Gynae Flashcards
Benign ovarian tumours:
- when should they be biopsied?
- 2 physiological?
- 1 germ cell?
- 2 epithelial?
If complex/multi-loculated on USS
Physiological:
- Follicular: commonest, non-rupture of dominant follicle or failure of atresia, regress after several cycles
- Corpus luteum: failure to breakdown of corpus luteum, may fill with fluid/blood, more likely to cause intraperitoneal bleeding than follicular
Germ cell:
- Dermoid (mature): lined with epithelium, may contain hair and teeth. Most common ovarian tumour <30, usually asymptomatic but may cause torsion
Epithelial:
- Serous cystadenoma: commonest benign epithelial tumour, bilateral in 20%
- Mucinous cyst adenoma: second commonest, typically large and may become massive, can rupture to cause pseudomyxoma peritonei
How long after TOP can pregnancy tests remain positive?
4 weeks
If still positive at this point it suggests incomplete abortion or persistent trophoblast
Investigations for heavy menstrual bleeding?
FBC in all women
If intermenstrual/postcoital bleeding, pain/pressure symptoms, or exam findings (e.g. bulky tender uterus suggesting adenomyosis), refer for routine TVUSS
Management of menorrhagia if requires contraception?
If doesn’t require contraception?
Requires contraception:
- Mirena
- COCP
- Long-acting progestogen (Depo-provera)
Doesn’t:
- Tranexamic acid or mefanamic acid (NSAID)
Subfertility primary care Ix?
Primary care:
- chlamydia screen
- Day 2-5 FSH/LH
- TSH, PRL, testosterone and rubella Ig (vaccinate if not immune)
- Mid-luteal progesterone (luteal phase always 14 days so 7 days before period due)
- semen analysis: repeat in 3 months if abnormal - make lifestyle changes, start taking zinc, selenium and VitC supplements
Subfertility secondary care Ix?
TVUSS - rule out masses, fibroids or polyps
Hyspetosalpingogram - dye injected and XR - confirm tubal patency (dye can cause tubal spasm -> false positive)
Laparoscopy and dye test gold standard - do if HSPG abnormal - pelvic pathology can be treated at the same time
Semen analysis - what to look for?
Must be 3-5 days since last ejaculation and be at lab within an hour
Volume >1.5ml pH >7.2 Conc >15 million/ml >4% normal morphology >32% motile >58% live
Key counselling points if couple struggling to conceive but <1 year?
Folic acid
BMI 20-25
Regular intercourse every 2-3 days
Smoking/drinking
Management of endometriosis?
1st line - NSAIDs and/or paracetamol
2nd line - add in COCP
Secondary care:
- GnRH analogues (lower oestrogen, induce ‘pseudomenopause’)
- Surgery - laparoscopic excision and laser treatment of endometriotic ovarian cysts
(unfortunately drug treatment has very little impact on fertility)
Complications of hysterectomy with antero-posterior repair?
- enterocoele
- vaginal vault prolapse
Urinary retention may occur acutely following operation but not usually a chronic complication
What happens during follicular phase?
- Initial fall in oestrogen and progesterone triggering menstruation
- steady increase in FSH and LH, and steady increase in oestrogen
FSH and LH complete first meiotic division to form secondary follicle
Oestrogen thins cervical mucus and stimulates endometrial thickening
As it nears completion, control of FSH/LH by oestrogen switches to positive feedback and there is a surge
- LH - greatest and stimulates ovulation
- FSH - occurs 12-36 huours after LH surge
What happens during luteal phase?
Always 14 days
Fall in FSH, LH and oestrogen, increase in progesterone which increases endometrial glandular secretions and vascularity (preparing it for implantation)
If fertilisation doesn’t occur, corpus luteum degenerates and progesterone decreases
If fertilisation occurs, embrue produces hCG which maintains corpus luteum, which maintains endometrium
Causes of menorrhagia?
