Day 6 Gynaecology

Question 1

A 24-year-old woman presents to the GP with vaginal bleeding.

She is 5-weeks pregnant.

She reports no abdominal pain, no dizziness, no shoulder tip pain.

There are no clots and she has passed less than a teaspoon amount of blood.

She has no history of ectopic pregnancy.

On examination, her heart rate is 85 beats per minute, blood pressure is 130/80 mmHg and her abdomen is soft, non-tender.

According to current NICE CKS guidance, what is the next most appropriate management step?

(2)

Answer 1

Pregnant women who are < 6 weeks gestation and present with vaginal bleeding and no pain can be managed expectantly

Monitor expectantly and advise to repeat pregnancy test in 7 days. If negative, this confirms miscarriage. If positive, or continued or worsening symptoms, refer to the early pregnancy assessment unit

Question 2

A 28-year-old woman attends the early pregnancy assessment unit at 7 weeks gestation due to heavy vaginal bleeding.

Which investigation was used to confirm miscarriage?

After 14 days of expectant management the patient attends for follow up. She describes ongoing light vaginal bleeding.

There are no signs of ectopic pregnancy and she is haemodynamically stable. Ultrasound scan confirms incomplete miscarriage.

What is the most appropriate next step?

Answer 2

1. Ultrasound confirms an intra-uterine miscarriage.

2. Medical management of a miscarriage involves giving vaginal misoprostol alone

Question 3

Long-term complications include of PCOS?

Answer 3

PCOS is a common disorder, which is often complicated by chronic anovulation and hyperandrogenism.

Long-term complications include:

• Subfertility
• Diabetes mellitus
• Stroke & transient ischaemic attack
• Coronary artery disease
• Obstructive sleep apnoea
• Endometrial cancer

Question 4

Jennifer is a 34-year-old woman presenting with pelvic pains. Her pelvic pain is excruciating and is not responding to paracetamol. The pain began 4 months ago and her pain starts approximately 4 days prior to her the start of menstruation. Her pain gets worse as she approaches the start of menstruation and gradually improves once her menstruation stops. She also notes that she is changing her menstrual pads every 4 hours.

She began her menstruating at the age of 15 years and her cycles tend to be fairly regular. On her previous cycles, she only had mild pains that settled down with paracetamol. Her cycles had not been heavy. She is sexually active but she uses a condom during sexual intercourse.

Pelvic examination is unremarkable with no abnormalities seen on speculum examination. Her abdomen examination was unremarkable.

What would be the most appropriate step in her management?

What is the diagnosis?

Answer 4

Prescribe ibuprofen and refer to gynaecology for further investigation

All patients with secondary dysmenorrhoea need to be referred to gynaecology for investigation

Question 5

A 20-year-old female is admitted with acute abdominal pain.

Examination reveals a diffusely tender abdomen.

During laparoscopy multiple fine lesions are noted between her liver and abdominal wall, her appendix appears normal.

What is the most likely diagnosis?

Answer 5

Hepatic adhesions are specific for Fitz-Hugh-Curtis syndrome.

The symptoms in the question are not enough to make a diagnosis and it is, therefore, the lesions that give the diagnosis, as they would not be present in any of the other options. It is a complication of PID causing inflammation of the liver capsule forming ‘Glisson’s Capsule’.

Question 6

A 35-year-old woman reports heavy periods.

She has always had this problem, since menarche aged 12.

Although she has never spoken to a doctor about this, she finally feels ‘enough is enough’ and wants to address it.

She has regular periods with a 28-day cycle.

She typically bleeds for 7 days, and for 4 of those she experiences blood clots and ‘flooding’.

The patient is nulliparous, and does not want children. Currently, she is in a sexual relationship, reliant on condoms.

Her past medical history and family history are unremarkable.

You arrange blood tests and a pelvic ultrasound scan which are unremarkable.

What is the most appropriate management option?

What is the second-most appropriate option?

Answer 6

Menorrhagia - intrauterine system (Mirena) is first-line

Tablet medications, such as the progesterone-only pill or combined oral contraceptive pill can be used to treat menorrhagia, but they are not first-line.

The intra-uterine system (IUS) should be offered as the first-line treatment for menorrhagia. It is highly-effective at stopping bleeding altogether, requires once-only intervention to establish (i.e. insertion) and offers a very reliable form of contraception.

Question 7

A 28-year-old woman with polycystic ovarian syndrome consults you as she is having problems becoming pregnant.

She has a past history of oligomenorrhea and has previously recently stopped taking a combined oral contraceptive pill.

Despite stopping the pill 6 months ago she is still not having regular periods.

Her body mass index is 28 kg/m^2.

Apart from advising her to lose weight, which one of the following interventions is most effective in increasing her chances of conceiving?

Answer 7

Infertility in PCOS - clomifene is typically used first-line

Whilst metformin has a role in the management of infertility it should be used second-line to anti-oestrogens such as clomifene. Similar questions to this often appear in which clomifene is not an option, in this case metformin is clearly the right answer.

Question 8

A 66-year-old woman presents to her general practitioner with a six month history of poorly-localised abdominal discomfort and a constant feeling of bloatedness.

Abdominal and pelvic examination is normal.

The GP was initially concerned about bowel malignancy and referred her for colonoscopy, which ruled this out.

The consultant gastroenterologist who performed the colonoscopy suggested that her symptoms might indicate irritable bowel syndrome.

The patient has no history of digestive disorders.

What should the GP’s next step be?

Answer 8

NICE guidelines state that serum CA125 should be performed if a woman - especially if aged 50 years old or over - has any of the following symptoms on a regular basis:

• abdominal distension or ‘bloating’
• early satiety or loss of appetite
• pelvic or abdominal pain
• increased urinary urgency and/or frequency

Question 9

A 29-year-old woman attends the fertility clinic with her partner. She has a history of regular 35-day menstrual cycles.

Which investigation is the best measure of ovulation?

Answer 9

The follicular phase of the menstrual cycle can be variable, however, the luteal phase (after ovulation) remains constant at 14 days.

The serum progesterone level will peak 7 days after ovulation has occurred. Therefore, in a 35-day cycle the follicular phase will be 21 days (ovulating on day 21), luteal phase 14 days. Therefore, the progesterone level will be expected to peak on day 28 (35-7).

