Day 6 Gynaecology Flashcards
A 24-year-old woman presents to the GP with vaginal bleeding.
She is 5-weeks pregnant.
She reports no abdominal pain, no dizziness, no shoulder tip pain.
There are no clots and she has passed less than a teaspoon amount of blood.
She has no history of ectopic pregnancy.
On examination, her heart rate is 85 beats per minute, blood pressure is 130/80 mmHg and her abdomen is soft, non-tender.
According to current NICE CKS guidance, what is the next most appropriate management step?
(2)
Pregnant women who are < 6 weeks gestation and present with vaginal bleeding and no pain can be managed expectantly
Monitor expectantly and advise to repeat pregnancy test in 7 days. If negative, this confirms miscarriage. If positive, or continued or worsening symptoms, refer to the early pregnancy assessment unit
A 28-year-old woman attends the early pregnancy assessment unit at 7 weeks gestation due to heavy vaginal bleeding.
Which investigation was used to confirm miscarriage?
After 14 days of expectant management the patient attends for follow up. She describes ongoing light vaginal bleeding.
There are no signs of ectopic pregnancy and she is haemodynamically stable. Ultrasound scan confirms incomplete miscarriage.
What is the most appropriate next step?
1. Ultrasound confirms an intra-uterine miscarriage.
2. Medical management of a miscarriage involves giving vaginal misoprostol alone
Long-term complications include of PCOS?
PCOS is a common disorder, which is often complicated by chronic anovulation and hyperandrogenism.
Long-term complications include:
- Subfertility
- Diabetes mellitus
- Stroke & transient ischaemic attack
- Coronary artery disease
- Obstructive sleep apnoea
- Endometrial cancer
Jennifer is a 34-year-old woman presenting with pelvic pains. Her pelvic pain is excruciating and is not responding to paracetamol. The pain began 4 months ago and her pain starts approximately 4 days prior to her the start of menstruation. Her pain gets worse as she approaches the start of menstruation and gradually improves once her menstruation stops. She also notes that she is changing her menstrual pads every 4 hours.
She began her menstruating at the age of 15 years and her cycles tend to be fairly regular. On her previous cycles, she only had mild pains that settled down with paracetamol. Her cycles had not been heavy. She is sexually active but she uses a condom during sexual intercourse.
Pelvic examination is unremarkable with no abnormalities seen on speculum examination. Her abdomen examination was unremarkable.
What would be the most appropriate step in her management?
What is the diagnosis?
Prescribe ibuprofen and refer to gynaecology for further investigation
All patients with secondary dysmenorrhoea need to be referred to gynaecology for investigation
A 20-year-old female is admitted with acute abdominal pain.
Examination reveals a diffusely tender abdomen.
During laparoscopy multiple fine lesions are noted between her liver and abdominal wall, her appendix appears normal.
What is the most likely diagnosis?
Hepatic adhesions are specific for Fitz-Hugh-Curtis syndrome.
The symptoms in the question are not enough to make a diagnosis and it is, therefore, the lesions that give the diagnosis, as they would not be present in any of the other options. It is a complication of PID causing inflammation of the liver capsule forming ‘Glisson’s Capsule’.
A 35-year-old woman reports heavy periods.
She has always had this problem, since menarche aged 12.
Although she has never spoken to a doctor about this, she finally feels ‘enough is enough’ and wants to address it.
She has regular periods with a 28-day cycle.
She typically bleeds for 7 days, and for 4 of those she experiences blood clots and ‘flooding’.
The patient is nulliparous, and does not want children. Currently, she is in a sexual relationship, reliant on condoms.
Her past medical history and family history are unremarkable.
You arrange blood tests and a pelvic ultrasound scan which are unremarkable.
What is the most appropriate management option?
What is the second-most appropriate option?
Menorrhagia - intrauterine system (Mirena) is first-line
Tablet medications, such as the progesterone-only pill or combined oral contraceptive pill can be used to treat menorrhagia, but they are not first-line.
