Core Revision
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 · Core Tools
DRCOG Core Tools
Contraceptive eligibility, bleeding in early pregnancy, hypertension in pregnancy and abnormal bleeding — the four places the DRCOG, and real women’s-health practice, most often catch people out. Commit to an answer before you see the reasoning. That moment of commitment is what makes it stick.
Commit to an answer before the reasoning unlocks. You get why the right answer is right, why not the others — the trap each wrong option sets — and the rule to carry into the exam.
UK MEC decoder
Six contraception vignettes that pin the CoSRH UKMEC category (1 to 4) for combined hormonal contraception and name the safe alternative.
Scenario 1 of 6
A 27-year-old wants to start the combined pill. She has migraines that are preceded by 20 minutes of zigzag visual disturbance. She is otherwise fit and well.
What is the UKMEC category for combined hormonal contraception here?
Choose one to unlock the reasoning.
Why
Migraine with aura is CHC Category 4 at any age. Aura marks a raised ischaemic stroke risk and oestrogen compounds it, so this is an absolute contraindication.
Why not the others
- Migraine-without-aura — Migraine without aura is generally Category 2 for starting CHC, but the zigzag visual warning is aura.
- Age-softens-it — Downgrading to Category 3 because she is young and well is wrong; age does not soften it.
- No-restriction — Category 1 ignores the stroke risk that aura plus oestrogen creates.
The rule
Migraine with aura is CHC Category 4, at any age. The copper IUD is UKMEC 1 and every progestogen-only method is UKMEC 2 (UKMEC 2025).
Scenario 2 of 6
A 34-year-old had a provoked DVT after orthopaedic surgery four years ago. She is no longer anticoagulated and asks about the combined pill.
What is the UKMEC category for combined hormonal contraception?
Choose one to unlock the reasoning.
Why
Past VTE, whether provoked or not and whether anticoagulated or not, is CHC Category 4. Offer an oestrogen-free method: the copper IUD is unrestricted and the LNG-IUS is also suitable.
Why not the others
- Provoked-so-fine — A provoked clot is still Category 4; the classification does not distinguish provoked from unprovoked for CHC.
- Cat-3-compromise — There is no middle ground here; past VTE is Category 4, not Category 3.
- Off-anticoagulant-so-safe — Being off anticoagulation does not lower the category; it stays Category 4.
The rule
Any past VTE is CHC Category 4, provoked or not, anticoagulated or not. A known thrombogenic mutation such as Factor V Leiden is also Category 4 even with no personal clot.
Scenario 3 of 6
A woman who is 3 weeks postpartum and fully breastfeeding, with no other risk factors, asks to start the combined pill now.
What is the UKMEC category for combined hormonal contraception today?
Choose one to unlock the reasoning.
Why
Breastfeeding plus less than 6 weeks postpartum is CHC Category 4, driven by postpartum thrombotic risk and the oestrogen effect on establishing lactation. Offer POP or implant, which are Category 1 immediately postpartum with no bridging.
Why not the others
- Six-week-window — Category 2 applies from 6 weeks to 6 months of breastfeeding; she is only 3 weeks postpartum.
- Breastfeeding-benign — Category 1 for breastfeeding only applies from 6 months, not at 3 weeks.
- Cat-3-hold — This early it is a firm Category 4, not a Category 3 compromise.
The rule
Breastfeeding and under 6 weeks postpartum is CHC Category 4; 6 weeks to 6 months is Category 2; from 6 months Category 1.
Scenario 4 of 6
A 41-year-old on a combined pill repeat has a blood pressure of 152/96 recorded twice today. She is untreated for hypertension.
What is the UKMEC category for continuing combined hormonal contraception?
Choose one to unlock the reasoning.
Why
Systolic 140 to 159 or diastolic 90 to 99 is CHC Category 3. The expected answer is to confirm the readings, assess the hypertension and discuss a method that does not raise blood pressure: the IUDs, implant and POP are Category 1 at any stage of hypertension, and the injectable is Category 2 (UKMEC 2025).
Why not the others
- All-HTN-is-Cat4 — Only 160/100 or above is Category 4; 152/96 sits in the Category 3 band.
- Near-normal-number — Treating 152/96 as trivial misreads the threshold; it is already Category 3.
- HTN-does-not-matter — Category 1 ignores that even adequately controlled hypertension on treatment is Category 3 for CHC.
