of polycystic ovarian syndrome (PCOS). (12 marks)
Examination
Height : short stature associated with chromosomal abnormality, e.g. Turner’s syndrome.
Weight/body mass index (BMI): polycystic ovary syndrome associated with raised BMI.
Secondary sexual characteristics/evidence of virilization:
Visual fields: homonymous hemianopia associated with pituitary tumour.
Pelvic examination: imperforate hymen, absent pelvic organs. (5 marks)
See Chapter 3, Gynaecology by Ten Teachers, 18th edition.Short answer questions 87
2 Write short notes on the five stages of puberty.
The events that occur in changes from a child to adult female usually occur in the following sequence:
1 Growth spurt
2 Breast development
3 Pubic hair growth
4 Menstruation
5 Axillary hair growth
The above sequence of events occurs in around 70 per cent of girls but there may be minor differences in timing. Tanner has described pubertal development in five stages. (3 marks)
The growth spurt starts at around 11 years of age owing to the effect of oestrogen and most girls have reached
their final height by the age of 15 with the fusion of the femoral endplate. (2 marks)
Breast bud development starts after the growth spurt in response to the production of oestradiol by the ovary.
This is due to an increase in the production of GnRH from the pituitary gland. In initial breast development, the
areola tissue appears more pronounced and then the breast tissue grows to become more confluent with the
areola as it develops. (2 marks)
Menarche is defined as the first menstrual period and occurs at any age between 9 and 17 years. Initially periods
can be very irregular and it can take from 5 to 8 years from the time of menarche for women to develop a regular cycle after full maturation of the hypothalamic–pituitary–ovarian axis. (3 marks)
Pubic hair growth initially begins on the labia and then gradually extends over the mons pubis. Axillary hair
growth is a late development. (2 marks)
See Chapter 3, Gynaecology by Ten Teachers, 18th edition.
Disorders of the menstrual cycle
3 A 45-year-old woman is referred by her general practitioner (GP) complaining of ‘heavy periods’. What are
the salient features in her history and examination?
History
Last menstrual period (LMP)/cycle length
Duration of bleeding
Passage of clots/flooding/number of sanitary protection used and how soaked
Intermenstrual bleeding and postcoital bleeding
Past gynecological history: pelvic inflammatory disease (PID; associated with increased loss), smear history, contraception – intrauterine contraceptive device (IUCD), which increases loss, or contraceptive pill, which regulates and usually decreases loss.
Symptoms of anaemia: lethargy, shortness of breath on exertion, syncope. (4 marks)88 Gynaecology
Clinical examination
General:
• Endocrine disorders (hirsutism, striae, goitre, skin pigmentation, tremor)
• Secondary sexual characteristics
• Signs of anaemia (tachycardia, pale sclerae)
• Liver disease, clotting disorder (bruising, petichaie)
Abdominal:
• Liver enlargement
• Pelvic mass (?fibroids)
Vagina:
• Signs of trauma, infection
• Visualize cervix for ectopic, malignancy (4 marks)
3a What investigations would you do if the patient had a regular 28-day cycle and no pelvic mass, and why?
Full blood count (FBC): anaemia, platelet function (1 mark)
3b What further tests would you do if she had an irregular cycle and why?
Thyroid function tests (TFTs): endocrine only if suspicion of thyroid disease
Serum β-human chorionic gonadotrophin (sβ-hCG): only if pregnancy suspected
Serum androgens: only if signs of hirsutism and acne
Prolactin: only if oligomenorrhoea or lactation
Coagulation screen: only if bruising, etc.
Urea and electrolytes (U&Es), liver function tests (LFTs): only if signs of renal/liver impairment
(6 marks)
3c What further tests could be done if all the above are normal or not clinically indicated (which is usually
the case), and why?
