-
Question 1
Incorrect
-
A 35-year-old woman had gone for her routine cervical smear and the result came back as inadequate. It was noted in her medical history that she had an inadequate smear 4 years ago but subsequent smears were fine. What should be the next course of action?
Your Answer: Repeat cervical smear in 12 months
Correct Answer: Repeat cervical smear in 3 months
Explanation:If a cervical smear is inadequate, it is recommended to repeat the test within 3 months. This is the correct course of action for the patient in question, as her routine smear was deemed inadequate. Referral for colposcopy is not necessary at this stage, as it is only indicated if there are two consecutive inadequate smears that are 3 months apart. Waiting for 3 years to repeat the smear would not be appropriate, as this is the interval for routine recall for a patient of her age. Similarly, waiting for 6 or 12 months to repeat the smear would not be appropriate, as these timeframes are only indicated for specific circumstances such as testing for cure following treatment or if the most recent smear was hrHPV positive without cytological abnormalities.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 2
Correct
-
A 56-year-old woman presents to her primary care physician with a complaint of urinary incontinence. She recently experienced a significant episode when she leaked urine while running to catch a bus. Previously, she had only noticed small leaks when coughing or laughing, and did not want to make a fuss. She reports no abdominal pain and has not had a menstrual period in 3 years. She has two children, both of whom were delivered vaginally and were large babies. Physical examination is unremarkable and a urine dipstick test is negative.
What is the most appropriate course of action for managing this patient's condition?Your Answer: Pelvic floor muscle training
Explanation:Treatment Options for Stress Urinary Incontinence
Stress urinary incontinence is a common condition in women, especially those who have had vaginal deliveries and are getting older. It is caused by weak sphincter muscles, leading to leakage during activities such as coughing, sneezing, laughing, or exercising. The first-line treatment for this condition is pelvic floor muscle training, which involves a minimum of eight contractions three times per day for 12 weeks.
However, it is important to note that other treatment options, such as oxybutynin, pelvic ultrasound scans, urodynamic studies, and bladder training, are not recommended for stress urinary incontinence. Oxybutynin is used for overactive bladder or mixed urinary incontinence, while pelvic ultrasound scans are not indicated for urinary incontinence. Urodynamic studies are not recommended for women with simple stress incontinence on history and examination, and bladder training is used for urgency or mixed urinary incontinence, not stress incontinence. Therefore, pelvic floor muscle training remains the most effective treatment option for stress urinary incontinence.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 3
Correct
-
A 27-year-old female patient 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 does not require daily attention. What contraceptive option would be suitable for her?
Your Answer: Intrauterine device
Explanation:If a woman is not starting her contraceptive method on the first day of her period, the time until it becomes effective varies. The only option that is effective immediately is an intrauterine device (IUD), which is a T-shaped device containing copper that is inserted into the uterus. Other methods, such as the progesterone-only pill (POP), combined oral contraceptive (COC), injection, implant, and intrauterine system (IUS), require a certain amount of time before they become effective. The POP requires 2 days, while the COC, injection, implant, and IUS all require 7 days before they become effective. It’s important to consider the effectiveness and convenience of each method before choosing the best option.
Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progesterone hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.
The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.
There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 4
Correct
-
A 28-year-old woman who has never given birth comes to the gynaecology clinic complaining of worsening menstrual pain over the past three years. Despite taking ibuprofen, she has found no relief. She is sexually active with her husband and experiences pain during intercourse. Additionally, she has dysuria and urgency when urinating. She has been trying to conceive for two years without success. During the examination, her uterus appears normal in size, but there is tenderness and uterosacral nodularity upon rectovaginal examination.
What is the most likely diagnosis?Your Answer: Endometriosis
Explanation:The patient’s symptoms of dysmenorrhoea, dyspareunia, and subfertility are classic signs of endometriosis, a common condition where endometrial tissue grows outside of the uterus. The presence of uterosacral nodularity and tenderness further supports this diagnosis. Some patients with endometriosis may also experience urinary symptoms due to bladder involvement or adhesions. Uterine leiomyoma, or fibroid, is a common pelvic tumor that causes abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction. However, it does not typically present with uterosacral nodularity and tenderness on rectal examination. Interstitial cystitis causes urinary frequency and urgency, with pain relieved upon voiding. Pelvic inflammatory disease presents with fever, nausea, acute pain, malodorous vaginal discharge, and cervical motion tenderness/adnexal tenderness.
Understanding Endometriosis
Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.
First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.
It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 5
Incorrect
-
A 32-year-old woman visits her GP with complaints of left-sided pelvic pain and deep dyspareunia at 16 weeks of pregnancy. She has not experienced any vaginal bleeding, discharge, or dysuria. Her pregnancy has been uncomplicated so far, and she has a gravid uterus that is large for her gestational age. Her vital signs are stable, with a temperature of 37.1ºC, blood pressure of 110/70 mmHg, heart rate of 70 beats/min, and respiratory rate of 18 breaths/minute. She had an intrauterine system for menorrhagia before conception and has no other medical history. What is the most probable cause of her symptoms?
Your Answer: Ectopic pregnancy
Correct Answer: Growth of pre-existing fibroids due to increased oestrogen
Explanation:During pregnancy, uterine fibroids may experience growth. These fibroids are common and often do not show any symptoms. However, in non-pregnant women, they can cause menorrhagia. In early pregnancy, they grow due to oestrogen and can cause pelvic pain and pressure. If they grow too quickly and surpass their blood supply, they may undergo ‘red degeneration’. This patient’s symptoms, including pelvic pain and a history of menorrhagia, suggest that the growth of pre-existing fibroids due to oestrogen may be the cause. However, further investigation with ultrasound is necessary to confirm this diagnosis. Ectopic pregnancies are rare in the second trimester and are typically detected during routine ultrasound scans. This patient is unlikely to have an ectopic pregnancy as her first ultrasound scan would have confirmed an intrauterine pregnancy. Pelvic inflammatory disease is not the most likely cause of this patient’s symptoms as it is associated with additional symptoms such as vaginal discharge and dysuria, and the patient would likely be febrile. The growth of pre-existing fibroids due to decreased progesterone is incorrect as progesterone, like oestrogen, is increased during pregnancy. This patient does not exhibit symptoms of dysuria, renal angle tenderness, or pyrexia.
Understanding Fibroid Degeneration
Uterine fibroids are non-cancerous growths that can develop in the uterus. They are sensitive to oestrogen and can grow during pregnancy. However, if the growth of the fibroids exceeds their blood supply, they can undergo a type of degeneration known as red or ‘carneous’ degeneration. This condition is characterized by symptoms such as low-grade fever, pain, and vomiting.
Fortunately, fibroid degeneration can be managed conservatively with rest and analgesia. With proper care, the symptoms should resolve within 4-7 days.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 6
Correct
-
A 50-year-old woman presents with severe itching in the perineal region, accompanied by pain during urination and painful intercourse. During examination, you observe white, polygonal papules on the labia majora that merge into a patch that affects the labia minora. There is one area of fissuring that bleeds upon contact. The skin appears white, thin, and shiny, with mild scarring. There is no vaginal discharge, and no other skin lesions are present on the body. What is the most probable diagnosis?
Your Answer: Lichen sclerosus
Explanation:Common Genital Skin Conditions: Symptoms and Treatment Options
Lichen sclerosus, candidiasis, contact dermatitis, lichen planus, and psoriasis are some of the most common skin conditions that affect the genital area. Each condition has its own set of symptoms and treatment options.
Lichen Sclerosus: This chronic inflammatory condition can affect any part of the body but is most commonly found in the genital area. It presents with pruritus, skin irritation, hypopigmentation, and atrophy. Treatment involves topical steroids and good hygiene.
Candidiasis: This fungal infection is associated with pruritus, burning sensation, erythema, and oedema of the vestibule. The most common characteristic is a thick, curd-like, white vaginal discharge.
Contact Dermatitis: This condition is often caused by changes to shower gel or washing detergent. It presents with pruritus, erythematosus skin, excoriations, and skin breaks, leading to ulceration and superimposed infection. Chronic contact dermatitis can lead to lichenoid changes.
Lichen Planus: This condition presents with purple, red plaques usually on the labia, with central erosion and overlying lacy, white, striated patch. It can cause scarring and narrowing of the introitus and dyspareunia.
Psoriasis: This condition is rare in the genital area but can appear in the inguinal creases and the labia majora. It presents with erythematous plaques with minimal white scale and is associated with itching and excoriations.
It is important to seek medical attention if you suspect you have any of these conditions. Treatment options may include topical or oral medications, good hygiene practices, and lifestyle changes.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 7
Incorrect
-
A 55-year-old woman comes to your GP clinic for the third time in the past month. She reports experiencing bloating, mild abdominal discomfort, and a decreased appetite. You have previously referred her for a colonoscopy, which did not reveal any signs of malignancy. However, she remains highly concerned about cancer due to her family history, as her mother, grandmother, and sister have all had breast cancer. Which marker would be the most suitable?
Your Answer:
Correct Answer: CA 125
Explanation:Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.
Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.
Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 8
Incorrect
-
A 33-year-old woman finds herself with an unexpected and undesired pregnancy. She has two children and experienced a miscarriage 4 years ago. Her medical history indicates subclinical hypothyroidism, but she is generally healthy. After an ultrasound scan estimates her gestation at 7 weeks and confirms an intrauterine pregnancy, she decides on a medical termination of pregnancy. What treatment options will be available to her?
Your Answer:
Correct Answer: Oral mifepristone and vaginal prostaglandins
Explanation:Medical abortions involve the use of mifepristone followed by at least one dose of prostaglandins and can be performed at any stage of pregnancy. The preferred method is oral mifepristone followed by vaginal administration of prostaglandins, such as misoprostol. This method is particularly suitable for pregnancies up to 7 weeks gestation, as it has a lower failure rate than surgical termination. The dosing schedule and location of administration may vary, with some women choosing to undergo the procedure at home rather than in a clinic. It is important to note that IM methotrexate is not used in terminations of pregnancy, but rather in the medical management of ectopic pregnancies, as well as in the treatment of certain cancers and rheumatoid conditions. Methotrexate and vaginal misoprostol is not a common combination for medical terminations, as mifepristone is typically used instead. Oral mifepristone alone is not sufficient for medical terminations, but may be used in cervical priming for surgical abortion in cases where misoprostol is contraindicated.
Termination of Pregnancy in the UK
The UK’s current abortion law is based on the 1967 Abortion Act, which was amended in 1990 to reduce the upper limit for termination from 28 weeks to 24 weeks gestation. To perform an abortion, two registered medical practitioners must sign a legal document, except in emergencies where only one is needed. The procedure must be carried out by a registered medical practitioner in an NHS hospital or licensed premise.
