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Question 1
Incorrect
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A 26-year-old woman presents to her GP with worsening lower abdominal pain over the past 48 hours. The pain is located in the suprapubic area and slightly to the left. She experienced some vaginal bleeding this morning, which she describes as light. The patient also reports shoulder pain that started after playing tennis. Her last menstrual period was seven weeks ago and was normal. She has a history of Chlamydia infection and admits to not practicing safe sex. On examination, she is tender in the left iliac fossa. Her blood pressure is 98/62 mmHg, and her pulse is 100/min. What is the most likely diagnosis?
Your Answer: Pelvic inflammatory disease
Correct Answer: Ruptured ectopic pregnancy
Explanation:Ectopic pregnancy presents with amenorrhoea, abdominal pain, vaginal bleeding, and shoulder tip pain indicating peritoneal bleeding.
Understanding Ectopic Pregnancy
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.
During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended 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 >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.
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This question is part of the following fields:
- Reproductive Medicine
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Question 2
Incorrect
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A 21-year-old young woman attends surgery concerned about painful periods. She reports normal blood loss and a regular cycle; she is not sexually active. Pelvic examination is normal.
Which of the following is the most appropriate treatment choice?Your Answer: Paracetamol
Correct Answer: Mefenamic acid
Explanation:According to NICE guidelines, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, or mefenamic acid should be the first-line treatment for primary dysmenorrhoea, unless contraindicated. Combined oral contraceptives (COCs) containing ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are also recommended for women who do not wish to conceive. However, for a non-sexually active woman, a non-hormonal drug would be more appropriate. Paracetamol can be prescribed if NSAIDs are not tolerated or contraindicated. Tranexamic acid is useful for menorrhagia, not dysmenorrhoea. The diagnosis of primary dysmenorrhoea is likely if menstrual pain starts 6-12 months after menarche, before menstruation, and lasts up to 72 hours, with non-gynaecological symptoms present, and a normal pelvic examination.
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This question is part of the following fields:
- Reproductive Medicine
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Question 3
Incorrect
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A 20-year-old female presents to the emergency department with left-sided pelvic pain and vaginal bleeding. She reports her last menstrual period was 8 weeks ago and has had a positive urinary pregnancy test. The patient is stable hemodynamically, and bloods have been taken for full blood count, renal and liver function, and C-reactive protein. What is the most suitable diagnostic test to determine the underlying cause of her symptoms?
Your Answer: Serum Beta-human chorionic gonadotrophin (BHCG) level
Correct Answer: Transvaginal ultrasound scan
Explanation:To confirm or rule out ectopic pregnancy, the recommended investigation is transvaginal ultrasound. This is because it provides clearer images of the uterus, ovaries, and endometrium, making it more effective in detecting ectopic pregnancies compared to transabdominal scans. While serum Beta-HCG levels are helpful in managing ectopic pregnancies, a single test cannot completely rule out the possibility. Pregnant women are generally advised against undergoing CT scans and abdominal X-rays.
Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.
There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingotomy, depending on the patient’s risk factors for infertility.
Salpingectomy is the first-line treatment for women with no other risk factors for infertility, while salpingotomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingotomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.
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This question is part of the following fields:
- Reproductive Medicine
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Question 4
Correct
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A 30-year-old woman has delivered a baby boy at 40 + 2 weeks gestation. She is now 3 weeks postpartum and is exclusively breastfeeding with plans to continue for at least 6 months. What contraceptive method should she avoid due to absolute contraindication?
Your Answer: Combined contraceptive pill
Explanation:Understanding Contraception: A Basic Overview
Contraception has come a long way in the past 50 years, with the development of effective methods being one of the most significant advancements in medicine. There are various types of contraception available, including barrier methods, daily methods, and long-acting methods of reversible contraception (LARCs).
Barrier methods, such as condoms, physically block sperm from reaching the egg. While they can help protect against sexually transmitted infections (STIs), their success rate is relatively low, particularly when used by young people.
Daily methods include the combined oral contraceptive pill, which inhibits ovulation, and the progesterone-only pill, which thickens cervical mucus. However, the combined pill increases the risk of venous thromboembolism and breast and cervical cancer.
LARCs include implantable contraceptives and injectable contraceptives, which both inhibit ovulation and thicken cervical mucus. The implantable contraceptive lasts for three years, while the injectable contraceptive lasts for 12 weeks. The intrauterine system (IUS) and intrauterine device (IUD) are also LARCs, with the IUS preventing endometrial proliferation and thickening cervical mucus, and the IUD decreasing sperm motility and survival.
It is important to note that each method of contraception has its own set of benefits and risks, and it is essential to consult with a healthcare provider to determine the best option for individual needs and circumstances.
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This question is part of the following fields:
- Reproductive Medicine
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Question 5
Incorrect
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Which one of the following statements regarding endometriosis is false?
Your Answer: Laparoscopy is the gold-standard investigation
Correct Answer: Laparoscopic findings correlate well with the severity of symptoms and can guide treatment
Explanation:Understanding Endometriosis
Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.
First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.
It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.
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This question is part of the following fields:
- Reproductive Medicine
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Question 6
Incorrect
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A 29-year-old woman visits the genitourinary medicine clinic with four fleshy, pigmented lesions on her vulva after starting a new relationship. What is the best initial course of action?
