CSA Revision Notes: For The

CSA REVISION NOTES FOR THE MRCGP Third Edition
CSA REVISION NOTES FOR THE MRCGP 3

3
This book helps you to revise and prepare for the CSA part of the MRCGP exam. The latest edition
features an additional four sections:
•• dietary advice for malnourished patients
•• ectopic pregnancy
•• patient refusing emergency management
CSA
•• wheeze in preschool children
A standardised format is used throughout to help you to improve your:
•• data gathering – a broad range of appropriate questions to ask the patient are provided and red
flags are highlighted where appropriate
•• interpersonal skills – each clinical problem is described using terms that you can use in your
explanations to patients
REVISION
•• clinical management – tells you which examinations to consider, which investigations to order,
and how to manage each clinical problem based on the latest guidelines and current best practice
•• consultations – to help you practise, every clinical case features a realistic role play scenario
Every clinical scenario in this latest edition has been updated and new appendices have been added
to cover domestic violence and discussions following an MI.
NOTES
Reviews of the earlier editions:
“Following the glowing reviews of this book I bought “This is an excellent aid to preparing for the CSA exam.
it for my CSA preparation. It is a very well written book I particularly like the scenarios given for role play
and a good resource for the CSA. I like the layout with that facilitate practising with a study partner. I would
different case scenarios presented in the CSA style.... I recommend it for GP registrars, VTS groups and GP
FOR THE
like the open questions and focused questions for each trainers.”
scenario and the role play idea at the end of each case
“ This book is brilliant ... I really like the ‘explanation
scenario. Interestingly this is the recommended read
to patient’ bits that remind you what the English
from our VTS programme.”
interpretation is rather than the medical jargon some
“This book is a must have for GP trainees revising for the of which you forget over the years.”
CSA. It is cleverly structured into problems that patients
“Excellent resource for MRCGP prep. Nice layout. Simple.
present with and covers all the areas which will be
Easy to read leading up to the exam when you want to
required for you in the CSA.”
quickly cover the curriculum.”
STANNET T / OSMOND
“Must buy for the CSA. Used it to brush up on my
“Still use it now a year on. Handy bite sized knowledge
knowledge and it worked for the exam! A great book
and simple but realistic cases.”
for future reference.”
www.scionpublishing.com
ISBN 978-1-907-90484-4
9 781907 904844
Jennifer Stannett and Sarah Osmond

CSA
REVISION
NOTES
FOR THE
MRCGP
00_CSA_Revision_Front 3rd edn-cpp.indd 1 15/11/2016 14:44

ALSO OF INTEREST
For more details see www.scionpublishing.com

Third Edition
CSA
REVISION
NOTES
FOR THE
MRCGP
Jennifer Stannett
BSc (Hons), MBChB, MRCGP, MRCPCH, DRCOG, DFSRH
GP in Bath
Sarah Osmond
MBChB, FRNZCGP
GP in Dumfriesshire

© Scion Publishing Limited, 2016
ISBN 978 1 907904 84 4
Third edition first published 2016
Second edition (ISBN 978 1 907904 07 3) published 2013
First edition published 2011
All rights reserved. No part of this book may be reproduced or transmitted, in any form
or by any means, without permission.
A CIP catalogue record for this book is available from the British Library.
Scion Publishing Limited

The Old Hayloft, Vantage Business Park, Bloxham Road, Banbury OX16 9UX, UK
www.scionpublishing.com
Important Note from the Publisher

The information contained within this book was obtained by Scion Publishing Ltd from
sources believed by us to be reliable. However, while every effort has been made to
ensure its accuracy, no responsibility for loss or injury whatsoever occasioned to any
person acting or refraining from action as a result of information contained herein can
be accepted by the authors or publishers.
Readers are reminded that medicine is a constantly evolving science and while the
authors and publishers have ensured that all dosages, applications and practices are
based on current indications, there may be specific practices which differ between
communities. You should always follow the guidelines laid down by the manufacturers
of specific products and the relevant authorities in the country in which you are
practising.
Although every effort has been made to ensure that all owners of copyright material
have been acknowledged in this publication, we would be pleased to acknowledge in
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Registered names, trademarks, etc. used in this book, even when not marked as such,
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Typeset by Phoenix Photosetting, Chatham, Kent, UK

Printed in the UK

Contents
Preface to the third edition ix
About the author x
Acknowledgements x
Preface xi
Abbreviations xiii
Introduction to the CSA examination 1

Format of the examination 1
Marking scheme 2
Tips for success 6
General practice consultation 9

Telephone consultation 9
Home visit 10
Angry patient 11
Breaking bad news 12
Patient with learning disabilities 14
Patient with hearing impairment 15
Patient refusing emergency management/hospital admission 16
Healthy people: promoting health and preventing disease 19

Hypercholesterolaemia 19
Hypertension 21
Obesity 23
Smoking cessation 25
Dietary advice for malnourished patients 27
Genetics in primary care 31

Antenatal screening for Down syndrome 31
Screening for sickle cell disease 33
Cystic fibrosis 34
Care of acutely ill people 37

Suicidal patient 37
Chest pain 39
Meningitis 40
Head injury 42
Ectopic pregnancyl 44
Child health 47
Nocturnal enuresis 47
Childhood constipation 49

Contents
Attention deficit hyperactivity disorder 51

Diarrhoea and vomiting 53
Wheeze in preschool children (1–5 years) 54
Care of older adults 57

Dementia 57
Falls 59
Women’s health 63
Menorrhagia 63
Amenorrhoea 64
Premenstrual syndrome 67
Polycystic ovary syndrome 68
Fibroids 71
Antenatal check 73
Urinary incontinence 76
Cervical screening 78
Infertility 79
Menopause 82
Men’s health 85
Haematuria 85
Benign prostatic hyperplasia 86
Prostate cancer 89
PSA testing 91
Testicular cancer 91
Erectile dysfunction 93
Testicular conditions 95
Vasectomy 96
Sexual health 99
Chlamydia 99
Pelvic inflammatory disease 101
Emergency contraception 102
Combined oral contraceptive pill 104
Termination of pregnancy 107
Care and palliative care of people with cancer 111

Palliative care and pain management 111
Mental health 115

Anxiety 115
Depression 117
Sleep disorders 119
Deliberate self harm 120
Post-traumatic stress disorder 122
vi

Contents
Cardiovascular125
Angina pectoris 125
Peripheral vascular disease 127
Palpitations 129
Respiratory131
Asthma 131
Chronic obstructive pulmonary disease 133
Gastrointestinal and renal 137

Dyspepsia 137
Rectal bleeding 139
Anaemia 140
Coeliac disease 142
Irritable bowel syndrome 144
Gallstones 146
Chronic kidney disease 148
ENT151
Sore throat 151
Labyrinthitis 153
Hearing loss 154
Tinnitus 156
Obstructive sleep apnoea 158
Ophthalmology161
Red eye 161
Neurology165
Headache 165
Migraine 167
Collapse and seizures 169
Multiple sclerosis 171
Parkinson’s disease 172
Temporal arteritis 174
Transient ischaemic attack 176
Rheumatology and musculoskeletal 179

Back pain 179
Shoulder pain 181
Knee pain 183
Osteoarthritis 186
Osteoporosis 188
Rheumatoid arthritis 190
Polymyalgia rheumatica 192
Tennis elbow 194
Carpal tunnel syndrome 195
vii

