450 SBAs in Clinical Specialties - Sexual and Reproductive Health and Urogynaecology Flashcards Preview

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Flashcards in 450 SBAs in Clinical Specialties - Sexual and Reproductive Health and Urogynaecology Deck (24)
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1. Gynaecological infections (1)

A 32-year-old woman has a routine cervical smear at her GP practice. The result returns as severe dyskaryosis. Following colposcopy and cervical biopsy, formal histological examination reveals cervical intraepithelial neoplasia 3 (CIN 3). Which of the following pathogens is the most likely to have caused this disease?

A. Candida albicans

B. Human immunodeficiency virus (HIV)

C. Human papilloma virus (HPV)

D. Herpes simplex

E. Treponema pallidum

C. Human papilloma virus (HPV)

1 C HPV (C) is attributed to the development of cervical intraepithelial neoplasia and adenocarcinoma. Of the subtypes of HPV, 16 and 18 are among the most highly oncogenic. These are responsible for around 70 per cent of all cervical cancer cases. Routine vaccination against the virus is now offered to all girls at around 12 years of age. Herpes simplex (D) is responsible for oral cold sores and genital herpes, not cervical cancer. Candida albicans (A) is a yeast which causes vaginal candidiasis or ‘thrush,’ which can cause pain and embarrassing discharge. HIV (B) is a retrovirus which is now readily treatable but as yet incurable. Immune destruction gradually causes the onset of opportunistic infection, and, eventually, an AIDS-defining infection. HIV-positive women are at high risk of contracting human papilloma virus and therefore at an increased risk of intraepithelial neoplasias. Treponema pallidum (E) is a spirochaete bacterium which is responsible for clinical syphilis infection. Histological examination of the cervix would not demonstrate any bacterium. Although young women with syphilis infection would be more likely than those without to have a concurrent HPV infection, and therefore a higher risk of cervical intraepithelial neoplasia, there is no direct link between the two and the risk is raised due to the confounding effect of sexual behaviour.

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2. Paediatric and adolescent gynaecology

A 15-year-old girl attends the paediatric gynaecology clinic with primary amenorrhoea and features of secondary breast development. She has intermittent abdominal bloating and is extremely worried that she is ‘not like other girls’. On speculum examination of the vagina, which is normal externally, a bulging red disc is seen 3 cm proximal to the introitus. What is the most likely diagnosis?

A. Turner’s syndrome

B. Congenital adrenal hyperplasia

C. Imperforate hymen

D. Anorexia nervosa

E. Delayed puberty

C. Imperforate hymen

2 C Primary amenorrhoea is a failure to start periods. To begin menstruating, the girl must be structurally normal and have a properly functioning hypothalamic-pituitary axis (HPA). The fact that this girl has normal external genitalia and has normal pubertal breast development suggests that secondary sexual development is occurring normally, and the HPA is functioning. The speculum examination reveals what is most likely to be haematocolpos – blood inside the vagina – the most common cause for which in the presence of amenorrhoea is an imperforate hymen (C). This is where the hymen does not separate at the time of the menarche and thereafter blood cannot escape with each period, but builds up behind the intact hymen. This would also explain her intermittent bloating. Patients with anorexia nervosa (D) would either have complete lack of secondary development, if the condition started early, or a secondary amenorrhoea. Turner’s syndrome (A) – XO karyotype – is associated with short stature, wide carrying angles, a broad chest and a lack of sexual development. Congenital adrenal hyperplasia (B) results from inadequate cortisol production positively feeding back on adrenocorticotrophic hormone production, resulting in adrenal hyperplasia and excessive adrogenic cortisol precursors. Females normally have ambiguous or masculinized genitals, and suffer from hyponatraemia, hyperkalaemia and dehydration. This girl has shown signs of secondary development, so (E) is incorrect.

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3. Management of miscarriage

A 19-year-old woman undergoes surgical evacuation of the retained products of conception (ERPC). Histological examination of the sample shows genetically abnormal placenta with a mixture of large and small villi with scalloped outlines, trophoblastic hyperplasia. What is the most likely diagnosis?

A. Choriocarcinoma

B. Degenerated uterine leimyoma

C. Uterine dysgerminoma

D. Hydatidiform mole

E. Complete miscarriage

D. Hydatidiform mole

3 D The pathological findings are consistent with a diagnosis of hydatidiform mole (D). Hydatidiform moles are part of a spectrum of pathological pregnancies and are essentially benign trophoblastic tumours. They occur in between 1:20 000 and 1:50 000 pregnancies. Risk factors include extremes of age, previous molar pregnancy and race; an increased rate of molar pregnancy is seen in people from South East Asia, although the reasons are unclear. Women usually present with unusual or heavy bleeding beyond the sixth week of pregnancy with a pregnancy which is larger than dates would suggest. Due to the size of theca lutein cysts, the ovaries are often enlarged. Pre-eclampsia, thyrotoxicosis and hyperemesis gravidarum are common in molar pregnancy. Diagnosis involves clinical assessment for the features above, coupled with serum beta hCG assessment (which is often significantly higher than would be expected in an early pregnancy) and ultrasonography which may demonstrate a classical ‘snowstorm appearance’. Follow-up is of vital importance to ascertain whether the hCG level is falling: if it does not, further treatment may be necessary, including surgical evacuation of the uterus. One in 80 women will go on to have a further molar pregnancy. Choriocarcinoma (A) is also a form of gestational trophoblastic disease, but it is aggressive and malignant. It readily metastasizes to the lungs. Closely related syncytiotrophoblasts and cytotrophoblasts are typical, with syncytiotrophoblasts often displaying abnormal nuclei containing cytoplasm with abnormally high eosiniphil counts. Hydatidiform moles can rarely progress to choriocarcinoma, and around half of all cases of choriocarcinoma will have developed from a hydatidiform mole. Degenerated uterine leimyoma (B) is the result of ‘red degeneration’ of a fibroid and would not show any histological features of pregnancy (e.g. trophoblasts). A complete miscarriage (E) constitutes a failed pregnancy in which all products of conception have been expelled from the uterine cavity. As there is still tissue found at ERPC, this cannot be the diagnosis. Dysgerminomas (C) are germ cell tumours which would be histologically distinct from molar pregnancy by the presence of lobular cells with fibrous stromal cells with lymphocytic invasion.

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4. urogynaecology

An 89-year-old woman attends the gynaecology clinic with a long history of a dragging sensation in the vagina. Apart from severe aortic stenosis, she has no significant medical history. She leaks fluid when she sneezes or coughs. On examination with a Sims’ speculum in the left lateral position, a grade 1 uterine prolapse is seen, with an additional cystocoele. What is the most appropriate management?

A. Vaginal hysterectomy with anterior colporrhapy (cystocoele repair)

B. Vaginal hysterectomy alone

C. Tension-free vaginal tape (TVT)

D. Weight loss and pelvic floor exercises

E. Twice weekly 0.1 per cent estriol cream and insertion of shelf pessary

E. Twice weekly 0.1 per cent estriol cream and insertion of shelf pessary

4 E This woman has symptomatic uterine and bladder prolapse into the vagina. When it is significant and symptomatic, surgical treatment is most appropriate. Urodynamic studies should be performed to guide the choice of operation. This woman, however, has a significant medical co-morbidity (severe aortic stenosis) which in a patient of her age makes her a poor surgical candidate: (A)–(C) are therefore least appropriate. Vaginal hysterectomy (A, B) is a suitable surgical therapy for women who have completed their family, have a normal sized uterus (enabling vaginal extraction) and would benefit from it (indications include uterine prolapse and heavy menstrual bleeding among others). Vaginal repairs (A) may be performed concurrently with vaginal hysterectomy, either of the anterior wall (anterior colporrhapy) or posterior wall (posterior colporrhapy) for cystocoele and rectocoele, respectively. TVT is a procedure for urinary stress incontinence involving the insertion of a tape, not under tension, underneath the urethra to support failed native tissue. Of the two non-operative interventions available, estriol cream and a shelf pessary (E) are most likely to bring symptomatic relief from her prolapse. Weight loss and pelvic floor exercises (D) would be appropriate non-medical interventions, though in a woman of 89 years weight loss and effective pelvic floor exercises are probably as unachievable as they are inadvisable.

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5. Incontinence

A 46-year-old woman presents to your clinic with a 6-year history of Incontinence. She has had four children by vaginal deliveries, has a body mass index (BMI) of 35 kg/m2 and suffers from hayfever. Initial examination reveals a very small cystocele. A mid-stream urine culture is negative and urodynamic studies show a weakened urethral sphincter. What is the most appropriate first line management?

