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Question 1
Incorrect
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A 23-year-old woman contacts her GP clinic seeking a more dependable form of contraception. She had visited her pharmacist the day before and received the levonorgestrel emergency contraceptive pill after engaging in unprotected sexual activity. As her healthcare provider, you recommend the combined oral contraceptive pill (COCP). What is the appropriate time for this patient to begin taking the COCP?
Your Answer: After she has had a negative pregnancy test
Correct Answer: Immediately
Explanation:Starting hormonal contraception immediately after using levonorgestrel emergency contraceptive pill is safe. However, if ulipristal was used, hormonal contraception should be started or restarted after 5 days, and barrier methods should be used during this time. Waiting for 7 or 30 days before starting hormonal contraception is unnecessary as levonorgestrel does not affect its efficacy. A pregnancy test is only recommended if the patient’s next period is more than 5-7 days late or lighter than usual, not routinely after taking levonorgestrel.
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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This question is part of the following fields:
- Gynaecology
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Question 2
Incorrect
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A 73-year-old woman with ovarian cancer is attending the gynaecological oncology clinic. The consultant is discussing her pre-surgical prognosis, which is based on her risk malignancy index (RMI). Can you identify the three components of the RMI?
Your Answer: CA125, co-morbidities, ultrasound (US) findings
Correct Answer: CA125, menopausal status, ultrasound (US) findings
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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This question is part of the following fields:
- Gynaecology
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Question 3
Incorrect
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A 25-year-old female presents with an ectopic pregnancy and requires surgical intervention. During laparoscopy, what is the most common location for the ectopic pregnancy to be found?
Your Answer: Isthmus
Correct Answer: Ampulla
Explanation:The most frequent location for ectopic pregnancy is the ampulla of the fallopian tube. While other sites are also feasible, the ampulla is the most prevalent, making it the most suitable response.
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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This question is part of the following fields:
- Gynaecology
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Question 4
Incorrect
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A 30-year-old woman presents to the Emergency Department (ED) with sudden onset of severe abdominal pain. She had an appendicectomy 10 years ago. She denies any recent per-vaginal (PV) bleeding and her last menstrual period was six weeks ago. On examination, she has tenderness and guarding in the right iliac fossa. She also complains of right shoulder tip pain.
Observations:
Investigation Result Normal value
Heart rate 110 beats per minute 60–100 beats per minute
Blood pressure 120/80 mmHg <120/<80 mmHg
Respiratory rate (RR) 16 breaths per minute 12–20 breaths per minute
O2 saturation 98% 94–99%
Temperature 37.2°C 36.5–37.5°C
What is the likely diagnosis?Your Answer: Ovarian torsion
Correct Answer: Ruptured ectopic
Explanation:Differential Diagnosis for Severe Iliac Fossa Pain in Reproductive-Age Women
Severe, sudden-onset pain in the right or left iliac fossa is a common symptom of ectopic pregnancy in reproductive-age women. This pain may be accompanied by vaginal bleeding, shoulder tip pain, syncopal episodes, and shock. To rule out pregnancy, a urinary beta human chorionic gonadotrophin hormone (b-HCG) test should be performed, followed by a transvaginal ultrasound scan to confirm the diagnosis.
Ovarian torsion may also cause iliac fossa pain, but it is unlikely to cause referred shoulder pain. Appendicitis is not a consideration in this scenario, as the patient does not have an appendix. Irritable bowel syndrome and inflammatory bowel disease are also unlikely diagnoses, as the patient’s tachycardia and right iliac fossa tenderness and guarding are not consistent with these conditions. Overall, a thorough evaluation is necessary to differentiate between these potential causes of severe iliac fossa pain in reproductive-age women.
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This question is part of the following fields:
- Gynaecology
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Question 5
Correct
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A 25-year-old woman presents to the GP with a three-day history of vaginal itching and thick, non-odorous white discharge. She had a similar complaint four months ago but has no other medical history. The patient is married and sexually active with her husband, and her menstrual cycle is regular, following a 28-day cycle. Vaginal pH testing shows a value of 4.3. What further tests should be conducted before initiating treatment?
