Revision aid, not clinical advice. This page is educational material written for exam preparation. It is not a substitute for the current guideline or for clinical judgement, and must not be relied on for the care of any individual. Always check up-to-date national guidance and verify independently before acting on anything here.

GP Diplomas

The DCSRH Diploma

A calm, structured route through the Diploma of the College of Sexual & Reproductive Healthcare (DCSRH) — the contraception and SRH diploma many GPs take, formerly the DFSRH. Here is what the qualification involves, and the tools we have built to revise for it. Alongside the theory, the Station Simulator lets you rehearse timed Assessment Half Day stations and mark yourself against a model answer.

This is the first of our GP Diplomas — qualifications GPs commonly take alongside the membership exams. The DCSRH sits on its own track because it is a separate portfolio qualification with its own assessments, not part of the AKT or MSRA.

What the diploma involves

Four assessment components

The DCSRH is a portfolio qualification, completed over up to two years. It is made up of four parts. Tap a card to see what each one asks of you.

Who it’s for & what you’ll need

  • Registered with a UK or Irish professional regulator, with a licence to practise if your regulator requires one.
  • Up-to-date resuscitation and anaphylaxis training, in line with current UK guidelines.
  • Access to a clinical setting and a CoSRH Registered Trainer for the five clinical assessments.

What you’ll cover (the e‑SRH syllabus)

Contraception UKMEC eligibility STIs Planning pregnancy Early pregnancy & abortion referral Psychosexual medicine Providing SRH care
Your DCSRH revision toolkit

Everything for the diploma, in one place

The same toolkit that powers our AKT revision, focused on the DCSRH theory paper (the OTA). Everything here is live now — 650 OTA-style questions, a ten-chapter Revision Guide, the five interactive decoders, Core Compass, the Core 10, timed mock OTAs and the Assessment Half Day station simulator.

Core Tools · Live · Five interactive decoders Core Tools — contraception, decoded Five free decoders for the contraception decisions the OTA keeps asking about — all built on UKMEC 2025, each with Learn and Test modes. UKMECMissed PillEmergency ContraceptionQuick Start & SwitchingPostpartum Timeline Open the Core Tools → Question Bank · Live The Question Bank 650 OTA-style single-best-answer questions across contraception, UKMEC 2025, specific populations and STI management — each with a Core Lens summary and an expandable deep dive. Start practising → Core Compass · LiveCore CompassSee your readiness across the ten syllabus domains at a glance, then build mock papers around your weak spots.Open the Core Compass →Core 10 · Live · Ten minutes a dayThe Core 10A daily ten-minute set of SRH questions, weighted to your weakest areas — an easy way to keep the habit warm without a full study block.Start my Core 10 →Mock tests · Live · 50 questions, 60 minutesMock testsTimed 50-question mock OTAs in the real exam format, marked instantly with the same NICE/CoSRH-linked explanations our questions carry.Sit a timed mock OTA →Core Lens · LiveCore LensThe answer layer behind the bank — a one-line summary first, the full reasoning when you want it, browsable by syllabus domain instead of question by question.Open the Core Lens →Section Guide · LivePassing it, section by sectionWhat the examiners are actually looking for in each of the four assessments — the ILP and e‑SRH, the OTA, the five clinical assessments and the Assessment Half Day — and the order that makes them easiest.Read the section guide → Revision Guide · Live · Ten chaptersThe Revision GuideTen chapters across the syllabus — the UKMEC to the menopause — each opening in the Core Lens, with questions to try before you read and recall questions at the end.Read the Revision Guide →Station Simulator · Live · Five timed stationsThe Station SimulatorA timed circuit of the stations you meet on the Assessment Half Day — simulated-patient counselling and examiner VIVA — then mark yourself honestly against a model answer.Run a circuit →Core Calendar · LiveCore CalendarSet the date you plan to sit the Online Theory Assessment and the plan works backwards — a nine-week run-up around a full-time job, with an optional Assessment Half Day countdown.Plan your diploma → Core Wisdom · Live Core Wisdom Our own SRH blog for the diploma — short pieces on contraception, UKMEC 2025, emergency contraception and quick-starting. Read the blog → Core Resources · Live Core Resources Our own SRH resource hub for the diploma — the CoSRH, the e‑SRH learning programme, UKMEC 2025, BASHH and NICE CKS. Browse resources →
Try before you buy

Try ten DCSRH questions, free

One question from each of ten DCSRH topics, with the same explanation members see after every answer: the Core Lens, a Deep Dive and a Founder’s Tip. No sign-up, no timer, nothing saved.

DCSRH · UKMEC eligibilityQuestion 1 of 10 · single best answer

UKMEC: current breast cancer and every hormonal method

Scenario: A 41-year-old woman is referred to a community contraception and sexual health clinic by her breast care nurse. She was diagnosed three months ago with an oestrogen receptor positive invasive ductal carcinoma of the left breast, is halfway through neoadjuvant chemotherapy and is listed for surgery, after which endocrine therapy is planned. She has regular, heavy periods, is in a stable relationship with a male partner, is sexually active and has been told firmly that she must not become pregnant during treatment. She has two children and does not want more. She has had no venous thromboembolism. She asks for the 52 mg levonorgestrel intrauterine system because a friend found it helpful for heavy bleeding.

Question: What is the most appropriate contraceptive advice?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is E: Suggest the copper intrauterine device, as every hormonal method is category 4 here.

Core Lens: High-Yield Takeaways

  • Current breast cancer is a clean sweep: UKMEC 2025 places combined methods, the progestogen-only pill, the implant, the injectable and the levonorgestrel intrauterine system all at category 4.
  • The copper device is category 1: it is the only long-acting option left to her and it needs no oncology permission.
  • Local is still hormonal: the levonorgestrel intrauterine system releases progestogen and is categorised with the hormonal methods, not with the copper device.
  • Progestogen is not exempt: the restriction is not about oestrogen, so dropping the oestrogen does not open a door.
  • She needs a method today: effective contraception during chemotherapy is a treatment issue, not something to postpone until the pathway is finished.
Click here for Deep Dive

The Row Where Hormone Means Hormone, Whatever the Route

Most of UKMEC rewards nuance. Conditions split by severity, by initiation and continuation, by mobility, by how long ago an event happened. Current breast cancer does none of that. It is one of the few rows where every hormonal method carries the highest category and the answer requires no weighing at all. The difficulty for candidates is not the rule but the instinct that fights it, which is that the levonorgestrel intrauterine system is somehow different because it works in the uterus. That belief is reinforced by the genuine usefulness of the system for heavy bleeding, and in a woman with an oestrogen receptor positive tumour on active treatment it is the wrong instinct. She also has a pressing reason to avoid pregnancy, which makes getting her onto an effective method today part of her cancer care.

Why This Is the Right Move

UKMEC 2025, published by the CoSRH (formerly FSRH), places current breast cancer at category 4 for combined hormonal contraception, the progestogen-only pill, the implant, the injectable and the levonorgestrel intrauterine system, and at category 1 for the copper intrauterine device. Category 4 means an unacceptable health risk, so none of the hormonal methods is available to her while her cancer is current. The copper intrauterine device delivers no hormone, is highly effective, is long-acting and is immediately reversible, which suits a woman who has been told not to conceive during treatment. Suggesting it, and explaining why the system she asked for is not an option, is the answer that is both correct and practical.

The consultation has to deal with her heavy periods as well, because they are the reason she asked for the levonorgestrel system and the copper device may make them heavier. Non-hormonal options should be named: tranexamic acid and a non-steroidal anti-inflammatory drug taken during menstruation are the usual first steps, and her oncology team will want to know about heavy bleeding during chemotherapy in any case. Time the fitting sensibly around her chemotherapy cycles and her neutrophil count rather than fitting on the day she is most immunosuppressed. Since she has completed her family, raise permanent methods including vasectomy for her partner as a planned future conversation, and write to her breast team so that the plan is shared.

Why the Other Options Don’t Fit

  • Option A – Advise that the 52 mg levonorgestrel intrauterine system is acceptable because it acts locally: The commonest misconception on this topic, and it is not a foolish one, since local delivery does produce much lower systemic levels and the system is used in other settings for endometrial protection. UKMEC 2025 nonetheless categorises it with the hormonal methods at category 4 in current breast cancer, and a woman on treatment for a hormone-sensitive tumour is not the place to test the theory
  • Option B – Arrange laparoscopic sterilisation as the only acceptable option during her treatment: She has completed her family, so permanent contraception is a legitimate long-term discussion, and this option borrows that legitimacy. A laparoscopic procedure under general anaesthesia in the middle of neoadjuvant chemotherapy is poorly timed, and a woman making an irreversible decision during cancer treatment is not making it in ideal circumstances. The copper device achieves the same protection reversibly
  • Option C – Offer the progestogen-only pill, since only oestrogen-containing methods are restricted: This applies the venous thromboembolism logic that governs most of the tables, where removing oestrogen lowers the category. Breast cancer does not work that way, because the concern is hormonal stimulation of a hormone-sensitive tumour, and the progestogen-only pill is category 4 alongside the combined pill. Offering it would give her a method she believes is safe when it is not
  • Option D – Recommend condoms alone until she has completed her cancer treatment: Condoms are hormone-free and carry no restriction, so on eligibility grounds nothing is wrong with them, and they should be encouraged for infection protection. Typical-use failure is far too high for a woman who has been told she must not conceive during chemotherapy, and the consequences of that failure during active treatment are serious. She deserves the most effective non-hormonal option available

“Red Flags” and Key Decision Points

  • Any hormonal method in current breast cancer: all are category 4, including the intrauterine system.
  • Neutropenia or thrombocytopenia: time the device fitting around the chemotherapy cycle and check counts.
  • Heavy bleeding during chemotherapy: tell the oncology team rather than managing it alone in the contraception clinic.
  • An existing hormonal method at diagnosis: removal needs to be arranged, not assumed.
  • Pregnancy risk during treatment: a teratogenic and oncological emergency, so contraception is cancer care.

