Which of the following statements is/are true?

• a)
  

  Type I submucosal fibroids have more than 50% of their volume protruding into the uterine cavity

  
  
• b)
  

  A level 2 hysteroscopic surgeon, according to the RCOG classification of operative hysteroscopic procedures, should be competent to perform resection of a uterine septum

  
  
• c)
  

  Cervical “ripening” agents should be used for all diagnostic hysteroscopies

  
  
• d)
  

  Uterine adhesiolysis for Asherman’s syndrome is associated with one of the highest risks of uterine perforation.

  
  
• e)
  

  Type I and II submucosal fibroids can be completely resected using the hysteroscopic morcellator.

Which of the following has been shown to decrease the risk of excessive fluid absorption at the time of hysteroscopic surgery?

• a)
  

  Ensuring that the procedure takes under 30mins to complete

  
  
• b)
  

  Use of the Hamou Hysteromat

  
  
• c)
  

  Pre-operative use of GnRH analogues

  
  
• d)
  

  Intracervical Vasopressin prior to cervical dilatation

  
  
• e)
  

  Maintaining an intrauterine pressure above the patients mean arterial pressure (MAP)

Which of the following statements is/are true?

• a)
  

  The risk of excessive fluid absorption at operative hysteroscopy is in the region of 1–2%

  
  
• b)
  

  Maintaining good visibility with bipolar resectoscopes may be more difficult than with monopolar resectoscopes due to formation of increased gas bubbles

  
  
• c)
  

  Postmenopausal women are more susceptible to “TUR” syndrome from excessive fluid absorption than premenopausal women.

  
  
• d)
  

  Absorption of 1.5 Liters of Normal saline can cause a fall in serum sodium by 10mmol/L

  
  
• e)
  

  The use of regional (e.g. epidurals) compared to general anesthesia during surgery has been conclusively shown to significantly decrease the risk of fluid absorption at time of operative hysteroscopic surgery.

During the resection of a large submucosal fibroid using glycine distension medium, it becomes apparent that the fluid deficit is 1.2 litres. Management should include which of the following?

• a)
  

  Cauterize all bleeding vessels to achieve hemostasis and then stop procedure

  
  
• b)
  

  If serum sodium is less than 120mmol/L commence on 1.5% normal saline aiming to correct the sodium concentration slowly at a rate of 1mmol/hr

  
  
• c)
  

  Transfer all patients to ICU for ongoing management and monitoring

  
  
• d)
  

  Avoid giving Furosemide until serum electrolytes are available

  
  
• e)
  

  Insert a urinary catheter to monitor output

Which of the following statements is/are true?

• a)
  

  National datasets for surgical technologies have denominator data to provide clear information regarding risks of complications

  
  
• b)
  

  The surgical dictum “Primum non nocere” means “first do no harm”

  
  
• c)
  

  Application of topical local anesthetic to the cervix during out-patient hysteroscopy is recommended for all patients

  
  
• d)
  

  National studies demonstrate that experienced hysteroscopic surgeons have less likelihood of complications during major hysteroscopic procedures

  
  
• e)
  

  Hysteroscopic morcellators have a quoted complication rate of 5%

Which of the following is/are true regarding ambulatory hysteroscopy (AH) services?

• a)
  

  Over 80% of UK gynaecology units in hospital settings have an AH service

  
  
• b)
  

  Over 40% of UK gynaecologists offer outpatient treatment of endometrial polyps

  
  
• c)
  

  Community-based AH is well established in the UK

  
  
• d)
  

  Virtual-Reality Simulation Training has been evaluated and there is good evidence to suggest that it improves technical skills for hysteroscopic sterilization.

  
  
• e)
  

  Large polyps >2cm are generally considered unsuitable for outpatient resection

The following statement(s) is/are true regarding fibroids:

• a)
  

  Type 0 submucous fibroids are suitable for hysteroscopic resection

  
  
• b)
  

  Type 1 submucous fibroids are suitable for hysteroscopic resection

  
  
• c)
  

  Type 2 submucous fibroids are suitable for hysteroscopic resection

  
  
• d)
  

  Hysteroscopic fibroid resection has good quality studies showing that it improves fertility.

  
  
• e)
  

  The PALM-COIEN classification of causes of abnormal uterine bleeding does not include fibroids.

