History and examination
1 With regard to clinical examination of the gynaecological patient:
a) Abdominal examination is mandatory as part of the gynaecological examination.
b) A chaperone is always needed for intimate examinations.
c) Palpation below a pelvic mass is possible.
d) Shifting dullness and fluid thrill can be seen due to urinary retention.
e) Bidigital examination can determine whether a pelvic mass is ovarian or uterine in origin.
Embryology, anatomy and physiology
2 The following statements apply to the human female pelvis:
a) The Fallopian tubes are lined by cilia to aid egg transport.
b) The middle portion of the Fallopian tube is called the ampulla.
c) The ovary is the only abdominal structure not covered by peritoneum.
d) The ovary is attached to the uterus by the round ligament.
e) The ovary has a central medulla of loose connective tissue and an outer cortex covered by cuboidal germinal
epithelium.
3 Considering the bladder and rectum:
a) The bladder capacity is normally 700 mL.
b) The base of the bladder is closely related to the cervix and upper vagina, and can be damaged at hysterectomy.
c) The ureter passes in the broad ligament in its lower portion and curves beneath the uterine artery, along the
lateral vaginal fornix before entering the trigone of the bladder.
d) In its upper portion the ureter lies anterior to the ovary.
e) The rectum is covered by peritoneum on its front and sides in the lower two-thirds.70 Gynaecology
Normal and abnormal sexual development and puberty
4 In the XY genotype:
a) Androgen insensitivity results in an XY genotype and female phenotype but with normal testes.
b) In 5-alpha-reductase deficiency, virilization of the cloaca fails to occur owing to the failure of the conversion
of testosterone to 17-hydroxyprogesterone.
c) In androgen insensitivity, Mullerian ducts regress owing to the production of Mullerian inhibitory factor.
d) In androgen insensitivity, the Wolffian ducts regress owing to the absence of an androgen receptor.
e) In 5-alpha-reductase deficiency, the Mullerian ducts fail to regress owing to the lack of Mullerian inhibitory
factor.
5 In an XX phenotype female:
a) Rokitansky’s syndrome is associated with failure of development of the uterus, cervix and vagina.
b) Often the ovaries are present in patients with Rokitansky’s syndrome.
c) A failure of fusion of the mesonephric ducts would cause an abnormality of the uterus and cervix, and is associated with a degree of reproductive failure.
d) In congenital adrenal hyperplasia, 21-hydroxylase deficiency prevents the production of 17-hydroxyprogesterone in the adrenal gland.
e) Virilization of the fetus can be secondary to drugs ingested by the mother.
The normal menstrual cycle
6 Within the follicular phase of the menstrual cycle:
a) The follicular phase is always 14 days long to allow development of the follicle.
b) Follicle-stimulating hormone (FSH) stimulates the granulosa cells to produce oestrogen.
c) Each cycle usually involves the development, growth and ovulation of a single follicle.
d) Follicles over 20 mm need to be drained with ultrasound guidance.
e) Oestrogen and inhibin have a positive feedback on the pituitary to release FSH and luteinizing hormone (LH).
7 In relation to ovulation:
a) LH induces thecal cells to produce oestrogen.
b) FSH induces a rise in LH receptors
c) Ovulation occurs 14 hours after the LH surge.
d) The release of an oocyte from the follicle requires a sperm to lyse the follicle membrane and results in
ovulation.
e) Ovulation can be confirmed by measurement of LH on day 14.
8 Within the luteal phase of the menstrual cycle:
a) The predominant hormone in the luteal phase is progesterone.
b) The granulosa cells of the corpus luteum have a rich vascular supply and have a yellow pigment owing to
accumulation of cholesterol.
c) The luteal phase varies in duration depending on the time taken to degenerate a corpus luteum.
d) The corpus luteum continues to degenerate in early pregnancy.
e) Low levels of oestrogen and progesterone are the best indicators of the perimenopause.Multiple choice questions 71
Disorders of the menstrual cycle
9 Definitions:
a) Polymenorrhoea is defined as prolonged increased menstrual flow.
b) Oligomenorrhoea is defined as menses occurring at a 21-day interval.
c) Hypermenorrhoea is defined as excessive regular menstrual loss.
d) Amenorrhoea is defined as absence of menstruation for more than 12 months.
e) Menorrhagia is defined as menses at intervals of 35 days.
