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?)
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
3
Q
when should you use expectant management?
A
for 7-14 days as FIRST LINE in women with confirmed miscarriage
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
5
Q
what do you offer if expectant management is not appropriate?
A
medical management
6
Q
what is the follow up to expectant management?
A
- take a pregnancy test after 3 weeks
- return if positive
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?)
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
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
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
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
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)
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
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
15
Q
ectopic pregnancy investigations
A
- ABCDE
- urine pregnancy test
- bimanual
- speculum
- bloods (serum bHCG, FBC, G&S)
- TVUSS
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
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
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
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)
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
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
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
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
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
25
what is the follow up for salpingectomy?
urine pregnancy test at 3 weeks
26
when can you offer a choice of either methotrexate or surgery?
```
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
```
27
what is important to note about methotrexate?
carries a greater risk of urgent re-admission
28
what should you offer Anti-D prophylaxis?
- all RhD-negative women who have a surgical management of ectopic pregnancy or miscarriage
- do not do Kleihauer test
29
when do you not offer anti-D prophylaxis?
- solely medical management
- threatened miscarriage
- complete miscarriage
- pregnancy of unknown origin
30
Counselling: risk factors for ectopic pregnancy
- PID
- smoking
- IUD/IUS
- assisted reproductive technology
- tubal surgery
31
PACES counselling: what do you need to explain in general
- 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
32
how would you explain medical management?
- 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
33
what should you explain regarding surgical management?
- 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
34
Clinical presentation of molar pregnancy (gestational trophoblastic disease)
- irregular vaginal bleeding
- hyperemesis
- large for dates uterus
- early failed pregnancy
- HTN
35
investigations for molar pregnancy
- 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)
36
1st line management for molar pregnancy?
- 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
37
when should you send for histological assessment?
- 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
38
where should patients be followed up?
- 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
39
what is the management of gestational trophoblastic neoplasia?
- single or multi-agent chemo (methotrexate may be used)
| - tx carries a risk of earlier menopause and secondary cancers
40
what information should you provide regarding future pregnancies?
- 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
41
Counselling: risk factors for molar pregnancy
- advanced maternal age (or younger than 20)
- prior molar preganncy (1-2% risk of recurrence)
- prior miscarriages
- asian heritage
42
how do you break the bad news?
- 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
43
causes of amenorrhoea or oligomenorrhoea
- low BMI
- hypothalamic lesions (e.g. glioma)
- hyperprolactinaemia/ prolactinoma
- POF
- PCOS
- Asherman's
- cervical stenosis
44
investigations for secondary amenorrhoea
- urinary/serum hCG
- gonadotrophins (low = hypo, high = ovarian cause)
- prolactin
- androgen (high in PCOS)
- oestradiol
- TFTs
45
what is the Rotterdam criteria for PCOS?
at least 2 of:
- oligo/anovulation (>2 years)
- clinical or biochemical features of hyperandrogenism
- polycystic ovaries on US
46
investigations of PCOS
- hormone profile: oestrogen, progesterone, FSH, LH, free testosterrone, LH:FSH index
- prolactin
- TFTs
- cortisol
- OGTT
- TVUSS
- BMI
47
management of menstrual issues in PCOS
- COCP
| - cyclial oral progesterone
48
management of subfertility in PCOS
- encourage weight loss
- clomiphene
- laparoscopic ovarian drilling (destroys ovarian stroma, may prompt ovulatory cycles)
49
what does clomiphene do?
- 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
50
what advice would you give regarding managing complications of PCOS?
- lifestyle advice
- weight reduction
- treatment of hirsutism/androgenic symptoms
51
how would you treat the hirsutism/ androgenic symptoms?
- topical eflornithine cream
- co-cyprindol (dianette)
- cyproterone acetate (antiandrogen)
- metformin
- GnRH analogues
- surgical tx (laser, electrolysis)
52
complications of PCOS
- metabolic syndrome (DM, heart disease)
- sleep apnoea
- CVD
- endometrial cancer (recommended withdrawal bleed every 3-4 months, endometrial thickness >7mm may be pathological)
53
summary of management of PCOS
- 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
54
PACES counselling for PCOS
- 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
55
how to diagnose premenstrual syndrome?
symptom diary over 2 cycles
56
conservative measures for premenstrual syndrome
- stress reduction
- alcohol and caffeine limitation
- exercise
- vitamins, St John's wort
57
what is mild premenstrual syndrome? How to manage?
no impact on personal, social, professional life
| - lifestyle advice (diet, exercise, sleep, smoking, alcohol cessation)
58
what is moderate premenstrual syndrome? Tx?
some impact on personal, social, professional life
- COCP (Yasmin best evidence based)
- Paracetamol/ NSAIDs
- referral for CBT
59
define severe premenstrual syndrome. Tx?