The rule
Systolic 140 to 159 or diastolic 90 to 99 is CHC Category 3; 160/100 or above is Category 4, stop. A blood pressure check before starting or continuing CHC is the most examinable safety-net in this topic.
Scenario 5 of 6
A 36-year-old has been on the combined pill for years. She smokes 20 cigarettes a day.
What is the UKMEC category for continuing combined hormonal contraception?
Choose one to unlock the reasoning.
Why
Age 35 or over plus 15 or more cigarettes a day is CHC Category 4. The expected answer is that CHC should not be continued: offer stop-smoking support and a progestogen-only method or an IUD, all Category 1 for smoking (UKMEC 2025).
Why not the others
- Under-fifteen-a-day — Age 35 or over with fewer than 15 a day is Category 3, but she smokes 20 a day, which is Category 4.
- Young-smoker-rule — Under 35 with any smoking is Category 2; she is 36, so that band does not apply.
- Long-time-user — Years of tolerating the pill does not lower the category; the current risk is Category 4.
The rule
Age 35 or over plus 15 or more cigarettes a day is CHC Category 4. Under 35, any smoking is Category 2; at 36 on 20 a day it is Category 4.
Scenario 6 of 6
A 36-year-old asks to continue the combined pill. She used to smoke 20 a day but stopped two years ago, and has no other risk factors.
What is the UKMEC category for combined hormonal contraception now?
Choose one to unlock the reasoning.
Why
Stopped smoking more than a year ago is Category 2, not Category 4. The key is to ask when she stopped.
Why not the others
- Ex-smoker-still-4 — Having stopped over a year ago drops her out of the Category 4 band; she is Category 2.
- Did-not-ask-when — A cautious Category 3 comes from failing to ask when she stopped smoking.
- No-restriction — Category 1 overshoots; an ex-smoker over a year out is Category 2, not unrestricted.
The rule
Ask when she stopped. Stopped smoking more than a year ago is Category 2, not Category 4.
Bleeding in early pregnancy
Six early-pregnancy bleeding vignettes that separate emergency from EPAU and name the diagnosis, anchored to NICE NG126.
Scenario 1 of 6
A 29-year-old at 7 weeks has had 2 days of light spotting and no pain. Observations are normal, the os is closed, and a pregnancy test is positive.
What is the most appropriate next step?
Choose one to unlock the reasoning.
Why
This is threatened miscarriage until proved otherwise. A closed os separates threatened from inevitable, but you cannot call it on the os alone because ectopic can present identically, so she still needs a scan.
Why not the others
- Most-settle-so-skip — Most threatened miscarriages settle, but that is not a licence to skip the scan.
- Over-call-emergency — She is stable with normal observations and a closed os; 999 over-escalates a case that needs EPAU.
- Os-tells-all — The os cannot rule out ectopic, which can present identically, so a scan is still required.
The rule
Bleeding with pain, at 6 weeks or more, or of uncertain gestation means EPAU referral (NICE NG126); only under 6 weeks, without pain or risk factors, is expectant management with a repeat pregnancy test after 7 to 10 days used. Transvaginal ultrasound is first-line imaging.
Scenario 2 of 6
A 31-year-old with 6 weeks of amenorrhoea has right iliac fossa pain building over 36 hours and brown spotting. She feels faint on standing. Pulse 108, BP 96/58.
What is the most appropriate action?
Choose one to unlock the reasoning.
Why
This is a ruptured ectopic. Pain precedes bleeding, the brown loss is decidual and the real blood is intra-abdominal. The expected answer is immediate emergency admission; while waiting, the usual steps are lying her flat, IV access and alerting the gynaecology team.
Why not the others
- EPAU-not-999 — Haemodynamic instability needs emergency admission now, not an EPAU appointment.
- Test-before-transfer — Do a pregnancy test only if instant; never delay transfer for it.
- Brown-is-benign — Brown loss is decidual and reassuring only on the surface; the danger is intra-abdominal blood.
The rule
Haemodynamic instability means 999 now, not an EPAU slot. Shoulder-tip pain and pain on defecation signal peritoneal blood, so ask.
Scenario 3 of 6
A 26-year-old at 9 weeks has heavy bleeding with clots and central cramp. The os is open with products visible in the canal. Pulse 88, BP 112/70.
What is the priority management step?
Choose one to unlock the reasoning.
Why
Miscarriage is under way. Products in the canal can cause cervical shock, a vagal bradycardia with hypotension that mimics haemorrhagic shock and resolves when the tissue is removed. Then arrange urgent gynaecology and scan for retained products.