Contents
Dermatology199
Eczema 199
Psoriasis 201
Acne 203
Endocrinology205
Diabetes 205
Hypothyroidism 207
Hyperthyroidism 209
Tired all the time 210
Chronic fatigue syndrome 212
Drug and alcohol problems 215

Alcohol abuse 215
Opiate addiction 217
Appendices
Appendix 1 – Clinical examinations 221
Appendix 2 – Sexual history taking 225
Appendix 3 – Mental state examination 226
– Abbreviated mental state examination 226
– Mental Capacity Act assessment 227
– The General Practitioner assessment of cognition
(GPCOG) 228
Appendix 4 – Driving and DVLA guidelines 230
Appendix 5 – When to suspect child maltreatment 233
Appendix 6 – Discussion following myocardial infarction 236
Appendix 7 – Domestic violence 237
viii

Preface to the third edition
This new updated edition is the result of both your helpful feedback and many hours
spent researching the latest clinical evidence and national guidelines.
I am delighted that the previous editions have helped so many candidates in their
exam preparation. I have therefore kept the basic format of the book the same. I
have added a few new topics, which I felt would be useful to the reader, and updated
existing topics.
The examination chapter has been updated as there have been many changes since
the last edition.
As with the previous edition, I would encourage readers to use this book like a revision
workbook in combination with seeing plenty of patients in the GP surgery.
I wish you the best of luck with the CSA exam and every success in general practice!
Jennifer Stannett
April 2016
ix

Acknowledgements
About the authors

Jennifer Stannett gained a biomedical sciences degree from the University of
Manchester before studying medicine at Leicester–Warwick Medical School. She spent
two years working in paediatrics before completing vocational GP training in London.
After spending a year travelling the world, she now works as a GP partner in Bath.
Sarah Osmond studied medicine at the University of Edinburgh. She then spent five
years working in New Zealand where she completed her GP training. She now works
as a GP partner in Dumfriesshire, Scotland.
Acknowledgements
I would like to thank Paul Dakin, my former GP trainer, for his help, advice and
inspiration to get involved in medical writing.
I would also like to thank my sister, Sarah, for her helpful comments and feedback, and
my mum for her help with the book illustrations.
Most importantly thanks to my parents and husband Jerime for being so supportive
over the years and helping me to reach my goals.

Preface to the first edition
This book provides a summary of clinical cases which could be tested in the CSA exam,
divided up into topics based on the MRCGP syllabus.
It aims to help prepare candidates for the CSA exam by providing a basic structure for
consulting, focusing on the three key areas of data gathering, clinical management
and interpersonal skills. The information is displayed in a concise manner in order to
provide a quick reference guide for the candidate. It does not contain detailed clinical
information. In the data gathering section, the most important aspects of history
taking have been included and usually, but not always, cover history of the presenting
complaint, past medical history, drug history, family history, and social history. Red
flags have also been highlighted, where relevant, to act as a prompt to the reader to ask
these important questions. Example questions have been included and these could be
asked to explore the patient’s ideas, concerns and expectations. I would also encourage
you to think of your own alternative questions which you may also ask in the exam.
In the clinical management section I have included possible investigation and

management options based on the latest UK guidelines. Not all options will be
appropriate in every case, so it is important for the reader to consider each case
individually.
Every case includes an explanation to the patient, which I hope will help the reader
to think about how they would discuss each condition with the patient in jargon-free
terms.
At the end of each case there is a role play scenario which can be practised in small
groups or with a study partner. The information given to the doctor is similar to that
which you will encounter in the CSA. The role player’s brief should not be read by the
doctor and so I suggest that the role player reads their information first and covers up
the information (a Post-it note is ideal) before showing the doctor their information.
Alternatively, the role player can read the brief to the doctor. The brief for the role
player has deliberately been kept quite short in order to make it quick and easy to
read, and the information in bold is that which should only be offered if asked about
specifically by the doctor. Other clinical details can be added by the role player if
necessary. The examination findings included in some cases can be given to the doctor
if specifically requested, or alternatively they provide a good opportunity to practise
these clinical examinations.
After completing each case in this book, it is important to reflect on how well you did
in the role play scenario, and how you might improve your performance. It may be
useful to ask the role player for their feedback. To make the most of the book, the role
play scenarios should be practised under exam conditions. If working with a study
partner, you could discuss each case in turn, teasing out various issues and then
practising the scenarios again, trying out different techniques and consultation styles.
xi

Preface
An explanation of the marking scheme and tips for success can be found in the first
chapter, and the book concludes with appendices summarising the different clinical
examinations which you could be expected to perform.
I would encourage readers to use this book like a workbook, gradually working
through each clinical topic, and annotating it with your own aides-memoire to
facilitate your learning. In the weeks leading up to the exam the book should be used
in combination with lots of real patient consultations in the GP surgery. Together these
will ensure that you go into the exam well prepared and confident.
Good luck!
Jennifer Stannett
December 2010
xii

Abbreviations
A&E Accident and emergency DVT Deep vein thrombosis
department ECG Electrocardiogram
ACE Angiotension converting enzyme ENT Ear, nose and throat
ACR Albumin creatinine ratio ESR Erythrocyte sedimentation rate
ADHD Attention deficit hyperactivity FBC Full blood count
disorder FEV1 Forced expiratory volume in 1
AF Atrial fibrillation second
AFP Alpha fetoprotein FH Family history
ALP Alkaline phosphatase FP10 Blank prescription
AMSE Abbreviated mental state FSH Follicle stimulating hormone
examination FVC Forced vital capacity
BMI Body mass index GFR Glomerular filtration rate
BNF British National Formulary GGT Gamma glutamyl transferase
BP Blood pressure GI Gastrointestinal
CBT Cognitive behavioural therapy GMC General Medical Council
CF Cystic fibrosis GnRH Gonadotrophin releasing hormone
CHD Coronary heart disease GORD Gastro-oesophageal reflux disease
CK Creatine kinase GTN Glyceryl trinitrate
CKD Chronic kidney disease GU Genito-urinary
CKS Clinical Knowledge Summaries Hb Haemoglobin
COCP Combined oral contraceptive pill HbA1C Glycosylated haemoglobin
COPD Chronic obstructive pulmonary hCG Human chorionic gonadotrophin
disease HDL High density lipoprotein
CPAP Continuous positive airways HONK Hyperosmolar non-ketosis
pressure HPC History of presenting complaint
CRP C-reactive protein HRT Hormone replacement therapy
CRT Capillary refill time IBD Inflammatory bowel disease
CT Computerised tomography IBS Irritable bowel syndrome
CVD Cardiovascular disease ICE Ideas, concerns and expectations
CVS Cardiovascular system ICP Intracranial pressure
CXR Chest X-ray IDDM Insulin-dependent diabetes
D&V Diarrhoea and vomiting mellitus
DEXA Dual energy X-ray absorptiometry IMB Intermenstrual bleeding
DH Drug history IRT Immuno-reactive trypsinogen
DKA Diabetic ketoacidosis IUCD Intra-uterine contraceptive device
DM Diabetes mellitus ITU Intensive Therapy Unit
DoH Department of Health IUD Intra-uterine device
DRE Digital rectal examination IVDU Intravenous drug user
DSH Deliberate self harm LABA Long acting beta agonist
DVLA Driver and Vehicle Licensing LDH Lactate dehydrogenase
Agency LDL Low density lipoprotein
xiii