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
60
investigations for heavy menstrual bleeding
- FBC
- coagulation screen if primary menorrhagia or FH of bleeding
- bimanual (adnexal masses or bulky uterus)
- speculum (cervical ectropion or polyp)
- TVUSS
61
what do you do if you suspect submucosal fibroids, polyps or endometrial pathology?
- 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
62
what do you need to consider when deciding management?
- preference
- comorbidities
- presence of fibroids/ polyps/ endometrial pathology
- pressure/ pain symptoms
63
acute management of heavy menstrual bleeding
- ABCDE
- fluid resus with IV colloids and blood transfusion
- correct coagulopathy
- treat cause
- ferrous sulphate
64
if there is no identified pathology, fibroids <3cm or adenomyosis, how do you treat?
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
65
tx of fibroids >3cm in diamater
- 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
66
GnRH analogue side effects
- hot flushes
- sweating
- vaginal dryness
- muscle stiffness
- osteoporosis
67
other potential treatment options
- uterine artery embolisation
- endometrial ablation (only if family is complete)
- magnetic resonance-guided focused US (MRgFUS)
68
PACES Counselling for fibroids
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)
69
investigations for dysmennorhoea
- bimanual (bulky/boggy uterus?)
- speculum (infection?)
- STI screen (PID?)
- TVUSS (fibroids, adenomyosis, endometriosis)
- MRI (adenomyosis)
- diagnostic laparoscopy (endometriosis +/- tx)
70
tx of dysmenorrhoea
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
71
3 options of emergency contraception and time limit
- Levonorgestrel (within 72 hours)
- ulipristal (within 120 hours)
- copper IUD (within 120 hours)
72
how does levonorgestrel (leveonelle) work? what are the things to remember about it?
- 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
73
how does Ulipristal (EllaOne) work? what do you need to remember with it?
- 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
74
what should you give for women weighing >70kg or BMI > 26?
- EllaOne is recommended (continue oral contraception after 5 days)
- If levonelle is taken, give double dose (3mg) and women should start ongoing contraception immediately
75
when can the copper IUD be used for emergency contraception?
- 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
76
how does copper IUD work?
- spermicide
- prevents implantation
- prophylactic antibiotics if at high risk of STI
77
what advice should you give alongside emergency contraception?
- offer STI screen
| - advise taking pregnancy test if next period is late
78
side effects of emergency contraception (not IUD)
- N&V
- headache
- breast tenderness
- abnormal menstrual bleeding
79
hormones and mechanism of COCP
ethinyl oestradiol + progestin
| prevents ovulation
80
how to take COCP
- 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
81
benefits of COCP
- effective if taken properly
- reversible upon stopping
- periods lighter, regular, less painful
- reduced risk of ovarian, endometrial and bowel cancer
82
disadvantages of COCP
- forgetting to take it
- no protection against STIs
- inc risk of VTE, breast cancer, cervical cancer, stroke, IHD
83
side effects of COCP
headache
nausea
breast tenderness
84
what should you do with COCP if vomit, if having surgery or taking antibiotics?
- 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
85
absolute contraindications to COCP
- <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)
86
what do you do if you miss 1 pill?
take last pill and current pill (even if that means 2 in 1 day)
no other contraception needed
87
what happens if there are 2 missed pills?
- 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
88
what hormones are in the POP?
- desogestrel (cerazette)
- levonorgestrel
- norethistrone
89
what is the MOA of the POP?
- thickens cervical mucus
| - desogestrel stops ovulation
90
when is the POP used?
only really in women who can't have COCP
91
how do you take the POP?
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
92
benefits and disadvantages of POP
```
Benefits: doesn't have risk of oestrogen pills
Disadvantages:
- must be taken at same time everyday
- irregular bleeding
- osteoporosis
- ovarian cysts
```
93
what to do if there is a missed pill?
<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
94
when might emergency contraception be needed?
if UPSI during this interval
95
side effects of POP
- irregulat vaginal bleeding
- acne
- breast tenderness
- mood changes
- headache
96
hormones in combined hormonal transdermal patch
norelgestromin + ethinyl oestradoil
97
how is it applied?
applied for 3 weeks (replace patch at end of each week)
| take 1 week off (withdrawal bleed)
98
what do you do if there is a delayed change <48 hours?
change immediately
| no further precautions
99
what do you do if there is delayed change >48 hours in week 1 or 2?
