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  • Question 1 - A 35-year-old female patient visits her GP seeking emergency contraception after engaging in...

    Correct

    • A 35-year-old female patient visits her GP seeking emergency contraception after engaging in unprotected sexual activity around 96 hours ago. She is presently undergoing treatment for pelvic inflammatory disease (PID) with antibiotics.

      Which emergency contraceptive would be the most suitable option for this patient?

      Your Answer: Ulipristal acetate (EllaOne)

      Explanation:

      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
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  • Question 2 - A 25-year-old woman visits her GP to discuss contraceptive options as she is...

    Correct

    • A 25-year-old woman visits her GP to discuss contraceptive options as she is in a committed relationship. She has been diagnosed with partial epilepsy and takes carbamazepine regularly. Additionally, she has a history of heavy menstrual bleeding. Apart from this, her medical history is unremarkable. What would be the most suitable contraception method for her at present?

      Your Answer: Intrauterine system (Mirena)

      Explanation:

      When choosing a contraceptive method, individual preferences and any cautions or contraindications must be taken into account. In this case, the priority is to find a method that won’t be affected by carbamazepine’s enzyme-inducing effect, such as the intrauterine system. While the combined oral contraceptive pill (COCP) could help with heavy bleeding, its failure rate would be high due to enzyme induction. Nexplanon may cause heavy bleeding and its low progesterone dose would also be affected by enzyme induction. Depo-Provera is an option, but prolonged use in young individuals could lead to reduced bone density. The Mirena intrauterine system would be effective in reducing heavy bleeding and providing reliable contraception alongside the anti-epileptic medication.

      Contraception for Women with Epilepsy

      Women with epilepsy need to consider several factors when choosing a contraceptive method. Firstly, they need to consider how the contraceptive may affect the effectiveness of their anti-epileptic medication. Secondly, they need to consider how their anti-epileptic medication may affect the effectiveness of the contraceptive. Lastly, they need to consider the potential teratogenic effects of their anti-epileptic medication if they become pregnant.

      To address these concerns, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommends that women with epilepsy consistently use condoms in addition to other forms of contraception. For women taking certain anti-epileptic medications such as phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine, the FSRH recommends the use of the COCP and POP as UKMEC 3, the implant as UKMEC 2, and the Depo-Provera, IUD, and IUS as UKMEC 1.

      For women taking lamotrigine, the FSRH recommends the use of the COCP as UKMEC 3 and the POP, implant, Depo-Provera, IUD, and IUS as UKMEC 1. If a COCP is chosen, it should contain a minimum of 30 µg of ethinylestradiol. By considering these recommendations, women with epilepsy can make informed decisions about their contraceptive options and ensure the safety and effectiveness of their chosen method.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 3 - A 29-year-old female patient visits her general practitioner complaining of dyspareunia and intermenstrual...

    Incorrect

    • A 29-year-old female patient visits her general practitioner complaining of dyspareunia and intermenstrual bleeding. She is not on any hormonal contraceptives. Following the exclusion of sexually transmitted infections and fibroids, she is referred for colposcopy. The diagnosis is a grade 1A squamous cell carcinoma of the cervix. The patient is married and desires to have children in the future. What is the best treatment option for her cancer?

      Your Answer: Short course of radiotherapy

      Correct Answer: Cone biopsy

      Explanation:

      If a woman with stage IA cervical cancer desires to preserve her fertility, a cone biopsy with negative margins may be considered as an option. However, for women who do not wish to have children, a hysterectomy with lymph node clearance is recommended. Cisplatin chemotherapy and radiotherapy are not appropriate for this stage of cervical cancer, while laser ablation is only used for cervical intraepithelial dysplasias. Radical trachelectomy is not recommended as it may negatively impact fertility.

      Management of Cervical Cancer Based on FIGO Staging

      Cervical cancer management is determined by the FIGO staging and the patient’s desire to maintain fertility. The FIGO staging system categorizes cervical cancer into four stages based on the extent of the tumor’s spread. Stage IA and IB tumors are confined to the cervix, with IA tumors only visible under a microscope and less than 7 mm wide. Stage II tumors have spread beyond the cervix but not to the pelvic wall, while stage III tumors have spread to the pelvic wall. Stage IV tumors have spread beyond the pelvis or involve the bladder or rectum.

      The management of stage IA tumors involves a hysterectomy with or without lymph node clearance. For patients who want to maintain fertility, a cone biopsy with negative margins can be performed, but close follow-up is necessary. Stage IB tumors are managed with radiotherapy and concurrent chemotherapy for B1 tumors and radical hysterectomy with pelvic lymph node dissection for B2 tumors.

      Stage II and III tumors are managed with radiation and concurrent chemotherapy, with consideration for nephrostomy if hydronephrosis is present. Stage IV tumors are treated with radiation and/or chemotherapy, with palliative chemotherapy being the best option for stage IVB. Recurrent disease is managed with either surgical treatment followed by chemoradiation or radiotherapy followed by surgical therapy.

      The prognosis of cervical cancer depends on the FIGO staging, with higher survival rates for earlier stages. Complications of treatments include standard surgical risks, increased risk of preterm birth with cone biopsies and radical trachelectomy, and ureteral fistula with radical hysterectomy. Complications of radiotherapy include short-term symptoms such as diarrhea and vaginal bleeding and long-term effects such as ovarian failure and fibrosis of various organs.

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      • Gynaecology
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  • Question 4 - A 32-year-old woman complains of a curd-like white vaginal discharge and experiences pain...

    Incorrect

    • A 32-year-old woman complains of a curd-like white vaginal discharge and experiences pain during sexual intercourse. What is the probable diagnosis?

      Your Answer: Bacterial vaginosis

      Correct Answer: Candida

      Explanation:

      Understanding Vaginal Discharge: Common Causes and Key Features

      Vaginal discharge is a common symptom experienced by many women, but it is not always a sign of a pathological condition. There are various causes of vaginal discharge, including physiological factors and infections. Some of the common causes of vaginal discharge include Candida, Trichomonas vaginalis, and bacterial vaginosis. However, less common causes such as gonorrhea, chlamydia, ectropion, foreign body, and cervical cancer can also lead to vaginal discharge.

      It is important to note that the key features of each cause of vaginal discharge can vary. For instance, Candida infection may present with a discharge that resembles cottage cheese, accompanied by vulvitis and itch. On the other hand, Trichomonas vaginalis infection may cause an offensive, yellow/green, frothy discharge, along with vulvovaginitis and a strawberry cervix. Bacterial vaginosis, another common cause of vaginal discharge, may present with an offensive, thin, white/grey, ‘fishy’ discharge.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 5 - A 28-year-old woman has been referred to the Infertility Clinic with her partner....

    Incorrect

    • A 28-year-old woman has been referred to the Infertility Clinic with her partner. They have been trying to conceive for almost one year now, having regular unprotected intercourse.
      Initial investigations, including thyroid function tests and mid-luteal phase progesterone and prolactin, are normal. Semen analysis is also normal. No sexually transmitted infections were detected on testing. The patient reports regular periods and a history of endometriosis.
      Which of the following is the next most appropriate investigation?

      Your Answer: Luteinising hormone (LH) and follicle-stimulating hormone (FSH) testing

      Correct Answer: Laparoscopy and dye

      Explanation:

      Investigating Infertility: Recommended Tests and Procedures

      When a patient presents with infertility, there are several tests and procedures that can be performed to identify the underlying cause. In the case of a patient with known co-morbidities such as previous ectopic pregnancy, pelvic inflammatory disease, or endometriosis, laparoscopy and dye is the most appropriate next step of investigation. This procedure involves Exploratory laparoscopy, allowing direct visualisation of the pelvis, and injection of dye into the uterus to assess tubal patency.

      Luteinising hormone (LH) and follicle-stimulating hormone (FSH) testing is typically performed when a patient has irregular menses, but may not be necessary for those with regular cycles and normal mid-luteal progesterone levels indicating ovulation. Basal body temperature charts are not recommended by NICE guidelines, as a mid-luteal phase progesterone blood test is a more accurate measure of ovulation.

      Cervical smears may be indicated if the patient is due for screening, but do not form part of infertility investigations. Hysterosalpingography is recommended by NICE guidelines for women without co-morbidities, but is not appropriate for those with a history of endometriosis. Understanding the appropriate tests and procedures for investigating infertility can help healthcare providers identify the underlying cause and develop an effective treatment plan.

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      • Gynaecology
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  • Question 6 - A 35-year-old woman presents to the emergency department with worsening left-sided abdominal pain....

    Correct

    • A 35-year-old woman presents to the emergency department with worsening left-sided abdominal pain. The pain started suddenly 4 hours ago and has been steadily getting worse. She reports that the pain started following intercourse. She is uncertain about the date of her last menstrual period as she currently has the Mirena coil fitted. She denies any vaginal bleeding or discharge. Apart from the pain, she has no other symptoms and her vital signs are stable.

