AKT Flashcards
LIST UKMEC3 categories for COCP
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
UKMEC 4 for COCP
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies (e.g. in SLE)
- Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
UK MEc3 for POP
- Examples of UKMEC 3 conditions include
- active liver disease or past tumour
- liver enzyme inducers
- breast cancer more than 5 years ago
- undiagnosed vaginal bleeding
- ischaemic heart disease and stroke (initiation = UKMEC2)
UKMEC4 for POP
- pregnancy
- breast cancer within the last 5 years
UKMECs for pts on Lamotrigine
- UKMEC 3: COCP
2.UKMEC1:POP,IUS,IUD, DEPOT, implant
UKMECs for pt phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS
How much ethinydiestrol should be in a COCP if chosen for epileptic pt
minimum of 30 µg of ethinylestradiol.
Postpartum cocntraception: when can POP be started
Anytime postpartum.
How many days of extra precaution needed if POP started after 21 days postpartum
2 days
Postpartum: how long is COCP contra-indicated in BREASTFEEDING mothers
<6 weeks postpartum- CI
6w-6months ukmec2
True or false:COCP reduces breast milk production in lactating mothers
True
For how many days should COCP not be used in a non-breastfeeding postpartum pt and why
21 days post partum - increased risk of VTE
How many days of extra precaution needed if COCPis started 21 days postpartum
7 days extra precaution needed
When can IUD be inserted after childbirth?
WITHIN 48hrs or after 4 weeks
What are the criteria for LACTATIONA Amennhorea to be successful and what is the percentage
Exclusively breastfeeding, <6m postpartum, no return of periods. (98% effective)
UKMEC3 for intrauterine devices iUS, IUD
- between 48 hours and 4 weeks postpartum (increased risk of perforation)
- initiation of method** in women with ovarian cancer
UKMEC4 for IUD, IUS
- pregnancy
- current pelvic infection, puerperal sepsis, immediate post-septic abortion
- unexplained vaginal bleeding which is suspicious
- uterine fibroids or uterine anatomical abnormalities distorting the uterine cavity
When should STIs be tested for before insertion of IUD/IUS
Chlamydia/gonnohorea in woman at risk of STI
If the woman requests it
When should prophylactic abx be given prior to insertion of iud/ius
Women at risk of STI if testing has not been completed
Which group of patients can never have oral contraception due to lack of effectiveness
gastric sleeve/bypass/duodenal switch
Also includes emergency contraception
At what weight is COCP transdermal patch not effective
Above 90kg
At what age is the COCP MEC2?
=/> 40 years
AT WHAT AGE is the deposit provera UKMEC2?
> /=45 years
True or False: The COCP may help preserve Bone mineral density in the peri-menopausal period
True
True or False: The COCP will make menopausal symptoms worse
False: COCP can make menopausal symptoms better
What dose of ethinyldiestrol is more suitable for women >40
<30 ug of ethinyldiestrol
When can women UNDER 50 stop non-hormonal contraceptives: IUD, Condoms, family planning
After 2 years of amennhorea
When can women 50 and ABOVE stop non0-hormonal contraception
AFTER 1 year of amennhorrea
Till what age can women continue the COCP till
Up to 50 years (49)
What contraceptive can a women aged 50 and above switch to from COCP?
Non hormonal or progesterone only method
What age can depot provera be continued till?
Up to 50 years (49)
What are the options for a woman aged 50 and above previously taking depot to switch contraception?
- Switch to non-hormonal and then stop after 2 years of amenhorea
- Switch to POP only method and stop as advised for progesterone only methods
How long can Implant, IUS and pOP be continued ?
Beyond 50 years
What are the options for a 50 year and above lady to stop POP, IUS, Implant?
- Check FSH and stop after 1 YEAR if >30
- Stop after 55 years if ammenhorrea
- If ongoing bleeding investigate
UKMEC3 for nexplanon
ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2),
unexplained, suspicious vaginal bleeding,
past breast cancer,
severe liver cirrhosis,
liver cancer
UKMEC4 for nexplanon
current breast cancer
How long does nexplanon last
3 years
How can irregular/heavy bleeding from nexplanon be managed and what else must be done if this does not work
- Add COCP
- Do a speculum to check for STIs if ongoingbleeding
What are side effects associated with progesterone
headache, nausea, breast pain
Which medications can effect the effectiveness of nexplanon implant . What extra precautions are needed.
Enzyme inducers , anti-epileptics, rifampicin
1. SWITCH TO A method not effected by enzyme inducers OR use extra precautions 28 days after stopping treatment
How many days of extra precaution are needed if nexplanon is NOT inserted in DAY 1 -5 of cycle?
7 days extra precaution are
How many extra days precaution is needed if nexplanon is NOT inserted on DAY 1-5 of cycle
7 days extra precaution
What is the most common adverse effect of Nexplanon
Irregular/heavy bleeding from nexplanon
What is the most effective contraceptive
Nexplanon - 0.07/100 failure rate
2 advantages of Nexplanon
- CAN Be inserted immediately after TOP
- doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
What are the types of emergency contraception available
Levonorgestrel, ulipristal acetate, IUD
What type of drug is urlipristal acetate and what is the mechanism of action
SELECTIVE Progesterone RECEPTOR MODULATOR
2. Inhibit ovulation
When can Ulipristal acetate be taken?
Up to 120hrs after UPSI
Can you take levonorgestrel and Ulipristal Acetate together?
NO
Can ulipristal acetate reduce the effectiveness of contraception?
Yes
When can hormonal contraception be restarted after taking Ulipristal acetate?
pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
Which patients should use ulipristal cautiously?
Asthmatics
How long does breastfeeding need to be delayed when taking Ulipristal acetate vs Levornogestrel
Ulipristal - delay 1 week
Levonorgestrel - can continue breastfeeding
Can ulipristal and levornogestrel be taken more than once in a cycle
Yes
What is the dose of ulipristal acetat
30mg
What is the mechanism of action of levornogestrel
Not fully understood. Stops ovulation and implantation
Up tlill when can Levornogestrel be taken and how effective is it
72hrs after UPS I 84% effective if taken in this time frame
When can hormonal contraception be restarted after-started after taking levornogestrel
Immediately
What is the dosing for levornogestrel?
- 1.5mg if </=70 kg or BMI <=26
- 3mg if >70 OR BMO >26
How many people vomit after levornogestrel and when can a repeat dose be taken
Vomiting occurs in 1%
Take repeat dose if occurs within 3 hours of taking
What is the most effective emergency contraception?
IUD
How long after UPSI can IUD be inserted
5 days after UPSI and up to 5 days after ovulation
What is mechanism of action of IUD?
Inhibit implantation and fertilisation (spermicide)
How effective is IUD
99%
If pt wants to remove IUD after insertion for emergency contraception, how long should it be kept in
Until next period
What is the method of action of COCP
Inhibit ovulation
What is the method of action of POP (except desogestrel)
Thickens cervical mucous
What is the method of action of medroxyprogesterone acetate (depo provera)?
Primary: inhibits ovulation
Also: thickens cervical mucous
What is the method of action of implant?
Primary: inhibit ovulation Also
ALSO :thickens cervical mucous
What is the method of action of IUS
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
What is the method of action of desogestrel
Inhibits ovulation
Which COCP and dose would you start someone new to COCP on?
Ethinyloestrodiol 30 ug and levornogestrel 150 mcg (Microgynon 30) or Ethinylestrodio 30ug and Norethisterone 150ug
What are the 2 new COCP in the market?
Qlaira ad YAZ
What does COCP QLAIRA contain and what is the regimen
Contains estrodiol valerate and dinogest. 28 tablets (26 with both hormones and 2 inactive). Oestrogen dose slowly decreases a progesterone increases. Done to mimic a natural cycle
How much does qLAIRA Cost?
Approx £8
What are the missed dose rules for Qlaira ?
Works on a 12 hour interval.
