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  • Question 1 - A mother of three brings her youngest daughter, aged 15, to the general...

    Incorrect

    • A mother of three brings her youngest daughter, aged 15, to the general practitioner (GP) as she is yet to start menstruating, whereas both her sisters had menarche at the age of 12.
      The patient has developed secondary female sexual characteristics and has a normal height. She reports struggling with headaches and one episode of galactorrhoea.
      Magnetic resonance imaging (MRI) reveals an intracranial tumour measuring 11 mm in maximal diameter.
      Given the most likely diagnosis, which of the following is the first-line management option?

      Your Answer: Surgery to remove the tumour

      Correct Answer: Medical treatment with cabergoline

      Explanation:

      The patient has primary amenorrhoea due to a macroprolactinoma, which is a benign prolactin-secreting tumor of the anterior pituitary gland. Treatment in the first instance is with a dopamine receptor agonist such as bromocriptine or cabergoline. Surgery is the most appropriate management if conservative management fails or the patient presents with visual field defects. Radiotherapy is rarely used. Exclusion of pregnancy is the first step in every case of amenorrhoea. Metoclopramide is a dopamine receptor antagonist and a cause of hyperprolactinaemia, so it should not be used to treat this patient. Thyroxine is not appropriate as hyperprolactinaemia is secondary to a pituitary adenoma. Indications for surgery are failure to respond to medical therapy or presentation with acute visual field defects.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 2 - A 16-year-old girl comes to her GP with a complaint of never having...

    Incorrect

    • A 16-year-old girl comes to her GP with a complaint of never having had a menstrual period. During the examination, the GP observes normal external female genitalia and a vagina that terminates as a blind pouch. The absence of a uterus or ovaries is palpable, and there is no growth of pubic or axillary hair. What karyotype abnormality is likely to be present in this patient?

      Your Answer: 45,XO

      Correct Answer: 46,XY

      Explanation:

      Genotypes and Associated Syndromes

      There are several genotypes that can lead to different syndromes.

      The genotype 46,XY can cause androgen insensitivity syndrome, where the patient is genotypically male but has complete resistance to testosterone. This results in the absence of male internal genitalia.

      The genotype 46,XX is associated with a phenotypically normal female.

      45,XO causes Turner syndrome, which is characterized by short stature, webbed neck, and streak gonads in girls.

      47,XXY causes Klinefelter syndrome in males, which is characterized by atrophic testes, azoospermia, wide-set nipples, female distribution of body hair, and mild intellectual disability.

      47,XYY causes tall stature, acne, and mild mental retardation in men. This genotype is also associated with aggressive behavior, but normal fertility.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 3 - A 28-year-old woman who has never given birth comes to the gynaecology clinic...

    Incorrect

    • A 28-year-old woman who has never given birth comes to the gynaecology clinic complaining of worsening menstrual pain over the past three years. Despite taking ibuprofen, she has found no relief. She is sexually active with her husband and experiences pain during intercourse. Additionally, she has dysuria and urgency when urinating. She has been trying to conceive for two years without success. During the examination, her uterus appears normal in size, but there is tenderness and uterosacral nodularity upon rectovaginal examination.

      What is the most likely diagnosis?

      Your Answer: Fibroid

      Correct Answer: Endometriosis

      Explanation:

      The patient’s symptoms of dysmenorrhoea, dyspareunia, and subfertility are classic signs of endometriosis, a common condition where endometrial tissue grows outside of the uterus. The presence of uterosacral nodularity and tenderness further supports this diagnosis. Some patients with endometriosis may also experience urinary symptoms due to bladder involvement or adhesions. Uterine leiomyoma, or fibroid, is a common pelvic tumor that causes abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction. However, it does not typically present with uterosacral nodularity and tenderness on rectal examination. Interstitial cystitis causes urinary frequency and urgency, with pain relieved upon voiding. Pelvic inflammatory disease presents with fever, nausea, acute pain, malodorous vaginal discharge, and cervical motion tenderness/adnexal tenderness.

      Understanding Endometriosis

      Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

      First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

      It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 4 - A 19-year-old female patient visits her doctor urgently seeking emergency contraception after having...

    Incorrect

    • A 19-year-old female patient visits her doctor urgently seeking emergency contraception after having unprotected sex 80 hours ago. She is currently on day 20 of her menstrual cycle. The doctor discovers that the patient was previously prescribed ellaOne (ulipristal acetate) for a similar situation just 10 days ago. What would be an appropriate emergency contraception method for this patient?

      Your Answer: Levonelle (levonorgestrel) pill

      Correct Answer: ellaOne (ulipristal acetate) pill

      Explanation:

      Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 5 - A 25-year-old female patient presents to her GP seeking emergency contraception. She started...

    Correct

    • A 25-year-old female patient presents to her GP seeking emergency contraception. She started taking the progesterone-only pill on day 10 of her menstrual cycle and had unprotected sex with a new partner 3 days later. She is concerned about the lack of barrier contraception used during the encounter. What is the best course of action for this patient?

      Your Answer: Reassurance and discharge

      Explanation:

      The progesterone-only pill requires 48 hours to become effective, except when started on or before day 5 of the menstrual cycle. During this time, additional barrier methods of contraception should be used. Since the patient is currently on day 10 of her menstrual cycle, it will take 48 hours for the POP to become effective. Therefore, having unprotected sex on day 14 of her menstrual cycle would be considered safe, and emergency contraception is not necessary.

      The intrauterine device can be used as emergency contraception within 5 days of unprotected sex, but it is not necessary in this case since the POP has become effective. The intrauterine system is not a form of emergency contraception and is not recommended for this patient. Levonorgestrel is a type of emergency contraception that must be taken within 72 hours of unprotected sex.

      Counselling for Women Considering the progesterone-Only Pill

      Women who are considering taking the progesterone-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. When starting the POP, immediate protection is provided if it is commenced up to and including day 5 of the cycle. If it is started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a combined oral contraceptive (COC), immediate protection is provided if the POP is continued directly from the end of a pill packet.

      It is important to take the POP at the same time every day, without a pill-free break, unlike the COC. If a pill is missed by less than 3 hours, it should be taken as normal. If it is missed by more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours. Diarrhoea and vomiting do not affect the POP, but assuming pills have been missed and following the above guidelines is recommended. Antibiotics have no effect on the POP, unless they alter the P450 enzyme system, such as rifampicin. Liver enzyme inducers may reduce the effectiveness of the POP.

      In addition to these specific guidelines, women should also have a discussion on sexually transmitted infections (STIs) when considering the POP. It is important for women to receive comprehensive counselling on the POP to ensure they are aware of its potential effects and how to use it effectively.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 6 - A 42-year-old female undergoes a cervical smear at her local clinic as part...

    Correct

    • A 42-year-old female undergoes a cervical smear at her local clinic as part of the UK cervical screening programme. Her result comes back as an 'inadequate sample'. What should be done next?

      Your Answer: Repeat the test within 3 months

      Explanation:

      If a cervical smear test performed as part of the NHS cervical screening programme is inadequate, it should be first tested for high-risk HPV (hrHPV) and then repeated within 3 months. Colposcopy should only be performed if the second sample also returns as inadequate. Returning the patient to normal recall would result in a delay of 3 years for a repeat smear test, which is not recommended as it could lead to a missed diagnosis of cervical cancer. Repeating the test in 1 month is too soon, while repeating it in 6 months is not in line with current guidelines.

      The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 7 - A 35-year-old woman presents to the clinic with a 1-year history of amenorrhoea...

    Incorrect

    • A 35-year-old woman presents to the clinic with a 1-year history of amenorrhoea and a milky discharge from both breasts. She is not taking any medications and a pregnancy test is negative. What is the next recommended test?

      Your Answer: Mammogram

      Correct Answer: Thyroid function tests

      Explanation:

      The patient’s amenorrhea and galactorrhea are caused by hyperprolactinemia, which requires initial management to exclude hypothyroidism, chronic renal failure, and pregnancy as underlying causes. A CT scan is not necessary in this scenario. However, after excluding primary hypothyroidism and chronic renal failure, formal visual field testing can be done to investigate potential changes in keeping with a pituitary adenoma. An MRI head can also be done to look for a pituitary adenoma. Although a mammogram is not relevant in this case, the patient should still undergo breast screening. If the discharge were bloody, a mammogram would be necessary to rule out breast carcinoma.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 8 - A 36-year-old patient undergoing IVF for tubal disease presents with abdominal discomfort, nausea,...

    Correct

    • A 36-year-old patient undergoing IVF for tubal disease presents with abdominal discomfort, nausea, and vomiting four days after egg retrieval. She has a history of well-controlled Crohn's disease and is currently taking azathioprine maintenance therapy. On examination, her abdomen appears distended. What is the most likely diagnosis in this scenario?

      Your Answer: Ovarian hyperstimulation syndrome

      Explanation:

      Understanding Ovarian Hyperstimulation Syndrome

      Ovarian hyperstimulation syndrome (OHSS) is a potential complication that can occur during infertility treatment. This condition is believed to be caused by the presence of multiple luteinized cysts in the ovaries, which can lead to high levels of hormones and vasoactive substances. As a result, the permeability of the membranes increases, leading to fluid loss from the intravascular compartment.

