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Obs & Gynae > Gynae > Flashcards

Gynae Flashcards

1
Q

What age range is cervical cancer most commonly seen in?

A

35-44

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2
Q

What are the two most common types of cervical cancer?

A
  1. Squamous cell carcinoma (80%)

2. Adenocarcinoma

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3
Q

What is the most common cause of cervical cancer?

A

HPV

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4
Q

What vaccination is given against cervical cancer?

A

HPV Vaccine

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5
Q

At what age is the HPV vaccine given and why?

A

12-13 (hopefully before they become sexually active)

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6
Q

Which strains of HPV are usually responsible for cervical cancer?

A

Type 16

Type 18

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7
Q

How does HPV promote the development of cancer?

A

It produces two proteins that inhibit tumour suprrosor genes

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8
Q

What cells make up the ectocervix?

A

Squamous cells

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9
Q

What cells make up the endocervix?

A

Collumnar cells

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10
Q

What is the squamocolumnar junction?

A

The junction at the cervix where the squamous cells transition into collumnar cells.

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11
Q

Where is the squamocolumnar junction?

A

Location varies throughout life

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12
Q

Why is the squamocolumnar junction the main target for HPV?

A

There is the largest turnover of cells there and so it can easily enter and remain

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13
Q

When is the squamocolumnar junction cell turnover most active and why does this matter?

A

During puberty, therefore this is when people are most at risk of HPV

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14
Q

What are the 3 categories of risk factor for cervical cancer?

A
  1. Increased risk of HPV
  2. Later detection of precancerous and cancerous changes (non-engagement with screening)
  3. Other risk factors
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15
Q

What factors increase the risk of catching HPV?

A
  • Early sexual activity
  • Multiple sexual partners
  • Sexual partners who have multiple partners
  • Unprotected sex
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16
Q

What are other risk factors for cervical cancer?

A
  • Not attending smears
  • Smoking
  • HIV
  • COCP > 5 years
  • Multigravida
  • Family history
  • Exposure to diethylstilbestrol during fetal development
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17
Q

What are the presenting symptoms of cervical cancer?

A
  • Asymptomatic (screening)
  • Abnormal vaginal bleeding (intermenstrual, postcoital, post-menopausal)
  • Vaginal discharge
  • Pelvic pain
  • Dyspareunia
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18
Q

How is suspected cervical cancer investigated?

A

Speculum examination
Swabs to exclude infection
Colposcopy

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19
Q

What appearances on colposcopy may indicate cervical cancer?

A

Ulceration
Inflammation
Bleeding
Visible tumour

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20
Q

What is dysplasia?

A

Premalignant change

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21
Q

What is the grading system used to measure the level of dysplasia in the cervix?

A

CIN- Cervical intraepithelial neoplasia

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22
Q

When is CIN decided?

A

At colposcopy (not cervical screening)

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23
Q

What are the different grades of cervical cancer?

A

CIN I: Mild dysplasia (1/3 thickness of epithelial layer- likely to return to normal)
CIN II: Moderate dysplasia( 2/3 thickness of epithelial layer- likely to turn into cancer)
CIN III: Severe dysplasia (very likely to turn into cancer)

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24
Q

What is CIN III otherwise known as?

A

Cervical carcinoma in situ

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25
Q

What does cervical screening involve?

A

Speculum examination and smear test to look for precancerous changes in the epithelial cells of the cervix

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26
Q

What is dyskaryosis?

A

Precancerous changes in cervical cells detected at smear

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27
Q

What is liquid based cytology?

A

The method of transporting the collected cervical cells: They are deposited from the brush into preservation fluid and taken to the lab to be examined under a microscope

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28
Q

What are smear cells tested for?

A

High-risk HPV- If not present the smear is considered negative/

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29
Q

What age women have smear tests and how frequently?

A

25-29 Every 3 years

50-64 Every 5 years

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30
Q

What are the exceptions to the cervical screening programme?

A

HIV+ve screened anually
Additional tests with previous CIN, immunocompromised
Pregnant women should wait until 12 weeks postpartum

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31
Q

What is cytology?

A

Diagnosing diseases by looking at single or small clusters of cells

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32
Q

What are the different options of cytology result?

A 
Inadequate
Normal
Borderline changes
Low-grade dyskaryosis
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Possible invasive squamous cell carcinoma
Possible glandular neoplasia
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33
Q

What is the management of women who are HPV positive with normal cytology?

A

Repeat HPV test after 12 months

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34
Q

What is the management of woemn who are HPV positive with abnormal cytology on smear?

A

Refer to colposcopy

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35
Q

What is the management of women who have an inadequate sample on smear?

A

Repeat after at least 3 months

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36
Q

What is colposcopy?

A

When a colposcope is used to magnify the cervix, allowing the epithelial lining to be examined in detail

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37
Q

What is used in colposcopy to view abnormal cells?

A

Acetic acid–> causes abnormal cells to appear white (acetowhite)
Schiller’s iodine test–> iodine solution stains healthy cells brown colour.

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38
Q

Why does acetic acid cause abnormal cells to appear white?

A

Pre-cancerous cells have more keratin so take up more acetic acid

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39
Q

What method can be used during colposcopy if abnormal cells are found?

A

LLETZ

Cone biopsy

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40
Q

What is LLETZ?

A

Large loop excision of the transformation zone: When a loop of electrical wire is used to remove abnormal tissue of the cervix

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41
Q

What method is used during colposcopy to remove a larger area of abnormal tissue?

A

Cone biopsy

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42
Q

What does a cone biopsy involve?

A

Cone-shaped piece of cervix is removed using a scalpel and then sent for histology

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43
Q

What are the different stages of cervical cancer?

A

Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis

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44
Q

What is CGIN?

A

Cervical glandular intra-epithelial neoplasia (very high risk dysplasia)

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45
Q

What are the usual treatments of CIN/ 1a?

A

LLETZ or Cone biopsy

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46
Q

What is the treatment of stage 1B-2A cervical cancer?

A

Radical hysterectomy and removal or lymph nodes with chemo/ radiotherapy

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47
Q

What is the treatment of stage 2b-4a cervial cancer?

A

Chemotherapy and radiotherapy

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48
Q

What is the treatment of stage 4b cervical cancer?

A

Combo of surgery, radio, chemotherapy and palliative care

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49
Q

What is pelvic exenteration?

A

An operation which removes most or all of the pelvic organs that may be used in advanced cervical cancer

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50
Q

What is Bevacizumab?

A

A monoclonal antibody that may be used in combination with other chemotherapies in the treatment of cervical cancer

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51
Q

What strains of HPV does the vaccine protect against and what do they cause?

A

6 & 11= Genital warts

16&18 = Cervical cancer

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52
Q

What type of cancer makes up the majority of endometrial cancer?

A

Adenocarcinoma (80%)

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53
Q

What does endometrial cancer depend on to grow?

A

Oestrogen-dependent cancer

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54
Q

What is the diagnosis for any woman presenting with postmenopausal bleeding until proven otherwise?

A

Endometrial cancer

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55
Q

What is the key risk factor for endometrial cancer?

A

Increased exposure to unopposed oestrogen

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56
Q

What is endometrial hyperplasia?

A

Precancerous thickening of the endometrium

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57
Q

What percentage of cases of endometrial hyperplasia go on to become endometrial cancer?

A

<5%

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58
Q

What are the two types of endometrial hyperplasia?

A

Hyperplasia without atypia

Atypical hyperplasia

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59
Q

How can endometrial hyperplasia be treated?

A

With progesterones:

  • Mirena coil
  • Oral progesterones
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60
Q

What is unopposed oestrogen?

A

Oestrogen without progesterone

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61
Q

What are the risk factors increase your exposure to unopposed oestrogen?

A 
Increased age
Early onset menstruation
Late menopause
Oestrogen only HRT
No/ fewer pregnancies
Obesity
PCOS
Tamoxifen
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62
Q

Why does PCOS lead to an increased exposure to unopposed oestrogen?

A

There is a lack of ovulation so there is no luteal phase with the corpus luteum producing progesterone.

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63
Q

What should be offered to women with PCOS to decrease their exposure to unopposed oestrogen?

