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  • Question 1 - A 25-year-old woman comes to the clinic complaining of abnormal vaginal discharge. She...

    Incorrect

    • A 25-year-old woman comes to the clinic complaining of abnormal vaginal discharge. She reports engaging in unprotected sexual activity multiple times this month. She has experienced similar symptoms in her late teens and early twenties.

      What test has the greatest sensitivity for the probable condition of the patient?

      Your Answer: First catch urine specimen with nucleic acid amplification test (NAAT)

      Correct Answer: Vulvo-vaginal swab with NAAT

      Explanation:

      Chlamydia is best diagnosed using nucleic acid amplification tests (NAATs), which are highly sensitive and specific. In clinical practice, NAATs are the preferred method of testing. For females, vulvo-vaginal swabs are the most effective, while urethral swabs are typically used for men. Although cultures are also highly sensitive and specific, they can be less effective due to various factors such as inadequate specimen collection and overgrowth of cell cultures. Additionally, cell culture is expensive and requires experienced technicians. Patients who test positive for chlamydia should also be advised on the risks associated with unprotected sex and offered long-acting contraceptives. A pregnancy test may also be necessary.

      Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

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  • Question 2 - A 65-year-old woman is being evaluated one week after being diagnosed with a...

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    • A 65-year-old woman is being evaluated one week after being diagnosed with a deep vein thrombosis in her left leg. She has started taking warfarin after receiving low-molecular weight heparin for five days. Her medical history includes depression, osteoporosis, breast cancer, and type 2 diabetes. Which medication she is currently taking is most likely to have contributed to her increased risk of developing a deep vein thrombosis?

      Your Answer: Sitagliptin

      Correct Answer: Tamoxifen

      Explanation:

      Prior to initiating tamoxifen treatment, women should be informed about the elevated risk of VTE, which is one of the most significant side effects of the medication. Additionally, tamoxifen has been linked to an increased risk of endometrial cancer.

      Risk Factors for Venous Thromboembolism

      Venous thromboembolism (VTE) is a condition where blood clots form in the veins, which can lead to serious complications such as pulmonary embolism (PE). While some common predisposing factors include malignancy, pregnancy, and the period following an operation, there are many other factors that can increase the risk of VTE. These include underlying conditions such as heart failure, thrombophilia, and nephrotic syndrome, as well as medication use such as the combined oral contraceptive pill and antipsychotics. It is important to note that around 40% of patients diagnosed with a PE have no major risk factors. Therefore, it is crucial to be aware of all potential risk factors and take appropriate measures to prevent VTE.

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  • Question 3 - A 30-year-old woman presents to clinic for her routine cervical smear test. She...

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    • A 30-year-old woman presents to clinic for her routine cervical smear test. She reports no symptoms.
      Upon examination, the smear reveals no signs of dysplasia, however, the pathologist observes the presence of fusiform protozoa in the sample.
      What is the most probable diagnosis?

      Your Answer: Candida infection

      Correct Answer: Trichomonas vaginalis infection

      Explanation:

      Trichomonas Vaginalis: The Most Common Non-Viral STI Worldwide

      Trichomonas vaginalis is a prevalent non-viral sexually transmitted infection that affects individuals worldwide. It is estimated that up to 20% of cases may be asymptomatic and can only be detected through routine cervical smear tests. However, typical symptoms include a copious frothy green/yellow vaginal discharge accompanied by pruritus. Symptoms tend to peak just after menses.

      Multiple sexual partners are a significant risk factor for contracting Trichomonas vaginalis. Pregnant women who contract the infection are at risk of delivering low birth weight babies and preterm delivery.

      The pathognomonic feature of Trichomonas vaginalis is the presence of fusiform protozoa on cytology. Treatment for this infection is with oral metronidazole. While other conditions can cause vaginitis, the presence of these protozoa is a clear indication of Trichomonas vaginalis.

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  • Question 4 - You are thinking about recommending hormone replacement therapy (HRT) to a 50-year-old woman...

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    • You are thinking about recommending hormone replacement therapy (HRT) to a 50-year-old woman who is experiencing bothersome menopausal symptoms. What is the accurate statement regarding HRT and the risk of venous thromboembolism (VTE)?

      Your Answer: Tibolone has a higher risk of VTE compared to oestrogen and progesterone preparations

      Correct Answer: Combined oestrogen + progestogen preparations have an increased risk of VTE compared to oestrogen only preparations

      Explanation:

      In women aged 50-59 who do not use HRT, the background incidence of VTE is 5 cases per 1,000. The use of oestrogen-only HRT increases the incidence by 2 cases per 1,000, while combined HRT increases it by 7 cases per 1,000. According to the BNF, tibolone doesn’t elevate the risk of VTE when compared to combined HRT.

      Adverse Effects of Hormone Replacement Therapy

      Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

      Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

      Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

      In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

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  • Question 5 - During a phone consultation, a 32-year-old transgender man seeks advice on cervical screening....

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    • During a phone consultation, a 32-year-old transgender man seeks advice on cervical screening. He is sexually active and had a normal cervical smear five years ago. However, he has changed GP practices and has not received any further invitations. He wants to know if he needs any further smear tests.

      The patient is generally healthy and has not experienced weight loss, dyspareunia, or abnormal vaginal bleeding. He has not had a period for over 18 months and is only taking testosterone therapy since his gender reassignment two years ago. He has no surgical history and doesn't smoke or drink alcohol.

      What is the most appropriate advice to give this patient regarding cervical screening?

      Your Answer: Patient doesn't require cervical screening as he is on testosterone therapy

      Correct Answer: Cervical screening should be offered to this patient

      Explanation:

      All sexually active individuals with a uterus, including transgender patients, should be offered cervical screening. This patient, who is sexually active and has an intact uterus, requires regular cervical smear tests regardless of their menstrual cycle or symptoms of abnormal vaginal bleeding. Testosterone therapy may affect the patient’s gender characteristics, but gender reassignment allows for legal recognition of their gender identity and rights, such as obtaining a new birth certificate, driving license, passport, and the ability to marry in their new gender. However, neither of these factors exempts the patient from cervical screening.

      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 those engaging in vaginal sex, condoms and dental dams are recommended to prevent sexually transmitted infections. Cervical screening and HPV vaccinations should also be offered. Those at risk of HIV transmission should be advised of pre-exposure prophylaxis and post-exposure prophylaxis.

      For individuals assigned female at birth with a uterus, testosterone therapy doesn’t provide protection against pregnancy, and oestrogen-containing regimens are not recommended as they can antagonize the effect of testosterone therapy. Progesterone-only contraceptives are considered safe, and non-hormonal intrauterine devices may also suspend menstruation. Emergency contraception may be required following unprotected vaginal intercourse, and either oral formulation or the non-hormonal intrauterine device may be considered.

      In patients assigned male at birth, hormone therapy may reduce or cease sperm production, but the variability of its effects means it cannot be relied upon as a method of contraception. Condoms are recommended for those engaging in vaginal sex to avoid the risk of pregnancy. The guidance stresses the importance of offering individuals options that take into account their personal circumstances and preferences.

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  • Question 6 - A 25-year-old woman comes in for a check-up. She reports not having a...

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    • A 25-year-old woman comes in for a check-up. She reports not having a normal period for approximately 7 months. Despite a recent negative pregnancy test, she remains concerned. The doctor orders blood tests, which reveal the following results:

      FSH 2.2 IU/L (0-20 IU/L)
      Oestradiol 84 pmol/l (100-500 pmol/l)
      Thyroid stimulating hormone 3.1 mIU/L
      Prolactin 2 ng/ml (0-10 ng/ml)
      Free androgen index 3 ( < 7 )

      What is the most probable cause of her symptoms?

      Your Answer: Prolactinoma

      Correct Answer: Excessive exercise

      Explanation:

      Secondary amenorrhoea is frequently caused by hypothalamic hypogonadism in highly athletic women. This condition can be attributed to stress or excessive physical activity. Premature ovarian failure would be indicated by elevated FSH levels in the blood.

      Understanding Amenorrhoea: Causes, Investigations, and Management

      Amenorrhoea is a condition characterized by the absence of menstrual periods. 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 with no 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.

      The causes of amenorrhoea vary depending on the type. Primary amenorrhoea may be caused by 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, and thyrotoxicosis. Meanwhile, secondary amenorrhoea may be caused by stress, excessive exercise, PCOS, Sheehan’s syndrome, Asherman’s syndrome, and other underlying medical conditions.

      To diagnose amenorrhoea, initial investigations may include pregnancy tests, full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels. Management of amenorrhoea involves treating the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause and treat the underlying cause accordingly. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis and other complications.

      In conclusion, amenorrhoea is a condition that requires proper diagnosis and management. Understanding the causes and appropriate investigations can help in providing the necessary treatment and care for women experiencing this condition.

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  • Question 7 - A 56-year-old woman presents with superficial dyspareunia. She went through the menopause at...

    Incorrect

    • A 56-year-old woman presents with superficial dyspareunia. She went through the menopause at the age of 53.

      Examination reveals atrophic vaginitis. You discuss possible treatments and she doesn't want any 'hormonal' oestrogen-containing preparations.

      Which of the following topical treatments would you recommend?

      Your Answer: KY® jelly

      Correct Answer: Sylk® moisturiser

      Explanation:

      Treatment for Dyspareunia in postmenopausal Women

      This postmenopausal woman is experiencing dyspareunia due to atrophic vaginitis caused by a lack of estrogen. While topical or systemic hormone replacement therapy can be effective treatments, this patient specifically doesn’t want hormonal treatment. In this case, the best option is Sylk moisturizer, one of two non-hormonal preparations available for vaginal atrophy. Replens is the other option.

      It’s important to note that KY jelly is a lubricant only and doesn’t come with an applicator. Sylk and Replens are classified as vaginal moisturizers, which can be applied every few days and provide long-lasting relief, including relief of itching. KY jelly, on the other hand, is only effective until the water evaporates, which is typically within an hour.

      In summary, for postmenopausal women experiencing dyspareunia due to atrophic vaginitis, non-hormonal vaginal moisturizers like Sylk and Replens can be effective treatments.

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  • Question 8 - A 26-year-old woman visits her GP complaining of severe lower abdomen pain, headache,...

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    • A 26-year-old woman visits her GP complaining of severe lower abdomen pain, headache, flushing, anxiety, and restlessness during her menstrual cycle. Her symptoms improve as she approaches the end of her period. Blood tests reveal no apparent cause, and a symptom diary suggests a possible diagnosis of premenstrual syndrome.

      According to NICE, which of the following is a potential treatment option for premenstrual syndrome?

      Your Answer: Diazepam

      Correct Answer: Selective serotonin reuptake inhibitors

      Explanation:

      According to NICE, the treatment of premenstrual syndrome should be approached from various angles, taking into account the severity of symptoms and the patient’s preferences. Effective treatment options include non-steroidal anti-inflammatory drugs taken orally, combined oral contraceptive, cognitive behavioural therapy and selective serotonin reuptake inhibitors. However, the copper intrauterine device, tricyclic antidepressants, diazepam and progestogen only pill are not recommended as treatment options.

      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 doesn’t 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 condition.

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  • Question 9 - A 28-year-old woman presents to you with concerns about her recent smear test...

    Correct

    • A 28-year-old woman presents to you with concerns about her recent smear test results. The report indicates 'mild dyskaryosis', but HPV triage shows that she is 'HPV negative'. She is anxious about the possibility of needing treatment for the dyskaryosis. What is the appropriate follow-up plan in this case?

      Your Answer: She should have a cervical smear in 3 years time

      Explanation:

      HPV Triage in NHS Cervical Cancer Screening Programme

      HPV triage is a new addition to the NHS cervical cancer screening programme. It involves testing cytology samples of women with borderline changes or mild dyskaryosis for high-risk HPV types that are linked to cervical cancer development. The aim is to refer only those who need further investigation and treatment, as low-grade abnormalities often resolve on their own.

      If a woman tests negative for high-risk HPV, she is simply returned to routine screening recall. However, if she tests positive, she is referred for colposcopy. HPV testing is also used as a ‘test of cure’ for women who have been treated for cervical intraepithelial neoplasia and have returned for follow-up cytology. Those who are HPV negative are returned to 3 yearly recall. This new approach ensures that women receive the appropriate level of care and reduces unnecessary referrals for colposcopy.

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  • Question 10 - A 27-year-old woman comes in seeking advice on contraception. She is currently on...

    Incorrect

    • A 27-year-old woman comes in seeking advice on contraception. She is currently on day 14 of her regular 28-30 day cycle and has no medical history or regular medications. She desires a method that is effective immediately and doesn't require daily attention. What contraceptive option would be suitable for her?

      Your Answer: Intrauterine system

      Correct Answer: Intrauterine device

      Explanation:

      If a woman is not starting her contraceptive method on the first day of her period, the only option that will be effective immediately is an intrauterine device (IUD). This device is a T-shaped plastic device that contains copper and is inserted into the uterus to provide contraception immediately.

      Other methods, such as the contraceptive injection, implant, and combined oral contraceptive (COC), as well as the intrauterine system (IUS), require 7 days to become effective if not started on the first day of menstruation. The progesterone-only pill (POP) is also not the best choice as it requires 2 days before becoming effective and must be taken every day. It is important to consider the effectiveness and convenience of each method when choosing a contraceptive.

      Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

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  • Question 11 - A 50-year-old woman visits her GP and asks for a blood test to...

    Incorrect

    • A 50-year-old woman visits her GP and asks for a blood test to confirm menopause. She reports experiencing tolerable vaginal dryness and her last menstrual period was 10 months ago. However, she has had intermittent vaginal bleeding in the past week, which has left her confused. Upon clinical examination, including a speculum examination, no abnormalities are found. What is the recommended course of action?

      Your Answer: Trial a short course of norethisterone

      Correct Answer: Refer for urgent hospital assessment

      Explanation:

      If a woman is 55 years or older and experiences postmenopausal bleeding (i.e. bleeding occurring more than 12 months after her last menstrual cycle), she should be referred through the suspected cancer pathway within 2 weeks to rule out endometrial cancer. As this woman is over 50 years old and has not had a menstrual cycle for over a year, she has reached menopause and doesn’t require blood tests to confirm it. The recent vaginal bleeding she has experienced is considered postmenopausal bleeding and requires further investigation to eliminate the possibility of endometrial cancer.

      Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Symptoms of endometrial cancer include postmenopausal bleeding, which is usually slight and intermittent at first before becoming heavier, and changes in intermenstrual bleeding for premenopausal women. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

      When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness of less than 4 mm. Hysteroscopy with endometrial biopsy is also commonly used for diagnosis. Treatment for localized disease typically involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may require postoperative radiotherapy. Progestogen therapy may be used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

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  • Question 12 - A 29-year-old female comes to her GP complaining of severe pain and swelling...

    Incorrect

    • A 29-year-old female comes to her GP complaining of severe pain and swelling around her vagina, making it difficult for her to sit, walk or have sexual intercourse. Upon examination, the left side of the labia majora appears red and inflamed, and a 4 cm tender, warm, tense mass is present at the four o'clock position in the vulvar vestibule. The patient is treated with marsupialisation.

      What is the probable diagnosis?

      Your Answer: Inclusion cyst

      Correct Answer: Bartholin's abscess

      Explanation:

      Marsupialisation is the definitive treatment for Bartholin’s abscess, which presents with sudden pain and difficulty urinating. On examination, a hard mass with surrounding cellulitis is found at the site of the Bartholin’s glands in the vulvar vestibule. The abscess is caused by infection of the Bartholin’s cyst. Bartholin’s cyst, on the other hand, is caused by a buildup of mucous secretions from the Bartholin’s glands and is typically asymptomatic unless it grows larger. Inclusion cysts, which are caused by vaginal wall trauma, are usually small and found on the posterior vaginal wall. Skene’s gland cysts, which form when the duct is obstructed, may cause dyspareunia or urinary tract infection symptoms. Vesicovaginal fistulas, which allow urine to continuously discharge into the vaginal tract, require surgical treatment.

      Understanding Bartholin’s Abscess

      Bartholin’s glands are two small glands situated near the opening of the vagina. They are typically the size of a pea, but they can become infected and swell, resulting in a Bartholin’s abscess. This condition can be treated in a variety of ways, including antibiotics, the insertion of a word catheter, or a surgical procedure called marsupialization.

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  • Question 13 - You encounter a 27-year-old woman who wishes to discuss her contraceptive options. She...

    Incorrect

    • You encounter a 27-year-old woman who wishes to discuss her contraceptive options. She has had difficulty finding a suitable pill and is considering a coil. She has no immediate plans for pregnancy and has never been pregnant before. She experiences heavy and painful periods and is concerned about the possibility of a coil exacerbating her symptoms. She has heard about the Mirena® intrauterine system from a friend but is curious about the new Kyleena® coil and how it compares to the Mirena®.

      What advice should you provide to this individual?

      Your Answer: The Mirena® and the Kyleena® IUS are only licensed for a maximum of 3 years use

      Correct Answer: The rate of amenorrhoea is likely to be less with the Kyleena® than the Mirena®

      Explanation:

      Compared to the Mirena IUS, the Kyleena IUS has a lower rate of amenorrhoea. The Kyleena IUS is a newly licensed contraceptive that contains 19.5mg of levonorgestrel and can be used for up to 5 years. However, it is not licensed for managing heavy menstrual bleeding or providing endometrial protection as part of hormonal replacement therapy, unlike the Mirena IUS. The Kyleena IUS is smaller in size than the Mirena coil, and the Jaydess IUS contains the least amount of LNG at 13.5mg but is only licensed for 3 years. While the lower LNG in the Kyleena IUS may result in a higher number of bleeding/spotting days, overall, the number of such days is likely to be lower than other doses of LNG-IUS. Women may prefer the Kyleena IUS over the Mirena IUS due to its lower systemic levonorgestrel levels.

      New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

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  • Question 14 - Ms. Smith, a 28-year-old woman who is currently 12 weeks into her first...

    Incorrect

    • Ms. Smith, a 28-year-old woman who is currently 12 weeks into her first pregnancy, presents with symptoms of vaginal thrush. After addressing her concerns, she inquires about pregnancy supplements. Ms. Smith has been taking a branded pregnancy multivitamin but wonders if it is necessary to continue taking it now that she is past the first trimester due to the cost. She is generally healthy, not taking any regular medications, and is receiving midwife-led care as her pregnancy has been deemed low risk. Additionally, there is no family history of spina bifida.

      What guidance should be provided to Ms. Smith?

      Your Answer: Folic acid, vitamin D, and calcium throughout the whole pregnancy

      Correct Answer: Folic acid preconception and until 12 weeks gestation, vitamin D throughout the whole pregnancy (except summer months)

      Explanation:

      Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

      Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

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  • Question 15 - Which one of the following statements regarding breast cancer screening is incorrect? ...

    Incorrect

    • Which one of the following statements regarding breast cancer screening is incorrect?

      Your Answer: The optimum time to take a cervical smear is around mid-cycle

      Correct Answer: Detection of cervical adenocarcinomas has significantly improved since the introduction of liquid based cytology

      Explanation:

      Although cervical cancer screening is effective in detecting squamous cell cancer, it may not be as effective in detecting adenocarcinomas. Even with the switch to liquid based cytology, the detection rate for adenocarcinomas has not improved.

