OSCE GYNAECOLOGY

1. 31 years old lady, Para 3, presented with heavy menstrual bleeding and vague lower
abdominal mass.

USS finding shows below:

a) What is the provisional diagnosis? (2 marks)

Uterine fibroid

b) 2 other origin that the mass can be originated from. (2 marks)

i- Ovary: Ovarian cyst/PCOS
ii- Tube & ovary: Tubo-ovarian abscess
iii- Endometrium: Endometrial Carcinoma

c) State 2 investigations (2 marks); *Infertility issue*

i- Tubal patency test: Hysterosalpingogram (HSG)/Laparoscopic Dye Test
ii- Ovary function: Day 2/3 serum FSH and LH or Day 21 serum progesterone

d) State your management (4 marks)

i- Myomectomy (Patient is still young, preserved fertility)
ii- GnRH analogue for 3 months prior to surgery (to reduce the menses
and shrink the fibroid)
2.
No hole

Graduated cm marking

A B

a) Name the above instrument (1 mark)

A: Curettage; B: Uterine sound

b) List 2 functions of it

Function of A:
i- Removal of retained product of conception
ii- Endometrial sampling/biopsy
iii- Remove decidua

Function of B:
i- To measure depth of uterus
ii- To know the position of uterus

c) Give 3 procedures that use the above instrument (3 marks)

i- Hysteroscopy
ii- Diagnostic Dilatation and Curettage (DD & C)
iii- Suction & curettage

d) List 4 gynecological causes of uterus larger than date (4 marks)

i- Uterine fibroid
ii- Molar pregnancy
iii- Benign ovarian cyst
iv- Pelvic mass

e) What are 2 complications of it (2 marks)

i- Uterine perforation
ii- Haemorrhage
iii- Genital tract trauma (Cervical)
iv- Infection
v- Asherman’s syndrome
vi- Permanent amenorrhea and infertility (removal of endometrial basal
layer)
3.

a) Name the above instrument (1 mark)

Hegar’s dilator (cervical dilator)

b) State 3 indications of it (3 marks)

i- Dilatation & curettage (D & C)
ii- Suction & curettage
iii- Hysteroscopy
iv- Endometrial biopsy

c) List 2 conditions to use it (2 marks)

i- Incomplete miscarriage
ii- Endometrial Carcinoma

d) What are 4 complications of it (4 marks)

i- Ascending infection
ii- Tissue trauma (cervical laceration)
iii- Uterus perforation
iv- Hemorrhage
v- Cervical incompetence
4. Look at the picture.

a) What is the examination? (1 mark)

Bimanual palpation

b) What do you look for? (5 marks)

i- To determine the position of uterus (anteverted)
ii- To locate uterine mass
iii- To locate adnexal mass
iv- To determine the size & consistency of mass
v- To feel for any fluid in Pouch of Douglas

c) Other investigations you want to do.

i- USS (TAS/TVS)
ii- CT scan
iii- MRI
5. 44 years old lady, Para 4, came in with post-coital bleed and foul smelling discharge.
No abdominal distension/ mass.

This is the finding of hysteroscopy:

a) Describe the abnormality (2 marks)

i- Fungating protruding growth at 4 to 7 o’clock

ii- Hypervascularization, contact bleeding

b) List 2 important history you want to ask. (2 marks)

i- Typical symptoms: post-coital bleeding, intermenstrual bleeding

ii- Any early exposure to sexual intercourse

iii- Long term of COCP used ( > 5 years)

iv- Immunocompromised state

c) What is the provisional diagnosis (1 mark)

Cervical cancer

d) What is mainstay treatment for this condition? (2 marks)

Wertheim’s (radical) hysterectomy followed by concurrent chemo, radiotherapy

e) List 4 complications related to surgical procedure (3 marks)

i- Haemorrhage

ii- Bladder or ureteric injury (Voiding dysfunction)

iii- Vesicovaginal fistula

iv- Infection
6. 36 years old married lady, Para 1, LCB 10 years ago, presented with irregular menses.

