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Hello, good afternoon. Good evening everyone. Thank you for attending the E OC exam preparation webinar. Thank you everyone for being with us. We are going to wait a little bit the rest to come uh to log in. Uh we are here uh with Professor Messinis the chair of standing Examinations on behalf of Cook. Thank you very much prof for us. It's an honor. And professor me, he's the head and the the head behind of this exam and he's here because he believes a lot of in but also see on the upcoming exam personally, I believe that it is very important for our personal training knowledge to sit on different levels of exam and the European Board and College of Folks and offers this opportunity for us in, in this. I think you better. Yes. Uh Thank you very much uh Sophia for the introduction. I will share my screen now. Uh Just to let you know that you can send your messages, your questions during the whole course. Of course, if there is something that you don't understand, please let us know to repeat it or uh I think we have the same problem. I think Sophia will have the sample. So you take advantage because there is some technical problem with the presentation. Now professor is going to log out and log in again. Yes, I will probably leave and come back again. Ok. So just to let you know that the next week we are having the European uh Congress of uh and uh gynecology. It's going to be in Thessaloniki and they are offering a full day special dedicates for the trainees in third of June. Uh We are also participating as and we are we welcoming all of you to go to the 10th winners meeting in uh Greece Puerto. Also, that's gonna be uh for very special for those that are interested in gynecological endoscopy training and pathway. Also, they are going to take place, get a certification exams and for next year, save the date and put the note on your calendar that in the June 2025 0 is going to organize the, their own uh congress with OC in a lovely Frankfurt Germany. So we're hoping that every one of you, they are going to support OC and be there as well. But above all this September, we're having our end o exchange event that we're going to have or not only for those that participate in the exchange, but also two days for all of us, you know, on Thursday, we're having the end of workshop about sexual and reproductive health and on a Friday a full scientific day about innovations in obstetric and in ecology. So all of you, you are welcome to come on this September. So now professor, if you are uh retry with your presentation, friends, OK. Yes, I think uh now see you can see the present. You can, you can hear me as well. OK. OK. Thank you again. Sofia sorry for this uh interruption and this uh slight technical problems, but OK, that may happen. So, uh dear colleagues, uh ladies and gentlemen, we are going to discuss about the European Fellowship exam in Tics and Gynecology that is organized by C we call it EO CC exam. This is in fact the organization by an, as you can see here. Uh That is very good work that was done by Endo by Sophia and may on this uh event today. I have nothing to disclose regarding this particular talk. Uh Well, the European Board and College of Obstetrics and Gynecology is a section of the U ES that is the European Union of Medical Specialties. And our examination uh started for the first time in 2016 and uh every year since then, it takes place. Uh We organized that uh on a yearly basis, but now we started having it twice a year. So the organization of the exam uh was based on the regulations and the rules of SMA, which is the Council for European Specialist Medical Assessment, which is an advisory board of U body of U ems, we collaborate with ozone that provides the electronic platform or zone is a private organization that is based on in on get in Sweden. And successful candidates become a European Fellow of Prosthetics and Gynecology and they can use the title of O OC. Uh this examination uh is not going to replace the national exams. So although in some uh countries in Europe, uh this uh has been adopted as a national exam. Uh we would like this to be extended to many countries in Europe. Uh In any case, this is complementary to the national examination and can be considered an additional to the visitation and accretion procedure to validate the quality of training. And so far more than 30 specialties organized uh European postgraduate medical assessments. The purpose of the examination is to assess the level of competency which includes the knowledge, the skills, judgment and the attitude of the candidates at an agreed European Union standard. This uh is expected to facilitate the mobility of obstetricians and gynecologists throughout the countries of the European Union. And not only that in your whole in factor. However, we should emphasize that passing the exams does not imply a license to practice. But this is a good qualification that can be used when you submit an application for a post in any European country. And the structure of the examination is part one and part two. Part one is the written exam. Part two is the oral exam and the candidates should pass both part one and part two in order to become fellows and use the title of OC. The organization of the exam uh is being done by the standing committee on examinations. And I heard I have the privilege to be the chair of this committee. Uh We have specific uh examination documents that have been uploaded to the website of c there is a question writing group that writes questions uh regularly. And there is also a quality assurance uh committee