Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Urogynaecology and Gynaecological Oncology Syllabus

In the current NHS Cervical Screening Programme, what is the primary screening test and the screening intervals?

Primary high-risk HPV (hrHPV) testing is performed first; cytology is used only as reflex triage if hrHPV is positive. Women aged 25-49 are screened every 3 (now moving to 5) years and 50-64 every 5 years, based on negative hrHPV results.

In HPV primary screening, what is the management of a woman who is hrHPV positive with negative reflex cytology?

She is recalled for repeat hrHPV testing in 12 months. If still hrHPV positive (even with negative cytology) at the repeat, she is referred to colposcopy; persistent infection over two further tests prompts colposcopy referral.

Which two HPV types are responsible for the majority of cervical cancers, and which vaccine covers them?

HPV 16 and 18 cause approximately 70% of cervical cancers; the Gardasil 9 (nonavalent) vaccine covers types 6, 11, 16, 18, 31, 33, 45, 52 and 58.

What does CIN grading represent histologically?

Cervical intraepithelial neoplasia describes dysplasia confined to the epithelium: CIN1 = dysplasia in the lower 1/3, CIN2 = lower 2/3, CIN3 = full thickness (but not breaching the basement membrane / no invasion).

What is the treatment of choice for CIN2/CIN3 and a key obstetric consequence?

Large loop excision of the transformation zone (LLETZ) is the standard treatment; it is associated with an increased risk of preterm birth in subsequent pregnancies, particularly with larger or repeated excisions.

What is the significance of VIN (vulval intraepithelial neoplasia) and its main subtypes?

VIN is a premalignant condition of the vulva. Usual-type (high-grade squamous, HPV-related) occurs in younger women; differentiated-type (dVIN, non-HPV related, associated with lichen sclerosus) occurs in older women and carries a higher and more rapid risk of progression to squamous cell carcinoma.

How is endometrial hyperplasia classified and what is the malignancy risk of each type?

By the presence of atypia: hyperplasia without atypia carries a low risk of progression (< 5% over 20 years); atypical hyperplasia (endometrial intraepithelial neoplasia) carries a high risk, with up to ~25-40% having concurrent or progressing to endometrial carcinoma.

What is the management of endometrial hyperplasia without atypia versus with atypia?

Without atypia: first-line is the levonorgestrel intrauterine system (LNG-IUS) with surveillance biopsies. With atypia: total hysterectomy (with bilateral salpingo-oophorectomy in postmenopausal women) is recommended; LNG-IUS only if fertility-sparing or unfit for surgery, with close surveillance.

What is the most common histological type of cervical cancer and the next most common?

Squamous cell carcinoma is the most common (about 70-80%), followed by adenocarcinoma.

In FIGO staging of cervical cancer, what defines Stage I versus the management of early-stage disease desiring fertility?

Stage I is confined to the cervix. Microinvasive (IA1) disease may be treated with cone biopsy/LLETZ; for early-stage tumours up to ~IB1 wishing to preserve fertility, radical trachelectomy with pelvic lymphadenectomy is an option; otherwise radical (Wertheim's) hysterectomy or chemoradiotherapy.

What is the standard treatment for locally advanced cervical cancer (FIGO stage IB3-IVA)?

Concurrent chemoradiotherapy (external beam radiotherapy plus cisplatin-based chemotherapy) followed by brachytherapy.

What is the most common gynaecological cancer in the UK and its commonest presenting symptom?

Endometrial (uterine) cancer; the commonest presenting symptom is postmenopausal bleeding.

What endometrial thickness threshold on transvaginal ultrasound prompts biopsy in a woman with postmenopausal bleeding?

An endometrial thickness greater than 4 mm warrants endometrial sampling (e.g. Pipelle biopsy or hysteroscopy with biopsy).

Differentiate Type 1 and Type 2 endometrial carcinoma.

Type 1: endometrioid, oestrogen-dependent, lower grade, better prognosis, associated with obesity and unopposed oestrogen. Type 2: non-endometrioid (serous, clear cell), oestrogen-independent, higher grade, poorer prognosis, often presents at later stage.

List key risk factors for endometrial cancer.

Obesity, unopposed oestrogen (including oestrogen-only HRT, tamoxifen), nulliparity, early menarche/late menopause, polycystic ovary syndrome, diabetes, and Lynch syndrome (hereditary non-polyposis colorectal cancer).

What is the most common type of ovarian cancer and the typical mode of presentation?

