1 History and examination
Outline a format for a gynaecological history, including headings and subheadings.
2 History and examination
Name the two devices seen in Figures 8.1 and 8.2, and outline the patient’s position for examination with each,
along with their clinical applications.
Figure 8.1 Reproduced from Monga A (ed) Gynaecology By
Ten Teachers, 18th edition. London: Edward Arnold 2006.
Figure 8.2 Reproduced from Monga A (ed) Gynaecology By
Ten Teachers, 18th edition. London: Edward Arnold 2006.100 Gynaecology
16
15
14
13
12
11
10
9
8
1
2 3
4
5
6
7
Figure 8.3 Adapted from Monga A (ed) Gynaecology By Ten Teachers, 18th edition. London: Edward Arnold 2006.
1
13 12
11
10
2
3 4 5 6 7 8 9
Figure 8.4 Adapted from Monga A (ed) Gynaecology By Ten Teachers, 18th edition. London: Edward Arnold 2006.
3 Embryology, anatomy and physiology
Label the diagrams below of the human female pelvis (Figures 8.3 and 8.4).Objective structured clinical examination questions 101
4 Normal and abnormal sexual development and puberty
Figure 8.5 Reproduced from Monga A (ed) Gynaecology By Ten Teachers, 18th edition. London: Edward Arnold 2006.
a) What clinical condition is demonstrated in this photograph?
b) What is the typical karyotype?
c) What are the typical clinical features?
d) What is the typical hormone profile of this patient?
e) What is the macroscopic appearance of the ovaries at laparotomy for this condition?
f) What are the two phases of treatment for this patient?
5 The normal menstrual cycle
Draw the menstrual cycle outlining changes in the hypothalamic, pituitary and ovarian hormone levels as well
as the effect on the endometrium.102 Gynaecology
6 The normal menstrual cycle
Label these histology sections of endometrium (Figure 8.6a and b) and match the characteristics with each phase.
(a) (b)
Figure 8.6 Illustrations kindly provided by Dr Colin Stewart; reproduced from Monga A (ed) Gynaecology By Ten Teachers, 18th
edition. London: Edward Arnold 2006.
Phase:
• Follicular phase
• Secretory phase
• Luteal phase
• Proliferative phase
Characteristics:
• Stromal oedema and glandular growth
• Glandular and stromal proliferation
• Pre-ovulation
• Postovulation
• Progesterone predominates
• Oestrogen predominates
7 Fertility control
List the various methods of contraception along with their failure rate per 100 per women years.
8 Fertility control
A 16-year-old girl attends a clinic having forgotten to take her pill 14 hours ago. How would you counsel her?Objective structured clinical examination questions 103
9 Fertility control
List the mode of action of the following contraceptives:
• Combined oral contraceptive pill
• Progesterone-only pill
• Depo
• Intrauterine device (IUD)
• Intrauterine system (IUS)
• Condoms
• Natural family planning
• Female sterilization
• Male sterilization
10 Infertility
A couple are referred to the infertility clinic having been trying to conceive a pregnancy after 2 years of unprotected intercourse. Mrs Smith is 29, has irregular periods (2–3 per year), she weighs 16 stone, has significant acne
and facial hair. She has no history of pelvic surgery or pelvic infections. Mr Smith has a normal semen analysis
and has children from a previous relationship. The investigations from the female partner are as follows:
Day 2 luteinizing hormone 12 u/L
Follicle-stimulating hormone 4 u/L
Prolactin Normal
Sex hormone binding globulin Reduced
Testosterone High
Day 24 progesterone 4 nmol/L
Hysterosalpingogram demonstrates bilateral fill and spill of both tubes with a normal uterine cavity. The ultrasound scan of her ovaries is shown below.