Question 10

A 51-year-old woman attends clinic with worsening perimenopause.

Since the previous year her periods have become irregular, and has also been suffering from low mood, night sweats and hot flushes.

The patient would like to undergo treatment to help with her symptoms, but is concerned about the risk of breast cancer.

Which treatment is most likely to increase her risk of breast cancer?

Answer 10

HRT: adding a progestogen increases the risk of breast cancer

Oestrogen-only HRT does not appear to increase the risk of breast cancer if used for less than 10 years. However oestrogen-only HRT increases endometrial cancer risk and should generally be avoided unless the patient has undergone hysterectomy.

Question 11

A 34-year-old woman attends clinic feeling generally unwell.

Her abdomen has become uncomfortable and distended over the last 2 days, and she is suffering from loose stools.

She also feels dyspnoeic on exertion.

On examination all observations are within normal range and there is generalised abdominal tenderness with no guarding.

The patient is undergoing fertility treatment and the previous week was injected with gonadorelin analogue.

Given the above history, which of the following is the most likely diagnosis?

Answer 11

Ovarian hyperstimulation syndrome is a potential side-effect of ovulation induction

OHSS often presents with gastrointestinal symptoms such as:

• nausea
• vomiting
• abdominal pain
• bloating
• diarrhoea

Other features of OHSS include:

• shortness of breath
• fever
• oliguria
• peripheral oedema

Question 12

OHSS presenting features

Answer 12

OHSS often presents with gastrointestinal symptoms such as:

• nausea
• vomiting
• abdominal pain
• bloating
• diarrhoea

Other features of OHSS include:

• shortness of breath
• fever
• oliguria
• peripheral oedema

Life-threatening, and can result in complications:

• such as thromboembolism
• dehydration
• pulmonary oedema
• acute kidney injury (AKI)

Question 13

A 50-year-old lady is undergoing staging for her confirmed ovarian cancer. Upon scanning, it is found that the tumour has spread beyond the ovary, but is still within the pelvis.

What stage is her cancer at?

Answer 13

Stage 2

Stage 1 = Tumour confined to ovary

Stage 2 = Tumour outside ovary but within pelvis

Stage 3 = Tumour outside pelvic but within abdomen

Stage 4 = Distant metastasis

Question 14

A 40-year-old woman presents to her GP with a history of menorrhagia, she notes that more recently her periods last 10 days and are very heavy.

In addition to this, she has no history of weight loss, her recent sexual health screen was negative and her examination findings are normal. She has two children and has completed her family.

What is the first line treatment in this patient?

Answer 14

Menorrhagia - intrauterine system (Mirena) is first-line

In this case, the patient has completed her family, in addition to this there is no suggestion in the information provided in the question that she may have an underlying pathology responsible for her menorrhagia.Therefore she is a candidate for pharmaceutical therapy.NICE CKS states that the Mirena coil is first line management in women whom long term contraception with an intrauterine device is acceptable.

Question 15

A 34-year-old woman has an unplanned and unwanted pregnancy. She has two children and also had a miscarriage 5 years ago.

Her past medical history includes subclinical hypothyroidism but she is otherwise fit and well.

An ultrasound scan is done and shows an intrauterine pregnancy and estimates her gestation as 7 weeks.

She has been counselled on her options and decides she wants a medical termination of pregnancy.

What medical treatment would she be offered?

Answer 15

Oral mifepristone and vaginal prostaglandins is correct.

This woman is only 7 weeks pregnant, which makes a medical termination more suitable than a surgical one as it has lower failure rates.

Women in the UK are given mifepristone followed by one or more doses of prostaglandins (usually vaginal misoprostol). Medical terminations are appropriate at any gestation, but the dosing schedule and location of administration can vary e.g. home vs clinic.

Question 16

Current law around abortion UK (1)

Key points (2)

Answer 16

The current law surround abortion is based on the 1967 Abortion Act. In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks*

Key points

two registered medical practitioners must sign a legal document (in an emergency only one is needed)

only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

Question 17

Methods of abortion and dates:

(3)

Answer 17

The method used to terminate pregnancy depend upon gestation

less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions

less than 13 weeks: surgical dilation and suction of uterine contents

more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)

Question 18

A 37-year-old female presents to her GP complaining of dyspareunia, irregular menstrual cycles for 6 months until she recently missed 3 periods.

She also complains of sudden hot flushes for the past 3 months.

Her only history of note includes previous breast cancer for which she was on chemotherapy and radiation.

Examination reveals no abnormalities and her pregnancy test is negative.

What is the most likely diagnosis?

Answer 18

Premature ovarian failure

Premature ovarian failure (POF) is defined as the cessation of menses for 1 year before the age of 40. It can, however, be preceded by irregular menstrual cycles. Common symptoms include hot flushes, vaginal dryness, vaginal atrophy, sleep disturbance, and irritability.

Strong risk factors for POF include a positive family history, exposure to chemotherapy/radiation and autoimmune disease.

Question 19

Strong risk factors for POF include:

(3)

Answer 19

Strong risk factors for POF include:

• a positive family history
• exposure to chemotherapy/radiation
• autoimmune disease.

Question 20

A 78-year-old woman presents with post-menopausal bleeding. She has had multiple episodes over the past 8 months.

She has to wear sanitary pads due to the bleeding, and says it can be quite heavy but denies any clots.

She does not have any bowel or urinary symptoms. She denies weight loss and is otherwise well.

She went through menopause at the age of 49 years and took hormone replacement therapy to reduce symptoms of hot flushes and mood swings for 3 years.

She has 1 child who was born by spontaneous vaginal delivery 50 years ago.

There is no family history of any gynaecological problems. What is the most likely diagnosis?

Answer 20

Endometrial cancer

Risk factors for endometrial cancer include …

• Increased age
• Nulliparity
• Unopposed oestrogen therapy
• Early onset of menarche and late onset of menopause
• Obesity

In women presenting with postmenopausal bleeding (PMB), we must rule out endometrial cancer. A speculum examination should first be performed to look for any obvious abnormalities and ultimately endometrial biopsy and hysteroscopy should be carried out in women over 40 years of age in order to diagnose endometrial cancer.

Question 21

A 50-year-old lady is commenced on tamoxifen for the treatment of an oestrogen receptor positive breast cancer.

Which malignancy is associated with tamoxifen use?