A. Fesoterodine 4 mg daily

B. Weight loss and pelvic physiotherapy

C. Tension free vaginal tape

D. Solifenacin 5 mg daily and pelvic physiotherapy

E. Anterior repair and insertion of a transobturator tape

B. Weight loss and pelvic physiotherapy

5 B This woman has symptoms and urodynamic evidence of stress incon-tinence. She does not have any urge symptoms or frank urinary incon tinence. Fesoterodine (A) and solifenacin (D) are used to treat urge incontinence. She has a high body mass index (BMI) which is an independent risk factor for developing stress incontinence. Conservative options should be attempted before more complex medical or surgical stratgies. A TVT (C) or a transobturator tape (TOT) (E) are both appropriate surgical options for persistent stress incontinence but simple measures should be undertaken first such as weight loss, smoking cessation and physiotherapy (B). The TOT procedure carries a lower risk of iatrogenic bladder damage as the tape is passed through the obturator foramen. The choice of procedure in practice often falls to the operator’s preference and surgical experience. In the presence of a cystocoele, an anterior repair may be appropriate but not as a first line treatment for symptomatic stress incontinence. For this reason option (B) is the correct answer.

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6. Gynaecological infections (2)

A 16-year-old girl attends the gynaecology clinic complaining of vaginal itching and lumpy labia. On examination the area is covered with vulval warts. Which is the causative pathogen for vulval warts?

A. Human papilloma virus type 16

B. Human papilloma virus type 18

C. Human papilloma virus type 6

D. Herpes simplex virus

E. Epidermophyton floccosum

C. Human papilloma virus type 6

6 C Human papilloma virus types 6 (C) and 11 are associated with vulval warts. Subtypes 16 (A) and 18 (B) are strongly associated with cervical cancer. Herpes simplex virus (D) causes cold sores on the lips or genital herpes, which are distinct from warts and have a papulovesicular morphology. Epidermophyton floccosum (E) is the fungus responsible for athlete’s foot which can manifest in the groin as jock itch or tinea cruris.

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7. Gynaecological infections (3)

A 25-year-old woman attends accident and emergency with an exquisitely sore, large swelling of her vagina which she noticed only a couple of days before. It has steadily got much bigger. On examination there is a soft fluctuant mass on the right labia minora which is very tender. What is the most appropriate management?

A. Marsupialization

B. Oral ofloxacin and metronidazole

C. Sebaceous cystectomy

D. Local 2 per cent clotrimazole (Canestan)

E. Referral to a vulval clinic

A. Marsupialization

7 A The clinical history and examination findings make it clear that this is a Bartholin’s abscess. The paired Bartholin’s glands, about 0.5 cm in diameter, are commonly found at the 4- and 8-o’clock positions in the labia minora. They are normally non-palpable. Their role is to secrete vaginal lubricant into the vestibule via the Bartholin’s ducts during sexual arousal. If the ducts become blocked, an abscess of the gland can develop. Treatment of this is normally with marsupialization (A): surgery involving opening the abscess and suturing its lining to the outside to create a permanent opening, thereby preventing recurrence. Oral antibiotics (B) may be useful after surgery, or before if the abscess is small, but not when it is large like in this case. Note however that ofloxacin and metronidazole are agents commonly used for pelvic inflammatory disease and not usually for abscesses. Sebaceous cystectomy (C), as the name implies, is a treatment for sebaceous cysts, and is only employed if the cyst is very symptomatic. Vaginal clotrimazole (D) is a treatment for thrush. Simple Bartholin’s abscesses do not require specialist assessment in a vulval clinic (E) unless there are signs of Bartholin’s gland malignancy which is very rare (

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8. Contraceptive risks

An 18-year-old woman attends clinic seeking contraceptive advice. She is currently using condoms only and is keen to start taking the combined oral contraceptive pill (COCP). Her sister used to take it but told her there were lots of problems with it. Her aunt has bowel cancer and she has no other past medical history. Appropriate counselling should cover all of the following except:

A. There is an overall 12 per cent risk in reduction of cancers

B. There is a small increase in cervical cancer with prolonged use (>8 years)

C. There is a reduction in the risk of bowel cancer

D. There is an increase in the risk of ovarian cancer

E. There is no need for a cervical smear prior to starting the pill

D. There is an increase in the risk of ovarian cancer

8 D It is important that before starting any therapy the patient is informed of the potential risks and benefits. There is a decreased risk of bowel (C) and rectal cancer with use of the COCP. The risk of any cancer developing overall is reduced by 12 per cent for women on the COCP (A) while there is a small but statistically significant increase in the risk of cervical cancer with prolonged use (B). Option (D) is the appropriate option because there is no proven increased risk of ovarian cancer in women taking the combined oral contraceptive: in fact there is a protective effect. Before starting the pill, a full sexual history should be taken. There is no requirement to start cervical smears (E) until she is 25 unless there are specific patient-specific risks of developing cervical neoplasia. There is a small increase in cervical cancer with prolonged pill usage but this risk is mitigated through regular routine cervical screening.

