MRCOG Part 2 – Gynaecological Problems EMQs

For each scenario described below, choose the single most appropriate treatment option. Each option may be used once, more than once or not at all.

• A 35-year-old woman presents with irregular heavy menstrual bleeding. Transvaginal ultrasound reveals an endometrial thickness of 14 mm. A biopsy confirms endometrial hyperplasia without atypia. She has no significant medical history and desires future fertility.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 15-year-old girl is evaluated for primary amenorrhoea. She has a short stature and webbed neck. Breast development is Tanner stage I, and there is no pubic hair. Karyotype analysis reveals 45X.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 16-year-old competitive gymnast presents with primary amenorrhoea. She has Tanner stage II breast development and normal pubic hair. Her BMI is 19, and she follows a rigorous training schedule. Laboratory results show low gonadotropins and normal prolactin levels.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 17-year-old girl presents with primary amenorrhoea and absent secondary sexual characteristics. She has anosmia, and her laboratory results show low gonadotrophins and oestradiol levels.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 6-year-old girl presents with vaginal bleeding and breast development (Tanner stage III). Examination reveals no pubic hair development. Pelvic ultrasound shows a unilateral ovarian mass. Oestradiol levels are elevated, and gonadotropins are suppressed.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 7-year-old girl presents with vaginal bleeding, breast development, and large, irregular café-au-lait spots. Imaging shows bone fibrous dysplasia.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• An 8-year-old girl presents with pubic and axillary hair development without breast development. She has no vaginal bleeding, and her growth velocity is normal. Hormonal studies show mildly elevated DHEA-S levels.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 5-year-old girl is brought in with isolated breast development (Tanner stage II). She has no pubic hair, no axillary hair, and no signs of accelerated growth. Hormonal studies are within normal limits.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• An 8-year-old girl presents with breast and pubic hair development, rapid height gain, and onset of menstruation. Hormonal studies confirm elevated gonadotropins with a pubertal pattern. Imaging of the brain is normal.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 4-year-old girl presents with pubic hair, clitoromegaly, and rapid growth. Hormonal studies show elevated 17-hydroxyprogesterone and DHEA-S. Imaging of the adrenal glands shows bilateral enlargement.

For each scenario described below, choose the single most appropriate management option. Each option may be used once, more than once or not at all.

• A 52-year-old woman presents with severe hot flushes and night sweats affecting her quality of life. She has previously had a total abdominal hysterectomy with ovarian conservation for fibroids with significant pressure symptoms and has a BMI of 34 kg/m².

For each scenario described below, choose the single most appropriate treatment option. Each option may be used once, more than once or not at all.

• A 69-year-old woman presents with postmenopausal bleeding. Transvaginal ultrasound reveals an endometrial thickness of 14 mm. A biopsy confirms endometrial hyperplasia without atypia. She has no significant medical history and has a BMI of 24.

For each scenario described below, choose the single most appropriate management option. Each option may be used once, more than once or not at all.

• A 52-year-old woman presents with severe hot flushes and night sweats affecting her quality of life. She has a BMI of 34 kg/m² and she has a medical history of previous ER positive breast cancer for which she takes ongoing adjuvant tamoxifen treatment.

For each scenario described below, choose the single most appropriate management option. Each option may be used once, more than once or not at all.

• A 60 year old woman presents with vulvovaginal irritation and pain on urination.  She underwent menopause four years ago and her symptoms have worsened since then and are significantly affecting her quality of life.  She does not have significant vasomotor symptoms or mood disturbance.  Her BMI is 31 kg/m² and she has a medical history of hypertension for which she takes amlodipine.

For each scenario described below, choose the single most appropriate management option. Each option may be used once, more than once or not at all.

• A 60 year old woman presents with vulvovaginal irritation and pain on urination.  She underwent menopause four years ago and her symptoms have worsened since then and are significantly affecting her quality of life.  She does not have significant vasomotor symptoms or mood disturbance.  Her BMI is 31 and she has a medical history of previous ER positive breast cancer for which she takes ongoing adjuvant tamoxifen treatment.

For each scenario described below, choose the single most appropriate management option. Each option may be used once, more than once or not at all.

• A 60 year old woman presents with vulvovaginal irritation and pain on urination.  She underwent menopause four years ago and her symptoms have worsened since then and are significantly affecting her quality of life.  She does not have significant vasomotor symptoms or mood disturbance.  Her BMI is 31 kg/m² and she has a medical history of hypertension for which she takes amlodipine.  She has tried vaginal oestrogen treatment without significant benefit.

For each scenario described below, choose the single most appropriate management option. Each option may be used once, more than once or not at all.

• A 60 year old woman presents with vulvovaginal irritation and pain on urination.  She underwent menopause four years ago and her symptoms have worsened since then and are significantly affecting her quality of life.  She does not have significant vasomotor symptoms or mood disturbance.  Her BMI is 31 kg/m² and she has a medical history of hypertension for which she takes amlodipine and she is awaiting bilateral hip replacements for severe osteoarthritis which significantly limits her mobility.

For each scenario described below, choose the single most appropriate management option. Each option may be used once, more than once or not at all.

• A 39 year old woman is known to be a BRCA1 mutation carrier and opts to have risk reduction surgery of bilateral salpingo-oophorectomy and bilateral mastectomy following completion of her family.  Post-operatively, histology confirms that there is no evidence of breast or ovarian malignancy.  Her BMI is 31 kg/m² and she has no other significant medical history.

