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Laura MRCOG Part 2 > 13) Gynaecological Problems - Other > Flashcards

13) Gynaecological Problems - Other Flashcards

1
Q

Analgesia for outpatient hysteroscopy

A

NSAIDs 1 hour before appointment.
Don’t recommend opiates.
Intra-cervical or para-cervical LA if cervical dilatation required or hysteroscope >5mm.

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2
Q

Cervical preparation before outpatient hysteroscopy

A

No

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3
Q

Perforation risk during outpatient hysteroscopy

A

0.002-1.7%

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4
Q

Size of hysteroscope for outpatient hysteroscopy

A

2.7mm with 3-3.5mm sheath

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5
Q

Distension media for outpatient hysteroscopy

A

Normal saline (quicker, improved image quality and reduces vasovagal)

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6
Q

Dilatation before outpatient hysteroscopy

A

Not as routine

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7
Q

Benefit of local anaesthetic into cervical canal

A

Reduced vasovagal reactions

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8
Q

When to apply local anaesthetic to ectocervix?

A

If tenaculum to be used

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9
Q

Conscious sedation during outpatient hysteroscopy?

A

No

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10
Q

Standard technique for outpatient hysteroscopy

A

Vaginoscopy

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11
Q

Overall risk of serious complications from diagnostic hysteroscopy (under GA)

A

2 in 1000

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12
Q

Very rare risks of diagnostic hysteroscopy under GA

A

Death (3-8 per 100,000)

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13
Q

Rare risks of diagnostic hysteroscopy under GA

A

Damage to bladder/bowel/blood vessels.

Infertility.

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14
Q

Uncommon risks of diagnostic hysteroscopy under GA

A

Damage to uterus

Failure to gain entry

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15
Q

Frequent risks of diagnostic hysteroscopy under GA

A

Infection

Bleeding

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16
Q

Features of dextran 32%

A

High viscosity fluid.
Hypertonic.

Good visualisation in presence of blood.
Anaphylaxis. Crystallisation within scope. Small absorbed volumes led rapidly to heart failure.

Never used!!

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17
Q

Viscosity of modern distension fluids

A

Low

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18
Q

Which fluids are isotonic?

A

NaCl
Hartmanns
5% Mannitol

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19
Q

Which isotonic fluids contain electrolytes and which don’t?

A

NaCL and hartmanns contain electrolytes.

Mannitol doesn’t contain electrolytes.

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20
Q

When do you need fluid without electrolytes?

A

Monopolar operative hysteroscopy

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21
Q

Which fluids are hypotonic?

A

1.5% Glycine
3% Sorbitol
5% Dextrose

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22
Q

Which hypotonic fluids contain electrolytes/don’t?

A

None of them contain electrolytes

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23
Q

Risks of hypotonic fluids

A

In excess they will cause dilutional hypervolaemia (can lead to cardiac failure), hyponatremia & cerebral oedema.

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24
Q

What is classed as fluid overload?

A

> 1000mL using hypotonic solutions or >2500mL using isotonic solutions (but lower thresholds in people with comorbidities and fluid deficit threshold should be discussed with anaesthetist pre-procedure)

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25
Q

Factors that increase the risk of fluid absorption

A 
High intrauterine distension pressures
Low mean arterial pressure
Deep myometrial penetration
Prolonged Surgery
Rsection of large vascular myxomas
Large uterine cavities
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26
Q

In which women are complications more likely?

A

Premenopausal women and those with cardiovascular/renal disease

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27
Q

Risks of isotonic fluids

A

Don’t cause hyponatremia but can cause hypervolaemia

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28
Q

Measures to reduce fluid absorption

A
  • Pre-op GnRH analogues in premenopausal women before hysteroscopic fibroid resection.
  • Intracervical injection of dilute vasopressin before dilatation
  • Intrauterine pressure as low as possible and lower than MAP
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29
Q

How to manage fluid overload?

A

Strict fluid balance monitoring
Catheter
Electrolytes
Fluid restriction/diuretics

If symptomatic - 3% hypertonic saline

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30
Q

How often should fluid deficit be measured throughout hysteroscopy?

A

Every 10 minutes

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31
Q

Incidence of gender variance in population

A

0.01-1%

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32
Q

Where should patients with gender dysphoria be referred?

A

Adults - GIC

Children - GIDS

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33
Q

What can GPs do whilst awaiting referral to GIC?

A

Bridging prescriptions with advice from gender specialist

34
Q

Eligibility criteria for gender treatments

A
  • Persistent and well documented gender dysphoria
  • Capacity
  • Significant medical or mental health concerns controlled
  • Achievable plan that has already been implemented or is about to be
35
Q

Option for adolescents with gender dysphoria

A

GnRH analogues

36
Q

Cross-sex hormone therapy for adults

A
  • GnRH analogues to suppress innate sex hormones

- “Add-back” of oestrogen or testosterone

37
Q

Percentage improvement in gender dysphoria with cross sex hormone therapy

38
Q

What blood test monitoring required for people on cross-sex hormone therapy?

A

BP, FBC, U&E, LFT, Fasting blood glucose, lipid profile, thyroid, oestrogen, testosterone, prolactin.

Every 6 months for 3 years and then yearly if stable.