Why not the others
- Routine-anti-D — Since June 2026 anti-D is not offered at all for miscarriage or ectopic up to and including 11+6 weeks, by any route (NICE NG126, 1.18.1). At 9 weeks she needs none.
- Send-home-bleeding — Heavy bleeding with an open os and products in the canal needs urgent gynaecology, not discharge.
- Missed-cervical-shock — Treating it purely as haemorrhagic shock misses that removing the tissue resolves the vagal picture.
The rule
Bradycardia alongside heavy bleeding with products in the os is cervical shock; remove the tissue.
Scenario 4 of 6
A 33-year-old has a positive test at 5 weeks with a mild left-sided niggle and no bleeding. She is stable. She has a previous ectopic and salpingectomy.
What is the safest plan?
Choose one to unlock the reasoning.
Why
A positive test plus pain plus a previous ectopic means EPAU now. At 5 weeks a scan may show a pregnancy of unknown location, which is not reassuring, so serial hCG 48 hours apart is used; a rise of 63 percent or more suggests intrauterine, while a suboptimal rise or plateau raises ectopic suspicion.
Why not the others
- She-feels-fine — Feeling fine is the commonest reason an ectopic gets sent home; it does not make review in a week safe.
- No-bleed-no-ectopic — Absence of bleeding does not exclude ectopic; pain precedes bleeding in tubal rupture.
- hCG-instead-of-referral — Serial hCG has a role, but it belongs within EPAU referral, not as a substitute for it.
The rule
Positive test plus pain plus previous ectopic means EPAU now. She feels fine is the commonest reason an ectopic gets sent home.
Scenario 5 of 6
A 30-year-old at 10 weeks has bleeding, vomiting out of proportion to her dates, and a uterus large for dates. She has had no booking scan.
What is the most likely diagnosis?
Choose one to unlock the reasoning.
Why
Very high hCG drives the disproportionate vomiting and can produce early pre-eclampsia or thyrotoxic features, with a snowstorm appearance on ultrasound; the diagnosis is histological. Refer to EPAU and, if a mole is confirmed, register with a specialist trophoblastic screening centre for hCG surveillance.
Why not the others
- Just-hyperemesis — Calling it hyperemesis alone misses the large-for-dates uterus and bleeding that complete the picture.
- Just-bleeding — Threatened miscarriage does not explain the disproportionate vomiting and enlarged uterus.
- Twins-explain-size — A multiple pregnancy accounts for size but not the bleeding plus disproportionate vomiting triad.
The rule
The classic triad is large-for-dates uterus, disproportionate vomiting and early bleeding: think molar pregnancy.
Scenario 6 of 6
A woman who is rhesus D negative is having surgical management of a miscarriage at 9 weeks. A colleague asks when anti-D is indicated.
When is anti-D indicated in early pregnancy loss?
Choose one to unlock the reasoning.
Why
NICE updated NG126 in June 2026 and the rule is now gestational, not procedural. Recommendation 1.18.1: do not offer anti-D for ectopic pregnancy or miscarriage up to and including 11+6 weeks — medical or surgical, instrumentation or not. At 9 weeks she needs none. From 12+0 to 12+6 (rec 1.18.2) anti-D is offered for medical management or a surgical procedure, at a minimum dose of 250 IU (50 micrograms).
Why not the others
- Anti-D-for-everyone — Still wrong, and now doubly so: nothing under 12+0 weeks warrants anti-D for miscarriage, by any route.
- Surgical-management — This was the correct answer under the old route-based rule, and it is the trap now. Since June 2026 the route of management is irrelevant below 12+0 weeks.
- Ectopic-only — Ectopic and miscarriage are treated identically by NG126: nothing below 12+0 weeks, and the same offer from 12+0 to 12+6.
The rule
Since June 2026 the question is the gestation, not the operation: nothing below 12+0 weeks for miscarriage or ectopic, and 250 IU from 12+0 to 12+6 (NICE NG126).
Hypertension in pregnancy
Six pregnancy hypertension vignettes that classify severity, spot pre-eclampsia red flags and set safe thresholds, anchored to NICE NG133.
Scenario 1 of 6
A 32-year-old at 33 weeks has a blood pressure of 146/94 recorded twice four hours apart. There is no proteinuria, she feels well and her bloods are normal.
How should you classify and act on this?
