EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What additional history would you take to assess Emily’s concerns?

• Prompt: What key factors must be explored regarding vaginal discharge?
• Prompt: What information is important regarding her menstrual history?

Q2. What investigations would you order to assess Emily’s reproductive health?

• Prompt: What screening tests are appropriate based on her history?
• Prompt: When is further hormonal testing required?

Q3. Outline an initial management plan, including cervical screening and STI testing.

• Prompt: What preventive strategies would you recommend?
• Prompt: How would you discuss contraception and fertility concerns?

Q4. How would you educate Emily on her diagnosis and future reproductive health?

• Prompt: How would you address her concerns about fertility?
• Prompt: What lifestyle modifications could help with PCOS and reproductive health?

Q5. Emily’s vaginal swab returns positive for chlamydia. What are your next steps?

• Prompt: How would you manage the infection and follow-up?
• Prompt: What partner notification and public health measures are required?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What additional history would you take to assess Emily’s concerns?

A thorough history is essential to assess Emily’s reproductive health concerns, including vaginal discharge, irregular periods, and fertility concerns.

1. Vaginal Discharge Assessment:

• Onset, duration, and characteristics: Colour, consistency, odour, amount.
• Associated symptoms: Itching, burning, dysuria, dyspareunia.
• Exacerbating factors: Sexual activity, menstrual cycle, douching.
• Partner symptoms: Any history of STIs in her partner.

2. Menstrual and Reproductive Health:

• Cycle length and regularity: Frequency, duration, flow.
• Other symptoms: Heavy bleeding, clotting, dysmenorrhoea.
• History of abnormal cervical screening results.

3. Sexual and Contraceptive History:

• Number of partners, condom use consistency.
• Current and past contraceptive use, compliance with OCP.
• History of STIs (previous chlamydia infection).

4. Fertility and PCOS History:

• Ovulation symptoms (mid-cycle pain, cervical mucus changes).
• Concerns about future pregnancy, previous pregnancy attempts.

5. General Health and Lifestyle Factors:

• BMI, exercise habits, diet (impact on PCOS and hormonal balance).
• Psychosocial stressors, mood, sleep quality.

A structured history allows differentiation between physiological discharge, infection, hormonal imbalance, or pathology.

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Q2: What investigations would you order to assess Emily’s reproductive health?

Investigations should be guided by her symptoms, history, and risk factors.

1. Cervical and STI Screening:

• Cervical Screening Test (CST) – due after 5 years.
• High-Risk HPV testing (if indicated by CST).
• STI Screen (NAAT swabs for chlamydia/gonorrhoea, serology for HIV, syphilis, hepatitis B/C).

2. Vaginal Discharge Investigations:

• Microscopy, culture, and PCR for bacterial vaginosis (BV), candidiasis, and trichomoniasis.

3. Hormonal and Metabolic Screening (if PCOS assessment needed):

• Serum testosterone, LH, FSH, and prolactin.
• Fasting glucose and insulin resistance markers.
• Thyroid function tests (TFTs) to exclude hypothyroidism.

4. Fertility and Menstrual Cycle Assessment (if indicated):

• Day 21 progesterone level (to confirm ovulation).

Early identification of STIs, hormonal imbalances, or cervical abnormalities guides appropriate management.

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Q3: Outline an initial management plan, including cervical screening and STI testing.

Emily’s management should be holistic, patient-centred, and evidence-based.

1. Preventive Health Measures:

• Perform cervical screening test (as it has been 5 years).
• STI screening (NAAT and serology) given new partner and past chlamydia history.

2. Vaginal Discharge Management:

• If physiological – reassurance and education.
• If infection – targeted treatment (e.g., metronidazole for BV, antifungal for candidiasis).

3. Menstrual Irregularity and PCOS Management:

• Lifestyle modifications: Encourage weight loss (even 5% can improve ovulation).
• OCP adherence: Discuss regular use for cycle regulation.
• Metformin (if insulin resistance present).

4. Fertility and Contraceptive Counselling:

• Discuss fertility awareness if pregnancy is desired in the future.
• Alternative contraceptive options (LARC, fertility-safe options).

5. Follow-Up and Monitoring:

• Review STI results and vaginal swab results in 1-2 weeks.
• Monitor PCOS symptoms and hormonal/metabolic parameters.

A multifaceted plan ensures effective symptom control and reproductive health optimisation.

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Q4: How would you educate Emily on her diagnosis and future reproductive health?

Patient education is essential for long-term reproductive well-being.

1. Reassurance and Normalisation:

• Physiological vs pathological discharge – what is normal.
• PCOS does not mean infertility – lifestyle changes and ovulation tracking can help.

2. STI Prevention and Sexual Health:

• Condom use even on OCP (reduces STI risk).
• Encourage regular STI screening with new partners.

3. PCOS and Menstrual Health Management:

• Importance of weight management for hormonal balance.
• Dietary advice (low GI, Mediterranean diet).
• Regular exercise and sleep hygiene impact on cycles.

4. Future Fertility Planning:

• Ovulation tracking for pregnancy planning.
• Referral to a fertility specialist if struggling to conceive after 12 months.

Clear, practical education improves adherence to treatment and lifestyle changes.

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Q5: Emily’s vaginal swab returns positive for chlamydia. What are your next steps?

A structured, evidence-based approach is required.

1. Treatment and Symptom Management:

• Azithromycin 1g single dose OR doxycycline 100mg BD for 7 days.
• Advise abstinence from sex for 7 days after treatment completion.

2. Contact Tracing and Partner Notification:

• Advise Emily to notify recent sexual partners (last 6 months).
• Provide partner treatment prescription (Expedited Partner Therapy).

3. STI Prevention and Safe Sex Counselling:

• Discuss consistent condom use.
• Encourage regular STI screening with new partners.

4. Follow-Up and Retesting:

• Retest in 3 months (due to reinfection risk).
• Monitor for PID symptoms (lower abdominal pain, fever, deep dyspareunia).

Timely treatment, partner management, and follow-up reduce long-term reproductive complications.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive history-taking covering vaginal discharge, menstrual cycle, and sexual health.
• Judicious use of investigations, including cervical screening, STI testing, and hormonal/metabolic panels.
• Patient-centred management, including preventive health, PCOS management, and STI treatment.
• Clear and supportive education, addressing fertility concerns, STI prevention, and lifestyle interventions.
• Appropriate follow-up for STI retesting and PCOS monitoring.

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PITFALLS

• Failing to assess for STIs in a sexually active patient with new partners.
• Not considering PCOS management holistically (beyond OCP).
• Inadequate discussion of fertility concerns, leading to anxiety.
• Delaying chlamydia treatment or missing partner notification.
• Lack of structured follow-up, increasing risk of complications.

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REFERENCES

• RACGP – RACGP Guidelines for STI Screening and Management
• GP Exams – Female genital check-up

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD