acute gynaecology + menopause

Question 1

ovarian torsion

Answer 1

where ovary twists in relation to surrounding connective tissue, fllopian tube + blood supply (adnexa) –> medical emergency

• torsion more likely with a cyst >5cm - dermoid
• more likely to occur during pregnancy

Question 2

ovarian torsion in premenopausal women vs post

Answer 2

pre - long infundibulopelvic ligaments that twist more easily, likely bening

post - likely malignant

25% of adenexal torsions occur in children
- twisting of adnexa + blood supply leads to ischaemia, necrosis -> ovary loss of function

Question 3

risk factors for ovarian torsion

Answer 3

ovarian mass - present in around 90%
of reproductive age
pregnancy
ovarian hyperstimulation syndrome

Question 4

ovarian torsion presentation

Answer 4

sudden onset severe unilateral pelvic pain - deap-seated colicky abdominal pain
pain is constant, gets progressively worse
assoc N+V
localised adenexal tenderness

palpable mass in pelvis - absence does not exclude diagnosis
occasionally can twist + untwist intermittently - pain that comes + goes

Question 5

ovarian torsion investigations

Answer 5

pelvis US - transvaginal ideal but transabdominal also fine
- “whirlpool sign”
- free fluid in pelvis
- oedema of ovary

doppler studies may show lack of blood flow

definitive diagnosis = laparoscopic surgery (also therapeutic)

Question 6

ovarian torsion management

Answer 6

laparascopic surgery
- untwist ovary + fix in place
- remove affected ovary - oophrectomy

laparotomy may be equired where there is large ovarian mass or malignancy is suspected

Question 7

complications of ovarian torsion

Answer 7

necrosis of ovary - loss of function
- other ovary usually compensates so fertility is not typically affected (loos of this one too = infertility + menopause)

• where necrotic ovary not removed - infection->abscess-> sepsis, may rupture resulting in peritonitis + adhesions

Question 8

pelvic inflammatory disease + causes

Answer 8

ascending infection from endocervix

• chlamydia, gonorrhoea
• mycoplasma
• endometritis
• enarobes

Question 9

pelvic inflammatory disease presentation

Answer 9

bilateral lower abdo pain
fever
deep dyspareunia
dysuria
abnormal vaginal bleeding
vaginal or cervical excitation
discharge
N+V in 50%

Question 10

pelvic inflammatory disease investigation

Answer 10

pregnancy test to exclude ectopic
high vaginal swab
screen for chlamydia + gonorrhoea

Question 11

management of pelvic inflammatory disease

Answer 11

Outpatient
o Ofloxacin + metronidazole 400mg twice daily
–> Patients <18 / at high risk of gonorrhoea, sexual contact, diplocci on microscopy = IM ceftriaxone + doxycycline

Inpatient
o IV ceftriaxone + IV metronidazole 3x a day + PO doxycycline

consider removing IUD, barrier contraceptive, contract tracing

Question 12

bartholins abscess

Answer 12

blocked ducked -> infection + swelling

bilateral glands 5+7 oclock
lubricates

investigation = swab

Mx = antibiotics (broad spectrum), incision + drainage

Question 13

menopause

Answer 13

point at which menstruation stops
- caused by lack of ovarian follicular function, resulting in changes in sex hormones assoc with menstrual cycle
- oestrogen + progesterone levels are low
- LH + FSH are high in response to an absence of neg feedback

Question 14

average symptoms duration of menopause

Answer 14

7.4yrs

average no of symptoms = 7

Question 15

menopause age

Answer 15

average = 51

premature ovarian insufficiency <40yrs
early menopause = 40-44yrs

perimenopause = irregular periods
postmenopause = no periods > 12months

Question 16

diagnosis of menopause

Answer 16

no routine FSH test in women >=45yrs
- except women >=50 on hormonal contraception who don’t want to continue till 55yrs

FSH levels x 2 (6weeks apart) possibly indicated
- women >45 with atypical symptoms
- women between 40-45 with menopausal symtpoms +/- iatrogenic ammenorhoea (hysterectomy, ablation)

FSH, E2, TFT, glucose, prolactin, FAI in -
- women <40
- check chromosomes + exclude autoimmune in <35

consider therapeutic trial of HRT

Question 17

contraindications of HRT

Answer 17

Hx of breast or endometrial cancer
coronary heart disease, TIA or stroke
active liver disease
unexplained vaginal bleeding

risks
- increased breast cancer risk - over 50s
- VTE risk when taken orally - NOT transdermally
- CVD risk >60s

Question 18

main benefits of HRT

Answer 18

vasomotor symptoms - hot flushes, night sweats
improve low ood
reduces osteoporosis risk
improve sexual + cognitive function
prevention/treatment of urogenital + vulvovaginal atrophy

Question 19

HRT management in women with premature ovarian sufficiency

Answer 19

give HRT till average age of menopause - 51

HRT does not add risk of breast ca compared to women without - just giving back what shes missing

continue with contraceptions

Question 20

genitourinary syndromes of menopause

Answer 20

atrophy of minora + majora
narrowing of vaginal opening - loss of vaginal fornix, thinning of vaginal wall, decrease length
reduced blood flow to vagina
petechial haemorrhage

Question 21

management of genitourinary syndromes of menopause

Answer 21

vaginal oestrogens
- does NOT causes hyperplasia or endometrial cancer long term

symptomatic
- lubricants
- vibrators
- cycle makes her tighten up + avoid/fear sex

Question 22

perimenopausal contraception

Answer 22

age <40
- premture insufficiency of ovaries might be transitional
- continue with contraception

age 40-49
- contraception can be stopped
— 2yrs after last natural menstrual period (not while on hormonal contraception) OR
— 2yrs after 2 results of FSH of >= 30, taken at least 4-6weeks apart

age >=50
- contraception can be stopped
—- 1 yr after last natural menstrual period OR
—-1yrs after 1 result of FSH >=30

age >=55
- contraception can be stopped even if still having periods due to poor oocyte quality
—- might consider continuing contraception for another year or 2 if periods troublesome

Question 23

UKMEC1 options for perimenopause

Answer 23

barrier
mirena or copper coil
progesterone only pill or implant
progesterone injection (under 45yrs)
- SE = weight gain + reduced bone mineral density

COCP = UKMEC2 after age 40