The intra-uterine system (IUS) should be offered as the first-line treatment for menorrhagia. It is highly-effective at stopping bleeding altogether, requires once-only intervention to establish (i.e. insertion) and offers a very reliable form of contraception.
A 28-year-old woman with polycystic ovarian syndrome consults you as she is having problems becoming pregnant.
She has a past history of oligomenorrhea and has previously recently stopped taking a combined oral contraceptive pill.
Despite stopping the pill 6 months ago she is still not having regular periods.
Her body mass index is 28 kg/m^2.
Apart from advising her to lose weight, which one of the following interventions is most effective in increasing her chances of conceiving?
Infertility in PCOS - clomifene is typically used first-line
Whilst metformin has a role in the management of infertility it should be used second-line to anti-oestrogens such as clomifene. Similar questions to this often appear in which clomifene is not an option, in this case metformin is clearly the right answer.
A 66-year-old woman presents to her general practitioner with a six month history of poorly-localised abdominal discomfort and a constant feeling of bloatedness.
Abdominal and pelvic examination is normal.
The GP was initially concerned about bowel malignancy and referred her for colonoscopy, which ruled this out.
The consultant gastroenterologist who performed the colonoscopy suggested that her symptoms might indicate irritable bowel syndrome.
The patient has no history of digestive disorders.
What should the GP’s next step be?
NICE guidelines state that serum CA125 should be performed if a woman - especially if aged 50 years old or over - has any of the following symptoms on a regular basis:
- abdominal distension or ‘bloating’
- early satiety or loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency
A 29-year-old woman attends the fertility clinic with her partner. She has a history of regular 35-day menstrual cycles.
Which investigation is the best measure of ovulation?
The follicular phase of the menstrual cycle can be variable, however, the luteal phase (after ovulation) remains constant at 14 days.
The serum progesterone level will peak 7 days after ovulation has occurred. Therefore, in a 35-day cycle the follicular phase will be 21 days (ovulating on day 21), luteal phase 14 days. Therefore, the progesterone level will be expected to peak on day 28 (35-7).
A 51-year-old woman attends clinic with worsening perimenopause.
Since the previous year her periods have become irregular, and has also been suffering from low mood, night sweats and hot flushes.
The patient would like to undergo treatment to help with her symptoms, but is concerned about the risk of breast cancer.
Which treatment is most likely to increase her risk of breast cancer?
HRT: adding a progestogen increases the risk of breast cancer
Oestrogen-only HRT does not appear to increase the risk of breast cancer if used for less than 10 years. However oestrogen-only HRT increases endometrial cancer risk and should generally be avoided unless the patient has undergone hysterectomy.
A 34-year-old woman attends clinic feeling generally unwell.
Her abdomen has become uncomfortable and distended over the last 2 days, and she is suffering from loose stools.
She also feels dyspnoeic on exertion.
On examination all observations are within normal range and there is generalised abdominal tenderness with no guarding.
The patient is undergoing fertility treatment and the previous week was injected with gonadorelin analogue.
Given the above history, which of the following is the most likely diagnosis?
Ovarian hyperstimulation syndrome is a potential side-effect of ovulation induction
OHSS often presents with gastrointestinal symptoms such as:
- nausea
- vomiting
- abdominal pain
- bloating
- diarrhoea
Other features of OHSS include:
- shortness of breath
- fever
- oliguria
- peripheral oedema
OHSS presenting features
OHSS often presents with gastrointestinal symptoms such as:
- nausea
- vomiting
- abdominal pain
- bloating
- diarrhoea
Other features of OHSS include:
- shortness of breath
- fever
- oliguria
- peripheral oedema
Life-threatening, and can result in complications:
- such as thromboembolism
- dehydration
- pulmonary oedema
- acute kidney injury (AKI)
A 50-year-old lady is undergoing staging for her confirmed ovarian cancer. Upon scanning, it is found that the tumour has spread beyond the ovary, but is still within the pelvis.
What stage is her cancer at?
Stage 2
Stage 1 = Tumour confined to ovary
Stage 2 = Tumour outside ovary but within pelvis
Stage 3 = Tumour outside pelvic but within abdomen
Stage 4 = Distant metastasis
A 40-year-old woman presents to her GP with a history of menorrhagia, she notes that more recently her periods last 10 days and are very heavy.
In addition to this, she has no history of weight loss, her recent sexual health screen was negative and her examination findings are normal. She has two children and has completed her family.
What is the first line treatment in this patient?
Menorrhagia - intrauterine system (Mirena) is first-line
In this case, the patient has completed her family, in addition to this there is no suggestion in the information provided in the question that she may have an underlying pathology responsible for her menorrhagia.Therefore she is a candidate for pharmaceutical therapy.NICE CKS states that the Mirena coil is first line management in women whom long term contraception with an intrauterine device is acceptable.
A 34-year-old woman has an unplanned and unwanted pregnancy. She has two children and also had a miscarriage 5 years ago.
Her past medical history includes subclinical hypothyroidism but she is otherwise fit and well.
An ultrasound scan is done and shows an intrauterine pregnancy and estimates her gestation as 7 weeks.
She has been counselled on her options and decides she wants a medical termination of pregnancy.
What medical treatment would she be offered?
Oral mifepristone and vaginal prostaglandins is correct.
This woman is only 7 weeks pregnant, which makes a medical termination more suitable than a surgical one as it has lower failure rates.
Women in the UK are given mifepristone followed by one or more doses of prostaglandins (usually vaginal misoprostol). Medical terminations are appropriate at any gestation, but the dosing schedule and location of administration can vary e.g. home vs clinic.
Current law around abortion UK (1)
Key points (2)
The current law surround abortion is based on the 1967 Abortion Act. In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks*
Key points
two registered medical practitioners must sign a legal document (in an emergency only one is needed)
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
Methods of abortion and dates:
(3)
The method used to terminate pregnancy depend upon gestation
less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
A 37-year-old female presents to her GP complaining of dyspareunia, irregular menstrual cycles for 6 months until she recently missed 3 periods.
She also complains of sudden hot flushes for the past 3 months.
Her only history of note includes previous breast cancer for which she was on chemotherapy and radiation.
Examination reveals no abnormalities and her pregnancy test is negative.
What is the most likely diagnosis?
Premature ovarian failure
Premature ovarian failure (POF) is defined as the cessation of menses for 1 year before the age of 40. It can, however, be preceded by irregular menstrual cycles. Common symptoms include hot flushes, vaginal dryness, vaginal atrophy, sleep disturbance, and irritability.
Strong risk factors for POF include a positive family history, exposure to chemotherapy/radiation and autoimmune disease.
Strong risk factors for POF include:
(3)
Strong risk factors for POF include:
- a positive family history
- exposure to chemotherapy/radiation
- autoimmune disease.
A 78-year-old woman presents with post-menopausal bleeding. She has had multiple episodes over the past 8 months.
She has to wear sanitary pads due to the bleeding, and says it can be quite heavy but denies any clots.
She does not have any bowel or urinary symptoms. She denies weight loss and is otherwise well.
She went through menopause at the age of 49 years and took hormone replacement therapy to reduce symptoms of hot flushes and mood swings for 3 years.
She has 1 child who was born by spontaneous vaginal delivery 50 years ago.
There is no family history of any gynaecological problems. What is the most likely diagnosis?
Endometrial cancer
Risk factors for endometrial cancer include …
- Increased age
- Nulliparity
- Unopposed oestrogen therapy
- Early onset of menarche and late onset of menopause
- Obesity
In women presenting with postmenopausal bleeding (PMB), we must rule out endometrial cancer. A speculum examination should first be performed to look for any obvious abnormalities and ultimately endometrial biopsy and hysteroscopy should be carried out in women over 40 years of age in order to diagnose endometrial cancer.
A 50-year-old lady is commenced on tamoxifen for the treatment of an oestrogen receptor positive breast cancer.
Which malignancy is associated with tamoxifen use?
