SCA online - Gender, reproductive, sex, womens

Question 1

Baldness differentials

Answer 1

Male pattern baldness (androgenic alopecia)
Telogen effluvium - sudden loss, triggered by stress
Trichotillomania - intentional pulling, psych
Alopecia areata - patchy loss, inflammatory cause

Question 2

Male pattern baldness (androgenic alopecia) Mx

Answer 2

Do nothing - this is natural.

Non drug - wigs, cosmetic camouflage, extensions

drug - scalp foam

Private - finasteride, scalp solutions, hair transplant

Question 3

Contraception in menopause

Answer 3

1st - COCP
- Contraindications: DVT/ breast ca/ liver disease/ migraine with aura/ smokers
- stop at 50yo

2nd - POP
- stop at 55yo

2nd - Depot
- CI: osteoporosis
- stop at 50yo

2nd - Implant
- stop at 55

2nd - Mirena coil
- last 10 years if inserted after 45yo

3rd - sterilisation

All progesterone-only preparations are adequate with HRT

Question 4

Gender dysphoria

Answer 4

Main priority is patients mental and physical wellbeing. Therefore the safest option is referral to gender specialist. As a GP, I can not prescribe hormone treatment, but can support you through out this process.

Ask about mental and physical health
be empathetic in consultation
Refer CAMHs if long waiting times for gender clinic
Offer family therapy, child psychology, counselling for both child and parents

Question 5

Erectile dysfunction Mx

Answer 5

Common condition
Mx - 1st Viagra/ Cailis
2nd refer to urology for vacuum pumps, penile injections, surgery
Manage other causes diabetes, cholesterol, HTN. Exercise and healthy diet, stop smoking, reduce alcohol

Question 6

Genital herpes

Answer 6

common viral STI. Need to go to GUM clinic for viral swabs for confirmation.
Can aquire the infection many years ago or may have spread from elsewhere eg fingers, mouth
there is no cure, but symptoms improve with time
Mx - PO aciclovir, avoid sex until lesion have healed, screen for other STI with self vaginal swab or urine sample - but aim to send to GUm clinic

Question 7

Causes of gynaecomastia

Answer 7

Physiological - puberty, old aging

Pathological - hypogonadism, hyperthyroid, pituitary tumour, testicular tumour, liver disease, ckd, cancers

Pharmacological - spironolactone, finasteride, SSRI, digoxin, metronidazole, anabolic steroids, alcohol

Question 8

Gynaecomastia Ix

Answer 8

Bloods - LFTs, UE, TFT hormones, tumour markers (afp, hcg)

USS breast if lumps felt

Question 9

Hyperemesis gravidarum

Answer 9

A more severe morning sickness during pregnancy - vomiting, unable to keep food/ fluids down

Mx - rest, eat and drink what you can, medications (cyclizine, promethazine) - if resistant to treatment for antenatal clinic

Admission if unwell - unable to take fluids, immunocompromised, dehydration, poor mental health

Question 10

Hypertension in pregnancy (<20/40)

Answer 10

Mx
restriction of dietary salt
if on ACEi/ ARB - stop and switch
if thiazide - stop and seek referral
Stop anti hypertensives if BP <110/70
Safe anti hypertensives include labetalol, Nifedipine
Give aspirin 75mg OD until 12/40
Urine protein:creatinine ratio >30 = significant proteinuria

Question 11

Providing care for travelling communities

Answer 11

Ask patient if wanting to be registered as permanent (use GP address) or temporary.
Stay registered with own GP even if moving out of area (just be aware can not do home visits if out of area)
Can use telephone calls for appointments rather than letters

Question 12

Infertility counselling

Answer 12

> 80% couples get pregnant within 1 year
90% couples get pregnant within 2 years

25% have no cause. common causes include ovulation problems, fallopian tube problems, pelvic conditions (PID, endomet), male issues

Key Qs - prev pregnancies, how long have been trying and last contraception, menstrual history, DDx PCOS, diabetes, thyroid; lifestyle, sexual health Hx

Male Key Qs - prev children, sexual hx, diabetes/ thyroid, steroids

Question 13

Infertility Mx

Answer 13

regular intercourse 2-3 times per week
take folic acid 400mcg OD
lifestyle - reduce stress, stop smoking and alcohol, health weight

Refer is trying for >1 year (or >35yo, known issues eg chemotherapy)

Question 14

Intermenstrual bleeding Ix

Answer 14

1st - Pregnancy test, STI screen (vaginal swabs), speculum exam (cervical polyps, ca, ectropion), hormone contraceptives can expect up to 6 months of break through bleeding

2nd - if bleeding >3 months and above all clear
pelvic USS (fibroids, polyps)
refer for hysteroscopy, endometrial biopsy

Question 15

Latex allergy

Answer 15

your immune system reacts to proteins within the rubber latex

latex can be found in condoms, balloons, gloves, rubber bands

Ix - skin prick testing through derm/ immunology

Mx - avoidance, MedicAlert band (highlight allergy), if anaphylactic then needs Epipen

Question 16

Erectile dysfunction Ix

Answer 16

Bloods - testosterone, FSH, LH, HCG, prolactin, HBA1C, TFT, LFT.
Obs - weight. blood pressure

Question 17

Menopause + HRT

Answer 17

Menopause - is the last period. Perimenopause is the period leading up to this point. As women get older, the hormone oestrogen reduces leading to symptoms such as mood swings, hot flushes, changes in periods.

Risk factors for HRT - Breast ca, undiagnosed vaginal bleeding, VTE, Recent MI, Liver disease, current pregnancy, clotting disorder

Question 18

Side-effects of HRT

Answer 18

VTE - reduce risk with transdermal preparations

CHD - no risk or protective against CHD

Stroke - increased risk above 60yo

Dementia - protective factor

Breast ca - combined is associated with increased risk

Question 19

HRT Mx

Answer 19

If perimenopausal (still having periods) = for cyclical HRT

If has uterus = Combined. Progesterone to protect the uterus lining.

Question 20

Testosterone in HRT

Answer 20

Indications - Low libido after other alternative have been used
Currently, GP should consult specialist before prescribing - eg needs to go to menopause clinic

Question 21

Contraception in HRT

Answer 21

if under 50yo/ perimenopause - need contraception.

POP - can be used to combined HRT. POP is given daily. Despite sequential or continuous HRT

COCP - only under 50yo due to risks. not advised.

IUS Mirena coil - both contraception and endometrial protection in HRT. effective for 5 years.

Progesterone depot/ implant - good for contraception, not for endometrial protection

Question 22

HRT bleeding

Answer 22

expected in first 6 months of starting or changing HRT.

If ongoing past 6 months may need further Ix such as USS or even biopsy - via gynaecologists

Need to examine for other causes of PVB - pelvic exam, STI screen

If bleeding started within 6 months of starting HRT and continues past 6 months, then change HRT. If still bleeding, then stop HRT if possible. if not possible or restarting HRT and bleeding then for pelvic USS>

Question 23

HRT and Breast cancer

Answer 23

Increased risk if on HRT for >5 years or older than 60yo.

Other risk factors - Obesity(BMI >29)

Question 24

Menorrhagia

Answer 24

causes - fibroids, endometriosis, other

Mx
1st - IUS Mirena coil
2nd - Tranexamic acid/ COCP/ cyclical POP
3rd - refer

Question 25

HPV

Answer 25

Common virus, passed through skin to skin contact, often sexual activity. The majority do not cause any problems and go away on their own. Some, can cause changes to the cells of the cervix.

HPV Positive means the virus is present

Dyskaryosis mean changes to the cells of the cervix

This does not mean cancer, but if not monitored, could become cancer later on.

Is it an STI? Technically yes, but it is extremely common and often harmless.

Remember, HPV is extremely common, it is nothing to be ashamed of and does not reflect on anyone’s character or behaviour.