Abbreviations
LFTs Liver function tests PPI Proton pump inhibitor

LMP Last menstrual period PR Per rectum (rectally)
LNG-IUS Levonorgestrel intra-uterine PRN As required
system PSA Prostate specific antigen
LVF Left ventricular failure PTSD Post-traumatic stress disorder
MC&S Microscopy, culture and PV Per vaginum (vaginally)
sensitivities PVD Peripheral vascular disease
MED3 Fit for work certificate QDS Quarter die sumendus (to be taken
MI Myocardial infarction four times a day)
MMSE Mini mental state examination RA Rheumatoid arthritis
MRI Magnetic resonance imaging RhF Rheumatoid factor
MSU Mid-stream urine RICE Rest, ice, compression, elevation
NAAT Nucleic acid amplification test ROM Range of movement
NAD No abnormalities detected RR Respiratory rate
NG Naso-gastric RUQ Right upper quadrant
NICE National Institute for Health and SC Sub-cutaneously
Clinical Excellence SE Side effect
NIDDM Non-insulin dependent diabetes SH Social history
mellitus SHBG Sex hormone binding globulin
NSAID Non-steroidal anti-inflammatory SL Sublingual
drug SOB Shortness of breath
NTDs Neural tube defects SSRI Selective serotonin re-uptake
OA Osteoarthritis inhibitor
OD Omni die (once daily) STI Sexually transmitted infection
O/E On examination SVT Supraventricular tachycardia
ON Omni nocte (every night) T3 Triiodothyronine
ONS Office of National Statistics T4 Thyroxine
OSAS Obstructive sleep apnoea TCC Transitional cell carcinoma
syndrome TDS Ter die sumendus (to be taken three
PALS Patient Advice and Liaison Service times a day)
PAPP-A Pregnancy-associated plasma TFTs Thyroid function tests
protein A TIA Transient ischaemic attack
PCB Post-coital bleeding TOP Termination of pregnancy
PCOS Polycystic ovarian syndrome TSH Thyroid stimulating hormone
PE Pulmonary embolus U&Es Urea and electrolytes
PEFR Peak expiratory flow rate UI Urinary incontinence
PHQ Patient health questionnaire UPSI Unprotected sexual intercourse
PID Pelvic inflammatory disease USS Ultrasound scan
PMB Post-menopausal bleeding UTI Urinary tract infection
PMR Polymyalgia rheumatica VT Ventricular tachycardia
PMS Pre-menstrual syndrome VTE Venous thromboembolism
PO Per os (orally) 2WW Two week wait
xiv

Women’s health
Menorrhagia
11 Heavy periods, often defined as blood loss >80 mls.
11 Cause is often not known, and this is referred to as ‘dysfunctional uterine bleeding’.
11 Other causes include fibroids, endometriosis, IUD in situ or hypothyroidism.
11 Management includes LNG-IUS, tranexamic acid, COCP or surgical options.
Data gathering
Open question
11 “Can you tell me more about the heavy periods that you’ve been experiencing?”
Focused/closed questions
HPC: “When did the heavy periods first start?”
“Was the heavy bleeding sudden in onset?” (red flag)
“How many times do you change pads/tampons in a typical day?”
“Do you get any clots in the blood or any flooding?”
“Are your periods more painful than usual?”
“Do you get any abdominal pain or abdominal bloating?”
“Are your periods regular? When was your last menstrual period?”
“Do you get any bleeding in between your periods or after sex?” (red flag)
“Are you using any contraception at present? If so,what?”
“When was your last smear test?”
“Any abnormal discharge or risks of any sexually transmitted infections?”
PMH: Any other medical conditions? Any previous gynaecological
surgery? Any previous pregnancies?
DH: “Are you on any regular medications?” (specifically enquire about
aspirin and anticoagulants)
FH: Any conditions that run in the family? Any bleeding disorders?
ICE: “Do you have any thoughts as to what might be causing the heavy
bleeding?”
“How is this problem affecting your day to day life?”
Examination: • Abdominal/pelvic examination (red flags include pelvic mass and
features of PID).
• Speculum examination (take swabs if infection is suspected).
N.B. Offer chaperone.
63

Amenorrhoea
Clinical management
Investigations
11 Blood tests – FBC, TFTs (only if symptomatic) , clotting screen (if suggestive
features in the history).
11 Vaginal/endocervical swabs for MC&S and STI screen (if at risk).
11 Ultrasound scan of pelvis (if concerned about structural abnormality).
Explanation to patient
11 Heavy periods often occur because the amount of a chemical called prostaglandin
is increased in the lining of the womb.
11 It can also be caused by fibroids (benign growths in the womb), endometriosis
(endometrial tissue grows outside the womb) or a hormonal problem.
Management
11 Menstrual diary.
11 LNG-IUS (Mirena) – reduces heavy menstrual bleeding (NICE first line).
11 Consider urgent referral to gynaecology if suspicious mass is detected.
11 Medications – tranexamic acid, COCP, norethisterone.
11 Safety net – to see GP if problem not improving.
11 Surgery – endometrial ablation, hysterectomy.
Role play
Information for doctor Additional information for role player
Patient: Ms JE PC: “I have been getting very heavy periods for the
Age: 26 years past 6 months”
SH: PhD student, lives with partner HPC: Period lasts 7 days. Changing tampons approx
PMH: migraine every 3 hours. Has clots. No flooding. Regular
DH: Nil periods (LMP 2 weeks ago). Also gets quite
FH: Nil severe abdominal pain during periods. No
Information: You are a GP Registrar. discharge. No IMB/PCB. Has copper IUD in
situ (fitted 8 months ago).
ICE: Would like some medication to help reduce
the heavy bleeding. Also keen to know what is
causing it.
O/E: Abdominal examination – lower abdominal
tenderness. Slight tenderness on PV
examination.
Amenorrhoea
11 Absence or cessation of menses, either classified as primary amenorrhoea (menses
not occurring by the time of expected menarche) or secondary amenorrhoea
(absence of menstruation for at least 6 consecutive months in women with
previously normal and regular menses).
11 Causes of primary amenorrhoea include constitutional delay, genito-urinary
malformation, Turner syndrome and testicular feminisation.
64

