OG Flashcards
Q: What is the only combined contraceptive patch licensed for use in the UK?
A: The Evra patch.
Q: How long is the patch cycle for the Evra patch?
A: 4 weeks.
Q: How often should the Evra patch be changed during the first 3 weeks of the cycle?
A: The patch should be changed once a week.
Q: What happens during the 4th week of the Evra patch cycle?
A: The patch is not worn, and a withdrawal bleed occurs.
Q: What should be done if the patch change is delayed at the end of week 1 or 2 and the delay is less than 48 hours?
A: The patch should be changed immediately, and no further precautions are needed.
Q: What should be done if the patch change is delayed at the end of week 1 or 2 and the delay is greater than 48 hours?
A: The patch should be changed immediately, and a barrier method of contraception should be used for the next 7 days. Emergency contraception may also be needed if unprotected intercourse occurred in the last 5 days.
Q: What should be done if patch removal is delayed at the end of week 3?
A: The patch should be removed as soon as possible, and a new patch should be applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
Q: What should be done if patch application is delayed at the end of a patch-free week?
A: Additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
Q: How does the combined oral contraceptive pill affect menstruation?
A: It usually makes periods regular, lighter, and less painful.
Q: Which cancers have a reduced risk with the use of the combined oral contraceptive pill?
A: Reduced risk of ovarian, endometrial, and colorectal cancer.
Q: What other protective health benefits does the combined oral contraceptive pill offer?
A: May protect against pelvic inflammatory disease, reduce ovarian cysts, benign breast disease, and acne vulgaris.
Q: What vascular risks are associated with the combined oral contraceptive pill?
A: Increased risk of venous thromboembolic disease, stroke, and ischemic heart disease, especially in smokers.
Q: Which cancers have an increased risk with the use of the combined oral contraceptive pill?
A: Increased risk of breast and cervical cancer.
Q: What temporary side effects may occur with the combined oral contraceptive pill?
A: Headache, nausea, and breast tenderness.
Q: Name a UKMEC 3 condition related to smoking.
A: More than 35 years old and smoking less than 15 cigarettes/day.
Q: Name a UKMEC 3 condition related to body weight.
A: BMI > 35 kg/m².
Q: Give two examples of UKMEC 3 conditions related to personal or family history of disease.
A: Family history of thromboembolic disease in first-degree relatives <45 years, controlled hypertension.
Q: List two UKMEC 3 conditions related to genetic factors or mobility.
A: Carrier of BRCA1/BRCA2 mutations, immobility (e.g., wheelchair use).
Q: Name a UKMEC 3 condition related to gallbladder disease.
A: Current gallbladder disease.
Q: Name a UKMEC 4 condition related to smoking.
A: More than 35 years old and smoking more than 15 cigarettes/day.
Q: What type of migraine is a UKMEC 4 contraindication?
A: Migraine with aura.
Q: List three UKMEC 4 conditions related to cardiovascular or thrombotic history.
A: History of thromboembolic disease or thrombogenic mutation, history of stroke or ischemic heart disease, positive antiphospholipid antibodies (e.g., in SLE).
Q: Name a UKMEC 4 contraindication related to breastfeeding.
A: Breastfeeding <6 weeks postpartum.
Q: What hypertension status is a UKMEC 4 contraindication?
A: Uncontrolled hypertension.
Q: How effective is the combined oral contraceptive pill (COC) when taken correctly?
A: Over 99% effective.
Q: What are some potential risks associated with the COC?
A: Small risk of blood clots, very small risk of heart attacks and strokes, increased risk of breast and cervical cancer.
Q: When starting the COC within the first 5 days of the cycle, is additional contraception needed?
A: No, additional contraception is not needed.
Q: What should be done if starting the COC after the first 5 days of the cycle?
A: Use alternative contraception (e.g., condoms) for the first 7 days.
Q: How often should the COC be taken?
A: The pill should be taken at the same time every day.
Q: What are two alternative COC regimens suggested in the 2019 guidelines?
A: Never having a pill-free interval or ‘tricycling’ (three 21-day packs back-to-back before a 4- or 7-day break).
Q: Is intercourse during the pill-free interval safe?
A: Only if the next pack is started on time.
Q: Name three situations where COC efficacy may be reduced.
A: Vomiting within 2 hours of taking the pill, medications causing diarrhoea or vomiting (e.g., orlistat), and taking liver enzyme-inducing drugs.
Q: Which antibiotics still require extra precautions with the COC?
A: Enzyme-inducing antibiotics such as rifampicin.
Q: What should be done if 1 combined oral contraceptive pill (COC) is missed at any time in the cycle?
A: Take the last missed pill immediately, even if it means taking two pills in one day, then continue as usual. No additional contraceptive protection is needed.
Q: What should be done if 2 or more COC pills are missed?
A: Take the last missed pill immediately, even if it means taking two pills in one day, continue taking pills daily, and use condoms or abstain from sex until pills have been taken for 7 consecutive days.
Q: If 2 or more pills are missed in week 1 (Days 1-7), what additional precaution should be considered?
A: Emergency contraception should be considered if unprotected sex occurred during the pill-free interval or in week 1.
Q: If 2 or more pills are missed in week 2 (Days 8-14), is emergency contraception needed?
A: No, emergency contraception is not needed if pills have been taken for 7 consecutive days prior.
Q: What should be done if 2 or more pills are missed in week 3 (Days 15-21)?
A: Finish the current pack and start a new pack the next day, omitting the pill-free interval.
Q: Why does the FSRH advise 7 days of protection after missed pills, even in later weeks?
A: It serves as a backup in case further pills are missed.
Q: What are two benefits of COCP use in the perimenopausal period?
A: Helps maintain bone mineral density and may reduce menopausal symptoms.
Q: What is the recommended estrogen dose for COCP in women over 40?
A: Less than 30 µg ethinylestradiol.
Q: What is a key consideration for Depo-Provera use in women over 40?
A: It may delay the return of fertility for up to 1 year.
Q: How does Depo-Provera affect bone health?
A: It is associated with a small loss in bone mineral density, usually recovered after discontinuation.
Q: When can contraception be stopped for women under 50 using non-hormonal methods?
A: After 2 years of amenorrhoea.
Q: When can contraception be stopped for women over 50 using non-hormonal methods?
A: After 1 year of amenorrhoea.
Q: What is the guidance for COCP use in women ≥50 years?
A: Stop COCP and switch to a non-hormonal or progestogen-only method.
Q: What is the role of the progestogen-only pill (POP) with hormone replacement therapy (HRT)?
A: It can be used with HRT if the HRT includes a progestogen component but cannot protect the endometrium alone.
Q: Which contraceptive method is licensed to provide the progestogen component of HRT?
A: The intrauterine system (IUS).
Q: If a woman over 50 using an implant, POP, or IUS is amenorrhoeic, when can contraception be stopped?
A: Check FSH and stop after 1 year if FSH ≥ 30 IU/L or stop at age 55.
Q: What are the main categories of contraception?
A: Barrier methods, daily methods, and long-acting reversible contraception (LARCs).
Q: Name a barrier method of contraception and its mechanism of action.
A: Condoms – Physical barrier preventing sperm from reaching the egg.
Q: How does the combined oral contraceptive pill work?
A: Inhibits ovulation.
Q: Name two risks associated with the COCP.
A: Increased risk of venous thromboembolism and breast/cervical cancer.
Q: How does the standard progestogen-only pill work (excluding desogestrel)?
A: Thickens cervical mucus to prevent sperm penetration.
Q: What additional mechanism does the desogestrel-containing progestogen-only pill have?
A: Inhibits ovulation.
Q: How long does the injectable contraceptive medroxyprogesterone acetate (Depo-Provera) last?
A: 12 weeks.
Q: What is the primary mechanism of action of the implantable contraceptive (etonogestrel)?
A: Inhibits ovulation.
Q: How long does the contraceptive implant last?
A: 3 years.
Q: How does the copper intrauterine device (IUD) work?
A: Decreases sperm motility and survival.
Q: How does the intrauterine system (IUS) work?
A: Prevents endometrial proliferation and thickens cervical mucus.
Q: What is a common side effect of LARCs like the implant, IUS, and POP?
A: Irregular bleeding.
Q: How does the combined oral contraceptive pill (COCP) prevent pregnancy?
A: It inhibits ovulation.
Q: What is the primary mode of action of the standard progestogen-only pill (excluding desogestrel)?
A: Thickens cervical mucus.
Q: How does the desogestrel-only pill differ from other progestogen-only pills?
A: It primarily inhibits ovulation and also thickens cervical mucus.
Q: What is the primary mechanism of the injectable contraceptive (medroxyprogesterone acetate)?
A: Inhibits ovulation.
Q: How does the implantable contraceptive (etonogestrel) prevent pregnancy?
A: Primarily inhibits ovulation and also thickens cervical mucus.
Q: What is the mode of action of the copper intrauterine contraceptive device (IUD)?
A: Decreases sperm motility and survival.
Q: What is the primary mechanism of the intrauterine system (IUS, levonorgestrel)?
A: Prevents endometrial proliferation and thickens cervical mucus.
Q: How does levonorgestrel emergency contraception work?
A: Inhibits ovulation.
Q: What is the mode of action of ulipristal for emergency contraception?
A: Inhibits ovulation.
Q: How does the copper IUD work as emergency contraception?
A: It is toxic to sperm and ovum and also inhibits implantation.
Q: How does obesity affect the use of the combined oral contraceptive pill (COCP)?
A: Obesity increases the risk of venous thromboembolism in women taking the COCP.
Q: What is the UKMEC classification for women with a BMI of ≥35 kg/m² using the COCP?
A: UKMEC 3 (disadvantages generally outweigh the advantages).
Q: Why might the combined contraceptive transdermal patch be less effective in certain patients?
A: It may be less effective in patients who weigh over 90 kg.
Q: Why can’t patients who have had a gastric sleeve, bypass, or duodenal switch use oral contraception?
A: Due to the lack of efficacy of oral contraception in these patients. This also includes emergency contraception.
Q: What is the recommended contraceptive method for all individuals at risk of sexually transmitted infections (STIs)?
A: Condoms and dental dams.
Q: What screening should be offered to all sexually active individuals with a uterus?
A: Cervical screening.
Q: What vaccinations should be offered to sexually active individuals?
A: Human papillomavirus (HPV) vaccinations and, for individuals engaging in anal sex or rimming, hepatitis A & B vaccinations.
Q: What should individuals at risk of HIV transmission be advised about?
A: The availability of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP).
Q: What contraceptive options are recommended for individuals who have had a hysterectomy and/or bilateral oophorectomy?
A: There is no need for contraception as these individuals are no longer at risk of pregnancy.
Q: What permanent contraception options may be considered for transgender individuals seeking them?
A: Fallopian tube occlusion or vasectomy.
Q: Does testosterone therapy provide protection against pregnancy in transgender men?
A: No, testosterone therapy does not provide protection against pregnancy.
Q: What is the recommended contraception for transgender men undergoing testosterone therapy?
A: Progesterone-only contraceptives, such as the intrauterine system (IUS) or injections, which may also suspend menstruation.
Q: What is the effect of estrogen-containing contraceptives in patients undergoing testosterone therapy?
A: Estrogen-containing contraceptives are not recommended as they can antagonize the effect of testosterone therapy.
Q: What is the recommended contraception for transgender men assigned female at birth but engaging in vaginal sex?
A: Condoms, as testosterone therapy does not prevent pregnancy.
Q: What should patients assigned male at birth who are undergoing hormone therapy for gender transition be advised regarding contraception?
A: Condoms should be recommended for individuals assigned male at birth who are engaging in vaginal sex to avoid the risk of pregnancy.
Q: What is the age of consent for sexual activity in the UK?
A: The age of consent for sexual activity in the UK is 16 years.
Q: What are the key points of the Fraser Guidelines?
Understand the professional’s advice
Be unlikely to inform their parents
Be likely to continue or begin having sexual intercourse
Suffer physical or mental harm without contraceptive treatment
Have their best interests met by receiving contraceptive treatment without parental consent.
Q: What is the legal requirement if a child under the age of 13 years seeks contraception?
A: Children under 13 years are considered unable to consent for sexual intercourse, and consultations should automatically trigger child protection measures.
Q: How soon after unprotected sexual intercourse (UPSI) should young people be advised to get STI tests?
A: STI tests should be done 2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI).
Q: What is the concern regarding the use of Depo-Provera (progesterone-only injections) in young people?
A: There are concerns about the effect of Depo-Provera on bone mineral density.
Q: What is the preferred long-acting reversible contraceptive method for young people?
A: The progesterone-only implant (Nexplanon) is the preferred LARC for young people.
Q: What is the mode of action of levonorgestrel in emergency contraception?
A: Levonorgestrel acts both to stop ovulation and inhibit implantation, although its mode of action is not fully understood.
Q: When should levonorgestrel be taken for emergency contraception?
A: Levonorgestrel should be taken as soon as possible, within 72 hours of unprotected sexual intercourse (UPSI). It may be offered after this period with reduced effectiveness and unlicensed indications.
Q: What should be done if vomiting occurs within 3 hours of taking levonorgestrel?
A: If vomiting occurs within 3 hours of taking levonorgestrel, the dose should be repeated.
Q: What is the dose of levonorgestrel for emergency contraception?
A: The standard dose of levonorgestrel is 1.5 mg, which should be doubled for women with a BMI >26 or weight over 70 kg, or if taking enzyme-inducing drugs.