uh that reviews the questions that are being uh written, submitted and prepares the papers for the exams. And also we organize preexam courses for uh uh the exams each year. And we also use examiners uh for the part two exam, which is the oral exam. And let's see briefly about the part one exam, the part one exam uh otherwise uh uh uh known as uh KBA, which means uh knowledge based assessment uh is completely online and therefore it is remotely controlled. Uh which means that the candidates are in fact uh invigilated via their own system. This is the first exam that uh uh was organized in 2016 that was in Torino. And that, as you can see at that time, it was inside, of course, because it's uh the pre COVID period. Uh but it is important to see that even at that time, the uh candidates use their own computer and the questions appeared on their screen at the time of the exam and they provided the sub submitted their responses answers via the system. And then uh everything disappeared from their screen. So there was no hard copy at all from the beginning. It was online, but now it is online with no physical presence at all. And these were people, some of them are still working uh on the same subject uh in c about the uh organization of the exams. So it was at that time in Torino. So when COVID started in 2020 it was very difficult to go in different places and organize onsite exams. So we started uh uh organizing that uh online. And uh as you can see, this was the first exam in October 2020. Although usually we organized exams in spring time at the time, we were very skeptical about how to do that. So we started the online exam. This is as you can see uh uh one room on uh on the desktop because there are 10 different rooms, in fact, so you can see people writing from their home, the exams, but they can be very clearly invigilated to via the system. Uh So they are in fact controlled for everything they are going to do. So the, the exams were uh after that were adopted. Uh and uh I mean, the online uh process of the exam because that was proven to be very effective. And therefore we started the uh online exam since then. And we continue for the written part of the exam in terms of the questions that we use. Uh There are two types of questions. It is the single best answer SBA as we call it or international called SBA. And the extended matching questions E MQ. At the beginning, we used also the MC QS which was uh the so called multiple choice with true and false in terms of the answer. But we have abandoned them because we consider Ba and TM Qs more objective in terms of assessing also not only the knowledge but part of the skills of as well of the candidates. So the two papers that we produce each time is one for obstetrics and one for gynecology. So the candidates uh sit for three hours for the aesthetic paper and three hours for the gynecology with uh one hour break in between each paper uh includes 65 questions, 35 SBA S and 30 em Qs and altogether they are 135 30 questions. Uh Certainly, uh uh the questions are uh more than this number in a way that it SB has one scenario. However, each E MQ has three scenarios which means 90 scenarios for DM QS plus 35 for the B1 125 scenarios which is questions and answers to be given for the ETS paper and 125 scenarios, questions answered, let's say for the gynecology paper altogether 250 questions. Yeah, we uh map the questions according to the curriculum. This is very important. The curriculum is uh so called P which is uh recognized by U EMS as uh European training requirements. And uh we uh according to the P, we divide that in different uh top of uh obstetrics, uh prenatal care, intrapartum care, postpartum and some general uh questions and the prenatal care includes the majority of the questions. 60%. Certainly prenatal is antenatal is medical disorders, is uh complications in pregnancy and many other issues that are related to the antenatal period before uh going to labor intrapartum problems during labor and postpartum. Of course, uh problems after delivery and the general management and knowledge skills may include for example, one question about statistics, but this is only one or two questions altogether. Now, regarding the gynecology again, uh we uh map the questions according to the topics uh to the P I mean as they are defined in the past benign gynecology, reproductive medicine, urogynecology, premalignancy, uh gynecological oncology, including breast disease, breast, very little about that may be one question or less some time. Uh Not at all, pediatric gynecology and sexual health and general management. Again, one or two questions, not always. And in total 30 M QS and 35 BA S, it is important to set the passmark to calculate the pass mark before uh the exam or even sometimes during or after the exam. Because there is a panel of 10 judges who use the so called modified method to set the past marker. And this is specific uh method that is a very well known internationally, that is objective method. So the pass mark is calculated according to this method. But at the same time, we also take into account the candidate's performance. Um and we combine to some extent these two, it is important following the exam to validate the assessment and we do that all the time. So what we do, we calculate the difficulty of the questions. Uh the reliability, which means the reproducibility whether in fact, if the exams are taken at another time will provide the same results. Uh And this is important also the discriminative power, whether they can discriminate between the good and the bad candidates in terms of the difficulty. This is an example here of gynecology exam. So you can see that there is a normal distribution apart from uh this column at the 0.8 which means that a group of questions were answered correctly by 8% of the candidates. Uh uh uh This is in fact the percentage of candidates who answered correctly. A certain number of questions. Yeah, apart from the difficult team, together with the discrimination index, uh we also, we also calculate the item discrimination. This is the distribution of the uh discrimination index. Uh again is the percentage here uh uh of candidates uh who answer specific questions but uh some of them are negative. Uh There should be no negative questions. If there are negative questions, we remove them afterwards because uh uh after the exams, you can in fact do these statistics and see whether uh the questions follow this distribution. But there are very few questions that may be removed. Uh maybe two or three or five questions out of the 250. This is the part one and then we go to the part two which is the scheme uh OS as you understand is the obs objective structured clinical examination. So this is the clinical part of the examination and it in fact assesses the clinical skills. It is very important not only to uh to assess the knowledge, which is of course with part one, but also to assess the skills, the clinical skills. Uh And this in fact, leads to the assessment and measurement of the candidate's clinical competency, which is uh very important. And this is the structure of the part two, the OS exams. There are stations, there are 10 stations. In fact, one of these stations is the preparatory station which means that there's no marking for that. So nine out of the 10 stations are with marks we use in some stations, simulators and actors. Doctors are, in fact, uh uh uh women who pretend to be the patients and therefore, the candidate may have to discuss with doctors who are very well known or at least they, they are very well aware of the the clinical case. And therefore this is normal examination because there are in fact clinical cases that are being discussed there. Here, you can see uh uh picture as uh of the 10 stations. Uh for example, in station one which is on the left uh corner up. Uh You can see three people. Uh One of these uh is the examiner on the left. Uh uh is this is the examiner and this is uh the actor and this is the candidate. So the candidate discussed with doctor and the um examiner may interfere. But uh usually it marks here what the, the the candidate performance of the candidate. In fact, in station two, there is a simulator and here this goes an ultrasound simulator in station three. It is only the candidate who prepares a powerpoint presentation and this presentation will, will be uh presented here in the next session and this is the examiner and the candidate. Uh so that uh uh has a few slides only should have no more than three slides in a specific topic. And this uh the examiner of course assesses knowledge. Uh Station five is a complex case here. You can see that there are more than uh one or two people. You can see that uh is this examiner nurses here as well, and this is a simulator and of course, the other stations are more or less similar. Some of them have simulators, others not to, they may discuss uh clinical cases, they may transmit bad news to uh the patient, the doctor. Uh they may also present or at least uh uh discuss the case with uh uh the, the senior doctor. And that is of course, something which uh assesses the skills, the competence and also the communication of the candidate. The calculation of pass mark uh is different uh the way at least it's been done in part two than in part one. Here, we uh are based on the candidates evaluation because the candidates mark the uh candidates uh performance and they consider the candidates, the candidates as failed the past or borderline. And we are based on the borderline score and the medium of the borderline score for each station is the passmark for the particular station. So each station has a different passmark than the other stations. So uh to pass the part two exam four, the candidate should pass seven out of the nine active stations if we consider 10 stations uh 70%. But it is more than that, in fact, seven out of the nine active stations plus the sum pass mark of all stations. And then when they pass of course, both part one and part two, they are awarded the certificate that says that they are fellows of. They are and this has been given to the fellows uh because they are becoming fellows, as I said, the web during the graduation ceremony that takes place every two years. In fact, because the Congress takes place every two years. In fact, this is organized in the context of the Congress uh of uh or otherwise, it's been mailed to the, I mean, it's be sent by regular mail to the candidates for this year. 2024. We had, uh, we have all, we had, we have two part exams, uh, that are virtually controlled. Uh, the, the candidates which is online, of course, the first exam for this year took place on the 16th of March. Uh, so this has been done already and the second is on the 34 of August 2024. Uh, the applications are open and they close one month before the exams. Uh, it is for 34th of July 2024. So for those who are interested in fact, can submit an application up to 31st of July. Uh, regarding the part two exam, we also have two exams for this year and these exams are on site, uh, exactly as it happened before COVID, we continue on site the part two exams. And now, of course, there's no problem with the COVID. Uh, and the first for this year