Cervical cancer highlights the disparities in healthcare for which of the following reasons?

• a)

  It is a disease restricted to mainly resource limited/developing countries

• b)

  Effective screening programs and treatments (LLETZ) are not always available in resource limited settings

• c)

  Women who lack medical insurance in developed countries are often excluded from screening and treatment

• d)

  Prophylactic vaccines are only available in developed countries

• e)

  Screening is no longer required due to the availability of prophylactic vaccines in developed countries

In the setting of a torrential bleed secondary to cervical cancer, resuscitative measures may be followed by vaginal packing for which of the following reasons?

• a)

  Vaginal packing will tamponade and stop all bleeding definitively.

• b)

  This may tamponade bleeding prior to uterine artery embolization as definitive management.

• c)

  Vaginal packing impregnated with fibrin pro-coagulant work by increasing local thrombosis.

• d)

  This is a temporary measure but the woman should be flagged for definitive management with radiation treatment.

• e)

  This is part of palliation

Endometrial adenocarcinoma of the uterus (type 1 cancer) is increasing in incidence for which of the following reasons?

• a)

  This is because it only affects older postmenopausal women and women are living to an older age.

• b)

  This is attributed to lifestyle factors including the obesity epidemic and rise in diabetes.

• c)

  This is because more women are using exogenous hormonal treatment.

• d)

  It is not a true reflection of an increase in incidence but rather better reporting of new cancers.

• e)

  Due to the concomitant increase in breast cancer and Tamoxifen use.

Gestational trophoblastic neoplasia should be considered in the differential of which of the following?

• a)

  Women less than 39 years of age with abnormal PV bleeding.

• b)

  Women with persistent bleeding after a second evacuation of the uterus for a miscarriage or molar pregnancy.

• c)

  Women with a positive pregnancy test.

• d)

  Women with a positive pregnancy test and /or persistent bleeding after an evacuation of uterus for a miscarriage or molar pregnancy or unusual symptoms and a positive pregnancy test and an empty uterus.

• e)

  Women with persistent bleeding after a positive pregnancy test and an empty uterus.

In which of the following conditions will SPRM administration reduce or eradicate heavy menstrual bleeding?

• a)

  When the bleeding is due to fibroids

• b)

  When the bleeding is due to dysfunctional uterine bleeding

• c)

  When the bleeding is due to endometrial carcinoma

• d)

  When the bleeding is due to coagulation abnormalities i.e. VW Disease

• e)

  When the bleeding occurs in cases of thrombocytopenia during chemotherapy

The following statement(s) is/are true regarding the diagnosis of endometrial polyps:

• a)

  Transvaginal scan has equivalent accuracy to hysteroscopy

• b)

  Blind endometrial biopsy will reliably detect polyp tissue

• c)

  3D ultrasound is more accurate than saline infusion sonography

• d)

  Saline infusion sonography is less painful than outpatient hysteroscopy

• e)

  Hysteroscopy has the highest accuracy for the diagnosis of endometrial polyps

The following is/are true regarding the treatment of endometrial polyps:

• a)

  Their removal is mandatory to resolve symptoms of abnormal uterine bleeding

• b)

  It is necessary in all cases

• c)

  It can be effected medically in most cases

• d)

  It is best done by dilatation and curettage or blind avulsion with polyp forceps

• e)

  It does not reduce the risk of recurrent postmenopausal bleeding

Polypectomy is best performed:

• a)

  By dilatation of the cervix and curettage of the endometrium

• b)

  In an outpatient setting

• c)

  Using monopolar electrosurgery

• d)

  With tissue removal systems

• e)

  Under direct hysteroscopic vision

The outpatient setting for the surgical removal of endometrial polyps is:

• a)

  Preferred by women

• b)

  Safer than procedures performed in hospital under general anaesthesia

• c)

  Is more successful

• d)

  Is non-inferior to treatment under general anaesthesia performed in an inpatient, hospital setting

• e)

  Cost-effective

At TVS or GIS, the endometrium can be systematically evaluated to determine the cause of postmenopausal bleeding and distinguish between cancer and benign conditions. Which of the following is/are true?

• a)

  An endometrial thickness over 15 mm is highly cancer suspect in a woman with postmenopausal bleeding

• b)

  An interrupted hypoechoic line between the endometrium and myometrium is a sign of hyperplasia

• c)

  Findings of Doppler flow with a single or double vessel indicate cancer

• d)

  Polyps with benign features at TVS and/or GIS should be removed

• e)

  In a postmenopausal woman, finding of an endometrial thickness of 7 mm effectively rules out endometrial abnormalities

Diagnosis of adenomyosis and leiomyomas require careful evaluation. Which of the following is/are true?