Choose one to unlock the reasoning.
Why
New hypertension after 20 weeks with no significant proteinuria is gestational hypertension. There is no admission at these figures, but obstetric-led surveillance is needed because many progress to pre-eclampsia, and NICE NG133 (1.4.1) advises a full assessment in a secondary care setting by a professional trained in hypertensive disorders of pregnancy.
Why not the others
- Over-admit — 146/94 does not need admission; it needs a full assessment in secondary care.
- Call-it-pre-eclampsia — With no proteinuria or organ dysfunction this is gestational hypertension, not pre-eclampsia.
- Under-refer — Routine review without specialist input misses that many cases progress to pre-eclampsia.
The rule
New hypertension after 20 weeks without proteinuria is gestational hypertension; it needs a full assessment in secondary care. NG133 aims for a target of 135/85, and labetalol is the first drug to consider.
Scenario 2 of 6
A 28-year-old at 36 weeks has a blood pressure of 158/104 with 3+ protein on dipstick and a PCR of 45. She has a headache she calls just tiredness and ankle swelling.
What is the diagnosis and immediate action?
Choose one to unlock the reasoning.
Why
This is pre-eclampsia: new hypertension after 20 weeks with significant proteinuria, where a PCR of 30 or more counts. Any headache in pre-eclampsia is a red flag. The expected answer is same-day admission to assess maternal and fetal wellbeing with FBC, LFTs, urea and electrolytes, CTG and growth; the definitive treatment is delivery.
Why not the others
- Missed-proteinuria — A PCR of 45 is significant proteinuria, so this is pre-eclampsia, not gestational hypertension.
- Headache-dismissed — Any headache in pre-eclampsia is a red flag, not tiredness.
- Treat-and-street — Starting an antihypertensive and sending her home ignores that she needs same-day admission.
The rule
New hypertension plus PCR 30 or more after 20 weeks is pre-eclampsia; admit the same day. Proteinuria is not required if there is other organ dysfunction.
Scenario 3 of 6
A 30-year-old at 34 weeks phones with a severe frontal headache, flashing lights, right-subcostal pain and two episodes of vomiting. Her blood pressure two weeks ago was 138/88.
What is the correct action?
Choose one to unlock the reasoning.
Why
These are imminent-eclampsia red flags: severe headache, visual disturbance, epigastric or right-upper-quadrant pain from liver capsule stretch, and vomiting. Admit now by ambulance if she is unwell or far away; secondary care will give magnesium sulfate, control blood pressure and plan birth.
Why not the others
- Old-reading-reassures — A normal blood pressure at the last visit does not exclude fulminant pre-eclampsia; symptoms trump an old reading.
- Indigestion-not-liver — Right-subcostal pain here is liver capsule stretch, not indigestion, and warrants emergency assessment.
- Under-triage — A routine review dangerously under-triages a woman with imminent-eclampsia red flags.
The rule
A normal blood pressure at the last visit does not exclude fulminant pre-eclampsia; symptoms trump an old reading.
Scenario 4 of 6
A 38-year-old with chronic hypertension takes ramipril and has a BMI of 34. She attends for pre-conception advice.
Which piece of advice is correct today?
Choose one to unlock the reasoning.
Why
NICE NG133 advises women taking an ACE inhibitor that there is an increased risk of congenital abnormalities if it is taken in pregnancy, and to discuss an alternative with the clinician managing their hypertension when planning pregnancy; if she conceives on it, it is stopped, preferably within 2 working days. Switching to labetalol, or nifedipine, before conception is the expected plan. Also plan aspirin 75 to 150 mg from 12 weeks because chronic hypertension is a high-risk factor. Folic acid 400 micrograms daily is the expected dose: under NICE NG247 (2025) a raised BMI on its own is no longer an indication for 5 mg.
Why not the others
- Continue-in-pregnancy — ACE inhibitors are not continued in pregnancy: NG133 advises stopping within 2 working days of a positive test, and discussing an alternative before conception.
- High-dose-folate — NICE NG247 (2025) removed a raised BMI on its own from the 5 mg list, so 400 micrograms is the expected answer unless another indication applies.
- No-aspirin-needed — Chronic hypertension is a high-risk factor, so aspirin from 12 weeks is indicated regardless of past pre-eclampsia.
The rule
Plan a switch away from ACE inhibitors and ARBs before conception (and stop them within 2 working days of a positive test); chronic hypertension warrants aspirin from 12 weeks; a raised BMI alone no longer needs 5 mg folic acid (NICE NG247).