10 Regarding the investigation of menorrhagia:
a) A full blood count is mandatory.
b) Thyroid function tests are mandatory.
c) A hysteroscopy and endometrial biopsy should be performed in women over the age of 25.
d) A pelvic ultrasound scan is only indicated if one is suspicious of a pelvic mass or fibroids.
e) A hormone profile including mid-luteal progesterone is essential to differentiate between ovulatory and
non-ovulatory dysfunctional bleeding.
Fertility control
11 With regard to the progesterone-only pill:
a) The progesterone-only pill has a higher failure rate in women under the age of 40 than in women over the
age of 40.
b) The progesterone-only pill has a lower risk of ectopic pregnancy.
c) The progesterone-only pill has a 3-hour window.
d) The progesterone-only pill has a better bleeding profile compared with the combined oral contraceptive pill
e) The progesterone-only pill has a quicker reversibility compared with the combined oral contraceptive pill.
12 Considering the depot injection and hormonal implants:
a) There are two types of depot injection. One contains medroxyprogesterone acetate 150 and lasts for 12 weeks,
the other contains norethisterone 200 and lasts for 8 weeks.
b) The depot is licensed for 2 years only, otherwise there is an increased risk of reduced bone density and
osteoporosis.
c) The depot can cause amenorrhoea but irregular bleeding is also a significant side effect
d) The Implanon implant involves five rods to be inserted in the upper arm and lasts for 5 years
e) With the Implanon implant, the return to ovulation after the implant is removed usually takes up to 1 year.
13 Concerning the intrauterine contraceptive device (IUCD):
a) Modern IUCDs can last for 5–10 years.
b) The levonorgestrel intrauterine system (Mirena) is licensed for 8 years.
c) Heavy bleeding can be a common side effect with the Mirena.
d) The risk of pelvic inflammatory disease is increased with IUCD use.
e) There is an increased risk of ectopic with IUCD use.
14 The combined oral contraceptive pill (COCP):
a) Inhibits ovulation.
b) Improves cycle control.
c) Has a 3-hour window.
d) Is relatively contraindicated in patients with acute/severe liver disease.
e) Has a risk of venous thromboembolism (VTE) of 15 per 100 000 in third-generation preparations.72 Gynaecology
Infertility
15 Considering successful conception:
a) The single most important factor affecting the chance of a couple conceiving is the age of the female partner.
b) The rates of conception rapidly decline after the age of 30.
c) Tubal infertility is the main cause of infertility in the Western world.
d) The chance of spontaneous conception in a young couple with no adverse fertility factors is 50 per cent per
cycle.
e) 85 per cent of healthy women aged 25 years will conceive after 12 months.
16 With regard to the investigation of the infertile couple:
a) A full hormone profile, tubal patency testing and semen analysis should be completed on all couples attending a referral for primary infertility.
b) A mid-luteal progesterone 25 nmol/L confirms ovulation.
c) A semen analysis should be performed prior to laparoscopy and dye to test for tubal patency.
d) Hysterosalpingogram, and laparoscopy and dye insufflation will gain similar information and either can be
used to assess tubal patency in all patients.
e) A single semen analysis with a volume of 1 mL, a concentration of 10 million/mL and 30 per cent reduced
motility confirms oligospermia, and serum testosterone, gonadotrophins and prolactin analysis should be
performed.
Disorders of early pregnancy
17 Concerning disorders of early pregnancy:
a) If the cervical os is open, it is a threatened miscarriage.
b) If transvaginal scan shows products of conception up to 20 mm in diameter, then surgical evacuation of the
uterus is essential.
c) Serum β-hCG levels are useful in dating a pregnancy up to 12 weeks.
d) Ultrasound appearances of retained products of conception of 15 mm would be consistent with a complete miscarriage.
e) A snowstorm appearance on ultrasound is suggestive of choriocarcinoma.