A

COCP
Mirena coil
Cyclical progesterones

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64
Q

Why is obesity a key risk factor for endometrial cancer?

A

Because adipose tissue is a source of oestrogen

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65
Q

Why is tamoxifen a risk factor for endometrial cancer?

A

It has an oestrogenic effect on the endometrium

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66
Q

What are additional risk factors for endometrial cancer not linked to unopposed oestrogen?

A

T2 Diabetes

Lynch syndrome

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67
Q

What is lynch syndrome?

A

HNPCC–> Hereditary condition that increases risk of colon and endometrial cancer

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68
Q

Why does T2 diabetes increase the risk of endometrial cancer?

A

Increased production of insulin may stimulate the endometrial cells.

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69
Q

What are the protective factors against endometrial cancer?

A

COPC
Mirena coil
Increased pregnancies
Smoking

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70
Q

Why is smoking protective in endometrial cancer/

A

Anti-oestrogenic

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71
Q

What are the key presenting factors of endometrial cancer?

A 
*Postmenopausal bleeding
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal discharge
Haematuria
Anaemia
Raised platelets
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72
Q

What 3 investigations are done to diagnose endometrial cancer?

A
  1. TVUS for endometrial thickness
  2. Pipelle biopsy
  3. Hysteroscopy
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73
Q

What endometrial thickness would be a reg flag for cancer in post menopausal women?

A

> 4mm

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74
Q

What is a pipelle biopsy?

A

Speculum examination where pipelle (thin tube) is inserted into uterus to take sample of endometrium

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75
Q

What are the different stages of endometrial cancer?

A

Stage 1: confined to uterus
Stage 2: Invades cervix
Stage 3: Invades ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond pelvis

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76
Q

How is endometrial cancer usually managed?

A

Total abdominal hysterectomy with bilateral salpinogo-oophorectomy (removal of uterus, cervix and adnexa)

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77
Q

What are the other treatment options for endometrial cancer?

A

Radical hysterectomy
Radiotherapy
Chemotherapy
Progesterone to slow progression

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78
Q

What does a radical hysterectomy involve?

A

Removal of uterus, cervix, adnexa, pelvic lymph nodes, surrounding tissues and top of vagina

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79
Q

Why do the majority of ovarian cancer cases present late?

A

Non-specific symptoms

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80
Q

What are the different types of ovarian cancer?

A

*Epithelial cell tumours
Dermoid cysts/ germ cell tumours
Sex cord-stromal tumours
Metastasis

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81
Q

What are teratomas?

A

Tumours that come from germ cells and may contain various tissue types.

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82
Q

How may germ cell tumours be recognised?

A

Raised alpha-fetoprotein and hCG

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83
Q

What is a Krukenberg tumour?

A

A metastasis in the ovary that has a characteristic signet-ring histology

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84
Q

What is the peak age for ovarian cancer?

A

60

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85
Q

What are the risk factors for ovarian cancer?

A 
Age (60)
BRCA genes
Increased no of ovulations
Obesity
Smoking
Recurrent use of clomifene (infertility treatment) 
Early onset periods 
Late menopause
No pregnancies
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86
Q

What factors increase the risk of ovarian cancer?

A

Factors that increase the number of ovulations ( early onset periods, late menopause, no pregnancies)

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87
Q

What are the protective factors for ovarian cancer?

A

Factors that reduce the number of ovulations:
COPC
Breastfeeding
Pregnancy

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88
Q

How does ovarian cancer present?

A

Non- specific

  • Abdominal bloating
  • Early satiety
  • Loss of appetite
  • Pelvic pain
  • Urinary symptoms
  • Weight loss
  • Abdominal/ pelvic mass
  • Ascites
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89
Q

Where may you get referred pain in ovarian cancer and why?

A

Hip or groin pain due to ovarian mass pressing on obturator nerve

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90
Q

What red flag signs would cause direct referall to 2 week wait clinic?

A

Ascites
Pelvic mass
Abdominal mass

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91
Q

What investigations can be done to look for ovarian cancer?

A 
CA125 blood test (>35) 
Pelvic ultrasound
RMI
CT scan
Histology
Paracentesis
Germ cell tumour markers
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92
Q

What is RMI

A

Risk of malignancy index

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93
Q

What factors does RMI take into account?

A

Menopausal status
USS findings
CA125 level

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94
Q

What are causes of raised CA125?

A 
Epithelial cell ovarian cancer
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
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95
Q

What are the stages of ovarian cancer?

A

Stage 1: Confined to ovary
Stage 2: Inside pelvis
Stage 3: Inside abdomen
Stage 4: Outside of abdomen

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96
Q

How is ovarian cancer managed?

A

With MDT using combination of surgery and chemotherapy

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97
Q

What is the most common type of vulval cancer?

A

90% squamous cell carcinomas

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98
Q

What are the risk factors for vulval cancer?

A

Advanced age (>75)
Immunosuppresssion
HPV infection
Lichen sclerosus

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99
Q

What is VIN?

A

Vulval intraepithelial neoplasia: premalignant condition affecting squamous epithelium of the skin

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100
Q

What is high grade squamous intraepithelial lesion?

A

Type of VIN associated with HPV infection (typically in women 35-50)

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101
Q

What is differentiated VIN?

A

Type of VIN associated with lichen sclerosus (typically in women 50-60)

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102
Q

What are the treatment options for VIN?

A

Watch & wait
Wide local excision
Imiquimod
Laser ablation

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103
Q

How does vulval cancer present?

A 
Vulval lump--> usually on labia majora (irregular, fungugating) 
Ulceration
Bleeding
Pain 
Itching
Lymphadenopathy in groin
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104
Q

How is vulval cancer diagnosed?

A

2WW referral
Biopsy of lesion
Sentinel node biopsy
Imaging for staging

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105
Q

What are the management options for vulval cancer?

A

Wide local excision
Groin lymph node dissection
Chemotherapy
Radiotherapy

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106
Q

What two muscles is the pelvic floor made up of?

A

Levator ani

Coccygeus

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107
Q

What 3 muscles make up the levator ani?

A

Pubococcygeus
Ileococcygeus
Puborectallis

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108
Q

What two holes are in the pelvic floor?

A 
Urogenital hiatus (passage of urethra)
Rectal hiatus (passage of anal canal)
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109
Q

What is the pelvic outlet?

A

the inferior opening of the pelvis that is bounded by coccyx, the ischial tuberosities, and the pubis symphysis

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110
Q

What makes up the pelvic outlet?

A

Urogenital and anal triangles

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111
Q

What is the perineal body?

A

The fibrous node at the centre of the perineum that is the connecting point for many muscles

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112
Q

What is an episiotomy and why is it used in labour?

A

Horizontal cut, to avoid tearing of the perineal body

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113
Q

What is the function of the pelvic floor muscles?

A

Support abdominal and pelvic viscera
Resist intra-pelvic/ abdominal pressure
Urinary and faecal continence

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114
Q

What ligaments support the uterus?

A

Round ligament
Cardinal ligaments
Uterosacral ligament

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115
Q

Where do the round ligaments insert and therefore in what position does this keep the uterus?

A

Pass through the inguinal canal and insert on the labia majora, keeping uterus anteverted

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116
Q

What happens to the round ligaments during pregnancy?

A

They stretch and may cause pain. The uterus may be more floppy after birth

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117
Q

Where to the cardinal ligaments originate/ insert and therefore how to they support the uterus?

A

Arise from cervix and attach to lateral pelvic wall

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118
Q

Where do the uterosacral ligaments insert and therefore how do they support the uterus?

A

Attach cervix to the sacrum, supporting it posteriorly

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119
Q

What supports the inferior aspect of the uterus?

A

The pelvic floor: levator ani, perineal membrane and perineal body

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120
Q

What are the 3 categories of ligaments in the female reproductive tract?

A

Broad ligament
Uterine ligaments
Ovarian ligaments

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121
Q

What is the broad ligament?

A

A flat sheet of peritoneum that extends from the lateral pelvic walls to support all of the internal femal genitalia/

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122
Q

What are the 3 regions that make up the broad ligament?

A

Mesometrium
Mesovarium
Mesosalpinx

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123
Q

What is contained in the broad ligament?