      Upon examination, her lower abdomen is tender on palpation but there is no guarding or rigidity. Pelvic exam including bimanual exam is unremarkable. The Mirena coil threads are clearly visualised. An ultrasound reveals free fluid in the pelvic cavity and a urinary pregnancy test is negative.

      What is the most likely diagnosis?

      Your Answer: Ruptured ovarian cyst

      Explanation:

      When an ovarian cyst ruptures, it can cause sudden and severe pain on one side of the pelvis, especially after sexual activity or strenuous exercise. During a physical exam, the lower abdomen may be tender, but there may not be any other noticeable abnormalities. An ultrasound can reveal the presence of fluid in the pelvic area. It’s important to note that ovarian or adnexal torsion can also cause similar symptoms, including sharp pain on one side, nausea, and vomiting. However, in this case, a palpable mass may be felt during a physical exam, and an ultrasound may show an enlarged ovary with reduced blood flow.

      Gynaecological Causes of Abdominal Pain in Women

      Abdominal pain is a common complaint among women, and it can be caused by various gynaecological disorders. To diagnose these disorders, a bimanual vaginal examination, urine pregnancy test, and abdominal and pelvic ultrasound scanning should be performed in addition to routine diagnostic workup. If diagnostic doubt persists, a laparoscopy can be used to assess suspected tubulo-ovarian pathology.

      There are several differential diagnoses of abdominal pain in females, including mittelschmerz, endometriosis, ovarian torsion, ectopic gestation, and pelvic inflammatory disease. Mittelschmerz is characterized by mid-cycle pain that usually settles over 24-48 hours. Endometriosis is a complex disease that may result in pelvic adhesion formation with episodes of intermittent small bowel obstruction. Ovarian torsion is usually sudden onset of deep-seated colicky abdominal pain associated with vomiting and distress. Ectopic gestation presents as an emergency with evidence of rupture or impending rupture. Pelvic inflammatory disease is characterized by bilateral lower abdominal pain associated with vaginal discharge and dysuria.

      Each of these disorders requires specific investigations and treatments. For example, endometriosis is usually managed medically, but complex disease may require surgery and some patients may even require formal colonic and rectal resections if these areas are involved. Ovarian torsion is usually diagnosed and treated with laparoscopy. Ectopic gestation requires a salpingectomy if the patient is haemodynamically unstable. Pelvic inflammatory disease is usually managed medically with antibiotics.

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      • Gynaecology
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  • Question 7 - A 56-year-old postmenopausal woman visits her GP complaining of increased urinary frequency and...

    Incorrect

    • A 56-year-old postmenopausal woman visits her GP complaining of increased urinary frequency and urgency for the past 4 days, along with two instances of urinary incontinence. She has a medical history of type 2 diabetes mellitus (managed with metformin) and diverticular disease. She does not smoke but admits to consuming one bottle of wine every night. During the examination, her heart rate is 106 bpm, and she experiences non-specific lower abdominal discomfort. Perineal sensation and anal tone are normal. What is the most probable cause of this patient's incontinence?

      Your Answer: Oestrogen deficiency

      Correct Answer: Urinary tract infection

      Explanation:

      Causes and Precipitants of Urge Incontinence: A Brief Overview

      Urge incontinence, characterized by involuntary leakage of urine associated with or following urgency, is a common condition in women. It is caused by overactivity of the detrusor muscle in the bladder wall, leading to irregular contractions during the filling phase and subsequent leakage of urine. While there are many causes and precipitants of urge incontinence, it is often difficult to identify a single factor in the presence of multiple contributing factors.

      Some of the common causes of urge incontinence include poorly controlled diabetes, excess caffeine and alcohol intake, neurological dysfunction, urinary infection or faecal impaction, and adverse medication effects. In the case of a patient presenting with a short history of symptoms, urinary tract infection is the most likely cause, and prompt treatment is necessary to prevent complications.

      It is important to rule out developing cauda equina, a medical emergency that can lead to paralysis, in patients presenting with short-term urinary incontinence. Normal anal tone and perineal sensation can help exclude this condition.

      Excess alcohol and caffeine intake can precipitate symptoms of urge incontinence by inducing diuresis, causing frequency and polyuria. Chronic constipation, particularly in patients with diverticular disease, can also compress the bladder and lead to urge incontinence symptoms. Systemic illnesses such as diabetes mellitus can cause glycosuria and polyuria, leading to bladder irritation and detrusor instability. Finally, oestrogen deficiency associated with postmenopausal status can cause vaginitis and urethritis, both of which can precipitate urge incontinence symptoms.

      In conclusion, urge incontinence is a complex condition with multiple contributing factors. Identifying and addressing these factors can help manage symptoms and improve quality of life for affected patients.

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      • Gynaecology
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  • Question 8 - A 70-year-old smoker presents to the Gynaecology clinic following a general practitioner’s referral....

    Incorrect

    • A 70-year-old smoker presents to the Gynaecology clinic following a general practitioner’s referral. Her presenting complaint is long-standing vulval irritation and itching. She has a past medical history of lichen sclerosus. On examination, there is an obvious growth in the vulval area. A biopsy is taken and sent for pathological analysis.
      What is the most common cause of vulval carcinoma?

      Your Answer: Basal cell carcinoma

      Correct Answer: Squamous cell carcinoma

      Explanation:

      Types of Vulval Cancer: Symptoms, Diagnosis, and Treatment

      Vulval cancer is a rare type of cancer that affects the external female genitalia. There are different types of vulval cancer, each with its own set of symptoms, risk factors, and treatment options. Here are some of the most common types of vulval cancer:

      Squamous cell carcinoma: This is the most common type of vulval cancer, accounting for about 85% of cases. It usually affects women over 60 who smoke or have a weakened immune system. Symptoms include vulval irritation or itching, and as the disease progresses, pain and discharge. Squamous cell carcinoma can be cured if caught early, and treatment usually involves surgical excision.

      Basal cell carcinoma: This type of vulval cancer is rare and usually occurs in sun-exposed areas of the skin. It is often treated with surgery.

      Sarcoma: Sarcoma is a rare type of vulval cancer that can occur at any age, including childhood. Treatment usually involves surgery and radiation therapy.

      Bartholin’s gland carcinoma: This is a rare cause of vulval cancer that affects the Bartholin glands, which are two small mucous-producing glands on either side of the vaginal opening. Risk factors include HPV infection and Paget’s disease of the vulva. It is often diagnosed late, as it is often confused with Bartholin gland cyst, which is a benign condition.

      Malignant melanoma: This is a rare type of vulval cancer that accounts for about 5% of cases. Symptoms include itching, bleeding, and an irregular border. Treatment usually involves surgery and chemotherapy.

      If you experience any symptoms of vulval cancer, such as itching, pain, or bleeding, it is important to see a doctor as soon as possible. Early diagnosis and treatment can improve your chances of a full recovery.

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      • Gynaecology
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  • Question 9 - A 35-year-old woman is suffering from menorrhagia and dysmenorrhoea, causing her to miss...

    Incorrect

    • A 35-year-old woman is suffering from menorrhagia and dysmenorrhoea, causing her to miss work and experience significant distress. She has not yet had children but hopes to in the future. An ultrasound of her pelvis reveals a 2 cm intramural fibroid and is otherwise normal. What is the best course of treatment for her symptoms?

      Your Answer: Myomectomy

      Correct Answer: Combined oral contraceptive pill (COCP)

      Explanation:

      Medical treatment can be attempted for uterine fibroids that are smaller than 3 cm and not causing distortion in the uterine cavity. The most suitable option for this scenario would be the combined oral contraceptive pill (COCP). Other medical management options include the intrauterine system, oral progesterone, and gonadotropin-releasing hormone agonists like goserelin. Hysterectomy would not be recommended for patients who wish to have children in the future. Hysteroscopic resection of fibroids is not necessary for fibroids that are smaller than 3 cm and do not cause distortion in the uterine cavity. Myomectomy should only be considered after trying out medical therapies like COCP, tranexamic acid, and levonorgestrel intrauterine system. It may be a suitable treatment for larger fibroids.

      Understanding Uterine Fibroids

      Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

      Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

      Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

      Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

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      • Gynaecology
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  • Question 10 - A 68-year-old woman has undergone a radical hysterectomy and bilateral salpingo-oophorectomy for endometrial...

    Incorrect

    • A 68-year-old woman has undergone a radical hysterectomy and bilateral salpingo-oophorectomy for endometrial carcinoma. She is attending her follow-up clinic to receive her results, and the consultant reports that the tumour was found to involve the right fallopian tube and ovary, but the vagina and parametrial tissue were free of tumour. All nodes submitted were negative for carcinoma. No distant metastases were present. According to the above description, how would you stage the tumour using the TNM 8 classification?

