Day 3 Gynaecology Flashcards
A 21-year-old woman presents for her dating scan after discovering she was pregnant 6 weeks ago, following a urinary pregnancy test.
Her ultrasound shows the pregnancy is extra-uterine and is located in her left fallopian tube. It is 20mm in size, is unruptured and has no cardiac activity.
She is currently reporting no symptoms, including no bleeding, cramping, vomiting or systemic symptoms her vitals are normal.
Her blood test results are as follows:
- β-hCG Today 740 IU/L
- β-hCG 1 week ago (Booking Appointment) 940 IU/L
There is no past medical history of note.
What is the most appropriate management to offer her?
Give safety netting advice and ask to return in 48 hours for serum β-hCG levels
Expectant management of an ectopic pregnancy can only be performed for
- An unruptured embryo
- <35mm in size
- Have no heartbeat
- Be asymptomatic
- Have a B-hCG level of <1,000IU/L and declining
You are working in general practice, a 53-year-old female presents with 2 months of per-vaginal (PV) bleeding.
She passed through the menopause at 49-years-old, her body mass index (BMI) is 34kg/m² and she drinks 18-units of alcohol a week.
She has only had one sexual partner her whole life.
She has no pain during sex or post-coital bleeding.
Which diagnosis is most likely?
Endometrial hyperplasia may present with :
intermenstrual bleeding
post-menopausal bleeding
menorrhagia
irregular bleeding
Types fo endometrial hyperplasia
(4)
simple
complex
simple atypical
complex atypical
Feature of endometrial hyperplasia
abnormal vaginal bleeding e.g. intermenstrual
Management of endometrial hyperplasia
(3)
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months.
The levonorgestrel intrauterine system may be used
atypia: hysterectomy is usually advised
A 30-year-old woman presents with ongoing, cyclical pain around the time of her periods. The pain starts several days before the period itself and can last until several days after. She also experiences pain during sexual intercourse, particularly with deep penetration.
Examination demonstrated tender nodularity in the posterior fornix.
The patient has already tried paracetamol and ibuprofen, but these are no longer effective.
What is the likely diagnosis?
What is the next most appropriate step?
If analgesia doesn’t help endometriosis then the
combined oral contraceptive pill or a progestogen should be tried
What is Clomifene used for in gynaecological medicine?
Clomifene is used to induce ovulation in a number of conditions.
What is Elagolix used for?
Elagolix is a relatively new gonadotropin-releasing hormone antagonist. It is licensed in the USA for endometriosis-related pain.
It is not widely used in the UK currently and so the next most appropriate option remains the combined contraceptive pill.
What is Leuprorelin?
Leuprorelin is a gonadotropin-releasing hormone agonist.
Whilst effective for the control of endometriosis-related pain, it is prescribed by specialists and would not be the next step after simple analgesia.
Endometriosis Clinical features
(7)
- chronic pelvic pain
- secondary dysmenorrhoea
- pain often starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
Endometriosis pelvic examination findings
(3)
reduced organ mobility
tender nodularity in the posterior vaginal fornix
visible vaginal endometriotic lesions
Investigations for endometriosis
(2)
laparoscopy is the gold-standard investigation
there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
Primarry treatments/management of endometriosis
(2)
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
if analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
Secondary treatments of endometriosis:
(2)
If analgesia/hormonal treatment does not improve symptoms, patient should be referred to secondary care.
Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
A 38-year-old G5P2 woman presents to antenatal clinic at 35+2 gestation.
Her pregnancy so far has been unremarkable apart from some moderate morning sickness experienced in the first trimester.
She complains of a number of minor symptoms.
Which of symptoms would be cause for concern and warrant further investigation?
(3)
Dysuria may be an indication of urinary tract infection which needs to be promptly treated in all stages of pregnancy.
UTI is associated with premature birth.
It is believed the localised inflammatory mediators associated with UTI trigger pre-term labour by irritating the neck of the uterus and cervix.
A 28-year-old woman presents to her GP with intermenstrual bleeding and dyspareunia. She does not use any hormonal contraceptives. After ruling out a sexually transmitted infection and fibroids, she is referred to colposcopy where she is diagnosed with a grade 1A squamous cell carcinoma of the cervix. She is married and hopes to have children in future.
Which treatment option is most appropriate for this woman’s cancer?
(3)
Women with stage IA cervical cancer may opt for a cone biopsy
with negative margins
if they wish to maintain their fertility
How are cervical intraepithelial dysplasias treated?
Laser ablation
How is cervical cancer managed?
The management of cervical cancer is determined by the FIGO staging and the wishes of the patient to maintain fertility.
A 52-year-old woman presents to her general practitioner (GP) to find out the result of her recent cervical smear.
Her two previous smears, taken 24 and 12 moths ago, were both positive for high-risk human papillomavirus (HPV), but showed no abnormal cytology.
She is informed that her most recent cervical smear was also positive for high-risk HPV.
What is the most appropriate step in this patient’s management?
Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy
Referral for colposcopy is correct because her 2nd repeat cervical smear sample was still hrHPV positive. Under the NHS cervical screening programme, this is an indication for colposcopy referral.
A 30-year-old woman is seen in the gynaecology department to discuss management of her newly diagnosed cervical cancer.
The staging of her disease revealed a small, malignant tumour, only visible on microscopy and 5mm wide.
The depth of the tumour was 2mm, without nodal or distant metastases, therefore classifying her disease as stage IA1.
She would like to maintain her fertility as she hasn’t started her family yet.
What is the most appropriate treatment option for this patient?
Women with stage IA cervical cancer may be considered for a cone biopsy with negative margins if they wish to maintain their fertility
Cone biopsy and close follow-up is correct. This woman’s cervical cancer is stage IA1 and she wishes to maintain fertility. So the best option for her is to have a cone biopsy with a close follow-up.
What is a trachelectomy?
(3)
Radical trachelectomy also called radical cervicectomy. This operation involves removing the cervix, the upper part of the vagina and surrounding supporting tissues.
Often lymph nodes in the pelvis are often removed to check whether cancer has spread beyond the cervix.
This option also preserves fertility but would only be indicated for IA2 tumours.
What is a risk factor for her condition?
Multiple pregnancy is a risk factor for hyperemesis gravidarum
Hyperemesis gravidarum associations
(4)
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
What is the prevalence of hyperemesis gravidum?
During which weeks is it most common?
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels.
Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*.
What are the referral criteria for nausea and vomiting in pregnancy?
(3)
Continued nausea and vomiting and is 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 with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
What is the hyperemesis gravidarum triad?
(3)
The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis hyperemesis gravidarum:
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Which scoring system is used to evaluate hyperemeis gravaridum?
Validated scoring systems such as the
Pregnancy-Unique Quantification of Emesis (PUQE) score
can be used to classify the severity of NVP.
Management of hyperemesis gravidarum (8)
Complications of hyperemesis gravidarum
(5)
Wernicke’s encephalopathy - is a neurological disease characterized by three main clinical symptoms: confusion, the inability to coordinate voluntary movement (ataxia) and eye (ocular) abnormalities
Mallory-Weiss tear -tear of the tissue of your lower esophagus.
Central Pontine Myelinolysis - In CPM, a rapid increase of sodium to correct low sodium levels (hyponatremia) damages nerve cells.
Acute Tubular Necrosis - kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure
fetal: small for gestational age, pre-term birth
A 24-year-old woman presents to the emergency department concerned that she cannot find the threads for her intra-uterine device and cannot get an appointment at her GP. She denies any pain, pyrexia, or atypical discharge. She has a regular 28-day menstrual cycle, and her last menstrual period was 7 days ago.
She has a transvaginal ultrasound as the threads are not visualised on speculum examination. The device is visualised and threads are found to be drawn back into the cervical canal. The threads are brought back into view. There is also noted to be a 4cm multiloculated cyst with strong blood flow in the right ovary.
What is the most appropriate action?
Complex (i.e. multi-loculated) ovarian cysts should be biopsied with high suspicion of ovarian malignancy
This patient has an incidental finding of a multiloculated cyst on the right ovary. Cysts that are found on ultrasound can be assessed using the IOTA criteria which help to classify cysts as being likely benign (‘B rules’) or malignant (‘M rules’). M rules include:
- Irregular, solid tumour.
- Ascites.
- At least 4 papillary structures.
- Irregular multilocular solid tumour with largest diameter ≥100 mm.
- Very strong blood flow.
Cysts that are found on ultrasound can be assessed using which criteria?
Which features indicate malignancy?
(5)
IOTA criteria
M rules include:
Irregular, solid tumour.
Ascites.
At least 4 papillary structures.
Irregular multilocular solid tumour with largest diameter ≥100 mm.
Very strong blood flow.
What are the types of ovarian cysts? (2)
Benign ovarian cysts - extremely common.
Complex (i.e. multi-loculated) - ovarian cysts should be biopsied to exclude malignancy.
A 22 year-old woman and her male partner present to their GP as they been unsuccessfully trying to conceive for 4 months.
Her periods have been regular and there is no obvious cause in her history.
What is the most appropriate next step in her management?
Address how the couple are having sexual intercourse and reassure the patient
A healthy couple can expect to take up to one year to conceive. Investigations are therefore usually performed after one year of regular attempts to conceive. It may however be prudent to address any mechanical reasons that are preventing the couple from conceiving, hence the sexual intercourse history.
Key conception counselling points
(4)
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
Conception statistics
(3)
Infertility affects around 1 in 7 couples.
Around 84% of couples who have regular sex will conceive within 1 year
92% will conceive within 2 year
Causes of infertility
(5)
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%
Basic investigations for infertility (2)
Basic investigations
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
A 37-year-old woman who is 15 weeks pregnant presents with abdominal pain.
The pain came on gradually and has been getting progressively worse for 3 days.
She is nauseated and has vomited twice this morning. She has a temperature of 38.4ºC, blood pressure is 116/82 mmHg and heart rate is 104 beats per minute.