Scenario 5 of 6
A 35-year-old at 29 weeks has a blood pressure of 172/112 and is asymptomatic. She asks to come back on Friday.
What is the correct response?
Choose one to unlock the reasoning.
Why
Sustained 160/110 or above is severe hypertension and needs immediate obstetric assessment regardless of symptoms; stroke risk does not wait for a headache. Blood pressure is lowered in a monitored setting, and proteinuria and red flags are checked while transport is arranged.
Why not the others
- Asymptomatic-is-safe — Being asymptomatic is the distractor; the number 172/112 is the decision.
- Treat-and-send — Do not start an antihypertensive and send her home; she needs monitored assessment.
- Repeat-later — Repeating in a week delays care for severe hypertension that needs same-day admission.
The rule
Sustained 160/110 or above is severe hypertension; the number is the decision, not the symptoms.
Scenario 6 of 6
A 41-year-old in her first pregnancy at 13 weeks has a BMI of 36 and normal blood pressure. She asks whether she should take aspirin.
What is the correct aspirin advice?
Choose one to unlock the reasoning.
Why
Aspirin 75 to 150 mg from 12 weeks is advised for more than one moderate risk factor. She has three: first pregnancy, age 40 or over, and BMI 35 or above.
Why not the others
- High-risk-only — Aspirin is not limited to one high-risk factor; more than one moderate factor also qualifies.
- Wait-for-HTN — Aspirin prophylaxis starts from 12 weeks on risk factors, not after hypertension appears.
- Too-late-start — Prophylactic aspirin begins from 12 weeks, not 20 weeks.
The rule
Aspirin 75 to 150 mg from 12 weeks: one high-risk factor or more than one moderate factor.
Abnormal bleeding decoder
Six abnormal bleeding vignettes that sort HMB, IMB, PCB and PMB and set the right pathway, anchored to NICE NG88, NG12 and NG23.
Scenario 1 of 6
A 63-year-old, 11 years postmenopausal, reports a single light bleed. She is on no HRT and has had normal smears.
What is the correct pathway?
Choose one to unlock the reasoning.
Why
Postmenopausal bleeding is endometrial cancer until proved otherwise. NG12 puts women aged 55 and over with PMB on a suspected cancer pathway referral, and a single light episode counts. Expect a transvaginal ultrasound for endometrial thickness.
Why not the others
- Smears-cover-it — Normal smears are irrelevant; screening does not screen for endometrial cancer.
- Single-bleed-benign — A single light episode still counts and needs the suspected-cancer pathway.
- Atrophy-first — Most PMB is atrophic vaginitis, but reassurance comes after investigation, not before.
The rule
At 55 and over, unexplained bleeding 12 months or more after the last period is a suspected cancer pathway referral (NG12), and under 55 one is considered; smears do not screen the endometrium.
Scenario 2 of 6
A 27-year-old reports postcoital bleeding for two months. She has a new partner and non-offensive discharge, and her HPV test a year ago was negative.
What is the correct workup?
Choose one to unlock the reasoning.
Why
Think chlamydial cervicitis until tested, but still examine. A speculum is mandatory in postcoital bleeding whatever the screening history, looking for ectropion, polyp, cervicitis or anything suspicious. Take a vulvovaginal NAAT for chlamydia and gonorrhoea plus a full screen including HIV and syphilis.
Why not the others
- HPV-covers-it — A negative HPV a year ago is reassuring but does not replace looking at the cervix.
- Smear-as-workup — Do not repeat the smear as an investigation of symptoms.
- Skip-the-speculum — Treating empirically without a speculum misses ectropion, polyp or a suspicious cervix.
The rule
Postcoital bleeding means a speculum every time; test for chlamydia, and a suspicious cervix means suspected-cancer referral regardless of screening history.
Scenario 3 of 6
A 41-year-old has 8-day periods with hourly flooding. Hb is 98 and ferritin 6. The uterus is normal size, there is no intermenstrual or postcoital bleeding, and her family is complete.
What is the first-line treatment?
Choose one to unlock the reasoning.
Why
For heavy menstrual bleeding with no structural or histological abnormality suspected, LNG-IUS is first line under NG88. Do an FBC in all women and treat the anaemia with oral iron; further investigation, such as outpatient hysteroscopy or pelvic ultrasound, is for women whose history or examination suggests submucosal fibroids, polyps, endometrial pathology or another structural cause — not for everyone (NG88).
