Menopause management UK Medical PG Practice Questions and MCQs
Practice UK Medical PG questions for Menopause management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Menopause management UK Medical PG Question 1: A 43-year-old woman presents with fatigue, weight gain, and cold intolerance. TSH is 22 mU/L, free T4 is low. Anti-TPO antibodies are positive. She is trying to conceive. What is the TSH target?
- A. $< 1.0 \mathrm{mU} / \mathrm{L}$
- B. $< 2.5 \mathrm{mU} / \mathrm{L}$ (Correct Answer)
- C. $< 4.0 \mathrm{mU} / \mathrm{L}$
- D. $< 6.0 \mathrm{mU} / \mathrm{L}$
- E. $< 10.0 \mathrm{mU} / \mathrm{L}$
Menopause management Explanation: ***< 2.5 \mathrm{mU} / \mathrm{L}$***
- For women with **hypothyroidism** who are trying to conceive or are in the first trimester of pregnancy, the recommended TSH target is generally **< 2.5 mU/L** to ensure optimal maternal and fetal outcomes.
- Achieving this target helps to reduce the risk of **infertility**, **miscarriage**, and adverse pregnancy complications such as **preterm birth** and **gestational hypertension**, while also supporting proper fetal neurodevelopment.
*$< 1.0 \mathrm{mU} / \mathrm{L}$*
- This target is generally considered **too stringent** and may lead to **over-treatment** with levothyroxine, potentially inducing iatrogenic hyperthyroidism symptoms.
- While very low TSH can be observed, it is not the standard recommendation for preconception in hypothyroidism and could be unnecessarily aggressive.
*$< 4.0 \mathrm{mU} / \mathrm{L}$*
- While a TSH of < 4.0 mU/L might be acceptable for non-pregnant adults with hypothyroidism, it is **insufficient** for women trying to conceive or in early pregnancy.
- Higher TSH levels during the preconception period and early pregnancy are associated with increased risks for both the mother and the fetus, necessitating a tighter TSH control.
*$< 6.0 \mathrm{mU} / \mathrm{L}$*
- This TSH target is significantly **too high** for a woman attempting to conceive and is typically considered for adults with **subclinical hypothyroidism** (TSH 4-10 mU/L) who are **not pregnant**.
- Maintaining TSH at this level during pregnancy substantially increases the risk of **adverse obstetric outcomes** and potential cognitive deficits in the offspring.
*$< 10.0 \mathrm{mU} / \mathrm{L}$*
- A TSH target of < 10.0 mU/L is far **too liberal** and would mean the patient remains **frankly hypothyroid** in the context of trying to conceive or during pregnancy.
- This target would not adequately address the patient's severe hypothyroid symptoms nor mitigate the significant risks to successful conception and healthy pregnancy progression.
Menopause management UK Medical PG Question 2: A 26-year-old woman presents with amenorrhea, galactorrhea, and headaches. Visual field defects are noted. What is the appropriate initial treatment?
- A. Transsphenoidal surgery
- B. Cabergoline (Correct Answer)
- C. Radiotherapy
- D. Observation
- E. Bromocriptine
Menopause management Explanation: ***Cabergoline***- **Cabergoline** is the preferred first-line treatment for suspected **prolactinomas** (indicated by amenorrhea and galactorrhea), regardless of tumor size, due to its high efficacy in normalizing prolactin levels and shrinking the tumor.- This drug, a **dopamine agonist**, can rapidly reduce tumor volume, often resolving the mass effect symptoms like headaches and **visual field defects**, which are crucial to address immediately.*Transsphenoidal surgery*- Surgery is generally reserved for patients who are intolerant of or unresponsive to maximal **dopamine agonist** therapy, or for specific tumor types (e.g., highly cystic).- Given the typical response rates of prolactinomas to medical therapy, surgery is not the appropriate **initial** treatment.*Radiotherapy*- Radiotherapy is typically reserved as a **tertiary treatment** for aggressive or malignant prolactinomas that have failed to respond to both dopamine agonists and surgical resection.- It carries risks of long-term pituitary dysfunction and damage to surrounding **neural structures**, making it inappropriate for initial management.*Observation*- Observation is only appropriate for asymptomatic patients with **microprolactinomas** (less than 10 mm) without mass effect or desire for fertility.- Since this patient has significant symptoms (galactorrhea, amenorrhea) and signs of mass effect (**visual field defects**), immediate intervention is necessary.*Bromocriptine*- Bromocriptine is also a **dopamine agonist** effective for prolactinomas but is generally considered a second-line option to Cabergoline.- **Cabergoline** is preferred due to its higher efficacy, longer half-life (allowing less frequent dosing), and better patient tolerability (fewer **gastrointestinal side effects**).