Relevance to Clinical Practice

Contraception is routinely forgotten in women having cancer treatment, which is how a woman ends up conceiving during chemotherapy. A sexual health service that takes referrals from breast care nurses has a specific job here: to give a woman an effective, hormone-free method quickly, to explain in plain language why the method she has heard about is closed to her, and to manage the bleeding problem she has without reaching for a progestogen. The explanation matters as much as the decision, because a woman told only that she cannot have the intrauterine system will conclude that contraception has been taken away. The other habit worth building is to ask every woman with a new hormone-sensitive cancer what contraception she is using, since implants and intrauterine systems fitted before the diagnosis do not remove themselves and nobody else will think to ask.

Founder’s Tip

In current breast cancer the whole hormonal column is a 4, intrauterine system included. Copper is the answer, and the heavy periods get tranexamic acid, not a progestogen.

Core Summary: Current breast cancer makes every hormonal method UKMEC category 4, including the 52 mg levonorgestrel intrauterine system despite its local action, and leaves the copper intrauterine device at category 1, so a woman on neoadjuvant chemotherapy who must avoid pregnancy should be offered the copper device with non-hormonal management of her heavy bleeding, not a progestogen-only method, not condoms alone and not sterilisation in the middle of treatment.
DCSRH · Contraception — methodsQuestion 2 of 10 · single best answer

Injectable: the six-month weight gain predictor in adolescents

Scenario: A 17-year-old attends a young people’s service for her third injection of intramuscular depot medroxyprogesterone acetate (DMPA) 150 mg, 6 months after starting the method. Her body mass index was 32 kg/m2 when she began and her weight was recorded at that visit. She is otherwise well, takes no medication and is happy with the method, but she says several friends have told her the injection makes you put on weight and she wants to know whether that is going to happen to her. You have her baseline weight in the record and she is willing to be weighed today before the injection is given.

Question: Which finding at this 6-month review would best predict continued weight gain?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is B: A gain of more than 5% of her baseline body weight over the first 6 months of use.

Core Lens: High-Yield Takeaways

  • The marker is proportional, not absolute: more than 5% of baseline body weight gained in the first 6 months of DMPA use predicts continued weight gain.
  • It has a population: the CoSRH (formerly FSRH) Progestogen-only Injectable guideline ties the marked weight gain to adolescents with a baseline body mass index of 30 or above.
  • Which makes the baseline weight essential: a percentage change cannot be calculated at 6 months if nobody weighed her at the first injection.
  • It is a counselling tool: the finding informs an honest conversation about continuing, not an instruction to stop the method.
  • Weight is a guideline-mandated topic under 18: particular attention to the risk of weight gain is part of counselling an adolescent before a first injection.
Click here for Deep Dive

Six Months In: The One Number That Earns Its Place

Weight is the commonest reason young women give for stopping the injection, and most of the advice offered about it is vague. Clinicians say that some people gain weight and some do not, which is true and useless. The CoSRH injectables guideline is more precise than that, and the precision is what this question tests. It identifies a group in whom weight gain is genuinely more marked, adolescents starting with a body mass index of 30 or above, and it identifies an early signal within that group: a gain of more than 5% of baseline body weight in the first 6 months of use marks the woman who is likely to go on gaining. The trap is the plausible absolute figure. Two kilograms means something very different to a woman of 50 kg and a woman of 95 kg, which is precisely why the marker is expressed as a proportion.

Why This Is the Right Move

The CoSRH Progestogen-only Injectable guideline (2014, amended July 2023) states that weight gain with DMPA is more marked in adolescents whose baseline body mass index is 30 kg/m2 or above, and that users who gain more than 5% of their baseline body weight within the first 6 months of use are likely to experience continued weight gain. This young woman is exactly the person the statement was written about: she is 17 and she started at 32 kg/m2. The prediction is useful because it arrives early enough to act on. At 6 months she has had three injections, she is still engaged with the service, and she has asked the question herself, so the information lands as an answer rather than as a lecture. Calculating it takes a scale and the number already in her notes.

What follows the calculation is a conversation, not a withdrawal. If she has crossed the threshold, say plainly that this pattern tends to continue, and offer her the genuine choice between carrying on with that knowledge and switching to a method without the association, such as the implant, an intrauterine method or an oestrogen-free pill. If she has not crossed it, that is reassuring and worth saying out loud. Either way, check that nothing else explains the change, ask about diet, activity, mood and any new medication, and avoid the trap of attributing every kilogram in a growing adolescent to the injection. Record the weight, record the percentage and record what she decided, so the next clinician has a trend rather than a single number.

Why the Other Options Don’t Fit

  • Option A – A gain of more than 2 kg since the first injection, whatever her starting weight was: An absolute threshold feels concrete and is easy to apply at the desk, which is why it is tempting. It is not the guideline’s marker, and it performs badly across body sizes: 2 kg is a substantial proportional change in a small woman and trivial in a larger one. The published signal is deliberately expressed as a percentage of her own baseline
  • Option C – A rise in her body mass index to 35 kg/m2 or above by the end of the first year of use: Body mass index bands are familiar and a move into a higher band sounds clinically meaningful. Two problems arise here. The threshold at the end of the first year is too late to inform the decision she is making now, and the guideline’s predictive statement is about change from her own baseline rather than arrival at any fixed band
  • Option D – Any weight gain at all in the first 3 months, which then always continues with further use: This has the right instinct, that early change matters, but it overstates it in two ways. Small early fluctuations are common and do not predict anything, and the word always is not how any weight association behaves. Applied literally it would flag most users and frighten young women out of a method that suits many of them
  • Option E – No early measurement predicts later gain, so her weight is simply recorded once a year: Therapeutic nihilism about weight is understandable, given how often the conversation goes badly, and annual recording is better than nothing. The guideline is more specific than this option allows, and abandoning the 6-month calculation throws away the one early signal that lets a young woman make an informed choice while she still has one

“Red Flags” and Key Decision Points

  • No baseline weight recorded: without it the 5% calculation is impossible, so weigh every adolescent at the first injection.
  • Rapid gain with new symptoms: thirst, oligomenorrhoea or striae deserve their own assessment rather than being blamed on the method.
  • Weight used as a threat: a marker that predicts is not a reason to withdraw a method from a young woman who wants it.
  • Disordered eating disclosed at review: this changes both the weight conversation and the individual bone risk-benefit balance.
  • The 6-month review not happening: injections given by an unscheduled clinician with no weight taken lose the signal entirely.

Relevance to Clinical Practice

This is a small piece of guidance with an unusually direct effect on practice. It tells you who to weigh, when to weigh her and what the number means, and it converts the least satisfying conversation in contraception into something specific. In a young people’s service the practical change is to put a weight in the record at the first injection as a matter of routine, because that single entry is what makes the 6-month calculation possible. At the review, do the arithmetic rather than asking whether she feels heavier. When the answer crosses 5%, say so honestly, explain that the pattern tends to continue, and lay out the alternatives without pressure. Young women stop methods because they feel misled, not because they gained weight, and a clinician who predicted the gain in advance is a clinician they come back to.

Founder’s Tip

Weigh her on the day you give the first injection. Six months later that one line in the notes is worth more than any amount of reassuring generalisation about how everyone is different.

Core Summary: In an adolescent starting DMPA with a baseline body mass index of 30 kg/m2 or above, a gain of more than 5% of her own baseline body weight within the first 6 months predicts continued weight gain and should prompt an honest discussion of continuing or switching, rather than an absolute weight threshold, a body mass index band reached a year later, or annual weighing with no early calculation.
DCSRH · Emergency contraceptionQuestion 3 of 10 · single best answer

EC: repeat oral EC when levonorgestrel was taken days ago

Scenario: A 22-year-old woman attends a young people’s service having taken levonorgestrel 1.5 mg four days ago after a condom failure. She has had a further episode of unprotected sex this morning. She weighs 60 kg, has regular 30-day cycles and is on day 12 today, takes no regular medication and is not breastfeeding. A copper intrauterine device has been offered and she has declined it, saying she does not want an internal examination. She has heard that ulipristal acetate is the stronger tablet and asks whether she should have that one this time.

Question: What is the most appropriate oral emergency contraception today?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is A: Advise a further levonorgestrel 1.5 mg dose, as ulipristal works less well within seven days of it.