Pelvic ultrasound scan: to assess for fibroids if uterus enlarged or endometrial polyps, if intermenstrual bleeding
Hysteroscopy/endometrial biopsy: as the patient is over the age of 40,Royal College of Obstetricians and Gynaecologists
(RCOG) guidelines recommend hysteroscopy and endometrial biopsy to exclude malignancy and assess correlation of endometrial phase with cycle (2 marks)
See Chapter 5, Gynaecology by Ten Teachers, 18th edition.
Fertility control
4 A 25-year-old woman attends the local family planning clinic to discuss various forms of contraception.
She has an irregular cycle, has had two partners in the past, but is in a new stable relationship and has one
daughter aged 3. What are the salient features within the history and examination that would help you to
help her choose one form of contraception over another?
Menstrual cycle: This woman has an irregular cycle but it is important to determine exactly the nature of her
bleeding, duration of bleeding and length between periods. It is also important to know whether she has any
breakthrough bleeding/intermenstrual bleeding. This can be a sign of infection and chlamydia swabs should be
taken. (3 marks)
Parity/plans for future pregnancies: It is important to know whether this woman plans any further pregnancies or
whether her family is complete. Usually it is not recommended for irreversible forms of contraception at this
stage as she has just started a new relationship and the incidence of regret following permanent sterilization is
much greater in the under 30 age group. (2 marks)Short answer questions 89
Sexual history: It is important to know the number of partners this woman has had, whether she has had any previous pelvic infections and whether she is now in a stable relationship. One should ask what forms of contraception she has tried in the past, as some of these may not have agreed with the individual and so would be
contraindicated to use again. (2 marks)
General gynaecological history: One should ask about smear history as well as any previous cervical or pelvic surgery.
Drug history: One should check whether the patient is taking any liver enzyme-inducing agents or antibiotics.
(2 marks)
Contraindications: Certain forms of contraception would be contraindicated, especially the combined pill. The
absolute contraindications to taking the combined oral contraceptive pill are:
• Circulatory disease, ischaemic heart disease, cerebrovascular accidents, significant hypertension, arterial or
venous thrombosis, any acquired or inherited thrombotic tendency or any significant risk factors for cardiovascular disease.
• Acute or severe liver disease.
• Oestrogen-dependent neoplasms, particularly breast cancer.
• Focal migraine. (4 marks)
The relative contraindications include:
• Generalized migraine.
• Long-term immobilization.
• Irregular vaginal bleeding, which has not had a diagnosis obtained.
• Less severe risk factors for cardiovascular disease, such as obesity, heavy smoking and diabetes. (4 marks)
Examination: One would want to know the patient’s weight, blood pressure as well as a general pelvic examination to assess uterine size and assess for pelvic masses. (1 mark)
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.
5 Outline the principal features that one would include in a consent form to women who are considering
sterilization in an outpatient appointment.
Female sterilization is generally performed by occlusion of the Fallopian tubes. This is done either using Filshie
clips, plastic rings or with the use of excision and ligation of the tubes. The procedure is performed usually
through laparoscopic surgery but can be performed as an open procedure, especially if concurrent surgery is
occurring, e.g. Caesarean section. (2 marks)
It is advisable to warn the patient that the procedure should be considered permanent and irreversible. Reversal
can be performed, but this is not provided under the National Health Service (NHS) and no guarantees can be
given about the success of reversal of sterilization. (2 marks)
Failure of sterilization should be explained and the rate of 1 in 200 should be quoted. Failure rates rise either due
to incomplete occlusion of the tubal lumen or recanalization of a previously appropriately occluded lumen. If
sterilization fails owing to application of clips in the wrong structure, such as the round ligament, this is
indefensible in court. It is, therefore, advisable to take photographs of the tubes once they are occluded at the
time of surgery. (3 marks)
The patient should be warned about the increased risk of ectopic pregnancy should they fall pregnant, although
this is still very unlikely. (1 mark)90 Gynaecology
If patients are using the combined oral contraceptive pill, their periods may be artificially light. Once they are
sterilized, they will stop taking the combined pill and their periods will return to their physiological status. If the
patient has had a history of menorrhagia, then one should warn them that the chance of this recurring is high
and alternative contraception, such as the Mirena, may be more appropriate. (1 mark)
All other forms of contraception should be discussed with the patient, including male sterilization, which is
safer, does not require a general anaesthetic and has a lower failure rate. (1 mark)
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.