Menopause management UK Medical PG Question 3: A 34-year-old woman presents with recurrent miscarriages and a history of DVT. Blood tests show prolonged APTT not correcting with mixing studies, and positive anticardiolipin antibodies. What is the most likely diagnosis?
- A. Factor V Leiden
- B. Protein C deficiency
- C. Antiphospholipid syndrome (Correct Answer)
- D. Lupus anticoagulant
- E. Von Willebrand disease
Menopause management Explanation: ***Antiphospholipid syndrome***
- This syndrome is defined by recurrent **venous or arterial thrombosis** (DVT) and/or **pregnancy morbidity** (recurrent miscarriages), occurring in the presence of specific antiphospholipid antibodies.
- The laboratory findings of positive **anticardiolipin antibodies** and a prolonged **APTT** (suggestive of lupus anticoagulant, an inhibitory antibody) that does not correct upon mixing strongly confirm the diagnosis of APS.
*Factor V Leiden*
- This condition is the most common inherited thrombophilia, characterized by resistance to cleavage by **Activated Protein C (APC)**, leading to increased clot risk.
- While it causes thrombosis (like DVT), it does not cause the autoantibody profile (anticardiolipin) or the characteristic uncorrectable **APTT** observed.
*Protein C deficiency*
- This is an inherited thrombophilia resulting from insufficient levels of the anticoagulant Protein C, leading to uncontrolled coagulation.
- It typically causes thrombosis but is not associated with obstetrical complications like **recurrent miscarriages** or the presence of **anticardiolipin antibodies**.
*Lupus anticoagulant*
- This is one of the specific antiphospholipid antibodies that define APS (causing the prolonged non-correcting **APTT** finding).
- While present in this patient, it is a *laboratory criterion* for Antiphospholipid Syndrome (the definitive clinical diagnosis), which encompasses both the antibodies and the clinical events (DVT and miscarriages).
*Von Willebrand disease*
- This is the most common inherited **bleeding disorder**, caused by deficiency or dysfunction of **von Willebrand factor** (vWF).
- It is characterized by mucocutaneous bleeding symptoms and is a disorder of **hemostasis**, not a thrombotic condition associated with DVT or recurrent miscarriages.
Menopause management UK Medical PG Question 4: A 54-year-old woman who had a total abdominal hysterectomy with conservation of ovaries for fibroid-related menorrhagia 6 years ago presents with a 12-month history of troublesome vasomotor symptoms, mood disturbance, and poor concentration affecting her work as a teacher. She also reports reduced libido which is causing relationship difficulties. She has no other medical history, BMI is 24 kg/m², and she does not smoke. Her blood pressure is 118/76 mmHg. What is the most appropriate HRT regimen to address all her symptoms?
- A. Transdermal estradiol patches 50 mcg twice weekly
- B. Oral estradiol 2 mg daily plus testosterone supplementation
- C. Transdermal estradiol patches plus oral micronised progesterone
- D. Tibolone 2.5 mg daily
- E. Transdermal estradiol patches with trial of testosterone supplementation if symptoms persist (Correct Answer)
Menopause management Explanation: ***Transdermal estradiol patches with trial of testosterone supplementation if symptoms persist***
- **Transdermal estradiol** is the first-line treatment for vasomotor symptoms, mood disturbance, and poor concentration in postmenopausal women, offering a lower **thromboembolic risk** compared to oral therapy by bypassing first-pass metabolism.
- For **reduced libido**, guidelines recommend optimizing **estrogen levels** initially. If sexual dysfunction persists after 3-6 months of adequate estrogenization, a trial of **testosterone supplementation** is indicated to address this specific symptom.
*Transdermal estradiol patches 50 mcg twice weekly*
- While **transdermal estradiol** effectively manages **vasomotor symptoms** and cognitive issues, this option does not explicitly account for the patient's persistent **low libido**.