If 2 missed pills then emergency contraception be
Day 1- 17 : Take missed pill immediately and the next tablet at the usual time (even if
means taking two on same day)Continue with the tablet taking in the normal way
Abstain or use an additional contraceptive method for 9 days
Day 18-24 : Discard the rest of the packet. Start taking the Day 1 pill from a new packet immediately and continue taking these pills at the correct time.Abstain or use an additional contraceptive method for 9 days
Day 25-26: Take the missed tablet immediately and the next tablet at the usual time
(even if it means taking two tablets on the same day). Additional contraception is not necessary
Day 27-28: Discard the forgotten table and continue tablet taking in the normal way.
Additional contraception is not necessary
What is in the contraceptive YAz
20mcg ethinylestradiol with 3mg drospirenone is soon to be launched in the UK. In the US and Europe it is branded as Yaz and has an interesting 24/4 regime, as opposed to the normal 21/7 cycle. The idea is that a shorter pill-free interval is both better for patients with troublesome premenstrual symptoms and is also more effective at preventing ovulation. Studies have shown Yaz causes less pre-menstrual syndrome and blood loss reduced by 50-60%.
Give 4 examples of traditional POP
Micronor, Noriday, Nogeston, Femulen)
What s the brand name of a desogestrel pill
Cerazette
What are the rules for a missed dose of transitional POP and desogestrel
3 hours interval for traditional, 12 hours for desogestrel
If more than 3 hours late:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
What is the most common adverse effect of POP
Irregular vaginal bleeding
How many extra days of precaution needed if pop STARTED after day 5 of cycle
2 days
When is extra precaution not needed whilst switching directly from COCP to POP
If switching directly from end of COCP pack (day 21)
How is the POP taken
Take everyday of cycle
What should you do if D+V whilst taking POP
Use same rules as if pills were missed
Do antibiotics have an effect on POP
No unless enzyme inducers like rifampicin (may reduce effectiveness)
What is the fifth most common malignancy in females?
Ovarian cancer
At what peak age does ovarian cancer incidence occur?
60 years
What is the typical prognosis for ovarian cancer?
Generally poor due to late diagnosis
What percentage of ovarian cancers are epithelial in origin?
Around 90%
What percentage of ovarian cancer cases are due to serous carcinomas?
70-80%
Where is it increasingly recognized that many ‘ovarian’ cancers originate?
Distal end of the fallopian tube
What genetic mutations are significant risk factors for ovarian cancer?
Mutations of the BRCA1 or BRCA2 gene
What are some risk factors related to ovulation for ovarian cancer?
- Early menarche
- Late menopause
- Nulliparity
What are some common clinical features of ovarian cancer?
- Abdominal distension and bloating
- Abdominal and pelvic pain
- Urinary symptoms (e.g., urgency)
- Early satiety
- Diarrhea
What initial test does NICE recommend for ovarian cancer diagnosis?
CA125 test
What conditions may raise the CA125 level?
- Endometriosis
- Menstruation
- Benign ovarian cysts
- Other conditions
What CA125 level indicates the need for an urgent ultrasound scan?
35 IU/mL or greater
Should CA125 be used for screening asymptomatic women for ovarian cancer?
No
What is the usual method for diagnosing ovarian cancer?
Diagnostic laparotomy
What is the typical management approach for ovarian cancer?
Combination of surgery and platinum-based chemotherapy
What percentage of women present with advanced disease at diagnosis?
80%
What is the all-stage 5-year survival rate for ovarian cancer?
46%
In which demographic is endometrial cancer classically seen?
Post-menopausal women
Around 25% of cases occur before menopause
What is the typical prognosis for endometrial cancer?
Good prognosis due to early detection
List the risk factors for endometrial cancer.
- Excess oestrogen
- Nulliparity
- Early menarche
*Tamoxifen
*Hereditary non polyposis colorectal carcinoma
*Metabolic syndrome : PCOS, Diabetes m, obesity
What can reduce the risk of endometrial cancer in women taking oestrogen?
Addition of a progestogen
The risk is eliminated if a progestogen is given continuously
Name three metabolic conditions that are risk factors for endometrial cancer.
- Obesity
- Diabetes mellitus
*PCOS
What hereditary condition is associated with an increased risk of endometrial cancer?
Hereditary non-polyposis colorectal carcinoma
Identify a protective factor against endometrial cancer.
Multiparity
True or False: Smoking is a protective factor against endometrial cancer.
True
The reasons for this are unclear
What is the classic symptom of endometrial cancer?
Postmenopausal bleeding
What is the typical progression of postmenopausal bleeding in endometrial cancer?
Usually slight and intermittent initially before becoming heavier
What symptoms might premenopausal women experience with endometrial cancer?
Menorrhagia or intermenstrual bleeding
Is pain a common symptom of endometrial cancer?
No, pain is not common and typically signifies extensive disease
What should be done for all women >= 55 years presenting with postmenopausal bleeding?
Refer using the suspected cancer pathway
What is the first-line investigation for suspected endometrial cancer?
Trans-vaginal ultrasound
What endometrial thickness measurement has a high negative predictive value?
< 4 mm
What procedure is used for further investigation of endometrial cancer?
Hysteroscopy with endometrial biopsy
What is the mainstay of management for endometrial cancer?
Surgery
What surgical procedure is typically performed for localized endometrial cancer?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
What treatment may be given to patients with high-risk endometrial cancer post-surgery?
Postoperative radiotherapy
What type of therapy is sometimes used in frail elderly women not suitable for surgery?
Progestogen therapy
What is endometrial hyperplasia?
An abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle
A minority of patients with endometrial hyperplasia may develop endometrial cancer.
List the types of endometrial hyperplasia.
- simple
- complex
- simple atypical
- complex atypical
These classifications help in determining the management approach.
What is a common feature of endometrial hyperplasia?
Abnormal vaginal bleeding e.g. intermenstrual
This symptom can be a key indicator for diagnosis.
What is the management for simple endometrial hyperplasia without atypia?
High dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
Regular monitoring is essential to assess treatment effectiveness.
What is usually advised for endometrial hyperplasia with atypia?
Hysterectomy is usually advised
This is due to the higher risk of progression to cancer.
What percentage of cervical cancer cases occur in women under the age of 45?
Around 50%
What are the highest incidence rates for cervical cancer in the UK by age group?
People aged 25-29 years
What are the two main types of cervical cancer?
- Squamous cell cancer (80%)
- Adenocarcinoma (20%)
What features may indicate cervical cancer?
- Detected during routine cervical cancer screening
- Abnormal vaginal bleeding
- Vaginal discharge
What is the most important factor in the development of cervical cancer?
Human papillomavirus (HPV), particularly serotypes 16, 18 & 33
List some other risk factors for cervical cancer.
- Smoking
- Human immunodeficiency virus
- Early first intercourse
- Many sexual partners
- High parity
- Lower socioeconomic status
- Combined oral contraceptive pill
What oncogenes do HPV 16 & 18 produce?
- E6
- E7
What is the role of the E6 gene in cervical cancer?
Inhibits the p53 tumour suppressor gene
What is the role of the E7 gene in cervical cancer?
Inhibits RB suppressor gene
True or False: Cervical cancer can be detected during routine cervical cancer screening.
True
Fill in the blank: HPV 16 & 18 produce the oncogenes _______ and _______.
E6 and E7
What is vulval intraepithelial neoplasia (VIN)?
A pre-cancerous skin lesion of the vulva that may result in squamous skin cancer if untreated.
What is the average age of a woman affected by vulval intraepithelial neoplasia (VIN)?
Around 50 years
Name four risk factors associated with vulval intraepithelial neoplasia (VIN).
- Human papilloma virus 16 & 18
- Smoking
HSV 2
LICHEN SCLERSUS
What are some features of vulval intraepithelial neoplasia (VIN)?
- Itching
- Burning
- Raised, well-defined skin lesions
What is the purpose of a biopsy in the investigation of vulval intraepithelial neoplasia (VIN)?
To obtain a histological diagnosis
What types of biopsy can be used for vulval intraepithelial neoplasia (VIN)?
- Punch biopsy
- Excisional biopsy
What tests are used for HPV testing in vulval intraepithelial neoplasia (VIN)?
- PCR
- In situ hybridisation for high-risk HPV DNA
What are two topical therapies used in the management of vulval intraepithelial neoplasia (VIN)?
