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General Gynaecology > All > Flashcards

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1
Q

Contraindications to endometrial ablation

A

Previous classical Caesarean
Previous myomectomy
Desire for future fertility
Pre-malignancy or malignancy of the endometrium (therefore sample endometrium prior to procedure)

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2
Q

Outcomes of a ablation?

A

40% amennorhoea after 12 months
70-90% lighter bleeding at 12 months
30% further treatment for HMB 12 months post procedure

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3
Q

Complications of ablation?

A 
Perforation with or without visceral injury.
Bleeding
Infection
Haematometra
Device failure
Visceral burns
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4
Q

Hypothalamic causes of secondary amenorrhea?

A 
Low BMI
Excessive exercise
Head injury or cranial irradiation
Hypothalamic lesions (craniopharyngioma or glioma) as the either compress hypothalamic tissue or block dopamine leading to hyperprolactinaemia
Systemic disorders eg TB, sarcoidosis
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5
Q

Pituitary causes of secondary amenorrhea

A
  1. Sheehans syndrome (prolonged severe hypotension secondary to major obstetric haemorrhage), pituitary in pregnancy is enlarged and sensitive to hypoxic insult.
  2. Prolactin secreting adenomas (micro if <1cm, macro if >1cm)
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6
Q

Ovarian causes of secondary amenorrhea

A
  1. PCOS

2. POI

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7
Q

Systemic causes of secondary amenorrhea

A 
Renal failure
Thyroid disease
Cushing disease
Liver disease
Diabetes mellitus
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8
Q

Drugs associated with secondary amenorrhea?

A

Domperidone
Metoclopromide
Phenothiazines

All are dopamine antagonists and therefor can result in hyperprolactinaemia

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9
Q

Adrenal causes of secondary amenorrhea

A
  1. Virilizing adrenal tumours

2. Late onset CAH

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10
Q

Examination in investigation of amenorrhea

A

General, BMI, secondary sexual characteristics.
Breast examination to look for excess hair growth and elicit galactorrhoea.
If a pituitary lesion is suspected then examination or visual fields looking for bitemporal hemianopia.
External genitalia and vaginal examination.

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11
Q

Side effects of cabergoline?

A 
Nausea
Headache
Postural hypotension
Raynaud’s
Aggression
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12
Q

Pathophysiology of endometriosis

A
  1. Implantation theory/retrograde menstruation
  2. Coelomic metaplasia theory
  3. Embolisation theory (lymph or blood vessels)
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13
Q

McCune Albright Syndrome triad

A

Polyostotic fibrous dysplasia
Cafe au lait skin lesions
Gonadotrophin independent (peripheral) precocious puberty

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14
Q

Live birth dates with IUI compared to IVF

A

IUI 12%

IVF 32%

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15
Q

Indications for pelvic +/- para-aortic lymph node dissection?

A

Tumour histology clear cell, serous, squamous or grad 2-3 endometriod.

Myometrial invasion >1/2

Isthmus-cervix extension

Tumour size >2cm

Extrauterine disease

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16
Q

Is presacral neurectomy effective in management of endometriosis?

A

Yes for midline pain however it needs a high degree of skill and is potentially hazardous.

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17
Q

When can aromatise inhibitors be used in endometriosis?

A

Only for those with rectovaginal endometriosis that is refractory to other medical or surgical treatment. Can be used in combination with a COCP or progestogen?

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18
Q

Anti adhesion products used in endometriosis?

A

Oxidised regenerated cellulose - surgicel, prevents adhesion formation.

Polytetrafluoroethylene surgical membrane and hyaluronic acid products are effective in the context of pelvic surgery but not specifically studied in endometriosis.

Icodextrin has no benefit

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19
Q

HRT in women with endometriosis?

A

Even for women who have had a hysterectomy, consider use of progesterone and oestrogen to limit disease reactivation and malignant transformation.

However need to balance the increased systemic risks of combined EP.

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20
Q

Sex cord stromal tumours

A

Granulosa cell - malignant and slow growing
Theca cell - women >60 and oestrogen secreting
Fibroma
Sertoli-Leydig cell - rare and benign

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21
Q

How long is the ovary viable for after torsion?

A

24-36 hours

Follow up of women who have undergone de-torsion suggests that ovarian function recovers.

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22
Q

At what stage of oogenesis in the Fetus is development arrested?

A

Prophase 1 of meiosis

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23
Q

Meiosis two of the secondary oocyte?