Your Answer: None needed, the diagnosis is clinical
Explanation:The diagnosis of vaginal candidiasis does not require a high vaginal swab if the symptoms are highly suggestive. In fact, the diagnosis can be made clinically based on the patient’s symptoms. For example, if a patient presents with thickened, white discharge that resembles cottage cheese and vaginal itching, along with a normal vaginal pH, it is very likely that they have vaginal candidiasis. It is important to note that glycated haemoglobin (HbA1c) is not necessary for diagnosis unless the patient has recurrent episodes of vaginal candidiasis, which may indicate diabetes mellitus. Additionally, a midstream urine sample is not useful in diagnosing vaginal candidiasis and should only be used if a sexually-transmitted infection is suspected.
Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.
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This question is part of the following fields:
- Gynaecology
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Question 6
Incorrect
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A 35-year-old woman visits her GP clinic urgently seeking advice as she had unprotected sex last night. She has recently started taking the combined oral contraceptive pill but missed two pills because she forgot to bring them along while on vacation. She is currently in the first week of a new pack. What steps should her GP take now?
Your Answer: Advise her to take an extra pill today, use barrier contraception for the next 7 days, no emergency contraception needed
Correct Answer: Advise her to take an extra pill today, use barrier contraception for the next 7 days and prescribe emergency contraception
Explanation:If a patient misses 2 pills in the first week of their combined oral contraceptive pill pack and has had unprotected sex during the pill-free interval or week 1, emergency contraception should be considered. The patient should take the missed pills as soon as possible and use condoms for the next 7 days. For patients who have only missed 1 pill, they should take it as soon as possible without needing extra precautions. If extra barrier contraception is needed for patients on the combined oral contraceptive pill, it should be used for at least 7 days. Patients on the progesterone-only pill only need barrier contraception for 2 days. Missing 1 pill at any time throughout a pack or starting a new pack 1 day late generally does not affect protection against pregnancy. Taking more than 2 contraceptive pills in a day is not recommended as it does not provide extra contraceptive effects and may cause side effects.
Missed Pills in Combined Oral Contraceptive Pill
When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.
However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.
If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.
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This question is part of the following fields:
- Gynaecology
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Question 7
Incorrect
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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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This question is part of the following fields:
- Gynaecology
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Question 8
Incorrect
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A 32-year-old woman visits a fertility clinic after trying to conceive for more than two years. She is worried that she may not be ovulating despite having a regular menstrual cycle lasting 30 days. She is not using any form of birth control and her pregnancy test is negative. What is the most effective method to detect ovulation?
Your Answer: Basal body temperature chart
Correct Answer: Progesterone level
Explanation:The most reliable way to confirm ovulation is through the Day 21 progesterone test. This test measures the peak level of progesterone in the serum, which occurs 7 days after ovulation. While the length of the follicular phase can vary, the luteal phase always lasts for 14 days. Therefore, if a woman has a 35-day cycle, she can expect to ovulate on Day 21 and her progesterone level will peak on Day 28. To determine when to take the test, subtract 7 days from the expected start of the next period (Day 21 for a 28-day cycle and Day 28 for a 35-day cycle). Basal body temperature charts and cervical mucous thickness are not reliable predictors of ovulation. Gonadotropins may be used to assess ovarian function in women with irregular menstrual cycles.
Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.
When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.
It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.
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This question is part of the following fields:
- Gynaecology
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Question 9
Incorrect
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Sophie is a 32-year-old mother of two, who is uncertain if she wants to have more children. She comes to you with a history of not having a period for the past 9 months. Sophie had regular menstrual cycles for 28 months after giving birth to her last child. She has never used any hormonal birth control or undergone any surgeries. Upon examination, her abdomen and gynecological areas appear normal, and there are no signs of hyperandrogenism. A pregnancy test confirms that she is not pregnant.
Lab results show a decrease in follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol levels, while prolactin, thyroid-stimulating hormone (TSH), and T4 levels are normal. A 10-day progestin challenge fails to induce a withdrawal bleed.
What is the underlying cause of Sophie's amenorrhea?Your Answer: Premature ovarian failure
Correct Answer: Hypothalamic dysfunction
Explanation:Caroline’s case of secondary amenorrhoea suggests a hypothalamic cause, as indicated by low levels of gonadotrophins (FSH and LH) and oestradiol. This is different from pituitary adenoma, which often presents with panhypopituitarism and normal prolactin levels, and premature ovarian failure, which is diagnosed in women under 40 with increased FSH levels and menopausal-like symptoms. PCOS is also unlikely as there is no hyperandrogenism or other symptoms present. Hypothalamic dysfunction can be caused by excessive exercise, stress, or dieting, which should be explored in the patient’s history.
