General gynaecology Flashcards

Question

What is the medical treatment for menorrhagia?

Answer 1

* Tranexamic acid: anti fibrinolytics which competitively blocks the conversion of plasminogen to plasmin thereby reducing fibrinolysis. Taken only during menses rather than daily usually from day 1 of menstruation to the end of heaviest flow. * Mefenamic acid (ponstan): NSAIDs which decreases synthesis of prostaglandings including PGE2 and PGF2a in the endometrium leading to vasoconstriction and reduced bleeding * COC pills: helps control mentrual cycle which is beneficial for irregular periods. Additional contraceptive effects * Progestogen (norethisterone): indicated in patients with contraindications to combined pills. This is not a form of contraceptive * Levonorgestrel releasing intrauterine system (Mirena)

Answer 2

Hysteroscopic endometrial ablation * Only indicatesd for menorrhagia due to dysfunctional uterine bleeding * Absence of large uterine fibroid or coexisting symptomatic adenomyosis or endometriosis in view of potentially worsening of dysmenorrhea after ablation. * Preop endometrial preparation with GnRH agonist (e.g. IM leuprolide) to thin the endometrium to facilitate tissue destruction * Preop cervical preparation with vaginal misoprostol which is a cervical riepning agent to dilate the cervix and avoid complications related to difficult passage of hysteroscope through cervical canal Benefits of procedure * 40-45/100 have lighter period, 40-45/100 stop menstruation, 4-10/100 have persistent or recurrent abnormal periods Consequences: pregnancy is contraindicated after endometrail ablation and is recommended only for women with completed family and definitely sure they no longer wish to have more children Procedure * GA/RA * Uterine cavity distended with glycine (conduction agent of monopolar) * Dilatation of cervix and passage of resectoscope with roller ball electrode (endometrial ablation) or shaved off with a cutting loop (endometrial resection) under hysteroscopic control Complications * Frequent complications: bleeding, uterine cramps, mild fluid overload * Serious complicatuions: hypoNa (absorption of glycine leading to fluid overload and electrolyte disturbances), cervical tear, failure to gain entry into uterine cavity, uterine perforation, pelvic infection, recurrence Hysterectomy: definitive treatment for uterine bleeding --> no fertility desires--> high patient satisfaction because it is curative and no drug related side effects

Answer 3

Primary dysmenorrhea: presence of recurrent, crampy, lower abd pain that occurs during menses in the absence of demonstratable disease that could account for these symptoms Secondary dysmenorrhea: occurs in women with an organic or psychological causes that can account for their symptoms such as adenomyosis, endometriosis or fibroids

Answer 4

* Adenomyosis: usually occurs in multiparous women, presents with painful vaginal bleeding (i.e. with dysmenorreha), dyspareunia and regularly enlarged uterus * Endometriosis * Submucosal fibroids: usually happen in primiparous or multiparous women, presents with painless vaginal bleeding and irregularly enlarged, non tender uterus. Fibroids are usually not painful and therefore dysmenorrhea is not typical. Submucosal fibroids can sometimes cause dysmenorrhea during attempted expulsion of submucosal fibroids (when it becomes fibroid polyp and when uterus tries to expel the fibroid polyp) * Chronic PID * Ovarian cysts * Asherman syndrome/intrauterine or pelvic adhesions: intrauterine adhesions (synechiae) caused by endometrial infection or currettage after miscarriage or abortion with partial or complete obliteration of uterine cavity

Answer 5

* Prostaglandins released from endometrial sloughing at the beginning of menses causes vasoconstrictions and myometrial contractions * Contractions are non rhythmic or incoordinate, occuring in high frequency and result in high intrauterine pressures * When intrauterine pressure exceeds arterial pressure, uterine ischemia develops and anaerobic metabolites accumulate which stimulates type C pain neurons resulting in pain