Question 26

HPV screening

Answer 26

ANY Dyskaryosis (or abnormal cytology) = needs colposcopy
- a special microscope to look at the cells of the cervix, done by a specialist

HPV +ve = repeat in 12 months
HPV +ve again = repeat in 12 months
HPV +ve again (3rd in 2 years) = colposcopy

HPV inadequate result = repeat in 3 months

Question 27

Needle-Stick injury

Answer 27

If <72 hours - go to A&E for post exposure prophylaxis

If >72 hours - come to GP
- explain risk of infection is low
tetanus vaccine

Question 28

Post Menstrual Bleeding risk factors for endometrial Ca

Answer 28

Oestrogen only HRT
early menarche/ late menopause
Infertility
Tamoxifen
PCOS
Obesity
Diabetes

Question 29

Post menopausal bleeding causes

Answer 29

Most serious - Endometrial Ca, cervical ca, vulval ca

Most Common - vaginal atrophy, endometrial hyperplasia, polyps

Question 30

Post menopausal bleeding Ix

Answer 30

if >55 + period free for >12 months = 2WW

if <55 or = consider 2WW - urgent USS first

Question 31

Pre-clampsia

Answer 31

A condition that only happens during pregnancy, results in high blood pressure and protein leaking from the kidneys into the urine
Symptoms include headache, tummy pain and swelling

HTN (BP >140/90)
Proteinuria (>1+)
After 20/40 gestation

Question 32

Risk factors for pre eclampsia and Mx

Answer 32

If 2 or more risk factors = start Aspirin 75mg OD

first pregnancy
>10yr since last pregnancy
>40yo
BMI >35
previous pre eclampsia
FHx first degree relative pre eclampsia
pre existing - diabetes/ renal disease/ HTN/ antiphospholipid antibodies

Question 33

Premature ejactulation

Answer 33

achievement of orgasm very soon after penetration or even before. This is extremely common and the vast majority of causes are harmless.

Causes:
Anxiety
Medication
Drugs (cocaine, amphetamine)
Chronic prostatitis
MS/ peripheral neuropathy
Erectile dysfunction

Question 34

Premature ejaculation Mx

Answer 34

• Self help
  masturbating 1-2 hours before sex
  thick condom, local anaesthetic condom
  taking breaks during sex
• Couples/ sexual therapy
• Medication (for anxiety)
  Sertraline however be aware these can also cause erectile dysfunction.
  Dapoxetine - license for premature ejaculations

Question 35

Severe PMS/ PMDD

Answer 35

Severe form of pre menstrual syndrome causing significant emotional and physical symptoms impacting daily life

Must:
Begins before menstruation
improves after menstruation

Symptoms:
Labile mood
irritability
feelings of hopelessness
anxiety

Question 36

PMDD Mx

Answer 36

Medication
- SSRI
- COCP (Yasmin)

Non pharmacological
- CBT, DBT
- regular exercise, healthy diet, management of stress

CAMHS if under 18

Question 37

PSA request

Answer 37

Prostate gland sits around the neck of the bladder. It can grow, compressing the urine tube, causing problems passing urine.

The prostate grows with age and this is normal

As with all tests, nothing is 100% accurate. A raised PSA can be due to cancer, but also harmless causes. Likewise a normal PSA, can not fully exclude cancer.

Therefore, a blood test (PSA) and examination are helpful to determine the probability of prostate cancer

If either are raised then for urology review

PSA reference points
40-49 >2.5
50-59 >3.5
60-69 >4.5
70-79 > 6.5

Question 38

Recurrent UTI (in older women)

Answer 38

Very common in post menopausal women - due to lack of oestrogen

Mx
Treat UTI and urine MCS
self initiate Abx if feeling symptoms arise or prophylactic abx
Urology if indicated
Topical oestrogen
Self care

Question 39

UTI Self care

Answer 39

Adequate hydration >1.5L/ day
Avoid douching (cleaning the inside of the vagina)
Wipe front to back
Post-coital urination
Post coital hygiene
Offer follow up after tried all above

Question 40

Serotonin syndrome

Answer 40

Excess serotonin (a naturally formed chemical within our body) - leading to headaches, confusion, fast heart rate, high blood pressure, dilated pupils, muscle stiffness. In severe cases can lead to fevers and seizures.

Caused by medications increasing serotonin levels
- Eg SSRI, Gabapentin, Tramadol

Must be addressed immediately
- mild = stop contributing medication - needs close monitoring and regular follow up
- mod to severe = hospital admission

Question 41

Chlamydia (STI) counselling

Answer 41

Ensure confidentiality
if safeguarding issues - ensure that this is not because anyone is in trouble, but that it is my job to keep you safe
Needs treatment and follow up a few months later to check is cured
Encourage safe sex - condom
Contraception
Check having consensual sex

Question 42

Teenage sex laws and safeguarding

Answer 42

Sex under 13yo is illegal - needs referral to child protection or police

Legal age of consent is 16 - however if both are under this age and same level of maturity, it is unlikely to prosecute.

Question 43

Ovarian cancer risk factors

Answer 43

Women (any women, particularly over 50 or >12 months ) +
bloating (IBS symptoms)
loss appetite
pelvic/ abdo pain
increased urinary frequency
weight loss
malaise

Question 44

Suspected ovarian ca Ix

Answer 44

Abdo and pelvic exam
2WW gynae - if ascites or mass found
Ca 125
if positive for USS
if USS positive for gynae 2WW

Question 45

Termination of pregnancy

Answer 45

“I understand that this is a personal and difficult decision to make.”

Full gynae Hx, confirm pregnancy, consensual sex, sex work

Termination can be carried up to 24 weeks gestation

Mx/
Self refer to specialist clinic
- medical or surgical management

Question 46

Testosterone replacement for men

Answer 46

Treat/ refer for treatment if Total Testosterone levels <12 and symptomatic

symptoms:
Low mood, ED, low energy

Mx
refer if necessary
treat other aspects eg low mood = counselling, SSRI; ED = sildenafil; improve diet and exercise, sleep, manage stress, reduce smoke/ alcohol/ drugs

Question 47

Urinary incontinence

Answer 47

Two types
- Urge - need to go urgently, often unable to get to toilet in time
- stress - coughs, sneezes, leaks
- Mixed - combination of both

Ix/
abdominal and pelvic examination
urine dip - infection

Question 48

Urge incontinence Mx

Answer 48

1st
- bladder training (physio, apps)
- lifestyle - reduce alcohol, caffiene, reduce fluids in evening

2nd - relax the bladder muscle, therefore less contractions
Oxybutynin, tolterodine
Mirabegron

3rd
Urology
BoTox to bladder

Question 49

Stress incontinence Mx

Answer 49

1st
- Pelvic floor exercise
- Lifestyle changes

2nd
- Duloxetine - increased urethral sphincter tone

3rd
- urology refer

Question 50

Vasectomy counselling

Answer 50

Form of birth control for men that cuts the vas deferens (which is the tube that connects sperm from the testicles to the penis)

Extremely but not 100% effective. Failure rate of 1/2000 men.

Can be reversible (not on NHS) but should be considered irreversible

Main side effect - long term testicular pain

Question 51

Autism Spectrum disorder (ASD)

Answer 51

Broad term referring to children’s challenges with communication and social situations.

Qs
- Social - how does the child play with others
- Communication - any delay in speech development
Imaginative - Do they have strong attachment to certain toys, do they struggle with imaginative play

Useful to get collateral Hx from parents, nursery/ school

Can be more difficult to see in girls - often shy, fewer friends, not into fashion

Question 52

Autism Mx

Answer 52

ICE - what do you think is going on? what do you know about autism? How would you feel if this is confirmed autism?

Majority of children with autism go to mainstream school and can cope with a little bit extra help in school

Local support groups
Speech and language groups
Behavioural specialists

Refer Community peads

Question 53

Stimming in Autism

Answer 53

Self stimulatory behaviour - repetitive movements, noises or actions to help manage stress
- very normal process of ASD, usually harmless - but scratching or head banging - may need further assessment to keep person safe

Differentials include - Tics, Tourettes, Myoclonus

Question 54

Carer breakdown

Answer 54

Normally irritable, low mood, low energy, high stress

TATT case really

Red flags - weight loss, fevers, bruising, weakness/ paraesthesia

DDx
- Infectious - HIV, Tb, viral
- Endocrine - thyroid, cushings, diabetes, anaemia
- psych - depression
- Chronic fatigue
- Heart failure, COPD
- Malignancy

Ix/
Examination, Bloods, Urinalysis, ECG

Review safeguarding for cared person!! eg carer using excessive mood stabilisers because patient is agitated.

Mx/
adult safeguarding group - if necessary
support groups
respite care
social services
Follow up

Question 55

Cold sore

Answer 55

small painful blister, usually on lips, due to common virus HSV. usually last 7-10 days. Very common, usually harmless, is contagious.