is scheduled for the 29th of June in Lisbon and the second for the ninth of November in Dubai. It is important to say that if a candidate failed in March last exam that we had, uh uh for part one, then he or she can sit the exam, the part one exam again on the 31st of August, which is an advantage. And of course, those who pass the part one exam can sit uh in Lisbon 29th of June, although now is closed, in fact, uh, but they had this opportunity or if they fail in Lisbon, they can see the game on the ninth of November in Dubai. So after this uh information about the structure of the exam and uh these important issues regarding the, the pass mark and uh um uh examination in general. Uh Here are some more general information but not very long. I'm not going to discuss the visibility criteria because you can find them on the website. Uh The website is here, you can see co dot eu it is important to say two things first that the candidates can sit part on examination after they have completed at least three years in their training program. So before completing their training period, but for part two examination, they should complete all they can attempt six months before completion of their training program. As this is recognized by their National Tics and Gynecology Societies or authorities. We also organized as I mentioned at the beginning, some preexam activities. So these are preexam courses. Uh for part one, we had one on in March before the, the part one exam in March. So and another one will be organized in June uh around about 20th of June just about a week or 10 days before the exam uh in Lisbon. And also we organize webinars uh not like this as we do today. The these are webinars uh that in which uh experts speak a scientific topic for one hour. This is free and we organize all these in collaboration with study Medic, which is a private organization uh from India. This is uh the Cook book, the O postgraduate Textbook of Tics and Gynecology. Uh You can see this is obstetrics. This is gynecology that is official book of Cook that has been edited by us. Here is a very nice uh two volumes book and uh that was published in 2022. And in fact, it was the winner in Upsetting the Oncology of the British Medical Association Medical Book Awards. So that is very important in fact, which means that it's a very good book and very useful as the publishers uh uh state here for, for the trainees. Certainly they can use any uh source. Uh And of course, the guidelines uh for, for a preparation and our exam uh has been recently uh appraised by uh Chaman U Ems. Uh It is very important uh this uh event here that happened by U MS which is recognized by U MS. So that means that this is a very uh good uh exam of good level, high level exam. Uh and it has been, has been recognized as an effort fellowship exam. And we, of course, we were awarded this certificate for that because they appraised the exam following visitations that they paid for the part one and part two exam. The EPOC um collaborates with the subspecialties. Uh Also for the exams. Apart from OC, there are exams uh in collaboration, for example, with the European Society of Human Reproduction and Embryology, which is reproductive medicine. And this is the E FRM exam, which is European FS of reproductive medicine. And the exam started in 2018 and take place every year since then. In fact, there is a joint committee in which uh uh uh members from uh C OC and from participate, collaborate together and organize exam. So it's very, very, a very, very uh active uh uh uh at least uh um or at least a procedure in terms of that, the people who are from, in fact, participate very actively in this uh as go which is the gynecological oncology. They have started their exams in any case. But recently I remember understanding was uh uh signed with uh and therefore there would be collaboration in many aspects also for the exams. U which is another specialty about the, the urogynecology. Uh There is a joint committee that has been created with and U but still we are at the beginning because uh UGA has to provide some more information about that. So it is their own uh activity but we will collaborate with them. And very recently, it is the collaboration with the European Society of contraception, they productive health. Uh And this, in fact, uh uh includes two projects. Uh one that is a diploma exam and the other is a fellowship exam diploma that it is called the European Diploma of sexually health and European uh fellowship of sexually productive health. The diploma uh uh will can be taken by junior doctors, general practitioners and midwives. And we start with this exam on the 12th of October. This is a Deb Cook exam. So the applications will open very soon at the beginning of June. While the fellowship exam will be decided, the date that the uh exams will start. This is for senior specialists, which means S obstetricians and gynecologists who particularly work in the field of uh contraception and reproductive health. And following this information, I think it would be interesting to show to you some examples regarding the B and just to understand what this uh uh mean. So starting with the single best answer the structure, it's a single best answer question has a title and a basically a clinical scenario. And there is a leading question that poses a single question that directs the candidates what to do next. And then there are five options which are potential answers they may be correct all of them, but only one of them is the best answer. So the candidate, in fact, in fact, has to identify the best answer. That's why they are called