GYN Flashcards
1
Q
Differentials for regular menorrhagia
A
- primary dysfunctional uterine bleeding
- uterine leiomyoma
- uterine endometriosis
- secondary dysfunctional uterine bleeding.
2
Q
Types of dysfunctional uterine bleeding
A
primary: anovular or ovular
secondary: bleeding disorder (Idiopathic thrombocytopenia, von willebrands diseasem or anticogulation therapy
3
Q
Uterine Tenderness suspicious of?
A
adenomyosis
4
Q
Investigations for heavy periods?
A
FBC - iron deficiency anaemia
TFT
USS- if indicated by bimanual examination (position size and number of fibroids)
endometrial biopsy- over 40 years of age because below 40 low risk of endometrial ca.
5
Q
What drug treatment is available for the treatment of menorrhagia?
A
Tranexamic acid - decease blood loss by 50%
Mefanamic acid= analgesia
COCP- regulate cycle
IUD- can cause irregularity for 9 months then a lot of women stop having periods
Danazol- acne, weight gain, and voice changes (androgen excess)
6
Q
Differentials for heavy and irregular periods?
A
- dysfunctional uterine bleed
- endometrial pathology
- Climateric
- Fibroids or adenomyosis
- ovarian pathology
7
Q
Annovular dysfunctional uterine bleeding causation:
A
high unopposed oestrogen levels
8
Q
What investigations would be most helpful in a woman presenting with heavy and irregular periods?
A
FBC- iron def. anaemia
FSH- (folicular stimulating hormone) check failure of ovarian function and also check beta hCG
USS- to exclude uterine and ovarian pathology. Endometrial thickness indicates endometrial pathology.
Outpatient hysteroscopy
Outpatient endometrial biopsy- carcinoma of the endometrium (women over 40)
9
Q
US pathology in a endometrial cancer over 40
A
endometrial thickness less than 4 mm very low risk
10
Q
Bleeding after vaginal intercourse differentials
A
- cervical ectropion
- cervical polyp
- cervicitis
- cervical carcinoma
11
Q
risk factors for cervical ectropion
A
pill. pregnancy, puberty
12
Q
investigations for intercourse bleeding after or during
A
cervical screening- obtain last smear
vaginal or cervical swabs fro microscopy and culture- only if infection suspected or if vaginal discharge
colposcopy and cervical biopsies= suspicion of malignancy or if cervical smear is abnormal
13
Q
ovarian tumour modified risk of malignancy score
A
Ux Mx CA125
Ultrasound- multilocular cyst, solid area, evidence of mets ascites or bilateral lesions
M- menopausal status 1 premenopausal and 3 postmenopausal
CA125
low less than 25
moderate 25-250
high greater than 250
14
Q
differential for pelvic mass
A
bladder tumour
intestinal tumour
diverticular disease
IBD
15
Q
Tumour markers to consider in suspected ovarian cancer in less than 40 year old
A
AFP, hCG, LDH, inhibin, oestradiol
16
Q
different types of benign ovarian Ca
A
non-neoplastic- functional: follicular cysts (less than 3 cm) pathological: PCOS, theca leutin, ovarian oedema
benign neoplastic- epithelial- serous, mucinous, brenner tumours
benign germ cell tumours- teratoma or dermoid cyst (may contain teeth can cause chemical peritonitis)
sex cord stromal tumours- sertoli leydig (virilization) lipoma
17
Q
cervical cancer screening criteria
A
sexually active women 25-64
three yearly for women 25-50 year old if normal 5 yearly till 64
three yearly identifies 95% of all abnormalities
18
Q
Management of abnormal smear tests- inflammatory
A
6% CIN I-II repeat un 6 months (if same result for 3 times- colposcopy)
19
Q
Management of abnormal pap smear - borderline nuclear changes
A
20-30% CIN II-III if high risk due to HPV pos. colposcopy repeat in three years if negative
20
Q
mild dyskaryosis - abnormal smear management
A
30% CIN II-III HPV pos- colposcopy if negative then smear in three years
21
Q
moderate dyskaryosis - mgx of abnormal smears
A
50-75% CIN II-III refer to colposcopy
22
Q
severe dyskaryosis
A
80-90% CIN II-III refer colposcopy
23
Q
abnormal smear- invasion
A
50% invasion refer to colposcopy
24
Q
abnormal glandular cells - abnormal smear
A
adenocarcinoma of the cervix- refer to colposcopy
25
principles behind colposcopy
endocervix is made up of two different layers endocervix is secretory glandular epithelium and the ectocervix is made up of stratified squamous epithelium. These meet together at the transformational zone. This is the magnification of this TZ area. They apply two chemicals (5% acetic acid and lugol’s iodine).
Looking for aceto-white epithelium, vascular abnormalities (mosaic and punctuation) and grossly abnormal vessels suggestive of micro-invasion.
26
referral for colposcopy
```
if HPV positive and borderline nuclear changes or dyskaryosis
moderate to severe dyskaryosis
smear suggestive of malignancy
glandular abnormality
3 consecutive abnormal smears
keratinising cells
post-coital bleeding
abnormal looking smears
```
27
Benefits of a large loop excision of the transformational zone
easy and safe
possible with local anaesthetic
diagnostic and therapeutic
28
complications of the large loop excision of the transformational zone
short term- haemorrhage, infection, vaso-vagal reaction, and anxiety
long term- cervical stenosis, cervical incompetence and premature delivery.