Women’s health
11 Causes of secondary amenorrhoea include hypothalamic failure, pregnancy and

lactation, premature ovarian failure, weight loss, polycystic ovarian syndrome and
depot or implant contraception.
Data gathering
Open question
11 “Can you tell me more about the problem with your periods?”
HPC: “Have you ever had periods? If so, when was your last menstrual period?”
“At what age did you start having periods (if secondary amenorrhoea)?”
“Is there any chance you could be pregnant?” “Are you sexually active
at present?” “What are you currently using for contraception?” (if
relevant)
“Have there been any recent change in your weight or any increase in
exercise?”
“Have you been more stressed than usual recently?”
“Have you noticed any changes to your skin or hair?”
“Any lower abdominal pain?” (haematocolpos)
“Any hot flushes or vaginal dryness?” (menopause/premature ovarian
failure)
“Have you ever had problems trying to get pregnant?”
“Any headache, problems with your vision or leakage of milk from your
breasts?” (red flags)
PMH: Any medical conditions? PCOS? Thyroid problems? Depression?
Eating disorders? Previous surgery?
DH: “Do you take any regular medications?” Any hormonal
contraceptives? Antipsychotics? Previous radiotherapy or
chemotherapy? Steroids?
FH: Any family history of menstrual problems? “When did your mother
and sister(s) start their periods?”
Any family history of stopping periods before 40 years of age?
SH: Occupation/Studying? Stress? Who lives with you at home? Any
problems? Illicit drug use, e.g. cocaine or opiates?
ICE: “Do you have any thoughts as to why your periods might have stopped?”
Examination
(based on NHS CKS, 2014, Amenorrhoea – management):
• BMI, BP.
• Examine for secondary sexual characteristics, e.g. Tanner Stages
(N.B. no intimate examinations in the CSA).
• Examine for hirsutism, clitoromegaly, galactorrhoea and
haematocolpos (if appropriate from history).
• Thyroid examination (if appropriate from history).
• Visual fields/fundoscopy (if pituitary tumour suspected).
• Cranial nerve examination.
• Pelvic examination – only in older women if appropriate.
65

Amenorrhoea
Clinical management
Investigations
11 Pregnancy test.
11 Blood tests – serum LH, FSH, prolactin, glucose, TSH, testosterone, SHBG.
11 Pelvic ultrasound scan.
11 If suspecting a prolactinoma refer to secondary care for an MRI of the brain.
11 Amenorrhoea is the absence of menstrual periods in a woman of reproductive age.
11 There may be a normal physiological explanation, for example, before puberty or
due to pregnancy, breast-feeding or menopause, or it may be due to contraception,
surgery or due to a medical condition.
Management
(based on NHS CKS, 2014, Amenorrhoea – management)
Primary amenorrhoea
11 Refer to a specialist any female who has not started menstruating by 14 years of age
and has no secondary sexual characteristics, or females with normal secondary
sexual characteristics who have not started menstruating by 16 years of age.
Secondary amenorrhoea
11 Treat the underlying cause once the diagnosis is confirmed, e.g. counselling if
stress induced or stopping any causative drugs.
11 Refer to a specialist if the cause cannot be established or if treatment in secondary
care is required.
11 The following conditions can usually be managed in primary care – PCOS,
menopause and amenorrhoea due to weight loss, stress or exercise.
11 Manage the risk of osteoporosis.
11 Safety net – if not resolving to return to GP.
Role play
Patient: Ms SL PC: “I have not had a period for the past 8 months”.
Age: 17 years HPC: Previously had periods. Started menstruating
SH: College student, lives with parents. aged 12 years. Also increased facial hair. No
Non-smoker. No alcohol or illicit drug skin changes. No headache or visual problems.
use. 6 kg weight gain in past 6 months. Sexually
PMH: Acne active – uses condoms. No abdo pain. No milk
DH: Nil leakage from breasts. Recent stress due to
Information:
Consultation with locum GP 2 weeks exams.
ago – tiredness, weight gain. TFTs FH: No menstrual problems.
checked and normal. BMI 34. You are ICE: Worried about being pregnant. Hoping for a
a GP partner. pregnancy test.
O/E: Pregnancy test – negative. Evidence of
hirsutism.
66

Women’s health
Premenstrual syndrome
11 Condition in which women experience certain symptoms each month before their
menstrual period.
11 Most commonly affects women aged between 30 and 40 years.
11 Symptoms may be physical (e.g. breast tenderness, bloating, headaches) and/or
psychological (e.g. tension, irritability, low mood, loss of libido).
11 Treatments include SSRIs, COCP or CBT.
Data gathering
Open question
11 “Can you describe the symptoms you experience prior to your period?”
HPC: “Do you suffer with any breast tenderness, bloating or headaches prior
to your period?”
“Do you experience any mood changes prior to your period?”
“Have you noticed any changes to your sex drive?”
“How long have you been experiencing these symptoms?”
“How long do they last for each time?”
“When in your cycle do you experience these symptoms?”
“Have you tried anything so far to relieve the symptoms?”
“Are you using any hormonal contraceptives?”
PMH: Any history of depression or any other medical conditions?
DH: “Do you take any regular medications?”
FH: Any family history of PMS?
SH: Occupation? Who lives with you at home? Smoking/alcohol/illicit
drug history?
ICE: “How have the symptoms been affecting your day to day life?”
Examination: • Nothing specific.
Clinical management
Investigations
11 Symptom diary (for two or three cycles and then review the woman with the diary).
11 PMS is quite a common problem, although it is only bad enough to affect daily life
in about 1 in 20 women.
11 There is no test for PMS and it is diagnosed purely on the symptoms described.
11 The cause is not known, although ovulation with the release of an egg appears to
trigger symptoms.
67

Polycystic ovary syndrome
Management
(based on NICE, 2014, CKS: Premenstrual syndrome. )
11 General advice about exercise, diet, stopping smoking, reducing alcohol intake,
regular sleep, and stress reduction.
11 Medications, e.g. new generation COC for moderate PMS, NSAIDs if pain is
predominant problem or SSRI if severe PMS.
11 Complementary therapy may be beneficial but studies are limited, e.g. reflexology,
evening primrose oil, vitamin B6 from day 14 to menses,, magnesium, calcium and
agnus castus.
11 CBT.
11 Information leaflet.
11 Safety net – refer to gynaecologist when simple measures have been explored but
have failed.
Role play
Patient: Ms TB PC: “I have terrible mood swings around the time of
Age: 21 years my period”.
SH: University student. Lives in shared HPC: “Something needs to be done because I got
student flat. Smokes 10 cigs/day. into trouble in a night club last weekend as I
Alcohol 30 units/week. got aggressive towards someone”. Also broke
FH: Nil up with boyfriend because of aggression/
PMH: Nil. No history of depression. mood. Gets occasional breast tenderness and
DH: Nil bloating. No headaches. Has had symptoms
Information:
You are a GP partner. Temporary for past year. Symptoms start 10 days before
patient. period.
ICE: Needs some medication to take around her
periods to help with mood.

11 Condition resulting in tiny cysts forming on the ovaries (at least 12 cysts).
11 Can result in abnormal periods, reduced fertility, excessive hair growth and acne.
11 Exact cause is unclear, but could be hereditary or linked to insulin resistance and/
or obesity.
11 Treatment depends on the symptoms, but includes weight loss, metformin and/or
hormonal contraception to regulate periods.
11 The figure on the next page shows how you could illustrate polycystic ovaries to
your patient.
68

Women’s health
Fallopian
tube
Cysts
Normal Developing
ovary egg
Uterus
Cervix
Vagina
Data gathering
Open questions
11 “What do you know about polycystic ovary syndrome?”
11 “Can you tell me more about your symptoms?”
HPC: “When was your last menstrual period?”
“Are your periods regular? Have there been any changes in your
periods recently?”
“Do you get any abdominal pain?”
“Have you noticed any skin changes or excessive hair growth?”
“Have there been any changes in your mood?”
“Have there been any changes in your weight?”
“Any problems trying to get pregnant?”
PMH: “Have you had any obstetric or gynaecological problems in the past?”
FH: Any family history of PCOS?
SH Smoking/alcohol/illicit drug history? Occupation? Stress?
ICE: “Was there anything in particular you were concerned about with
these symptoms?” (common concerns include fertility and self esteem
issues)
Examination: • BMI.
• BP.
• Examination for acne and hirsutism.
• Pelvic examination.
69