A

Follows immediately after meiosis 1. However it arrests in metaphase and remains here until fertilisation.
If the egg is penetrated by a spermatozoon this activates the egg and meiosis II is completed 3hrs later.

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24
Q

Describe capacitation

A

Process that the spermatozoa must undergo to become competent to fertilise the oocyte.

Occurs within cervical mucus and involves removal of inhibitory mediators such as cholesterol from the sperm surface, tyrosine phosphorylation, and calcium ion influx.

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25
Q

Acrosome reaction

A

When a capacitated sperm passes through the cumulus cells surrounding the oocyte and the release of hydrolytic enzymes from the acrosome via exocytosis.

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26
Q

Which circumstance is it possible for a Fetus to have alloimmune thrombocytopenia? Ie what do the parents have to be?

A

Mother HPA-1a negative

Father HPA-1a positive

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27
Q

How long does it take for new sperm to be generated and reach the ejaculatory duct?

A

74 days

Therefore wait 3 months prior to repeating a semen analysis

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28
Q

Asthenospermia

A

Low total motility

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29
Q

Teratozoospermia

A

Low percentage of normal forms

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30
Q

Three investigations for tubal patency?

A

Hysterosalpingogram

HyCoSy - hysterosalpingocontrast sonography

Laparoscopy and tubal dye studies.

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31
Q

Mechanism of action of metformin?

A

Decreases hepatic glucose production, decreases intestinal absorption of glucose, and lowers free fatty acid concentrations thus reducing gluconeogenesis

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32
Q

Tests available to check correct veress needle placement?

A

Pressure check.

Saline check.

Hanging drop test.

Equal distension and tympanic sound to all quadrants after attaching gas.

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33
Q

What test is performed to look for fragile X syndrome?

A

FMR1 mutation testing

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34
Q

Autoimmune adrenal insufficiency is a cause of secondary amenorrhea. How is this tested for?

A

ACA (anti-adrenal) antibodies

21OH antibodies

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35
Q

Contraindications to bisphosphonate therapy

A

Oesophageal disorders

CKD (eGFR <30-35ml/min)

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36
Q

Non hormonal therapies for VMS?

A

All of the following have been shown to be superior to placebo in RCTs.

Gabapentin
Venlafaxine
Desvenlafaxine
Paroxetine
Fluoxetine
Citalopram
Escitalopram

Ie gabapentin and SSRIs

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37
Q

HRT and ovarian cancer risk?

A

Association remains uncertain. Potentially an increased risk of serous and endometriod subtypes but this is not consistent across studies.

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38
Q

Amsel criteria for BV?

A 
At least three of;
Characteristic discharge
Clue cells on wet microscopy
pH >4.5
Fishy odour on adding alkali to slide
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39
Q

Which culture medium is used for growth of candida?

A

Sabouraud’s

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40
Q

Hepatitis B prophylaxis for a non-immune individual?

A

500IU of hepatitis B immunoglobulin within 7 days but ideally within the first 48 hours following exposure.

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41
Q

Vertical transmission risk of hepatitis C?

A

1-3% if HCV-RNA negative
4-6% if RNA positive

Not an indication for Caesarean section unless also HIV positive

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42
Q

Indicator diseases of AIDS?

A 
Non-Hodgkin’s lymphoma
Kaposi’s sarcoma
CMV retinitis
Pneumocystis carinii pneumonia
Candida oesophagitis
Cerebral toxoplasmosis
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43
Q

Side effects of HAART for HIV?

A

Nausea, diarrhoea and lethargy are common.

Can be highly toxic and can cause lactic acidosis, hepatitis, peripheral neuropathy, and pancreatitis.

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44
Q

Four common causative agents in PID?

A 
Chlamydia
Gonorrhoea
Mycoplasma genitalium
E.coli
Peptostreptococcus
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45
Q

Ulipristal acetate and emergency contraception?

A

Selective progesterone receptor modulator.

Most effective of the oral ECPs
Not available in NZ
Effective up to 5 days
30mg

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46
Q

Pelvic infection risk after insertion of IUD?

A

1/300 in the first 20 days following insertion

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47
Q

IUD and pregnancy?

A

Should exclude ectopic pregnancy and remove IUD.

50% spontaneous miscarriage rate.

Risk of APH, TPTL, and adherent placenta if left in situ.

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48
Q

Risks of vasectomy?

A

Infection
Hematoma
Localised swelling
Post vasectomy pain syndrome 3-8% (most likely due to a granuloma)

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49
Q

Dose of hormone in mirena?