- change immediately
- use barrier contraception for 7 days
- consider emergency contraception if UPSI within previous 5 days or in extended patch free period
100
what do you do if there is delayed removal >48 hours in week 3?
- remove immediately
- apply next patch on usual start date of next cycle
- no additional contraception needed
101
what do you do if there is delayed removal at the end of the patch-free week?
use barrier contraception for 7 days
102
pros and cons of patch
- tricycling is possible
- no increased risk of clots
- patch adherence and skin sensitivity can be porblem
103
what hormone is in the mirena (LNG-IUS)?
- progesterone: levonorgestrel
104
what is the moa of the mirena?
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
105
side effects of mirena
- acne
- breast tenderness
- mood disturbance
- headaches
106
what is jaydess?
smaller form of LNG-IUS
effective for contraception but nor for heavy periods
lasts for 3 years
smaller so easier to put in
107
What hormone is in the implant?
etonogestrel
| progesterone
108
MOA of the implant
- prevents ovulation
- inserted subdermally into non-dominant arm
- works for 3 years
- fertility restored immediately after removal
109
side effects of implant
- progestogenic side effects (irregular bleeding, mood changes, breast tenderness, nausea)
- additional contraception needed if not inserted on day 1-5 of menstrual cycle
110
what can reduce its efficacy?
antiepileptic drugs and rifampicin
111
hormone in the injection (depo-provera)
medroxyprogesterone acetate (progesterone)
112
things to remember about the injection
- lasts for 12-14 weeks
| - use contraception for first 7 days unless given during first 5 days of cycle
113
disadvantages of injection
- can cause weight gain
- cause reduced bone density, irregular periods
- may take 6-12 months for fertility to return
114
Moa of copper coil
causes sterile inflammation
| spermidicide
115
side effects of copper coil
heavy painful periods
risk of expulsion
infection
perforation
116
what is the important thing to remember about the copper coil compared to other LARCs?
- all LARCs take 1 week to become effective except copper coil
- can be inserted at any point in menstrual cycle
117
PACES counselling for contraception
- 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
118
fraser guidelines for contraception in <16 year olds
- 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
-
119
what is laparoscopic sterilisation?
- 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
120
advice for women considering sterilisation
- irreversible
- vasectomy is safer, quicker, associated with less morbidity
- high proportion of women regret it
- does not protect against STIs
121
for how long is contraception needed after sterilisation?
- laparoscopic: next menstrual period
| - hysteroscopic: 3 months
122
how is hysteroscopic sterilisation carried out?
- performed as outpatient without GA
- expanding strings inserted into tubal ostia via hysteroscope
- induces fibrosis in cornual section of fallopian tube over 3 months
123
explain the vasectomy
- interrupting vas deferens to provide permanent occlusion
| - small risk of scrotal haematoma and infection
124
when should semen analysis be conducted after vasectomy?
12 weeks to confirm the absence of spermatozoa in ejaculate
125
Termination of pregnancy service providers
- marie stopes UK
- British pregnancy advisory service (BPAS)
- GUM
- family planning clinic
126
medical management of TOP
- mifepristone (oral) followed by 24-48 hours later by misoprostol (vaginal, buccal, sublingual)
- suitable at any gestation
- simple analgesia
127
where should medical management at 0-9 weeks be carried out?
- 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
128
where should medical management be carried out at 9+ weeks?
- clinical setting (increased bleeding and discomfort)
| - repeat doses of misoprostol needed every 3 hours until expulsion (max 5 doses)
129
what special consideration is needed after 21+6 weeks?
- Feticide (intracardiac KCI injection)
| - should be given to eliminate possibility of aborted foetus showing any signs of life
130
surgical management when less than 14 weeks
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)
131
what surgical management should be used for more than 14 weeks?
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
132
what are the risk of surgical management?
- failure to end pregnancy
- haemorrhage
- infection
- perforation
133
what is important to do with all abortion patients?
- discuss insertion of long acting reversible contraception
134
PACES counselling for TOP
- explain options available based on gestation (medical and surgical)
- best option dependent on how mnay weeks pregnant they are (higher gestation = more pregnancy tissue)
135
how would you explain medical management in PACES?
- 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
how do you explain the surgical management of TOP in paces?