Figure 8.7 Reproduced from Monga A (ed) Gynaecology By Ten Teachers, 18th edition. London: Edward Arnold 2006.
a) What is the likely diagnosis?
b) How would you initially try to counsel and manage this patient?104 Gynaecology
11 Disorders of early pregnancy
A 17-year-old woman presents to the early pregnancy assessment unit complaining of 7 weeks’ amenorrhoea,
nausea and vomiting, breast tenderness, moderate bleeding and intermittent abdominal pain.
a) On examination, she has a normal pulse and blood pressure, there are no signs of peripheral shutdown, she
has no adnexal tenderness, the cervix is closed and non-tender. Urinary pregnancy test is positive. What are
the possible diagnoses?
b) A transvaginal scan demonstrates a gestation sac of 30 mm., a yolk sac, a fetal pole and a fetal heart is clearly
seen beating. A large haematoma of 40 mm is seen adjacent to the gestation sac. A corpus luteum was noted
on the right ovary measuring 25 mm and the left ovary was normal. There was no free fluid or any other
adnexal mass noted. What are the diagnosis and your initial management?
c) Two weeks later, the woman returns for a repeat scan, as she has experienced further bleeding. On ultrasound, the gestation sac measures 29 mm, the yoke sac is seen but no fetal heart movements are seen. What
would you do next?
12 Benign diseases of the uterus and cervix
a) Label this figure indicating the typical location of fibroids.
6
5
1
4
2
3
Figure 8.8 Adapted from Monga A (ed) Gynaecology By Ten Teachers,
18th edition. London: Edward Arnold 2006.
b) What are the typical clinical presentations of fibroids?
c) What are the different types of degeneration that fibroids can undergo?
13 Benign diseases of the uterus and cervix
A 34-year-old nulliparous woman from Ghana is referred by her general practitioner (GP) complaining of menorrhagia, dysmenorrhoea, urinary frequency, right loin pain and constipation. On examination, she is normotensive
with a pulse of 98 beats per minute, she has pale sclerae and she has a pelvic mass, which is the same size as a 25-week
pregnancy. Her last menstrual period was a week ago and was extremely heavy and has just stopped.
a) What are the possible diagnoses?
b) What investigations would you perform and why?
c) An ultrasound scan shows a large, fundal, subserous fibroid and several submucous fibroids, the largest being
of 3 cm in diameter. They do not appear to impinge on the uterine cavity. The renal ultrasound scan shows
normal renal tracts with no evidence of obstruction. A mid-stream urine confirms that the patient had a urinary tract infection; this was treated and her loin pain improved. Haemoglobin was low, with a mean corpuscular volume. What options would you offer to the patient?Objective structured clinical examination questions 105
14 Malignant diseases of the uterus and cervix
Figure 8.9 Courtesy of Mr KS Metcalf; reproduced from Monga A (ed) Gynaecology By Ten Teachers, 18th edition. London: Edward
Arnold 2006.
a) What is shown in the picture above?
b) What does this colposcopic finding show?
c) What is the likely diagnosis?
d) What is the treatment for this condition?
e) Which virus strains are thought to be causative in developing this condition?
f) Why is it important to treat this?
g) What is the follow-up for these patients?
15 Infections in gynaecology
A 20-year-old woman presents with a 3-day history of pelvic pain, vaginal discharge and fever. She had unprotected intercourse 10 days ago with her new partner. On examination, she has cervical excitation, a mucopurulent discharge and tenderness in both adnexae.
a) What is the most likely diagnosis?
b) What is the commonest cause?
c) What are the other possible causes?
d) What cells do the main causative organisms colonize?
e) What tests are used to make the diagnosis?
f) What are the commonest treatments?
g) What other precautions have to be taken?
h) What are the risks associated with subsequent pregnancy?106 Gynaecology
a) What is seen in the photograph above?
b) What condition is this associated with and what is the causative organism?
c) What is the natural history of infection?
d) How is it transmitted?
e) What type of organism is the virus?
f) How does this replicate?
g) How is the diagnosis made and how is the disease monitored?
h) What is the treatment of choice?
17 Urogynaecology
This is a urinary diary of an 80-year-old woman who complains of urinary incontinence:
Time Day 1 Day 2 Day 3
Volume in Urine out Volume in Urine out Volume in Urine out
(mL) (mL) (mL) (mL) (mL) (mL)
7 am 250 200 220
8 am 300 330 330 100
9 am 100 150
10 am 200 75 100 100
11 am 330 200 50
12 pm 100 100 50
1 pm 100 75
2 pm 175 200 100
3 pm 100 75 450
4 pm 75 100 75
5 pm 50
6 pm 400 50 450 100 50
7 pm 50 450
8 pm 100 100 330 50 100
9 pm 200 75 50 100
10 pm 330 300
11 pm 100 100
12 am 100
(Continued)
16 Infections in gynaecology
Figure 8.10 Reproduced from Monga A (ed) Gynaecology By Ten Teachers, 18th edition. London: Edward Arnold 2006.Objective structured clinical examination questions 107
a) What is this patient’s bladder functional capacity?
b) What is the patient’s daytime frequency?
c) What is the patient’s night-time frequency?
d) What are the possible diagnoses?
