Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Gynaecology: Benign, Menstrual and Reproductive Disorders Syllabus

Gynaecology: Benign, Menstrual and Reproductive Disorders syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Gynaecology: Benign, Menstrual and Reproductive Disorders in Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG), not a summary of it.

1. 1

   Menstrual Disorders

   4 topics

   • Heavy menstrual bleeding
     • Assessment, investigation and PALM-COEIN classification
     • Medical and surgical management
   • Amenorrhoea and oligomenorrhoea
     • Primary and secondary amenorrhoea
   • Dysmenorrhoea and premenstrual syndrome
   • Abnormal uterine bleeding investigation pathways
2. 2

   Benign Gynaecological Conditions

   5 topics

   • Uterine fibroids and adenomyosis
   • Endometriosis
     • Pathophysiology, diagnosis and staging
     • Medical and surgical management
   • Benign ovarian cysts and masses
   • Benign vulval and vaginal conditions
   • Pelvic pain: acute and chronic
3. 3

   Endocrine and Reproductive Disorders

   4 topics

   • Polycystic ovary syndrome
     • Rotterdam criteria and metabolic associations
   • Hyperprolactinaemia and pituitary disorders
   • Hirsutism, virilisation and androgen disorders
   • Disorders of sexual development
4. 4

   Menopause and Mid-life Health

   4 topics

   • Diagnosis and symptoms of the menopause
   • Hormone replacement therapy
     • Benefits, risks and regimens
     • Non-hormonal alternatives
   • Premature ovarian insufficiency
   • Osteoporosis and long-term health consequences
5. 5

   Paediatric and Adolescent Gynaecology

   3 topics

   • Common prepubertal gynaecological problems
   • Puberty: normal and disordered
   • Adolescent menstrual and contraceptive needs

Gynaecology: Benign, Menstrual and Reproductive Disorders flashcards for Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG)

25 of 53 cards from the Gynaecology: Benign, Menstrual and Reproductive Disorders deck — real questions with worked answers.

1. How is heavy menstrual bleeding (HMB) defined clinically (NICE/practical definition)?

   Excessive menstrual blood loss that interferes with a woman's physical, social, emotional and/or material quality of life. The historical objective threshold is blood loss $>80\ \text{mL}$ per cycle, but diagnosis is now based on patient-reported impact rather than measured volume.

2. What first-line investigation does NICE recommend for all women presenting with heavy menstrual bleeding?

   A full blood count (FBC) to assess for iron-deficiency anaemia, taken in parallel with starting treatment when appropriate. Further tests (e.g. ferritin, coagulation screen for von Willebrand disease, hysteroscopy, pelvic/transvaginal ultrasound) are targeted to history and examination findings.

3. What is the NICE first-line medical treatment for heavy menstrual bleeding when long-term contraception is acceptable?

   The levonorgestrel-releasing intrauterine system (LNG-IUS, e.g. Mirena), provided the woman wants to use it for at least 12 months. It can reduce menstrual blood loss by around $70\text{-}90\%$.

4. List the non-hormonal medical options for HMB and their mechanisms.

   Tranexamic acid (antifibrinolytic, reduces loss by ~$50\%$, taken on bleeding days) and NSAIDs such as mefenamic acid (inhibit prostaglandin synthesis, reduce loss by ~$25\text{-}30\%$ and ease dysmenorrhoea). Neither provides contraception.

5. Define amenorrhoea and distinguish primary from secondary.

   Amenorrhoea is the absence of menstruation. Primary: no menarche by age 15 with normal secondary sexual characteristics (or by 13 with none). Secondary: cessation of established menstruation for $\geq 6$ months (or 3 cycles) in a previously menstruating woman.

6. How is oligomenorrhoea defined?

   Infrequent menstruation with cycle length greater than 35 days, resulting in fewer than 9 periods per year (commonly 4-9). It is most often associated with anovulation, the commonest cause being polycystic ovary syndrome.

7. What baseline endocrine tests are used to investigate secondary amenorrhoea?

   Pregnancy test first, then serum FSH and LH, prolactin, TSH, oestradiol, and testosterone. High FSH suggests ovarian failure; low FSH/LH suggests hypothalamic-pituitary cause; raised prolactin suggests hyperprolactinaemia; raised testosterone/LH:FSH ratio suggests PCOS.

8. In hypothalamic (functional) amenorrhoea, what is the characteristic hormonal pattern and common precipitants?

   Low GnRH pulsatility producing low FSH, low LH and low oestradiol (hypogonadotrophic hypogonadism). Precipitants include excessive exercise, low body weight/energy availability, eating disorders and chronic stress.

9. What is the difference between primary and secondary dysmenorrhoea?

   Primary dysmenorrhoea is painful menstruation without underlying pelvic pathology, usually starting 6-12 months after menarche, due to prostaglandin-mediated uterine contractions. Secondary dysmenorrhoea is pain caused by pathology (e.g. endometriosis, adenomyosis, fibroids, PID) and typically begins years after menarche.

10. What is the first-line treatment for primary dysmenorrhoea?

    NSAIDs (e.g. ibuprofen, mefenamic acid), which inhibit prostaglandin synthesis. The combined oral contraceptive pill is an effective alternative or second-line, especially if contraception is also desired.