- 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
subfertility investigations
- blood hormone profile
- STI screen
- TVUSS
- measurement of ovarian reserve
- tubal assessment
- semen analysis
138
What do you look at in blood hormone profile?
- look at early follicular phase FSH, LH, oestradiol levels (day 2-3)
- anti-mullerian hormone (assess ovarian reserve)
- mid-luteal progesterone (confirm ovulation)
139
what do you look for if they have irregular menstrual cycle?
- TFTs
- prolactin
- testosterone
140
other than the STI screen, what other viruses should be tested for if assisted reproductive technology is being considered?
- HIV
- Hep B
- Hep C
141
what do you look for with TVUSS?
- assessment of pelvic anatomy
- antral follicle count (parameter of ovarian reserve)
- identify pathology
142
what is ovarian reserve?
- 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
what antral follicle count is a good indicator of ovarian reserve?
```
<4 = poor response
16+ = good response
```
144
how is the tubal assessment carried out?
- using hysterosalpingography (HSG) using X-ray/ US/ laparoscopy and dye
- only performed if risk factors for tubal damage
145
how is semen analysis carried out?
- 2 test done 3 months apart
146
what are the options for medical management of subfertility?
- ovulation induction (clomiphene or FSH)
- intrauterine insemination
- donor insemination
- IVF
- donor egg with IVF
147
when is ovulation induction indicated?
if anovulatio (PCOS, idiopathic)
148
when is intrauterine insemination indicated?
- unexplained subfertility
- anovulation unresponsive to OI
- mild male factor
- minimal to mild endometriosis
149
when is donor insemination indicated?
- presence of azoospermia
- single women
- same sex couples
150
when is IVF indicated?
- patients with tubal pathology
| - patients who underwent treatments with no success
151
when is donor egg with IVF indicated?
- women whose egg quality is poor
| - previous surgery/ chemo where ovarian function was affected
152
surgical management options for subfertility?
- operative laparoscopy to treat disease and restore anatomy
- myomectomy
- tubal surgery
- laparoscopic ovarian drilling
153
indication of operative laparoscopy?
- adhesions
- endometriosis
- ovarian cyst
154
when might myomectomy help?
fibroid uterus
155
when can tubal surgery be used?
blocked fallopian tubes amenable to repair
156
when might laparoscopic ovarian drilling be used?
PCOS unresponsive to medical treatment
157
PACES counselling: risk factors for subfertility
- advanced maternal age
- smoking
- alcohol use
- obesity
- irregular periods
- STI
158
PACES counselling for subfertility
- 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
menopause: diet and lifestyle advice
- stop smoking
- reduce alcohol consumption
- normal BMI
- alternative treatements (no scientific basis): acupuncture, hypnosis, herbal remedies
160
types of HRT
1. oestrogen alone (Elleste Solo)
| 2. oestrogen with progesterone (Elleste Duet)
161
when should oestrogen alone be given?
- only suitable for women who have had hysterectomy
| - if BMI>30, oestrogen only HRT should be given as trandermal patch
162
how should oestrogen with progestogen be given?
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
when is continuous vs cyclical contraception used?
cyclical - peri-menopause
| continous - post-menopause
164
routes of HRT
- oral
- transdermal
- vaginal creams (if vaginal symptoms)
165
benefits of HRT
- improved vasomotor symptoms, sleep and performance
- prevention of osteoporosis
- improved genital tract symptoms (dryness, dyspareunia)
166
what are the risks of HRT?
- breast cancer (to lesser extent, endometrial)
- CVD
- VTE
167
side effects of HRT
- oestrogenic: breast tenderness, nausea, headaches
| - progestogenic: fluid retention, mood swings, depression
168
absolute contraindications to HRT
- pregnancy
- breast cancer
- endometrial cancer
- uncontrolled HTN
- current VTE
- current thrombophilia
169
non hormonal treatments used in menopause
- alpha agonists (e.g. clonidine)
- beta blockers (e.g. propanolol)
- SSRIs (e.g. fluoxetine): particularly effective for vasomotor symptoms
- symptomatic: lubricants, osteoporosis treatments
170
investigations for premature ovarian insufficiency
- 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
how can people with premature ovarian insufficiency still have children?
- IVF using eggs from donor/ own frozen eggs
- surrogacy
- adoption
172
what risks do people with POI have?
- osteoporosis: regular DEXA scans, all should get HRT
- stroke
- heart disease
173
summary of lifestyle measures for menopause
- regular exercise
- weight loss
- reduce stress
- sleep hygiene
174
summary of HRT
- CI
- No uterus/ uterus
- RIsks
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
Summary of non-HRT alternatives for menopause
- vasomotor: fluoxetine, citalopram, venlafaxine
- vaginal dryness: lubricant
- psychological: self help, CBT, SSRIs
- urogenital: topical oestrogens, lubricants
176
PACES counselling for menopause
- 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
investigations for BV
- vaginal pH
- whiff test
- gram-stain
- HIV test
- NAAT
- VDRL
178
Tx and advice for BV
- oral or IV metronidazole (5-7 days)
- alternative: topical clindamycin
- advice: avoid vaginal douching and excessive genital washing
179
risks of BV in pregnancy
- preterm labour
| - chorioamionitis
180
what antifungal treatment would you prescribe most women with vulvovaginal candidiasis?
- intravaginal antifungal cream/ pessary (clotrimazole)
or
- oral antifungal (fluconazole, itraconazole)
181
what antifungal would you prescribe for women >60?
- oral as easy to administer
182
what antifungal for girls aged 12-15?
- topical clotrimazole 1% applied 2-3 times a day
| - do not prescribe intravaginal or oral antifungal
183
what antifungal for pregnant women?
intravaginal clotrimazole
| do not use oral antifungals
184
what should you prescribe if vulval symptoms are present?
- topical imidazole (clotrimazole, ketoconazole) in addition to an oral or intravaginal antifungal
185
what is recurrent vulvovaginal candidiasis? what should do?
- 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
advice to give women with thrush
- 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
what about a male sexual partner in a women in thrush?
- do not routinely treat asymptomatic sexual partner
| - male partner could get candida balanitis
188
summary of treatment with doses of thrush
- Local: clotrimaxole 500mg PV stat
- Oral: itraconazole 200mg PO BD for 1 day or fluconazole 150mg PO stat
- pregnancy: only local treatments
189
PACES counselling for thrush
- risk factors: recent antibiotic use, oral contraceptive, DM, excessive washing
- explain diagnosis
- explain tx
- explain hygiene measures
190
TV ix and tx
- vaginal pH, whiff test, gram-stain, HIV test, NAAT, VDRL
| - tx: metronidazole 2g oral single dose
191
chlamydia ix and tx
- 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
advice/ follow up to give people with chlamydia
- avoid sex until treatment has been completed
- recommend STI screen
- refer to GUM for partner notification and treatment
- follow up by 5 weeks
193
gonorrhoea ix and tx
Ix: NAAT and swab
1st line: ceftriaxone ig IM + azithromycin 1g oral
- safe to use in pregnancy
- alternative: doxy instead of azithromycin
194
investigations in PID
- 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
management of PID
- 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
follow up of PID
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
complications of PID
- infertility
- ectopic pregnancy
- chronic pelvic pain
- up tp 30% need hopsital admissions
198
PACES counselling for PID
- 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
genital warts Ix and Tx
Ix: clinical diagnosis, viral culture, HSV PCR
- oral aciclovir
- symptomatic treatment (e.g. paracetamol, ibruprofen)
200
genital warts treatment
- OPTIONAL because lesions are benign
- cyrotherapy (if single and large)
- topical podophyllotoxin (if multiple and non-keratinised)
- alternative: imiquimod, sinecatechins
- surgical techniques
201
syphillis IX
- 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
management of syphillis
IM benzathine penicillin
| 2nd: doxycycline
203
what warning comes with syphillis treatment and how do you prevent this?
Jarisch-Herxheimer reaction
oral prednisolone as a preventative measure
N.B. contact tracing
204
classification of urinary incontinence
- 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
investigations of urinary incontinence
- 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
urge incontinence management
- 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
stress incontinence management
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
PACES counselling for urinary incontinence
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
risk factors for vaginal prolase
- age
- multiparity
- obesity
- menopause
- smoking
- heavy lifting
- constipation
- connective tissue disorders
210
grading systems for vaginal prolapse
- 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
lifestyle adjustments for vaginal prolapse
- maintaining healthy weight
- stop smoking
- avoid heavy lifting
212
management of vaginal prolapse
- 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
surgical management of vaginal prolapse
- 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
PACES counselling for vaginal prolapse
- 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
ovarian torsion investigations
- FBC (high WCC?)
- pregnancy test
- speculum (PID?)
- bimanual (adnexal mass?)
- urinalysis (rule out ureteric colic)
- TVUSS with doppler measurement of bloof flow
216
what cysts are more likely to undego torsion?