A

The ovarian and uterine arteries
Ovarian ligament
Round ligament
Suspensory ovary ligament

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124
Q

What ligaments are associated with the ovary?

A

Ovarian ligament

Suspensory ligament of ovary

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125
Q

What is pelvic organ prolapse?

A

The descent of pelvic organs into the vagina

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126
Q

What causes prolapse?

A

Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder

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127
Q

What are the different types of prolapse?

A

Uterine
Vault
Rectocele
Cystocele

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128
Q

What is a vault prolapse and in which patients does it occur?

A

When the top of the vagina (the vault) descends into the vagina. Only occurs in women that have had a hysterectomy

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129
Q

What is a rectocele?

A

When the rectum prolapses forward into the vagina

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130
Q

How may a rectocele present?

A

Constipation due to faecal loading. (may have to press to open bowels)
Urinary retention
Palpable lump in vagina

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131
Q

Where is the defect in a rectocele?

A

The posterior vaginal wall

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132
Q

What is a cystocele?

A

When the bladder prolapses backwards into the vagina

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133
Q

Where is the defect in a cystocele?

A

Anterior vaginal wall

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134
Q

What is a cystourethrocele?

A

Prolapse of both the bladder and urethra

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135
Q

What are the risk factors for pelvic organ prolapse?

A 
Multiple vaginal deliveries
Instrumental delivery
Prolonged or traumatic delivery
Obesity
Advanced age/ postmenopausal
COPD (chronic coughing)
Chronic constipation
Smoking
Tissue disorders
Hysterectomy
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136
Q

Why does chronic straining (e.g. COPD, constipation) increase the risk of prolapse?

A

Increases intra-abdominal pressure

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137
Q

How does prolapse usually present?

A 
Dragging/ heavy sensation
Urinary symptoms
Bowel symptoms
Sexual dysfunction
Palpable lump/ mass
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138
Q

What are the urinary symptoms that should be taken in a history?

A 
Incontinence (stress or urge)
Urgency
Frequency
Weak stream
Retention
Dysuria
Nocturia
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139
Q

What bowel symptoms should be taken in a history?

A

Constipation
Incontinence
Urgency

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140
Q

How do you examine a prolapse?

A

Abdominal exam to look for masses
Sim’s speculum to examine vaginal walls (may need to lie left lateral)
Pelvic USS to look for mass

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141
Q

What are the different grades of uterine prolapse?

A

Grade 1= Uterus in upper part of vagina
Grade 2= Uterus descended to opening of vagina
Grade 3= Uterus protudes out vagina
Grade 4= Uterus completely out the vagina

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142
Q

What are the 3 management options for pelvic organ prolapse?

A
  1. Conservative
  2. Vaginal pessary
  3. Surgery
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143
Q

What is the conservative management for prolapse?

A

Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes
Vaginal oestrogen cream (reduce dryness and irritation)

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144
Q

What lifestyle changes are recommended for prolapse?

A

Weight loss
Reduced caffeine & alcohol intake
Reduce heavy lifting
Incontinence pads

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145
Q

What are the different types of pessaries that can be used?

A 
Ring
Shelf
Gellhorn
Cube
Donut
Hodge
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146
Q

How often should pessaries be changed?

A

Every 4 months

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147
Q

What management is no longer recommended to treat prolapse?

A

Mesh repairs as they have a lot of complications and don’t have good evidence as to effectiveness.

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148
Q

What are the two types of urinary incontinence?

A

Urge incontinence

Stress incontinence

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149
Q

What is urge incontinence?

A

Overactivity of the detrusor muscle of the bladder

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150
Q

How does urge incontinence present?

A

Sudden urge to pass urine
Rush to the bathroom
Leaking before reaching bathroom

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151
Q

What is stress incontinence?

A

When increased pressure on the bladder overcomes the pelvic floor and sphincter muscles

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152
Q

How does stress incontinence usually present?

A

Urinary leakage when laughing, coughing, lifting or surprised

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153
Q

What is mixed incontinence?

A

Combination of urge and stress incontinence

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154
Q

What is overflow incontinence?

A

When chronic urinary retention (due to an obstruction) results in an overflow of urine without the urge to pass urine/

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155
Q

What can cause overflow incontinence?

A

Anticholinergics
Fibroids
Pelvic tumours
Neurological conditions (MS, Diabetic neuropathy, spinal cord injuries)

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156
Q

What are the risk factors for urinary incontinence?

A 
Increased age
Previous pregnancies and vaginal deliveries
Increased BMI
Postmenopausal
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions
Cognitive impairment/ dementia
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157
Q

What modifiable risk factors can contribute to incontinence?

A

Caffeine consumption
Alcohol consumption
Medications
BMI

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158
Q

What should be assessed on examination of incontinence?

A 
Pelvic tone
Prolapse
Atrophic vaginitis
Urethral diverticulum 
Pelvic masses
Ask patient to cough to look for leakage from urethra
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159
Q

What is urethral diverticulum?

A

Where an outpouching forms next to the urethra which can get filled with urine during urination.

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160
Q

How is the strength of the pelvic muscles assessed?

A

Using bimanual examination and asking woman to squeeze against fingers

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161
Q

How is pelvic muscle tone graded?

A 
Oxford grading system: 
0= no contraction
1= faint contraction
2= weak 
3= moderate with some resistance
4= good contraction
5= strong contraction
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162
Q

How is incontinence investigated?

A 
Take thorough history
Bladder diary (>3 days) 
Urine dipstick for infection
Bladder scan 
Urodynamic testing
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163
Q

Why is a bladder scan done in incontinence investigations?

A

To measure the post- void residual bladder volume to assess for incomplete emptying

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164
Q

What is urodynamic testing?

A

Range of tests to assess presence and severity of urinary symptoms

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165
Q

What happens in urodynamic testing?

A

Catheters are inserted into bladder and rectum to measure and compare the pressures. The bladder is filled with liquid and measures are taken

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166
Q

What measures are taken in urodynamic testing?

A 
Cystometry (detrusor muscle contraction/ pressure) 
Uroflowmetry (flow rate) 
Leak point pressure
Post-void residual bladder volume
Video urodynamic testing
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167
Q

What is the leak point pressure?

A

The point at which the bladder pressure results in leakage of urine

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168
Q

What is the management of stress incontinence?

A

Lifestyle modification
Pelvic floor excercises
Surgery
Duloxetine

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169
Q

What is the lifestyle management of stress incontinence?

A

Avoid caffiene, diuretics and overfilling the bladder
Avoid excessive or restricted fluid intake
Weight loss

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170
Q

What is duloxetine and what is its action?

A

SNRI antridepressant that increases activity of nerve that stimulated urethral sphincter, improving its function

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171
Q

What are the surgical options to treat stress incontinence?

A

Tension-free vaginal tape
Autologous sling
Colposuspension
Intramural urethral bulking

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172
Q

How long should ladies with stress incontinence try pelvic floor exercises before surgery is advised?

A

At least 3 months

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173
Q

What is the management of urge incontinence?

A

Bladder retraining
Anticholinergics
Mirabegron
Invasive procedures

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174
Q

What is the first line treatment for urge incontinence and what does it involve?

A

Bladder retraining: Gradually increasing time between voiding

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175
Q

What are the side effects of anticholinergic medications?

A 
Dry mouth & eyes
Urinary retention
Constipation
Postural hypotension
Cognitive decline
Memory problems
Worsening of dementia
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176
Q

What is the most common anticholinergic used and what is its action?

A

Oxybutynin

Block the action of acetylcholine which reduces abnormal bladder contractions/

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177
Q

What is Mirabegron and why would it be used instead of an anticholinergic?

A

Beta-3 agonist, similar to an antimuscarinic

Less of an anticholinergic burden

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178
Q

When is Mirabegron contraindicated?

A

In uncontrolled hypertension as it increases blood pressure by stimulating sympathetic nervous system

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179
Q

What are the invasive third line options for treating overactive bladder?

A

Botulinium toxin (botox) injection
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion

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180
Q

What is amenorrhoea?

A

Lack of menstrual periods

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181
Q

What is primary amenorrhoea?

A

When the patient has never started periods

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182
Q

What are the causes of primary amenorrhoea?