29
Management of low grade CIN I
60% spontaneously regress, conservative management colposcopy 6 months
LLETZ if persistent
30
high grade CIN II-III management
has a higher malignant potential (20-30% CIN III)
large loop excision
fo-up cytology and high risk HPV test at 6 months, if neg. smear in 3 years
31
35 year old woman with pelvic pain, irritability, bloated ness, and breast pain 3-4 days before her period. Differentials?
1. Premenstrual syndrome
2. secondary dysmenorrhea (endometriosis (adenomyosis) and PID
3. Pelvic venous congestion
32
35 year old woman with pelvic pain, irritability, bloated ness, and breast pain 3-4 days before her period. History support diagnosis?
Premenstrual syndrome common around 35. These periods wer light and not heavy. If they were heavy that is more in keeping with the picture of adenomyosis.
33
35 year old woman with pelvic pain, irritability, bloated ness, and breast pain 3-4 days before her period. what other things would you like to ask?
tension, aggression, depression, and fluid retention are other common symptoms of PMS. screen for depression or criminal acts or disability which is involved in 3% of cases.
34
35 year old woman with pelvic pain, irritability, bloated ness, and breast pain 3-4 days before her period. What investigations would you undertake?
FBC= looking for any signs of anaemia, or WBC elevation or infection.
Symptom diary: diagnosis confirmed by establishing a cyclical nature.
USS- might show ovarian endometrioma (chocolate cysts)
diagnostic- to rule out any organic cause for pelvic pain.
35
35 year old woman with pelvic pain, irritability, bloated ness, and breast pain 3-4 days before her period. Treatment options
supportative- patient education and sympathetic care and reassure
relaxation therapy
treatment has 75% placebo success rate.
Medical- COCP, evening primrose oil.
Vitamen B6
SSRI if severe
high dose oestrogen (but need to combine with progesterone)
GnRH agonists stop ovarian function temporarily- diagnostic and therapeutic
36
45 year old who has menopausal symptoms with a family history of osteoporosis and wants to start HRT. What additional questions to ask?
depression, loss of libido, hair loss, dry skin and painful intercourse as a result of a dry vagina. check if family history osteoporosis, breast cancer, or ischeamic heart disease. RF colles fracture or hip fracture sedentary lifestyle and low body mass index.
37
someone who presents with menopausal symptoms and want to start HRT. What clinical exam will you preform?
GE including taking the BP. breast screening. pelvic examination if not up to date with smears.
38
investigations in a woman wanting to start HRT
patient genetic counselling and BRAC 1 and BRAC 2 mutations if 2 more more first degree relatives have breast cancer (mom or sisters).
39
treatment options for HRT
if the patient has a womb- combines oestrogen and progesterone
oestrogen only if undergone hysterectomy
different types- oral, patch, implants and gel.
needs to be counselling especially if she has RF heart disease and breast cancer.
40
How can you improve a patients compliance with HRT?
Listen- lifestyle and concerns about treatment
Education- realistic expectations on what to expect
Benefits- symptomatic relief and long term better for osteoporosis
risks- cancer and thromboembolism
method and administration of HRT come to a informed choice
regular follow=up
give information leaflet
41
screening program before starting HRT
Pretreatment= blood pressure, weight, breast examination, cervical smear, and pelvic examination
6 monthly- weight and BP measurement
yearly- breast examination
three yearly mammogram, cervical smear
42
Benefits of Morena coil use. what is the active drug in the Mirena?
it is a contraceptive but also can be used in HRT reduce breast cancer risk in comparison with systemic perpetration. Levonorgestrel
43
36 year old complains of involuntary urinary loss on exercise, sneezing, or coughing. Onset after the birth of her first child 10 years ago, which was assisted with forceps. She is fit and healthy, but has to wear sanitary pads all the time. Voids 5-6 times per days and once at night without difficulty. DIFFERENTIALS?
1. sphincter incompetence (stress incontinence)
2. detrusor instability (urge incontinence)
3. mixed incontinence (GSI and detrusor instability)
4. Neurological disorder (uncommon)
44
36 year old complains of involuntary urinary loss on exercise, sneezing, or coughing. Onset after the birth of her first child 10 years ago, which was assisted with forceps. She is fit and healthy, but has to wear sanitary pads all the time. Voids 5-6 times per days and once at night without difficulty. what details in the history support the diagnosis?
The involuntary loss of urine due to the from rising in abdominal pressure (during exercise, sneezing, or coughing) suggests sphincter incompetence. childbirth (difficult) is a risk factor.
45
36 year old complains of involuntary urinary loss on exercise, sneezing, or coughing. Onset after the birth of her first child 10 years ago, which was assisted with forceps. She is fit and healthy, but has to wear sanitary pads all the time. Voids 5-6 times per days and once at night without difficulty. additional questions?
history of urgency or history of recurrent UTI? frequency more than 6 times per day and there is nocturnal frequency- detrusor instability
sphincter incompetence= associated with multiparty, prolonged labour, and symptoms of uterovaginal prolapse and faecal incontinence.