      Your Answer: T3b N0 M0

      Correct Answer: T3a N0 M0

      Explanation:

      Stages of Endometrial Carcinoma: TNM Classification Explained

      Endometrial carcinoma is a type of cancer that affects the lining of the uterus. The TNM classification system is used to describe the extent of the cancer and guide treatment decisions. Here are some common stages of endometrial carcinoma:

      T3a N0 M0: This stage describes endometrial carcinoma that involves the uterine serosa or adnexae, but has not spread to lymph nodes or other organs.

      T3b N0 M0: This stage describes endometrial carcinoma that involves the vagina or parametrial tissues, but has not spread to lymph nodes or other organs.

      T1a N0 M0: This stage describes endometrial carcinoma that is confined to the endometrium or has invaded less than half of the myometrium, without lymph node or distal metastases.

      T1b N0 M0: This stage describes endometrial carcinoma that is confined to the uterus but has invaded more than half of the myometrium, without lymph node or distal metastases.

      T2 N0 M0: This stage describes endometrial carcinoma that involves the cervix but has not spread beyond the uterus, without lymph node or distal metastases.

      Understanding the stage of endometrial carcinoma is important for determining the best treatment options and predicting outcomes.

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      • Gynaecology
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  • Question 11 - A 67-year-old postmenopausal woman comes to you with complaints of bloating, unintended weight...

    Correct

    • A 67-year-old postmenopausal woman comes to you with complaints of bloating, unintended weight loss, dyspareunia, and an elevated CA-125. What is the most appropriate term to describe the initial spread of this cancer, given the probable diagnosis?

      Your Answer: Local spread within the pelvic region

      Explanation:

      Ovarian cancer typically spreads initially through local invasion, rather than through the lymphatic or hematological routes. This patient’s symptoms, including IBS-like symptoms, irregular vaginal bleeding, and a raised CA125, suggest ovarian cancer. The stages of ovarian cancer range from confined to the ovaries (Stage 1) to spread beyond the pelvis to the abdomen (Stage 3), with local spread within the pelvis (Stage 2) in between. While lymphatic and hematological routes can also be involved in the spread of ovarian cancer, they tend to occur later than local invasion within the pelvis. The para-aortic lymph nodes are a common site for lymphatic spread, while the liver is a common site for hematological spread.

      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.

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      • Gynaecology
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  • Question 12 - A 35-year-old woman comes to the clinic asking for the progesterone-only injectable contraceptive....

    Incorrect

    • A 35-year-old woman comes to the clinic asking for the progesterone-only injectable contraceptive. She reports that she has used it before and it has been effective for her. However, she has a medical history of migraines with aura and irritable bowel syndrome. She is currently undergoing treatment for breast cancer and is awaiting further tests for unexplained vaginal bleeding. Additionally, she is a heavy smoker, consuming around 20 cigarettes per day. What makes this contraceptive method unsuitable for her?

      Your Answer: Migraine with aura

      Correct Answer: Current breast cancer

      Explanation:

      Injectable progesterone contraceptives should not be used in individuals with current breast cancer, as it is an absolute contraindication as per the UK medical eligibility criteria. Smoking more than 15 cigarettes a day is also a contraindication for the combined oral contraceptive pill, while migraine with aura is a contraindication for the same. Additionally, unexplained vaginal bleeding is a contraindication for starting the intrauterine device (IUD) or the intrauterine system (IUS).

      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 13 - A 27-year-old woman is being consented for a diagnostic laparoscopy for endometriosis. Apart...

    Incorrect

    • A 27-year-old woman is being consented for a diagnostic laparoscopy for endometriosis. Apart from dysmenorrhoea, menorrhagia and difficulty conceiving, she has no past medical history. She takes ibuprofen during menses, but does not take any other medication. She has never had surgery before, and appears nervous.
      What common side-effect of laparoscopy should she be cautioned about prior to the procedure?

      Your Answer: Pulmonary embolus

      Correct Answer: Shoulder pain

      Explanation:

      During laparoscopy, carbon dioxide gas is used to inflate the abdomen for better visibility and access to abdominal organs. However, after surgery, the remaining gas can cause referred pain in the C3-5 nerve distribution by pressing on the diaphragm. While pulmonary embolus is a potential side effect of any surgery, it is unlikely in a young patient who is not immobilized for long periods. Incontinence is also unlikely in a young, nulliparous woman, even with the risk of urinary tract infection from the catheter used during surgery. Flatulence is not a common side effect as the gas is not passed into the colon. Finally, sciatic nerve damage is not a concern during abdominal surgery as it is a common side effect of hip arthroplasty, which involves a posterior approach to the hip.

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      • Gynaecology
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  • Question 14 - A 27-year-old woman presents for cervical cancer screening and her results indicate positive...

    Incorrect

    • A 27-year-old woman presents for cervical cancer screening and her results indicate positive high-risk HPV and low-grade dyskaryosis on cytology. What should be the next course of action?

      Your Answer: Repeat sample at 3 months

      Correct Answer: Refer for colposcopy

      Explanation:

      If a patient’s cervical cancer screening sample is positive for high-risk HPV and shows cytological abnormalities, the next step according to guidelines is to refer the patient for a colposcopy. During this procedure, the cervix is closely examined to identify any disease. If significant abnormalities are found, loop excision of the transformation zone may be necessary. It is not appropriate to return the patient to normal recall without further investigation. Repeating the sample in 3 months is not necessary for a patient with high-risk HPV and requires specialist assessment. However, repeating the sample in 3 months may be considered if the initial sample was inadequate. Similarly, repeating the sample in 12 months is not the next step and may only be recommended after colposcopy. At this stage, the patient needs further assessment. Repeating the sample in 12 months may be considered if the patient has high-risk HPV with normal cytological findings.

      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 15 - A 35-year-old woman visits her GP with complaints of worsening menstrual pain in...

    Correct

    • A 35-year-old woman visits her GP with complaints of worsening menstrual pain in recent months. The pain is not relieved by ibuprofen and is aggravated during sexual activity. During the clinical examination, adnexal tenderness is observed. The GP suspects that endometriosis may be the underlying cause of her dysmenorrhoea. What is the most suitable initial investigation for suspected endometriosis cases?

      Your Answer: Transvaginal ultrasound (TVUS)

      Explanation:

      Investigations for Endometriosis: Methods and Recommendations

      Endometriosis is a common cause of dysmenorrhoea, and various investigations are available to diagnose it. The National Institute for Health and Care Excellence (NICE) recommends transvaginal ultrasound (TVUS) as the first-line investigation for suspected endometriosis. TVUS can detect ovarian endometriomas or involvement of structures like the uterosacral ligament. However, a definitive diagnosis of endometriosis can only be made by laparoscopy, which is a minimally invasive procedure. Laparotomy with biopsy is rarely used due to longer recovery times and increased risk of complications. Magnetic resonance imaging (MRI) pelvis is not recommended as the first-line investigation, but it may be considered if there is suspicion of deep endometriosis affecting other organs like the bowel or bladder. Transabdominal ultrasound is only considered if TVUS cannot be done. In conclusion, TVUS and laparoscopy are the preferred methods for investigating endometriosis, with other investigations being considered only in specific situations.

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      • Gynaecology
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  • Question 16 - A 25-year-old woman comes to see you for advice on contraception. She has...

    Incorrect

    • A 25-year-old woman comes to see you for advice on contraception. She has just started taking the progesterone-only pill (POP) and is leaving for a vacation with her partner tomorrow. They have both been tested for STIs and the results were negative. She wants to know if it's safe to have unprotected sex while on holiday.

      What guidance would you provide her?

      Your Answer: Use condoms for the first 3 days

      Correct Answer: Use condoms for the first 48 hours

      Explanation:

      To ensure effectiveness, it is important to note that the progesterone-only pill (POP) requires 48 hours before it can be relied upon as a form of contraception. During this time, it is recommended to use additional precautions such as condoms. However, after the initial 48 hours, no further precautions are necessary as long as the POP is taken at the same time each day within a 3-hour window. It is important to note that the POP does not protect against sexually transmitted infections (STIs), so the use of condoms as a barrier method may be discussed for long-term protection. However, as the patient and her partner have recently tested negative for STIs, this may not be necessary at this time. In contrast, if the patient was prescribed the combined oral contraceptive pill (COCP), it is advised to use condoms for the first 7 days.

      Counselling for Women Considering the progesterone-Only Pill

      Women who are considering taking the progesterone-only pill (POP) should receive counselling on various aspects of the medication. One of the most common potential adverse effects is irregular vaginal bleeding. When starting the POP, immediate protection is provided if it is commenced up to and including day 5 of the cycle. If it is started later, additional contraceptive methods such as condoms should be used for the first 2 days. If switching from a combined oral contraceptive (COC), immediate protection is provided if the POP is continued directly from the end of a pill packet.