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9. Subfertility treatments

A 49-year-old woman presents to a private clinic expressing her desire to become pregnant. She has no past medical history. Initial investigations show that she still has ovarian function, is ovulating and is having regular periods. An ultrasound of her pelvis shows no structural abnormality and an hysterosalpingography demonstrates patent fallopian tubes. Analysis of her partner’s semen is normal. Which would not be an appropriate first line management option?

A. In vitro fertilisation (IVF)

B. Intracytoplasmic sperm implantation

C. Intrauterine insemination

D. Clomiphene

E. Egg donation IVF

D. Clomiphene

9 D Most students, and indeed many postgraduate trainees, will have little experience with which to tackle this question since only in private practice would a 49-year-old woman normally be offered IVF. The important point is that in 2008 the average success rate of IVF with a patient’s own eggs if she was over 44 years old was 2.5 per cent. (A), (B) and (C) would be appropriate measures to try and achieve a pregnancy. Option (E) may well provide a better success rate as the donor’s eggs will be potentially of a better quality than the patient’s. Clomiphene is the wrong answer. Clomiphene is a selective oestrogen receptor modulator which, by inhibiting negative feedback on the hypothalamus, increases the production of gonadotrophins. In this way, it is used to induce ovulation. Given that the woman in this case is ovulating, treatment with clomiphene would be inappropriate.

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10. urge incontinence

A 42-year-old woman presents to the urogynaecology clinic with a 3-year history of urge incontinence. She has features of an overactive bladder and is desperate to start treatment for her problem as it is affecting her quality of life. She opts for medical treatment. What is the most appropriate first line pharmacological therapeutic?

A. Darifenacin

B. Oxybutynin

C. Fesoterodine

D. Solifenacin

E. Oxybutynin dermal patch

B. Oxybutynin

10 B A diagnosis of an overactive bladder can be based on history.

Urodynamic studies will confirm the diagnosis but this is an invasive procedure. It is appropriate in most women to start a trial of therapy and assess the response. Conservative measures include keeping a bladder diary and bladder retraining. The first line treatment is immediate release oxybutynin (B). All of the other answers (A, C, D, E) are appropriate second line agents. It is important to counsel the patients about the side effects of antimuscarinics which include dry mouth, constipation and urinary retention. If there is no improvement following trials of alternative medical treatments, and if diagnosis of overactive bladder is confirmed with urodynamic studies, other treatment modalities such as sacral nerve stimulation may be appropriate.

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11. Assisted reproductive technologies

A 41-year-old woman is about to undergo her first cycle of IVF. As part of the consultation, she is counselled about the maternal and fetal risks involved with IVF-conceived pregnancies. All of the following occur in such pregnancies except:

A. Increased risk of low birth weight infants

B. Increased risk of fetal congenital abnormalities

C. Decreased risk of ectopic pregnancies

D. Increased risk of small for gestational age (SGA) fetuses in singleton pregnancies

E. Increased risk of maternal pregnancy-induced hypertension (PIH)

C. Decreased risk of ectopic pregnancies

11 C Since the birth of the first baby conceived through IVF in 1978, IVF has offered women the chance of successful healthy pregnancy which nature would have otherwise denied them. There is good evidence demonstrating various increased maternal and fetal risks of IVF-conceived pregnancies compared with natural conception. There is in fact an increased risk of ectopic pregnancies, not a reduced risk (C). There is an increased risk of fetal congenital abnormalities (B). IVF pregnancies are more likely than naturally conceived pregnancies to be multiple (twins, triplets etc.), which carry their own increased risks such as pre-eclampsia. There is an increase in SGA babies (D) and low birth weight deliveries (A). If the pregnancy is a result of egg donation there is an as yet unexplained a seven-fold increase in PIH (E).

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12. Pre-termination assessment

A 16-year-old presents to the termination of pregnancy service 6 weeks into her second pregnancy requesting surgical termination (STOP). What is not required as part of her work-up for the procedure?

