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PACES management > Gynae > Flashcards

Gynae Flashcards

1
Q

Miscarriage: Investigations

A
  • urine pregnancy test
  • speculum (is cervical os open?)
  • bimanual (ectopic?)
  • TVUSS
  • endocervical/ high vaginal swab
  • FBC, CRP
  • uirne dip/ MSU
  • G&S (RhD -ve?)
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2
Q

Management of threatened miscarriage

A

if woman has vaginal bleeding + confirmed intrauterine pregnancy with foetal HR

  • return for further assessment if bleeding gets worse/ persists beyond 14 days
  • routine antenatal care if bleeding stops
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3
Q

when should you use expectant management?

A

for 7-14 days as FIRST LINE in women with confirmed miscarriage

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4
Q

when should you explore other options?

A
  • inc risk of haemorrhage (e.g. late first trimester)
  • previous adverse event ass/ w/ pregnancy
  • inc risk from haemorrhage effects (e.g. unable to have blood transfusion)
  • evidence of infection
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5
Q

what do you offer if expectant management is not appropriate?

A

medical management

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6
Q

what is the follow up to expectant management?

A
  • take a pregnancy test after 3 weeks

- return if positive

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7
Q

when do you offer a repeat scan (7-14 days) after expectant management?

A
  • if bleeding/ pain has not started (suggests miscarriage has not begun)
  • persisting/ increasing bleeding and pain (incomplete miscarriage?)
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8
Q

what do you offer for medical management for miscarriage?

A

vaginal misoprostol (can offer oral)
repeated on day 3 if expulsion is incomplete
- bleeding not started within 24 hours = come back
- offer pain release and anti-emetics
- inform pt what to expect (vaginal bleeding, pain, diarrhoea, vomiting)
- take preg test 3 weeks after
- 10% failure rate

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9
Q

What is surgical management of miscarriage?

A
  • manual vacuum aspiration under local anaesthetic
  • surgical management in theatre under general
  • vaginal/ sunlingual misoprostol used to ripen cervix/ facilitate cervical dilatation
  • anti-D prophylaxis to all rhesus-negative women undergoing surgical management
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10
Q

Counselling: risk factors for miscarriage

A
  • advanced maternal age
  • previous miscarriages
  • chronic conditions (e.g. uncontrolled diabetes)
  • uterine or cervical anomalies
  • smoking
  • alcohol and illicit drug use
  • underweight/ overweight
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11
Q

how do you break the bad news?

A
  • explain diagnosis
  • reassure that this is common and under reported
  • risk increases with age
  • most of the time there is no cause
  • explain management options (expectant, medical, surgical)
  • if medical explain what to expect (pain, bleeding, nausea)
  • antiemetics and pain relief
  • advise pregnancy test after 3 weeks
  • safety net: return is symptoms get worse, bleeding persists after 7-14 days
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12
Q

investigations for recurrent miscarriages

A
  • screen for APL (lupus anticoagulant, anti-cardiolipin, diagnostic = 2 positive results at least 12 weeks apart)
  • cytogenetic analysis (of products of conception in last miscarriage, of partners peripheral blood)
  • TVUSS for uterine abnormalities
  • screen for inherited thrombophilia (e.g. factor V leiden)
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13
Q

management of recurrent miscarriages

A
  • APL: low dose aspirin + LMWH in future pregnancies reduces risk of miscarriages
  • if abnormal parental genetics –> clinical geneticist referral
  • cervical issues may be treated with cerclage
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14
Q

Counselling: recurrent miscarriages

A
  • after 3 miscarriages, there are grounds for further investigations
  • explain inv that will be requested (blood tests: clotting, cytogenetics, APL screen and USS)
  • if abnormality detected, there may be tx options to improve chances of future successful pregnancies
  • but explain good chance that the results will be inconclusive
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15
Q

ectopic pregnancy investigations

A
  • ABCDE
  • urine pregnancy test
  • bimanual
  • speculum
  • bloods (serum bHCG, FBC, G&S)
  • TVUSS
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16
Q

which patients are suitable for expectant management of ectopic pregnancies?

A
  • haemodynamically stable, asymptomatic
  • size <30mm
  • no foetal heartbeat
  • serum nCG < 200 IU/L and declining
  • compatible if there is another intrauterine pregnancy
  • pt should have serial hCG measurements until levels are undetectable
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17
Q

What should you say to patients undergoing surgical or medical management of ectopic pregnancy?

A
  • advice on how to contact HCP if needed

- when to get help in an emergency

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18
Q

what do you offer for medical management of ectopic pregnancy?

A

IM methotrexate first line

if able to attend follow up and meet criteria

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19
Q

what are the criteria for medical management of ectopic pregnancy?

A
  • no significant pain
  • unruptured ectopic pregnancy
  • with adnexal mass <35mm
  • no visible heart bear
  • serum b-hCG < 1500 iU/L
  • no intrauterine pregnancy (confirmed by USS)
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20
Q

what is the follow up information for pt after medical management of ectopic pregnancy?

A
  • take 2 serum hCG measurements at days 4 and 7
  • take 1 serum hCG per week until negative result
  • avoid sex during tx
  • avoid conceiving for 3 months after methotrexate
  • avoid alcohol and prolonged exposure to sunlight
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21
Q

when do you offer surgical management as first line of ectopic pregnancy?

A
  • unable to return for follow up
  • significant pain
  • adenexal mass >35mm
  • ectopic pregnancy with foetal heartbeat visible of USS
  • serum b-HCG> 5000 iU/L
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22
Q

what operation if performed for surgical management of ectopic pregnancy?

A
  • laparoscopic if poss
  • offer salpingetctomy if other risk factors for infertility
  • consider salpingotomy if there are risk factors for infertility or contralateral tube damage
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23
Q

what warning should you say regarding women undergoing salpingotomy?

A

1/5 women who have salpingotomy need further tx

methotrexate and/or salpingectomy

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24
Q

what is the follow up for salpingotomy?

A
  • 1 serum hCG at 1 week

- then serum hCG per week until -ve test result is obtained

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25
Q

what is the follow up for salpingectomy?

A

urine pregnancy test at 3 weeks

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26
Q

when can you offer a choice of either methotrexate or surgery?

A 
if b-HCF is 1500-5000 iU/L
and
- no significant pain
- unruptured ectopic pregnancy
- adnexal mass <35mm
- no visible heartbeat
- no intrauterine pregnancy identified on USS
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27
Q

what is important to note about methotrexate?

A

carries a greater risk of urgent re-admission

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28
Q

what should you offer Anti-D prophylaxis?

A
  • all RhD-negative women who have a surgical management of ectopic pregnancy or miscarriage
  • do not do Kleihauer test
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29
Q

when do you not offer anti-D prophylaxis?

A
  • solely medical management
  • threatened miscarriage
  • complete miscarriage
  • pregnancy of unknown origin
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30
Q

Counselling: risk factors for ectopic pregnancy

A
  • PID
  • smoking
  • IUD/IUS
  • assisted reproductive technology
  • tubal surgery
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31
Q

PACES counselling: what do you need to explain in general

A
  • explain diagnosis (implantation of a pregnancy outisde the womb, meaning its not viable)
  • explain risks of ectopic (damage to surrounding structures, bleeding and rupture)
  • explain tx options available are based on USS and level of pregnancy hormone in blood
  • explain tx options
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32
Q

how would you explain medical management?

A
  • explain administration (1 x IM injection)
  • manage expectations (tummy pain, nausea, diarrhoea for few days)
  • can go home after injection but will need to come back a couple of times over next week for blood test
  • avoid sex during tx
  • don’t conceive for 3 months
  • avoid drinking alcohol and excessive exposure to sunlight
  • explain may be a risk of tx failure that requires further intervention
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33
Q

what should you explain regarding surgical management?

A
  • salpingectomy is best procedure
  • salpingotomy can be considered if fertility issues or problems with contralateral tube
  • salpingotomy has 1/5 risk of requiring further intervention
  • reassure that fertility isn’t drastically reduced by salpingectomy vs salpingotomy
  • explain follow up
  • discuss ongoing contraception
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34
Q

Clinical presentation of molar pregnancy (gestational trophoblastic disease)

A
  • irregular vaginal bleeding
  • hyperemesis
  • large for dates uterus
  • early failed pregnancy
  • HTN
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35
Q

investigations for molar pregnancy

A
  • urine pregnancy test
  • bimanual (large for dates uterus)
  • speculum
  • USS (snowstorm or cluster of grapes)
  • serum b-hCG = v high for gestation
  • FBC, G&S, TSH (hCG can mimic TSH)
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36
Q

1st line management for molar pregnancy?

A
  • suction curettage (for complete and partial moles)
  • done under GA and cervix may be ripened before procedure
  • perform urine pregnancy test 3 weeks after medical management
  • anti-D prophylaxis required
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37
Q

when should you send for histological assessment?

A
  • histological assessment of material obtained from medical/ surgical management of all failed pregnancies = to exclude trophoblastic disease
  • don’t need to do it after terminated of pregnancy
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38
Q

where should patients be followed up?

A
  • trophoblastic screening centre
  • follow up is individualised
  • depends on hCG level at 56 days of pregnancy event
  • if reverted to normal: follow up 6 months from date of uterine evacuation
  • not reverted to normal: follow up 6 months from normalisation of hCG
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39
Q

what is the management of gestational trophoblastic neoplasia?