- It overlooks the recommended step of considering **testosterone supplementation** if sexual desire issues are not resolved with estrogen alone.
*Oral estradiol 2 mg daily plus testosterone supplementation*
- **Oral estrogen** carries a higher risk of **venous thromboembolism (VTE)** and may not be the optimal choice for a low-risk woman when a transdermal option is available.
- Initiating **testosterone** concurrently with initial HRT is generally not recommended; it's typically considered only after adequate **estrogenization** has failed to improve libido.
*Transdermal estradiol patches plus oral micronised progesterone*
- This patient has undergone a **total abdominal hysterectomy**, meaning she no longer has a uterus, and therefore does not require **progesterone** for endometrial protection.
- The addition of **progesterone** in a woman without a uterus is unnecessary and can introduce additional side effects without benefit.
*Tibolone 2.5 mg daily*
- **Tibolone** has estrogenic, progestogenic, and **androgenic properties**, which could potentially address libido; however, it is not typically the first-line HRT, especially for multiple symptoms where a standard estrogen-progestogen (or estrogen-only) regimen is usually preferred.
- It is associated with an increased risk of **stroke** in women over 60 years of age, making transdermal estradiol a generally safer initial choice.
Menopause management UK Medical PG Question 5: A 41-year-old parous woman requests contraception following the birth of her third child 4 weeks ago. She is not breastfeeding and is considering the combined oral contraceptive pill, which she used successfully between her previous pregnancies. She had an uncomplicated vaginal delivery with estimated blood loss of 400ml. She is a non-smoker with BMI of 26 kg/m² and no medical history of note. According to UKMEC criteria, when can she safely commence the combined oral contraceptive pill?
- A. At 3 weeks postpartum
- B. At 2 weeks postpartum
- C. Immediately, as she is not breastfeeding
- D. At 6 weeks postpartum (Correct Answer)
- E. At 12 weeks postpartum
Menopause management Explanation: ***At 6 weeks postpartum*** - In non-breastfeeding women without additional risk factors, the **combined oral contraceptive pill (COCP)** is classified as **UKMEC 2** (benefits outweigh risks) or UKMEC 1 only after **6 weeks postpartum**. - The postpartum period is associated with a significantly increased risk of **venous thromboembolism (VTE)**, which remains elevated until 6 weeks; starting COCP earlier carries an **unacceptable health risk**. *At 3 weeks postpartum* - Starting COCP between **21 days and 6 weeks** postpartum in non-breastfeeding women is classified as **UKMEC 3**, meaning the risks generally outweigh the benefits. - Although the absolute risk of VTE begins to decline after 3 weeks, it is still considered too high to routinely recommend **estrogen-containing** methods. *At 2 weeks postpartum* - Prior to **21 days (3 weeks)** postpartum, the use of COCP is classified as **UKMEC 4**, indicating an unacceptable health risk due to the peak in **hypercoagulability**. - Women are advised to use **progestogen-only** methods or barrier methods if contraception is required this early in the puerperium. *Immediately, as she is not breastfeeding* - Immediate initiation is contraindicated because the **prothrombotic state** of pregnancy does not resolve instantly upon delivery, regardless of breastfeeding status. - The classification for using COCP before 21 days is **UKMEC 4**, even in the absence of other risk factors like smoking or high BMI. *At 12 weeks postpartum* - Delaying initiation until **12 weeks** is unnecessary for this patient as she is a **non-smoker** with a normal BMI and no other VTE risk factors. - By 6 weeks, the VTE risk typically returns to baseline, making it safe to prescribe the pill according to **UKMEC guidelines**.
Menopause management UK Medical PG Question 6: A 58-year-old woman with type 2 diabetes mellitus and a BMI of 31 kg/m² presents requesting continuation of her HRT. She was diagnosed with premature ovarian insufficiency at age 39 and has been taking continuous combined HRT (oral estradiol 2 mg with dydrogesterone 10 mg) since then. She currently has good glycaemic control (HbA1c 48 mmol/mol) on metformin alone and has no microvascular or macrovascular complications. She has no other cardiovascular risk factors and does not smoke. What is the most appropriate advice regarding HRT continuation?
