3a Obstetrics & Gynaecology Flashcards
How would you manage menopause? This includes premature ovarian failure.
Current or previous breast cancer you do NOT give hormonal treatment
- Can give venlafaxine instead (clonidine, gabapentin)
Premature ovarian failure
- Depending on preferences you can use COCP or HRT until 51 years
With uterus
- You MUST give progestogen (Mirena, cyclical or continous // refer below), if not they are at risk of endometrial hyperplasia and cancer
< 50 years and 2 years of amenorrhoea OR > 50 years with 1 year of amenorrhoea (no need for contraception)
- Continuous progestogen + oestrogen
Mirena use (as it provides continuous progestogen) in all ages
- Continuous oestrogen
< 50 years and < 2 years of amenorrhoea OR > 50 years with < 1 year amenorrhoea (those in this category still require effective contraception)
- Continuous oestrogen + cyclical progestogen to induce withdrawal bleeding (can be every 3m if irregular bleeding)
Others: CBT, vaginal oestrogen + moisturiser (no need to give progestogen)
What are some signs and symptoms of menopause?
Vasomotor
- Hot flushes and sweats
- Chills
Emotional
- Mood swings low mood and anxiety
- Decreased libido
Systemic
- Brain fog/memory
- Fatigue and insomnia (think cannot sleep due to sweats/flushes)
- Dry and thinned skin
- Hair loss
- Weight gain
- Muscle/joint aches
- Headaches
GU:
- Dysuria, increased UTIs
- Vaginal dryness and atrophy
- Superficial dyspareunia
- Prolapse
What can cause premature menopause? Are there any complications?
Premature menopause is the cessation of menstruation < 40 years of age
Iatrogenic:
- Hysterectomy + bilateral salpingoophrectomy
- Chemoradiotherapy
Idiopathic
Familial
Fragile X syndrome
Turner syndrome
Others: inhibin B mutation, autoimmune disease, enzyme deficiency
Complications:
- Osteoporosis
- CVD
- Alzheimer’s
How does adenomyosis differ from endometriosis? How would you manage adenomyosis?
Adenomyosis is when there is endometrial tissue in the myometrium (hence oestrogen dependent, cyclical pain and resolves after menopause)
- Results in menorrhagia, cyclical dysmenorrhoea, infertility and dyspareunia
- Uterus is tender and boggy (softer than fibroids)
Who gets adenomyosis?
- Older multiparous women (vs younger nulliparous women in endometriosis)
Investigations
- TVUSS
- GS is hysterectomy and biopsy
You would manage adenomyosis like you would for menorrhagia:
Desire for fertility
- Mefanemic acid (NSAID - hence use if there is also dysmenorrhoea)
- Tranexamic acid (antifibrinolytic)
Desire for contraception
- Mirena IUS 1st line
- COCP or cyclical POP 2nd line
- Hysterectomy/uterine artery embolisation/endometrial ablation
What is lichen sclerosis? Who gets LS, and how do you treat it? What are some complications of untreated LS?
Lichen sclerosis is inflammation of the skin (caused by lymphocytes)
Can present in males and females of any age
- But F>M
- More common in middle aged women
Risk factors
- Autoimmune disease (e.g., coeliac, T1DM, alopecia, hypothyroidism, Addison’s, vitiligo)
Presentation:
- Dry, thin (atrophic), shiny paper-like skin white-patches
- Lichenification and hyperkeratosis
- Itching and soreness
- Can appear red/bleeding with excoriations if scratching
Female:
- Figure 8 appearance
- Superficial dyspareunia due to narrowed interoitus
Male:
- Unretractile or tightly adhered foreskin/prepuce (BXO and phimosis)
- White band around tip of foreskin
Complications:
- Vulval cancer (squamous cell carcinoma)
- Reabsorption of the labia minora
- Fusion of foreskin/phimosis
Diagnosis: biopsy
- Not required to start treatment! Only if unresponsive
Management
- Refer to dermatology
- Potent topical steroids (clobetasol) + emollients
What are some risk factors for developing vulval cancer? How does vulval cancer present?