A
  • single or multi-agent chemo (methotrexate may be used)

- tx carries a risk of earlier menopause and secondary cancers

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40
Q

what information should you provide regarding future pregnancies?

A
  • do not conceive until follow up is complete
  • barrier contraception until b-HCG normalises
  • COCP can be used once normalised
  • avoid IUDs until hCG has normalised (risk of uterine perforation)
  • if receiving chemo, do NOT conceive for 1 year after completion of tx
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41
Q

Counselling: risk factors for molar pregnancy

A
  • advanced maternal age (or younger than 20)
  • prior molar preganncy (1-2% risk of recurrence)
  • prior miscarriages
  • asian heritage
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42
Q

how do you break the bad news?

A
  • explain the diagnosis (when foetus doesn’t form properly, baby doesn’t develop, instead there is an irregular mass of pregnancy tissue)
  • explain risks (improtant to treat because it can invade and damage other tissues)
  • explain immediate management (suction curettage)
  • explain follow up (referall to trophoblastic screening centre to monitor pregnancy hormone levels)
  • molar pregnancy does not affect fertility
  • do not try to get pregnant until after follow up
  • further treatment may be necessary
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43
Q

causes of amenorrhoea or oligomenorrhoea

A
  • low BMI
  • hypothalamic lesions (e.g. glioma)
  • hyperprolactinaemia/ prolactinoma
  • POF
  • PCOS
  • Asherman’s
  • cervical stenosis
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44
Q

investigations for secondary amenorrhoea

A
  • urinary/serum hCG
  • gonadotrophins (low = hypo, high = ovarian cause)
  • prolactin
  • androgen (high in PCOS)
  • oestradiol
  • TFTs
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45
Q

what is the Rotterdam criteria for PCOS?

A

at least 2 of:

  • oligo/anovulation (>2 years)
  • clinical or biochemical features of hyperandrogenism
  • polycystic ovaries on US
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46
Q

investigations of PCOS

A
  • hormone profile: oestrogen, progesterone, FSH, LH, free testosterrone, LH:FSH index
  • prolactin
  • TFTs
  • cortisol
  • OGTT
  • TVUSS
  • BMI
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47
Q

management of menstrual issues in PCOS

A
  • COCP

- cyclial oral progesterone

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48
Q

management of subfertility in PCOS

A
  • encourage weight loss
  • clomiphene
  • laparoscopic ovarian drilling (destroys ovarian stroma, may prompt ovulatory cycles)
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49
Q

what does clomiphene do?

A
  • 1st line in women with normal BMI
  • induce ovulation if subfertility is issue
  • used for up to 6 months
  • inc risk of multiple pregnancy
  • selective oestrogen receptor modulator (SERM)
  • can be given with/without metformin
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50
Q

what advice would you give regarding managing complications of PCOS?

A
  • lifestyle advice
  • weight reduction
  • treatment of hirsutism/androgenic symptoms
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51
Q

how would you treat the hirsutism/ androgenic symptoms?

A
  • topical eflornithine cream
  • co-cyprindol (dianette)
  • cyproterone acetate (antiandrogen)
  • metformin
  • GnRH analogues
  • surgical tx (laser, electrolysis)
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52
Q

complications of PCOS

A
  • metabolic syndrome (DM, heart disease)
  • sleep apnoea
  • CVD
  • endometrial cancer (recommended withdrawal bleed every 3-4 months, endometrial thickness >7mm may be pathological)
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53
Q

summary of management of PCOS

A
  • general: weight reduction, COCP to regulate cycle
  • Hirsutism + ACNE: COCP, co-cyprindiol, topical efloenithine cream for hair removal
  • Infertility: weight loss first, then clomiphene +/- metformin, surgical laparoscopic ovarian drilling, gonadotrophins
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54
Q

PACES counselling for PCOS

A
  • risk factors: FH, obesity
  • explain diagnosis (disease with no clear cause, leads to abnormalities in hormone levels)
  • explain very common 1/10
  • explain main consequences (irregular periods, subfertility, metabolic syndrome, CVD, acne)
  • explain management tailored to pt biggest concern
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55
Q

how to diagnose premenstrual syndrome?

A

symptom diary over 2 cycles

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56
Q

conservative measures for premenstrual syndrome

A
  • stress reduction
  • alcohol and caffeine limitation
  • exercise
  • vitamins, St John’s wort
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57
Q

what is mild premenstrual syndrome? How to manage?

A

no impact on personal, social, professional life

- lifestyle advice (diet, exercise, sleep, smoking, alcohol cessation)

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58
Q

what is moderate premenstrual syndrome? Tx?

A

some impact on personal, social, professional life

  • COCP (Yasmin best evidence based)
  • Paracetamol/ NSAIDs
  • referral for CBT
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59
Q

define severe premenstrual syndrome. Tx?

A

causes withdrawal from social, professional activities. prevents normal functioning

  • Tx same as moderate PMS
  • SSRI (initially trial for 3 months)
  • GnRH analogues, transdermal oestrogen, suregry
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60
Q

investigations for heavy menstrual bleeding

A
  • FBC
  • coagulation screen if primary menorrhagia or FH of bleeding
  • bimanual (adnexal masses or bulky uterus)
  • speculum (cervical ectropion or polyp)
  • TVUSS
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61
Q

what do you do if you suspect submucosal fibroids, polyps or endometrial pathology?

A
  • offer outpatient hysteroscopy
  • consider biopsy at time of hysteroscopy is high risk
  • if declined, offer pelvic USS
  • if >45 years and suspected intrauterine pathology, do pipelle biopsy
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62
Q

what do you need to consider when deciding management?

A
  • preference
  • comorbidities
  • presence of fibroids/ polyps/ endometrial pathology
  • pressure/ pain symptoms
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63
Q

acute management of heavy menstrual bleeding

A
  • ABCDE
  • fluid resus with IV colloids and blood transfusion
  • correct coagulopathy
  • treat cause
  • ferrous sulphate
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64
Q

if there is no identified pathology, fibroids <3cm or adenomyosis, how do you treat?

A
  1. LNG-IUS
  2. Hormonal: COCP, cyclical oral progestogens. Non-hormonal: tranexamic acid (CI: renal impairment, thrombotic disease), NSAIDS e.g. mefenamic acid
  3. Surgical: endometrial ablation (need contraception), hysterectomy
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65
Q

tx of fibroids >3cm in diamater

A
  • non-hormonal: tranexamic acid, NSAIDs
  • hormonal: LUG-IUS, COCP, cyclical oral progestogens, ulipristal acetate
  • surgical: transcervical resection of fibroids, myomectomy, hysterectomy
  • consider pre treatment with GnRH analogues if fibroids causing distortion of anatomy
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66
Q

GnRH analogue side effects

A
  • hot flushes
  • sweating
  • vaginal dryness
  • muscle stiffness
  • osteoporosis
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67
Q

other potential treatment options

A
  • uterine artery embolisation
  • endometrial ablation (only if family is complete)
  • magnetic resonance-guided focused US (MRgFUS)
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68
Q

PACES Counselling for fibroids

A

risk factors: increasing age until menopause, early puberty, obesity, Afro-Caribbean, FH

  • explain diagnosis (common smooth muscle masses that can cause heavy menstrual bleeding and fertility issues)
  • very common (inc in prevalence with age until menopause)
  • explain management: HMB (LNG-IUS, COCP), fertility (surgery, tranexamic acid), symptomatic (tranexamic acid)
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69
Q

investigations for dysmennorhoea

A
  • bimanual (bulky/boggy uterus?)
  • speculum (infection?)
  • STI screen (PID?)
  • TVUSS (fibroids, adenomyosis, endometriosis)
  • MRI (adenomyosis)
  • diagnostic laparoscopy (endometriosis +/- tx)
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70
Q

tx of dysmenorrhoea

A
  1. NSAIDs
  2. COCP (prevents ovulation, progestogens may be useful to cause anovulation/amenorrhoea)
    - LNG-IUS
    - lifestyle changes (exercise, vegetarian)
    - heat
    - GnRH (useful in short term for symptom control if awaiting hysterectomy)
    - surgery
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71
Q

3 options of emergency contraception and time limit

A
  • Levonorgestrel (within 72 hours)
  • ulipristal (within 120 hours)
  • copper IUD (within 120 hours)
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72
Q

how does levonorgestrel (leveonelle) work? what are the things to remember about it?

A
  • stops ovulation
  • inhibits implantation
  • safe, well tolerated
  • if vomiting occurs within 2 hours, dose should be repeated
  • can be used more than once in a menstrual cycle
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73
Q

how does Ulipristal (EllaOne) work? what do you need to remember with it?

A
  • progesterone receptor modulator
  • inhibits ovulation
  • should not be used with levonorgesterol
  • if pt normally uses hormonal contraception, should restart 5 days after ulipristal
  • caution if severe asthma
  • don’t use more than once in cycle
  • if vomiting within 3 hours of dose, repeat it
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74
Q

what should you give for women weighing >70kg or BMI > 26?

A
  • EllaOne is recommended (continue oral contraception after 5 days)
  • If levonelle is taken, give double dose (3mg) and women should start ongoing contraception immediately
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75
Q

when can the copper IUD be used for emergency contraception?

A
  • ideally within 120 hours of UPSI

- if presenting more than 5 days after, IUD must be fitted up to 5 days after likely ovulation date

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76
Q

how does copper IUD work?