Core Lens: High-Yield Takeaways

  • The cross-interaction runs both ways: the CoSRH (formerly FSRH) Emergency Contraception guideline warns that ulipristal acetate could be less effective if a progestogen was taken in the preceding 7 days.
  • Her levonorgestrel counts as that progestogen: a dose 4 days ago sits inside the 7-day window, so switching drugs today is not the upgrade it appears to be.
  • Repeating is allowed: the guideline accepts that oral emergency contraception can be used again after further unprotected sex in the same cycle.
  • The mirror rule is the 5 days after ulipristal: a progestogen taken then can blunt ulipristal, which is why hormonal contraception waits 5 days.
  • The device answers both problems: the copper intrauterine device is unaffected by anything she has already swallowed and remains the most effective option.
Click here for Deep Dive

Last Week’s Tablet Still Matters

She is asking a sensible question and the intuitive answer is wrong. Ulipristal acetate is the more effective oral method in most head-to-head comparisons, so trading up looks like better care. The obstacle is pharmacological rather than clinical: ulipristal is a selective progesterone-receptor modulator, and progestogen sitting on the same receptors interferes with it. The guideline handles this with a simple pair of time windows, and candidates tend to remember one of them and forget the other. Everyone learns to wait 5 days after ulipristal before starting a hormonal method. Far fewer remember that ulipristal itself may be weakened when a progestogen has been taken in the 7 days before it, which is exactly this woman four days after a levonorgestrel tablet.

Why This Is the Right Move

The CoSRH Emergency Contraception guideline (2017, amended April 2026) states that emergency contraception may be repeated after a further episode of unprotected sex in the same cycle, so doing nothing is not an option: she has had unprotected sex this morning on day 12 of a regular 30-day cycle, with the earliest likely ovulation still a few days away. The guideline also sets out the two-way interaction between progestogens and ulipristal acetate. A progestogen taken in the 5 days after ulipristal can reduce its effect, and ulipristal could itself be less effective if a progestogen was taken in the 7 days before it. Her levonorgestrel dose 4 days ago falls squarely inside that earlier window. Repeating levonorgestrel, which has no such restriction, is the oral option that is not compromised by what she has already taken.

Re-offer the copper intrauterine device before you settle for a tablet, because it is unaffected by any of this and is still within its window for today’s episode. If she holds to her refusal, record it and move on without pressure; a young person who feels pushed towards an examination may not come back. Then use the consultation properly. Two emergencies in five days is a contraception problem, not a run of bad luck, and a method she can start today is the real intervention. Levonorgestrel allows a hormonal method to be started immediately, which ulipristal would have delayed by 5 days. Offer sexually transmitted infection testing, ask about pressure or coercion as you would at any repeat attendance, and arrange a pregnancy test if her period is more than 7 days late.

Why the Other Options Don’t Fit

  • Option B – Give ulipristal acetate 30 mg instead, since it is the more effective oral method at any point in the cycle: The premise is largely true and this is the answer most candidates choose. It ignores the receptor interaction. With levonorgestrel taken 4 days ago, the guideline warns that ulipristal may be less effective, so the theoretical advantage of the stronger drug is being spent on a dose that may not perform as advertised
  • Option C – Offer no further emergency contraception, as the dose four days ago still covers her: A common misunderstanding, and an understandable one, because patients and clinicians both talk about being covered. Levonorgestrel acts on the single episode that preceded it by delaying ovulation; it confers no forward protection. Sex this morning is a new exposure and needs its own decision
  • Option D – Prescribe ulipristal acetate 30 mg today and a second dose in five days: A scheduled second dose has no basis in the guideline, which supports repeating a dose after further unprotected sex rather than on a timetable. It also compounds the first problem by choosing ulipristal within 7 days of her levonorgestrel, and a future tablet does nothing about the exposure that has already happened this morning
  • Option E – Reassure her that emergency contraception cannot be repeated within the same cycle: This sounds like a safety rule and is sometimes repeated as one, which is why it tempts. The guideline is clear that both oral methods can be used more than once in a cycle, each episode being assessed on its own. Refusing a second dose leaves a woman with a real exposure and no intervention at her most fertile point

“Red Flags” and Key Decision Points

  • Any progestogen in the previous 7 days: ulipristal may be blunted, so levonorgestrel or the device is preferred.
  • Repeated emergency contraception: the underlying problem is the missing ongoing method.
  • Unprotected sex inside the fertile window: re-offer the device rather than assume the tablet is enough.
  • A second attendance within a week: ask about pressure, coercion and whether condoms are being used at all.
  • A period more than 7 days late: pregnancy test, whichever tablet was used.

Relevance to Clinical Practice

The question to add to every emergency contraception consultation is what she has already taken, not just when she had sex. A levonorgestrel tablet from earlier in the week, a desogestrel pill swallowed yesterday or a recently missed progestogen-only pill all sit inside the 7-day window that weakens ulipristal, and each one flips the oral choice towards levonorgestrel. It is a question that takes seconds and it is routinely missed, because the drug history is asked about regular medicines rather than about tablets from a pharmacy counter. The other practical point is that a second emergency within days is a prompt, not a nuisance: it is the moment when a young woman is most receptive to starting something that works, and choosing levonorgestrel keeps that door open today rather than in 5 days.

Founder’s Tip

Ulipristal is the stronger tablet right up until somebody has had a progestogen in the last week. Ask what she took, not just when she had sex.

Core Summary: After a further episode of unprotected sex, emergency contraception may be repeated, but a levonorgestrel dose 4 days ago falls within the 7 days in which the CoSRH guideline warns ulipristal acetate could be less effective, so a further levonorgestrel 1.5 mg dose is the appropriate oral choice with the copper device re-offered, rather than switching to ulipristal or withholding treatment.
DCSRH · STI managementQuestion 4 of 10 · single best answer

STI: first-line treatment of early syphilis

Scenario: A 29-year-old woman attends an integrated sexual health clinic with a two-week history of a non-itchy rash over her trunk, palms and soles, a sore mouth and swollen glands in her neck. She had a new male partner four months ago. Her treponemal antibody test is positive and her RPR titre is 1:64, and the team diagnoses secondary syphilis. Her HIV test is negative, her pregnancy test is negative and she has a copper intrauterine device. She has no drug allergies and takes no regular medication. She has heard from a friend that the syphilis injection is very painful and asks whether she could have tablets instead.

Question: What is the most appropriate treatment?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is E: Single intramuscular benzathine penicillin G 2.4 million unit dose with lidocaine.

Core Lens: High-Yield Takeaways

  • One injection treats early syphilis: the BASHH syphilis guideline 2024 recommends benzathine penicillin G 2.4 million units intramuscularly as a single dose for primary, secondary and early latent syphilis.
  • The pain problem has an answer: a lidocaine-containing benzathine penicillin preparation is now licensed and recommended for tolerability, replacing the old teaching that there was no local anaesthetic option.
  • Tablets are second line: doxycycline 100 mg twice daily for 14 days is a listed alternative for early syphilis, kept for when benzathine penicillin cannot be given or is still declined once her worry about pain has been addressed.
  • Macrolides have gone: azithromycin is no longer an option anywhere in the 2024 guideline because of resistance and clinical failure.
  • Weekly doses are for late disease: three weekly injections belong to late latent, cardiovascular and gummatous syphilis, not to secondary syphilis.
Click here for Deep Dive

The Painful Injection Is Now the Kinder Choice

Secondary syphilis announces itself: a rash that spares nobody’s palms and soles, mucosal changes, lymphadenopathy and a high RPR titre. The diagnosis here is secure and staged. The decision the question tests is what happens next, when a frightened patient asks for tablets because of a story about a painful injection. The trap is to let a reasonable preference steer the prescription towards a second-line oral course, or towards the single oral dose that used to be offered and no longer is. The better answer is to keep the most effective and simplest treatment, a single intramuscular dose of benzathine penicillin, and to deal with the real problem, which is pain. The 2024 guideline does exactly that by recommending the lidocaine-containing preparation, so the clinician can meet her concern without compromising the cure.

Why This Is the Right Move

The BASHH UK national guideline on the management of syphilis 2024 (Kingston and colleagues) recommends benzathine penicillin G 2.4 million units intramuscularly as a single dose for primary, secondary and early latent syphilis. It also reflects a change many candidates will not have met: a benzathine penicillin formulation containing lidocaine is now licensed and recommended for tolerability. The guideline lists alternatives for early syphilis when benzathine penicillin is not used: procaine penicillin 600,000 units intramuscularly daily for 10 days, doxycycline 100 mg twice daily for 14 days, ceftriaxone 500 mg to 1 g daily for 10 days, or amoxicillin 500 mg four times daily with probenecid 500 mg four times daily for 14 days. Each asks more of the patient than one injection does, and oral courses depend on adherence over two weeks. Macrolides are no longer an option at any stage.

Explain the treatment before giving it. A Jarisch-Herxheimer reaction, with fever, aches and a flare of the rash within hours of the first dose, is common in secondary syphilis; it is self-limiting, is not an allergy and should not stop treatment. Arrange clinical and RPR follow-up at 3, 6 and 12 months after treatment, looking for a four-fold fall in titre as the marker of adequate response. Partner notification for secondary syphilis looks back two years, and contacts need testing or epidemiological treatment. Complete her screen for chlamydia and gonorrhoea, and repeat HIV testing if exposure was recent. Her copper device needs no change. Advise her to avoid sex until the rash and any lesions have healed and her partners have been assessed.

Why the Other Options Don’t Fit

  • Option A – Azithromycin 2 g orally as a single dose, which avoids an injection altogether: A single oral dose sounds like the perfect answer to her fear, and macrolides once appeared in older syphilis guidance. The 2024 guideline has removed them entirely because of macrolide resistance and treatment failure, so this is no longer an option at any stage
  • Option B – Benzathine penicillin G 2.4 million units intramuscularly once a week for three weeks: The drug and dose are right, which makes this attractive. Three weekly injections are the regimen for late latent, cardiovascular and gummatous syphilis. Secondary syphilis is early syphilis and is treated with one dose, so this would triple her injections for no gain
  • Option C – Doxycycline 100 mg orally twice daily for 14 days, as she would prefer tablets: Doxycycline is a genuine alternative for early syphilis, and respecting preference is good practice. It is a second-line option for when the injection cannot be given or is still declined after counselling, not a substitute offered before her fear of pain has been addressed, and two weeks of twice-daily tablets carries an adherence risk the injection does not
  • Option D – Procaine penicillin 600,000 units intramuscularly once daily for 10 days: This is a listed alternative for early syphilis and is still penicillin. It swaps one injection for ten daily injections and ten clinic visits, which answers her fear of injections in the worst possible way and adds nothing in efficacy for her

“Red Flags” and Key Decision Points

  • Visual, hearing or neurological symptoms: assess for ocular, otic or neurosyphilis, which is treated differently.
  • A positive pregnancy test: follow the separate 2024 joint guideline on syphilis in pregnancy, which is penicillin-based.
  • Genuine penicillin allergy: choose from the listed alternatives, never a macrolide.
  • Fever and a worse rash hours after the injection: expect a Jarisch-Herxheimer reaction and reassure rather than label an allergy.
  • No four-fold fall in RPR on follow-up: review for treatment failure or re-infection.

Relevance to Clinical Practice

Most people diagnosed with early syphilis will be treated in a GUM or integrated sexual health clinic, but GPs, practice nurses and pharmacists are often the first to hear the worry about the injection. The practical change from the 2024 guideline is that pain is now something to manage rather than accept: the lidocaine-containing preparation is licensed and recommended, and saying so often turns a request for tablets into consent for the injection. When a patient still cannot accept an injection or has a genuine penicillin allergy, the oral alternative is doxycycline for 14 days, with a frank conversation about adherence and follow-up. Document the stage, the RPR titre at diagnosis and the date of treatment, because every later result is interpreted against them, and start partner notification in the same consultation.

Founder’s Tip

When a patient asks for tablets because the injection hurts, fix the pain, not the prescription – one well-tolerated jab beats two weeks of hoping the tablets get taken.

Core Summary: A woman with secondary syphilis and no penicillin allergy should receive a single intramuscular dose of benzathine penicillin G 2.4 million units, now available in a licensed lidocaine-containing preparation that addresses her fear of pain, rather than azithromycin, which the 2024 BASHH guideline has removed, the three-dose late-syphilis regimen, or doxycycline or procaine penicillin, which are second-line alternatives.
DCSRH · Providing SRH careQuestion 5 of 10 · single best answer

Consent: applying the Fraser criteria to a 15-year-old

Scenario: A 15-year-old attends her GP surgery alone asking to start the combined pill. She has been in a relationship with a 16-year-old boy from her school for eight months; they have sex regularly and always use condoms, but she wants something more reliable. She does not want her mother told and, after the GP explores this, still declines, though she agrees to think about talking to her older sister. She explains back accurately how the pill works, its risks and that it does not protect against infections, and says they will keep having sex whatever the GP decides. The safeguarding assessment finds no coercion or exploitation. She is a non-smoker without migraine, her blood pressure is 112/70 mmHg, her BMI is 21 and her period started three days ago.

Question: What is the most appropriate next step?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is D: Prescribe it, recording how each of the five Fraser criteria has been met.

Core Lens: High-Yield Takeaways

  • The Fraser guidelines: set out in Gillick v West Norfolk [1985] by Lord Fraser, they allow contraceptive advice and treatment for an under-16 without parental knowledge when five conditions are met.
  • The five limbs: she understands the advice; she cannot be persuaded to involve her parents; she is likely to have sex regardless; her physical or mental health is likely to suffer without contraception; and her best interests require it without parental consent.
  • Encourage, do not require: the second limb asks the clinician to try to persuade her to involve a parent, not to make that a condition of treatment.
  • Write each limb down: the note should show how every criterion was assessed and met, in her words where possible, together with the safeguarding assessment.
  • Clinical checks still apply: Fraser answers whether she can have contraception without her parents; UKMEC, blood pressure and BMI answer whether this method is safe for her.
Click here for Deep Dive

Five Boxes, and Every One Needs a Sentence

Most clinicians know that a 15-year-old can be given contraception without her parents’ knowledge. Fewer can recite the five Fraser criteria, and fewer still document them properly. This vignette has been built so that every limb is answered in the stem: she explains the pill back accurately, she declines to involve her mother after genuine exploration, she says she will continue to have sex, pregnancy is a real risk to her health and future, and her best interests point towards reliable contraception. The distractors therefore represent the ways clinicians go wrong when they feel uneasy: demanding a parent, worrying about assisting an offence, referring by reflex, or rationing care as leverage. The right answer is not just to prescribe, but to prescribe with a record that shows the reasoning.

Why This Is the Right Move

In Gillick v West Norfolk [1985], the House of Lords held that a young person under 16 can consent to medical treatment if she has sufficient understanding and intelligence, and Lord Fraser set out the specific conditions for giving contraceptive advice or treatment without parental knowledge. Those five limbs are: that she understands the advice; that she cannot be persuaded to inform her parents or allow the clinician to do so; that she is likely to begin or continue having sex with or without contraception; that her physical or mental health, or both, are likely to suffer without contraceptive advice or treatment; and that her best interests require the clinician to give advice or treatment without parental consent. GMC guidance for doctors on 0-18 years reflects the same approach, placing the young person’s welfare first. Here each limb is met, so prescribing is lawful and appropriate.

The record is part of the answer. For each limb, write what she said or demonstrated: her explanation of how the pill works and its risks; the discussion about involving her mother and her agreement to consider her sister; her statement that sex will continue; the pregnancy risk if she relies on condoms alone; and why prescribing is in her best interests. Record the safeguarding assessment, including her partner’s age and the absence of coercion or exploitation. Clinically, her blood pressure, BMI and history raise no UKMEC concerns for combined hormonal contraception, and starting within the first five days of her cycle means no additional precautions are needed. Advise continued condom use for STI protection, offer an STI screen, and arrange an early review and then annual reviews.

Why the Other Options Don’t Fit

  • Option A – Ask her to return with a parent, as under-16s cannot consent to contraception: This is the position the Gillick case was brought to establish, and the House of Lords rejected it in 1985. An under-16 who is competent can consent to contraception, and the Fraser guidelines exist precisely for young people who will not involve a parent. Insisting on one would most likely leave her using condoms alone or nothing
  • Option B – Decline to prescribe, because providing it would assist an unlawful act: The concern that giving contraception to an under-16 encourages or assists unlawful intercourse was argued in Gillick itself, so this is a genuine historical position rather than a straw man. It was rejected: a clinician acting in good faith to protect a young person from pregnancy, within the Fraser guidelines, is not committing an offence, and later legislation reflects the same principle
  • Option C – Make a referral to children’s social care before any prescription is issued: Safeguarding assessment is mandatory for every young person, and some 15-year-olds do need a referral. Here the assessment found no coercion or exploitation, so a reflex referral is not indicated and delaying contraception for it would expose her to avoidable pregnancy. Referral follows identified risk, not age alone
  • Option E – Supply condoms only until she agrees to tell one of her parents: Condoms are worth supplying, and encouraging parental involvement is part of the second Fraser limb. Making effective contraception conditional on disclosure turns encouragement into coercion, contradicts the purpose of the Fraser guidelines and leaves her relying on the method she has told you she wants to move beyond

“Red Flags” and Key Decision Points

  • A limb that is not met: if she cannot explain the method back or is ambivalent about sex, pause and explore before prescribing.
  • Features of exploitation: an older partner, gifts, alcohol or drugs, secrecy demanded by the partner or going missing change the safeguarding picture.
  • Under 13: a child cannot consent to sex in law, so any sexual activity is a child protection matter.
  • A note that just says “Fraser competent”: record each limb and the evidence for it.
  • UKMEC conditions: migraine with aura, hypertension or a VTE history would change the method, not the Fraser decision.

Relevance to Clinical Practice

Under-16s requesting contraception are common in general practice and young people’s services, and the difference between good and poor care is usually not the decision but the process. A clinician who works through the five limbs aloud with the young person, genuinely encourages parental or other trusted-adult involvement, completes a safeguarding assessment and writes it all down is both protecting her and protecting themselves. The method choice still follows ordinary clinical rules: a history for UKMEC conditions, blood pressure and BMI for combined methods, and an honest discussion of LARC options. Finally, confidentiality is what brings young people back, so tell her clearly what will stay confidential and the rare circumstances in which it would not.

