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OG29.1,OG31.1,OG32.1-2,OG34.6 | Benign Gynaecology — Practice Quiz
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A 38-year-old woman presents with heavy menstrual bleeding and a pelvic mass. Ultrasound shows a 4 cm fibroid distorting the uterine cavity. According to the FIGO leiomyoma subclassification system, which type number best describes a fibroid entirely within the endometrial cavity?
Correct. Type 0 (pedunculated intracavitary) is entirely within the endometrial cavity with no intramural extension. Type 1 is submucous with <50% intramural; Type 2 is submucous with ≥50% intramural; Type 3 is entirely intramural but contacts the endometrium.
FIGO Type 0 fibroids are entirely intracavitary — pedunculated submucous — and are the most amenable to hysteroscopic myomectomy.
The FIGO classification uses 0–8 numbering. Type 0 = pedunculated intracavitary (entirely in cavity). Submucous types 0–2 are treated hysteroscopically.
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A 32-year-old woman with a known fibroid uterus is 22 weeks pregnant and presents with sudden-onset localised uterine pain and a low-grade fever. Which type of fibroid degeneration is most likely?
Correct. Red (carneous) degeneration is the classic degeneration in pregnancy, typically presenting in the second trimester with acute localised pain, low-grade fever, and uterine tenderness over the fibroid. It results from venous occlusion and infarction.
Red degeneration in pregnancy is managed conservatively with analgesia (paracetamol/opioids) and hydration; it is self-limiting.
Carneous (red) degeneration is the hallmark pregnancy-associated complication of fibroids. Hyaline is the commonest degeneration overall but is asymptomatic; cystic follows hyaline; sarcomatous change is rare and not pregnancy-specific.
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A 60-year-old multiparous woman presents with a sensation of 'something coming down' per vaginum, worse on standing. Examination in the left lateral position using a Sims' speculum reveals the cervix reaching the vaginal introitus. According to the POP-Q staging system, this corresponds to which stage?
Correct. In POP-Q staging, Stage II means the most distal prolapse point is within 1 cm proximal or distal to the hymenal ring (i.e., between -1 and +1 cm). The cervix reaching the introitus corresponds to point at 0 (the hymen), placing it firmly in Stage II.
POP-Q Stage II (prolapse to or near the hymen) is where many women first become symptomatic; surgical planning requires the hymen as the reference, not the introitus visually.
POP-Q uses the hymenal ring as zero reference. Stage I: most distal point >1 cm above hymen; Stage II: within 1 cm of hymen (either side); Stage III: >1 cm beyond hymen but not complete eversion; Stage IV: complete eversion/procidentia.
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A 55-year-old woman with second-degree uterine prolapse is to undergo surgical repair. Before surgery, which investigation is most important to perform to avoid worsening urinary symptoms postoperatively?
Correct. Urodynamic studies are mandatory before prolapse repair because up to 40% of women with prolapse have occult (masked) stress urinary incontinence. If not identified pre-operatively and treated concurrently, the repair may unmask this incontinence.
Urodynamics before prolapse repair is the 'pessary-surgery decision hinge' — always identify occult stress incontinence to avoid unmasking it after repair.
While urine culture is routine, urodynamics is the essential pre-surgical investigation here. Occult SUI is present in up to 40% of prolapse patients and must be identified before surgery to plan a concurrent continence procedure if needed.
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A 48-year-old woman reports 10 months of irregular periods, hot flushes, and night sweats. Her FSH is 42 IU/L. She asks about the diagnosis. Menopause is defined as:
Correct. Menopause is defined as the permanent cessation of menstruation resulting from loss of ovarian follicular activity, diagnosed retrospectively after 12 consecutive months of amenorrhoea with no other pathological or physiological cause. This woman at 10 months has not yet reached that threshold — she is in perimenopause.
Perimenopause (this patient's current status) precedes the 12-month amenorrhoea threshold. FSH and symptoms support the diagnosis but the 12-month criterion is definitive.
The definition is precise: 12 consecutive months of amenorrhoea (not 6), no pathological cause, and the diagnosis is retrospective — you can only call it menopause looking back from the 12-month mark. FSH elevation alone is not diagnostic.
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Which of the following is the FIRST hormonal change to occur as a woman approaches menopause?