A
  • spermicide
  • prevents implantation
  • prophylactic antibiotics if at high risk of STI
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77
Q

what advice should you give alongside emergency contraception?

A
  • offer STI screen

- advise taking pregnancy test if next period is late

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78
Q

side effects of emergency contraception (not IUD)

A
  • N&V
  • headache
  • breast tenderness
  • abnormal menstrual bleeding
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79
Q

hormones and mechanism of COCP

A

ethinyl oestradiol + progestin

prevents ovulation

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80
Q

how to take COCP

A
  • 1 tablet per day for 3 weeks
  • followed by 1 week off
  • if started on first 5 days of cycle (28 days) = immediate protection
  • caution if woman has shorter cycle
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81
Q

benefits of COCP

A
  • effective if taken properly
  • reversible upon stopping
  • periods lighter, regular, less painful
  • reduced risk of ovarian, endometrial and bowel cancer
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82
Q

disadvantages of COCP

A
  • forgetting to take it
  • no protection against STIs
  • inc risk of VTE, breast cancer, cervical cancer, stroke, IHD
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83
Q

side effects of COCP

A

headache
nausea
breast tenderness

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84
Q

what should you do with COCP if vomit, if having surgery or taking antibiotics?

A
  • if vomit within 2 hours of taking, take another
  • stop at least 4 weeks before surgery
  • antibiotics: take care, extra precautions may be needed, discuss with GP
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85
Q

absolute contraindications to COCP

A
  • <6 weeks postpartum and breastfeeding
  • smoker (>15/day) over age of 35
  • HTN (>160 or >100)
  • current/ past history of VTE
  • IHD
  • history of CVA
  • complicated valvular heart disease (pulmonary HTN, AF)
  • migraine with aura
  • current breast cancer
  • diabetes with complications
  • severe cirrhosis
  • liver tumour (adenoma or hepatoma)
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86
Q

what do you do if you miss 1 pill?

A

take last pill and current pill (even if that means 2 in 1 day)
no other contraception needed

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87
Q

what happens if there are 2 missed pills?

A
  • take last pill and current pill (even if that means 2 in 1 day)
  • then continue taking pills
  • 2 missed in week 1: consider emergency contraception
  • 2 missed in week 2: no need for emergency contraception
  • 2 missed in week 3: finish pills in current pack, start new pack immediately with no pill free break
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88
Q

what hormones are in the POP?

A
  • desogestrel (cerazette)
  • levonorgestrel
  • norethistrone
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89
Q

what is the MOA of the POP?

A
  • thickens cervical mucus

- desogestrel stops ovulation

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90
Q

when is the POP used?

A

only really in women who can’t have COCP

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91
Q

how do you take the POP?

A

1 pill at same time every day
no pill free week
if starting within 5 days of cycle = immediate protection
if starting at any other time, use additional measures for first 48hrs
if switching from COCP, provides immediate protection

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92
Q

benefits and disadvantages of POP

A 
Benefits: doesn't have risk of oestrogen pills
Disadvantages:
- must be taken at same time everyday
- irregular bleeding
- osteoporosis
- ovarian cysts
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93
Q

what to do if there is a missed pill?

A

<3 hours late: continue as normal
3+ hours late: take missed pill ASAP, continue with rest of pack, extra precautions until pill has been taken for 48hrs
- if missed 2+, take last missed pill and next pill, use barrier methods for 48hrs

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94
Q

when might emergency contraception be needed?

A

if UPSI during this interval

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95
Q

side effects of POP

A
  • irregulat vaginal bleeding
  • acne
  • breast tenderness
  • mood changes
  • headache
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96
Q

hormones in combined hormonal transdermal patch

A

norelgestromin + ethinyl oestradoil

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97
Q

how is it applied?

A

applied for 3 weeks (replace patch at end of each week)

take 1 week off (withdrawal bleed)

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98
Q

what do you do if there is a delayed change <48 hours?

A

change immediately

no further precautions

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99
Q

what do you do if there is delayed change >48 hours in week 1 or 2?

A
  • change immediately
  • use barrier contraception for 7 days
  • consider emergency contraception if UPSI within previous 5 days or in extended patch free period
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100
Q

what do you do if there is delayed removal >48 hours in week 3?

A
  • remove immediately
  • apply next patch on usual start date of next cycle
  • no additional contraception needed
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101
Q

what do you do if there is delayed removal at the end of the patch-free week?

A

use barrier contraception for 7 days

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102
Q

pros and cons of patch

A
  • tricycling is possible
  • no increased risk of clots
  • patch adherence and skin sensitivity can be porblem
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103
Q

what hormone is in the mirena (LNG-IUS)?

A
  • progesterone: levonorgestrel
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104
Q

what is the moa of the mirena?

A

thins lining of uterus
prevents implantation
- periods = lighter, less painful
- additional contraception for 7 days after insertion unless inserted in first 7 days of cycle

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105
Q

side effects of mirena

A
  • acne
  • breast tenderness
  • mood disturbance
  • headaches
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106
Q

what is jaydess?

A

smaller form of LNG-IUS
effective for contraception but nor for heavy periods
lasts for 3 years
smaller so easier to put in

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107
Q

What hormone is in the implant?

A

etonogestrel

progesterone

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108
Q

MOA of the implant

A
  • prevents ovulation
  • inserted subdermally into non-dominant arm
  • works for 3 years
  • fertility restored immediately after removal
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109
Q

side effects of implant

A
  • progestogenic side effects (irregular bleeding, mood changes, breast tenderness, nausea)
  • additional contraception needed if not inserted on day 1-5 of menstrual cycle
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110
Q

what can reduce its efficacy?

A

antiepileptic drugs and rifampicin

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111
Q

hormone in the injection (depo-provera)

A

medroxyprogesterone acetate (progesterone)

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112
Q

things to remember about the injection

A
  • lasts for 12-14 weeks

- use contraception for first 7 days unless given during first 5 days of cycle

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113
Q

disadvantages of injection

A
  • can cause weight gain
  • cause reduced bone density, irregular periods
  • may take 6-12 months for fertility to return
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114
Q

Moa of copper coil

A

causes sterile inflammation

spermidicide

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115
Q

side effects of copper coil

A

heavy painful periods
risk of expulsion
infection
perforation

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116
Q

what is the important thing to remember about the copper coil compared to other LARCs?

A
  • all LARCs take 1 week to become effective except copper coil
  • can be inserted at any point in menstrual cycle
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117
Q

PACES counselling for contraception

A
  • key aspects of history (history/ FH of VTE, migraine, cancer, stroke, HTN, menstrual problems e.g. heavy periods)
  • explain contraception can be split into long acting and short acting
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118
Q

fraser guidelines for contraception in <16 year olds

A
  • young person understands professional advice
  • young person cannot be persuaded to inform parents
  • young person is likely to begin or continue having sex with/ without contraceptive treatment
  • unless young person receives contraceptive treatment, their health are likely to suffer
  • ## young person best interests require them to receive contraceptive advice or treatment with or without parental consent
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119
Q

what is laparoscopic sterilisation?

A
  • occludes fallopian tube using filshie clips
  • contraception should be used until next menses after procedure
  • valid consent as leads to permanent loss of fertility
  • high surgical risk = hysteroscopic approach
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120
Q

advice for women considering sterilisation

A
  • irreversible
  • vasectomy is safer, quicker, associated with less morbidity
  • high proportion of women regret it
  • does not protect against STIs
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121
Q

for how long is contraception needed after sterilisation?

A
  • laparoscopic: next menstrual period

- hysteroscopic: 3 months

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122
Q

how is hysteroscopic sterilisation carried out?

A
  • performed as outpatient without GA
  • expanding strings inserted into tubal ostia via hysteroscope
  • induces fibrosis in cornual section of fallopian tube over 3 months
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123
Q

explain the vasectomy

A
  • interrupting vas deferens to provide permanent occlusion

- small risk of scrotal haematoma and infection

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124
Q

when should semen analysis be conducted after vasectomy?

A

12 weeks to confirm the absence of spermatozoa in ejaculate

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125
Q

Termination of pregnancy service providers

A
  • marie stopes UK
  • British pregnancy advisory service (BPAS)
  • GUM
  • family planning clinic
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126
Q

medical management of TOP

A
  • mifepristone (oral) followed by 24-48 hours later by misoprostol (vaginal, buccal, sublingual)
  • suitable at any gestation
  • simple analgesia
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127
Q

where should medical management at 0-9 weeks be carried out?

A
  • administered at home
  • provided patient is easy to follow up and can seek medical attention if necessary
  • bleeding usually followed for up to 2 weeks
  • urine pregnancy test in 2-3 weeks
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128
Q

where should medical management be carried out at 9+ weeks?

A
  • clinical setting (increased bleeding and discomfort)

- repeat doses of misoprostol needed every 3 hours until expulsion (max 5 doses)

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129
Q

what special consideration is needed after 21+6 weeks?

A
  • Feticide (intracardiac KCI injection)

- should be given to eliminate possibility of aborted foetus showing any signs of life

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130
Q

surgical management when less than 14 weeks

A

Vacuum aspiration

  • gently dilating cervix and using vacuum suction to evacuate uterine cavity
  • Local or GA
  • cervix pre-treated with misoprostal
  • prophylactic antibiotics (metronidazole given to reduce infection risk)
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131
Q

what surgical management should be used for more than 14 weeks?