      Understanding Cervical Cancer Screening in the UK

      Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

      The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

      In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

      While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

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  • Question 16 - You encounter a 36-year-old woman who complains of vaginal discharge. She has a...

    Incorrect

    • You encounter a 36-year-old woman who complains of vaginal discharge. She has a history of bacterial vaginosis (BV) and has been treated for it around five times in the past year. A high vaginal swab reveals BV once again, and her vaginal pH remains >4.5. She is bothered by the unpleasant odor and requests further treatment. She has had a copper intrauterine device (IUD) for three years.

      In addition to prescribing a 7-day course of oral metronidazole, what other recommendations could you make?

      Your Answer: Advise oral probiotics

      Correct Answer: Consider removing the IUD and advising the use of an alternative form of contraception

      Explanation:

      There is not enough evidence to recommend any specific treatment for recurrent BV in primary care. However, in women with an intrauterine contraceptive device and persistent BV, it may be advisable to remove the device and suggest an alternative form of contraception.

      Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

      Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

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  • Question 17 - A 26-year-old female presents with a history of recurrent urinary tract infections over...

    Incorrect

    • A 26-year-old female presents with a history of recurrent urinary tract infections over the past year. An abdominal ultrasound is performed and the results indicate normal size kidneys and no abnormalities in the urinary tract. The liver, spleen, and pancreas are also reported as normal. However, a 4 cm simple ovarian cyst is noted on the left ovary while the right ovary and uterus appear normal. What would be the most suitable course of action?

      Your Answer: Start a combined oral contraceptive pill

      Correct Answer: Repeat ultrasound in 12 weeks

      Explanation:

      Consider referral if the cyst remains after 12 weeks.

      When a patient presents with suspected ovarian cysts or tumors, the first imaging modality used is typically ultrasound. The ultrasound report will indicate whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and whether they are experiencing symptoms. It is important to note that ovarian cancer diagnosis is often delayed due to a vague presentation.

      For premenopausal women, a conservative approach may be taken, especially if they are younger than 35 years old, as malignancy is less common. If the cyst is small (less than 5 cm) and reported as simple, it is highly likely to be benign. A repeat ultrasound should be scheduled for 8-12 weeks, and referral should be considered if the cyst persists.

      Postmenopausal women, on the other hand, are unlikely to have physiological cysts. Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynecology for assessment.

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  • Question 18 - A 29-year-old mother comes to your clinic worried about her painful breasts. She...

    Incorrect

    • A 29-year-old mother comes to your clinic worried about her painful breasts. She is currently nursing her 7-day-old baby but expresses her concern that her milk is not flowing properly and her baby is having difficulty latching and suckling. Her breasts are not leaking, and she feels fine. Her vital signs are normal. During the examination, both breasts are swollen and enlarged. They seem slightly red, and touching them is painful. Which of the following is the best course of action?

      Your Answer: Reassure her this is normal and no intervention necessary

      Correct Answer: Hand expression of breast milk

      Explanation:

      The patient has breast engorgement and should be advised to feed the infant with no restrictions on frequency and length of feeds. Analgesia with opioids is not recommended, and support measures such as breast massage and cold gel packs are the mainstay of treatment. Mastitis is a differential diagnosis, but hospital admission is not necessary unless there are signs of sepsis or rapidly progressing infection. Other causes of breast pain or discomfort in breastfeeding women include a full breast, a blocked duct, mastitis, or a breast abscess. Deep breast pain may also be caused by ductal infection, spasm of the ducts, persistent reaction to nerve trauma, or prolactin-induced mastalgia.

      Breastfeeding Problems and Management

      Breastfeeding can come with its own set of challenges, but most of them can be managed with proper care and attention. Some common issues include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These problems can be addressed by seeking advice on positioning, breast massage, and using appropriate creams and suspensions.

      Mastitis is a more serious condition that affects around 1 in 10 breastfeeding women. It is important to seek treatment if symptoms persist or worsen, including systemic illness, nipple fissures, or infection. The first-line antibiotic is flucloxacillin, and breastfeeding or expressing should continue during treatment. If left untreated, mastitis can lead to a breast abscess, which requires incision and drainage.

      Breast engorgement is another common issue that can cause pain and discomfort. It usually occurs in the first few days after birth and can affect both breasts. Hand expression of milk can help relieve the discomfort of engorgement, and complications can be avoided by addressing the issue promptly.

      Raynaud’s disease of the nipple is a less common but still significant problem that can cause pain and blanching of the nipple. Treatment options include minimizing exposure to cold, using heat packs, avoiding caffeine and smoking, and considering oral nifedipine.

      Concerns about poor infant weight gain can also arise, prompting consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight until weight gain is satisfactory is also recommended. With proper management and support, most breastfeeding problems can be overcome, allowing for a successful and rewarding breastfeeding experience.

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  • Question 19 - A 35-year-old woman comes in for a check-up on her asthma management. Upon...

    Incorrect

    • A 35-year-old woman comes in for a check-up on her asthma management. Upon reviewing her medical history, you notice that she has never had a Pap smear and bring this to her attention. She discloses that she is a lesbian and has never engaged in sexual activity with a man. What advice should you provide in this situation?

      Your Answer: She doesn't need to have a smear but does need a one-off HPV test

      Correct Answer: She should have cervical screening as per normal

      Explanation:

      Lesbian and bisexual women are at risk of contracting HPV, the virus responsible for causing cervical cancer, through genital contact or oral sex. As a result, it is important for them to undergo regular cervical screening. However, the uptake of screening among lesbian women is significantly lower than that of the general female population, often due to misinformation provided by healthcare providers.

      Understanding Cervical Cancer Screening in the UK

      Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

      The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

      In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

      While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

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  • Question 20 - A morbidly obese 35-year-old patient comes to see you. She has been amenorrhoeic...

    Incorrect

    • A morbidly obese 35-year-old patient comes to see you. She has been amenorrhoeic for 10 years, has male pattern hirsutism and had an ultrasound scan demonstrating polycystic ovaries 8 years ago.

      She has recently lost 3 kg in weight and has been spotting blood per vagina for two weeks. She has come to see you asking if the weight loss may have caused her ovaries to start working again. You examine for local causes of bleeding, and the vagina and cervix appear healthy. Pregnancy test is negative.

      What should you do?

      Your Answer: Check FSH:LH ratio

      Correct Answer: Suspected cancer referral

      Explanation:

      Management of Suspicious Bleeding in a High-Risk Patient

      This patient has several risk factors for endometrial dysplasia and cancer, including obesity, polycystic ovarian syndrome, and long-term amenorrhea. Recently, she has experienced a change in her bleeding pattern from amenorrhea to spotting, which requires ruling out any suspicious causes. According to NICE guidelines, women aged 55 years and over with postmenopausal bleeding should be referred for an appointment within 2 weeks for endometrial cancer. For women under 55 years, a suspected cancer pathway referral should be considered. A direct access ultrasound scan may also be considered for women aged 55 years and over with unexplained symptoms of vaginal discharge, thrombocytosis, haematuria, low haemoglobin levels, thrombocytosis, or high blood glucose levels.

      In this case, checking a day 21 progesterone is not useful as the patient is amenorrheic. The FSH:LH ratio may be helpful in diagnosing polycystic ovarian syndrome, but it will not guide management in this case. The use of a coil may be considered after a TVUS to measure endometrial thickness if the patient is deemed low risk. Overall, it is important to promptly investigate any suspicious bleeding in high-risk patients to ensure early detection and management of any potential malignancies.

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  • Question 21 - A 45-year old woman comes to your GP clinic for her yearly pill...

    Incorrect

    • A 45-year old woman comes to your GP clinic for her yearly pill review. She has been using Cerazette®, a progesterone-only pill, for the past 3 years. She is in good health.

      What is an accurate statement about the progesterone-only pill (POP)?

      Your Answer: The POP is associated with an increased risk of myocardial infarction (MI) in women >40 years old

      Correct Answer: The POP is not associated with an increased risk of stroke in women >40 years old

      Explanation:

      The progestogen-only pill (POP) is available in different formulations including desogestrel, norethisterone, and levonorgestrel. The DSG pill may be more effective in suppressing ovulation and managing pain associated with endometriosis, menstruation, and ovulation. There is no evidence of increased risks of stroke, MI, VTE, or breast cancer associated with POP use. The traditional POP becomes more effective in older users. The UKMEC category for women over 45 years is 1 if there are no other contraindications.

      Pros and Cons of the Progestogen Only Pill

      The progestogen only pill, also known as the mini-pill, has its advantages and disadvantages. One of its main advantages is its high effectiveness, with a failure rate of only 1 per 100 woman years. It also doesn’t interfere with sex and its contraceptive effects are reversible upon stopping. Additionally, it can be used while breastfeeding and in situations where the combined oral contraceptive pill is contraindicated, such as in smokers over 35 years of age and women with a history of venous thromboembolic disease.

      However, the progestogen only pill also has its disadvantages. One common adverse effect is irregular periods, with some users not having periods while others may experience irregular or light periods. It also doesn’t protect against sexually transmitted infections and has an increased incidence of functional ovarian cysts. Common side-effects include breast tenderness, weight gain, acne, and headaches, although these symptoms generally subside after the first few months. Overall, the progestogen only pill may be a suitable contraceptive option for some women, but it’s important to weigh its pros and cons before deciding to use it.

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  • Question 22 - A 32-year-old woman has reached out for a phone consultation to discuss her...

    Correct

    • A 32-year-old woman has reached out for a phone consultation to discuss her recent cervical smear results. She underwent routine screening and is currently not experiencing any symptoms. Her last smear test was conducted 3 years ago and was normal. The results of her recent test are as follows:

      High-risk human papillomavirus (hrHPV): POSITIVE.
      Cytology: NEGATIVE.

      What should be the next course of action in managing her case?

      Your Answer: Repeat cervical smear in 12 months

      Explanation:

      For individuals who test positive for high-risk human papillomavirus (hrHPV) but receive a negative cytology report during routine primary HPV screening, the recommended course of action is to repeat the HPV test after 12 months. If the HPV test is negative at this point, the individual can return to routine recall. However, if the individual remains hrHPV positive and cytology negative, another HPV test should be conducted after a further 12 months. If the individual is still hrHPV positive after 24 months, they should be referred to colposcopy. It is important to note that repeating the cervical smear in 3 months or waiting 3 years for a repeat smear would not be appropriate in this scenario. Additionally, routine referral to colposcopy is not necessary unless there is abnormal cytology.

      Understanding Cervical Cancer Screening Results

      The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

      If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

      For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

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  • Question 23 - Which one of the following statements regarding dysmenorrhoea is accurate? ...

    Incorrect

    • Which one of the following statements regarding dysmenorrhoea is accurate?

      Your Answer: Around 10% of women experience dysmenorrhoea

      Correct Answer: The pain of secondary dysmenorrhoea typically develops 3-4 days before the onset of the period

      Explanation:

      The approach to managing secondary dysmenorrhoea varies depending on the root cause.

      Understanding Dysmenorrhoea

      Dysmenorrhoea is a medical condition that is characterized by excessive pain during the menstrual period. It is classified into two types: primary and secondary dysmenorrhoea. Primary dysmenorrhoea affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. It is caused by excessive endometrial prostaglandin production. The pain typically starts just before or within a few hours of the period starting and is felt as suprapubic cramping pains that may radiate to the back or down the thigh. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, while combined oral contraceptive pills are used second line.

      On the other hand, secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but normal copper coils may worsen the condition.

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  • Question 24 - Linda is a 38-year-old woman who presents with sudden onset left iliac fossa...

    Incorrect

    • Linda is a 38-year-old woman who presents with sudden onset left iliac fossa pain which woke her up from her sleep. She has taken some paracetamol, but the pain is still 10/10 in intensity. On further questioning, she tells you that she has recently undergone hormonal treatment for IVF and developed ovarian hyperstimulation syndrome as a result. For the last few days she has been feeling nauseous and bloated, however, her symptoms were starting to improve until she developed the pain overnight.

      On examination she is afebrile. Her abdomen is not distended, however, there is guarding on palpation of the left iliac fossa.

      What is the most likely diagnosis?

      Your Answer: Pelvic inflammatory disease

      Correct Answer: Ovarian torsion

      Explanation:

      If you experience ovarian hyperstimulation syndrome, your chances of developing ovarian torsion are higher. This is because the ovary becomes enlarged, which increases the risk of torsion. If you experience sudden pelvic pain and vomiting on one side, it may be a sign of ovarian torsion.

      While an ovarian cyst can cause pelvic pain, the sudden onset of pain suggests a cyst accident, such as rupture, haemorrhage, or torsion.

      Pelvic inflammatory disease typically causes pelvic pain, fever, and abnormal vaginal bleeding.

      Appendicitis usually causes pain in the right iliac fossa.

      Understanding Ovarian Torsion

      Ovarian torsion is a condition where the ovary twists on its supporting ligaments, leading to a compromised blood supply. This can result in partial or complete torsion of the ovary. When the fallopian tube is also affected, it is referred to as adnexal torsion. The condition is commonly associated with ovarian masses, pregnancy, and ovarian hyperstimulation syndrome. Women of reproductive age are also at risk of developing ovarian torsion.

      The most common symptom of ovarian torsion is sudden, severe abdominal pain that is often colicky in nature. Other symptoms include vomiting, distress, and in some cases, fever. Adnexal tenderness may be detected during a vaginal examination. Ultrasound may reveal free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for ovarian torsion.

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  • Question 25 - A 26-year-old G4P3 woman presents with a lump in the breast, having stopped...

    Incorrect

    • A 26-year-old G4P3 woman presents with a lump in the breast, having stopped breastfeeding her youngest child one week ago. She has a history of mastitis during breastfeeding her older children. On examination, a non-tender lump is found in the left breast at the three o'clock position, 4 cm away from the nipple. The skin overlying the lump appears unaffected. Her vital signs are as follows:

      Heart rate: 88, respiratory rate: 12, blood pressure: 110/70 mmHg, Oxygen saturation: 98%, Temperature: 37.4 Cº.

      What is the probable diagnosis, and what is the most appropriate next step in investigation?

      Your Answer: Galactocele, fine need aspiration and cytology of fluid

      Correct Answer: Galactocele, no further investigation necessary

      Explanation:

      Galactocele and breast abscess can be distinguished based on clinical history and examination findings, without the need for further investigation. Recent discontinuation of breastfeeding is a common risk factor for both conditions. However, galactoceles are typically painless and non-tender on examination, with no signs of infection, while breast abscesses are usually associated with local or systemic signs of infection. Although the patient’s history of mastitis raises suspicion for a breast abscess, the absence of tenderness, erythema, and fever strongly suggests a galactocele in this case.

      Understanding Galactocele

      Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and doesn’t cause any local or systemic signs of infection.

      In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and doesn’t require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.

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  • Question 26 - A 22-year-old woman has reported experiencing occasional post-coital and intermenstrual bleeding for approximately...

    Incorrect

    • A 22-year-old woman has reported experiencing occasional post-coital and intermenstrual bleeding for approximately 2 months. She has no complaints of dyspareunia or pelvic discomfort. During a speculum examination, no abnormalities were detected. She consents to being tested for Chlamydia and Gonorrhoea.

      Which test would be the most suitable to conduct?

      Your Answer: A venous blood test

      Correct Answer: A vulvovaginal swab

      Explanation:

      For women, the appropriate location to take swabs for chlamydia and gonorrhoea is the vulvo-vaginal area, specifically the introitus.

      Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

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  • Question 27 - A 26-year-old woman presents to your GP practice 8 months after receiving the...

    Incorrect

    • A 26-year-old woman presents to your GP practice 8 months after receiving the subdermal contraceptive implant (Nexplanon). She experienced light irregular bleeding for the first six months of implant use, but has since noticed a change in her bleeding pattern. She now experiences vaginal bleeding almost every day for the past two months. She denies any pain, dyspareunia, or change in vaginal discharge. She has not experienced any postcoital bleeding. Prior to receiving the implant, she had regular periods with a 28-day cycle and no intermenstrual bleeding. She has had one regular male partner for the past three months, and before that, she had a different regular male partner for six months. Her last normal smear test was three years ago.

      What is the most appropriate course of action?

      Your Answer: Advise her that she should change contraceptive methods

      Correct Answer: Clinical examination of cervix and sexually transmitted infection screen

      Explanation:

      The FSRH advises that women who experience problematic bleeding for more than three months after starting the contraceptive implant should undergo a clinical examination, including a speculum, and be screened for sexually transmitted infections if they are at risk. If a woman is experiencing these symptoms, it is not recommended to repeat her smear test outside of the screening program. Instead, if her cervix appears abnormal, she should be referred for colposcopy.

      Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

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  • Question 28 - A 35-year-old woman comes to the clinic seeking contraception. She wants to ensure...

    Incorrect

    • A 35-year-old woman comes to the clinic seeking contraception. She wants to ensure she is protected against any possibility of pregnancy. She had taken the combined oral contraceptive pill in the past but discontinued it long before having her two children. During the consultation, she discloses that she had unprotected sex four days ago.

      Under what circumstances can the copper intrauterine device be used as an emergency contraceptive?

      Your Answer: If she has already taken the progesterone emergency contraception pill within the past three days

      Correct Answer: It may be inserted at any time in the cycle, within five days of the first episode of unprotected sexual intercourse

      Explanation:

      Copper IUD as Emergency Contraception in the UK

      A copper-containing intrauterine device (IUD) can be used as emergency contraception in the UK. It can be inserted within 120 hours (five days) of the first episode of unprotected sexual intercourse or up to five days after the earliest expected date of ovulation, regardless of the number of episodes or time since unprotected sex. A negative pregnancy test is not required before insertion of the copper IUD as emergency contraception.

      It is important to note that the copper IUD should not be used from 48 hours to four weeks postpartum, as it falls under the UK medical eligibility criteria category 3. This means that it is advised not to be used during this time. Additionally, there is no need for the patient to have taken the progesterone emergency contraception pill beforehand as they will be using the copper device as their emergency contraception. Overall, the copper IUD is a safe and effective option for emergency contraception in the UK.

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  • Question 29 - A 32-year-old woman presents with a history of painful periods and deep pain...

    Incorrect

    • A 32-year-old woman presents with a history of painful periods and deep pain during intercourse. She has previously been diagnosed with irritable bowel syndrome and has experienced lower abdominal pain. She is concerned about the impact of the pain on her desire to start a family. What is the recommended course of management?

      Your Answer: Discuss benefits of intrauterine system

      Correct Answer: Refer to gynaecology

      Explanation:

      If a woman experiences both deep dyspareunia and lower abdominal pain, it is probable that she has endometriosis. However, if she is trying to conceive, she cannot use initial treatment options like the combined pill. To confirm the diagnosis, a laparoscopy is the preferred method. A pelvic ultrasound is not the most effective way to diagnose endometriosis and may not show any abnormalities in cases of mild to moderate disease.