Why not the others
- Scan-everybody — Ultrasound is not for everyone; with a normal history and examination and no red flags, treat first.
- TXA-first — Tranexamic acid is a non-hormonal option if she declines the IUS, not the first-line treatment.
- Straight-to-surgery — A completed family does not justify jumping to hysterectomy over the LNG-IUS.
The rule
Heavy menstrual bleeding with no structural cause suspected is LNG-IUS first line. If she declines, offer tranexamic acid or an NSAID.
Scenario 4 of 6
A 47-year-old has erratic cycles of 21 to 40 days with occasional intermenstrual bleeding. Her BMI is 38 and she has type 2 diabetes.
What is the correct next step?
Choose one to unlock the reasoning.
Why
This is not just perimenopause. Obesity, type 2 diabetes and anovulation are unopposed-oestrogen risks for endometrial hyperplasia or cancer, so persistent intermenstrual bleeding at this age with this profile needs endometrial assessment. NICE NG88 points to outpatient hysteroscopy with endometrial biopsy where persistent intermenstrual bleeding or risk factors such as obesity suggest endometrial pathology.
Why not the others
- Just-her-hormones — Calling it perimenopause at 47 misses endometrial cancer in a high-risk profile.
- Regulate-not-investigate — Starting contraception to regulate cycles without assessment skips the endometrial workup she needs.
- Blame-the-BMI — Attributing it to obesity and doing no workup ignores the raised endometrial cancer risk.
The rule
Perimenopausal intermenstrual bleeding with unopposed-oestrogen risk means assess the endometrium, do not assume hormones.
Scenario 5 of 6
A 54-year-old has been on sequential combined HRT for two years and now has new unscheduled bleeding. Her last menstrual period was three years ago.
What is the correct response?
Choose one to unlock the reasoning.
Why
Unscheduled bleeding in the first 6 months of starting HRT, or 3 months after a change, is common and can be managed by adjusting the HRT (BMS 2026), but beyond that, or new after an established pattern, it needs investigation, and two years in is not settling-in. Check compliance and interactions and refer for endometrial assessment; on HRT the BMS uses different thickness thresholds (7 mm or less on sequential, 4 mm or less on continuous combined HRT).
Why not the others
- HRT-explains-it — Bleeding is only expected early or as a scheduled withdrawal bleed on sequential HRT, not new at two years.
- Settling-in — The settling-in window is the first 3 to 6 months, so two years in is not it.
- Stop-and-wait — Stopping HRT and reviewing in six months delays the endometrial assessment she needs now.
The rule
New unscheduled HRT bleeding beyond the first 3 to 6 months means investigate the endometrium. More than 12 months past the last period favours continuous combined over sequential.
Scenario 6 of 6
A 66-year-old with postmenopausal bleeding is examined and has a transvaginal ultrasound showing an endometrial thickness of 3 mm.
How should you interpret this result?
Choose one to unlock the reasoning.
Why
A transvaginal ultrasound endometrial thickness of 4 mm or less makes endometrial cancer unlikely; above 4 mm points to biopsy or hysteroscopy. Examination still matters because a cervical or vulval lesion changes the pathway.
Why not the others
- Over-investigate — A 3 mm endometrium is within the reassuring range and does not on its own mandate hysteroscopy.
- Biopsy-regardless — PMB does not always need biopsy; a thin endometrium of 4 mm or less makes cancer unlikely.
- Skip-the-exam — A thin endometrium does not remove the need to examine for a cervical or vulval lesion.
The rule
Endometrial thickness of 4 mm or less makes cancer unlikely; above 4 mm means biopsy or hysteroscopy. Still examine.
Twenty-eight cards on the highest-yield DRCOG facts. Grade yourself honestly; the spacing does the rest.
What do UKMEC categories 1 to 4 mean?
A four-point scale for how safe a method is for a given person.
- 1: no restriction
- 2: advantages generally outweigh risks
- 3: risks usually outweigh advantages, not recommended unless other methods unavailable or unacceptable, specialist judgement
- 4: unacceptable health risk, do not use
What is the CHC category for migraine with aura?
Category 4 at any age.
- Aura marks raised ischaemic stroke risk and oestrogen compounds it
- Migraine without aura is generally Category 2 for starting CHC
- Age does not soften it
What is the CHC category for past VTE?