The patient complains of leakage with coughing as well as urgency, frequency, nocturia and occasional urge
incontinence. Formal cystometry is performed and the results are given below:
Time Day 1 Day 2 Day 3
Volume in Urine out Volume in Urine out Volume in Urine out
(mL) (mL) (mL) (mL) (mL) (mL)
1 am 100 100
2 am 100 100
3 am 100 100
4 am 100
5 am 100
6 am
Maximum capacity 280 mL
First sensation 80 mL
First urgency 90 mL
Maximum detrusor pressure A peak up to 20 cm of water was noted after a cough
Voided volume 320 mL
Flow rate 20 mL/second
Detrusor pressure at peak flow 60 cm of water
e) What is the diagnosis?
f) This woman had cystometry due to multiple mixed symptoms. What are the other indications for urodynamics?108 Gynaecology
18 Urogynaecology
1 2 3 4 5
8 7 6
a) What does the picture above show?
b) What is it used to treat?
c) What was the traditional procedure used to treat USI?
d) What are the main consequences of colposuspension?
e) What are the advantages of TVT over colposuspension?
19 Uterovaginal prolapse
a) Label the diagram below.
Figure 8.12 Reproduced from Lewis TLT, Chamberlain GVP (eds), Gynaecology by Ten Teachers, 15th edition. London: Edward
Arnold 1990.
b) Describe the three mechanisms of support for pelvic organs.
Figure 8.11Objective structured clinical examination questions 109
20 Uterovaginal prolapse
Classification and grading of prolapse
a) Complete the following table:
Figure 8.13
a) What is shown in this picture?
b) List indications for the use of this procedure.
c) List the complications of this procedure.
Organ Compartment Nomenclature of prolapse
1 Anterior 7
2 8
3 Posterior 9
4 10
5 Apex 11
6 12
b) Describe the grading system with regards to primary, secondary and tertiary prolapse.
21 The menopause
A 50-year-old woman with no significant past obstetric history and no previous operations attends your clinic
requesting hormone replacement therapy (HRT).
a) What are the contraindications to HRT?
b) What are the modes of delivery for HRT?
c) What are the sites of action of oestrogen?
d) When should progesterone be administered?
e) What are the two types of oestrogen and progesterone regime, and when should they be used?
22 Common gynaecological procedures110 Gynaecology
23 Common gynaecological procedures
Figure 8.14 Reproduced from Monga A (ed) Gynaecology By Ten Teachers, 18th edition. London: Edward Arnold 2006.
a) What is the image seen in the photograph?
b) What is the instrument used to provide this image?
c) What are the indications for this procedure?
d) What are the complications of the procedure?OSCE answers 111
Name, age, occupation
Main presenting complaint
History of presenting complaint
• Menstrual history:
• Pattern of bleeding (regular/irregular)
• Amount of loss (clots/flooding/sanitary protection)
• Intermenstrual bleeding
• Pelvic pain: ? related to cycle, site and nature, radiation
• Dyspareunia (superficial/deep)
• Vaginal discharge
• Fertility history/urogynaecology questions
Menstrual cycle:
• Menarche
• Number of days bleeding/number of days between periods
• First day of last menstrual period
Past gynaecological history:
• Previous investigations and procedures
• Smear history
Past obstetric history:
• Number of previous pregnancies
• Number of previous live births, stillbirths, miscarriages, terminations
• Birth weights and mode of delivery of live births
Sexual and contraceptive history:
• Dyspareunia
• Sexually transmitted diseases
• Contraception
Previous medical history/drug history and allergies
Social history:
• Occupation
• Smoking and alcohol intake
Systemic enquiry
OSCE answers
1 History and examination
See Chapter 1, Gynaecology by Ten Teachers, 18th edition.
2 History and examination
Figure 8.1: Sims’ speculum. The patient lies in the left lateral position; it is used to inspect the vault and anterior
vaginal wall.