Infertility
6 A couple attend the infertility clinic for the first time having been trying to conceive a pregnancy for the
last 12 months of unprotected intercourse. What are the salient points in the history?
Maternal age: Rates of conception rapidly decline after the age of 35. (1 mark)
Parity and gravidity: ages and modes of delivery of previous pregnancies. (2 marks)
Menstrual cycle: regularity of menstrual cycle suggests but does not confirm ovulation; oligomenorrhoea or
amenorrhoea may be suggestive of an ovulatory disorder. (1 mark)
Contraception: previous contraception is important, as some contraceptives, such as the Depo, can have a prolonged effect. (1 mark)
Disorders suggestive of a general endocrine problem: one should list in the history symptoms that may suggest an
endocrine disorder that can affect ovulation. (1 mark)
Tubal disease: one should look in the history for risk factors for tubal disease, such as a history of sexually transmitted diseases/PID, pelvic abscesses, previous pelvic or abdominal surgery, tubal surgery, and previous ectopic
pregnancies. (2 marks)
General history: one should ask about smear history, rubella status and blood group, if known, as well as discussing pre-conceptual folic acid, which should be taken for 3 months periconception. On general examination,
one should look for signs of raised BMI, signs of hirsutism and other endocrine disorders and secondary sexual
characteristics. On abdominal examination, one should inspect for signs of previous abdominal/pelvic surgery
and vaginal examination should be performed. Swabs should be taken for chlamydia, gonorrhoea and other sexually transmitted diseases, and a smear should be obtained if patient has not had one as part of the normal recall
process. (4 marks)
History and examination of male partner: this is essential. One should note age, history of any children in this
relationship or other relationships, smoking, alcohol use and occupation. It is important to enquire about testicular trauma, undescended testes, mumps and previous sexually transmitted diseases. On examination, one
should assess the size of each testis, check for varicoceles and descent, and note secondary sexual characteristics.
One should also discuss quite openly the couple’s frequency and timing of coitus to ensure this is occurring during the fertile time of the woman’s cycle (i.e. 14 days prior to menstrual period). (4 marks)
See Chapter 7, Gynaecology by Ten Teachers, 18th edition.Short answer questions 91
Disorders of early pregnancy
7 Write short notes on threatened miscarriage, missed miscarriage and incomplete miscarriage.
Threatened miscarriage
This is defined as bleeding in early pregnancy of 24 weeks’ gestation. The patient presents with vaginal bleeding
that may be associated with suprapubic pain.On vaginal examination, the cervical os is closed.Ultrasound demonstrates a gestational sac with a fetal pole and the fetal heart is seen. There may or may not be an intra-uterine
haematoma present. (3 marks)
Missed miscarriage
Patients may present either with minimal bleeding, old blood loss or no bleeding at all. Sometimes the diagnosis is made incidentally at ultrasound scan when patients come for a routine 12 week or 20 week scan. The diagnosis is confirmed if ultrasound shows an embryo of 20 weeks with no fetal heart and no signs of expulsion.
Alternatively, a gestation sac of 20 mm and no embryo, or a fetal pole of 6 mm with no fetal heart seen
would be classified as a missed miscarriage. Management can be either medically induced miscarriage or surgical
evacuation. (3 marks)
Incomplete miscarriage
Patients usually present with heavy bleeding and cramping pain, and have partial expulsion of the products of
conception. On speculum examination, if the cervical os is open, it is termed an ‘inevitable miscarriage’. A transvaginal scan will show products of conception within the uterine cavity. The management can be either expectant, surgical evacuation or medical, and depends on the size of the products of conception within the uterine
cavity. As a general rule, if the products of conception are 50 mm, then surgical or medical evacuation would
be recommended. (4 marks)
See Chapter 8, Gynaecology by Ten Teachers, 18th edition.
