UK Medical Licensing Assessment (UKMLA) Reproductive, Sexual and Women's Health Syllabus

What is the definition of recurrent miscarriage and one key investigation?

Three or more consecutive pregnancy losses before 24 weeks. Investigations include antiphospholipid antibody screen (lupus anticoagulant, anticardiolipin), parental karyotyping and pelvic ultrasound for uterine anomalies.

What is the typical hCG pattern, ultrasound finding and first-line management of an ectopic pregnancy?

Serum hCG that fails to rise appropriately (suboptimal rise, often $<63\%$ in 48 h) with an empty uterus; an adnexal mass may be seen. Management options: expectant, medical (IM methotrexate) or surgical (salpingectomy/salpingotomy) depending on size, hCG and stability.

Distinguish complete from partial hydatidiform mole by karyotype and origin.

Complete mole: diploid ($46,XX$ usually), entirely paternal in origin (empty ovum fertilised), no fetal tissue. Partial mole: triploid (e.g. $69,XXY$), one maternal and two paternal sets, with some fetal tissue. Both need referral to a trophoblastic disease centre.

What is the management of a threatened miscarriage with a viable intrauterine pregnancy and bleeding at 7 weeks?

Expectant management. If the woman is $\geq 6$ weeks with bleeding, consider vaginal micronised progesterone if there is a history of previous miscarriage; repeat scan in 1 week to confirm viability. Anti-D is not required for threatened miscarriage before 12 weeks.

Which women require anti-D prophylaxis after a sensitising event, and what test quantifies large feto-maternal haemorrhage?

RhD-negative, non-sensitised women after sensitising events (delivery, bleeding, ECV, trauma, surgical management of miscarriage). Routine antenatal anti-D is given at 28 weeks. The Kleihauer test quantifies feto-maternal haemorrhage to guide additional anti-D dosing.

What defines postpartum (puerperal) sepsis and the most common causative organisms?

Infection of the genital tract from rupture of membranes/delivery up to 6 weeks postpartum. Common organisms: group A Streptococcus (Streptococcus pyogenes), E. coli, and Staphylococcus aureus. Group A Strep can cause rapid deterioration.

What are the upper legal time limit and the two-doctor requirement for termination of pregnancy under the UK Abortion Act 1967?

Most terminations are legal up to $24$ weeks (Ground C, risk to physical/mental health) with two registered doctors agreeing. There is no upper limit for grounds such as serious fetal abnormality (Ground E) or grave risk to the woman's life.

Compare medical and surgical methods of termination of pregnancy.

Medical: mifepristone (antiprogestogen) followed 24–48 h later by misoprostol (prostaglandin); used at any gestation. Surgical: vacuum aspiration (up to ~14 weeks) or dilatation and evacuation (later). All women are screened for chlamydia and offered contraception.

How are maternal mortality figures categorised (direct vs indirect) and what is currently the leading cause of direct maternal death in the UK?

Direct deaths result from obstetric complications (e.g. thrombosis, haemorrhage, pre-eclampsia, sepsis); indirect deaths from pre-existing/new disease aggravated by pregnancy (e.g. cardiac disease). Thrombosis and thromboembolism is the leading direct cause; cardiac disease is the leading overall cause.

Define stillbirth, neonatal death and perinatal mortality rate.

Stillbirth: fetal death at/after $24$ weeks gestation. Neonatal death: death of a liveborn baby within the first 28 days. Perinatal mortality rate = (stillbirths + early neonatal deaths) per 1000 total births.

Define menorrhagia (heavy menstrual bleeding) and state the first-line medical treatment in a woman not wanting contraception.

Heavy menstrual bleeding is excessive menstrual loss interfering with quality of life. First-line if no structural cause and contraception not desired: tranexamic acid (antifibrinolytic) and/or mefenamic acid (NSAID) during menses. The levonorgestrel IUS is first-line overall if contraception is acceptable.

Define primary and secondary dysmenorrhoea and the first-line treatment of primary dysmenorrhoea.

Primary: painful periods with no underlying pathology, typically starting with menarche. Secondary: due to underlying pathology (endometriosis, fibroids, adenomyosis, PID), often starting later. First-line for primary: NSAIDs (e.g. mefenamic acid); then combined oral contraceptive pill.

What is the PALM-COEIN classification used for, and what do the two groups represent?

FIGO classification of causes of abnormal uterine bleeding. PALM = structural causes (Polyp, Adenomyosis, Leiomyoma/fibroid, Malignancy/hyperplasia); COEIN = non-structural (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified).

Describe the typical clinical features distinguishing fibroids, adenomyosis and endometriosis.