Endometrial cancer - risk factors include: tamoxifen
Tamoxifen is an oestrogen receptor antagonist in breast tissues. However, at other sites, such as the endometrium it may act as an agonist. Hence the reason for increasing risk of endometrial cancer.
A 21-year-old woman visits her GP, two weeks after having a medical termination of pregnancy.
She took a urine pregnancy test this morning and is worried that the termination was unsuccessful as the urinary pregnancy test is still positive.
When should her pregnancy test have become negative if the termination has been successful?
Negative 2 weeks from today
Termination of pregnancy: Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
A 45-year-old woman attends the GP surgery as she is experiencing heavy vaginal bleeding.
Her cycle is regular and there is no intermenstrual or postcoital bleeding. She has no significant gynaecological history, and takes no regular medications. She does not have a regular partner, and uses condoms for contraception.
She does not want children. What is the most appropriate first line treatment?
Menorrhagia - intrauterine system (Mirena) is first-line
The combined oral contraceptive pill, tranexamic acid, and mefenamic acid may all provide symptomatic relief but would not be the first line treatment.
A 45-year-old lady who has never had a male partner, has just moved to the UK with her female partner.
She has registered as a new patient at your practice and during the new patient assessment she asks you how often she will be called for cervical screening.
She has no indications to be screened more frequently than the routine recall in the UK.
You advise her that she will be called for cervical screening:
Every 3 years
A 43-year-old woman presents as she has not had a period for the past six months.
She is concerned that she may be going through an ‘early menopause’.
How is premature ovarian failure defined?
(3)
The onset of menopausal symptoms
and
elevated gonadotrophin levels
before the age of 40 years
A 32-year-old female presents with lower abdominal pain.
She is 8 weeks pregnant.
A simple ovarian cyst is evident on transvaginal ultrasound. An 8-week intrauterine pregnancy is also confirmed.
What is the most appropriate management of the cyst?
(3)
Reassure patient that this is normal and leave the cyst alone
In early pregnancy, ovarian cysts are usually physiological - known as a corpus luteum.
They will usually resolve from the second trimester on wards.
Reassurance is important in the above situation as maternal anxiety is likely to be high.
Anxiety in pregnancy should be avoided wherever possible in order to avoid adverse outcomes to both mother and foetus.
A 33-year-old woman attends for a routine cervical smear.
A positive high-risk human papillomavirus (hrHPV) result prompts the GP to recall her inin how long for another smear?
At this repeat smear, the same result is demonstrated and so the GP recalls her in a further 12 months. At the second repeat smear (third overall), hrHPV is now negative.
The patient has no significant past medical history, nor family history.
What is the most appropriate course of action?
1. 12 months
2. Repeat smear in 3 years
Cervical cancer screening: if 2nd repeat smear at 24 months is now hrHPV -ve → return to routine recall
A 36-year-old with menorrhagia is investigated and found to have a 1.5 cm uterine fibroid which is not distorting the uterine cavity.
She has three children and wants ongoing contraception, but is using only condoms at the moment.
What is the most appropriate initial treatment for her menorrhagia?
IUS/Mirena
If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)
You are prescribing hormone replacement therapy (HRT) for a 48-year-old woman who is fit and well but is experiencing severe menopausal symptoms. She wants to know about the risks and benefits of the different types of HRT.
Which of the following answers is correct regarding the risk of cancer with different HRT preparations?
HRT: adding a progestogen increases the risk of breast cancer
A 17-year-old girl who is nine weeks pregnant has a surgical termination of pregnancy. She feels well a few hours after the procedure. Which of the following risks is most common following a TOP?
Infection can happen in up to 10% of TOP cases.
Antibiotics are given to reduce the risk of infection. Signs and symptoms of an infection are unlikely to occur so soon after the procedure.
A 34-year-old woman from Chad presents with continuous dribbling incontinence after having her 2nd child.
Apart from prolonged labour the woman denies any complications related to her pregnancies.
She is normally fit and well.
What is the most likely diagnosis?
