General gynaecology

Question 1

what are the phases of the menstrual cycle and what do they contain?

Answer 1

Follicular phase - FSH and LH driven maturation of follicle. LH surge causes rupture and release of oocyte

Luteal phase - progesterone released by corpus luteam causes proliferation of endometrium. Corpus luteum lives for 14 days

Menses - corpus luteum degenerates –> drop in progesterone and shedding of endometrial lining (menses over 5-7 days)

Question 2

How does the menstrual cycle differ in successful pregnancy

Answer 2

hCG released by sperm enables survival of corpus luteum –> continuous progesterone production

Progesterone taken over by placenta once it has formed

Question 3

Definition and physiology of menopause

Answer 3

= amenorrhoea for 12 months

Exhaustion of ovarian reserve, leading to high serum FSH (>30 IU/L is indicative)

Question 4

Symptoms in menopause

Answer 4

Vasomotor - hot flushes
GU atrophy, dyspareunia, bleeding and dryness
Irregular menstruation –> amenorrhoea

Question 5

Contraindications for Hormone Replacement therapy (HRT)

Answer 5

unexplained PV bleeding
oestrogen dependent cancer
Uncontrolled HTN
Hx of breast cancer, TE, stroke/MI/Angina

Question 6

Side effects of HRT

Answer 6

oestrogen - breast tenderness, cramps, nausea, bloating
Progesterone - PMS symptoms
bleeding - PV

Question 7

Risks associated with HRT?

Answer 7

VTE (no risk with transdermal therapy) + Stroke
Breast cancer (small increase)
Ovarian cancer (if used for >5yrs)
Endometrial cancer (only if oestrogen only therapy)

Question 8

Classification of abnormal bleeding

Answer 8

Normal = 25ml/4-5 days/month

Too much - menorrhagia
Too little - oligomenorrhoea - <9 periods in a year
Too frequent - polymenorrhoea
Absent - amenorrhoea

Question 9

Investigations in abnormal bleeding

Answer 9

Serum/urine pregnancy test
FBC - IDA, TFTs (hypothyroid –> menorrhagia)
Clotting screen - APTT, vWBd
Endometrial biopsy

Question 10

Management of abnormal menstrual bleeding

Answer 10

Mirena coil - IUS - stop bleeds

Mefenamic Acid (NSAID) - reduces prostaglandins

Tranexamic acid (most effective but ^SE)

Question 11

Management of PMS

Answer 11

Ovulation suppression agents - COCP, GnRH antagonists, progesterone

SSRI/SNRIs if desire to keep fertile

Question 12

Clinical features of PCOS

Answer 12

Hyperandrogenism - hirsutism, acne, alopecia
Hyperinsulinaemia - obese, T2DM, acanthosis nigricans
Sub/infertility - oligo/amenorrhoea

Question 13

What is the Rotterdam criteria

Answer 13

2/3 diagnostic for PCOS

1) Polycystic ovaries - >12 peripheral follicles, or ^ovarian volume
2) oligo/anovulation
3) clinical/biochemical hyperandrogenism

Question 14

Investigations in PCOS

Answer 14

serum free and total testosterone (2xSD above the mean = +ve)

OGTT, serum prolactin, fasting lipid panel
Pelvic USS

Question 15

Management of PCOS

Answer 15

1) weight loss - even by 5% can yield significant improvements
2) improve menstrual regularity - COCP, metformin, orlistat, progestogens
3) improve subfertility - ovarian drilling, Clomifene (induce ovulation), IVF

Question 16

Investigation and management of Endometriosis

Answer 16

TV - US

Suppress ovarian function - COCP, medroxyprogesterone (suppress HPO axis)
GnRH agonist - blocks HPO axis
NSAIDs for pain

Surgical - hysterectomy, ablation, Adhesiolysis

Question 17

Investigations in PID

Answer 17

Pregnancy test
WCC - confirm infection
Vaginal/endocervical swab + NAAT test

Question 18

Management of PID

Answer 18

Abx - Cephalosporin e.g. Ceftriaxone
+ Oral Doxycycline

+ Metronidazole if anaerobic cover required

2nd line - fluoroquinolone e.g. levofloxacin