Founder’s Tip

“Fraser competent” is a conclusion, not a note. If the five reasons are not in the record, a colleague reading it later cannot tell you did the work.

Core Summary: A 15-year-old who understands the combined pill, will not involve her mother, will continue having sex, is at risk of pregnancy without it and has no safeguarding concerns meets all five Fraser criteria, so the GP should prescribe and document each limb, rather than insisting on a parent, refusing for fear of assisting an offence, referring by reflex or rationing contraception to force disclosure.
DCSRH · Planning pregnancyQuestion 6 of 10 · single best answer

Preconception: a woman found to be rubella non-immune

Scenario: A 28-year-old woman attends a community contraception clinic to plan a pregnancy. She was born abroad, has no record of childhood immunisation, and preconception blood tests arranged at her last visit show that she is rubella antibody negative. She is well, takes no medication other than folic acid 400 micrograms daily, and her body mass index is 24. She has taken a desogestrel progestogen-only pill correctly for two years, with no missed pills, and a urine pregnancy test today is negative. She and her partner hope to conceive within a few months and she asks what should happen about the rubella result.

Question: What is the most appropriate management?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is A: Advise MMR vaccination now and avoid pregnancy for the recommended interval after it.

Core Lens: High-Yield Takeaways

  • Rubella protection is sorted before, not during, pregnancy: a woman planning a pregnancy without two documented doses of MMR is offered MMR preconception, because the vaccine cannot be given once she is pregnant; UKHSA states there is no requirement for rubella antibody testing.
  • MMR is a live attenuated vaccine: it is contraindicated in pregnancy, which is why the opportunity is the preconception visit and not the booking appointment.
  • Contraception continues through the interval: she keeps taking her progestogen-only pill and avoids conception for one month after the last dose, as the Green Book advises.
  • Congenital rubella syndrome is the reason: maternal rubella in early pregnancy causes deafness, cataract, cardiac defects and neurodevelopmental damage.
  • Immunoglobulin is not a substitute: UKHSA advises that human normal immunoglobulin is not routinely used after rubella exposure because there is no evidence that it is effective, and it confers no immunity before conception.
Click here for Deep Dive

The Vaccine You Can Only Give Before She Conceives

A rubella antibody negative result in a woman planning pregnancy is an unusual thing in medicine: a problem with a solution that has a closing window. MMR protects her, but it is a live attenuated vaccine and cannot be given in pregnancy, so the only time it can be offered is now, while she is still using contraception. The trap in this question is the pull towards antenatal care. Rubella feels like an antenatal topic, and several options quietly defer the vaccine into pregnancy or beyond it. The other trap is the opposite error: giving the vaccine correctly and then failing to say the second half of the sentence, which is that she must not conceive immediately afterwards. The vaccine and the interval are one piece of advice, not two.

Why This Is the Right Move

Standard UK preconception practice is to establish rubella immunity before pregnancy and to offer MMR to a susceptible woman at that point, with a clear instruction to avoid conception for the recommended interval after vaccination. She is not pregnant today, has taken her progestogen-only pill correctly and has a negative test, so she can be vaccinated at this visit. The practical advice is to continue the pill without interruption, to conceive only after the advised interval has elapsed, and to return if she has any doubt about the timing. Because she has no record of childhood immunisation, she should be brought into the routine schedule rather than given a single opportunistic dose and forgotten, and the vaccination should be recorded so that the antenatal team can see it.

Use the visit for everything else that is easier before pregnancy than during it. Confirm her folic acid dose and check whether any higher-risk indication applies, advise vitamin D 10 micrograms daily, discuss alcohol and smoking, offer cervical screening if due, and consider varicella history, since a woman with no immunisation record may be susceptible to that as well. Explain in plain terms why rubella matters: infection in early pregnancy can cause congenital rubella syndrome, with deafness, eye and cardiac defects and neurodevelopmental problems, and the risk is highest in the first trimester. That explanation is usually what converts a vaccine that feels optional into one she actually attends for.

Why the Other Options Don’t Fit

  • Option B – Arrange MMR at her booking appointment once the pregnancy is confirmed and established: Booking is where a great deal of preventive care is delivered, so this has the right instinct and the wrong vaccine. MMR is live attenuated and is contraindicated in pregnancy, so it cannot be given at booking. A susceptible woman who conceives before vaccination spends her whole pregnancy unprotected and is offered the vaccine only after delivery, which is a worse outcome than the one available today
  • Option C – Give MMR today and tell her that contraception can be stopped straight away: This gets the vaccine right and then discards the precaution that goes with it. Standard advice after a live vaccine is to avoid conception for a defined interval, and telling her to stop the pill immediately invites exactly the situation the interval exists to prevent. The value of vaccinating preconception depends on the woman not conceiving in the days that follow
  • Option D – Reassure her that she can conceive now and be vaccinated after delivery instead: Postpartum MMR is real practice, offered to women found susceptible in pregnancy, which is what makes this plausible. It is a fallback for women whose susceptibility is discovered too late, not a plan to choose when the vaccine can be given today. Choosing it deliberately leaves her exposed throughout the pregnancy that matters most
  • Option E – Refer her for human normal immunoglobulin instead, as live vaccines cannot be used: The premise is half correct, since live vaccines are avoided in pregnancy, but she is not pregnant. Human normal immunoglobulin is not routinely used even after exposure in pregnancy, because there is no evidence that it is effective, and it does not produce lasting immunity, so it cannot substitute for vaccination before conception. Referring her for it would consume time and protect her from nothing

“Red Flags” and Key Decision Points

  • A live vaccine and an unprotected woman: confirm she is not pregnant and is using reliable contraception before giving MMR.
  • The interval left unsaid: the advice to delay conception after vaccination is part of the vaccination, not an optional extra.
  • No childhood immunisation record: think about completing the schedule and about varicella susceptibility too.
  • Susceptibility discovered in pregnancy: vaccinate after delivery and advise avoidance of contact with rubella in the meantime.
  • A missed opportunity at a contraception visit: the preconception visit is often the last contact before she stops her method.

Relevance to Clinical Practice

Contraception clinics see women at the exact moment when live vaccines are still possible, and that makes rubella status worth asking about whenever a woman raises pregnancy plans. The practical change is to pair three things in one entry: vaccinate, continue contraception, and give the interval before conception. Women who were born or immunised abroad, or who have no record at all, are the group most often found susceptible, and they are also the group least likely to be picked up by an assumption that everyone had MMR at school. Record the dose and the advice clearly so the antenatal team is not repeating the conversation, and offer the same check to her partner and household where relevant. Rubella is rare in the UK now precisely because this conversation keeps happening.

Founder’s Tip

MMR is the vaccine with a deadline. If a woman tells you she is planning a pregnancy, her rubella status is a better use of the next thirty seconds than almost anything else in the consultation.

Core Summary: A woman planning pregnancy who is found to be rubella antibody negative should be offered MMR now, while she is not pregnant and still using contraception, and advised to continue her method and avoid conception for the recommended interval afterwards, rather than deferring the live vaccine to booking or to after delivery, stopping contraception on the day of vaccination, or substituting immunoglobulin.
DCSRH · Early pregnancy & abortionQuestion 7 of 10 · single best answer

Early pregnancy: first-line management of a missed miscarriage

Scenario: A 32-year-old woman in her second pregnancy is seen in the early pregnancy assessment unit at 9 weeks by dates. A scan a week ago showed an intrauterine pregnancy with no fetal heartbeat, and today’s repeat transvaginal scan, reviewed by a second sonographer, confirms a missed miscarriage. She has had only light spotting, her pulse and blood pressure are normal, and she has no fever, offensive discharge or pelvic tenderness. She has no bleeding disorder, would accept a blood transfusion if one were needed, and her first pregnancy ended in an uncomplicated vaginal birth. She is willing to consider any option and asks what is normally recommended first.

Question: What is the most appropriate first-line management?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is A: Advise expectant management for 7 to 14 days in the first instance.

Core Lens: High-Yield Takeaways

  • Expectant first: NICE NG126 makes expectant management for 7 to 14 days the first-line approach for a woman with a confirmed diagnosis of miscarriage.
  • The diagnosis is already secure: two scans a week apart, with a second sonographer’s review, have confirmed the missed miscarriage, so more imaging adds delay and nothing else.
  • First-line is not the only line: medical and surgical management are offered when waiting is unacceptable to her, unsuitable for her, or does not work.
  • She has none of the reasons to move on: no heavy bleeding, no infection, no bleeding disorder, no refusal of transfusion and no previous traumatic pregnancy experience.
  • The end point is a urine test: if bleeding and pain settle, a urine pregnancy test at 3 weeks confirms resolution, and a positive result brings her back.
Click here for Deep Dive

Waiting Is a Treatment, Not a Delay

A missed miscarriage is usually found on a scan, often in a woman who had no idea anything was wrong, and the natural response from her and from the clinician is to want it dealt with. That instinct pushes towards tablets or theatre. NICE NG126 asks for something harder to say out loud: for most women, the first-line management of a confirmed miscarriage is to wait, with support, for 7 to 14 days. This woman is the textbook candidate. The diagnosis has been confirmed on a repeat scan, she is well, and every factor that would make waiting unsafe or unkind has been asked about and excluded in the stem. The trap is to treat a confirmed diagnosis as a reason to intervene, or to treat expectant management as doing nothing at all.