Lichen sclerosis
HPV 16 and 18 infection
Old age
Presentation
- Itching and soreness
- Persistent lump + ulceration
- Dysuria or painful urination
- Hx of recurrent ‘UTI or thrush’
- PMH of HPV, VIN or lichen sclerosis
What is Asherman’s syndrome?
Formation of adhesions within the uterine cavity due to previous trauma (TOP, hysteroscopy and biopsy, intrauterine surgery [e.g., removal of fibroids or RPOC])
Presentation
- Asymptomatic is NOT Asherman’s
- Dysmenorrhoea
- Lighter menstrual bleeding
- Infertility or recurrent miscarriage
Investigations
- GS: hysteroscopy
- Hysterosalpingography
- Sonohysterography
- MRI
Management
- Conservative management
- Adhesiolysis during hysteroscopy
When are patients first called for cervical screening? What happens to the samples?
25 years (until 65 years)
- Every 3 years from 25-49
- Every 5 years from 50
- Can request 1x after 65 if no screening since age < 50
The samples are first tested for high-risk HPV
- Only if HPV + will they be sent for cytology
What is atrophic vaginitis and its management?
Atrophic vaginitis is the thinning, irritation and inflammation of vaginal tissue due to the lack of oestrogen after menopause
Presents with:
- Superficial dyspareunia
- Dryness/itching/soreness
- Loss of libido
- Recurrent UTI
- Prolapse
Management:
- Vaginal moisturises, lubricants and vaginal oestrogen
- DO NOT give vaginal oestrogen if previous breast cancer or oestrogen sensitive cancers
What is PCOS and how will patients present? Which is higher in PCOS: LH or FSH?
Pathophysiology
- Low FSH compared to LH means excess androgens are produced in comparison to what is needed to make oestrogen (LH stimulates theca cells to produce androgens which are used by FSH stimulated granulosa cells to make oestrogen; androgens are then converted to testosterone!)
- Hence no progesterone from corpus luteum meaning no/irregular menstruation
- Weight gain = increased fat cells + insulin resistance + oestrogen production
LH is higher than FSH in PCOS
- Normally FSH is meant to be higher
Triad (2/3 required)
- Oligomenorrhoea/amenorrhoea
- Hyperandrogenism (biochemical or clinical)
- Cystic ovaries (ovary > 10mL or > 12 follicles in 1 ovary)
Presentation
- Oligomenorrhoea/amenorrhoea
- Infertility
- Weight gain, fatigue, low mood
- Acne
- Hirsutism and virilization (male-pattern baldness)
- Acanthosis nigricans
- Possible dysmenorrhoea and menorrhagia
What is endometriosis and how would someone present? What is the typical triad? How would you investigate endometriosis?
What is endometriosis?
- Endometrial tissue outside of the endometrium BUT not in myometrium (commonly affecting the uterosacral ligament, ovaries, pouch of Douglas, fallopian tube, peritoneum, bladder and bowel but can also affect the lungs!)
- Oestrogen dependent so will resolve with menopause
Typical patient
- Nulliparous young female
Risk factors (high oestrogen)
- Nulliparity
- Early menarche
Triad
- Deep dyspareunia + menorrhagia + cyclical dysmenorrhoea
Other features
- Haematochezia
- Haematuria
- Infertility
- Dyschezia
- Dysuria
- Fatigue, depression
- Constipation
- Chronic pelvic pain (dull/heavy)
Investigation and examination
- Examination: speculum (fixed retroverted uterus + endometrial nodules on posterior wall/fornix) + bimanual (adnexal mass)
- GS: laparoscopy + biopsy (BUT you do not need this to treat)
- TVUSS/TAUSS is NORMAL
- N.B., Ca-125 can be raised
How would you manage endometriosis? What are some complications of endometriosis?
Aim of medical management is to reduce oestrogen fluctuation/abolish cycle!
Endometriosis = endometrial tissue
Conservative:
- COCP continuously first line if wanting contraception
- Mefanamic acid first line if wanting fertility
- POP/GnRH analogues - only pre-operation /implant/injection/Mirena IUS
Surgical:
- Ablation/excision of nodules to preserve fertility
- Hysterectomy + bilateral salpingoophrectomy
Complications
- Adhesion formation
- Infertilty
- Ectopic pregnancy
- IBD association
Can you tell me about fibroids?