A

Dilatation and Evacuation

  • required good cervical dilatation to remove larger foetal parts
  • misoprostol (3 hours before surgery) to ripen surgery and allow easier dilatation
  • contents of uterus are extracted using aspiration
  • USS needed to confirm evacuation
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132
Q

what are the risk of surgical management?

A
  • failure to end pregnancy
  • haemorrhage
  • infection
  • perforation
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133
Q

what is important to do with all abortion patients?

A
  • discuss insertion of long acting reversible contraception
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134
Q

PACES counselling for TOP

A
  • explain options available based on gestation (medical and surgical)
  • best option dependent on how mnay weeks pregnant they are (higher gestation = more pregnancy tissue)
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135
Q

how would you explain medical management in PACES?

A
  • one pill will be taken by mouth
  • followed by another in 24-48 hours with buccal/ sublingual/ oral
  • bleeding can last about 2 weeks
  • pregnancy test after 3 weeks
  • occasionally unsuccessful and requires surgical removal
136
Q

how do you explain the surgical management of TOP in paces?

A
  • involves gently dilating the cervix and removing the pregnancy tissue using a suction tube
  • only takes about 10 mins
  • may need to ripen the cervix before
  • can be done under general or local
137
Q

subfertility investigations

A
  • blood hormone profile
  • STI screen
  • TVUSS
  • measurement of ovarian reserve
  • tubal assessment
  • semen analysis
138
Q

What do you look at in blood hormone profile?

A
  • look at early follicular phase FSH, LH, oestradiol levels (day 2-3)
  • anti-mullerian hormone (assess ovarian reserve)
  • mid-luteal progesterone (confirm ovulation)
139
Q

what do you look for if they have irregular menstrual cycle?

A
  • TFTs
  • prolactin
  • testosterone
140
Q

other than the STI screen, what other viruses should be tested for if assisted reproductive technology is being considered?

A
  • HIV
  • Hep B
  • Hep C
141
Q

what do you look for with TVUSS?

A
  • assessment of pelvic anatomy
  • antral follicle count (parameter of ovarian reserve)
  • identify pathology
142
Q

what is ovarian reserve?

A
  • remaining number of oocytes in ovaries
  • declines after 35 years
  • can help predict response to ovarian stimulation by ART
  • antral follicle count is good indicator of ovarian reserve
143
Q

what antral follicle count is a good indicator of ovarian reserve?

A 
<4 = poor response
16+ = good response
144
Q

how is the tubal assessment carried out?

A
  • using hysterosalpingography (HSG) using X-ray/ US/ laparoscopy and dye
  • only performed if risk factors for tubal damage
145
Q

how is semen analysis carried out?

A
  • 2 test done 3 months apart
146
Q

what are the options for medical management of subfertility?

A
  • ovulation induction (clomiphene or FSH)
  • intrauterine insemination
  • donor insemination
  • IVF
  • donor egg with IVF
147
Q

when is ovulation induction indicated?

A

if anovulatio (PCOS, idiopathic)

148
Q

when is intrauterine insemination indicated?

A
  • unexplained subfertility
  • anovulation unresponsive to OI
  • mild male factor
  • minimal to mild endometriosis
149
Q

when is donor insemination indicated?

A
  • presence of azoospermia
  • single women
  • same sex couples
150
Q

when is IVF indicated?

A
  • patients with tubal pathology

- patients who underwent treatments with no success

151
Q

when is donor egg with IVF indicated?

A
  • women whose egg quality is poor

- previous surgery/ chemo where ovarian function was affected

152
Q

surgical management options for subfertility?

A
  • operative laparoscopy to treat disease and restore anatomy
  • myomectomy
  • tubal surgery
  • laparoscopic ovarian drilling
153
Q

indication of operative laparoscopy?

A
  • adhesions
  • endometriosis
  • ovarian cyst
154
Q

when might myomectomy help?

A

fibroid uterus

155
Q

when can tubal surgery be used?

A

blocked fallopian tubes amenable to repair

156
Q

when might laparoscopic ovarian drilling be used?

A

PCOS unresponsive to medical treatment

157
Q

PACES counselling: risk factors for subfertility

A
  • advanced maternal age
  • smoking
  • alcohol use
  • obesity
  • irregular periods
  • STI
158
Q

PACES counselling for subfertility

A
  • still chance of getting pregnancy naturally
  • explain you would like to start investigations (blood test looking at hormone levels, USS looking at structure of uterus and follicle count and HSG if risk factors)
  • encourage continuing regular unprotected sex at least every other day
  • management options depending on likely cause of subfertility
159
Q

menopause: diet and lifestyle advice

A
  • stop smoking
  • reduce alcohol consumption
  • normal BMI
  • alternative treatements (no scientific basis): acupuncture, hypnosis, herbal remedies
160
Q

types of HRT

A
  1. oestrogen alone (Elleste Solo)

2. oestrogen with progesterone (Elleste Duet)

161
Q

when should oestrogen alone be given?

A
  • only suitable for women who have had hysterectomy

- if BMI>30, oestrogen only HRT should be given as trandermal patch

162
Q

how should oestrogen with progestogen be given?

A

progestogen necessary to protect endometrium
Cyclical:
- monthly: oestrogen every day of the month + progesterone for last 14 days of month
- three monthly: oestoegn every day for 3 months + progesterone for last 14 days
Continuous:
- always on oestrogen and progesterone

163
Q

when is continuous vs cyclical contraception used?

A

cyclical - peri-menopause

continous - post-menopause

164
Q

routes of HRT

A
  • oral
  • transdermal
  • vaginal creams (if vaginal symptoms)
165
Q

benefits of HRT

A
  • improved vasomotor symptoms, sleep and performance
  • prevention of osteoporosis
  • improved genital tract symptoms (dryness, dyspareunia)
166
Q

what are the risks of HRT?

A
  • breast cancer (to lesser extent, endometrial)
  • CVD
  • VTE
167
Q

side effects of HRT

A
  • oestrogenic: breast tenderness, nausea, headaches

- progestogenic: fluid retention, mood swings, depression

168
Q

absolute contraindications to HRT

A
  • pregnancy
  • breast cancer
  • endometrial cancer
  • uncontrolled HTN
  • current VTE
  • current thrombophilia
169
Q

non hormonal treatments used in menopause

A
  • alpha agonists (e.g. clonidine)
  • beta blockers (e.g. propanolol)
  • SSRIs (e.g. fluoxetine): particularly effective for vasomotor symptoms
  • symptomatic: lubricants, osteoporosis treatments
170
Q

investigations for premature ovarian insufficiency

A
  • LH, FSH, oestrogen, testosterone, TFTs, antral follicle count, anti-Mullerian hormone
  • diagnostic: 2 x FSH results >30 (these should be 4-6 weeks apart)
171
Q

how can people with premature ovarian insufficiency still have children?

A
  • IVF using eggs from donor/ own frozen eggs
  • surrogacy
  • adoption
172
Q

what risks do people with POI have?

A
  • osteoporosis: regular DEXA scans, all should get HRT
  • stroke
  • heart disease
173
Q

summary of lifestyle measures for menopause

A
  • regular exercise
  • weight loss
  • reduce stress
  • sleep hygiene
174
Q

summary of HRT

  • CI
  • No uterus/ uterus
  • RIsks
A

CI: current/ past breast cancer, undiagnosed vaginal bleeding, untreated endometrial hyperplasia
No uterus: oestrogen only (patch if obese)
Uterus: should be given with progesterone component
Risks: VTE, stroke, CHF, breast and ovarian cancer

175
Q

Summary of non-HRT alternatives for menopause

A
  • vasomotor: fluoxetine, citalopram, venlafaxine
  • vaginal dryness: lubricant
  • psychological: self help, CBT, SSRIs
  • urogenital: topical oestrogens, lubricants
176
Q

PACES counselling for menopause

A
  • explain the changes that typically occur at menopause (hot flushes, sexual dysfunction, mood changes)
  • explain lifestyle factors (healthy diet, weight loss, smoking cessation)
  • explain medical options (HRT, SSRIs, topical lubricants/oestrogens) –> tailor to need of pt, explain risks/SEs
  • explain need for contraception (until >1 year amenorrhoeic if >50yrs, until >2 years amenorrhoeic if <50yrs)
177
Q

investigations for BV

A
  • vaginal pH
  • whiff test
  • gram-stain
  • HIV test
  • NAAT
  • VDRL
178
Q

Tx and advice for BV

A
  • oral or IV metronidazole (5-7 days)
  • alternative: topical clindamycin
  • advice: avoid vaginal douching and excessive genital washing
179
Q

risks of BV in pregnancy

A
  • preterm labour

- chorioamionitis

180
Q

what antifungal treatment would you prescribe most women with vulvovaginal candidiasis?

A
  • intravaginal antifungal cream/ pessary (clotrimazole)
    or
  • oral antifungal (fluconazole, itraconazole)
181
Q

what antifungal would you prescribe for women >60?

A
  • oral as easy to administer
182
Q

what antifungal for girls aged 12-15?

A
  • topical clotrimazole 1% applied 2-3 times a day

- do not prescribe intravaginal or oral antifungal

183
Q

what antifungal for pregnant women?

A

intravaginal clotrimazole

do not use oral antifungals

184
Q

what should you prescribe if vulval symptoms are present?