Transvaginal USS Findings Laparoscopic view of ovary

i. Interpret the finding (3 marks)

Transvaginal USS Laparoscopic view

1. Presence of > 8 follicular cyst,
size < 10 mm, situated at the
periphery
2. Thickened/increased ovarian
stroma (center part)
Size of ovary > 4 cm (big ovary)
Pearl white in colour
Curly

ii. What is the provisional diagnosis? (1 mark)

Polycystic Ovarian Syndrome (PCOS)

iii. What other investigations should be done? (2 marks)

Blood test (Androgen; will be ↑ - either due to ↑ LH @ ↑ insulin-associated
condition in PCOS):
*Testosterone
*DHEA (Dehydroepiandrosterone)
*DHEAS (Dehydroepiandrosterone sulfate)
*Androstenedione
+ LH: FSH (ratio of 3:1)

iv. What is the management? (4 marks)

*based on presentation of patient:
i- Menstrual disturbances (2⁰ amenorrhoea/oligomenorrhoea) + Hirsutism:
 COCP to regulate menses (the best is Diane-35; as it has
antiandrogenic effect as well; as ↑ androgen is the root of the cause)

ii- Subfertility: Ovulation induction agent (Clomate/Femara),

Metformin or Laparoscopic ovarian drilling
iii-
7.

A B C Transvaginal USS of ovary: D

This picture shows: 34 years old lady married for 5 years, nulliparous with history of
irregular menses since 10 years ago, not on any methods of contraception. She wishes
to have a child. Transvaginal USS shows polycystic ovarian features.

a) Describe the features finding (2 marks)

A: Hirsutism
B: Obesity
C: Acne
D: Polycystic Ovarian features (> 8 follicular cyst with each diameter < 10 mm
situated at the periphery; increased ovarian stroma at the center)

b) What is the provisional diagnosis? (1 mark)

Polycystic Ovarian Syndrome (PCOS)

c) How do you diagnose it? (4 marks)

By 2 out of 3 features stated in Rotterdam Criteria:
1. Menstrual disturbance (2⁰ amenorrhoea/oligomenorrhea)
2. Clinical or biochemical evidence of hyperandrogenism
3. USS of ovary shows polycystic ovarian features (2 features)

d) What is the most likely cause the infertility? (1 mark)

Anovulatory cycle

e) What are the other 2 long term complications associated with PCOS? (2 marks)
i- Recurrent miscarriage (due to ↓ progesterone – no effective corpus luteum;
causing unable to maintain the pregnancy in 1st 3 months of gestation – after 3
months progesterone is secreted by placenta to maintain the pregnancy)
ii- Metabolic syndrome (DM, Cardiovascular Disease, GDM in next pregnancy)
iii- Endometrial Hyperplasia & Endometrial Carcinoma (due to ↓
progesterone; causing endometrial hyperplasia as oestrogen take the upper
hand)
iv- Osteoporosis
v-
8. Look at the picture.

A B

a) Name the procedure (A) (1 mark)

Laparoscopic surgery

b) List 4 indications of the procedure (4 marks)

i- Diagnostic and therapeutic of ectopic pregnancy
ii- Diagnostic Laparoscopic & dye test (Tubal patency test in infertility)
iii- Endometrioma, PID
iv- Bilateral tubal ligation (BTL), cystectomy
v- Laparoscopic myomectomy, hysterectomy
vi- PCOS : ovarian drilling

c) List 4 benefits of it (4 marks)

i- Shorter recovery time and hospitalization
ii- Early mobilization to prevent DVT
iii- Lower requirement of analgesic, minimal pain and adhesion
iv- Cosmetic value
v- Fast healing and recovery.
vi- Less wound complication (dehiscence, infection)

d) List 2 complications (2 marks)

i- Major vessels injury
ii- Bowel injury
e) Describe finding in B and C

B C
-Multiple adhesions -Chocolate cyst located laterally
*Pitz Hugh Curtis Syndrome: Perihepatic -Active foci (red/black in colour; if white:
lesion fibrous foci)
-Tubo-ovarian mass with pus -Adhesions
-Fluid in Pouch of douglas
PID Endometrioma

f) What is the disadvantages of this procedure

i- Longer duration of surgery
ii- Loss of 3d view
iii- Risk of visceral/ vessel injury
iv- Loss of dexterity (limit movement)
9. Picture of uterus with right adnexal mass and appendages

1. What is the most likely diagnosis?

Benign ovarian cyst

2. List 3 likely symptoms.

i- Abdominal swelling
ii- Acute lower abdominal pain
iii- Urinary symptoms
iv- Bowel symptoms

3. List 2 relevant investigations

i- Ultrasound scan
ii- CTscan/MRI
iii- Tumour markers

4. Depending on your diagnosis, what is the most appropriate treatment if the patient is
young?
i- Ovarian cyst: Ipsilateral cystectomy / oophorectomy
ii- Ovarian Carcinoma: TAHBSO, omentectomy, lymphadenectomy +/- ,
adjuvant chemotherapy if
10.

a) State your diagnosis (2 marks)

Uterovaginal prolapse

b) List down 4 risk factor for the diagnosis in Question (2) (4M)
i- H/O Prolonged Labour
ii- H/O Big Babies Delivered Vaginally
iii- H/O Chronic Cough / Constipation
iv- Increased Intra-Abdominal Pressure i.e Ascites, Pelvic Tumours/ Masses
v- Multiparity
vi- Menopausal (age)
vii- Previous pelvic surgery
viii- Difficult delivery
ix- Loss of muscle tone

c) State 2 treatment modalities for the above diagnosis (3M)

i- Vaginal ring pessary and lifestyle modification
ii- Surgical: vaginal hysterectomy

d) Name 1 preventive therapy (1M)

Pelvic floor exercise (Kegel exercise)

e) What is the advice given to the patient?

Reduce weight
Take balanced diet – to avoid constipation
Avoid heavy lifting object
11. Look at the picture.

Contraceptive benefit: Contraceptive benefit:

1. Can be use as emergency 1. Long acting, rapid
contraception A B reversible contraception
2. Does not require
a) Name the device (2 marks) compliance
A: Copper intrauterine device: Copper IUCD 3. Low failure rate
 can be use up to 10 years (failure rate of 0.8% in 1st year of use)
B: Mirena (Levonogestrel releasing-intrauterine system): IUS
 can be use up to 5 years (failure rate of 0.1% in 1st year of use)

b) What is the mode of action? (2 marks)

A: Copper’s toxic effect for both sperm and ovum prior to fertilization
B: Local hormonal effect on cervix and endometrium; prevent implantation
(dramatic reduction of menstrual loss – as endometrial lining atrophic & alter mucous)

c) List 3 non-contraceptive benefit of device (B) (3 marks))

i- Use to treat heavy menstrual bleeding
ii- Use to treat dysmenorrhea
iii- Use as one of HRT regime

d) List 3 complications of the device (3 marks)

i- Ectopic pregnancy (*Copper IUCD: 3- 5 %; Mirena: < 1%)
ii- Dislodge/missing IUD
iii- Perforated uterus
iv- PID (presented with foul-smelling PV discharge/lecorrhoea)
v- Dysmenorrhea, menorrhagia
vi- Intermenstrual bleeding
vii- Pelvic pain, dyspareunia

e) List its contraindication (absolute/relative)

i- Active or current infection (PID/STD)
ii- Unexplained PV bleeding
iii- Untreated cervical/endometrial carcinoma
iv- Malignant trophoblastic Disease
v- Know uterus malformation
vi- Pelvic mass (fibroid)
 vii- Previous ectopic / PID
viii- Copper allergy in device A

f) What are the benefits of device A?

i- Good compliance
ii- Longer duration (up to 10 years)
iii- Reduce risk of endometrial cancer, cervical cancer
iv- Can be remove anytime
v- Quick return of fertility

g) What is the difference between hormonal and copper IUCD

Hormonal Copper
3-5 years 12 years
Low dose progestin Hormone free
Reduce menstrual cramp Increase bleeding, cramp
Thicken cervical mucus Affect sperm movement
Lighten/ eliminate menses No change in period irregularity

vi-
12. Look at the picture.