Your Answer: Topical aciclovir
Correct Answer: Topical podophyllum
Explanation:For the treatment of genital warts, topical podophyllum is recommended for multiple, non-keratinised warts, while cryotherapy is recommended for solitary, keratinised warts. Cryotherapy can also be used as an initial treatment for genital warts.
Understanding Genital Warts
Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common culprits. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.
The warts themselves are small, fleshy protrusions that are typically 2-5mm in size and may be slightly pigmented. They can cause discomfort, itching, and even bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is often used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.
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This question is part of the following fields:
- Reproductive Medicine
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Question 7
Correct
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A 35 year-old woman has been diagnosed with fibroids and has been attempting to conceive for 2 years. She has been undergoing evaluation at the sub-fertility clinic and all tests have come back normal except for the presence of three uterine fibroids, which are asymptomatic. Her partner's semen analysis showed no abnormalities.
What are the most suitable treatment options in this scenario?Your Answer: Myomectomy
Explanation:If a woman with large fibroids is experiencing fertility issues, the most effective treatment option that also preserves her ability to conceive in the future is myomectomy. However, depending on the specifics of the procedure, the woman may need to consider delivery options, such as a caesarean section, due to the risk of uterine rupture.
While GnRH agonists can shrink fibroids and make them easier to remove surgically, they also temporarily turn off the ovaries, inhibiting ovulation and making pregnancy impossible during treatment. Additionally, fibroids tend to regrow after treatment is stopped. However, when combined with myomectomy, GnRH agonists can be a suitable treatment option.
Endometrial ablation, on the other hand, destroys the endometrial lining, making it impossible for an embryo to implant. Uterine artery embolisation is also not recommended for women trying to conceive, as it significantly reduces blood supply to the uterus, making it impossible for a fetus to implant and grow.
Understanding Uterine Fibroids
Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.
Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.
Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.
Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.
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This question is part of the following fields:
- Reproductive Medicine
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Question 8
Correct
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A 28-year-old female patient contacts her GP seeking guidance on folic acid supplements. She and her partner are attempting to conceive, and she has never been pregnant before. She is in good health overall, with a history of asthma that she manages with a salbutamol inhaler as needed. Her BMI is 31 kg/m2, and she has no notable family medical history. What recommendations should she receive?
Your Answer: 5mg folic acid from now until the 12th week of pregnancy
Explanation:Pregnant women with obesity (BMI >30 kg/m2) are recommended to take a high dose of 5mg folic acid from before conception until the 12th week of pregnancy. This is because obesity puts them at a higher risk of neural tube defects. The suggestion of taking 400 micrograms would be for women who are not at a higher risk. Therefore, the other answers provided are incorrect.
Folic Acid: Importance, Deficiency, and Prevention
Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.
To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.
In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.
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This question is part of the following fields:
- Reproductive Medicine
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Question 9
Correct
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A 35-year-old woman who is 36 weeks pregnant arrives at the Emergency Department complaining of severe and constant abdominal pain. She experienced some vaginal bleeding an hour ago, but it has mostly subsided, leaving only a small amount of bloody discharge. Upon obstetric examination, her uterus is firm, woody, and extremely tender. She appears pale and clammy, with a pulse of 102 bpm and a blood pressure of 98/65 mmHg. What is the probable diagnosis?
Your Answer: Placental abruption
Explanation:Antepartum hemorrhage can be caused by placental abruption, which may result in vaginal bleeding, abdominal pain, and a firm or woody uterus. In some cases, the bleeding may be concealed, and the fetus may be difficult to feel or hear. It is important to note that young and healthy women may not show signs of shock until they have lost a significant amount of blood. Contractions during labor typically come in waves and do not cause a woody or tender uterus or low blood pressure. Placenta previa is another common cause of antepartum hemorrhage, but it is usually painless.
Placental Abruption: Causes, Symptoms, and Risk Factors
Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.
The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.
In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.
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This question is part of the following fields:
- Reproductive Medicine
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Question 10
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A 56-year-old woman complains of experiencing pain during sexual intercourse with her partner for the past year. She denies any discharge but mentions that her vagina feels dry and sore frequently. She has attempted to alleviate the soreness by using vaginal moisturisers and lubricants, which she believes have provided some relief. During the examination, the vagina appears dry and pale. What is the most appropriate treatment method for the probable diagnosis?
Your Answer: Topical oestrogen cream
Explanation:Post-menopausal women often experience atrophic vaginitis, which is characterized by symptoms such as vaginal dryness, dyspareunia, and occasional spotting. During examination, the vagina may appear dry and pale. Treatment options include the use of vaginal lubricants and moisturizers. If these prove ineffective, topical oestrogen cream may be prescribed.
Atrophic vaginitis is a condition that commonly affects women who have gone through menopause. Its symptoms include vaginal dryness, pain during sexual intercourse, and occasional spotting. Upon examination, the vagina may appear dry and pale. The recommended treatment for this condition is the use of vaginal lubricants and moisturizers. If these do not provide relief, a topical estrogen cream may be prescribed.
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This question is part of the following fields:
- Reproductive Medicine
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