- Imiquimod
- 5-Fluorouracil
What is the aim of surgical interventions in vulval intraepithelial neoplasia (VIN)?
To achieve complete removal of dysplastic areas while preserving normal anatomy and function as much as possible.
Name a surgical technique used in the management of vulval intraepithelial neoplasia (VIN).
- Wide local excision
- Laser ablation
- Partial vulvectomy
What does follow-up and surveillance for vulval intraepithelial neoplasia (VIN) involve?
Regular monitoring with repeat colposcopy and biopsy if recurrence or progression is suspected.
What percentage of vulval cancers are squamous cell carcinomas?
Around 80%
This statistic highlights the most common type of vulval cancer.
What is the typical age demographic for vulval cancer diagnosis?
Women over the age of 65 years
This indicates that vulval cancer is more prevalent in older women.
How many cases of vulval cancer are diagnosed in the UK each year?
Around 1,200 cases
This statistic shows the rarity of vulval cancer.
Name a risk factor for vulval cancer.
- Human papilloma virus (HPV) infection
- Vulval intraepithelial neoplasia (VIN)
- Immunosuppression
- Lichen sclerosus
These factors increase the likelihood of developing vulval cancer.
What are common features of vulval cancer?
- Lump or ulcer on the labia majora
- Inguinal lymphadenopathy
- May be associated with itching, irritation
These symptoms can help in identifying vulval cancer.
True or False: Vulval cancer is common among young women.
False
Vulval cancer is relatively rare and primarily affects older women.
Fill in the blank: Most vulval cancers are _______.
squamous cell carcinomas
This term refers to the predominant type of vulval cancer.
What is inguinal lymphadenopathy in relation to vulval cancer?
A feature that may indicate the presence of vulval cancer
It refers to swollen lymph nodes in the groin area.
What are fibroids?
Benign smooth muscle tumours of the uterus
They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
In which demographic are fibroids more common?
Afro-Caribbean women
Rare before puberty and develop in response to oestrogen.
What are some symptoms of fibroids?
Asymptomatic, menorrhagia, iron-deficiency anaemia, bulk-related symptoms, lower abdominal pain, bloating, urinary symptoms, subfertility
Rare features include polycythaemia secondary to autonomous production of erythropoietin.
What is the most common diagnostic tool for fibroids?
Transvaginal ultrasound
What is the management for asymptomatic fibroids?
No treatment needed other than periodic review to monitor size and growth
What treatment options are available for menorrhagia secondary to fibroids?
- Levonorgestrel intrauterine system (LNG-IUS)
- NSAIDs (e.g. mefenamic acid)
- Tranexamic acid
- Combined oral contraceptive pill
- Oral progestogen
- Injectable progestogen
LNG-IUS is useful if the woman also requires contraception but cannot be used if there is distortion of the uterine cavity.
What are some medical treatments to shrink/remove fibroids?
- GnRH agonists
- Ulipristal acetate (not currently used due to liver toxicity concerns)
GnRH agonists may reduce fibroid size but are typically for short-term treatment due to side effects like menopausal symptoms and loss of bone mineral density.
What are the surgical options for fibroid treatment?
- Myomectomy (abdominally, laparoscopically, or hysteroscopically)
- Hysteroscopic endometrial ablation
- Hysterectomy
- Uterine artery embolization
What is the prognosis for fibroids after menopause?
Fibroids generally regress after menopause
What complications can arise from fibroids?
- Subfertility
- Iron-deficiency anaemia
- Red degeneration (haemorrhage into tumour during pregnancy)
Some complications such as subfertility and iron-deficiency anaemia have been mentioned previously.
What is the upper limit for termination of pregnancy as per the 1990 amendment to the Abortion Act?
24 weeks gestation
The original limit was 28 weeks gestation before the amendment.
How many registered medical practitioners must sign a legal document for an abortion?
Two registered medical practitioners (or one in an emergency)
This is a requirement under the current abortion law.
Who is allowed to perform an abortion according to the law?
Only a registered medical practitioner
The procedure must take place in an NHS hospital or licensed premises.
What prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation?
Anti-D prophylaxis
This is crucial to prevent Rh sensitization.
What is mifepristone commonly referred to as?
RU486
It is an anti-progestogen used in medical abortions.
What follows the administration of mifepristone in a medical abortion?
Prostaglandins (e.g. misoprostol)
This is done 48 hours later to stimulate uterine contractions.
What is a multi-level pregnancy test?
A pregnancy test that detects the level of hCG
It is required in 2 weeks to confirm that the pregnancy has ended.
List three surgical options for abortion.
- Manual vacuum aspiration (MVA)
- Electric vacuum aspiration (EVA)
- Dilatation and evacuation (D&E)
These are transcervical procedures used to end a pregnancy.
What is cervical priming in the context of surgical abortion?
Use of misoprostol +/- mifepristone before procedures
This helps prepare the cervix for surgery.
What types of anesthesia may be offered to women undergoing surgical abortion?
- Local anaesthesia alone
- Conscious sedation with local anaesthesia
- Deep sedation
- General anaesthesia
The choice depends on the procedure and patient preference.
According to NICE, what is recommended regarding the choice of abortion procedure up to 23+6 weeks’ gestation?
Women should be offered a choice between medical or surgical abortion
Patient decision aids are usually provided to help with informed decision-making.
True or False: After 9 weeks, medical abortions become more common.
False
Medical abortions become less common due to factors like the likelihood of seeing products of conception.
What must a person believe to not be guilty of an offence under the law relating to abortion?
That the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk
This includes risks to the physical or mental health of the pregnant woman or existing children.
Fill in the blank: The 1967 Abortion Act allows termination if there is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be _______.
seriously handicapped
This clause is part of the criteria for legal abortion.
What exceptions exist where the limits of the Abortion Act do not apply?
*continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family;
*or that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;
*or that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated;
- there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
These exceptions allow for termination beyond the specified limits. (24 weeks)
What is the minimum days of abstinence required before performing a semen analysis?
3 days
The analysis can also be performed after a maximum of 5 days of abstinence.
What is the maximum time frame for delivering a semen sample to the lab?
1 hour
Timely delivery is crucial for accurate analysis.
What is the minimum volume of semen considered normal?
> 1.5 ml
What is the minimum pH level for a normal semen analysis?
> 7.2
What is the minimum sperm concentration for normal semen results?
> 15 million / ml
What percentage of normal forms is required for sperm morphology?
> 4%
What is the minimum percentage of progressive motility considered normal?
> 32%
What is the minimum percentage of live spermatozoa required for normal vitality?
> 58%
Define recurrent miscarriage and give 6 causes
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women
Causes
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
What does premenstrual syndrome (PMS) describe?
The emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle
When does PMS occur?
In the presence of ovulatory menstrual cycles
At what life stages does PMS not occur?
- Prior to puberty
- During pregnancy
- After menopause
What are some emotional symptoms of PMS?
- Anxiety
- Stress
- Fatigue
- Mood swings
What are some physical symptoms of PMS?
- Bloating
- Breast pain
How can mild PMS symptoms be managed?
With lifestyle advice
What specific lifestyle advice is recommended for mild PMS symptoms?
- Regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates
- General advice on sleep, exercise, smoking, and alcohol
What type of medication may benefit moderate PMS symptoms?
A new-generation combined oral contraceptive pill (COCP)
Give an example of a COCP that may benefit moderate PMS symptoms.
Yasmin (drospirenone 3 mg and ethinylestradiol 0.030 mg)
What treatment may be beneficial for severe PMS symptoms?
A selective serotonin reuptake inhibitor (SSRI)
How may SSRIs be taken for PMS treatment?
- Continuously
- Just during the luteal phase (e.g., days 15-28 of the menstrual cycle)
What is premature ovarian insufficiency?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
Occurs in around 1 in 100 women.
What are some causes of premature menopause?
- Idiopathic
- Family history
- Bilateral oophorectomy
- Hysterectomy with preservation of ovaries
- Radiotherapy
- Chemotherapy
- Infection (e.g. mumps)
- Autoimmune disorders
- Resistant ovary syndrome (due to FSH receptor abnormalities)
Idiopathic is the most common cause.