single best answer. There is no negative marking for wrong answers and also there is no negative marking for more than one response to a question. And here is an example of a patient with Menorrhagia. You can see the title is Menorrhagia and then is the scenario and then this is the leading question. So the scenario will read the scenario for you just to see uh uh roughly what uh uh I mean, they contain what the scenarios contain is a 48 year old Paris woman with a BMI of 28 kg per square meter presents with a two year history of progressively increasing menstrual loss. She reports that one year ago, a three centimeters intramural fibroid was seen by ultrasound. She was then prescribed or medications to attempt to control her menses with little success and her cycles have remained regular occurring every 28 to 32 days. An abdominal ultrasound scan shows the fibroid measuring nine centimeters in diameter. As you can see, 48 year old is important, increased menstrual loss, three years, one year ago, three centimeters, fibroid and cycle remained regular, but one year later, fibroid nine centimeters. So which of the following options is the most appropriate management. And there are five options as you can see it may be the administration of ulipristal, maybe laparoscopic myomectomy, maybe three months administration of generates agonist followed by abdominal myomectomy, maybe total abdominal hysterectomy or uterine artery emboli embolization. Well, it is important here to take into account two things first that the fibroid within a year from six centimeters became nine centimeters that the patient is 48 years old parish woman. So he's not interested about reproduction anymore. And therefore, we have to be more careful because this uh uh rapid increase in the fibroid may in a sarcoma or something like that. So, although laparoscope Myer for example, could be um non or all the others. It seems that the best answer here is total abdominal hysterectomy. Now, the second is about uh intrapartum care is a 32 year old woman with a BMI of 26 kg per square meter is admitted at 38 weeks of her first pregnancy with uterine contractions occurring every 10 and 10 minutes every uh sorry, every three and 10 minutes and lasting 30 to 40 seconds. The cervix is found to be three centimeter dilated and 1.5 centimeter long artificial rupture of membranes reveal slight meconium staining but no cord is palpable. And after 20 minutes of continuous cardiotocographic monitoring, deep type two late decelerations of the fetal heart rate are recorded. So here is 38 weeks with contractions with three centimeters. So it is early labor of the cervix dilated and meconium staining and type two day late deceleration. So, it's fetal distress in the early labor. Uh One can uh uh uh try various uh uh things. Uh for example, administration of oxygen, uh the left lateral position tocolytics, uh mediated delivery or ph from the fetal scalp. And of course, uh with all this in history, the best answer here is immediate delivery, which means of course, cesarean section. A third question as ba is about infertility treatment. A 29 year old woman with be 32 presents with primary infertility of two years duration. She has periods every 3 to 4 months and hirsutism. Uh his, her associate in tubes, semen analysis is normal. So here is a young patient with primary infertility, three of two years with oligomenorrhea and which means Polycystic Ovary syndrome and uh B and tubes, no problem with the sperm. So it is anovulatory infertility. So, in fact, it is ovulation induction. And the leading question is which of the following is the most appropriate ablation induction method. And there are various options here as you can see five. But can we ask the audience if they want to try to answer the? Yes, of course. So if somebody wanted to answer this question, yes, they would. Yeah, we can wait a few seconds. You can put your answers if you want to participate to see, they can do that again. Yes, of course. I will put mine and see, I cannot see the answer, but you can tell me the answer. OK. Have you received any? Only mine don't decide. Yeah, just try. We are between us. I'm gonna try creating a poll. I think some people might be quite shy. OK? So thank you and D NT it's not D ND, it's D nt just in case that you want to answer one of the last ones. So what is the answer? Sorry ID and C or B and C? What did you say? No? Because there's ABCD ABC. That's why not. Yeah. Is, is e the last one is e sorry about the mistake. Yes. Yeah. Now, now uh may has created a poll so they can answer. So we have two answers of D and M BI don't know which one is it? So that right? Oh Total six. So the majority answer of DD ABCD you mean is OK, which is on me? Yeah. So the fourth option. OK. So the answer is b in fact, why is BI will explain to you certainly in, according to the guidelines and the studies that exist. Letrozole, in fact, is uh better is best in the way that it provides a higher accumulative life birth rate than closing. The thing here is that if you look at the uh options, it doesn't say Letrozole, it says Letrozole plus Metformin, which is not correct in a way that we not combine Letrozole with Metformin because Letrozole is effective on its own, it does not need to gi to, to give Metformin as well. So if that is not the option, then the next best option is clomifen because both these drugs, Letrozole and Clomi are first line treatment and can be used independently. But certainly if you have the option, Clomi or Letrozole, letrozole is in fact the best, but it should be written. So sometimes there may be some destructors, you