A
  • topical imidazole (clotrimazole, ketoconazole) in addition to an oral or intravaginal antifungal
185
Q

what is recurrent vulvovaginal candidiasis? what should do?

A
  • 4+ episodes per year
  • check compliance with previous treatment
  • confirm initial diagnosis (high vaginal seab)
  • exclude predisposing factors
  • consider using induction-maintenance regime, with daily treatment for 1 week followed by maintenance treatment weekly for 6 weeks
186
Q

advice to give women with thrush

A
  • return if symptoms have not resolved in 7-14 days
  • avoid predisposing factors: using shower gels/fem hygiene products, cleaning vulval area more than once per day, washing underwear in bio washing powder, vaginal douching, wearing tight fitting/non-absorbant clothing
  • wash vulval area with soap substitute
  • use simple emollient to moisturize vulval area
  • consider probiotics orally
187
Q

what about a male sexual partner in a women in thrush?

A
  • do not routinely treat asymptomatic sexual partner

- male partner could get candida balanitis

188
Q

summary of treatment with doses of thrush

A
  • Local: clotrimaxole 500mg PV stat
  • Oral: itraconazole 200mg PO BD for 1 day or fluconazole 150mg PO stat
  • pregnancy: only local treatments
189
Q

PACES counselling for thrush

A
  • risk factors: recent antibiotic use, oral contraceptive, DM, excessive washing
  • explain diagnosis
  • explain tx
  • explain hygiene measures
190
Q

TV ix and tx

A
  • vaginal pH, whiff test, gram-stain, HIV test, NAAT, VDRL

- tx: metronidazole 2g oral single dose

191
Q

chlamydia ix and tx

A
  • Ix: NAAT and swab
  • doxycycline 100mg BD for 7 days (if CI: azithromycin (3 days) or erythromycin (10-14 days) or ofloxacin)
  • in pregnancy: erythromycin, azithromycin
192
Q

advice/ follow up to give people with chlamydia

A
  • avoid sex until treatment has been completed
  • recommend STI screen
  • refer to GUM for partner notification and treatment
  • follow up by 5 weeks
193
Q

gonorrhoea ix and tx

A

Ix: NAAT and swab
1st line: ceftriaxone ig IM + azithromycin 1g oral
- safe to use in pregnancy
- alternative: doxy instead of azithromycin

194
Q

investigations in PID

A
  • FBC, CRP (?infection)
  • endocervical swab (chlamydia and gonorrhoea)
  • high vaginal swab (anaerobes e.g. BV)
  • speculum (looks for signs of inflammation/discharge)
  • bimanual exam (cervical excitation, adnexal massess e.g. tubo-ovarian abscess)
  • blood cultures if febrile
  • detailed sexual history
  • TVUSS (if thinking tubo-ovarian abscess)
195
Q

management of PID

A
  • consider removal of IUD if in situ
  • outpt antibiotic regimen (ceftriaxone 500mg IM, doxycycline 100mg BD for 14 days, metronidazole 400mg BD for 14 days)
  • alternatives: ofloxacin and metronidazole for 14 days
  • if pyrexial or oral management has failed: IV cefoxitin and doxycycline or IV clindamycin and gentamicin)
  • STI screening and contact tracing (azithromycin 1g single dose), advice barrier contraception, counsel small risk of subfertility
196
Q

follow up of PID

A

i- f OP, seen within 72hrs to assess response, if no improvement admit for IV Abx
- further follow up at 2-4 weeks to ensure resolution, reiterate importance of STIs, reassure that if compliant, fertility is not affected

197
Q

complications of PID

A
  • infertility
  • ectopic pregnancy
  • chronic pelvic pain
  • up tp 30% need hopsital admissions
198
Q

PACES counselling for PID

A
  • risk factors: younger women (<25yrs), STI, multiple partners, past PID
  • assess whether severely unwell and needing admission !!
  • explain diagnosis (infection that has spread up to womb)
  • explain risks
  • explain treated with antibiotics (1 injection, 2 tablets taken for 14 days)
  • do not have sex until course is complete
  • recommend full STI screen, encourage contact tracing
  • discuss contraception (consider removal of IUD)
  • follow up in 3 days and 2-4 weeks
199
Q

genital warts Ix and Tx

A

Ix: clinical diagnosis, viral culture, HSV PCR

  • oral aciclovir
  • symptomatic treatment (e.g. paracetamol, ibruprofen)
200
Q

genital warts treatment

A
  • OPTIONAL because lesions are benign
  • cyrotherapy (if single and large)
  • topical podophyllotoxin (if multiple and non-keratinised)
  • alternative: imiquimod, sinecatechins
  • surgical techniques
201
Q

syphillis IX

A
  • serology
  • direct detection of T. pallidum from infectious lesions (microscopy or PCR)
  • non-treponemal serological tests: Rapid plasma reagin (RPR), veneral disease reference laboratory (VDRL) –> show rising titres during acute/active infection that drop with time/following treatment, useful for monitoring tx
  • other treponemal tests: enzyme or chemiluminescene immunoassays (EIA/CLIA) or Treponema pallidium particle or haemagglutination assau (TPPA/ TPHA). May be negative in early disease, repeat at 4-6 weeks
202
Q

management of syphillis

A

IM benzathine penicillin

2nd: doxycycline

203
Q

what warning comes with syphillis treatment and how do you prevent this?

A

Jarisch-Herxheimer reaction
oral prednisolone as a preventative measure
N.B. contact tracing

204
Q

classification of urinary incontinence

A
  • overactive bladder/ urge incontinence: detrusor overactivity
  • stress incontinence: leaking small amounts when coughing/laughing
  • mixed incontinence: urge and stress
  • overflow incontinence: bladder outlet obstruction e.g. prostate enlargement
205
Q

investigations of urinary incontinence

A
  • bladder diaries (minimum 3 days)
  • vaginal exam (exclude prolapse, check if can initiate voluntary contraction of pelvic floor muscles “Kegel” exercise, ask pt to cough to check for fluid leakage)
  • urine dip and culture
  • urodynamic testing (if mixed incontinence)
206
Q

urge incontinence management

A
  • conservative: avoid caffeinated/artificially flavoured drinks, aim for 1.5-2.5L of water per day, lose weight
  • 1st line: bladder retraining for 6 weeks (gradually increase intervals between voiding)
  • 2nd line: bladder stabilsiing drugs - ANTIMUSCARINICS (e.g. oxbutynin)
  • 3rd line: mirabegron - BETA-3 AGONIST (if concern about anti-Ach SE in frail elderly)
  • 4th line: surgical procedures (botox, PTNS or SNS)
207
Q

stress incontinence management

A
  1. pelvic floor muscle training (8 contractions 3x per day for 3 months)
    Adjunct: medical - DULOXETINE
  2. surgical procedures: retropubic mid-urethral tape procedures, bulking (injection into urethral sphincter), autologous fascial slings, burch colposuspension
208
Q

PACES counselling for urinary incontinence

A

risk factors: stress (age, traumatic delivery, obesity, previous pelvic surgery), urge (age, obesity, smoking, FH, DM)

  • explain diagnosis and mechanism
  • explain lifestyle measures (controlling fluid intake, avoid caffeine, lose weight)
  • explain treatment (urge = bladder retraining for 6 weeks trying to gradually inc time between going to toilet, stress = pelvic floor training for 3 months)
  • explain medical and surgical options
209
Q

risk factors for vaginal prolase

A
  • age
  • multiparity
  • obesity
  • menopause
  • smoking
  • heavy lifting
  • constipation
  • connective tissue disorders
210
Q

grading systems for vaginal prolapse

A
  • POP-Q (measures different anatomical landmarks in relation to hymen)
  • Shaw’s (more commonly used, looks at extent of descent of prolapse)
  • Baden-Walker (like Shaw’s but uses hymen as reference point)
211
Q

lifestyle adjustments for vaginal prolapse

A
  • maintaining healthy weight
  • stop smoking
  • avoid heavy lifting
212
Q

management of vaginal prolapse

A
  • pelvic floor exercises
  • oestrogens: pill, patch, cream, implant
  • vaginal ring pessary (changes every 6 months)
    SE of vaginal ring: unpleasant discharge, irritation, UTI, interference with sex
213
Q

surgical management of vaginal prolapse

A
  • pelvic repair surgery (sacrocolpopexy, colporrhaphy)
  • hysterectomy (and McCall culdoplasty)
  • colpoclesis (closing part/ all of vagina) = only considered in women with advanced prolapse, previous measures haven’t worked, don’t intent on sex
214
Q

PACES counselling for vaginal prolapse

A
  • RFs: multiparity, age, obesity, prolonged second stage of labour, heavy lifting
  • explain diagnosis
  • explain lifestyle modifications (lose weight, healthy diet, stop smoking)
  • explain conservative measures (pelvic floor exercises, oestrogens)
  • explain ring pessary or surgery
215
Q

ovarian torsion investigations

A
  • FBC (high WCC?)
  • pregnancy test
  • speculum (PID?)
  • bimanual (adnexal mass?)
  • urinalysis (rule out ureteric colic)
  • TVUSS with doppler measurement of bloof flow
216
Q

what cysts are more likely to undego torsion?