Clinical management
Investigations
11 Blood test – total and free testosterone, SHBG, free androgen index, prolactin, TSH*.
11 Glucose tolerance test – if symptoms suggestive of PCOS, obese or FH of diabetes.
11 Pregnancy test (if appropriate).
*LH and FSH are not routinely recommended for diagnosis of PCOS, but may help to
rule out other causes (RCOG, 2007, Green-top guideline 33: Long term consequences of
polycystic ovary syndrome).
11 PCOS is a condition which can affect a woman’s menstrual cycle, fertility,
hormones and aspects of her appearance. It can also affect long-term health.
11 Cysts develop on the ovaries which results in an imbalance of the hormones
produced by the ovaries.
11 The ovaries produce more testosterone which can result in excessive hair growth
and acne. The hormones released by the ovary are responsible for controlling the
menstrual cycle and so this can also be affected.
11 Some patients may no longer ovulate which will result in fertility problems.
Management
11 Lifestyle changes – weight loss, healthy balanced diet, exercise and smoking cessation.
11 Metformin (topic for debate but not recommended for initiation in primary care.
Recent RCTs have not shown metformin to reduce weight or restore menstrual
regularity in women with PCOS).
11 Co-cyprindiol (Dianette) – if symptoms of acne or hirsutism.
11 Other hormonal contraceptives to regulate periods.
11 Hirsutism – hair removal creams, electrolysis, laser treatment, or eflornithine.
11 Fertility problems – clomiphene can be beneficial but refer to gynaecology first.
11 Offer annual fasting glucose/HbA1c, fasting lipids and BP.
11 In pregnancy check GTT before 20 weeks’ gestation.
11 Safety net – refer to a specialist if the above measures are not improving symptoms.
Role play
Patient: Ms SS PC: “I have come today to get the results of my

Age: 23 years ultrasound scan”.
PMH: Nil HPC: LMP 8 months ago. Has noticed increased facial
DH: Nil hair. No skin changes. No abdominal pain and
SH: Non-smoker. Waitress. no mood changes. No other gynaecological
Information:
Saw locum GP 1 month ago due symptoms. Never tried to conceive.
to secondary amenorrhoea and FH: Sister has PCOS.
hirsutism. USS of pelvis confirms ICE: Thinks that she might also have PCOS. Would like
polycystic ovaries. You are a GP medication to get rid of the increased facial hair.
Registrar. O/E: BMI – 34. BP 130/70. Abdo exam – mild lower
abdominal tenderness. No masses.
70

Women’s health
Fibroids
11 Benign growths in the uterus.
11 Very common, affecting at least 1 in 4 women in their lifetime.
11 Commonest in the 30–50 year age group and in Afro–Caribbean women.
11 Symptoms only occur in about one-third of women with fibroids.
11 Can be treated with medication, LNG-IUS or with surgery.
11 The figure below shows how you could illustrate fibroids to your patient.
Pedunculated submucosal fibroid
Pedunculated subserosal fibroid
Intermural fibroid
Data gathering
Open questions
11 “Can you tell me more about your symptoms?”
11 “The recent ultrasound scan you had has confirmed fibroids: what do you know
about fibroids?”
Closed/focused questions
HPC: “Are your periods regular?”
“Are your periods heavier than usual?”
“Any bleeding in between your periods or after sex?” (red flags)
“Have you noticed any abdominal pain or swelling?”
“Have you experienced any back pain?”
“Have you experienced any pain during sexual intercourse?”
71

Fibroids
“Do you have any urinary symptoms?”

“Has there been any weight loss?” (red flag)
FH: Any family history of fibroids?
SH: Smoking/alcohol/illicit drug history? Occupation?
ICE: “What were you hoping we could do to help with your symptoms?”
Examination: • Abdominal examination.
• Vaginal examination.
• Speculum examination – to rule out other causes, e.g. cervical
pathology, STI.
Clinical management
Investigations
11 FBC – if concerned about anaemia.
11 Hysteroscopy or laparoscopy – in secondary care.
11 Fibroids are non-cancerous growths which form in the womb, usually as a result of
an overgrowth of smooth muscle cells.
11 They can cause symptoms such as heavy bleeding, abdominal swelling and urinary
problems.
11 They can increase or decrease in size with time. During pregnancy they often
increase in size due to the increased level of a hormone called oestrogen.
Management
11 Observation and safety net – if symptoms not improving return to GP.
11 Medication – tranexamic acid, NSAIDs, COCP, GnRH analogue to shrink the fibroids.
11 LNG-IUS (Mirena) – can be difficult to insert into uterus when fibroids present.
11 Referral to secondary care if fibroids are large (>3 cm) or if symptoms not
improving despite medication. Further treatment options include endometrial
ablation, uterine artery embolisation, hysterectomy, and myomectomy.
Role play
Patient: Mrs JS PC: “I was asked to come in to discuss the results of
Age: 34 years my pelvic ultrasound scan”.
PMH: Nil. No previous pregnancies. HPC: Lower abdominal pain for the past couple of
DH: Ibuprofen 400 mg TDS/PRN months. Also heavy periods. LMP 2 weeks ago.
SH: Non-smoker, no alcohol intake. Regular periods. No urinary symptoms. No
Teacher. abdominal swelling. No weight loss.
Information:
Recently seen by locum GP due to ICE: Worried she might have cancer.
abdominal pain and menorrhagia. O/E: Lower abdominal tenderness. Abdomen soft.
Results of pelvic USS – numerous No masses palpable. PV exam – slightly bulky
fibroids visible in endometrium. uterus.
Largest 5 cm × 4 cm diameter. You are
a GP partner.
72

Women’s health
Antenatal check
11 All pregnant women in the UK are offered a series of antenatal appointments
during their pregnancy.
11 In the case of an uncomplicated pregnancy, this care should be provided by
midwives and GPs (NICE, 2008, CG62: Antenatal care).
11 In an uncomplicated pregnancy, nulliparous women are offered 10 antenatal
appointments, and parous women are offered 7 appointments.
11 The first booking appointment is around 10–12 weeks.
11 The antenatal checks include weight, blood pressure, urine dipstick for protein,
glucose and leucocytes, and blood tests for blood group, rhesus group and infections.
11 The growth of the baby is checked using symphysis–fundal height (SFH), and the
position of the baby is also checked in the later stages of pregnancy.
11 Ultrasound scans are carried out at 12 and 20 weeks gestation, and screening tests
for Down syndrome, sickle cell diseases and thalassaemias are also offered.
11 Some women require additional care during pregnancy, including those with
cardiac conditions, insulin dependent diabetes, epilepsy or if BMI <18 or >30.
Data gathering
Open question
11 “How is the pregnancy going so far?”
“When is your expected date of delivery?”
“Are you getting any abdominal pains?” (red flag)
“Have you noticed any vaginal bleeding?” (red flag)
“Have you felt any kicks or the baby moving?” (only relevant from
approximately 20 weeks gestation)
“Do you have any ankle swelling?” (mainly occurs in the latter stages
of pregnancy)
“Any history or concerns of domestic violence in the household?” (red flag ;
see Appendix 7)
PMH: “Do you suffer from any medical conditions?” “Any previous
pregnancies?” “Any previous pregnancy complications?” “Any previous
gynaecological problems?” “Any mental health problems?” (red flag)
FH: “Any medical conditions which run in the family?”
DH: Do you take any regular medications?
“Have you been taking folic acid?”
SH: Who lives with you at home? Support? Occupation? Smoking/
alcohol/illicit drug history?
ICE: “Do you have any concerns about the pregnancy?”
Examination: • See clinical management.
73