Contraceptive benefit:
1. Reversible contraception
2. Emergency contraception

a) Name the above drug.

Combined oral contraceptive pills (COCP)

b) What is the content?

i- Synthetic oestrogen (ethinyl estradiol) : 15 – 35 ug
ii- 2nd generation progesterone; derivatives of norethindrone and
lenovogestrel

c) List 4 contraindications of it (4 marks)

Absolute
*Breastfeeding < 6 months
*Multiple risk of cardiovascular disease
*Severe hypertension (> 160/110 mmhg)
*Past hx of DVT
*Current breast cancer
Relative
*Obesity, hyperlipidaemia
*DM with vascular disease
*Mild-moderate hypertension

d) List 4 non-contraceptive benefits of it (4 marks)

i- Protect from ovarian and endometrial carcinoma (about 50%)
ii- Treat PCOS, acne, Endometriosis, BEO/DUB
iii- Reduce risk of PID, improve pre-menstrual symptom
iv- Regulate menses, reduce flow of menses, treat dysmenorrhea

e) List 4 side effect of it (4 marks)

i- Weight gain
ii- Enlarged breast & breast pain
iii- Depressed mood, mood swing
iv- Headache, nausea
13. 54 years old lady, Para 3, LCB 15 years ago, presented with 2 years history of
amenorrhea. On further questioning, she has hot flushes, mood swing and loss of
libido. She fractured her right arm because of light fall during doing house chores.
She went to GP. The blood result was as follow.

Parameters Result Normal Range

FSH 200 IU/l 20 – 24 IU/l
LH 120 IU/l 22 – 52 IU/l
Oestrogen 80 mmol/L 30 – 50 mmol/L
Bone density < -3 -2 -1

a) Interpret the result (2 marks)

i- High FSH & LH hormone
ii- Reduce bone density

b) What are 2 diagnoses? (2 marks)

i- Menopause
ii- Osteoporosis

c) Currently, what is the proven method in treating this condition? (1 mark)

Hormonal Replacement Therapy (HRT); ideally given minimum 5 years; but usually
shorter than that (2 – 3 years)

d) List 4 risks of (b)/5 histories you want to ask before giving (b)? ) (5 marks)
i- Carcinoma (Breast, Endometrial, Ovarian Ca)
ii- Coronary Artery Disease
iii- Venous thromboembolism/underlying thrombophilia
iv- Stroke
v- Uninvestigated uterine bleeding/large uterine fibroids/benign hx in the past

e) List 4 side effect of HRT (4 marks)

Oestrogen-related (dose-related: Progestogen related

will settle in a few weeks) (pre-menstrual-like symptoms)
* Breast enlargement * Breast tenderness
* Nausea * Acne
* Dyspepsia * Increase appetite; Constipation
* Leg cramps * Mood swing/ irritability/ depression
 * Fluid retention/bloated
* Headaches
14. This is 65 years old married lady, Para 1, LCB 10 years ago, post-menoupause 7 years
ago, presented with heavy post-menoupausal bleeding. Ultrasounds below shows line
(A) measured 14 mm.

a) What is the line (A) measured in the ultrasound? (1 mark)

Endometrial thickness of uterus
( Endometrial hyperplasia > 4 mm in post-menopause women)

b) What is the most likely diagnosis in this lady (1 mark)

Endometrial carcinoma

c) List 2 other possible causes in perimenoupasal women? (2 marks)

iii- Endometrial hyperplasia
iv- Endometrial polyp

b) What are next investigations should be done in her? (3 marks)

i- Blood investigations: tumour marker (Ca-125, Ca 19-9)
ii- Hysteroscopy and diagnostic dilatation and curettage (DD & C)

c) What is your next management? (3 marks)

Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAHBSO) and
Lymph Node sampling; either followed or not followed by adjunct
chemoradiotherapy 6 cycles (depends on several factors)
15. Look at the picture.