A

52mg levonorgestrel

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50
Q

Time to return to fertility for mirena?

A

As early as 1 month.

97% have menses within 3 months.

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51
Q

Time to return of fertility for jadelle/implanon?

A

Ovulation can occur as early as 7-14 days

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52
Q

NZ current abortion rate?

A

Statistics from 2017.

13.7/1000 women age 15-44 years.

Overall numbers were 13,285 in 2017.

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53
Q

Teenage abortion rate in NZ?

A

9.2/1000 for 15-19 year olds

Significant reduction since 2007 where it was 26.7/1000

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54
Q

Regimen for medical abortion prior to 63 days?

A 
Mifepristone 200mg
Misoprostol 800mcg (24-28 hours later)

RANZCOG guidelines say safe to give miso at home at this gestation and should be administered bucally.

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55
Q

Factors increasing risk of progression of HPV infection in the context of cervical cancer?

A

Cigarette smoking (risk of squamous carcinoma but not of adenocarcinoma).
>5 term pregnancies
Early age at first full term pregnancy
Immune deficiency
Oral contraceptive use >5yrs
Do-infection with other sexually transmitted diseases

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56
Q

HPV types included in gardasil 9?

A 
6
11
16
18
31
33
45
52
58
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57
Q

Predicted reduction in cervical cancer from new screening programme?

A

31-36% for unvaccinated women

24-29% for vaccinated women

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58
Q

HPV vaccine is made from?

A

Virus like proteins

Do not contain live, attenuated or killed virus

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59
Q

Indications to perform a cone biopsy?

A

Unable to visualise the upper limit of the transformation zone and the woman has a high grade abnormality

Unsatisfactory colposcopy and review of cytology confirms high grade abnormalities

Suspected presence of an additional glandular abnormality

Suspicion of an early invasive cancer

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60
Q

A radical hysterectomy involves removal of?

A

Uterus, cervix, upper 1/3-1/2 of vagina, and parametrium (round, broad, cardinal and uterosacral ligaments).

Tubes and ovaries are not routinely removed unless they look normal or the woman is postmenopausal.

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61
Q

Differentials for cervical smear report of possible high grade infra-epithelial neoplasia?

A 
CIN
Invasive cervical cancer
VIN
VAIN
Immature squamous metaplasia
Active HPV infection
Inflammation/infection 
Squamous cell carcinoma in situ
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62
Q

Malignancies associated with lynch syndrome?

A 
Colorectal (predominantly right sided)
Endometrial
Ovarian
Stomach
Small bowel
Hepatobiliary
Renal pelvis
Ureter
Brain
Sebaceous
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63
Q

Amsterdam II criteria?

A

Three or more relatives with genetic syndrome cancers Eg Lynch, one of whom is first degree.
Involve at least two generations.
One or more cancers diagnosed prior to 50 yrs age.

Sensitivity of 22% but specificity of 98%

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64
Q

What structures are removed in a radical vulvectomy?

A

Entire vulva down to the level of the deep fascia of the thigh, the periosteum of the pubis and the inferior fascia of the urogenjtal diaphragm.

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65
Q

Further investigations you may need to consider if you diagnose a mucinous borderline tumour?

A

Gastroscopy
Colonoscopy

Intestinal subtype is associated with pseudomyxoma peritoneui and appendices neoplasm.

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66
Q

Which malignancies are associated with Peutz-Jeghers syndrome?

A

Sex cord stromal tumours

Adenoma malignum

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67
Q

High risk features of borderline tumours?

A

Invasive implants
DNA aneuploidy
Higher stage disease
Micropapillary projections in a serous tumour

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68
Q

Prognosis of borderline tumours?

A

> 97% survival at 5 years

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69
Q

Epidemiological factors most protective against developing ovarian Ca?

A

COCP use - RR 30% for every 5 years of use

High parity - 25% risk reduction after one child and 20% with subsequent births. Breastfeeding also associated with risk reduction of 20% for every year of breastfeeding.

Age - premenopausal women less likely

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70
Q

RMI>200

A

Referral to gynae oncology

Sensitivity of 78% and specificity of 87% for malignancy

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71
Q

Indications for referral for genetic testing for BRCA?

A

3 or more relatives on one side of the family with breast or ovarian ca, or ovarian/bowel/uterine.
Known BRCA or lunch in affected members
2 or more relatives and bilateral breast Ca
Male breast Ca
Breast and ovarian Ca in same person
Breast cancer <45 years

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72
Q

Sensitivity of pipelle endometrial biopsy?