Antenatal check
Clinical management
(based on NICE, 2008, CG62: Antenatal care)
First contact with a healthcare professional

11 Provide information on folic acid supplements, lifestyle advice and antenatal
screening.
Lifestyle advice
11 Smoking cessation – nicotine replacement therapy can be used in pregnancy.
11 Alcohol consumption – avoid alcohol in the first 3 months if at all possible. If
women choose to drink alcohol, drink no more than 1–2 units of alcohol once or
twice a week.
11 Folic acid supplement prior to conception until 12 weeks gestation – 400 mcg daily
(or 5 mg daily if your risk of having a child with a neural tube defect is increased,
e.g. coeliac disease, diabetes or if taking anti-convulsants).
11 Vitamin D supplements during pregnancy and breast-feeding if inadequate stores
– 10 mcg daily.
11 Dietary advice – avoid uncooked meat, fish and eggs (toxoplasmosis), liver (vitamin
A), soft cheeses and pâté (listeria) and unpasteurised milk. Restrict caffeine intake
to no more than 200 mg daily (2 mugs of instant coffee or tea).
11 Advise on which drugs to avoid, e.g. NSAIDs.
11 Exercise – encourage gentle exercise (avoid contact sports).
Management of nausea and morning sickness

11 Very common in the early weeks of pregnancy and can happen at any time of the
day (usually disappears around 12th to 14th week).
11 Try eating dry toast or a plain biscuit before getting up in the morning.
11 Eat small amounts often.
11 Drink plenty of fluids.
11 Avoid greasy and spicy foods.
11 Antihistamines, e.g. metoclopramide.
11 Ginger and P6 acupressure may be beneficial.
11 Consider hyperemesis gravidarum if persistent vomiting.
Booking appointment
11 Identify women who may need additional care.
11 Calculate BMI.
11 Measure BP and check urine for proteinuria and leucocytes.
11 Offer blood test for blood group, rhesus D status, FBC, haemoglobinopathies, Hep
B, HIV, rubella immunity and syphilis.
11 Offer screening for Down syndrome.
11 Offer ultrasound scans for gestational age assessment at 12 weeks and to check for
any fetal anomalies at 20 weeks.
11 Inform women under 25 years about the national chlamydia screening programme.
74

Women’s health
11 Determine if any risk factors for gestational diabetes* or pre-eclampsia.

11 Inform women about maternity benefits available, e.g. free prescriptions and
dental care during pregnancy and 12 months after.
*Gestational diabetes
11 Risk factors include BMI >30, previous macrosomic baby weighing >4.5 kg,
previous gestational diabetes, family history of diabetes or a family origin with a
high incidence of diabetes.
11 The 2 hour 75 g oral glucose tolerance test (OGTT) should be offered to pregnant
women at risk at 24–28 weeks of gestation (or earlier if previous gestational
diabetes).
25 weeks (nulliparous women)

11 Measure BP and check urine for proteinuria.
11 Measure symphysis–fundal height (SFH).
28–34 weeks
11 Check SFH.
11 Offer further screening for anaemia.
11 Offer anti-D prophylaxis for those women who are rhesus D negative.
11 Discuss a birth plan.
36–38 weeks
11 Check position of baby, and refer for external cephalic version if breech.
11 Discuss breast-feeding and postnatal care.
41 weeks
11 If not yet given birth, refer for membrane sweep and induction of labour.
Travel
11 Wear car seat belts above and below bump rather than over it.
11 There is an increased risk of DVT if flying – wear compression hosiery for long haul
flights where possible.
11 Discuss vaccinations and travel insurance if travelling abroad.
11 Most airlines will not allow women to travel if >36 weeks pregnant (>32 weeks if
multiple pregnancies).
11 Airlines may require a certificate after 28 weeks stating the pregnancy is progressing
normally.
11 Most airlines will also not allow women to travel if history of premature delivery,
cervical incompetence or PV bleeding.
75

Urinary incontinence
Role play
Patient: Mrs SC HPC: Currently 30 weeks pregnant. Hasn’t felt baby

Age: 32 years moving for the past 24 hours. No vaginal
PMH: Nil bleeding or abdominal pain. First pregnancy.
SH: Married, Store manager. Non-smoker. 20 week scan – NAD.
No alcohol intake. ICE: A bit worried that she hasn’t felt fetal
DH: Pregnancy multivitamins movements.
FH: Nil O/E: BP 100/60. Urine dip – NAD . SFH 26 cm, no
Information:
Has appointment today for routine 30 fetal heart sounds heard.
week antenatal check. You are a GP
Registrar. Uncomplicated pregnancy
so far.
Urinary incontinence
11 Involuntary leakage of urine, estimated to affect about 3 million people in the UK.
11 Different types include stress, urge, mixed and overflow incontinence.
11 Management includes lifestyle changes, pelvic floor exercises, bladder training or
medication.
Data gathering
Open question
11 “Can you tell me more about the problems with your bladder?”
Closed/focused questions
HPC: “How often do you lose control of your bladder?” “Is it only when
coughing or sneezing, or does it occur at any time?”
“Are you incontinent in the day and night?”
“Have you tried any treatments so far?”
“Do you suffer with frequent urine infections?”
“Do you have any burning pain when you pass urine?”
“Have you noticed any blood in the urine or vaginal bleeding?” (red
flag)
“Have you noticed a lump coming down from your vagina?”
“Do you have any problems with your bowels?”
“How many cups of tea or coffee do you drink daily?” “Any other
caffeine intake?”
“How much do you drink in the evening?”
DH: Do you take any regular medications? Diuretics?
FH: Any family history of bladder problems? Any weight loss? (red flag)
SH: Smoking/alcohol/illicit drug history? Occupation?
76

Women’s health
PMH: Any previous operations? “Any previous obstetric problems or urinary

problems?”
ICE: “How is this problem impacting on your daily life?”
Examination: •
Abdominal examination – to check for masses and any
enlargement of bladder or kidneys.
• Digital rectal examination – in males to examine prostate.
• Sims speculum examination to check for vaginal prolapse.
Clinical management
Investigations
11 Urinalysis – blood, glucose, protein, leucocytes, nitrites.
11 Urodynamics (only after conservative management).
11 U&Es.
11 There are different types of urinary incontinence:
!! Stress incontinence occurs when the pressure in the bladder becomes too great
and urine leaks from the bladder outlet. This is often due to the pelvic floor
muscles being weak.
!! Urge incontinence is when you get an urgent desire to pass urine and are unable
to get to the toilet in time. It’s often due to a problem with the bladder muscles
sending wrong messages to the brain.
!! Mixed incontinence is a combination of stress and urge incontinence.
!! Overflow incontinence is due to an obstruction of the outflow of urine.
Management
(NICE, 2013, CG171: Urinary incontinence in women)
Stress incontinence
11 [followed by these bullet pts:]
11 Pelvic floor exercises are first line (8 contractions, 3x daily for minimum 3 months).
11 If not improving refer if patient wishes.
11 Duloxetine may be an option in women preferring to avoid surgery.
Urge incontinence
11 [followed by these bullet pts:]
11 Lifestyle advice – reduce caffeine, modify fluid intake, weight loss.
11 Bladder retraining.
11 Intravaginal oestrogen therapy may be beneficial in post-menopausal women.
11 Antimuscarinic drugs, e.g oxybutynin, solifenacin.
11 Mirabegron is the new medical option if antimuscarinics are not effective or not
tolerated (alternative is solifenacin).
11 Refer to secondary care for surgical management if conservative management hasn’t
helped or if there is a symptomatic prolapse visible at or below the vaginal introitus.
11 Urgently refer if microscopic haematuria and aged 50 years or over, visible
haematuria, suspected pelvic mass arising from the urinary tract or recurrent or
persistent UTI associated with haematuria in those aged 40 years or older.
77