Answer 6

* Pain over lower abd or suprapubic area radiating down to anterior aspects of thigh * Cramping and intermittently intense but may be a continuous dull ache * Onset at 1-2 days before menses or on the day of menses * Lasts for 2-3 days * Usually develops within first 2 years of menarche * Associated with nausea, vomiting, diarrhea, headache, dizziness and fatigue * Resolution of symptoms with NSAIDs

Answer 7

* Age of onset: onset after age 25 as secondary dysmenorrhea usually develops later in reproductive age. Occurs in first few cycles of menarche: congenital uterine outlet obstruction). Late onset without a history of previous dysmenorrhea Clinical features * AUB: menorrhagia/oligomenorrhea/intermenstrual bleeding * Non midline pelvic pain * Presence of dyspareunia * Progression in symptom severity * Absence of nausea, vomiting, diarrhea, headache, dizziness and fatigue Treatment related: little/no response to NSAIDs or hormonal contraception or both

Answer 8

Amenorrhea: absence of menses and can be transient, intermittent or permanent condition resulting from dysfunction of hypothalamus, pituitary, ovaries, uterus or vagina Cryptomenorrhea: hidden menstruation --> endometrial shedding occurs but menstrual loss cannot escape due to blockage of parts of lower genital tract usually due to congenital malformations.

Answer 9

* Primary amenorreah: absence of menses by age 14 with failure to grow properly or develop secondary sexual characteristics. Absence of menses by age 16 in the presence of normal growth and normal secondary sexual characteristics * Secondary amenorrhea: absence of menses for >3 consecutive cycles (total of at least 3 of the previous cycle intervals) in women who have menses before or. Absence of menses for >6 months in women who have menses before * Oligomenorrhea: cycle lengths >6 weeks in most of the cycles or number of menses <5 per year

Answer 10

Hypothalamus * Functional hypothalamic amenorrhea: stress, anorexia, nervosa, weight loss, excessive excercise, severe illness * Idiopathic hypogonadotrophic hypogonadism: isolated GnRH deficiency * Kallmann syndrome: isolated GnRH deficiency + anosmia * Irradiation of sellar tumors * Traumatic brain injury Pituitary * Hyperprolactinemia: uncommon cause of primary amenorrhea (usually secondary) * Pituitary tumors: craniopharyngioma, meningioma Ovary * Fragile X syndrome * Turner syndrome: female with classical karyotype 45, XO. Gonadal dysgenesis with oocytes and follicles undergo apoptosis and hence no ovarian estrogen secretion * Swyer syndrome (46, XY, gonadal dysgenesis): pure gonadal dysgenesis. Male genotype with female phenotype. Fibrous streak gonad cannot secrete anti-Mullerian hormone resulting in persistent mullerian structures. Uterus and fallopian tubes are normally formed but gonads not functional * Polycystic ovarian syndrome (PCOS): ovulatory dysfunction and hyperandrogenism. Rotterdam criteria: oligo-ovulation or anovulation, hyperandrogenism (clinical/biochemical), polycystic ovaries (sonographic) Uterus/outflow tract * Imperforate hymen * Transverse vaginal septum * Vaginal agenesis (MRKH syndrome): agenesis or hypoplasia of Mullerian duct system (also known as Mullerian agenesis). * Androgen insensitivity syndrome (testicular feminization syndrome): X linked recessive disorder with 46, XY karyotypine. Male genotype with female phenotype. External genitilia is female in appearance but tetes may be palpable in the labia or inguinal area. Undescended tests along normal cource of descent. Testes produce Mullerian inhibiting substance which causes regression of all Mullerian structures including fallopian tubes, uterus and upper third of the vagina. Normal breast development occurs (peripheral conversion of androgen to estrogen). Little or no pubic and axillary hair (requires androgen to mature). Others: constitutional delay of puberty