Category 4, provoked or not, anticoagulated or not.
- The copper IUD is unrestricted and the LNG-IUS is also a safe oestrogen-free option
- POP and implant are broadly usable at Category 2
- A known thrombogenic mutation such as Factor V Leiden is also Category 4 even with no personal clot
How does breastfeeding change the CHC category by postpartum time?
Under 6 weeks Category 4; 6 weeks to 6 months Category 2; from 6 months Category 1.
- Driven by postpartum thrombotic risk and the oestrogen effect on lactation
- POP and implant are Category 1 immediately postpartum with no bridging
What are the CHC categories for raised blood pressure?
Systolic 140 to 159 or diastolic 90 to 99 is Category 3; 160/100 or above is Category 4.
- Adequately controlled hypertension on treatment is also Category 3
- The IUDs, implant and POP are Category 1 at any stage of hypertension; the injectable is Category 2 (UKMEC 2025)
What are the CHC categories for smoking and age?
Age 35 or over with 15 or more a day is Category 4.
- Age 35 or over with fewer than 15 a day is Category 3
- Under 35 with any smoking is Category 2
- Stopped more than a year ago is Category 2, so ask when she stopped
Which methods can be used when CHC is Category 4 for migraine with aura?
The copper IUD is Category 1; every progestogen-only method is Category 2 (UKMEC 2025).
- POP, implant, injectable and LNG-IUS: Category 2 — advantages generally outweigh risks
- The copper IUD is the only Category 1 option, and it is not a progestogen-only method
Which presentations should trigger a pregnancy test in a woman of reproductive age?
Abdominal or pelvic pain, bleeding, collapse, shoulder-tip pain, or unexplained diarrhoea and vomiting.
- Ectopic is the great mimic
- Positive test plus pain, or bleeding at 6 weeks or more or of uncertain gestation, means EPAU referral (NG126)
When is early-pregnancy bleeding an emergency versus an EPAU referral?
A&E now for haemodynamic instability or significant concern about pain or bleeding (NICE NG126).
- Pain with abdominal, pelvic or cervical motion tenderness: immediate referral to the early pregnancy assessment service
- Bleeding with pain, at 6 weeks or more, or of uncertain gestation: EPAU referral
- Under 6 weeks, bleeding without pain or risk factors: expectant management, repeat pregnancy test after 7 to 10 days
What does a closed os tell you in early-pregnancy bleeding?
It separates threatened from inevitable miscarriage, but you cannot call it on the os alone.
- Ectopic can present identically, so a scan is still needed
- Transvaginal ultrasound is first-line imaging
What is cervical shock?
Vagal bradycardia with hypotension caused by products sitting in the cervical canal.
- It mimics haemorrhagic shock and resolves when the tissue is removed
- Bradycardia alongside heavy bleeding is the clue
When is anti-D indicated in early pregnancy loss?
Only from 12+0 weeks — nothing below that, whatever the route.
- Up to and including 11+6 weeks: do not offer anti-D for miscarriage, ectopic or threatened miscarriage — medical, surgical or expectant (NG126 1.18.1)
- 12+0 to 12+6 weeks: offer at least 250 IU for medical management or a surgical procedure (1.18.2); consider it for threatened miscarriage with heavy or recurrent bleeding (1.18.3)
- Do not use a Kleihauer test to quantify feto-maternal haemorrhage here (1.18.5)
What are the risk factors for ectopic pregnancy?
Anything that damages or slows the tube, plus contraception failures.
- Previous ectopic, tubal surgery, PID, endometriosis
- Assisted conception, smoking
- Conception with an IUD or POP in situ
What is the classic triad for gestational trophoblastic disease?
Large-for-dates uterus, disproportionate vomiting and early bleeding.
- Very high hCG drives the vomiting and a snowstorm appearance on ultrasound
- Diagnosis is histological; confirmed mole is registered with a specialist screening centre
How are the hypertensive disorders of pregnancy defined?
By timing and by proteinuria or organ dysfunction.
- Chronic: before pregnancy or under 20 weeks
- Gestational: new after 20 weeks, no significant proteinuria
- Pre-eclampsia: new hypertension after 20 weeks plus proteinuria, maternal organ dysfunction or uteroplacental dysfunction
What are the severity bands for hypertension in pregnancy?
NICE NG133 uses two bands: hypertension, 140/90 or more, and severe hypertension, 160/110 or more.
The older mild and moderate bands are not used in NG133.