      Endometriosis is a condition where endometrial tissue grows outside of the uterus, affecting around 10% of women of reproductive age. Symptoms include chronic pelvic pain, painful periods, pain during sex, and subfertility. Diagnosis is made through laparoscopy, and treatment depends on the severity of symptoms. First-line treatments include NSAIDs and hormonal treatments such as the combined oral contraceptive pill or progestogens. If these do not improve symptoms or fertility is a priority, referral to secondary care may be necessary. Treatment options in secondary care include GnRH analogues and surgery, with laparoscopic excision or ablation of endometriosis plus adhesiolysis recommended for women trying to conceive. Ovarian cystectomy may also be necessary for endometriomas.

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  • Question 30 - A 44-year-old woman presents with perimenopausal symptoms including heavy, irregular periods, hot flashes,...

    Incorrect

    • A 44-year-old woman presents with perimenopausal symptoms including heavy, irregular periods, hot flashes, vaginal dryness, and anxiety. After counseling, she chooses to undergo hormone replacement therapy (HRT) and is currently using the progestogen-only pill for contraception. She decides to switch to the Mirena intrauterine device (IUD) for contraception and as the progesterone component of her HRT. What is the duration of the Mirena's license for use in combination with HRT?

      Your Answer: 2 years

      Correct Answer: 4 years

      Explanation:

      The recommended duration for using Mirena as the progestogen component of HRT is 4 years, according to the British National Formulary and NICE guidelines. However, for contraception purposes, the license allows for use up to 5 years.

      For women using the levonorgestrel-releasing intrauterine device solely for contraception or heavy menstrual bleeding, it can be retained for a longer period. If the patient is 45 years or older and no longer menstruating, the device can be kept until menopause (confirmed by FSH testing), even if it exceeds the recommended duration (off-label use).

      If the patient is still menstruating, the levonorgestrel intrauterine device can be left in place for up to 7 years (off-label use) if the bleeding pattern is satisfactory.

      New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

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  • Question 31 - A 26-year-old woman comes to her GP for her first cervical smear. The...

    Incorrect

    • A 26-year-old woman comes to her GP for her first cervical smear. The GP offers a chaperone, but she declines. During the examination of the introitus, the GP observes a painless lump of 1 cm diameter in the labium. The Bartholin's gland on the right-hand side is not palpable. The woman reports that she has never noticed anything unusual before.

      What would be the best course of action?

      Your Answer: Incision and drainage

      Correct Answer: Reassurance

      Explanation:

      If Bartholin’s cysts are asymptomatic, there is no need for any intervention. However, if they cause symptoms or affect the appearance, they can be treated by incision and drainage. In women over 40, a biopsy may be recommended by some gynaecologists to rule out carcinoma.

      If the cyst becomes infected and turns into an abscess, the initial treatment would be marsupialisation. Alternatively, a word catheter can be inserted. Antibiotics are not effective in managing a cyst that is not accompanied by an abscess.

      Bartholin’s cyst occurs when the Bartholin duct’s entrance becomes blocked, causing mucous to build up behind the blockage and form a mass. This blockage is usually caused by vulval oedema and is typically sterile. These cysts are often asymptomatic and painless, but if they become large, they may cause discomfort when sitting or superficial dyspareunia. On the other hand, Bartholin’s abscess is extremely painful and can cause erythema and deformity of the affected vulva. Bartholin’s abscess is more common than the cyst, likely due to the asymptomatic nature of the cyst in most cases.

      Bartholin’s cysts are usually unilateral and 1-3 cm in diameter, and they should not be palpable in healthy individuals. Limited data suggest that around 3000 in 100,000 asymptomatic women have Bartholin’s cysts, and these cysts account for 2% of all gynaecological appointments. The risk factors for developing Bartholin’s cyst are not well understood, but it is thought to increase in incidence with age up to menopause before decreasing. Having one cyst is a risk factor for developing a second.

      Asymptomatic cysts generally do not require intervention, but in older women, some gynaecologists may recommend incision and drainage with biopsy to exclude carcinoma. Symptomatic or disfiguring cysts can be treated with incision and drainage or marsupialisation, which involves creating a new orifice through which glandular secretions can drain. Marsupialisation is more effective at preventing recurrence but is a longer and more invasive procedure. Antibiotics are not necessary for Bartholin’s cyst without evidence of abscess.

      References:
      1. Berger MB, Betschart C, Khandwala N, et al. Incidental Bartholin gland cysts identified on pelvic magnetic resonance imaging. Obstet Gynecol. 2012 Oct;120(4):798-802.
      2. Kaufman RH, Faro S, Brown D. Benign diseases of the vulva and vagina. 5th ed. Philadelphia, PA: Elsevier Mosby; 2005:240-249.
      3. Azzan BB. Bartholin’s cyst and abscess: a review of treatment of 53 cases. Br J Clin Pract. 1978 Apr;32(4):101-2.

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  • Question 32 - What is the failure rate of sterilisation for women? ...

    Correct

    • What is the failure rate of sterilisation for women?

      Your Answer: 1 in 200

      Explanation:

      The failure rate of female sterilisation is 1 in 200.

      Understanding Female Sterilisation

      Female sterilisation is a common method of permanent contraception for women. It has a low failure rate of 1 per 200 and is usually performed by laparoscopy under general anaesthetic. The procedure is generally done as a day case and involves various techniques such as clips (e.g. Filshie clips), blockage, rings (Falope rings) and salpingectomy. However, there are potential complications such as an increased risk of ectopic pregnancy if sterilisation fails, as well as general risks associated with anaesthesia and laparoscopy.

      In the event that a woman wishes to reverse the procedure, the current success rate of female sterilisation reversal is between 50-60%. It is important for women to understand the risks and benefits of female sterilisation before making a decision.

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  • Question 33 - A 35-year-old female patient has contacted the clinic for a telephonic consultation regarding...

    Incorrect

    • A 35-year-old female patient has contacted the clinic for a telephonic consultation regarding an increase in her vaginal discharge. She reports no vaginal soreness, dysuria, or bleeding and doesn't feel sick. The patient had an intrauterine system (Mirena coil) inserted two weeks ago. She has a history of multiple bacterial vaginosis episodes.

      What would be the best course of action for managing this situation?

      Your Answer: Prescribe intravaginal clindamycin 2% once daily for 7 days

      Correct Answer: Ask the patient to come in for examination and further assessment

      Explanation:

      For women who are at high risk of STIs, have recently undergone a gynaecological or obstetric procedure (including delivery), or are pregnant, it is recommended to undergo an examination. In cases of new-onset vaginal discharge, an intimate examination is advised. If the patient has had an intrauterine system inserted recently and is experiencing a recurrence of bacterial vaginosis, an examination should be conducted before determining the next course of action.

      Understanding Vaginal Discharge: Common and Less Common Causes

      Vaginal discharge is a common symptom experienced by many women, but it is not always a sign of a serious health issue. In fact, some amount of discharge is normal and helps to keep the vagina clean and healthy. However, when the discharge is accompanied by other symptoms such as itching, burning, or a foul odor, it may be a sign of an underlying condition.

      The most common causes of vaginal discharge include Candida, Trichomonas vaginalis, and bacterial vaginosis. Candida is a fungal infection that can cause a thick, white discharge that resembles cottage cheese. Trichomonas vaginalis is a sexually transmitted infection that can cause a yellow or green, frothy discharge with a strong odor. Bacterial vaginosis is a bacterial infection that can cause a thin, gray or white discharge with a fishy odor.

      Less common causes of vaginal discharge include gonorrhea, chlamydia, ectropion, foreign bodies, and cervical cancer.

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  • Question 34 - Linda is a 32-year-old woman who presents with a 6 month history of...

    Incorrect

    • Linda is a 32-year-old woman who presents with a 6 month history of chronic pelvic pain and dysmenorrhoea that is beginning to impact her daily life, especially at work. During the consultation, Linda mentions experiencing painful bowel movements that begin just before her period and persist throughout it.

      As her healthcare provider, you suspect endometriosis. Linda asks you about the best way to confirm this diagnosis.

      What is the definitive test that can be done to confirm endometriosis for Linda?

      Your Answer: Serum CA125 level

      Correct Answer: Laparoscopic visualisation of the pelvis

      Explanation:

      According to NICE guidelines, laparoscopy is the most reliable method of diagnosing endometriosis in patients.

      To confirm the presence of endometriosis, it is necessary to perform a laparoscopic examination of the pelvis, regardless of whether a transvaginal or transabdominal ultrasound appears normal.

      If a thorough laparoscopy is conducted and no signs of endometriosis are found, the patient should be informed that she doesn’t have the condition and offered alternative treatment options.

      Endometriosis is a condition where endometrial tissue grows outside of the uterus, affecting around 10% of women of reproductive age. Symptoms include chronic pelvic pain, painful periods, pain during sex, and subfertility. Diagnosis is made through laparoscopy, and treatment depends on the severity of symptoms. First-line treatments include NSAIDs and hormonal treatments such as the combined oral contraceptive pill or progestogens. If these do not improve symptoms or fertility is a priority, referral to secondary care may be necessary. Treatment options in secondary care include GnRH analogues and surgery, with laparoscopic excision or ablation of endometriosis plus adhesiolysis recommended for women trying to conceive. Ovarian cystectomy may also be necessary for endometriomas.

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  • Question 35 - A 28-year-old female patient presents to her GP with concerns about a lump...

    Incorrect

    • A 28-year-old female patient presents to her GP with concerns about a lump in her right breast. The patient reports that she first noticed the lump approximately two months ago and it has remained persistent without any noticeable increase in size. Upon examination, the GP observes a smooth, mobile 2 cm lump in the infero-lateral quadrant with no associated skin or nipple changes. The patient denies any family history of breast cancer and has no lumps in her axilla.

      What is the recommended course of action for managing this patient's breast lump?

      Your Answer: Urgent breast clinic referral

      Correct Answer: Routine breast clinic referral

      Explanation:

      A woman under 30 years old who presents with an unexplained breast lump, with or without pain, may not meet the 2-week-wait referral criteria but can still be referred for further evaluation. The most likely diagnosis is a fibroadenoma, which is a common benign breast lump that often occurs in younger women. These lumps are typically firm, smooth, and highly mobile, and can be described as a breast mouse due to their tendency to move away from the examiner’s hand. While a referral to a breast clinic is necessary, routine referral is appropriate given the low likelihood of cancer. There is no need to arrange mammograms or ultrasounds as these will be done by the breast clinic. Reviewing the patient in one month is unnecessary as the lump has persisted for two months and is not cyclical. Urgent referral to a breast clinic is not necessary given the patient’s age and low likelihood of breast cancer. According to NICE CKS, a 2-week-wait referral is recommended for those over 30 years old with an unexplained breast lump, or over 50 years old with unilateral nipple changes. Consideration of a 2-week-wait referral is also recommended for those over 30 years old with an unexplained lump in the axilla or skin changes suggestive of breast cancer.

      In 2015, NICE released guidelines for referring individuals suspected of having breast cancer. If a person is 30 years or older and has an unexplained breast lump with or without pain, they should be referred using a suspected cancer pathway referral for an appointment within two weeks. Similarly, if a person is 50 years or older and experiences discharge, retraction, or other concerning changes in one nipple only, they should also be referred using this pathway. If a person has skin changes that suggest breast cancer or is 30 years or older with an unexplained lump in the axilla, a suspected cancer pathway referral should be considered for an appointment within two weeks. For individuals under 30 years old with an unexplained breast lump with or without pain, a non-urgent referral should be considered.

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  • Question 36 - A 49-year-old female presents with complaints of superficial dyspareunia. Her medical history includes...

    Correct

    • A 49-year-old female presents with complaints of superficial dyspareunia. Her medical history includes treatment for two UTIs in the past six months, an IUS fitted at age 47, and two years of taking the lower dose of oestrogen only HRT for hot flashes. What is the most suitable course of action from the options provided below?

      Your Answer: She should be offered vaginal oestrogen therapy in addition to her oral HRT

      Explanation:

      Topical Oestrogens for Genitourinary Symptoms of Menopause

      Topical oestrogens can be used alongside transdermal/oral HRT to treat genitourinary symptoms of menopause. In fact, systemic HRT doesn’t improve these symptoms in 10-15% of women. Topical oestrogens are effective in these cases and can be combined with systemic HRT.

      Combined HRT is not better than oestrogen-only therapy for treating genitourinary symptoms, and progestogens are only used for endometrial protection. If a patient already has protection via an IUS, combination therapy would not be beneficial. Topical oestrogen preparations have been shown to improve vaginal symptoms, including vaginal atrophy and pH decrease, and to increase epithelial maturation compared to placebo or non-hormonal gels.

      It is important to note that systemic absorption of vaginal oestrogen is very low. Therefore, topical oestrogens work better for genitourinary symptoms of menopause compared to oral HRT and can be used in combination. According to NICE NG23, vaginal oestrogen should be offered to women with urogenital atrophy, including those on systemic HRT, and treatment should continue for as long as needed to relieve symptoms.

      If vaginal oestrogen doesn’t relieve symptoms, the dose can be increased after seeking advice from a healthcare professional with expertise in menopause. Women should be informed that symptoms often return when treatment is stopped, but adverse effects from vaginal oestrogen are very rare. They should report any unscheduled vaginal bleeding to their GP. Additionally, moisturisers and lubricants can be used alone or in addition to vaginal oestrogen for vaginal dryness. Routine monitoring of endometrial thickness during treatment for urogenital atrophy is not necessary.

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  • Question 37 - A 45-year-old woman presents to her GP with complaints of green-brown nipple discharge....

    Incorrect

    • A 45-year-old woman presents to her GP with complaints of green-brown nipple discharge. She reports no other breast changes and is in good health. She has breastfed three children and is not using any hormonal contraception. What is the primary cause of brown-green nipple discharge?

      Your Answer: Breast cancer

      Correct Answer: Duct ectasia

      Explanation:

      The most common cause of brown-green nipple discharge is duct ectasia. This condition is often found in women around menopause and is caused by the dilation of the milk duct due to aging. It may or may not be accompanied by a small lump under the nipple.

      While breast cancer can also cause nipple discharge, it is usually bloody and only comes from one nipple. A prolactinoma, a benign pituitary tumor that produces prolactin, can cause bilateral lactation and a cream-colored discharge.

      Fat necrosis of the breast is typically caused by blunt trauma to the breast, resulting in a hard lump, but no nipple discharge. Paget’s disease of the nipple is characterized by a change in the skin of the nipple and areola, but there is usually no associated nipple discharge.

      Understanding Nipple Discharge: Causes and Assessment

      Nipple discharge is a common concern among women, and it can be caused by various factors. Physiological discharge may occur during breastfeeding, while galactorrhea may be triggered by emotional events or certain medications. Hyperprolactinemia, pituitary tumors, mammary duct ectasia, and intraductal papilloma are other possible causes of nipple discharge.

      To assess patients with nipple discharge, a breast examination should be conducted to determine the presence of a mass lesion. If a mass is detected, triple assessment is recommended to evaluate the condition. Reporting of investigations should follow a system that uses a prefix denoting the type of investigation, such as M for mammography, followed by a numerical code indicating the findings.

      For non-malignant nipple discharge, endocrine disease should be excluded, and smoking cessation advice may be given for duct ectasia. In severe cases of duct ectasia, total duct excision may be necessary. Nipple cytology is generally unhelpful in diagnosing the cause of nipple discharge.

      Understanding the causes and assessment of nipple discharge is crucial in providing appropriate management and treatment for patients. Proper evaluation and reporting of investigations can help in identifying any underlying conditions and determining the best course of action.

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  • Question 38 - A 55-year-old female presents with concerns related to reduced libido. This has been...

    Incorrect

    • A 55-year-old female presents with concerns related to reduced libido. This has been causing problems with her husband and she feels rather down. They both deny any external factors or relationship issues.

      In her past history she has had ovarian failure associated with a hysterectomy three years ago and is being treated with oestradiol 1 mg daily.

      Which of the following would be the most appropriate treatment for this patient?

      Your Answer: Add norethisterone

      Correct Answer: Optimise oestrogen replacement

      Explanation:

      Treatment options for hypoactive sexual desire disorder in women

      Hypoactive sexual desire disorder is a common issue among postmenopausal women and those who have undergone ovarian failure. While counselling and lifestyle changes may be effective in cases where the primary cause is stress or relationship issues, they may not be enough in cases where hormonal imbalances are the root cause.

      If depression is the primary cause, it may need to be treated, but some antidepressants can actually worsen the problem by reducing libido. In cases where hormones are inadequate, hormone replacement therapy (HRT) may be necessary, but caution should be exercised, and an opinion from a specialist may be wise.

      Androgen patches are sometimes used to treat hormone-deficient women, but their effectiveness is controversial, and they may have negative effects on the liver and cholesterol. Progestogens are not necessary for women who have had a hysterectomy and may actually make symptoms worse. Overall, treatment options for hypoactive sexual desire disorder should be tailored to the individual and their specific needs.

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  • Question 39 - Emma is a 27-year-old woman who visited her GP for a routine smear...

    Incorrect

    • Emma is a 27-year-old woman who visited her GP for a routine smear test. While conducting the test, a 2 cm lump was discovered just lateral to the introitus. Emma reported no accompanying symptoms.

      What would be the most suitable course of action?

      Your Answer: Marsupialisation

      Correct Answer: Do nothing

      Explanation:

      Bartholin’s cysts that are asymptomatic do not need any treatment and can be managed conservatively.

      In cases where the cysts are recurrent or causing discomfort, marsupialisation or balloon catheter insertion can be considered as management options. These procedures have been shown to decrease the likelihood of recurrence.

      If an abscess is suspected, antibiotics may be necessary. Symptoms of an abscess include pain, swelling, redness, and fever.

      Women who are 40 years old or older should be referred for a biopsy to rule out the possibility of carcinoma.

      Bartholin’s cyst occurs when the Bartholin duct’s entrance becomes blocked, causing mucous to build up behind the blockage and form a mass. This blockage is usually caused by vulval oedema and is typically sterile. These cysts are often asymptomatic and painless, but if they become large, they may cause discomfort when sitting or superficial dyspareunia. On the other hand, Bartholin’s abscess is extremely painful and can cause erythema and deformity of the affected vulva. Bartholin’s abscess is more common than the cyst, likely due to the asymptomatic nature of the cyst in most cases.

      Bartholin’s cysts are usually unilateral and 1-3 cm in diameter, and they should not be palpable in healthy individuals. Limited data suggest that around 3000 in 100,000 asymptomatic women have Bartholin’s cysts, and these cysts account for 2% of all gynaecological appointments. The risk factors for developing Bartholin’s cyst are not well understood, but it is thought to increase in incidence with age up to menopause before decreasing. Having one cyst is a risk factor for developing a second.

      Asymptomatic cysts generally do not require intervention, but in older women, some gynaecologists may recommend incision and drainage with biopsy to exclude carcinoma. Symptomatic or disfiguring cysts can be treated with incision and drainage or marsupialisation, which involves creating a new orifice through which glandular secretions can drain. Marsupialisation is more effective at preventing recurrence but is a longer and more invasive procedure. Antibiotics are not necessary for Bartholin’s cyst without evidence of abscess.