Why This Is the Right Move

NICE NG126, Ectopic pregnancy and miscarriage (2019, with the miscarriage recommendations amended in 2023), recommends expectant management for 7 to 14 days as the first-line strategy for women with a confirmed diagnosis of miscarriage. Many women pass the pregnancy tissue at home within that window without drugs, anaesthesia or an operation. The guideline then describes when other options should be explored instead: a woman at increased risk of haemorrhage, one for whom a previous experience such as stillbirth or antepartum haemorrhage makes waiting distressing, one at greater risk from the effects of bleeding, such as a woman with a coagulopathy or who cannot have a transfusion, and one with evidence of infection. Expectant management that a woman does not want is not first-line for her either.

Expectant management is an active plan, so it needs a script. Explain what to expect: bleeding heavier than a period, with cramping pain as the tissue passes. Give her pain relief advice and a named 24-hour contact. Tell her that if bleeding and pain have settled within 7 to 14 days she should take a urine pregnancy test at 3 weeks and return if it is positive. If bleeding has not started by the end of the window, or it is persisting or getting worse, she should be seen again and usually rescanned, and the conversation about medical or surgical management reopens. Anti-D is not needed for expectant management even if she is rhesus D-negative. Give her written information and make clear that she can change her mind at any point.

Why the Other Options Don’t Fit

  • Option B – Arrange manual vacuum aspiration under local anaesthetic this week: Manual vacuum aspiration is a genuine NG126 option, done under local anaesthetic, and many women value its speed and certainty, which is why it tempts. It is not the first-line recommendation for a woman with no reason to avoid waiting, and offering a procedure first quietly turns her choice into the clinician’s default. If she declines expectant management, it is a reasonable next conversation
  • Option C – Book surgical management in theatre under general anaesthetic: Surgery under general anaesthetic is the option many clinicians trained on, and it remains right when bleeding is heavy, infection is present or she chooses it after counselling. Here it adds anaesthetic risk, a theatre slot and a procedure to a situation that may resolve by itself within a fortnight. It is a later option for this well woman, not the opening one
  • Option D – Offer mifepristone followed by misoprostol 48 hours later as first line: This is the correct medical regimen for a missed miscarriage, which is exactly what makes it a strong distractor. Its place is when expectant management is unacceptable to her or has not worked. Leading with tablets skips the first-line step that NG126 sets out and brings drug side effects and faster, heavier bleeding to a woman who may need neither
  • Option E – Repeat the transvaginal scan in 7 days before discussing management: Repeat scanning is correct when the diagnosis is uncertain, and a half-remembered rule about waiting a week for a second scan makes this attractive. That step has already happened: last week’s scan and today’s scan, with a second sonographer’s review, agree. Another scan now delays the information she needs today without changing what will be offered

“Red Flags” and Key Decision Points

  • Heavy bleeding or haemodynamic change: soaking pads hourly, dizziness or collapse ends expectant management and needs urgent review.
  • Fever, offensive discharge or pelvic tenderness: evidence of infection is a reason to move away from expectant management.
  • A bleeding disorder or refusal of blood products: the effects of haemorrhage would be more serious, so explore medical or surgical options.
  • A previous traumatic pregnancy experience: stillbirth or a previous distressing loss can make waiting at home unacceptable, and that counts.
  • No bleeding by 14 days, or bleeding that persists: rescan and reopen the discussion about medical or surgical management.

Relevance to Clinical Practice

Many women who have a missed miscarriage diagnosed will talk it through again with someone outside the early pregnancy unit: a GP, a practice nurse or a sexual health clinician they already know. Knowing that expectant management is the NICE first-line plan lets that clinician reinforce it rather than undermine it with a well-meant suggestion that the pregnancy should simply be cleared. It also means knowing its limits: the warning signs for bleeding and infection, the 3-week urine pregnancy test and the point at which to rescan. The same contact is a natural moment to ask how she is coping, to raise contraception if she does not want to conceive again soon, and to make sure she knows that choosing tablets or a procedure instead is her right if waiting at home feels unbearable.

Founder’s Tip

Expectant management is a prescription, not the absence of one: write down the window, the warning signs, the phone number and the date of the pregnancy test, and she will feel managed rather than abandoned.

Core Summary: A well woman with a missed miscarriage confirmed on repeat scan, and no increased risk of haemorrhage, infection, coagulopathy or previous traumatic pregnancy experience, should be offered expectant management for 7 to 14 days as the NICE NG126 first-line approach, with a urine pregnancy test at 3 weeks, rather than immediate tablets, manual vacuum aspiration, theatre or yet another scan.
DCSRH · Psychosexual medicineQuestion 8 of 10 · single best answer

Psychosexual: erectile dysfunction as a cardiovascular marker

Scenario: A 41-year-old man of South Asian heritage books a GP appointment asking for a prescription of sildenafil. For 5 months his erections have been less firm and harder to maintain with his wife, and he now avoids sex. He plays five-a-side football each week with no chest pain, breathlessness or palpitations. He has never smoked, takes no medicines and has not had blood tests for several years. His father had a myocardial infarction at 52 and his brother has type 2 diabetes. His BMI is 30 kg/m2 and his blood pressure today is 152/94 mmHg. He says he would like the tablets today so he can get things back to normal.

Question: What is the most appropriate approach?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is B: Assess his cardiovascular risk and request blood tests before choosing treatment.

Core Lens: High-Yield Takeaways

  • The teaching line: the BSSM erectile dysfunction guideline states that a man with erectile dysfunction and no cardiac symptoms is a cardiac patient until proven otherwise.
  • Every new presentation: all men presenting with erectile dysfunction should have their cardiovascular risk factors assessed, with fasting glucose, a lipid profile and a morning testosterone.
  • Stratify before prescribing: men are graded as low, intermediate or high cardiovascular risk; low-risk men are managed in primary care and high-risk men are referred to cardiology before treatment.
  • PDE5 inhibitors remain first line: the guideline makes a PDE5 inhibitor first-line therapy, so the assessment shapes when and how to prescribe, not whether he deserves treatment.
  • The erection is the messenger: vascular erectile dysfunction can precede symptomatic coronary disease, which makes this consultation a cardiovascular opportunity.
Click here for Deep Dive

The Prescription He Asked For, After the Assessment He Needs

This man wants a quick fix, and sildenafil would very likely work. The temptation is to give it and move on, particularly as he is young, active and has no cardiac symptoms. That is exactly the scenario the British Society for Sexual Medicine had in mind when it wrote that a man with erectile dysfunction and no cardiac symptoms is a cardiac patient until proven otherwise. He has several risk markers stacked together: South Asian heritage, a father with a myocardial infarction at 52, a brother with type 2 diabetes, a BMI of 30 kg/m2 and a raised blood pressure reading. Erectile dysfunction in this context may be the first sign of endothelial disease. The question tests whether the candidate will pause to assess and stratify that risk before prescribing, rather than either skipping the assessment or overreacting with a cardiology referral.

Why This Is the Right Move

The BSSM guideline on the management of erectile dysfunction (2017) recommends that all men presenting with new erectile dysfunction have their cardiovascular risk factors assessed, with fasting glucose, a lipid profile and a morning testosterone. It uses a graded low, intermediate and high-risk approach based on the Princeton consensus to decide how safe sexual activity and treatment are and who needs further evaluation. Men at low cardiovascular risk can be managed in primary care; men at high risk should be referred to cardiology before treatment for erectile dysfunction begins. Once that is settled, the guideline makes PDE5 inhibitors such as sildenafil, tadalafil and vardenafil first-line therapy (Recommendation 9, level 1a evidence, grade A), alongside lifestyle and risk factor modification.

In this consultation that means a structured history of exercise tolerance and cardiac symptoms, which his football helps with, a check for nitrate use, and a repeat blood pressure with confirmation of hypertension through the usual pathway. Request the baseline bloods and calculate a formal cardiovascular risk score once results are back. Explain why you are doing this, framing it as looking after his heart as well as his sex life, and agree a short interval to review the results. Most men like him will be low or intermediate risk and can then start a PDE5 inhibitor with lifestyle advice on weight, activity and alcohol. Address the relationship and the avoidance he describes, since anxiety often compounds an organic cause, and offer his wife a place in the conversation if he wishes.