A 
Abnormal functioning of the hypothalamus or pituitary
Abnormal functioning of gonads
Structural pathology (imperforate hymen= when the hymen covers opening of the vagina)
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183
Q

What is secondary amenorrhoea?

A

When the patient has previously had periods that have now stopped (for >6months)

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184
Q

What are some causes of secondary amenorrhoea?

A 
Pregnancy
Menopause
Physiological stress (excessive excercise, low BMI, chronic disease, psychosocial factors)
PCOS
Contraceptives
Premature ovarian insufficiency
Thyroid abnormalities
Prolactinoma
Cushing's syndrome
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185
Q

What are the different types of abnormal uterine bleeding?

A 
Menorrhagia
Amenorrhea
Oligomenorrhoea
Post-menopausal bleeding
Post-coital bleeding
Dysmenorrhea
Dysfunctional uterine bleeding
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186
Q

What are the differential presentations in gynaecology?

A 
Amenorrheoa
Irregular menstruation
Intermenstrual bleeding
Dysmenorrhoea
Menorrhagia
Postcoital bleeding
Pelvic pain
Vaginal discharge
Pruritus vulvae
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187
Q

What is oligomenorrhea?

A

Infrequent menstrual bleeding

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188
Q

What does irregular uterine bleeding indicate?

A

Annovulation of irregular ovulation

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189
Q

What are the causes of irregular menstruation?

A 
Extremes of reproductive age
PCOS
Physiological stress
Medications
Hormonal imbalances
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190
Q

What are the key causes of intermenstrual bleeding?

A 
Hormonal contraception
Cervical ectropion
Polpys
*Cervical, endometrial or vaginal cancer
STI's
Pregnancy
Ovulation
Medications
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191
Q

What is dysmenorrhoea?

A

Particularly painful periods

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192
Q

What are the causes of dysmenorrhoea?

A 
Primary (no underlying pathology) 
Endometriosis/ adenomyosis
Fibroids
PID
Copper coil
Cervical/ ovarian cancer
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193
Q

What is menorrhagia?

A

Heavy menstrual bleeding

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194
Q

What are the causes of menorrhagia?

A 
Dysfunctional uterine bleeding
Extremes of reproductive age
Fibroids
Endometriosis/ adenomysosis
PID
Contraceptives (copper coil)
Anticoagulants
Bleeding disorders
Endocrine disorders
Connective tissue disorders
Endometrial hyperplasia
Cancer
(PCOS)
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195
Q

What is Dysfunctional uterine bleeding?

A

Bleeding with no identifiable cause

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196
Q

What are the key causes of postcoital bleeding?

A 
Idiopathic
Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
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197
Q

What are some causes of pelvic pain?

A 
UTI
Dysmenorrheoa
IBS
Ovarian cysts
Endometriosis
PID
Ectopic pregnancy
Appendicitis
Mittelshcmerz
Pelvic adhesions
Ovarian torsion
IBD
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198
Q

What may abnormal discharge indicate?

A 
Bacterial vaginosis
Cadidiasis
STI's 
Cervical ectropion
Polyps
Malignancy
pregnancy
Contraception
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199
Q

What is pruritis vulvae?

A

Itching of the vulva and vagina

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200
Q

What are the causes of pruritis vulvae?

A 
Irritants (e.g. soap ) 
Atrophic vaginitis
Infections
Skin conditions
Malignancy 
Stress
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201
Q

At what age is primary amenorrhoea defined?

A

13 with no other evidence of pubertal development

15 with other signs of puberty

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202
Q

When does puberty normally start in girls?

A

8-14

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203
Q

When does puberty normally start in boys?

A

9-15

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204
Q

What are the causes of primary amenorrhoea?

A 
Hypogonadism (Hypogonadotropic hypogonadism
or Hypergonadotropic hypogonadism)
Kallman syndrome
Congenital adrenal hyperplasia
Androgen insensitivity syndrome
Structural pathology
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205
Q

What is hypogonadism?

A

Lack of oestrogen and testosterone

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206
Q

What is hypogonadotropic hypogonadism?

A

Deficiency of LH and FSH leading to oestrogen deficiency

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207
Q

What are the potential causes of hypogonadotropic hypogonadism?

A 
Hypopituitarism
Hypothalamus or pituitary damage
Chronic conditions
Excessive exercise/ dieting
Constitutional delay in growth and development
Endocrine disorders
Kallman syndrome
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208
Q

What is Hypergonadotropic hypogonadism?

A

When the gonads fail to respond to the stimulation from gonadotrophins

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209
Q

What are the gonadotropin hormoness?

A

LH & FSH

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210
Q

What are the causes of Hypergonadotropic hypogonadism?

A

Damage to gonads (torsion, cancer, infection)
Congenital absence of ovaries
Turner’s syndrome

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211
Q

What is Kallman syndrome?

A

Genetic condition that causes hypogonadotrophic hypogonadism, with failure to start puberty

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212
Q

What is congenital adrenal hyperplasia?

A

A congenital condition causing the underproduction of cortisone and aldosterone and the overproduction of androgens from birth.

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213
Q

What is androgen insensitivity syndrome?

A

Condition where tissues are unable to respond androgen hormones (testosterone) so male characteristics do not develo, resulting in a female phenotype with male internal pelvic organs.

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214
Q

What is the aims of assessment of primary amenorrhoea?

A

Look for evidence of puberty and assess for possible underlying causes

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215
Q

What are the conditions for investigating primary amenorrhoea?

A

No evidence of pubertal changes at 13 or some evidence of puberty with no progression after 2 years

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216
Q

What are the initial steps in the assessment of primary amenorrhoea?

A

Detailed history

Examine height, weight, stage of development and features of underlying conditions

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217
Q

What are the initial investigations into primary amenorrhoea?

A

Assess for underlying conditions
Hormonal blood tests
Genetic testing
Imaging

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218
Q

What investigations would be done to look for underlying conditions in primary amenorrhoea?

A
  • FBC/ ferritin (anaemia)
  • U&E’s (kidney disease)
  • Anti-TTG, anti- EMA
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219
Q

What investigations would be done to look for hormonal abnormalities in primary amenorrhoea?

A 
FSH/ LH
Thyroid function
Insulin-like growth factor 1 (GH deficiency) 
Prolactin
Testosterone
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220
Q

What imaging can be done to look into primary amenorrhoea?

A

Wrist X-ray to assess bone age
Pelvic ultrasound
MRI brain (pituitary pathology)

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221
Q

How is primary amenorrhoea?

A

Treat cause:

  • Hormone replacement
  • Reassurance and observation
  • Weight gain/ stress reduction
  • Manage chronic/ endocrine condition
  • Pulsatile GnRH
  • COCP
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222
Q

What is the definition of secondary amenorrhea?

A

No menstruation for >3months after previously regular periods
OR >6 months after previous irregular periods

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223
Q

What are the main causes of secondary amenorrhea?

A 
Pregnancy 
Menopause
Hormonal contraception
Hypothalamic/ pituitary/ thyroid/ uterine pathology
PCOS
Hyperprolactinaemia
Physiological/ psychological stress
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224
Q

Why does physiological/ psychological stress cause amenorrhoea?

A

In circumstances where the body may not be fit for pregnancy, the hypothalamus reduces the production of GnRH, leading to hypogonadotropic hypogonadism.

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225
Q

What is the main cause of hyperprolactinaemia and why does it cause amenorrhoea?

A

Pituitary adenoma secreting prolactin.

High prolactin levels have negative feedback on the hypothalamus, reducing its release of GnRH/

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226
Q

How is secondary amenorrhoea investigated?

A

History+ examination
Hormonal blood tests
USS pelvis (PCOS)

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227
Q

What hormonal blood tests are done to look into secondary amenorrhoea?

A 
HcG to rule out pregnancy
LH/ FSH
Prolactin
TSH, T3/T4
Testostrone
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228
Q

How is secondary amenorrhoea managed?

A

Treat cause (may need replacement hormones)

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229
Q

What are patients with amenorrhoea associated with low oestrogen levels at risk of?

A

Osteoporosis

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230
Q

What is PMS and at what stage of the menstrual cycle does it occur?

A

Pre-menstrual syndrome

Luteal phase

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231
Q

What are management options for severe PMS?