What are common features of premature ovarian insufficiency?
- Climacteric symptoms (hot flushes, night sweats)
- Infertility
- Secondary amenorrhoea
- Raised FSH and LH levels (e.g. FSH > 30 IU/L)
- Low oestradiol (e.g. < 100 pmol/l)
Elevated FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart.
What symptoms are associated with climacteric in premature ovarian insufficiency?
Hot flushes and night sweats
Symptoms are similar to those of the normal climacteric.
What is the management for premature ovarian insufficiency?
Hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of 51 years
HRT does not provide contraception in case spontaneous ovarian activity resumes.
Fill in the blank: Elevated FSH levels should be demonstrated on ______ taken 4-6 weeks apart.
2 blood samples
True or False: Hysterectomy with preservation of the ovaries can advance the age of menopause.
True
What is the average age of menopause?
51 years
Fill in the blank: Resistant ovary syndrome is due to ______ abnormalities.
FSH receptor
What is polycystic ovary syndrome (PCOS)?
A complex condition of ovarian dysfunction affecting 5-20% of women of reproductive age
What are common features of PCOS?
- Subfertility and infertility
- Menstrual disturbances: oligomenorrhoea and amenorrhoea
- Hirsutism and acne (due to hyperandrogenism)
- Obesity
- Acanthosis nigricans (due to insulin resistance)
Which hormonal levels are typically seen in PCOS?
- Hyperinsulinaemia
- High levels of luteinizing hormone (LH)
What is the significance of the LH:FSH ratio in PCOS?
Raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis
What investigations are useful for diagnosing PCOS?
- Pelvic ultrasound for multiple cysts
- FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)
- Check for impaired glucose tolerance
What are the Rotterdam criteria for diagnosing PCOS?
Diagnosis can be made if 2 of the following 3 are present:
* Infrequent or no ovulation (no menstruation)
* Clinical and/or biochemical signs of hyperandrogenism
* Polycystic ovaries on ultrasound (≥ 12 follicles or increased ovarian volume > 10 cm³)
What does a pelvic ultrasound show in PCOS?
Multiple cysts on the ovaries
How can testosterone levels present in women with PCOS?
Testosterone may be normal or mildly elevated; if markedly raised, consider other causes
What is SHBG and how is it affected in PCOS?
SHBG is normal to low in women with PCOS
What should be done before making a formal diagnosis of PCOS?
Perform investigations to exclude other conditions
True or False: Acanthosis nigricans is associated with insulin resistance in PCOS.
True
Fill in the blank: The aetiology of PCOS is not fully ______.
understood
What does pelvic inflammatory disease (PID) describe?
Infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries, and the surrounding peritoneum
PID usually results from ascending infection from the endocervix.
What is the most common causative organism of PID?
Chlamydia trachomatis
Other causative organisms include Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis.
List some features of pelvic inflammatory disease (PID).
- Lower abdominal pain
- Fever
- Deep dyspareunia
- Dysuria
- Menstrual irregularities
- Vaginal or cervical discharge
- Cervical excitation
What investigation should be done to exclude an ectopic pregnancy in suspected PID?
A pregnancy test
Other investigations include a high vaginal swab, which is often negative, and screening for Chlamydia and Gonorrhoea.
What is the first-line management for PID?
Stat IM ceftriaxone + followed by 14 days of oral doxycycline + oral metronidazole
This regimen is preferred to avoid systemic fluoroquinolones where possible.
What is the second-line management for PID?
Oral ofloxacin + oral metronidazole
According to RCOG guidelines, what should be considered in mild cases of PID regarding intrauterine contraceptive devices?
Intrauterine contraceptive devices may be left in
The more recent BASHH guidelines suggest that removal of the IUD should be considered for better short-term clinical outcomes.
What is perihepatitis, also known as Fitz-Hugh Curtis Syndrome, and how common is it in PID cases?
It occurs in around 10% of cases and is characterized by right upper quadrant pain
Perihepatitis may be confused with cholecystitis.
What are some potential complications of PID?
- Infertility (risk may be as high as 10-20% after a single episode)
- Chronic pelvic pain
- Ectopic pregnancy
True or False: Dysuria is a common feature of pelvic inflammatory disease (PID).
True
Fill in the blank: PID is usually the result of _______ infection from the endocervix.
[ascending]
What hormone’s pulse frequency increases during the early follicular phase to stimulate FSH and LH release?
Gonadotropin-releasing hormone (GnRH)
What does FSH stimulate in the mid-follicular phase?
Estradiol production
What type of feedback does estradiol produce on the hypothalamus and pituitary gland in the mid-follicular phase?
Negative feedback
What is the unique switch in feedback mechanism of estradiol during the luteal phase?
From negative to positive feedback
What does the surge of LH secretion during the luteal phase lead to?
Follicular rupture and ovulation
What are the three main categories of anovulation?
- Class 1: Hypogonadotropic hypogonadal anovulation-notably hypothalamic amenorrhoea (5-10% of women)
- Class 2: Normogonadotropic normoestrogenic anovulation-polycystic ovary syndrome (80% of cases)
- Class 3: Hypergonadotropic hypoestrogenic anovulation-premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
What is the percentage of women affected by Class 1 anovulation?
5-10%
What condition is associated with Class 2 anovulation affecting 80% of cases?
Polycystic ovary syndrome (PCOS)
What is typically required for conception in Class 3 anovulation?
In-vitro fertilisation (IVF) with donor oocytes
What is the ideal goal of ovulation induction?
Induce mono-follicular development and subsequent ovulation
What is the first-line treatment for patients with polycystic ovarian syndrome?
Exercise and weight loss
What effect can a modest 5% weight loss have on women with PCOS?
Ovulation can spontaneously return
What is the first-line medical therapy for patients with PCOS according to UptoDate?
Letrozole
What is the mechanism of action of letrozole?
Aromatase inhibitor that increases FSH production
What are the side effects associated with letrozole?
- Fatigue (20%)
- Dizziness (10%)
What percentage of women with PCOS respond to clomiphene citrate treatment?
80%
What is the mechanism of action of clomiphene citrate?
Selective estrogen receptor modulator (SERM) that blocks negative feedback of estrogens
What are the side effects of clomiphene citrate?
- Hot flushes (30%)
- Abdominal distention and pain (5%)
- Nausea and vomiting (2%)
What therapy is primarily used for women with Class 1 ovulatory dysfunction?
Gonadotropin therapy
What is the risk associated with gonadotropin therapy for women with PCOS?
Higher risk of multi-follicular development and multiple pregnancy
What is the potential life-threatening side effect of ovulation induction?
Ovarian hyperstimulation syndrome (OHSS)
What are the potential complications of ovarian hyperstimulation syndrome (OHSS)?
- Hypovolaemic shock
- Acute renal failure
- Venous or arterial thromboembolism
What is the risk percentage of severe OHSS occurring in women undergoing ovarian induction?
Less than 1%
What are the management strategies for severe OHSS?
- Fluid and electrolyte replacement
- Anti-coagulation therapy
- Abdominal ascitic paracentesis
- Pregnancy termination
What is the initial imaging modality for suspected ovarian cysts/tumours?
Ultrasound
How are ovarian cysts classified in ultrasound reports?
Cysts are classified as either simple or complex
Simple cysts are unilocular and more likely to be physiological or benign, while complex cysts are multilocular and more likely to be malignant.
What factors influence the management of ovarian cysts?
The age of the patient and whether the patient is symptomatic
Why is the diagnosis of ovarian cancer often delayed?
Due to a vague presentation
What approach may be taken for premenopausal women with ovarian cysts?
A conservative approach may be taken, especially if < 35 years
What is the likelihood of malignancy in premenopausal women with small simple cysts (< 5 cm)?
Highly likely to be benign
What should be arranged if a small simple cyst in a premenopausal woman persists?
A repeat ultrasound should be arranged for 8-12 weeks and referral considered
What is true about physiological cysts in postmenopausal women?
By definition, physiological cysts are unlikely
What should be done for any postmenopausal woman with an ovarian cyst?
She should be referred to gynaecology for assessment
What are the main types of benign ovarian cysts?