The method used to terminate a pregnancy depends on the gestation period. For pregnancies less than nine weeks, mifepristone (an anti-progesterone) is administered, followed by prostaglandins 48 hours later to stimulate uterine contractions. For pregnancies less than 13 weeks, surgical dilation and suction of uterine contents is used. For pregnancies more than 15 weeks, surgical dilation and evacuation of uterine contents or late medical abortion (inducing ‘mini-labour’) is used.
The 1967 Abortion Act outlines the circumstances under which a person shall not be guilty of an offence under the law relating to abortion. These include if two registered medical practitioners are of the opinion, formed in good faith, that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family. The limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is a risk of serious physical or mental injury to the woman.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 9
Incorrect
-
A 28-year-old woman visits her GP complaining of heavy, irregular vaginal bleeding that has been ongoing for 4 weeks and is becoming unbearable. She denies experiencing abdominal pain, unusual vaginal discharge, or dysuria. The patient has been sexually active with her partner for 6 months and had the Nexplanon implant inserted 4 weeks ago.
Upon examination, the patient's abdomen is non-tender, her heart rate is 79/min, her respiratory rate is 17/min, her blood pressure is 117/79 mmHg, her oxygen saturation is 98%, and her temperature is 37.5°C. A negative pregnancy test is obtained.
What treatment options is the GP likely to suggest to alleviate the patient's symptoms?Your Answer:
Correct Answer: 3-month course of the combined oral contraceptive pill
Explanation:To manage unscheduled bleeding, which is a common side effect of Nexplanon, a 3-month course of the combined oral contraceptive pill may be prescribed. This will not only provide additional contraception but also make periods lighter and more regular. Prescribing a progesterone-only pill is not recommended as it can also cause irregular bleeding. A single dose of intramuscular methotrexate is not appropriate as the patient is not showing any symptoms of an ectopic pregnancy. Urgent referral for endometrial cancer is also not necessary as the patient’s age and symptoms suggest that the bleeding is most likely due to the contraceptive implant.
Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progesterone hormone etonogestrel to prevent ovulation and thicken cervical mucous. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.
The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.
There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 10
Incorrect
-
A 64-year-old postmenopausal woman visits her General Practitioner (GP) complaining of dyspareunia, increased urinary frequency, and vaginal dryness. She reports no vaginal bleeding, discharge, or haematuria, and there are no signs of vasomotor or psychological menopausal symptoms. What is the accurate statement about treating vaginal atrophy in postmenopausal women?
Your Answer:
Correct Answer: Following cessation of treatment, symptoms recur
Explanation:Management of Vaginal Atrophy in Menopausal Women
Menopausal women often experience vaginal atrophy due to oestrogen deficiency, leading to a variety of symptoms such as dyspareunia, burning, irritation, vaginal discharge, and bleeding. It is crucial to rule out urinary and sexually transmitted infections and perform a speculum examination to exclude malignancy in the presence of vaginal bleeding. Topical therapy is the first-line management for vaginal atrophy, which can be either hormonal or non-hormonal. Hormonal treatments are more effective but have more side-effects, while non-hormonal treatments provide symptom relief to a number of patients. A combination of both therapies is also an option for maximal symptom relief. Systemic hormonal replacement therapy is offered to women who have both vaginal and systemic menopausal symptoms. Vaginal bleeding is a common side-effect of hormonal treatment and requires further investigation if it persists after the first six months of therapy.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 11
Incorrect
-
A 32-year-old woman visits a fertility clinic after trying to conceive for more than two years. She is worried that she may not be ovulating despite having a regular menstrual cycle lasting 30 days. She is not using any form of birth control and her pregnancy test is negative. What is the most effective method to detect ovulation?
Your Answer:
Correct Answer: Progesterone level
Explanation:The most reliable way to confirm ovulation is through the Day 21 progesterone test. This test measures the peak level of progesterone in the serum, which occurs 7 days after ovulation. While the length of the follicular phase can vary, the luteal phase always lasts for 14 days. Therefore, if a woman has a 35-day cycle, she can expect to ovulate on Day 21 and her progesterone level will peak on Day 28. To determine when to take the test, subtract 7 days from the expected start of the next period (Day 21 for a 28-day cycle and Day 28 for a 35-day cycle). Basal body temperature charts and cervical mucous thickness are not reliable predictors of ovulation. Gonadotropins may be used to assess ovarian function in women with irregular menstrual cycles.
Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.
When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.
It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 12
Incorrect
-
A 50-year-old woman visits her GP to receive the results of her recent cervical smear. Her two previous smears, taken 18 and 6 months ago, were positive for high-risk human papillomavirus (HPV) but showed no abnormal cytology. The GP informs her that her most recent cervical smear also tested positive for high-risk HPV. What is the best course of action for managing this patient?
Your Answer:
Correct Answer: Refer for colposcopy
Explanation:If a patient’s 2nd repeat cervical smear at 24 months is still positive for high-risk human papillomavirus (hrHPV), the correct course of action is to refer them for colposcopy. This is in line with the NHS cervical screening programme guidelines.
Cytological examination of the smear would not change the management of the patient and is therefore not the correct option. Regardless of cytological findings, a patient with a third hrHPV positive smear would be referred for colposcopy.
Repeating the cervical smear in 5 years is not appropriate for this patient as it is only recommended for those with negative hrHPV results.
Repeating the cervical smear after 6 months is not indicated as a test of cure for cervical intraepithelial neoplasia in this case.