What are fibroids?
- Leiomyomas // smooth muscle tumours
- Types: submucosal, pedunculated, subserosal, intramural
- They are oestrogen dependent and resolve after menopause
Risk factors
- Multiparous
- Older age
- BME
- Early menarche/late menopause/later first pregnancy
- Family history
Presentation
- Can be asymptomatic
- Enlarged uterus/abdominal mass that should be non-tender
- Menorrhagia
- Dysmenorrhea
- Pressure symptoms (frequency, urgency, constipation)
- Abdominal pain and deep dyspareunia
Investigations: TV or TAUSS
Management (like menorrhagia)
- All > 3cm or submucosal then refer to gynaecology
- If < 3cm and wanting contraception = Mirena IUS 1st line (others ref. > 3cm)
- If > 3cm and wanting contraception = cyclical POP/COCP
- Conservative and wanting fertility = tranexamic acid or mefanamic acid
- To improve fertility: myomectomy
- Others: uterine artery embolisation
- Definitive: hysterectomy
- N.B., can give GnRH analogues prior to surgery to shrink the fibroids
What are endometrial polyps?
Outgrowths of endometrial tissue
Causes menorrhagia
TVUSS
Hysteroscopy + biopsy/resection
Can you summarise endometrial hyperplasia and its management for me?
Presents as post-menopausal bleeding, menorrhagia or intermenstrual bleeding
Risk factors (think unopposed oestrogen or lack of progesterone)
- PCOS
- Oestrogen only HRT
- Granulosa cell tumour
- Obesity (due to aromatase in fat cells = increased oestrogen production)
- Tamoxifen use
- Nulliparity
- Early menarche and late menopause
- HNPCC
Protective factors
- COCP/POP/IUS/implant/injection
- Smoking
- Hysterectomy
Types of hyperplasia
- Simple/complex typical/atypical
Investigations
- TVUSS (> 4mm is abnormal if post-menopausal)
- Hysteroscopy + biopsy
Management (if no atypical features)
- Mirena IUS
- Continuous POP
- Other progesterone contraceptions
- Follow up every 6 months!
Management if atypical
- Hysterectomy
- Mirena if surgery not desired
Complications
- Endometrial cancer
What are some causes of post-coital bleeding?
Cervical cancer
Ectropion
Atrophic vaginitis
STI
Vaginal cancer
Polyps
What are some causes of post-menopausal bleeding?
Remember 2WW TVUSS if > 55 with PMB
ENDOMETRIAL CANCER UNTIL PROVEN OTHERWISE
Endometrial hyperplasia
Vaginal/vulval cancer
Atrophic vaginitis
STI
Fibroids/polyps
HRT
Ovarian cancer (especially theca cell)
? Has it come from the bowel/bladder
Investigations
- TVUSS 1st line
- Hysteroscopy + biopsy is GOLD STANDARD
What are some causes of inter-menstrual bleeding?
Endometrial cancer
Endometrial hyperplasia
Fibroids
Polyps
Cervical cancer
Ectropion
Miscarriage
Ectopic pregnancy
STI
Contraception use (especially first few months of progesterone contraception)
Spotting during ovulation or implantation
What are the risk factors for developing cervical cancer? Are there any protective factors?
Persistent HPV infection (16 and 18)
Risk factors:
- Long-acting contraceptive (COCP/POP/IUS/IUD)
- Multiple sexual partners
- Early first intercourse
- No vaccination uptake or non-attendance at screening
- Smoking
Protective:
- HPV vaccine
- Condom use
What are the risk factors for developing endometrial cancer? Are there any protective factors?
Risk factors (think unopposed oestrogen or lack of progesterone)
- PCOS
- Oestrogen only HRT
- Granulosa cell tumour
- Obesity (due to aromatase in fat cells = increased oestrogen production)
- Tamoxifen use
- Nulliparity
- Early menarche and late menopause
- HNPCC
Protective factors
- COCP/POP/IUS/implant/injection
- Smoking
- Hysterectomy
Can you tell me about hydatidiform moles?