Physiological cysts, benign germ cell tumours, benign epithelial tumours, benign sex cord stromal tumours
What should be done with complex ovarian cysts?
They should be biopsied to exclude malignancy
What is the commonest type of ovarian cyst?
Follicular cysts
What causes follicular cysts?
Non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
How do follicular cysts typically behave over time?
They commonly regress after several menstrual cycles
What is a corpus luteum cyst?
A cyst that forms when the corpus luteum fills with blood or fluid instead of breaking down
What is more likely to occur with a corpus luteum cyst compared to follicular cysts?
Intraperitoneal bleeding
What is a dermoid cyst also known as?
Mature cystic teratomas
What can dermoid cysts contain?
Skin appendages, hair, and teeth
What is the median age of diagnosis for dermoid cysts?
30 years old
What percentage of dermoid cysts are bilateral?
10-20%
What is the most common benign epithelial tumour?
Serous cystadenoma
In which demographic are serous cystadenomas typically seen?
Middle-aged women
What is the typical imaging appearance of serous cystadenomas?
Thin-walled, anechoic or low-level echo cyst; may have thin septations
What is the second most common benign epithelial tumour?
Mucinous cystadenoma
What symptoms may present with mucinous cystadenomas?
Abdominal distension, discomfort, or pressure symptoms
What is a potential complication if a mucinous cystadenoma ruptures?
Pseudomyxoma peritonei
Fill in the blank: Serous cystadenomas are usually _____ or _____ with thin walls.
unilocular, multilocular
True or False: Dermoid cysts are usually symptomatic.
False
What is a characteristic feature of mucinous cystadenomas on ultrasound imaging?
Multiloculated cyst with varying echogenicity due to mucin content
What are the types of benign ovarian germ cell tumours
Dermoid cyst
What are the 2 types of benign epithelial ovarian tumours
- Mucinous cytsadenoma
- Serous cystadenoma
What is a threatened miscarriage?
Painless vaginal bleeding occurring before 24 weeks, typically at 6 - 9 weeks.
The bleeding is often less than menstruation and complicates up to 25% of all pregnancies.
What are the characteristics of a threatened miscarriage?
Cervical os is closed and bleeding is less than menstruation.
Occurs before 24 weeks of pregnancy.
What defines a missed (delayed) miscarriage?
A gestational sac containing a dead fetus before 20 weeks without the symptoms of expulsion.
May involve light vaginal bleeding/discharge and disappearance of pregnancy symptoms. Pain is not usually a feature.
What is a ‘blighted ovum’ or ‘anembryonic pregnancy’?
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen.
This occurs in the context of a missed (delayed) miscarriage.
What are the symptoms of an inevitable miscarriage?
Heavy bleeding with clots and pain.
Cervical os is open.
What characterizes an incomplete miscarriage?
Not all products of conception have been expelled, accompanied by pain and vaginal bleeding.
Cervical os is open.
What are the phases of the menstrual cycle?
Menstruation, Follicular phase, Ovulation, Luteal phase
Menstruation (Days 1-4), Follicular phase (Days 5-13), Ovulation (Day 14), Luteal phase (Days 15-28)
What occurs during the Follicular phase (Days 5-13)?
Development of follicles, one follicle becomes dominant
Follicular phase is also known as the proliferative phase.
What changes occur in the endometrium during the Follicular phase?
Proliferation of endometrium
This occurs under the influence of estrogen, particularly oestradiol.
What triggers ovulation in the menstrual cycle?
Acute release of LH due to high levels of oestradiol
This happens when the egg has matured.
What is the role of the corpus luteum during the Luteal phase?
Secretes progesterone
The corpus luteum forms after ovulation and is responsible for maintaining the uterine lining.
What happens to the corpus luteum if fertilization does not occur?
Degenerates and progesterone levels fall
This leads to the onset of menstruation.
What is the cervical mucus like during the Follicular phase?
Thick and forms a plug across the external os
This helps to prevent sperm from entering the uterus.
What changes occur in cervical mucus just prior to ovulation?
Becomes clear, low viscosity, and stretchy
This quality is termed spinnbarkeit.
What happens to basal body temperature during the Follicular phase?
Falls prior to ovulation
This is due to the influence of oestradiol.
What occurs to basal body temperature after ovulation?
Rises in response to higher progesterone levels
This rise is an indicator of the luteal phase.
What hormone levels rise during the Luteal phase?
Progesterone and oestradiol
Progesterone is secreted by the corpus luteum.
6 Causes of mennhoragia , and current definition
Menorrhagia: causes
Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The assessment and management of heavy periods has therefore shifted towards what the woman considers to be excessive and aims to improve quality of life measures.
Causes
1. dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
2. anovulatory cycles: these are more common at the extremes of a women’s reproductive life
3. uterine fibroids
4. hypothyroidism
5. intrauterine devices*
6. pelvic inflammatory disease
7. bleeding disorders, e.g. von Willebrand disease
*this refers to normal copper coils. Note that the intrauterine system (Mirena) is used to treat menorrhagia
What is the average age for women in the UK to go through menopause?
51 years old
Menopause marks the end of menstrual cycles.
What is the climacteric?
The period prior to menopause where women may experience symptoms as ovarian function starts to fail
Symptoms can include hot flashes, mood changes, and sleep disturbances.
When is effective contraception recommended for women over 50?
12 months after the last period
This is to prevent unintended pregnancies during the transition to menopause.
When is effective contraception recommended for women under 50?
24 months after the last period
The extended period accounts for potentially longer fertility windows.
What is menopause?
Permanent cessation of menstruation due to loss of follicular activity.
How is menopause diagnosed?
Clinical diagnosis usually made when a woman has not had a period for 12 months.
What percentage of postmenopausal women experience menopausal symptoms?
Roughly 75%.
How long do menopausal symptoms typically last?
Typically last for 7 years but may vary.
What are the three categories of menopause management?
- Lifestyle modifications
- Hormone replacement therapy (HRT)
- Non-hormone replacement therapy
What lifestyle modifications can help with hot flushes?
Regular exercise, weight loss, and reduce stress.
What can help with sleep disturbances during menopause?
Avoiding late evening exercise and maintaining good sleep hygiene.
What lifestyle changes can improve mood during menopause?
Sleep, regular exercise, and relaxation.
What is the recommended management for cognitive symptoms during menopause?
Regular exercise and good sleep hygiene.
What are the contraindications for hormone replacement therapy (HRT)?
- Current or past breast cancer
- Any oestrogen-sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
What percentage of women are treated with HRT for menopausal symptoms?
Roughly 10%.
What is the risk associated with unopposed oestrogens in women with a uterus?
Increased risk of endometrial cancer.
What type of HRT is given to women without a uterus?
Oestrogen alone, either orally or in a transdermal patch.
What are the risks associated with HRT treatment?
- Venous thromboembolism
- Stroke
- Coronary heart disease
- Breast cancer
- Ovarian cancer
What medications can be used for vasomotor symptoms as a non-HRT management?
Fluoxetine, citalopram, or venlafaxine.
What can be used to treat vaginal dryness?
Vaginal lubricant or moisturiser.
What are some options for managing psychological symptoms during menopause?
- Self-help groups
- Cognitive behaviour therapy
- Antidepressants
What should be prescribed for urogenital atrophy?
Vaginal oestrogen.
How long may HRT be required for managing vasomotor symptoms?
2-5 years.
What is important to tell women when stopping HRT?
Gradually reducing HRT is effective at limiting recurrence only in the short term.
When should a woman be referred to secondary care for menopause management?
If treatment has been ineffective, ongoing side effects, or unexplained bleeding.
What percentage of couples will conceive within 1 year of having regular sex?
84%
This statistic highlights the typical conception rates for couples trying to conceive.
What are the main causes of infertility?
- Male factor: 30%
- Unexplained: 20%
- Ovulation failure: 20%
- Tubal damage: 15%
- Other causes: 15%
These percentages indicate the distribution of infertility causes among couples.
What is the first basic investigation for infertility?
Semen analysis
This test is crucial for assessing male fertility.
When should serum progesterone be measured in a typical 28-day cycle?