A 
Lifestyle changes
COCP
SSRI antidepressants
CBT
Oestrogen patches
GnRH analogues
Hysterectomy
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232
Q

How much blood to women typically lose per menstural period?

A

40ml

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233
Q

How many ml of blood is counted as menorrhagia?

A

> 80ml

In practice: changing pads 1-2 hours, bleeding >7days, passing large clots

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234
Q

What investigations are performed first line in menorrhagia?

A

Speculum and bimanual examination

FBC (Anaemia)

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235
Q

What would you be looking for with a speculum examination in menorrhagia?

A

Fibroids
Ascites
Cancer

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236
Q

When would an outpatient hysteroscopy be arranged for menorrhagia?

A

Suspected submucosal fibroids
Suspected endometrial hyperplasia/ cancer
Persistent intermenstrual bleeding

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237
Q

When would a pelvic/ transvaginal USS be arranged for menorrhagia?

A

Possible large fibroids
Possible adenomyosis
Examination difficult to interpret (obesity)
Hysteroscopy declined

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238
Q

What additional tests can be done into menorrhagia after examination?

A 
Hysteroscopy
USS
Swabs
Coagulation screen
Ferritin
Thyroid function tests
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239
Q

How is menorrhagia managed?

A

Manage underlying pathology

  1. Mirena coil
  2. COPC
  3. Cyclical oral progesterones
  4. If contraception not acceptable: TXA
  5. If all else fails: Endometrial ablation/ hysterectomy
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240
Q

What is TXA and how does it work?

A

Transexamic acid: antifibronlytic that reduces bleeding

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241
Q

What are fibroids?

A

Benign tumours of the smooth muscle of the uterus

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242
Q

What percentage of older women have fibroids?

A

40-60%

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243
Q

What reaction to fibroids have to oestrogen?

A

Oestrogen-sensitive so grow in response

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244
Q

What are the 4 types of fibroid?

A

Intramural
Subserosal
Submucosal
Pedunculated

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245
Q

Where are intramural fibroids located?

A

Within the myometrium

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246
Q

Where are subserosal fibroids located?

A

Just below the outer layer of the uterus, filling the abdominal cavity

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247
Q

Where are submucosal fibroids located?

A

Just below the endometrium

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248
Q

What are pedunculated fibroids?

A

Those on a stalk, often invading the uterine space

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249
Q

How might fibroids present?

A 
Asymptomatic
Menorrhagia
Prolonged menstruation
Abdominal pain (wores on menstruation) 
Bloating/ fullness in abdomen
Urinary/ bowl symptoms due to pressure
Deep dyspareunia
Reduced dertility
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250
Q

What may abdominal/ bimanual examination reveal with suspected fibroids?

A

Palpable mass or enlarged firm uterus

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251
Q

Why may fibroids cause heavy/ prolonged menstrual bleeding?

A

May put pressure against endometrium
May prevent uterus from contracting properly to stop bleeding
May stimulate growth of blood vessels
May increase surface area of endometrium leading to more tissue loss

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252
Q

What investigations are done to confirm fibroids?

A

Hysteroscopy
Pelvic USS
MRI scanning

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253
Q

What is the medical management for fibroids <3cm?

A
  1. Mirena coil
  2. NSAIDS/ TXA
  3. COCP
  4. Cyclical oral progesterones
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254
Q

What are the surgical options for smaller fibroids?

A

Endometrial ablation
Resection
Hysterectomy

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255
Q

What are the medical management options for fibroids >3cm?

A

Symptomatic management (NSAIDS/ TXA)
Mirena coil
COCP
Cyclical oral progesterones

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256
Q

What are the surgical options for fibroids >3cm?

A

Uterine artery embolisation
Myomectomy
Hysterectomy

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257
Q

What is myomectomy?

A

Surgical removal of fibroids

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258
Q

What might be used to reduce the size of fibroids before surgery?

A

GnRH agonists (Zoladex, Prostap) to reduce the amount of oestrogen maintaining the fibroid

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259
Q

What is uterine artery embolisation?

A

When a catheter is inserted into the femoral artery and X-ray guided to the fibroid where particles are injected to block the arterial supply to the fibroid

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260
Q

What is laparoscopic vs laparotomy surgery?

A 
Laparoscopic= key-hole
Laparotomy= surgical incision
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261
Q

What are the complications of fibroids?

A 
Heavy menstrual bleeding
Reduced fertility
Pregnancy complications
Constipation
UTI/ Urinary outflow obsrtuction
Red degeneration
Torsion
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262
Q

What is red degeneration of fibroids?

A

Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply (usually during pregnancy), presenting with severe abdominal pain, fever, tachycardia and vomiting.

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263
Q

What is the treatment for red degeneration?

A

Supportive with rest, fluids and analgesia.

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264
Q

What is endometriosis?

A

When endometrial tissue grows outside the uterus

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265
Q

What is adenomyosis?

A

Endometrial tissue within the myometrium

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266
Q

What are the main symptoms of endometriosis?

A 
Cyclical pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility
Cyclic bleeding in stool/ urine
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267
Q

What is deep dyspareunia?

A

Pain on deep sexual intercourse

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268
Q

Why is pelvic pain the main symptom of endometriosis?

A

During menstruation, the ectopic endomatrial tissue also sheds its lining and bleeds, causing irritation and inflammation of the tissues

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269
Q

What complication can localised bleeding and inflammation lead to in endometriosis?

A

Adhesions (scar tissue that binds organs together).

Can cause chronic, non-cyclic pain

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270
Q

What may examination reveal in endometriosis?

A

Visible endometrial tissue in the vagina on speculum examination
Fixed cervix
Tenderness in vagina, cervix or adnexa

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271
Q

How is endometriosis diagnosed?

A

Pelvic USS

Laparoscopic surgery with biopsy of lesions

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272
Q

What is the initial management of endometriosis?

A

Establish diagnosis with clear explanation

Analgesia for pain (NSAIDs/ paracetamol

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273
Q

What management options can be tried before definitie laparoscopic diagnosis of endometriosis?

A 
COPC
POP
Medroxyprogesterone acetate injection
Implant
Mirena
GnRH agonist
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274
Q

What are the surgical management options of endometriosis?

A

Laparoscopic surgery to excise/ ablate tissue and adhesions

Hysterectomy

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275
Q

What is used to treat cyclical pain in endometriosis and why?

A
  • Hormonal contraceptives to stop ovulation and reduce endometrial thickening/
  • Induce menopause-like state with GnRH agonists.
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276
Q

In which women is adenomyosis more common?

A

Older women

Multiparous women

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277
Q

How does adenomyosis present?

A

Dysmenorrhoea (painful periods)
Menorrhagia (heavy periods)
Dyspareunia (painful intercourse

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278
Q

How is adenomyosis diagnosed?

A

Examination (enlarged, tender uterus)
TVUS = 1st line
MRI/ abdominal USS
Histological examination after hysterectomy= gold standard

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279
Q

How is adenomyosis managed?

A
  • Same as for heavy menstrual bleeding:
    1. Contraception
    2. TXA/ Mefenamic acid
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280
Q

What are the complications of adenomyosis associated with pregnancy?

A 
Infertility
Miscarriage
Preterm birth
Small for gestational age 
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
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281
Q

What is cervical ectropion?

A

When the columnar epithelium of the endocervix extends out to the ectocervix and is visible

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282
Q

How does cervical ectropion usually present and why?

A

With postcoital bleeding as the endocervical cells are more fragile and prone to trauma.

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283
Q

What are the risk factors for cervical ectropion?

A

Higher oestrogen levels:

  • Younger women
  • COCP use
  • Pregnancy
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284
Q

What is the transformation zone?

A

The border between the columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix

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285
Q

How else might cervical ectropion present?

A

Increased discharge
Bleeding
Dyspareunia

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286
Q

When would ectropion be treated and how?

A

If there is problematic bleeding, it can be cauterised with silver nitrate or cold coagulation during colposcopy.

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287
Q

What is classified as the menopause?

A

When a woman has had no periods for 12 months

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288
Q

What is the average age of menopause?

A

51

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289
Q

What is perimenopause?