8 A 20-year-old woman has had an episode of amenorrhoea lasting for 6 weeks and 5 days, having had a previous regular 28-day cycle. She presents with right iliac fossa pain and light vaginal bleeding. She has had
a previous history of chlamydia but no other medical illnesses, and is not taking any medication. On
examination, she is in pain and distressed. The patient’s pulse is 89 beats per minute, she had a blood pressure of 120/70 mmHg. Abdominal examination and vaginal examination exhibited tenderness in the right
iliac fossa with guarding. She was also tender in the right adnexum on vaginal examination. Urinary pregnancy test was positive. What are the possible differential diagnoses and what investigations would you
perform and why?
Ectopic pregnancy is the most likely diagnosis that needs to be excluded before any other diagnosis can be made.
Other possible diagnoses that need to be considered include appendicitis, corpus luteum/ovarian cyst pain and
threatened miscarriage. (4 marks)
A full blood count should be obtained to assess if the patient is anaemic. If there has been any concealed bleeding into the peritoneal cavity of any significance, a full blood count will show a drop in the haemoglobin.
A tachycardia may be attributed to anaemia but also may be due to her pain and distress. (2 marks)
Blood should be taken to determine blood group, and serum saved and cross-matched in case the patient
requires subsequent surgery or transfusion. If the patient is rhesus negative and has a surgical intervention, she
may require anti-D prophylaxis. (1 mark)
The maternal sβ hCG levels should be quantified and can be useful in raising suspicions for an ectopic pregnancy, if ultrasound scan shows an empty uterus and the sβ hCG is 1000 IU/L. (1 mark)
An ultrasound scan should be arranged to assess whether there is a viable intrauterine pregnancy. The adnexae
can also be assessed for masses/ovarian cysts as well as looking for other suspicious features, such as free fluid in
the pouch of Douglas, which would correlate with internal bleeding. (2 marks)92 Gynaecology
The most likely diagnosis is an ectopic pregnancy. In view of the patient’s distress, she requires an urgent diagnostic laparoscopy. If this demonstrated an ectopic pregnancy, then the surgeon should proceed to a salpingectomy if the contralateral tube looks normal or salpingostomy if the contralateral Fallopian tube looks diseased.
(2 marks)
See Chapter 8, Gynaecology by Ten Teachers, 18th edition.
Benign diseases of the uterus and cervix
9 Write short notes on the principles of a screening programme.
There are ten principles of screening that are now adopted by the World Health Organisation.
1 The condition should be an important health problem. (1 mark)
2 There should be a recognizable latent or early symptomatic stage. (1 mark)
3 The natural history of the condition, including development from latent to declared disease, should be
adequately understood. (1 mark)
4 There should be an accepted treatment for patients with recognized disease and early intervention will alter
prognosis compared with treatment of later manifested disease. (1 mark)
5 There should be a suitable test or examination. (1 mark)
6 The test should be acceptable to the population. (1 mark)
7 There should be an agreed policy on whom to treat as patients. (1 mark)
8 Facilities for diagnosis and treatment should be available. (1 mark)
9 The cost of screening (including diagnosis and treatment of patients diagnosed) should be economically
balanced in relation to possible expenditure to medical care of patients with declared disease. (1 mark)
10 Screening should be a continuing process and not a ‘once and for all’ project. (1 mark)
See Chapter 9, Gynaecology by Ten Teachers, 18th edition.