• a)

  Characteristic findings of myomas include circumferential flow and well defined borders

• b)

  Multiple small uterine lesions with uniform echostructure are common in leiomyosarcomas

• c)

  The presence of fan shaped shading is sufficient to diagnose adenomyosis

• d)

  MRI is the first choice for diagnosis and mapping of myomas

• e)

  Small polyps and myomas can be removed by use of small dimensional hysteroscopes

As to the relation between the AUB and age group which of the following is/are true?

• a)

  In younger patients the most frequent finding is dysfunctional bleeding.

• b)

  During the climacteric, endocervical and endometrial polyps are the most frequent causes.

• c)

  During the perimenopause, findings of malignancy are the major cause.

• d)

  The patient with AUB during the menopause should be investigated due to the possibility of endometrial cancer, and, whenever possible, should be submitted to hysteroscopy with biopsy.

• e)

  Endometrial atrophy is the major factor responsible for AUB during the menopause.

When the myomas cause AUB, which of the following is/are true?

• a)

  There is an increase in uterine vascularization

• b)

  There is an alteration in the uterine contractility pattern

• c)

  There is an increase in endometrial surface

• d)

  There is exposure and ulceration of the submucosal myoma surface

• e)

  There is venous uterine ectasia by compression of the venous plexus due to nodules.

As to the clinical investigation in cases of AUB and uterine myoma, which of the following is/are true?

• a)

  In a patient with AUB, and uterine myoma on ultrasonography, no other investigation is needed since the cause of the bleeding has already been identified.

• b)

  Magnetic resonance should only be requested for patients for whom conservative treatment is chosen who present with a very large uterus or numerous myomas.

• c)

  A postmenopausal patient with a uterine myoma and bleeding should be submitted to hysteroscopy, or if this is not possible, to uterine curettage.

• d)

  The complaint of abundant or prolonged menstrual bleeding is more likely related to a myoma than intermenstrual bleeding.

• e)

  In the post menopause, a patient with a uterine myoma may be submitted to a hysterectomy without investigation of the uterine cavity.

The following is/are true related to iron deficiency anaemia:

• a)

  Iron deficiency is the most common cause of anaemia world wide

• b)

  Women with amenorrhoea may be at risk of ID and IDA

• c)

  Increased hepcidin levels result in increased iron absorption from the gut

• d)

  Ferroportin is a transnuclear protein which exports iron into the blood from enterocytes and macrophages

• e)

  Diagnosing iron deficiency with a serum ferritin cut-off < 15μg/L is more sensitive and more specific than using a cut-off of 30ng/mL.

The following is/are further true related to iron deficiency anaemia:

• a)

  Transferrin saturation is a measure of absolute iron for red cell production

• b)

  When compared to oral therapy, parenteral iron results in better haemoglobin levels at 12 weeks

• c)

  Drinking tea when taking an iron preparation will decrease its absorption from the gut

• d)

  Ferric iron is less soluble than ferrous iron in physiological pH environments

• e)

  Ferric polymaltose complex stabilized by polymaltose has similar bioavailability to ferrous salts but its uptake is actively rather than passively controlled.

Which of the following best describes the definition of heavy menstrual bleeding, according to the National Institute for Health and Clinical Excellence (NICE)?

• a)

  Greater than or equal to 80 ml mean blood loss in a menstrual period

• b)

  A score on the pictorial bleeding assessment chart of greater than or equal to 150

• c)

  Excessive menstrual blood loss that interferes with a woman’s physical, social, emotional, and/or material quality of life

• d)

  A score on the Aberdeen Menorrhagia Severity Scale of greater than or equal to 50

• e)

  The need to change sanitary products more than every 2 hours

Which of the following statement(s) correctly characterizes outcome measurement in studies on heavy menstrual bleeding?

• a)

  Objectively measured menstrual blood loss is the most important outcome to assess

• b)

  General health-related quality of life questionnaires are sufficient to characterize the impact of symptoms

• c)

  A standard set of core outcome measures for heavy menstrual bleeding is currently available

• d)

  Bleeding-specific quality of life questionnaires are essential for outcome assessment

• e)

  Cost-effectiveness measures are an important component

Which of the following is/are a key consideration for implementing patient-reported outcome assessment into clinical practice, according to the International Society for Quality of Life Research (ISOQOL)?