Answer 11

* Pregnancy test: measurement of serum/urine B-hCG level (always rule out pregnancy as 1st step) * TFT: TSH to detect hypothyroidism or hyperthyroidism. Hypothyroidism as a cause of hyperprolactinemia should be ruled out * Serum prolactin level: stress, sleep, excercise, intercourse and meals can cause serum prolactin transiently and thus prolactin level should be repeated once before pituitary MRI is ordered. Screening for hypothyroidism is necessary since it will lead to hyperprolactinemia * Serum FSH and estradiol (E2) level: assessment of estrogen status to interpret with FSH values and guide therapy in hypoestrogenic patients which require estrogen therapy for preventing bone loss. Decreased E2 and increased FSH level: dx of ovarian insufficiency can be made if serum FSH >25IU/L on 2 occasions separates by >4 weeks apart. Indicates hypergonadotrophic hypogonadism such as primary and secondary ovarian insufficiency Decreased E2 and FSH level: indicates hypogonadotrophic hypogonadism such as hypothalmaic or pituitary disorders * Progesterone withdrawal test (MPA): progestational challenge with MPA 10mg/day for 7 days. Assessment of estrogen status to interpret with FSH values and guide therapy in hypoestrogenic patients which requires estrogen therapy for preventing bone loss. Presence of withdrawal bleeding = endogenous estrogen production + dx of anovulation can be made. Absence of withdrawal bleeding = hypoestrogenism (OR) outflow tract disorder * Combined estrogen and progesterone withdrawal test (CEPWT): give COCs to check for withdrawal bleeding. Absence of withdrawal bleeding = outflow tract disorders (or) non functioning endometrium (asherman syndrome) * Karyotyping: vaginal (mullerian) agenesis)MRKH) = 46XX (arrange USG urinary tract to look for associated abnormalities). Turner syndrome = 45XO (monosomy X). Swyer sndrome = 46XY (advise gonadectomy due to risk of maignant transformation. Androgen insensitivity syndrome (testicular feminization syndrome): 46XY * Serum LH level: increased LH: FSH ratio in PCOS although it is no longer 1 of the diagnostic criteria * Serum testosterone, DHEAS and 17-hydroxyprogesterone level: patients with hirsutism should have blood taken for serum testosterone and 17-hydroxyprogesterone. Performed in the presence of clinical hyperandrogenism for biochemical confirmation. Severe biochemical hyperandrogenism followed by checking erum 17-hydroxyprogesterone to rule out 21 hydroxylase deficiency (CAH). Suggests PCOS and androgen secreting tumors.

Answer 12

Menopause is the permanent cessation of menstrual period due to loss of ovarian follicular activity and is defined after 1 year of amenorrhea without any other obvious physiological or pathological cause Climacteric: critical period around menopause when ovarian function is gradually declining. Extended period that begins years before and lasting yearsr after menopause itself. Menopause transition or peimenopuase begins on average 4 years before the final menstrual period. * Time of decreasing estrogen level and elevated FSH deu to hypothalamic-pituitary hyperactivity from the lack of negative feedback by follicular hormones.

Answer 13

* Natural menopause * Premature menopause: defined as menopause that occured before 40 years old. Referred to as primary ovarian insufficiency (premature ovarian failure) * Surgical menopause: surgery that involves removal of ovaries (oophorectomy)

Answer 14

Beneficial effects * Improvement in lipid profiles (decreased LDL and increased HDL) * Enhanced endothelial dysfunction * Improved insulin sensitivity Potential AE of estrogen * Increase in serum triglyerides level * Prothrombotic effect including reduction in serum fibrinogen, factor 7 and antithrombin 3 * Proinflammatory effect including increase in hepatic synthesis of vascular inflammatory markers such as CRP

Answer 15

* Natural * Iatrogenic menopause: oophorectomy, hysterectomy, post chemo, post radio * Infection: TB, post mumps infection * Autoimmune disease

Answer 16

Normally retrospective dx

Answer 17

* Breast bloating and tenderness * Weight gain * Mood symptoms * Breakthrough bleeding

Answer 18

Uterine fibroid (leiomyoma)

