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1. Hyperplasia

Definition & Pathogenesis

• Obesity — peripheral conversion of androgens to estrogens in adipose tissue
• Menopause / Perimenopause — anovulatory cycles
• Polycystic ovarian syndrome (PCOS)
• Functioning granulosa cell tumors of the ovary
• Exogenous estrogen — unopposed estrogen replacement therapy
• Excessive cortical stromal function (cortical stromal hyperplasia)

Classification (WHO / EIN System)

Morphology

• Increased gland-to-stroma ratio with variation in gland size and shape
• May show cystic dilation or back-to-back glands focally, but some intervening stroma is retained
• Cytologic features similar to normal proliferative endometrium
• Low malignant potential (~1–3%)

• Complex patterns of glands with nuclear atypia — rounded, vesicular nuclei with prominent nucleoli
• Back-to-back glands, markedly reduced stroma
• High malignant potential; often concurrent with carcinoma

Management

• Progestin therapy — oral (medroxyprogesterone acetate), parenteral, or levonorgestrel IUD
• Follow-up endometrial biopsy every 3 months
• Risk of progression is low; many regress

• Hysterectomy is the definitive treatment, especially in postmenopausal women (rules out concurrent carcinoma)
• Progestin therapy (oral, parenteral, or LNG-IUD) may be used in women who desire fertility or are poor surgical candidates — with close follow-up (biopsy every 3 months); recurrence risk ~50%
• After successful pregnancy, lack of regression should prompt hysterectomy

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2. Polyp Diagnosis

Types of Clinically Relevant Polyps

Endometrial Polyps

• Most are asymptomatic (incidental finding)
• Can cause intermenstrual bleeding, heavy menstrual bleeding, irregular bleeding, postmenopausal bleeding, and dysmenorrhea
• Associated with tamoxifen use and infertility
• Incidence increases with age throughout reproductive years; prevalence ~5.8% in premenopausal women, ~11.8% in postmenopausal women

1. Transvaginal ultrasound (TVUS): Suspected when endometrial thickening is seen; vascular "feeder vessel" pattern on Doppler helps distinguish polyps from fibroids and malignancy. Note: endometrial thickening is NOT specific — hyperplasia, polyp, and carcinoma all cause thickening.
2. Saline infusion sonohysterography (SIS/SHG): Confirmation with saline contrast improves visualization of intracavitary lesions.
3. Hysteroscopy: Gold standard — allows direct visualization and simultaneous removal.
4. Endometrial biopsy / D&C: Tissue sampling for histologic confirmation.
5. Hysterosalpingogram (HSG): Can detect filling defects.

• In premenopausal women: premalignant change 0.2–24%, malignancy 0–13%
• Higher risk in postmenopausal women with bleeding
• Up to 2.5% of polyps may harbor foci of endometrial carcinoma
• Spontaneous regression occurs in ~27% at 1 year (more likely for smaller polyps)

• Hysteroscopic polypectomy — treatment of choice; simultaneous diagnosis and treatment
• Removal may improve fertility in infertile patients
• Observation acceptable for small, asymptomatic polyps in premenopausal women

Cervical Polyps

• Pedunculated protrusions from the cervical canal; usually benign
• Cause: abnormal bleeding (postcoital, intermenstrual), vaginal discharge
• Postmenopausal cervical polyps frequently coexist with endometrial polyps; women on tamoxifen with cervical polyps have significantly higher risk of concomitant endometrial polyps
• Diagnosis: Direct visualization; tissue sent for histology
• Management: Simple avulsion/twisting at the base; hysteroscopy recommended when endometrial polyps are suspected

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3. Ectopic Pregnancy — Treatment

Definition & Epidemiology

Clinical Presentation (Classic Triad)

• Pelvic/abdominal pain
• Amenorrhea
• Abnormal vaginal bleeding

Risk Factors

• Prior salpingitis / PID
• Previous ectopic pregnancy
• Intrauterine contraceptive device (IUD)
• Tubal ligation
• Assisted reproductive technology (ART)

Diagnosis

• Serum β-hCG + transvaginal ultrasound (first-line)
• Discriminatory zone: when β-hCG >1,500–2,000 mIU/mL, an intrauterine gestational sac should be visible; absence suggests ectopic
• Culdocentesis: aspiration of non-clotting blood (>2 mL, hematocrit >3%) from the cul-de-sac indicates hemoperitoneum; positive in ~70% of proven ectopics