Obesity
Non-organic: DUB, contraception
Pregnancy (miscarriage, ectopic etc)
Systemic: hypothyroid, diabetes, adrenal disease, ITP, von Willebrand, renal, liver disease
Local:
PID, trauma, fibroids, IUD/IUS, cervical ectropion/polyps, cervical/endometrial malignancy, endometrial: hyperplaisia, endometriosis, adenomyosis, polyp
What is DUB?
Anovulatory?
Ovulatory?
Abnormal bleeding in the absence of any underlying pathology
Anovulatory:
Seen at extremes of fertility, assoc w irregular cycles - endometrium not being regularly shed so when bleeds happen they tend to be heavy
Ovulatory:
Poor quality egg and follicle which fails to produce enough progesterone, causing failure to fully shed endometrium
Ix DUB?
It is a diagnosis of exclusion
PV exam
FBC, TFT, LFT, coag
USS, hysteroscopy or endometrial sampling if Hx suggests
Management of DUB?
Symptoms:
- tranexamic acid - bleeding
- mefanamic acid - pain
Periods: 1st - mirena 2nd - COCP 3rd - IM progestogens 4th - GnRH analogues/Danazol - dampen HPA axis and induce menopause
Surgical:
endometrial ablation
hysterectomy
Primary/secondary amenorrhoea?
Causes of each?
Prim: no period by 15, or by 13 in girls with no secondary sex characteristics
- imperforate hymen (normal developement)
- Turner’s (short stature 45XO)
- Testicular feminisation (female phenotype, male genotype)
- anorexia, exercise etc
Secondary: cessation of periods for 3-6 months when previously normal, no pregnancy
- Pregnancy, menopause
- PCOS
- drugs: withdrawal from COCP, recreational, steroids
- stress, weight loss, over exercising, obesity
- Kallman, Turner, Prader Willi
- THYROID, renal, pituitary, haemochromatosis
Causes of oligomenorrhoea?
PCOS
Menopause
Withdrawal from contraception, recreational, steroids
Stress, weight loss, exercise, obesity
Ix a/oligo-menorrhoea?
PREGNANCY
FSH, LH, oestrogen, progesterone, prolactin, TFT, U&E, coeliac
Low FSH/LH = pituitary cause
High = ovarian cause
Rotterdam criteria?
Oligomenorrhoea and/or anovulation
Hyperandrogenism (acne, hirsutism, acanthosis nigricans)
Ovaries:
- 12+ follicles in each ovary (2-9mm diameter) or ovarian volume >10ml
Tests to do for PCOS?
Normal amenorrhoea tests
Plus:
- fasting glucose/OGTT
- fasting lipids
- pelvic USS
Menegement PCOS hirsutism?
PCOS infertility?
General: Lifestyle & monitor for diabetes, HTN, hyperlipidaemia
Hirsutism:
- COCP
- topical eflornithine
Infertility:
- weight reduction
- Letrozole or Clomifene (stimulates ovulation)
- Metformin
- gonadotrophins
- IVF
Causes of intermenstrual bleeding?
Pregnancy
Hormonal contraception
Infection (chlamydia/PID)
Cervical (ectropion, polyps, carcinoma)
Causes of post-coital bleeding?
Vaginitis (any cause)
Infection (chlamydia)
Endometrial (carcinoma)
Cervical (ectropion, polyp, malignancy)
Causes of postmenopausal bleeding?
Oestrogen withdrawal Vaginal (atrophy, malignancy) Cervical (polyp, malignancy) Uterine (hyperplasia, malignancy, polyp, fibroid) Ovarian (malignancy - theca cells)
Depot:
- MOA? Length of cover?
- Pearl?
- CI?
- Risks?
- initiating?