Why the Other Options Don’t Fit

  • Option A – Advise that erectile difficulty at his age is usually stress-related and needs no tests: Psychological factors are common in younger men and often contribute, so this has some truth. It ignores his risk profile entirely: family history, ethnicity, weight and a raised blood pressure. The guideline expects every new presentation to have cardiovascular risk factors and baseline bloods assessed, whatever the age
  • Option C – Prescribe sildenafil today and review him only if the tablets do not work: This gives him the first-line drug he asked for, and sildenafil is usually safe in a man with no nitrate use, so it is a near miss. It skips the risk stratification the guideline places before treatment, leaves a raised blood pressure unexplored and treats the erectile dysfunction as the whole problem rather than a possible sign of vascular disease
  • Option D – Refer to cardiology for an exercise stress test before any treatment is offered: Cardiology referral is the right step for a man at high cardiovascular risk, which is why it appeals. He has no cardiac symptoms and good exercise tolerance, and his risk has not yet been quantified. Referring before assessment skips the primary care stratification that decides who actually needs specialist cardiac evaluation
  • Option E – Suggest he buys sildenafil over the counter from a community pharmacy instead: Sildenafil is available from pharmacies after a pharmacist consultation, so this seems a convenient shortcut. It sends a man with several unassessed cardiovascular risk factors away from the one consultation where they could be identified. A pharmacist would reasonably refer him back for the assessment he has just been denied

“Red Flags” and Key Decision Points

  • Chest pain, breathlessness or palpitations on exertion: assess and treat the cardiac problem before erectile dysfunction treatment.
  • Any nitrate or riociguat: PDE5 inhibitors are contraindicated and an alternative is needed.
  • High cardiovascular risk on stratification: refer to cardiology before starting treatment.
  • Raised glucose or low testosterone on baseline bloods: each changes management and needs its own plan.
  • Poor exercise tolerance: an inability to manage moderate exertion questions the safety of sexual activity.

Relevance to Clinical Practice

In a GP surgery or a sexual health clinic, a request for sildenafil is one of the few times a middle-aged man with no symptoms asks for help, and it should be used. The practical change is to treat every new presentation of erectile dysfunction as the start of a cardiovascular assessment: blood pressure, weight, smoking, family history, exercise tolerance, fasting glucose, lipids and a morning testosterone. Stratify risk, refer the minority at high risk and treat the majority in primary care with a PDE5 inhibitor and lifestyle change. Explain the link to him honestly, as it often motivates change more effectively than general health advice. Code the erectile dysfunction and the risk factors, and make sure the follow-up for his blood pressure actually happens.

Founder’s Tip

When a man asks for sildenafil, give him a blood pressure check and a lipid profile first – he came for his erections and may leave with his heart attended to as well.

Core Summary: A man with new erectile dysfunction and no cardiac symptoms but several risk factors should be treated as a cardiac patient until proven otherwise, with cardiovascular risk assessed, baseline bloods taken and risk stratified before a PDE5 inhibitor is chosen, rather than being reassured, given sildenafil straight away, sent to cardiology first or directed to buy it over the counter.
DCSRH · Menopause & later lifeQuestion 9 of 10 · single best answer

Menopause: using FSH to stop contraception over 50

Scenario: A 52-year-old woman attends a community sexual health clinic. She has taken the desogestrel 75 microgram pill for 6 years and has had no bleeding for the past 3 years. She has occasional hot flushes, does not take HRT and has no medical problems. She would like to stop contraception if it is safe to do so and does not want to keep taking the pill until 55 unless she has to. At her request, her GP checked a serum FSH 2 weeks ago while she continued the pill as usual, and the result was 64 IU/L. She is in a relationship with a male partner and does not want another pregnancy.

Question: What is the most appropriate advice?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is E: Stop the pill after a further year, as the FSH suggests ovarian insufficiency.

Core Lens: High-Yield Takeaways

  • Who the test is for: FSH can help decide when to stop contraception in women over 50 who are amenorrhoeic on a progestogen-only method other than the injection.
  • The threshold: a level above 30 IU/L indicates ovarian insufficiency, and 64 IU/L is well above it.
  • Not a same-day stop: a raised FSH supports stopping after a further year of contraception, not stopping today.
  • Progestogen-only pills do not distort the result: unlike combined hormonal contraception and HRT, the desogestrel pill does not make FSH uninterpretable.
  • Testing is optional: she could instead continue to 55 and stop without any test.
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Amenorrhoea on the Pill Tells You Nothing; FSH Can Tell You Something

Women on progestogen-only methods often reach their fifties without any idea whether they have gone through the menopause, because the method itself commonly stops bleeding. Three years without a bleed on desogestrel is not evidence of anything. That is why the question is about FSH: in a small, defined group, a blood test can do what the bleeding pattern cannot. This woman sits squarely in that group: over 50, amenorrhoeic, on a non-injectable progestogen-only method, and keen to stop. The traps are to overreact to the result by stopping today, to dismiss it by confusing the desogestrel pill with the combined pill, or to ignore the test’s value altogether by insisting on 55. The question tests the rule and its limits together.

Why This Is the Right Move

The CoSRH (formerly FSRH) Contraception for Women Aged Over 40 guideline (2017, amended May 2025) states that FSH measurement may be used to help decide when to stop progestogen-only contraception in women over 50 who are amenorrhoeic, and that a level above 30 IU/L indicates ovarian insufficiency. The testing is restricted to women on non-injectable methods: the progestogen-only pill, the implant and the LNG-IUS. A single raised result does not prove that ovulation has ended for good, which is why the result supports stopping after one further year of contraception rather than immediately. Her level of 64 IU/L, taken while she continued the pill, is valid. She can continue desogestrel for 12 more months and then stop, or she can choose to continue to 55, when all contraception can be stopped.

Explain the plan in plain terms and write down the stop date. Some local protocols repeat a raised FSH to confirm it before starting the one-year countdown; follow yours if it does. Make sure she understands that stopping the pill may unmask vasomotor symptoms and, rarely, a bleed. Any bleeding after she stops needs assessment, because postmenopausal bleeding is not a normal return of periods. Offer a discussion of HRT if her flushes become troublesome, and remind her that HRT itself is not contraception, so the stop date should be set before any HRT starts. Condoms remain advisable for STI protection with a new partner at any age.

Why the Other Options Don’t Fit

  • Option A – Advise stopping the pill today, as the FSH confirms she is postmenopausal: A level of 64 IU/L is high, and it is tempting to treat it as a diagnosis. But FSH fluctuates in the late perimenopause and a single raised value does not guarantee that ovulation will not resume. The guideline uses the result to start a further year of contraception, not to stop on the day of the result
  • Option B – Continue the pill until 55, as FSH cannot guide stopping a progestogen-only pill: Continuing to 55 is a perfectly safe choice, so this is a near miss. But the reasoning is wrong: FSH testing exists precisely for amenorrhoeic women over 50 on progestogen-only methods. She has said she wants to stop sooner if safe, and the test gives her a valid route to do so
  • Option C – Disregard the result, as desogestrel suppresses FSH and makes it unreliable: This confuses two rules. Combined hormonal contraception and HRT suppress the pituitary and make FSH uninterpretable. A progestogen-only pill does not, which is why the guideline allows testing on it. The injectable is the progestogen-only exception, and even there timing matters. Her result can be used
  • Option D – Repeat the FSH in her pill-free week before giving any advice: Pill-free intervals belong to combined hormonal contraception, where a test might be timed around the break. The desogestrel pill is taken every day without a break, so there is no pill-free week in which to test. Her existing result was taken correctly while she continued the pill and can be acted on

“Red Flags” and Key Decision Points

  • Combined pill or HRT: FSH is uninterpretable, so do not use it to decide when to stop.
  • DMPA: DMPA suppresses FSH, so a test is taken just before the next injection if one is used at all.
  • Under 50: this FSH-based stopping rule is not for women under 50.
  • Bleeding after stopping: treat bleeding after a year of amenorrhoea off hormones as postmenopausal bleeding.
  • Age 55: all contraception can be stopped at 55 without any test.

Relevance to Clinical Practice

Stopping contraception is one of the commonest questions in the fifties, and the answer depends on the method as much as on the woman. For a woman over 50 on a progestogen-only pill, implant or LNG-IUS, FSH is a legitimate tool, and a raised level converts an open-ended “keep going until 55” into a firm date. The practical change is to record the result, its date, the method in use and the agreed stop date in one line, so a pharmacist or GP colleague can act on it without re-testing. Offer testing as a choice, not a requirement: some women prefer simply to continue to 55. When she stops, make sure she knows which symptoms to report, and link the conversation to menopause care rather than leaving it at the contraception review.

Founder’s Tip

On a progestogen-only method over 50, a high FSH is not a finish line, it is a countdown. Give her the date, in writing.

Core Summary: A 52-year-old amenorrhoeic on the desogestrel pill with an FSH of 64 IU/L has evidence of ovarian insufficiency and can stop contraception after a further year, because the test is valid on non-injectable progestogen-only methods over 50, rather than stopping today, discounting the result, retesting in a pill-free week that does not exist or insisting on continuing to 55.
DCSRH · Prescribing — postpartumQuestion 10 of 10 · single best answer

Breastfeeding: a woman with raised BMI after caesarean at three weeks

Scenario: A 35-year-old woman is seen at a GP surgery three weeks after an emergency caesarean section for failure to progress. She is breastfeeding, with one formula feed at night, and her wound is healing well. Her BMI is 36 and her estimated blood loss at operation was 1200 ml, recorded as a postpartum haemorrhage, although she did not need a transfusion. She is fully mobile, does not smoke, has no personal or family history of venous thrombosis and had no pre-eclampsia. She and her partner want to resume intercourse this week and she wants effective contraception starting today. She used a levonorgestrel 150 microgram/ethinylestradiol 30 microgram pill before this pregnancy and would like it back, and she has also read about having a coil fitted.

Question: What is the most appropriate plan today?