Answer 21

Endometrial cancer - risk factors include: tamoxifen

Tamoxifen is an oestrogen receptor antagonist in breast tissues. However, at other sites, such as the endometrium it may act as an agonist. Hence the reason for increasing risk of endometrial cancer.

Question 22

A 21-year-old woman visits her GP, two weeks after having a medical termination of pregnancy.

She took a urine pregnancy test this morning and is worried that the termination was unsuccessful as the urinary pregnancy test is still positive.

When should her pregnancy test have become negative if the termination has been successful?

Answer 22

Negative 2 weeks from today

Termination of pregnancy: Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast

Question 23

A 45-year-old woman attends the GP surgery as she is experiencing heavy vaginal bleeding.

Her cycle is regular and there is no intermenstrual or postcoital bleeding. She has no significant gynaecological history, and takes no regular medications. She does not have a regular partner, and uses condoms for contraception.

She does not want children. What is the most appropriate first line treatment?

Answer 23

Menorrhagia - intrauterine system (Mirena) is first-line

The combined oral contraceptive pill, tranexamic acid, and mefenamic acid may all provide symptomatic relief but would not be the first line treatment.

Question 24

A 45-year-old lady who has never had a male partner, has just moved to the UK with her female partner.

She has registered as a new patient at your practice and during the new patient assessment she asks you how often she will be called for cervical screening.

She has no indications to be screened more frequently than the routine recall in the UK.

You advise her that she will be called for cervical screening:

Answer 24

Every 3 years

Question 25

A 43-year-old woman presents as she has not had a period for the past six months. She is concerned that she may be going through an 'early menopause'. **How is premature ovarian failure defined?** (3)

Answer 25

The onset of **menopausal** **symptoms** and **elevated** **gonadotrophin** **levels** **before the age of 40 years**

Question 26

A 32-year-old female presents with lower abdominal pain. She is 8 weeks pregnant. A simple ovarian cyst is evident on transvaginal ultrasound. An 8-week intrauterine pregnancy is also confirmed. **What is the most appropriate management of the cyst?** (3)

Answer 26

**Reassure patient that this is normal and leave the cyst alone** In early pregnancy, ovarian cysts are usually physiological - known as a **corpus** **luteum**. **They will usually resolve from the second trimester on wards.** Reassurance is important in the above situation as maternal anxiety is likely to be high. Anxiety in pregnancy should be avoided wherever possible in order to avoid adverse outcomes to both mother and foetus.

Question 27

A 33-year-old woman attends for a routine cervical smear. **A positive high-risk human papillomavirus (hrHPV) result prompts the GP to recall her inin how long for another smear?** At this repeat smear, the same result is demonstrated and so the GP recalls her in a further 12 months. At the second repeat smear (third overall), hrHPV is now negative. The patient has no significant past medical history, nor family history. What is the most appropriate course of action?

Answer 27

**1. 12 months** **2. Repeat smear in 3 years** Cervical cancer screening: if 2nd repeat smear at 24 months is now hrHPV -ve → return to routine recall

Question 28

A 36-year-old with menorrhagia is investigated and found to have a 1.5 cm uterine fibroid which is not distorting the uterine cavity. She has three children and wants ongoing contraception, but is using only condoms at the moment. What is the most appropriate initial treatment for her menorrhagia?

Answer 28

IUS/Mirena **If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity,** medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)

Question 29

You are prescribing hormone replacement therapy (HRT) for a 48-year-old woman who is fit and well but is experiencing severe menopausal symptoms. She wants to know about the risks and benefits of the different types of HRT. Which of the following answers is correct regarding the risk of cancer with different HRT preparations?

Answer 29

HRT: adding a progestogen increases the risk of breast cancer

Question 30

A 17-year-old girl who is nine weeks pregnant has a surgical termination of pregnancy. She feels well a few hours after the procedure. Which of the following risks is most common following a TOP?

Answer 30

**Infection can happen in up to 10% of TOP cases.** Antibiotics are given to reduce the risk of infection. Signs and symptoms of an infection are unlikely to occur so soon after the procedure.

Question 31

A 34-year-old woman from Chad presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well. What is the most likely diagnosis?

Answer 31

Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.

Question 32

A 35 year-old lady attends the GP practice complaining of heavy painless periods which are interrupting with her lifestyle and causing her distress at work. She is currently in the process of trying for a family. The most suitable option is: (2)

Answer 32

Tranexamic acid is the first-line non-hormonal treatment for menorrhagia As her periods are painless, there is no need for her to take mefenamic acid, an NSAID, which is also not recommended in pregnancy.

Question 33

A 34-year-old lady presents to the gynaecology department complaining of heavy, painful periods, and difficulty conceiving. She is concerned, as she and her husband would like to start a family soon. On further investigation, an ultrasound scan reveals a 4.5cm submucosal uterine fibroid. Which one of the following treatments is most appropriate to treat her fibroids?

Answer 33

The only effective treatment for large fibroids causing problems with fertility is myomectomy if the woman wishes to conceive in the future

Question 34

A 21-year-old student attends your general practice clinic to discuss a recent positive pregnancy test result. Following lengthy discussion with her partner and family has decided that she wants an abortion. You find the consultation particularly difficult, as you do not personally agree with abortion and are currently caring for several patients who have been struggling to conceive. What should you do?

Answer 34

Discuss her options and explain that due to your personal beliefs, you will arrange for her to see another doctor in this instance who will make necessary arrangements

Question 35

A 28-year-old woman had attended for her routine cervical smear which is performed without any issues. The GP receives the result of smear that it was positive for high-risk HPV but there was no evidence of cytological abnormalities. What is the most appropriate next step?

Answer 35

Repeat cervical smear in 12 months Cervical cancer screening: if sample is hrHPV +ve + cytologically normal → repeat smear at 12 months

Question 36

Answer 36

Nausea and vomiting in pregnancy: admission should be considered in cases of ketonuria and/or weight loss despite use of oral anitemetics

Question 37

A 45-year-old pregnant asylum seeker who has just arrived to the UK from Syria presents to the general practitioner for their first scan at 22 weeks. An ultrasound scan identifies a 'snow-storm' appearance with no foetal parts. What is the most likely diagnosis?