Endometriosis and adenomyosis
10 Outline the four theories for the pathophysiology of endometriosis.
1 Menstrual regurgitation and implantation. One theory is that endometriosis occurs as a result of retrograde
menstruation and that implantation of endometrial glands and tissue occurs into the peritoneal surface. This
has been shown to occur in experimental models. (2 marks)
2 Coelomic epithelium transformation. Another theory is that peritoneal cells and cells in the ovary which are
derived from the Mullerian duct undergo dedifferentiation back to their primitive origin and then transform
into endometrial cells. It is not yet known what might stimulate this dedifferentiation. (2 marks)
3 Genetic and immunological factors. Some women of certain genetic/immunological predisposition may possess factors that render them susceptible to the development of endometriosis. This is substantiated by a
familial tendency as well as racial tendencies. (2 marks)
4 Vascular lymphatic spread. Occasionally endometriosis can be found inside and outside the peritoneal cavity,
such as skin, kidney and lung. This may occur due to embolization of endometrial tissue via vascular lymphatic
channels or at surgery. (2 marks)
See Chapter 10, Gynaecology by Ten Teachers, 18th edition.Short answer questions 93
11 A GP refers a 30-year-old woman with menorrhagia and pelvic pain. He suggests she may have
endometriosis. What are the salient features in her history and on clinical examination? What are the
possible differential diagnoses? What investigations would you perform to confirm the diagnosis?
History
The salient features include dysmenorrhoea, the demonstration of cyclical pelvic pain, deep dyspareunia, a history of subfertility or infertility. Bladder symptoms may include cyclical haematuria or ureteric obstruction, and
bowel symptoms may include cyclical rectal bleeding or pain on defaecation. (3 marks)
Examination
One would try and elicit pain in the pouch of Douglas by palpation over the rectovaginal septum and uterosacral
ligaments. It is sometimes possible to palpate nodules of endometriosis on rectovaginal examination. Bidigital
examination may help palpate any pelvic masses such as endometriomas. (3 marks)
Differential diagnoses
These would be adenomyosis, pelvic inflammatory disease or bowel pathology (irritable bowel syndrome).
(1 mark)
Investigations
These would include an ultrasound scan to exclude any endometriomata. A CA 125 is of little clinical use but
may be slightly raised in endometriosis. A diagnostic laparoscopy with or without tubal patency testing will confirm a diagnosis of endometriosis, and endometrial explants can be seen within the peritoneal cavity.
(4 marks)
See Chapter 10, Gynaecology by Ten Teachers, 18th edition.
12 Write short notes on the differences in epidemiology, symptomatology, investigation and treatment of
endometriosis and adenomyosis.
Adenomyosis tends to affect women between the age of 30 and 40, whereas endometriosis tends to affect women
in their late 20s and 30s. (2 marks)
Women with adenomyosis present with increasingly severe secondary spasmodic dysmenorrhoea and increased
menorrhagia. On examination, they tend to have a tender uterus, particularly pre-menstrually. In women with
an endometrioma, tenderness is usually elicited in the pouch of Douglas, rectovaginal septum and adnexae.
(3 marks)
The diagnosis of adenomyosis can sometimes be suspected on ultrasound, if there is asymmetrical irregular
echogenicity within the myometrium. Magnetic resonance imaging provides further enhanced images and is the
investigation of choice. If the patient has endometriosis, ultrasound may demonstrate the presence of
endometriomas. The diagnosis of adenomyosis can only truly be made at hysterectomy, as it is a histological
finding. (3 marks)
Endometriosis can be treated by simple analgesia. Inhibition of ovulation using the combined oral contraceptive pill and GnRH analogues can give symptomatic relief. Ablation, resection or total abdominal hysterectomy
and bilateral salpingo-oophorectomy are more definitive. Adenomyosis is treated definitively by hysterectomy.
(2 marks)
See Chapter 10, Gynaecology by Ten Teachers, 18th edition.94 Gynaecology
Benign diseases of the ovary
13 Outline the different strategies for the management of a single 4 cm ovarian cyst in the pre-menopausal,
pregnant and postmenopausal woman.
Pre-menopausal
Cysts on the ovary can be physiological, benign or malignant. Physiological cysts usually measure less than 40 cm.