Answer 19

Uterine artery embolization (general features) * Both uterine arteries blocked * Relieve adverse symptoms due to uterine fibroids which include menorrhagia and pressure symptoms: fibroid will shrink by 40-70% by volume. Menorrhagia and dysmenorrhea will improve in 80% of patients Indications * Symptomatic fibroids who might otherwise be advised to have surgical treatment * Symptomatic fibroids where multiple or difficult myomectomy will be encountered * Symptomatic fibroids but wish to avoid surgery or unwilling to receive blood transfusion * Women indicating desire for future fertility

Answer 20

* Asymptomatic uterine fibroids * Evidence of pregnancy * Evidence of uterine malignancy * Evidence of current genitourinary infection or malignancy * Evidence of pedunculated submucosal fibroids, dominant pedunculated serosal fibroids (attachment point < 50%) * Concurrent use of GnRH agonist (GnRHa) * History of allergic reaction to contrast medium and renal impairment * Refusal to undergo hysterectomy following peri- or post-UAE complications

Answer 21

* Patients should be fasted 6 hours prior to the procedure * Performed under LA and conscious sedation * Small catheter is inserted into femoral artery under the groin area and is directed deeply to each uterine artery in turn * Another smaller catheter (coaxial catheter) may be inserted through the original catheter * Small particles will be injected to block uterine arteries and their branches * Continuous monitoring of vital signs such as BP and pulse after procedures * Diet as tolerated (DAT) after the procedure and IV fluid can be stopped once diet waswell-tolerated * Allow mobilization after 6 hours 1st FU 2 weeks after the procedure. Second FU 3 months after MRI appointment. FU MRI will be arranged at 3 months after the procedure

Answer 22

Procedures * Under consious sedation * IV set and catheter inserted into urinary bladder * USG beam burns the uterine fibroid from outside the body * IV fluids and analgesics continued after procedure * Discharged from hospital when pain is under control and can eat adequately

Answer 23

* Hysteroscopic endometrial ablation Only indicated for menorrhagie due to dysfunctional uterine bleeding. Pregnancy contraindicated after endometrial ablation and is recommened only for women with completed family. * Myomectomy * Hysterectomy Total abd hysterectomy: **cutoff uterine size >12 weeks** Vaginal hysterectomy + laparoscopic assistance: **cutoff uterine size <12 weeks** Laparoscopic assisted vaginal hysterectomy (LAVH): upper part of uterus is freed laparoscopically, lower part of uterus is freed vaginally. QMH favors LAVH due to presence of expertise for VH. Adv: smaller bad wounds/less painful/fast post op recovery. Total laparoscopic hysterectomy (TLH): same as LAVH except lower part of the uterus is freed laparoscopically. Discussion for bilateral salpingectomy or bilateral salpingooopherectomy (BSO): considered if there is concomitant ovarian pathology. * Removal in premenopausal women requires hormonal therapy which has risks including CA breast, DVT and gallstones * Prophylactic BSO should be discussed with post menopausal women: 5 in100 chance of future operation for ovarian pathology. Removal of tubes reduces risk of CA ovary * Prophylactic bilateral salpingectomy should be discussed with premenopausal women

Answer 24

* Unable to get pregnant * No menstruation * Does not affect coitus * Does not affect hormonal status if ovaries are not removed but ovarian failure may occur 2-4 years earlier than natural menopause by unknown mechanism possibly due to impairment in ovarian blood supply.

