Answers to Single Best Answer (SBA) questions – part two

Chapter 1

• Q1. Answer: c – Puborectalis

Laterally, the muscle sheets of the iliococcygeus and ischiococcygeus are oblique/transverse. The medial fibres of the puborectalis are inserted into the upper part of the perineal body and the succeeding fibres turn medially behind the anorectal flexure, and are inserted into the anococcygeal raphe and the tip of the coccyx.

• Q2. Answer: b – The isthmus

Female sterilization involves occluding the entire lumen of both tubes, which is best performed in the narrow isthmic portion, using clips, sutures, rings or diathermy.

Chapter 3

• Q1. Answer: c – A multicystic appearance to the ovaries on ultrasound suggests constitutional puberty.

Children with precocious puberty should be under the care of a paediatric endocrinologist, although not all children will need treatment. Café-au-lait skin pigmentation suggests McCune–Albright syndrome, which is very rare. A radiological skeletal survey of the long bones is indicated if this syndrome is suspected; otherwise, an X-ray of the hand to determine bone age is more appropriate. A multicystic appearance to the ovaries on ultrasound is seen in normal puberty, and so may be seen with constitutional or cerebral precocious puberty.

• Q2. Answer: c – X-ray for bone age is a first-line investigation.

X-ray for bone age is a first-line investigation for both delayed and precocious puberty. Delayed puberty in girls is defined as the absence of physical manifestations of puberty by the age of 13 years. Short stature is commonly seen with constitutional delay. Reassurance may suffice for management of constitutional delay. Anorexia is a recognised cause of hypogonadotrophic hypogonadism.

Chapter 5

• Q1. Answer: c – Hysteroscopy

Hysteroscopy should only be performed selectively to assess for structural intrauterine abnormalities. Hysterosalpingography assesses for tubal patency, and AMH and luteal phase progesterone (which is taken on day 21 for women with a 28-day cycle) are all first-line investigations, as is BMI.

• Q2. Answer: c – Multivitamins have been associated with an improvement in sperm parameters.

Multivitamins are recommended for all men whose partners are trying to conceive.

Testicular biopsy can confirm non-obstructive azoospermia (in men with a raised FSH and azoospermia); this is not purely diagnostic, as islands of spermatogenesis can be identified on occasion. Sperm can be extracted at the time of testicular biopsy and used for intracytoplasmic sperm injection (ICSI).

The chance of live birth is 14% per cycle for unstimulated donor insemination (DI) and 15% for stimulated DI.

Surgery is no longer recommended for varicocele in otherwise asymptomatic men, as there is no evidence that this improves sperm count. Pregnancy rates are around 30% following re-anastomotic surgery more than 10 years after the original vasectomy.

Chapter 7

• Q1. Answer: d – Levonorgestrel-releasing intrauterine system (LNG-IUS)

The IUS can be considered when fibroids measure less than 3 cm and cause no distortion of the uterine cavity. Fibroids of this size are unlikely to be causing pressure-related symptoms to surrounding organs, nor do they significantly contribute to heavy menstrual bleeding as the cavity is undisturbed. Myomectomy and hysterectomy carry a risk of surgical complications (and myomectomy would be technically challenging with such a small fibroid). Uterine artery embolisation (UAE) and Gonadotropin releasing hormone (GnRH) analogues have more side effects than the LNG-IUS.

• Q2. Answer: d – Inhibits plasminogen activator.

Antifibrinolytics, such as tranexamic acid, work by inhibiting plasminogen activator, thereby reducing the fibrinolytic activity in the endometrium. This stabilises clot formation in the spiral arterioles and reduces menstrual blood loss.

• Q3. Answer: d – High vaginal swab, including tests for chlamydia and gonorrhoea

This woman describes secondary dysmenorrhoea, which requires investigation. This refers to dysmenorrhoea developing over many years after menarche and is the result of an underlying pathology. Pain usually starts 3 to 4 days before the onset of the period. Possible causes include endometriosis, adenomyosis, pelvic inflammatory disease and fibroids. Swabs are helpful in excluding active pelvic infections, which are generally more prevalent in younger, sexually active populations. If pelvic masses such as fibroids are suspected on examination, a pelvic ultrasound may be useful. A trial of the progesterone-only pill or LNG-IUS would be reasonable after excluding sexually transmitted infections. If this is unsuccessful, or symptoms persist, diagnostic laparoscopy could be considered. However, since this carries risks of operative complications, it would not be the first investigation indicated.

Chapter 9

• Q1. Answer: e – Side effect of tricyclic antidepressants

Vasomotor symptoms may be caused by calcium channel antagonists and antidepressant drugs, especially the tricyclic class of medication. Premature ovarian insufficiency (POI) is less likely given that she has a regular menstrual cycle. Hyperthyroidism can cause palpitations, but is unlikely to cause hot flushes. Phaeochromocytoma can cause episodes of palpitations and nausea, but these are usually associated with sweating rather than hot flushes. Premenstrual syndrome does not usually cause vasomotor symptoms.

• Q2. Answer: e – History of breast cancer

Use of estrogen-containing hormone replacement therapy (HRT) is widely considered to be contraindicated following breast carcinoma (including intraductal carcinoma) and following endometrial carcinoma. Uterine fibroids do not preclude the use of HRT. Women with a history of endometrial hyperplasia who wish to use HRT can use an LNG-IUS for continuous progesterone cover while taking systemic estrogen or consider continuous combined HRT. Obesity and anti-phospholipid antibodies are relative risk factors for venous thromboembolism (VTE) and not absolute contraindications to the use of HRT.

• Q3. Answer: b – Cyclical combined HRT

The commonest indication for starting HRT is for the relief of vasomotor symptoms. This woman has a uterus; therefore, the HRT must have estrogen and progesterone, that is, combined. The progesterone is important as unopposed estrogen therapy would increase her risk of developing endometrial hyperplasia and endometrial malignancy. The LNG-IUS can be used with systemic estrogen for endometrial protection; however, when used alone, it will not affect her vasomotor symptoms. Clonidine is no more effective than placebo at managing vasomotor symptoms. There is no conclusive evidence that evening primrose oil is effective.