7 days prior to expected next period, typically on day 21
This timing is important for accurately assessing ovulation.
What serum progestogen level indicates ovulation?
> 30 nmol/l
This level suggests that ovulation has occurred.
What should be done if serum progestogen levels are consistently low?
Refer to specialist
Low levels may indicate a need for further evaluation and intervention.
What is the recommended daily dose of folic acid for women before conception?
0.4 mg per day
This supplementation helps reduce the risk of neural tube defects.
What is the recommended daily dose of folic acid for women with specific risk factors?
5 mg per day
This higher dose is for women with a history of neural tube defects, those on anti-epileptic medication, or with diabetes.
What is the recommended BMI range for women trying to conceive?
20-25
Maintaining a healthy BMI is important for fertility.
How often should couples engage in sexual intercourse when trying to conceive?
Every 2 to 3 days
Regular intercourse increases the chances of conception.
True or False: Smoking and drinking advice is part of infertility counselling.
True
Lifestyle factors such as smoking and drinking can affect fertility.
What are common side effects of hormone replacement therapy (HRT)?
Nausea, breast tenderness, fluid retention and weight gain
These side effects can vary among individuals and may require monitoring.
What is the increased risk of breast cancer associated with HRT?
Increased by the addition of a progestogen; relative risk of 1.26 at 5 years in the WHI study
The risk is related to the duration of use and declines after stopping HRT.
How does the risk of breast cancer change after stopping HRT?
The risk begins to decline and reaches the same level as in women who have never taken HRT by 5 years
This indicates the reversibility of the risk associated with HRT.
What is the recommendation regarding oestrogen as HRT for women with a womb?
Oestrogen by itself should not be given; a progestogen should be added
This is to reduce the risk of endometrial cancer.
What happens to the risk of endometrial cancer when a progestogen is added to HRT?
It is reduced but not completely eliminated
The BNF states that the additional risk is eliminated if a progestogen is given continuously.
What is the relationship between progestogen and the risk of venous thromboembolism (VTE) with HRT?
The risk is increased by the addition of a progestogen; transdermal HRT does not appear to increase the risk
NICE recommends referring high-risk women to haematology before starting treatment.
What other risks are associated with hormone replacement therapy?
- Increased risk of stroke
- Increased risk of ischaemic heart disease if taken more than 10 years after menopause
These risks highlight the need for careful patient selection and monitoring.
What is hyperemesis gravidarum most common between?
8 and 12 weeks
It may persist up to 20 weeks.
List four risk factors for hyperemesis gravidarum.
- Increased levels of beta-hCG
- Multiple pregnancies
- Trophoblastic disease
- Nulliparity
- Obesity
- Family or personal history of NVP
True or False: Smoking is associated with an increased incidence of hyperemesis.
False
Smoking is associated with a decreased incidence of hyperemesis.
What are the NICE referral criteria for nausea and vomiting in pregnancy?
- Continued nausea and vomiting unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting with ketonuria and/or weight loss greater than 5% of body weight despite treatment
- Confirmed or suspected comorbidity
What triad is present for the diagnosis of hyperemesis gravidarum?
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
What validated scoring system can classify the severity of NVP?
Pregnancy-Unique Quantification of Emesis (PUQE) score
List three simple management measures for hyperemesis gravidarum.
- Rest and avoid triggers
- Bland, plain food, particularly in the morning
- Ginger
Name two first-line medications for hyperemesis gravidarum.
- Oral cyclizine
- Oral promethazine
What combination drug is commonly used for NVP?
Doxylamine/pyridoxine
Pyridoxine monotherapy is commonly used outside of the UK but is not recommended in RCOG guidelines.
What are the second-line medications for hyperemesis gravidarum?
- Oral ondansetron
- Oral metoclopramide
- Oral domperidone
What is a potential risk associated with ondansetron during the first trimester?
Small increased risk of the baby having a cleft lip/palate
What should be discussed with pregnant women if ondansetron is used?
Risks associated with ondansetron
Why should metoclopramide not be used for more than 5 days?
It may cause extrapyramidal side effects
What is used for rehydration in hyperemesis gravidarum?
Normal saline with added potassium
List three complications that women with hyperemesis gravidarum may develop.
- Dehydration
- Weight loss
- Electrolyte imbalances
What other complications are associated with hyperemesis gravidarum?
- Acute kidney injury
- Wernicke’s encephalopathy
- Mallory-Weiss tear
- Venous thromboembolism
- Fetal outcome
True or False: Studies show significant evidence of adverse outcomes for birth weight with mild-moderate symptoms.
False
Studies generally show little evidence of adverse outcomes.
What may severe NVP linked to multiple admissions result in?
A small increase in preterm birth and low birth weight
What should be performed in all women with heavy menstrual bleeding?
A full blood count should be performed
This is to assess for anemia and other blood-related issues.
When should a routine transvaginal ultrasound scan be arranged for heavy menstrual bleeding?
If symptoms suggest a structural or histological abnormality, such as intermenstrual or postcoital bleeding, pelvic pain, and/or pressure symptoms
Other indications include abnormal pelvic exam findings.
What is the first-line treatment for heavy menstrual bleeding that does not require contraception?
Either mefenamic acid 500 mg tds (esp if dysmenorrhea as well) or tranexamic acid 1 g tds
Both treatments should be started on the first day of the period.
What should be done if there is no improvement in heavy menstrual bleeding after initial treatment?
Try another drug while awaiting referral
This allows for further management options to be explored.
What are the first-line options for heavy menstrual bleeding that requires contraception?
Options include:
* Intrauterine system (Mirena)
* Combined oral contraceptive pill
* Long-acting progestogens
These options help in managing both bleeding and contraception.
What short-term option can be used to rapidly stop heavy menstrual bleeding?
Norethisterone 5 mg tds
This is typically used for quick management of heavy bleeding.
What are uterine fibroids sensitive to?
Oestrogen
What can happen to uterine fibroids during pregnancy?
They can grow
What occurs if the growth of fibroids outstrips their blood supply?
They can undergo red or ‘carneous’ degeneration
What are the typical symptoms of fibroid degeneration?
Low-grade fever, pain, and vomiting
How is fibroid degeneration usually managed?
Conservatively with rest and analgesia
What is the typical duration for resolution of fibroid degeneration?
4-7 days
Fill in the blank: Uterine fibroids can undergo _______ degeneration if their growth exceeds blood supply.
red or ‘carneous’
True or False: Fibroid degeneration usually resolves within 10 days.
False
What does FGM stand for?
Female genital mutilation
What is the definition of female genital mutilation?
All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
What is Type 1 FGM?
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
What is Type 2 FGM?
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
What is Type 3 FGM?
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
What is Type 4 FGM?
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
What is endometriosis?
A common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity.
What percentage of women of reproductive age are affected by endometriosis?
Around 10%.
List the clinical features of endometriosis.
- Chronic pelvic pain
- Secondary dysmenorrhoea- pain starts days before bleeding
- Deep dyspareunia
*subfertility
What is secondary dysmenorrhoea?
Painful menstruation that is often linked to an underlying condition, such as endometriosis.
When does pain often start in relation to bleeding in endometriosis?
Days before bleeding.
What are some non-gynaecological symptoms associated with endometriosis?
- Urinary symptoms (e.g. dysuria, urgency, haematuria)
- Dyschezia (painful bowel movements)
What findings may be observed during a pelvic examination in a patient with endometriosis?
- Reduced organ mobility
- Tender nodularity in the posterior vaginal fornix
- Visible vaginal endometriotic lesions
What is the gold-standard investigation for endometriosis?
Laparoscopy.
What should be done if a patient has significant symptoms of endometriosis?
The patient should be referred for a definitive diagnosis.
What are the recommended first-line treatments for symptomatic relief of endometriosis?
- NSAIDs
- Paracetamol
What hormonal treatments may be tried if analgesia does not help in endometriosis management?
- Combined oral contraceptive pill
- Progestogens (e.g. medroxyprogesterone acetate)
If analgesia or hormonal treatment does not improve symptoms, what should be considered next?
Referral to secondary care.
What are GnRH analogues used for in the treatment of endometriosis?
They induce a ‘pseudomenopause’ due to low oestrogen levels.
Does drug therapy significantly impact fertility rates in endometriosis?
No, it does not seem to have a significant impact.
What surgical options may be considered for women with endometriosis who have not responded to medical treatment?
Surgery may be an option.
What does NICE recommend for women trying to conceive who have endometriosis?
Laparoscopic excision or ablation of endometriosis plus adhesiolysis.
What is recommended for endometriomas during surgery in women with endometriosis?
Ovarian cystectomy.
What is a common examination finding in ectopic pregnancy?
abdominal tenderness
Abdominal tenderness is often noted during physical examination of a patient suspected to have an ectopic pregnancy.
What does cervical excitation indicate in the context of ectopic pregnancy?
cervical motion tenderness
Cervical excitation, or cervical motion tenderness, is a sign that may suggest an ectopic pregnancy during examination.
What does NICE advise regarding the examination for an adnexal mass in suspected ectopic pregnancy?
NOT to examine for an adnexal mass
NICE advises against examining for an adnexal mass due to the increased risk of rupturing the pregnancy.
What examination is recommended by NICE for ectopic pregnancy?
a pelvic examination to check for cervical excitation
Despite the advice against examining for an adnexal mass, a pelvic examination for cervical excitation is still recommended.
In cases of pregnancy of unknown location, what serum bHCG level suggests an ectopic pregnancy?
> 1,500
Serum bHCG levels greater than 1,500 are indicative of a potential ectopic pregnancy when the location of the pregnancy is unknown.
What is dyspareunia?
Pain during or after sexual intercourse.
How can dyspareunia be classified?
According to where the pain is felt.
What is a cause of superficial dyspareunia related to sexual arousal?
Lack of sexual arousal.
What condition may cause superficial dyspareunia due to hormonal changes?
Vaginal atrophy (e.g. post-menopausal).
Which infections can lead to superficial dyspareunia?
- Vaginitis secondary to infection (e.g. Candida, Trichomonas)
- Painful episiotomy scar
- Vaginismus.
What are some causes of deep dyspareunia?
- Pelvic inflammatory disease
- Endometriosis
- Cervicitis secondary to infection (e.g. Chlamydia)
- Prolapsed ovaries in the pouch of Douglas
- Adenomyosis
- Fixed retroverted uterus.
Fill in the blank: Superficial dyspareunia can be caused by _______.
[Lack of sexual arousal]
True or False: Vaginismus is a cause of deep dyspareunia.
False.
What type of dyspareunia is caused by pelvic inflammatory disease?
Deep dyspareunia.
Fill in the blank: A painful episiotomy scar can lead to _______.
[Superficial dyspareunia]
What is primary dysmenorrhoea?
A condition with no underlying pelvic pathology affecting up to 50% of menstruating women.
When does primary dysmenorrhoea typically appear?
Within 1-2 years of menarche.
What is thought to be partially responsible for primary dysmenorrhoea?
Excessive endometrial prostaglandin production.
When does pain typically start in primary dysmenorrhoea?
Just before or within a few hours of the period starting.
What type of pain is associated with primary dysmenorrhoea?
Suprapubic cramping pains that may radiate to the back or down the thigh.
What is the first-line management for primary dysmenorrhoea?
NSAIDs such as mefenamic acid and ibuprofen.
What is the effectiveness of NSAIDs in managing primary dysmenorrhoea?
Effective in up to 80% of women.
How do NSAIDs work in the treatment of primary dysmenorrhoea?
By inhibiting prostaglandin production.
What is used as a second-line treatment for primary dysmenorrhoea?
Combined oral contraceptive pills.
What is secondary dysmenorrhoea?
Dysmenorrhoea that develops many years after menarche due to underlying pathology.
When does pain typically start in secondary dysmenorrhoea?
3-4 days before the onset of the period.
List some causes of secondary dysmenorrhoea.
- Endometriosis
- Adenomyosis
- Pelvic inflammatory disease
- Intrauterine devices
- Fibroids
What does NICE recommend for patients with secondary dysmenorrhoea?
Referring all patients to gynaecology for investigation.
What is cervical ectropion?
A condition where the stratified squamous epithelium meets the columnar epithelium on the ectocervix.
What causes an increase in columnar epithelium on the ectocervix?
Elevated oestrogen levels during the ovulatory phase, pregnancy, or combined oral contraceptive pill use.
What are two common features of cervical ectropion?
- Vaginal discharge
- Post-coital bleeding
When is ablative treatment indicated for cervical ectropion?
Only used for troublesome symptoms.
Fill in the blank: Elevated _______ levels can lead to cervical ectropion.
[oestrogen]
True or False: Cervical ectropion is characterized by the presence of only stratified squamous epithelium on the ectocervix.
False
What is an example of an ablative treatment for cervical ectropion?
‘Cold coagulation’
What is a common reason women in early pregnancy seek medical attention?
Bleeding in the first trimester
Bleeding can indicate various conditions, including miscarriage or ectopic pregnancy.
What are the main differential diagnoses for bleeding in the first trimester?
- Miscarriage
- Ectopic pregnancy
- Implantation bleeding
- Cervical ectropion
- Vaginitis
- Trauma
- Polyps
- Miscellaneous conditions
Ectopic pregnancy is particularly important as it can be life-threatening.
When should a woman with a positive pregnancy test and concerning symptoms be referred to an early pregnancy assessment service?
Immediately if she has:
* Pain and abdominal tenderness
* Pelvic tenderness
* Cervical motion tenderness
These symptoms suggest a possible ectopic pregnancy.
What is the management guideline for women with bleeding if the pregnancy is greater than or equal to 6 weeks gestation?
They should be referred to an early pregnancy assessment service
This applies if the gestation is uncertain or confirmed to be more than 6 weeks.
What is the most important investigation for identifying the location of the pregnancy in cases of bleeding?
Transvaginal ultrasound scan
It helps determine the presence of a fetal pole and heartbeat.
What should be done if a woman has bleeding and the pregnancy is less than 6 weeks gestation but has no pain or risk factors for ectopic pregnancy?
They can be managed expectantly
Women should be advised to return if bleeding continues or pain develops.
What follow-up actions should women take if they experience bleeding and are less than 6 weeks pregnant?
- Return if bleeding continues or pain develops
- Repeat a urine pregnancy test after 7-10 days
- Return if the test is positive
- A negative test indicates miscarriage
This approach helps monitor the situation safely.
What is more common in presentations to gynaecology: Bartholin’s abscess or Bartholin’s cyst?
Bartholin’s abscess
Bartholin’s abscess is three times more common than the cyst due to the asymptomatic nature of cysts.
What is the typical size and characteristics of Bartholin’s cysts?
1-3 cm in diameter, usually unilateral, soft, painless lump
The Bartholin’s glands should not be palpable in health.
How can a Bartholin’s cyst be best examined?
Felt between a finger at the posterior vaginal introitus and a thumb lateral to the labium
This examination reveals the soft lump characteristic of a cyst.
What are the risk factors for developing Bartholin’s cyst?
Poorly understood, but incidence increases with age up to menopause, and having one cyst is a risk factor for another
Only 10% of cysts occurred in women over age 40 in one study.
What is the general intervention for asymptomatic Bartholin’s cysts?
No intervention required
Some gynaecologists advocate incision and drainage with biopsy for older women to exclude carcinoma.
What treatments are recommended for symptomatic or disfiguring Bartholin’s cysts?
Incision and drainage or marsupialisation
Marsupialisation is thought to be more effective at preventing recurrence.
What is marsupialisation?
Creating a new orifice for glandular secretions by incising the gland, everting it, and suturing the epithelial lining against the skin
This procedure is longer and more invasive than simple drainage.
True or False: Antibiotics are recommended for Bartholin’s cyst without evidence of abscess.
False
There is no place for antibiotic use in this setting.
What does assisted reproductive technologies refer to?
Techniques and procedures performed to achieve pregnancy including intrauterine insemination, IVF, intra-cytoplasmic sperm injection, donor insemination, egg donation, pre-gestational testing, and surrogacy.
What is intrauterine insemination?
The process of introducing sperm directly into the uterus.