11. How is premenstrual syndrome (PMS) diagnosed and what severity definition exists?

    PMS is diagnosed by prospective symptom recording over 2 cycles, with psychological/physical symptoms confined to the luteal phase and resolving by the end of menstruation. Premenstrual dysphoric disorder (PMDD) is the severe form with marked mood symptoms causing significant functional impairment.

12. What are the recommended treatments for severe PMS/PMDD?

    SSRIs (luteal-phase or continuous) are first-line for psychological symptoms; the combined contraceptive pill (especially drospirenone-containing, continuous regimen) is also first-line. Severe refractory cases may use estradiol patches with cyclical progestogen, GnRH analogues with add-back HRT, or rarely bilateral oophorectomy.

13. In the investigation pathway for abnormal uterine bleeding, when should endometrial biopsy/hysteroscopy be performed?

    For women with persistent intermenstrual or postcoital bleeding, treatment failure, or those aged $\geq 45$ years with HMB (or younger with risk factors such as obesity, PCOS, unopposed oestrogen, tamoxifen, Lynch syndrome), to exclude endometrial hyperplasia or carcinoma.

14. What classification system describes the causes of abnormal uterine bleeding, and what does the acronym stand for?

    The FIGO PALM-COEIN system. Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia. Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified.

15. How are uterine fibroids classified by location, and which type most affects fertility and bleeding?

    By location: submucosal (distort the cavity), intramural (within myometrium), and subserosal (project outward); pedunculated forms also occur. Submucosal fibroids most commonly cause heavy menstrual bleeding and impair fertility/implantation. FIGO grades them 0-8.

16. What is the typical ultrasound and clinical picture of adenomyosis, and how does it differ from fibroids?

    Adenomyosis is endometrial glands/stroma within the myometrium, causing a diffusely bulky, globular, tender uterus with heavy painful periods. Ultrasound/MRI shows a thickened junctional zone and myometrial cysts. Fibroids are discrete, well-circumscribed masses. MRI is the most accurate non-invasive test; definitive diagnosis is histological.

17. What medical agent can shrink fibroids preoperatively, and what is the mechanism and limitation?

    GnRH agonists (e.g. goserelin) induce a hypo-oestrogenic state, shrinking fibroids and correcting anaemia before surgery. Limited to short-term use (usually $\leq 6$ months) due to menopausal side effects and bone loss; fibroids regrow after stopping. Add-back HRT can mitigate side effects.

18. What are the classic symptoms and the diagnostic gold standard for endometriosis?

    Cyclical pelvic pain, dysmenorrhoea, deep dyspareunia, subfertility, and cyclical bowel/bladder symptoms. The gold standard for diagnosis is laparoscopic visualisation (ideally with histological confirmation), though MRI/ultrasound can detect ovarian endometriomas and deep disease.

19. What are the medical treatment options for endometriosis-associated pain?

    First-line: NSAIDs plus hormonal suppression — combined contraceptives or progestogens (continuous, to induce amenorrhoea). Second-line: GnRH agonists with add-back HRT, or the LNG-IUS. These suppress ovarian activity and ectopic endometrial tissue but are not used when pregnancy is sought.

20. What is an endometrioma and what is its characteristic ultrasound appearance?

    An ovarian cyst filled with altered (old) blood from endometriosis, the 'chocolate cyst'. On transvaginal ultrasound it appears as a unilocular cyst with homogeneous low-level (ground-glass) internal echoes and no solid vascular areas.

21. How are most simple ovarian cysts in premenopausal women managed, and what size threshold guides follow-up?

    Simple cysts $<5\ \text{cm}$ usually resolve spontaneously and need no follow-up. Cysts of $5\text{-}7\ \text{cm}$ warrant yearly ultrasound follow-up; cysts $>7\ \text{cm}$ are considered for MRI or surgical assessment as ultrasound may not fully characterise them.

22. What is the Risk of Malignancy Index (RMI) and its components?

    $\text{RMI} = U \times M \times \text{CA125}$, where $U$ = ultrasound score (0, 1, or 3 based on number of suspicious features), $M$ = menopausal status (1 premenopausal, 3 postmenopausal), and CA125 is the serum level in U/mL. An RMI $>200$ indicates high risk and referral to gynaecological oncology.

23. Name three common benign ovarian cyst/tumour types and a defining feature of each.

    Functional cysts (follicular/corpus luteal — physiological, resolve spontaneously); mature cystic teratoma/dermoid (contains skin, hair, teeth, fat; risk of torsion); and serous/mucinous cystadenoma (epithelial; mucinous can become very large).

24. What is lichen sclerosus, its hallmark features, and its main long-term risk?

    A chronic inflammatory vulval dermatosis causing intense pruritus, white atrophic 'parchment/figure-of-eight' plaques, architectural loss (fusion of labia, clitoral hood burying). Treated with potent topical corticosteroids (e.g. clobetasol). Carries a small (~$4\text{-}5\%$) lifetime risk of vulval squamous cell carcinoma, requiring surveillance.

25. What is a Bartholin's cyst/abscess and how is it managed?

    Obstruction of a Bartholin's duct causes a cyst; secondary infection produces a painful abscess at the posterior vaginal introitus (4 and 8 o'clock positions). Management of symptomatic cases is marsupialisation or Word catheter insertion to create a permanent drainage tract; antibiotics if cellulitis. Biopsy in women $>40$ to exclude carcinoma.

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