Treatment

A. Surgical Treatment

• Hemodynamically unstable patient
• Ruptured ectopic
• Contraindications to methotrexate
• Failed medical management

1. Salpingectomy (linear) — removal of the affected tube
   • Lower risk of repeat ectopic (4% vs 10% with salpingostomy)
   • Standard when contralateral tube is normal
2. Salpingostomy (linear salpingotomy) — incision over the pregnancy, trophoblast removed, tube preserved
   • Higher subsequent intrauterine pregnancy rate (RR 1.24) but more repeat ectopics
   • Preferred when contralateral tube is damaged
3. Laparoscopy is preferred over laparotomy (less morbidity, faster recovery)

B. Medical Treatment — Methotrexate

• Hemodynamically stable
• No evidence of rupture
• Unruptured tube <4 cm (relative contraindication if ≥4 cm)
• No fetal cardiac activity on ultrasound (relative contraindication if present)

1. Single-dose: MTX 50 mg/m² IM — simpler, less toxic; β-hCG checked on days 4 and 7; if <15% decline, second dose given
2. Multi-dose: MTX 1 mg/kg IM alternating with leucovorin (folinic acid rescue) — more effective for higher β-hCG levels but more side effects
3. Two-dose protocol — intermediate option

• Serum β-hCG, CBC with differential, liver function tests, creatinine, blood type & screen
• Chest X-ray if pulmonary disease history
• Administer RhoGAM if Rh-negative

• Avoid alcohol, NSAIDs, folic acid-containing multivitamins, and sexual intercourse until β-hCG is negative
• Report severe/prolonged pain (lower abdominal pain is normal for 10–14 days)
• Report heavy vaginal bleeding

• Weekly β-hCG until non-pregnant levels
• Tubal rupture can still occur even with falling β-hCG
• Cul-de-sac fluid is a common finding; does not mandate surgery unless hemodynamic instability or significant hematocrit drop occurs
• ~4–5% of women require surgery after failed methotrexate

• GI: nausea, vomiting, stomatitis, abdominal pain (30–40%)
• Bone marrow suppression, alopecia, elevated liver enzymes, pneumonitis, dermatitis
• Leucovorin reduces side effects in multi-dose regimens

C. Expectant Management

• Considered only for very select patients with low, declining β-hCG (<1,000 mIU/mL), small ectopic, no pain, and strict compliance for close monitoring
• Risk of rupture persists

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4. Abortion — In Detail

Definition & Types

• Spontaneous abortion (miscarriage) — involuntary loss
• Induced abortion — intentional termination (elective or therapeutic)
• Unsafe abortion — performed without necessary skills or in inadequate conditions

Epidemiology

• ~56.3 million abortions/year globally (2010–2014); 25% of all pregnancies
• ~25 million unsafe abortions annually; 47,000 women die per year from unsafe abortion
• In the US, ~88% of legal abortions occur in the first trimester (<13 weeks)
• Mortality rate for legal abortion: 0.7 per 100,000 procedures vs. maternal mortality 8.8 per 100,000 live births

Safety

• Risk increases exponentially with gestational age
• Aspiration abortion at ≤8 weeks: mortality 0.3/100,000 → rises to 6.7/100,000 at ≥18 weeks
• Even late D&E (>18 weeks) is safer than continuing pregnancy (maternal mortality comparison)
• Legal abortion is extremely safe; illegal abortion carries high complication and death rates

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First-Trimester Methods (<13 weeks)

1. Vacuum Curettage (Aspiration Abortion)

• Most common method for first-trimester abortion
• Performed under local anesthesia ± moderate sedation; usually outpatient
• Cervical preparation: metal/plastic dilators OR misoprostol 400 μg vaginally/buccally 3–4 hours before
• Cannula: 5–12 mm plastic vacuum cannula with manual (modified 50-mL syringe, effective through 10 weeks) or electric pump
• Antibiotic prophylaxis: single dose doxycycline (taken night before procedure)
• Major complications (requiring hospitalization, surgery, or transfusion): 0.16%
  • Incomplete abortion 0.33%
  • Hemorrhage 0.13%
  • Infection 0.27%
  • Uterine perforation 0.01%

2. Medical Abortion (Medication Abortion)

• Approved up to 70 days from last menstrual period (off-label evidence supports full first trimester)
• Efficacy: ~97% in early first trimester; slightly higher at earlier gestational ages
• Mifepristone: progesterone receptor antagonist — blocks progesterone, sensitizes uterus to prostaglandins, causes decidual breakdown
• Misoprostol: PGE1 analog — causes uterine contractions and cervical softening
• Main effects/side effects: Uterine cramping, bleeding, nausea, vomiting, diarrhea
• Serious adverse events: ~0.3% (excess bleeding requiring transfusion; infection even rarer)
• Mortality risk: 0.00063% — 14 times lower than risk of live birth

• Ectopic pregnancy (treat separately)
• IUD in place (remove first)
• Chronic adrenal failure
• Long-term corticosteroid therapy
• Allergy to mifepristone, misoprostol, or prostaglandins
• Hemorrhagic disorder
• Inherited porphyria

• Heavy/prolonged bleeding: up to 8% bleed for ≥30 days
• Need for surgical curettage: 2% at ≤49 days, 3% at 50–56 days, 5% at 57–63 days
• Infection (rare); Clostridium sordellii deaths prompted prophylactic doxycycline use and switch from vaginal to buccal misoprostol

• Methotrexate + misoprostol — effective but slower
• Misoprostol alone — 800 μg vaginally, repeated at 24 h if needed; ~91% efficacy up to 56 days

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Second-Trimester Methods (13–24 weeks)

1. Dilation and Evacuation (D&E)

1. Osmotic dilators:
   • Laminaria japonica (seaweed stems) or Dilapan-S hydrophilic rods inserted into cervical canal
   • Absorb water → swell → mechanical dilation + endogenous prostaglandin synthesis
   • Removed the following day; sufficient dilation achieved for specialized forceps + large-bore vacuum cannula
2. Misoprostol — can replace osmotic dilators; 1,200 μg multidose regimen reported with <2% major complications in experienced hands
3. Mifepristone — as adjunct or replacement for osmotic dilators; no difference in complications vs. osmotic dilators + misoprostol

• Cervical dilation + specialized forceps to remove fetal parts
• Large-bore vacuum cannula to evacuate placenta
• Ultrasound guidance is helpful

• Wide cervical dilation → membrane rupture → assisted breech delivery → decompression of after-coming fetal head → intact delivery of fetus
• Feticidal agents often used before late second-trimester procedures

• Intra-amniotic or intrafetal digoxin — 1.5 mg intra-amniotic; induces fetal demise within 24 hours
• Intracardiac potassium chloride (KCl) — both are efficacious with minimal maternal adverse effects

2. Labor Induction Methods

• Serial osmotic dilators + misoprostol to induce labor → assisted expulsion
• High-dose oxytocin protocols

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Summary Table

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🏥 OSCE CASES: Hyperplasia, Polyp, Ectopic Pregnancy & Abortion

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CASE 1 — Endometrial Hyperplasia

Station Information

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Patient Vignette

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History to Elicit

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Examination Findings

• BMI: 34 kg/m²
• Abdomen: Soft, no masses, no tenderness
• Speculum: Atrophic changes; minimal blood-stained discharge
• Bimanual: Uterus slightly bulky, no adnexal masses

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Investigations Provided

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OSCE Questions & Model Answers

Endometrial Hyperplasia with Atypia (EIN — Endometrial Intraepithelial Neoplasia). Using the WHO/EIN classification:

• Benign endometrial hyperplasia (no atypia) — low malignant risk (~1–3%)
• EIN / Atypical hyperplasia — premalignant; ~30% progression to carcinoma; ~40–50% may have concurrent carcinoma
• Endometrial adenocarcinoma

• Unopposed estrogen HRT (no progestogen added)
• Obesity (peripheral androgen → estrogen conversion)
• Type 2 diabetes (hyperinsulinemia stimulates estrogenic activity)
• Postmenopausal state
• Family history of endometrial cancer

PTEN tumor suppressor gene inactivation — found in >20% of hyperplasias. PTEN normally inhibits the PI3K/AKT signaling pathway. When PTEN is lost, PI3K/AKT becomes overactive and enhances estrogen receptor-driven gene expression, promoting endometrial overgrowth. Cowden syndrome (germline PTEN mutation) carries high risk of endometrial carcinoma.

Total hysterectomy is the definitive treatment — it removes the risk of concurrent carcinoma (present in 40–50% of EIN cases) and prevents progression. Bilateral salpingo-oophorectomy is also typically performed. Surgical staging may be indicated if carcinoma is found.