      It is important to take the POP at the same time every day, without a pill-free break, unlike the COC. If a pill is missed by less than 3 hours, it should be taken as normal. If it is missed by more than 3 hours, the missed pill should be taken as soon as possible, and extra precautions such as condoms should be used until pill taking has been re-established for 48 hours. Diarrhoea and vomiting do not affect the POP, but assuming pills have been missed and following the above guidelines is recommended. Antibiotics have no effect on the POP, unless they alter the P450 enzyme system, such as rifampicin. Liver enzyme inducers may reduce the effectiveness of the POP.

      In addition to these specific guidelines, women should also have a discussion on sexually transmitted infections (STIs) when considering the POP. It is important for women to receive comprehensive counselling on the POP to ensure they are aware of its potential effects and how to use it effectively.

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  • Question 17 - A 49-year-old woman visits her GP for a routine cervical smear. Later, she...

    Incorrect

    • A 49-year-old woman visits her GP for a routine cervical smear. Later, she receives a phone call informing her that the smear was insufficient. She recalls having an inadequate smear more than ten years ago.

      What is the correct course of action in this situation?

      Your Answer: Repeat smear in 3 years

      Correct Answer: Repeat smear in 3 months

      Explanation:

      When a cervical cancer screening smear is inadequate, the recommended course of action is to repeat the smear within 3 months. It is not necessary to consider any previous inadequate smears from a decade ago. Therefore, repeating the smear in 1 month or 3 years is not appropriate. Referral for colposcopy or gynaecology is also not necessary at this stage, as it should only be considered if the second smear in 3 months’ time is also inadequate.

      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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  • Question 18 - A 25-year-old woman complains of abdominal pain that has been ongoing for 3...

    Incorrect

    • A 25-year-old woman complains of abdominal pain that has been ongoing for 3 months. Upon conducting an abdominal ultrasound, an 8 cm mass is detected in her right ovary. Further examination reveals the presence of Rokitansky's protuberance. What is the probable diagnosis?

      Your Answer: Follicular cyst

      Correct Answer: Teratoma (dermoid cyst)

      Explanation:

      Teratomas, also known as dermoid cysts, are non-cancerous tumors that originate from multiple germ cell layers. These tumors can produce a variety of tissues, including skin, hair, blood, fat, bone, nails, teeth, cartilage, and thyroid tissue, due to their germ cell origin.

      Mature cystic teratomas have a white shiny mass or masses projecting from the wall towards the center of the cyst. This protuberance is called the Rokitansky protuberance and is where hair, bone, teeth, and other dermal appendages usually arise from.

      While ovarian malignancy is rare in young females, suspicion can be assessed using the risk of malignancy index (RMI), which takes into account serum CA-125 levels, ultrasound findings, and menopausal status.

      Understanding the Different Types of Ovarian Cysts

      Ovarian cysts are a common occurrence in women, and they can be classified into different types. The most common type of ovarian cyst is the physiological cyst, which includes follicular cysts and corpus luteum cysts. Follicular cysts occur when the dominant follicle fails to rupture or when a non-dominant follicle fails to undergo atresia. These cysts usually regress after a few menstrual cycles. Corpus luteum cysts, on the other hand, occur when the corpus luteum fails to break down and disappear after the menstrual cycle. These cysts may fill with blood or fluid and are more likely to cause intraperitoneal bleeding than follicular cysts.

      Another type of ovarian cyst is the benign germ cell tumour, which includes dermoid cysts. Dermoid cysts are also known as mature cystic teratomas and are usually lined with epithelial tissue. They may contain skin appendages, hair, and teeth. Dermoid cysts are the most common benign ovarian tumour in women under the age of 30, and they are usually asymptomatic. However, torsion is more likely to occur with dermoid cysts than with other ovarian tumours.

      Lastly, there are benign epithelial tumours, which arise from the ovarian surface epithelium. The most common benign epithelial tumour is the serous cystadenoma, which bears a resemblance to the most common type of ovarian cancer (serous carcinoma). Serous cystadenomas are bilateral in around 20% of cases. The second most common benign epithelial tumour is the mucinous cystadenoma, which is typically large and may become massive. If it ruptures, it may cause pseudomyxoma peritonei.

      In conclusion, understanding the different types of ovarian cysts is important for proper diagnosis and treatment. Complex ovarian cysts should be biopsied to exclude malignancy, while benign cysts may require monitoring or surgical removal depending on their size and symptoms.

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  • Question 19 - A 16-year-old girl presents to the Emergency Department accompanied by her mother. She...

    Incorrect

    • A 16-year-old girl presents to the Emergency Department accompanied by her mother. She complains of a 3-day history of right iliac fossa and suprapubic pain. She does not complain of vomiting, although she does mention that she has lost her appetite. Her bowel habit is regular and she describes no urinary symptoms. Her last menstrual period was 4 weeks ago and she should be starting her period soon. On asking, she states that she has never been sexually active.
      Examination reveals suprapubic tenderness and some right iliac fossa tenderness, inferior to McBurney’s point. Her vitals are normal otherwise. Her blood test results are as follows:
      Investigation Result Normal value
      Haemoglobin 123 g/l 115–155 g/l
      White cell count (WCC) 11.1 × 109/l 4–11 × 109/l
      Platelets 290 × 109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.3 mmol/l 3.5–5.0 mmol/l
      Urea 4.5 mmol/l 2.5–6.5 mmol/l
      Creatinine 35 mmol/l 50–120 mmol/l
      Amylase 35 U/l < 200 U/l
      LFTs Normal
      Her urine dipstick shows 1+ of leukocytes, 1+ of proteins and a trace of blood, but is otherwise normal.
      Which of the following tests is the next step in investigating this girl?

      Your Answer: Abdominal/pelvic ultrasound

      Correct Answer: Beta human choriogonadotropin (β-hCG) test

      Explanation:

      Diagnostic Tests and Imaging for Lower Abdominal Pain in Women

      Lower abdominal pain in women can have various causes, including appendicitis, urinary tract infection, ovarian or tubal pathology, pelvic inflammatory disease, ruptured ectopic pregnancy, mesenteric adenitis, and other less common pathologies. To determine the cause of the pain, several diagnostic tests and imaging techniques can be used.

      Beta human choriogonadotropin (β-hCG) test is essential for every woman of reproductive age admitted with lower abdominal pain. This test helps determine the pregnancy status, which can guide further investigations. An abdominal/pelvic ultrasound can detect acute ovarian and other gynecological pathology. It is also useful in assessing biliary pathology and involvement in pancreatitis. However, it is not very sensitive in detecting appendicitis.

      If the diagnosis is uncertain, admitting the patient for observation and review in 12 hours can help determine if any other signs or symptoms develop or change. A CT scan would be inappropriate without checking the patient’s pregnancy status, as it could be harmful to the fetus. However, it can be useful in delineating acute intestinal pathology such as inflammatory bowel disease, bowel obstruction, and renal calculi.

      Finally, an erect chest X-ray can help determine if there is bowel perforation by assessing for air under the diaphragm. This investigation is critical in the presence of a peritonitic abdomen.

      In conclusion, a combination of diagnostic tests and imaging techniques can help determine the cause of lower abdominal pain in women and guide appropriate treatment.

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  • Question 20 - Samantha, a 50-year-old woman visits your clinic complaining of menopausal symptoms. She reports...

    Incorrect

    • Samantha, a 50-year-old woman visits your clinic complaining of menopausal symptoms. She reports experiencing mood swings, irritability, hot flashes, night sweats, and a decreased sex drive. These symptoms are affecting her daily routine and work life. Samantha has had no surgeries and has three children. A friend recommended oestrogen hormone replacement therapy (HRT) and Samantha is interested in trying it out.

      What is the primary danger of prescribing oestrogen-only HRT instead of combined HRT for Samantha?

      Your Answer: Unopposed oestrogen increases her risk of heart disease

      Correct Answer: Unopposed oestrogen increases her risk of endometrial cancer

      Explanation:

      The correct statement is that unopposed oestrogen increases the risk of endometrial cancer. Combined oestrogen and progesterone HRT can reduce the risk of endometrial cancer in patients with a uterus, while patients without a uterus should be prescribed oestrogen-only HRT as combined HRT is less well tolerated. The statement that unopposed oestrogen increases the risk of breast cancer is incorrect, as both types of HRT can increase the risk of breast cancer, with combined HRT potentially increasing the risk more than oestrogen-only. Additionally, the statement that unopposed oestrogen increases the risk of heart disease is incorrect, as oestrogen has a protective role in inhibiting the development of atherosclerosis, which can reduce the risk of heart disease. Finally, the statement that unopposed oestrogen increases the risk of osteoporosis is also incorrect, as HRT can be prescribed to prevent or treat osteoporosis in some patients and can reduce the risk of fracture instead of increasing it.

      Adverse Effects of Hormone Replacement Therapy

      Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.

      Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.

      Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.

      HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).

      Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.

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  • Question 21 - A 23-year-old woman student presents to her general practitioner (GP) with menstrual irregularity....