Fibroids (leiomyomas): firm enlarged non-tender 'bulky' uterus, menorrhagia, pressure symptoms. Adenomyosis: bulky, tender, 'boggy' uterus with menorrhagia and dysmenorrhoea in older parous women. Endometriosis: cyclical pelvic pain, dysmenorrhoea, deep dyspareunia, subfertility; 'chocolate cysts' (endometriomas).

What is the gold-standard diagnostic investigation for endometriosis and the medical/surgical treatment options?

Gold standard: laparoscopy (with biopsy). Treatment: analgesia/NSAIDs, hormonal suppression (COCP, progestogens, GnRH analogues), and surgical ablation/excision of deposits; severe disease may need hysterectomy with bilateral salpingo-oophorectomy.

What are the diagnostic Rotterdam criteria for polycystic ovary syndrome?

Two of three required: (1) oligo-/anovulation, (2) clinical or biochemical hyperandrogenism (hirsutism, raised testosterone), (3) polycystic ovaries on ultrasound ($\geq 12$ follicles or ovarian volume $>10\ mL$). Often associated with raised LH:FSH ratio and insulin resistance.

What organisms cause pelvic inflammatory disease and what is the recommended outpatient antibiotic regimen?

Commonly Chlamydia trachomatis and Neisseria gonorrhoeae (plus anaerobes/Mycoplasma genitalium). Typical outpatient regimen: IM ceftriaxone (single dose) plus oral doxycycline and metronidazole for 14 days.

What is Fitz-Hugh-Curtis syndrome?

Perihepatitis (inflammation of the liver capsule with 'violin-string' adhesions) caused by ascending pelvic infection, typically Chlamydia or gonorrhoea, presenting with right upper quadrant pain alongside PID.

Classify urinary incontinence into its two main types and give first-line management of each.

Stress incontinence (leakage on raised intra-abdominal pressure): first-line pelvic floor muscle training ($\geq 3$ months), then surgery (e.g. colposuspension/sling) or duloxetine. Urge incontinence/overactive bladder: bladder training ($\geq 6$ weeks), then antimuscarinics (e.g. oxybutynin) or mirabegron.

How is pelvic organ prolapse graded using the POP-Q stage system in simple terms?

Graded by how far the leading edge descends relative to the hymen: Stage 0 no prolapse; Stage 1 $>1\ cm$ above the hymen; Stage 2 within $1\ cm$ of the hymen; Stage 3 $>1\ cm$ beyond but not full descent; Stage 4 complete eversion/procidentia.

Define the menopause and the hormonal changes that characterise it.

Permanent cessation of menstruation, diagnosed retrospectively after $12$ months of amenorrhoea (mean age ~51). Hormonally: low oestrogen with high FSH and LH (loss of negative feedback). Premature menopause/POI is before age $40$.

What is the key principle governing whether oestrogen-only or combined HRT is prescribed?

Women with a uterus need combined oestrogen plus progestogen (the progestogen protects against endometrial hyperplasia/cancer). Women without a uterus can have oestrogen-only HRT. Add testosterone for low libido if needed.

State the main risks associated with combined HRT.

Increased risk of breast cancer (with combined HRT, related to duration), venous thromboembolism (lower with transdermal route), stroke (oral oestrogen), and—if started late—possible cardiovascular risk. Transdermal HRT avoids the first-pass VTE risk.

Describe the UK cervical screening programme: ages, intervals and the primary test used.

Women/people with a cervix aged 25–64 are screened. Primary test is high-risk HPV testing; if HPV-positive, cytology (reflex) is performed. Intervals: every 3 years for ages 25–49 and every 5 years for ages 50–64 (now moving to 5-yearly if HPV-negative).

What is cervical intraepithelial neoplasia (CIN) and how do CIN grades relate to management?

CIN is dysplasia of the cervical squamous epithelium graded by depth: CIN1 (lower third, often regresses—monitored), CIN2 (two-thirds), CIN3 (full thickness, carcinoma in situ). CIN2/3 is treated, usually by large loop excision of the transformation zone (LLETZ).

Which HPV subtypes cause most cervical cancer and which are covered by the UK vaccine?

High-risk types 16 and 18 cause ~70% of cervical cancers. The Gardasil 9 vaccine covers 16, 18, 31, 33, 45, 52, 58 (oncogenic) plus 6 and 11 (genital warts), offered to all children around age 12–13.

What is the classic presentation and main risk factors for endometrial cancer?

Postmenopausal bleeding is the cardinal symptom. Risk factors reflect unopposed oestrogen excess: obesity, nulliparity, early menarche/late menopause, PCOS, tamoxifen, oestrogen-only HRT, Lynch syndrome. Investigated with transvaginal ultrasound (endometrial thickness $>4\ mm$) and hysteroscopy + biopsy.

What tumour marker and risk-stratification tool are used for a suspected ovarian malignancy, and the commonest histological type?

CA-125 is the tumour marker; the Risk of Malignancy Index ($RMI = U \times M \times CA\text{-}125$) combines ultrasound score, menopausal status and CA-125. The commonest ovarian cancers are epithelial (serous) carcinomas. BRCA1/2 mutations markedly raise risk.

What is lichen sclerosus, its typical appearance and its key long-term risk?

A chronic inflammatory vulval dermatosis causing itchy, white, atrophic 'parchment-like' or figure-of-eight perianal skin changes. Treated with potent topical steroids (e.g. clobetasol). It carries a small increased risk of vulval squamous cell carcinoma, so requires monitoring.

Rank common reversible contraceptives by typical-use effectiveness and name the most effective category.

LARCs (long-acting reversible contraceptives) — the implant, IUS and copper IUD — are most effective ($>99\%$, user-independent). The implant is the single most effective. Oral pills, patch and ring are effective but more failure-prone with typical use; barrier methods least effective.

What are the key UKMEC contraindications to the combined oral contraceptive pill (UKMEC 4)?

Absolute contraindications include migraine with aura, history of VTE/known thrombophilia, BP $\geq 160/100$, smoking $\geq 15$/day at age $\geq 35$, current breast cancer, $<6$ weeks postpartum and breastfeeding, and major surgery with immobilisation. These reflect the prothrombotic/oestrogenic risks.

Compare the emergency contraception options and their time windows.

Copper IUD: most effective, insert up to 5 days after unprotected sex or 5 days after expected ovulation. Ulipristal acetate (ellaOne): oral, up to 120 h (5 days). Levonorgestrel: oral, up to 72 h (3 days, higher dose if BMI $>26$). The copper IUD is the only one that prevents implantation directly.

Compare the discharge characteristics of bacterial vaginosis, candidiasis and trichomoniasis.

Bacterial vaginosis: thin grey-white fishy-smelling discharge, pH $>4.5$, clue cells, no soreness (treat metronidazole). Candidiasis: thick white 'cottage cheese' discharge with itch, normal pH (treat clotrimazole/fluconazole). Trichomoniasis: frothy yellow-green offensive discharge, 'strawberry cervix', pH $>4.5$ (treat metronidazole).

Describe the presentation and treatment of genital chlamydia and gonorrhoea.

Chlamydia trachomatis: often asymptomatic; commonest UK STI; treat with doxycycline 7 days. Neisseria gonorrhoeae: purulent urethral/cervical discharge; treat with IM ceftriaxone single dose. Both require partner notification and a test of cure for gonorrhoea.

Outline the stages of untreated syphilis and the causative organism.

Caused by Treponema pallidum. Primary: painless chancre. Secondary: widespread maculopapular rash (incl. palms/soles), condylomata lata. Latent: asymptomatic, positive serology. Tertiary: gummata, cardiovascular and neurosyphilis. Treated with IM benzylpenicillin.

Define subfertility and the standard first-line investigations of the couple.

Failure to conceive after $12$ months of regular unprotected intercourse (or 6 months if woman $>35$). Investigations: semen analysis (male); mid-luteal (day 21) progesterone to confirm ovulation, and tubal patency (HSG or laparoscopy) plus chlamydia screening (female).

A day-21 progesterone confirms ovulation at what threshold, and what does this assume about cycle length?

A mid-luteal serum progesterone $>30\ \text{nmol/L}$ confirms ovulation. 'Day 21' assumes a 28-day cycle; it should be taken 7 days before the expected next period, so adjust timing for longer/shorter cycles.

What is the structure of a sexual health/STI risk assessment consultation?

Take a focused sexual history: nature/date of last sexual contact, partner's gender and risk, sites of exposure, condom use, symptoms, previous STIs and testing, contraception, and assess risk for HIV/blood-borne viruses. Offer appropriate triple-site testing, partner notification, safeguarding screening and health promotion.

What is HELLP syndrome and its three laboratory components?

A severe variant of pre-eclampsia: Haemolysis, Elevated Liver enzymes, and Low Platelets. Presents with right upper quadrant/epigastric pain, nausea and malaise; definitive management is delivery.

What is the definition of prolonged pregnancy and the rationale for offering induction?

Pregnancy continuing beyond $42^{+0}$ weeks (post-term). Induction of labour is typically offered between 41 and 42 weeks to reduce the increased risks of stillbirth, meconium aspiration and placental insufficiency associated with prolongation.

Describe obstetric cholestasis: presentation, key investigation and main fetal risk.

Pruritus (especially palms and soles) without rash in the second/third trimester, with raised serum bile acids and transaminases. Main fetal risk is stillbirth, so delivery is often planned around 37–38 weeks; ursodeoxycholic acid may relieve itch.