Figure 8.2: Cusco’s (bivalve) speculum. The patient lies in the lithotomy position; it is used to inspect the
exposed cervix.
See Chapter 1, Gynaecology by Ten Teachers, 18th edition.112 Gynaecology
3 Embryology, anatomy and physiology
Figure 8.3: 1, Right ureter; 2, ovary; 3, rectouterine fold; 4, posterior fornix; 5, cervix uteri; 6, rectal ampulla; 7,
anal canal; 8, vagina; 9, urethra; 10, bladder; 11, vesicouterine recess; 12, fundus of uterus; 13, external iliac vessels; 14, ovarian ligament; 15, uterine tube; 16, suspensory ligament of ovary.
Figure 8.4: 1, Fundus; 2, peritoneum (serous layer); 3, oviduct; 4, myometrium; 5, endometrium; 6, anatomical
internal os; 7, lateral fornix; 8, external os; 9, vagina; 10, cervix; 11, isthmus; 12, cornu; 13, body.
See Chapter 2, Gynaecology by Ten Teachers, 18th edition.
4 Normal and abnormal sexual development and puberty
a) Turner’s syndrome.
b) 45XO.
c) Webbed neck, short stature, wide carrying angle of arms and widely spaced nipples.
d) Low levels of oestradiol with high levels of follicle-stimulating hormone (FSH) and luteinizing hormone
(LH).
e) Macroscopically the ovaries appear streaked.
f) There are two phases of treatment. First, at puberty, hormone replacement therapy (HRT) is instigated for
the development of secondary sexual characteristics. Second, when the patient wishes to become pregnant,
she will require the aid of donor eggs and sperm, which could then be inserted into the uterus.
See Chapter 3, Gynaecology by Ten Teachers, 18th edition.
5 The normal menstrual cycle
LH
U/L
22
20
16
18
14
8 6 4 2 0
10
1.4
1.8
1000
500
1500
40
20
2.4
2.0
2.2
0.2
0.4
0.6
1.3
0.8
1.0
10
30
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 2 4 6 8
P4
nmol/U Inhibin
IU/mL
Key
LH
E2
pmol/L
Endometrium Menstruation
Ovarian + pituitary hormones
Folliculor Secretory Menstruation
Ovulation
Day of the
menstrual
cycle
12
E2 P4 Inhibin
Figure 8.15 Adapted from Monga A (ed) Gynaecology By Ten Teachers, 18th edition. London: Edward Arnold 2006.OSCE answers 113
E2, oestradiol; LH, luteinizing hormone; P4, progesterone.
See Chapter 4, Gynaecology by Ten Teachers, 18th edition.
6 The normal menstrual cycle
Contraceptive method Failure rate per 100 women years
Combined oral contraceptive pill 0.1–1
Progesterone-only pill 1–3
Depo-Provera 0.1–2
Implanon 0
Copper-bearing intrauterine device (IUD) 1–2
Levonorgestrel-releasing IUD 0.5
Male condom 2–5
Female diaphragm 1–15
Persona 6
Natural family planning 2–3
Vasectomy 0.02
Female sterilization 0.13
Figure a Figure b
Follicular phase Luteal phase
Proliferative phase Secretory phase
Glandular and stromal proliferation Stromal oedema and glandular growth
Pre-ovulation Postovulation
Oestrogen predominates Progesterone predominates
See Chapter 4, Gynaecology by Ten Teachers, 18th edition.
7 Fertility control
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.114 Gynaecology
How late
are you?
Less than
12 hours late
Don’t worry. Just take
the delayed pill at
once, and further
pills as usual.
That’s all.
More than
12 hours late
• Take the most recently
delayed pill now
• Discard any earlier
missed pills
• Use extra precautions
(condom, for instance)
for the next 7 days
How many pills are left
in the pack after the most
recently delayed pill?
7 or more
pills
When you have finished
the pack, leave the usual
7-day break before starting
the next pack
Fewer than 7
pills
When you have
finished the pack, start
the next pack next day,
without a break
Figure 8.16 Reproduced with permission from Loudon N, Glasier A, Gebbie A (eds), Handbook of family planning and reproductive
health care, 3rd edn. London: Churchill Livingstone 2000.
8 Fertility control
Patients who have forgotten to take their pill should be counselled using the following algorithm.