- A. Continue current HRT as benefits outweigh risks given her premature ovarian insufficiency (Correct Answer)
- B. Switch to transdermal HRT as oral preparations are contraindicated in diabetes
- C. Discontinue HRT immediately as she has now reached the age of natural menopause
- D. Continue HRT but add aspirin for cardiovascular protection
- E. Reduce to the lowest dose of HRT and plan to stop within 6 months
Menopause management Explanation: ***Continue current HRT as benefits outweigh risks given her premature ovarian insufficiency***
- In patients with **premature ovarian insufficiency (POI)**, HRT is typically recommended until at least the average age of natural menopause (51 years) and can be continued beyond that based on **individual risk-benefit assessment**.
- This patient has **well-controlled type 2 diabetes** (HbA1c 48 mmol/mol) without complications and no other **cardiovascular risk factors**, making the continuation of her current regimen appropriate.
*Switch to transdermal HRT as oral preparations are contraindicated in diabetes*
- **Type 2 diabetes** itself is not a contraindication to oral HRT; under **UKMEC 2** criteria, the benefits generally outweigh the risks if there are no vascular complications.
- While **transdermal HRT** is preferred in patients with a high risk of **Venous Thromboembolism (VTE)** or obesity, it is not mandatory if the patient is stable on an oral preparation.
*Discontinue HRT immediately as she has now reached the age of natural menopause*
- There is no arbitrary **upper age limit** for HRT; the decision to continue should be based on persistent symptoms and the patient's **overall health profile**.
- Women with a history of **POI** may require longer treatment durations to mitigate long-term risks such as **osteoporosis** and cardiovascular disease.
*Continue HRT but add aspirin for cardiovascular protection*
- **Low-dose aspirin** is not routinely indicated for primary prevention in diabetic patients unless there is a high **10-year cardiovascular risk** or established vascular disease.
- HRT is not an independent indication for starting **antiplatelet therapy** in a woman with well-controlled diabetes and no macrovascular complications.
*Reduce to the lowest dose of HRT and plan to stop within 6 months*
- Tapering or stopping HRT is a personal choice; however, there is no medical requirement to stop within a fixed timeframe if the patient is **asymptomatic** and clinical risks are low.
- Abruptly planning to stop within 6 months for a patient who has required therapy since age 39 may lead to a recurrence of **vasomotor symptoms** and a decline in **bone mineral density**.
Menopause management UK Medical PG Question 7: A 35-year-old woman with a history of previous ectopic pregnancy treated by laparoscopic salpingectomy 2 years ago presents requesting long-acting reversible contraception. She is in a new relationship and wishes to avoid pregnancy. She has regular periods, BMI of 25 kg/m², no other medical history, and is a non-smoker. She is particularly concerned about the risk of another ectopic pregnancy. What is the most appropriate contraceptive method to recommend?
- A. Copper intrauterine device
- B. 52 mg levonorgestrel intrauterine system
- C. Etonogestrel subdermal implant (Correct Answer)
- D. Combined oral contraceptive pill
- E. Depot medroxyprogesterone acetate injection
Menopause management Explanation: ***Etonogestrel subdermal implant***
- The **subdermal implant** is the most effective contraceptive method available, with a failure rate of <0.1%, thereby minimizing the **absolute risk** of any pregnancy, including ectopic.
- Unlike intrauterine methods, the implant primarily works by **inhibiting ovulation**, meaning if a rare contraceptive failure occurs, it is highly likely to be an **intrauterine pregnancy** rather than an ectopic one.
*Copper intrauterine device*
- While the **copper IUD** reduces the absolute risk of ectopic pregnancy compared to using no contraception, it mainly prevents **intrauterine implantation** rather than ovulation.
- If a pregnancy does occur with a copper IUD in situ, there is a higher **relative risk** that the pregnancy will be ectopic compared to other methods.
*52 mg levonorgestrel intrauterine system*
- Like the copper IUD, the **LNG-IUS** is a highly effective LARC (UKMEC 1 for history of ectopic pregnancy), but it works largely through **local progestogenic effects** on cervical mucus and the endometrium.
- While it significantly reduces the overall pregnancy rate, the risk of a pregnancy being ectopic if the device fails is higher than with the **subdermal implant**.
*Combined oral contraceptive pill*
- The **combined oral contraceptive pill** is not classified as a **long-acting reversible contraceptive (LARC)**, which is specifically what the patient requested.