Cervical screening
Role play
Patient: Mrs JW PC: Urinary incontinence

Age: 47 years HPC: Has urinary incontinence intermittently
SH: Married, has 3 children. Alcohol 10 for past 8 months but it is becoming more
units weekly. frequent (now daily). Occurs mainly after
PMH: Nil coughing, sneezing or exercise. No blood in
DH: Nil the urine. No abdominal pain. No pain when
Information:
No recent consultations. You are a GP passing urine. Not tried any treatments so
partner. far. Two urine infections in the past year. No
constipation or weight loss. Drinks 4 cups
of tea daily. No excessive fluid intake in
evening. No dragging sensation down below.
ICE: Has heard about surgery to help this problem
and is keen to find out more.
O/E: Abdo exam – NAD. Sims speculum exam –
small prolapse of posterior vaginal wall.
Cervical screening
11 Offered to all women aged between 25 and 65 in England and Northern Ireland
(20–65 years in Scotland and Wales).
11 The aim is to detect any pre-cancerous cells.
11 The screening is carried out 3-yearly from 20 or 25 years to 50 years and then
5-yearly until aged 65.
11 Risk factors for cervical cancer include HPV infection, smoking and
immunocompromised states such as HIV.
Data gathering
Open question
11 “What do you understand about an abnormal cervical smear result?”
HPC: “Have you had any irregular menstrual bleeding?”
“Have you had any bleeding in between your periods or after sex?” (red
flags)
“Any pain during sexual intercourse?” (red flag)
“Have you noticed any abnormal vaginal discharge?” If so, enquire
about colour, consistency and smell.
“Do you have any abdominal pain?”
“Have you recently noticed any weight loss?” (red flag)
78

Women’s health
“Any urinary symptoms?”

“Are you sexually active at present? If so, do you use condoms?”
“How many sexual partners have you had in the past 3 months?”
“Any past history of sexually transmitted infections?”
PMH: “Any previous abnormal cervical smear tests?”
DH: Current contraceptives?
FH: Any family history of breast cancer, cervical cancer or other
gynaecological cancers?
SH: “Do you smoke?” Who lives with you at home? Occupation?
ICE: “Did you have any specific concerns about your smear test result?”
Examination: • Liquid cervical smear test via speculum examination.
Clinical management
Investigations
11 Refer for colposcopy if moderate or severe dyskaryosis or two consecutive results
showing mild dyskaryosis.
11 Cells are gently scraped from the neck of the womb using a plastic brush.
11 These cells are then sent to the lab to be examined under a microscope.
11 If there are any abnormal cells seen, you may be referred for a colposcopy.
11 A colposcopy is a detailed examination of the cervix using an instrument called a
colposcope. It allows a more detailed view of any abnormal cells in the cervix, and a
further sample of tissue can be taken if necessary.
11 If the colposcopy reveals an abnormal result, you may need further treatment to
remove or destroy the abnormal cells in your cervix. This can be done using laser
treatment or by cutting out the affected area. If there are only mild changes in the
cervix, the abnormal cells may return to normal on their own.
Management
11 Smoking cessation.
11 Offer STI screening, if appropriate, and sexual health education.
11 Treatment for abnormal cells include cryotherapy, loop diathermy, laser treatment
or cold coagulation (organised by gynaecologist).
11 Safety net – review if symptoms worsen and arrange follow-up smear tests.
11 Information – www.cancerscreening.nhs.uk/cervical.
79

Infertility
Role play
Patient: Ms TS PC: “I was asked to come in to discuss my cervical

Age: 28 years smear results”
SH: Single, lives alone, smoker, 15 units HPC: Has had intermenstrual and some post-coital
alcohol/wk bleeding for past few months. No dyspareunia
FH: Mum has breast cancer. No abdo pain. No weight loss. LMP 1 week
Information:
Had smear test done 4 weeks ago. ago. No previous abnormal smear tests. Last
Results – moderate dyskaryosis. You smear test 3 years ago. No vaginal discharge.
are a GP Partner. Has been with current sexual partner for 3
months – having UPSI.
DH: Microgynon
PMH: Chlamydia infection 6 months ago.
ICE: Worried about why she was called to come
in. Worried that she might have cervical
cancer because of the symptoms.
Infertility
11 A woman of reproductive age who has not conceived after 1 year of unprotected
vaginal sexual intercourse, in the absence of any known cause of infertility, should
be offered further clinical assessment and investigation along with her partner
(NICE, 2013, CG156: Fertility problems).
11 Approximately 1 in 7 couples have difficulty conceiving.
Data gathering
Open question
11 “Can you tell me more about your problems trying to get pregnant?”
“For how long have you been trying to conceive?”
HPC:
“When was your last menstrual period?” “Are your periods
regular?”
“Have you noticed any bleeding in between your periods or after
intercourse?” (red flag)
“Do you have any abdominal pain?”
“How often are you having intercourse?”
“When did you stop using any contraception?”
“Have you ever been pregnant before?” “Any miscarriages or
terminations?”
“Has your partner had any children before?”
Take a full sexual history – see Appendix 2.
80

Women’s health
PMH: Any medical conditions? Any history of pelvic inflammatory disease,

endometriosis or ectopic pregnancy? Any previous gynaecological
surgery? Any history of depression? Any previous STIs? Any history of
mumps or testicular problems? ()
SH: Who lives with you at home? Occupation? Stress? Alcohol/smoking/
illicit drug history?
FH: Any family history of fertility problems?
DH: Do you take any regular medications? (teratogenic medications?)
Any over the counter medications?
ICE: “Do you have any thoughts as to why you are having difficulties
conceiving?”
Examination: • BMI, BP.
• Observe for hirsutism and acne (PCOS) .
• Vaginal and speculum examination.
• Abdominal examination.
• In males consider testicular examination.
Clinical management
Investigations
11 Blood tests – day 21 progesterone, serum LH and FSH (if irregular menstrual
cycle).
11 Semen analysis ().
11 Screen for chlamydia before undergoing any uterine instrumentation.
11 Rubella screening.
11 Pelvic ultrasound scan if indicated from history.
11 It is important to be reassured that 84% of all couples will conceive within 1 year if
they are aged under 40, do not use contraception and have regular intercourse.
11 There are various different reasons for fertility problems, some of which are
related to the man and some to the woman. Further tests can help to establish the
cause.
11 There are options to help which include advice about lifestyle changes, medications
and referral to a fertility specialist.
Management
(based on NICE, 2013, CG156: Fertility problems)
11 Lifestyle advice – smoking cessation, reduce alcohol and caffeine intake, healthy
diet, weight loss, exercise.
11 Sexual intercourse every 2–3 days optimises the chance of pregnancy.
11 Folic acid supplements.
11 Fertility support group.
11 Counselling.
11 Refer to fertility clinic for further investigations/management if not pregnant after 1
year despite above measures.
81