Pedunculated fibroid

Subserosal fibroid
Intramural fibroid
Submucosal fibroid

a) Label the picture (4 marks)

b) List 3 typical symptoms of the above condition (3 marks)

a. Heavy menstrual bleeding (submucosal or intramural fibroid)
b. Compressive symptoms (subserosa fibroid)
c. Subfertility (subserosa fibroid that located at tube, submucosa, large
intramural fibroid)

c) How to diagnose it? (1 mark)

Ultrasound

d) What is choice of treatment? (2 marks)

i- Myomectomy
ii- Hysterectomy

e) What are the indications of medical treatment (GnRH analogue, Esmia)?

i- Too shrink a huge fibroid
ii- To do laparoscopic surgery (reduce morbidity)
iii- Waiting for surgery
iv- Symptomatic patient: To reduce menses
16. Look at the picture. (Subfertility)

A: Normal B
b) What is the investigation done? (1 mark)
Hysterosalpingogram (HSG) (to look for structural cause only)

c) What is the use of this test? (1 mark)

Tubal patency test

d) Describe picture (B)? (4 marks)

*Right tube: Spillage of the dye can be seen showing normal patency of the
right tube
*Left tube: no spillage of dye seen, with fluid accumulated at the end of the
left tube with pocketed areas suggesting blocked left tube

e) What can be the possible cause of it? (3 marks)

i- Endometriosis
ii- Pelvic Inflammatory disease (PID)
iii- Previous surgery
(Gynecological: Ectopic pregnancy, oophorectomy /Surgery: Appendicectomy)

f) What the other investigation that is more useful? (1 mark)

Diagnostic Laparoscopic Dye Test (can look for both structural & functional cause)
17. A 48-year-old Malay lady presented to emergency department with the complaints of
nausea and vomiting. She missed her menses for 3 months duration. On physical
examination, her abdomen was corresponded to 16 week of gestational size (uterus
larger than date).

a) What is your DDx. (8 marks)

i. Hyperemesis gravidarum
ii. Twin pregnancy
iii. Molar pregnancy
iv. Etopic pregnancy
v. AGE
vi. UTI
vii. Food poisoning
viii. Hyperthyroidism
ix. Pyelonephritis

The ultrasound finding shows: MOLAR PREGNANCY

a) Describe the ultrasound findings (2 marks)

Snow storm appearance/honey comb.
Abnormal endometrial echo complex with numerous cystic sacs

b) List 4 investigations you would like to do to confirm the diagnosis (4 marks)

i- Serum B-hcg >100 000 iu
ii- FBC-anemia and infection
iii- Urine FEME
iv- Urine

c) List your further management to this patient (4 marks)

i- Counsel patient about possible operation complications
ii- Pre evacuation and post evacuation serum B-hcg level
iii- Group Cross Match (GXM)
iv- Pre evacuation chest x-ray
v- Keep nil by mouth
vi- Insert iv line
vii- Suction and evacuation
viii- Post evacuation, start Iv oxytoxin
ix- Monitor, vital signs, input/output chart post op, pad chart
x- Follow up molar clinic to review B-hcg and HPE result
xi- There is a role of chemo therapy – methotrexate, if during the surveillance,
the serum B-hcg does not improving
18. Look at the picture

A B

a) Name the device (2 marks)