Answer 25

* Presence of tissue resembling endometrial glands and stroma within the myometrium of the uterus * Ectopic endometrial tissues appear to induce hypertrophy and hyperplasia of surrounding myometrium resulting in diffusely enlarged uterus

Answer 26

Macroscopic appearance: grossly global enlargement of uterus. Spongy appearance with no cleavage plane Microscopic appearance: pathognomonic feature of adenomyosis is the presence of endometrial tissue within the myometrium at a distance of at least 1 power field

Answer 27

* Menorrhagia * Dysmenorrhea: pain due to bleeding and swelling of endometrial islands confined by myometrium * Chronic pelvic pain * Dyspareunia PE: uterine tenderness, uniformly diffusely enlarged uterus (often termed globular enlargement analogous to the concentric enlargement of the pregnant uterus) Biochemical tests: endometrial biopsy (indicated to rule out other causes of menorrhagia)

Answer 28

Transvaginal ultrasound (TVUS) MRI scan * Especially T2Wi Findings suggestive of adenomyosis * Asymmetric thickening of the myometrium (posterior myometrial typically thicker) * Increased myometrial heterogeneity * Loss of a clear endomyometrial border * Linear striations radiating out from the endometrium * Presnece of myometrial cysts Thickening of junctional zone of the myometrium * Junctional zone is a structurally distinct region (appearing as a dark band on T2W MRI) that separates the subendometrial myometrium from the outer myometrium * >12mm generally dx of hte disease and <8mm excluding adenomyosis

Answer 29

Dysmenorrhea +dyspareunia + infertility (+ chronic pelvic pain) Endometrial glands and stroma that occurs outside the uterine cavity Estrogen dependent, benign, inflammatory disease

Answer 30

 Nulliparity  Prolonged exposure to endogenous estrogen * Early menarche < 12 (Normal = 10 – 16) * Late menopause > 55 (Normal = 40 – 55) * Shorter menstrual cycles

Answer 31

* Proliferation and bleeding at different sites * Ectopic endometriotic tissues that induce inflammation, fibrosis and adhesions o Endometrial deposits and also leakage from chocolate cysts induce pelvic inflammation and adhesion formation between posterior uterus, ovaries, fallopian tubes and sometimes bowel and bladder o Adhesions are sometimes dense and obliterates POD causing bowel or ureteric obstruction

Answer 32

* NSAIDs: mefenamic acid (ponstan) is 1st line treatment of pelvic pain including endometriosis related pain. Avoid selective COX2 inhibitor in women who desire conception (can delay ovulation) * COC pills: 1st line treatment for endometriosis related pain --> microgynon 30 (ethinyl estradiol +levonorgestrel) --> suppress ovarian fuunction and hence endogenous estrogen production that supports the growth of endometriosis. * Progestin only treatment: indicated in patients who are unable to take or prefer to avoid COCs. Oral dienogest. IM medroxyprogesterone acetate (MPA) every 3 months * Gonadotrophin releasing hormone (GnRH) agonist + add back therapy (estrogen/progestogens --> reduces AE such as decreased BMD and menopausal symptoms). GnRH agonist binds to GnRH receptors which paradoxically decreases pituitary secretion of LH and FSH due to down regulation of GnRH receptors and pituitary desensitization. Suppress ovarian follicular growth and ovulation resulting in low levels of circulating estradiol and progesterone. e.g. leuprolide/goserelin/buserelin/nafarelin * Danazol: androgens that suppres HPO axis and decrease endogenous production

Answer 33

Physiological cyst: follicular cyst, corpus luteal cyst Pathological cysts: endometrioma, cystic component of benign or malignant neoplasm Cutoff size is 7cm for physiological cyst and any cysts >7cm are unlikely to be physiological. USG repeated in physiological cyst in around 4 months to allow cyst to resolve

Answer 34

RMI = U x M x CA125 Ultrasound status: scored 1 point for each of the following characteristics (multilocular cyst, solid areas, metastasis, ascites, bilateral lesion) U=0 (ultrasound score of 0 point), U = 1 (ultrasound score of 1 point), U=3 (ultrasound score of 2-5 points) Menopausal status. M= 1 (premenopaussal), M = 3 (post menopausal). Post menopausal is defined as no period for more than 1 year or a woman over 50 yearrs of age who has had a hysterectomy Interpretation: RMI >200 suggest the risk of ovarian malignancy and should be referred to a speciaist or gynaecological oncology team.

