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Master CPS - Reproductive Health
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HIGH YIELD NOTES ~5 min read

Core Concepts

Reproductive health covers physical, mental, and social well-being related to the reproductive system. Key physiology revolves around the Hypothalamic-Pituitary-Gonadal (HPG) axis, which regulates gonadal function (ovaries/testes) via GnRH, FSH, and LH. These hormones control the production of sex steroids (oestrogen, progesterone, testosterone), which exert effects on target organs. Understanding the menstrual cycle, spermatogenesis, and fertility windows is fundamental for managing reproductive conditions.

Clinical Presentation

Abnormal Uterine Bleeding (AUB): Menorrhagia, metrorrhagia, post-coital bleeding (PCB), post-menopausal bleeding (PMB).
Pelvic Pain: Acute (e.g., PID, ruptured cyst), chronic (e.g., endometriosis, adhesions), dysmenorrhoea, dyspareunia.
Vaginal Discharge/Itch: Pruritus vulvae, malodorous or discoloured discharge.
Scrotal Pain/Lumps: Acute pain, gradual onset pain, swelling, palpable masses.
Lower Urinary Tract Symptoms (LUTS) in men: Frequency, urgency, hesitancy, weak stream, nocturia, haematuria (macroscopic or microscopic).
Erectile Dysfunction (ED): Inability to achieve/maintain erection.
Infertility: Inability to conceive after regular unprotected intercourse for 12 months (or 6 months if >35 years).
Menopausal Symptoms: Hot flushes, night sweats, vaginal dryness, mood changes, sleep disturbance.
Sexual Health Concerns: Dysuria, genital lesions, contact with STI.

Diagnosis (Gold Standard)

Diagnosis begins with a thorough history and clinical examination.

Vaginal/Cervical Swabs:
- High Vaginal Swab (HVS) for Candida, Bacterial Vaginosis, Trichomonas.
- Endocervical Swab (ECS) or urine sample (first-pass urine) for Chlamydia and Gonorrhoea (NAAT).
Urine Tests: Dipstick and Midstream Urine (MSU) for UTI; Urine cytology for haematuria.
Blood Tests:
- FBC (anaemia in AUB), TFTs, Prolactin (AUB, galactorrhoea, infertility).
- FSH/LH/Oestradiol (menopause, PCOS, infertility).
- Testosterone (PCOS, ED).
- PSA (Prostate Specific Antigen) for prostate cancer screening/monitoring (after discussion of pros/cons).
Imaging:
- Pelvic Ultrasound (Transvaginal preferred for gynaecology): Uterine fibroids, ovarian cysts, endometrial pathology, PCOS.
- Scrotal Ultrasound: Differentiate testicular torsion vs. epididymitis, characterise testicular/epididymal lumps (hydrocele, varicocele, tumour).
Cervical Screening: Cervical cytology +/- HPV testing as per national guidelines.
Semen Analysis: Initial investigation for male infertility.

Management (First Line)

Contraception: Offer tailored advice based on individual needs, medical history, and contraindications. Options include COCP, POP, implant, injection, IUD/IUS, barrier methods.
Abnormal Uterine Bleeding:
- Menorrhagia: Tranexamic acid, Mefenamic acid, Mirena IUS (highly effective), COCP.
- Post-Coital Bleeding (PCB): Exclude cervical pathology (smear), infection. Cervical ectropion can be cause.
- Post-Menopausal Bleeding (PMB): Urgent 2-week wait referral to gynaecology to exclude endometrial cancer.
Pelvic Pain:
- Dysmenorrhoea: NSAIDs, COCP, Mirena IUS.
- Pelvic Inflammatory Disease (PID): Oral antibiotics (e.g., Doxycycline + Metronidazole). Partner notification and screening.
- Endometriosis: NSAIDs, COCP (continuous use), specialist referral for GnRH analogues or surgery.
Vaginal Discharge:
- Candidiasis: Topical (e.g., Clotrimazole) or oral (Fluconazole) antifungals.
- Bacterial Vaginosis (BV): Oral or topical Metronidazole.
- STIs (Chlamydia, Gonorrhoea, Trichomonas): Specific antibiotics (e.g., Doxycycline for Chlamydia, Ceftriaxone for Gonorrhoea). GUM referral for contact tracing and management.
Menopause: Lifestyle modification, Hormone Replacement Therapy (HRT) – oestrogen-only (if hysterectomy) or combined oestrogen + progestogen. Vaginal oestrogen for localised symptoms.
Benign Prostatic Hyperplasia (BPH): Lifestyle advice, alpha-blockers (e.g., Tamsulosin), 5-alpha reductase inhibitors (e.g., Finasteride). Refer to urology if symptoms persist or for complications.
Erectile Dysfunction (ED): Address underlying causes (diabetes, CVD), lifestyle changes. First-line medical: PDE5 inhibitors (e.g., Sildenafil).
Infertility: Initial advice on timed intercourse, basic investigations (FBC, TFT, prolactin, semen analysis, pelvic USS), referral to secondary care after 12 months (or 6 months if female >35).

Exam Red Flags

Post-menopausal bleeding: Always refer via 2-week wait pathway for endometrial cancer exclusion.
Acute severe scrotal pain, swelling, and tenderness (especially in adolescent/young adult males): Suspect Testicular Torsion – Surgical Emergency, immediate referral to A&E.
Persistent unilateral testicular lump: Suspect Testicular Cancer – Urgent 2-week wait referral to urology.
New onset LUTS with haematuria (even microscopic), palpable prostate nodule, or rapidly rising PSA: Urgent urology referral (e.g., suspected prostate cancer/bladder cancer).
Sudden onset severe pelvic pain with signs of shock (tachycardia, hypotension), especially in a woman of childbearing age: Suspect ruptured ectopic pregnancy or ovarian torsion – Emergency admission.
Pelvic Inflammatory Disease (PID) with systemic signs of sepsis: Urgent admission for intravenous antibiotics.
Suspected Child Sexual Abuse or Vulnerable Adult concerns: Follow safeguarding procedures immediately.

Sample Practice Questions

Question 1

A 28-year-old woman presents to the emergency department with a 3-day history of lower abdominal pain, deep dyspareunia, and an offensive vaginal discharge. She reports a new sexual partner in the last month. On examination, her temperature is 38.2°C, and there is bilateral lower abdominal tenderness with guarding. A speculum examination reveals mucopurulent discharge from the cervix and cervical motion tenderness. What is the most appropriate initial management step?

A) Prescribe a single dose of oral azithromycin and advise her to return if symptoms worsen.

B) Arrange an immediate pelvic ultrasound scan to rule out appendicitis or ovarian pathology.

C) Initiate empiric broad-spectrum antibiotic therapy for suspected Pelvic Inflammatory Disease (PID).

D) Take endocervical swabs for Chlamydia trachomatis and Neisseria gonorrhoeae and await results before starting treatment.

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Question 2

A 28-year-old woman seeks contraception. She smokes 15 cigarettes a day, has a BMI of 32, and suffers from migraines with aura. She is concerned about unplanned pregnancy. Which of the following contraceptive methods is absolutely contraindicated for her?

A) Progestogen-only pill (POP)

B) Copper intrauterine device (IUD)

C) Combined oral contraceptive pill (COCP)

D) Progestogen-only injectable

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Question 3

A 52-year-old woman presents to her GP complaining of severe hot flushes, night sweats, and significant mood swings, which are impacting her quality of life. She is keen to explore options for hormone replacement therapy (HRT). Her past medical history includes a deep vein thrombosis (DVT) 5 years ago, which resolved with anticoagulation. She is currently otherwise healthy, a non-smoker, and her blood pressure is well-controlled. Which of the following is an absolute contraindication to initiating combined HRT in this patient?

A) Previous deep vein thrombosis (DVT)

B) Family history of breast cancer

C) Osteoporosis

D) Mild endometriosis

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