A- Cusco’s speculum
B- Sim’s speculum

b) What are 4 uses of it? (4 marks)

i- To visualize the cervix and vaginal wall
ii- To allows the application of local instruments to the cervix or obtaining
swaps. (pap smear)
iii- Allows insertion and removing of IUD,
iv- Performing Hysterosalpingography
v- Taking a premenstrual endometrial biopsy & taking a surface biopsy
scraping of the cervix.

c) List possible complication of its use

i- Post-procedural pain
ii- Trauma to local tissue of vagina and cervix
iii- Bleeding
iv- Infection
19. Look at the picture:

A B

a) What is the type of the drug given above?

i- Clomate tablet (clomiphene citrate) – anti-oestrogen agent
ii- Novartis (letrozole)

b) What are the indications of it?

i- Polycystic ovary syndrome
ii- Ovulatory induction and augmentation
iii- Male infertility-stimulate sperm production

c) List contraindications of its usage

i- Allergic to clomiphene
ii- Liver disease
iii- Abnormal vaginal bleeding
iv- An uncontrolled adrenal gland or thyroid disorder
v- An ovarian cyst (unrelated to polycystic ovary syndrome)
vi- Pregnant
20. Look at the picture.

A B C
a) What is the classification of the above drugs?
COCP

b) What is its use?

Inhibit follicular development and prevent ovulation
Thinning of endometrium
Thickening of cervical mucus

c) List the potential benefits of its usage

50% reduction in risk of ovarian and endometrial cancer
Improvement in acne
Reduction in heavy menstrual bleeding
Regulation of menstrual cycle
Alleviation of dysmenorrhea
Treatment of hirsuitism and PCOS
Treatment of premenstrual syndrome
Reduction in risk of colorectal cancer

d) Side effect of the above medication?

Gastrointestinal symptom-nausea/vomiting/perceive weight gain
Breast tenderness
Mood swing
Headache
Loss of libido

e) What is the absolute contraindication for its usage?

Pregnancy
Cerebrovascular accident
Thromboembolism
Liver diseases
Estrogen-dependent tumors (breast cancer)
Undiagnosed genital tract bleeding
Recent trophoblastic disease
Ischaemic heart disease
21. Look at the picture.

a) Name the instrument (2 mark)

Uterine manipulator

b) List 2 indications of its use (2 marks)

i- During laparoscopic cystectomy
ii- Total Hysterectomy by laparoscopy
iii- Surgical treatment of the rectovaginal wall endometriosis
iv- Posterior extractive colpotomy

c) List 2 contraindications of its use (2 marks)

i- Huge uterine mass
ii- Gynecological malignancy (endometrial ca)
iii- Uterine or tubal infection (pyometra-spillage of pus to abdominal cavity)
iv- Pregnancy or suspected pregnancy
v- Media allergy

d) List 2 the complications? (2 marks)

i- Injury to adjacent organs
ii- Perforation of the uterine wall
iii- Cramping
iv- Infection

e) What other devices that may aid in the process? (2 marks)

i- Pneumooccluder balloon
ii- Colpotomy ring
22. Look at the picture.

a) Name the above procedure (1 mark)

Cervical surclage

b) What is the indication of the procedure (2 marks)

i- Dilated or shortened cervix (with risk factor preterm)
ii- Cervix has a large traumatic laceration
iii- History of three or more second-trimester pregnancy losses or extreme
premature deliveries (potential cervical insufficiency)
iv- Emergency cerclage may be considered in women in whom the cervix has
dilated to < 4 cm without contractions before 24 weeks of gestation

c) Absolute and relative contraindications to cerclage.