A

95-99% sensitive for endometrial cancer if hyperplasia/cancer is >50% of cavity

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73
Q

What is attrition bias?

A

When members of the original cohort are lost or excluded after the outcome has occurred.

Trials need to document withdrawals, losses to follow up, protocol deviations, and exclusions.

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74
Q

What is prevalence?

A

A measurement of all individuals affected by a disease at a particular time

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75
Q

Incidence?

A

Measurement of the number of new individuals who contract a disease during a particular period of time

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76
Q

Types of observational studies?

A

Cohort - prospective or retrospective

Case control

Cross sectional

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77
Q

Difference between parametric and non-parametric tests?

A

Parametric tests can be performed on normally distributed data.

Non parametric tests are used when the data is skewed. This is the same circumstance when a median is more relevant than a mean.

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78
Q

How is a standard error calculated?

A

The standard deviation of the sample is divided by the square root of the number of observations in the sample.

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79
Q

How is a confidence interval calculated?

A

The sample mean +/- 1.96x the standard error for a 95% confidence interval

80
Q

Branches of the anterior division of the internal iliac artery

A 
Uterine
Umbilical
Inferior vesical
Middle rectal
Obturator
Inferior gluteal
Internal pudendal
81
Q

Tips to identify uterine artery off anterior internal iliac artery?

A

Uterine artery originates 6cm distal from the bifurcation of the common iliac.

Follow the obliterated umbilical artery as it will always lead backwards to the uterine.

Ligate medial to lateral to avoid the ureter

82
Q

Which distension media should be used for hysteroscopy with monopolar diathermy?

A

Hypertonic solution such as glycine or sorbitol as it is non conducting

83
Q

How is vapourisation of tissues achieved?

A

Cut

Non-contact

84
Q

How is fulguration achieved?

A

Coag

Non-contact

85
Q

How is dessication achieved?

A

Cut or coag

Contact

86
Q

What is the estimated rate of serious complications at laparoscopic surgery?

A

3-8/1000

87
Q

Physical properties and physiological effects of household current?

A

Low frequency alternating current

Neuromuscular stimulation and potential cardiac arrest.
Rapid tissue heating at entry and exit points leading to severe burns

88
Q

Physiological effects and physical properties of electrosurgery?

A

High frequency alternating current 400-500kHz

Prevents neuromuscular stimulation.
“Burning” the controlled ability to cut and coagulate

89
Q

Benefits of vaginal hysterectomy over laparoscopic based on nieboer et al Cochrane review findings

A

Shorter operations

Lower rate of substantial bleeding

90
Q

Benefits of vaginal hysterectomy over abdominal hysterectomy based on nieboer te et al Cochrane review?

A

Shorter hospital stay
Quicker return to normal activities
Fewer episodes of post op fever
Fewer infections

91
Q

How is a free androgen index calculated?

A

Total testosterone divided by SHBG x 100

92
Q

Anticipated effect of ovarian electrocautery on women with PCOS?

A

Over 60% normalisation of SHBG and androgens for up to 20 years.

Demonstrated in a long term cohort study

93
Q

Definition of metabolic syndrome

A 
Elevated BP > 130/85
Increased waist circumference >88cm
Elevated fasting blood glucose levels 
Reduced HDL cholesterol
Elevated triglyceride levels
94
Q

Urinary tract anomalies associated with mullerian anomalies

A

Duplex collecting system
Pelvic or horseshoe kidney
Renal agenesis

95
Q

Features of a dysgerminoma

A

2% ovarian neoplasms and 75% occur in adolescents and young adults.
May develop within a gonadoastoma in an XY female
Growth is usually rapid therefore presentation is with abdominal enlargement and pain due to rupture with haemoperitoneum or torsion.
If tumour is hormonally active then menstrual irregularities may occur.
Elevated LDH

96
Q

Mechanism of action of mirena?

A

Levonorgestrel leads to changes in the endometrium such as pseudo-decidualisation, glandular atrophy, leukocytic infiltration and a decrease in glandular and stromal mitoses.

Ultimately thins and stabilises myometrium

97
Q

Regression rate hyperplasia without atypia with observation alone?

A

74.2%-81%

98
Q

Regression rate of hyperplasia without atypia when treated with progestogens?

A

89-96%

99
Q

Regression rates of hyperplasia without atypia at six months of mirena and PO progestogerone?

A

Mirena = 100%

PO progesterone = 64%

100
Q

Risk of lymph node metastasis in 1B Vulval cancers?