know, and probably this a distractor here. Uh uh So you should know uh these uh issues, you know, but it's OK. All right. II continue. Yeah, please. Yeah, please. OK. So in terms of SB, I'm not going to show you any um more, but here is what, in fact, uh uh the question looks like on your screen when you receive them from uh orone. So you would have to click on that uh the specifically, you know, option. Now, let's discuss about the em QS the, the extended matching questions and the structure, the structure is uh different than uh uh SBA is not very much different. There is a title with the F as with BA S. There is a list of options as with B but the list of options here is at least 10. While with BA it is five, there is a leading statement which is very important because this will direct you the candidate to uh uh what uh she or he has to do uh next and there are three clinical scenarios or cases uh that are included. So because of the three clinical scenarios and the list of options that is extended, that's why the E MPS are called extended matching questions. And in each uh of the three scenarios, there will be different um of course scenario, but the topic will be in all three scenarios related to the title, which is the thing. So what the candidates is advised to do is to read the leading statement first and then the scenario and then the candidate may be able to answer the question before looking at the list of options. Then by reading the option list, the candidate may more easily identify the proper answer. I ignored the majority of the others. But in case, the answer is not included in the list, then the scenario should be read again to make sure that uh there are important details, uh important keywords, for example, clues that have not been omitted. So it is important to go to the leading statement and go to the scenario and then uh answer the scenario yourself and then go to the list and see whether this answer is in the list of options. Example here, hypertensive disorders in pregnancy. So we go to the leading statement. Uh We ignore the options at the moment for each one of the following scenarios, select the most appropriate management. It is important to see what the scenario is for, is for management. Is for treatment is for diagnosis is for the course is intervention or what it is that is important. Uh from the list of options, of course, you would take the, the uh most appropriate management and each option may be used once more than once or not at all. So the scenario one is 60 si uh 36 year old woman in her first pregnancy, attends antenatal clinic for booking at 12 weeks. She is on treatment with insulin because of diabetes mellitus type one. Her BM I is 36 and her BP is 130/85 with no proteinura. So the important keywords here as is 12 weeks pregnant, uh first pregnancy of course, and she has diabetic uh diabetes, sorry about uh and the BP is normal but is marginally normal as you can see because if it is 140/90 then it is uh abnormal with no opportunity. So what would be the best management here? Can you think about it? Now, we have, we have another poll that we are waiting for the answers. Now they are answering. OK. The majority till now is the eye aspirin daily. OK. So I think uh because the majority has that. Yes, say that is aspirin. In fact, because the patient with diabetes uh uh is prone to develop uh hypertension. So it's better to give aspirin according to the guidelines. Of course. OK. Scenario number 2, 36 year old woman in her second pregnancy, attends antenatal clinic at 39 plus three weeks. In her past history, there is a normal vaginal delivery two years ago. She's currently under antihypertensive treatment due to chronic hypertension. Her BP is 145/95 with no proteinuria and fetal presentation is cephalic and the a non stress test uh is uh uh normal. So here is 39 plus three weeks with on treatment for chronic hyperten hypertensive. In fact, the pressure is increased 145/95. So, cephalic presentation, no problem with the baby. So, what are we going to do with that? Please l let us create a new pole again in a plan. May uh perfect. Let us give us two seconds, bro. Yes, sir. The new, the new they are answering the majority are d induction of labor. Very good. That is the uh best answer for this. Next scenario is a 31 year old woman in her first pregnancy, attends antenatal clinic at 34 weeks for review. Her BP is 145 or, or 95 and two plus proteinuria. Uh Presentation is cephalic NST is very active with no contractions and the biophysical profile shows no abnormalities. So it's 34 weeks. No term is preterm. Of course, before 3437 BP slightly elevated and proteinuria. So it is preeclampsia, mild preeclampsia but the embryo is OK. The fetus is OK. So what do we suggest here again? We are having a fall? Mhm It's 5050 between C and E and now the response are raising again. C and E um Yeah. Yeah. So let us see if there are any other answers. Yeah. E is where it is leading now. Betamethasone. OK. Yeah. So the correct or at least the best answer in fact is to review in one week because 34 still uh everything seems to be ok under control and the the baby is OK. So next uh is um gynecology or endocrinology here or this is amenorrhea, Leora and the leading statement is about treatment for each one of the following scenarios like the most appropriate treatment from the list of options. Again, each option may be used once more than once or not at all. So scenario number one, a 15 year old girl presents at the gynecological endocrine clinic, complaining of primary amenorrhea, clinical examination shows no secondary sexual characteristics. Laboratory investigation shows serum f age 75 L age 40 units per liter in this 10 per male. Her cardio is 45. 