Repeating the cervical smear after 12 months is also not appropriate as this is the patient’s 2nd repeat smear that is hrHPV positive. It would only be considered if it was their routine smear or 1st repeat smear that was hrHPV positive and there were no cytological abnormalities.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 13
Incorrect
-
A 28-year-old woman presents to the Emergency Department with sudden and severe lower abdominal pain and vaginal bleeding that started 2 hours ago. The pain is progressively worsening. Upon examination, she is hypotensive, tachycardic, and apyrexial, with tenderness in the lower abdomen and guarding and rebound. She had a positive pregnancy test a week ago and reports her last menstrual period was 6 weeks ago. An ultrasound scan shows haemoperitoneum and left tubal rupture. The patient has been advised to undergo laparotomy for a ruptured ectopic pregnancy. Which part of the fallopian tube is most likely to rupture due to ectopic pregnancies?
Your Answer:
Correct Answer: Isthmus
Explanation:Types of Ectopic Pregnancy in the Fallopian Tube
Ectopic pregnancy, a condition where the fertilized egg implants outside the uterus, can occur in different parts of the Fallopian tube. Here are the different types of ectopic pregnancy in the Fallopian tube and their characteristics:
1. Isthmus – Ectopic pregnancy in the isthmus is rare but can occur. The tube is rigid, making rupture occur earlier than in other parts of the tube.
2. Interstitial part – This is the proximal segment of the tube embedded within the uterine wall. Ectopic pregnancy in this part is very rare and is more likely to occur in women who have had ipsilateral salpingectomy.
3. Ampulla – Ectopic pregnancy occurs most frequently in the ampullary part of the tube, which is relatively wide. Rupture usually occurs about 2 months after the last menstrual period, but it happens later than in the isthmus due to the elasticity of the tube.
4. Fimbrial end – Ectopic pregnancy near the fimbrial end can result in an ovarian pregnancy, which is rare and not associated with pelvic inflammatory disease or an intrauterine device.
5. Cornua – Pregnancy may implant itself in the cornua, which is the opening of the Fallopian tube. Combined with interstitial pregnancies, this represents a small percentage of all ectopic pregnancies.
Knowing the different types of ectopic pregnancy in the Fallopian tube can help in early detection and management of this potentially life-threatening condition.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 14
Incorrect
-
A 20-year-old female comes to the clinic complaining of secondary amenorrhoea that has been going on for four months. She has also lost around 8 kg during this time and currently has a BMI of 17.4 kg/m2. What is the most probable diagnosis for her condition?
Your Answer:
Correct Answer: Anorexia nervosa
Explanation:Anorexia as a Cause of Secondary Amenorrhoea
This young woman is experiencing secondary amenorrhoea, which is the absence of menstrual periods for at least three months after previously having regular cycles. Her low BMI and weight loss suggest that anorexia is the most likely cause of her amenorrhoea. Anorexia is an eating disorder characterized by a distorted body image and an intense fear of gaining weight, leading to severe calorie restriction and weight loss.
In this case, the anorexia has likely caused a hypogonadotropic hypogonadism, which is a condition where the pituitary gland fails to produce enough hormones to stimulate the ovaries to produce estrogen. This hormonal imbalance can lead to a range of symptoms, including amenorrhoea, infertility, and osteoporosis.
It is important to address the underlying cause of secondary amenorrhoea, as it can have long-term health consequences. Treatment for anorexia may involve a combination of therapy, nutritional counseling, and medication. Once the underlying cause is addressed, menstrual cycles may resume, but it may take several months for regular cycles to return.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 15
Incorrect
-
A 30-year-old nulliparous woman arrives at the emergency department with a positive home pregnancy test and symptoms of diarrhoea and mild abdominal discomfort that have been present for 6 hours. She has not been using any regular contraception and her last menstrual period was 8 weeks ago. The patient has a history of pelvic inflammatory disease. A transvaginal ultrasound shows a 40mm foetal sac at the ampulla of the fallopian tube without a visible heartbeat, and her serum B-HCG level is 1200 IU/L. What is the definitive indication for surgical management in this case?
Your Answer:
Correct Answer: Foetal sac size
Explanation:Surgical management is recommended for all ectopic pregnancies with a foetal sac larger than 35mm or a serum B-hCG level exceeding 5,000 IU/L, as per NICE guidelines. Foetal sacs larger than 35mm are at a higher risk of spontaneous rupture, making expectant or medical management unsuitable. The size of the foetal sac is measured using transvaginal ultrasound. Detection of a foetal heartbeat on transvaginal ultrasound requires urgent surgical management. A history of pelvic inflammatory disease is not an indication for surgical management, although it is a risk factor for ectopic pregnancy. Serum HCG levels between 1,500IU/L and 5,000 IU/L may be managed medically if the patient can return for follow-up and has no significant abdominal pain or haemodynamic instability. A septate uterus is not an indication for surgical management of ectopic pregnancy, but it may increase the risk of miscarriage.
Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.
There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.
Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 16
Incorrect
-
A 23-year-old female presents to the Emergency Department with sudden-onset, right-sided lower abdominal pain over the past few hours. She has associated nausea and vomiting. The pain has now reached the point of being unbearable. She denies any fever, vaginal bleeding, dysuria or altered bowel habits. She has no significant past medical history. She does not take any regular medications.
On examination, she appears to be in significant pain, clutching at her right lower abdomen, which is tender on palpation. Normal bowel sounds are present. There is a palpable adnexal mass on pelvic examination. She is slightly tachycardic. A pregnancy test is negative and urinalysis is normal.