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.
A 35 year-old lady attends the GP practice complaining of heavy painless periods which are interrupting with her lifestyle and causing her distress at work.
She is currently in the process of trying for a family.
The most suitable option is:
(2)
Tranexamic acid is the first-line non-hormonal treatment for menorrhagia
As her periods are painless, there is no need for her to take mefenamic acid, an NSAID, which is also not recommended in pregnancy.
A 34-year-old lady presents to the gynaecology department complaining of heavy, painful periods, and difficulty conceiving.
She is concerned, as she and her husband would like to start a family soon.
On further investigation, an ultrasound scan reveals a 4.5cm submucosal uterine fibroid.
Which one of the following treatments is most appropriate to treat her fibroids?
The only effective treatment for large fibroids causing problems with fertility is myomectomy if the woman wishes to conceive in the future
A 21-year-old student attends your general practice clinic to discuss a recent positive pregnancy test result.
Following lengthy discussion with her partner and family has decided that she wants an abortion.
You find the consultation particularly difficult, as you do not personally agree with abortion and are currently caring for several patients who have been struggling to conceive.
What should you do?
Discuss her options and explain that due to your personal beliefs, you will arrange for her to see another doctor in this instance who will make necessary arrangements
A 28-year-old woman had attended for her routine cervical smear which is performed without any issues.
The GP receives the result of smear that it was positive for high-risk HPV but there was no evidence of cytological abnormalities.
What is the most appropriate next step?
Repeat cervical smear in 12 months
Cervical cancer screening: if sample is hrHPV +ve + cytologically normal → repeat smear at 12 months
Nausea and vomiting in pregnancy: admission should be considered in cases of ketonuria and/or weight loss despite use of oral anitemetics
A 45-year-old pregnant asylum seeker who has just arrived to the UK from Syria presents to the general practitioner for their first scan at 22 weeks.
An ultrasound scan identifies a ‘snow-storm’ appearance with no foetal parts.
What is the most likely diagnosis?
Hydatidiform mole - ‘snow storm’ appearance on ultrasound scan
A complete hydatidiform mole occurs when all of the genetic material comes from the father.
There will be no foetal parts present and snowstorm appearance is seen on ultrasound.
Vaginal bleeding early in pregnancy is often the presenting feature.
A 37-year-old female has a cervical smear test at her general practice, as part of the UK cervical cancer screening programme. The results come back as hrHPV positive. Cytology shows normal cells.
In accordance with current guidelines, the cervical smear test is repeated 12 months later, which is still hrHPV positive. Cytology is repeated, which again shows normal cells.
A cervical smear test performed a further 12 months later, is still hrHPV positive, and cytology remains normal.
What is the most appropriate action?
Colposcopy
Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy
A 80-year-old woman presents with a 5 month history of urinary incontinence when she coughs or sneezes. She has tried pelvic floor exercises for the last 3 months but has not found them helpful. She is extremely worried about having surgery and would rather have medical treatment for her incontinence.
What kind of incontinence does she have?
What is the first-line drug therapy to treat her presentation?
What would not be prescribed?
Duloxetine may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention
Oxybutynin is an anticholinergic drug used for the treatment of urge incontinence or symptoms of detrusor overactivity. Oxybutynin is contraindicated in frail, older women at risk of deterioration in their health.
Mirabegron is used in patients with urge incontinence who can not tolerate antimuscarinic/anticholinergic drugs. It is a beta-3 adrenergic agonist which relaxes the bladder.
A 26-year-old woman is referred to the gynaecology clinic with severe dysmenorrhoea and a clinical history suggestive of endometriosis.
She has tried paracetamol and ibuprofen with little benefit.
She is not planning to start a family for the next couple of years.
What is the recommended first-line management, providing that there are no contraindications?
Combined oral contraceptive pill (COCP)
Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE published guidelines in 2017:
- 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
Second-line treatments for endometriosis
(3)
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:
- GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
- drug therapy unfortunately does not seem to have a significant impact on fertility rates
- surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility