Master CPS - Reproductive Health
for MSRA

What the MSRA Tests in CPS - Reproductive Health

CPS - Reproductive Health tests your ability to manage common presentations in primary care and emergency settings: abnormal uterine bleeding, subfertility, contraception, menopause, sexually transmitted infections, and pregnancy complications. You must demonstrate knowledge of NICE and RCOG guidelines, first-line pharmacological and surgical treatments, diagnostic criteria (e.g., PALM-COEIN for AUB, Rotterdam for PCOS), and red-flag symptoms (e.g., postmenopausal bleeding, ectopic pregnancy). The exam prioritises safe triage, appropriate referral, and evidence-based prescribing. Expect clinical vignettes requiring you to choose the next best step—investigation, treatment, or counselling—rather than rare pathology.

High-Yield Concepts

• Abnormal Uterine Bleeding (AUB) – PALM-COEIN Classification: NICE 2018: first-line for heavy menstrual bleeding without structural abnormality is levonorgestrel-releasing intrauterine system (LNG-IUS). For fibroids, use UAE or myomectomy if fertility desired. Postmenopausal bleeding: urgent referral (2-week wait) for endometrial biopsy; transvaginal ultrasound measuring endometrial thickness >4 mm is suspicious.
• PCOS Diagnosis – Rotterdam Criteria: Two of three: oligo/anovulation, clinical/biochemical hyperandrogenism (e.g., free androgen index >5, Ferriman-Gallwey score ≥8), polycystic ovaries on ultrasound (≥20 follicles per ovary or ovarian volume ≥10 mL). Exclude other causes (thyroid, prolactin, congenital adrenal hyperplasia). First-line for anovulatory infertility: letrozole 2.5–5 mg daily for 5 days (NICE 2023).
• Ectopic Pregnancy – Diagnosis and Management: Triad: amenorrhoea, pelvic pain, vaginal bleeding. If haemodynamically stable with β-hCG >1500 IU/L and no intrauterine pregnancy on TVUS, consider ectopic. First-line surgical: laparoscopic salpingectomy (or salpingotomy if contralateral tube damaged). Medical: methotrexate 50 mg/m² IM if unruptured, mass <35 mm, no fetal cardiac activity, β-hCG <5000 IU/L, and reliable follow-up.
• Contraception – UKMEC Categories: UKMEC 1: no restriction (e.g., COC in non-smoker <35). UKMEC 4: unacceptable risk (e.g., COC in migraine with aura). Emergency contraception: copper IUD up to 5 days post-unprotected sex (most effective); oral ulipristal acetate 30 mg up to 120 hours, or levonorgestrel 1.5 mg up to 72 hours (less effective if BMI >26).
• Menopause – NICE 2015/2024 Guidelines: Diagnose perimenopause based on vasomotor symptoms and menstrual irregularity (age >45). FSH not routinely needed. First-line HRT: oestrogen (oral/transdermal) plus progestogen if uterus intact. For early menopause (<45), HRT recommended until average age of menopause (~51). Contraindications: breast cancer, unexplained vaginal bleeding, active VTE. Vaginal oestrogen for GSM without progestogen.
• STI – Chlamydia and Gonorrhoea Management: Chlamydia: first-line doxycycline 100 mg BD for 7 days (azithromycin 1 g single dose if contraindicated). Gonorrhoea: ceftriaxone 1 g IM single dose plus azithromycin 1 g oral (due to rising resistance). Test of cure for gonorrhoea (NAAT) at 2 weeks. All partners should be offered testing and treatment; contact tracing is essential.
• Subfertility – Initial Investigations: NICE: refer after 1 year of unprotected intercourse (or 6 months if female >35). Basic tests: mid-luteal progesterone (day 21 for 28-day cycle) to confirm ovulation; semen analysis (two samples if abnormal); rubella immunity; chlamydia screen. For female >40, start FSH and AMH to assess ovarian reserve. Tubal patency: hysterosalpingography or laparoscopy.
• Miscarriage – Definition and Management: Threatened miscarriage: vaginal bleeding with closed cervix, viable fetus on scan. Missed miscarriage: fetal pole >7 mm with no heartbeat or gestational sac >25 mm with no fetal pole. Medical management: misoprostol 800 mcg vaginal/sublingual (after mifepristone 200 mg oral if >10 weeks). Surgical: manual vacuum aspiration or ERPC. Anti-D if rhesus-negative >12 weeks.

Common Traps in CPS - Reproductive Health Questions

• Confusing 'postmenopausal bleeding' with perimenopausal spotting—any bleeding >12 months after last period requires urgent referral.
• Assuming all patients with PCOS need metformin—NICE only recommends it for anovulation if clomiphene/letrozole fails or for glucose intolerance.
• Using azithromycin as first-line for chlamydia—doxycycline is now preferred due to azithromycin resistance concerns.
• Forgetting to check renal function before methotrexate for ectopic—contraindicated if creatinine >1.5 mg/dL or liver enzymes elevated.
• Thinking that a negative urine pregnancy test rules out ectopic—always check serum β-hCG if symptoms suggestive.
• Prescribing combined oral contraceptive in a migraineur without aura—UKMEC 3 for migraine without aura, but UKMEC 4 if aura present.

How to Revise CPS - Reproductive Health for the MSRA

Prioritise NICE guidelines for AUB, PCOS, menopause, and subfertility—these are recurring themes. Questions often present as 'next step in management' with distractors like 'start COC' when LNG-IUS is first-line, or 'do FSH' when clinical diagnosis suffices. Practise interpreting ultrasound findings (endometrial thickness, ovarian volume) and β-hCG trends. Focus on safety: when to refer (ectopic, postmenopausal bleeding, ovarian torsion), drug interactions (HRT and VTE risk), and contraindications. Use the 'ABCDE' approach for acute gynaecological presentations. Review UKMEC for contraception counselling scenarios.

Practise it: MedLumen has 50 CPS - Reproductive Health questions for the MSRA, each with a full explanation and references.