Q: What is ulipristal and how does it work for emergency contraception?
A: Ulipristal is a selective progesterone receptor modulator (EllaOne) that primarily inhibits ovulation.
Q: When should ulipristal be taken for emergency contraception?
A: Ulipristal should be taken as soon as possible, and no later than 120 hours (5 days) after UPSI.
Q: Can levonorgestrel and ulipristal be used together for emergency contraception?
A: No, concomitant use of levonorgestrel and ulipristal is not recommended.
Q: What precautions should be taken when using ulipristal?
A: Ulipristal may reduce the effectiveness of hormonal contraception, and contraception with the pill, patch, or ring should be started 5 days after taking ulipristal. Barrier methods should be used during this period. Caution is advised in patients with severe asthma, and breastfeeding should be delayed for one week after taking ulipristal.
Q: What is the most effective method of emergency contraception?
A: The most effective method of emergency contraception is the copper intrauterine device (IUD), which is 99% effective.
Q: How soon must a copper IUD be inserted after UPSI?
A: A copper IUD must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date if the woman presents later.
Q: Can a copper IUD be used as long-term contraception?
A: Yes, a copper IUD can be left in situ for long-term contraception. If the patient wants it removed, it should be kept in place until the next period.
Q: When is a copper IUD recommended for emergency contraception?
A: A copper IUD should be offered to all women as the most effective method of emergency contraception if the criteria for insertion are met. If not, oral emergency contraception should be considered.
Q: What are the factors to consider when selecting contraception for women with epilepsy?
The effect of the contraceptive on the effectiveness of anti-epileptic medication.
The effect of anti-epileptic medication on the effectiveness of the contraceptive.
The potential teratogenic effects of anti-epileptic drugs if the woman becomes pregnant.
Q: What is the UKMEC classification for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, or oxcarbazepine?
UKMEC 3: Combined oral contraceptive pill (COCP) and progestogen-only pill (POP).
UKMEC 2: Implant.
UKMEC 1: Depo-Provera, intrauterine device (IUD), intrauterine system (IUS).
Q: What is the UKMEC classification for women taking lamotrigine?
UKMEC 3: Combined oral contraceptive pill (COCP).
UKMEC 1: Progestogen-only pill (POP), implant, Depo-Provera, intrauterine device (IUD), intrauterine system (IUS).
Q: What is the primary mechanism of action of Nexplanon?
A: The primary mechanism of action of Nexplanon is preventing ovulation. It also works by thickening the cervical mucus.
Q: How long does Nexplanon last, and how effective is it?
A: Nexplanon lasts for 3 years and has a failure rate of 0.07/100 women-years, making it the most effective form of contraception.
Q: What are the advantages of using Nexplanon?
Highly effective with a low failure rate.
Long-acting (lasts 3 years).
Does not contain oestrogen, so can be used by women with a history of thromboembolism, migraine, etc.
Can be inserted immediately following a termination of pregnancy.
Q: What are the disadvantages of Nexplanon?
Requires a trained professional for insertion and removal.
Additional contraceptive methods are needed for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.
Q: What are the main adverse effects of Nexplanon?
Irregular/heavy bleeding (sometimes managed with co-prescription of the combined oral contraceptive pill).
‘Progestogen effects’ such as headache, nausea, and breast pain.
Q: What drugs may interact with Nexplanon?
A: Enzyme-inducing drugs such as certain antiepileptics and rifampicin may reduce the efficacy of Nexplanon. Women should be advised to switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.
Q: What are the contraindications for Nexplanon?
UKMEC 3: Ischaemic heart disease, stroke (for continuation, if initiation then UKMEC 2), unexplained/suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer.
UKMEC 4: Current breast cancer.
Q: How often is Depo-Provera administered and what is its active ingredient?
A: Depo-Provera is administered as an intramuscular injection every 12 weeks and contains medroxyprogesterone acetate 150mg. It can be given up to 14 weeks after the last dose without the need for extra precautions.
Q: What is the primary mechanism of action of Depo-Provera?
A: Depo-Provera primarily inhibits ovulation. Secondary effects include thickening of cervical mucus and thinning of the endometrium.
Q: What are the disadvantages of using Depo-Provera?
The injection is not reversible once given.
There may be a delayed return to fertility, which could take up to 12 months.
Q: What are the common adverse effects of Depo-Provera?
Irregular bleeding.
Weight gain.
Potential increased risk of osteoporosis (should only be used in adolescents if no other contraceptive method is suitable).
Not quickly reversible, and fertility may take varying time to return.
Q: What are the contraindications for Depo-Provera?
UKMEC 4: Current breast cancer.
UKMEC 3: Past breast cancer.
Q: What is the primary mode of action of the IUD and IUS?
IUD: Prevents fertilization by decreasing sperm motility and survival, possibly due to copper ions.
IUS: Levonorgestrel prevents endometrial proliferation and causes cervical mucus thickening.
Q: What are the counseling points for IUD and IUS regarding reliability and duration?
IUD: Can be relied upon immediately following insertion. Copper IUDs are effective for 5 years, and some IUDs with copper on the stem and arms are effective for up to 10 years.
IUS: Can be relied upon after 7 days. The most common IUS (Mirenaµ) is effective for 5 years, and if used for endometrial protection in women taking oestrogen-only hormone replacement therapy, it is only licensed for 4 years.
Q: What potential problems can arise from using the IUD and IUS?
IUDs may make periods heavier, longer, and more painful.
The IUS may cause initial frequent uterine bleeding and spotting, but later results in intermittent light menses, less dysmenorrhoea, and in some cases, amenorrhoea.
Uterine perforation: up to 2 per 1000 insertions, higher in breastfeeding women.
Increased risk of ectopic pregnancy, though the absolute number of ectopic pregnancies is reduced compared to not using contraception.
Infection: small increased risk of pelvic inflammatory disease in the first 20 days post-insertion.
Expulsion: Risk is about 1 in 20, especially in the first 3 months.
Q: What are the major clinical indicators of fertility in natural family planning?
Changes in cervical mucus
Changes in the cervix
Changes in basal body temperature
Q: When should contraception be started after giving birth?
A: Contraception should be started after day 21 postpartum.
Q: What is the recommendation for starting the progestogen-only pill (POP) postpartum?
A: The POP can be started at any time postpartum; additional contraception should be used for the first 2 days.
Q: What is the UKMEC category for the combined oral contraceptive pill (COCP) for breastfeeding women less than 6 weeks postpartum?
A: UKMEC 4 (absolutely contraindicated).
Q: Why is the combined oral contraceptive pill (COCP) not recommended in the first 21 days postpartum?
A: There is an increased risk of venous thromboembolism during this time.
Q: What should be done when using the combined oral contraceptive pill (COCP) postpartum after day 21?
A: Additional contraception should be used for the first 7 days.
Q: When can an intrauterine device (IUD) or intrauterine system (IUS) be inserted postpartum?
A: It can be inserted within 48 hours of childbirth or after 4 weeks.
Q: What is the effectiveness of the lactational amenorrhoea method (LAM) for postpartum contraception?
A: LAM is 98% effective if the woman is fully breastfeeding, amenorrhoeic, and <6 months postpartum.
Q: What is the most common adverse effect of the progestogen-only pill (POP)?
A: Irregular vaginal bleeding.
Q: When should the progestogen-only pill (POP) be started to provide immediate contraception?
A: If commenced up to and including day 5 of the cycle.
Q: If switching from a combined oral contraceptive (COC) to the progestogen-only pill (POP), when will protection be immediate?
A: If the POP is continued directly from the end of the COC pill packet (i.e., Day 21).
Q: How should the progestogen-only pill (POP) be taken?
A: It should be taken at the same time every day, without a pill-free break (unlike the COC).
Q: What should be done if the progestogen-only pill (POP) is missed within 3 hours?
A: Continue taking the POP as normal.
Q: What should be done if the progestogen-only pill (POP) is missed by more than 3 hours?
A: Take the missed pill as soon as possible, continue with the rest of the pack, and use additional contraception (e.g., condoms) for 48 hours.
Q: How should the progestogen-only pill (POP) be managed if there is diarrhoea or vomiting?
A: Continue taking the POP but assume the pills have been missed, and follow the missed pill guidelines.
Q: Do antibiotics affect the effectiveness of the progestogen-only pill (POP)?
A: No, antibiotics have no effect on the POP, unless they alter the P450 enzyme system (e.g., rifampicin).
Q: How long can a missed progestogen-only pill (POP) be before additional precautions are needed?
A: If the pill is missed for more than 3 hours (or 12 hours for Cerazette), additional precautions should be used for 48 hours.
Q: What should be done if a traditional progestogen-only pill (POP) is missed by less than 3 hours?
A: No action is required, continue taking the pill as normal.
Q: What should be done if a traditional progestogen-only pill (POP) is missed by more than 3 hours?
A: Take the missed pill as soon as possible, and follow the missed pill instructions below.
Q: What should be done if Cerazette (desogestrel) is missed by less than 12 hours?
A: No action is required, continue taking the pill as normal.
Q: What should be done if Cerazette (desogestrel) is missed by more than 12 hours?
A: Take the missed pill as soon as possible, and follow the missed pill instructions below.
Q: What action should be taken if a progestogen-only pill (POP) is missed by more than 3 hours (traditional POPs) or 12 hours (Cerazette)?
A: Take the missed pill as soon as possible, take the next pill at the usual time (which may mean taking two pills in one day), continue with the rest of the pack, and use extra precautions (e.g., condoms) for 48 hours.
Q: What is adenomyosis?
A: Adenomyosis is the presence of endometrial tissue within the myometrium.
Q: What are the features of adenomyosis?
A: Dysmenorrhoea, menorrhagia, and an enlarged, boggy uterus.
Q: What is the first-line investigation for adenomyosis?
A: Transvaginal ultrasound is the first-line investigation.
Q: What are the management options for adenomyosis?
A: Symptomatic treatment, tranexamic acid for menorrhagia, GnRH agonists, uterine artery embolisation, and hysterectomy (considered the ‘definitive’ treatment).
Q: What is primary amenorrhoea?
A: Primary amenorrhoea is the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics, or by 13 years of age in girls with no secondary sexual characteristics.
Q: What is secondary amenorrhoea?
A: Secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea.
Q: What are some causes of primary amenorrhoea?
A: Gonadal dysgenesis (e.g., Turner’s syndrome), testicular feminisation, congenital malformations of the genital tract, functional hypothalamic amenorrhoea (e.g., secondary to anorexia), congenital adrenal hyperplasia, and imperforate hymen.
Q: What are some causes of secondary amenorrhoea?
A: Hypothalamic amenorrhoea (e.g., secondary to stress or excessive exercise), polycystic ovarian syndrome (PCOS), hyperprolactinaemia, premature ovarian failure, thyrotoxicosis, Sheehan’s syndrome, and Asherman’s syndrome (intrauterine adhesions).
Q: What initial investigations should be done for amenorrhoea?
A: Exclude pregnancy with urinary or serum bHCG, full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, androgen levels, and oestradiol.
Q: What does low gonadotrophin levels indicate in amenorrhoea?
A: Low gonadotrophin levels suggest a hypothalamic cause.
Q: What does raised gonadotrophin levels indicate in amenorrhoea?
A: Raised gonadotrophin levels suggest an ovarian problem, such as premature ovarian failure.
Q: How is primary amenorrhoea managed?
A: Investigate and treat any underlying cause, and hormone replacement therapy may be beneficial for conditions like primary ovarian insufficiency due to gonadal dysgenesis (e.g., Turner’s syndrome).
Q: How is secondary amenorrhoea managed?
A: Exclude pregnancy, lactation, and menopause (in women 40 years or older), and treat the underlying cause.
Q: What is Androgen Insensitivity Syndrome (AIS)?
A: Androgen Insensitivity Syndrome is an X-linked recessive condition due to end-organ resistance to testosterone, causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is also known as testicular feminisation syndrome.
Q: What are the features of Androgen Insensitivity Syndrome?
A: Primary amenorrhoea, little or no axillary and pubic hair, undescended testes causing groin swellings, and breast development due to the conversion of testosterone to oestradiol.
Q: How is Androgen Insensitivity Syndrome diagnosed?
A: Diagnosis is made through a buccal smear or chromosomal analysis revealing a 46XY genotype, and after puberty, testosterone concentrations are in the high-normal to slightly elevated range for postpubertal boys.
Q: What is the management for Androgen Insensitivity Syndrome?
A: Management includes counselling to raise the child as female, bilateral orchidectomy due to the increased risk of testicular cancer from undescended testes, and oestrogen therapy.
Q: What is atrophic vaginitis?
A: Atrophic vaginitis is a condition that often occurs in post-menopausal women, characterized by vaginal dryness, dyspareunia (painful intercourse), and occasional spotting. On examination, the vagina may appear pale and dry.
Q: How is atrophic vaginitis treated?
A: Treatment for atrophic vaginitis includes vaginal lubricants and moisturisers. If these do not provide relief, topical oestrogen cream can be used.
Q: What are the main differential diagnoses for bleeding in the first trimester?
A: The main differential diagnoses for bleeding in the first trimester are miscarriage, ectopic pregnancy (which is potentially life-threatening), implantation bleeding (diagnosis of exclusion), and miscellaneous conditions such as cervical ectropion, vaginitis, trauma, and polyps.
Q: What are the worrying symptoms suggesting an ectopic pregnancy?
A: Worrying symptoms for an ectopic pregnancy include pain and abdominal tenderness, pelvic tenderness, and cervical motion tenderness. Women with a positive pregnancy test and any of these symptoms should be referred to an early pregnancy assessment service.
Q: How should a pregnancy > 6 weeks gestation with bleeding be managed?
A: If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and there is bleeding, the woman should be referred to an early pregnancy assessment service. A transvaginal ultrasound is the most important investigation to determine the location of the pregnancy and whether there is a fetal pole and heartbeat.
Q: How should a pregnancy < 6 weeks gestation with bleeding but no pain be managed?
A: If the pregnancy is < 6 weeks gestation with bleeding but no pain or risk factors for ectopic pregnancy, women can be managed expectantly. They should be advised to return if bleeding continues or pain develops, repeat a urine pregnancy test after 7-10 days, and return if it is positive. A negative pregnancy test indicates that the pregnancy has miscarried.
Q: What is the most common type of cervical cancer?
A: The most common type of cervical cancer is squamous cell carcinoma, which accounts for 80% of cases. Adenocarcinoma makes up 20% of cases.
Q: What are the common features of cervical cancer?
A: Common features of cervical cancer include abnormal vaginal bleeding (postcoital, intermenstrual, or postmenopausal bleeding) and vaginal discharge. It may also be detected during routine cervical cancer screening.
Q: What is the most important risk factor for cervical cancer?
A: The most important risk factor for cervical cancer is infection with human papillomavirus (HPV), particularly serotypes 16, 18, and 33.
Q: What are other risk factors for cervical cancer?
A: Other risk factors include smoking, human immunodeficiency virus (HIV), early first intercourse, multiple sexual partners, high parity, lower socioeconomic status, and the use of the combined oral contraceptive pill.
Q: What is the main aim of cervical cancer screening?
A: The main aim of cervical cancer screening is to detect pre-malignant changes, rather than to detect cancer itself.
Q: How has the cervical cancer screening program evolved?
A: The cervical cancer screening program evolved from examining smears for dyskaryosis (which may indicate cervical intraepithelial neoplasia) to introducing HPV testing. HPV testing allows further risk-stratification, where HPV-negative results are treated as normal.
Q: What is the current cervical cancer screening system in the UK?
A: The UK now uses an HPV-first system, where a sample is first tested for high-risk HPV strains, and cytological examination is only performed if the HPV test is positive.
Q: Who is eligible for cervical cancer screening in the UK and how often is it done?
Cervical screening is offered to all women aged 25-64:
Ages 25-49: every 3 years
Ages 50-64: every 5 years
Screening is not offered to women over 64.
Q: When should cervical screening be delayed during pregnancy?
A: Cervical screening during pregnancy is usually delayed until 3 months postpartum unless the screening was missed or there were previous abnormal smears.
Q: How are negative hrHPV results managed?
A: For negative hrHPV results, individuals are returned to the normal recall schedule unless they are on the test of cure (TOC) pathway or are being followed up for incompletely excised CIN, CGIN, SMILE, or cervical cancer.
Q: What happens if hrHPV is positive?
A: If hrHPV is positive, the sample is examined cytologically. If the cytology is abnormal, colposcopy is performed. If the cytology is normal, the test is repeated in 12 months.
Q: What is the management for normal cytology with positive hrHPV?
A: If the cytology is normal but hrHPV is positive, the test is repeated in 12 months. If hrHPV is negative at 12 months, the patient returns to normal recall. If hrHPV is still positive, the test is repeated again at 24 months. If hrHPV is negative at 24 months, the patient returns to normal recall; if still positive, colposcopy is performed.
Q: What happens if the sample is inadequate?
A: If the sample is inadequate, it should be repeated in 3 months. If two consecutive samples are inadequate, colposcopy should be performed.
Q: What is the first step in managing patients previously treated for CIN?
A: The first step is inviting individuals who have been treated for CIN1, CIN2, or CIN3 for a test of cure with a repeat cervical sample in the community, 6 months after treatment.
Q: What is the most common treatment for CIN?
A: The most common treatment for CIN is Large Loop Excision of the Transformation Zone (LLETZ). Alternative techniques include cryotherapy.
Q: How is the management of cervical cancer determined?
A: The management of cervical cancer is determined by the FIGO staging and the patient’s wishes regarding fertility preservation.
Q: What is cervical ectropion?
A: Cervical ectropion occurs when elevated oestrogen levels cause a larger area of columnar epithelium to be present on the ectocervix, where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. It is common during the ovulatory phase, pregnancy, and with combined oral contraceptive pill use.
Q: What are the features of cervical ectropion?
A: The features of cervical ectropion include vaginal discharge and post-coital bleeding.
Q: How is cervical ectropion treated?
A: Ablative treatments, such as cold coagulation, are used only for troublesome symptoms.
Q: What are the features of a complete hydatidiform mole?
A: The features of a complete hydatidiform mole include vaginal bleeding, an abnormally large uterus for the gestational age, very high serum hCG levels, and a “snow storm” appearance of mixed echogenicity on ultrasound.
Q: What are the causes of delayed puberty with short stature?
A: The causes of delayed puberty with short stature include Turner’s syndrome, Prader-Willi syndrome, and Noonan’s syndrome.
Q: What are the causes of delayed puberty with normal stature?
A: The causes of delayed puberty with normal stature include polycystic ovarian syndrome (PCOS), androgen insensitivity, Kallmann’s syndrome, and Klinefelter’s syndrome.
Q: What is primary dysmenorrhoea and its management?
A: Primary dysmenorrhoea occurs without underlying pelvic pathology, affecting up to 50% of menstruating women. It typically starts 1-2 years after menarche and is thought to be caused by excessive prostaglandin production. Management includes NSAIDs (e.g., mefenamic acid, ibuprofen), which inhibit prostaglandin production, and combined oral contraceptives as a second-line treatment.
Q: What is secondary dysmenorrhoea and its causes?
A: Secondary dysmenorrhoea develops many years after menarche and is caused by underlying conditions. It usually starts 3-4 days before the period. Causes include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices (except Mirena), and fibroids.
Q: What is the management for secondary dysmenorrhoea?
A: NICE recommends referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
Q: What are the typical features of ectopic pregnancy?
A: Ectopic pregnancy presents with a history of 6-8 weeks of amenorrhoea, lower abdominal pain (due to tubal spasm), and vaginal bleeding (usually darker and less than a normal period). Additional symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Pregnancy symptoms like breast tenderness may also be reported.
Q: What are the examination findings in ectopic pregnancy?
A: Examination may reveal abdominal tenderness, cervical excitation (cervical motion tenderness), and an adnexal mass. However, NICE advises against examining for an adnexal mass due to the risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is recommended.
Q: How can ectopic pregnancy be diagnosed in the case of pregnancy of unknown location?
A: Serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy in cases of pregnancy of unknown location.
Q: What are the risk factors for ectopic pregnancy?
A: Risk factors include anything that slows the ovum’s passage to the uterus, such as damage to the tubes (e.g., from pelvic inflammatory disease or surgery), previous ectopic pregnancies, endometriosis, intrauterine contraceptive devices (IUCD), progesterone-only pill use, and in vitro fertilization (IVF), with 3% of IVF pregnancies being ectopic.
Q: What is the investigation of choice for ectopic pregnancy?
A: The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.
Q: What are the three management options for ectopic pregnancy, and when are they used?
Expectant management: Used if the ectopic is <35mm, unruptured, asymptomatic, with no fetal heartbeat, hCG <1,000 IU/L, and compatible with another intrauterine pregnancy. It involves monitoring the patient over 48 hours to check for changes in symptoms or hCG levels.
Medical management: Used for unruptured ectopics <35mm, with no significant pain, no fetal heartbeat, hCG <1,500 IU/L, and compatible with another intrauterine pregnancy. Methotrexate is used if the patient is willing to attend follow-up.
Surgical management: Indicated for ectopics >35mm, or if the ectopic is ruptured, with pain, visible fetal heartbeat, or hCG >5,000 IU/L. This can involve salpingectomy (first-line for women without infertility risk) or salpingotomy (considered for women with infertility risk factors).
Q: What is the most common location for ectopic pregnancy?
A: 97% of ectopic pregnancies are tubal, with most occurring in the ampulla. The isthmus is more dangerous if affected.
Q: What is the main aetiology of endometrial cancer?
A: The main aetiology of endometrial cancer is excess oestrogen, which can arise from factors such as nulliparity, early menarche, late menopause, unopposed oestrogen, obesity, diabetes mellitus, and polycystic ovarian syndrome. Additionally, tamoxifen use and hereditary non-polyposis colorectal carcinoma can increase the risk.
Q: What are the common symptoms of endometrial cancer?
A: The classic symptom of endometrial cancer is postmenopausal bleeding, which typically starts as slight and intermittent before becoming heavier. Premenopausal women may experience menorrhagia or intermenstrual bleeding. Pain is uncommon but may indicate more advanced disease, and vaginal discharge is unusual.
Q: How is endometrial cancer investigated?
A: The first-line investigation for endometrial cancer is transvaginal ultrasound. A normal endometrial thickness (< 4 mm) has a high negative predictive value. If further investigation is required, hysteroscopy with endometrial biopsy is performed.
Q: What is the main treatment for endometrial cancer?
A: The main treatment for endometrial cancer is surgery. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is used for localized disease, while patients with high-risk disease may receive postoperative radiotherapy. Progestogen therapy may be used in frail elderly women not suitable for surgery.
Q: What is endometrial hyperplasia?
A: Endometrial hyperplasia is an abnormal proliferation of the endometrium that occurs beyond the normal proliferation seen during the menstrual cycle. A minority of cases may progress to endometrial cancer.
Q: What are the common features of endometrial hyperplasia?
A: The most common feature of endometrial hyperplasia is abnormal vaginal bleeding, such as intermenstrual bleeding.
Q: How is endometrial hyperplasia managed?
Simple endometrial hyperplasia without atypia: High-dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may also be used.
Atypical hyperplasia: Hysterectomy is usually advised.
Q: What is endometriosis?
A: Endometriosis is a common condition where ectopic endometrial tissue grows outside of the uterine cavity. It affects around 10% of women of reproductive age.
Q: What are the clinical features of endometriosis?
Chronic pelvic pain
Secondary dysmenorrhoea (pain before bleeding)
Deep dyspareunia (pain during intercourse)
Subfertility
Non-gynaecological symptoms such as urinary symptoms (dysuria, urgency, haematuria) and dyschezia (painful bowel movements)
On pelvic examination, there may be reduced organ mobility, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions.
Q: What is the gold-standard investigation for endometriosis?
A: Laparoscopy is the gold-standard investigation for endometriosis.
Q: What is the management of endometriosis?
First-line treatment: NSAIDs and/or paracetamol for symptomatic relief.
Hormonal treatments: Combined oral contraceptive pill or progestogens (e.g., medroxyprogesterone acetate) if analgesia is ineffective.
Secondary care: For patients whose symptoms persist or for those prioritizing fertility, treatment options include:
GnRH analogues (induce a pseudomenopause with low estrogen)
Surgery: Laparoscopic excision or ablation of endometriosis and adhesiolysis, which can improve fertility. Ovarian cystectomy may be considered for endometriomas.
Q: What is female genital mutilation (FGM)?
A: Female genital mutilation (FGM) refers to procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
Q: What are the WHO classifications of FGM?
Type 1: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora, with or without excision of the clitoris (infibulation).
Type 4: All other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization.
Q: What is fibroid degeneration and how does it occur?
A: Fibroid degeneration occurs when uterine fibroids, which are sensitive to oestrogen, outgrow their blood supply. This can result in red or “carneous” degeneration.
Q: What are the symptoms of fibroid degeneration?
A: Symptoms typically include low-grade fever, pain, and vomiting.
Q: How is fibroid degeneration managed?
A: Management is usually conservative with rest and analgesia. The condition typically resolves within 4-7 days.
Q: What are the differential diagnoses for abdominal pain in females?
Mittelschmerz: Mid-cycle pain with a sharp onset, usually without systemic disturbance. Diagnosed via full blood count and ultrasound. Treated conservatively.
Endometriosis: Associated with menstrual irregularity, infertility, pain, and deep dyspareunia. Diagnosed with ultrasound and laparoscopy. Treated medically, with surgery for complex cases.
Ovarian torsion: Sudden onset of colicky abdominal pain, vomiting, and adnexal tenderness. Diagnosed via ultrasound and treated with laparoscopy.
Ectopic gestation: Symptoms of pregnancy without intrauterine pregnancy, presenting with abdominal pain and circulatory collapse in some cases. Diagnosed with ultrasound and beta HCG levels. Treated with laparoscopy or laparotomy if unstable, often with salpingectomy.
Pelvic inflammatory disease: Bilateral lower abdominal pain, vaginal discharge, dysuria, and fever. Diagnosed with full blood count, vaginal swabs, and amylase levels. Treated medically.
Q: How is heavy menstrual bleeding (menorrhagia) defined?
A: Menorrhagia is defined based on the woman’s perception of excessive bleeding, as quantifying blood loss is difficult. Previously, it was defined as blood loss >80 ml per menses.
Q: What is the first step in investigating heavy menstrual bleeding?
A: The first step is to perform a full blood count in all women presenting with heavy menstrual bleeding.
Q: When should a transvaginal ultrasound be arranged for heavy menstrual bleeding?