      OHSS is more commonly seen following gonadotropin or hCG treatment, and it is rare with Clomiphene therapy. Approximately one-third of women undergoing in vitro fertilization (IVF) may experience a mild form of OHSS. The Royal College of Obstetricians and Gynaecologists (RCOG) has classified OHSS into four categories: mild, moderate, severe, and critical.

      Symptoms of OHSS can range from abdominal pain and bloating to more severe symptoms such as thromboembolism and acute respiratory distress syndrome. It is important to monitor patients closely during infertility treatment to detect any signs of OHSS and manage the condition appropriately. By understanding OHSS and its potential risks, healthcare providers can work to minimize the occurrence of this complication and ensure the safety of their patients.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 9 - A 57-year-old woman has been experiencing bloating and weight loss for the past...

    Incorrect

    • A 57-year-old woman has been experiencing bloating and weight loss for the past 6 months. Her blood tests reveal a high CA-125 level. What type of cancer is typically associated with an elevated CA-125 in this age group?

      Your Answer: Breast cancer

      Correct Answer: Ovarian cancer

      Explanation:

      Tumour Markers for Different Types of Cancer

      Tumour markers are substances that are produced by cancer cells or by the body in response to cancer. They can be detected in blood, urine, or tissue samples and can help in the diagnosis, monitoring, and treatment of cancer. Here are some tumour markers for different types of cancer:

      – Ovarian cancer: CA125 is highly suggestive of ovarian cancer.
      – Colorectal cancer: CEA is a tumour marker for bowel cancer.
      – Breast cancer: CA 15–3 is a tumour marker for breast cancer.
      – Pancreatic cancer: CA19–9 is a tumour marker for pancreatic cancer.
      – Rectal cancer: Unfortunately, there is no specific marker for rectal cancer.

      It is important to note that tumour markers are not always reliable and can be elevated in non-cancerous conditions as well. Therefore, they should be used in conjunction with other diagnostic tests and clinical evaluations.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 10 - A 30-year-old married woman has been struggling with infertility for a while. Upon...

    Incorrect

    • A 30-year-old married woman has been struggling with infertility for a while. Upon undergoing an ultrasound, it was discovered that her ovaries are enlarged. She has also been experiencing scant or absent menses, but her external genitalia appears normal. Additionally, she has gained weight without explanation and developed hirsutism. Hormonal tests indicate decreased follicle-stimulating hormone (FSH) and increased luteinising hormone (LH), increased androgens, and undetectable beta human chorionic gonadotropin. What is the most likely cause of her condition?

      Your Answer: Gonadal dysgenesis, monosomy X variant

      Correct Answer: Polycystic ovarian syndrome (PCOS)

      Explanation:

      Understanding Polycystic Ovarian Syndrome (PCOS) and Related Conditions

      Polycystic ovarian syndrome (PCOS) is a hormonal disorder that affects women of reproductive age. It is characterized by enlarged ovaries with many atretic follicles but no mature antral follicles. This leads to increased production of luteinizing hormone (LH), which stimulates the cells of the theca interna to secrete testosterone. Peripheral aromatase then converts testosterone to estrogen, which suppresses follicle-stimulating hormone (FSH) secretion and upregulates LH secretion from the adenohypophysis. This results in decreased aromatase production in granulosa cells, low levels of estradiol, and failure of follicles to develop normally.

      To remember the signs and symptoms of PCOS, use the mnemonic PCOS PAL. PCOS is associated with male pattern balding (alopecia), hirsutism, obesity, hypertension, acanthosis nigricans (thickening and hyperpigmentation of the skin), and menstrual irregularities (oligo- or amenorrhea). It can also cause hypogonadotropic hypogonadism, which is characterized by impaired secretion of gonadotropins from the pituitary, including FSH and LH. This condition can be caused by various factors, such as Kallmann syndrome and GnRH insensitivity. Gonadal dysgenesis, monosomy X variant, is another condition that affects sexually juvenile women with an abnormal karyotype (45, X). It results in complete failure of development of the ovary and therefore no secondary sexual characteristics. Chronic adrenal insufficiency (or Addison’s disease) is another condition that can cause anorexia, weight loss, and hyperpigmentation of the skin in sun-exposed areas.

      It is important to note that early pregnancy is not a possibility in women with PCOS who are not ovulating. Additionally, if a woman with PCOS were pregnant, she would have elevated beta human chorionic gonadotropin. Understanding these conditions and their associated symptoms can help healthcare providers diagnose and manage PCOS effectively.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 11 - In the study of contraception modes, researchers examine the cell structure of sperm....

    Incorrect

    • In the study of contraception modes, researchers examine the cell structure of sperm. In the case of the copper intrauterine device (IUD), which cellular structure is affected by its mode of action?

      Your Answer: Cell wall

      Correct Answer: Golgi apparatus

      Explanation:

      How the Copper IUD Affects Different Parts of Sperm

      The copper IUD is a popular form of birth control that works by preventing fertilization. It does this by affecting different parts of the sperm. The Golgi apparatus, which contributes to the acrosome of the sperm, is inhibited by the IUD, preventing capacitation. The mitochondria, which form the middle piece of the sperm, are not affected. The nucleus is also unaffected. Sperm do not have cell walls, so this is not a factor. Finally, the centrioles contribute to the flagellum of the sperm, but the copper IUD does not target this part of the sperm. Understanding how the copper IUD affects different parts of the sperm can help individuals make informed decisions about their birth control options.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 12 - A 52-year-old woman comes to the postmenopausal bleeding clinic complaining of continuous vaginal...

    Correct

    • A 52-year-old woman comes to the postmenopausal bleeding clinic complaining of continuous vaginal bleeding for the past 2 weeks. What would be your initial investigation in the clinic?

      Your Answer: Trans-vaginal ultrasound

      Explanation:

      TVUS is the recommended initial investigation for PMB, unless there are contraindications. This is because it provides the most accurate measurement of endometrial thickness, which is crucial in determining if the bleeding is due to endometrial cancer.

      Understanding Postmenopausal Bleeding

      Postmenopausal bleeding refers to vaginal bleeding that occurs after a woman has gone 12 months without a menstrual period. While most cases do not involve cancer, it is important to rule out this possibility in all women. The most common cause of postmenopausal bleeding is vaginal atrophy, which occurs due to a reduction in estrogen following menopause. Other causes include hormone replacement therapy, endometrial hyperplasia, endometrial cancer, cervical cancer, ovarian cancer, and vaginal cancer.

      To investigate postmenopausal bleeding, women over the age of 55 should undergo an ultrasound within two weeks to check for endometrial cancer. If referred on a cancer pathway, a transvaginal ultrasound is the preferred method of investigation. Treatment options depend on the underlying cause of the bleeding. For vaginal atrophy, topical estrogen and lifestyle changes can help alleviate symptoms, while HRT may also be used. If the bleeding is due to a specific type of HRT, switching to a different preparation may be helpful. In cases of endometrial hyperplasia, dilation and curettage may be necessary to remove excess tissue.

      Overall, it is important for women experiencing postmenopausal bleeding to seek medical attention and undergo appropriate testing to rule out any serious underlying conditions.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 13 - A 32-year-old woman has been experiencing fatigue, bloating, and significant weight loss over...

    Incorrect

    • A 32-year-old woman has been experiencing fatigue, bloating, and significant weight loss over the past two months. She visits her GP, who discovers that two of her first-degree relatives died from cancer after asking further questions. During the physical examination, the GP observes an abdominal mass and distension. The GP is concerned about the symptoms and orders a CA-125 test, which returns as elevated. What gene mutation carries the greatest risk for the condition indicated by high CA-125 levels?

      Your Answer: c-myc

      Correct Answer: BRCA1

      Explanation:

      Based on the patient’s symptoms and an elevated level of CA-125, it is likely that she has ovarian cancer. Additionally, her family history of cancer in first-degree relatives and early onset cancer suggest the possibility of an inherited cancer-related gene. One such gene is BRCA1, which increases the risk of ovarian and breast cancer in those who have inherited a mutated copy. Other tumour suppressor genes, such as WT1 for Wilm’s tumour, Rb for retinoblastoma, and c-Myc for Burkitt lymphoma, confer a higher risk for other types of cancer.

      Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

      Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

      Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 14 - A 47-year-old woman presents to her General Practitioner (GP) with a 1-month history...

    Correct

    • A 47-year-old woman presents to her General Practitioner (GP) with a 1-month history of post-coital bleeding, vaginal discomfort and intermittent vaginal discharge. She feels lethargic and reports unintentional weight loss. She is a single mother of two children and lives in shared accommodation with one other family. She is a smoker of 30 cigarettes a day. She has not engaged with the cervical screening programme.
      Examination reveals a white lump on the cervix, associated with surface ulceration.
      Cervical carcinoma is suspected.
      Which of the following is a risk factor for developing cervical carcinoma?

      Your Answer: Smoking

      Explanation:

      Risk Factors for Cervical Carcinoma: Understanding the Role of Smoking, HPV, and Other Factors

      Cervical carcinoma is a type of cancer that affects the cervix, the lower part of the uterus. While the exact causes of cervical carcinoma are not fully understood, several risk factors have been identified. In this article, we will explore some of the key risk factors associated with the development of cervical carcinoma, including smoking, HPV infection, late menopause, nulliparity, obesity, and the use of contraceptive pills.