In which cases is intrauterine insemination typically used?
- Cervical scarring
- Poor sperm count
- Poor sperm mobility
- Difficulty with penetrative sexual intercourse
- Couples with HIV positive and negative partners.
How is sperm prepared for intrauterine insemination?
Sperm is collected via masturbation, then ‘washed’ and filtered to form a concentrated specimen.
What is the recommendation regarding intrauterine insemination for patients with unexplained infertility?
It is not recommended.
What does IVF stand for?
In vitro fertilisation.
What is the primary goal of IVF?
To stimulate egg production, collect eggs, and fertilise them with harvested sperm in vitro.
What is a traditional method of IVF?
Placing the egg and sperm in a dish where the sperm must penetrate the egg.
What is intra-cytoplasmic sperm injection?
A method where sperm is inserted directly into the egg cytoplasm using a micropipette.
What is the significance of using intra-cytoplasmic sperm injection?
It allows fertilisation in cases of severely compromised sperm mobility or difficult egg penetration.
What happens to the fertilised embryo in IVF?
It is reintroduced into the uterus of the child-carrying party.
What is the success rate of IVF in women over 44 years?
2%.
What does IVF allow for regarding genetic disorders?
Screening of embryos for specific genetic disorders using pre-implantation genetic diagnosis.
What are some examples of conditions that can be tested through IVF?
- Alpha thalassaemia
- Early-onset dementia
- Motor neurone disease with an identified genetic cause
- Huntingdon’s disease.
What are the risks associated with pre-implantation genetic diagnosis?
Risk of damage to embryos tested and possibility that all embryos carry the condition.
What is surrogacy?
The process of a third party carrying a foetus for another couple.
In which situations might surrogacy be considered?
- Couples without a uterus
- Those with uterine abnormalities
- Individuals who have suffered multiple miscarriages or failed IVF implantations.
What is the distinction between ‘full’ and ‘partial’ surrogacy?
- Full surrogacy: surrogate not genetically related to the foetus
- Partial surrogacy: surrogate’s egg is fertilised and re-implanted.
What legal advice is recommended for patients pursuing surrogacy?
Seek legal counsel prior to commencing the procedure.
In surrogacy who is the legal mother of the child?
It can be a highly controversial reproductive technology as, by law, the party giving birth to the child is its legal mother. Patients pursuing this option are strongly advised to seek legal counsel prior to commencing the procedure.
Alpha
What is Alpha-fetoprotein (AFP)?
A protein produced by the developing fetus
AFP is often measured in maternal blood during pregnancy.
What conditions can lead to increased levels of AFP?
- Neural tube defects (meningocele, myelomeningocele, anencephaly)
- Abdominal wall defects (omphalocele, gastroschisis)
- Multiple pregnancy
Elevated AFP levels can indicate potential fetal abnormalities.
What conditions are associated with decreased levels of AFP?
- Down’s syndrome
- Trisomy 18
- Maternal diabetes mellitus
Low levels of AFP can suggest chromosomal abnormalities or maternal health issues.
What do NICE recommend regarding vitamin D for pregnant women?
‘All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding.’
What is the recommended daily intake of vitamin D for pregnant and breastfeeding women?
10 micrograms of vitamin D per day.
What supplement is suggested for pregnant women to meet their vitamin D needs?
Healthy Start multivitamin supplement.
When was the advice for pregnant and breastfeeding women to take vitamin D confirmed?
2012.
Who advised that all pregnant and breastfeeding women should take a daily vitamin D supplement?
The Chief Medical Officer.
What is the purpose of taking vitamin D during pregnancy and breastfeeding?
To ensure the mother’s requirements for vitamin D are met and to build adequate fetal stores for early infancy.
Which groups of women should take particular care regarding vitamin D intake?
Women at risk, such as those who are Asian, obese, or have a poor diet.
True or False: It is not necessary for pregnant women to maintain adequate vitamin D stores.
False.
Fill in the blank: Pregnant and breastfeeding women are advised to take _______ micrograms of vitamin D daily.
10
What are the NICE recommendations for antenatal visits in the first pregnancy if uncomplicated?
10 antenatal visits
These visits are crucial for monitoring the health of the mother and fetus.
How many antenatal visits are recommended for subsequent pregnancies if uncomplicated?
7 antenatal visits
This is a reduction compared to the first pregnancy.
Do women need to see a consultant if the pregnancy is uncomplicated?
No
Routine care can be managed by primary healthcare providers.
What is the recommended timing for the booking visit?
8 - 12 weeks (ideally < 10 weeks)
This visit is essential for initial assessments.
What general information is provided during the booking visit?
Diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
This information helps promote a healthy pregnancy.
What tests are included in the booking bloods/urine?
- FBC
- Blood group
- Rhesus status
- Red cell alloantibodies
- Haemoglobinopathies
- Hepatitis B
- Syphilis
- HIV test offered to all women
- Urine culture for asymptomatic bacteriuria
These tests are vital for screening and managing potential health issues.
What is the purpose of the early scan at 10 - 13+6 weeks?
Confirm dates and exclude multiple pregnancy
Accurate dating is crucial for prenatal care.
When is Down’s syndrome screening performed?
11 - 13+6 weeks
This includes a nuchal scan.
What routine care is performed at 16 weeks?
Information on anomaly and blood results; BP and urine dipstick check
If Hb < 11 g/dl, consider iron.
What is the purpose of the anomaly scan at 18 - 20+6 weeks?
To check for physical abnormalities in the fetus
This scan is a critical part of prenatal care.
What routine care is conducted at 25 weeks for primiparous women?
BP, urine dipstick, symphysis-fundal height (SFH)
Monitoring growth and health is essential at this stage.
What additional care is provided at 28 weeks?
- BP
- Urine dipstick
- SFH
- Second screen for anaemia and atypical red cell alloantibodies
- If Hb < 10.5 g/dl, consider iron
- First dose of anti-D prophylaxis to rhesus negative women
This is crucial for managing maternal and fetal health.
What routine care is performed at 31 weeks for primiparous women?
Routine care as above
Similar assessments are repeated to ensure ongoing health.
What additional information is provided at 34 weeks?
Information on labour and birth plan; second dose of anti-D prophylaxis to rhesus negative women
This is important for preparing for delivery.
What routine check is performed at 36 weeks?
Check presentation and offer external cephalic version if indicated
This helps address potential delivery complications.
What information is discussed at 38 weeks?
Routine care as above
Continuation of monitoring and preparation for birth.
What is discussed at 40 weeks for primiparous women?
Discussion about options for prolonged pregnancy
Important for planning next steps if pregnancy goes beyond term.
What is discussed at 41 weeks?
Discuss labour plans and possibility of induction
Preparing for delivery is critical at this stage.
What conditions should women be offered screening for during pregnancy?
- Anaemia
- Bacteriuria
- Blood group, Rhesus status and anti-red cell antibodies
- Down’s syndrome
- Fetal anomalies
- Hepatitis B
- HIV
- Neural tube defects
- Risk factors for pre-eclampsia
- Syphilis
These screenings are important to ensure maternal and fetal health during pregnancy.
Which screenings should be offered depending on the history of the woman?
- Placenta praevia
- Psychiatric illness
- Sickle cell disease
- Tay-Sachs disease
- Thalassaemia
These conditions may require additional monitoring or interventions based on individual patient history.
True or False: Women should be offered screening for bacterial vaginosis during pregnancy.
False
Bacterial vaginosis is not recommended for screening in pregnancy.
Fill in the blank: Women should NOT be offered screening for _______ during pregnancy.
Chlamydia
Chlamydia screening is not routinely recommended for pregnant women.
List 7 conditions that women should NOT be screened for during pregnancy.
- Cytomegalovirus
- Fragile X
- Hepatitis C
*Bacterial vaginosis
*Chlamydia
*Group B Streptococcus
*Toxoplasmosis
These conditions do not have recommended screening protocols in pregnancy.
What is one of the conditions screened for that relates to fetal development?
Neural tube defects
Screening for neural tube defects is crucial for early detection and management.
What condition related to infections is screened for during pregnancy?
HIV
Screening for HIV is essential to prevent transmission to the fetus.