Answer 37

**Hydatidiform** **mole** - 'snow storm' appearance on ultrasound scan A complete hydatidiform mole occurs when all of the genetic material comes from the father. There will be no foetal parts present and snowstorm appearance is seen on ultrasound. Vaginal bleeding early in pregnancy is often the presenting feature.

Question 38

A 37-year-old female has a cervical smear test at her general practice, as part of the UK cervical cancer screening programme. The results come back as hrHPV positive. Cytology shows normal cells. In accordance with current guidelines, the cervical smear test is repeated 12 months later, which is still hrHPV positive. Cytology is repeated, which again shows normal cells. A cervical smear test performed a further 12 months later, is still hrHPV positive, and cytology remains normal. What is the most appropriate action?

Answer 38

Colposcopy Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy

Question 39

A 80-year-old woman presents with a 5 month history of urinary incontinence when she coughs or sneezes. She has tried pelvic floor exercises for the last 3 months but has not found them helpful. She is extremely worried about having surgery and would rather have medical treatment for her incontinence. What kind of incontinence does she have? What is the first-line drug therapy to treat her presentation? What would not be prescribed?

Answer 39

**Duloxetine** may be used in patients with **stress** **incontinence** who don't respond to pelvic floor muscle exercises and decline surgical intervention **Oxybutynin** is an anticholinergic drug used for the treatment of **urge incontinence** or symptoms of detrusor overactivity. Oxybutynin is contraindicated in frail, older women at risk of deterioration in their health. **Mirabegron** is used in patients with **urge** **incontinence** who can not tolerate antimuscarinic/anticholinergic drugs. It is a beta-3 adrenergic agonist which relaxes the bladder.

Question 40

A 26-year-old woman is referred to the gynaecology clinic with severe dysmenorrhoea and a clinical history suggestive of endometriosis. She has tried paracetamol and ibuprofen with little benefit. She is not planning to start a family for the next couple of years. What is the recommended first-line management, providing that there are no contraindications?

Answer 40

**Combined oral contraceptive pill (COCP)** Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE published guidelines in 2017: * NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief * if analgesia doesn't help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried

Question 41

Second-line treatments for endometriosis (3)

Answer 41

If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include: - GnRH analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels - drug therapy unfortunately does not seem to have a significant impact on fertility rates - surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Question 42

A 19-year-old woman has a positive pregnancy test and is found to have an ectopic pregnancy after an intrauterine pregnancy is excluded. She has no pain or other symptoms at this time. Her serum beta-human chorionic gonadotropin (B-hCG) level is 877 IU/L. A transvaginal ultrasound reveals a 24mm adnexal mass but no heartbeat. There is no free fluid in the abdomen. She is given the option of expectant management but declines this. What is the first line treatment?

Answer 42

The National Institute for Health and Care Excellence (NICE) states that if a woman has a small (\<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of \<1500 IU/L, no intrauterine pregnancy and no pain, then first line treatment should be with **methotrexate** as long as the patient is willing to attend for follow-up.

Question 43

A 23-year-old female presents to the GP with concerns about her mood during her period. She has been suffering from symptoms for the past 6 months despite making lifestyle changes. The week before her period she has noticed a significant change in her mood. She feels incredibly low and anxious, with poor concentration. Her irritability is starting to have an impact on her job as a primary school teacher. There are no other physical symptoms, and she feels her normal self for the rest of the month. Her medical history includes migraine with aura. Given the likely diagnosis, what is the most appropriate treatment for this patient?

Answer 43

**SSRIs, either continuously or during the luteal phase, may help premenstrual syndrome​** The Mirena IUS is incorrect as it is not used in the treatment of PMS. It is the first-line treatment in the management of menorrhagia.

Question 44

What definition is used to classify bleeding as 'abnormally heavy'?

Answer 44

The definition of menorrhagia has changed to reflect the woman's subjective experience rather than trying to quantify blood loss

Question 45

A 65-year-old woman presents to the GP with urinary incontinence. Her symptoms occur all day, and she has also noticed that when she does manage to go voluntarily her flow of urine is very poor. On examination, the GP can feel a distended bladder even though the patient has just urinated while waiting for the appointment. Given this woman's presentation, what is the most likely diagnosis?

Answer 45

Urinary overflow incontinence Bladder still palpable after urination, think retention with urinary overflow

Question 46

A 74-year-old woman sees her GP when ongoing urinary symptoms. She reports 'leaks' whenever she coughs or sneezes. Despite regular pelvic floor muscle exercises, these episodes of incontinence are still occurring. Upon discussion of possible management options, the patient states that she would not like any form of surgical intervention for this problem. **What is the diagnosis? What is the next appropriate treatment option?**

Answer 46

**Duloxetine** may be used in patients with **stress** **incontinence** who don't respond to pelvic floor muscle exercises and decline surgical intervention This patient is suffering from stress incontinence. As pelvic floor muscle exercises have failed to improve her symptoms, duloxetine is the next step in management in patients who decline surgical intervention.

Question 47

A 55-year-old lady comes to see you as she is suffering from hot flushes. She finds these come on randomly and are interfering with her work as a barrister, particularly if she gets them whilst she is in court. She is reluctant to try hormone replacement therapy due to the side effects but was wondering if there is anything else that could help her. Which one of the following medications can she be prescribed?

Answer 47

Fluoxetine NICE guidelines advise that menopausal women suffering from vasomotor symptoms can be given a selective serotonin uptake inhibitor (SSRI) such as fluoxetine. Clonidine is also licensed for the treatment of vasomotor symptoms in menopause, however, there is limited evidence of its efficacy, and it is associated with side effects including dry mouth, sedation, depression and fluid retention. Gabapentin may also be effective for reducing hot flushes, however, further research is currently being done on this.

Question 48

A 57-year-old female presents due to problems with urine leakage over the past six months. She describes frequent voiding and not always being able to get to the toilet in time. **She denies losing urine when coughing or sneezing.** **What is the most appropriate initial treatment?**

Answer 48

**Bladder retraining​** **Stress incontinence**: caused by weak urethral sphincters which are controlled by pelvic floor muscles (which can be exercised) **Urge incontinence**: caused by overactive detrusor muscle (which can be neurologically re-trained)

Question 49

A 39-year-old woman presents to her general practitioner with what she describes as 'Pre-menstrual syndrome'. She describes severe pain that occurs 3-4 days before the start of her period each month which stops her from being able to go to work. She has a regular 29-day cycle which has only started being painful in the past year. She is nulliparous and uses the progesterone-only pill for contraception. **What is the most appropriate management of this patient?**

Answer 49

All patients with secondary dysmenorrhoea need to be referred to gynaecology for investigation This patient has secondary dysmenorrhoea as her pain precedes the first day of her menstrual cycle. Secondary dysmenorrhoea is associated with pathologies such as pelvic inflammatory disease, endometriosis, adenomyosis, and fibroids. As it is pathological, it must be investigated further with a referral to gynaecology.