Inhibits ovulation - provides cover for 12-14 weeks
Pearl index 0.3%
CI:
- BREAST CANCER
- cardiac disease
- undiagnosed vaginal bleeding
Risks:
- osteoporosis (avoid in young if possible)
- weight gain
- delay in return of fertility (10 months)
- irregular bleeding (settles with time)
Cover with condoms unless <5 days of cycle or TOP, and <21 days post partum
Copper coil:
- MOA? Length of cover?
- Pearl?
- CI?
- Risks?
- initiating?
Prevents fertilisation - can leave in for 5-10 years
Pearl 0.5%
CI:
- peptic ulcer disease
- PID
- Abnormal uterine anatomy
- endometrial/cervical cancer
- Pregnancy - risk of ectopic
SE:
- prolonged, heavy periods
- pain, infection, uterine perforation
Initiating:
- within first 7 days of period or up to 5 days after UPSI/ovulation
- immediately after TOP
- <2 days or >4 weeks post-partum
Mirena:
- MOA? Length of cover?
- Pearl?
- CI?
- Risks?
- initiating?
Prevents implantation
Can stay in for 5 years
Pear 0.2%
CI:
- same as IUD
Risks:
- irregular menstrual bleeding (usually becomes lighter with most becoming amenorrhoeic)
Initiating:
- any time if not pregnant needs 7 days cover
- <2 days or >4 weeks post-partum
- Immediately after TOP
Implant:
- MOA? Length of cover?
- Pearl?
- CI?
- interactions?
- Risks?
- initiating?
Inhibits ovulation
3 years
0.07
CI:
- Breast cancer
- IHD
- unexplained vaginal bleeding
- liver cirrhosis
Interactions:
Enzyme inducers like rifampicin, phenytoin; and obesity - need to change earlier
Problems:
- Irregular bleeding
- Headache, nausea, brest pain (progestogen effect)
Initiating:
- No cover if <5 days of cycle, <21 days post-partum, <5 days post TOP
- otherwise 7 days cover
Transdermal patch:
- regimen?
- how many days off before efficacy lost?
- Problems?
Patch applied for 1 week, 3 weeks in a row, then a week off (can be worn for 9 days max)
2 days
Obesity - reduced efficacy
Breast pain, nausea, painful periods
Thrombosis risk
Vaginal ring:
- regimen?
Ring inserted for 21 days followed by 7 day ring free period
COCP
- MOA?
- initiating?
- after emergency contraception?
- Benefits?
inhibits ovulation
Starting:
- <5 days no cover
- > 5 days, 7 days cover
- Can be started immediately after TOP, or 3 weeks post-partum if not breast feeding (CI in breast feeding)
Immediately after levonelle
5 days after EllaOne
Benefits:
- improves acne
- improves premenstrual symptoms
- protects against ovarian, endometrial and colorectal cancer
SE of COCP?
Minor:
- increased BP, mood swings, N&V
Major:
- Increased VTE risk (>35, smoking, immobility, long haul, puerperium, high altitude >1 week)
- Increased CVD risk
- Increased risk of breast and cervical cancer
What are the absolute CI for COCP?
>35 smoking 15 a day Migraine with aura Hx VTE or IHD/stroke Breastfeeding <6 weeks puerperium HTN >160/110 Current breast cancer Major surgery with prolonged immobilisation Antiphospholipid syndrome Liver cirrhosis/cancer
COCP missed pills?
Illness?
1 missed, <48 hours - take the missed pill and carry on (even if it means 2 in a day)
2+ missed - take the most recent pill (even if it means 2 in a day), disregard other previous ones, continue with pack
If missed in:
- day 1-7: 7 days cover and emergency contraception
- day 8-14: if pills are missed after 7 consecutive days of contraception then no EC needed*
- day 15-21: finish pills in current pack and omit pill free interval
*(theoretically could take 7 days on 7 days off with no issue)
illness:
- vomiting <2 hours - take again
- Take again it more than 24 hours of diarrhoea
POP:
- MOA?
- Initiation?
- CI?
- SE?
- when is it generally used?