Pick an answer to reveal the explanation.

CorrectIncorrect

The correct answer is E: Start a progestogen-only pill or implant today, deferring combined methods and any device.

Core Lens: High-Yield Takeaways

  • Breastfeeding under six weeks settles it: combined hormonal contraception is UKMEC category 4, so the combined pill is out whatever else is true.
  • Her thrombotic risk factors stack on top: caesarean delivery, a BMI of 36 and a significant blood loss each independently delay combined methods to six weeks.
  • Three weeks is the wrong week for a device: insertion between forty-eight hours and four weeks postpartum is avoided because of expulsion risk.
  • Progestogen-only methods remain open: the pill and the implant can be started at any time postpartum in any feeding pattern.
  • Do not send her away empty-handed: she plans to resume intercourse this week and ovulation can return from around day twenty-one.
Click here for Deep Dive

Three Closed Doors and One Open One

This is a stacking question, and the trap is that each element on its own invites a different answer. Her risk factors look serious enough to make a candidate reach for the most conservative option and defer everything. Her mobility and her intact wound look reassuring enough to make another candidate start the combined pill. Her interest in a coil looks like an easy win. What the question rewards is working through the elements in order and noticing that three of the four doors are closed for three different reasons, while one is wide open and has been all along. Combined methods are barred twice over, by breastfeeding under six weeks and by a cluster of postpartum thrombotic risk factors. A device is barred by the calendar. The progestogen-only methods were never restricted at all.

Why This Is the Right Move

UKMEC 2025 rates combined hormonal contraception as category 4 in a breastfeeding woman less than six weeks postpartum, and category 4 means an unacceptable health risk with no balancing to be done. Even setting breastfeeding aside, the CoSRH (formerly FSRH) Contraception After Pregnancy guideline (2017, amended 2020) delays combined methods to six weeks in any woman with an added venous thromboembolism risk factor, and it names caesarean delivery, a BMI of 30 or more, postpartum haemorrhage, transfusion, immobility, pre-eclampsia and smoking. She has three of those. Intrauterine contraception is governed by timing: unrestricted within forty-eight hours of birth, avoided between forty-eight hours and four weeks because of the expulsion risk, and unrestricted again from four weeks. At three weeks she sits in the middle of the window that is avoided.

Progestogen-only methods carry none of these restrictions. The progestogen-only pill and the etonogestrel implant are category 1 at every postpartum stage in any feeding pattern and may be started immediately after birth, so either can be started or fitted today. This matters because she is past day twenty-one, ovulation can have resumed, and she intends to resume intercourse this week. Start her today with the appropriate run-in precautions: two days for a traditional or desogestrel pill, seven days for the implant. Then set the two dates that make this a plan rather than a refusal. Combined methods can be reconsidered at six weeks, with her raised BMI counselled as an ongoing factor. Intrauterine contraception can be arranged from four weeks, which is next week, with perforation risk explained as higher in breastfeeding women.

Why the Other Options Don’t Fit

  • Option A – Arrange a 52 mg levonorgestrel intrauterine system to be fitted later this week: The method is an excellent choice for her and the timing is wrong by a matter of days. Insertion between forty-eight hours and four weeks postpartum is avoided because expulsion risk is markedly increased, and perforation risk is higher again in a breastfeeding woman. Booking the same device for a week later, once she is four weeks postpartum, is the correct version of this idea
  • Option B – Give the combined pill now, because her caesarean was three weeks ago and she is fully mobile: Mobility is genuinely protective and the reasoning is not foolish, but it weighs one factor against several. She is breastfeeding at under six weeks, which is category 4 on its own, and she carries a caesarean, a BMI of 36 and a 1200 ml blood loss. No amount of mobility converts that into a safe start today
  • Option C – Offer the contraceptive patch, as the transdermal route avoids the thrombotic risk of tablets: The patch is combined hormonal contraception and carries the same categories as the pill and the ring. Avoiding first-pass metabolism does not reduce systemic oestrogen exposure or thrombotic risk, and the UKMEC tables are written by method class precisely so that a change of route cannot be used to sidestep a category 4
  • Option D – Recommend she uses condoms alone until the six-week check and decides then: This treats a closed door as a closed consultation. She is past day twenty-one, plans to resume intercourse this week, and has asked for effective contraception today, while progestogen-only methods have been available to her since the day of delivery. Three weeks of condoms in a woman who has not asked for them is a foreseeable unplanned pregnancy

“Red Flags” and Key Decision Points

  • Calf pain, breathlessness or pleuritic chest pain: a postpartum woman with these needs assessment for venous thromboembolism, not contraception advice.
  • Wound pain, fever or offensive lochia: exclude sepsis before any device is contemplated.
  • Risk factors that stack: caesarean, raised BMI and haemorrhage together are more than the sum of their categories.
  • The forty-eight hour to four week window: the one period in which device insertion is deliberately avoided.
  • Day twenty-one: the point from which ovulation may have returned and additional precautions become necessary.

Relevance to Clinical Practice

Women are commonly seen for the first time after a complicated delivery at two to three weeks, often by a clinician who did not deliver them and is working from a discharge summary. The habit worth building is to take the elements in a fixed order: feeding status, then thrombotic risk factors, then days since delivery, then what she has asked for. That order produces the answer here in under a minute and stops a raised BMI or a caesarean being used as a reason to offer nothing. Give her a method the same day, name the two future dates explicitly, and write them in the notes so the six-week check becomes a review rather than a fresh start. Counsel the higher perforation risk at device insertion while breastfeeding and arrange the thread check afterwards. Finally, use the visit for the rest of postnatal care: wound, mood, feeding and weight.

Founder’s Tip

When the risk factors pile up postnatally, the answer is almost never nothing. Work out which doors are shut and for how long, then walk her through the one that was never locked.

Core Summary: At three weeks postpartum a breastfeeding woman with a caesarean, a BMI of 36 and a 1200 ml blood loss cannot have combined hormonal contraception, which is category 4 on feeding status alone and delayed to six weeks by her thrombotic risk factors, and cannot have a device fitted inside the forty-eight hour to four week window, so she should start a progestogen-only pill or implant today with a device booked from four weeks and combined methods reconsidered at six.
Dr David Palethorpe
David’s tip
“The ILP looks like the big lift, but it’s the OTA that catches people out — it rewards knowing UKMEC cold and being comfortable prescribing at the edges, postpartum and perimenopausal. Build that habit early and the rest of the diploma feels lighter.”
Dr David Palethorpe, Co-Founder & GP Partner (MBBS, BSc (Hons), MRCGP)

A note on accuracy and independence. Diploma structure and terminology follow the College of Sexual & Reproductive Healthcare (CoSRH), which renamed from the FSRH in 2025; the diploma is the DCSRH, formerly the DFSRH. Contraception content uses UKMEC 2025. Always check the current requirements on the CoSRH website before applying — Core Revision is an independent educational platform and is not affiliated with CoSRH or the RCGP.

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Questions? Email admin@corerevision.com

Core Revision Ltd, registered in England & Wales, company no. 16956954. Registered office: 71–75 Shelton Street, Covent Garden, London, WC2H 9JQ.

© 2026 Core Revision Ltd. All rights reserved.

Core Revision Ltd is an independent educational platform and is not affiliated with the RCGP or the College of Sexual & Reproductive Healthcare (CoSRH).

Written by practising UK GPs — Dr Victoria Hammond and Dr David Palethorpe. Education only — always confirm against current guidance. Core Revision is an independent revision resource.

Quick answers about the DCSRH

Checked against the CoSRH's own pages on 16 October 2026.

How does the DCSRH work?

You complete four assessments signed off by a CoSRH Registered Trainer: an Independent Learning Portfolio, five Summative Clinical Assessments, the Online Theory Assessment and the Assessment Half Day. You have two years from approval. Most candidates take about 12 months.

Do I need a trainer for the DCSRH?

Yes. You cannot apply until a CoSRH Registered Trainer has agreed to support you. Trainers take on limited numbers, so start that conversation early.

What is the DCSRH Online Theory Assessment?

50 single-best-answer questions in one hour, taken online and open book, with a 60% pass mark.

How much does the DCSRH cost?

Enrolment is £331 at 2026 prices, including your first theory attempt. Theory resits are £93 each. Diplomate membership is £142 (2026). Your trainer sets their own fees. CoSRH estimates the total at £473 to £1,300 or more.

Who can do the DCSRH?

Healthcare professionals registered in the UK or Ireland who work in primary care, community services or integrated sexual health services. CoSRH names doctors, nurses, midwives, pharmacists and physician associates.

Is the DFSRH the same as the DCSRH?

The DCSRH replaced the DFSRH; the College was formerly the FSRH. The DCSRH is a new pathway and CoSRH says learning from a previous diploma does not usually carry over.

What do I get with Core Revision's DCSRH access?

650 questions in the style of the Online Theory Assessment across 12 modules, timed mock theory papers, the ten-chapter revision guide and the Station Simulator for the Assessment Half Day. Access is £49.99 for 12 months. You can try ten questions free first.

Our free guides to the DCSRH

Dates, fees, format and revision plans, checked against the college’s own pages. Newest first. Still choosing a diploma? Compare all eight side by side.