A

8%

101
Q

Five proven benefits of HRT

A

Reduction in vasomotor symptoms
Reduction in vaginal dryness and dyspareunia
Improved quality of life
Reduction in colorectal cancer risk
Reduction in all cause mortality
Reduction in the risk of hip fracture and osteoporosis

102
Q

HRT use after 60 years is associated with?

A

Increased risk of stroke when used >60 years or >10yrs post menopause
Increased risk of breast cancer with prolonged use past 5 years
Increased risk of coronary artery disease

103
Q

Mechanism of action of letrozole?

A

Aromatise inhibitor.

Suppresses ovarian secretion of estradiol and therefore reduced negative feedback on the hypothalamus.

104
Q

Side effects of bromocriptine?

A

GI disturbance

Hypotension

105
Q

Chance of regression or microprolactinoma with pregnancy/breastfeeding?

A

40%

106
Q

Side effects of Clomiphene?

A

Abdominal distension
Breast tenderness
Nausea and vomiting
- all due to high estrogen

Hot flushes due to LH

107
Q

Markers of critical OHSS?

A 
Tense ascites/large hydrothorax
Haematocrjt >0.55
WCC >25
Oliguria or anuria
VTE
ARDS
108
Q

How do dopamine agonists work in preventing OHSS?

A

Reduce the expression of VEGF receptors

109
Q

Estimated rate of serious complications at laparoscopy?

A

3-8/1000

110
Q

Electro surgical waveform needed to achieve dessication of tissue?

A

Cut or coag

Contact with tissue

111
Q

What is fulgaration and how is it achieved?

A

Action of electrical arcs on tissue leading to superficial tissue destruction and large amounts of carbonisation.

Caused by coagulation setting and non-contact

112
Q

Vessels from which the ureter derives it’s blood supply?

A 
Ureteric branch from renal artery
Gonadal artery
Internal iliac -> inferior vesical
Uterine
Vesical
113
Q

Causes of CA 125

Elevation?

A 
Fibroids
Adenomyosis
Endometriosis
PID
Acute cyst events
TB
Cirrhosis
Hepatitis
Pancreatitis
Peritonitis
Pleuritis
Other primary tumours with metastases to the peritoneum
114
Q

What percentage of ovarian cancer is related to a genetic syndrome?

A

10%

115
Q

What is denonvilliers fascia?

A

Rectovaginal septum that is the posterior equivalent of the pubocervical fascia. Extends from vaginal apex to the perineal body

116
Q

Duloxetine?

A

SNRI
Only pharmacological management option for stress urinary incontinence.
Acts in the spinal cord where it increases pudendal nerve activity and therefore increases urethral sphincter closure.
20mg bd

117
Q

How is a burch colposuspension performed?

A

Two non-absorbable sutures are places through the full thickness of the paravaginal fascia at each side of the bladder neck.

Each is then attached to the iliopectineal ligament 3-4cm from the midline of the pubic bone.

118
Q

Differential diagnoses for urge and occasional stress incontinence?

A 
UTI
Vulvovaginal atrophy
Spinal cord lesion
Overactive bladder syndrome
Multiple sclerosis
Pelvic mass
Peripheral neuropathy
Temporary causes such as diuretics, caffeine, alcohol
119
Q

What are the benefits of TV mesh as per evidence?

A

Probable benefit for repair success and longevity for anterior compartment.

No benefit for repair success and longevity for vault or posterior compartment.

Possible benefit for severe prolapse, particularly after a failed primary procedure.

120
Q

What are the complications associated with transvaginal mesh?

A 
Mesh exposure/erosion
Vaginal stricture/scarring
Fistula
Dyspareunia
Unprovoked pelvic pain at rest
Pain symptoms that may not completely resolve with mesh removal
121
Q

Caution with TV mesh implants in which patients?

A

Primary prolapse cases
Younger patients <50
Postmenopausal patients who are unable to use Ovestin cream
Chronic pelvic pain
Lesser grades of prolapse
Posterior compartment prolapse without significant apical descent

122
Q

Centres involved in micturition?

A

Cerebral - voluntary inhibition
Brain stem - pontine micturition centre
Supra-sacral - sympathetic supply
Sacral - parasympathetic supply

123
Q

Innervation of the levator ani?

A

Nerve to levator ani (S4)

Pudendal nerve (S2-4) - inferior rectal and perineal branches

124
Q

Mechanisms of levator ani injury?

A

Avulsion

Irreversible over-distension leading to micro-trauma

Necrosis and damage to the pudendal nerve and sacral plexus

125
Q

Diagnosing a levator ani muscle injury?

A
  1. Larger genital hiatus
  2. Distance between two puborectalis attachments of >3.5 finger widths
  3. Ultrasound - puborectalis to side wall attachment not seen on all three central slices
  4. MRI - hypersignal of puborectalis, thinning or thickening, rupture of muscular insertion
126
Q

Reducing risk of pelvic floor injury at vaginal delivery?

A

Ventouse > forceps if clinically appropriate

Pudendal or epidural to relax the pelvic floor

Prevention of OASIS

Avoid a prolonged second stage

Counsel re large fetal size/head circumference

Pelvic floor exercises during and after pregnancy

127
Q

What is an abdominal sacro-colpopexy?

A

Apical suspension of the vault with a permanent mesh fixed to the longitudinal ligament of the sacrum.
Attached to anterior and posterior aspects of the vault

128
Q

Where should sutures be placed for a sacrospinous fixation?

A

1.5-2cm medial to the ischial spines

Can be done bilaterally but commonly unilateral on the RHS

129
Q

Frequency of anterior compartment prolapse after sacrospinous fixation?

A

8-30%

130
Q

Theory behind hot flashes?

A

Increase in pulsatile release of FSH.

Narrowed thermoregulatory zone. Inappropriate peripheral vasodilatation with increased digital cutaneous blood flow.

Perspiration leads to rapid heat loss and a decrease in core body temperature below normal.

Estrogen administration restores the thermoneutral zone to normal

131
Q

What type of drug is teriparatide?

A

Recombinant parathyroid hormone

132
Q

Postmenopausal adrenal function?

A

Progesterone synthesis decreases or is absent (main supply corpus luteum).

DHEA and DHEAS decrease with age

Androstenedione is produced and peripherally converted to estrone as well as testosterone.
If high cortisol (eg stress) then low androstenedione = hot flashes, accelerated bone loss

133
Q

Drugs that can cause hot flashes?

A

Anti hypertensives and anti depressants as at high doses they can affect vascular reactivity

134
Q

What marks the early menopause transition?

A

Persistent difference of 7 days or more in length of consecutive cycles

135
Q

Late menopause is marked by?

A

Periods of amenorrhea of 60 days or more, frequent anovulation, and the onset of perimenopausal symptoms

136
Q

Menopausal symptoms that are likely to improve with HRT?

A

Vasomotor
Vaginal dryness
Sleep disturbance
Joint symptoms

137
Q

First line management for women with menopausal symptoms?

A 
Life style changes including:
Stress reduction
Regular exercise
Optimal weight management
Appropriate diet
Avoidance of smoking, excessive alcohol and caffeine
138
Q

HRT reduction in VMS compared with placebo?

A

87% reduction

139
Q

HRT and cholecystitis?

A

Increased risk with 12 extra cases per 1000 women per 5 years

140
Q

Transdermal HRT is preferred for which women?

A

Migraine
Abnormal LFTs
Increased risk of VTE

No increased risk of stroke >60 years with transdermal 50microgram or less dose

141
Q

RANZCOG recommended monitoring while on HRT?

A

Review after 6 months of commencing therapy

General health, breast check and mammogram every 2 years

Check cervical screening is up to date

Bone densiometry when indicated

Investigate any unexpected vaginal bleeding after 6 months of therapy

142
Q

Which drugs should be avoided in women on tamoxifen with breast Ca?

A

Paroxetine
Fluoxetine

Gabapentin is a good choice for these women

143
Q

Benefits of HRT?

A 
Decreased risk of fragility fracture
Decreased risk of colorectal cancer
Reduction in all cause mortality
Improved quality of life
87% reduction in vasomotor symptoms compared to placebo
144
Q

Endometrial cancer risk in women on tamoxifen postmenopausal?

A

RR 4.01

Incidence 2-3/1000/year

145
Q

What are the names of the two trials that show HRT is not supported in breast cancer survivors?

A

HABITS

Stockholm

146
Q

Aromatase inhibitors and osteoporosis?

A

Increased risk
Regular bone mineral density measurements
If drug therapy is needed bisphosphonates are first line

147
Q

Medical history for a woman consulting for HRT?

A

Gynae - LMP, bleeding pattern, past surgery, current HRT use, need for contraception?

Medical - including VTE, breast cancer, CVD including HTN, diabetes, osteoporosis, depression, recurrent UTI, thyroid and liver disease

Family history - CVD, CVA, osteoporosis, dementia, cancer

Smoking
Alcohol
Current meds
Social history

148
Q

What is the dose of tibolone?