      Smoking is a significant risk factor for cervical carcinoma, accounting for 21% of cases in the UK. Nicotine and cotinine, two chemicals found in tobacco smoke, may directly damage DNA in cervical cells and act as a cofactor in HPV-driven carcinogenesis.

      Persistent infection with HPV is the strongest risk factor for cervical carcinoma. Other risk factors include early sexual activity, low socio-economic status, co-infection with HIV, immunosuppression, and a family history of cervical carcinoma. Late menopause is a known risk factor for ovarian and endometrial carcinoma, but not cervical carcinoma. Nulliparity is associated with ovarian and endometrial carcinoma, but not cervical carcinoma. Obesity is a risk factor for endometrial carcinoma, but not cervical carcinoma.

      The combined oral contraceptive pill has been associated with a small increase in the risk of developing cervical carcinoma, but there is no evidence to support an association with the progesterone-only pill.

      In conclusion, understanding the risk factors associated with cervical carcinoma is important for prevention and early detection. Quitting smoking, practicing safe sex, and getting regular cervical cancer screenings can help reduce the risk of developing this type of cancer.

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      • Gynaecology
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  • Question 15 - A 26-year-old primigravida has a spontaneous vaginal delivery at 38+2 weeks gestation. It...

    Incorrect

    • A 26-year-old primigravida has a spontaneous vaginal delivery at 38+2 weeks gestation. It is midwife-led and uncomplicated. She is seen by the obstetric team the next day on the post-natal ward as she is requesting contraception. Her medical history and allergies are negative. She is formula-feeding the baby. Before getting pregnant, she was taking the combined oral contraceptive pill and wants to resume it. She mentions that she couldn't tolerate the progesterone-only pill and doesn't prefer the intra-uterine system.

      What are the counseling points for this patient?

      Your Answer: This can be prescribed and taken immediately

      Correct Answer: This can be prescribed and taken from 21 days post-partum

      Explanation:

      The COCP should not be prescribed in the first 21 days post-partum due to the increased risk of venous thromboembolism. Breastfeeding patients should use caution when taking the COCP. Physiological parameters return to normal by 3 months post-partum, but it would be inappropriate to make the patient wait that long to resume the COCP. Pregnancy is a hypercoagulable state, increasing the risk of venous thromboembolism.

      After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

      The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

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      • Gynaecology
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  • Question 16 - A 26-year-old patient presents with a 3-day history of vaginal discharge, without itching...

    Correct

    • A 26-year-old patient presents with a 3-day history of vaginal discharge, without itching or bleeding. She is normally fit and well, without past medical history. There is no history of sexually transmitted infections. She is sexually active and has a progesterone implant for contraception.
      Examination reveals a soft, non-tender abdomen. On pelvic examination, you notice the vagina has a white-grey coating on the walls and a fishy odour. A small amount of grey vaginal discharge is also seen. The cervix looks normal, and there is no cervical excitation. Observations are stable.
      Which of the following is the most likely diagnosis?

      Your Answer: Bacterial vaginosis

      Explanation:

      Common Causes of Vaginal Discharge: Symptoms and Treatment

      Bacterial vaginosis, Trichomonas vaginalis, Candidiasis, gonorrhoeae, and Pelvic inflammatory disease are some of the most common causes of vaginal discharge in women.

      Bacterial vaginosis is caused by an overgrowth of anaerobic bacteria and loss of lactobacilli in the vagina. It presents with a grey-white, thin discharge with a fishy odour and an increased vaginal pH. Metronidazole is the treatment of choice.

      Trichomonas vaginalis is a sexually transmitted infection that presents with a yellow-green discharge and an erythematosus cervix with a punctate exudate.

      Candidiasis is a fungal infection associated with pruritus, burning, erythema, and oedema of the vestibule. The vaginal discharge is thick, curd-like, and white.

      gonorrhoeae can be asymptomatic or present with abdominal pain, mucopurulent discharge, cervicitis, dyspareunia, or abnormal bleeding.

      Pelvic inflammatory disease is the result of an ascending infection and presents with dyspareunia, lower abdominal pain, menstrual irregularities, irregular bleeding, and a blood stained, purulent vaginal discharge. Cervicitis and cervical excitation are also present.

      Proper diagnosis and treatment are essential to prevent complications and improve the quality of life of affected women.

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      • Gynaecology
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  • Question 17 - A mother brings her 13-year-old daughter to the GP with concerns about her...

    Incorrect

    • A mother brings her 13-year-old daughter to the GP with concerns about her daughter's lack of menstrual periods and cyclical pain. Upon examination, the daughter appears to be in good health. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Imperforate hymen

      Explanation:

      The topic of primary amenorrhoea is being discussed, where the patient is experiencing cyclical pain but has not had any evidence of menstruation. This eliminates certain possibilities such as mullerian agenesis and constitutional delay, which are typically painless. Turner syndrome is also unlikely as it is often accompanied by distinct physical features and health issues. Pregnancy cannot be ruled out entirely, but it is improbable given the patient’s lack of menarche and cyclical pain. Therefore, imperforate hymen is the most probable diagnosis.

      Amenorrhoea refers to the absence of menstruation, which can be primary (when menarche has never occurred) or secondary (when the patient has not had periods for more than six months despite having had them in the past). Primary amenorrhoea is diagnosed if the patient has not had a period by the age of 14 without any secondary sexual characteristics, or over the age of 16 if such characteristics are present. The causes of primary amenorrhoea can include constitutional delay (when the patient is a late bloomer but has secondary sexual characteristics) or anatomical issues such as mullerian agenesis (where the patient has varying degrees of absence of female sexual organs despite developing secondary sexual characteristics).

      Common Causes of Delayed Puberty

      Delayed puberty is a condition where the onset of puberty is later than the normal age range. This can be caused by various factors such as genetic disorders, hormonal imbalances, and chronic illnesses. Delayed puberty with short stature is often associated with Turner’s syndrome, Prader-Willi syndrome, and Noonan’s syndrome. These conditions affect the growth and development of the body, resulting in a shorter stature.

      On the other hand, delayed puberty with normal stature can be caused by polycystic ovarian syndrome, androgen insensitivity, Kallmann syndrome, and Klinefelter’s syndrome. These conditions affect the production and regulation of hormones, which can lead to delayed puberty.

      It is important to note that delayed puberty does not necessarily mean there is a serious underlying condition. However, it is recommended to consult a healthcare professional if there are concerns about delayed puberty. Treatment options may include hormone therapy or addressing any underlying medical conditions.

      In summary, delayed puberty can be caused by various factors and can be associated with different genetic disorders. It is important to seek medical advice if there are concerns about delayed puberty.

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  • Question 18 - A 49-year-old woman visits her GP for her routine cervical smear, which is...

    Incorrect

    • A 49-year-old woman visits her GP for her routine cervical smear, which is performed without any complications. She receives a notification that her cervical smear is negative for high-risk strains of human papillomavirus (hrHPV).
      What should be the next course of action?

      Your Answer:

      Correct Answer: Repeat cervical smear in 3 years

      Explanation:

      If the sample is negative for high-risk strains of human papillomavirus (hrHPV), the patient should return to routine recall for their next cervical smear in 3 years, according to current guidance. Cytological examination is not necessary in this case as it is only performed if the hrHPV test is positive. Repeating the cervical smear in 3 months or 5 years is not appropriate as these are not the recommended timeframes for recall. Repeating the cervical smear after 12 months is only indicated if the previous smear was hrHPV positive but without cytological abnormalities.

      The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

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  • Question 19 - A 28-year-old woman has been experiencing severe dysmenorrhoea for a prolonged period and...

    Incorrect

    • A 28-year-old woman has been experiencing severe dysmenorrhoea for a prolonged period and seeks consultation at the gynaecological clinic. The consultant suspects adenomyosis as the underlying cause but wants to confirm the diagnosis and exclude other possible pathologies before initiating treatment. What is the most appropriate imaging modality for diagnosing this condition?

      Your Answer:

      Correct Answer: MRI Pelvis

      Explanation:

      MRI is the most effective imaging technique for diagnosing adenomyosis, which is the presence of endometrial tissue in the myometrium. While ultrasound can also aid in diagnosis, it is not as reliable as MRI. Laparoscopy is used to diagnose endometriosis, but it cannot detect adenomyosis as it occurs within the uterine wall. CT is not a suitable imaging technique for adenomyosis as it cannot differentiate between different types of tissue. Hysterosalpingography is used for imaging the uterine lining and fallopian tubes, typically during fertility treatment, but it cannot provide an image of the myometrium.

      Understanding Adenomyosis

      Adenomyosis is a medical condition that occurs when endometrial tissue grows within the muscular walls of the uterus. This condition is more common in women who have had multiple pregnancies and are nearing the end of their reproductive years. Symptoms of adenomyosis include painful menstrual cramps, heavy menstrual bleeding, and an enlarged and tender uterus.

      To diagnose adenomyosis, doctors typically use magnetic resonance imaging (MRI) as it is the most effective method. Treatment options for adenomyosis include managing symptoms with pain relief medication, using tranexamic acid to control heavy bleeding, and administering gonadotropin-releasing hormone (GnRH) agonists to reduce estrogen levels. In severe cases, uterine artery embolization or hysterectomy may be necessary. Hysterectomy is considered the definitive treatment for adenomyosis.

      In summary, adenomyosis is a condition that affects the uterus and can cause painful menstrual cramps, heavy bleeding, and an enlarged uterus. It is more common in women who have had multiple pregnancies and are nearing the end of their reproductive years. Diagnosis is typically done through MRI, and treatment options include managing symptoms, medication, and surgery.

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  • Question 20 - Sarah is a 28-year-old woman who underwent cervical cancer screening 12 months ago...

    Incorrect

    • Sarah is a 28-year-old woman who underwent cervical cancer screening 12 months ago and the result showed positive for high-risk human papillomavirus (hrHPV) with a negative cytology report.

      She has now undergone a repeat smear and the result is once again positive for hrHPV with a negative cytology report.

      What would be the most suitable course of action to take next?

      Your Answer:

      Correct Answer: Repeat sample in 12 months

      Explanation:

      According to NICE guidelines for cervical cancer screening, if the first repeat smear at 12 months is still positive for high-risk human papillomavirus (hrHPV), the next step is to repeat the smear 12 months later (i.e. at 24 months). If the patient remains hrHPV positive but cytology negative at 12 months, they should have another HPV test in a further 12 months. If the patient becomes hrHPV negative at 24 months, they can return to routine recall. However, if they remain hrHPV positive, cytology negative or inadequate at 24 months, they should be referred to colposcopy.

      The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

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  • Question 21 - A 28-year-old transgender male patient (assigned female at birth) comes to the clinic...

    Incorrect

    • A 28-year-old transgender male patient (assigned female at birth) comes to the clinic seeking advice on contraception. He is receiving testosterone therapy from the gender identity clinic and has a uterus, but plans to have surgery in the future. He is sexually active with a male partner and wants to explore other contraceptive options besides condoms. What recommendations can you provide for this patient?

      Your Answer:

      Correct Answer: A combined oral contraceptive pill is not suitable

      Explanation:

      Not all hormonal contraceptives are contraindicated for patients assigned female at birth undergoing testosterone therapy. The combined oral contraceptive pill, which contains oestrogen, should be avoided as it may interfere with the effects of testosterone therapy. However, the copper intrauterine device and progesterone-only pill are acceptable options as they do not have any adverse effects on testosterone therapy. The vaginal ring, which also contains oestrogen, should also be avoided.

      Contraceptive and Sexual Health Guidance for Transgender and Non-Binary Individuals

      The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies.

      For individuals engaging in vaginal sex where there may be a risk of pregnancy and/or sexually transmitted infections, condoms and dental dams are recommended. Cervical screening and human papillomavirus vaccinations should also be offered to sexually active individuals with a uterus. Those engaging in anal sex and rimming should be advised of the risk of hepatitis A & B and offered vaccinations. Individuals at risk of HIV transmission should be advised of the availability of pre-exposure prophylaxis and post-exposure prophylaxis as required.

      For patients seeking permanent contraception, a fallopian tube occlusion or a vasectomy may be the most appropriate solution and neither would be affected by hormonal therapy. Testosterone therapy does not provide protection against pregnancy, and oestrogen-containing regimes are not recommended in patients undergoing testosterone therapy. Progesterone-only contraceptives are considered safe, and the intrauterine system and injections may also suspend menstruation. Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding.

      In patients assigned male at birth, there may be a reduction or cessation of sperm production with certain therapies, but the variability of effects means they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients engaging in vaginal sex wishing to avoid the risk of pregnancy. Emergency contraception may be required in patients assigned female at birth following unprotected vaginal intercourse, and either of the available oral emergency contraceptive options may be considered. The non-hormonal intrauterine device may also be an option, but it may have unacceptable side effects in some patients.

      Overall, the guidance stresses the importance of individualized care and communication in contraceptive and sexual health decisions for transgender and non-binary individuals.

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  • Question 22 - A 55-year-old woman comes to your GP clinic for the third time in...

    Incorrect

    • A 55-year-old woman comes to your GP clinic for the third time in the past month. She reports experiencing bloating, mild abdominal discomfort, and a decreased appetite. You have previously referred her for a colonoscopy, which did not reveal any signs of malignancy. However, she remains highly concerned about cancer due to her family history, as her mother, grandmother, and sister have all had breast cancer. Which marker would be the most suitable?

      Your Answer:

      Correct Answer: CA 125

      Explanation:

      Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.

      Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.

      Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.

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  • Question 23 - A 28-year-old dentist presents to the General Practitioner (GP) with symptoms of irregular...

    Incorrect

    • A 28-year-old dentist presents to the General Practitioner (GP) with symptoms of irregular menstrual bleeding associated with abdominal discomfort. She often does not have periods for months at a time. She is also overweight and has always had a history of hirsutism. The patient is concerned that she may have polycystic ovarian syndrome.
      A pelvic ultrasound is ordered to confirm the diagnosis.
      Which of the following is the most common site of referred ovarian pain?

      Your Answer:

      Correct Answer: The periumbilical region

      Explanation:

      Understanding the Referred Pain of Ovarian Inflammation

      The ovaries receive both sympathetic and parasympathetic innervation, with the nerve supply running along the suspensory ligament of the ovary. Ovarian pain is typically referred to the periumbilical region due to its sympathetic nerve supply originating at T10. Inflammation of an ovary can also cause referred pain to the inner thigh through stimulation of the adjacent obturator nerve. While pain may radiate to the suprapubic area, the most common site of ovarian pain is the periumbilical region. Pain in the hypochondria is more commonly associated with liver, gallbladder, or cardiac conditions. Understanding the referred pain of ovarian inflammation can aid in diagnosis and treatment.

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  • Question 24 - A 25-year-old woman, who has never been pregnant, complains of chronic pain in...

    Incorrect

    • A 25-year-old woman, who has never been pregnant, complains of chronic pain in her pelvis and sacrum during her menstrual cycle. Her temperature is 37.2 degrees Celsius. During the examination, there is tenderness in her posterior vaginal fornix and uterine motion tenderness. A pelvic ultrasound shows no abnormalities. What is the subsequent diagnostic test recommended?

      Your Answer:

      Correct Answer: Laparoscopy

      Explanation:

      When it comes to patients with suspected endometriosis, laparoscopy is considered the most reliable investigation method.

      Understanding Endometriosis

      Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.

      First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.

      It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.

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  • Question 25 - A 17-year-old girl presents with a 48-hour history of increasing abdominal pain and...

    Incorrect

    • A 17-year-old girl presents with a 48-hour history of increasing abdominal pain and vomiting. What is the next most appropriate step in the management of this patient?

      Your Answer:

      Correct Answer: Pregnancy test

      Explanation:

      Recommended Investigations for Abdominal Pain in Women of Childbearing Age

      Abdominal pain in women of childbearing age requires careful investigation to rule out potential life-threatening conditions such as ectopic pregnancy. The following investigations are recommended:

      1. Pregnancy test: All women of childbearing age presenting with abdominal pain must have a pregnancy test to rule out an ectopic pregnancy, regardless of the location of the pain.

      2. Abdominal radiograph: This may be the next investigation following the pregnancy test, to rule out bowel obstruction.

      3. Ultrasound: This may be indicated to assess for appendicitis, gallstone disease, or ovarian torsion, among others. However, this should take place after testing for pregnancy.

      4. Exploratory laparoscopy: This would be too invasive at this stage but may take place after investigation.

      5. Prophylactic antibiotics: This will be indicated if the patient requires abdominal surgery, but at present, we do not know if this patient has an abdominal, gynaecological, or urology pathology. Prophylactic antibiotics would be premature at this point.

      In conclusion, a thorough investigation is necessary to determine the cause of abdominal pain in women of childbearing age. The above investigations should be conducted in a systematic manner to ensure timely and accurate diagnosis.

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  • Question 26 - A 19-year-old visits her doctor to discuss birth control options. After being informed...

    Incorrect

    • A 19-year-old visits her doctor to discuss birth control options. After being informed about the different choices, she decides to begin taking a progesterone-only pill. Currently, she is on day 16 of her regular 29-day menstrual cycle. If she were to start taking the pill today, how many more days would she need to use additional contraception to avoid getting pregnant?

      Your Answer:

      Correct Answer: 2 days

      Explanation:

      The effectiveness of different contraceptives varies in terms of the time it takes to become effective if not started on the first day of the menstrual cycle. The intrauterine device is the only method that is instantly effective at any time during the cycle as it reduces sperm motility and survival. The progesterone only pill takes at least 2 days to work if started after day 5 of the cycle and is immediately effective if started prior to day 5. The combined oral contraceptive pill, injection, implant, and intrauterine system take 7 days to become effective and work by inhibiting ovulation, thickening cervical mucous, and preventing endometrial proliferation. Side effects of the progesterone only pill may include menstrual irregularities, breast tenderness, weight gain, and acne.

      Counselling for Women Considering the progesterone-Only Pill

      Women who are considering taking the progesterone-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. When starting the POP, immediate protection is provided if it is commenced up to and including day 5 of the cycle. If it is started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a combined oral contraceptive (COC), immediate protection is provided if the POP is continued directly from the end of a pill packet.

      It is important to take the POP at the same time every day, without a pill-free break, unlike the COC. If a pill is missed by less than 3 hours, it should be taken as normal. If it is missed by more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours. Diarrhoea and vomiting do not affect the POP, but assuming pills have been missed and following the above guidelines is recommended. Antibiotics have no effect on the POP, unless they alter the P450 enzyme system, such as rifampicin. Liver enzyme inducers may reduce the effectiveness of the POP.