    Correct

    • A 23-year-old woman student presents to her general practitioner (GP) with menstrual irregularity. Her last menstrual period was 5 months ago. On examination, the GP notes an increased body mass index (BMI) and coarse dark hair over her stomach. There are no other relevant findings. The GP makes a referral to a gynaecologist.
      What is the most probable reason for this patient's menstrual irregularity?

      Your Answer: Polycystic ovarian syndrome (PCOS)

      Explanation:

      Possible Causes of Amenorrhea and Hirsutism in Women

      Amenorrhea, the absence of menstrual periods, and hirsutism, excessive hair growth, are symptoms that can be caused by various conditions. Polycystic ovarian syndrome (PCOS) is a common cause of anovulatory infertility and is diagnosed by the presence of two out of three criteria: ultrasound appearance of enlarged ovaries with multiple cysts, infrequent ovulation or anovulation, and clinical or biochemical evidence of hyperandrogenism. Turner syndrome, characterized by short stature, webbed neck, and absence of periods, is a genetic disorder that would not cause primary amenorrhea. Hyperprolactinemia, a syndrome of high prolactin levels, can cause cessation of ovulation and lactation but not an increase in BMI or hair growth. Premature ovarian failure has symptoms similar to menopause, such as flushing and vaginal dryness. Virilizing ovarian tumor can also cause amenorrhea and hirsutism, but PCOS is more likely and should be ruled out first.

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  • Question 22 - A 65-year-old retired librarian presents to her General Practitioner complaining of a feeling...

    Incorrect

    • A 65-year-old retired librarian presents to her General Practitioner complaining of a feeling of fullness in her vagina. She states that this feeling is present at all times. On further questioning she also has a 1-year history of urinary frequency and has been treated for urinary tract infections in two instances in the past year. She has never smoked and is teetotal.
      What is the most likely diagnosis?

      Your Answer: Bartholin cyst

      Correct Answer: Cystocele

      Explanation:

      Common Vaginal Conditions: Symptoms and Management

      Cystocele: A weakening of pelvic muscles can cause the bladder to prolapse into the vagina, resulting in stress incontinence, frequent urinary tract infections, and a dragging sensation or lump in the vagina. Management ranges from conservative with pelvic floor exercises to surgery.

      Rectocele: Women with a rectocele experience pressure and a lump in the vagina, as well as difficulty with bowel movements. Treatment may involve pelvic floor exercises or surgery.

      Bartholin cyst: A blocked Bartholin gland can lead to a cyst that presents as a tender mass in the vaginal wall. Treatment involves incision and drainage, as well as antibiotics.

      Vaginal cancer: Symptoms include vaginal or postcoital bleeding, vaginal discharge, and persistent pelvic pain.

      Bladder cancer: Painless hematuria is a common symptom, with risk factors including smoking, working in the aniline dye industry, or previous infection with Schistosoma haematobium.

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  • Question 23 - A 42-year-old woman has a hysterectomy due to severe dysmenorrhoea after exhausting pharmacological...

    Incorrect

    • A 42-year-old woman has a hysterectomy due to severe dysmenorrhoea after exhausting pharmacological options. Several months later, she experiences a vaginal vault prolapse and is referred to gynaecologists. What is the most appropriate surgical intervention for her?

      Your Answer: Bilateral oophorectomy

      Correct Answer: Sacrocolpopexy

      Explanation:

      Sacrocolpopexy is the recommended treatment for vaginal vault prolapse. This surgical procedure involves suspending the vaginal apex to the sacral promontory, typically using the uterosacral ligaments for support. Other surgical options include anterior colporrhaphy for repairing a cystocele, vaginoplasty for reconstructing the vagina, vaginal hysterectomy for removing the uterus via the vagina, and bilateral oophorectomy for removing the ovaries. However, these options would not be appropriate for treating vaginal vault prolapse as the ovaries are not involved in the underlying pathology.

      Understanding Urogenital Prolapse

      Urogenital prolapse is a condition where one of the pelvic organs descends, causing protrusion on the vaginal walls. This condition is prevalent among postmenopausal women, affecting around 40% of them. There are different types of urogenital prolapse, including cystocele, cystourethrocele, rectocele, uterine prolapse, urethrocele, and enterocele.

      Several factors increase the risk of developing urogenital prolapse, such as increasing age, vaginal deliveries, obesity, and spina bifida. The condition presents with symptoms such as pressure, heaviness, and a sensation of bearing down. Urinary symptoms such as incontinence, frequency, and urgency may also occur.

      Treatment for urogenital prolapse depends on the severity of the condition. If the prolapse is mild and asymptomatic, no treatment may be necessary. Conservative treatment options include weight loss and pelvic floor muscle exercises. A ring pessary may also be used. In severe cases, surgery may be required. The surgical options for cystocele/cystourethrocele include anterior colporrhaphy and colposuspension. Uterine prolapse may require hysterectomy or sacrohysteropexy, while posterior colporrhaphy is used for rectocele.

      In conclusion, urogenital prolapse is a common condition among postmenopausal women. It is important to understand the different types, risk factors, and treatment options available to manage the condition effectively.

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  • Question 24 - A 29-year-old female patient visits her GP with complaints of vaginal soreness, itchiness,...

    Correct

    • A 29-year-old female patient visits her GP with complaints of vaginal soreness, itchiness, and discharge. During the examination, the doctor notices an inflamed vulva and thick, white, lumpy vaginal discharge. The cervix appears normal, but there is discomfort during bimanual examination. The patient has a medical history of asthma, which is well-controlled with salbutamol, and type one diabetes, and has no known allergies. What is the most suitable next step in her care, considering the most probable diagnosis?

      Your Answer: Prescribe oral fluconazole as a single oral dose

      Explanation:

      If a patient presents with symptoms highly suggestive of vaginal candidiasis, a high vaginal swab is not necessary for diagnosis and treatment can be initiated with a single oral dose of fluconazole. Symptoms of vaginal candidiasis include vulval soreness, itching, and thick, white vaginal discharge. Prescribing oral metronidazole as a single dose or taking a high vaginal swab would be incorrect as they are used to treat Trichomonas vaginalis infections or bacterial vaginosis, respectively.

      Vaginal candidiasis, also known as thrush, is a common condition that many women can diagnose and treat themselves. Candida albicans is responsible for about 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain factors such as diabetes mellitus, antibiotics, steroids, pregnancy, and HIV can increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, itching, vulval erythema, fissuring, and satellite lesions. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy, with oral fluconazole 150 mg as a single dose being the first-line treatment according to NICE Clinical Knowledge Summaries. If there are vulval symptoms, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments. Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and a high vaginal swab for microscopy and culture should be performed to confirm the diagnosis. A blood glucose test may be necessary to exclude diabetes, and differential diagnoses such as lichen sclerosus should be ruled out. An induction-maintenance regime involving oral fluconazole may be considered. Induction involves taking oral fluconazole every three days for three doses, while maintenance involves taking oral fluconazole weekly for six months.

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  • Question 25 - A 38-year-old woman who has a history of injecting heroin has just received...

    Incorrect

    • A 38-year-old woman who has a history of injecting heroin has just received a positive HIV diagnosis. During her initial visits to the HIV clinic, she is offered a cervical smear. What is the recommended follow-up for her as part of the cervical screening program?

      Your Answer: 6 monthly cervical cytology

      Correct Answer: Annual cervical cytology

      Explanation:

      Due to a weakened immune response and reduced clearance of the human papillomavirus, women who are HIV positive face an elevated risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer. If HIV positive women have low-grade lesions (CIN1), these lesions may not clear and could progress to high-grade CIN or cervical cancer. Even with effective antiretroviral treatment, these women still have a high risk of abnormal cytology and an increased risk of false-negative results. Therefore, it is recommended that women with HIV receive cervical cytology at the time of diagnosis and annually thereafter for screening purposes.

      Understanding Cervical Cancer: Risk Factors and Mechanism of HPV

      Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.

      The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.

      The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.

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  • Question 26 - A 23-year-old woman schedules a routine appointment. She has begun a sexual relationship...

    Incorrect

    • A 23-year-old woman schedules a routine appointment. She has begun a sexual relationship and wants to start long term contraception as she and her partner do not plan on having children anytime soon. Her mother was diagnosed with breast cancer a decade ago, and the patient, along with her family, underwent testing at the time. She was found to have a BRCA1 mutation. Based on FSRH guidelines, what is the safest contraception method available?

      Your Answer: Combined oral contraceptive

      Correct Answer: Copper coil

      Explanation:

      If a woman has a suspected or personal history of breast cancer or a confirmed BRCA mutation, the safest form of contraception for her is the copper coil. The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides guidelines for the choice of contraception, grading non-barrier contraceptives on a scale of 1-4 based on a woman’s personal circumstances. Contraceptive methods that fall under category 1 or 2 are generally considered safe for use in primary care. In this case, all forms of contraception except the combined pill (category 3) can be offered, with the copper coil being the safest option as it falls under category 1.