      References:
      1. Berger MB, Betschart C, Khandwala N, et al. Incidental Bartholin gland cysts identified on pelvic magnetic resonance imaging. Obstet Gynecol. 2012 Oct;120(4):798-802.
      2. Kaufman RH, Faro S, Brown D. Benign diseases of the vulva and vagina. 5th ed. Philadelphia, PA: Elsevier Mosby; 2005:240-249.
      3. Azzan BB. Bartholin’s cyst and abscess: a review of treatment of 53 cases. Br J Clin Pract. 1978 Apr;32(4):101-2.

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  • Question 40 - A 28-year-old female presents to the Emergency Department with severe vomiting and diarrhoea...

    Incorrect

    • A 28-year-old female presents to the Emergency Department with severe vomiting and diarrhoea accompanied by abdominal bloating. She has been undergoing ovulation induction treatment. On ultrasound examination, ascites is observed. Her blood test results are as follows:

      - Hemoglobin (Hb): 130 g/L (normal range for females: 115-160 g/L)
      - Platelets: 300 * 109/L (normal range: 150-400 * 109/L)
      - White blood cells (WBC): 10 * 109/L (normal range: 4.0-11.0 * 109/L)
      - Sodium (Na+): 133 mmol/L (normal range: 135-145 mmol/L)
      - Potassium (K+): 5.0 mmol/L (normal range: 3.5-5.0 mmol/L)
      - Urea: 10 mmol/L (normal range: 2.0-7.0 mmol/L)
      - Creatinine: 110 µmol/L (normal range: 55-120 µmol/L)
      - C-reactive protein (CRP): 8 mg/L (normal range: <5 mg/L)
      - Hematocrit: 0.5 (normal range for females: 0.36-0.48)

      What is the medication that is most likely to have caused these side effects?

      Your Answer: Raloxifene

      Correct Answer: Gonadotrophin therapy

      Explanation:

      Ovarian hyperstimulation syndrome can occur as a result of ovulation induction, as seen in this case with symptoms such as ascites, vomiting, diarrhea, and high hematocrit. Different medications can be used for ovulation induction, with gonadotrophin therapy carrying a higher risk of ovarian hyperstimulation syndrome compared to other options like clomiphene citrate, raloxifene, letrozole, or anastrozole. It is likely that the patient in question was given gonadotrophin therapy.

      Understanding Ovulation Induction and Its Categories

      Ovulation induction is a common treatment for couples who have difficulty conceiving naturally due to ovulation disorders. The process of ovulation requires a balance of hormones and feedback loops between the hypothalamus, pituitary gland, and ovaries. Anovulation can occur due to alterations in this balance, which can be classified into three categories: hypogonadotropic hypogonadal anovulation, normogonadotropic normoestrogenic anovulation, and hypergonadotropic hypoestrogenic anovulation. The goal of ovulation induction is to induce mono-follicular development and subsequent ovulation, leading to a singleton pregnancy.

      There are various forms of ovulation induction, starting with the least invasive and simplest management option first. Exercise and weight loss are typically the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss. Letrozole is now considered the first-line medical therapy for patients with PCOS due to its reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate. Clomiphene citrate is a selective estrogen receptor modulator that acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. Gonadotropin therapy tends to be the treatment used mostly for women with hypogonadotropic hypogonadism.

      One potential side effect of ovulation induction is ovarian hyperstimulation syndrome (OHSS), which can be life-threatening if not identified and managed promptly. OHSS occurs when ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space. The severity of OHSS varies, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction. Management includes fluid and electrolyte replacement, anticoagulation therapy, abdominal ascitic paracentesis, and pregnancy termination to prevent further hormonal imbalances.

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  • Question 41 - A male patient is prescribed oral testosterone replacement therapy. A Mirena® IUS has...

    Incorrect

    • A male patient is prescribed oral testosterone replacement therapy. A Mirena® IUS has been fitted and will be used for protection against endometrial hyperplasia.

      For what length of time is the Mirena® licensed for use as protection against endometrial hyperplasia?

      Your Answer: 5 years

      Correct Answer: 4 years

      Explanation:

      Mirena® License for Contraception and Endometrial Hyperplasia Protection

      At the moment, question stats are not available, but it is likely that many people will choose 5 years as the answer for Mirena®’s duration of use for contraception. However, it is important to note that while Mirena® is licensed for up to 5 years for contraception and idiopathic menorrhagia, it is only licensed for 4 years for protection against endometrial hyperplasia during oestrogen replacement therapy. This means that individuals using Mirena® for this purpose should have it replaced after 4 years to ensure continued protection. It is crucial to follow the recommended duration of use for Mirena® to ensure its effectiveness and safety.

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  • Question 42 - Samantha is an 72-year-old woman who visits your clinic to inquire about breast...

    Incorrect

    • Samantha is an 72-year-old woman who visits your clinic to inquire about breast cancer screening. She has been receiving regular mammograms, but she recently discovered that the NHS stops screening at 71. Samantha wants to know if she can still receive NHS screening mammograms.

      Your Answer: No, but she can have a private referral

      Correct Answer: Yes, she can self-refer

      Explanation:

      The NHS is extending its breast screening initiative to cover women between the ages of 47 and 73. Women over this age can still undergo screening by making their own arrangements.

      Breast Cancer Screening and Familial Risk Factors

      Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme, with mammograms offered every three years. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually. Women over 70 years may still have mammograms but are encouraged to make their own appointments.

      For those with familial risk factors, NICE guidelines recommend referral to a breast clinic for further assessment. Those with one first-degree or second-degree relative diagnosed with breast cancer do not need referral unless certain factors are present in the family history, such as early age of diagnosis, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, or complicated patterns of multiple cancers at a young age. Women with an increased risk of breast cancer due to family history may be offered screening from a younger age.

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  • Question 43 - A 25-year-old woman is seeking advice on switching from the progesterone-only pill to...

    Incorrect

    • A 25-year-old woman is seeking advice on switching from the progesterone-only pill to combined oral contraception due to irregular bleeding. She is concerned about the risk of blood clotting adverse effects but there are no contraindications to the combined pill. What advice should be given to her regarding additional contraception when making the switch?

      Your Answer: 14-days of additional barrier contraception is needed

      Correct Answer: 7-days of additional barrier contraception is needed

      Explanation:

      When switching from a traditional POP to COCP, 7 days of barrier contraception is needed. The safest option is to recommend 7 days of barrier contraception while commencing the combined oral contraceptive to prevent unwanted pregnancy. 10 or 14 days of additional barrier contraception is not required, and 3 days is too short. It is safest to recommend 7 days of additional contraception.

      Special Situations for Combined Oral Contraceptive Pill

      Concurrent Antibiotic Use:
      In the UK, doctors have previously advised that taking antibiotics concurrently with the combined oral contraceptive pill may interfere with the enterohepatic circulation of oestrogen, making the pill ineffective. As a result, extra precautions were advised during antibiotic treatment and for seven days afterwards. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines, abandoning the previous approach. The latest edition of the British National Formulary (BNF) has also been updated in line with this guidance. Precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

      Switching Combined Oral Contraceptive Pills:
      The BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice on switching combined oral contraceptive pills. The Clinical Effectiveness Unit of the FSRH has stated in the Combined Oral Contraception guidelines that the pill-free interval doesn’t need to be omitted. However, the BNF advises missing the pill-free interval if the progesterone changes. Given the uncertainty, it is best to follow the BNF.

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  • Question 44 - A 17-year-old girl presents to you today. She is currently in a relationship...

    Incorrect

    • A 17-year-old girl presents to you today. She is currently in a relationship and has started having sexual intercourse while using condoms as contraception. She expresses her desire to switch to hormonal contraception and has chosen the combined contraceptive pill, Rigevidon, as she has no contraindications. During the consultation, you discover that she is on day 4 of her menstrual cycle. What guidance do you provide her regarding commencing the pill at this stage of her cycle?

      Your Answer: Use this as the 'pill free week' and start taking the pill on day 8 of her cycle

      Correct Answer: Start pill - there is no need for additional contraception

      Explanation:

      To avoid the need for additional barrier contraception, the woman should begin taking the pill immediately as she is currently menstruating and therefore not at risk of pregnancy. The combined contraceptive pill, except for Qlaira and Zoely, can be started within the first five days of a menstrual cycle without requiring further contraception. If started on day six or later, seven days of barrier contraception or abstinence is recommended. Waiting until day eight or the next menstrual period is unnecessary as the starting rules remain the same.

      Pros and Cons of the Combined Oral Contraceptive Pill

      The combined oral contraceptive pill is a highly effective method of birth control with a failure rate of less than one per 100 woman years. It is a convenient option that doesn’t interfere with sexual activity and its contraceptive effects are reversible upon stopping. Additionally, it can make periods regular, lighter, and less painful, and may reduce the risk of ovarian, endometrial, and colorectal cancer. It may also protect against pelvic inflammatory disease, ovarian cysts, benign breast disease, and acne vulgaris.

      However, there are also some disadvantages to consider. One of the main drawbacks is that people may forget to take it, which can reduce its effectiveness. It also offers no protection against sexually transmitted infections, so additional precautions may be necessary. There is an increased risk of venous thromboembolic disease, breast and cervical cancer, stroke, and ischaemic heart disease, especially in smokers. Temporary side effects such as headache, nausea, and breast tenderness may also be experienced.

      Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

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  • Question 45 - A 27-year-old woman comes to the clinic seeking emergency contraception. She had unprotected...

    Incorrect

    • A 27-year-old woman comes to the clinic seeking emergency contraception. She had unprotected sex within the last 24 hours and is not currently using any regular form of birth control. Her menstrual cycle is regular, with her last period occurring 12 days ago. She has no known medical conditions. Upon reviewing her medical records, you discover that she used levonorgestrel for emergency contraception 20 days ago.

      She asks for your advice on what options are available for emergency contraception. How should you respond?

      Your Answer: Ulipristal can only be used once in a cycle, and therefore advise levonorgestrel or the intrauterine copper device

      Correct Answer: She can use levonorgestrel or ulipristal, or the intrauterine copper device

      Explanation:

      It is now recommended to use both levonorgestrel and ulipristal more than once in the same menstrual cycle. According to the current guidelines from the Faculty of Sexual and Reproductive Healthcare (FSRH), if a woman has already taken either medication once or more in a cycle, she can be offered it again after further unprotected sexual intercourse in the same cycle. However, if she has already taken one medication, the other should not be taken within a certain timeframe. It is important to note that the intrauterine copper device is the most effective form of contraception and should be offered to eligible patients. Advising that no emergency contraception is needed when a woman is at risk of pregnancy is incorrect.

      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, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

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  • Question 46 - A 35-year-old woman presents for contraceptive advice. She wishes to resume taking the...

    Incorrect

    • A 35-year-old woman presents for contraceptive advice. She wishes to resume taking the combined oral contraceptive pill (COCP) after a 12-year hiatus due to a new relationship. She is in good health with no significant medical history, but she does smoke occasionally, averaging 2-3 cigarettes per day. Her body mass index (BMI) is 26 kg/m².

      According to the guidelines of the Faculty of Sexual & Reproductive Healthcare (FSRH), what is the most appropriate advice to provide regarding the COCP?

      Your Answer: The COCP is absolutely contraindicated

      Correct Answer: The disadvantages outweigh the advantages and alternative methods should be used

      Explanation:

      The FSRH has issued UKMEC recommendations for the combined oral contraceptive pill (COCP) due to the heightened risk of cardiovascular disease. According to these guidelines, the COCP is classified as UKMEC 2 for individuals under the age of 35. For those over the age of 35 who smoke less than 15 cigarettes per day, the COCP is classified as UKMEC 3. However, for those over the age of 35 who smoke more than 15 cigarettes per day, the COCP is classified as UKMEC 4. Progestogen-only contraceptives, on the other hand, are not associated with an increased risk of cardiovascular disease and are therefore classified as UKMEC 1, regardless of the patient’s age or cigarette intake.

      The choice of contraceptive for women may be affected by comorbidities. The FSRH provides UKMEC recommendations for different conditions. Smoking increases the risk of cardiovascular disease, and the COCP is recommended as UKMEC 2 for women under 35 and UKMEC 3 for those over 35 who smoke less than 15 cigarettes/day, but is UKMEC 4 for those who smoke more. Obesity increases the risk of venous thromboembolism, and the COCP is recommended as UKMEC 2 for women with a BMI of 30-34 kg/m² and UKMEC 3 for those with a BMI of 35 kg/m² or more. The COCP is contraindicated for women with a history of migraine with aura, but is UKMEC 3 for those with migraines without aura and UKMEC 2 for initiation. For women with epilepsy, consistent use of condoms is recommended in addition to other forms of contraception. The choice of contraceptive for women taking anti-epileptic medication depends on the specific medication, with the COCP and POP being UKMEC 3 for most medications, while the implant is UKMEC 2 and the Depo-Provera, IUD, and IUS are UKMEC 1. Lamotrigine has different recommendations, with the COCP being UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS being UKMEC 1.

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  • Question 47 - A 13-year-old girl arrives at the clinic with her mother who wants to...

    Incorrect

    • A 13-year-old girl arrives at the clinic with her mother who wants to know more about HPV vaccination. Which of the following statements about HPV vaccination is not true?

      Your Answer: HPV is the main aetiological factor in the development of cervical cancer

      Correct Answer: Cervarix has the advantage over Gardasil of offering protection against genital warts

      Explanation:

      Protection against genital warts is an advantage offered by Gardasil, as opposed to Cervarix.

      The human papillomavirus (HPV) is a known carcinogen that infects the skin and mucous membranes. There are numerous strains of HPV, with strains 6 and 11 causing genital warts and strains 16 and 18 linked to various cancers, particularly cervical cancer. HPV infection is responsible for over 99.7% of cervical cancers, and testing for HPV is now a crucial part of cervical cancer screening. Other cancers linked to HPV include anal, vulval, vaginal, mouth, and throat cancers. While there are other risk factors for developing cervical cancer, such as smoking and contraceptive pill use, HPV vaccination is an effective preventative measure.

      The UK introduced an HPV vaccine in 2008, initially using Cervarix, which protected against HPV 16 and 18 but not 6 and 11. This decision was criticized due to the significant disease burden caused by genital warts. In 2012, Gardasil replaced Cervarix as the vaccine used, protecting against HPV 6, 11, 16, and 18. Initially given only to girls, boys were also offered the vaccine from September 2019. The vaccine is offered to all 12- and 13-year-olds in school Year 8, with the option for girls to receive a second dose between 6-24 months after the first. Men who have sex with men under the age of 45 are also recommended to receive the vaccine to protect against anal, throat, and penile cancers.

      Injection site reactions are common with HPV vaccines. It should be noted that parents may not be able to prevent their daughter from receiving the vaccine, as information given to parents and available on the NHS website makes it clear that the vaccine may be administered against parental wishes.

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  • Question 48 - You are evaluating a 28-year-old female patient who is being treated by a...

    Correct

    • You are evaluating a 28-year-old female patient who is being treated by a rheumatologist. Despite taking methotrexate and sulfasalazine, she did not experience satisfactory results and is now on leflunomide. The rheumatologist has advised her to continue taking her combined oral contraceptive pill, but she is interested in starting a family in the future. What is the recommended waiting period after discontinuing leflunomide before attempting to conceive?

      Your Answer: At least 2 years

      Explanation:

      Women and men who are taking leflunomide must use effective contraception for a minimum of 2 years and 3 months respectively after discontinuing the medication, similar to the requirements for thalidomide.

      Leflunomide: A DMARD for Rheumatoid Arthritis

      Leflunomide is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage rheumatoid arthritis. It is important to note that this medication has a very long half-life, which means that its teratogenic potential should be taken into consideration. As such, it is contraindicated in pregnant women, and effective contraception is essential during treatment and for at least two years after treatment in women, and at least three months after treatment in men. Caution should also be exercised in patients with pre-existing lung and liver disease.

      Like any medication, leflunomide can cause adverse effects. Some of the most common side effects include gastrointestinal issues such as diarrhea, hypertension, weight loss or anorexia, peripheral neuropathy, myelosuppression, and pneumonitis. To monitor for any potential complications, patients taking leflunomide should have their full blood count (FBC), liver function tests (LFT), and blood pressure checked regularly.

      If a patient needs to stop taking leflunomide, it is important to note that the medication has a very long wash-out period of up to a year. To help speed up the process, co-administration of cholestyramine may be necessary. Overall, leflunomide can be an effective treatment option for rheumatoid arthritis, but it is important to carefully consider its potential risks and benefits before starting treatment.

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  • Question 49 - You see a 45-year-old woman who has been taking the combined oral contraceptive...

    Incorrect

    • You see a 45-year-old woman who has been taking the combined oral contraceptive pill (COCP) for the last 12 years. She has recently become a patient at your practice and has not had a medication review in a long time. Despite being a non-smoker, having a normal BMI, and having no relevant medical history, she still requires contraception as she is sexually active and having regular periods. After discussing the risks and benefits of the COCP with her, she is hesitant to discontinue its use.

      Which of the following statements regarding the COCP is accurate?

      Your Answer: The UK eligibility criteria category for using the COCP in a woman >35 with no other contraindications is 2

      Correct Answer:

      Explanation:

      For women over 40, it is recommended to consider a COC pill containing less than 30 µg ethinylestradiol as the first-line option due to the potentially lower risks of VTE, cardiovascular disease, and stroke compared to formulations with higher doses of estrogen. COCP can also help reduce menstrual bleeding and pain, which may be beneficial for women in this age group. However, it is important to consider special considerations when prescribing COCP to women over 40.

      Levonorgestrel or norethisterone-containing COCP preparations should be considered as the first-line option for women over 40 due to the potentially lower risk of VTE compared to formulations containing other progestogens. The UKMEC criteria for women over 40 is 2, while for women from menarche until 40, it is 1. The faculty of sexual and reproductive health recommends the use of COCP until age 50 if there are no other contraindications. Women aged 50 and over should be advised to use an alternative, safer method for contraception.

      Extended or continuous COCP regimens can be offered to women for contraception and to control menstrual or menopausal symptoms. COCP is associated with a reduced risk of ovarian and endometrial cancer that lasts for several decades after cessation. It may also help maintain bone mineral density compared to non-use of hormones in the perimenopause.

      Although meta-analyses have found a slightly increased risk of breast cancer among women using COCP, there is no significant risk of breast cancer ten years after cessation. Women who smoke should be advised to stop COCP at 35 as this is the age at which excess risk of mortality associated with smoking becomes clinically significant.

      Women over the age of 40 still require effective contraception until they reach menopause, despite a significant decline in fertility. The Faculty of Sexual and Reproductive Healthcare (FSRH) has produced specific guidance for this age group, titled Contraception for Women Aged Over 40 Years. No method of contraception is contraindicated by age alone, with all methods being UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The FSRH guidance provides specific considerations for each method, such as the use of COCP in the perimenopausal period to maintain bone mineral density and reduce menopausal symptoms. Depo-Provera use is associated with a small loss in bone mineral density, which is usually recovered after discontinuation. The FSRH also provides a table detailing how different methods may be stopped based on age and amenorrhea status. Hormone replacement therapy cannot be relied upon for contraception, and a separate method is needed. The FSRH advises that the POP may be used in conjunction with HRT as long as the HRT has a progestogen component, while the IUS is licensed to provide the progestogen component of HRT.