Physiological cysts are more common in this age group. An ultrasound and CA 125 may help differentiate
whether the cyst is sinister or pathological. Sinister findings would be septae, solid elements or large cysts.
If the cyst appears suspicious and may or may not have elevated tumour markers, discussion at a multidisciplinary meeting is advisable to decide on whether surgery is indicated and what procedure would be most appropriate. If the cyst is symptomatic (painful), then treatment either by laparoscopy or laparotomy would be warranted.
(4 marks)
Pregnant
Cysts are often found asymptomatically at ultrasound, at antenatal clinic or at Caesarean section. The risk of torsion is increased in pregnancy due to the movement of the pelvic organs out of the pelvis as the gravid uterus
grows. Ultrasound monitoring during each trimester is sufficient provided the patient remains asymptomatic.
Surgery should be avoided until 14 weeks to reduce the risk of miscarriage and intervention with a corpus
luteum, which should have regressed by 12 weeks. Surgery is usually contemplated if the patient’s symptoms are
serious, such as significant pain, cyst rupture and significant bleeding or torsion. Tocolysis is often used at the
time of surgery to reduce the risk of miscarriage and pre-term labour. (4 marks)
Postmenopausal
Physiological cysts on the ovary are unlikely in the postmenopause but can still be found. Evaluation of the cyst
using ultrasound, CA 125, Doppler and the patient’s age can be entered into an equation to give a risk of malignancy (relative malignancy index; RMI). If the risk of malignancy score is low and the patient is asymptomatic,
they can be left alone with no further follow-up. If the malignancy score is high, then referral and discussion
through a multidisciplinary team meeting should be arranged, with possible subsequent hysterectomy and bilateral oopherectomy, if malignancy is suspected. (4 marks)
See Chapter 11, Gynaecology by Ten Teachers, 18th edition.Short answer questions 95
Benign diseases of the ovary
14 A 40-year-old patient presents with a history of ovarian cysts in the past. She is admitted with acute
abdominal pain after 2 weeks of pelvic discomfort and urinary frequency. On examination, there is a
mass palpable arising out of the pelvis. What is the differential diagnosis? What are the salient features in
the history and examination, and how would you investigate the patient?
The most likely differential diagnoses would include a benign ovarian cyst, cyst rupture or torsion, urinary
retention, fibroids (possibly degenerating). Other less likely diagnoses would include appendicitis with appendix abscess, PID/pyo-/hydrosalpinx. (3 marks)
Salient features in the history would include the last menstrual period (if late exclude pregnancy) and cycle
length, contraception, previous ovarian cysts or fibroids, sexual history, pain (whether this was associated with
vomiting or rigors as this may be suggestive of appendicitis/torsion/PID). Shoulder-tip pain or bleeding may be
indicative of ectopic pregnancy.
(3 marks)
On ultrasound, benign cysts tend to be large and unilocular simple cysts, whereas malignant tumours have septae, often solid or semisolid, and are larger. A raised CA 125 is strongly suggestive of ovarian carcinoma, but can
also be mildly elevated in endometriosis and pelvic inflammatory disease. If ultrasound and CA 125 suggest a
malignancy, a computerized tomography scan is mandatory to evaluate further the nature of the cyst as well as
nodal spread. (4 marks)
See Chapter 11, Gynaecology by Ten Teachers, 18th edition.
Malignant disease of the uterus and cervix
15 A 65-year-old woman presents in clinic with a single episode of postmenopausal bleeding. Write short
notes on the investigation and management of such a patient.
The likely differential diagnoses include atrophic vaginal tissues, endometrial polyp or endometrial carcinoma.