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.OSCE answers 115
9 Fertility control
Effect on cervical
Inhibition Barrier between mucus and prevention Toxicity to
Contraceptive method of ovulation gametes of implantation male gametes
Combined oral contraceptive pill
Progesterone-only pill 4%
Depo
IUD
IUS
Condoms
Natural family planning
Female sterilization
Male sterilization
See Chapter 6, Gynaecology by Ten Teachers, 18th edition.
10 Infertility
a) Polycystic ovary syndrome.
b) One should initially counsel the patient regarding the diagnosis and implications of polycystic ovary syndrome. Explain that polycystic ovary syndrome is a condition typified by insulin resistance, an irregular
cycle, hirsutism and weight gain. The main problems are anovulation, irregular periods and women usually
present either because of oligomenorrhoea and wanting a regular cycle (these women are usually treated
with the combined oral contraceptive pill) or infertility. One should also explain that there are risks of
unopposed oestrogen and that there is a slightly higher risk of endometrial carcinoma later on in life if these
patients do not have progesterone. There is also a risk of developing hypercholesterolaemia and non-insulindependent diabetes mellitus in later life.
If patients reduce their body mass index by 5 per cent, 30 per cent will achieve ovulation spontaneously and those
that do not will be much more receptive to ovulation induction. Ovulation induction can be in the form of oral
clomifene citrate or by gonadotrophin therapy, if patients are clomifene resistant. It is important to discuss the
risks of multiple pregnancy and ovarian hyperstimulation, if ovulation induction is embarked upon.
See Chapter 7, Gynaecology by Ten Teachers, 18th edition.
11 Disorders of early pregnancy
a) A threatened miscarriage with a viable intrauterine pregnancy, a non-viable intrauterine pregnancy (missed
miscarriage/incomplete miscarriage), ectopic pregnancy and molar pregnancy.
b) The diagnosis is a threatened miscarriage with a viable intrauterine pregnancy. Initially, one should reassure
the mother that the fetus is viable and the fetal heart can be seen. One should explain the presence of the
haematoma has demonstrated some bleeding. It may resolve but she may have further bleeding and may still
lose the pregnancy. Initially, one would plan to rescan the pregnancy in 2 weeks’ time to confirm viability and
see if the haematoma is resolving. However, you should explain to the patient that she may have further
bleeding/pain, which may suggest that she is miscarrying, and if this does occur, she should return to the
hospital. She should be given a telephone number to contact the hospital at all times.116 Gynaecology
c) Explain to the patient that the pregnancy is now not viable and that she will need to have the uterus evacuated. This can be done either by expectant, medical or surgical procedures. Surgical evacuation is the most
effective, but those managed with expectant and medical management are efficient in 50 and 65 per cent of
cases, respectively. One should give the woman contact numbers for self-help groups, for support groups and
also a contact number, if she wishes any further information. She should be given advice about subsequent
pregnancies and that usually one would advise her to refrain from trying to conceive again until she has had
subsequent periods.
See Chapter 8, Gynaecology by Ten Teachers, 18th edition.
12 Benign diseases of the uterus and cervix
a) 1, Subserous; 2, submucosal; 3, cervical; 4, intramural; 5, intracavity polyp; 6, pedunculated fibroid.
b) Menorrhagia, pelvic mass, pressure symptoms (urinary frequency), pain (if fibroid is undergoing degeneration).
c) Red, hyaline, cystic, calcification, malignant.
See Chapter 9, Gynaecology by Ten Teachers, 18th edition.
13 Benign diseases of the uterus and cervix
a) The most likely diagnoses is fibroids, but an ovarian cyst with concomitant menorrhagia and adenomyosis is
also possible. It is likely that the pelvic mass is causing related pressure symptoms, with urinary frequency
resulting from pressure against the bladder and possible right ureteric compression by the fibroid causing
renal dilatation.
b) The following investigations would be performed.
• A full blood count to exclude anaemia.
• A pelvic ultrasound scan to determine the nature of the mass to try to distinguish a fibroid from an ovarian
mass.
• A computerized tomography scan may be necessary, if there are inconclusive results from the ultrasound scan.
• A renal ultrasound scan/intravenous pyelogram to assess whether there is ureteric obstruction and dilatation of the renal pelvices.
