and Janesh Gupta2
(1)
Fetal Medicine, Rainbow Hospitals, Hyderabad, Telangana, India
(2)
University of Birmingham Birmingham Women’s Hospital, Birmingham, UK
SRH1
SRH1 Answer: E
Explanation
Hot flushes begin as a sudden sensation of heat centred on the face and upper chest which rapidly becomes generalised. The sensation of heat lasts a few minutes, can be associated with profuse perspiration and can be followed by chills and shivering. Symptoms result from inappropriate peripheral vasodilatation leading to rapid heat loss and a decrease in core body temperature, and shivering then occurs to restore the core temperature to normal.
Approximately two-third of postmenopausal women will experience hot flushes, with 10–20 % experiencing severe symptoms. For most women, symptoms spontaneously resolve within a few years. However, one-third of postmenopausal women will experience symptoms for up to 5 years, and 20 % will have symptoms for up to 15 years. For women with surgically induced menopause, 90 % experience hot flushes during the first year.
References
Tong IL. Nonpharmacological treatment of postmenopausal symptoms. Obstet Gynaecol. 2013;15:19–25.
SRH2
SRH2 Answer: E
Explanation
Nexplanon® is a progestogen-only subdermal implant that has now replaced the contraceptive implant, Implanon. Nexplanon and Implanon are bioequivalent (i.e. they both contain 68 mg etonogestrel and they have the same release rate and 3-year duration of action). The progestogen-only implant is a long-acting reversible method of contraception (LARC). The primary mode of action is to prevent ovulation. Implants also prevent sperm penetration by altering the cervical mucus and possibly prevent implantation by thinning the endometrium. The implant is a highly effective contraceptive. The overall pregnancy rate reported in the National Institute of Health and Care Excellence (NICE) guideline on long-acting reversible contraception is <1 in 1000 over 3 years.
SRH3
SRH3 Answer: A
Explanation
COC may be recommended for women who are not breastfeeding the baby. However, in breastfeeding women, it is recommended that COC not be used (WHO category 4, unacceptable health risk). Evidence suggested a reduction in milk volume (assessed by weight gain following morning feeds, weekly infant weight and supplements) associated with COC use from day 14 postpartum.
SRH4
SRH4 Answer: A
Explanation
Treatment of BV is recommended for all women who are symptomatic of vaginal discharge. Up to 50 % of women with a clinical diagnosis of BV are asymptomatic. When present, however, the symptoms include a profuse, malodorous vaginal discharge. The offensive smell is due to the production of amines by anaerobic bacteria and is often worse after sex and during menses, when the higher pH causes further release of the amines. The discharge itself is usually white, thin and homogenous and not associated with any inflammation of the vulva or vagina. The diagnosis of a Candida infection can be made entirely clinically, based on the symptoms and signs. They include vulval itching or soreness, curdy white vaginal discharge without a smell, dysuria or superficial dyspareunia. Vulval itching is the most common symptom, and the discharge might be absent in 50 % of cases. The clinical signs include erythema of the vulva or vagina, vulval fissuring and oedema and satellite lesions.
References
McCathie R. Vaginal discharge: common causes and management. Curr Obstet Gynaecol. 2006;16:211–7.
SRH5
SRH5 Answer: C
Explanation
Missing pills or starting the pack late may make your pill less effective. The chance of pregnancy after missing pills depends on when pills are missed and how many pills are missed. A pill is late when you have forgotten to take it at the usual time. A pill has been missed when it is more than 24 h since the time you should have taken it.
If you miss one pill anywhere in your pack or start the new pack 1 day late, you will still have contraceptive cover.
However, missing two or more pills or starting the pack two or more days late (more than 48 h late) may affect your contraceptive cover. As soon as you realise you have missed any pills, take the last pill you missed immediately. In particular, during the 7-day pill-free break, your ovaries are not getting any effects from the pill. If you make this pill-free break longer by forgetting two or more pills, your ovaries might release an egg and there is a real risk of becoming pregnant.
References
Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit CEU Statement. Missed pill recommendations; 2011.
SRH6
SRH6 Answer: E
Explanation
The main feature of primary syphilis is one or more chancres. These macules develop within 90 days of inoculation and become papular, indurated and then ulcerate. They are usually painless. They are classically solitary and can appear anywhere on the body, although usually at the inoculation site. The ulcers resolve within 3 weeks, differentiating them from herpes ulcers, which resolve more quickly.