A

The time around the menopause, where the woman may be experiencing symptoms and irregular periods

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290
Q

What time period is the perimenopause?

A

The time leading up to the last period and the 12 months afterwards

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291
Q

What is classified as premature menopause?

A

Menopause before age 40.

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292
Q

What causes menopause?

A

Lack of ovarian follicular function, resulting in low oestrogen & progesterone and high LH and FSH

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293
Q

What are the symptoms of perimenopause?

A 
Hot flushes
Emotional instability/ low mood
Premenstrual syndrome
Irregular periods/ change in quantity
Joint pains
Vaginal dryness/ atrophy
Reduced libido
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294
Q

What are the risks of the lack of oestrogen caused by menopause?

A

Cardiovascular disease
Osteoporosis
Pelvic organ prolapse
Urinary incontinence

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295
Q

What blood test can be used to help diagnose menopause and when would it be necessary?

A

FSH blood test:
Women <40 with suspected premature menopause
Women 40-45 with symptoms or change in cycle

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296
Q

How long should women continue to use contraception after their last menstrual period?

A

2 years if <50

1 year if >50

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297
Q

What are vasomotor symptoms?

A

Those that occur due to the constriction/ dilation of blood vessels (e.g. hot flushes, night sweats, palpitations, BP changes)

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298
Q

How long to perimenopausal vasomotor symptoms usually last?

A

2-5 years

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299
Q

What are the treatment options for symptomatic menopause?

A 
None
HRT
Tibolone
Clonidine
CBT
SSRI's
Testosterone
Vaginal oestrogen
Vaginal mousturisers
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300
Q

What is the cause of premature menopause?

A

Premature ovarian insufficiency

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301
Q

What causes Premature ovarian insufficiency?

A

Hypergonadotropic hypogonadism:

  • Idiopathic
  • Latrogenic
  • Autoimmune
  • Genetic
  • Infections
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302
Q

How is Premature ovarian insufficiency diagnosed?

A

Women <40 presenting with typical menopausal symptoms and elevated FSH on two consecutive occasions

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303
Q

How is premature ovarian insufficiency managed?

A

Hormone replacement therapy until at least normal menopausal age, to reduce risks of osteoporosis, cardiovascular risks etc.

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304
Q

What are the two options of HRT for women with premature ovarian insufficiency?

A

Traditional HRT

COCP

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305
Q

What is HRT?

A

Hormone replacement therapy- giving exogenous oestrogen to alliviate menopausal symptoms

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306
Q

In what women should progesterone be given along with oestrogen and why?

A

Those with a uterus to prevent endometrial hyperplasia and cancer

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307
Q

What can unopposed oestrogen do to the endometrium?

A

cause endometrial hyperplasia, increasing the risk of cancer

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308
Q

What HRT therapy would women without a uterus be given?

A

Oestrogen only

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309
Q

What HRT therapy would women that still have periods be given?

A

Cyclical HRT with cyclical progesterone and breakthrough bleeds

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310
Q

What HRT therapy would women with a uterus and >12 months without periods be given?

A

Continuous combined HRT

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311
Q

What are the non-hormonal treatment options for menopausal symptoms?

A 
Lifestyle changes
CBT
Clonidine
SSRI's
Venlafaxine
Gabapentin
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312
Q

What lifestyle changes may improve menopausal symptoms?

A

Diet, exercise, weight loss, stop smoking, reduce alcohol, reduce caffeine, reduce stress

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313
Q

What is Clonidine?

A

Agonist of alpha-adrenergic and imidazoline receptors in the brain.

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314
Q

What is the action of Clonidine?

A

Lowers blood pressure and heart rate, and can reduce hot flushes and other vasomotor symptoms

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315
Q

What are some common side effects of Clonidine?

A

Dry mouth
Headaches
Dizziness
Fatigue

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316
Q

What are the indications for HRT?

A
  • Replacing hormones in premature ovarian insufficiency
  • Reducing vasomotor symptoms
  • Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
  • Reducing risk of osteoporosis in women under 60 years
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317
Q

What are the risks of HRT?

A

Increased risk of:

  • Breast cancer
  • Endometrial cancer
  • VTE
  • Stroke
  • Coronary artery disease
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318
Q

In which women do the risks of HRT not apply?

A
  • Not increased risk compared to other women <50
  • No risk of endometrial cancer in those without a uterus
  • No risk of coronary artery disease with oestrogen-only HRT
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319
Q

What are the contraindications to HRT?

A 
Undiagnosed abnormal bleeding
Endometrial hyperplasia/ cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or MI
Pregnancy
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320
Q

What is assessed before starting HRT?

A 
Full Hx for contraindications
FH for risk of cancer/ VTE
BMI 
BP
Screening is up to date
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321
Q

What are the 3 steps to consider when choosing HRT formulation?

A

Step 1: Are the symptoms local or systemic?
Step 2: Does she have a uterus?
Step 3: Have they had a period in the last 12 months?

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322
Q

What is given if the woman has local symptoms?

A

Topical treatments (e.g. topical oestrogen cream or tablets)

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323
Q

What are the two options for delivering systemic oestrogen?

A

Oral (tablet)

Transdermal (patches or gels)

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324
Q

What are the 3 options for delivering progesterone?

A

Oral
Transdermal
Intrauterine system (Mirena coil)

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325
Q

What are progestogens?

A

Any chemicals that target and stimulate progesterone receptors

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326
Q

What are progestins?

A

Synthetic progesterones

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327
Q

What are the 2 classes of progesterone used in HRT?

A

C19 and C21, can be sweitched if woman is having side effects

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328
Q

What is the best way of delivering oestrogen and why?

A

Via patches due to the decreased rrisk of VTE

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329
Q

What is the best way of delivering progesterone and why?

A

With and IUD
Has added benefits of contraception and treating HMP
Will not experience progestogenic side effects

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330
Q

What is tibolone?

A

A synthetic steroid that stimulates oestrogen and progesterone receptors, used as a form of continuous combined HRT.

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331
Q

After how long on HRT should there be a follow up and how long should women persist to allow it to work/ side effects to reside?

A

3 months

332
Q

What are the oestrogenic side effects of HRT?

A 
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
333
Q

What are the progestogenic side effects of HRT?

A 
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
334
Q

What is PCOS?

A

Polycystic ovarian syndome

335
Q

What are the characteristic features of PCOS?

A 
Ovarian cysts
Infertility
Oligomenorrhea/ amenorrhoea
Hyperandrogenism
Insulin resistance
336
Q

What is oligoovulation?

A

Irregular, infrequent ovulation

337
Q

What is hirsutism?

A

The growth of thick, dark hair (often on the face)

338
Q

What is the diagnostic criteria for PCOS?

A

2 out of 3:

  • Oligoovulation/ Anovulation
  • Hyperandrogenism
  • Polycystic ovaries on USS
339
Q

How would oligoovulation/ anovulation present?

A

Irregular or absent periods

340
Q

What are the effects of hyperandrogenism?

A

Hirsutism and acne

341
Q

What is the Rotterdam criteria?

A

The criteria for making a diagnosis of PCOS

342
Q

How does PCOS usually present?

A 
Infrequent/ absent menstruation
Infertility
Obesity
Hirsutism
Acne
Hair growth in male pattern
343
Q

What additional features may also be found in PCOS?

A 
Insulin resistance/ diabetes
Acanthosis nigricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia/ cancer
Obstructive sleep apnoea
Depression/ anxiety
Sexual problems
344
Q

What is acanthosis nigricans?

A

Thick, rough skin usually in the axilla and elbows that occurs with insulin resistance

345
Q

What are other causes of hirsutism?

A

Medications
Ovarian/ adrenal tumours
Cushing’s syndrome
Congenital adrenal hyperplasia

346
Q

What happens to insulin levels with insulin resistance?

A

The pancreas produces more in order to get a response

347
Q

What effects does insulin have in PCOS?

A
  • Promotes the release of androgens from the ovaries and adrenal glands
  • Supresses SHBG production in the liver, therefore promoting hyperandrogenism
348
Q

What is SHBG and what is its action?

A

Sex hormone-binding globulin/ Binds to androgens and suppresses their function.

349
Q

What do higher levels of insulin result in?