Answer 35

Oral contraceptives: suppression of HPO axis so new cyst will not form. However it does not help with regression of current cyst

Answer 36

Symptomatic relief Delineate nature of cyst Prevent complications such as bleeding, torsion and rupture Prevent malignancy

Answer 37

Laparotomy cutoff: cyst >10cm Laparoscopy cutoff: cyt <10cm

Answer 38

Premenopausal women: repeat USG scan in 4 months and discuss surgery Post menopausal women: repeat USG scan and CA125 in 4 months to look for interval change anf close case if the cyst size is static for 3 consecutive times

Answer 39

* Corpus luteal cysts are very vascularized and can bleed causing haemoperitoenum * Dermoid cysts (benign mature cystic teratoma) tend to have torsion since the cysts are heavy in weight and very mobile * Endometriotic cysts tends not to have torsion since there are dense adhesions * Endometriotic cysts tends to recur and may require post operative OC pills Ovarian torsion * Salvage of the torsed ovary by untwisting the vascular pedicle should be considered * Bivalve technique: opening of ovarian cortex with a linear incision to salvage a torsed ovary. Decreases intraovarian pressure caused by venous occlusion * Oophorectomy: indicated with ovaries with severe necrosis and non viable appearance Rupture of ovarian cyst: release of cystic fluid/blood that may irritate the peritoneal cavity. Dermoid cyst contains sebaceous fluid, hair, fat, bone or cartilage and rupture of these cysts results in severe peritoneal irritation. Must exclude ruptured ectopic pregnancy which has similar clinical presentation Management: expectant management in uncomplicated rupture of cyst in the absence of haemodynamic instability, blood loss, fever and leukocytosis. Laparoscopic surgery for ongoing hemorrhage that needs to be controlled or haemodynamic instability.

Answer 40

Oligo-amenorrhea + infertility +hirsutism + obesity

Answer 41

Gonadotrophin stimulation is required for ovarian steroidogenesis GnRH pulse generator in hypothalmaus is resistant to the negative feedback from progesterone in patietns with PCOS * High GnRH pulse frequency increases LH and decreases FSH * Promotes androgen production by theca cells by LH stimulation: LH action at ovarian level is enhanced in PCOS. LH receptors are overexpressed in theca and granulosa cells from polycystic ovaries Insulin resistance and compensatory hyperinsulinemia * Hyperinsulinemia contributes to excess androgens in several ways: facilitates LH stimulates androgen synthesis by ovarian theca cells. * Inhibits hepatic synthesis of sex hormone binding globulin (SHBG) leading to an increase in free testosterone level * Hyperandrogenemia favors excess abd fat deposition exacerbating insulin resistance and hyperinsulinemia. Further enhances the secretion of ovarian androgens

Answer 42

* Increased androgen levels due to stimulation by LH * Increased adrenal androgen levels including androstenedione, DHEA and testosterone * Increased estrogen levels due to conversion from androgens in fatty tissues and ovaries: high estrogen environment feedback on pituitary gland gonadotrophin secretion leading to relative excess of LH secretion compared to FSH (increased LH:FSH ratio>3) * Failure of ovulation since deveoping Graafian follicle depends upon stimulation of FSH * Decreased conversion of androgen to estrogen by ovarian aromatase by FSH stimulation

Answer 43

* Macroscopic appearance: bilateral adrenal and lobular ovaries * Microscopic appearance: multiple atretic follicles representing the polycystic features, thecal cell hyperplasia, generalized increased in stroma

Answer 44

 Obesity  Type I/II/ Gestational DM  Family history of PCOS in 1st degree relative  History of premature adrenarche  Oligo-ovulatory infertility

Answer 45

Rotterdam consensus *20 or more follicles (has been changed)