18 With regard to miscarriage:
a) Total loss of conception after fertilization is around 50–70 per cent.
b) The total rate of clinical miscarriage is around one-quarter to one-third of all pregnancies.
c) Miscarriage is much greater before 6 weeks than after 9 weeks.
d) The rate of miscarriage is the same in women over 40 years of age compared with women under 40.
e) The most common cause of spontaneous miscarriage is infection.
19 In relation to molar pregnancy:
a) The uterus often appears larger on palpation than one would expect for gestation.
b) Hyperemesis is often seen in patients with molar pregnancies.
c) Ultrasound is not useful in the diagnosis of molar pregnancy and the diagnosis is usually made on histology.
d) Complete hydatidiform molar pregnancies have a diploid chromosomal constitution owing to duplication
of paternal chromosomes and no maternal complement.
e) Partial molar pregnancies are usually diploid with duplication of the maternal set of chromosomes.Multiple choice questions 73
20 Considering ectopic pregnancy:
a) The rate of ectopic pregnancy is 0.5 per cent of all pregnancies.
b) Ectopic pregnancy is associated with Group B streptococcus infection.
c) Laparoscopic salpingectomy is the treatment of choice if the other tube is normal.
d) The rate of persistent trophoblast is increased if the patient has a laparoscopic salpingotomy rather than
salpingectomy.
e) Methotrexate is contraindicated if the mass is 1 cm in diameter on ultrasound.
Benign diseases of the uterus and cervix
21 Indicate which of the following statements are true or false:
a) The transformation zone is an area of the cervix that marks the junction of the squamous epithelium of the
ectocervix and vagina and the columnar epithelium binding the endocervix and the uterine cavity.
b) The situation of the transformation zone is affected by hormones and is easily visible at ovulation, pregnancy
and in women using the combined oral contraceptive pill.
c) Outpouching of the columnar epithelium is termed as cervical erosion.
d) Columnar epithelium undergoes dysplasia to squamous epithelium under normal physiological conditions.
e) Vaginal discharge and postcoital bleeding seen in association with an ectopy can be initially treated with cold
coagulation.
Benign diseases of the ovary
22 In dermoid cysts:
a) The malignancy rate is low (around 2 per cent).
b) 50 per cent are bilateral.
c) They are often lined by embryonic mesodermal structures.
d) Struma ovarii are dermoid tumours predominantly made of thyroid tissue.
e) Complications include torsion, chemical peritonitis and rupture.
23 In sex cord tumours:
a) All granulosa cell tumours are malignant, but are usually confined to the ovary and have a good prognosis.
b) Call–Exner bodies are pathognomonic of theca cell tumours.
c) Many theca cell tumours cause postmenopausal bleeding and endometrial carcinoma.
d) Meigs’ syndrome is the combination of fibroma, ascites and pleural effusions.
e) Virilization is seen as 75 per cent of Sertoli–Leydig cell tumours.
24 The following factors on ultrasound are suspicious of malignancy:
a) A single loculated cyst of 7 cm diameter.
b) Multiple cysts around the periphery of the ovary with a dense stroma.
c) A single frond floating within a cyst.
d) Solid elements and septae.
e) Calcification and fats.74 Gynaecology
Malignant disease of the uterus and cervix
25 With regard to cervical cancer:
a) Cervical cancer is the third commonest cancer in women worldwide.
b) The incidence of cervical cancer has become far more common in young women since the 1980s.
c) The rate of deaths from cervical carcinoma has remained steady in recent years.
d) Human papillomavirus (HPV) types 14 and 18 are the most commonly associated with cervical cancer.
e) Cervical cancer is associated with previous infection with herpes simplex virus.
26 Concerning the cervical screening programme:
a) It is important when taking a smear that the squamocolumnar junction is identified and sampled.
b) Smears should be taken between the ages of 25 and 64.
c) Smears should be taken during pregnancy.
d) The screening programme screens for pre-malignant changes in the squamous and columnar epithelia
e) Mild dyskaryosis on smear is consistent with cervical intraepithelia or neoplasia (CIN1).
27 The following are risk factors for the development of cervical cancer:
a) HPV types 14, 17 and 31.
b) HPV types 16 and 18.
c) Family history of cervical cancer.
d) Smoking.
e) Previous chlamydial infection.
28 The following are risk factors for the development of endometrial cancer:
a) Obesity.
b) Diabetes.
c) Multiparity.
d) Early menopause.
e) Unopposed oestrogen therapy.
29 Considering treatments for cervical cancer:
a) Preclinical invasive disease that is a depth of 6 mm and a width of 7 mm can be treated by large loop excision
of the transformation zone alone.
b) The risk of nodal involvement is 5 per cent if the depth of preclinical invasion is 3 mm.
c) A Wertheim’s hysterectomy involves removal of the uterus, cervix, paracervical tissue, lymph node sampling
and the upper two-thirds of the vagina.
d) At Wertheim’s hysterectomy, the ovaries can be conserved.
e) One main complication of Wertheim’s hysterectomy is poor bladder emptying owing to division of the S2,3,4
nerve roots of the pudendal nerve.
Carcinoma of the ovary and Fallopian tube
30 Regarding carcinoma of the ovary:
a) It is most common in developing countries.
b) The incidence is similar to carcinoma of the endometrium with similar prognosis.
c) The peak age is 80–90 years old.
d) The majority are epithelial in origin.
e) The mainstay of treatment is surgery and radiotherapy combined.Multiple choice questions 75
31 The following primary malignancies metastasize to ovary:
a) Lung.
b) Stomach.
c) Breast.
d) Thyroid.
e) Bone.
32 The following are risk factors for ovarian cancer:
a) Early menarche.
b) Early menopause.
c) Combined oral contraceptive pill usage.
d) Infertility.
e) Implanon implants.
33 In relation to ovarian cancer:
a) In the normal population, there is a lifetime risk of developing ovarian cancer of 5 per cent.
b) This usually applies to cystadenoma malignancy.
c) If a patient has one relative with ovarian cancer, their risk is increased to 10 per cent.
d) If a patient has two first-order affected relatives, their risk increases to 20 per cent.
e) BRCA1 or 2 gene-positive patients have a lifetime risk of ovarian cancer of 25 per cent.
34 The following are appropriate investigations for ovarian cancer:
a) Computerized tomography of the abdomen and pelvis.
b) Barium enema.
c) Intravenous pyelogram (IVP).
d) Ultrasound scan.
e) CA 125.
35 The following are common side effects of cisplatin use:
a) Peripheral neuropathy and hearing loss.
b) Hyperkalaemia.
c) Hypomagnesiumaemia.
d) Renal damage.
e) Visual disturbances.
36 The following are epithelial tumours:
a) Mucinous tumour.
b) Theca cell tumour.
c) Teratoma.
d) Brenner cell tumour.
e) Androblastoma.
37 Considering dysgerminomas:
a) The peak age is over the age of 45.
b) CA 125 is elevated in 50 per cent of cases.
c) They are mainly solid rather than cystic in nature.
d) They can cause a rise in alpha-fetoprotein and β-hCG.
e) Immature teratomas are benign and are commonly called dermoid tumours.76 Gynaecology
Conditions affecting the vulva and vagina
38 The following are causes of pruritis vulvae:
a) Lichen sclerosus.
b) Nephrotic syndrome.
c) Atrophy.
d) Vaginal discharge.
e) Diabetes.
39 The following apply to lichen sclerosis:
a) Sites commonly affected are the labia majora and mons pubis.
b) Labial adhesions.
c) White plaques.
d) It is commonly associated with autoimmune disorders such as diabetes and pernicious anaemia.
e) Areas of dark red–brown pigmentation.
Infections in gynaecology
40 The following are causes of benign vulval ulcers:
a) Tertiary syphilis.
b) Chancroid.
c) Herpes.
d) HPV infection.
e) Ulcerative colitis.
41 With regard to the lower genital tract:
a) The lower genital tract is lined by stratified squamous epithelium throughout life.
b) Vaginal pH is increased under the influence of oestrogen.
c) The pH after the menopause is around 7.0.
d) Candidal infection is increased in pregnancy, with combined oral contraceptive pill usage and broad-spectrum
antibiotic usage.
e) Candida is the commonest cause of abnormal vaginal discharge in women of childbearing age.