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  • Question 50 - You are reviewing the results of a cervical smear test for a 33-year-old...

    Incorrect

    • You are reviewing the results of a cervical smear test for a 33-year-old patient. The test has come back as high-risk human papillomavirus (hrHPV) negative and it is noted that this is a repeat test. Upon further review, you see that this is the patient's second repeat test following an abnormal result at a routine screening 2 years ago. Her last test was 6 months ago when she tested hrHPV positive. Cytologically normal. She has not been invited for a colposcopy.

      What would be the most appropriate next step in this case?

      Your Answer: Recommend a repeat smear in 12 months' time

      Correct Answer: Return to routine recall (in 3 years)

      Explanation:

      If the results of the 2nd repeat smear at 24 months show that the patient is now negative for high-risk human papillomavirus (hrHPV), the appropriate action is to return to routine recall in 3 years. This is based on the assumption that the patient had an initial abnormal smear 2 years ago, which showed hrHPV positive but with normal cytology. The patient then had a repeat test at 12 months, which also showed hrHPV positive but with normal cytology. If the patient had still been hrHPV positive, she would have been referred for colposcopy. However, since she is now negative, there is no need for further testing or repeat smear in 4 weeks or 12 months. It is also not necessary to check cytology on the sample as the latest cervical screening programme doesn’t require it if hrHPV is negative. It is important to note that transient hrHPV infection is common and doesn’t necessarily indicate a high risk of cervical cancer.

      Understanding Cervical Cancer Screening Results

      The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

      If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

      For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

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  • Question 51 - A 42-year-old woman seeks guidance on contraception options. She has a new partner...

    Incorrect

    • A 42-year-old woman seeks guidance on contraception options. She has a new partner but is certain she doesn't want to have any more children. Lately, she has noticed an increase in the heaviness of her periods and has experienced some intermenstrual bleeding. What is the recommended course of action?

      Your Answer: Suggest she considers female sterilisation

      Correct Answer: Refer to gynaecology

      Explanation:

      Referral to gynaecology is necessary to rule out endometrial cancer due to the patient’s past experience of intermenstrual bleeding.

      Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Symptoms of endometrial cancer include postmenopausal bleeding, which is usually slight and intermittent at first before becoming heavier, and changes in intermenstrual bleeding for premenopausal women. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.

      When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness of less than 4 mm. Hysteroscopy with endometrial biopsy is also commonly used for diagnosis. Treatment for localized disease typically involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may require postoperative radiotherapy. Progestogen therapy may be used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.

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  • Question 52 - Samantha is a 32-year-old female who has been dealing with premenstrual syndrome (PMS)...

    Incorrect

    • Samantha is a 32-year-old female who has been dealing with premenstrual syndrome (PMS) for a few years. She experiences lower abdominal cramping and bloating 1-2 days before her menstrual period. Recently, she found herself becoming more irritable and upset with her coworkers, which is out of character for her. What advice can you offer to help improve her PMS symptoms?

      Your Answer: 4-5 hourly large balanced meals rich in protein and fats

      Correct Answer: 2-3 hourly small balanced meals rich in complex carbohydrates

      Explanation:

      To manage premenstrual syndrome, it is recommended to make specific lifestyle changes such as consuming 2-3 hourly small balanced meals that are rich in complex carbohydrates. This is because complex carbohydrates are more nutrient-dense and higher in fiber compared to simple carbohydrates. Consuming complex carbohydrates in smaller, frequent meals helps to stabilize blood sugar levels and provide the body with essential nutrients throughout the day, which can help control PMS symptoms. Other options have not been proven to improve the severity of symptoms.

      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 doesn’t 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 condition.

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  • Question 53 - A 27-year-old woman has come to the sexual health clinic complaining of a...

    Incorrect

    • A 27-year-old woman has come to the sexual health clinic complaining of a thick, foul-smelling vaginal discharge that has been present for a week. She has no medical history and is not taking any medications. During the examination, vulvitis is observed, but her cervix appears normal. A sample taken from a vaginal swab and examined under light-field microscopy reveals motile trophozoites, and NAAT results are pending. What is the most suitable treatment based on these findings?

      Your Answer: Fluconazole

      Correct Answer: Metronidazole

      Explanation:

      Trichomoniasis is a sexually transmitted infection caused by a protozoan parasite called Trichomonas vaginalis. It is more common in women than men, and many women with the infection do not experience any symptoms. In order to diagnose trichomoniasis, a sample of vaginal discharge is collected and examined under a microscope for the presence of motile trophozoites. Confirmation of the diagnosis can be done through molecular testing. Treatment typically involves taking oral metronidazole for a specified period of time. Other sexually transmitted infections, such as Chlamydia, gonorrhea, and candidiasis, require different treatments.

      Comparison of Bacterial Vaginosis and Trichomonas Vaginalis

      Bacterial vaginosis and Trichomonas vaginalis are two common sexually transmitted infections that affect women. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while Trichomonas vaginalis is caused by a protozoan parasite. Both infections can cause vaginal discharge and vulvovaginitis, but Trichomonas vaginalis may also cause urethritis in men.

      The vaginal discharge in bacterial vaginosis is typically thin and grayish-white, with a fishy odor. The pH of the vagina is usually higher than 4.5. In contrast, the discharge in Trichomonas vaginalis is offensive, yellow/green, and frothy. The cervix may also appear like a strawberry. The pH of the vagina is also higher than 4.5.

      To diagnose bacterial vaginosis, a doctor may perform a pelvic exam and take a sample of the vaginal discharge for testing. The presence of clue cells, which are vaginal cells covered in bacteria, is a hallmark of bacterial vaginosis. On the other hand, Trichomonas vaginalis can be diagnosed by examining a wet mount under a microscope. The motile trophozoites of the parasite can be seen in the sample.

      Both bacterial vaginosis and Trichomonas vaginalis can be treated with antibiotics. Metronidazole is the drug of choice for both infections. For bacterial vaginosis, a course of oral metronidazole for 5-7 days is recommended. For Trichomonas vaginalis, a one-off dose of 2g metronidazole may also be used. It is important to complete the full course of antibiotics to ensure that the infection is fully treated.

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  • Question 54 - A 50-year-old lady presents to your clinic after receiving a health screen at...

    Incorrect

    • A 50-year-old lady presents to your clinic after receiving a health screen at a private clinic. The results showed a slightly elevated CA 125 level of 55 (normal range 0-35). She provides you with a printout of her normal FBC, LFT, U&E, height, weight, and ECG. Her QRisk2 score is 8.4%. During the consultation, she mentions experiencing occasional bloating, but a VE examination reveals no abnormalities. What is the best course of action for this patient?

      Your Answer: Refer on two week wait to gynaecology

      Correct Answer: Arrange an ultrasound scan of her abdomen and pelvis

      Explanation:

      Elevated Ca125 and Normal Examination: What to Do Next?

      This patient has an elevated Ca125 but a normal examination. Although the elevated result was detected during screening, she admits to experiencing bloating, which can be an early symptom of ovarian cancer. However, it’s important to note that Ca125 can be elevated for non-malignancy reasons, and if the ovarian cancer is not epithelial in origin, the Ca125 can be normal.

      According to NICE guidelines, if a woman has symptoms that suggest ovarian cancer, serum CA125 should be measured in primary care. If the serum CA125 is 35 IU/ml or greater, an ultrasound scan of the abdomen and pelvis should be arranged. If the ultrasound suggests ovarian cancer, the woman should be referred urgently for further investigation.

      If a woman has a normal serum CA125 (less than 35 IU/ml) or a CA125 of 35 IU/ml or greater but a normal ultrasound, she should be assessed carefully for other clinical causes of her symptoms and investigated if appropriate. If no other clinical cause is apparent, she should be advised to return to her GP if her symptoms become more frequent and/or persistent.

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  • Question 55 - Sophie is 25 years old and has just received treatment from you for...

    Incorrect

    • Sophie is 25 years old and has just received treatment from you for bacterial vaginosis after consulting with you about her vaginal discharge. Her chlamydia and gonorrhoea swabs came back negative. She contacts you again to ask if she should inform her partner about her condition and if he needs to be treated.

      Your Answer: Ask her partner to attend for investigation at the GP surgery,

      Correct Answer: No, bacterial vaginosis is not classed as an STI so no partner notification is necessary

      Explanation:

      Partner notification is not necessary for bacterial vaginosis as it is not considered a sexually transmitted infection.

      Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

      Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

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  • Question 56 - A 50-year-old accountant presents with a 4 months history of occasional loose stools...

    Incorrect

    • A 50-year-old accountant presents with a 4 months history of occasional loose stools and bloating. Due to a heavy workload, she has not had the chance to visit her GP until now. She denies any vomiting or recent travel and has not noticed any mucous or blood in her stools. She has a history of anxiety and a strong family history of irritable bowel syndrome. During examination, her vital signs are normal, and her abdomen is visibly bloated but soft and non-tender. Bowel sounds are active, and rectal examination is unremarkable. What would be the most crucial next step in managing this patient?

      Your Answer: Check faecal calprotectin

      Correct Answer: Check CA125

      Explanation:

      If a woman aged 50 or above reports symptoms resembling irritable bowel syndrome within the past year, it is important to consider the possibility of ovarian cancer. While IBS is uncommon in this age group, ovarian cancer can present with similar nonspecific symptoms, and it is crucial to rule out any serious conditions.

      Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

      Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

      There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

      To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

      Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

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  • Question 57 - A 28-year-old woman comes in with lower abdominal pain. She believes she is...

    Incorrect

    • A 28-year-old woman comes in with lower abdominal pain. She believes she is approximately 8 weeks pregnant according to her last menstrual period and has been feeling fine until 5 days ago when she started experiencing some lower abdominal discomfort that has been gradually intensifying. What should be avoided during her evaluation?

      Your Answer: Urine hCG assessment

      Correct Answer: Examination for an adnexal mass

      Explanation:

      NICE advises against examining an adnexal mass as it may lead to rupture.

      Understanding Ectopic Pregnancy

      Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is a medical emergency that requires immediate attention. Women with ectopic pregnancy typically experience lower abdominal pain, which is often the first symptom. The pain is usually constant and may be felt on one side of the abdomen. Vaginal bleeding is another common symptom, which is usually less than a normal period and may be dark brown in color. Women with ectopic pregnancy may also experience dizziness, fainting, or syncope.

      During a physical examination, doctors may find abdominal tenderness and cervical excitation, also known as cervical motion tenderness. However, they are advised not to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels above 1,500 suggest an ectopic pregnancy.

      In summary, ectopic pregnancy is a serious condition that requires prompt medical attention. Women who experience lower abdominal pain and vaginal bleeding should seek medical help immediately. Early diagnosis and treatment can prevent complications and improve outcomes.

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  • Question 58 - You have a telephone consultation with Sarah, a 49-year-old woman who is worried...

    Incorrect

    • You have a telephone consultation with Sarah, a 49-year-old woman who is worried about experiencing menopausal symptoms. She reports having hot flashes, insomnia, and mood swings. Her last period was 12 months ago, and she is not using any hormonal contraception. Sarah has tried non-hormonal methods, but they have not been effective. She has never had a hysterectomy and has no history of breast cancer. Sarah smokes 10 cigarettes a day.

      With a weight of 75 kg and a height of 160 cm, Sarah's BMI is calculated to be 29.3 kg/m2. She is not currently pregnant.

      Sarah is seeking advice on the best HRT option as there are many available. Which HRT option would you recommend for her?

      Your Answer: Cyclical combined transdermal preparation

      Correct Answer: Continuous combined transdermal preparation

      Explanation:

      The appropriate HRT for Annie, who is postmenopausal and at risk of venous thromboembolism due to her smoking and obesity, is a continuous combined transdermal preparation. This is because she requires the progestogen component for endometrial protection and oral preparations should be avoided in her case. Cyclical preparations, both oral and transdermal, are not indicated as she has been amenorrhoeic for over 12 months.

      Hormone Replacement Therapy: Uses and Varieties

      Hormone replacement therapy (HRT) is a treatment that involves administering a small amount of estrogen, combined with a progestogen (in women with a uterus), to alleviate menopausal symptoms. The indications for HRT have changed significantly over the past decade due to the long-term risks that have become apparent, primarily as a result of the Women’s Health Initiative (WHI) study.

      The most common indication for HRT is vasomotor symptoms such as flushing, insomnia, and headaches. Other indications, such as reversal of vaginal atrophy, should be treated with other agents as first-line therapies. HRT is also recommended for women who experience premature menopause, which should be continued until the age of 50 years. The most important reason for giving HRT to younger women is to prevent the development of osteoporosis. Additionally, HRT has been shown to reduce the incidence of colorectal cancer.

      HRT generally consists of an oestrogenic compound, which replaces the diminished levels that occur in the perimenopausal period. This is normally combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer. The choice of hormone includes natural oestrogens such as estradiol, estrone, and conjugated oestrogen, which are generally used rather than synthetic oestrogens such as ethinylestradiol (which is used in the combined oral contraceptive pill). Synthetic progestogens such as medroxyprogesterone, norethisterone, levonorgestrel, and drospirenone are usually used. A levonorgestrel-releasing intrauterine system (e.g. Mirena) may be used as the progestogen component of HRT, i.e. a woman could take an oral oestrogen and have endometrial protection using a Mirena coil. Tibolone, a synthetic compound with both oestrogenic, progestogenic, and androgenic activity, is another option.

      HRT can be taken orally or transdermally (via a patch or gel). Transdermal is preferred if the woman is at risk of venous thromboembolism (VTE), as the rates of VTE do not appear to rise with transdermal preparations.

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  • Question 59 - A 42-year-old female comes to see you at the GP surgery complaining of...

    Correct

    • A 42-year-old female comes to see you at the GP surgery complaining of hot flashes. Her LMP was 13 months ago. She wants to have some blood tests to confirm she has gone through the menopause.

      What is the most appropriate management from the list below?

      Your Answer: She can be advised that she has gone through the menopause. No bloods required

      Explanation:

      Diagnosing Menopause According to NICE NG23

      According to NICE NG23 guidelines, menopause can be diagnosed without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms. Perimenopause can be diagnosed based on vasomotor symptoms and irregular periods, while menopause can be diagnosed in women who have not had a period for at least 12 months and are not using hormonal contraception. Menopause can also be diagnosed based on symptoms in women without a uterus.

      However, in women aged 40 to 45 years with menopausal symptoms, including a change in their menstrual cycle, and in women aged under 40 years in whom menopause is suspected, a FSH test may be considered to diagnose menopause.

      In the case of a woman aged over 45 years with amenorrhoea for over 12 months, a clinical diagnosis of menopause can be made without the need for blood tests. It is important to note that premature ovarian failure is not a concern in this case as the woman is aged 48.

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  • Question 60 - Which of the following is an absolute contraindication to the use of the...

    Correct

    • Which of the following is an absolute contraindication to the use of the progesterone only pill for women?

      Your Answer: Breast cancer 3 years ago

      Explanation:

      Contraindications for Progestogen Only Pill

      The UK Medical Eligibility Criteria (UKMEC) is used to determine whether a woman is suitable for a particular type of contraceptive. The criteria categorize potential cautions and contraindications into four levels. UKMEC 1 indicates no restriction for the use of the contraceptive method, while UKMEC 2 suggests that the advantages outweigh the disadvantages. UKMEC 3 indicates that the disadvantages generally outweigh the advantages, and UKMEC 4 represents an unacceptable health risk.

      Examples of UKMEC 3 conditions that may prevent a woman from taking the progestogen only pill include active liver disease or past tumour, liver enzyme inducers, breast cancer more than 5 years ago, undiagnosed vaginal bleeding, and ischaemic heart disease and stroke (initiation = UKMEC2). On the other hand, UKMEC 4 conditions such as pregnancy and breast cancer within the last 5 years are considered unacceptable health risks and would prevent a woman from taking the progestogen only pill. It is important to consult with a healthcare provider to determine if the progestogen only pill is a suitable contraceptive option.

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  • Question 61 - A 29-year-old woman schedules a routine appointment to discuss her cervical screening outcomes....

    Incorrect

    • A 29-year-old woman schedules a routine appointment to discuss her cervical screening outcomes. Regrettably, her last two samples have been reported as insufficient. What is the best course of action for these findings?

      Your Answer: Colposcopy within 2 weeks

      Correct Answer: Colposcopy within 6 weeks

      Explanation:

      If a woman has two consecutive inadequate samples during cervical cancer screening, she should be referred for colposcopy. This is because if the cytology results are abnormal and show high-grade dyskaryosis (moderate or severe), colposcopy should be offered within 2 weeks. For those with inadequate, borderline, or low-grade dyskaryosis (mild) results, they should receive an appointment within 6 weeks. It is not possible for the woman to return to routine recall as her samples were inadequate. Repeat hrHPV tests would only be necessary if the woman had positive hrHPV and normal cytology results.

      Understanding Cervical Cancer Screening Results

      The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

      If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

      For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

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  • Question 62 - A 42-year-old female presents for contraception advice. She had the intrauterine device inserted...

    Incorrect

    • A 42-year-old female presents for contraception advice. She had the intrauterine device inserted after being diagnosed with breast cancer seven years ago, which was treated successfully. However, she has noticed that her periods have become heavier since having the device and is interested in exploring other contraceptive options. What advice should be given regarding her contraception?

      Your Answer: She should be advised that she could use barrier contraception, the intrauterine device, intrauterine system or progesterone only pill

      Correct Answer: She should be advised to use barrier contraception or the intrauterine device only

      Explanation:

      Contraception Options for Patients with Past Breast Cancer

      Patients with a past history of breast cancer should be advised to use barrier contraception or the intrauterine device (IUD) only. Hormonal containing contraception, including progestogens, are UKMEC 3 in these patients. This means that the benefits of using hormonal contraception may outweigh the risks, but caution should be taken and alternative options should be considered.

      The IUD and implant are also UKMEC 3 in patients with past breast cancer, while the IUD and progesterone-only pill are also considered UKMEC 3. It is important for patients to discuss their options with their healthcare provider and weigh the potential benefits and risks of each method before making a decision. By considering all options and taking precautions, patients with past breast cancer can still have access to effective contraception while minimizing potential risks.

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  • Question 63 - A 28-year-old woman complains of multiple occurrences of vaginal candidiasis that have not...

    Incorrect

    • A 28-year-old woman complains of multiple occurrences of vaginal candidiasis that have not responded to OTC or prescribed treatments. As per the guidelines of the British Association of Sexual Health and HIV (BASHH), what is the minimum frequency of yearly episodes required to diagnose recurrent vaginal candidiasis?

      Your Answer: Two or more episodes per year

      Correct Answer: Four or more episodes per year

      Explanation:

      According to BASHH, recurrent vaginal candidiasis is characterized by experiencing four or more episodes per year. This criterion is significant as it helps determine the need for prophylactic treatment to prevent future recurrences.

      Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

      Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

      Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

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  • Question 64 - A patient in her early 30s calls in tears, requesting to speak with...

    Incorrect

    • A patient in her early 30s calls in tears, requesting to speak with a doctor regarding her cervical screening test results. She has received a letter asking her to attend for colposcopy, and the results state 'Abnormal with borderline or low-grade cell changes.' She is distressed and wants to know if the test has detected cancer.

      What is the typical meaning of this result?

      Your Answer: Carcinoma in situ

      Correct Answer: Premalignant changes

      Explanation:

      The primary objective of cervical screening is to identify pre-cancerous alterations rather than detecting cancer.

      Understanding Cervical Cancer Screening in the UK

      Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

      The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.

      In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

      While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.

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  • Question 65 - You see a 55-year-old lady in your family planning clinic. She is fit...

    Incorrect

    • You see a 55-year-old lady in your family planning clinic. She is fit and well with no relevant past medical history. She has been taking the combined oral contraceptive pill for 10 years. She takes no other medication, has no relevant family history. Her blood pressure (BP) and BMI are normal. She takes the COCP as contraception as she is still having regular periods.

      Which statement below is true?

      Your Answer: The COCP will not alleviate menopausal symptoms

      Correct Answer: She should be advised to stop taking the COCP for contraception, and prescribe an alternative, safer method

      Explanation:

      For women over 40, combined hormonal contraception (COCP) can be beneficial in reducing menstrual bleeding and pain, as well as alleviating menopausal symptoms. However, it is important to consider certain factors when prescribing COCP to women over 40. The UKMEC criteria for women over 40 is 2, while for women from menarche until 40, it is 1. The Faculty of Sexual and Reproductive Health recommends the use of COCP until age 50, provided there are no other contraindications. However, women over 50 should be advised to switch to a safer alternative method of contraception, as the risks associated with COCP use outweigh the benefits. Women who smoke should stop using COCP at 35, as smoking increases the risk of mortality. While COCP is associated with a reduced risk of ovarian and endometrial cancer, there is a slightly increased risk of breast cancer among women using COCP, which diminishes after 10 years of cessation. Women using COCP for non-contraceptive benefits after the age of 50 should be considered on an individual basis using clinical judgement and informed choice.

      Women over the age of 40 still require effective contraception until they reach menopause, despite a significant decline in fertility. The Faculty of Sexual and Reproductive Healthcare (FSRH) has produced specific guidance for this age group, titled Contraception for Women Aged Over 40 Years. No method of contraception is contraindicated by age alone, with all methods being UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years). The FSRH guidance provides specific considerations for each method, such as the use of COCP in the perimenopausal period to maintain bone mineral density and reduce menopausal symptoms. Depo-Provera use is associated with a small loss in bone mineral density, which is usually recovered after discontinuation. The FSRH also provides a table detailing how different methods may be stopped based on age and amenorrhea status. Hormone replacement therapy cannot be relied upon for contraception, and a separate method is needed. The FSRH advises that the POP may be used in conjunction with HRT as long as the HRT has a progestogen component, while the IUS is licensed to provide the progestogen component of HRT.

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  • Question 66 - A 44-year-old woman has contacted you for a phone consultation regarding her recent...

    Incorrect

    • A 44-year-old woman has contacted you for a phone consultation regarding her recent cervical smear test results. She has undergone her first cervical smear test as part of the routine screening programme and is currently not experiencing any symptoms. She has no significant medical history but is a smoker, consuming 10 cigarettes per day. Additionally, she is not sexually active. Her test results indicate a negative high-risk human papillomavirus (hrHPV) status. What would be the appropriate next step in managing her case?

      Your Answer: Repeat cervical smear in 5 years

      Correct Answer: Repeat cervical smear in 3 years

      Explanation:

      If the cervical cancer screening sample is negative for hrHPV, the patient can return to routine recall and should have a repeat cervical smear in 3 years. It is important for individuals, even if they are not sexually active, to attend routine cervical smear tests. No further cervical smears are required if the patient has no previous relevant history. A repeat cervical smear in 12 months is not necessary as the routine recall for this age group is every 3 years. Similarly, a repeat cervical smear in 5 years is not appropriate for this patient as routine cervical smear tests are every 5 years for individuals between the ages of 50 and 64 years.

      Understanding Cervical Cancer Screening Results

      The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

      If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

      For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

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  • Question 67 - Sarah is a 28-year-old woman who underwent cervical cancer screening 18 months ago...

    Incorrect

    • Sarah is a 28-year-old woman who underwent cervical cancer screening 18 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: Refer for colposcopy

      Correct Answer: Repeat sample in 12 months

      Explanation:

      According to NICE guidelines for cervical cancer screening, if a person’s first repeat smear at 12 months is still positive for high-risk human papillomavirus (hrHPV), they should have another smear test 12 months later (i.e. at 24 months after the initial test). If the person remains hrHPV positive but has negative cytology results at 12 and 24 months, they should be referred to colposcopy. However, if they become hrHPV negative at 24 months, they can return to routine recall.

      Understanding Cervical Cancer Screening Results

      The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

      If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

      For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

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  • Question 68 - A 55-year-old woman presents with symptoms of hot flashes, night sweats, mood swings,...

    Incorrect

    • A 55-year-old woman presents with symptoms of hot flashes, night sweats, mood swings, vaginal dryness, and reduced libido. She has not had a period for 12 months and has an intact uterus. Despite being obese, she has no other risk factors and has been informed about the potential risks and benefits of hormone replacement therapy (HRT). What would be the most suitable HRT regimen for her?

      Your Answer: Transdermal continuous combined regimen

      Correct Answer: Transdermal cyclical regimen

      Explanation:

      The appropriate HRT regimen for this patient is a transdermal cyclical one, as she has had a period within the last year. As she has an intact uterus, a combined regimen with both oestrogen and progesterone is necessary. Given her increased risk of venous thromboembolism and cardiovascular disease due to obesity, transdermal preparations are recommended over oral options. Low-dose vaginal oestrogen is not sufficient for her systemic symptoms. An oestrogen-only preparation is not appropriate for women with a uterus. A transdermal continuous combined regimen is not recommended within 12 months of the last menstrual period. If the patient cannot tolerate the transdermal option, an oral cyclical regimen may be considered.

      Managing Menopause: Lifestyle Modifications, HRT, and Non-HRT Options

      Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 months. Menopausal symptoms are common and can last for several years. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.

      Lifestyle modifications can help manage symptoms such as hot flashes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended.

      HRT is an effective treatment for menopausal symptoms, but it is not suitable for everyone. Women with current or past breast cancer, any oestrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia should not take HRT. HRT brings certain risks, including an increased risk of venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer.

      Non-HRT options include fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturisers for vaginal dryness, self-help groups, cognitive behaviour therapy, or antidepressants for psychological symptoms, and vaginal oestrogen for urogenital symptoms.

      When stopping HRT, it is important to gradually reduce the dosage to limit recurrence in the short term. Women should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.

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  • Question 69 - What is a risk factor for breast cancer? ...

    Incorrect

    • What is a risk factor for breast cancer?

      Your Answer: Early menopause

      Correct Answer: Younger first time mothers

      Explanation:

      Factors affecting breast cancer risk

      Breast cancer risk is influenced by various factors. Women who experience late menopause, early menarche, and use combined oral contraceptive pills are at an increased risk of developing breast cancer. Additionally, older first-time mothers are also at a higher risk. However, childbearing can reduce the risk of breast cancer. According to Cancer Research UK, women who have had children have a 30% lower risk of developing breast cancer compared to those who have not.

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  • Question 70 - A 38-year-old female presents with a breast complaint. She has developed a patch...

    Correct

    • A 38-year-old female presents with a breast complaint. She has developed a patch of eczema on her right breast. She has no previous history of any skin conditions or anything similar.
      The patch of eczema has been present for four weeks. Two weeks ago, she was seen by a doctor who prescribed her a potent topical steroid and an emollient to use. She has been using these daily as directed but has not seen any improvement in her skin.
      On clinical examination, there is a unilateral patch of breast eczema affecting the right breast. There are no palpable breast lumps or nipple changes and no axillary lymphadenopathy.
      What is the most appropriate course of action?

      Your Answer: Refer her urgently to a breast specialist

      Explanation:

      Suspected Cancer Referral for Breast Cancer

      According to NICE guidance on suspected cancer: recognition and referral (NG12), individuals with certain symptoms should be considered for a suspected cancer pathway referral for breast cancer. These symptoms include skin changes that suggest breast cancer or an unexplained lump in the axilla for individuals aged 30 and over.

      It is important to note that a suspected cancer pathway referral means that the individual should be seen by a specialist within 2 weeks of referral. This allows for prompt diagnosis and treatment, which can greatly improve outcomes for individuals with breast cancer.

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  • Question 71 - A 25-year-old woman has been exposed to a case of meningitis and is...

    Incorrect

    • A 25-year-old woman has been exposed to a case of meningitis and is prescribed a short course of rifampicin. She is currently using Nexplanon. What advice should be given?

      Your Answer: No further action is needed

      Correct Answer: Nexplanon cannot be relied upon - suggest a Depo-Provera injection to cover

      Explanation:

      To ensure reliable contraception, it is recommended to take a two-month course of Cerazette (desogestrel) as Nexplanon may not be dependable.

      Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

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  • Question 72 - A 23-year-old woman presents to you with concerns about the possibility of pregnancy...

    Incorrect

    • A 23-year-old woman presents to you with concerns about the possibility of pregnancy after engaging in consensual, unprotected sexual intercourse last night. She is currently on day 10 of her menstrual cycle and had taken the morning-after-pill seven days ago after a similar incident. She had stopped taking her combined oral contraceptive pill four weeks ago and was scheduled to have a levonorgestrel intrauterine system inserted next week. Her medical history is unremarkable, and she has a height of 180cm and a weight of 74kg (BMI 22.8). What is the most appropriate course of action to prevent pregnancy?

      Your Answer: Insert copper intrauterine device immediately

      Correct Answer: Levonorgestrel at double dose by mouth

      Explanation:

      The correct answer is to double the dose of levonorgestrel to 3 mg by mouth for this patient, as she has a weight of over 70kg, despite having a healthy BMI. This information is based on the BNF guidelines.

      Inserting a copper intrauterine device would not be the best option for this patient, as she already has plans for levonorgestrel device insertion and may be using it for additional hormonal benefits, such as reducing the heaviness of her bleeding.

      Inserting the levonorgestrel uterine system would not provide the emergency contraception required for this patient, as it takes about 7 days to become effective. Therefore, it is not appropriate in this situation.

      The standard dose of levonorgestrel 1.5mg would be given to females who weigh less than 70 kg or have a BMI less than 26. However, in this case, it would be inappropriate due to the patient’s weight being over 70kg.

      It would be risky to suggest to this patient that she doesn’t need to take another form of emergency contraception, as the initial pill may not have prevented ovulation during this cycle.

      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, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

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  • Question 73 - Which of the following increases the risk of breast cancer? ...

    Correct

    • Which of the following increases the risk of breast cancer?

      Your Answer: Hormone replacement therapy

      Explanation:

      1. Having First Child at a Young Age

      Decreases Risk: Having the first child at a young age is actually associated with a lower risk of breast cancer. Women who have their first child before age 30, especially before age 20, tend to have a reduced risk compared to those who have children later in life or not at all.

      Explanation: Early pregnancy reduces the total number of menstrual cycles a woman has over her lifetime, reducing exposure to estrogen and progesterone, which are associated with breast cancer development.

      2. Early Menopause

      Decreases Risk: Experiencing menopause at an earlier age is associated with a lower risk of breast cancer.

      Explanation: Early menopause means fewer menstrual cycles and reduced lifetime exposure to estrogen, which is linked to the development of breast cancer.

      3. Multiparity (Having Multiple Pregnancies)

      Decreases Risk: Having multiple pregnancies generally reduces the risk of breast cancer.

      Explanation: Similar to having a first child at a young age, multiple pregnancies lower the total number of menstrual cycles and thereby reduce lifetime hormone exposure, decreasing breast cancer risk.

      4. A Mother Who Has Breast-Fed Her Baby

      Decreases Risk: Breastfeeding is associated with a lower risk of breast cancer.

      Explanation: Breastfeeding reduces the number of menstrual cycles, which reduces hormone exposure. Additionally, lactation may lead to changes in breast cells that make them more resistant to cancer.

      5. Hormone Replacement Therapy (HRT)

      Increases Risk: Hormone replacement therapy, particularly combined estrogen-progesterone therapy, is associated with an increased risk of breast cancer.

      Explanation: HRT increases the exposure to estrogen and progesterone, which can promote the development and growth of hormone-sensitive breast cancer cells. The risk is higher with longer duration of use and decreases after stopping the therapy.

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  • Question 74 - A 40-year-old woman visits her GP complaining of breast discharge. The discharge is...

    Incorrect

    • A 40-year-old woman visits her GP complaining of breast discharge. The discharge is only from her right breast and is blood-stained. The patient reports feeling fine and has no other symptoms. During the examination, both breasts appear normal with no skin changes. However, a tender and fixed lump is palpable beneath the right nipple. No additional masses are detected upon palpation of the axillae and tails of Spence.

      What is the probable diagnosis based on the given information?

      Your Answer: Pituitary prolactinoma

      Correct Answer: Intraductal papilloma

      Explanation:

      Blood stained discharge from the nipple is most commonly associated with an intraductal papilloma, which is a benign tumor that develops within the milk ducts of the breast. Surgical excision is the recommended treatment for papillomas, with histology performed to rule out any signs of breast cancer.

      Breast fat necrosis, on the other hand, is typically caused by trauma and presents as a firm lump in the breast tissue. It is not associated with nipple discharge and usually resolves on its own.

      Fibroadenomas are another type of benign breast lump that are small, non-tender, and mobile. They do not cause nipple discharge and do not require treatment.

      Mammary duct ectasia is a condition where the breast ducts become dilated, often leading to blockage. It is most common in menopausal women and can cause nipple discharge, although this is typically thick, non-bloody, and green in color. Surgery may be necessary in some cases.

      While pituitary prolactinoma is a possible cause of nipple discharge, it typically presents as bilateral and non-bloodstained. Larger prolactinomas can also cause vision problems due to pressure on the optic chiasm.

      Understanding Nipple Discharge: Causes and Assessment

      Nipple discharge is a common concern among women, and it can be caused by various factors. Physiological discharge may occur during breastfeeding, while galactorrhea may be triggered by emotional events or certain medications. Hyperprolactinemia, pituitary tumors, mammary duct ectasia, and intraductal papilloma are other possible causes of nipple discharge.

      To assess patients with nipple discharge, a breast examination should be conducted to determine the presence of a mass lesion. If a mass is detected, triple assessment is recommended to evaluate the condition. Reporting of investigations should follow a system that uses a prefix denoting the type of investigation, such as M for mammography, followed by a numerical code indicating the findings.

      For non-malignant nipple discharge, endocrine disease should be excluded, and smoking cessation advice may be given for duct ectasia. In severe cases of duct ectasia, total duct excision may be necessary. Nipple cytology is generally unhelpful in diagnosing the cause of nipple discharge.

      Understanding the causes and assessment of nipple discharge is crucial in providing appropriate management and treatment for patients. Proper evaluation and reporting of investigations can help in identifying any underlying conditions and determining the best course of action.

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  • Question 75 - A 48-year-old patient has requested a consultation to discuss the outcome of her...

    Incorrect

    • A 48-year-old patient has requested a consultation to discuss the outcome of her recent smear test. The test showed normal cytology and was negative for high-risk human papillomavirus (hrHPV). However, her previous smear test 6 months ago showed normal cytology but was positive for hrHPV.

      What guidance would you provide to the patient after receiving her latest smear test result?

      Your Answer: Return to routine recall in 5 years time

      Correct Answer: Return to routine recall in 3 years time

      Explanation:

      If the result of the first repeat smear at 12 months for cervical cancer screening is negative for high-risk human papillomavirus (hrHPV), the patient can resume routine recall. This means they should undergo screening every 3 years from age 25-49 years or every 5 years from age 50-64 years. However, if the repeat test is positive again, the patient should undergo another HPV test in 12 months. If the cytology sample shows dyskaryosis, the patient should be referred for colposcopy.

      Understanding Cervical Cancer Screening Results

      The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

      If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

      For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

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  • Question 76 - A 15-year-old girl comes to the clinic complaining of breast pain that has...

    Incorrect

    • A 15-year-old girl comes to the clinic complaining of breast pain that has been ongoing for 4 months. She reports a dull ache in both breasts that occurs 1-2 weeks before her period. She has no other medical issues and is not sexually active.

      Upon examination, there are no palpable breast lumps or skin changes.

      What is the next best course of action in managing this patient's symptoms?

      Your Answer: Commence the progesterone-only pill

      Correct Answer: Advice on a supportive bra and simple analgesia

      Explanation:

      The initial treatment for cyclical mastalgia is a supportive bra and basic pain relief.

      Cyclical breast pain is a common condition that affects up to two-thirds of women, typically beginning two weeks before their menstrual cycle. Breast pain, in the absence of other breast cancer symptoms such as a lump or changes in the nipple or skin, is not linked to breast cancer. Referral to a breast specialist may be considered if the pain is severe enough to impact quality of life or sleep and doesn’t respond to first-line treatment after three months, but there is no need for referral in this case.

      Antibiotics are not recommended for the treatment of cyclical breast pain, as there is no evidence to support their use.

      According to current NICE CKS guidelines, the combined oral contraceptive pill or progesterone-only pill should not be used to treat cyclical breast pain, as there is limited evidence of their effectiveness compared to a placebo.

      The first-line approach to managing cyclical breast pain involves advising patients to wear a supportive bra and take basic pain relief. This is based on expert consensus, which suggests that most cases of cyclical breast pain can be managed conservatively with a watchful-waiting approach, as long as malignancy has been ruled out as a cause.

      Cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle and is not usually associated with point tenderness of the chest wall. The underlying cause is difficult to identify, but focal lesions such as cysts may be treated to provide symptomatic relief. Women should be advised to wear a supportive bra and conservative treatments such as standard oral and topical analgesia may be used. Flaxseed oil and evening primrose oil are sometimes used, but neither are recommended by NICE Clinical Knowledge Summaries. If the pain persists after 3 months and affects the quality of life or sleep, referral should be considered. Hormonal agents such as bromocriptine and danazol may be more effective, but many women discontinue these therapies due to adverse effects.

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  • Question 77 - A 25-year-old woman comes to you with complaints of feeling low for a...

    Incorrect

    • A 25-year-old woman comes to you with complaints of feeling low for a week every month, just before her period starts. She reports feeling tearful and lacking motivation during this time, but her symptoms improve once her period begins. Although her symptoms are bothersome, they are not affecting her work or personal life. She has a regular 30-day cycle, doesn't experience heavy or painful periods, and denies any intermenstrual bleeding. She is in a committed relationship and uses condoms for contraception, with no plans to conceive in the near future. What treatment options can you suggest to alleviate her premenstrual symptoms?

      Your Answer: Insertion of an intrauterine contraceptive device

      Correct Answer: A new generation combined contraceptive pill

      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 doesn’t 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 condition.

