General Gynaecology Stuff

Question 1

What is a fixed retroverted uterus a sign of?

Answer 1

Endometriosis

Deposits of ectopic tissue on the utero-sacral ligament pull the uterus from anteverted to retroverted position

Question 2

What are the features of imperforate hymen?

Answer 2

The hymen does not have an opening, hence the blood cannot flow out during menstruation.

This leads to primary amenorrhoea even with development of secondary sexual characteristics and cyclical pain

Question 3

At what age can someone consent to sexual intercourse?

Answer 3

A child under the age of 13 is always considered to be unable to consent for sexual intercourse

Question 4

What blood tests are done for amenorrhoea?

Answer 4

HCG - Rule of pregnancy
Gonadotrophins 
Oestrodiol 
Prolactin 
Androgens - Raised in PCOS
TFT

Question 5

What are the different methods of abortion?

Answer 5

Less than 9 weeks: Mifepristone (anti-progestogenic) followed 48 hours later by prostaglandins (misoprostol) 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’)

Question 6

What is used for incomplete/missed miscarriage?

Answer 6

Misoprostol alone

Question 7

What is the definition and types of precocious puberty?

Answer 7

Early onset of puberty
8 in a girl
9 in a boy

Causes:
Central - Gonadotrophin dependent
Peripheral - Gonadotrophin independent
Peripheral is always pathological. Normally the result of exogenous ingestion of oestrogen or a hormone-producing tumour

Question 8

What is the definition of delayed onset of puberty?

Answer 8

No secondary sexual characteristics by the age of 14

Question 9

What is the definition of Amenorrhoea?

Answer 9

Primary amenorrhoea - No periods by the age of 16
Secondary amenorrhoea - No periods for more than 6 months after previously having periods

Oligomenorrhoea - Period cycles longer than 35 days with <9 periods a year

Question 10

What are causes of hypogonadotrophic hypogonadism?

Answer 10

• Hypothalamic Disorders
§ Excessive exercise, weight loss and stress
§ Lesions (craniopharyngioma, glioma)
§ Head injuries
§ Kallmann’s syndrome (Lack of GnRH)
§ Sarcoidosis, TB
§ Progestogens, HRT, dopamine antagonists

• Pituitary Disorders
§ Adenomas (prolactinoma is most common)
§ Pituitary necrosis (e.g. Sheehan’s syndrome)
§ Iatrogenic (surgery, radiotherapy)
§ Congenital failure of pituitary development

Question 11

What is the cause of hypergonadotrophic hypogonadism?

Answer 11

Polycystic ovarian syndrome

Question 12

What is Asherman syndrome?

Answer 12

Secondary amenorrhoea due to endometrial scarring

Question 13

What are investigations for amenorrhoea/oligomenorrhoea?

Answer 13

○ A pregnancy test should be carried out if the patient is sexually active
○ Blood can be taken to measure hormone levels
§ Raised LH + raised testosterone –> PCOS
§ Raised FSH –> POF
§ Raised prolactin –> prolactinoma
§ Thyroid function if clinically indicated
○ Ultrasound would be useful to visualise polycystic ovaries
○ MRI can be used to visualise the pituitary gland
○ Other investigations include:
§ Hysteroscopy - Asherman syndrome, cervical stenosis
§ Karyotyping - Turner’s and other chromosomal abnormalities

Question 14

What are the clinical features of polycystic ovarian syndrome?

Answer 14

Rotterdam consensus criteria: 2/3 of the following:
• Amenorrhoea/Oligomenorrhoea
• Clinical/Biochemical Hyperandrogenism
• Polycystic ovaries on ultrasound

Other features:
	• Acne
	• Acanthosis nigricans
	• Hirsutism 
	• Subfertility
	• Obesity
	• Risk of T2DM
	• Risk of cardiovascular event

Question 15

What is the management of polycystic ovarian syndrome?

Answer 15

COCP to regulate menstruation

Cyclical oral progesterone to regulate withdrawal bleed

If fertility an issue, clomiphene to induce ovulation

Lifestyle advice - Diet and exercise

Ovarian drilling - May prompt ovulatory cycles

Treatment of hyperandrogenism:
• Cyproterone acetate (antiandrogen)
• Topical eflornithinecream

Question 16

What are the clinical features of premenstrual syndrome?

Answer 16

Psychological, behavioural and physical symptoms that begin during the luteal phase and resolve by the end of menstruation

Symptoms:
	• Irritability
	• Depression
	• Bloating
	• Abdominal pain
	• Mastalgia
	• Headache

Question 17

What is the management of premenstrual syndrome?

Answer 17

1st line (Mild-Moderate) = Conservative management
• Exercise
• Diet
• Stress management (Consider counselling)
• Reduced alcohol/caffeine

2nd line (Moderate-Severe) = COCP or SSRIs if severe
CBT for depression

Last line = Hysterectomy plus bilateral salpingo-oophorectomy

Question 18

What are the symptoms of menopause?

Answer 18

• Dysmenorrhoea
  
  • Hot flushes
  • Vaginal dryness
  • Weight gain
  • Mood changes
  • Night sweats

Question 19

What biochemical changes are seen in menopause?

Answer 19

Normally menopause is a clinical diagnosis, however if unsure, investigations include:

* Serial FSH measurements = Raised
* Serial oestradiol measurements = Low
* Vaginal exam = Vaginal atrophy

Question 20

What is the management of menopause?

Answer 20

Hormone replacement therapy
• Normally used till symptoms of menopause subside (1-2 years)
• Taken orally
• Combination of oestrogen + progesterone
• Transdermal implant available if oral not possible
• Should be used for 3 months before concluding ineffective

Question 21

What additional considerations must be made with regards to HRT?

Answer 21

• If they have had a hysterectomy, oestrogen-only HRT is given
  
  • If they are perimenopausal, cyclical HRT is given (Oestrogen every day, but progesterone only for last 14 days)
  • If they only have local symptoms (vaginal dryness), they can be given vaginal oestrogen cream or a pessary

Question 22

What are the causes of secondary amenorrhoea/oligomenorrhoea?

Answer 22

Premature ovarian insufficiency
PCOS
Hyperprolactinaemia

Question 23

What are the clinical features of premature ovarian syndrome?

Answer 23

Menopause before the age of 40

Investigations:

• FSH/LH (Rise)
• Oestrogen (Falls)

Question 24

What is the management of premature ovarian syndrome?

Answer 24

Most causes treated with COCP

After 40, switch to HRT

Question 25

What are contraindications to HRT?

Answer 25

• Suspected malignancy
  
  • Breast cancer
  • Endometrial cancer
  • Thrombophilia (Factor V Leiden)
  • Current VTE

Question 26

What are the risks of HRT?

Answer 26

• Increased risk of breast cancer
  
  • Increased risk of ovarian cancer
  • Increased risk of CVD/Stroke in older women
  • Increased risk of VTE

Question 27

What is Ovarian Hyperstimulation Syndrome?

Answer 27

Typically during IVF, when excess hormone therapy is given, which results in multiple luteinised cysts that secrete oestrogen, progesterone and vascular endothelial growth factor. This leads to increased membrane permeability and fluid loss.

Stages:
Mild - Abdominal pain/bloating
Moderate - +N&V, Ascites on ultrasound
Severe - +Clinical ascites, hypoproteinaemia, oliguria
Critical - +DVT, ARDS, Anuria, Tense ascites

Question 28

How do you differentiate VIN from vulval carcinoma?

Answer 28

VIN is typically white and plaque-like. It also does not infiltrate the basement membrane
Vulval carcinoma is typically red and ulcerated. It invades the basement membrane