A

Higher levels of androgens (e.g. testosterone)

Halting development of follicles in the ovaries

350
Q

What does reduced follicle develop cause?

A

Annovulation

Multiple partially developed follicles (seen as polycystic ovaries on scan)

351
Q

What investigations are done into PCOS?

A

Blood tests
Pelvic or transvaginal ultrasound
OGTT for diabetes

352
Q

What blood tests are done to diagnose PCOS?

A 
Testosterone
SHBG (Sex hormone-binding globulin)
LH
FSH
Prolactin
TSH
353
Q

What would hormonal blood tests typically show in PCOS?

A

Raised LH
Raised LH:FSH ratio
Raised testosterone
Raised insulin

354
Q

What imaging is the gold standard for visualising the ovaries?

A

TVUS

355
Q

What may be seen on USS of PCOS?

A

‘String of pearl’ appearance of follicles around the ovary

356
Q

What is the diagnostic criteria for PCOS on USS?

A
  • 12 or more developing follicles in one ovary

- Ovarian volume of >10cm^3

357
Q

What are the key risks associates with PCOS?

A

Obesity
T2 Diabetes
Hypercholesterolaemia
Cardiovascular disease

358
Q

How can the risks associated with PCOS be reduced?

A 
Weight loss
Low GI, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensives
Statins
359
Q

What is the main management of PCOS and why?

A

Weight loss- alone can restore fertility and regular menstrution, improve insulin resistance and reduce other symptoms

360
Q

What medication can be used to help weight loss in women with BMI over 30?

A

Orlistat (lipase inhibitor that stops absorption of fat in intestines)

361
Q

What cancer are women with PCOS more at risk of and why?

A 
Endometrial cancer:
-Amenorrhoea means they don't produce sufficient progesterone, resulting in endometrial hyperplasia
Also have other RF's= 
-Obesity
-Diabetes
-Insulin resistance
362
Q

At what endometrial thickness would women need to be referred for a biopsy to exclude endometrial hyperplasia/ cancer?

A

> 10mm

363
Q

What are the options for reducing the risk of endomtrial cancer in women with PCOS?

A
  • Mirena coil (continuous protection)

- Inducing a withdrawal bleed every 3-4 months with cyclical progesterones of COPC

364
Q

How can infertility be managed in PCOS?

A

Weight loss
Clomifene
Laparoscopic ovarian drilling
IVF

365
Q

What is the action of Clomifene?

A

Stimulates the release of gonadotropins, leading to the development of follicles and initiating ovulation

366
Q

How is hirsutism managed in PCOS?

A

Weight loss
COPC: Co-cyprindiol= has anti-androgenic effect
Topical eflornithine

367
Q

What is the risk of co-cyprindol and therefore how long should it be used for?

A

Increased risk of VTE so is stopped after 3 months

368
Q

How is acne managed in PCOS?

A

COPC

Topical, retinoids, antibiotics or azelaic acid

369
Q

What are functional ovarian cysts?

A

Fluid-filled sacs that relate to the fluctuating hormones of the menstrual cycle

370
Q

In which women are ovarian cysts more a cause for concern?

A

Postmenopausal women

371
Q

How are ovarian cysts usually diagnosed?

A

Found incidentally on pelvic USS

372
Q

How may ovarian cysts presents?

A
  • Usually asymptomatic
  • Pelvic pain
  • Bloating/ fullness
  • Palpable mass
  • May have acute pelvic pain if there is a complications
373
Q

What are the two types of functional cysts?

A

Follicular cycsts

Corpus luteum cysts

374
Q

What are follicular cysts?

A

When the developing follicle fails to rupture and release the egg, a cyst can persist

375
Q

What is the most common ovarian cyst?

A

Follicular cyst

376
Q

What are corpus luteum cysts?

A

Cysts that occur when the corpus luterum fails to break down and instead fills with fluid

377
Q

What are other types of ovarian cyst?

A 
Serous cystadenoma
Mucinous cystadenoma
Endometrioma
Dermoid cyst/ germ cell tyous 
Sex cord-stromal tumours
378
Q

What investigations are done into ovarian cysts?

A

USS

CA125 tumour marker

379
Q

What is the management of a <5cm simple cyst in premenopausal women?

A

No action required- will resolve in 3 cycles

380
Q

What is the management of a 5-7cm simple cyst in premenopausal women?

A

Routine referal to gynaecology and yearly USS monitoring

381
Q

What is the management of a <7cm simple cyst in premenopausal women?

A

MRI scan or surgical evaluation

382
Q

What is the management of cysts in postmenopausal women?

A

If there is raised CA125, 2WW referral to gynaecology

If simple <5cm, USS monitoring every 4-6 months

383
Q

What is the management of persistent or enlarging cysts?

A

Laparoscopic surgical intervention (ovarian cystectomy with possible oophorectomy)

384
Q

What are the main complications of ovarian cysts?

A

Torsion
Haemorrhage into cyst
Rupture

385
Q

What is Meig’s syndrome?

A

Triad of:

  • Ovarian fibroma (benign ovarian tumour)
  • Pleural effusion
  • Ascites
386
Q

What is ovarian torsion?

A

When the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply

387
Q

What is the main causes of ovarian torsion?

A
  • An ovarian mass >5cm (e.g. cyst or tumour)

- Before menarche when the infundibulopelvic ligaments are longer

388
Q

What is the main presenting feature of ovarian torsion?

A

Sudden onset severe unilateral pelvic pain that gets progressively worse and is associated with nausea and vomiting

389
Q

What would be found on examination of ovarian torsion?

A

Localised tenderness with possible palpable mass

390
Q

How is ovarian torsion diagnosed?

A

Pelvic USS or TVUS

391
Q

What is found on USS of ovarian torsion?

A

‘Whirlpool sign’
Free fluid in pelvis
Oedema of ovary

392
Q

How is a definitive diagnosis of ovarian torsion made?

A

Laparoscopic surgery

393
Q

What is the management of ovarian surgery?

A

Emergency laparoscopic surgery to either untwist it (detorsion) or remove it (oophorectomy)

394
Q

What are the complications of ovarian torsion?

A

Ischaemia and necrosis to the ovary
If not removed, infection which can lead to an abscess and sepsis. If it ruptures it can result in peritonitis and adhesions.

395
Q

What is Asherman’s syndrome?

A

Where adhesions form within the uterus and cause symptoms

396
Q

When does Asherman’s syndrome usually occur?

A

After pregnancy-related dilation and curettage

397
Q

What is D&C and when would it be performed?

A

Dilation and curettage: dilating cervix and scraping uterine lining to treat retained products of conception or after uterine surgery or infection

398
Q

What is endometrial curettage and what are the complications?

A

Scraping the endometrium, which can damage the basal layer and cause adhesions

399
Q

What may uterine adhesions cause?

A

May bind uterine walls together or seal the endocervix shut, leading to physical obstructions and distortion that can cause infertility, frequent miscarriages and menstrual abnormalities

400
Q

What is the typical presentation of Asherman’s syndrome?

A

Presents following recent D&C, uterine surgery or endometritis with:

  • Secondary amenorrhoea
  • Lighter periods
  • Dysmenorrhoea
  • Infertiity
401
Q

How is Asherman’s syndrome diagnosed?

A

Hysteroscopy =GS
Hysterosalpingography
Sonohysterography
MRU scan

402
Q

How is Asherman’s syndrome managed?

A

Dissection of adhesions during hysteroscopy

403
Q

What are Nabothian cysts?

A

Fluid-filled cysts on the surface of the cervix

404
Q

Why do nabothian cysts develop?

A

When the squamous epithelium of the ectocervix covers the mucus-secreting columnar epithelium of the endocervix, the mucus becomes trapped and forms a cyst.

405
Q

What us atrophic vaginitis?

A

Dryness and atrophy of the vaginal mucosa related to lack of oestrogen

406
Q

In what women does atrophic vaginitis occur?

A

Women entering menopause

407
Q

What happens to the epithelial lining of the vagina in response to oestrogen?

A

It becomes thicker, more elastic and produces secretions

408
Q

What happens to the vaginal mucosa as oestrogen levels fall?

A

It becomes thinner, less elastic and more dry making it more prone to inflammation

409
Q

How does atrophic vaginitis present?