A

2.5mg daily Po

149
Q

Dose of gabapentin for HRT?

A

300-900mg/day

150
Q

Four categories of menopausal symptoms?

A

Vasomotor
Psychological
General physical
Urogenital/sexual

151
Q

Disadvantages of oral oestrogen for HRT?

A

Increased risk of VTE

Increased risk of cholelithiasis

Increased SHBG = decreased testosterone

Increased TBG = therefore if hypothyroidism May need to increase thyroxine dose

Administration of a total higher dose

152
Q

Disadvantages of transdermal oestrogen HRT?

A

Patches can cause skin irritation and rarely an allergic reaction

Gel can be sticky and inconvenient

Occasionally poorly absorbed

Women may forget to change 2x weekly patch

153
Q

What non hormonal methods have evidence to support efficacy for management of menopausal symptoms?

A 
SSRI/SNRI
Clonidine
Gabapentin
Hypnosis
CBT
Stellate ganglion blockade

All improve vasomotor symptoms

154
Q

Advice re androgen therapy for low sexual desire?

A

Transdermal cream or pellets

Treatment effects may take 6-8 weeks

Stop if no benefit by 6 months

Side effects of excessive dosage include masculinisation

155
Q

Risks for women taking HRT after 60?

A

Increased risk of CVA if >60 or greater than 10 years post menopause. 8 more cases per 10,000 women.

Increased risk of breast cancer with prolonged HRT use >5 years. 8 more cases per 10,000 women.

Increased risk of coronary artery disease

Increased risk of thrombosis. 6 extra PE and 18 extra DVT

156
Q

Disadvantage of lifestyle changes for management of hot flashes?

A

Minimal effect on frequency of symptoms but may reduce severity of tolerability

157
Q

Does gabapentin improve vaginal symptoms related to menopause?

A

No

But equal to HRT in management of VMS

158
Q

Side effects of tibolone?

A

Headache
Acne
Increased hair growth
Irregular bleeding

159
Q

Advantages of tibolone in LIFT trial

A

Reduction in vasomotor symptoms
Endometrial protection
Improved vulvovaginal atrophy

No increase in risk of VTE, breast Ca, endometrial Ca or CV disease.

Increased risk of stroke however of 2.19

160
Q

How do oral bisphosphonates work?

A

Prevent osteoclast action.

Eg alendronate, risendronate.

161
Q

Estrogen causes the environment of the vagina to be?

A

Glycogen rich

Glycogen then gets broken down to lactic acid causing the pH of the vagina to be <4.5

162
Q

Properties of lactobacilli?

A

Prevent long term colonisation of the vagina by adhering to vaginal epithelial cells

Produce lactic acid

Produce hydrogen peroxide

Produce bacteriocins

163
Q

Bacteria that predominate in BV?

A

Gardnerella
Prevotella
Mycoplasma hominis

164
Q

Treatment of recurrent episodes of candida?

A

Recurrent episodes = >4/year

Fluconazole 100mg Po weekly for six months

165
Q

Features of disseminated gonococcal infection?

A

Arthritis
Skin lesions
Endocarditis
Meningitis

166
Q

Treatment for herpes?

A

Treat any primary episode regardless of timing of onset.
Valaciclovir 500mg Po bd for 7/7 or aciclovir 400mg po tds for 7/7.

Only treat recurrent episodes if during pro drone or 24 hours of lesion onset. Valaciclovir 500mg op be for 3/7 or aciclovir 800mg Po tds for 2/7

167
Q

In utero features of congenital syphillis?

A

Hydrops
(Skin thickening, Polyhydramnios, Placental thickening, Serious cavity effusions)

Hepatomegaly
Splenomegaly

Can also cause IUD and preterm birth

168
Q

What is antibiotic stewardship?

A

Strategies to improve the use of antimicrobials:
Enhance patient outcomes
Decrease resistance
Decrease unnecessary costs

169
Q

Four key features of innate immunity?

A

Complement cascade
Cytokines
Anatomical barriers
Leukocytes

169
Q

PEACH study?

A

Effectiveness of antibiotics in PIS and preventing long term complications.

Women were treated with cefoxitin and doxycycline and pregnancy rates at three years were similar or higher than the generally population

169
Q

Medical considerations for a patient presenting with rape?