A. Antibiotic prophylaxis for Chlamydia

B. Gaining consent from her mother

C. Contraception discussion

D. Explaining the risks of STOP

E. Explaining that the risk of uterine perforation is one in 300

B. Gaining consent from her mother

12 B This patient is 16 years old and is therefore able to consent to an operation under the concept of ‘Gillick competence’. If she shows that she has the capacity to consent to the procedure then parental request is unnecessary (B). Screening for Chlamydia or treating empirically should be offered (A). A very important part of a termination of pregnancy service is to offer women post-termination contraception (C). The risks of a termination (D), including bleeding, infection, failure of the procedure, the need for a repeat procedure and perforation of the uterus (E), must be explained clearly to the patient for consent to be valid. Perforation of the uterus occurs in approximately one in 300 surgical terminations of pregnancy.

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13. Subfertility (1)

A 35-year-old woman is seen in the assisted conception unit. She has been trying to conceive for 4 years. In this period she has been having regular intercourse. Her periods have been irregular and recently she has had no periods at all. Her BMI is 19.5 kg/m2, she has had an appendectomy and is otherwise well. Her biochemistry comes back as follows: luteinizing hormone (LH) 0.5 IU/L, follicle-stimulating hormone (FSH) 1.0 IU/L, prolactin 490 mIU/L, thyroxine (T4) 12, thyroid stimulating hormone (TSH) 4.2 mIU/L, oestradiol 60 pmol/L. What is the most likely cause of her subfertility?

A. Polycystic ovarian syndrome (PCOS)

B. Hypothyroidism

C. Microprolactinoma

D. Hypothalamic hypogonadism

E. Anorexia

D. Hypothalamic hypogonadism

13 D From these results you can see that her pituitary is not producing FSH and LH in adequate quantities to cause the ovaries to produce oestradiol. In fact, the negative feedback loop is not activated – the pituitary is not responding to the low oestradiol levels by increasing the FSH as in the menopause. Therefore, this could be attributed to hypothalamic hypogonadism. Her BMI is at the low end of normal but is not pathological (E). Her prolactin (C) level is normal. A microprolactinoma can be diagnosed on MRI of the brain. Her TSH (B) is at the high end of normal but again is not pathological and could not explain her sub-fertility. The diagnosis of PCOS (A) needs two of oligo/anovulation, signs of hyperandrogenism or polycystic ovaries. Although we do not have any comment about the ovaries or clinical hyperandrogenism, the pituitary profile is not typical of PCOS.

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14. Pre-conception advice

A 19-year-old comes to you for some pre-conception advice. Some members of her family and her partner’s family have a sickle cell anaemia. She reveals that her sister and his sister are both affected. Tests have shown that they are both carriers. What is the chance that if their child was a boy he would have sickle cell anaemia?

A. 50 per cent

B. 67 per cent

C. 100 per cent

D. 33 per cent

E. 25 per cent

E. 25 per cent

14 E Sickle cell anaemia is an autosomal recessive condition. The gender of the offspring is irrelevant as sickle cell is not an X-linked condition. If both parents are carriers of this autosomal recessive gene then the chance of having a child with sickle cell anaemia is 25 per cent, being a carrier 50 per cent and not being affected at all 25 per cent. Other autosomal recessive conditions include Tay–Sachs disease, phenylketonuria and cystic fibrosis.

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15. Post-coital bleeding

An 18-year-old girl is seen in the colposcopy clinic after having had persistent post-coital bleeding. She has been sexually active since the age of 14 and has no past medical history. She is studying for her A-levels and has been doing a lot of reading. She is concerned that she might have cervical cancer. Which of the following is not a risk factor for cervical cancer?

A. Herpes simplex virus (HSV)

B. Smoking

C. HIV

D. Use of the oral contraceptive pill

E. Multiparity

A. Herpes simplex virus (HSV)

15 A Cervical cancer typically affects women between the age of 45 and 55. The majority of cancers are squamous cell with 10 per cent being adenocarcinomas. There is a clear association with human papilloma virus (HPV) but there is no clear association with HSV (A). Smoking (B) is an independent risk factor and any condition that renders the patient immunocompromised, such as HIV (C), increases the risk of cervical carcinoma. There is an association with COCP use (D) and having children (E). Both of these are not causal factors for the development of cervical cancer but instead are relative risk factors conferred by the increased sexual activity associated with them.