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  • Question 78 - Liam is a 25-year-old man with a diagnosis of cyclical mastalgia. At what...

    Incorrect

    • Liam is a 25-year-old man with a diagnosis of cyclical mastalgia. At what point would you anticipate his breast pain to be most severe?

      Your Answer: During the follicular phase

      Correct Answer: Around menses

      Explanation:

      The intensity of cyclical mastalgia changes depending on the menstrual cycle phase. It is most severe during menstruation and starts during the luteal phase, gradually worsening until menstruation. However, it improves during the follicular phase. This type of mastalgia is linked to hormonal fluctuations and is not influenced by seasonal changes.

      Cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle and is not usually associated with point tenderness of the chest wall. The underlying cause is difficult to identify, but focal lesions such as cysts may be treated to provide symptomatic relief. Women should be advised to wear a supportive bra and conservative treatments such as standard oral and topical analgesia may be used. Flaxseed oil and evening primrose oil are sometimes used, but neither are recommended by NICE Clinical Knowledge Summaries. If the pain persists after 3 months and affects the quality of life or sleep, referral should be considered. Hormonal agents such as bromocriptine and danazol may be more effective, but many women discontinue these therapies due to adverse effects.

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  • Question 79 - A 21-year-old woman decides to opt for an implantable contraceptive. What distinguishes Nexplanon...

    Correct

    • A 21-year-old woman decides to opt for an implantable contraceptive. What distinguishes Nexplanon from Implanon as its primary benefit?

      Your Answer: New design makes the insertion of implants that are too deep less likely

      Explanation:

      Implanon and Nexplanon are both subdermal contraceptive implants that slowly release the hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is an updated version of Implanon with 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 doesn’t contain estrogen, making it suitable for women with a history of thromboembolism or migraines. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraception is required for the first 7 days if not inserted on days 1-5 of the 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 may reduce the efficacy of Nexplanon, and women should switch to a different method or use additional contraception until 28 days after stopping the treatment. Contraindications include ischaemic heart disease/stroke, unexplained vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Breast cancer is a UKMEC 4 condition, meaning it represents an unacceptable risk if the contraceptive method is used.

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  • Question 80 - A 25-year-old woman presents to her GP with complaints of vaginal itching and...

    Correct

    • A 25-year-old woman presents to her GP with complaints of vaginal itching and pain while urinating. She reports that these symptoms are interfering with her daily life, particularly during sexual intercourse. She has noticed a change in the appearance of her discharge, which now has a curd-like texture, but there is no change in odor. She is concerned that she may have contracted an STI. She denies any increase in urinary frequency or urgency. She has no significant medical history but had an IUD inserted six months ago.

      What is the most appropriate method for diagnosing this patient?

      Your Answer: Based on symptoms

      Explanation:

      The diagnosis of vaginal candidiasis doesn’t necessarily require a high vaginal swab if the symptoms are highly indicative of the condition. According to NICE guidelines, if a patient presents with classic symptoms such as thick-white discharge, dysuria, itching, and dyspareunia, objective testing is not necessary to confirm the diagnosis. Therefore, the patient can be prescribed oral fluconazole without the need for a swab.

      It is incorrect to assume that a healthcare professional or self-collected high vaginal swab is necessary for diagnosis. As mentioned earlier, the patient’s symptoms are highly suggestive of candidiasis, making a swab unnecessary.

      Similarly, a mid-stream urine sample for sensitivities is not appropriate in this case. This type of test would be more suitable if the patient had symptoms indicative of a urinary tract infection. However, since the patient denies urinary urgency and frequency, a UTI is unlikely. The change in discharge consistency, which is characteristic of vaginal candidiasis, further supports this diagnosis. Therefore, a urine sample is not required.

      Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

      Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

      Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

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  • Question 81 - A 25-year-old woman presents to the clinic seeking emergency contraception. She had unprotected...

    Incorrect

    • A 25-year-old woman presents to the clinic seeking emergency contraception. She had unprotected sexual intercourse 24 hours ago and has not had any other instances of unprotected sex. She has no history of using emergency contraception or regular contraception. Her last menstrual period was 12 days ago, and she has a regular 30-day cycle. She has a medical history of severe asthma and takes oral steroids. She declines the use of an intrauterine device.

      On examination, her blood pressure is 120/80 mmHg, and her body-mass index is 35 kg/m2.

      What is the next appropriate step in managing this patient?

      Your Answer: Explain to the patient that oral emergency contraception is unlikely to be effective, and advise the patient to re-consider the copper intra-uterine device

      Correct Answer: Offer the patient levonorgestrel 3 mg, and advice the patient to perform a pregnancy test within 3-weeks

      Explanation:

      It is incorrect to advise the patient that she doesn’t require emergency contraception as she is at risk of pregnancy. Although oral emergency contraception may not be effective if taken after ovulation, the patient’s last menstrual period was only 10 days ago, making it a potential option. The patient has declined an intrauterine device, which is the most effective option, but should not be pressured into using it for emergency contraception. Ulipristal acetate is not recommended for the patient due to her severe asthma and use of oral steroids. It is important to note that patients with a BMI over 26 or weight over 70 kg should be given a double dose of levonorgestrel for emergency contraception. Additionally, it is crucial to discuss ongoing contraception and sexual health with the patient.

      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, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

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  • Question 82 - A 35-year-old teacher presents with heavy periods. She reports using 8-10 pads daily...

    Incorrect

    • A 35-year-old teacher presents with heavy periods. She reports using 8-10 pads daily during her 10-day long periods. She has two children and doesn't want any more at this time. She experiences mild cramping but no pain. Her busy schedule makes it difficult for her to remember to take medication daily. Blood tests reveal iron deficiency and she is prescribed iron tablets. Pelvic ultrasound shows no abnormalities. What is the recommended initial treatment for menorrhagia in this patient?

      Your Answer: Progesterone only pill

      Correct Answer: Mirena

      Explanation:

      Treatment Options for Menorrhagia

      Menorrhagia, or heavy menstrual bleeding, can be effectively treated with the Mirena intrauterine device. It is important to note that the Mirena also serves as a long-term contraceptive, making it a suitable option for many women. The copper coil, on the other hand, can actually increase vaginal bleeding and should be avoided in cases of menorrhagia. While the combined oral contraceptive pill is a viable option, it may not be the best choice for women with busy or unpredictable lifestyles. The progesterone-only pill is a third-line option, but there is no reason not to use the Mirena as a first-line treatment. Non-steroidal anti-inflammatory drugs like mefenamic acid may be helpful for dysmenorrhoea, but are not typically used for menorrhagia. For more information on treatment options for menorrhagia, visit http://cks.nice.org.uk/menorrhagia#!scenario.

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  • Question 83 - A 35-year-old woman comes to your clinic after discovering that she is pregnant....

    Incorrect

    • A 35-year-old woman comes to your clinic after discovering that she is pregnant. She had the Mirena coil inserted for heavy periods approximately nine months ago. She inquires about whether she needs to have her Mirena coil removed.

      What is the appropriate guidance concerning the removal of the Mirena coil?

      Your Answer: The Mirena coil can be removed at any stage of the pregnancy

      Correct Answer: The Mirena coil should not be removed if the pregnancy is diagnosed after 12 weeks gestation

      Explanation:

      Contraception and Pregnancy

      When a woman becomes pregnant while using contraception, it is usually recommended to stop or remove the method. However, it is important to note that contraceptive hormones do not typically harm the fetus.

      If an intrauterine method is in place when pregnancy is diagnosed, the woman should be informed of the potential risks of leaving it in-situ, such as second-trimester miscarriage, preterm delivery, and infection. While removal in the first trimester carries a small risk of miscarriage, it may reduce the risk of adverse outcomes. If the threads of the intrauterine contraceptive are visible or can be retrieved, it should be removed up to 12 weeks gestation, but not after this point.

      Overall, it is important for women to discuss their contraceptive options with their healthcare provider and to inform them if they suspect they may be pregnant.

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  • Question 84 - A 68-year-old male presents with an increase in breast tissue that he finds...

    Incorrect

    • A 68-year-old male presents with an increase in breast tissue that he finds embarrassing. He denies any recent weight gain and further questioning reveals no significant findings. The patient has a medical history of ischemic heart disease, atrial fibrillation, prostate cancer, and osteoarthritis of both hips. He is currently taking atorvastatin, bisoprolol, goserelin, GTN spray, lansoprazole, naproxen, and ramipril. Which medication from his current regimen could be responsible for his presenting complaint?

      Your Answer: Ramipril

      Correct Answer: Goserelin

      Explanation:

      The patient’s gynaecomastia is likely caused by taking goserelin for prostate cancer. Goserelin is a GnRH agonist that increases luteinising hormone and testosterone levels, leading to a change in oestrogen: androgen ratio and resulting in gynaecomastia. Bisoprolol, a β-blocker, may cause bronchospasm and bradycardia, while lansoprazole, a proton pump inhibitor, may lead to hyponatraemia and hypomagnesaemia. Naproxen, a non-steroidal anti-inflammatory drug, may worsen asthma symptoms and cause upper gastrointestinal haemorrhage.

      Understanding Gynaecomastia: Causes and Drug Triggers

      Gynaecomastia is a condition characterized by the abnormal growth of breast tissue in males, often caused by an increased ratio of oestrogen to androgen. It is important to distinguish the causes of gynaecomastia from those of galactorrhoea, which is caused by the actions of prolactin on breast tissue.

      Physiological changes during puberty can lead to gynaecomastia, but it can also be caused by syndromes with androgen deficiency such as Kallman’s and Klinefelter’s, testicular failure due to mumps, liver disease, testicular cancer, and hyperthyroidism. Additionally, haemodialysis and ectopic tumour secretion can also trigger gynaecomastia.

      Drug-induced gynaecomastia is also a common cause, with spironolactone being the most frequent trigger. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids. However, it is important to note that very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa.

      In summary, understanding the causes and drug triggers of gynaecomastia is crucial in diagnosing and treating this condition.

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  • Question 85 - A 28-year-old woman comes to you after finding out she is pregnant two...

    Incorrect

    • A 28-year-old woman comes to you after finding out she is pregnant two months after getting a progesterone-only implant. She wants to continue the pregnancy but is concerned about the effects of the hormone on the fetus.

      What advice would you give to this patient?

      Your Answer: Terminate the pregnancy

      Correct Answer: Remove contraceptive implant

      Explanation:

      Contraceptive Hormones and Pregnancy

      Women who are using contraceptive hormones should not worry about any harm to the fetus if they become pregnant. It is not necessary to terminate the pregnancy for this reason. If the woman chooses to abort the pregnancy, the contraceptive implant can be left in place for ongoing contraception. Referral to an early pregnancy assessment unit or for an anomaly scan is also unnecessary as there is no risk to the fetus.

      However, it is important to remove the progesterone-only implant as soon as pregnancy is confirmed. The only exception to this is if an intrauterine device is in place and pregnancy is diagnosed after 12 weeks. In such cases, the contraception should not be removed. Women can be reassured that contraceptive hormones are safe and effective for preventing pregnancy, and should not hesitate to use them if desired.

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  • Question 86 - A 55-year-old woman presents with urgency and frequency. Three weeks ago she consulted...

    Incorrect

    • A 55-year-old woman presents with urgency and frequency. Three weeks ago she consulted with a colleague as she felt 'dry' during intercourse. She has been treated for urinary tract infections on multiple occasions in the past but urine culture is always negative. Her only medication is continuous hormone replacement therapy which she has taken since her periods stopped three years ago. A vaginal examination is performed which shows no evidence of vaginal atrophy and no masses are felt. An ultrasound is requested:

      Both kidneys, spleen and liver are normal size. Outline of the bladder normal. 3 cm simple ovarian cyst noted on left ovary. Right ovary and uterus normal

      What is the most appropriate next step?

      Your Answer: Refer for bladder retraining

      Correct Answer: Urgent referral to gynaecology

      Explanation:

      Investigation is necessary for any ovarian mass found in a woman who has undergone menopause.

      When a patient presents with suspected ovarian cysts or tumors, the first imaging modality used is typically ultrasound. The ultrasound report will indicate whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and whether they are experiencing symptoms. It is important to note that ovarian cancer diagnosis is often delayed due to a vague presentation.

      For premenopausal women, a conservative approach may be taken, especially if they are younger than 35 years old, as malignancy is less common. If the cyst is small (less than 5 cm) and reported as simple, it is highly likely to be benign. A repeat ultrasound should be scheduled for 8-12 weeks, and referral should be considered if the cyst persists.

      Postmenopausal women, on the other hand, are unlikely to have physiological cysts. Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynecology for assessment.

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  • Question 87 - Which one of the following features is least consistent with Trichomonas vaginalis? ...

    Incorrect

    • Which one of the following features is least consistent with Trichomonas vaginalis?

      Your Answer: Vaginal pH < 4.5

      Correct Answer:

      Explanation:

      A pH level greater than 4.5 is linked to Trichomonas vaginalis and bacterial vaginosis.

      Comparison of Bacterial Vaginosis and Trichomonas Vaginalis

      Bacterial vaginosis and Trichomonas vaginalis are two common sexually transmitted infections that affect women. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while Trichomonas vaginalis is caused by a protozoan parasite. Both infections can cause vaginal discharge and vulvovaginitis, but Trichomonas vaginalis may also cause urethritis in men.

      The vaginal discharge in bacterial vaginosis is typically thin and grayish-white, with a fishy odor. The pH of the vagina is usually higher than 4.5. In contrast, the discharge in Trichomonas vaginalis is offensive, yellow/green, and frothy. The cervix may also appear like a strawberry. The pH of the vagina is also higher than 4.5.

      To diagnose bacterial vaginosis, a doctor may perform a pelvic exam and take a sample of the vaginal discharge for testing. The presence of clue cells, which are vaginal cells covered in bacteria, is a hallmark of bacterial vaginosis. On the other hand, Trichomonas vaginalis can be diagnosed by examining a wet mount under a microscope. The motile trophozoites of the parasite can be seen in the sample.

      Both bacterial vaginosis and Trichomonas vaginalis can be treated with antibiotics. Metronidazole is the drug of choice for both infections. For bacterial vaginosis, a course of oral metronidazole for 5-7 days is recommended. For Trichomonas vaginalis, a one-off dose of 2g metronidazole may also be used. It is important to complete the full course of antibiotics to ensure that the infection is fully treated.

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  • Question 88 - A 24-year-old female patient complains of dysuria, malaise, vaginal pain, fever, and myalgia....

    Incorrect

    • A 24-year-old female patient complains of dysuria, malaise, vaginal pain, fever, and myalgia. During a vaginal examination, several painful ulcerations are discovered around the vagina and perineum. Urinalysis shows trace leukocytes, no nitrites, and microscopic haematuria. Swabs are taken and sent for testing, and a urine MCS is also sent. What is the most suitable treatment for the most probable diagnosis?

      Your Answer: Trimethoprim at night for 3 days

      Correct Answer: Valaciclovir twice daily for 10 days

      Explanation:

      The patient is likely experiencing genital ulcers and systemic symptoms due to a primary herpes simplex genital infection, which commonly causes painful ulcers. While waiting for swab results, treatment should be initiated with an antiviral such as valaciclovir for a longer course in an initial infection.

      If a simple urinary tract infection is suspected, trimethoprim for 3 days may be appropriate. However, dysuria and trace leukocytes can also be indicative of primary herpes simplex infection.

      Valaciclovir is the correct treatment for this patient, but a 3-day course is insufficient for a primary infection and would be more appropriate for a recurrence of genital herpes.

      If lymphogranuloma venereum is suspected, doxycycline daily for 7 days may be appropriate. However, this is less likely in this case as it typically leads to painless ulceration and is uncommon.

      If a complicated urinary tract infection is suspected, trimethoprim for 7 days may be appropriate. However, given the presence of painful ulceration, herpes infection is the most likely cause regardless of urinalysis results and dysuria.

      Understanding STI Ulcers

      Genital ulcers are a common symptom of several sexually transmitted infections (STIs). One of the most well-known causes is the herpes simplex virus (HSV) type 2, which can cause severe primary attacks with fever and subsequent attacks with multiple painful ulcers. Syphilis, caused by the spirochaete Treponema pallidum, has primary, secondary, and tertiary stages, with a painless ulcer (chancre) appearing in the primary stage. Chancroid, a tropical disease caused by Haemophilus ducreyi, causes painful genital ulcers with a sharply defined, ragged, undermined border and unilateral, painful inguinal lymph node enlargement. Lymphogranuloma venereum (LGV), caused by Chlamydia trachomatis, has three stages, with the first stage showing a small painless pustule that later forms an ulcer, followed by painful inguinal lymphadenopathy in the second stage and proctocolitis in the third stage. LGV is treated with doxycycline. Other causes of genital ulcers include Behcet’s disease, carcinoma, and granuloma inguinale (previously called Calymmatobacterium granulomatis). Understanding the different causes of STI ulcers is crucial in diagnosing and treating these infections.

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  • Question 89 - A 63-year-old woman comes in for a check-up. She has been experiencing unusual...

    Incorrect

    • A 63-year-old woman comes in for a check-up. She has been experiencing unusual lower back pain for the last couple of months. After an x-ray of her lumbar spine, it was suggested that she may have spinal metastases, but there is no indication of a primary tumor. She was sent for a series of tumor marker tests and referred to an oncologist. Which of the following is most commonly linked to elevated levels of CA 15-3?

      Your Answer: Ovarian cancer

      Correct Answer: Breast cancer

      Explanation:

      Breast cancers can be detected by the presence of the tumour marker CA 15-3.

      Understanding Tumour Markers

      Tumour markers are substances that can be found in the blood, urine, or tissues of people with cancer. They are used to help diagnose and monitor cancer, as well as to determine the effectiveness of treatment. Tumour markers can be divided into different categories, including monoclonal antibodies against carbohydrate or glycoprotein tumour antigens, tumour antigens, enzymes, and hormones. However, it is important to note that tumour markers usually have a low specificity, meaning that they can also be present in people without cancer.

      Monoclonal antibodies are a type of tumour marker that target specific carbohydrate or glycoprotein tumour antigens. Some examples of monoclonal antibodies and their associated cancers include CA 125 for ovarian cancer, CA 19-9 for pancreatic cancer, and CA 15-3 for breast cancer.

      Tumour antigens are another type of tumour marker that are produced by cancer cells. Examples of tumour antigens and their associated cancers include prostate specific antigen (PSA) for prostatic carcinoma, alpha-feto protein (AFP) for hepatocellular carcinoma and teratoma, carcinoembryonic antigen (CEA) for colorectal cancer, S-100 for melanoma and schwannomas, and bombesin for small cell lung carcinoma, gastric cancer, and neuroblastoma.

      Understanding tumour markers and their associations with different types of cancer can aid in the diagnosis and management of cancer. However, it is important to interpret tumour marker results in conjunction with other diagnostic tests and clinical findings.

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  • Question 90 - At her pill check, a 28-year-old woman inquires about transitioning from Microgynon 30...