Understanding Amenorrhoea: Causes, Investigations, and Management
Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls without secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.
There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.
The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.
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This question is part of the following fields:
- Gynaecology
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Question 10
Correct
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A 25-year-old female presents to her GP with symptoms of vaginal candidiasis, including 'cottage cheese'-like discharge, itching, and dyspareunia. She has had four previous presentations with similar symptoms in the past year. The patient is in good health and does not report any other symptoms. She is not taking any regular medications. What test would be most helpful in investigating a possible underlying cause for her recurrent vaginal candidiasis?
Your Answer: HbA1c
Explanation:In cases of recurrent vaginal candidiasis, it is recommended to consider a blood test to rule out diabetes as a potential underlying condition. Other predisposing factors such as immunosuppression, pregnancy, and antibiotic or steroid usage should also be evaluated. While HIV testing is important, a CD4+ T-cell count is not the first line investigation and HIV testing is typically done using antibody, antigen, or nucleotide testing. A full blood count may be useful to assess the patient’s general health, but it is not the most likely cause of recurrent vaginal candidiasis. HbA1c testing should be done to assess for diabetes mellitus, and a pregnancy test and HIV test may also be indicated. While a high vaginal swab can confirm the diagnosis, it will not provide information about any underlying diseases.
Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.
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This question is part of the following fields:
- Gynaecology
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Question 11
Correct
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A 32-year-old woman complains of a curd-like white vaginal discharge and experiences pain during sexual intercourse. What is the probable diagnosis?
Your Answer: Candida
Explanation:Understanding Vaginal Discharge: Common Causes and Key Features
Vaginal discharge is a common symptom experienced by many women, but it is not always a sign of a pathological condition. There are various causes of vaginal discharge, including physiological factors and infections. Some of the common causes of vaginal discharge include Candida, Trichomonas vaginalis, and bacterial vaginosis. However, less common causes such as gonorrhea, chlamydia, ectropion, foreign body, and cervical cancer can also lead to vaginal discharge.
It is important to note that the key features of each cause of vaginal discharge can vary. For instance, Candida infection may present with a discharge that resembles cottage cheese, accompanied by vulvitis and itch. On the other hand, Trichomonas vaginalis infection may cause an offensive, yellow/green, frothy discharge, along with vulvovaginitis and a strawberry cervix. Bacterial vaginosis, another common cause of vaginal discharge, may present with an offensive, thin, white/grey, ‘fishy’ discharge.
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This question is part of the following fields:
- Gynaecology
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Question 12
Incorrect
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A 20-year-old woman comes to the clinic 72 hours after having unprotected sex and requests emergency contraception. She had her last period 5 days ago and has no significant medical history or regular medications. Her BMI is 23 kg/m2 and her blood pressure is 118/72 mmHg. She decides to take ulipristal (Ella-One) for emergency contraception and also expresses interest in starting a combined oral contraceptive pill (COCP). She asks when she can begin taking it. What advice should be given?
Your Answer: She should start taking the COCP from 7 days after taking ulipristal
Correct Answer: She should start taking the COCP from 5 days after taking ulipristal
Explanation:Women who have taken ulipristal acetate should wait for 5 days before starting regular hormonal contraception. This is because ulipristal may reduce the effectiveness of hormonal contraception. The same advice should be given for other hormonal contraception methods such as the pill, patch, or ring. Barrier methods should be used before the effectiveness of the COCP can be assured. If the patient is starting the COCP within the first 5 days of her cycle, barrier methods may not be necessary. However, in this case, barrier methods are required. The patient can be prescribed the COCP if it is her preferred method of contraception. There is no need to wait until the start of the next cycle before taking the pill, as long as barrier methods are used for 7 days.
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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This question is part of the following fields:
- Gynaecology
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Question 13
Incorrect
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A 20-year-old woman visits her GP complaining of discharge. She mentions having a recent sexual partner without using barrier protection. During the examination, the doctor observes thick cottage-cheese-like discharge. The patient denies experiencing any other notable symptoms. What is the probable diagnosis?
Your Answer: Bacterial vaginosis
Correct Answer: Candida albicans
Explanation:Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.