A form of gestational trophoblastic disease
Risk factors: extremes of reproductive age, Asian, previous molar pregnancy
Partial mole: normal ova is fertilised by 2 sperm (or 1 sperm which eventually duplicates)
Complete mole: abnormal ‘empty’ ova is fertilised by 2 sperm
Presentation
- Hyperemesis gravidarum
- Amenorrheoa
- Rapidly enlarging uterus (larger than expected for gestational age)
- Bleeding
- THYROTOXICOSIS (hCG mimics TSH)
Investigations
- TVUSS (snowstorm appearance due to all the theca-luteal cysts)
- Serum beta-hCG
- Uterine evacuation + biopsy/histology of products
Management
- Urgent complete evacuation of uterus +/- anti-D
- +/- chemoradiotherapy
- Monitor beta-hCG levels every 2w until normal
- No longer need to monitor after subsequent pregnancies
Complications
- Malignancy/recurrence
- Choriocarcinoma
- Invasive mole (from complete mole)
What is hyperemesis gravidarum? What is the diagnostic triad?
Pathophysiology
- Excessive vomiting causing dehydration and ketosis
Risk factors
- First trimester
- Female foetus
- Molar pregnancy
- Multiple pregnancy
- FHx or previous hyperemesis gravidarum
- Hyperthyroidism
- Smoking is protective
Presentation
- Excessive vomiting
- Triad: > 5% weight loss + dehydration + electrolyte imbalance
Investigations
- USS
- LFT, U&E
- Urine dipstick + MSU
Management
- A to E resuscitation + NBM if necessary
- Anti-emetics: PO promethazine or cyclizine
- 2nd line: prochlorperazine or metoclopramide or ondansetron
== Do not use metoclopramide for longer than 5 days
- Hospital admission for IV fluids + antiemetics + enteral feeding
- Others: ginger, P6 acupuncture/pressure point stimulation
- K+ and B1 replacement
- LMWH
- Steroids (prednisolone, hydrocortisone) last line
Complications
- Wernicke’s encephalopathy
- Hypovolaemic shock, AKI, liver failure
- Metabolic alkalosis
- Mallory-Weiss tear
- Central pontine myelinosis
- Preterm delivery
When would you admit someone with hyperemesis gravidarum to hospital?
Electrolyte imbalance
Ketones in urine
> 5% pre-pregnancy weight has been lost
Not tolerating oral intake
What is an ectopic pregnancy? How could it present and how do you manage?
What are the symptoms of miscarriage and do we perform any investigations? What is the management of miscarriage?
Miscarriage is the loss of a foetus before 24 weeks of gestation
Risk factors
- Early pregnancy
- Maternal health problems
- Abnormal foetus
- Weak cervix
- Abnormal uterus
Presentation
- PV bleeding (can be heavy) after a period of amenorrhoea
- Abdominal pain
Management (+ anti-D if surgical management)
- Watchful waiting
- PV misoprostol or surgical/vacuum removal of products of conception
- Measure beta-hCG // take a pregnancy test after 3 weeks
What are the types of miscarriage?
Recurrent miscarriage = 3 or more consecutive miscarriages
Threatened miscarriage
- Abdominal pain + bleeding but cervical os is closed on examination
Inevitable miscarriage
- Abdominal pain + bleeding but cervical os is open on examination
Complete miscarriage
- Abdominal pain + bleeding + closed os and no products visible on USS
Incomplete miscarriage
- Abdominal pain + bleeding but products visible on USS
Missed miscarriage
- Dead foetus on USS
- ‘Empty sac’ or ‘blighted ovum’
How can terminations of pregnancy be performed? What is the timeframe allowed?
Requires 2 practitioners to approve TOP
All GA can use medical or surgical TOP
< 24 weeks:
- Pregnancy carries risk of harm (physical/mental) to mother
- Pregnancy carries risk of harm (physical/mental) to other dependants
No limit if:
- Foetus has significant disability
- Pregnancy is life-threatening to mother
- Pregnancy will cause grave injury to mother (physically or mentally)
What is used?