Inhibits ovulation and thickens cervical mucus
Initiating:
- immediate protection if <5 days
- 2 days protection if >5 days
- immediate protection if going straight on from day 21 of COCP
CI:
- breast cancer
SE:
- irregular bleeding, headaches
Generally used when COCP CI (e.g. breast feeding, >35 and smoking)
POP:
- missed pills?
- illness?
- interactions?
Take at same time every day - no pill free break
If <3 hours late, no cover
If >3 hours late, take missed pill ASAP and cover for 2 days
P450 inducers reduce effectiveness
Levonelle:
- what is it? MOA?
- timing and how many times per cycle?
- vomiting?
- Efficacy?
- Cautions?
- starting hormonal contraceptives afterwards?
Levonorgestrel - high dose progesterone - inhibits ovulation and stops implantation
Up to 3 days after UPSI, many times per cycle
Take again if vomit within 2 hours
84% effective in 72 hours
Obesity, enzyme inducers
Can start contraceptives immediately
Why is injection contraceptive contraindicated 50+ y/o?
Osteoporosis
Are progestogen-only contraceptives safe alongside HRT?
yes
What contraceptive is the only one capable of being part of HRT?
Mirena
Male patient on anti androgen treatment such as GnRH analogues (goserilin), oestradiol, finasteride, cyproterone - does he need contraception?
Yes
Unexplained vaginal bleeding is a CI for what contraceptives?
IUS and IUD
How long are Kyleena and Jaydess effective for?
Jaydess - 3 years
Kyleena - 5 years
Is age a CI for any contraceptive?
Usually no - apart from
> 35 and smoking 15/day CI for COCP
> 40 UKMEC 2 for COCP
> 45 UKMEC 2 for depo
STOP injectable contraceptive 50+, osteoporosis
Why might COCP be used in perimenopausal women?
Contraceptive, helps maintain bone mineral density, may help reduce menopausal symptoms
What contraceptives are preferred in epilepsy?
Depo, IUD or IUS
Lamotrigine:
- all bar COCP
POP post-partum?
Start from 21 days, barrier for 2 days
COCP post-partum?
NOT <6 weeks if breastfeeding
CAN give >6 weeks, even if breastfeeding (UKMEC 2), although it can reduce breast milk production
If not breastfeeding, can start from day 21
If on day 21, immediate contraception
If after day 21, barrier for 7 days
When can IUS/IUD be inserted post-partum?
<2 days or >4 weeks
Lactational amenorrhoea as contraception?
98% effective in first 6 months providing fully breastfeeding with no supplementation and remains amenorrhoeic
Contraception for a woman taking testosterone to become a man?
Cu IUD, condoms, or any progesterone-only contraception
IUD/IUS and ectopics?
The proportion of penalties that are ectopic is increased
BUT the absolute number of ectopics is reduced compared to a woman not using contraception
If breastfeeding - hormonal emergency contraceptive?
Levonelle preferred as ullipristal requires you to take a break from breastfeeding for a week
Levonelle in obesity?
Double dose
If vomiting within 3 hours of taking emergency contraceptive?
Repeat dose
If a POP contains desorgestrel - missed pill?
12 hour window instead of 3 hour
How long after stopping COCP are women amenorrhoeic?
Up to 3 months
COCP and surgery?
Stop 4 weeks before, restart 2 weeks after
POP may be used
EllaOne:
- what is it? MOA?
- When can it be used?
- How many times per cycle?
- CI?
- starting contraceptives?
- breastfeeding?
Ullipristal acetate - progesterone receptor modulator, inhibits ovulation
Up to 5 days post intercourse
> 1 time
Asthma
Restart contraceptives 5 days after
Take a 1 week break in breastfeeding
Cu-IUD as an emergency contraceptive:
- when?
- what may be given at the same time?
up to 5 days post-UPSI
OR
>5 days if <5 days post expected ovulation
Prophylactic abx if at risk of STI
Changes in circulating oestrogen post-menopause?
E2 levels reduced as mainly made from theca cells in ovaries
E1 proportion increases, produced by adipose/adrenals
Long term complications of menopause?
Osteoporosis
Increased risk of cardiovascular and cerebrovascular disease
What is adenomyosis?
Features?
Ix?
Management?
Presence of endometrium in myometrium
Dysmenorrhoea
Menorrhagia
enlarged, boggy uterus
Ix: MRI
Rx:
- GnRH analogues
- Hysterectomy
General advice for menopause? Non-HRT symptomatic relief options for: - vasomotor symptoms? - vaginal dryness? - psychological?
Weight loss, smoking cessation, complementary therapies
Vasomotor: fluoxetine, citalopram, velafaxine, clonidine
Vaginal dryness:
- topical oestrogen (can be used alongside HRT)
- vaginal lubricant or moisturiser
Psych: CBT, antidepressants, self-help
When should perimenopausal women be referred to secondary care?
Inability to control symptoms
ongoing side effects
Unexplained vaginal bleeding
Contraindications for HRT?
- current/past breast cancer
- any oestrogen-sensitive cancer
- undiagnosed vaginal bleeding
- untreated endometrial hyperplasia
Sequential HRT: who, regimen and time limit?
Used in perimenopausal women with a uterus
Give oestrogen for 28 days and progesterone for last 14
Used for a maximum of 2 years
Continuous HRT: who?
Used in postmenopausal women with a womb, or peri- who have used sequential for 2 years already
First line for perimenopausal women who want a bleed free HRT regimen?
Oestrogen only + mirena
Risks of HRT:
- VTE?
- Stroke?
- Endometrial Ca?
- Ovarian Ca?
- CVD?
- Dementia?
VTE: higher risk in all but highest in combined and in first year of treatment. Lowered with exercise and transdermal application
Stroke: higher is in all, no difference between regimens
Endometrial: Only in women with uterus, higher in sequential but eliminated by continuous
Ovarian: Small increased risk with all, eliminated when stopped
CVD: increased risk of combined started >10 years after menopause
Dementia: Increased risk of alzheimers if started over the age of 50
What is premature ovarian failure? Most common cause? Causes of primary ovarian failure: - autoimmune? - chromosomal? - other?
Menopause <45 years old
Idiopathic - most common, often familial
Primary ovarian failure:
- autoimmune - hypothyroidism, addisons, diabetes, SLE, RA
- chromosomal - turners, down’s
- other - resistant ovary syndrome (FSH resistance)
Causes of secondary ovarian failure:
- drug-induced?
- surgical?
- infective?
Chemo/Radiotherapy
Bilateral oophorectomy
TB/Mumps
Features of premature ovarian failure?
Tests?
Management?
Same as menopause - hot flushes, night sweats, infertility
Tests:
- FSH and LH >40 on 2 occasions 6 weeks apart
- Oestradiol <100
Management:
<52: HRT or COCP
>52: HRT
Hormone replacement essential to reduce risk of long term complications
If IUD in situ whilst pregnant?
Remove after 12 weeks
Presentation of ectopic? Findings on exam? What not to do? Where are they usually? Potential natural histories?
Pelvic/abdo pain, bleeding, shoulder tip pain or pain on urination/defaecation (if peritoneal bleeding)
Abdo tenderness
Cervical excitation
DO NOT feel for adnexal mass if suspecting ectopic - risk of rupture
Most common in ampulla
Highest risk of rupture in isthmus
3% in ovary, cervix or peritoneum
Tubal abortion
Tubal absorption
Tubal rupture
Ix for ectopic?
PREGNANCY TEST
TVUSS
Criteria for management of ectopics:
- expectant?
- medical?
- surgical?
Expectant:
- size <35mm, asymptomatic, no heart beat
- hCG <1000
- if another intrauterine pregnancy
- measure bHCG 48 hours later, and if rise or symptoms manifest then intervention performed
Medical:
- size <35mm, no heart beat, no significant pain
- hCG <1500
- NOT if another intrauterine pregnancy
- give the patient methotrexate, and must be willing to attend follow up
Surgical:
- if above conditions not met
- hCG >1500
- If another intrauterine pregnancy
- salpingectomy or salpingotomy
Complete and partial mole?
Management?
How long before getting pregnant?
Complete: sperm duplicates in an empty egg - diploid but no foetal parts
Partial: haploid egg fertilised by 2 sperm, or 1 sperm which duplicates - triploid, has foetal parts
Surgical evacuation of uterus and follow up hCG testing
DO NOT get pregnant for 12 months
Bleeding in first trimester if:
- <6 weeks?
- 6+ weeks or uncertain gestation?
If NO PAIN, then manage expectantly and repeat pregnancy test in 7-10 days. Return if pain and if pregnancy test still positive
If negative, miscarriage.
If 6+ weeks or uncertain gestation, refer to EPAU
What is primary and secondary dysmenorrhoea?
Management of each?
Primary:
- pain begins hours before of after bleeding with period. Suprapubic cramping which can radiate to thighs
- usually begins within 1-2 years of menarche
Rx:
1. Ibuprofen/mefanamic acid
2. COCP
Secondary:
- develops many years after menarche
- pain starts 3-4 days before bleeding
- causes: adenomyosis, endometriosis, PID, Cu-IUD, fibroids
- Refer to gynae
FSH/LH in turner’s syndrome?
Raised
Primary gonadal dysgenesis
What happens in ovarian hyper stimulation syndrome?
Multiple cysts form, causes systemic leaky capillaries with fluid shifting into extravascular space. This results in vomiting, diarrhoea, ascites etc
Comps: hypovolaemic shock, AKI, venous/arterial thrombosis
Management:
- fluid and electrolyte replacement
- anticoagulation
- ascites paracentesis
- TOP to prevent further hormonal imbalance
How often should HIV+ women have cervical smears?
Annually
Woman who gets bloating, spasmodic iliac fossa pain and some constipation around periods?
IBS
Abdo pain, bloating, change in bowel habits
5 female factors which warrant early referral to infertility clinic?
5 male factors?
Female:
- age >35
- amenorrhoea
- previous pelvic surgery
- previous STI
- abnormal genital examination
Male:
- previous surgery on genitalia
- previous STI
- varicocele
- significant systemic illness
- abnormal genital exam
When should you not do expectant management for miscarriage?
- Increased risk of haemorrhage (e.g. coagulopathy, unable to have transfusion)
- Previous adverse/traumatic experience with it
- Infection
3 components of RMI for ovarian cancer?
Menopausal status
CA125
USS findings
How do clomifene and metformin work in PCOS in helping fertility?
Clomifene - SERM that causes GnRH release from hypothalamus thus increasing LH/FSH
Metforming - insulin resistance causes hyperinsulinaemia thus hyperandrogenism which arrests antral follicular development. Treats insulin resistance
Woman due a smear when pregnant?
Reschedule until at least 3 months post-delivery
Initial investigations for urinary incontinence?
If they have post-void symptoms (feeling of incomplete emptying)?
If unsure what type of incontinence?
- bladder diary 3 days
- pelvic exam to exclude prolapse and pelvic floor muscle weakness
(remember neuro exam S2-S4!!!) - Urinalysis
Post-void:
- post-void residual
If unsure what type:
- urodynamic studies
Cystoscopy may also be used
Management when urge incontinence is predominant?
- bladder retraining at least 6 weeks
- Antimuscarinics (oxybutinin, darifenacin, tolterodine)
- Mirabegron
- Botox
(desmopressin for nocturia)
Management when stress incontinence is predominant?
- Pelvic floor exercises for at least 3 months, incontinence ring
- vaginal oestrogen (if post-menopausal)
- Surgical - colposuspension/fascial sling
- duloxetine - if deny surgery
If someone has treatment for CIN when should their next smear be?
6 months later
52 y/o woman has been amenorrhoeic for 3.5 years (since 3 months after her Mirena coil insertion) and presents with 3 days vaginal bleeding and 2 episodes of postcoital bleeding. Management?
Refer to PMB clinic for USS/endometrial biopsy
Woman shows up for cervical screening but has symptoms of intermenstrual bleeding and postcoital bleeding for the past 2 months - what should you do?
Don’t do smear, refer straight to gynae (not colposcopy)
Screening is for asymptomatic patients
Causes of overflow incontinence in women?
Nerve damage (diabetes, alcoholism, surgery)
Neoplasm
Why does PCOS increase risk of endometrial cancer?
oligo/a-menorrhoea with pre-menopausal levels of oestrogen promotes hyperplasia
Diagnostic criteria for hyperemesis?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte disturbance
Chlamydia type of bacteria?
Ix?
Rx?
Gm -ve intracellular
M: MSSU
F: swab
for PCR/NAAT
Rx: Doxy 1 week
or Azith 1g 1 dose if pregnant
Gonorrhoea bacteria type?
Ix?
Rx?
Gv -ve diplococci
M: MSSU
F: swab
for PCR/NAAT
Rx: 1g Ceftriaxone IM
Genital herpes Ix?
Rx?
If pregnant/labour?
Swab base of ulcer for PCR (50% HSV1 and HSV2)
Rx: analgesia and aciclovir
Pregnant - risk of 1st trimester miscarriage
Labour - C section
Trichomonas features?
Rx?
Frothy green discharge
Itch
Strawberry cervix
Metronidazole
Cause of genital warts?
Management?
HPV 6-11
Raised, pale, roughened lesions
If solitary and keritanised - cryotherapy
If multiple or non-keratinised - topical podophyllum
Crabs - features?
Rx?
Parasitic infection
Itch, visible eggs
Malathion
Features of thrush?
Rx?
M: spotty white balanitis
F: thick white discharge, intense itch, white spots on cervix
M & F - swab
Rx: clotrimazole
Bacterial vaginosis features?
Rx?
Fishy discharge
Clue cells
Metronidazole
Syphilis tests?
What stays positive and what stays negative?
Cardiolipin tests - RPR or VLDR
Test for non-specific antibody to cardiolipin
(false positive in APS, pregnancy etc)
Treponema specific antibody - TPHA
After treatment:
VLDR/RPR - are negative
TPHA - remain positive
Pt gets penicillin for syphillis and comes out in a rash a few hours later with fever and tachycardia?
Jarish-Herxheimer reaction
No wheeze or hypotension
Rx: paracetamol
Due to release of endotoxins from dying bacteria
Management if initial infertility investigations reveal mild endometriosis, mild male factor infertility or unexplained?
Try for another year
Ix for suspected vesicovaginal fistula?
Urinary dye studies
Premenstrual syndrome:
- what is it?
- how is it managed (mild, mod severe)?
Anxiety, stress, fatigue, mood swings, bloating and breast pain - comes on in luteal phase of cycle and stops just before menstruation
Mild - lifestyle with frequent small meals with complex carbs
Mod - COCP continuously
Severe - SSRI taken continuously or just during luteal phase
Management of endometrial hyperplasia if simple without nuclear atypic?
If any other type?
High dose progestogens with repeat sampling in 3-4 months, IUS may be used
Any others - Hysterectomy with BSO
Most common complications of TOP?
Infection - 10%
Haemorrhage (1%), most likely >20 weeks gestation
Retained tissue (1%)
Failure (1%)
Cervical injury (1%)
At what CD4+ level should people receive Co-trimoxazole for pneumocystis prophylaxis in HIV?
200