Answer 46

Principle = periodic induction of withdrawal bleeding to protect the endometrium against endometrial hyperplasia and carcinoma secondary to chronic unopposed estrogen stimulation COC pills: 1st line treatment if fertility is unwanted (good cycle control + provide contraception + protect endometrium + ameliorarte hyperandrogenic symptoms due to androgen lowering effect (by increasing SHBG) Newer generation pills with lower androgenicity (e.g. Yasmin, Marvelon, Mercilon) may be more beneficial since greater androgenicitiy may impair glucose tolerance Periodic progestogen pills: protects endometrium + avoid metabolic AE of estrogen which is useful in women manifesting metabolic disturbances such as glucose intolerance No therapeutic effect on hyperandrogenic symptoms and contraception Provera 10mg daily x 10-14 days once every 2-3 months

Answer 47

Clomiphene citrate CC (clomid). Alternative: letrozole (aromatase inhibitor) 1st line treatment if pregnancy is wished. Start on day 2-6 following a spontaneous or progestogen induced bleeding and continue for 5 days Dosage. Starting dose: CC 50mg daily or letrozole 2.5mg daily Step up to CC100mg daily or letrozole 5mg daily if no ovulatoary response Maximum dose is CC 150mg daily or letrozole 7.5mg daily Effectiveness: ovulation rate = 80%, conception rate = 22% per ovulatory cycle MoA: SERM with both estrogen aagonist and anatagonist effect that increases gonadotrophin release. Primarily acts on the levl o of hypothalmus which interferes with receptor cycling and effectively depletes hypothalamic ERs. Inhibits the normal estrogen negative feedback mechanism which results in increased pulsatile GnRH secretion from hypothalamus and subsequently pituitary gonadotrophins including LH and FSH release Side effects: vasomotor flushes, abd pain anda bloating, multiple pregnancy is rare Metformin (not as 1st line treatment) Gonadotropins: 2nd line treatment of CC resistant patients Laparoscopic ovarian drilling (LOD): alternative to gonadotropin treatment in patients with CC resistance. In vitro fertilization: 3rd line treatment for those failing ovulation induction treatment or those with other concurrent indications for IVF

Answer 48

involves any or all of the uterus, fallopian tubes and ovaries due to ascending spread of microorganisms. Does not specify the exact location of infection. Does not involve vaginal and vulva infection (anything above cervix) Accompanied by involvement of neighbouring pelvic organs resulting in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis and tuboovarian abscess --> preferred terms.

Answer 49

* Surgical emergency cannot be excluded * Clinically severe disease * Tubo-ovarian abscess (TOA) * PID in pregnancy * Irresponsive or intolerance to oral medications Must cover neisseria gonorrhoea, chlamydia trachomatis, anaerobes, gram negative facultative bacteria and streptococci

Answer 50

Clinical improvement within 3 days Things to be considered: o Tubo-ovarian abscess (TOA) o Retained products of gestation o Other causes of abdominal pain o Drug fever o Drug adherence o Removal of IUCD (IUCD can left-in-situ in women with clinically mild PID but shall be removed in severe PID after commencement of antibiotics) o Septic pelvic thrombophlebitis

Answer 51

* Endometriosis (effective in relieving endometriosis associated): GnRH agonist + add back therapy (estrogen or/and progestogen reduces side effects such as decreased BMG and menopausal symptoms without negative effect on the efficacy of treatment of GnRHa * Uterine fibroids * Thinning agent for hysteroscopic procedures such as endometrial polyp/dysfunctional uterine bleeding (must exclude adenomyosis and uterine fibroid before doing hysteroscopic endometrial ablation) --> IM leuprolide to visualize/destroy endothelium easier Not certain * Pituitary down regulation (in long protocal of IVF and induction of ovulation) * Before and during chemotherapy for breast cancer to preserve ovarian function

Answer 52

No, the uterus and fibroid is alrady highly vascularized during pregnancy. If operate on during C-section there will be increased post partum hemorrhage. Myomectomy only indicated if it is accidentally ligated, hence will need to operate on and suture the wound.