Epithelial ovarian cancer (most commonly high-grade serous carcinoma); it typically presents late with vague symptoms such as bloating, abdominal distension, early satiety, pelvic pain and change in bowel habit.

How is the Risk of Malignancy Index (RMI) calculated for an ovarian mass?

$RMI = U \times M \times CA125$, where $U$ is the ultrasound score, $M$ is the menopausal status score, and $CA125$ is the serum level in U/mL. An RMI greater than 250 indicates high risk and referral to a cancer centre.

Which inherited gene mutations most significantly increase the risk of ovarian (and tubal) cancer?

BRCA1 and BRCA2 mutations (and Lynch syndrome / mismatch repair gene mutations); BRCA1 carriers have a lifetime ovarian cancer risk of around 40-60% and BRCA2 carriers around 10-30%.

Where is high-grade serous ovarian carcinoma now believed to most often originate?

From the epithelium of the fimbrial end of the fallopian tube (serous tubal intraepithelial carcinoma, STIC), rather than the ovarian surface epithelium itself.

What tumour markers are useful in a young woman with a suspected germ cell or sex-cord ovarian tumour?

AFP (alpha-fetoprotein) and hCG for germ cell tumours (e.g. yolk sac, dysgerminoma, choriocarcinoma), LDH for dysgerminoma, and inhibin/oestradiol for granulosa cell tumours.

What is the standard treatment approach for advanced epithelial ovarian cancer?

Maximal cytoreductive (debulking) surgery aiming for no macroscopic residual disease, combined with platinum-based chemotherapy (carboplatin and paclitaxel); chemotherapy may be given as neoadjuvant before interval debulking in advanced/unresectable disease.

What is the most common histological type of vulval cancer and a key route of spread?

Squamous cell carcinoma; it spreads predominantly via the lymphatics to the inguinofemoral lymph nodes, and nodal status is the most important prognostic factor.

What is the role of sentinel lymph node biopsy in early vulval cancer?

For unifocal tumours less than 4 cm with clinically negative groin nodes, sentinel lymph node biopsy reduces the morbidity (lymphoedema, wound breakdown) associated with full inguinofemoral lymphadenectomy while accurately staging the groin.

What is the most common type of vaginal cancer, and what is the rare type linked to in-utero exposure?

Squamous cell carcinoma is the most common (often HPV-related); clear cell adenocarcinoma of the vagina is the rare type associated with in-utero diethylstilbestrol (DES) exposure.

What are the principles of multidisciplinary team (MDT) management in gynaecological oncology?

All cancers should be discussed by an MDT including gynaecological oncologists, pathologists, radiologists, oncologists, and clinical nurse specialists, ensuring accurate staging, individualised treatment planning, and holistic supportive care.

Which validated risk-assessment scores should be used pre-operatively to stratify venous thromboembolism and what is standard prophylaxis?

VTE risk should be assessed against bleeding risk; for major gynaecological/oncology surgery, mechanical prophylaxis (intermittent pneumatic compression / anti-embolism stockings) plus pharmacological LMWH is used, with extended LMWH prophylaxis (28 days) after surgery for pelvic cancer.

What constitutes valid consent for gynaecological surgery following the Montgomery ruling?

Consent must include disclosure of material risks that a reasonable patient in that position would attach significance to (patient-centred standard), the nature of the procedure, reasonable alternatives including doing nothing, and must be given voluntarily by a competent patient.

State the main advantages of minimal access (laparoscopic) surgery over laparotomy.

Reduced post-operative pain, shorter hospital stay, faster recovery and return to normal activity, less blood loss, smaller scars and reduced wound complications/adhesions, though with risk of specific access-related visceral and vascular injuries.

What are recognised serious complications of laparoscopic entry and how is the primary trocar risk reduced?

Vascular injury (major vessels) and visceral (bowel) injury during Veress needle or primary trocar insertion. Risk is reduced using techniques such as the open (Hasson) entry or Palmer's point entry in women at risk of periumbilical adhesions, and verifying intraperitoneal placement before insufflation.

In enhanced recovery after surgery (ERAS) for gynaecological procedures, name key interventions and the principle behind early management of a post-operative complication such as ureteric injury.

ERAS includes pre-operative carbohydrate loading and counselling, avoidance of bowel prep, minimal fasting, multimodal opioid-sparing analgesia, early mobilisation, early oral intake and early catheter removal. Suspected ureteric injury (e.g. flank pain, ileus, raised creatinine, urinoma) requires prompt imaging and early urological repair/stenting, as early recognition improves outcome.