• Progestin therapy — levonorgestrel IUD (Mirena, first choice) or oral medroxyprogesterone acetate / norethisterone
• Endometrial biopsy every 3 months to monitor response
• Recurrence risk ~50%; once pregnancy achieved or regression fails → hysterectomy
• Multidisciplinary discussion with oncology and reproductive medicine

• Nuclear atypia: Rounded, vesicular nuclei with prominent nucleoli
• Back-to-back glands with minimal intervening stroma
• Loss of normal gland architecture
• Increased mitotic activity

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Marking Scheme

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CASE 2 — Polyp Diagnosis

Station Information

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Patient Vignette

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Investigations Provided

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OSCE Questions & Model Answers

Endometrial polyp (AUB-P under the PALM-COEIN classification of abnormal uterine bleeding).

Hysteroscopy — allows direct visualization of the uterine cavity and simultaneous removal of the polyp (hysteroscopic polypectomy). Histological analysis of the removed tissue confirms diagnosis and excludes malignancy.

Tamoxifen — a selective estrogen receptor modulator (SERM) used in breast cancer treatment. It acts as an estrogen antagonist in breast tissue but has partial estrogen agonist effects on the endometrium, leading to endometrial proliferation, polyps, and increased risk of endometrial carcinoma. Women on tamoxifen with a cervical polyp should also be evaluated for concurrent endometrial polyps.

PALM-COEIN classifies causes of abnormal uterine bleeding:

• PALM (Structural): Polyp, Adenomyosis, Leiomyoma, Malignancy + Hyperplasia
• COEIN (Non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified Polyp = AUB-P

• Premenopausal women: premalignant change 0.2–24%; malignancy 0–13%
• Postmenopausal women with bleeding: higher risk
• Overall: up to 2.5% may harbor endometrial carcinoma
• This patient's tamoxifen use further increases her risk → all polyps in tamoxifen users should be removed and sent for histology

Yes. Evidence suggests that hysteroscopic polypectomy improves pregnancy rates in infertile patients. Even asymptomatic polyps should be removed in women desiring conception. It also provides tissue for histology to exclude malignancy, which is important given her tamoxifen use.

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Marking Scheme

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CASE 3 — Ectopic Pregnancy

Station Information

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Patient Vignette

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Examination Findings

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Investigations

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OSCE Questions & Model Answers

Ruptured right tubal ectopic pregnancy. Evidence:

• Positive pregnancy test + amenorrhea = pregnant
• β-hCG 3,800 > discriminatory zone (1,500–2,000) → intrauterine sac should be visible if IUP
• No intrauterine gestational sac on TVUS
• Right adnexal mass with "ring of fire" (vascular trophoblastic ring on Doppler)
• Free fluid in pouch of Douglas = hemoperitoneum
• Hemodynamic instability (BP 94/60, HR 112) = ruptured

EMERGENCY — Stabilize and take to theatre immediately:

1. IV access × 2 large-bore cannulae
2. IV fluid resuscitation (crystalloid bolus; cross-match 4 units blood)
3. Oxygen — high-flow
4. Urgent bloods: FBC, U&E, coagulation, group & crossmatch
5. Inform anaesthetics and theatre — emergency laparoscopy / laparotomy
6. Administer Anti-D immunoglobulin (patient is Rh-negative)
7. Remove IUD intraoperatively

• Laparoscopic salpingectomy (preferred) — remove the affected tube; lower repeat ectopic rate (4% vs 10%)
• Laparoscopic salpingostomy — incise tube, remove trophoblast, preserve tube; preferred if contralateral tube is damaged; higher subsequent IUP rate (RR 1.24) but higher repeat ectopic rate
• Laparotomy — if laparoscopy unavailable or patient too unstable

No. Absolute contraindications to methotrexate in this patient:

• Hemodynamically unstable (BP 94/60, HR 112)
• Evidence of rupture (free fluid/hemoperitoneum) Methotrexate is only appropriate for hemodynamically stable, unruptured ectopic pregnancies <4 cm without cardiac activity.