A 
Emergency contraception
Hepatitis B vaccination
HIV post exposure prophylaxis if within 72hours
Tetanus
Antibiotics if bitten
Hepatitis A if anal rape
Antibiotic prophylaxis for STIs
170
Q

Incubation period for vulvovaginal HPV/warts?

A

2 weeks to 18 months

May have an initial latent phase where no signs or symptoms are exhibited or may be unaware of a primary episode.

171
Q

What commonly used drugs depress sperm quantity and quality?

A 
Opioids
Chemotherapy
Nitrofurantoin
Spironolactone
Anabolic and corticosteroids
Anti-fungal agents
Finasteride
172
Q

Anatomy of the inferior epigastric artery?

A

Arises from the external iliac artery and anastomoses superiority with the superior epigastric artery.

Origin is superior and medial to the inguinal ligament and ascends in an oblique path along the medial border of the deep inguinal ring then punctures the transversals fascia and ascends to enter the rectus sheath just beneath the arcuate line

173
Q

How is the inferior epigastric artery identified?

A

Medial to the entry of the round ligament into the inguinal canal

Identify the obliterated umbilical arteries as the inferior epigastric artery lies lateral to these

174
Q

Why is primary hypogonadism in males more likely to be associated with decreased sperm production than testosterone production?

A

Diseases usually damage the seminiferous tubules to a greater degree than the Leydig cells.

Gynaecomastia is common due to testicular aromatase activity leading to an increased conversion of testosterone to estradiol.

175
Q

Guiding principles of cross border reproductive care?

A

Health and safety - eg multiple pregnancies, infectious diseases risk

Autonomy

Equity

176
Q

Circumstances where surrogacy May be appropriate?

A

Where uterine factors are the cause of infertility

Serious maternal medical conditions of high risk if pregnant eg pulmonary hypertension provided the woman is still fit enough to look after the child following delivery

Multiple failed IVF cycles

Multiple miscarriages

177
Q

In statistics, what is a significance level?

A

The probability of rejecting the null hypothesis when it is true.

178
Q

Branches of the external iliac artery?

A

Inferior epigastric

Deep circumflex -> femoral

179
Q

Posterior branch of the internal iliac artery gives off which vessels?

A

Iliolumbar
Lateral sacral
Superior gluteal

180
Q

The retropubic space is also known as?

A

The space of retzius

181
Q

What is the single most important factor to reduce injury from primary trocar placements?

A

Intra-abdominal pressure

Ideally 20-25mmHg

182
Q

Circumstances where a Palmer’s point entry should be considered?

A

Suspected or known periumbilical adhesions

Previous umbilical hernia

After three failed insufflation attempts at the umbilicus

Morbid obesity or very thin women (or Hasson)

183
Q

When is written consent required?

A

Patient will be under GA

Participation in any research

Procedure is experimental

Significant risk of adverse effects to the patient

184
Q

Mechanisms of electro surgical injuries?

A 
Insulation failure
Lateral thermal spread
Direct application
Direct coupling
Capacitive coupling
Return electrode or alternative site burns
185
Q

What is capacitive coupling?

A

Electric current is transferred from one conductor, through intact insulation to another conductive material without direct contact.

Example is combination metal/plastic ports

186
Q

What is coaptation?

A

Contact with tissue leads to dissipation of heat over a wide area.

More diffuse and gentle heating and sealing of small to medium vessels

187
Q

What to consider regarding prophylactic BSO during hysterectomy for benign conditions?

A

Risk of developing ovarian cancer

Risk factors for CVD, osteoporosis, dementia and depression

Absolute and relative contraindications to HRT

188
Q

What are the four domains of the consensus bundle for prevention of surgical site infections?

A

Readiness
Recognition and prevention
Response
Reporting and systems learning

189
Q

What does the WASHING pneumonic stand for?

A 
W = weight
A = antibiotic resistant skin flora (MRSA)
S = smoking cessation
H = hygiene, skin preparation
I = immune deficiency status
N = nutritional status
G = glycemic control
190
Q

What are the three different types of surgical site infections?

A

Superficial incisional
Deep incisional
Organ or space

191
Q

What is the lifetime incidence of invasive cervical cancer in Australia?

A

1/162

192
Q

What is the incidence of precocious puberty in girls?

A

1/5000-10,000

193
Q

Colposcopic appearance of VIN?

A

White area with prominent surface and clearly defined border

Red macular area with velvety surface

Dark papular area, generally multi focal with dark brown pigmentation

Papillomatous white/grey rough surface with visible capillaries

General Gynaecology (1 decks)

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