(3 marks)
Initial investigations involve examination of the lower genital tract looking for atrophic tissues, as well as bimanual examination to assess uterine size and feel for parametrial thickening, which would be suggestive of
malignancy. (3 marks)
Pelvic ultrasound scan is useful to measure endometrial thickness and, if this is 4mm,the patient can be reassured
that the risk of malignancy is almost zero, providing they have only had a single episode of postmenopausal bleeding.In this instance,the patients can be discharged but should reattend if they have any further bleeding.Outpatient
hysteroscopy and Pipelle aspiration of the endometrium is useful if the endometrial thickness is 4mm. Rigid
saline hysteroscopy occasionally needs to be performed under general anaesthesia for patients who cannot tolerate
outpatient hysteroscopy. Another indication for rigid saline hysteroscopy would be if the patient has findings on
ultrasound suggestive of a polyp, which cannot be removed in the outpatient setting. (4 marks)
Treatment would depend on the cause. If the patient has atrophic tissues, then topical oestrogens are appropriate. A polypectomy can be utilized, if there is a single polyp that is benign, and the mainstay of treatment for
endometrial carcinoma is total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without
postoperative radiotherapy. Bilateral pelvic lymph nodes and para-aortic node sampling is often performed, if
there are concerns regarding malignancy. (3 marks)
See Chapter 12, Gynaecology by Ten Teachers, 18th edition.96 Gynaecology
Carcinoma of the ovary and Fallopian tube
16 Write short notes on the classification of epithelioid tumours of the ovary.
Epithelioid tumours can be classified into serous, mucinous, endometrioid, clear cell, Brenner and undifferentiated tumours. (1 mark)
With regard to serous tumours, the majority have solid and cystic elements, are often bilateral and have psammoma bodies present on histology. (2 marks)
Mucinous tumours account for 10 per cent of the malignant tumours of the ovary. They are usually multilocular thin-walled cysts with a smooth surface full of mucinous fluid. Mucinous cysts often have exceedingly large
dimensions. (2 marks)
Endometrioid tumours resemble the endometrium of the uterus in histology. They are often cystic unilocular
cysts containing turbid, brown fluid. A total of 15 per cent are associated with an endometrial cancer of the
uterus. (2 marks)
Clear cell tumours are the least common epithelial tumours and often coexist with endometrioid tumours or
endometriosis. (2 marks)
Borderline tumours account for 10 per cent of ovarian tumours. They are usually confined to the ovary and have
a better prognosis. (1 mark)
See Chapter 13, Gynaecology by Ten Teachers, 18th edition.
Infections in gynaecology
17 Write short notes on candida, bacterial vaginosis and trichomoniasis vaginalis.
Candida
This is a fungal infection usually caused by the Candida albicans organism in 80 per cent of women. It is not sexually transmitted and women usually present with an itchy sore vagina and vulva, and a curdy white discharge.
Topical treatment is usually sufficient with clotrimazole 500 mg, although oral fluconazole is an alternative.
(3 marks)
Bacterial vaginosis
This is not a sexually transmitted disease. It is typically caused by anaerobic organisms, such as Gardnerella vaginalis, Bacteroides, Mobiluncus and Micoplasma. Women typically present with an offensive fishy discharge.
Diagnosis is made on composite Ansel criteria. These criteria are: (1) a pH of 4.5; (2) a fishy smell on the application of potassium hydrochloride; (3) ‘clue’ cells on microscopy and it is treated with either oral or topical
metronidazole. There is an increased risk of second trimester miscarriage and preterm labour, and women with
a history of this should be screened and treated for the organisms. (4 marks)
Trichomoniasis vaginalis
This is a sexually transmitted disease, the incidence of which is falling in the UK. Women usually present with a
yellow or green discharge. Examination of the cervix shows multiple punctate haemorrhages, which gives the
characteristic ‘strawberry’ cervix. The diagnosis is made after culturing organisms in Fireberg Whittington
medium. The treatment of choice is metronidazole. (3 marks)
See Chapter 15, Gynaecology by Ten Teachers, 18th edition.Short answer questions 97
Urogynaecology
18 A 35-year-old woman presents with a 2-year history of involuntary loss of urine on exercise and coughing. Write short notes on the salient features in her history and examination. What investigations would
you arrange and why?