- dermoid cysts most likely
- endometriomas are least likely
- ovarian cyst >5cm diameter is at risk of torsion (can have elective cystectomy)
217
management of ovarian torison
- laparoscopic detortion
- 2nd line: salpingo-oophorectomy
- if cyst present = cystecomy
- if surgery not prompt enough, may need to remove necrotic ovary
218
PACES counselling for ovarian torsion
- 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
functional ovarian cysts investigations
- TVUSS
- CA125
- RFs: fertility treatments, tamoxifen, pregnancy, hypothyroidism, smoking
220
conservative management of functional ovarian cysts
- 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
medical management of functional ovarian cysts
recurrent functional cysts can be prevented by preventing ovulation (usually with COCP)
222
surgical management of functional ovarian cysts
- TVUSS is VITAL before surgery to characterise mass and determine risk malignancy index (RMI)
223
how do you calculate the RMI and what does this mean?
RMI = ultrasound features of cyst + menopausal status + CA125
if malignant = rfereall to gynae oncology, will need total abdominal hysterectomy with BSO
224
when is a laparoscopy indicated?
- haemodynamic compromise
- likely of torsion
- no relief of symptoms within 48hrs of presentation
225
how is management guided by patient age?
- younger: consider removing cysts >5cm due to risk of torsion
- older: consider removing suspicious cysts (e.g. mutloloculated due to risk of cancer)
226
when do ovarian cysts rupture?
- most common with functional cysts
| - can rupture spontaneously or due to trauma (sex or sports)
227
how is an ovarian cyst rupture managed?
- 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
germ cell tumour management
- ovarian cystectomy
- surgery particularly necessary if: symptomatic, 5+cm diameter, enlarging
- surgery prevents torsion and allows histological analysis
229
investigations for endometriosis
- bimanual exam (masses, retroverted uterus)
- speculum exam
- TVUSS (endometrioma?)
- diagnostic laparoscopy
230
what can be used to treat pelvic pain associated with endoemetriosis?
- analgesics
| - hormonal ovarian suppression
231
when can medical treatment of presumed endometriosis be started?
- 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
what else could be managed in endometriosis treatment?
- co-existing diseases such as IBS and constipation (seen in up to 80% of cases)
233
what medical therapy can be used for endometriosis?
- 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
surgical treatment options for endometriosis
- fertility sparing surgery
| - hysterectomy and oophorectomy
235
what is fertility sparing surgery?
- 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
how can a hysterectomy and oophorectomy help?
- 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
summary of 1st, 2nd, 3rd and 4th line treatments for endometriosis
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
PACES counselling - endometriosis
- 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
chronic pelvic pain - investigations
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
management of chronic pelvic pain
- 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
specific treatments of:
- interstitial cystitis
- fibromyalgia
- vulvodynia
- interstitial cystitis: avoid dietray triggers, amitriptylin or gabapentin
- fibromylagia: NSAIDs, physio
- vulvodynia: topical local anaesthetic, amitriptyline or gabapentin
242
Tx of cervical ectropion
| - extra tests to do
- change from oestrogen based hormonal contraceptives
- cervical ablation
- cervical and lower genital tract swabs = exclude STI
- smear = exclude cervical premalignancy/malignancy
243
Tx of cervical stenosis
surgical dilatation of cervix under USS or hysteroscopic guidance
244
Ix of endometrial polyps
- TVUSS
- outpatient hysteroscopy and saline infusion sonography
- tests involve distending uterine cavity
245
management of endometrial polyps
- small polyps may resolve spontaneously
| - polypectomy recommended to alleviate AUB symptoms/ optimise fertility/ exclude hyperplasia or cancer
246
Asherman syndrome treatment
- surgical breakdown of intrauterine adhesions (adhesiolysis)
- N.B. risks further uterine trauma
- visualised using TVUSS, HSG or hysteroscopy
247
main medical treatments for HMB in fibroids
- conservative management if asymptomatic fibroids
- LNG-IUS
- tranexamic acid
- mefenamic acid
- COCP
248
when might these treatments be ineffective?
- in presence of submucous fibroids or an enlarged uterus that is palpable abdominally
249
what are the medical treatments for fibroids?
- 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
surgical treatments for fibroids
- minimally invasive hysteroscopic surgery (remove submucous fibroids/polyps)
251
what are the options if the patient has a bulky fibroid uterus that is causing pressure symptoms/ where HMB is refractory to medical interventions?
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
what is the radiological treatment for fibroids?