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16. Mixed urinary incontinence

A 49-year-old comes to the urogynaecology clinic with a history of leaking urine for the last year. There are associated stress symptoms and some urge symptoms. Interestingly she says that it seems to come from inside the vagina as well. She had a hysterectomy last year for endometrial cancer and had quite a prolonged recovery. She has a BMI of 30 kg/m2, does not smoke and is otherwise fit and well. You are suspicious that she might have a vesico-vaginal fistula secondary to her operation. What is the most appropriate first line investigation?

A. Examination under anaesthesia (EUA) and cystoscopy

B. Pelvic MRI

C. Instillation of methylene blue into the urinary bladder and speculum examination

D. Pelvic computed tomography

E. Urodynamic study

C. Instillation of methylene blue into the urinary bladder and speculum examination

16 C Vesico-vaginal fistulae are common around the world, mainly as a result of obstructed labour. The fetal head can sit adjacent to the bladder for days before medical help is sought. By this time the tissues become necrotic, break down and a fistula develops. In resource-rich countries the most common cause is pelvic surgery. This woman may have a connection from the bladder to the vagina. A simple test you could do in clinic is to pass a catheter and fill the bladder with some methylene blue dye (C). You can then perform a speculum examination to see if the dye is in the vagina. Second line investigation would involve an EUA and cystoscopy (A). Urodynamics (E) and imaging (B, D) are unlikely to aid in diagnosis as stress incontinence is the loss of native supporting tissue allowing incontinence and is likely to be undetectable on x-ray. Once a fistula has been identified, referral to a centre that has experience in repair is advised. They can be repaired abdominally or vaginally depending on their site and size.

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17. Emergency contraception

A 16-year-old girl presents to your surgery with a history of unprotected sexual intercourse (UPSI) 70 hours ago. Her last menstrual period was 8 days ago. Her only past medical history of note is that of epilepsy which is well controlled by carbamazepine. She is worried about becoming pregnant, does not want her mother to find out and is in a hurry to get home before suspicions are raised. Which of the following options are available to her?

A. Take the combined oral contraceptive pill (COCP) continuously for the next month

B. A copper intrauterine device (IUD) should be inserted with prior screening for sexually transmitted infections (STIs)

C. Levonorgestrel 1.5 mg should be given as she is within 72 hours of UPSI

D. Reassure and tell her to come back when she has made her mind up as ulipristal can be taken up to 7 days after UPSI

E. Reassure her that she is in the safe part of her cycle and she should try and use condoms in the future

C. Levonorgestrel 1.5 mg should be given as she is within 72 hours of UPSI

17 C This is a difficult conversation under time pressures. Ideally you would prefer to counsel the patient about all the options of emergency contraception and the ramifications of unprotected sexual intercourse. An important part of your counselling will involve future contraception advice. This patient has three options for emergency contraception. A copper IUD (B) inserted up to 5 days after the UPSI, the progesterone antagonist Ulipristal (D) up to 5 days after and the more common levonorgesterol 1.5 mg within 72 hours (C). She meets the timeline for all options. Importantly she is taking an enzyme inducer carbamazepine so you could not guarantee the success of levonorgesterol. The Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH) recommends increasing the dose of levonorgesterol to 3 mg but this is off licence. A copper coil would be the most appropriate contraception under these circumstances, also allowing you to perform a full STI screen simultaneously. Option (A) would not be effective as an emergency contraception and she is on an enzyme-inducing drug. Option (E) is not appropriate as depending on her cycle length she may well ovulate in the next 5–6 days. Sperm can survive for a week so she may well fall pregnant if no action is taken.

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18. Contraception

A 40-year-old woman comes to your clinic alone wanting an effective form of contraception. She has two children from a previous marriage and has recently started a new relationship. She says that she does not want any further children. She has regular heavy periods, no menopausal symptoms and she is otherwise well with no past medical history. A recent ultrasound showed a normal sized uterus and pipelle biopsy revealed normal secretory endometrial tissue. What is the most appropriate form of contraception?