- Anti-D to all >= 10+0 even if medical TOP
- PO Mifepristone + PV misoprostol 48 hours apart // if 10+1 onwards, take misoprostol every 3 hours until products are passed
- Surgical (suction or dilation + curettage) + MTZ/doxycycline prophylaxis
How would you induce labour?
What is failure to progress in labour and how do you manage it?
What is pelvic inflammatory disease? What is the antibiotic regimen of choice?
What is bacterial vaginosis and how does it present?
Bacterial vaginosis = loss of normal vaginal flora due to overgrowth of anaerobes (gardnerella, mycoplasma hominids, mobiluncus, prevotella)
It is not an STI!
Risk factors:
- Sexual activity (semen)
- Douching
- Use of bubble baths/antiseptics/bath shampoos
- BME
Presentation
- Asymptomatic
- Greyish-whiteish foul-smelling (fishy) discharge that is quite watery and thin
- NO itching or dyspareunia
Examination:
- Speculum
- Abdominal if necessary
Investigations (not necessary to swab for microscopy and staining)
- HVS or low self-swab for microscopy (salt and pepper appearance, clue cells)
- Narrow range pH paper (> 4.5)
- Whiff test +
BV diagnostic criteria (Amsel)
- Clue cells and low WCC
- pH > 5.5
- Whiff test + smells like fish
- Grey-white discharge
Do you treat bacterial vaginosis? Tell me about the different approaches if someone is and is not pregnant.
Offer all self-care advice
- Avoid douching
- Avoid bath products (shampoos, bubble baths, antiseptics)
Non-pregnant:
- PO metronidazole 1st line
- Intravaginal metronidazole or clindamycin (think clINdamycin goes INside)
In pregnancy: never give STAT metronidazole in pregnancy
- Asymptomatic = consult obstetrics
- Symptomatic = PO metronidazole > vaginal metronidazole or clindamycin
What are the complications of BV in pregnancy?
Miscarriage or stillbirth
PPROM, premature labour, low birthweight baby
Endometritis postpartum
What is the “baby blues” triad? When does it start and end?
Tearfulness
Anxious
Irrritable
Starts within a few days of birth and resolves by 14 days post-partum
How long is Mirena licensed as HRT?
4 years
Would you investigate menopause?
Not if >= 45 years
If < 45 years then FSH must be raised > 25 IU/L in 2 samples at least 4 weeks apart with > 4 months of amenorrhoea
What are some complications of HRT?
What is the most common cause of PV discharge in women of child-bearing age?
Bacterial vaginosis
What discharge do you see with BV?
Grey-white thin discharge that smells like fish
NO itching/dyspareunia
How would trichomonas discharge appear?
What is trichomonas vaginalis and how will patients present?
What are ‘triple swabs’ and what do they test for?
What are some non-malignant differentials for breast lumps?
What are the different types of breast cancer?
What are some presenting symptoms of breast cancer?
When would you 2-week wait someone for suspected breast cancer?
What are the causes of cyclical dysmenorrhoea?
Adenomyosis
Endometriosis
Fibroids
Polyps
Ovarian cysts
What are some causes of menorrhagia?
Gynaecological:
- Dysfunctional uterine bleeding
- Copper coil
- PID
- Fibroids
- Polyps
- Endometrial cancer/hyperplasia
- Endometriosis
- Ademonymosis
- PCOS
Systemic:
- Bleeding disorders and anticoagulant use
- Liver/kidney disease
- Hypothyroidism
How would you manage menorrhagia in a woman wanting fertility?
Tranexamic acid if no associated dysmenorrhoea
Mefanamic acid if associated with dysmenorrhoea
How would you manage menorrhagia in a woman who does not want fertility?
Manage underlying causes (fibroids, polyps, endometriosis)
Management for menorrhagia without other causes
- Mirena IUS (licensed for 5 years) // not if fibroid > 3cm or other structural abnormalities of the uterus
- COCP
- Cyclical POP
Specialist management for menorrhagia without other causes:
- Uterine artery embolisation
- Endometrial ablation (N.B., can be difficult to spot endometrial cancer after ablation!)
- Hysterectomy