- 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
summary of fibroid treatment
1st line symptomatic: LNG-IUS
or tranexamic acid or COCP
GnRH agonists to reduce size of fibroid
surgery: myomectomy, hysteroscopic endometrial ablation, hysterectomy
254
investigations of adenomyosis
- exam: bulky and boggy uterus
- US: haemorrhage-filled, distended endometrial glands
- MRI: best investigation
255
management of adenomyosis
- 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
lichen planus 1st and 2nd line treatments
1st: high dose topical steroids (e.g. Clobetasol)
2nd: topical calcineurin inhibitor (e.g. Tacrolimus)
if vaginal stenosis, dilatation with manual measures
257
lichen sclerosus 1st and 2nd line
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
possible underlying causes of pruritus vulvae
- infection
- eczema
- contact dermatitis
259
treatment of contact dermatitis
- 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
treatment of seborrhoeic dermatitis
- ketoconazole shampoo as body wash
- use of emollients
- mildly anxiolytic antihistamine at night (hydroxyzine)
261
conservative treatment for Bartholin's cyst/abscess
is abscess is discharging and patient is well --> treat with flucloxacillin
262
what further treatment may be needed for Bartholin's cyst?
- 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
PACES couselling for Bartholin's cyst
- 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
treatment of vaginismus
- 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
things to remember with FGM
- 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
what is de-infibulation?
- 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
investigations for ovarian cancer
- TVUSS
- Tumour markers
- Risk of malignant index
- CT/MRI
268
what would you assess with TVUSS?
- size
- consistency
- presence of solid elements
- bilaterality
- presence of ascites
- extraovarian disease (peritoneal thickening and omental deposits)
269
what tumour marker? what else can raise it?
CA125
| also raised in pregnancy, endometriosis and alcoholic liver disease
270
how do you calculate the RMI?
```
from
- menopausal status
- pelvic US features
- CA125
used to triage pelvic masses
score >250 considered high risk
```
271
who should get a CT/MRI?
- 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
Surgical management of ovarian cancer
- 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
chemotherapy for ovarian cancer
1st line: platinum compound with paclitaxel
| 3 weeks apart for 6 cycles
274
what plantinum compounds are used and what is the MOA?
- 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
how does paclitaxel work?
- causes microtubular damage
- prevents replication and cell division
- pre-emptive steroids to reduce SE and hypersensitivity
- causes total loss of body hair
276
what is bevacizumab?
- monoclonal antibody against VEGF
- inhibits angiogenesis
- treatment for recurrent disease
- if disease recurs, mostly palliative
277
summary of Ix and tx of ovarian cancer
Ix: CA125
- if >35IU/mL refer for urgent USS of Abdo and pelvis
Tx: surgery and platinum-based chemo
278
PACES counselling
- 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
treatment of sex cord stromal tumour
- 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
treatment of germ cell tumour
- exploratory laparatomy to remove tumour and assess contralateral spread to other ovary
- peritoneal biopsies and sampling of enlarged nodes
281
when is post-op chemo given in germ cell tumours? what is the regime?
- depends on stage
- most common regime: bleomycin, etoposide, cisplatin (BEP)
- given as 3-4 tx 3 weeks apart
- 90% cure rates
282
Ix of endometrial cancer
- RF
- TVUSS: endometrial thickness (if >4mm need further hysteroscopy +/- biopsy)
- Hysteroscopy and biopsy: complex hyperplasia with atypia = premalignant condition
- Staging: MRI and FIGO
283
FIGO staging
```
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
management of endometrial cancer
- 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
what are bad prognostic features for endometrial cancer?
- age
- grade 3 tumours
- type 2 histology
- deep myometrial invasion
- lymphovascular space invasion
- nodal involvement
- distal mets
286
when generally is hormone/progestogen therapy used?
frail elderly women who are not suitable for surgery
287
how to diagnose endometrial hyperplasia?
- TVUSS
- biopsy
- diagnostic hysteroscopy
288
general management of EH without atypia
- <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
medical and surgical management of EH without atypia
- 1st: progestogens (LNG-IUS, minimum of 6 months)
| - surgical: hysterectomy
290
management of EH with atypia not preserving fertility
total hysterectomy (and BSO if post-menopausal)
291
management of EH with atypia preserving fertility
1: LNG-IUS
2: oral progestogens
routine endometrial surveillance with biopsies every 3 months
refer to specialist if want to conceive
292
PACES counselling for endometrial hyperplasia
- 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
key features of focused history for cervical smear
- LMP
- gynae history (IMB, PCB, discharge)
- sexual history (changed partners recently)
- contraception
- obstetric features desires
- smoking?