A: A transvaginal ultrasound should be arranged if symptoms suggest a structural or histological abnormality, such as intermenstrual or postcoital bleeding, pelvic pain, or abnormal pelvic exam findings.
Q: What is the treatment for heavy menstrual bleeding in women who do not require contraception?
A: In women who do not require contraception, either mefenamic acid 500 mg tds or tranexamic acid 1 g tds is recommended. Both are started on the first day of the period.
Q: What is the treatment for heavy menstrual bleeding in women who require contraception?
A: In women who need contraception, the first-line option is an intrauterine system (Mirena). Other options include the combined oral contraceptive pill and long-acting progestogens.
Q: What are common side effects of hormone replacement therapy (HRT)?
A: Common side effects of HRT include nausea, breast tenderness, fluid retention, and weight gain.
Q: What is a potential complication of HRT related to breast cancer?
A: HRT can increase the risk of breast cancer, especially with the addition of a progestogen. The relative risk in the Women’s Health Initiative (WHI) study was 1.26 at 5 years. The risk declines after stopping HRT and returns to baseline within 5 years.
Q: How does HRT affect the risk of endometrial cancer?
A: Oestrogen alone increases the risk of endometrial cancer in women with a uterus. This risk is reduced but not eliminated by the addition of a progestogen. The risk is said to be eliminated if a progestogen is given continuously.
Q: How does HRT affect the risk of venous thromboembolism (VTE)?
A: HRT increases the risk of VTE, especially with the addition of a progestogen. Transdermal HRT does not appear to increase the risk of VTE. Women at high risk for VTE should be referred to haematology before starting HRT.
Q: How does HRT affect the risk of stroke and heart disease?
A: HRT increases the risk of stroke and ischaemic heart disease, particularly if started more than 10 years after menopause.
Q: What is hyperemesis gravidarum, and how does it relate to nausea and vomiting in pregnancy (NVP)?
A: Hyperemesis gravidarum is an extreme form of nausea and vomiting during pregnancy, occurring in around 1% of pregnancies. It is related to elevated beta-hCG levels and is most common between 8 and 12 weeks but can persist up to 20 weeks.
Q: What are the risk factors for hyperemesis gravidarum?
A: Risk factors include increased levels of beta-hCG, multiple pregnancies, trophoblastic disease, nulliparity, obesity, and a personal or family history of NVP. Smoking is associated with a decreased incidence of hyperemesis.
Q: What are the referral criteria for nausea and vomiting in pregnancy (NVP)?
A: Admission is considered for continued nausea and vomiting unable to keep liquids down, ketonuria, weight loss (>5% of body weight), or a co-existing condition like diabetes that may be adversely affected. A lower threshold for admission is recommended for women with a co-existing condition.
Q: What is the diagnostic triad for hyperemesis gravidarum according to the RCOG?
A: The diagnostic triad includes 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance.
Q: What medications are used to manage hyperemesis gravidarum?
A: First-line medications include oral cyclizine or promethazine, prochlorperazine or chlorpromazine, and a combination of doxylamine/pyridoxine. Second-line options are oral ondansetron, metoclopramide, or domperidone, with caution due to side effects. IV hydration may be needed in severe cases.
Q: What complications can arise from hyperemesis gravidarum?
A: Complications include dehydration, weight loss, electrolyte imbalances, acute kidney injury, Wernicke’s encephalopathy, oesophagitis, Mallory-Weiss tear, and venous thromboembolism.
Q: What are the common long-term complications of vaginal hysterectomy with an antero-posterior repair?
A: Common long-term complications include enterocoele and vaginal vault prolapse.
Q: What is a potential acute complication following hysterectomy?
A: Urinary retention may occur acutely following hysterectomy, but it is not usually a chronic complication.
Q: What are the common causes of infertility?
A: Common causes include male factor (30%), unexplained (20%), ovulation failure (20%), tubal damage (15%), and other causes (15%).
Q: What is the purpose of serum progesterone testing in infertility investigations?
A: Serum progesterone is tested 7 days prior to the expected next period (typically on day 21 of a 28-day cycle) to assess ovulation.
Q: How should serum progesterone levels be interpreted?
< 16 nmol/l: Repeat test, if consistently low refer to specialist.
16 - 30 nmol/l: Repeat test.
30 nmol/l: Indicates ovulation.
Q: What are key counselling points for infertility management?
A: Key points include taking folic acid, maintaining a BMI between 20-25, having regular sexual intercourse every 2 to 3 days, and offering smoking and drinking advice.
Q: At what age does the average woman in the UK go through menopause?
A: The average woman in the UK goes through menopause at 51 years old.
Q: What are the three main categories for managing menopause?
Lifestyle modifications
Hormone replacement therapy (HRT)
Non-hormone replacement therapy
Q: What lifestyle modifications can help manage menopause symptoms?
Hot flushes: Regular exercise, weight loss, and stress reduction
Sleep disturbance: Avoiding late evening exercise and maintaining good sleep hygiene
Mood: Sleep, regular exercise, and relaxation
Cognitive symptoms: Regular exercise and good sleep hygiene
Q: What are the contraindications for hormone replacement therapy (HRT)?
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Q: What type of HRT should be used in women with a uterus?
A: In women with a uterus, combined HRT (oestrogen and progestogen) should be used, either orally or transdermally, to reduce the risk of endometrial cancer.
Q: What type of HRT should be used in women without a uterus?
A: In women without a uterus, oestrogen alone (either orally or in a transdermal patch) can be used.
Q: What are some risks associated with HRT?
Venous thromboembolism: Slight increase with all forms of oral HRT; no increased risk with transdermal HRT
Stroke: Slight increase with oral oestrogen HRT
Coronary heart disease: Slight increase with combined HRT
Breast cancer: Increased risk with all combined HRT, but no increased risk of dying from breast cancer
Ovarian cancer: Increased risk with all HRT
Q: What are the non-HRT treatments for menopause?
Vasomotor symptoms: Fluoxetine, citalopram, or venlafaxine
Vaginal dryness: Vaginal lubricant or moisturiser
Psychological symptoms: Self-help groups, cognitive behavioural therapy (CBT), or antidepressants
Urogenital symptoms: Vaginal oestrogen can be prescribed for urogenital atrophy, and moisturisers or lubricants can also be used.
Q: When should a woman be referred to secondary care for menopause management?
A: Referral to secondary care is necessary if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.
Q: What changes in periods may occur during menopause?
Change in the length of menstrual cycles
Dysfunctional uterine bleeding
Q: What are vasomotor symptoms and how common are they?
A: Vasomotor symptoms, affecting around 80% of women, include hot flushes and night sweats, and they may continue for up to 5 years.
Q: What are the urogenital changes that occur in menopause?
A: Urogenital changes, affecting around 35% of women, include vaginal dryness, atrophy, and urinary frequency.