0, so is a 15 year old with primary menorrhea, no sexual characteristics, secondary very high FS H and L age, very low iron cardio type. Put the diagnosis of Turner syndrome and we have to treat the patient. So she we give to her as well. Perfect there is another answer. If you're going to answer on the chat box, it K estrogen low dose also because in the poll there is. Yeah, perfect. Can you hear me? Yes. Yes, perfectly. Now we're having the problem at the same time. Yes. Yes, we'll hear you. Do you hear us, bro? Sophia? Can you hear me? Yes, we do. Yes. Yes, we can. So the leading answer is uh a he doesn't hear as many prof can you hear us? Hello? I'm Yeah, I see her. Um OK, we'll show you the answer is K it's estrogen, low dose. When we have uh you, you can hear me. Can II speak then OK. Now, uh if we had a, a girl with uh amenorrhea and uh with no secondary character, we try to develop uh breast and uh pubic hair. And uh so that means secondary sexual character. We always start with low dose estrogen and we give only estrogen for about one year or if e earlier than one year, the, the, the girl shows uh uh menstrual bleeding, then we add progesterone and we increase then the dose of estrogen. So this is the guideline. So we do not give the oral contraceptives. OK. Now, next scenario is a 22 year old single woman with a BMI of 32 and Oligouria attends the local outpatient clinic. Her menstrual periods appear every 3 to 4 months, her hormonal profile. So serum FSH 6.7 LH 9.5 prolactin 20 nanogram, Perel testosterone, 1.4 the normal is less or equal to 1.2 nanogram per L. And further laboratory investigation shows glucose intolerance. I uh I mean here is young girl, is 22 year old woman. Uh with uh oliguria and normal legs and testosterone elevated, which means anovulation plus uh androgen hyperandrogenemia. So it is again P OS but with glucose intolerance, I understand that it is difficult to uh communicate or at least I cannot hear you and don't know, I don't know why this happens. Uh uh But uh in, in this case, uh of course, I will give you the answer, which is uh um administration of Metformin. Metformin is the uh a substance that uh sensitizes uh the patient to insulin because there is insulin resistance usually in these cases. So, by giving Metformin, we reduce the resistance. And uh this is uh a drug that also reduces the sugar, the blood sugar uh because of the glucose intolerance. And this uh woman here is single woman. So he is not interested in becoming pregnant. And therefore the administration of her contraceptives uh is not necessary to be uh uh at least uh uh adopted as a treatment. So that is the Metformin. And the third scenario is a 21 year old woman has been referred to the gynecological endocrine based clinic because of 12 month secondary amenorrhea. Over the last 15 months, she lost 18 kg and her BM I is now 17 kg square meter. Her weight has not increased despite an effort for nutrition interventions, her serum FSH is 4.3 LH 2.1 is low 15. She's in good mood and understands that her amenorrhea is possibly related to the loss of weight. So here is a contra amenorrhea gain a young woman 21 year old and uh uh she lost weight and therefore she has a hypothalamic problem. That's why FSH in the las are reduced and OL is very low. So, in this case, we treat the patient with estrogen because uh uh of uh uh the possib, I mean the risk for uh osteopenia and we prefer to give transdermal estradiol plus cyclic or progestin instead of oral contraceptives. Uh that is uh better uh because it bypasses the liver. But also uh it does not suppress the hypothalamus in a way that done with oral contraceptives. So see, this sys the system may recover in that way. Can you hear me? Yes, we do. Can you hear us? Oh, now, I, now I can hear you. So in this question, pro the question that uh was leading was d generate analogs, not c transdermal plus uh cyclic or a pro thing. But you see this patient has lost weight, has hypothalamic suppression if you give, generates analog, which you suppress pu more. This is not treatment. This is not, not a good selection you know, uh the so generates analogs will suppress the pituitary more already. The FSH is 4.3 and LA is 2.1 LH is suppressed more during the hypothalamic uh you know, uh dysfunction. Um So it's not a good selection. And so she needs uh a replacement therapy because of the risk of uh uh osteopenia and osteoporosis. OK. OK. I think there's no more scenarios and this is what you can see in terms of the question on the screen. OK. You can see all three scenarios on one page plus the options. So you can choose then the right answer. I think that yes, we do have two questions in the chart. So thank you for this. Uh Can I, can I stop sharing? What do you think? Yeah. Can I stop? Yeah. Yes. So we, I can see you then after that. Ok. Um So first question we have there. Can you see the question? Yeah. Will you have a pre exam before the August, please? Yes, the answer is yes, we will have one and this will be uh it has not been scheduled yet, but uh you should expect it to be between uh one and two weeks before the exams. So, in the second half of August. Ok. Ok. And another question, another one is uh from uh Brenna, apart from the cook book and the study medic talks. Are there any specific generals that will be recommended for our preparation. Well, I mean, uh there is not any other specific, you can use any text, you wanted any textbook or uh medical journals, of course. And the guidelines because