Question 50

An 83-year-old lady attends with a history of falls. She has a past medical history of osteoporosis, constipation, frequent urinary tract infections, ischaemic heart disease and urge incontinence. After a thorough history and examination, you decide that these are likely multifactorial related to a combination of physical frailty, poor balance and medication burden. Which urinary medication should you stop in the first instance?

Answer 50

**Oxybutynin** should not be used in the frail elderly population due to increased risk of falls. Safer alternatives include solifenacin and tolterodine. Mirabegron, a newer drug on the market, may also be useful as it thought to have less anti-cholinergic side effects.

Question 51

A 28-year-old woman presents to the GP complaining of incidences of dyspareunia, as well as dysuria, and dysmenorrhoea. Bimanual examination reveals generalised tenderness, a fixed, retroverted uterus and uterosacral ligament nodules. You refer her for laparoscopy to confirm the suspected diagnosis of endometriosis. **What is the most appropriate initial management option?** **What are the second-line treatments?**

Answer 51

**NSAIDs and/or paracetamol are the recommended first-line treatments for endometriosis** if analgesia doesn't help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate (depo injections) should be tried **If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:** * GnRH analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels * drug therapy unfortunately does not seem to have a significant impact on fertility rates * surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Question 52

A 26-year-old woman attended for her first cervical screening 4 months ago. On examination her cervix appeared normal. The first cervical smear taken was returned as 'inadequate' by the lab. The sample was repeated 3 months later and you have just noted that the repeat sample was also returned as 'inadequate'. How should this woman be followed up as part of the cervical cancer screening programme?

Answer 52

**Referral for colposcopy** Following a first 'inadequate' sample a repeat sample should be taken within 3 months. If the repeat sample is also 'inadequate' the patient should be referred for colposcopy.

Question 53

A 26-year-old woman attended for her first cervical screening appointment. On examination her cervix appeared normal. The results were returned as 'HPV positive' with 'normal cytology'. The sample was repeated 12 months later. The results are now returned again as 'HPV positive' with 'normal cytology'. How should this woman be followed up as part of the cervical cancer screening programme?

Answer 53

Repeat cervical screening in 12 months

Question 54

A 26-year-old woman attended for her first cervical screening appointment. On examination her cervix appeared normal. The results were returned as 'HPV positive' with 'normal cytology'. She has returned for her repeat sample at 12 months. She feels well in herself and has a new partner. She has experienced some post-coital and intermenstrual bleeding for the past 3 months. What is the most appropriate management of this patient?

Answer 54

**The correct answer is: Referral to gynaecology** Patients who have gynaecological symptoms which could be suggestive of cervical cancer, such as inter-menstrual bleeding(IMB) or post-coital bleeding(PCB) should examined and referred for review at a gynaecological clinic. Although other diagnoses, such as sexually transmitted infection or ectropion, are more likely than cervical cancer, screening should not be performed on symptomatic patients. If examination of the abdomen and cervix were provided as an answer, this would have been appropriate, however, this is not one of the available options.

Question 55

A 35-year-old woman attends your GP practice, she is known to you as she is having trouble conceiving and has been trying for a baby for the past 8 months. She comes today as she has noticed her periods have been getting heavier over the past year or so. She hasn't mentioned this previously as she thought it was due to her getting older, but now her periods have become unmanageable and she has had episodes of flooding. After taking a full history you examine her abdomen, which is soft, non-tender, but you can palpate a supra-pubic mass. **What is the most likely cause of her menorrhagia? (1)** **How would her menorrhagia be managed? (6)**

Answer 55

**_Fibroids_** The combination of menorrhagia, subfertility and an abdominal mass in this patient points towards fibroids above everything else. It's important to rule out ectopic pregnancy, but the patient would be more unstable and complaining of pain. **_Management of menorrhagia secondary to fibroids_** * levonorgestrel intrauterine system (LNG-IUS) - useful if the woman also requires contraception - *cannot be used if there is distortion of the uterine cavity* * NSAIDs e.g. mefenamic acid * tranexamic acid * combined oral contraceptive pill * oral progestogen * injectable progestogen

Question 56

Treatment to shrink/remove fibroids | (6)

Answer 56

**_medical_** * GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment * ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxicity **_surgical_** * myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically * hysteroscopic endometrial ablation * hysterectomy **_uterine artery embolization_**

Question 57

A 39-year-old female with a history of chronic pelvic pain is diagnosed with endometriosis. Which one of the following is not a recognised treatment for this condition? * Dilation and curettage * Gonadotrophin-releasing hormone analogues * Combined oral contraceptive pill * Medroxyprogesterone acetate * Intrauterine system (Mirena)

Answer 57

* Dilation and curettage

Question 58

A 25-year-old woman attends cervical cancer screening. Her sample has come back as being positive for high-risk HPV and cytology shows low-grade dyskaryosis. What is the next step in this situation?

Answer 58

**Refer for colposcopy** Cervical cancer screening: if sample is hrHPV +ve + cytologically abnormal → colposcopy

Question 59

A 25-year-old woman at 15 weeks gestation of her first pregnancy returns to her general practitioner with tremor after starting a medication during pregnancy for hyperemesis gravidarum. On examination, the patient has a resting tremor in their left hand and increased upper limb tone. What medication was the patient most likely prescribed?

Answer 59

Metoclopramide is an option for nausea and vomiting in pregnancy, but it should not be used for more than 5 days due to the risk of extrapyramidal effects

Question 60

An 82-year-old lady presents with urinary straining, poor flow, incomplete emptying of the bladder, and urinary incontinence. Urodynamics demonstrates voiding detrusor pressure of 90 cm H20 (normal value \< 70 cm) peak flow rate of 5 mL/second (normal value \> 15 mL/second) **What is the most likely diagnosis?**

Answer 60

**A high voiding detrusor pressure with a low peak flow rate is indicative of bladder outlet obstruction**. Therefore the most likely answer is overflow incontinence.