Neuro- MS secondary symptoms
46
36 year old complains of involuntary urinary loss on exercise, sneezing, or coughing. Onset after the birth of her first child 10 years ago, which was assisted with forceps. She is fit and healthy, but has to wear sanitary pads all the time. Voids 5-6 times per days and once at night without difficulty. physical examination preformed with a comfortably full bladder. what would you look for on examination?
incontinence- ask the patient to cough
pelvic exam= normal
but could have pelvic mass (fibriod)
Neurological= sphincter incompetence, evidence of peritoneal deficiency on inspection and uterovaginal collapse.
47
36 year old complains of involuntary urinary loss on exercise, sneezing, or coughing. Onset after the birth of her first child 10 years ago, which was assisted with forceps. She is fit and healthy, but has to wear sanitary pads all the time. Voids 5-6 times per days and once at night without difficulty. Investigations:
MSU - exclude urinary tract infection
urodynamic investigations- to differentiate between sphincter incompetence and detrusor instability. In sphincter incompetence urodynamics are normal.
48
TASK draw out the difference between normal bladder, genuine stress incontinence and detrusor instability
look at page 114
49
surgical treatment for heavy periods
either hysterectomy or endometrial ablation therapy. Hysterectomy may need to remove ovaries to decrease the risk of ovarian ca and then suppliment with HRT. Endometrial ablation- amennohorea is not guaranteed and hysterectomy may be required at he time of surgery. Sterilisation may need to be consdiered as well.
50
Hysterectomy effect on sex life and other things to counsel on.
A hysterectomy is a removal of the womb, not the vagina. Therefore a hysterectomy will effect the ability to conceive, not the the ability to have sex. Sex is a mixture of psychological and physical factors. The ability to have sex will remain unchanged. Some things it can effect though- the nerve supply to the bladder can be effected and increase in incidence of IBS and constipation.
51
A girl in her 20s presenting with infrequent periods. She is athletic and has lost some weight. not sexually active and home pregnancy test is negative. Differential
Secondary amenorrhoea- stress-related amenorrhoea, PCOS, hyperprolactinaemia, hyper/hypothyroidism
Premature menopause
Rare but on the diif: tumour pituitary adenoma, hormone producing tumor (ovarian) anatomical: transverse vaginal septum or hymen, vaginal or uterine atresia
chromosomal: turners
psychological: anorexia nervousa
52
Primary and secondary Amenorrhoea
primary: lack of menstruation by 16 years of age in a girl with normal growth and secondary sex characteristics
Secondary: amenorrhoea for 6 months for a woman who previously had periods.
53
Premature Menopause
menopause before the age of 35 years
54
A girl in her 20s presenting with infrequent periods. She is athletic and has lost some weight. not sexually active and home pregnancy test is negative. What additional questions do you want to ask?
Food- what is a typical day for you?
Weight- how much weight loss?
training- how much exercise per day?
Menstrual history: what was baseline normal?
PCOS: acne, hair growth,
Ask about breast discharge. Any headache or changes in vision? Ask about change in bowels, change in temperature, anxiety, tremors.
Menopausal symptoms- night sweats, mood swings, hot flushes.
drug history: progesterones, tranquilizers
55
Examination of a woman with secondary amenorrhoea
weight, height (BMI), general appearance tremor, anxiety? male pattern baldness? Male pattern hair growth? Stigmata or straie pulse (tachycardia, A. fib- hyperthyroid) abdominal mass- ovarian secreting tumor or pregnancy.
56
Investigations in secondary amenorrhoea
pregnancy test, LH and FSH, LH:FSH ratio/ measurement of 3:1 would indicate PCOS and a FSH level of greater than 25 is likely premature menopause.
Serum prolactin
USS (cysts on the ovaries in PCOS- thick endometrium in PCOS thin= premature menopause) TFT- if symptomatic
57
Treatment for womans triad
supportative, diet and decrease exercise should recover periods
58
PCOS treatment
COCP, ovulation induction (clomiphene citrate) (metformin- decrease insulin resistance) surgical ovarian drilling
59
early menopause treatment
Combined oral contracptive pill, combined HRT and mirena coil can be used for hormone replacement for four years.
60
hyperprolactinaemia treatment
bromocriptine (parkinsons meds and also for NMS), cabergoline (dopamine agonists)
61
Abnormal cervical smear- 35 year old single women multiparty and separated from the father.
1. cervical cancer
2. CIN type changes
3. glandular changes
4. inflammatory changes
62
abnormal cervical smear= what additional questions do you want to ask?
Ask about past smears?
Ask about prior HPV positivity.
ask about symptoms of cervical CA and those are post-coital bleeding and any pain during intercourse or intermenstraul bleeding.
RF multiparty and multiple sexual partners
social history: smoking and alcohol status have you ever been diagnosed with a sexually transmitted disease, age of first intercourse, vaginal discharge.
63
abnormal cervical smear- examination
examination of the external genitalia to determine with there are any dermatological lesions indicative of STI
Speculum examination and bimanual examination cervical mass, fixity, pelvic mass and tenderness. Swab any discharge and note any signs of infection.
colposcopy if the changes are CIN II-III with HPV positivity. I am looking for aceto white changes looking at the vascularity of the cervix and any obvious ectropion or polyp.
64
What are the treatment and monitoring process for abnormal cervical smears.
If there is inflammatory changes- test and treat active infection and then repeat in three months and then refer.
If there is dyskaryosis nuclear changes (CIN 2-3)
if HPV positive- colposcopy
if negative borderline or mild dyskaryosis repeat in 3 years
if it moderate to severe then you need to refer to colposcopy.
abnormal glandular cells refer to colposcopy.
65
colposcopy explain management of abnormal results
acetic acid and legols iodine
directed punch biopsy =histology
CIN low grade or high grade.
low- monitor cytology every 6 months if persistent then you can do lletz
high grade= 3-5% 2 20-30% 3 in 10 yrs - lletz
cone biopsy.
66
complications of a LLETZ procedure
short term and long term
short complications: bleeding, infection, anxiety, vasovagal
long term: cervical incompetence. cervical stenosis
67
68 year Woman who is menopausal and abdomen distension. Presents with gradual enlargement fo the abdomen, changes in bowel habit and weight loss- differential diagnosis
1. ovarian carcinoma
2. fibroids
3. pregnancy test
4. ascites
5. bladder
6. bowel problems
68
68 year Woman who is menopausal and abdomen distension. Presents with gradual enlargement fo the abdomen, changes in bowel habit and weight loss.. what other questions would you ask?
Pc: night sweats, amount of weight loss, change in bowel habit- blood in stools or urine. Is she getting any PV bleeding? urination problems? neurological symptoms like tingling sensations?
past medical: obesity, nulliparity, other cancers?
gyn history: smears abnormal or any STI
Medication: Tamoxpihen Breast cancer? hormone replacement therapy, contraceptive use
family history: breast cancer, bowel cancer,
social history: smoker, drinker,
69
68 year Woman who is menopausal and abdomen distension. Presents with gradual enlargement fo the abdomen, changes in bowel habit and weight loss what re you looking for on clinical examination?
general observation: cachexia, muscle wasting, jaundice stigmata of GI disease. increased juglar return, tracheal devation, lymphadenopathy
resp and cardiovascular examination listening for any added sounds.
percussion- plural effusion.
breast examination
GI examination: ascites, mass= palpation fixed, solid percussion. bladder. shifting dullness. hepatomegaly, splenomegaly
legs- ankle oedema
bimanual examination
70
68 year Woman who is menopausal and abdomen distension. Presents with gradual enlargement of the abdomen, changes in bowel habit and weight loss what investigations are you going to do?
```
FBC- anaemia
U and E- electrolyte balance creatinine eGFR renal failure
LFT- liver involvement chemotherapy treatment baseline
CA125 antigen serology (RMI)
CEA- bowel cancer
USS - determine ascites
CXR- pleural effusion
ascitic sample- cytology
```
71
68 year Woman who is menopausal and abdomen distension. Presents with gradual enlargement fo the abdomen, changes in bowel habit and weight loss what treatment options are appropriate?
supportive: pain relief and drainage
surgical: excision of tumour hysterectomy bilateral salpingo-oophorectomy, omentectomy, debunking of tumour (less than 2 cm)
medical: chemotherapy carboplatin and platinum agents
72
baseline investigations before chemo in ovarian ca
CT scan- responsiveness to treatment.
UE= renal function creatinine clearance
histological diagnosis.
73
54 year old woman presents with amenorrhoea for the past 18 months and then has started PV bleeding. Smears normal two years ago and she is not on HRT. Differentials?
1. atrophic vaginitis
2. Endometrial carcinoma UPO
3. endometrial hyperplasia, polyp
4. cervical polyp or ca
5. infection
6. Adnexal malignancy
74
54 year old woman presents with amenorrhoea for the past 18 months and then has started PV bleeding. Smears normal two years ago and she is not on HRT.. Additional questions can be asked?
Pc ask about postcoital bleeding, ask about permenaupasal symptoms sure as hot flushes, night sweats. Ask about weight loss. Ask about loss of blood volume if there is any discharge?
past med/surgical history:
HTN, diabetes, obesity
medication: allergies
HRT. past use of oral contraceptives
family history: endometrial cancer, breast, bowel cancer.
social history: smoker or drinker
75
54 year old woman presents with amenorrhoea for the past 18 months and then has started PV bleeding. Smears normal two years ago and she is not on HRT. Examination?
GE: pallor, obesity, weight loss
lymphadenopathy
speculum examination: atrophic vaginitis and cervical polyps or carcinoma
bimanual examination: uterus size, shape, mobility
76
54 year old woman presents with amenorrhoea for the past 18 months and then has started PV bleeding. Smears normal two years ago and she is not on HRT. investigations?
outpatient endometrial biopsy- histological diagnosis
USS- because if the endometrium is less than 4 mm than the diagnosis of endometrial ca is unlikely
look also at the adnexal mass (ovarian tumour can present with post men bleed)
outpatient hysteroscopy- uterine cavity to look for polyps
outpatient D and C= if above not applicable.
