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  • Question 1 - A 20-year-old woman was diagnosed with an early miscarriage 3 weeks ago through...

    Incorrect

    • A 20-year-old woman was diagnosed with an early miscarriage 3 weeks ago through transvaginal ultrasound. She has no significant medical history and was G1P0. Expectant management was chosen as the course of action. However, she now presents with light vaginal bleeding that has persisted for 10 days. A recent urinary pregnancy test still shows positive results. She denies experiencing cramps, purulent vaginal discharges, fever, or muscle aches. What is the next appropriate step in managing her condition?

      Your Answer: Prescribe oral mifepristone alone

      Correct Answer: Prescribe vaginal misoprostol alone

      Explanation:

      The appropriate medical management for a miscarriage involves administering vaginal misoprostol alone. This is a prostaglandin analogue that stimulates uterine contractions, expediting the passing of the products of conception. Oral methotrexate and oral mifepristone alone are not suitable for managing a miscarriage, as they are used for ectopic pregnancies and terminations of pregnancy, respectively. The combination of oral misoprostol and oral mifepristone, as well as vaginal misoprostol and oral mifepristone, are also not recommended due to limited evidence of their efficacy. The current recommended approach is to use vaginal misoprostol alone, as it limits side effects and has a strong evidence base.

      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.

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      • Gynaecology
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  • Question 2 - A 30-year-old woman has been discharged from hospital with a diagnosis of systemic...

    Correct

    • A 30-year-old woman has been discharged from hospital with a diagnosis of systemic lupus erythematosus (SLE) with antiphospholipid antibodies. Her antibodies remained positive at 12 weeks and she is now on hydroxychloroquine monotherapy. She has a healthy BMI and blood pressure, does not smoke, and has no personal or family history of venous or arterial thrombosis or breast cancer. She is requesting to restart the combined pill. How would you advise her on this?

      Your Answer: There is an unacceptably high clinical risk and she cannot use the pill anymore

      Explanation:

      The appropriate answer is that the woman cannot use the pill anymore due to an unacceptably high clinical risk. She has developed systemic lupus erythematosus (SLE) with positive antiphospholipid antibodies, which is classified as UK Medical Eligibility Criteria for Contraceptive Use UKMEC 4, meaning it is an absolute contraindication. The risks of arterial and venous thrombosis would be too high if she were to restart the combined pill, and alternative contraceptive options should be considered. It is important to note that both SLE with positive antiphospholipid antibodies and isolated presence of antiphospholipid antibodies are classified as UKMEC 4 conditions, but not the diagnosis of antiphospholipid syndrome. The advantages of using the pill generally outweigh the risks is an incorrect answer, as it is equivalent to UKMEC 2. The correct answer would be applicable if the woman did not test positive for any of the three antiphospholipid antibodies or if she did not test positive again after 12 weeks. The risks usually outweigh the advantages of using the combined pill is also incorrect, as it is equivalent to UKMEC 3. Lastly, there is no risk or contraindication to her restarting the combined pill is an incorrect answer, as it is equivalent to UKMEC 1.

      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.

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      • Gynaecology
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  • Question 3 - A 63-year-old woman presents with complaints of abdominal swelling, vomiting, and weight loss...

    Incorrect

    • A 63-year-old woman presents with complaints of abdominal swelling, vomiting, and weight loss that have been progressively worsening over the past 6 months. She has a 30-year history of smoking. Imaging reveals bilateral ovarian tumors and a mass in the stomach. A biopsy taken during gastroscopy confirms the presence of adenocarcinoma. What histological characteristics are expected in the ovarian masses?

      Your Answer: Transitional cells

      Correct Answer: Signet ring cells

      Explanation:

      Different Types of Ovarian Tumours and their Histological Features

      Ovarian tumours can be classified into various types based on their histological features. Here are some examples:

      Krukenberg tumours:
      These are secondary tumours that originate from the gastrointestinal tract and metastasize to the ovaries. They are characterized by the presence of signet ring cells.

      Fibromas:
      These are benign ovarian tumours that can cause Meigs’ syndrome. They contain spindle-shaped fibroblasts.

      Granulosa cell tumours:
      These are ovarian tumours that are most commonly seen in the first few decades of life. They contain Call-Exner bodies, which are follicles containing eosinophils.

      Brenner tumours:
      These are benign ovarian tumours that contain transitional cells.

      Mucinous cystadenomas:
      These are benign ovarian tumours that contain cells that resemble endocervical cells. However, if the tumour is malignant, it may not have this characteristic feature.

      In conclusion, the histological features of ovarian tumours can provide important clues about their origin and potential malignancy.

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      • Gynaecology
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  • Question 4 - A 28-year-old woman who has never given birth comes to the gynaecology clinic...

    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.

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      • Gynaecology
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  • Question 5 - A 35-year-old woman presents for her routine cervical smear. The GP informs her...

    Incorrect

    • A 35-year-old woman presents for her routine cervical smear. The GP informs her that the result is positive for high-risk human papillomavirus (hrHPV) and schedules a follow-up smear in 12 months. At the second smear, the same result is obtained, and the GP schedules another follow-up smear in 12 months. However, at the third smear (now 37 years old), the hrHPV result is negative. The patient has no significant medical or family history.

      What is the most appropriate course of action?

      Your Answer: Repeat smear in 5 years

      Correct Answer: Repeat smear in 3 years

      Explanation:

      The correct course of action for a patient who has a second repeat smear at 24 months that is hrHPV negative is to return to routine recall in 3 years. If the result had been positive, the patient would need to be recalled in 12 months for a repeat smear. Referring for colposcopy would only be necessary if the patient had tested positive for hrHPV. Repeating the smear in 3 months or 12 months would also be incorrect, as the patient has already had two smears and the third result will determine the next course of action. Repeating the smear in 5 years would only be appropriate for older women during routine screening.

      The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

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      • Gynaecology
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  • Question 6 - A 27-year-old female comes to the GP seeking advice on her contraceptive options....

    Incorrect

    • A 27-year-old female comes to the GP seeking advice on her contraceptive options. She has been relying on condoms but has recently entered a new relationship and wants to explore other methods. She expresses concern about the possibility of gaining weight from her chosen contraception.
      What should this woman avoid?

      Your Answer: Combined oral contraceptive pill

      Correct Answer: Injectable contraceptive

      Explanation:

      Depo-provera is linked to an increase in weight.

      If this woman is concerned about weight gain, it is best to avoid depo-provera, which is the primary injectable contraceptive in the UK. Depo-provera can cause various adverse effects, including weight gain, irregular bleeding, delayed return to fertility, and an increased risk of osteoporosis.

      While some users of the combined oral contraceptive pill have reported weight gain, a Cochrane review does not support a causal relationship. There are no reasons for this woman to avoid the combined oral contraceptive pill.

      The progesterone-only pill has not been associated with weight gain and is safe for use in this woman.

      The intra-uterine system (IUS) does not cause weight gain in users and is a viable option for this woman.

      The subdermal contraceptive implant can cause irregular or heavy bleeding, as well as progesterone-related side effects such as headaches, nausea, and breast pain. However, it is not typically associated with weight gain and is not contraindicated for use in this situation.

      Injectable Contraceptives: Depo Provera

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

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

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

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      • Gynaecology
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  • Question 7 - A 30-year-old woman visits her doctor seeking guidance on contraception and opts for...

    Correct

    • A 30-year-old woman visits her doctor seeking guidance on contraception and opts for the intrauterine system. What is the predominant side effect that she should be informed about during the initial 6 months of having the intrauterine system inserted?