Question 61

A 62-year-old woman presents with post-menopausal bleeding. **Which one of the following is not a risk factor for endometrial cancer?** * Diabetes mellitus * Late menopause * Obesity * Past history of combined oral contraceptive pill use * Nulliparity

Answer 61

Past history of combined oral contraceptive pill use

Question 62

Answer 62

Premature ovarian failure

Question 63

A 25 year old woman with a known diagnosis of premenstrual syndrome (PMS) attends her GP requesting some medical treatment. She has made the suggested lifestyle modifications, with little improvement in her symptoms. She is not planning on starting a family any time soon. Which of the following treatments would be most suitable to offer her, assuming that there are no contraindications?

Answer 63

* moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP) * severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)

Question 64

A 64-year-old lady presents to the GP with urinary incontinence. On further questioning, she notes that the symptoms of incontinence are worst after she coughs or sneezes. She has had 4 children, all through vaginal delivery, the last of which was 30 years ago. These symptoms have been worsening for the last 6-weeks. Given this woman's presentation, investigation should be ordered?

Answer 64

**In patients with urinary incontinence, make sure to rule out a UTI and diabetes mellitus** This question is asking about the investigation of a 64-year-old woman with urinary incontinence. In this situation she is likely suffering from stress incontinence, however, a urinalysis should be performed in order to exclude diabetes or a urinary tract infection that could be the cause of, or worsening her symptoms.

Question 65

You are a FY-1 doctor working in obstetrics. For one day a week you are based in the early pregnancy assessment unit (EPAU). You are assessing a 31-year-old female with a suspected threatened miscarriage. How will this present? (3)

Answer 65

Painless vaginal bleeding closed cervical os

Question 66

A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding **What is the most likely diagnosis?**

Answer 66

Large **ovarian cysts** may lead to abdominal swelling and pressure effects on the bladder.

Question 67

A 23-year-old woman complains of anorexia, vomiting, fever and abdominal pain. The pain was initially periumbilical but is now worse in the lower abdomen. What is the most likely diagnosis?

Answer 67

Appendicitis

Question 68

.A 28-year-old woman complains of a two year history of bad period pains which are not controlled by NSAIDs or the combined contraceptive pill. She also reports significant pains during intercourse. What is the most likely diagnosis?

Answer 68

Endometriosis

Question 69

SYMPTOMS **Uterine Fibroids (4)** vs **Ovarian Cysts (4)**

Answer 69

**Uterine Fibroids** * Heavy, prolonged, painful periods * dyspareunia * constipation/bloating * fatigue/anaemia **Ovarian Cysts** * Irregular/missed periods * weight gain * hirsutism * infertility

Question 70

**Risk factors (anything slowing the ovum's passage to the uterus)** **(6)**

Answer 70

**Risk factors (anything slowing the ovum's passage to the uterus)** * damage to tubes (pelvic inflammatory disease, surgery) * previous ectopic * endometriosis * IUCD * progesterone only pill * IVF (3% of pregnancies are ectopic)

Question 71

A 33-year-old woman presents to the emergency department with worsening left-sided abdominal pain. She reports the pain started suddenly 5 hours ago and has been steadily getting worse. The pain started suddenly following intercourse. She is unsure 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 observations are stable. 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. Ultrasound shows free fluid in the pelvic cavity. Urinary pregnancy test is negative. **What is the most likely diagnosis?**

Answer 71

**Ruptured ovarian cyst:** sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity Ruptured ovarian cyst presents as sharp unilateral pain immediately following intercourse or strenuous exercise. Bimanual examination in non-severe cases is generally unremarkable but the lower abdomen is tender. Ultrasound shows free fluid in the pelvic cavity.

Question 72

A 40-year-old woman had attended for her routine cervical smear which is performed without any issues. The GP receives the result that the sample from the smear was inadequate. According to her records, she previously had an inadequate smear 6 years ago but this had not been an issue with subsequent smears. What is the most appropriate next step?

Answer 72

Cervical cancer screening: if smear inadequate then repeat within 3 months

Question 73

A 27-year-old woman who is currently 39 weeks pregnant comes to see you complaining of itching down below. She has thick white discharge. Given the likely diagnosis, which one of the following treatment options would you advise? Which treatment can't she receive?

Answer 73

**Clotrimazole pessary** This patient has thrush which is treated with antifungal medication. This patient is pregnant, therefore **cannot be given oral fluconazole as this is contraindicated in pregnancy** due to its association with congenital abnormalities.

Question 74

Metronidazole is used in the treatment of which GOSH conditions?

Answer 74

Bacterial vaginosis and Trichomonas vaginalis

Question 75

Bacterial vaginosis and Trichomonas vaginalis are treated using which medication?

Answer 75

**Metronidazole** is used in the treatment of bacterial vaginosis and Trichomonas vaginalis.

Question 76

A 48-year-old woman visits her general practitioner with a 6-week history of unbearable hot flushes and vaginal dryness. She suspects that she is going through menopause. Her past medical history includes hypothyroidism and psoriasis. She takes regular levothyroxine and has the Mirena intrauterine system in situ. **What is the most appropriate additional treatment to initiate for this patient?**

Answer 76

Estradiol The Mirena intrauterine system is licensed for use as the progesterone component of HRT for 4 years

Question 77

A couple in their 20s come into their GP after failing to conceive despite having regular sexual intercourse for 6 months, and ask you for advice. What is the most appropriate course of action for you to take?

Answer 77

It is recommended in this case that couples should have regular sexual intercourse for a period of **12 months**. Regular sexual intercourse is defined as intercourse every 2-3 days.

Question 78

A 47-year-old woman attends her GP surgery for a routine cervical smear. Subsequently, she is telephoned and informed that the smear was inadequate. She remembers previously having an inadequate smear over a decade ago. Which of the following is the appropriate course of action?