- Its efficacy is highly dependent on **user compliance**, and typical use failure rates are significantly higher than those of the implant or IUS.
*Depot medroxyprogesterone acetate injection*
- Although highly effective, the **DMPA injection** is not categorized as a LARC because it requires administration every 12 to 13 weeks.
- It effectively inhibits ovulation, but the patient's request for a **long-acting** method makes the implant a more suitable and convenient choice.
Menopause management UK Medical PG Question 8: A 49-year-old woman commenced on sequential combined HRT (transdermal estradiol 50 mcg patches changed twice weekly plus oral micronised progesterone 200 mg for 14 days each month) 6 months ago for troublesome vasomotor symptoms. She reports good symptom control but has persistent irregular bleeding throughout the month, not just during the expected withdrawal bleed. Her last menstrual period before starting HRT was 14 months ago. Pelvic examination is normal. What is the most appropriate next step in management?
- A. Continue current regimen and reassure that irregular bleeding is expected in the first year
- B. Switch to continuous combined HRT regimen
- C. Arrange transvaginal ultrasound to assess endometrial thickness (Correct Answer)
- D. Stop HRT for 3 months then restart with a different preparation
- E. Add tranexamic acid during bleeding episodes
Menopause management Explanation: ***Arrange transvaginal ultrasound to assess endometrial thickness***
- Persistent **unscheduled bleeding** on HRT for more than 6 months, or a new change in bleeding pattern, necessitates investigation to exclude **endometrial hyperplasia** or malignancy.
- A **transvaginal ultrasound (TVUS)** is the first-line investigation to assess the **endometrial thickness (ET)**; in postmenopausal women, an ET >4mm typically requires an endometrial biopsy.
*Continue current regimen and reassure that irregular bleeding is expected in the first year*
- While irregular bleeding is common in the first 3-6 months of HRT, persistence beyond **6 months** requires clinical evaluation and cannot be dismissed as "expected."
- This patient is technically **postmenopausal** (LMP was 14 months ago), making any unscheduled bleeding more concerning for **endometrial pathology**.
*Switch to continuous combined HRT regimen*
- Although **continuous combined HRT** is the standard for postmenopausal women to avoid withdrawal bleeds, switching regimens before investigating irregular bleeding is unsafe.
- Initiating a new regimen may mask underlying **endometrial stimulation** or pathology caused by the previous sequential therapy.
*Stop HRT for 3 months then restart with a different preparation*
- Stopping HRT would likely cause a return of **vasomotor symptoms** without providing a diagnosis for the current irregular bleeding.
- This approach delays the necessary **diagnostic workup** (ultrasound/biopsy) required to rule out serious intrauterine issues.
*Add tranexamic acid during bleeding episodes*
- **Tranexamic acid** is an antifibrinolytic used to reduce heavy menstrual loss but does not address the **underlying etiology** of irregular unscheduled bleeding.
- Using it in this context is inappropriate as it treats the symptom while ignoring the risk of **endometrial malignancy**.
Menopause management UK Medical PG Question 9: A 28-year-old woman with well-controlled ulcerative colitis on mesalazine presents requesting contraception. She was recently started on azathioprine 150 mg daily by her gastroenterologist. She is in a stable relationship and desires highly effective contraception. She has regular menstrual cycles, BMI of 22 kg/m², and is a non-smoker with no other medical history. According to UKMEC criteria, which statement regarding contraceptive options is correct for this patient?
- A. The etonogestrel implant is UKMEC 3 due to azathioprine interaction
- B. The copper intrauterine device is UKMEC 3 due to immunosuppression
- C. The combined oral contraceptive pill is UKMEC 1 with no restrictions (Correct Answer)
- D. The levonorgestrel intrauterine system is UKMEC 2 due to increased infection risk
- E. The depot medroxyprogesterone acetate injection is UKMEC 3 due to inflammatory bowel disease
Menopause management Explanation: ***The combined oral contraceptive pill is UKMEC 1 with no restrictions***
- For patients with **Inflammatory Bowel Disease (IBD)** like ulcerative colitis that is uncomplicated and well-controlled, the **Combined Oral Contraceptive (COC)** is classified as **UKMEC 1**, indicating no restriction.
- There is no clinically significant **drug interaction** between **azathioprine** and hormonal contraceptives, including the COC, meaning its efficacy is not compromised and its use is safe.