The uterus is palpable just above the umbilicus and a fetal heart beat is heard via hand-held Doppler.
On speculum examination the cervix is closed and there is no blood.
She has a history of menorrhagia due to uterine fibroids.
This is her first pregnancy.
What is the most likely diagnosis?
What is the management?
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration.
This usually presents with low-grade fever, pain and vomiting.
The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Associations of uterine fibroids
(2)
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
Management of menorrhagia secondary to fibroids
(9)
- Management of menorrhagia secondary to fibroids
- levonorgestrel intrauterine system (LNG-IUS)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity
- NSAIDs e.g. mefenamic acid
- tranexamic acid
- combined oral contraceptive pill
- oral progestogen
- injectable progestogen
Treatment to shrink/remove fibroids
(5)
medical
- GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
- ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxicity
surgical
- myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
- hysteroscopic endometrial ablation
- hysterectomy
uterine artery embolization
A 17-year-old woman presents to general practice concerned that she has never had a menstrual period. On examination, she has minimal axillary or pubic hair and has underdeveloped breast tissue for her age. She is of normal height and weight. She has no noted past medical history.
A beta-HCG test is negative.
The general practitioner orders some blood tests, as shown below.
FSH - High
LH - High
What is the most likely cause of her amenorrhoea?
Gonadal dysgenesis
Raised FSH/LH in primary amenorrhoea - consider gonadal dysgenesis (e.g. Turner’s syndrome)
The above scenario describes a young woman presenting with primary amenorrhoea (given that she has never had a menstrual period before), in addition to underdevelopment of secondary sexual characteristics. Given her raised FSH and LH levels, the most likely cause of her primary amenorrhoea is gonadal dysgenesis.
Gonadal dysgenesis is a congenital condition in which the gonads are atypically developed, and may be functionless. This can be seen in syndromes such as Turner’s syndrome. Due to the abnormal gonads, androgens are not produced in response to FSH and LH from the anterior pituitary gland. This results in the underdevelopment of secondary sexual characteristics, and in females will cause primary amenorrhoea. FSH and LH levels will continue to remain high due to the absence of negative feedback from oestrogen on the hypothalamus.
Amenorrhoea types
Primary:
Seconary:
Amenorrhoea may be divided into:
primary:
- defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development),
- or by 13 years of age in girls with no secondary sexual characteristics
secondary:
- cessation of menstruation for 3-6 months in women with previously normal and regular menses,
- or 6-12 months in women with previous oligomenorrhoea
Primary amenorrhoea causes
(6)
gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
Secondary amenorrhoea (after excluding pregnancy)
(7)
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Features of Vaginal candidiasis
(4)
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
What are satellite lesions?
generally to describe smaller lesions near the edges of a principal lesion.
A 51 year-old woman presents to her GP with a nine month history of urinary incontinence. Examination of her abdomen is normal.
Urinalysis is normal.
A diagnosis of detrusor muscle over-activity is made and the patient is commenced on oxybutynin.
What is the mechanism of oxybutynin?
It competitively inhibits the postganglionic type 1, 2 and 3 muscarinic receptors.
The contraction of the detrusor muscle is controlled by muscarinic cholinergic receptors, with oxybutynin being a direct antimuscarinic agent.
By contrast, serotonin and noradrenaline are important for sympathetic control, which intrinsically reduces detrusor muscle activity.
How is urge incontinence initially managed?
Which 3 antimuscarinic drugs are used?
Which drug should be avoided in “frail older women”?
Which drug should be used instead in “frail older women”?
(3)
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinics are first-line
- NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
- Immediate release oxybutynin should, however, be avoided in ‘frail older women’
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
How is stress incontinence managed?
(4)
pelvic floor muscle training
- NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
- a combined noradrenaline and serotonin reuptake inhibitor
- mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction
Types of urinary incontinence (3)
Medical management of miscarriages:
(5)
‘Using tablets to expedite the miscarriage’
Vaginal misoprostol - Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
Should be given with antiemetics and pain relief
Surgical management of miscarriages:
(3)
Surgical management
‘Undergoing a surgical procedure under local or general anaesthetic’
The two main options are
- vacuum aspiration (suction curettage)
- surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
Investigation for women who present with postmenopausal bleeding
(3)
Investigation
women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
Management of endometrial cancer
(3)
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy.
Patients with high-risk disease may have post-operative radiotherapy
progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
Vaginal candidiasis management
(3)
options include local or oral treatment
NICE Clinical Knowledge Summaries recommends:
- oral fluconazole 150 mg as a single dose first-line
- clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
- If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
What medication is most likely to have caused this side effect?
Which condition is she suffering from?
Gonadotrophin therapy is associated with an increased risk of ovarian hyper stimulation syndrome
Typical presentation of ovarian hyperstimulation syndrome is with:
- ascites
- vomiting and diarrhoea
- high haematocrit
Letrozole mechanism of action
aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
Clomiphene citrate mechanism of action
(2)
Selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens.
This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development