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This question is part of the following fields:
- Gynaecology
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Question 14
Incorrect
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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: Hysterosalpingography
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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This question is part of the following fields:
- Gynaecology
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Question 15
Correct
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A 28-year-old female patient presents to her GP complaining of cyclical pelvic pain and painful bowel movements. She has previously sought treatment from gynaecology and found relief with paracetamol and mefenamic acid, but the pain has returned and she is seeking alternative options. She is not pregnant but plans to start a family within the next few years. What would be the most appropriate next step in managing her condition from the options provided below?
Your Answer: Combined oral contraceptive pill
Explanation:If simple analgesia with paracetamol and NSAIDs is not effective in treating endometriosis symptoms, hormonal treatment with the combined oral contraceptive pill or a progesterone should be considered.
Although a referral to gynaecology may be necessary due to the recurrence of symptoms and potential pelvic/bowel involvement, primary care can offer further treatment options in the meantime. Hormonal treatment is recommended for this patient, and the combined oral contraceptive pill or any of the progesterone options can be used. As the patient plans to start a family soon, a hormonal option that can be quickly reversed is the most suitable.
Buscopan is not an appropriate treatment for endometriosis, as it only provides relief for menstrual cramps and is not a cure. It may be used to alleviate symptoms associated with irritable bowel syndrome.
Injectable depo-provera is not the best option for this patient, as it can delay the return of fertility, which conflicts with her desire to start a family within the next year.
Opioid analgesia is not recommended for endometriosis treatment, as it carries the risk of side effects and dependence. It is not a long-term solution for managing symptoms.
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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This question is part of the following fields:
- Gynaecology
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Question 16
Correct
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A 35-year-old woman visits your gynaecology clinic for a follow-up appointment after being diagnosed with a symptomatic 6mm intramural fibroid. She has been experiencing this issue for several months and is being considered for surgery as a result. Since she has not yet finished having children, an open myomectomy has been determined to be the best surgical option. What is a typical complication that can occur after this procedure?
Your Answer: Adhesions
Explanation:Understanding Uterine Fibroids
Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.
Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.
Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.
Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.
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This question is part of the following fields:
- Gynaecology
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Question 17
Incorrect
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A 28-year-old female patient arrives at the emergency department complaining of intense pain in her left lower quadrant. Upon conducting a pregnancy test, it is discovered that she is pregnant. Her medical history reveals that she had an appendectomy at the age of 18 due to a ruptured appendix.
After undergoing a vaginal ultrasound, it is revealed that she has an unruptured tubal pregnancy on the left side. The ultrasound also shows adhesions at the distal end of the right fallopian tube.
What would be the most appropriate course of action for management?Your Answer: Vaginal misoprostol
Correct Answer: salpingostomy
Explanation:When a woman with risk factors for infertility, such as damage to the contralateral tube, has an ectopic pregnancy requiring surgical management, it is recommended to consider salpingostomy instead of salpingectomy. In this case, the woman has a left-sided ectopic pregnancy and a damaged right tube, making salpingostomy a more appropriate option to preserve her fertility. Methotrexate is not suitable for this case due to the severity of pain, and monitoring for 48 hours is not appropriate either. Expectant management is only recommended for small, asymptomatic ectopic pregnancies without cardiac activity.
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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This question is part of the following fields:
- Gynaecology
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Question 18
Incorrect
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A 55-year-old woman is being staged for her ovarian cancer diagnosis. The scan reveals that the tumor has extended beyond the ovary, but remains within the pelvic region. What is the stage of her cancer?
Your Answer: 3
Correct Answer: 2
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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This question is part of the following fields:
- Gynaecology
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Question 19
Incorrect
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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: Repeat cervical smear in 5 years
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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This question is part of the following fields:
- Gynaecology
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Question 20
Correct
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A 25-year-old female comes to see her GP with concerns about her mood during her menstrual cycle. She has been experiencing symptoms for the past 8 months despite making lifestyle changes. The week before her period, she notices a significant change in her mood, feeling extremely low and anxious with poor concentration. Her irritability is starting to affect her work as a primary school teacher. She has no other physical symptoms and feels like her usual self for the rest of the month. She has a medical history of migraine with aura.
What is the most appropriate treatment for this patient, given the likely diagnosis?Your Answer: Fluoxetine
Explanation:Understanding Premenstrual Syndrome (PMS)
Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and does not occur before puberty, during pregnancy, or after menopause.
Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.
Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.
Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this common condition.
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This question is part of the following fields:
- Gynaecology
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