42 Concerning herpes simplex virus:
a) The diagnosis is made on endocervical swabs.
b) Urinary retention and perineal pain are a common presentation.
c) Reactivation of the virus occurs after colonization of neurones in Onuf’s nucleus.
d) Secondary infection in pregnancy necessitates delivery by lower segment Caesarean section.
e) Treatment with antiviral drugs is useful in established disease.
43 In relation to syphilis:
a) The causative organism is Treponema pallidum.
b) The TPHA is the most sensitive and specific test for syphilis.
c) Primary infection usually presents with a painful ulcer on the perineum.
d) Primary and secondary syphilis are not life threatening; however, tertiary neurosyphilis is life threatening,
hence the importance of making the diagnosis.
e) Early treatment is with quadruple therapy of rifampicin, isoniazid, pyrazinamide and ethambutol.Multiple choice questions 77
Urogynaecology
44 Which of the following is true?
a) Stress incontinence is the diagnosis of involuntary loss of urine in association with a rise in intra-abdominal
pressure in the absence of detrusor contraction.
b) Detrusor overactivity is the urodynamic observation of an involuntary increase in detrusor pressure during
filling, which may be spontaneous but which may also be provoked by a cough. It is associated with urgency
and occasional urge incontinence, frequency and nocturia.
c) Acute urinary tract infection or constipation can present as urinary incontinence in the elderly.
d) Urodynamic stress incontinence is usually ideopathic but, in a number of patients, may be caused by neuropathy, previous incontinence surgery and outflow obstruction.
e) Poor urinary stream is diagnostic of urethral obstruction.
Uterovaginal prolapse
45 Regarding the pathophysiology of pelvic organ prolapse:
a) Pelvic organ prolapse is commoner in nulliparous women than in multiparous women.
b) Pelvic organ prolapse is never seen in nulliparous women.
c) Prolapse is commoner after the menopause partly due to oestrogen deficiency.
d) Epidural in labour is a risk factor for the subsequent development of prolapse.
e) Forceps delivery is a risk factor for the development of prolapse.
The menopause
46 Within the human ovary:
a) The follicles are centrally placed in the medulla.
b) The cortex and medulla contain stroma of endodermal origin.
c) The stromal cells of the cortex and medulla produce predominantly androgens.
d) There is a decline in the number of primordial follicles from around 7 million at 6 months gestation to 1.5 million
at birth.
e) Around 400–000 follicles that are present at puberty will progress to ovulation.
47 Considering the pathophysiology of the menopause:
a) Oestrogen is produced in the granulosa cells of the developing follicle.
b) Oestrogen is produced from the precursors of androstenedione and testosterone by the enzyme 17-hydroxylase.
c) Theca cells are stimulated by FSH and granulosa cells are stimulated by LH.
d) The first change in the endocrine system associated with the menopause is a fall in the hormone inhibin produced by the ovary.
e) Levels of FSH start to fall as a secondary effect in the menopause and thus prevent stimulation of the ovaries
to produce oestrogen.
Common gynaecological procedures and medico-legal aspects of gynaecology
48 With regard to abdominal and vaginal hysterectomy.
a) Vaginal hysterectomy can only be performed if there is uterovaginal prolapse.
b) Abdominal hysterectomy is indicated if there is a suspicion of malignancy.
c) The recovery from a vaginal hysterectomy is slower compared to abdominal hysterectomy.
d) Recovery from a Pfannenstiel incision is quicker than from a midline incision.
e) The incidence of haematoma formation is greater after abdominal hysterectomy than after a vaginal
hysterectomy.78 Gynaecology
49 Which of the following statements are true?
a) In induced abortion, the gestation is not to exceed 26 weeks.
b) The decision can be made by any registered doctor or medical practitioner as long as they are acting in good
faith.
c) Pre-operative assessment of patients before termination includes a vaginal examination to date the pregnancy and, if there is any uncertainty about date, an ultrasound scan would be indicated.
d) The patient should have a chlamydia swab performed before theatre, as the incidence of chlamydia is higher
in patients attending for termination of pregnancy.
e) A failed termination of pregnancy and continuation of the pregnancy is greater if termination is performed
after 10 weeks.
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