A
  • dermoid cysts most likely
  • endometriomas are least likely
  • ovarian cyst >5cm diameter is at risk of torsion (can have elective cystectomy)
217
Q

management of ovarian torison

A
  • laparoscopic detortion
  • 2nd line: salpingo-oophorectomy
  • if cyst present = cystecomy
  • if surgery not prompt enough, may need to remove necrotic ovary
218
Q

PACES counselling for ovarian torsion

A
  • RFs: ovarian cysts, ovarian tumours, pregnancy, tubal ligation, long ovarian ligaments
  • explain diagnosis (ovary has twisted)
  • surgery needed to untwist it
  • explain that there is likely to be a cyst on ovary which will be removed at time of surgery
  • explain that there is a risk that the ovary may be necrotic and needs removal
219
Q

functional ovarian cysts investigations

A
  • TVUSS
  • CA125
  • RFs: fertility treatments, tamoxifen, pregnancy, hypothyroidism, smoking
220
Q

conservative management of functional ovarian cysts

A
  • analgesia and observation for cyst rupture or haemorrhage
  • address any predisposing factors (e.g. bleeding disorders)
  • haemorrhagic cysts should have follow up TVUSS to check for resolution
  • if simple, uniloculated cyst, arrange repeat USS in 4-6 weeks
221
Q

medical management of functional ovarian cysts

A

recurrent functional cysts can be prevented by preventing ovulation (usually with COCP)

222
Q

surgical management of functional ovarian cysts

A
  • TVUSS is VITAL before surgery to characterise mass and determine risk malignancy index (RMI)
223
Q

how do you calculate the RMI and what does this mean?

A

RMI = ultrasound features of cyst + menopausal status + CA125
if malignant = rfereall to gynae oncology, will need total abdominal hysterectomy with BSO

224
Q

when is a laparoscopy indicated?

A
  • haemodynamic compromise
  • likely of torsion
  • no relief of symptoms within 48hrs of presentation
225
Q

how is management guided by patient age?

A
  • younger: consider removing cysts >5cm due to risk of torsion
  • older: consider removing suspicious cysts (e.g. mutloloculated due to risk of cancer)
226
Q

when do ovarian cysts rupture?

A
  • most common with functional cysts

- can rupture spontaneously or due to trauma (sex or sports)

227
Q

how is an ovarian cyst rupture managed?

A
  • usually conservative (pain releif)
  • if evidence of active bleeding, laparoscopy and cautery
  • admit for observation if in a lot of pain
  • if cyst continues to recur, require elective cystectomy
228
Q

germ cell tumour management

A
  • ovarian cystectomy
  • surgery particularly necessary if: symptomatic, 5+cm diameter, enlarging
  • surgery prevents torsion and allows histological analysis
229
Q

investigations for endometriosis

A
  • bimanual exam (masses, retroverted uterus)
  • speculum exam
  • TVUSS (endometrioma?)
  • diagnostic laparoscopy
230
Q

what can be used to treat pelvic pain associated with endoemetriosis?

A
  • analgesics

- hormonal ovarian suppression

231
Q

when can medical treatment of presumed endometriosis be started?

A
  • if clinical exam/ TVUSS are normal without need for invasive laparoscopy
  • if no symptom relief is achieved after 3-6 months, laparoscopy should be considered
232
Q

what else could be managed in endometriosis treatment?

A
  • co-existing diseases such as IBS and constipation (seen in up to 80% of cases)
233
Q

what medical therapy can be used for endometriosis?

A
  • analgesics (NSAIDs for pelvic pain, avoid opiated as could worsen IBS)
  • COCP (if no CI and no pregnancy)
  • progestogens (induce amenorrhea in those with CI to COCP)
  • GnRH agonists (relieve severity/ symptoms, 1 monthly injections not to be used >6 months as risk of osteoporosis)
  • other hormonal agents (current research into aromatase inhibitors)
234
Q

surgical treatment options for endometriosis

A
  • fertility sparing surgery

- hysterectomy and oophorectomy

235
Q

what is fertility sparing surgery?

A
  • laparoscopic
  • endometriotic chocolate cysts should have their inner cyst lining excised to reduce recurrence
  • could result in damage to ovarian tissue so if pt is receiving fertility tx, only drainage should be done
  • deposits of superficial peritoneal endometriosis can be ablated/excised
  • risk of recurrence following surgery is high so long term medical therapy started straight after
236
Q

how can a hysterectomy and oophorectomy help?

A
  • remove uterus and ovaries and all visible endometriosis lesions considered in women who have completed their family and failed to respond to conservative treatments
  • will not necessary cure symptoms/disease
  • oestrogen only HRT started immediately after once patient is mobile
237
Q

summary of 1st, 2nd, 3rd and 4th line treatments for endometriosis

A

Ix: diagnostic laparoscopy
1st: NSAIDS/paracetamol or COCP/progestogens
2nd: GnRH analogues
3rd: Danazol (androgen)
4th: hysterectomy with BSO
Surgery: laparoscopic excision and laser treatment

238
Q

PACES counselling - endometriosis

A
  • RFs: early menarche, FH, nulliparity, prolonged menstruation, short menstrual cycle
  • explain diagnosis (condition where the tissue that lines the womb starts appearing outside the womb
  • very common (10% women of reproductive age)
  • management options (conservative = NSAIDs, medical = COCP, LNG-IUS< POP, surgical = diagnostic laparoscopy and excision/ablation)
  • explain potential impact on fertility
239
Q

chronic pelvic pain - investigations

A

History should explore
- pattern or pain
- association with other problems (psychological, bladder, bowel
- effect of movement and posture
Examination:
- abdominal and pelvic (? tenderness ?masses)
Genital tract swab
Pelvic USS (if potential mass suspected)
Urinalysis and MC&S
MRI (to further investigate of pelvic masses or suspected deep infiltrating endometriosis)

240
Q

management of chronic pelvic pain

A
  • general (diet, hydration, exercise, sexual health)
  • analgesia (NSAIDs, opiates, paracetamol)
  • if clinical exam and USS normal in women with cyclical chronic pelvic pain = trial of hormonal treatment
  • hormonal treatments: COCP, LNG-IUS, systemic progestogens, GnRH analogues
  • structural pathology treated surgically
  • if pain persists, referral to pain management
241
Q

specific treatments of:

  • interstitial cystitis
  • fibromyalgia
  • vulvodynia
A
  • interstitial cystitis: avoid dietray triggers, amitriptylin or gabapentin
  • fibromylagia: NSAIDs, physio
  • vulvodynia: topical local anaesthetic, amitriptyline or gabapentin
242
Q

Tx of cervical ectropion

- extra tests to do

A
  • change from oestrogen based hormonal contraceptives
  • cervical ablation
  • cervical and lower genital tract swabs = exclude STI
  • smear = exclude cervical premalignancy/malignancy
243
Q

Tx of cervical stenosis

A

surgical dilatation of cervix under USS or hysteroscopic guidance

244
Q

Ix of endometrial polyps

A
  • TVUSS
  • outpatient hysteroscopy and saline infusion sonography
  • tests involve distending uterine cavity
245
Q

management of endometrial polyps

A
  • small polyps may resolve spontaneously

- polypectomy recommended to alleviate AUB symptoms/ optimise fertility/ exclude hyperplasia or cancer

246
Q

Asherman syndrome treatment

A
  • surgical breakdown of intrauterine adhesions (adhesiolysis)
  • N.B. risks further uterine trauma
  • visualised using TVUSS, HSG or hysteroscopy
247
Q

main medical treatments for HMB in fibroids

A
  • conservative management if asymptomatic fibroids
  • LNG-IUS
  • tranexamic acid
  • mefenamic acid
  • COCP
248
Q

when might these treatments be ineffective?

A
  • in presence of submucous fibroids or an enlarged uterus that is palpable abdominally
249
Q

what are the medical treatments for fibroids?

A
  • injectable GnRH agonist (only effective medical treatment): induces menopausal state but poorly tolerated because of severe menopausal symptoms
  • Ulipristal acetate (selective progesterone receptor modulator): reduced fibroid volume, alleviates HMB symptoms
250
Q

surgical treatments for fibroids

A
  • minimally invasive hysteroscopic surgery (remove submucous fibroids/polyps)
251
Q

what are the options if the patient has a bulky fibroid uterus that is causing pressure symptoms/ where HMB is refractory to medical interventions?

A
  1. myomectomy (if preservation of fertility)
  2. surgical removal of fibroids with uterine conservation
  3. hysterectomy
    hysterectomy and myomectomy could be preceded by GnRH agonist pre-treatment for 3 months to reduce bulk and vascularity of fibroids
252
Q

what is the radiological treatment for fibroids?