What ultrasound finding would be indicative of the likely diagnosis?Your Answer:
Correct Answer: Whirlpool sign
Explanation:Ultrasound imaging may reveal a whirlpool sign in cases of ovarian torsion, which is strongly indicated by the patient’s history and examination. The beads-on-a-string sign is typically associated with chronic salpingitis, while hypoechoic masses are often indicative of fibroids. A snow-storm appearance is a characteristic finding in complete hydatidiform mole.
Understanding Ovarian Torsion
Ovarian torsion is a medical condition that occurs when the ovary twists on its supporting ligaments, leading to a compromised blood supply. This condition can be partial or complete and may also affect the fallopian tube, which is then referred to as adnexal torsion. Women who have an ovarian mass, are of reproductive age, pregnant, or have ovarian hyperstimulation syndrome are at a higher risk of developing ovarian torsion.
The most common symptom of ovarian torsion is sudden, severe abdominal pain that is colicky in nature. Patients may also experience vomiting, distress, and in some cases, fever. Upon examination, adnexal tenderness may be detected, and an ultrasound may show free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic for this condition.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 17
Incorrect
-
A 27-year-old nulliparous woman has presented to her General Practitioner (GP), requesting an appointment to discuss contraceptive options. She has previously relied on condoms for contraception but would now prefer alternative means of contraception. Her last menstrual period was one week ago. Her previous cervical smears were normal, and she denies any symptoms consistent with a diagnosis of a sexually transmitted infection. She has a past medical history of epilepsy, for which she takes regular carbamazepine, and menorrhagia secondary to several large uterine fibroids, for which she takes tranexamic acid. She does not wish to have children in the near future. She does not smoke. The GP decides to take a blood pressure reading and calculates the patient’s body mass index (BMI):
Investigation Result
Blood pressure 132/71 mmHg
BMI 28 kg/m2
Which of the following would be the contraceptive most suited to the patient?Your Answer:
Correct Answer: progesterone-only injectable
Explanation:Contraceptive Options for Patients with Uterine Fibroids and Carbamazepine Use
Patients with uterine fibroids and concurrent use of carbamazepine may have limited contraceptive options due to drug interactions and uterine cavity distortion. The progesterone-only injectable is a suitable option as it does not interact with enzyme inducers and is not affected by uterine cavity distortion. The copper intrauterine device and levonorgestrel-releasing intrauterine system are not recommended in this case. The progesterone-only implant and combined oral contraceptive pill have severe interactions with carbamazepine, reducing their efficacy. It is important to consider individual patient factors and discuss all available contraceptive options with them.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 18
Incorrect
-
A 24-year-old woman presents to a gynaecology clinic with persistent pain during sexual intercourse. Despite previous attempts with NSAIDs and progesterone-only hormonal treatments, her symptoms have not improved. She has a medical history of migraine with aura. The pain is most severe with deep penetration and worsens towards the end of her menstrual cycle. She also experiences dysmenorrhoea. During pelvic examination, tender nodularity is noted at the posterior vaginal fornix.
What is the most appropriate course of action for managing this patient's likely diagnosis?Your Answer:
Correct Answer: GnRH analogues
Explanation:If paracetamol and NSAIDs have not effectively controlled symptoms of endometriosis, GnRH analogues may be used as a next step in treatment. This is the appropriate course of action for a woman presenting with symptoms of deep dyspareunia and dysmenorrhoea, along with tender nodularity on examination in the posterior vaginal fornix. As endometriosis is exacerbated by rising oestrogen levels during the luteal phase of the menstrual cycle, inducing a menopause state with GnRH analogues can help alleviate symptoms. However, it is important to note that this treatment can cause menopause-like side effects and should only be initiated by specialists after careful consideration of the potential risks and benefits. The use of combined oral contraceptive pills is not recommended in this case due to the woman’s medical history of migraine with aura. Similarly, IM ceftriaxone and PO doxycycline are not appropriate treatments as they are used to manage pelvic inflammatory disease, which presents differently and is not influenced by hormones. Intra-uterine devices are also not recommended as a treatment for endometriosis as they lack a hormonal component and can worsen symptoms.
Understanding Endometriosis
Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.
First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.
It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 19
Incorrect
-
A 25-year-old patient is worried about her amenorrhea for the past 3 months. She has a body mass index of 33 kg/m² and severe acne. A pregnancy test came back negative. Upon testing, her results are as follows:
Investigation Result Normal value
Testosterone 3.5 nmol/l 0.21-2.98 nmol/l
Luteinizing hormone (LH) 31 u/l 3-16 u/l
Follicle-stimulating hormone (FSH) 5 u/l 2-8 u/l
What is the most probable diagnosis?Your Answer:
Correct Answer: Polycystic ovary syndrome
Explanation:Differential Diagnosis for Secondary Amenorrhoea: Polycystic Ovary Syndrome, Cushing’s Syndrome, Primary Ovarian Failure, Hypothalamic Disease, and Adrenal Tumour
Secondary amenorrhoea, the cessation of menstruation after previously menstruating, can have various causes. In a patient who is overweight, has acne, and slightly elevated testosterone and LH levels, polycystic ovary syndrome (PCOS) is a likely diagnosis. PCOS is characterized by small cysts in the ovaries and is linked to insulin resistance, hypertension, lipid abnormalities, and increased risk for cardiovascular disease. Hirsutism is also common in PCOS.
Cushing’s syndrome is a potential differential diagnosis for this patient, but blood results would show suppression of LH and FSH, not elevation. Primary ovarian failure is much rarer than PCOS and would show elevated serum FSH levels. Hypothalamic disease is less likely in this patient with multiple risk factors for PCOS, as it would result in decreased production of gonadotropin-releasing hormone and lower than normal detectable serum levels of LH and FSH. An adrenal tumour, particularly an adenoma, could rarely lead to amenorrhoea, but would also present with other symptoms such as palpitations and weight loss. Other adrenal tumours that secrete sex hormones are even rarer and would also be associated with weight loss.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 20
Incorrect
-
A 27-year-old nulliparous woman presents to Accident and Emergency, accompanied by her partner. She complains of right iliac fossa pain that started yesterday and has progressively got worse. She feels nauseated and had one episode of diarrhoea. Her last menstrual period was six weeks ago; she takes the combined oral contraceptive pill for contraception, but is not always compliant.
She is mildly tachycardic at 106 bpm. Pelvic examination reveals a scanty brown discharge and cervical excitation. She mentions she had her left tube removed, aged 19, for torsion.
Which of the following is the most appropriate management?Your Answer:
Correct Answer: Laparoscopic salpingostomy
Explanation:Management of Ectopic Pregnancy: Laparoscopic Salpingostomy
Ectopic pregnancy, defined as pregnancy occurring outside the uterine cavity, is a serious condition that requires prompt diagnosis and management. Laparoscopic salpingostomy is a preferred method of treatment for ectopic pregnancies, but it may not be suitable for all cases.
Diagnosis of ectopic pregnancy can be challenging as it presents with non-specific symptoms such as lower abdominal/pelvic pain, vaginal discharge, and urinary symptoms. A urinary pregnancy test and an ultrasound scan are necessary to confirm the diagnosis. In emergency cases where the patient is haemodynamically unstable, laparotomy may be necessary.
Laparoscopic salpingectomy, the removal of the tube containing the ectopic pregnancy, is the gold standard for treating ectopic pregnancies. However, if the patient has only one Fallopian tube, laparoscopic salpingostomy, where the tube is incised, the ectopic removed, and the tube repaired, is preferred to preserve the patient’s chances of conceiving naturally in the future.
A single intramuscular dose of methotrexate may be used as medical management of an ectopic pregnancy, but only if certain conditions are met. These include the absence of significant pain, an unruptured ectopic pregnancy, and a serum βhCG level of <1500 iu/l. In cases where right iliac fossa pain is present in a woman of reproductive age, associated with vaginal discharge, cervical excitation, and the last menstrual period of >4 weeks before, ectopic pregnancy should be treated as the primary diagnosis until proven otherwise. Referral to the surgical team may be necessary to rule out appendicitis.
In conclusion, laparoscopic salpingostomy is a suitable method of treatment for ectopic pregnancies in patients with only one Fallopian tube. Early diagnosis and prompt management are crucial in ensuring the best possible outcome for the patient.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 21
Incorrect
-
A 32-year-old woman, who was recently diagnosed with polycystic ovary syndrome (PCOS), has been struggling with persistent hirsutism and acne since her teenage years. She expresses that this is now impacting her self-confidence and she has not seen any improvement with over-the-counter acne treatments. When asked about her menstrual cycles, she reports that they are still irregular and she has no plans to conceive at the moment. What is the most suitable next step in managing this patient?
Your Answer:
Correct Answer: Co-cyprindiol
Explanation:Co-cyprindiol is a medication that combines cyproterone acetate and ethinyl estradiol. It is commonly used to treat women with PCOS who have hirsutism and acne. Cyproterone acetate is an anti-androgen that reduces sebum production, leading to a reduction in acne and hirsutism. It also inhibits ovulation and induces regular withdrawal bleeds. However, it should not be used solely for contraception due to its higher risk of venous thromboembolism compared to other conventional contraceptives.
Topical retinoids are a first-line treatment for mild to moderate acne. They can be used alone or in combination with benzoyl peroxide.
Clomiphene citrate is a medication used to induce ovulation in women with PCOS who wish to conceive. It has been associated with increased rates of pregnancy.
Desogestrel is a progesterone-only pill that induces regular bleeds and provides contraception. However, its effect on improving acne and hirsutism is inferior to combination drugs like co-cyprindiol.
Isotretinoin is a medication that regulates epithelial cell growth and is used to treat severe acne resistant to other treatments. It is highly teratogenic and should only be started by an experienced dermatologist in secondary care. Adequate contraceptive cover is necessary, and patients should avoid conception for two years after completing treatment.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 22
Incorrect
-
A gynaecologist is performing a hysterectomy for leiomyomata and menorrhagia on a 44-year-old woman. Once under anaesthesia, the patient is catheterised, and the surgeon makes a Pfannenstiel incision transversely, just superior to the pubic symphysis. After opening the parietal peritoneum, he identifies the uterus and makes a shallow, transverse incision in the visceral peritoneum on the anterior uterine wall, and then pushes this downwards to expose the lower uterus.
What is the most likely reason for this?Your Answer:
Correct Answer: The bladder is reflected downwards with the peritoneum
Explanation:Surgical Manoeuvre for Safe Access to the Gravid Uterus
During Gynaecological surgery, a specific manoeuvre is used to safely access the gravid uterus. The bladder is reflected downwards with the peritoneum, which also displaces the distal ureters and uterine tubes. This displacement renders these structures less vulnerable to damage during the procedure. The ovarian arteries, which are branches of the aorta, are not affected by this manoeuvre. However, the uterine artery needs to be pushed down for safe ligation as the ureters typically run superior to it. The sigmoid colon is also displaced out of the operating field using this manoeuvre, reducing the risk of injury. While the ovarian arteries are unlikely to be injured during surgery as they are more lateral, the incidence of ureteric injury is 1-2% in Gynaecological surgery, with 70% of these injuries occurring during the tying off of the uterine pedicle.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 23
Incorrect
-
You are seeing a teenager for her 6-month follow up appointment following a normal vaginal delivery. She wishes to stop breastfeeding as her baby requires specialised formula feeds.
Which medication can be prescribed to suppress lactation in this scenario?Your Answer:
Correct Answer: Cabergoline
Explanation:When it is necessary to stop breastfeeding, Cabergoline is the preferred medication for suppressing lactation. This is because Cabergoline is a dopamine receptor agonist that can inhibit the production of prolactin, which in turn suppresses lactation. It should be noted that Norethisterone has no effect on lactation, Misoprostol is used to soften the cervix during labor induction, and Ursodeoxycholic acid is a bile acid chelating agent used to treat cholestasis in pregnancy.
Techniques for Suppressing Lactation during Breastfeeding
Breastfeeding is a natural process that provides essential nutrients to newborns. However, there may be situations where a mother needs to suppress lactation. This can be achieved by stopping the lactation reflex, which involves stopping suckling or expressing milk. Additionally, supportive measures such as wearing a well-supported bra and taking analgesia can help alleviate discomfort. In some cases, medication may be required, and cabergoline is the preferred choice. By following these techniques, lactation can be suppressed effectively and safely.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 24
Incorrect
-
A 27-year-old woman presents to her doctor to discuss the results of her recent cervical smear. She is sexually active with one partner for the past 6 months and denies any history of sexually transmitted infections or post-coital bleeding. The results of her cervical smear show low-grade dyskaryosis and a positive human papillomavirus test. What is the next best course of action for this patient?
Your Answer:
Correct Answer: Colposcopy
Explanation:If a patient’s cervical smear shows abnormal cytology and a positive result for a high-risk strain of human papillomavirus, the next step is to refer them for colposcopy to obtain a cervical biopsy and assess for cervical cancer. This patient cannot be discharged to normal recall as they are at significant risk of developing cervical cancer. If the cytology is inadequate, it can be retested in 3 months. However, if the cytology shows low-grade dyskaryosis, colposcopy and further assessment are necessary. Delaying the repeat cytology for 6 months would not be appropriate. If the cytology is normal but the patient is positive for high-risk human papillomavirus, retesting for human papillomavirus in 12 months is appropriate. However, if abnormal cytology is present with high-risk human papillomavirus, colposcopy and further assessment are needed.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hr HPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 25
Incorrect
-
A 38-year-old African-Caribbean woman presents to Gynaecology Outpatients with heavy periods. She has always experienced heavy periods, but over the past few years, they have become increasingly severe. She now needs to change a pad every hour and sometimes experiences leaking and clots. The bleeding can last for up to 10 days, and she often needs to take time off work. Although there is mild abdominal cramping, there is no bleeding after sex. She is feeling increasingly fatigued and unhappy, especially as she was hoping to have another child. She has one child who is 7 years old, and she had a vaginal delivery. Her periods are regular, and she is not using any contraception. On examination, she appears well, with a soft abdomen, and a vaginal examination reveals a uterus the size of 10 weeks. Her blood tests show a haemoglobin level of 9, and the results of a pelvic ultrasound scan are pending.
What is the most appropriate management option based on the clinical information and expected ultrasound results?Your Answer:
Correct Answer: Myomectomy
Explanation:Treatment options for menorrhagia caused by fibroids in a patient hoping to conceive
Menorrhagia, or heavy menstrual bleeding, can be caused by fibroids in the uterus. In a patient hoping to conceive, treatment options must be carefully considered. One option is myomectomy, which involves removing the fibroids while preserving the uterus. However, this procedure can lead to heavy bleeding during surgery and may result in a hysterectomy. Endometrial ablation, which destroys the lining of the uterus, is not suitable for a patient hoping to have another child. Tranexamic acid may help reduce bleeding, but it may not be a definitive treatment if the fibroids are large or in a problematic location. Laparoscopic hysterectomy, which removes the uterus, is a definitive treatment for menorrhagia but is not suitable for a patient hoping to conceive. The Mirena® intrauterine system is an effective treatment for menorrhagia but is not suitable for a patient hoping to conceive. Ultimately, the best treatment option for this patient will depend on the size and location of the fibroids and the patient’s desire to conceive.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 26
Incorrect
-
A 29-year-old female presents to the early pregnancy assessment unit at 7 weeks gestation with heavy vaginal bleeding. An ultrasound confirms an intra-uterine miscarriage. After 14 days of expectant management, the patient returns for a follow-up appointment. She reports experiencing light vaginal bleeding and is still haemodynamically stable without signs of ectopic pregnancy. An ultrasound scan confirms an incomplete miscarriage. What would be the most suitable course of action?
Your Answer:
Correct Answer: Vaginal misoprostol
Explanation:When managing a miscarriage, medical treatment typically involves administering vaginal misoprostol alone. According to the NICE miscarriage Clinical Knowledge Summary, medical management is recommended if expectant management is not suitable or if a woman continues to experience symptoms after 14 days of expectant management. Misoprostol can be given orally or vaginally. If products of conception are not expelled after medical treatment or if symptoms persist after 14 days of expectant management, manual vacuum aspiration or surgical management may be considered. However, hospitalization and observation are not usually necessary unless the patient is experiencing hemodynamic instability. In most cases, women can take misoprostol and complete the miscarriage at home. Oral methotrexate is used for medical management of ectopic pregnancy.
Management Options for Miscarriage
Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.
Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.
Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.