    Incorrect

    • At her pill check, a 28-year-old woman inquires about transitioning from Microgynon 30 to Qlaira. What is the accurate statement about Qlaira?

      Your Answer: Venous thromboembolism is less likely compared to other COCPs

      Correct Answer: Users take pills for every day of the 28 day cycle

      Explanation:

      Qlaira is taken daily for a 28-day cycle, with 26 pills containing estradiol +/- dienogest and 2 inactive pills. The dose of estradiol decreases gradually while the dose of dienogest increases during the cycle.

      Choice of Combined Oral Contraceptive Pill

      The combined oral contraceptive pill (COCP) comes in different variations based on the amount of oestrogen and progestogen and the presentation. For first-time users, it is recommended to use a pill containing 30 mcg ethinyloestradiol with levonorgestrel/norethisterone. However, two new COCPs have been developed in recent years, namely Qlaira and Yaz, which work differently from traditional pills.

      Qlaira is a combination of estradiol valerate and dienogest with a quadriphasic dosage regimen designed to provide optimal cycle control. The pill is taken every day for a 28-day cycle, with 26 pills containing estradiol +/- dienogest and two pills being inactive. The dose of estradiol is gradually reduced, and that of dienogest is increased during the cycle to give women a more natural cycle with constant oestrogen levels. However, Qlaira is more expensive than standard COCPs, and there is limited safety data to date.

      On the other hand, Yaz combines 20mcg ethinylestradiol with 3mg drospirenone and has a 24/4 regime, unlike the normal 21/7 cycle. This shorter pill-free interval is better for patients with troublesome premenstrual symptoms and is more effective at preventing ovulation. Studies have shown that Yaz causes less premenstrual syndrome, and blood loss is reduced by 50-60%.

      In conclusion, the choice of COCP depends on various factors such as cost, safety data, and missed pill rules. It is essential to consult a healthcare provider to determine the most suitable COCP based on individual needs and medical history.

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  • Question 91 - What is a factor that increases the risk of developing ovarian cancer? ...

    Incorrect

    • What is a factor that increases the risk of developing ovarian cancer?

      Your Answer: BMI less than 20

      Correct Answer: Infertility treatment

      Explanation:

      Recognizing Risk Factors for Ovarian Cancer in Primary Care

      It can be challenging to diagnose ovarian cancer in primary care, as patients often present with vague abdominal symptoms. However, early detection is crucial for improving outcomes. One way to increase early detection rates is to recognize the risk factors for ovarian cancer. The Macmillan organization has compiled a list of possible risk factors, including family history, age, early menarche, late menopause, HRT use, endometriosis, and ovarian cysts before the age of 30. Protective factors include pregnancy, increased numbers of children, combined oral contraceptive use, and hysterectomy. By asking a few questions about risk factors and family history, primary care providers can better assess the risk of ovarian cancer in their patients. It is important to consider ovarian cancer as a possibility, particularly in women with predominantly gastrointestinal symptoms. By recognizing the risk factors and being alert to the possibility of ovarian cancer, primary care providers can improve early detection rates and ultimately improve patient outcomes.

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  • Question 92 - A 42-year-old woman with oestrogen receptor positive breast cancer presents for follow-up, four...

    Correct

    • A 42-year-old woman with oestrogen receptor positive breast cancer presents for follow-up, four months after initiating tamoxifen therapy. What is the most probable adverse effect that may arise in this patient?

      Your Answer: Hot flashes

      Explanation:

      Hot flashes are a common side-effect of tamoxifen, as stated in the BNF. Although alopecia and cataracts are also listed as possible side-effects, they are not as frequently observed as hot flashes, particularly in women who have not yet reached menopause.

      Tamoxifen and its Adverse Effects

      Tamoxifen is a medication used in the treatment of breast cancer that is positive for oestrogen receptors. It is classified as a Selective oEstrogen Receptor Modulator (SERM) and works by acting as an antagonist and partial agonist of the oestrogen receptor. However, the use of tamoxifen can lead to several adverse effects. These include menstrual disturbances such as vaginal bleeding and amenorrhoea, as well as hot flashes which can cause 3% of patients to stop taking the medication due to climacteric side-effects. Additionally, tamoxifen increases the risk of venous thromboembolism and endometrial cancer.

      To manage breast cancer, tamoxifen is typically prescribed for a period of 5 years following the removal of the tumour. However, due to the risk of endometrial cancer associated with tamoxifen, an alternative medication called raloxifene may be used. Raloxifene is a pure oestrogen receptor antagonist and carries a lower risk of endometrial cancer. It is important for patients to discuss the potential risks and benefits of tamoxifen and other medications with their healthcare provider before starting treatment.

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  • Question 93 - You encounter a 24-year-old woman at your family planning clinic who wishes to...

    Incorrect

    • You encounter a 24-year-old woman at your family planning clinic who wishes to initiate the combined oral contraceptive pill (COCP). She has no significant medical history, but she does smoke 5-10 cigarettes per day. Her BMI and blood pressure are both within normal ranges. Her aunt was diagnosed with endometrial cancer at the age of 55.

      Which of the following statements is accurate?

      Your Answer: The UK medical eligibility criteria for this patient is category 3

      Correct Answer: COCP is associated with a reduced risk of ovarian cancer

      Explanation:

      The use of combined hormonal contraceptive pills can lead to a decreased risk of ovarian and endometrial cancer that can last for many years even after discontinuation. However, for women under 35 years of age who smoke, the UKMEC category is 2, indicating that the benefits of using the method generally outweigh the potential risks. For women over 35 years of age who smoke, the UKMEC category is 3 if they smoke less than 15 cigarettes a day and 4 if they smoke more than 15 cigarettes a day.

      While some meta-analyses have shown a slightly increased risk of breast cancer among women using COCP, there is no significant risk of breast cancer after 10 years of discontinuation. Additionally, COCP can help reduce menstrual bleeding and pain, as well as alleviate menopausal symptoms.

      Pros and Cons of the Combined Oral Contraceptive Pill

      The combined oral contraceptive pill is a highly effective method of birth control with a failure rate of less than one per 100 woman years. It is a convenient option that doesn’t interfere with sexual activity and its contraceptive effects are reversible upon stopping. Additionally, it can make periods regular, lighter, and less painful, and may reduce the risk of ovarian, endometrial, and colorectal cancer. It may also protect against pelvic inflammatory disease, ovarian cysts, benign breast disease, and acne vulgaris.

      However, there are also some disadvantages to consider. One of the main drawbacks is that people may forget to take it, which can reduce its effectiveness. It also offers no protection against sexually transmitted infections, so additional precautions may be necessary. There is an increased risk of venous thromboembolic disease, breast and cervical cancer, stroke, and ischaemic heart disease, especially in smokers. Temporary side effects such as headache, nausea, and breast tenderness may also be experienced.

      Despite some reports of weight gain, a Cochrane review did not find a causal relationship between the combined oral contraceptive pill and weight gain. Overall, the combined oral contraceptive pill can be a safe and effective option for birth control, but it is important to weigh the pros and cons and discuss any concerns with a healthcare provider.

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  • Question 94 - A 30-year-old lady presents following an ultrasound pelvis which found a 2cm fibroid....

    Incorrect

    • A 30-year-old lady presents following an ultrasound pelvis which found a 2cm fibroid. This was an incidental finding and on direct questioning, she reports no menorrhagia, no compressive symptoms and no history of difficulties conceiving. On examination, her abdomen was soft and non tender.

      What is the MOST SUITABLE NEXT step in management?

      Your Answer: Levonorgestrel-releasing intrauterine system

      Correct Answer: Repeat ultrasound in one year

      Explanation:

      Management of Asymptomatic Fibroids in Women

      The absence of menorrhagia is an important point to note in the management of asymptomatic fibroids in women. According to guidelines, annual follow-up to monitor size and growth is recommended for such cases. However, routine referral to a gynaecologist is not required unless there are symptoms that have not improved despite initial treatments, complications, fertility or obstetric problems associated with fibroids, or a suspicion of malignancy. Treatment options for menorrhagia associated with fibroids are available but have no role in the management of small asymptomatic fibroids. NSAIDs and/or tranexamic acid should be stopped if symptoms have not improved within three menstrual cycles. It is important to consider these factors when managing asymptomatic fibroids in women.

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  • Question 95 - A 35-year-old woman came to see your colleague two weeks ago with a...

    Incorrect

    • A 35-year-old woman came to see your colleague two weeks ago with a five day history of pain, redness and swelling of her left breast. She was given seven days of flucloxacillin. She has returned and it is no better; if anything it is slightly worse.

      There is no discharge. She stopped Breastfeeding her last child eight months ago. She is otherwise very well. Her mother had breast cancer in her 60s and her maternal aunt had bowel cancer in her 70s.

      On examination about half of the breast is erythematous, and the affected breast seems larger than the other side. There is no discrete mass to feel but the whole of the swollen area is indurated. She has a palpable axillary lymph node on that side. Her pulse is 80 bpm and her temperature is 36.2°C.

      Which of these options would you select?

      Your Answer: Suggest she expresses milk to try to reduce her symptoms and review if not settling

      Correct Answer: Treat with anti-inflammatories and refer urgently to breast clinic

      Explanation:

      Recognizing Inflammatory Breast Cancer

      Most GPs and patients are familiar with the presentation of a breast lump, but inflammatory breast cancer can present in a more unusual way, making a swift diagnosis difficult. However, simply considering the possibility of this rare form of breast cancer can help pick out relevant information in the patient’s history and examination. Inflammatory breast cancer is not common, accounting for only 1-4% of all breast cancers, which can lead to delayed diagnosis in primary care. Patients with a personal or family history of breast cancer, symptoms of non-lactational mastitis that do not respond to antibiotics, palpable lymphadenopathy, involvement of more than 1/3 of the breast, and an absence of fever should be considered at high risk for inflammatory breast cancer.

      It is important for GPs to ask about family history of breast cancer and check and record temperature when seeing patients with mastitis. Blindly prescribing another course of antibiotics, especially when the patient doesn’t have a fever or symptoms of infection, may delay diagnosis. Suggesting milk expression would be reasonable for lactational mastitis, but not for a patient who stopped breastfeeding six months ago. Attempting to aspirate would not be advisable for a generalist in a primary care setting, even if an abscess were suspected. Referring the patient to the Emergency department for assessment by a breast surgeon would be a wiser strategy.

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  • Question 96 - A 25-year-old woman who is taking the combined oral contraceptive pill (COCP) seeks...

    Incorrect

    • A 25-year-old woman who is taking the combined oral contraceptive pill (COCP) seeks advice. She is currently on day 15 of her cycle and has missed her last two pills. Before this, she had taken her pill correctly every day. She had unprotected sex 10 hours ago and is unsure if she needs emergency contraception to avoid pregnancy.

      What advice should she be given?

      Your Answer: To arrange oral emergency contraception

      Correct Answer: No emergency contraception is required and to continue taking her pill as normal

      Explanation:

      If the patient has missed two pills between days 8-14 of her cycle but has taken the previous 7 days of COCP correctly, emergency contraception is not necessary according to the Faculty of Sexual and Reproductive Health. Since the patient is not in need of emergency contraception, offering a hormonal-based option would be inappropriate. However, if emergency contraception is required, options include EllaOne (ulipristal acetate) up to 120 hours after unprotected intercourse or Levonelle (levonorgestrel) up to 96 hours after unprotected intercourse.

      Inserting a copper IUD to prevent pregnancy would also be inappropriate in this case. If the patient is having difficulty remembering to take her pill correctly and is interested in long-acting contraception, counseling her on options such as intrauterine devices, subnormal contraceptive implants, and the contraceptive injection would be appropriate.

      It is important to note that emergency contraception can be prescribed up to 120 hours after unprotected sexual intercourse, but its effectiveness decreases over time. Therefore, advising a patient to take emergency contraception within 12 hours would be incorrect.

      The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during 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. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she 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 seven days on, seven days off.

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  • Question 97 - You come across a 30-year-old woman with a breast lump that has been...

    Correct

    • You come across a 30-year-old woman with a breast lump that has been there for 4 weeks. She is generally healthy and takes only the combined hormonal contraceptive pill (COCP). There is no history of breast cancer in her family.

      After examining the patient, you refer her to the breast clinic for further investigation under the 2-week wait scheme. She inquires about what she should do regarding her COCP.

      Your Answer: 2

      Explanation:

      The UKMEC provides guidance for healthcare providers when selecting appropriate contraceptives based on a patient’s medical history. For women with an undiagnosed breast mass, starting the combined hormonal contraceptive pill is considered UKMEC 3, while continuing its use is classified as UKMEC 2. It is important to note that hormonal contraceptives may impact the prognosis of women with current or past breast cancer, which is classified as UKMEC 4 and UKMEC 3, respectively. Women with benign breast conditions or a family history of breast cancer are classified as UKMEC 1.

      The choice of contraceptive for women may be affected by comorbidities. The FSRH provides UKMEC recommendations for different conditions. Smoking increases the risk of cardiovascular disease, and the COCP is recommended as UKMEC 2 for women under 35 and UKMEC 3 for those over 35 who smoke less than 15 cigarettes/day, but is UKMEC 4 for those who smoke more. Obesity increases the risk of venous thromboembolism, and the COCP is recommended as UKMEC 2 for women with a BMI of 30-34 kg/m² and UKMEC 3 for those with a BMI of 35 kg/m² or more. The COCP is contraindicated for women with a history of migraine with aura, but is UKMEC 3 for those with migraines without aura and UKMEC 2 for initiation. For women with epilepsy, consistent use of condoms is recommended in addition to other forms of contraception. The choice of contraceptive for women taking anti-epileptic medication depends on the specific medication, with the COCP and POP being UKMEC 3 for most medications, while the implant is UKMEC 2 and the Depo-Provera, IUD, and IUS are UKMEC 1. Lamotrigine has different recommendations, with the COCP being UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS being UKMEC 1.

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  • Question 98 - A 21-year-old female with no significant medical or family history presents to surgery...

    Incorrect

    • A 21-year-old female with no significant medical or family history presents to surgery requesting to start an oral contraceptive pill. If a combined pill is selected, which of the following options would be the most appropriate?

      Your Answer: Ethinylestradiol 35 mcg with norethisterone 1 mg

      Correct Answer: Ethinylestradiol 30 mcg with levonorgestrel 150 mcg

      Explanation:

      For individuals using the combined oral contraceptive pill for the first time, the faculty suggests a pill containing 30 mcg of estrogen.

      Choice of Combined Oral Contraceptive Pill

      The combined oral contraceptive pill (COCP) comes in different variations based on the amount of oestrogen and progestogen and the presentation. For first-time users, it is recommended to use a pill containing 30 mcg ethinyloestradiol with levonorgestrel/norethisterone. However, two new COCPs have been developed in recent years, namely Qlaira and Yaz, which work differently from traditional pills.

      Qlaira is a combination of estradiol valerate and dienogest with a quadriphasic dosage regimen designed to provide optimal cycle control. The pill is taken every day for a 28-day cycle, with 26 pills containing estradiol +/- dienogest and two pills being inactive. The dose of estradiol is gradually reduced, and that of dienogest is increased during the cycle to give women a more natural cycle with constant oestrogen levels. However, Qlaira is more expensive than standard COCPs, and there is limited safety data to date.

      On the other hand, Yaz combines 20mcg ethinylestradiol with 3mg drospirenone and has a 24/4 regime, unlike the normal 21/7 cycle. This shorter pill-free interval is better for patients with troublesome premenstrual symptoms and is more effective at preventing ovulation. Studies have shown that Yaz causes less premenstrual syndrome, and blood loss is reduced by 50-60%.

      In conclusion, the choice of COCP depends on various factors such as cost, safety data, and missed pill rules. It is essential to consult a healthcare provider to determine the most suitable COCP based on individual needs and medical history.

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  • Question 99 - Injectable depot-provera ...

    Incorrect

    • Injectable depot-provera

      Your Answer: Levonorgestrel intrauterine system

      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. As a result, the copper intrauterine device is the only suitable contraception option available.

      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 Noristerat, another injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks. The BNF gives different advice regarding the interval between injections, stating that a pregnancy test should be done if the interval is greater than 12 weeks and 5 days. However, this is not commonly adhered to in the family planning community.

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  • Question 100 - Samantha is a 26-year-old woman who complains of bilateral breast tenderness before her...

    Incorrect

    • Samantha is a 26-year-old woman who complains of bilateral breast tenderness before her period. She also observes that her breasts feel lumpier than usual. The discomfort is unbearable, and she wants to know the best course of action. Since Samantha has just completed her menstrual cycle, there is no pain when her breasts are palpated, and there are no detectable lumps.

      What is the primary treatment option for Samantha?

      Your Answer: Vitamin E

      Correct Answer: A supportive bra

      Explanation:

      The initial treatment for cyclical mastalgia involves wearing a supportive bra and taking simple analgesia, as stated by NICE guidelines. This type of breast pain is linked to hormonal changes during the menstrual cycle. Simple analgesia options include paracetamol and NSAIDs, while codeine is not advised. The use of Cerazette, a progesterone-only contraceptive pill, may exacerbate breast tenderness. NICE guidelines do not recommend the use of vitamin E or primrose oil.

      Cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle and is not usually associated with point tenderness of the chest wall. The underlying cause is difficult to identify, but focal lesions such as cysts may be treated to provide symptomatic relief. Women should be advised to wear a supportive bra and conservative treatments such as standard oral and topical analgesia may be used. Flaxseed oil and evening primrose oil are sometimes used, but neither are recommended by NICE Clinical Knowledge Summaries. If the pain persists after 3 months and affects the quality of life or sleep, referral should be considered. Hormonal agents such as bromocriptine and danazol may be more effective, but many women discontinue these therapies due to adverse effects.

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  • Question 101 - A 28-year-old woman visits her GP with complaints of vaginal itching and increased...

    Incorrect

    • A 28-year-old woman visits her GP with complaints of vaginal itching and increased discharge with a peculiar consistency, but no odour. During the examination, the GP observes erythema in the areas surrounding her vagina, along with some clumpy white discharge. The patient reports experiencing dysuria but no abdominal pain, and her urine appears pale yellow. She also mentions having three similar episodes in the past year. What possible conditions should be considered for this patient?

      Your Answer: Measure TSH, free T3 and T4 levels to rule out hyperthyroidism

      Correct Answer: A blood test to rule out diabetes

      Explanation:

      In cases of recurrent vaginal candidiasis, it is important to consider a blood test to rule out diabetes as a potential underlying cause. This is because poorly controlled diabetes can increase the risk of Candida growth. While it is important to treat the symptoms of the infection, it is also crucial to investigate any predisposing factors that may be contributing to the recurrence.

      Measuring TSH, free T3 and T4 levels to rule out hyperthyroidism is not necessary as there is no link between an overactive thyroid and Candida infections. Similarly, mid-stream urine to rule out UTI is not necessary unless the patient’s symptoms suggest a urinary tract infection. Referral to a specialist is also not necessary as recurrent vaginal candidiasis can be managed in primary care with an induction-maintenance regimen of antifungals. Specialist referral may only be necessary if the infective organism is resistant to treatment or if it is a non-albicans Candida species.

      Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

      Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

      Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.