The following statements is/are true regarding endometrial polyps:

• a)
  

  Hysteroscopic morcellators have been shown to be more acceptable than electrical resection at removing endometrial polyps in the outpatient setting.

  
  
• b)
  

  Hysteroscopic morcellators have been shown to be quicker than electrical resection at removing endometrial polyps in the outpatient setting

  
  
• c)
  

  Saline infusion sonography is as sensitive as hysteroscopy for identification of endometrial polyps

  
  
• d)
  

  Saline infusion sonography is more sensitive than transvaginal ultrasound for identification of endometrial polyps

  
  
• e)
  

  Around 10% of women presenting with fertility problems have endometrial polyps

The following statement(s) is/are true of diagnostic tests for abnormal uterine bleeding:

• a)
  

  In pre-menopausal women endometrial thickness (ET) is best assessed on day 12 -16 of the menstrual cycle.

  
  
• b)
  

  In pre-menopausal women the upper limit of endometrial thickness (ET) is well defined

  
  
• c)
  

  Post-menopausal women with an endometrial thickness of >4mm should have an endometrial biopsy.

  
  
• d)
  

  Reducing the ET threshold to less than currently recommended will result in more false positives

  
  
• e)
  

  For cancerous endometrial disease direct visualisation with hysteroscopy is the ‘gold-standard’ for diagnosis.

Which of the following is/are features of endometrial cancer on hysteroscopy

• a)
  

  Fibrous myometrial bands

  
  
• b)
  

  Friable cells

  
  
• c)
  

  Thickened endometrium

  
  
• d)
  

  Haemorrhagic cavity

  
  
• e)
  

  Cystic “bubble wrap” appearance

During hysteroscopic surgery normally intra-vasation increases when the target pathology is more deeply embedded in the myometrium. The reason(s) for this is/are which of the following?

• a)
  

  There are more vessels deeper in the myometrium

  
  
• b)
  

  A higher fluid pressure is needed deeper in the myometrium

  
  
• c)
  

  There are more veins instead of arteries deeper in the myometrium

  
  
• d)
  

  There are more arteries instead of veins deeper in the myometrium

  
  
• e)
  

  Vessels are larger deeper in the myometrium

The following statements is/are true regarding laparoscopic sterilisation

• a)
  

  In developed countries nearly all interval sterilisations and increasingly post-partum sterilisations are performed by laparoscopy

  
  
• b)
  

  Bipolar sterilisation was the first method of laparoscopic tubal occlusion to achieve wide spread use

  
  
• c)
  

  Unipolar sterilisation is associated with a higher incidence of complications

  
  
• d)
  

  Bipolar sterilisation is considered safer for patients than unipolar sterilisation

  
  
• e)
  

  The Filshie clip was approved by the FDA in 2006

The following statements is/are true regarding hysteroscopic sterilisation

• a)
  

  The hysteroscopic sterilisation technique has been developed to avoid the risks of the laparoscopic route

  
  
• b)
  

  The use of thermal electrocoagulation for hysteroscopic sterilisation in the 1970’s resulted in an overall bilateral occlusion rate of 95 %

  
  
• c)
  

  Chemical sterilisation using quinacrine placed hysteroscopically is reported to have a 1–2% failure rate

  
  
• d)
  

  A high failure rate has been reported with the ovabloc intra tubal device

  
  
• e)
  

  The Adiana hysteroscopic sterilisation technique was withdrawn in 2012

The following statements is/are true regarding Essure hysteroscopic sterilisation

• a)
  

  It is performed using a 2cm long device

  
  
• b)
  

  Occlusion of the tubal lumen is demonstrated within one week of placement

  
  
• c)
  

  Patients are instructed to use alternative contraception until 3 months after insertion

  
  
• d)
  

  Generally in the US an HSG is required for confirmation of occlusion according to the FDA whilst in another countries an x-ray or a TVS is used

  
  
• e)
  

  Successful bilateral device placement is achieved in over 90% of cases in the office setting

Regarding Essure hysteroscopic sterilisation which of the following statements is/are true?