39
Q

Oestrogen used in M->F hormonal treatment

A

Estradiol (bio-identical) 1-6mg/day

40
Q

Target serum estradiol levels during hormonal therapy

A

Upper level of follicular phase oestrogen

41
Q

Effect of adrenal androgens in M->F hormonal therapy

A

Androstenedione and DHEA not suppressed.
Low potency but can be converted to testosterone/DHT. - if need to prevent this can use finasteride, or use cyproterone/spironolactone.

42
Q

Mechanism of action of finasteride

A

5a-reductase inhibitor

43
Q

VTE in transgender women

A

Estradiol doesn’t increase the risk but if risk factors for VTE then give transdermal.

44
Q

Liver in transgender women

A

Oestrogen causes obstructive liver dysfunction - if present use topical instead of oral.

45
Q

Breast cancer in transgender women

A

Same risk as background male population but should receive breast screening (transmit also eligible if breast tissue still remaining)

46
Q

Risk of testosterone treatment in transmen

A

Induces production of EPO –> Polycythaemia –> CVA.

Ensure testosterone near lower end of normal before next dose and can use venesection if polycythaemia occurs.

47
Q

When to recommend hysterectomy in transmen and what monitoring if they decline?

A

After 4-5 years of testosterone.

2 yearly ultrasound assessment if not.

48
Q

Eligibility for gender reassignment surgery

A

12m living in gender role and 12m of continuous endocrine treatment

49
Q

Effect of gender treatment on fertility

A
  • Surgery will lead to irreversible sterility.
  • Oestrogen reversible reduction in testicular volume + poor quality semen
  • Testosterone reversible amenorrhoea and may affect follicular function.
50
Q

Contraception during gender treatment

A

Transgender men on testosterone treatment should still use barrier contraception if required as risk of pregnancy (even if GnRH analogues) and testosterone is teratogenic.

51
Q

When should gamete storage be performed?

A

Ideally offered pre-hormones, but if already using then interrupt for 3m

52
Q

Duration of gamete storage

A

10 years usually. Extended to 55 years for transgender individuals.

53
Q

Effect of testosterone on ovaries

A

Cortical and theca thickening similar to PCOS

54
Q

Preferred route for hysterectomy in transmen and why?

A

Vaginal/laparoscopic to minimise scarring of abdomen in case it becomes donor site for phalloplasty

55
Q

Implications of Gender Recognition Certificate

A

New hospital records in new name.
Must then be no disclosure in medical records to patient’s former gender or any treatments, unless consent has been obtained.

56
Q

Prevalence of HIV in transwomen

57
Q

Percentage of women undertaking >150 minutes of exercises each week

58
Q

Proportion of women reporting an adverse effect of menstruation on athletic performance

59
Q

Energy balance

A

45kcal/kg fat free mass/day

60
Q

Consequences of chronic low energy availability

A

RED-S

Syndrome of consequences including metabolism, bone health, immunity, CVS, psychological, menstrual and reproductive

61
Q

What is the “female athlete triad”?

A

Menstrual dysfunction, impaired bone health, sub fertility.

62
Q

Proportion of amenorrhoea in general population/athletes

A

5% general population
65% long distance runners
79% ballet dancers

63
Q

At what level of energy availability is LH pulsatility disrupted?

A

20-25 kcal/kg

64
Q

Proportion of athletes with delayed menarche

A

7% athletes overall, 22% in high risk sports (average delay 4y in gymnasts)

65
Q

What is the effect of intense exercise on sub fertility?

A

> 1h/day with energy expenditure >6kcal/min - 6 x increased risk

66
Q

IVF outcomes in those with intense exercise

A

40% less likely to achieve live birth
3 x increased risk cycle cancellation
2 x increased risk miscarriage

67
Q

Exercise and miscarriage

A

HIT around implantation may increase risk miscarriage

68
Q

Proportion of athletes with clinical eating disorders

69
Q

BMD difference in RED-S

A

10-20% lower BMD

70
Q

Prevalence of urinary incontinence in athletes

A

36% (3 x more likely than sedentary controls)

2 x more likely during training than competition

71
Q

Current diagnostic criteria for low EA

A

BMI <17.5 or recent weight loss >10% over 1 month

72
Q

Investigations in low EA

A

low LH, low FSH, low estradiol, normal testosterone.
Low AMH.
Polycystic ovaries on USS>

73
Q

Diagnosis of osteoporosis in athletes

A

Z score <2 (<2.5 normal population)

74
Q

Management of RED-S

A

Increase energy intake or reduce expenditure.

Increase calorie intake by 300-600 per day with target BMI >18.5

75
Q

When to say someone with RED-S can’t compete and can’t train?

A

Eating disorder
Serious medical condition related to low EA
Extreme weight loss techniques resulting in dehydration/life threatening condition
Severe ECG abnormalities

76
Q

When to say someone with RED-S can train and compete fully?

A 
Healthy eating
Appropriate EA
Healthy endocrine function
Normal BMD
Healthy MSK system
77
Q

Medical management involved in RED-S

A
  • Transdermal oestrogen with progestogen after 12m conservative management
  • Barrier contraceptives
  • Calcium supplementation 1.5g
78
Q

Which drugs are prohibited by doping agency?

A

SERM
Clomifene
GH
(LH/hCG in males but not females)

79
Q

Improvement in incontinence after PFE in sportswomen

80
Q

Pre-treatment if ART used in sportswomen

Laura MRCOG Part 2 (56 decks)

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