the daily practice is based on the guidelines and the guidelines are used by many uh scientific organizations and uh like for example, UG A R MS um nice and many others. So I mean, it's up to you uh to find the, the the best way to go to the correct answers. But there are many of them and the majority of the questions in fact are based on, on this, on the guidelines. The thing I themselves are is that are enough for the preparation, the two recommended textbook from, for those that are the two volumes, the textbook is, did you ask about the textbook? Uh Yes, yes, yes. The the these are two volumes as you. So yes, I think this is enough. Uh It's a very good book. In fact, it has been written by many uh you know, very well known people uh on the specific field, each one of them. So it is very good and covers the whole, you know, uh curriculum of OK, I actually have a question. Um I'm just wondering because we are all from like different countries. Do you have any tips on how we can approach and answer clinical scenario questions? Because I find that for example, in Ireland, every hospital does different things different, a different consultant. And then also there's there's variation between the countries as well. How should we kind of approach and answer this clinical scenario questions? Well, may you see certainly there are differences but in many countries also produce guidelines uh based also on the international guidelines. I think the difference is not very uh large, you know, difference, but uh I cannot give you, you know, ee definite answer on that. But of course, if you follow the international guidelines, I think at least the questions are written based on the international guidelines. Do you think it would be, um, you know, how sometimes we are studying for a few different exams at the same time? Do you think that's a wise thing to do or we should focus on studying one cup of exam at a time? Well, I mean, uh it's up to you. If you, if you are a talent, then you can do that, you know. Yeah, II had someone who text me the question because they can't seem to write it. Um They said that what, what would the success rate of candidates pass, uh success rate of candidates passing the exam? And what are some of the common mistakes that the candidates make during the exam? And how can they avoid them? Well, I mean, the passing rate uh probably means the, the, the number of candidates who pass the exams is that the passing rate overall passing rate per year is around 40 to 50%. Uh, both part one and part two because they have to pass, I mean, there may be, for instance, in part 2 70% or 80% but they have to pass both part one and part two. So that, uh, has an average passing rate, which is around 40 to 50%. And what do you find are the common mistakes that these candidates make? Like, how do we increase our passing passing rate? Uh There are, well, I mean, if they don't answer the questions correctly, uh when we analyze the data after the exams, uh we see that sometimes some of the questions are answered in the, the majority by the majority of those who fail the exams done by those who pass the exams. Which means that these particular questions may not discriminate. This does not mean that the question is not good. The question is very good sometimes. But the thing is that no, either, neither the, the, the, the failures, the failed nor the past the passing candidates. No, the question, you know, so that's why they do not answer it correctly. You would expect those who pass the question who pass the exams to answer uh the majority of the questions and those who fail uh to do the opposite. But sometimes this happens. But there aren't many of these questions. We reviewed these questions we removed from the final calculation and then we use them in the subsequent exam but there are not any specific, you know, points that you can say about that. Uh What, what is uh I mean, the main uh points or uh they, they fail, they do not answer correctly. I mean, there's a variability anyway. Thanks very much. Thank you very much. I think the time is up the it's 806. So uh for local time, depending from where are you? Of course, II would like to thank you again, all of you for attending this webinar and uh specialty prof messinis for his kindness and generous to be with us to share his knowledge and experience about the exam. And also would like to take advantage to say that also offers and OC offers a, a discount code for the textbook and handbook of sexual reproductive health care um books. So if anyone is interesting about uh sitting on the diploma or certificate, upcoming exams, you can have also the textbook and the handbook of o. So please conduct us in order to share the discount code in order to gain 20% discount. And uh we're waiting. If you have any other inquiries, please share it with us and we will share it with prof of course. And thank you very much. Thank you very much, Sofia and uh all the attendees and uh I hope they will decide about taking the exams and they should not be afraid of this. You know, if they are good candidates, they will pass the exams and for just for a positive last comment that the pass rate it's always above 60% dot So don't be scared to sit on the exam. It's a very good passing rate, I think. Yeah, I think it's a very good passing rate because even you know, in rug the passing rate is not uh higher than that. Mm. Ok. And yeah, thank you. Thank you very much all of you. Thank you to evening tonight to anyone and good morning if everyone is a little bit more far away from us. Bye bye bye, bye bye. Thank you. Bye bye. Thank you. Bye bye bye.