      Your Answer: Irregular bleeding

      Explanation:

      During the initial 6 months after the intrauterine system is inserted, experiencing irregular bleeding is a typical adverse effect. However, over time, the majority of women who use the IUS will experience reduced or absent menstrual periods, which is advantageous for those who experience heavy menstrual bleeding or prefer not to have periods.

      Intrauterine contraceptive devices include copper IUDs and levonorgestrel-releasing IUS. Both are over 99% effective. The IUD prevents fertilization by decreasing sperm motility, while the IUS prevents endometrial proliferation and thickens cervical mucous. Potential problems include heavier periods with IUDs and initial bleeding with the IUS. There is a small risk of uterine perforation, ectopic pregnancy, and infection. New IUS systems, such as Jaydess® and Kyleena®, have smaller frames and less levonorgestrel, resulting in lower serum levels and different rates of amenorrhea.

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      • Gynaecology
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  • Question 8 - A 27-year-old woman visits her GP seeking advice on contraception. She and her...

    Correct

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

      Your Answer: Implantable contraceptive

      Explanation:

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

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

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

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

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      • Gynaecology
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  • Question 9 - Linda is an 80-year-old woman who has been experiencing urinary incontinence for the...

    Correct

    • Linda is an 80-year-old woman who has been experiencing urinary incontinence for the past 2 years without relief. Her symptoms occur when she laughs or coughs, but she has not had any episodes of nocturia. She has tried pelvic floor exercises and reducing caffeine intake, but these have not improved her symptoms. Her urinalysis shows no signs of infection, and a pelvic examination does not reveal any uterine prolapse. Linda has declined surgical intervention. What is the next best course of action for managing her incontinence?

      Your Answer: Duloxetine

      Explanation:

      If pelvic floor muscle exercises and surgical intervention are not effective, duloxetine can be used to treat stress incontinence in patients. However, it is important to rule out other potential causes such as infection before starting treatment. Non-pharmacological management should be attempted first, including pelvic floor exercises and reducing caffeine intake. Duloxetine is a medication that works as a serotonin/norepinephrine reuptake inhibitor and may cause side effects such as nausea, dizziness, and insomnia. For urge incontinence, antimuscarinic agents like oxybutynin, tolterodine, and solifenacin are typically used as first-line treatment. If these are not effective, a β3 agonist called mirabegron can be used as a second-line therapy.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

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      • Gynaecology
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  • Question 10 - A 16-year-old woman presents with primary amenorrhoea. She is of normal height and...

    Correct

    • A 16-year-old woman presents with primary amenorrhoea. She is of normal height and build and has normal intellect. Her breast development is normal, and pubic hair is of Tanner stage II. Past history revealed an inguinal mass on the right side, which was excised 2 years ago. Ultrasonography of the lower abdomen reveals no uterus.
      Which of the following tests will help in diagnosis of the condition?

      Your Answer: Karyotype

      Explanation:

      Diagnosis of Androgen Insensitivity Syndrome: A Case Study

      The presented case strongly suggests the presence of androgen insensitivity syndrome, a condition where a patient’s phenotype and secondary sexual characteristics differ from their karyotype and gonads. In this case, the patient is likely to have a karyotype of 46,XY and be a male pseudohermaphrodite. Androgen insensitivity syndrome is associated with mutations in the AR gene, which codes for the androgen receptor. In complete androgen insensitivity, the body cannot respond to androgens at all, resulting in a female phenotype, female secondary sexual characteristics, no uterus, and undescended testes.

      Karyotyping is the key diagnostic investigation to confirm the diagnosis of androgen insensitivity syndrome. Serum oestradiol levels may vary according to the type of androgen insensitivity disorder and are unlikely to aid the diagnosis. Pituitary MRI may be a second diagnostic investigation if karyotype abnormalities are ruled out. Transvaginal ultrasound is not necessary if an abdominal ultrasound has already been performed and showed an absent uterus.

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      • Gynaecology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Gynaecology (6/10) 60%
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