Methotrexate 50 mg/m² IM (single dose protocol):

• Pre-treatment: CBC, LFTs, creatinine, blood group, RhoGAM if Rh-negative
• β-hCG on day 1, 4, 7
• If <15% decline between day 4 and 7 → second dose
• Avoid: alcohol, NSAIDs, folic acid supplements, sexual intercourse until β-hCG negative
• Weekly β-hCG until undetectable
• Return if severe pain, heavy bleeding, or dizziness (signs of rupture)
• ~95–96% success rate in eligible patients

• Prior PID / salpingitis — tubal scarring and impaired ciliary motility
• IUD use — does not cause ectopic but if pregnancy occurs with IUD in situ, higher proportion are ectopic
• Previous ectopic pregnancy, tubal surgery, smoking, assisted reproduction

Paradoxical bradycardia (vasovagal response) can occur with significant intraperitoneal bleeding — it should NOT falsely reassure the clinician. Blood in the peritoneal cavity does NOT consistently correlate with peritoneal signs, blood pressure, or pulse rate.

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Marking Scheme

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CASE 4 — Abortion

Station Information

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Patient Vignette

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Counselling Framework (to be demonstrated)

1. Non-judgmental, empathetic approach
2. Confirm gestational age and exclude ectopic
3. Explain all options: continue pregnancy, adoption, termination
4. If termination chosen: explain methods available at 8 weeks
5. Discuss risks, aftercare, contraception
6. Document informed consent

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OSCE Questions & Model Answers

At 8 weeks (within first trimester), two main options:

A. Medical Abortion (Medication Abortion):

• Mifepristone 200 mg orally + Misoprostol 800 μg buccally 24–48 hours later
• FDA-approved up to 70 days (10 weeks) from LMP
• Efficacy: ~97% in early first trimester
• Completely outpatient; can self-administer misoprostol at home
• Side effects: cramping, bleeding (intended effects), nausea, vomiting, diarrhea
• Serious adverse events: ~0.3%

B. Surgical Abortion — Vacuum Curettage (Aspiration):

• Manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA)
• Single outpatient visit; local anaesthesia ± sedation
• Cervical preparation: misoprostol 400 μg vaginally/buccally 3–4 hours before
• Major complications: 0.16%; overall complication rate 1.26%
• Prophylactic doxycycline given preoperatively

• Ectopic pregnancy (must be excluded first — critical)
• IUD in place — must be removed before starting treatment
• Chronic adrenal failure
• Long-term corticosteroid therapy
• Allergy to mifepristone, misoprostol, or other prostaglandins
• Hemorrhagic disorder / anticoagulation
• Inherited porphyria

The IUD must be removed before initiating medical abortion. Proceeding with mifepristone/misoprostol while an IUD is in situ is a contraindication. The IUD should be removed at the clinic visit before medication is dispensed.

Mifepristone is a selective progesterone receptor modulator / competitive progesterone antagonist — it binds to progesterone receptors with high affinity but acts as an antagonist. This blocks the effect of natural progesterone on the endometrium, causing:

• Decidual breakdown and endometrial shedding
• Cervical softening
• Sensitization of the uterus to prostaglandins Misoprostol (PGE1 analogue) then induces uterine contractions and expulsion of the pregnancy.

Dilation and Evacuation (D&E) — most common midtrimester method:

• Requires cervical preparation first:
  • Laminaria japonica or Dilapan-S osmotic dilators (inserted 12–24 hours before; absorb water → swell → dilate cervix mechanically + prostaglandin release)
  • Misoprostol alone (multidose, e.g., 1,200 μg)
  • Mifepristone as adjunct
• Combination of: specialized forceps + large-bore vacuum cannula
• Ultrasound guidance recommended
• Feticidal agents (for late second trimester): intra-amniotic digoxin (1.5 mg) or intracardiac KCl — both effective with minimal maternal adverse effects

Intact D&E: Wide dilation → membrane rupture → breech delivery → decompression of after-coming fetal head

• Legal abortion mortality: 0.7 per 100,000 procedures
• Maternal mortality (live birth): 8.8 per 100,000 live births
• Medical abortion (mifepristone/misoprostol) mortality: 0.00063% — 14× lower than risk of live birth
• D&E beyond 18 weeks is still safer than continuing pregnancy to term
• Risk increases with gestational age: 0.3/100,000 at ≤8 weeks → 6.7/100,000 at ≥18 weeks

• Contraception should be started immediately after abortion (same day)
• Options: combined oral contraceptive pill, progestogen-only pill, injectable, implant, IUD (can be inserted immediately after surgical abortion), condoms
• Counsel that fertility returns almost immediately after abortion

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Marking Scheme

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Quick-Reference Summary Card

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