• a)

  The outcome assessment should usually be performed at 6 months and 1 year

• b)

  There are well defined standardised times for reporting

• c)

  Interviewer completed questionnaires are superior to self-completed questionnaires

• d)

  The clinician determines the goals for collecting patient reported outcomes

• e)

  Results should be shared directly with patients

The first FIGO system that contains definitions of normal and abnormal uterine bleeding symptoms includes which of the following definitions of menorrhagia, metrorrhagia and dysfunctional uterine bleeding?

• a)

  Categorization of symptoms based on menstrual frequency

• b)

  Categorization of symptoms based on menstrual regularity

• c)

  Categorization of symptoms based on menstrual duration

• d)

  Categorization of symptoms based on menstrual volume

• e)

  Allowing the patient to self-define the symptom of heavy menstrual bleeding based upon the impact on quality of life

The PALM-COEIN system is which of the following?

• a)

  A method of categorizing the results of investigation of women with abnormal uterine bleeding in the reproductive years

• b)

  An algorithm designed to lead to a diagnosis of the cause of abnormal uterine bleeding

• c)

  Appropriate for diagnosing women with postmenopausal bleeding.

• d)

  An acronym for a set of symptoms that may or may not contribute to the cause of abnormal uterine bleeding in the reproductive years

• e)

  A guide to treatment for women with AUB

The following is/are included in the PALM-COEIN system classification?

• a)

  Anti-coagulant therapy

• b)

  Pregnancy related causes of bleeding

• c)

  Anovulation

• d)

  Congenital abnormalities of the uterus

• e)

  Incidental ovarian cyst on TVS

Structural evaluation of the endometrial cavity is accurately performed with

• a)

  Endometrial biopsy

• b)

  D & C

• c)

  Contrast hysterosonography

• d)

  Hysteroscopy

• e)

  CT scan

Which of the following is/are true regarding uterine fibroids?

• a)

  Uterine fibroids are present in 70-80 % of all women by age 40

• b)

  They are the leading cause of hysterectomy in the USA

• c)

  The cost of all procedures related to them is in excess of $30 billion US yearly in the USA

• d)

  Progesterone is considered as the leading growth signal

• e)

  These are benign smooth muscle cell tumours and are usually genetically identical to host tissue

Regarding ulipristal acetate usage the following is/are true?

• a)

  PAECs in the endometrium are PRM Associated Endometrial Changes

• b)

  Endometrial histology of PAECs includes altered glandular architecture

• c)

  Endometrial histology of PAECs includes extensive glandular epithelial collapse

• d)

  The epithelium appears essentially inactive with rare mitoses.

• e)

  Mild irreversible thickening has been demonstrated

Regarding ulipristal acetate usage the following is/are also true?

• a)

  Endometrial changes are reversible following cessation of therapy

• b)

  Epithelial proliferation has been shown

• c)

  Stromal proliferation has been shown

• d)

  PAECs can also be observed in a significant number of untreated patients

• e)

  The significance of PAECs is well known

Regarding the action of UPA which of the following is/are true?

• a)

  The mechanism of cessation of bleeding is mainly associated with changes in the appearance of capillaries

• b)

  Spiral arteries with thick muscular walls are particularly affected

• c)

  There does not appear to be an anti-angiogenic effect

• d)

  The molecular basis of action is well described

• e)

  There is a major effect on the endometrial cytokine milieu

Regarding the action of UPA on fibroids which of the following is/are true?

• a)

  The mechanism of the decrease in fibroid size is clearly a consequence of the interruption of the growth signal from progesterone.

• b)

  This involves multiple molecular pathways including apoptosis

• c)

  This involves multiple molecular pathways including extracellular matrix signalling.

• d)

  TGF α signalling modification is also involved

• e)

  TGF β signalling modification is also involved

Regarding iron and its metabolism which of the following is/are true?

• a)

  Hepcidin is primarily synthesised in the kidney

• b)

  In response to high tissue levels of iron expression of hepcidin increases

• c)

  In response to high circulating levels of iron expression of hepcidin increases

• d)

  The transcription of hepcidin is inhibited in iron deficiency

• e)

  The transcription of hepcidin is inhibited in the presence of tissue hypoxia

Further regarding iron and its metabolism which of the following is/are true?

• a)

  Hepcidin is crucial for regulating both gut iron absorption and erythrocyte recycling

• b)

  Ferroportin is a transmembrane protein than transports iron from the inside to the outside of a cell.

• c)

  In ID, hepatic production of transferrin and expression of transferrin receptors by the bone marrow and other tissues increases

• d)

  Levels of hepcidin are low in pre-menopausal and menstruating women

• e)

  Levels of hepcidin return to approximate parity with men in the post-menopausal period.