For each scenario described below, choose the single most appropriate treatment option. Each option may be used once, more than once or not at all.

• A 69-year-old woman presents with postmenopausal bleeding. Transvaginal ultrasound reveals an endometrial thickness of 14 mm. A biopsy confirms endometrial hyperplasia without atypia. She has no significant medical history and has a BMI of 24.  She is treated with a  Levonorgestrel Intrauterine System and repeat endometrial biopsy at 6 months shows progression to endometrial hyperplasia with atypia.

For each scenario described below, choose the single most appropriate treatment option. Each option may be used once, more than once or not at all.

• A 46-year-old woman presents with irregular heavy menstrual bleeding and perimenopausal symptoms of hot flushes and night sweats. Transvaginal ultrasound reveals an endometrial thickness of 14 mm. A biopsy confirms endometrial hyperplasia without atypia. She has no significant medical history and has a BMI of 24.  She is Para 2, having had two previous Caesarean sections and her family is complete. She is treated with a Levonorgestrel Intrauterine System and repeat endometrial biopsy at 6 and 12 months shows persistent hyperplasia without atypia.

For each scenario described below, choose the single most appropriate treatment option. Each option may be used once, more than once or not at all.

• A 46-year-old woman presents with irregular heavy menstrual bleeding and perimenopausal symptoms of hot flushes and night sweats. Transvaginal ultrasound reveals an endometrial thickness of 14 mm. A biopsy confirms endometrial hyperplasia without atypia. She has no significant medical history and has a BMI of 44.  She is Para 2, having had two previous Caesarean sections and her family is complete. She is treated with a Levonorgestrel Intrauterine System and repeat endometrial biopsy at 6 and 12 months shows resolution of the hyperplasia.

For each scenario described below, choose the single most appropriate treatment option. Each option may be used once, more than once or not at all.

• A 59 year old woman presents with a single episode of post-menopausal bleeding.  Transvaginal ultrasound confirms a small endometrial polyp measuring 12 x 8mm and endometrial thickness of 3.5mm.  On examination, the polyp is protruding through the cervix and this is avulsed in clinic and sent for histology which subsequently confirms the presence of focal atypical hyperplasia.

For each scenario described below, choose the single most appropriate treatment option. Each option may be used once, more than once or not at all.

• A 42 year old nulliparous woman is seen in gynaecology clinic with heavy irregular menstrual bleeding.  She has a BMI of 45 and has Type 2 diabetes for which she takes metformin and insulin.  Outpatient hysteroscopy and biopsy confirms endometrial hyperplasia without atypia.  She declines to have any treatment that contains hormones as she is actively trying to conceive.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 17-year-old girl presents with primary amenorrhoea. She has normal breast development (Tanner stage V) and pubic hair (Tanner stage IV). Physical examination reveals a short blind ending vagina. Ultrasound confirms the absence of the uterus and normal ovaries.

For each scenario described below, choose the single most diagnosis. Each option may be used once, more than once or not at all.

• A 16-year-old girl presents with primary amenorrhoea, severe acne, and hirsutism. She is overweight with a BMI of 30. Ultrasound reveals multiple small ovarian follicles.

• A 66-year-old woman presents to the emergency department with a 12-hour history of sudden-onset, severe left lower abdominal pain and nausea. She is not sexually active and has been postmenopausal for 16 years. She denies vaginal bleeding or discharge. On examination, her observations are normal but she has marked tenderness in the left iliac fossa. Her CRP is mildly raised at 33 and white cell count is 11.0 x10⁹/L. A transvaginal ultrasound reveals an enlarged, left ovary containing an irregular complex multilocular cystic structure measuring 7cm containing solid areas and five papillary structures, a small amount of ascites and reduced venous flow on Doppler.  Her CA-125 is 723 IU/ml.

• A 19-year-old woman presents with a second episode of sudden-onset left iliac fossa pain and vomiting within six months. She previously underwent laparoscopic detorsion for left ovarian torsion with a normal-appearing ovary and no cysts. This time, transvaginal ultrasound again shows an enlarged left ovary with peripheral follicles, and Doppler flow is reduced. She is haemodynamically stable and not pregnant.

• A 26-year-old nulliparous woman presents with sudden-onset severe right iliac fossa pain and vomiting that started 8 hours ago. She has no significant medical or surgical history. Her menstrual cycles are regular and she is not pregnant. On examination, she is afebrile and haemodynamically stable but in significant pain. Transvaginal ultrasound reveals a 7 cm right ovarian mass with heterogeneous echogenicity and calcifications consistent with a dermoid cyst (mature cystic teratoma). The ovary is enlarged, and Doppler flow shows reduced venous signal. She is taken to theatre for laparoscopy, and the ovary appears dusky but not necrotic.

• A 39-year-old woman presents with recurrent episodes of intermittent sudden-onset severe lower left sided abdominal pain, nausea, and vomiting which began two weeks ago and has now become constant and severe. Her last menstrual period was 2 weeks ago. She has had three previous Caesarean sections and had tubal sterilisation during the last Caesarean. She has no significant medical history, and is not pregnant. Ultrasound shows a 6.5 cm enlarged left ovary with peripheral follicles, no arterial or venous Doppler flow, and moderate free fluid in the pelvis. She is taken for urgent diagnostic laparoscopy. Intraoperatively, the ovary is twisted twice, appears black, necrotic, and friable, with no signs of reperfusion after detorsion. There is no obvious cystic pathology.