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  • Question 1 - A 27-year-old woman visits her GP seeking advice on contraception. She and her...

    Incorrect

    • A 27-year-old woman visits her GP seeking advice on contraception. She and her partner frequently travel abroad for charity work and are not planning to have children at the moment. The woman is undergoing treatment for pelvic inflammatory disease and desires a low-maintenance contraceptive method that does not require her to remember to take it. The GP has already emphasized the significance of barrier protection in preventing the transmission of sexually transmitted infections. What is the most suitable contraceptive option for her?

      Your Answer: Intrauterine system

      Correct Answer: Implantable contraceptive

      Explanation:

      The most effective form of contraception for young women who desire a low-maintenance option and do not want to remember to take it daily is the implantable contraceptive. This option is particularly suitable for those with busy or unpredictable lifestyles, such as those planning to travel. While the intrauterine device is also effective for 5 years, it is contraindicated for those with active pelvic inflammatory disease. The implantable contraceptive, which lasts for 3 years, is a better option in this case. Injectable contraceptive is less suitable as it only lasts for 12 weeks.

      Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progesterone hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

      The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

      There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 2 - A 28-year-old woman was recently requested by her GP practice to come in...

    Incorrect

    • A 28-year-old woman was recently requested by her GP practice to come in for a repeat smear test. Her previous test results 18 months ago indicated that the sample was positive for high risk HPV (hrHPV), but cytologically normal. The patient is feeling quite nervous about being called back and has asked the practice nurse what the next steps will be. If the results come back as hrHPV negative, what course of action will the patient be recommended to take?

      Your Answer: Repeat the test again in 1 month

      Correct Answer: Return to normal recall

      Explanation:

      For cervical cancer screening, if the first repeat smear test after 12 months shows a negative result for high risk HPV (hrHPV), the patient can return to routine recall. However, if the initial smear test shows a positive result for hrHPV but is cytologically normal, the patient will be called back for a repeat test after 12 months. If the second test also shows a negative result for hrHPV, the patient can return to normal recall. On the other hand, if the second test is still positive for hrHPV but cytologically normal, it will be repeated again after 12 months.

      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 3 - A 56-year-old woman presented with pruritus in the perineal area, associated with pain...

    Incorrect

    • A 56-year-old woman presented with pruritus in the perineal area, associated with pain on micturition and dyspareunia. She had thin, hypopigmented skin, with white, polygonal patches which, in areas, formed patches.
      She returns for review after a 3-month trial of clobetasol proprionate, which has failed to improve symptoms. There is no evidence of infection, and her observations are stable.
      Which of the following is the next most appropriate step in this patient’s management?

      Your Answer: Ultraviolet (UV) phototherapy

      Correct Answer: Topical tacrolimus

      Explanation:

      Treatment Options for Lichen Sclerosus: Topical Tacrolimus as Second-Line Therapy

      Lichen sclerosus is a chronic inflammatory condition that commonly affects the genital area in men and women, presenting with pruritus and skin irritation. First-line treatment involves high-potency steroids, but if the patient fails to respond, the next step is topical calcineurin inhibitors such as tacrolimus. This immunosuppressant reduces inflammation by inhibiting the secretion of interleukin-2, which promotes T-cell proliferation. However, chronic inflammatory conditions like lichen sclerosus increase the risk of vulval carcinoma, so a tissue biopsy should be obtained if the lesion is steroid-resistant. UV phototherapy and oral retinoids are not recommended as second-line therapy due to uncertain risks, while surgical excision is reserved for severe cases. The combination of potent steroids with antibacterial or antifungal properties is a first-line option in cases of superimposed infection.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 4 - A 47-year-old woman presents to her General Practitioner (GP) with a 1-month history...

    Incorrect

    • 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:

      Correct 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.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 5 - A 28-year-old woman visits her GP complaining of heavy, irregular vaginal bleeding that...

    Incorrect

    • A 28-year-old woman visits her GP complaining of heavy, irregular vaginal bleeding that has been ongoing for 4 weeks and is becoming unbearable. She denies experiencing abdominal pain, unusual vaginal discharge, or dysuria. The patient has been sexually active with her partner for 6 months and had the Nexplanon implant inserted 4 weeks ago.

      Upon examination, the patient's abdomen is non-tender, her heart rate is 79/min, her respiratory rate is 17/min, her blood pressure is 117/79 mmHg, her oxygen saturation is 98%, and her temperature is 37.5°C. A negative pregnancy test is obtained.

      What treatment options is the GP likely to suggest to alleviate the patient's symptoms?

      Your Answer:

      Correct Answer: 3-month course of the combined oral contraceptive pill

      Explanation:

      To manage unscheduled bleeding, which is a common side effect of Nexplanon, a 3-month course of the combined oral contraceptive pill may be prescribed. This will not only provide additional contraception but also make periods lighter and more regular. Prescribing a progesterone-only pill is not recommended as it can also cause irregular bleeding. A single dose of intramuscular methotrexate is not appropriate as the patient is not showing any symptoms of an ectopic pregnancy. Urgent referral for endometrial cancer is also not necessary as the patient’s age and symptoms suggest that the bleeding is most likely due to the contraceptive implant.

      Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progesterone hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.

      The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.

      There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 6 - A 25-year-old woman presents to the GP with a three-day history of vaginal...

    Incorrect

    • 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:

      Correct 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.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 7 - A 60-year-old woman presents with urinary frequency, recurrent urinary tract infections and stress...

    Incorrect

    • A 60-year-old woman presents with urinary frequency, recurrent urinary tract infections and stress incontinence. She is found to have a cystocoele. The woman had four children, all vaginal deliveries. She also suffers from osteoarthritis and hypertension. Her body mass index (BMI) is 32 and she smokes 5 cigarettes per day.
      What would your first line treatment be for this woman?

      Your Answer:

      Correct Answer: Advise smoking cessation, weight loss and pelvic floor exercises

      Explanation:

      Treatment Options for Symptomatic Cystocoele: Lifestyle Modifications, Medications, and Surgeries

      Symptomatic cystocoele can be treated through various options, depending on the severity of the condition. The first line of treatment focuses on lifestyle modifications, such as smoking cessation and weight loss. Topical oestrogen may also be prescribed to post- or perimenopausal women suffering from vaginal dryness, urinary incontinence, recurrent urinary tract infections, or superficial dyspareunia. Inserting a ring pessary is the second line of treatment, which needs to be changed every six months and puts the patient at risk of ulceration. Per vaginal surgery is the third line of treatment, which is only possible if the cystocoele is small and puts the patient at risk of fibroids and adhesions. Hysterectomy is not recommended as it increases the risk of cystocoele due to the severance of the uterine ligaments and reduction in support following removal of the uterus.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 8 - A 35-year-old woman has recently been diagnosed with breast cancer and is awaiting...

    Incorrect

    • A 35-year-old woman has recently been diagnosed with breast cancer and is awaiting surgery. She has started a new relationship and is seeking advice on contraception. In her previous relationship, she used the depo injection and is interested in restarting it. She is a non-smoker, has no history of migraines or venous thromboembolism, and has a BMI of 23 kg/m². Which contraception option would be most suitable for her?

      Your Answer:

      Correct Answer: Copper intrauterine device

      Explanation:

      Injectable progesterone contraceptives are not recommended for individuals with current breast cancer due to contraindications. This applies to all hormonal contraceptive options, including Depo-Provera, which are classified as UKMEC 4. The copper intrauterine device is the only suitable contraception option in such cases.

      Injectable Contraceptives: Depo Provera

      Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150 mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucous thickening and endometrial thinning.

      However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.

      It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 9 - A 25-year-old female patient presents to her GP seeking emergency contraception. She started...

    Incorrect

    • 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:

      Correct 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 10 - A 14-year-old girl has had apparently normal appearance of secondary sexual characteristics, except...

    Incorrect

    • A 14-year-old girl has had apparently normal appearance of secondary sexual characteristics, except that she has not menstruated. A pelvic examination reveals a mobile mass in her left labium major and a shallow, blind-ending vagina without a cervix, but otherwise normal female external genitalia. Ultrasound reveals no cervix, uterus or ovaries. Karyotype analysis reveals 46,XY.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Androgen insensitivity syndrome (AIS)

      Explanation:

      Disorders of Sexual Development: An Overview

      Disorders of sexual development (DSD) are a group of conditions that affect the development of the reproductive system. Here are some of the most common DSDs:

      Androgen Insensitivity Syndrome (AIS)
      AIS is a condition where cells cannot respond to androgens, resulting in disrupted sexual development. Patients with complete AIS have a female phenotype with male internal genitalia, while those with partial or mild AIS may have a mix of male and female characteristics. Treatment involves careful gender assignment and hormone replacement therapy.

      Turner Syndrome
      Turner syndrome is a condition where patients are missing all or part of an X chromosome, resulting in premature ovarian failure and delayed puberty. Patients are phenotypically female with normal external genitalia.

      Klinefelter’s Syndrome
      Klinefelter’s syndrome is a chromosomal aneuploidy where patients have an extra copy of an X chromosome, resulting in hypogonadism and infertility. Patients are phenotypically male with normal external genitalia.

      Congenital Adrenal Hyperplasia
      Congenital adrenal hyperplasia is a group of conditions associated with abnormal enzymes involved in the production of hormones from the adrenals. Patients may have ambiguous genitalia at birth and later present with symptoms of polycystic ovary syndrome or hyperpigmentation.

      5-α Reductase Deficiency
      5-α reductase deficiency is a condition where patients have a mutation in the SDR5A2 gene, resulting in disrupted formation of external genitalia before birth. Patients may have ambiguous genitalia at birth and later show virilisation during puberty. Patients are infertile.

      Treatment for DSDs involves hormone replacement therapy and supportive care. It is important to provide psychosocial support for patients and their families.

    • This question is part of the following fields:

      • Gynaecology
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