Answer 78

Cervical cancer screening: if smear inadequate then repeat within 3 months

Question 79

A 26-year-old woman visits her general practitioner with painful menstrual bleeding. She has a regular 28-day cycle and bleeds for approximately 5-6 days each month. She denies heavy bleeding and does not pass clots. The pain is debilitating and often requires her to take at least 2 days off work each month. Her past medical history includes a deep vein thrombosis (DVT) following the delivery of her son 2 years ago. She takes no regular medications and has no allergies. What is the initial step in the management of this patient?

Answer 79

**Management of dysmonorhoea (2)** NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production combined oral contraceptive pills are used the second line

Question 80

An 84-year-old woman is reviewed by her general practitioner after she noticed a new, painless lump in her groin. She first noticed the lump 3 weeks ago, which has since grown slightly. On examination, there is a hard lump on her right labia majora and she has right inguinal lymphadenopathy. Her past medical history is unremarkable, and she has no known allergies. Which of the following is the most likely diagnosis?

Answer 80

Older woman with labial lump and inguinal lymphadenopathy → ?**vulval carcinoma**

Question 81

What is a Bartholin's cyst?

Answer 81

A Bartholin's cyst is a small, fluid-filled cyst that is caused by an obstructed Bartholin's gland duct.

Question 82

What is Condylomata lata?

Answer 82

Condylomata lata is a benign vulval lesion, which refers to the wart-like lesions seen in secondary syphilis.

Question 83

Which factor puts women most at risk of miscarriage?

Answer 83

obesity

Question 84

A 24-year-old female presents with a one day history of dysuria and urinary frequency. She was diagnosed with a simple urinary tract infection and prescribed a three day course of trimethoprim. She returns two weeks later with new onset vaginal discharge. A whiff test is negative and no clue cells are observed on microscopy. What is the most likely explanation?

Answer 84

The patients vaginal discharge is most likely caused by a fungal infection Candidial infection ('thrush') is extremely common and is often precipitated or exacerbated by recent antibiotic exposure, so this is the most likely cause in this case. Vaginal discharge is not a feature of a urinary tract infection.

Question 85

Expectant management of an ectopic pregnancy can only be performed for: (5)

Answer 85

**Expectant management of an ectopic pregnancy can only be performed for:** ## Footnote 1) An unruptured embryo 2) \<35mm in size 3) Have no heartbeat 4) Be asymptomatic 5) Have a B-hCG level of \<1,000IU/L and declining

Question 86

An 18-year-old girl presents to her GP with discharge. She reports a new sexual partner with whom she is not using barrier protection. On examination thick cottage-cheese like discharged is visualised. She reports no other symptoms of note. What is the most likely diagnosis?

Answer 86

Cottage-cheese like discharge is almost pathognomonic of **thrush**

Question 87

A 23-year-old female presents to her GP with a positive urine pregnancy test, believing she is 4-5 weeks pregnant. She is anxious as she has recently heard a friend had an ectopic pregnancy and wants to know if she is at increased risk. Her notes state that she had an intrauterine system (IUS) removed 8 months ago and was treated for a Chlamydia infection 5 years ago. She had a cervical ectropion identified at a gynaecology appointment 2 months ago after a 3cm simple ovarian cyst was seen on ultrasound. The patient also reports attending a party two nights ago where she drank excessively. Prior to her pregnancy test today she would usually drink a bottle of wine a week. Which feature of this patient's history could increase her risk?

Answer 87

Pelvic inflammatory disease increases the risk of an ectopic pregnancy (chlmydia) **Risk factors (anything slowing the ovum's passage to the uterus)** * damage to tubes (pelvic inflammatory disease, surgery) * previous ectopic * endometriosis * IUCD * progesterone only pill * IVF (3% of pregnancies are ectopic)

Question 88

Sabrina is a 16-year-old woman presenting with abdominal pains. The abdominal pain was around her lower abdomen and is crampy in nature and occasionally radiates to her back. Her pain normally comes on approximately 4-12 hours before the onset of her menstruation and lasts throughout the menstruation period. She also feels increasingly fatigues during this period. No abdominal pains were noted outwith her menstruation period. Sabrina has just started menstruation 1 year ago. Her menstrual flow was normal and she only experienced minor pains during her previous menstrual cycles. She is not currently sexually active with no previous sexual partners. She denies any vaginal discharge or bleeding in between cycles. She remains unsure if she wants children in the near future. Given the likely diagnosis, what is the likely 1st line treatment?

Answer 88

uterine fibroids/dysmenorrhea NSAIDs such as mefenamic acid are the first-line treatment for primary dysmenorrhoea

Question 89

A 27-year-old woman presents to her GP with a 7-month history of amenorrhea. 8 months ago she stopped taking the pill to try for a baby. She tells you that she has always had problems with her period, which are usually quite strong and irregular, which is why she had been taking the pill since the age of 15. On questioning, she admits to recent weight gain of approximately 4 kg. A pregnancy test that she took yesterday was negative. There is no other significant medical or family history of note. What is the most likely explanation for this patient’s symptoms?

Answer 89

Use of the combined oral contraceptive pill can mask an underlying polycystic ovarian syndrome in women who would otherwise experience symptoms

Question 90

A 29-year-old female has a cervical smear test as part of the UK cervical cancer screening programme. Her results return as hrHPV positive. The sample is examined cytologically, which shows normal cells. As per guidelines, the cervical smear test is repeated 12 months later, which is still hrHPV positive. Cytology is repeated, which again shows normal cells. What is the most appropriate action?

Answer 90

Repeat the test in 12 months Cervical cancer screening: if 1st repeat smear at 12 months is still hrHPV +ve → repeat smear 12 months later (i.e. at 24 months)

Question 91

A 38-year-old woman re-presents to her general practitioner after lifestyle changes and three months of pelvic floor exercises fail to control her urinary stress incontinence. She tells the doctor that she is keen for further treatment but does not want surgical management. **What is the most appropriate next step in this patients management?**

Answer 91

**Duloxetine** may be used in patients with **stress** **incontinence** who don't respond to pelvic floor muscle exercises and decline surgical intervention Prescription of **oxybutynin** would be wrong as this is indicated in **urge** **incontinence** if bladder re-training fails to improve symptoms.

Question 92

You are called to see a 25-year-old 10 week pregnant lady in the Emergency Department complaining of abdominal pain and heavy vaginal bleeding. Her observations are normal and she is afebrile, on ultrasound a fetal heart rate is still present and the uterus is the size expected. On examination her cervical os is closed. How would you classify her miscarriage?

Answer 92

Threatened

Question 93

A 38-year-old woman complains that she is experiencing hot flushes and has not had a period for the past five months. She is worried that she going through an 'early menopause'. What is the most appropriate investigation to diagnose premature ovarian failure?

Answer 93

Follicle stimulating hormone (FSH) level is raised significantly in menopausal patients. Test FSH to confirm menopause

Question 94

A 46-year-old female presents with a 6 month history of abdominal pain and menorrhagia. On examination the abdomen is non-tender and the uterus feels bulky. What is the most likely diagnosis?

Answer 94

**Fibroids** (**Leiomyoma**) are a common cause of menorrhagia and abdominal pain in a menstruating female. If the fibroids are large the uterus can feel bulky on examination. An abdominal ultrasound confirming an enlarged uterus with multiple masses is virtually diagnostic.

Question 95

How would Adenomyosis present? | (3)

Answer 95

abdominal pain and menorrhagia abdomen is non-tender and the uterus feels bulky we would expect **imaging** to reveal a '**boggy**' **uterus** with **sub** **endometrial** **linear** striations.

Question 96

A 34-year-old woman has oligomenorrhoea with only 1-2 menstrual periods a year. She also has mild acne and hirsutism. Her pelvic ultrasound scan confirms the appearance of polycystic ovaries, with normal endometrial thickness. She is sexually active and is not using any regular contraception, but does not wish to get pregnant for another 3 years. Her body mass index (BMI) is 37 kg/m2. Her HbA1c is normal. What is the most appropriate treatment?

Answer 96

Levonorgestrel-releasing intrauterine system The main symptom of concern in this scenario is oligomenorrhoea. In women with PCOS, intervals between menstruation of more than 3 months (or fewer than 4 per year) increase the risk of endometrial hyperplasia and carcinoma. Therefore inducing a withdrawal bleed every 3-4 months or preventing proliferation of the endometrium is recommended. This can be achieved with a cyclical oral progestogen (e.g. medroxyprogesterone) for at least 12 days a month, a combined oral contraceptive (COC), or levonorgestrel-releasing intrauterine system (LNG-IUS).

Question 97

A 28-year-old woman has troublesome hirsutism affecting her face, upper arms and chest. It is affecting her self-esteem and she is keen on further treatment for this symptom. She also has irregular menstrual cycles which vary between 19 and 45 days in length. She has no other medical problems and does not smoke. She has a BMI of 29 kg/m2 and blood pressure of 136/88 mmHg. Her HbA1c is normal. She does not wish to get pregnant at this time. What is the most appropriate treatment?

Answer 97

**Combined oral contraceptive** The COC would be appropriate in this patient in managing both her symptoms of hyperandrogenism and irregular periods. She does not appear to have any contraindications to this drug.

Question 98

A 35-year-old woman has irregular periods, acne and hirsutism. She has also been trying to conceive with her partner for 6 months but has been unsuccessful. A pelvic ultrasound scan has confirmed the presence of polycystic ovaries. She has tried losing weight and her current BMI is 28 kg/m2. Her HbA1c is normal. What is the most appropriate treatment?

Answer 98

**Referral to fertility services** As this woman has a known cause of infertility in the form of PCOS, she should be referred immediately to fertility services for consideration of further treatment. NICE recommends that these women be offered **clomifene** **citrate** or **metformin**, or a combination of the two, as first-line treatment. If this proves unsuccessful, laparoscopic ovarian drilling or gonadotrophins may be considered.

Question 99

A 48-year-old female smoker attends the GP for information regarding contraception. Her last menstrual period was 9 months ago and she is convinced that she has 'gone through the menopause'. The most suitable form of contraception is:

Answer 99

**The intrauterine system (IUS)** The menopause is a retrospective diagnosis and is said to occurred 12 months after the last menstrual period. Women who menopause under the age of 50 require contraception for at least 2 years after their last menstrual period. Those over the age of 50 require only 1 year of contraception. In view of this, it would be inappropriate to say this lady does not require any contraception because she is protected. Similarly prescribing the COCP for only 12 months would be equally inappropriate. The fact that she is also a smoker would mean that the risks outweigh the benefits of the COCP as she is over the age of 35. Hormone replacement therapy should not be used solely as a form of contraception and barrier methods are less effective than the other types of contraception listed thus the most appropriate answer is the IUS. This will take the patient through the menopause and can be used for 7 years (off-licence) or 2 years after her last menstrual period.

Question 100

Kathryn is a 29-year-old woman who attended for cervical cancer screening 12 months ago and the result was positive for high-risk human papillomavirus (hrHPV) with a negative cytology report. She has just attended for a repeat smear and the result is positive again for hrHPV with a negative cytology report. What is the most appropriate next step?

Answer 100

Repeat sample in 12 months Cervical cancer screening: if 1st repeat smear at 12 months is still hrHPV +ve → repeat smear 12 months later (i.e. at 24 months)

Question 101

A 29-year-old nulliparous female presents to gynaecology clinic with a history of worsening menstrual pain for three years. There is no relief from ibuprofen. She is sexually active with her husband and reports pain during intercourse. Dysuria and urgency in urination are also present. She has been trying to conceive for the past two years, but failed. On examination, her uterus is of normal size. Rectovaginal exam reveals uterosacral nodularity and tenderness. Which of the following is the most likely diagnosis?

Answer 101

The classic symptoms of endometriosis are pelvic pain, dysmenorrhoea, dyspareunia and subfertility This could be fibroids without the subfertility\*

Question 102

Answer 102

**Complete** **hydatidiform** **mole** - presents with uterus size greater than expected for gestational age and abnormally high serum hCG

Question 103

A 65-year-old female presents to the outpatient clinic complaining of urinary incontinence. She complains of involuntary loss of urine while coughing or laughing. There is no urinary urgency or nocturia. A routine pelvic examination is normal. Despite proper pelvic floor muscle exercises for the past five months, her symptoms have not improved. She doesn't want any surgical procedures. **Which of the following is the best treatment option for this patient?**

Answer 103

**Duloxetine** may be used in patients with **stress** **incontinence** who don't respond to pelvic floor muscle exercises and decline surgical intervention **Antimuscarinic** (**oxybutynin**) and **beta-3 agonist (mirabegron)** are used if urge incontinence is predominant.