• Hysteroscopy may be necessary to assess the uterine cavity.
c) As the patient is relatively asymptomatic from her anaemia, she could have iron supplementation rather than
risk a blood transfusion. Depending on her fertility wishes, one would need to discuss the following treatments.
• Mirena, if her uterine cavity is normal; this may give some symptomatic relief.
• Transcervical resection of the fibroid, if the main problem is from the submucous fibroid.
• A myomectomy, if the patient wishes to retain fertility.
• Total abdominal hysterectomy, the patient does not wish to remain fertile.
• Selective angiographic embolization is a new treatment for fibroids but cannot be used if a woman wants
to become pregnant in the future.
• It is always worth giving adjunctive gonadotrophin-releasing hormone agonist pre-treatment for 2–3
months to reduce the bulk of vascularity of fibroids prior to surgery.
See Chapter 9, Gynaecology by Ten Teachers, 18th edition.OSCE answers 117
14 Malignant diseases of the uterus and cervix
a) Colposcopy of the cervix.
b) Acetowhite staining, mosaicism and punctuation.
c) Cervical intraepithelial neoplasia 3.
d) Large loop excision of the transformation zone (LLETZ).
e) Human papillomavirus (HPV) strains 16 and 18 are the most commonly associated with cervical cancer.
f) Cervical intraepithelial neoplasia (CIN) has the potential to develop to an invasive malignancy, although in
itself does not have malignant properties. Treatment, therefore, involves removing the abnormal cells completely down to a depth of 10 mm.
g) Current guidelines recommend a smear and colposcopy at 6 months after the large loop excision of the
transformation zone (LLETZ) procedure, then a smear by the GP 12 months post-LLETZ and then annually
for 9 years. After this, if the smears remain normal, the patient can go back to having 3-yearly smears.
See Chapter 12, Gynaecology by Ten Teachers, 18th edition.
15 Infections in gynaecology
a) Acute pelvic inflammatory disease.
b) Chlamydia.
c) Ascending infection from instrumentation of the uterus/intrauterine contraceptive device (IUCD) usage,
previous pelvic surgery, appendicitis, sexually transmitted diseases, such as gonorrhoea.
d) The columnar cells of the cervix.
e) ELISA (enzyme-linked immunosorbent assay). This is the commonest investigation; however, it has limited
sensitivity. Direct fluorescent antibody test (DFA) can be performed, which is more specific.
f) Doxycycline and azithromycin.
g) Contact tracing and treatment of other sexual partners.
h) Ectopic pregnancy.
See Chapter 15, Gynaecology by Ten Teachers, 18th edition.
16 Infections in gynaecology
a) Kaposi’s sarcoma.
b) The condition is the acquired immunodeficiency syndrome (AIDS), which is caused by the human immunodeficiency virus (HIV).
c) 20 per cent of people who acquire HIV have an acute seroconversion illness typified by fever, generalized lymphadenopathy and a maculate erythematous rash, pharyngitis and conjunctivitis. The majority of people are
asymptomatic. Affected individuals then develop a steady decline in their immune function over a number of
years. This usually presents with non-life-threatening opportunistic infections, such as recurrent candidiasis,
shingles and frequent episodes of genital or oral herpes. Hairy oral leukoplakia may come and go, and is pathopneumonic of immunodeficiency. If left untreated, full-blown AIDS will develop usually within 10 years.
d) Transmission is by sexual intercourse and contamination with blood products, such as needle stick injury.
e) It is a single-stranded RNA retrovirus.
f) The gp120 protein binds to the CD4 receptor of the T cells. It then hijacks the cell and uses the viral reverse
transcriptase enzyme to produce viral DNA.
g) Seroconversion can be determined by finding antibodies to the gp120 protein. The disease is monitored by
measuring the CD4 lymphocyte count.
h) Combination antiviral drugs are used, which target the reverse transcriptase enzyme and viral proteases.
These do improve life expectancy but are expensive.
See Chapter 15, Gynaecology by Ten Teachers, 18th edition.118 Gynaecology
17 Urogynaecology
a) 100 mL.
b) 10–11.
c) 3.
d) Detrusor overactivity or urinary tract infection.
e) The likely diagnosis is detrusor overactivity. This is due to the fact that a rise in detrusor pressure was seen
on filling. In addition, the patient complained of urgency in association with a rise in detrusor pressure and
this confirmed detrusor overactivity.
f) Previous unsuccessful continence surgery, voiding disorder, neuropathic bladder, investigation prior to
embarking on incontinence surgery.