• a)
  

  The cumulative 9 year failure rate is 0.2 % on the basis of follow up data

  
  
• b)
  

  20 % of gestations were categorised as luteal phase pregnancies which means the gestation already existed at the time of the Essure device placement

  
  
• c)
  

  In 70 % of the evaluable post-Essure reported pregnancies, the patient failed to use additional contraception after the procedure

  
  
• d)
  

  According to the MAUDE database the most frequently reported adverse event was pain (47.5 %)

  
  
• e)
  

  There seems to be no relation in the experience of the physician and the frequency of misplacement, perforation and expulsion of the Essure micro-inserts

The following statements is/are true regarding fibroids and their diagnosis and pre-operative evaluations:

• a)
  

  The FIGO system says that a type 1 fibroid is a lesion that is entirely intra mural with no extension to the endometrial surface

  
  
• b)
  

  It is accepted that Saline Infusion Sonography (SIS) does not improve the diagnostic accuracy of trans vaginal scanning (TVS)

  
  
• c)
  

  The only contraindications to SIS are pregnancy and pelvic infection

  
  
• d)
  

  Gel Installation sonography (GIS) is a new technique which may allow further definition of the uterine cavity

  
  
• e)
  

  3D contrast ultrasonography has a low reproducibility for measuring the protrusion of the fibroid into the cavity

Regarding hysteroscopic morcellation

• a)
  

  Operative hysteroscopy using traditional electrical resectoscopes has a short learning curve

  
  
• b)
  

  The first tissue morcellator was the Myosure produced by Hologic

  
  
• c)
  

  The Truclear system avoids the risks of thermal injury from the spread of electrical energy

  
  
• d)
  

  Saline solution is used for distension and irrigation

  
  
• e)
  

  Using the Truclear system endometrial polyps, small fibroids and chronically retained products of conception can be removed

Regarding distension and irrigation of the uterine cavity during operative hysteroscopy:

• a)
  

  Isotonic fluid overload can be treated with diuretics

  
  
• b)
  

  Only 1.5 % glycine should be used with monopolar electrosurgical operative procedures

  
  
• c)
  

  Nausea and malaise are the earliest findings of fluid overload and may be seen with sodium levels less than 5 mmols per litre

  
  
• d)
  

  During surgery for submucous fibroids, intravasation of fluid is related to surgery time and the characteristics of the fibroid

  
  
• e)
  

  Bladder catheterisation is routinely indicated

Regarding operative hysteroscopy

• a)
  

  The learning curve can be long

  
  
• b)
  

  High volume surgeons performing more than 20 hysteroscopic myomectomies annually resect more tissue and a higher amount of tissue per time than low volume surgeons

  
  
• c)
  

  There is a significant difference in complication rates between high and low volume surgeons

  
  
• d)
  

  Prophylactic antibiotic prophylaxis is mandatory during operative hysteroscopy

  
  
• e)
  

  When a perforation is caused by an activated instrument (either electrosurgical or morcellator) they can be managed conservatively

The following statements is/are true regarding staffing, training and accreditation of Ambulatory Hysteroscopy:

• a)
  

  The joint guidelines of RCOG-BSGE best practice in “outpatient hysteroscopy” explicitly recommends one additional health care professional to assist with the procedure

  
  
• b)
  

  The role of nurse hysteroscopist is well developed in Europe

  
  
• c)
  

  In-patient admission of patients from the ambulatory setting is a rare occurrence

  
  
• d)
  

  The BSGE provides formal accreditation in ambulatory hysteroscopy

  
  
• e)
  

  The European Society of Gynaecological Endoscopy had developed a robust package of training in ambulatory hysteroscopy

Regarding infrastructure for Ambulatory Hysteroscopy (AH)

• a)
  

  Ambulatory hysteroscopy should be conducted close to a formal theatre setting

  
  
• b)
  

  The quality of the video/camera/monitor is not an important aspect of the ambulatory hysteroscopy set up

  
  
• c)
  

  CO ₂ is the preferred distension medium in the ambulatory setting

  
  
• d)
  

  Research has compared the effect of size of the outer sheath of hysteroscopes on pain and success rate

  
  
• e)
  

  There is insufficient evidence to suggest preferential use of rigid or flexible hysteroscopes

Regarding service development in ambulatory hysteroscopy:

• a)
  

  According to the 2008 RCOG Standards in Gynaecology “outpatient operative hysteroscopy” should be available to all patients

  
  
• b)
  

  Organisational change theory suggests that unless consensus is present across professionals there is little chance of its successful development

  
  
• c)
  

  Research has shown for ambulatory hysteroscopy a significant reduction in mean pain scores with use of local anaesthetic

  
  