A. Combined oral contraceptive pill with

B. Mirena coil

18 B Although there is much in the press about the cardiovascular/ carcinogenic/venous thromboembolism (VTE) risks of the COCP there is no contraindication to prescribing them in a low risk woman (A). The DFRSH states that there is a small increase in the risk of breast cancer and a recent study suggested that VTE risk was lower if oestrogen was

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19. Secondary amenorrhoea

In a busy gynaecology clinic you are assessing a 22-year-old woman who has not had a period for 18 months. She is not pregnant and previously had regular periods. She has had two surgical terminations of pregnancies (STOP), an underactive thyroid gland and an appendectomy. Clinical examination is unremarkable with a BMI kg/m2 of 20. Biochemical investigations reveal a T4 of 17 pmol/L, TSH 4.6 kg/m2, prolactin of 570 mU/L, and testosterone of 42 ng/dL. LH and FSH are normal. Vaginal ultrasound shows a normal sized uterus and the left ovary contain four cysts. Which of the answers listed below is the most likely cause?

A. Polycystic ovarian syndrome (PCOS)

B. Prolactinoma

C. Sheehan’s syndrome

D. Asherman’s syndrome

E. Anorexia nervosa

D. Asherman’s syndrome

19 D PCOS (A) is a multisystem disorder classically diagnosed by two of the following three criteria: anovulation/oligo-ovulation, biochemical or physical evidence of hyperandrogenism and an ultrasound scan showing 12 or more follicles in the ovary. This woman has secondary amenorrhoea but has no evidence of PCOS physically, biochemically or on ultrasound. Her prolactin level (B) is at the high end of normal. With a prolactinoma one should be vigilant for visual field defects. If the adenoma compresses the optic chiasm you can develop visual field defects. Other symptoms of hyperprolactinaemia include galactorrhea. Sheehan’s syndrome (C) is a post-partum complication, classically after a large haemorrhage causing hypoperfusion of the pituitary gland leading to ischaemia and necrosis. She has not carried a pregnancy past the first trimester so this is not possible. Her BMI is normal but further questioning would be needed to ascertain whether this was the cause. In light of a normal LH and FSH, anorexia (E) being the cause is unlikely as it leads to a hypothalamic hypogonadism. Asherman’s syndrome (D) is intrauterine scar tissue and adhesion formation seen after instrumentation of the uterus. It is not common but should be considered with a history of two STOPs. To diagnose, a hysteroscopy would need to be performed.

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20. Subfertility (2)

A 26-year-old woman is otherwise fit and well has been trying to conceive for over 2 years. On questioning she has regular periods and has been having regular intercourse. There are no abnormalities on clinical examination. What would be your first line investigations for her subfertility?

A. Day 14 FSH and LH, ultrasound and hysterosalpingogram (HSG), semen analysis

B. Day 1–3 FSH and LH, mid-luteal progesterone, semen analysis

C. Day 1–3 FSH and LH, mid-follicular progesterone, semen analysis

D. Random LH, FSH, HSG, semen analysis

E. Ultrasound, laparoscopy, semen analysis

B. Day 1–3 FSH and LH, mid-luteal progesterone, semen analysis

20 B The causes of subfertility can be viewed broadly as male and female. Semen analysis is vital in the assessment of the subfertile couple. Female causes include anovulation, tubal/uterine blockage and endometriosis. It would be advisable to check day 1–3 LH and FSH as well as a mid-luteal phase progesterone (B). This will give you the best indication as to whether the woman is ovulating. If she is not ovulating then pregnancy will not be possible. Further investigations can include an ultrasound to look at the size of the uterus and the presence of fibroids/polyps. An HSG is an assessment of tubal patency. A laparoscopy (E) would be considered after all the above to investigate endometriosis and direct vision of tubal patency by passing dye through the cervix and watching it exit via the fimbrial ends of the fallopian tubes. (A) would not be an appropriate first step as day 14 – around ovulation – would provide little information to help your diagnosis. You would expect an LH surge to be present at this time. A mid-follicular phase progesterone (C) would be low. Mid-luteal phase progesterone >30 nmol/L would lead you to believe that she is ovulating. Answer (D) has no place in the initial investigation as it is important to know whereabouts in the cycle this woman is.

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21. Semen analysis

A 42-year-old man undergoes semen analysis as part of the investigation of subfertility with his wife. What result would most likely contribute to their subfertility?

A. Sperm count 30 million/mL

B. Volume 2.5 mL

C. 40 per cent have normal motility

D. 5 per cent normal morphology

E. pH 7.4

C. 40 per cent have normal motility

21 C Male factor subfertility is the cause for somewhere between 25 and

40 per cent of subfertile couples. The average ejaculate volume is 1.5–6 mL (B) and the pH should be between 7.2 and 8.0 (E). The sample is considered normal if 4 per cent or more have normal morphology (D). Sperm count should be over 15 million per millilitre (A). Fifty per cent of the sperm should have normal motility so (C) is the correct answer.