77
54 year old woman presents with amenorrhoea for the past 18 months and then has started PV bleeding. Smears normal two years ago and she is not on HRT. What is the treatment?
Supportative if no pathology found.
medical: vaginal oestrogen cream atrophic vaginitis
progestogens for simple endo hyperplasia with atypia.
surgical: polypectomy, total hysterectomy and bilateral saplings=oopherectomy
endometrial ca- adjuvant radiotherapy.
hormone therapy- high dose progesterone= thins the lining of the womb and stops bleeding. symptomatic therapy
78
My smear is unsatisfactory do I have cancer?
smear- abnormal cells present it does not mean you have cancer, but you may have precancerous cells. This is why we need further investigations or management.
Blood test- HPV
referral for colposcopy- need for punch biopsy or LLETZ
treatment laser/cold coagulation/ LLETZ
regular follow up smears are need according to finding.
79
I have warts will I get cancer... counsel this woman
many factors are linked with the development of cancer, warts is just one of them.
warts are very common and there are different types.
the risk of developing cancer is small.
regular cervical smears are important to identify cervical cancer.
80
vaginal discharge- 25 year old woman with vulval itching and discharge. cervical smear was normal. She has started a new relationship and is taking the OCP. no urinary symptoms. She recently had the flu. Differentials?
1. infection- fungal- candida bacterial- trichomonas vaginalis, bacterial vaginosis, chlamydia, gonorrhoea, herpes.
2. inflammation
3. foreign body
4. cervical ectropion.
81
vaginal discharge- 25 year old woman with vulval itching and discharge. cervical smear was normal. She has started a new relationship and is taking the OCP. no urinary symptoms. She recently had the flu. RF this women has?
COCP, a new sexual partner, broad spectrum antibiotics. Can be risk factors for a candida infection. urinary symptoms would give a more gonorrhoea, chlamydia or herpes picture.
82
vaginal discharge- 25 year old woman with vulval itching and discharge. cervical smear was normal. She has started a new relationship and is taking the OCP. no urinary symptoms. She recently had the flu. Other questions to ask?
Discharge- colour, consistency, smell
green- bacterial vaginosis
thick white- candida
grey frothy- trichomonas
yellow mucopurulent- chlamydia or gonorrhoea.
use of douching, talcum powder, tight synthetic undergarments.
polyuria and polydipsia- may have diabetes.
family history= diabetes
83
vaginal discharge- 25 year old woman with vulval itching and discharge. cervical smear was normal. She has started a new relationship and is taking the OCP. no urinary symptoms. She recently had the flu. What examination?
Vaginal examination: vulva looking for any hermetic lesion (vesicles) or abcesses or any dermatological stigmata. erythema and congestion= candida
Speculum examination: looking for any lesions (reddish purple spots- trichomonas), inflammation, ectropion
when removing speculum swab the discharge and note volume, consistency, and colour, and smell. bimanual examination: pelvic tenderness- PID
84
vaginal discharge- 25 year old woman with vulval itching and discharge. cervical smear was normal. She has started a new relationship and is taking the OCP. no urinary symptoms. She recently had the flu. What investigations?
urine dipstick: UTI or glycouria
MSU- microscopy and culture
PH of discharge- alkaline indicates more bacterial like trichomonas and bacterial vaginitis
microscopy of the discharge- mycelial filaments and spores candida
motile flagellated protozoa- trichomonas
gram stain of discharge- blue cells- trichomonas gram neg diploccoci in gonoccocal infection
vaginal and cervical swabs- STI
85
vaginal discharge- 25 year old woman with vulval itching and discharge. cervical smear was normal. She has started a new relationship and is taking the OCP. no urinary symptoms. She recently had the flu. Treatment?
supportive: reassure and also give lifestyle advice loose fitting clothes, cotton underwear, and avoiding douching.
Medical: no organisms no tx if persistant tx like candida
candida- clotrimazole cream or oral flucanozole
86
Treatment of Trichomonas infection or bacterial vaginosis
metronidazole
87
Treatment of chlamydia
doxycycline
88
treatment of gonococci infection
penicillin and erythromycin
89
herpes treatment
aciclovir
90
treatment for cervical ectropion if symptomatic
cryotherapy
91
a 22 year old woman presents with fever lower abdominal pain and foul smelling discharge. Her last menstrual period was 1 week ago. She had recently changed her sexual partner. No urinary or bowel symptoms. differential?
1. Acute Pelvic Inflammatory disease
- STI
- IUD
- secondary PID
2. Acute Abdomen
- ectopic pregnancy
- ovarian cyst
- bowel condition
92
a 22 year old woman presents with fever lower abdominal pain and foul smelling discharge. Her last menstrual period was 1 week ago. She had recently changed her sexual partner. No urinary or bowel symptoms. What is it most likely?
PID pyrexia, pelvic pain, and foul smelling discharge result of PID. RF new sexual partner.
93
a 22 year old woman presents with fever lower abdominal pain and foul smelling discharge. Her last menstrual period was 1 week ago. She had recently changed her sexual partner. No urinary or bowel symptoms. What additional questions would you want to ask?
nature and onset of pain (SOCRATES)
pattern of fever (swinging- pelvic abscess)
sexual history obtained number of sexual partners, causal sexual encounters, history of STI, and previous hx of PID
medication: IUD
94
a 22 year old woman presents with fever lower abdominal pain and foul smelling discharge. Her last menstrual period was 1 week ago. She had recently changed her sexual partner. No urinary or bowel symptoms. what investigation?
GE vitals and temp.
inspection of the vulva, vagina, and cervix sample taken for micro
separate swabs for gonorrhoea and chlamydia. bimanual examination= show pain. Pelvic exam to show mass.
95
a 22 year old woman presents with fever lower abdominal pain and foul smelling discharge. Her last menstrual period was 1 week ago. She had recently changed her sexual partner. No urinary or bowel symptoms. Investigations?
```
urine hcg
FBC- WBC elevation
U and E renal effects if sepsis is suspected
USS= ovarian cyst or mass
MSU- microscopy and culture
vaginal and cervical swabs
blood culture
```
96
a 22 year old woman presents with fever lower abdominal pain and foul smelling discharge. Her last menstrual period was 1 week ago. She had recently changed her sexual partner. No urinary or bowel symptoms. treatment
supportive: ABC and call senior help if shocked. Resuscitate
do your sepsis screen
Medical: Sepsis screen and tailor abx to culture and sensitivity
surgical:
PID= pelvic mass not responding to treatment
acute abdomen= laparotomy
97
A 30 year old nulliparity woman presents with severe and incapacitating menstrual pain. gradually increasing over the past few months. Intercourse painful and using condoms. Differentials?
1. endometriosis
2. Chronic PID
3. primary dysmenorrhea
98
A 30 year old nulliparity woman presents with severe and incapacitating menstrual pain. gradually increasing over the past few months. Intercourse painful and using condoms. What is your working dx?
endometriosis due to the fact that primary dysmenorrhea occurs in teenagers. painful intercourse and painful periods is typical of endometriosis= nulliparous woman of high social class.
99
A 30 year old nulliparity woman presents with severe and incapacitating menstrual pain. gradually increasing over the past few months. Intercourse painful and using condoms. Additional questions?
pelvic pain caused by endometriosis typically starts several says before the period and then remains severe in intensity several days after. primary- eases within the first two days. previous infertility and positive family history will support that diagnosis. endometriosis is associated with bowel and bladder symptoms.
100
A 30 year old nulliparity woman presents with severe and incapacitating menstrual pain. gradually increasing over the past few months. Intercourse painful and using condoms. clinical examination?
speculum examination spots or nodules of endometriosis in the vagina particularly the posterior fornix. bimanual examination to show fixity and pelvic tenderness = endometriosis or PID
nodularity of the uterosacral ligament= endometriosis esp. the left side
also may have adnexal mass
101
A 30 year old nulliparity woman presents with severe and incapacitating menstrual pain. gradually increasing over the past few months. Intercourse painful and using condoms. Investigations?
investigation for gyn infections
USS- ovarian endometriosis
laparoscopy= diagnosis of pelvic endometriosis
102
A 30 year old nulliparity woman presents with severe and incapacitating menstrual pain. gradually increasing over the past few months. Intercourse painful and using condoms. treatment?
supportative: endometriosis is not a curable disease
monitor the disease by US or MRI
Medical: analgesia= NSAIDs
COCP= given continuously for 6 months. If relief than endometriosis is likely. The treatment can then be given up to 38-40 years of age.
progestogen- oral injectable or IUD
103
surgical treatment for endometriosis
mild- few peritoneal spots of laparoscopy no scarring- surgical ablation or excision, medical treatment for 3-6 months
moderate= above plus minor scarring surgical ablation or excision plus adhesiolysis plus medical tx for 6 months
Severe= above plus severe scarring an tubal blockage. surgical excision of endometriosis (hysterectomy and oophorectomy) medical treatment for 6 months as for moderate endometriosis after consecutive surgery.
104
A woman is having a diagnostic laparoscopy. Address her concerns.
Why the procedure is happening- ask what symptoms she has been having and knowledge. Does carry risks but is a low risk procedure.
Go through the steps of the procedure= GA, belly button area small hole to put telescope
surgeon then examines the pelvic organs and reproductive organs. minimal scarring.
possible damage to the organs in the cavity.
complications are dealt with in the operation.
anaesthetic risks
written leaflet
105
A woman has a diagnostic laparoscopy, she is wondering what happens next.
your test showed a completely normal pelvis. About half of the women who undergo this procedure will have normal pelvis. This is reassuring that you do not have evidence of endometriosis adhesions, or PID
but it does not tell us if you have IBS
pain is managed with painkillers
scarring is minimal
pain doesn’t improve or gets worse then return.
follow-up combines pain clinic.
written info
106
young couple present with a history of being unable to conceive despite unproductive intercourse. female partner has regular menses with an unremarkable gyncological history. They have been timing the intercourse with her ovulation cycle. The make partner had mumps as a kid. Differentials?