      Understanding Contraception: A Basic Overview

      Contraception has come a long way in the past 50 years, with the development of effective methods being one of the most significant advancements in medicine. There are various types of contraception available, including barrier methods, daily methods, and long-acting methods of reversible contraception (LARCs).

      Barrier methods, such as condoms, physically block sperm from reaching the egg. While they can help protect against sexually transmitted infections (STIs), their success rate is relatively low, particularly when used by young people.

      Daily methods include the combined oral contraceptive pill, which inhibits ovulation, and the progesterone-only pill, which thickens cervical mucous. However, the combined pill increases the risk of venous thromboembolism and breast and cervical cancer.

      LARCs include implantable contraceptives and injectable contraceptives, which both inhibit ovulation and thicken cervical mucous. The implantable contraceptive lasts for three years, while the injectable contraceptive lasts for 12 weeks. The intrauterine system (IUS) and intrauterine device (IUD) are also LARCs, with the IUS preventing endometrial proliferation and thickening cervical mucous, and the IUD decreasing sperm motility and survival.

      It is important to note that each method of contraception has its own set of benefits and risks, and it is essential to consult with a healthcare provider to determine the best option for individual needs and circumstances.

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  • Question 27 - A 35-year-old teacher visits her General Practitioner (GP) with complaints of abnormal discharge...

    Correct

    • A 35-year-old teacher visits her General Practitioner (GP) with complaints of abnormal discharge and vaginal discomfort. She also reports experiencing dyspareunia. During a speculum examination, the GP observes a curdy, white discharge covering the vaginal walls with a non-offensive odour. The GP also notes some vulval excoriations. What infection is likely causing this woman's discharge?

      Your Answer: Candidiasis

      Explanation:

      Common Causes of Vaginal Discharge: Symptoms, Diagnosis, and Treatment

      Vaginal discharge is a common symptom experienced by women, and it can be caused by various infections. Here are some of the most common causes of vaginal discharge, along with their symptoms, diagnosis, and treatment options.

      Candidiasis: This infection is caused by Candida fungi, particularly Candida albicans. Symptoms include vaginal itch, thick discharge with a consistency similar to cottage cheese, vaginal discomfort, and pain during sexual intercourse. Diagnosis is usually clinical, and treatment includes good hygiene, emollients, loose-fitting underwear, and antifungal cream or pessary, or oral antifungal medication.

      Trichomoniasis: This infection is caused by the parasite Trichomonas vaginalis. Symptoms include dysuria, itch, and yellow-green discharge that can have a strong odor. Up to 50% of infected individuals are asymptomatic.

      Bacterial vaginosis: This infection is caused by an overgrowth of anaerobes in the vagina, most commonly Gardnerella vaginalis. Symptoms include a thin, white discharge, vaginal pH >4.5, and clue cells seen on microscopy. Treatment of choice is oral metronidazole.

      Streptococcal infection: Streptococcal vulvovaginitis presents with inflammation, itch, and a strong-smelling vaginal discharge. It is most commonly seen in pre-pubertal girls.

      Chlamydia: Although Chlamydia infection can present with urethral purulent discharge and dyspareunia, most infected individuals are asymptomatic. Chlamydia-associated discharge is typically more purulent and yellow-clear in appearance, rather than cheese-like.

      In conclusion, proper diagnosis and treatment of vaginal discharge depend on identifying the underlying cause. It is important to seek medical attention if you experience any symptoms of vaginal discharge.

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

    Incorrect

    • 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: Fibroid

      Correct 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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  • Question 29 - A 25-year-old woman comes to you with complaints of feeling low for about...

    Incorrect

    • A 25-year-old woman comes to you with complaints of feeling low for about a week every month, just before her period starts. She reports feeling tearful and lacking motivation during this time, but her symptoms improve once her period begins. Although her symptoms are bothersome, they are not affecting her work or personal life. She has a regular 28-day cycle, experiences no heavy or painful periods, and denies any inter-menstrual bleeding. She is in a committed relationship and uses condoms for contraception, without plans to conceive in the near future. What treatment options can you suggest to alleviate her premenstrual symptoms?

      Your Answer: Selective serotonin re-uptake inhibitor (SSRI)

      Correct Answer: A new generation combined contraceptive pill

      Explanation:

      Understanding Premenstrual Syndrome (PMS)

      Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and does not occur before puberty, during pregnancy, or after menopause.

      Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.

      Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.

      Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this common condition.

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      • Gynaecology
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  • Question 30 - A 29-year-old female presents to the early pregnancy assessment unit at 7 weeks...

    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: Admission and observation

      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.

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  • Question 31 - A 28-year-old woman with menorrhagia and dysmenorrhoea attends the clinic with her mother....

    Incorrect

    • A 28-year-old woman with menorrhagia and dysmenorrhoea attends the clinic with her mother. She tells you that her mother has had a hysterectomy to treat menorrhagia, which found growths in the uterus. She is worried that the condition is hereditary, how this will affect her fertility and whether she is at risk of cancer.
      Which of the following is most suitable for a definitive diagnosis of the condition described in this scenario?

      Your Answer: Magnetic resonance imaging (MRI) scan of the abdomen and pelvis

      Correct Answer: Ultrasound scan of the abdomen and pelvis

      Explanation:

      Diagnosis of Fibroids: Ultrasound vs CT Scan vs MRI

      Fibroids, or leiomyomatas, are common tumours of smooth muscle origin found in the uterus and cervix. They can cause symptoms such as heavy periods, dysmenorrhoea, and lower abdominal pain. Risk factors include Afro-Caribbean origin, obesity, nulliparity, and family history. Clinical examination may reveal a palpable abdominal mass or a uterus palpable on bimanual examination, but ultrasound is the preferred diagnostic tool. CT scans are reserved for complex cases, while MRI is used for localisation and characterisation of fibroids. A full blood count is also important to diagnose and treat anaemia associated with heavy periods.

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      • Gynaecology
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  • Question 32 - A 26-year-old patient presents with a 3-day history of vaginal discharge, without itching...

    Correct

    • A 26-year-old patient presents with a 3-day history of vaginal discharge, without itching or bleeding. She is normally fit and well, without past medical history. There is no history of sexually transmitted infections. She is sexually active and has a progesterone implant for contraception.
      Examination reveals a soft, non-tender abdomen. On pelvic examination, you notice the vagina has a white-grey coating on the walls and a fishy odour. A small amount of grey vaginal discharge is also seen. The cervix looks normal, and there is no cervical excitation. Observations are stable.
      Which of the following is the most likely diagnosis?

      Your Answer: Bacterial vaginosis

      Explanation:

      Common Causes of Vaginal Discharge: Symptoms and Treatment

      Bacterial vaginosis, Trichomonas vaginalis, Candidiasis, gonorrhoeae, and Pelvic inflammatory disease are some of the most common causes of vaginal discharge in women.

      Bacterial vaginosis is caused by an overgrowth of anaerobic bacteria and loss of lactobacilli in the vagina. It presents with a grey-white, thin discharge with a fishy odour and an increased vaginal pH. Metronidazole is the treatment of choice.

      Trichomonas vaginalis is a sexually transmitted infection that presents with a yellow-green discharge and an erythematosus cervix with a punctate exudate.

      Candidiasis is a fungal infection associated with pruritus, burning, erythema, and oedema of the vestibule. The vaginal discharge is thick, curd-like, and white.

      gonorrhoeae can be asymptomatic or present with abdominal pain, mucopurulent discharge, cervicitis, dyspareunia, or abnormal bleeding.

      Pelvic inflammatory disease is the result of an ascending infection and presents with dyspareunia, lower abdominal pain, menstrual irregularities, irregular bleeding, and a blood stained, purulent vaginal discharge. Cervicitis and cervical excitation are also present.

      Proper diagnosis and treatment are essential to prevent complications and improve the quality of life of affected women.

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  • Question 33 - A 73-year-old woman with ovarian cancer is attending the gynaecological oncology clinic. The...

    Incorrect

    • A 73-year-old woman with ovarian cancer is attending the gynaecological oncology clinic. The consultant is discussing her pre-surgical prognosis, which is based on her risk malignancy index (RMI). Can you identify the three components of the RMI?

      Your Answer: CA125, co-morbidities, ultrasound (US) findings

      Correct Answer: CA125, menopausal status, ultrasound (US) findings

      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.

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  • Question 34 - A 27-year-old female receives a cervical smear test through the UK cervical screening...

    Incorrect

    • A 27-year-old female receives a cervical smear test through the UK cervical screening programme and is found to be hrHPV positive. However, her cytological examination shows no abnormalities. What is the best course of action to take?

      Your Answer: Repeat the test within 3 months

      Correct Answer: Repeat the test in 12 months

      Explanation:

      If a cervical smear test is hrHPV positive but cytologically normal, the recommended course of action is to repeat the test in 12 months. This is in contrast to negative hrHPV results, which are returned to normal recall. Abnormal cytology results require colposcopy, but normal cytology results do not. It is important to note that returning to normal recall is not appropriate in this case, as the patient’s higher risk status warrants a repeat test sooner than the standard 3-year interval. Repeating the test within 3 or 6 months is also not recommended.