Absolute contraindications:
i- Active labor
ii- Active vaginal bleeding
iii- Abruptio placenta
iv- Premature rupture of membranes
v- Chorioamnionitis
Relative contraindications:
i- Prolapsed membranes
ii- Vaginal spotting

d) List 4 complications of it (4 marks)

i- increased medical interventions
ii- puerperal pyrexia
iii- sepsis
iv- premature rupture of membranes/ premature labour,
v- cervical dystocia,
vi- cervical laceration at delivery
e) What other precautions/next management? (3 marks)
i- Look for evidence of chorioamnionitis (suspicious of sepsis, emergency
removal)
ii- Urine for culture and sensitivity and vaginal cultures for bacterial
vaginosis
iii- Serial transvaginal ultrasonography should be performed every ½ weeks
iv- Beyond 23 weeks consider corticosteroids if signs and symptoms of
preterm delivery
v- Cerclage is generally –
a. Removed electively at 36 to 38 weeks’ gestation.
b. Emergency removal due to premature labour /unresponsive to
tocolysis /sepsis sign
23. Look at the picture.

a) Name the instrument (1 mark)

Pap smear’s sampling cytobrush

b) What does it use for? (2 marks)

To get sample for pap smear screening

c) What other investigations should be done? (2 marks)

High vaginal swab
Ultrasonography of uterus, and adnexa region

d) If the result comes back as abnormal, what is your next management? (5 marks)
I will counsel the patient on colposcopy examination for diagnosis and treatment
because there is 70% of sensitivity of cervical smear to detect CIN.
Biopsy will be taken to further stage the disease and managed accordingly.
When the colposcopy examination was negative, the next examination will be
arranged at 6 months duration.

e) List the type of pap smear

i- Conventional – wooden spatula with glass slide
ii- Liquid based cytology – brush and fixative bottle

f) Who should be screened with pap smear?

Women who are sexually active
Reproductive women between the age of 20 – 65 years old
When 2 consecutive result are negative – repeat 3 years interval
24. Look at the picture

a) Name the instrument (1 mark)

Pipelle

b) List 2 uses/indications of it? (2 marks)

i- Abnormal uterine bleeding
ii- Endometrial biopsy
iii- Endometrial cancer
iv- Endometrial hyperplasia

c) What is the contraindication of its use? (2marks)

i- Pregnancy
ii- Acute vaginal/ cervical infection
iii- PID
iv- Clotting disorder

d) List possible complication from its usage (2 marks)

i- Prolonged bleeding
ii- Infection (fever)
iii- Uterine perforation
iv- Post procedural pain

e) List other method of endometrial sampling (2 marks)

Diagnostic dilatation and curettage

f) Advantage of (a) against (e) (2 marks)

i- Operative setting is an outpatient clinic, rather than an operating room.
ii- May be performed without anesthesia or with only local anesthesia.
iii- Minimally invasive option for diagnosis of endometrial cancer, hyperplasia,
and other endometrial pathology
25. Look at the picture.

A B

a) Describe your finding in A. (2 marks)

There are multiple outgrowths from endometrial lining (polyps/tubular
adenoma), with smooth surface and regular margin, no ulceration or necrosis
area noted.
The surrounding area was highly vascularized.

b) What is B?
Snare polypectomy using loop electrocautery

c) What is your diagnosis (1 marks)

Endometrial polyps

d) What is the possible differential diagnosis? (2 marks)

Endometrial hyperplasia
Endometrial carcinoma

e) What are the common presenting symptoms? (3 marks)

Post-menopausal bleeding
Intermenstrual bleeding
Menorrhagia

f) The next management is … (2 mark)

Removal of endometrial polyps, and send for histopathology.

g) List examinations to diagnose (c)

i- bimanual examination- assess uterine position and tenderness
ii- Pelvic U/S- uterus is enlarged, thickened endometrial, distinctive growths
of the mucous having a homogeneous structure.
 iii- Hysteroscopy - visualisation of single/multiple, round
formation/outpouching mucosa in uterine cavity, pale pink colour
number, size, location of the polyps
iv- Transvaginal sonogram - focal rounded echogenic mass in the region of
the uterine cavity
v- Sonohysterogram - mass projecting into the uterine cavity

h) What are common indications for sonohysterography?

Abnormal uterine bleeding
Infertility

i) List possible complication of (c)

i- anemia
ii- infertility
iii- increase probability of miscarriage
iv- susceptible to malignant transformation