*The etonogestrel implant is UKMEC 3 due to azathioprine interaction*
- The **etonogestrel implant** (Nexplanon) is a progestogen-only method that is generally classified as **UKMEC 1** for women with well-controlled IBD and no known interaction with **azathioprine**.
- UKMEC 3 indicates that risks generally outweigh benefits, which is not applicable to the implant in this context, as it is a highly effective and safe option.
*The copper intrauterine device is UKMEC 3 due to immunosuppression*
- The **copper intrauterine device (Cu-IUD)** is classified as **UKMEC 1** for women on immunosuppressants like **azathioprine**, as the risk of infection is not significantly increased.
- Current evidence does not support a significantly higher risk of **Pelvic Inflammatory Disease (PID)** in immunosuppressed women using IUDs, especially when IBD is stable.
*The levonorgestrel intrauterine system is UKMEC 2 due to increased infection risk*
- The **levonorgestrel intrauterine system (LNG-IUS)** is classified as **UKMEC 1** for women with well-controlled IBD, even when on immunosuppressive therapy such as **azathioprine**.
- Similar to the copper IUD, the theoretical concern for **infection risk** in immunocompromised patients using LNG-IUS is not supported by evidence to warrant a UKMEC 2 classification.
*The depot medroxyprogesterone acetate injection is UKMEC 3 due to inflammatory bowel disease*
- **Depot medroxyprogesterone acetate (DMPA) injection** is classified as **UKMEC 2** for women with IBD, not UKMEC 3, primarily due to theoretical concerns.
- The main concern with DMPA in IBD relates to potential **bone mineral density (BMD) loss**, which could theoretically be exacerbated by malabsorption in severe or uncontrolled IBD, though this patient's UC is well-controlled.
Menopause management UK Medical PG Question 10: A 52-year-old woman presents with troublesome vaginal dryness and dyspareunia. She went through natural menopause 3 years ago. She is reluctant to take systemic HRT as she had a previous venous thromboembolism 4 years ago related to prolonged immobilization following a fractured ankle. She has no other medical problems and takes no regular medications. Examination reveals vaginal atrophy with no other abnormalities. What is the most appropriate initial management?
- A. Vaginal oestrogen therapy (estriol pessaries or estradiol tablets) (Correct Answer)
- B. Systemic transdermal oestrogen-only HRT
- C. Vaginal moisturizers and lubricants only
- D. Ospemifene 60 mg daily
- E. Systemic continuous combined oral HRT with low-dose oestrogen
Menopause management Explanation: ***Vaginal oestrogen therapy (estriol pessaries or estradiol tablets)*** - This is the most appropriate initial management for **genitourinary syndrome of menopause (GSM)**, as it directly treats **vaginal atrophy** with minimal systemic absorption. - Due to its localized effect and low systemic absorption, **vaginal oestrogen** is considered safe even in patients with a history of **venous thromboembolism (VTE)**, as it does not significantly increase VTE risk.*Systemic transdermal oestrogen-only HRT* - While transdermal HRT has a lower **VTE risk** compared to oral preparations, any systemic HRT is generally contraindicated (UKMEC 4) in individuals with a past **thromboembolic event**. - Systemic therapy is also not indicated when the symptoms are solely localized to **vaginal atrophy**, as seen in this patient.*Vaginal moisturizers and lubricants only* - These provide symptomatic relief for **vaginal dryness** and **dyspareunia** but do not address or reverse the underlying **atrophic changes** in the vaginal tissue. - They are typically used for mild symptoms, as an adjunct, or when hormonal therapy is absolutely contraindicated or refused.*Ospemifene 60 mg daily* - **Ospemifene** is a **selective oestrogen receptor modulator (SERM)** specifically approved for moderate to severe dyspareunia due to menopause, but it carries a boxed warning regarding an increased risk of **venous thromboembolism**. - Therefore, it is not a suitable option for a patient with a history of **VTE**.*Systemic continuous combined oral HRT with low-dose oestrogen* - **Oral HRT** carries the highest risk of **VTE** due to its first-pass hepatic effects and is strongly contraindicated in patients with a history of **venous thromboembolism**. - Furthermore, systemic combined HRT is used to treat systemic menopausal symptoms and protect the endometrium; this patient's symptoms are localized to the vagina.
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