      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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  • Question 35 - A 38-year-old woman has given birth to her second and final child at...

    Correct

    • A 38-year-old woman has given birth to her second and final child at 40 weeks gestation. She has been in the third stage of labor for 70 minutes and has lost 2900 ml of blood. Her previous baby was delivered via elective c-section. She has a history of pelvic inflammatory disease. An antenatal ultrasound was performed due to her risk factors, but the results were not seen by the delivery team until now. What is the most effective treatment for the underlying issue?

      Your Answer: Hysterectomy

      Explanation:

      In cases where delayed placental delivery is observed in patients with placenta accreta, hysterectomy is the recommended treatment. This patient has a history of previous caesarean-section and pelvic inflammatory disease, indicating a likely placenta accreta, which was also diagnosed antenatally on ultrasound. The optimal management approach involves leaving the placenta in-situ and performing a hysterectomy to avoid potential haemorrhage from attempts to actively remove the placenta. While medical management with oxytocin and ergometrine may help manage post-partum haemorrhage, it is not a definitive treatment option. Cord traction is also unlikely to be effective as the placenta is abnormally implanted into the uterine wall. Waiting another 30 minutes is not advisable due to the risk of further bleeding.

      Understanding Placenta Accreta

      Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.

      There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.

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  • Question 36 - A 16-year-old girl visits her nearby pharmacy at 11 am on Tuesday, asking...

    Correct

    • A 16-year-old girl visits her nearby pharmacy at 11 am on Tuesday, asking for the morning-after pill. She discloses that she had unprotected sex around 10 pm on the previous Saturday and is not using any birth control method. She specifically asks for levonorgestrel, as her friend had taken it a few weeks ago. Is it possible for her to receive levonorgestrel as an emergency contraception option?

      Your Answer: Yes, as it can be taken up to 72 hours later

      Explanation:

      Levonorgestrel can still be taken within 72 hours of unprotected sexual intercourse (UPSI) in this case. Ulipristal acetate can also be taken up to 120 hours later, but the efficacy of oral options may have decreased after 61 hours. The copper coil is not a suitable option as the patient has declined any form of birth control. Therefore, the correct answer is that levonorgestrel can still be taken within 72 hours of UPSI.

      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.

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      • Gynaecology
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  • Question 37 - A 25-year-old woman, who has never been pregnant, complains of chronic pain in...

    Incorrect

    • A 25-year-old woman, who has never been pregnant, complains of chronic pain in her pelvis and sacrum during her menstrual cycle. Her temperature is 37.2 degrees Celsius. During the examination, there is tenderness in her posterior vaginal fornix and uterine motion tenderness. A pelvic ultrasound shows no abnormalities. What is the subsequent diagnostic test recommended?

      Your Answer: CA-125

      Correct Answer: Laparoscopy

      Explanation:

      When it comes to patients with suspected endometriosis, laparoscopy is considered the most reliable investigation method.

      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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  • Question 38 - A 30-year-old female presents with menorrhagia that has not responded to treatment with...

    Correct

    • 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: 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.

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  • Question 39 - A prospective study is designed to compare the risks and benefits of combined...

    Incorrect

    • A prospective study is designed to compare the risks and benefits of combined oestrogen and progesterone replacement therapy versus oestrogen-only replacement therapy in patients aged < 55 years, who are within 10 years of their menopause. One group of women will receive systemic oestrogen and progesterone for 4 years (HRT group) and the second group will receive the same systemic dose of oestrogen (without progesterone) for the same period (ERT group). The levonorgestrel intrauterine system is placed in women of the second group to counterbalance the effect of systemic oestrogen on the endometrium. The study will only include women who have not undergone a hysterectomy.
      Which one of the following outcomes is most likely to be observed at the end of this study?

      Your Answer: The ERT group will most likely have a higher rate of cardiovascular diseases than the HRT group

      Correct Answer: The HRT group will most likely have a higher rate of breast cancer, compared to the general population

      Explanation:

      Hormone Replacement Therapy: Risks and Benefits

      Hormone Replacement Therapy (HRT) and Estrogen Replacement Therapy (ERT) are commonly used to alleviate symptoms of menopause, such as hot flashes and vaginal dryness. However, these treatments come with potential risks and benefits that should be carefully considered.

      One of the main concerns with HRT is the increased risk of breast cancer, particularly with combined estrogen and progesterone therapy. The absolute risk is small, but it is important to discuss this with a healthcare provider. On the other hand, HRT and ERT have been shown to reduce the risk of osteoporosis and bone fractures.

      Another potential risk of HRT and ERT is an increased risk of deep vein thrombosis. However, the risk may be lower with HRT compared to ERT. Additionally, both treatments have been shown to reduce all-cause mortality in women under 60.

      Oestrogen replacement therapy (without progesterone) may reduce the risk of cardiovascular diseases, but it is important to note that the risk of breast cancer may not be significantly altered.

      Overall, the decision to use HRT or ERT should be based on an individual’s symptoms, medical history, and potential risks and benefits. It is important to discuss these options with a healthcare provider and make an informed decision.

      Weighing the Risks and Benefits of Hormone Replacement Therapy

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  • Question 40 - A 38-year-old woman is seeking advice on contraception options. She has been relying...

    Correct

    • A 38-year-old woman is seeking advice on contraception options. She has been relying on barrier methods but is now interested in exploring long-acting reversible contraceptives (LARCs), specifically the progesterone-only depo injection. What medical conditions would make this method of contraception unsuitable for her?

      Your Answer: Current breast cancer

      Explanation:

      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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  • Question 41 - A 55-year-old woman comes to your GP clinic for the third time in...

    Correct

    • 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: 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.

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  • Question 42 - A 19-year-old female contacts her GP clinic with concerns about forgetting to take...

    Correct

    • A 19-year-old female contacts her GP clinic with concerns about forgetting to take her combined oral contraceptive pill yesterday. She is currently in the second week of the packet and had unprotected sex the previous night. The patient is calling early in the morning, her usual pill-taking time, but has not taken today's pill yet due to uncertainty about what to do. What guidance should be provided to this patient regarding the missed pill?

      Your Answer: Take two pills today, no further precautions needed

      Explanation:

      If one COCP pill is missed, the individual should take the missed pill as soon as possible, but no further action is necessary. They should also take the next pill at the usual time, even if that means taking two pills in one day. Emergency contraception is not required in this situation, as only one pill was missed. However, if two or more pills are missed in week 3 of a packet, it is recommended to omit the pill-free interval and use barrier contraception for 7 days.

      Missed Pills in Combined Oral Contraceptive Pill

      When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.

      However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.

      If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.

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  • Question 43 - A 35-year-old woman visits her GP and reports experiencing postcoital bleeding for the...

    Incorrect

    • A 35-year-old woman visits her GP and reports experiencing postcoital bleeding for the past three months. She denies any pain during intercourse and has not noticed any abnormal vaginal discharge except for the bleeding. She continues to have regular menstrual cycles. What is the most probable diagnosis in this scenario?

      Your Answer: Ovarian cyst

      Correct Answer: Cervical polyps

      Explanation:

      Postcoital Bleeding

      Postcoital bleeding is a condition that occurs when there is trauma to superficial lesions within the vaginal tract. This can be caused by a variety of factors, including cervical trauma, cervical polyps, endometrial and cervical carcinoma, cervicitis, and vaginitis. In some cases, invasive cervical carcinoma may be found in those who are referred to the hospital, accounting for 3.8% of cases.

      Vaginitis is also a possibility, but it is more common in elderly patients with low estrogen levels. On the other hand, salpingo-oophoritis, which is usually caused by pelvic inflammatory disease from sexually transmitted infections, typically presents with deep dyspareunia and purulent vaginal discharge. However, post-coital bleeding is highly unlikely to be caused by salpingo-oophoritis.

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  • Question 44 - What is the appropriate management for endometrial cancer? ...

    Correct

    • What is the appropriate management for endometrial cancer?

      Your Answer: Most patients present with stage 1 disease, and are therefore amenable to surgery alone

      Explanation:

      1. The initial stage of endometrial cancer typically involves a hysterectomy and bilateral salpingo-oophorectomy.
      2. Diagnosis of endometrial cancer requires an endometrial biopsy.
      3. Radiotherapy is the preferred treatment over chemotherapy, especially for high-risk patients after a hysterectomy or in cases of pelvic recurrence.
      4. Lymphadenectomy is not typically recommended as a routine procedure.
      5. Progestogens are no longer commonly used in the treatment of endometrial cancer.

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

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

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  • Question 45 - A 27-year-old female comes to the GP seeking advice on her contraceptive options....

    Correct

    • 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: 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 46 - A 14-year-old girl comes to your GP clinic seeking contraception. She has been...