      In addition to these specific guidelines, women should also have a discussion on sexually transmitted infections (STIs) when considering the POP. It is important for women to receive comprehensive counselling on the POP to ensure they are aware of its potential effects and how to use it effectively.

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  • Question 27 - A 43-year-old woman presents to the clinic to discuss contraception. She has not...

    Incorrect

    • A 43-year-old woman presents to the clinic to discuss contraception. She has not had a period for 10 months. Her blood pressure reading in clinic is 120/76 mmHg and she smokes 10 cigarettes per day. She has a history of successfully treated breast cancer 3 years ago. Which contraceptive method would you recommend?

      As this woman has not had a period for 10 months, she may be entering the perimenopausal period. However, as she is under the age of 50, she still requires contraception. Based on her past history of breast cancer, hormonal methods of contraception are not recommended due to the potential risks. Therefore, a copper intrauterine device (Cu-IUD) would be the best option for her. According to the UK Medical Eligibility Criteria for Contraceptive Use, the Cu-IUD is a UKMEC Category 1 for women with a history of breast cancer. It is important to discuss the risks and benefits of each contraceptive method with the patient before making a final decision.

      Your Answer:

      Correct Answer: Copper Intrauterine Device (Cu-IUD)

      Explanation:

      This individual has reached the postmenopausal stage, indicated by the absence of menstruation for 12 consecutive months. However, despite being postmenopausal, she still requires contraception as she is below the age of 50. According to guidelines, women who use non-hormonal contraception can discontinue after one year of amenorrhea if they are over 50 years old, and after two years if they are under 50 years old. Given her history of breast cancer, a copper coil is the most suitable option as all other hormonal methods are classified as UKMEC Category 3, which may pose an unacceptable risk.

      Women over 40 years old still need effective contraception until menopause. All methods of contraception are generally safe for this age group, except for the COCP and Depo-Provera which have some limitations. COCP use may help maintain bone mineral density and reduce menopausal symptoms, but a pill with less than 30 µg ethinylestradiol may be more suitable for women over 40. Depo-Provera use is associated with a small loss in bone mineral density and may cause a delay in the return of fertility for up to 1 year for women over 40. The FSRH provides guidance on how to stop different methods of contraception based on age and amenorrhea status. HRT cannot be relied upon for contraception, and a separate method is needed. The POP may be used with HRT as long as the HRT has a progesterone component, while the IUS is licensed to provide the progesterone component of HRT.

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  • Question 28 - Which one of the following statements regarding cervical ectropion is incorrect? ...

    Incorrect

    • Which one of the following statements regarding cervical ectropion is incorrect?

      Your Answer:

      Correct Answer: Is less common in women who use the combined oral contraceptive pill

      Explanation:

      Understanding Cervical Ectropion

      Cervical ectropion is a condition that occurs when the columnar epithelium of the cervical canal extends onto the ectocervix, where the stratified squamous epithelium is located. This happens due to elevated levels of estrogen, which can occur during the ovulatory phase, pregnancy, or with the use of combined oral contraceptive pills. The term cervical erosion is no longer commonly used to describe this condition.

      Cervical ectropion can cause symptoms such as vaginal discharge and post-coital bleeding. However, ablative treatments such as cold coagulation are only recommended for those experiencing troublesome symptoms. It is important to understand this condition and its symptoms in order to seek appropriate medical attention if necessary.

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  • Question 29 - A 23-year-old woman student presents to her general practitioner (GP) with menstrual irregularity....

    Incorrect

    • A 23-year-old woman student presents to her general practitioner (GP) with menstrual irregularity. Her last menstrual period was 5 months ago. On examination, the GP notes an increased body mass index (BMI) and coarse dark hair over her stomach. There are no other relevant findings. The GP makes a referral to a gynaecologist.
      What is the most probable reason for this patient's menstrual irregularity?

      Your Answer:

      Correct Answer: Polycystic ovarian syndrome (PCOS)

      Explanation:

      Possible Causes of Amenorrhea and Hirsutism in Women

      Amenorrhea, the absence of menstrual periods, and hirsutism, excessive hair growth, are symptoms that can be caused by various conditions. Polycystic ovarian syndrome (PCOS) is a common cause of anovulatory infertility and is diagnosed by the presence of two out of three criteria: ultrasound appearance of enlarged ovaries with multiple cysts, infrequent ovulation or anovulation, and clinical or biochemical evidence of hyperandrogenism. Turner syndrome, characterized by short stature, webbed neck, and absence of periods, is a genetic disorder that would not cause primary amenorrhea. Hyperprolactinemia, a syndrome of high prolactin levels, can cause cessation of ovulation and lactation but not an increase in BMI or hair growth. Premature ovarian failure has symptoms similar to menopause, such as flushing and vaginal dryness. Virilizing ovarian tumor can also cause amenorrhea and hirsutism, but PCOS is more likely and should be ruled out first.

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  • Question 30 - A 50-year-old woman presents with severe itching in the perineal region, accompanied by...

    Incorrect

    • A 50-year-old woman presents with severe itching in the perineal region, accompanied by pain during urination and painful intercourse. During examination, you observe white, polygonal papules on the labia majora that merge into a patch that affects the labia minora. There is one area of fissuring that bleeds upon contact. The skin appears white, thin, and shiny, with mild scarring. There is no vaginal discharge, and no other skin lesions are present on the body. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Lichen sclerosus

      Explanation:

      Common Genital Skin Conditions: Symptoms and Treatment Options

      Lichen sclerosus, candidiasis, contact dermatitis, lichen planus, and psoriasis are some of the most common skin conditions that affect the genital area. Each condition has its own set of symptoms and treatment options.

      Lichen Sclerosus: This chronic inflammatory condition can affect any part of the body but is most commonly found in the genital area. It presents with pruritus, skin irritation, hypopigmentation, and atrophy. Treatment involves topical steroids and good hygiene.

      Candidiasis: This fungal infection is associated with pruritus, burning sensation, erythema, and oedema of the vestibule. The most common characteristic is a thick, curd-like, white vaginal discharge.

      Contact Dermatitis: This condition is often caused by changes to shower gel or washing detergent. It presents with pruritus, erythematosus skin, excoriations, and skin breaks, leading to ulceration and superimposed infection. Chronic contact dermatitis can lead to lichenoid changes.

      Lichen Planus: This condition presents with purple, red plaques usually on the labia, with central erosion and overlying lacy, white, striated patch. It can cause scarring and narrowing of the introitus and dyspareunia.

      Psoriasis: This condition is rare in the genital area but can appear in the inguinal creases and the labia majora. It presents with erythematous plaques with minimal white scale and is associated with itching and excoriations.

      It is important to seek medical attention if you suspect you have any of these conditions. Treatment options may include topical or oral medications, good hygiene practices, and lifestyle changes.

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  • Question 31 - A 32-year-old nulliparous woman is undergoing evaluation at the Infertility Clinic. Initial assessments,...

    Incorrect

    • A 32-year-old nulliparous woman is undergoing evaluation at the Infertility Clinic. Initial assessments, including thyroid function tests and mid-luteal phase progesterone and prolactin levels, are within normal limits. Semen analysis also shows no abnormalities. No sexually transmitted infections were found.
      She experiences regular and heavy menstrual periods, accompanied by dysmenorrhoea that begins 1-2 days before the onset of bleeding. She also reports deep dyspareunia. A transvaginal ultrasound reveals no abnormalities.
      Which investigation is most likely to provide a definitive diagnosis?

      Your Answer:

      Correct Answer: Exploratory laparoscopy

      Explanation:

      Diagnostic Modalities for Endometriosis: Exploratory Laparoscopy, Transabdominal Ultrasound, Hysterosalpingography, MRI Abdomen Pelvis, and CA-125

      Endometriosis is a condition where endometrial tissue grows outside the endometrial cavity, causing cyclical proliferation and bleeding. It can lead to scarring, adhesions, and cysts with haemorrhagic contents. The classic symptoms are dyspareunia, infertility, cyclical pelvic pain, and dysmenorrhoea. Diagnosis is often made through Exploratory laparoscopy, where small, dark purple-black spots on the peritoneum can be identified and sampled for histological analysis. Transabdominal ultrasound is not very sensitive at detecting small deposits, but can detect endometriotic cysts. Hysterosalpingography is recommended for investigating infertility and recurrent miscarriage, but is not a definitive diagnosis for endometriosis. MRI of the pelvis is sensitive for endometriomas and adnexal masses, but not small deposits. CA-125 testing is not recommended for diagnosis.

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  • Question 32 - A 70-year-old woman with a lengthy history of vulval lichen sclerosus et atrophicus...

    Incorrect

    • A 70-year-old woman with a lengthy history of vulval lichen sclerosus et atrophicus complains of escalating itching and bleeding upon contact of the vulva. Upon examination, a 2.2 cm unilateral ulcer with an aggressive appearance is discovered. Biopsy results indicate invasive squamous cell carcinoma. There is no clinical indication of lymph node metastasis, and the patient is in good health. What is the suggested course of action?