History
Urinary symptoms suggestive of stress incontinence: When and how much does the patient leak? How many pads
does the patient use (how many during the day, how many during the night)? (2 marks)
Urinary symptoms suggestive of detrusor overactivity: Does the patient leak at night? Does the patient complain of
urgency, urge incontinence, frequency and nocturia? (2 marks)
Voiding symptoms: Are there any voiding difficulties, such as poor urinary stream, incomplete micturition or
deviated stream? (1 mark)
Bowel symptoms: constipation, perineal splinting, digitations, irritable bowel. (1 mark)
Past gynaecological history: any relevant previous surgery (e.g. colposuspension). (1 mark)
Past obstetric history: particular relevance should be noted to previous deliveries, the mode of delivery and the
birth weight of each child, as stress incontinence is associated with trauma to the pelvic floor (macrosomia, forceps)
(1 mark)
Examination
General examination: patient’s BMI, nicotine-stained fingers (suggestive of smoking), and abdominal palpation
for abdominal and pelvic masses.
Vaginal examination: Particular attention should be paid to look for atrophic changes in the lower genital tract
and prolapse. Stress incontinence should also be demonstrated by asking the patient to cough. (2 marks)
Investigations
Mid-stream urine: to exclude urinary tract infection.
Urinary diary: to record the patient’s fluid intake and output. This can help to note the patient’s functional
capacity and the severity of incontinence episodes, as well as educating the patient about their bladder habits.
Pad test: This can help quantify urine loss.
Uroflowmetry and video-cystourethography: Uroflowmetry is performed as part of urodynamic assessment and
will help assess the patient’s voiding and exclude a voiding difficulty. Cystometry can be performed either by
using saline or a radio-opaque filling medium, and video-cystourethography can then be performed. This will
diagnose urodynamic stress incontinence, if leakage occurs as a result of coughing in the absence of a rise in
detrusor pressure, and detrusor overactivity, if the detrusor pressure rises inappropriately associated with
urgency symptoms. (4 marks)
See Chapter 16, Gynaecology by Ten Teachers, 18th edition.98 Gynaecology
The menopause
19 Outline the effects of the menopause and its hypo-oestrogenic state on a woman’s physiology.
Symptoms of the menopause are usually stimulated by a fall in circulating oestrogen and may occur prior to the
absolute level defined at the postmenopause of 100pmol/L. Symptoms include tiredness, hot flushes, night
sweats, insomnia, vaginal dryness and urinary frequency. (3 marks)
Various physiological changes occur and these can affect different systems of the body. The predominant systems
affected are the skeletal and cardiovascular systems. Oestrogen acts to prevent bone turnover by balancing the
equilibrium between bone resorption and bone formation. A low circulating oestrogen is associated with a
greater bone resorption rate over bone formation in the trabecular bone. Trabecular bone has a higher surface
area, thus postmenopausal women are at particular risk of osteopaenia and osteoporosis. They are also at higher
risk of traumatic fractures, typically of the distal radius and neck of femur.
(3 marks)
The cardiovascular system is the second major physiological system affected in the postmenopausal period and
the incidence of myocardial infarction rises significantly at this time. A hypo-oestrogenic state is associated by
significant changes in the lipid profile that predisposes women to atheroma. These include raised total cholesterol, lower HDL (high-density lipoprotein) cholesterol and a high LDL (low-density lipoprotein). Triglycerides
remain at similar levels to those in the pre-menopausal state. Oestrogen also causes vasoconstriction, owing to
reduction in the production of nitrogen synthase. Large randomized controlled trials have shown no benefit and
possibly a deleterious effect on the cardiovascular system with the administration of hormone replacement therapy; therefore it is not recommended to start this as a treatment or prevention of cardiovascular disease.
(4marks)
See Chapter 18, Gynaecology by Ten Teachers, 18th edition.
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