Mx/
If unwell/ immunocompromised/ dehydrated - hospital admission
Generally - fluids, analgesia, rest. Can still go to school
Check safeguarding - who spends time with child

Question 56

Constipation in children

Answer 56

Very common

Qs - diet, fluid intake, PEG feeding, medications (+side effects), activity levels, psychological factors, is this recurrent

Red flags - vomiting, abdo pain, blood in stool, urinary retention

Question 57

Constipation in children Mx

Answer 57

Lifestyle- address underlying causes - diet, fluid, movement

Laxatives
- movicol/ laxido

Follow up

Referral to paeds if necessary

Question 58

Domestic abuse/ violence

Answer 58

This can take many forms - physical, sexual, financial, psychological - this is a way of controlling somebody and is a crime

Red flags
- any children involved?

Qs
- support from friends or family (safe place to go)
- patients mental health

Ensure confidentiality - but may need to involve other if safeguarding issues

Refer
- Independent Domestic violence Advisors (IDVA) service
- Domestic abuse helplines, charities, support groups (national domestic abuse helpline)

Arrange follow up regular

Question 59

Downs screening

Answer 59

Genetic problems, an extra copy of chromosome 21 in the cells of the body. Often people with Downs syndrome have learning disability, the extent can range. Most children with downs live happy and fulfilled lives.

Risk by age
20yo = 1:1500
30yo = 1:800
40yo = 1:100

Screening
- Combined test at 11-14/40 - Blood (bHCG, PAPP-A) and USS (nuchal translucency)
- If late, then Quad test at 20/40

Diagnostic test
- Chorionic villus sampling (sample from placenta)
- Amniocentesis (sample from amniotic fluid)
Both are invasive and carry small risk of miscarriage

Question 60

Female genital mutilation

Answer 60

Procedure of deliberate injury to female genitals. Common procedure in certain cultures, ages infancy to 15. This is illegal in UK and is form of child abuse.
Cause long term problems with sex, childbirth and mental health - there are no benefits to FGM

Refer
Police non urgent - 101
Support groups
Child safeguarding
NSPCC
NHS gynae or FGM specialist

Question 61

Forced Marriage

Answer 61

Qs
- Mood (mental health)
- Physical health
- Safety at home
- Support network
- Coping mechanisms
- Finances

Refer - Forced Marriage Unit (FMU), speak to local support groups

Question 62

Substance abuse during pregnancy

Answer 62

Ensure confidentiality and safety for mother

Substance Hx - what, how (needles?), how much
Obstetric Hx - pregnancy so far - further tests, HIV, Hep
Psychosocial - own mental health, social support networks, ?safeguarding

Mx/
be non judgemental
specialist services - substance misuse services, antenatal care
mental health support - MDT approach
encourage folic acid
Buprenorphine/ Methadone - if on heroin
Screen bloods - HIV, Hep, syphillis
Stop smoking
regular follow ups

Question 63

Fragility hip fracture

Answer 63

Signs and symptoms will be less pronounced than a traumatic hip fracture. Fragility fracture due to frailty (osteoporosis)

Symptoms:
pain in groin/ hip - radiate to knee/ lower back

Examination:
Bruising/ swelling, reduced ROM, short externally rotated leg, tenderness

Risk factors - Medications
Corticosteroids, PPIs, SSRI, Depo contraception, Pioglitazone, Letrozole/ Anastrozole

Question 64

PTSD

Answer 64

Anxiety disorder caused by distressing events.

Features include - Flashbacks/ Nightmares, feelings of isolation, guilt, irritability. Difficulty sleeping/ concentrating. If severe, can impact daily life.

Mx
high risk of suicide - same day crisis review
Address any mental, physical and social concerns - F2F review
Refer to psychiatry - therapy and medications - eye movement desensitization and reprocessing therapy, trauma-focused CBT
Specific support for veterans
Support groups

Question 65

Safeguarding

Answer 65

Any concerns - see vulnerable person/ child F2F

“this could involve social services, but I want to reassure you that their (and our) primary goal is to ensure the child’s safety and well being. They are not there to separate families unnecessarily but to support families in creating safe environments for children”

Full Hx
- describe any injuries or events
- who has access to child
- who is to be trusted