      Your Answer:

      Correct Answer: Simple vulvectomy and bilateral inguinal lymphadenectomy

      Explanation:

      Treatment Options for Vulval Cancer: Simple Vulvectomy and Bilateral Inguinal Lymphadenectomy

      Vulval cancer is a rare form of cancer that accounts for less than 1% of cancer diagnoses. The labia majora are the most common site, followed by labia minora. Squamous cell carcinoma is the most common type of vulval cancer, with carcinoma-in-situ being a precursor lesion that does not invade through the basement membrane. Risk factors for developing vulval cancer include increasing age, exposure to HPV, vulval lichen sclerosus et atrophicus, smoking, and immunosuppression.

      Patients may present with symptoms such as itching, pain, easy-contact bleeding of the vulva, changes in vulval skin, or frank ulcers/masses. The first lymph node station for metastases is the inguinal group. Surgery is the primary treatment for vulval cancer, with a simple vulvectomy and bilateral inguinal lymphadenectomy being the usual surgery performed, even in the absence of clinically palpable groin lymph nodes.

      Radiotherapy is commonly used before and/or after surgery depending on the stage of the disease, but it is not curative and would not be offered in isolation to an otherwise healthy patient. Chemotherapy is not usually used as a primary treatment but is offered in disseminated malignancy. Wide local excision is only used for lesions less than 2 cm in diameter with a depth of less than 1 mm. Lesions larger than this require vulvectomy and lymph node clearance due to the risk of metastasis.

      In conclusion, a simple vulvectomy and bilateral inguinal lymphadenectomy are the mainstay of treatment for vulval cancer, with radiotherapy and chemotherapy being used in certain cases. Early detection and treatment are crucial for improving outcomes in patients with vulval cancer.

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  • Question 33 - A 25-year-old primigravida patient at 6 weeks gestation presents with suprapubic pain and...

    Incorrect

    • A 25-year-old primigravida patient at 6 weeks gestation presents with suprapubic pain and spotting. She also complains of shoulder-tip pain and nausea. Upon observation, her oxygen saturations are at 98% in room air, blood pressure is at 109/79 mmHg, heart rate is at 107 bpm, and temperature is at 36.9ºC. Further investigations reveal an empty uterine cavity with tubal ring sign on transvaginal ultrasound and evidence of a 41 mm complex adnexal mass. Her Hb levels are at 107 g/L (115 - 160), platelets at 380 * 109/L (150 - 400), WBC at 10.8 * 109/L (4.0 - 11.0), and b-HCG at 1650 IU/L (< 5). What is the most appropriate management plan for this patient?

      Your Answer:

      Correct Answer: Laparoscopic salpingectomy

      Explanation:

      Surgical management is recommended for ectopic pregnancies that are larger than 35mm or have a serum B-hCG level greater than 5,000 IU/L. In this case, the patient is experiencing typical symptoms of an ectopic pregnancy, including vaginal bleeding and referred shoulder tip pain. The ultrasound confirms the presence of a tubal ectopic, with a mass exceeding 35mm and tubal ring sign. Therefore, a laparoscopic salpingectomy is the appropriate surgical intervention.
      Adrenalectomy is not relevant in this case, as the complex adnexal mass refers to the ectopic pregnancy located near the ovaries, uterus, and fallopian tubes, not the adrenal glands.
      Expectant management is not suitable for this patient, as her serum b-hCG is significantly elevated, and the mass exceeds 35mm in size.
      Medical management with methotrexate is an option for ectopic pregnancies that are smaller than 35mm or have a serum B-hCG level below 5,000 IU/L.
      Ultrasound-guided potassium chloride injection is an alternative to methotrexate for medical management, but it is not currently standard practice in the UK.

      Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

      There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

      Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

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  • Question 34 - A 29-year-old female patient comes in with a complaint of excessive menstrual bleeding....

    Incorrect

    • A 29-year-old female patient comes in with a complaint of excessive menstrual bleeding. She reports having to change her pads every hour due to saturation with blood. She is not experiencing any other symptoms and has no plans of having children in the immediate future. After a routine examination, what is the best course of action for management?

      Your Answer:

      Correct Answer: Intrauterine system

      Explanation:

      According to NICE CG44, when heavy menstrual bleeding is not caused by any structural or histological abnormality, the first recommended treatment is the intrauterine system, also known as Mirena.

      Managing Heavy Menstrual Bleeding

      Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.

      To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.

      For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.

      [Insert flowchart here]

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  • Question 35 - A 19-year-old female visits the nearby sexual health clinic after engaging in unprotected...

    Incorrect

    • A 19-year-old female visits the nearby sexual health clinic after engaging in unprotected sexual activity four days ago. She is not using any contraception and prefers an oral method over an invasive one. What is the most suitable course of action?

      Your Answer:

      Correct Answer: Prescribe ulipristal

      Explanation:

      The appropriate option for emergency contraception in this case is ulipristal, which can be prescribed up to 120 hours after unprotected sexual intercourse. Levonorgestrel, which must be taken within 72 hours, is not a suitable option. Insertion of an intrauterine device or system is also inappropriate as the patient declined invasive contraception. Mifepristone is not licensed for emergency contraception.

      Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

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  • Question 36 - A 65-year-old retired librarian presents to her General Practitioner complaining of a feeling...

    Incorrect

    • A 65-year-old retired librarian presents to her General Practitioner complaining of a feeling of fullness in her vagina. She states that this feeling is present at all times. On further questioning she also has a 1-year history of urinary frequency and has been treated for urinary tract infections in two instances in the past year. She has never smoked and is teetotal.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Cystocele

      Explanation:

      Common Vaginal Conditions: Symptoms and Management

      Cystocele: A weakening of pelvic muscles can cause the bladder to prolapse into the vagina, resulting in stress incontinence, frequent urinary tract infections, and a dragging sensation or lump in the vagina. Management ranges from conservative with pelvic floor exercises to surgery.

      Rectocele: Women with a rectocele experience pressure and a lump in the vagina, as well as difficulty with bowel movements. Treatment may involve pelvic floor exercises or surgery.

      Bartholin cyst: A blocked Bartholin gland can lead to a cyst that presents as a tender mass in the vaginal wall. Treatment involves incision and drainage, as well as antibiotics.

      Vaginal cancer: Symptoms include vaginal or postcoital bleeding, vaginal discharge, and persistent pelvic pain.

      Bladder cancer: Painless hematuria is a common symptom, with risk factors including smoking, working in the aniline dye industry, or previous infection with Schistosoma haematobium.

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  • Question 37 - A 50-year-old woman visits her GP with a complaint of hot flashes that...

    Incorrect

    • A 50-year-old woman visits her GP with a complaint of hot flashes that have been bothering her for the past 2 months, particularly at night, causing sleep and work disturbances. She expresses feeling exhausted and embarrassed at work, sweating profusely during the attacks, and carrying extra clothes to change. She is emotional and shares that she has been avoiding sexual intercourse due to pain. She has no medical history and is not on any medication. Her menstrual cycle is still ongoing but has become irregular, occurring once every 2-3 months. After a thorough discussion, she decides to start HRT. What would be the most suitable HRT regimen for this patient?

      Your Answer:

      Correct Answer: Oestradiol one tablet daily for a 3-month period, with norethisterone on the last 14 days

      Explanation:

      Understanding Hormone Replacement Therapy (HRT) for perimenopausal Symptoms

      perimenopausal symptoms can significantly affect a woman’s daily routine, work, and mood. Hormone Replacement Therapy (HRT) is one of the treatment options available for managing these symptoms. However, before commencing HRT, patients need to be consulted and informed of the risks and benefits associated with this treatment.

      HRT can be either oestrogen replacement only or combined. Combined HRT is given to women who have a uterus, as oestrogen alone can increase the risk of developing endometrial cancer. Combined HRT can be either cyclical or continuous, depending on the patient’s menopausal status.

      For women with irregular menses, a cyclical regime is indicated. This involves taking an oestrogen tablet once daily for a 3-month period, with norethisterone added on the last 14 days. Patients on this regime have a period every three months. Once a woman has completed a year on cyclical therapy or has established menopause, then she can change to combined continuous HRT.

      It is important to note that oestrogen-only HRT is only given to women who have had a hysterectomy. Oestrogen therapy alone increases the risk of developing endometrial hyperplasia and endometrial carcinoma. Therefore, in women who have a uterus, combined HRT, with the addition of a progesterone, is preferred to reduce this risk.

      In summary, HRT is a treatment option for perimenopausal symptoms. The type of HRT prescribed depends on the patient’s menopausal status and whether they have a uterus. Patients need to be informed of the risks and benefits associated with HRT before commencing treatment.

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  • Question 38 - A 25-year-old woman presents with vaginal discharge. She describes it as a thin,...

    Incorrect

    • A 25-year-old woman presents with vaginal discharge. She describes it as a thin, greyish, watery discharge. It is painless and has a fishy odour.
      Which is the appropriate treatment?

      Your Answer:

      Correct Answer: Metronidazole 400 mg twice a day for a week

      Explanation:

      Appropriate Treatment Options for Vaginal Infections

      Bacterial vaginosis is a common vaginal infection that results in a decrease in lactobacilli and an increase in anaerobic bacteria. The typical symptoms include a white, milky, non-viscous discharge with a fishy odor and a pH greater than 4.5. The recommended treatment for bacterial vaginosis is metronidazole 400 mg twice a day for a week.