Correct. The first hormonal change is a rise in FSH, occurring years before the final menstrual period. As the ovarian follicular reserve declines, inhibin B falls first, removing negative feedback on FSH — so FSH rises early. Oestrogen levels fluctuate widely and only fall consistently late in the transition.
FSH >10 IU/L in the early follicular phase (day 2-3) indicates diminished ovarian reserve; FSH >25-30 with 12-month amenorrhoea confirms menopause. Inhibin B falls first, driving FSH up.
The earliest marker of the menopausal transition is the rise in FSH (due to falling inhibin B from the depleting follicular reserve). LH rises later; oestradiol fluctuates rather than falling consistently until the final transition.
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A 65-year-old woman, 15 years post-menopause, presents with a single episode of vaginal bleeding. She is otherwise asymptomatic. What is the single most important first step in her management?
Correct. The cardinal rule is: PMB = endometrial carcinoma until proven otherwise. No matter how benign the presentation, endometrial carcinoma must be excluded before attributing bleeding to any other cause. Approximately 10% of PMB is due to endometrial carcinoma. Immediate investigation (TVS for endometrial thickness + endometrial sampling if indicated) is mandatory.
PMB = endometrial carcinoma until proven otherwise. TVS endometrial thickness ≤4 mm in a postmenopausal woman on no HRT has high NPV for carcinoma, but endometrial sampling is required if the thickness is >4 mm or if bleeding recurs.
Clinical reassurance is NEVER acceptable for PMB without investigation. Even typical-seeming atrophic presentations harbour carcinoma in ~10% of cases. The rule is: investigate first, diagnose second, treat third.
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In investigating post-menopausal bleeding, a transvaginal ultrasound shows an endometrial thickness of 6 mm in a woman not on HRT. What is the next appropriate step?
Correct. The cut-off for endometrial sampling in a postmenopausal woman NOT on HRT is >4 mm endometrial thickness. At 6 mm, endometrial biopsy (pipelle or hysteroscopy-directed biopsy) is mandatory to histologically exclude carcinoma.
TVS threshold: ≤4 mm = low risk (can observe if asymptomatic), >4 mm = biopsy. Pipelle biopsy has ~90-95% sensitivity for endometrial carcinoma but hysteroscopy allows direct visualisation and targeted biopsy.
The threshold for tissue sampling in a postmenopausal woman not on HRT is >4 mm. At 6 mm, sampling is mandatory. Watchful waiting or HRT without histology is not acceptable — it delays diagnosis of a potential carcinoma.
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A 28-year-old woman presents with severe progressive dysmenorrhoea, dyspareunia, and infertility for 3 years. CA-125 is mildly elevated. Laparoscopy is planned. Which is the gold-standard investigation for diagnosing endometriosis?
Correct. Diagnostic laparoscopy with histological confirmation (biopsy) is the gold standard for diagnosing endometriosis. TVS and MRI are useful for detecting endometriomas and deep infiltrating disease but cannot identify superficial peritoneal implants. CA-125 is non-specific and non-diagnostic.
The single most common reason for delayed diagnosis of endometriosis is normalisation of dysmenorrhoea. Laparoscopy is both diagnostic and therapeutic in the same sitting.
Laparoscopy with biopsy = gold standard. TVS is excellent for endometriomas (chocolate cysts) but misses superficial implants. MRI is good for deep infiltrating endometriosis. CA-125 is elevated in many conditions and is not diagnostic.
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A 35-year-old woman with confirmed adenomyosis presents with severe menorrhagia and dysmenorrhoea. She has completed her family. Which is the definitive treatment for adenomyosis?
Correct. Hysterectomy is the only definitive treatment for adenomyosis since the disease is entirely confined to the myometrium. Medical treatments (COC, LNG-IUS, GnRH analogues) suppress symptoms but do not cure the disease and effects are temporary. In a woman who has completed her family, hysterectomy is appropriate.
Unlike endometriosis (which requires excision of all implants), adenomyosis is entirely uterine — so only hysterectomy cures it. LNG-IUS is the best fertility-sparing option for symptom suppression.
All medical therapies for adenomyosis (COC, progestogens, GnRH analogues, LNG-IUS) are suppressive but not curative — symptoms recur when stopped. Hysterectomy is definitive because adenomyosis is confined to the uterus.
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