• d)
  

  Para-cervical injection of local anaesthetic is the least effective method to reduce pain during ambulatory hysteroscopy

  
  
• e)
  

  The vaginoscopic approach to ambulatory hysteroscopy reduces procedural pain

Regarding hysteroscopy in the ambulatory setting:

• a)
  

  There is little evidence to suggest that ambulatory hysteroscopy avoids complications and allows quicker recovery and lower costs

  
  
• b)
  

  Miniaturisation of high resolution hysteroscopes has adversely affected optical performance

  
  
• c)
  

  Ambulatory hysteroscopy allows accurate diagnose of submucous fibroids and polyps

  
  
• d)
  

  Currently ambulatory hysteroscopy is available in over 80 % of trusts in the UK

  
  
• e)
  

  There is clear existing evidence to support the safety and effectiveness of ambulatory endometrial ablation and hysteroscopic sterilisation concomitantly

Regarding first generation endometrial ablation the following statement(s) is/are correct

• a)
  

  Laser Ablation is easy to perform

  
  
• b)
  

  Endometrial Thinning Agents have no effect on short-term post-operative outcomes

  
  
• c)
  

  Endometrial Thinning Agents have no effect on long-term post-operative outcomes

  
  
• d)
  

  Rollerball ablation in comparison to TCRE shows no difference in re-intervention rates in long term follow up

  
  
• e)
  

  All three first generation endometrial ablation techniques have similar complication rates

Regarding second generation endometrial ablation the following statement(s) is/are correct

• a)
  

  Rollerball ablation was found to provide better results compared with cryo-ablation

  
  
• b)
  

  Rollerball ablation was found to provide better results compared with thermal balloon ablation

  
  
• c)
  

  The duration of surgery was consistently shorter with second generation compared to first generation ablation

  
  
• d)
  

  Analysis of the IBD-HMB database comparing first and second generation showed a significant difference in effectiveness defined as satisfaction with treatment outcome

  
  
• e)
  

  There is no evidence that first or second generation ablation are superior to each other

Regarding the second generation endometrial ablation techniques the following statement(s) is/are correct

• a)
  

  Bipolar radiofrequency is associated with a higher amenorrhea rates

  
  
• b)
  

  Surgery is shorter with bipolar radiofrequency ablation

  
  
• c)
  

  Bipolar radiofrequency ablation results in reduced pre-menstrual syndrome scores

  
  
• d)
  

  With bipolar radiofrequency ablation women are more likely to require additional surgery

  
  
• e)
  

  Data from UK hospital statistics show a significant difference increase in the overall number of inpatient ablation techniques

Positive prognostic parameters for increased satisfaction and/or amenorrhoea after endometrial ablation include

• a)
  

  Older age

  
  
• b)
  

  Uterine cavity length of greater than 10 cm

  
  
• c)
  

  Presence of submucous fibroids

  
  
• d)
  

  Pre-operative dysmenorrhoea

  
  
• e)
  

  Caucasian ethnicity

Recent innovations in office hysteroscopy include:

• a)
  

  Tissue removal systems

  
  
• b)
  

  Sterilization

  
  
• c)
  

  Tower free systems

  
  
• d)
  

  Monopolar electrosurgery

Regarding adverse events during office hysteroscopy:

• a)
  

  Paracervical and intracervical anaesthesia have been shown to be the most effective routes for delivering local anaesthesia for diagnostic hysteroscopy?

  
  
• b)
  

  Vaginoscopy is associated with greater pain than traditional techniques utilising vaginal instrumentation?

  
  
• c)
  

  Vaginoscopy is associated with fewer vaso-vagal reactions than traditional methods?

  
  
• d)
  

  Office polypectomy is as traumatic to the uterus as uterine polypectomy undertaken under taken under general anaesthesia?

Regarding diagnostic hysteroscopy:

• a)
  

  Hysteroscopy performed in conjunction with directed endometrial biopsy has high accuracy in diagnosing endometrial hyperplasia and cancer?

  
  
• b)
  

  Hysteroscopy is the gold standard test for focal intrauterine pathologies such as polyps and submucous fibroids?

  
  
• c)
  

  Diagnostic hysteroscopy in the office is more painful than miniature endometrial biopsy?

  
  
• d)
  

  Adenomyosis can be reliably detected by hysteroscopic inspection of the uterine cavity?