A
  • uterine artery embolisation: embolise both uterine arteries under radiological guidance, induced infarction and degeneration of fibroids
  • complications: fever, infection, fibroid expulsion, potential ovarian failure
  • adequate counselling important because effect on reproductive function is uncertain
253
Q

summary of fibroid treatment

A

1st line symptomatic: LNG-IUS
or tranexamic acid or COCP
GnRH agonists to reduce size of fibroid
surgery: myomectomy, hysteroscopic endometrial ablation, hysterectomy

254
Q

investigations of adenomyosis

A
  • exam: bulky and boggy uterus
  • US: haemorrhage-filled, distended endometrial glands
  • MRI: best investigation
255
Q

management of adenomyosis

A
  • any tx that induced amenorrhoea will relieve pain and excessive bleeding
  • use of progestin LARCs should be considered (LNG-IUS< DepoProvero, short-term GnRH agonists)
  • symptoms return rapidly on ceasing treatment
  • hysterectomy only definitive treatment
256
Q

lichen planus 1st and 2nd line treatments

A

1st: high dose topical steroids (e.g. Clobetasol)
2nd: topical calcineurin inhibitor (e.g. Tacrolimus)
if vaginal stenosis, dilatation with manual measures

257
Q

lichen sclerosus 1st and 2nd line

A

good skin care
1st: strong steroid ointments (e.g. clobetasol proprionate for 3 months)
2nd: topical calcineurin inhibitor
biopsy if condition doesn’t resolve with treatment

258
Q

possible underlying causes of pruritus vulvae

A
  • infection
  • eczema
  • contact dermatitis
259
Q

treatment of contact dermatitis

A
  • identifiy and remove irritants (e.g. soap)
  • consider mild topical steroid (e.g. hydrocortisone 1%) for 7-10 days
  • consider stronger steroid (betamethasone valerate) if severe or skin is lichenified
  • recommend emollient as soap sub
  • consider referral to derm for patch testing
260
Q

treatment of seborrhoeic dermatitis

A
  • ketoconazole shampoo as body wash
  • use of emollients
  • mildly anxiolytic antihistamine at night (hydroxyzine)
261
Q

conservative treatment for Bartholin’s cyst/abscess

A

is abscess is discharging and patient is well –> treat with flucloxacillin

262
Q

what further treatment may be needed for Bartholin’s cyst?

A
  • may require incision and drainage
  • may need insertion of word catheter to maintain patency for several weeks
  • may be managed surgically by marsupialization of cyst (suture the internal aspect of cyst to outside of cyst to prevent reforming under GA)
263
Q

PACES couselling for Bartholin’s cyst

A
  • RFs: nulliparous, child-bearing age, previous Bartholin’s cyst
  • explain diagnosis: blockage of a duct in your vagina, it has become infected
  • explain management (conservative with observation and Abx, word catheter insertion, marsupialisation, recommend STI screen)
264
Q

treatment of vaginismus

A
  • vaginal dilators
  • psychological influences (e.g. mentioning that you are using “small speculum” can reinfore idea)
  • encourage self exploeation at home with perineal massage and stretching of vagina with fingers
  • explore patients anxieties, consider whether surgery is best option
265
Q

things to remember with FGM

A
  • any case must be reported in notes
  • children <18 years: referral to police and social services
  • mandatory duty to tell appropriate agency will not apply to at risk or suspected cases >18yrs
  • check to see if there are young girls in family who are at risk
266
Q

what is de-infibulation?

A
  • reversal of infibulation
  • should be identified pre-conceptually
  • should be performed with adequate analgesia
  • incision made along vulval incision scar
  • women receive prior urinary infection screening and given appropriate antibitoics
  • access to specialist services and support groups
267
Q

investigations for ovarian cancer

A
  • TVUSS
  • Tumour markers
  • Risk of malignant index
  • CT/MRI
268
Q

what would you assess with TVUSS?

A
  • size
  • consistency
  • presence of solid elements
  • bilaterality
  • presence of ascites
  • extraovarian disease (peritoneal thickening and omental deposits)
269
Q

what tumour marker? what else can raise it?

A

CA125

also raised in pregnancy, endometriosis and alcoholic liver disease

270
Q

how do you calculate the RMI?

A 
from
- menopausal status
- pelvic US features
- CA125
used to triage pelvic masses
score >250 considered high risk
271
Q

who should get a CT/MRI?

A
  • pelvic pathology at intermediate/high risk of malignancy should receive CT/MRI
  • CT: extrapelvic disease and staging
  • MRI: determine operability
  • other investigations: CXR, ECG, FBC, U&E, LFT
272
Q

Surgical management of ovarian cancer

A
  • aims to stage disease and remove all visible tumour (cytoreduction)
  • total abdominal hysterectomy and BSO with omentectomy and lymph node resection
  • young women with early stage may want fertility sparing surgery
  • after surgery, MDT discussion regarding cancer
273
Q

chemotherapy for ovarian cancer

A

1st line: platinum compound with paclitaxel

3 weeks apart for 6 cycles

274
Q

what plantinum compounds are used and what is the MOA?

A
  • most effective in ovarian cancer
  • cause cross linkage of DNA strands = cell cycle arrest
  • carboplatin main one used (less nephrotoxic and less nausea than cisplatin)
275
Q

how does paclitaxel work?

A
  • causes microtubular damage
  • prevents replication and cell division
  • pre-emptive steroids to reduce SE and hypersensitivity
  • causes total loss of body hair
276
Q

what is bevacizumab?

A
  • monoclonal antibody against VEGF
  • inhibits angiogenesis
  • treatment for recurrent disease
  • if disease recurs, mostly palliative
277
Q

summary of Ix and tx of ovarian cancer

A

Ix: CA125
- if >35IU/mL refer for urgent USS of Abdo and pelvis
Tx: surgery and platinum-based chemo

278
Q

PACES counselling

A
  • RF: age, FH, obesity, HRT, endometriosis, smoking, diabetes
  • protective factors: COCP, pregnancy, breastfeeding, hysterectomy
  • explain diagnosis
  • explain that further Ix may be necessary
  • explain definitive management will be surgical +/- chemo
279
Q

treatment of sex cord stromal tumour

A
  • based on age and wish to preserve fertility
  • YOUNG: unilateral salpingo-oophorectomy, endometrial sampling and staging
  • OLDER: full surgical staging
  • granulosa cell tumours recur after many years = long term follow up
  • surgery mainstay
  • no effective chemo
280
Q

treatment of germ cell tumour

A
  • exploratory laparatomy to remove tumour and assess contralateral spread to other ovary
  • peritoneal biopsies and sampling of enlarged nodes
281
Q

when is post-op chemo given in germ cell tumours? what is the regime?

A
  • depends on stage
  • most common regime: bleomycin, etoposide, cisplatin (BEP)
  • given as 3-4 tx 3 weeks apart
  • 90% cure rates
282
Q

Ix of endometrial cancer

A
  • RF
  • TVUSS: endometrial thickness (if >4mm need further hysteroscopy +/- biopsy)
  • Hysteroscopy and biopsy: complex hyperplasia with atypia = premalignant condition
  • Staging: MRI and FIGO
283
Q

FIGO staging

A 
I: confined to uterine body
IA: less than 50% invasion
IB: more than 50% invasion
II: tumour invading cervix
III: local +/- regional spread of tumour
IIIA: invades serosa of uterus
IIIB: invades vagina +/- parametrium
IIIC: metastases to pelvic +/- para-aortic nodes
IV: tumour invades bladder and bowel and distant mets
284
Q

management of endometrial cancer

A
  • surgery (mainstay = total hysterectomy with BSO)
  • adjuvant treatment (post-op radiotherapy, chemo for metastatic disease)
  • hormone treatment ((high dose progestins e.g. LNG-IUS)
  • women referred to specialist to discuss ovarian conservation/ egg retrieval
285
Q

what are bad prognostic features for endometrial cancer?

A
  • age
  • grade 3 tumours
  • type 2 histology
  • deep myometrial invasion
  • lymphovascular space invasion
  • nodal involvement
  • distal mets
286
Q

when generally is hormone/progestogen therapy used?

A

frail elderly women who are not suitable for surgery

287
Q

how to diagnose endometrial hyperplasia?

A
  • TVUSS
  • biopsy
  • diagnostic hysteroscopy
288
Q

general management of EH without atypia

A
  • <5% of becoming malignant in 20 years
  • reversible factors (e.g. obesity, HRT) should be addressed
  • observation alone may be considered
  • endometrial surveillance every 6 months
289
Q

medical and surgical management of EH without atypia

A
  • 1st: progestogens (LNG-IUS, minimum of 6 months)

- surgical: hysterectomy

290
Q

management of EH with atypia not preserving fertility

A

total hysterectomy (and BSO if post-menopausal)

291
Q

management of EH with atypia preserving fertility

A

1: LNG-IUS
2: oral progestogens
routine endometrial surveillance with biopsies every 3 months
refer to specialist if want to conceive

292
Q

PACES counselling for endometrial hyperplasia

A
  • explain diagnosis (abnormal thickening of endometrium)
  • explain taken seriously because of risk of progression to cancer
  • explain management (no atypia: LNG-IUS and review in 3 months, atypia: total hysterecomy + BSO)
293
Q

key features of focused history for cervical smear

A
  • LMP
  • gynae history (IMB, PCB, discharge)
  • sexual history (changed partners recently)
  • contraception
  • obstetric features desires
  • smoking?
  • immunosuppression?
294
Q

what happens if a smear is missed due to pregnancy?

A

should be done 3 months after delivery

295
Q

explain the smear procedure

A
  • explain it (internal exam using a small plastic tube and a small brush)
  • CHAPERONE
  • use gel
  • warn before insertion
  • 5 rotation clockwise, 10 dips in pot
  • label sample, dispose of brush/speculum
  • offer patient tissue and allow them to get dressed
296
Q

explanation of result

A
  • cytology result should come within 2 weeks
  • explain role of cervical screening (catch potentially cancerous changes at early stage)
  • most of time, abnormal changes do NOT mean cancer but warrants further investigation
297
Q

what to do if:

  • mild/borderline
  • anything worse
  • inadequate sample
A
  • mild/borderline: do HPV test then refer to coloposcopy

- anything worse: repeat smear (if 3 inadequate samples = coloposcopy)

298
Q

how do you explain coloposcopy

A
  • like a speculum but uses microscope to look at cervix
  • liquid applied to help identify any abnormal areas and biopsies taken
  • some women treated at time using LLETZ
  • if biopsy taken, result in 4 weeks
299
Q

risks and aftercare for colposcopy

A

bleeding/infection

no tampons or sex for 4 weeks

300
Q

what is recommended for the different CINs?