      Azithromycin is the treatment of choice for Chlamydia, but it is not appropriate for bacterial vaginosis. acyclovir is used to treat herpes infections, which is not the cause of this patient’s symptoms. Fluconazole is a treatment option for vaginal candidiasis, but it is unlikely to be the cause of this patient’s symptoms. Pivmecillinam is used to treat urinary tract infections, which is not the cause of this patient’s symptoms.

      In conclusion, the appropriate treatment for bacterial vaginosis is metronidazole, and other treatments should be considered based on the specific diagnosis.

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  • Question 39 - A 28-year-old woman is scheduled for an elective laparoscopic cholecystectomy in 2 months....

    Incorrect

    • A 28-year-old woman is scheduled for an elective laparoscopic cholecystectomy in 2 months. She is currently taking the combined oral contraceptive pill and no other medications. What actions should be taken regarding her surgery and pill usage?

      Your Answer:

      Correct Answer: Stop the pill 4 weeks before surgery and restart 2 weeks after surgery

      Explanation:

      It is a common scenario for surgical patients to face an increased risk of venous thromboembolism when they are on the pill and undergoing surgery, particularly abdominal or lower limb surgery. Therefore, it is necessary to discontinue the pill.

      However, stopping the pill too early would increase the risk of pregnancy, and restarting it too soon after surgery would still pose a risk due to the surgery’s effects on coagulation. Ceasing the pill on the day of surgery would not eliminate the risk of clotting either.

      The best course of action is to stop the pill four weeks before surgery to allow for a return to normal coagulation levels. Then, restarting it two weeks after surgery would allow the procoagulant effects of surgery to subside.

      The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

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  • Question 40 - A 20-year-old female patient visits your clinic after having unprotected sex 3 days...

    Incorrect

    • A 20-year-old female patient visits your clinic after having unprotected sex 3 days ago. She is concerned about the possibility of getting pregnant as she is not using any form of contraception. The patient has a medical history of severe asthma and major depression, and is currently taking sertraline 25mg once daily, salbutamol inhaler 200 micrograms as needed, beclomethasone 400 micrograms twice daily, and formoterol 12 micrograms twice daily. She is currently on day 26 of a 35-day menstrual cycle. What is the most appropriate course of action to prevent pregnancy in this patient?

      Your Answer:

      Correct Answer: Intra-uterine device

      Explanation:

      Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

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  • Question 41 - A 63-year-old woman presents with complaints of abdominal swelling, vomiting, and weight loss...

    Incorrect

    • A 63-year-old woman presents with complaints of abdominal swelling, vomiting, and weight loss that have been progressively worsening over the past 6 months. She has a 30-year history of smoking. Imaging reveals bilateral ovarian tumors and a mass in the stomach. A biopsy taken during gastroscopy confirms the presence of adenocarcinoma. What histological characteristics are expected in the ovarian masses?

      Your Answer:

      Correct Answer: Signet ring cells

      Explanation:

      Different Types of Ovarian Tumours and their Histological Features

      Ovarian tumours can be classified into various types based on their histological features. Here are some examples:

      Krukenberg tumours:
      These are secondary tumours that originate from the gastrointestinal tract and metastasize to the ovaries. They are characterized by the presence of signet ring cells.

      Fibromas:
      These are benign ovarian tumours that can cause Meigs’ syndrome. They contain spindle-shaped fibroblasts.

      Granulosa cell tumours:
      These are ovarian tumours that are most commonly seen in the first few decades of life. They contain Call-Exner bodies, which are follicles containing eosinophils.

      Brenner tumours:
      These are benign ovarian tumours that contain transitional cells.

      Mucinous cystadenomas:
      These are benign ovarian tumours that contain cells that resemble endocervical cells. However, if the tumour is malignant, it may not have this characteristic feature.

      In conclusion, the histological features of ovarian tumours can provide important clues about their origin and potential malignancy.

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  • Question 42 - A 30-year-old nulliparous patient presents to the Gynaecology Clinic with complaints of severe...

    Incorrect

    • A 30-year-old nulliparous patient presents to the Gynaecology Clinic with complaints of severe menstrual pain and pain during intercourse. She reports that the symptoms have been progressively worsening. An ultrasound of the pelvis reveals a 4-cm cyst in the right ovary. The serum CA-125 level is 225 (0–34 iu/ml). What is the probable diagnosis?

      Your Answer:

      Correct Answer: Ectopic endometrial tissue

      Explanation:

      The patient is likely suffering from endometriosis, which is the presence of endometrial tissue outside of the uterus. This condition can cause subfertility, chronic pelvic pain, dysmenorrhoea, and dyspareunia. It may also lead to an increase in serum CA-125 levels and the development of ovarian deposits known as chocolate cysts. Acute appendicitis and ovarian neoplasms are unlikely causes of the patient’s symptoms, while mittelschmerz only causes mid-cycle pain and does not explain the elevated CA-125 levels. Granulosa cell tumors of the ovary typically secrete inhibin and estrogen, making endometriosis a more likely diagnosis. Symptoms of ovarian cancer are often vague and include abdominal discomfort, bloating, back and pelvic pain, irregular menstruation, loss of appetite, fatigue, and weight loss. Risk factors for ovarian cancer include not having children, early first menstruation and last menopause, hormone replacement therapy, endometriosis, and the BRCA genes. In this age group, germ cell tumors are the most likely ovarian carcinoma.

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  • Question 43 - A 25-year-old woman presents with an ectopic pregnancy that has been confirmed by...

    Incorrect

    • A 25-year-old woman presents with an ectopic pregnancy that has been confirmed by ultrasound. However, the ultrasound report only mentions that the ectopic pregnancy is located in the 'left fallopian tube' without providing further details. To ensure appropriate management, you contact the ultrasound department to obtain more specific information. Which location of ectopic pregnancy is most commonly associated with a higher risk of rupture?

      Your Answer:

      Correct Answer: Isthmus

      Explanation:

      The risk of rupture is higher in ectopic pregnancies that are located in the isthmus of the fallopian tube. This is because the isthmus is not as flexible as other locations and cannot expand to accommodate the growing embryo/fetus. It should be noted that ectopic pregnancies can occur in various locations, including the ovary, cervix, and even outside the reproductive organs in the peritoneum.

      Understanding Ectopic Pregnancy: The Pathophysiology

      Ectopic pregnancy is a medical condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. According to statistics, 97% of ectopic pregnancies occur in the fallopian tube, with most of them happening in the ampulla. However, if the implantation occurs in the isthmus, it can be more dangerous. The remaining 3% of ectopic pregnancies can occur in the ovary, cervix, or peritoneum.

      During ectopic pregnancy, the trophoblast, which is the outer layer of the fertilized egg, invades the tubal wall, leading to bleeding that may dislodge the embryo. The natural history of ectopic pregnancy involves three possible outcomes: absorption, tubal abortion, or tubal rupture.

      Tubal abortion occurs when the embryo dies, and the body expels it along with the blood. On the other hand, tubal absorption occurs when the tube does not rupture, and the blood and embryo are either shed or converted into a tubal mole and absorbed. However, if the tube ruptures, it can lead to severe bleeding, shock, and even death.

      In conclusion, understanding the pathophysiology of ectopic pregnancy is crucial in diagnosing and managing this potentially life-threatening condition. Early detection and prompt treatment can help prevent complications and improve outcomes.

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  • Question 44 - A 30-year-old female presents with menorrhagia that has not responded to treatment with...

    Incorrect

    • A 30-year-old female presents with menorrhagia that has not responded to treatment with non-steroidal anti-inflammatory drugs.

      She underwent sterilisation two years ago.

      What would be the most suitable treatment for her?

      Your Answer:

      Correct Answer: Intrauterine system (Mirena)

      Explanation:

      Treatment Options for Menorrhagia

      Menorrhagia, or heavy menstrual bleeding, can be a distressing condition for women. Current guidelines recommend the use of Mirena (IUS) as the first line of treatment, even for women who do not require contraception. Patient preference is important in the decision-making process, but IUS is still the preferred option.

      If IUS is not suitable or preferred, there are several other treatment options available. Tranexamic acid, a medication that prevents the breakdown of blood clots, is a second-line option. Non-steroidal anti-inflammatory drugs (NSAIDs) and combined oral contraceptive pills can also be used to prevent the proliferation of the endometrium.

      If these options are not effective, oral or injected progestogens can be used to prevent endometrial proliferation. Gonadotrophin-releasing hormone (GnRH) agonists, such as Goserelin, are also available as a last resort.

      It is important for women to discuss their options with their healthcare provider and choose the treatment that is best for them. With the variety of options available, there is likely a treatment that can effectively manage menorrhagia and improve quality of life.

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  • Question 45 - A 35-year-old woman is being evaluated for obesity, hirsutism, and oligomenorrhea. After an...

    Incorrect

    • A 35-year-old woman is being evaluated for obesity, hirsutism, and oligomenorrhea. After an ultrasound scan, she is diagnosed with polycystic ovarian syndrome (PCOS). As she desires to conceive, her physician prescribes metformin to enhance her fertility. What is the mechanism of action of metformin in treating PCOS?

      Your Answer:

      Correct Answer: Increases peripheral insulin sensitivity

      Explanation:

      Polycystic ovarian syndrome patients commonly experience insulin resistance, which can result in complex alterations in the hypothalamic-pituitary-ovarian axis.