Menopause
!! Women with ovulation disorders such as PCOS should be offered clomifene

citrate as first line to induce ovulation.
!! Couples in which the woman is aged under 40 at the time of treatment, and who
have an identifiable cause for their fertility problems, or who have had infertility
for at least 2 years duration should be offered up to three stimulated cycles of
in vitro fertilisation. Unfortunately, due to financial pressures, one in five PCTs
have reduced the number of treatment cycles that they are able to offer.
Role play
Patient: Mrs KS PC: “I’ve been trying to get pregnant for the past 14
Age: 32 years months and have had no success”
PMH: Nil HPC: Never been pregnant before. Partner has
DH: Nil never had children. Having unprotected sex
Information:
No previous consultations. You are a 4¥ weekly. LMP 3 weeks ago. Regular periods.
GP Registrar. No abdominal pain. No abnormal vaginal
bleeding. No previous STIs.
SH: Married 3 years ago. Lives with husband and
husband’s sister. Accountant. Stressful job.
Non-smoker, 5 units alcohol/week. No illicit
drug use.
ICE: Worried about why she can’t conceive and
wants referral to fertility specialist.
O/E: BMI – 23. BP 110/70. Abdominal and vaginal
exam – NAD. No hirsutism or acne.
Menopause
11 Permanent cessation of ovarian function, typically occurring around the age of 50
years.
11 A woman has reached menopause when she has not had a period for 1 year if over
50 years or if no periods for 2 years in those under 50 years.
11 If menopause occurs under the age of 45 years it is known as premature menopause.
Data gathering
Open question
11 “Can you tell me more about the menopausal symptoms you have been
experiencing?”
“Have you noticed any changes to your periods?”
82

Women’s health
“Have you experienced any hot flushes, night sweats or headaches?”

“Have you noticed any mood changes, loss of sex drive or difficulty
sleeping?”
“Have you noticed any vaginal dryness?”
“Any abdominal pain or swelling of the abdomen?” (red flag)
“Any bleeding at least 1 year after your periods had stopped?” (red
flag)
“Any previous mammograms?” “What were the results?”
“Are you currently using any contraception and if so, what?”
FH: Any family history of premature menopause? Any family history of
osteoporosis?
SH: Smoking/alcohol/illicit drug history? Who lives with you at home?
Occupation?
ICE: “Are these symptoms affecting your day to day life?”
Examination: • BP, BMI.
• Breast examination.
Clinical management
Investigations
11 FSH – helpful in cases of premature menopause.
11 Pregnancy test – if relevant.
11 The menopause naturally occurs when the ovaries stop producing eggs and this
results in lower levels of the female hormone oestrogen.
11 Various symptoms can occur including mood changes, hot flushes and changes
to the vagina and genital skin. For some people these symptoms can be quite
debilitating, and treatment is required to help alleviate these symptoms.
Management
(based on NICE, 2015, NG23: Menopause: diagnosis and management)
11 Lifestyle changes – healthy diet, exercise.
11 HRT
!! Usually oestrogen/progesterone combined, or oestrogen only if previous
hysterectomy
!! Preparations include tablets, patches and gels
!! Different types include cyclical combined and continuous combined:
– cyclical combined is suitable for those still experiencing erratic menstrual
bleeding. Oestrogen is taken daily, and progesterone is added for the last
12–14 days of the cycle. You will continue to get monthly periods.
– continuous combined preparations are used once a woman has not had a
natural period for at least a year. It involves a daily dose of oestrogen and
progesterone and you will not get monthly bleeds.
83

Menopause
!! Benefits include reducing symptoms of hot flushes and may protect against
osteoporosis
!! Disadvantages include small increased risk of breast cancer, DVT and
endometrial cancer.
11 Tibolone – synthetic steroid hormone which helps with hot flushes, sweats and
vaginal dryness. Useful for women who cannot take oestrogen and has lower breast
cancer risk.
11 Clonidine – relieves hot flushes.
11 Topical oestrogens.
11 Vaginal lubricants
11 SSRIs – effective for hot flushes (not licensed).
11 Safety net – if no improvement in symptoms return to GP. Patients on HRT should
be followed up 3 months after starting treatment, and then 6–12 monthly thereafter.
Reviews should include BP, weight and breast examination.
Role play
Patient: Ms PO PC: Menopausal symptoms

Age: 54 years HPC: Experiencing bad hot flushes and some mood
SH: Lives alone, school teacher. Non- swings and vaginal dryness. LMP 8 months
smoker. ago. No bleeding since. Also has problems
PMH: Breast cancer sleeping. Last mammogram 9 months ago –
DH: Tamoxifen 20 mg OD NAD.
Information:
Last saw GP 1 month ago for FH: Breast cancer (sister).
medication review. You are a locum ICE: Would like to know what she could take to help
GP. with her menopausal symptoms.
O/E: BP 120/80, BMI 24. Breast exam – NAD.
84

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CSA REVISION NOTES FOR THE MRCGP Third Edition

CSA REVISION NOTES FOR THE MRCGP 3

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For more details see www.scionpublishing.com

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Important Note from the Publisher

Typeset by Phoenix Photosetting, Chatham, Kent, UK

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Introduction to the CSA examination 1

General practice consultation 9

Healthy people: promoting health and preventing disease 19

Genetics in primary care 31

Care of acutely ill people 37

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Attention deficit hyperactivity disorder 51

Care of older adults 57

Care and palliative care of people with cancer 111

Mental health 115

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Gastrointestinal and renal 137

Rheumatology and musculoskeletal 179

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Drug and alcohol problems 215

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About the authors

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In the clinical management section I have included possible investigation and

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LFTs Liver function tests PPI Proton pump inhibitor

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11 Causes of secondary amenorrhoea include hypothalamic failure, pregnancy and

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Polycystic ovary syndrome

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Patient: Ms SS PC: “I have come today to get the results of my

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Pedunculated submucosal fibroid

Pedunculated subserosal fibroid

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“Do you have any urinary symptoms?”

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First contact with a healthcare professional

Management of nausea and morning sickness

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Introduction to the CSA examination 1

General practice consultation 9

Healthy people: promoting health and preventing disease 19

Genetics in primary care 31

Care of acutely ill people 37

Attention deficit hyperactivity disorder 51

Care of older adults 57

Care and palliative care of people with cancer 111

Mental health 115

Gastrointestinal and renal 137

Rheumatology and musculoskeletal 179

Drug and alcohol problems 215

Patient: Ms SS PC: “I have come today to get the results of my

Patient: Mrs SC HPC: Currently 30 weeks pregnant. Hasn’t felt baby

PMH: Any previous operations? “Any previous obstetric problems or urinary

Patient: Ms TS PC: “I was asked to come in to discuss my cervical

PMH: Any medical conditions? Any history of pelvic inflammatory disease,