Q: What psychological symptoms can be seen during menopause?
A: Psychological symptoms can include anxiety and depression (seen in around 10% of women) and short-term memory impairment.
Q: What are the longer-term complications of menopause?
Osteoporosis
Increased risk of ischaemic heart disease
Q: What is dysfunctional uterine bleeding?
A: Dysfunctional uterine bleeding refers to menorrhagia in the absence of underlying pathology and accounts for approximately half of the cases.
Q: What are common causes of menorrhagia?
Dysfunctional uterine bleeding
Anovulatory cycles (more common at the extremes of a woman’s reproductive life)
Uterine fibroids
Hypothyroidism
Intrauterine devices (copper coils)
Pelvic inflammatory disease
Bleeding disorders (e.g., von Willebrand disease)
Q: How does the intrauterine system (Mirena) relate to menorrhagia?
A: The intrauterine system (Mirena) is used to treat menorrhagia, unlike normal copper coils, which can be a cause.
Q: What is a threatened miscarriage, and when does it typically occur?
A: A threatened miscarriage is painless vaginal bleeding occurring before 24 weeks, typically between 6-9 weeks. The bleeding is often less than menstruation, and the cervical os remains closed. It complicates up to 25% of pregnancies.
Q: What is a missed (delayed) miscarriage, and how is it diagnosed?
A: A missed (delayed) miscarriage occurs when a gestational sac contains a dead fetus before 20 weeks without symptoms of expulsion. The mother may have light vaginal bleeding/discharge, and pregnancy symptoms disappear, but pain is not usually present. The cervical os is closed, and when the gestational sac is >25mm with no visible embryo/fetus, it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy.’
Q: What is an inevitable miscarriage, and what are the features?
A: An inevitable miscarriage involves heavy bleeding with clots and pain, and the cervical os is open.
Q: What characterizes an incomplete miscarriage?
A: An incomplete miscarriage occurs when not all products of conception have been expelled. It involves pain and vaginal bleeding, with the cervical os being open.
Q: What are the common causes of early miscarriage?
A: Chromosomal abnormalities account for about 50% of early miscarriages.
Q: What are some risk factors for miscarriage?
A: Risk factors include advanced maternal age (especially women over 35), a history of previous miscarriages, previous large cervical cone biopsy, lifestyle factors such as smoking, alcohol consumption, and obesity, and medical conditions such as uncontrolled diabetes and thyroid disorders.
Q: What is recurrent miscarriage, and how common is it?
A: Recurrent miscarriage is defined as three or more consecutive miscarriages, affecting about 1% of couples.
Q: What is expectant management for miscarriage?
A: Expectant management involves waiting for a spontaneous miscarriage to occur, typically for 7-14 days. If it is unsuccessful, medical or surgical management may be considered.
Q: What situations may require medical or surgical management for miscarriage?
A: These situations include increased risk of hemorrhage, late first trimester miscarriage, coagulopathies or inability to have a blood transfusion, previous adverse pregnancy experiences, and evidence of infection.
Q: How is medical management of miscarriage performed for missed miscarriage?
A: Medical management involves administering oral mifepristone, followed 48 hours later by misoprostol to induce uterine contractions and expel products of conception.
Q: How is medical management of incomplete miscarriage performed?
A: A single dose of misoprostol (vaginal, oral, or sublingual) is given, and antiemetics and pain relief should be offered. A pregnancy test should be performed 3 weeks later.
Q: What are the surgical options for miscarriage management?
A: The two main surgical options are vacuum aspiration (suction curettage) under local anesthetic as an outpatient or surgical management in theatre under general anesthetic, previously referred to as evacuation of retained products of conception.
Q: What is the most common type of ovarian cancer?
A: Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas.
Q: What are some key risk factors for ovarian cancer?
A: Key risk factors include family history with mutations in BRCA1 or BRCA2 genes, and many ovulations (e.g. early menarche, late menopause, nulliparity).
Q: What are common clinical features of ovarian cancer?
A: Common symptoms include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms (e.g. urgency), early satiety, and diarrhea.
Q: What is the first investigation recommended for suspected ovarian cancer?
A: A CA125 test is done initially to assess for ovarian cancer. If the level is 35 IU/mL or greater, an urgent ultrasound scan of the abdomen and pelvis should be ordered.
Q: What is the role of ultrasound in ovarian cancer diagnosis?
A: Ultrasound is used to further investigate after an elevated CA125 test result.
Q: How is ovarian cancer typically managed?
A: Management typically involves a combination of surgery and platinum-based chemotherapy.
Q: What is a complex ovarian cyst, and how should it be managed?
A: A complex ovarian cyst is multi-loculated and should be biopsied to exclude malignancy.
Q: What are follicular cysts?
A: Follicular cysts are the most common type of ovarian cyst, caused by the non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle. They typically regress after several menstrual cycles.
Q: What is a corpus luteum cyst?
A: A corpus luteum cyst forms when the corpus luteum fails to break down after ovulation, filling with blood or fluid. It is more likely to cause intraperitoneal bleeding than follicular cysts.
Q: What is a dermoid cyst?
A: A dermoid cyst (mature cystic teratoma) is a benign germ cell tumor, often containing skin appendages, hair, and teeth. It is the most common benign ovarian tumor in women under 30, with a median age of diagnosis at 30. It may cause torsion more frequently than other ovarian tumors.
Q: What is a serous cystadenoma?
A: A serous cystadenoma is the most common benign epithelial ovarian tumor, resembling serous carcinoma, the most common type of ovarian cancer. It is bilateral in about 20% of cases.
Q: What is a mucinous cystadenoma?
A: A mucinous cystadenoma is the second most common benign epithelial ovarian tumor. These cysts are typically large and may become massive. If ruptured, they may cause pseudomyxoma peritonei.
Q: What is the initial imaging modality for suspected ovarian cysts/tumors?
A: The initial imaging modality is ultrasound.
Q: What is the management approach for premenopausal women with ovarian cysts?
A: For younger women (especially those under 35 years), a conservative approach may be taken if the cyst is small (e.g., <5 cm) and classified as ‘simple,’ as malignancy is less common. A repeat ultrasound should be arranged for 8-12 weeks, and referral should be considered if the cyst persists.
Q: What is the management approach for postmenopausal women with ovarian cysts?
A: Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynaecology for assessment, as physiological cysts are unlikely at this stage.
Q: What is ovarian hyperstimulation syndrome (OHSS)?
A: Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment, where high levels of oestrogens, progesterone, and vasoactive substances like vascular endothelial growth factor (VEGF) lead to increased membrane permeability and fluid loss from the intravascular compartment.
Q: What treatments are most commonly associated with OHSS?
A: OHSS is more likely to occur following gonadotropin or hCG treatment and is rarely seen with clomifene therapy. Up to one-third of women undergoing IVF may experience a mild form of OHSS.