- Sustained 160/110 or above needs immediate obstetric assessment regardless of symptoms
What counts as significant proteinuria in pre-eclampsia?
PCR of 30 mg/mmol or more, or ACR of 8 mg/mmol or more.
- Proteinuria is not required if there is other organ dysfunction
- That includes rising creatinine, deranged LFTs, falling platelets, haemolysis or neurological features
What are the imminent-eclampsia red flags?
Severe headache, visual disturbance, epigastric or RUQ pain, vomiting, sudden oedema and clonus.
- Epigastric or RUQ pain is liver capsule stretch, not indigestion
- Any headache in pre-eclampsia is a red flag
- A normal BP at the last visit does not exclude fulminant pre-eclampsia
Which antihypertensives are used and which are contraindicated in pregnancy?
Labetalol first line; nifedipine if unsuitable; methyldopa a further alternative.
- ACE inhibitors and ARBs: increased risk of congenital abnormalities; NG133 advises stopping them within 2 working days of a positive test, and discussing alternatives when planning pregnancy
- Thiazide-like diuretics: possible increased risk of congenital abnormalities and neonatal complications, so alternatives are discussed
- Target 135/85 or below
Who needs aspirin prophylaxis and at what dose?
Aspirin 75 to 150 mg daily from 12 weeks until the birth (NICE NG133).
- One high-risk factor: previous hypertensive disease of pregnancy, CKD, autoimmune disease, type 1 or 2 diabetes, chronic hypertension
- Or more than one moderate factor: first pregnancy, age 40 or over, pregnancy interval of more than 10 years, BMI 35 or above, family history of pre-eclampsia, multi-fetal pregnancy
When is 5 mg folic acid needed instead of 400 micrograms?
5 mg for higher-risk women; 400 micrograms as standard until 12 weeks.
- A personal, partner or family history of NTD, or a previous affected pregnancy; diabetes; sickle cell disease or thalassaemia; medicines that affect folate (such as some antiepileptics)
- A BMI of 30 or above on its own no longer qualifies (NICE NG247, 2025)
How do you sort abnormal bleeding into HMB, IMB, PCB and PMB?
By pattern, and each points to different pathology.
- HMB: excessive loss interfering with quality of life, defined by her
- IMB: polyp, chlamydia, hormonal contraception; always exclude cervical and endometrial pathology
- PCB: think cervix, ectropion, cervicitis or chlamydia, polyp; exclude cervical cancer
- PMB: bleeding 12 months or more after the last period; a suspected cancer pathway referral at 55 and over, considered under 55 (NG12)
What is the rule for postmenopausal bleeding?
Endometrial cancer until proved otherwise.
- NG12: aged 55 and over with PMB go on a suspected cancer pathway referral; consider it under 55
- A single light episode counts
- Normal smears are irrelevant; screening does not screen for endometrial cancer
What endometrial thickness makes cancer unlikely in PMB?
4 mm or less on transvaginal ultrasound.
- Above 4 mm points to biopsy or hysteroscopy
- On HRT the BMS uses 7 mm or less (sequential) and 4 mm or less (continuous combined)
- Still examine, as a cervical or vulval lesion changes the pathway
What is first-line treatment for HMB with no structural cause?
LNG-IUS, under NG88.
- If she declines, non-hormonal options are tranexamic acid or an NSAID such as mefenamic acid
- Hormonal alternatives are CHC or cyclical oral progestogens
- Do an FBC in all and treat anaemia with oral iron
What are the unopposed-oestrogen risks for endometrial hyperplasia or cancer?
States of unopposed oestrogen exposure.
- Obesity, type 2 diabetes, anovulation
- PCOS, nulliparity, late menopause
- Tamoxifen, oestrogen-only HRT with a uterus
How do you work up postcoital bleeding?
Speculum examination every time, plus infection screening.
- Vulvovaginal NAAT for chlamydia and gonorrhoea plus a full sexual health screen including HIV and syphilis
- Do not repeat the smear as an investigation of symptoms
- A suspicious cervix means suspected-cancer referral regardless of screening history
When is unscheduled bleeding on HRT expected versus concerning?
Common in the first 6 months of starting, or 3 months after a change; investigate beyond that (BMS 2026).
- New bleeding after an established pattern needs endometrial assessment
- On sequential HRT a scheduled withdrawal bleed is expected
- More than 12 months past the last period favours continuous combined over sequential
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