It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 27
Incorrect
-
A 20-year-old woman comes to the clinic 72 hours after having unprotected sex and requests emergency contraception. She had her last period 5 days ago and has no significant medical history or regular medications. Her BMI is 23 kg/m2 and her blood pressure is 118/72 mmHg. She decides to take ulipristal (Ella-One) for emergency contraception and also expresses interest in starting a combined oral contraceptive pill (COCP). She asks when she can begin taking it. What advice should be given?
Your Answer:
Correct Answer: She should start taking the COCP from 5 days after taking ulipristal
Explanation:Women who have taken ulipristal acetate should wait for 5 days before starting regular hormonal contraception. This is because ulipristal may reduce the effectiveness of hormonal contraception. The same advice should be given for other hormonal contraception methods such as the pill, patch, or ring. Barrier methods should be used before the effectiveness of the COCP can be assured. If the patient is starting the COCP within the first 5 days of her cycle, barrier methods may not be necessary. However, in this case, barrier methods are required. The patient can be prescribed the COCP if it is her preferred method of contraception. There is no need to wait until the start of the next cycle before taking the pill, as long as barrier methods are used for 7 days.
Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 28
Incorrect
-
A 25-year-old woman, presenting with a 4-month history of severe mood swings, breast tenderness and reduced cognitive ability to perform functions at work, comes for a review with her diary of symptoms corresponding to a period of three cycles. She attends work regularly during these episodes and goes out with friends, but does not enjoy it as much and is less productive.
Going through the diary, symptoms occur during the luteal phase and resolve 2–3 days into menstruation.
Blood tests, including thyroid function tests, are normal. She has tried the progesterone implant, which made her symptoms worse; therefore, she is not currently using any contraception.
A diagnosis of premenstrual syndrome (PMS) is made.
Which of the following is the next step in the management of this patient?Your Answer:
Correct Answer: Combined oral contraceptive pill (COCP)
Explanation:Management of Premenstrual Syndrome (PMS)
Premenstrual Syndrome (PMS) is a diagnosis of exclusion, characterized by cyclical psychological, behavioral, and physical symptoms during the luteal phase of the menstrual cycle. The exact causes are not yet identified, but studies suggest that the effects of hormones on serotonin and GABA signaling may have a significant role, in addition to psychological and environmental factors.
For moderate PMS, the National Institute for Health and Care Excellence (NICE) recommends the use of new-generation combined oral contraceptives, which prevent the natural cyclical change in hormones seen in the physiological menstrual cycle. Continuous use, rather than cyclical, showed better improvement. Response is unpredictable, and NICE suggests a trial of three months, and then to review.
Referral to a specialist clinic is reserved for women who have severe PMS, resistant to medication, that cannot be managed in the community. Fluoxetine, a selective serotonin reuptake inhibitor, has been used successfully in the treatment of women with severe PMS symptoms or in women with moderate PMS that fails to respond to other treatments.
Lifestyle modification advice is given to patients with mild PMS, including regular exercise, restriction in alcohol intake, smoking cessation, regular meals, regular sleep, and stress reduction. St John’s wort, an over-the-counter herbal remedy, has shown improvement of symptoms in some studies, but its safety profile is unknown, and it can interact with prescribed medication. Its use is at the discretion of the individual, but the patient needs to be warned of the potential risks.
Management Options for Premenstrual Syndrome (PMS)
-
This question is part of the following fields:
- Gynaecology
-
-
Question 29
Incorrect
-
A 30-year-old female presents with menorrhagia that has not responded to treatment with non-steroidal anti-inflammatory drugs.
She underwent sterilisation two years ago.
What would be the most suitable treatment for her?Your Answer:
Correct Answer: Intrauterine system (Mirena)
Explanation:Treatment Options for Menorrhagia
Menorrhagia, or heavy menstrual bleeding, can be a distressing condition for women. Current guidelines recommend the use of Mirena (IUS) as the first line of treatment, even for women who do not require contraception. Patient preference is important in the decision-making process, but IUS is still the preferred option.
If IUS is not suitable or preferred, there are several other treatment options available. Tranexamic acid, a medication that prevents the breakdown of blood clots, is a second-line option. Non-steroidal anti-inflammatory drugs (NSAIDs) and combined oral contraceptive pills can also be used to prevent the proliferation of the endometrium.
If these options are not effective, oral or injected progestogens can be used to prevent endometrial proliferation. Gonadotrophin-releasing hormone (GnRH) agonists, such as Goserelin, are also available as a last resort.
It is important for women to discuss their options with their healthcare provider and choose the treatment that is best for them. With the variety of options available, there is likely a treatment that can effectively manage menorrhagia and improve quality of life.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 30
Incorrect
-
A 25-year-old female visits her doctor for contraception. She has a medical history of depression and spina bifida, which requires her to use a wheelchair. Additionally, she has a family history of ovarian cancer and is a regular smoker, consuming 15 cigarettes per day. What would be a contraindication for initiating the use of the combined oral contraceptive pill (COCP) in this patient?
Your Answer:
Correct Answer: Her wheelchair use
Explanation:Wheelchair users should not be prescribed the COCP as their immobility increases the risk of developing DVTs, outweighing the benefits of using this form of contraception (UKMEC 3). Past history of depression, family history of ovarian cancer, and smoking history are not significant factors in determining the suitability of COCP use.
The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.
-
This question is part of the following fields:
- Gynaecology
-
00
Correct
00
Incorrect
00
:
00
:
0
00
Session Time
00
:
00
Average Question Time (
Mins)