1. primary infertility
- male factor
- tubal block
- an-ovulation
- unexplained infertility
107
young couple present with a history of being unable to conceive despite unproductive intercourse. female partner has regular menses with an unremarkable gyncological history. They have been timing the intercourse with her ovulation cycle. The make partner had mumps as a kid. additional questions?
pelvic pain and PV discharge? - tubal block
| Male factor- genera health, testicular decent, urethral discharge, STI, occupational exposure
108
young couple present with a history of being unable to conceive despite unproductive intercourse. female partner has regular menses with an unremarkable gyncological history. They have been timing the intercourse with her ovulation cycle. The make partner had mumps as a kid. Investigations?
Woman- GE PCOS- obesity and hirsutism
breast- galactorrhoea
speculum- discharge or infection
bimanual examination- uterine fixity and tenderness PID or endometriosis
Male- virilization, gynecomastia, cryptorchidism, varicoceles, testicular size, epididymal, and prostatic tenderness
109
young couple present with a history of being unable to conceive despite unproductive intercourse. female partner has regular menses with an unremarkable gyncological history. They have been timing the intercourse with her ovulation cycle. The make partner had mumps as a kid. Investigations?
semen analysis- three days after abstinence= three specimens at monthly intervals. low sperm count microbiological tests for infection and antibodies for anti-sperm. karyotype and hormonal assays FSH, LH and testosterone
mid-luteal serum progesterone= confirm ovulation
chlamydia infection
USS= polycystic ovaries
Laparoscopy- pelvic adhesions hx of infection, endometriosis or positive chlamydia infection
Rubella IGG- to confirm female partners immunity to rubella
110
young couple present with a history of being unable to conceive despite unproductive intercourse. female partner has regular menses with an unremarkable gyncological history. They have been timing the intercourse with her ovulation cycle. The make partner had mumps as a kid. treatment
```
Medical: infection- treat
hypogonadotrophic hypogondism- clomiphene citrate or gonadotropin
surgical- varicocele high ligation
obstruction of vas deferens- vasovasostomy
IVF
assisted contraception
donor insemination
intrauterine insemination
intracytoplasmic sperm injection
```
111
28 year old woman presents with the inability to conceive despite unprotected intercourse for 18 months. periods are erratic with sometimes 6 weeks between. stopped taking the pill 18 months ago, but periods were irregular anyway. Male fathered a child in a past relationship. Differentials?
1. Primary infertility
- anovulation- PCOS prolactinema
- unexplained infertility
112
28 year old woman presents with the inability to conceive despite unprotected intercourse for 18 months. periods are erratic with sometimes 6 weeks between. stopped taking the pill 18 months ago, but periods were irregular anyway. Male fathered a child in a past relationship. Additional questions?
recent weight changes, hirtuism should be noted. history of galactorrhoea indicating hyperprolactinaemia. past history of STI or family history of PCOS
113
28 year old woman presents with the inability to conceive despite unprotected intercourse for 18 months. periods are erratic with sometimes 6 weeks between. stopped taking the pill 18 months ago, but periods were irregular anyway. Male fathered a child in a past relationship. Examination:
GE obesity or hirisutism may indicate PCOS
breast examination- galactorrhoea
speculum and bimanual examination
male partner examined.
114
28 year old woman presents with the inability to conceive despite unprotected intercourse for 18 months. periods are erratic with sometimes 6 weeks between. stopped taking the pill 18 months ago, but periods were irregular anyway. Male fathered a child in a past relationship.
Investigations?
```
Mid=luteal serum progesterone- ovulation
LH and FSH= PCOS LH:FSH
TFT= on if hyperprolactinemia
semen analysis
chlamydia infection
USS Polycystic ovaries
laparoscopy and dye hydrotubation and hysterosalpingography - pelvic adhesions, endometriosis or positive chlamydia
Rubella IgG
```
115
28 year old woman presents with the inability to conceive despite unprotected intercourse for 18 months. periods are erratic with sometimes 6 weeks between. stopped taking the pill 18 months ago, but periods were irregular anyway. Male fathered a child in a past relationship.
Treatment
folic acid supplement
timing the intercourse with ovulation
induction of ovulation clomiphene citrate
Medical: PCOS gondatrophins if above not successful
hyperprolactinaemia- bromocriptine
surgical- ovarian drilling- PCOS
IVF last resort
116
A 32 year old woman nurse presents with a 18 month history of inability to conceive after removal of IUD. IUD had been in place for 3 years. Her periods are regular with mild pain and she is with the same partner that fathered her other children. differentials?
1. secondary infertility
- tubal blockage
- unexplained infertility
117
A 32 year old woman nurse presents with a 18 month history of inability to conceive after removal of IUD. IUD had been in place for 3 years. Her periods are regular with mild pain and she is with the same partner that fathered her other children. More questions?
past gyncological history and obs history:
pelvic infection= history of deliveries with fever after delivery and foul lochia
gyn history of vaginal discharge with pelvic pain
endometriosis associated with tubal blockage
ask about male as well. timing and frequency of intercourse is important.
118
A 32 year old woman nurse presents with a 18 month history of inability to conceive after removal of IUD. IUD had been in place for 3 years. Her periods are regular with mild pain and she is with the same partner that fathered her other children. Examination?
speculum examination: discharge or infection
bimanual examination: tenderness or fixity PID or endometriosis
male pattern fro testicular size and varicocele.
119
A 32 year old woman nurse presents with a 18 month history of inability to conceive after removal of IUD. IUD had been in place for 3 years. Her periods are regular with mild pain and she is with the same partner that fathered her other children. Investigations?
```
laproscopy and dye hydrotubation and hysperosalpingography - tubal blockage
mid-luteal serum progesterone- ovulation
semen analysis- male factor
chlamydia infection
USS- if abnormal pelvic exam
Rubella IgG- immunity
```
120
A 32 year old woman nurse presents with a 18 month history of inability to conceive after removal of IUD. IUD had been in place for 3 years. Her periods are regular with mild pain and she is with the same partner that fathered her other children. Treatment:
Medical: treat pelvic infection
endometriosis- medical treatment for 1-2 stage leads to delay in pregnancy
surgical:
endometriosis- ablation, excision at laproscopy improves fertility
tubal block- adhesions, salpingectomy, excision of blocked segment and re-anastomosis.
IVF
121
Explain the ovulation cycle and when the best time for intercourse to improve chances of pregnancy.
Ovulation is 14 days prior to the period cycle. Sperm stay alive in womb for 4 days the egg stays alive for 24 hours. Therefore it is best to have intercourse a couple days before ovulation. So if you have a 30 day cycle day 16 is the day of ovulation. As long as intercourse happens every 36-48 hours during the fertile period sperm will be in the vicinity of the egg at the time of ovulation. The likelihood of pregnancy is 15-25 % chance even in a perfectly normal couple having intercourse at the right time.
122
A 28 year old woman is asking for drugs to stimulate the ovaries to produce eggs.
Her luteal phase progesterone levels are 7, 12, 9 (needs to be over 20)
prolactin is normal (150-500)
LH normal (1.8-13.4)
FSH normal (3-12) LH:FSH ratio greater than 2 - 12:4
rubella immune
male factor normal semen
The main reason for this patient’s infertility is her low progesterone levels during the mid-luteal phase. Also with the LH:FSH ratio greater than 2 PCOS considered.
First line therapy is to put her on Clomiphene citrate which will stimulate ovulation. Starting dose is 50 mg a day from day 2-6 progesterone levels in the luteal phase should be rechecked to make sure treatment is working. If no response can be titrated upwards to a maximum of 150mg/day. treatment is a maximum of 6 ovulatory months. Pregnacy 50% chance but loss occurs 20% of that time. risk of ovarian cancer. another treatment is injectable gondotrophins.
123
32 year old woman had unprotected sex during her mid cycle and went to the family planning clinic with the need for emergency contraception. Needs long term contraception plan wishes to delay preganancy by three years. She smokes 10 cigarettes a day. treatment
Emergency contraception can be given with the morning after pill needs to be taken within 72 hours after last protected sex. the sooner it is taken the better.
The yuzpe regimen 2 COCP are taken and repeated after 12 hours
Progesterone only pills taken 12 hours apart and initiated within 24 hours after intercourse= prevents 89% of pregnancies
Copper coil placed within 5 days of intercourse can usually prevent implantation.
124
A 27 year old woman with 3 children requests sterilisation. Additional questions?
What does she have in mind?
Past medical history: blood clots bleeding disorders, diabetes
prior surgery any complications
Past gyn history when was her last smear?
Periods regular or irregular?
sexual history
family history of breast or ovarian cancer
social: smoking status and
125
A 27 year old woman wishes to be sterilised
Recommend the mirena coil (1:500) it scores better at protecting women from unwanted pregnancy than tubal ligation (1:200) . It is a very small dose of hormone and it can be left in for 5 years for contraceptive and also hormone replacement therapy after menopause. There is a small risk that if you do get pregnant that that pregnancy will be an ectopic pregnancy. Many women after 6 months no longer have a period. Risk of pelvic infection and perforation.
126
Contraception after delivery.
-fully breastfeeding 98% contraception until periods return, baby turns 6 months and breast feeding is reduced.
-mini-pill can be used in breastfeeding, but compliance is an issue
-Depot provera 3 month contraceptive
-IUCD can be placed after the delivery of placenta or 6 weeks postnatally.
sterilisation 3 months after delivery.
127
How should I take the morning after pill
two forms of emergency contraception:
Levonelle 2 tablets taken 12 hours apart
then the combined pill ethinyloestradiol and levonorgestrel taken and repeated 12 hours apart.
- nausea and vomiting take domperidone
use barrier methods until next period
return fro follow-up
128
How do I take the oral contraceptive pill?
1. start on day one of the cycle
2. Take everyday for three weeks
3. then stop taking them for a week or continue to take the placebo pills.
4. This should enable you to have a withdrawal bleed.
5. Then restart a new packet for 21 days
give written information about the pill. If vomiting will need additional protection. If on abx will need additional protection during and 7 days after stopping. What if I miss a pill? pill during the first 14 days take the most recent and use a condom for 7 days. If the last 7 days take recent pill and start new packet without stopping and use barrier protection for 7 days. SE, follow up, STI protection= barrier methods.