- immunosuppression?
294
what happens if a smear is missed due to pregnancy?
should be done 3 months after delivery
295
explain the smear procedure
- 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
explanation of result
- 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
what to do if:
- mild/borderline
- anything worse
- inadequate sample
- mild/borderline: do HPV test then refer to coloposcopy
| - anything worse: repeat smear (if 3 inadequate samples = coloposcopy)
298
how do you explain coloposcopy
- 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
risks and aftercare for colposcopy
bleeding/infection
| no tampons or sex for 4 weeks
300
what is recommended for the different CINs?
CIN1: likely to resolve spontaneously, offer follow up smear in 12 months
CIN2,3 and CGIN: recommend removal
301
what is LLETZ?
- 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
what are the risks of LLETZ?
large excision/ repeat excisions associated with increased risk of midtrimester miscarriage and preterm delivery
303
what is a cone biopsy?
- used less frequently
- only performed if large area of tissue needs to be removed
- GA
304
other tx of CIN
cryotherapy, laser treatment, cold coagulation, hysterectomy
305
what needs to happen for all patients who undergo treatment for CIN?
- 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
what is the HPV vaccine and when is it given?
national vaccination programme for school girls aged 12-13
| quadrivalent vaccone = 6, 13, 16 and 18
307
PACES counselling for CIN
- 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
what should be done for preclinical lesions: stage 1A cervical cancer?
- 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
what should be done for clinically invasive cervical carcinoma: stage 1B?
- 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
what is the mainstay of treatment if tumour is beyond cervix?
stage 2-4
| radiotherapy is mainstay
311
surgery for cervical cancer
- Stage 1B = radical hysterectomy with pelvic lymph node dissection
- ovaries can be spared in pre-menopausal women
- high cure rate
312
risks of this operation
- bladder dysfunction (atony)
- sexual dysfunction (vaginal shortening)
- lymphodema (due to pelvic lymph node removal, management = leg elevation, good skin care, massage)
313
what are the pelvic lymph nodes that get dissected?
- obtruator n odes
| - internal and external illiac nodes
314
what are the pelvic lymph nodes that get dissected?
- obtruator n odes
| - internal and external illiac nodes
315
what are the pelvic lymph nodes that get dissected?
- obtruator nodes
| - internal and external illiac nodes
316
2 ways of delivering radiotherapy in cervical cancer
- 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
risks of radiotherapy
- 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
chemotherapy in cervical cancer
usually cisplatin
| usually given in conjunction with radiotherapy
319
surgical treatment for vulvar cancer
VULVAL excision
- radical surgical excision
- aim for clear margin (10mm)
- large lesions may be shrunk with neoadjuvant radiotherapy with chemo
320
what happens if groin lymph nodes are involved?
- full inguinofemoral lymphadenectomy
| - very morbid procedure (complications = wound healing, infection, VTE, chronic lymphodema)
321
how may full groin lymphadenectomy be avoided?
- 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
when is radiotherapy given for vulvar cancer?
- adjuvant is indicated if excision margins are close or 2+ groin node metastasis
- radical radiotherapy is pt unfit for surgery
323
when is part-partum contraception needed?
- after day 21
| - lactational amenorrhoea = 98% effective if woman is fully breast-feeding, amenorrhoeic and <6 months post-partum
324
options for post-partum contraception
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
FIGO staging for endometrial cancer
I: uterus
II: uterus + cervix
III: adnexa
IV: distant and bladder/bowel
326
FIGO for ovarian cancer
I: limited to ovaries
II: pelvic extnesion (e.g. uterus)
III: abdominal extension other than pelvic
IV: distant mets
327
FIGO for cervical cancer
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
types of functional ovarian cysts
- 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
types of inflammatory ovarian cysts
- 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
types of germ cell cyst
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
types of epithelial cysts
- 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
types of sex cord stromal cysts
- 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
A-G for abortion act
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
IVF Eligibility UK in women <40 years
offered 3 cycles by NHS if:
- UPSI for 2 years
OR
- not been able to get pregnant after 12 cycles of artificial insemination
335
IVF eligibility UK in women 40-42
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
what additional criteria are CCGs likely to have?
- not having children already from current/previous relationships
- being healthy weight
- not smoking
- falling within certain age range
337
how much can IVF cost privately?
£5000 per cycle