    Incorrect

    • A 14-year-old girl comes to your GP clinic seeking contraception. She has been in a relationship with her 15-year-old boyfriend for 10 months. What is the best initial step to take?

      Your Answer: Explore the reasons why contraception is needed, Respect her autonomy, maintain confidentiality and give her a prescription

      Correct Answer: Contact the relevant safeguarding lead as this is a child protection issue.

      Explanation:

      Even if a child is Gillick competent, they are still unable to consent to sexual intercourse if they are under the age of 13. Therefore, any interaction with this age group should prompt child protection measures to be taken. Simply prescribing medication or ignoring the situation would not be in compliance with this protocol.

      When it comes to providing contraception to young people, there are legal and ethical considerations to take into account. In the UK, the age of consent for sexual activity is 16 years, but practitioners may still offer advice and contraception to young people they deem competent. The Fraser Guidelines are often used to assess a young person’s competence. Children under the age of 13 are considered unable to consent to sexual intercourse, and consultations regarding this age group should trigger child protection measures automatically.

      It’s important to advise young people to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse. Long-acting reversible contraceptive methods (LARCs) are often the best choice for young people, as they may be less reliable in remembering to take medication. However, there are concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density, and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice. The progesterone-only implant (Nexplanon) is therefore the LARC of choice for young people.

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      • Gynaecology
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  • Question 47 - A 27-year-old woman presents to the Emergency Department with abdominal pain and nausea...

    Incorrect

    • A 27-year-old woman presents to the Emergency Department with abdominal pain and nausea for the past few hours. She has irregular menstrual cycles and cannot recall her last period. The patient appears distressed and unwell, with tenderness noted in the right iliac fossa upon examination. Speculum examination is unremarkable, but cervical excitation and right adnexal tenderness are present on vaginal examination. Vital signs reveal a temperature of 37.8 °C, blood pressure of 90/60, heart rate of 110 bpm, and respiratory rate of 22 with oxygen saturations of 100% on room air. A positive urine beta-human chorionic gonadotropin (β-HCG) test is obtained, and the urine dipstick shows 1+ leukocytes and 1+ blood. What is the most likely diagnosis?

      Your Answer: Pelvic inflammatory disease

      Correct Answer: Ectopic pregnancy

      Explanation:

      Possible Causes of Abdominal Pain and Signs of Shock in Women: Differential Diagnosis

      When a woman presents with abdominal pain and signs of shock, it is important to consider several possible causes. One of the most urgent and life-threatening conditions is ectopic pregnancy, which should be suspected until proven otherwise. A positive pregnancy test and pain localized to one side, especially with evidence of shock, are key indicators. The patient should be given intravenous access, blood tests, serum β-HCG, group and save, and a transvaginal ultrasound scan if stable. If necessary, she may need to undergo a laparoscopy urgently.

      Other conditions that may cause abdominal pain in women include urinary tract infection, acute appendicitis, pelvic inflammatory disease, and miscarriage. However, these conditions are less likely to present with signs of shock. Urinary tract infection would show leukocytes, nitrites, and protein on dipstick. Acute appendicitis would cause pain in the right iliac fossa, but cervical excitation and signs of shock would be rare unless the patient is severely septic. Pelvic inflammatory disease would give rise to pain in the right iliac fossa and cervical excitation, but signs of shock would not be present on examination. Miscarriage rarely presents with signs of shock, unless it is a septic miscarriage, and the cervical os would be open with a history of passing some products of conception recently.

      In summary, when a woman presents with abdominal pain and signs of shock, ectopic pregnancy should be considered as the most likely cause until proven otherwise. Other conditions may also cause abdominal pain, but they are less likely to present with signs of shock. A thorough differential diagnosis and appropriate diagnostic tests are necessary to determine the underlying cause and provide timely and effective treatment.

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      • Gynaecology
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  • Question 48 - A 38-year-old woman presents with a gradual masculinisation process, including deepening of her...

    Incorrect

    • A 38-year-old woman presents with a gradual masculinisation process, including deepening of her voice, increased body hair, and clitoral enlargement. Ultrasonography shows a tumour in the left ovarian hilus, and her 17-ketosteroid excretion is elevated. The histopathology confirms a diagnosis of hilus cell tumour, with large, lipid-laden tumour cells. Which cells in the male reproductive system are homologous to the affected cells?

      Your Answer: Epithelial cells in epididymis

      Correct Answer: Leydig cells

      Explanation:

      Homologous Cells in Male and Female Reproductive Systems

      The male and female reproductive systems have homologous cells that perform similar functions. Leydig cells, also known as pure Leydig cell tumors, are found in both males and females. In females, these cells are located in the ovarian hilus and secrete androgens, causing masculinization when a tumor arises. Sertoli cells, on the other hand, have a female homologue called granulosa cells, both of which are sensitive to follicle-stimulating hormone. Epithelial cells in the epididymis have a vestigial structure in females called the epoophoron, which is lined by cells similar to those found in the epididymis. Spermatocytes have female homologues in oocytes and polar bodies, while spermatogonia have female homologues in oogonia. Understanding these homologous cells can aid in the diagnosis and treatment of reproductive system disorders.

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      • Gynaecology
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  • Question 49 - A 30-year-old married woman has been struggling with infertility for a while. Upon...

    Correct

    • A 30-year-old married woman has been struggling with infertility for a while. Upon undergoing an ultrasound, it was discovered that her ovaries are enlarged. She has also been experiencing scant or absent menses, but her external genitalia appears normal. Additionally, she has gained weight without explanation and developed hirsutism. Hormonal tests indicate decreased follicle-stimulating hormone (FSH) and increased luteinising hormone (LH), increased androgens, and undetectable beta human chorionic gonadotropin. What is the most likely cause of her condition?

      Your Answer: Polycystic ovarian syndrome (PCOS)

      Explanation:

      Understanding Polycystic Ovarian Syndrome (PCOS) and Related Conditions

      Polycystic ovarian syndrome (PCOS) is a hormonal disorder that affects women of reproductive age. It is characterized by enlarged ovaries with many atretic follicles but no mature antral follicles. This leads to increased production of luteinizing hormone (LH), which stimulates the cells of the theca interna to secrete testosterone. Peripheral aromatase then converts testosterone to estrogen, which suppresses follicle-stimulating hormone (FSH) secretion and upregulates LH secretion from the adenohypophysis. This results in decreased aromatase production in granulosa cells, low levels of estradiol, and failure of follicles to develop normally.

      To remember the signs and symptoms of PCOS, use the mnemonic PCOS PAL. PCOS is associated with male pattern balding (alopecia), hirsutism, obesity, hypertension, acanthosis nigricans (thickening and hyperpigmentation of the skin), and menstrual irregularities (oligo- or amenorrhea). It can also cause hypogonadotropic hypogonadism, which is characterized by impaired secretion of gonadotropins from the pituitary, including FSH and LH. This condition can be caused by various factors, such as Kallmann syndrome and GnRH insensitivity. Gonadal dysgenesis, monosomy X variant, is another condition that affects sexually juvenile women with an abnormal karyotype (45, X). It results in complete failure of development of the ovary and therefore no secondary sexual characteristics. Chronic adrenal insufficiency (or Addison’s disease) is another condition that can cause anorexia, weight loss, and hyperpigmentation of the skin in sun-exposed areas.

      It is important to note that early pregnancy is not a possibility in women with PCOS who are not ovulating. Additionally, if a woman with PCOS were pregnant, she would have elevated beta human chorionic gonadotropin. Understanding these conditions and their associated symptoms can help healthcare providers diagnose and manage PCOS effectively.

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      • Gynaecology
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  • Question 50 - As you review your daily results, you come across a cervical smear test...

    Incorrect

    • As you review your daily results, you come across a cervical smear test for a 32-year-old patient. The result indicates that it is a repeat test and states that she is 'high-risk human papillomavirus (hrHPV) negative'. Upon further examination of her medical records, you discover that this is her second repeat test after an abnormal result during a routine screening two years ago. Her last test was 12 months ago, where she tested 'hrHPV positive. Cytologically normal'. Interestingly, she has never been invited for a colposcopy. What would be the most appropriate next step in this situation?

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

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

      Explanation:

      If a patient’s 2nd repeat smear at 24 months is now negative for high-risk human papillomavirus (hrHPV), the correct course of action is to return to routine recall in 3 years. This assumes that the patient had an initial abnormal smear 2 years ago, which showed hrHPV positive but normal cytology, and a repeat test at 12 months that was also hrHPV positive but cytologically normal. If the patient had still been hrHPV positive, they would have been referred for colposcopy. However, since they are now negative, they can go back to routine recall. The latest cervical screening programme does not require cytology to be performed if hrHPV is negative, so it would be inappropriate and impractical for the GP to request cytology on the sample. There is no need to repeat the smear in 4 weeks or 12 months, as transient hrHPV infection is common and self-resolves, and does not necessarily indicate a high risk of cervical cancer.

      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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Gynaecology (18/50) 36%
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