      Managing Polycystic Ovarian Syndrome

      Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is associated with high levels of luteinizing hormone and hyperinsulinemia. Management of PCOS is complex and varies depending on the individual’s symptoms. Weight reduction is often recommended, and a combined oral contraceptive pill may be used to regulate menstrual cycles and manage hirsutism and acne. If these symptoms do not respond to the pill, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.

      Infertility is another common issue associated with PCOS. Weight reduction is recommended, and the management of infertility should be supervised by a specialist. There is ongoing debate about the most effective treatment for infertility in patients with PCOS. Clomiphene is often used, but there is a potential risk of multiple pregnancies with anti-oestrogen therapies like Clomiphene. Metformin is also used, either alone or in combination with Clomiphene, particularly in patients who are obese. Gonadotrophins may also be used to stimulate ovulation. The Royal College of Obstetricians and Gynaecologists (RCOG) published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS.

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  • Question 46 - A 17-year-old student presents to the genito-urinary medicine (GUM) clinic. She is worried...

    Incorrect

    • A 17-year-old student presents to the genito-urinary medicine (GUM) clinic. She is worried about a fishy-smelling green vaginal discharge that she has developed. The symptoms have been ongoing for two weeks and include pruritus, dysuria and frequency. Vaginal swabs were taken and revealed a motile flagellate on wet film microscopy.
      What is the causative organism for this patient's symptoms?

      Your Answer:

      Correct Answer: Trichomonas vaginalis

      Explanation:

      Trichomonas vaginalis is a protozoan that causes trichomoniasis, characterized by a green-yellow discharge with a foul odor. Men usually do not show symptoms, while women may experience dysuria, frequent urination, and itching. Treatment involves taking oral metronidazole for seven days. Although complications are rare, pregnant women with trichomoniasis may experience premature labor. The disease is sexually transmitted, so a thorough sexual history should be taken.

      Neisseria gonorrhoeae is a diplococcus that causes gonorrhea, which may be asymptomatic in women but can cause vaginal discharge and painful urination. Treatment involves a single intramuscular injection of ceftriaxone 500 mg.

      Chlamydia trachomatis is an intracellular organism that causes chlamydia, which is often asymptomatic in women but may cause cervicitis, urethritis, or salpingitis. Treatment involves a single oral dose of azithromycin 1 g.

      Candida albicans causes thrush, which is characterized by white curd-like discharge, red and sore vulva, and hyphae visible on microscopy. Treatment involves using clotrimazole in pessary or topical form, with fluconazole used for resistant cases.

      Treponema pallidum causes syphilis, which may present as a painless ulcer in the genital area called a chancre. Treatment involves using benzathine penicillin. While secondary and further stages of syphilis are becoming rare, it is important to seek treatment promptly.

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  • Question 47 - A 16-year-old woman is admitted surgically with acute-onset lower abdominal pain. On examination,...

    Incorrect

    • A 16-year-old woman is admitted surgically with acute-onset lower abdominal pain. On examination, she has a tender left iliac fossa.
      Which of the following is the most appropriate next test?

      Your Answer:

      Correct Answer: Pregnancy test (ß-hCG)

      Explanation:

      Investigations for Abdominal Pain in Women of Childbearing Age

      When a woman of childbearing age presents with abdominal pain, it is important to consider the possibility of gynaecological problems, including ectopic pregnancy. The first step in investigation should be to ask about the patient’s last menstrual period and sexual history, and to perform a pregnancy test measuring β-human chorionic gonadotrophin (β-hCG) levels in urine or serum.

      Proctoscopy is unlikely to be beneficial in the absence of specific gastrointestinal symptoms. Ultrasonography may be useful at a later stage to assess the location and severity of an ectopic pregnancy, but transvaginal ultrasound is preferable to transcutaneous abdominal ultrasound.

      Specialist gynaecological opinion should only be sought once there is a high index of suspicion for a particular diagnosis. Laparoscopy is not indicated at this point, as less invasive tests are likely to yield the diagnosis. Exploratory laparoscopy may be considered if other investigations are inconclusive.

      Investigating Abdominal Pain in Women of Childbearing Age

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  • Question 48 - A 22-year-old student contacts the GP telephone clinic seeking advice. Her housemate has...

    Incorrect

    • A 22-year-old student contacts the GP telephone clinic seeking advice. Her housemate has been diagnosed with meningococcal meningitis and she has been prescribed ciprofloxacin as a preventive measure. However, she is hesitant to take it as she fears it may interfere with the effectiveness of her contraceptive pill. She has a medical history of migraine with aura, but no allergies. Although she is unsure about the type of contraceptive pill she uses, she takes it daily without any breaks. What precautions should she take regarding her contraceptive pill while taking ciprofloxacin?

      Your Answer:

      Correct Answer: No change

      Explanation:

      The patient is likely taking the progesterone-only contraceptive pill due to her history of migraine with aura and daily use of the contraceptive pill. According to the BNF, antibacterials that do not induce liver enzymes do not affect the effectiveness of oral progesterone-only preparations. As ciprofloxacin is a cytochrome P450 inhibitor and not an inducer, the patient’s contraception is not affected, and she does not require additional barrier contraception. However, if the patient were taking rifampicin, an alternative for meningococcal contact prophylaxis, she would need to use barrier contraception during and for four weeks after stopping treatment. Rifampicin is a potent enzyme inducer, which can decrease the plasma concentration and efficacy of contraceptive pills.

      Counselling for Women Considering the progesterone-Only Pill

      Women who are considering taking the progesterone-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. When starting the POP, immediate protection is provided if it is commenced up to and including day 5 of the cycle. If it is started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a combined oral contraceptive (COC), immediate protection is provided if the POP is continued directly from the end of a pill packet.

      It is important to take the POP at the same time every day, without a pill-free break, unlike the COC. If a pill is missed by less than 3 hours, it should be taken as normal. If it is missed by more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours. Diarrhoea and vomiting do not affect the POP, but assuming pills have been missed and following the above guidelines is recommended. Antibiotics have no effect on the POP, unless they alter the P450 enzyme system, such as rifampicin. Liver enzyme inducers may reduce the effectiveness of the POP.

      In addition to these specific guidelines, women should also have a discussion on sexually transmitted infections (STIs) when considering the POP. It is important for women to receive comprehensive counselling on the POP to ensure they are aware of its potential effects and how to use it effectively.

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  • Question 49 - A 28-year-old female patient visits her GP complaining of irregular menstrual cycles. She...

    Incorrect

    • A 28-year-old female patient visits her GP complaining of irregular menstrual cycles. She reports using a period tracking app on her phone, which shows that she had five periods in the past year, occurring at unpredictable intervals. During the consultation, she mentions the development of dense, dark hair on her neck and upper lip. Additionally, she has been experiencing worsening acne for a few years. If other potential causes are eliminated, what is necessary for the patient to fulfill the diagnostic criteria for her likely condition?

      Your Answer:

      Correct Answer: Diagnosis can be made clinically based on her symptoms

      Explanation:

      To diagnose PCOS, at least two out of three features must be present: oligomenorrhoea, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound. In this case, the patient has oligomenorrhoea and clinical signs of hyperandrogenism, making a clinical diagnosis of PCOS likely. However, NICE guidelines recommend ruling out other potential causes of menstrual disturbance before confirming the diagnosis. BMI measurement is not necessary for diagnosis, although obesity is a common feature of PCOS. Testing for free or total testosterone levels is also not essential if clinical signs of hyperandrogenism are present.

      Polycystic ovary syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.

      To diagnose PCOS, a range of investigations may be performed, including pelvic ultrasound to detect multiple cysts on the ovaries. Other useful baseline investigations include FSH, LH, prolactin, TSH, testosterone, and sex hormone-binding globulin (SHBG). While a raised LH:FSH ratio was once considered a classical feature of PCOS, it is no longer thought to be useful in diagnosis. Testosterone may be normal or mildly elevated, but if markedly raised, other causes should be considered. SHBG is typically normal to low in women with PCOS, and impaired glucose tolerance should also be checked.

      To formally diagnose PCOS, other conditions must first be excluded. The Rotterdam criteria state that a diagnosis of PCOS can be made if at least two of the following three criteria are present: infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound scan. Polycystic ovaries are defined as the presence of at least 12 follicles measuring 2-9 mm in diameter in one or both ovaries, and/or an increased ovarian volume of over 10 cm³.

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  • Question 50 - A 35-year-old woman comes to her GP complaining of menorrhagia. She reports that...

    Incorrect

    • A 35-year-old woman comes to her GP complaining of menorrhagia. She reports that her periods have been lasting for 10 days and are very heavy. She denies any recent weight loss and her recent sexual health screening was negative. On examination, there are no abnormalities. She has completed her family and has two children. What is the initial treatment option for this patient?

      Your Answer:

      Correct Answer: Intrauterine system (Mirena coil)

      Explanation:

      For patients with menorrhagia who have completed their family and do not have any underlying pathology, pharmaceutical therapy is recommended. The first-line management for these patients, according to NICE CKS, is the Mirena coil, provided that long-term contraception with an intrauterine device is acceptable.

      Managing Heavy Menstrual Bleeding

      Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.

      To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.

      For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.

      [Insert flowchart here]

    • This question is part of the following fields:

      • Gynaecology
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