See Chapter 16, Gynaecology by Ten Teachers, 18th edition.
18 Urogynaecology
a) Tension-free vaginal tape (TVT) sling.
b) Urodynamic-proven stress incontinence (USI).
c) Colposuspension.
d) 70–90 per cent long-term success in treating stress incontinence. Long-term risk of poor voiding (5 per cent),
de novo detrusor overactivity (5 per cent), intermittent self-catheterization ( 1 per cent) and rectocele.
e) Performed under local anaesthetic, less invasive, shorter hospital stay, quicker recovery, similar success rates
but less risk of voiding disorder, de novo detrusor overactivity and no increased risk of developing a rectocele.
See Chapter 16, Gynaecology by Ten Teachers, 18th edition.
19 Uterovaginal prolapse
a) 1, Internal urethral orifice; 2, vagina; 3, cervix; 4, rectovaginal pouch; 5, rectum; 6, uterosacral ligament; 7,
transverse cervical (cardinal) ligament; 8, pubocervical fascia.
b) The mechanisms of support for pelvic organs are:
• Muscular supports of the levator ani which forms the pelvic diaphragm.
• Endofascial supports in the form of the uterosacral, cardinal and pubocervical ligaments.
• The posterior angulation of the vagina, thus preventing pelvic organs falling through the vagina when the
patient is standing.
See Chapter 17, Gynaecology by Ten Teachers, 18th edition.
20 Uterovaginal prolapse
a) 1, Urethra; 2, bladder; 3, rectum; 4, omentum/small bowel; 5, uterus; 6, vault; 7, urethrocele; 8, cystocele; 9,
rectocele; 10, enterocele; 11, uterine prolapse; 12, vault prolapse.
b) Grading:
• Primary prolapse is deviation from its anatomical position but not to the level of the hymenal ring/introitus.
• Secondary prolapse is deviation of the organ from its anatomical position to the level of the introitus but
not beyond.
• Tertiary prolapse is deviation of the organ from its anatomical position beyond the hymenal ring.
See Chapter 17, Gynaecology by Ten Teachers, 18th edition.OSCE answers 119
21 The menopause
a) Absolute contraindications include present or suspected pregnancy, suspicion of breast cancer, suspicion of
endometrial cancer, acute active liver disease, uncontrolled hypertension or confirmed venous thrombotic
event. Relative contraindications include the presence of uterine fibroids, a past history of benign breast disease, unconfirmed venous thromboembolic episode, chronic stable liver disease and migraine.
b) Topical, oral, transdermal and subcutaneous implant.
c) Bone (arrests and reverses bone loss), cardiovascular system (reduces vasomotor symptoms, alters lipid profile and increases risk of venous thrombosis), genitourinary system (reduces atrophy) and central nervous
system.
d) Progesterone is required to protect the endometrium in women who have not had a hysterectomy.
e) Sequential HRT for women below 54 or who have been amenorrhoeic for less than 2 years, and continuous
combined HRT for women over 54 who have been amenorrhoeic for 2 years.
See Chapter 18, Gynaecology by Ten Teachers, 18th edition.
22 Common gynaecological procedures
a) Rigid hysteroscope.
b) Postmenopausal bleeding, irregular menstruation/intermenstrual bleeding in women over the age of 35, persistent menorrhagia, persistent discharge, suspected uterine malformation and suspected Asherman’s syndrome.
c) Complications include perforation of the uterus and cervical damage at the time of cervical dilatation, risk
of infection and ascending of infection, if already present.
See Appendix 1, Gynaecology by Ten Teachers, 18th edition.
23 Common gynaecological procedures
a) This is a laparoscopic view of endometriosis. Endometriosis is scored using the American fertility scoring
system.
b) The instrument is called a laparoscope.
c) The indications for laparoscopy include suspected ectopic pregnancy, undiagnosed pelvic pain, tubal
patency testing, and sterilization or an operative laparoscopy.
d) Complications include damage to intra-abdominal structures, such as the bowel or major blood vessels.
Herniation through port sites is also possible through larger port sites, such as a 10 mm or larger port.
See Appendix 1 and 2, Gynaecology by Ten Teachers, 18th edition.
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