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22. Assisted reproduction

A 46-year-old women in her fifth IVF cycle is admitted to the emergency department 4 days after egg collection. She is complaining of a swollen abdomen and shortness of breath. She is reviewed and a diagnosis of ovarian hyperstimulation syndrome (OHSS) is made. Which of the following is not a clinical feature/complication of OHSS?

A. Hydrothorax

B. Deep vein thrombosis

C. Haemodilution D. Oliguria

E. Marked ascites

C. Haemodilution D. Oliguria

22 C OHSS is diagnosed after ovarian stimulation in IVF cycles. Thirty-three per cent of all IVF cycles will lead to mild OHSS and 3–8 per cent into severe OHSS. It typically presents with abdominal pain and swelling and vomiting. It is important to consider differentials including an ectopic pregnancy, pelvic infection, ovarian cyst torsion or appendicitis. Classically the blood will become haemoconcentrated (C) with a hypoproteinaemia and ascites (E) will be present which may lead to a pleural effusion (A). The ovaries will be enlarged on ultrasound and in severe OHSS will be over 12 cm. Due to the haemoconcentration these patients are at particularly high risk of venous thromboembolism (B) so thromboembolic decompression stockings and enoxaparin while in hospital is appropriate. This is partly attributable to the hypoproteinaemia – low albumin – leading to decreased intravascular plasma and hypercoagulability. If the OHSS is severe there may be problems perfusing the kidneys well if much of the intravascular volume is being drawn into the third space by the decrease in oncotic pressure in the blood vessels. This may lead to oliguria. Fluid balance and management is key to these patients.

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23. Primary amenorrhoea

A 17-year-old girl comes to clinic with her mother as she has not started having periods yet and they are worried. On examination she is of short stature, with a slightly widened neck and has no secondary sexual characteristics and there is no obvious abnormality of the external genitalia. What is the most likely diagnosis form this limited information?

A. Androgen insensitivity syndrome

B. Turner’s syndrome

C. Congenital adrenal hyperplasia

D. Kallmann’s syndrome

E. Rokitansky’s syndrome

B. Turner’s syndrome

23 B Androgen insensitivity syndrome (AIS) (A) is very unlikely in a female as carriers are not generally affected and the likelihood of a fertile male with AIS is very small. Turner’s syndrome (B) is most likely because of the sexual development, short stature and the neck webbing. Turner’s syndrome is 46×0 leading to gonadal dysgenesis and sterility. Congenital adrenal hyperplasia (C) is autosomal recessive and is a disruption of steroid production. There are various enzymes that lead to different versions but the most common is 21 hydroxylase deficiency. This leads to hyperandrogenism and virilization of the female genitalia. Kallmann’s syndrome (D) would have been the next best answer as it is a result of decreased gonadotrophin-releasing hormone leading to hypogonadism, delayed puberty and lack of secondary sexual characteristics. Rokitansky’s syndrome (E) is characterized by Müllerian agenesis. So a girl will be 46XX, will have ovaries that function and will develop secondary sexual characteristics. There will, however, be no development of fallopian tubes or uterus and she may have a shortened vagina.

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24. Vaginal discharge

A 22-year-old woman presents to the GUM clinic with an offensive smelling discharge. She is sexually active and is in a monogamous relationship. She describes no pain or soreness just an offensive smelling discharge. After examination and taking swabs for the second time she is diagnosed with bacterial vaginosis. Which of the following organisms is not likely to be the cause?

A. Gardnerella species

B. Mobiluncus

C. Bacteroides

D. Trichomonas

E. Mycoplasma

D. Trichomonas

24 D Bacterial vaginosis (BV) is not felt to be a sexually transmitted disease but

is seen in people who are sexually active. It is a result of an imbalance of the naturally occurring flora in the vagina. It presents as an off-white offensive discharge with a fishy odour. Diagnosis is made with swabs showing clue cells and a loss of vaginal acidity. Trichomonas (D) is a separate infection caused by a protozoon that leads to a greenish discharge. It is a sexually transmitted infection. All the other flora above are responsible for bacterial vaginosis. (A, B, C and E) can all cause BV secondary to the reduction in the normal levels of lactobacilli found in the vagina. This reduction may be due to a recent antibiotic course or a change in pH of the vagina allowing these other bacteria to multiply.