A

CIN1: likely to resolve spontaneously, offer follow up smear in 12 months
CIN2,3 and CGIN: recommend removal

301
Q

what is LLETZ?

A
  • Large Loop Excision of the Transformational Zone
  • removal of abnormal cells using then wire that is heated by electric current
  • can be done at time of colposcopy
  • AKA loop diathermy
302
Q

what are the risks of LLETZ?

A

large excision/ repeat excisions associated with increased risk of midtrimester miscarriage and preterm delivery

303
Q

what is a cone biopsy?

A
  • used less frequently
  • only performed if large area of tissue needs to be removed
  • GA
304
Q

other tx of CIN

A

cryotherapy, laser treatment, cold coagulation, hysterectomy

305
Q

what needs to happen for all patients who undergo treatment for CIN?

A
  • test of cure 6 months later
  • high risk HPV test and cytological assessment
    if NEGATIVE: routine recall
    if POSITIVE: repeat colposcopy to identify residual/untreated CIN
306
Q

what is the HPV vaccine and when is it given?

A

national vaccination programme for school girls aged 12-13

quadrivalent vaccone = 6, 13, 16 and 18

307
Q

PACES counselling for CIN

A
  • explain purpose of screening and results
  • explain management
    CIN1: repeat smear in 1 year
    CIN2, 3 and CGIN: LLETZ or cone biopsy
    LLETZ: OPT procedure with local anaesthetic
    Cone biopsy: used for larger lesions, done under GA
    Risk: mid-trimester pregnancy loss and preterm birth
  • explain follow up: repeat smear in 6 months for test of cure
308
Q

what should be done for preclinical lesions: stage 1A cervical cancer?

A
  • microscopic tumours usually picked up incidentally
  • small lesions removed with clear margin
  • co-existing CIN also excised
  • only need local excision with clear margin
309
Q

what should be done for clinically invasive cervical carcinoma: stage 1B?

A
  • tumours are large, fertility-preserving treatment more difficult
  • if small volume disease confined to cervix = radical hysterectomy and bilateral pelvic node dissection (Wertheim’s hysterectomy)
  • if fertility-sparing required = radical trachelectomy = removal of cervix and upper vagina and pelvic node dissection
  • pelvic radiotherapy is as effective as surgery
310
Q

what is the mainstay of treatment if tumour is beyond cervix?

A

stage 2-4

radiotherapy is mainstay

311
Q

surgery for cervical cancer

A
  • Stage 1B = radical hysterectomy with pelvic lymph node dissection
  • ovaries can be spared in pre-menopausal women
  • high cure rate
312
Q

risks of this operation

A
  • bladder dysfunction (atony)
  • sexual dysfunction (vaginal shortening)
  • lymphodema (due to pelvic lymph node removal, management = leg elevation, good skin care, massage)
313
Q

what are the pelvic lymph nodes that get dissected?

A
  • obtruator n odes

- internal and external illiac nodes

314
Q

what are the pelvic lymph nodes that get dissected?

A
  • obtruator n odes

- internal and external illiac nodes

315
Q

what are the pelvic lymph nodes that get dissected?

A
  • obtruator nodes

- internal and external illiac nodes

316
Q

2 ways of delivering radiotherapy in cervical cancer

A
  • external beam radiotherapy (given over 4 weeks, each delivery of radiotherapy lasts 10 mins)
  • internal radiotherapy (rods of radioactive selenium is inserted into affected area, effects extend up tp 5mm away from rod)
317
Q

risks of radiotherapy

A
  • lethargy
  • bowel and bladder urgency
  • skin erythema (external beam radiotherapy)
  • long term: fibrosis, vaginal stenosis, cystitis-like symptoms, malabsoprtion, mucous diarrhoea, radiotherapy induced menopause
318
Q

chemotherapy in cervical cancer

A

usually cisplatin

usually given in conjunction with radiotherapy

319
Q

surgical treatment for vulvar cancer

A

VULVAL excision

  • radical surgical excision
  • aim for clear margin (10mm)
  • large lesions may be shrunk with neoadjuvant radiotherapy with chemo
320
Q

what happens if groin lymph nodes are involved?

A
  • full inguinofemoral lymphadenectomy

- very morbid procedure (complications = wound healing, infection, VTE, chronic lymphodema)

321
Q

how may full groin lymphadenectomy be avoided?

A
  • sentinel lymph node biopsy (first node that the area drains to)
  • done by injecting a dye and radioactive nucleotide
  • if sentinel node is positive = full groin lymphadenectomy
322
Q

when is radiotherapy given for vulvar cancer?

A
  • adjuvant is indicated if excision margins are close or 2+ groin node metastasis
  • radical radiotherapy is pt unfit for surgery
323
Q

when is part-partum contraception needed?

A
  • after day 21

- lactational amenorrhoea = 98% effective if woman is fully breast-feeding, amenorrhoeic and <6 months post-partum

324
Q

options for post-partum contraception

A
  1. Progestogens (PoP, Depo-Provera, Nexplanon): started any time postpartum, after day 21 additional contraception for first 2 days, small amount enters breastmilk but not harmful
  2. COCP: absolute contraindications (breastfeeding and <6weeks postpartum), if not breast feeding can be started from day 21 to provide immediate contraception , after day 21 used additional contraception for 7 days
  3. Copper IUD or LNG-IUS: inserted within 48hrs of childbirth or after 4 weeks
325
Q

FIGO staging for endometrial cancer

A

I: uterus
II: uterus + cervix
III: adnexa
IV: distant and bladder/bowel

326
Q

FIGO for ovarian cancer

A

I: limited to ovaries
II: pelvic extnesion (e.g. uterus)
III: abdominal extension other than pelvic
IV: distant mets

327
Q

FIGO for cervical cancer

A

I: cervix
II: invades beyond the cervix but not pelvic wall or lower 1/3 of vagina
III: extends to pelvic wall and/or lower 1.3 of vagina and/ore causes hydronephrosis
IV: extended beyond pelvis and has involved mucosa or bladder or rectum

328
Q

types of functional ovarian cysts

A
  • FOLLICULAR (most common ovarian cyst): >3mm, USS = thin walled, unilocular, anechoic
  • CORPUS LUTEAL: occurs after ovulation, may rupture at end of menstrual cycle, USS = diffusely thick wall, <3cm, lacey pattern
  • THECA LUTEIN: associated with pregnancy, can cause HTN, often bilateral, resolve spontaneously, USS = bilaterally enlarged, multicystic ovaries, thin-walled and anechoic
329
Q

types of inflammatory ovarian cysts

A
  • TUBO-OVARIAN abscesses: PID, tender adnexal mass, USS = ovary and tube can’t be distinguished from mass
  • ENDOMETRIOMA: chocolate cyst, ass. w/ endometriosis, USS = unilocular with ground glass echoes
330
Q

types of germ cell cyst

A

DERMOID

  • mature: benign, solid or cystic. USS = unilocular, diffusely or partially echogenic mass, may contain teeth, no internal vascularity
  • immature: contains embryonic elements, malignant
331
Q

types of epithelial cysts

A
  • SEROUS CYSTADENOMA (most common ovarian neoplasm): unilocular, often bilateral, USS = unilocular, anechoic, no flow on colour Doppler
  • MUCINOUS CYSTADENOMA: large, USS = multiloculated, many thin separations, low echogenicity
  • BRENNER TUMOUR: small, urothelial-like epithelium. USS = hypoechoic, calcifications
332
Q

types of sex cord stromal cysts

A
  • FIBROMA: benign, no endocrine production, USS = solid, hypoechoic mass
  • THECOMA: benign, may produce oestrogens, USS = variable, echogenic, hypoechoic or anechoic
  • GRANULOSA: produce oestrogen, USS = varibale, may appear solif or cystic
333
Q

A-G for abortion act

A

A: continuance RISKS LIFE of pregnant woman more than if terminated
B: termination is necessary to prevent GRAVE and PERMANENT injury to health of woman
C: <24 weeks and continuation involves GREATER RISK to health of woman
D: < 24 weeks and continuation involved RISK TO EXISTING CHILD health
E: substantial risk that if child were born, would be SERIOUSLY HANDICAPPED
F: to SAVE THE LIFE of pregnant woman
G: prevent GRAVE PERMANENT injury to woman

334
Q

IVF Eligibility UK in women <40 years

A

offered 3 cycles by NHS if:
- UPSI for 2 years
OR
- not been able to get pregnant after 12 cycles of artificial insemination

335
Q

IVF eligibility UK in women 40-42

A

offered 1 cycle by NHS if:

  • trying to get pregnant for 2 years or haven’t got pregnant after 12 cycles of artificial insemination
  • Never had IVF before
  • No evidence of low ovarian reserve
  • have been informed about additional implication of IVF at this age
336
Q

what additional criteria are CCGs likely to have?

A
  • not having children already from current/previous relationships
  • being healthy weight
  • not smoking
  • falling within certain age range
337
Q

how much can IVF cost privately?

A

£5000 per cycle

PACES management (7 decks)

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