Secondary syphilis comprises multisystem involvement within 2 years. Features vary but classically include a generalised polymorphic rash often affecting the palms and soles. Alopecia, mucocutaneous lesions, uveitis, meningitis, cranial nerve palsies, hepatitis, splenomegaly, periostitis and glomerulonephritis might also occur.
References
Kieran E, Hay DP. Sexually transmitted infections. Curr Obstet Gynaecol. 2006;16:218–25.
SRH7
SRH7 Answer: D
Explanation
N. gonorrhoeae is a Gram-negative intracellular diplococcus. The primary sites of infection in women are the cervix (85–95 % of cases) and the urethra (65–75 % of cases).
Other sites that might be involved include the rectum (25–50 %), the oropharynx (5–15 %) and the conjunctiva. Gonorrhoea is the second most common pathogen causing PID and Fitz–Hugh–Curtis syndrome, with the attendant risk of long-term sequelae, as with Chlamydia. Gonorrhoea has been associated with miscarriage, premature labour and neonatal infection. In about 1 % of cases infection can spread haematogenously to the distant site, resulting in disseminated gonococcal infection with manifestations ranging from tendon/joint pain to meningitis or endocarditis.
References
Kieran E, Hay DP. Sexually transmitted infections. Curr Obstet Gynaecol. 2006;16:218–25.
SRH8
SRH8 Answer: C
Explanation
It is the most common STI in the UK. Between 3 % and 5 % of sexually active women attending UK general practices test positive for Chlamydia. Most women (80 %) are asymptomatic. If symptoms occur, this will generally be within 3 weeks of infection and comprise postcoital or intermenstrual bleeding, dysuria, lower abdominal pain and/or purulent vaginal discharge. The severity of the symptoms is variable. Approximately one-third of women will progress to ascending infection, presenting with PID. Even short delays in treatment of PID will markedly increase the risk of subsequent complications, which include infertility, ectopic pregnancy and chronic pelvic pain.
References
Kieran E, Hay DP. Sexually transmitted infections. Curr Obstet Gynaecol. 2006;16:218–25.
SRH9
SRH9 Answer: E
Explanation
A diagnosis of PID, and empirical antibiotic treatment, should be considered and usually offered in any young (under 25) sexually active woman who has recent onset, bilateral lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded. PID may be symptomatic or asymptomatic. Even when present, clinical symptoms and signs lack sensitivity and specificity (the positive predictive value of a clinical diagnosis is 65–90 % compared to laparoscopic diagnosis).
Testing for gonorrhoea and Chlamydia in the lower genital tract is recommended since a positive result supports the diagnosis of PID. The absence of infection at this site does not exclude PID however.
An elevated ESR or C-reactive protein also supports the diagnosis but is non-specific.
The absence of endocervical or vaginal pus cells has a good negative predictive value (95 %) for a diagnosis of PID, but their presence is non-specific (poor positive predictive value—17 %).
SRH10
SRH10 Answer: D
Explanation
Rifampicin-like drugs (e.g. rifampicin, rifabutin) are the only antibiotics that are enzyme inducers and that have consistently been shown to reduce serum levels of ethinyl estradiol. Pregnancies have also been reported following concomitant use of COC and a wide range of antimicrobial agents, including penicillins, tetracyclines, macrolides, fluoroquinolones and imidazole antifungal drugs, which are not enzyme inducers.
Women who do not wish to change from a combined method while on short-term treatment with an enzyme-inducing drug (and for 28 days after stopping treatment) may opt to continue using a COC containing at least 30 μg EE, the patch or ring together with additional contraception. An extended or tricycling regimen should be used with a hormone-free interval of 4 days. Additional contraception should be continued for 28 days after stopping the enzyme-inducing drug.
With the exception of the very potent enzyme inducers rifampicin and rifabutin, women who are on an enzyme-inducing drug and who do not wish to change from COC may increase the dose of COC to at least 50 μg EE (maximum 70 μg) and use an extended or tricycling regimen with a pill-free interval of 4 days.
SRH11
SRH11 Answer: A
Explanation
Progestogen-only injectable contraception containing DMPA works primarily by inhibiting ovulation. There is thickening of cervical mucus inhibiting sperm penetration into the upper reproductive tract. In addition, changes to the endometrium make it an unfavourable environment for implantation. Repeat injections of DMPA should be planned at 12-week intervals. The SPC suggests that DMPA can be given up to 12 weeks and 5 days since the last injection
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