A

Itching
Dryness
Dyspareunia
Bleeding caused by localised inflammation

410
Q

What are the effects of reduced oestrogen on menopausal women?

A

atrophic vaginitis
Pelvic organ prolapse and stress incontinence due to lack of oestrogen maintaining connective tissue
Increased infections due to change in vaginal pH and microbial flora

411
Q

What will examination of atrophic vaginitis show?

A 
Pale mucosa
Thin skin
Reduced skin folds
Erythema
Inflammation
Dryness
Sparse pubic hair
412
Q

How can atrophic vaginitis be managed?

A 
Vaginal lubricants
Topical oestrogen (cream, pessaries, tablets, ring)
413
Q

What are Bartholin’s glands?

A

The pair of glands on either side of the vaginal opening

414
Q

What is a Bartholin’s cyst?

A

When Bartholin’s gland gets blocked and the gland swells and becomes tender

415
Q

What happends when a Bartholin’s cyst becomes infected?

A

It forms a Bartholin’s abscess (red, hot tender abscess draining pus)

416
Q

How are Bartholin’s cysts managed?

A

Usually resolve with good hygeine, analgesia and warm compresses

417
Q

How are Bartholin’s abscesses managed?

A

Antibiotics

May need surgical intervention

418
Q

What is lichen sclerosus?

A

Chronic inflammatory skin condition that presents with patches of shiny white skin

419
Q

Where is most affected by lichen sclerosus?

A

The labia, perineum and perianal skin

420
Q

What causes lichen sclerosus?

A

Autoimmune condition

421
Q

What is the typical presentation of lichen sclerosis?

A

Women aged 45-60
Vulval itching
Vulva skin changes

422
Q

What is the Koebner phenomenon?

A

When the signs and symptoms are made worse by friction to the skin

423
Q

What are other potential symptoms of lichen sclerosus?

A 
Itching
Soreness and pain
Skin tightness
Superficial dyspareunia
Erosions
Fissures
424
Q

What is the appearance of lichen sclerosus?

A 
'Porcelain-white' colour
Shiny
Tight
Thin
Slightly raised
May be fissures, cracks, erosions and plaques
425
Q

How is lichen sclerosus managed?

A 
Topical steroids (Clobetasol propionate/ Dermovate) 
Emollients
426
Q

What are the complications of lichen sclerosus?

A

5% risk of developing squamous cell carcinoma of vulva
Pain/ discomfort
Sexual dysfunction
Bleeding

427
Q

What is FGM?

A

Female genital mutliation

428
Q

Where is FGM most commonly practiced?

A 
African countries (Somalia most common) , Ethiopia, sudan, 
Yemen, Kurdistan, Indonesia, Asia
429
Q

What are the 4 types of FGM?

A

1: Removal or part/ all of clitoris
2: Removal or clitoris and labia minora and/or majora
3: Narrowing/ closing of vaginal orifice
4: all other unecessary procedures to the female genitalia

430
Q

What risk factors should be looked out for to identify cases of FGM?

A
  • Coming from community that practices FGM
  • Having relatives affected by FGM
  • Declining examintaion of cervical screening
431
Q

What are the immediate complications of FGM?

A 
Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence
432
Q

What are the long term complications of FGM?

A 
Vaginal/ pelvic infections
UTI's 
Dysmenorrhea
Dyspareunia/ sexual dysfunction
Infertility/ pregnancy complications
Psychological issues/ depression
433
Q

How is FGM managed?

A
  • Mandatory reporting of all cases under 18 to the police (and social services, paeds, specialty FGM services, counselling)
  • Educate about the legality and consequences
  • In patients >18 use risk assessment tool as to whether to report.
  • De-infibulation (corrects closure of vaginal orifice)
434
Q

What are the main congenital structural abnormalities of the reproductive tract?

A

Bicornuate uterus
Imperforate hymen
Transverse vaginal septae
Vaginal hypoplasia and agenesis

435
Q

In embryological development, where do the upper vagina, cervix, uterus and fallopian tubes develop from?

A

The paramesonephric (Mullerian) ducts

436
Q

Why do males not develop a uterus?

A

Anti-Mullerian hormone

437
Q

What is a bicornuate uterus?

A

When there are two horns to the uterus, giving it a heart shaped appearance

438
Q

What are the potential complications of a bicronuate uterus?

A

Miscarriage
Premature birth
Malpresentation

439
Q

What is imperforate hymen?

A

Where the hymen is fully formed without opening and covers the opening of the vagina

440
Q

When will imperforate hymen be discovered?

A

When the female starts the menstruate and the menses are sealed in the vagina

441
Q

What is the presentation of imperforate hymen?

A

Cyclical pelvic pain and cramping without vaginal bleeding

442
Q

What is the diagnosis and treatment of imperforate hymen?

A 
Diagnosis= clinical examination
Treatment= surgical incision
443
Q

What happens if imperforate hymen is not treated?

A

Retrograde menstruation which leads to endometriosis

444
Q

What is transverse vaginal septae?

A

When there is a wall of tissue running horizontally across the vagina, either perforate or imperforate (sealed or with a hole)

445
Q

How will perforate transverse vaginal septae present?

A

Difficulty with intercourse of tampon use

446
Q

How will imperforate transverse vaginal septae present?

A

Cyclical pelvic symptoms without menstruation

447
Q

How is transverse vaginal septae diagnosed?

A

Examination
USS
MRI

448
Q

How is transverse vaginal septae treated?

A

Surgical correction

449
Q

What is vaginal hypoplasia?

A

An abnormally small vagina

450
Q

What is vaginal agenesis?

A

An absent vagina

451
Q

What causes vaginal hypoplasia/ agenesis?

A

Failure of the Mullerian ducts to develop properly

452
Q

What is androgen insensitivity syndrome?

A

Where cells are unable to respond to androgen hormones due to lack of androgen receptors

453
Q

What causes androgen insensitivity syndrome?

A

X-linked recessive genetic condition

454
Q

What happens to the excess androgens in androgen insensitivity syndrome?

A

They are converted into oestrogen

455
Q

What is the genotype/ phenotype of patients with androgen insensitivity syndrome?

A

Genetically male (XY chromosome) with female external phenotype due to lack of androgens.

456
Q

How does androgen insensitivity syndrome present?

A

Inguinal hernias in infancy

Primary amenorrhoea at puberty

457
Q

What will be the results of hormone tests in androgen insensitivity syndrome?

A

Raised LH
Normal/ raised FSh
Normal/ raised testosterone
Raised oestrogen

458
Q

How is androgen insensitivity syndrome managed?

A 
MDT
Bilateral orchidectomy to avoid testicular tumours
Oestrogen therapy
Vaginal dilators/ therapy 
Support/ counselling
459
Q

How long should a couple try to conceive before investigating for infertility?

A

12 months

460
Q

How many couple struggle to conceive naturally?

A

1 in 7

461
Q

After how long of trying to conceive should investigation for infertility be initiated in women over 35 ?

A

6 months

462
Q

What are the causes of infertility?

A 
Sperm problems (30%)
Ovulation problems (25%) 
Tubal problems (15%)
Uterine problems (10%)
Unexplained (20%)
463
Q

What general advice is given to couples trying to get pregnant?

A
  • Take 400mcg folic acid dily
  • Aim for healthy BMI
  • Avoid smoking and excessive drinking
  • Reduce stress
  • Aim for intercourse every 2-3 days
  • Avoid timing intercourse and it leads to increased stress
464
Q

What are the initial infertility investigations performed in primary care?

A 
BMU
Chlamydia screen
Semen analysis
Female hormonal testing
Rubella immunity
465
Q

What does female hormone testing involve when investigating infertility?

A
  • Serum LH/ FSH day 2-5
  • Serum progesterone on day 21
  • Anti-Mullerian hormone
  • Thyroid function tests
  • Prolactin
466
Q

What do high FSH levels indicate?

A

That there is poor ovarian reserve so the pituitary gland is producing extra FSH to try to stimulate follicular development

467
Q

What might high LH levels indicate?

A

PCOS

468
Q

What does a low level of progesterone on day 21 indicate?

A

That ovulation has not occurred so there is no corpus luteum secreting it

469
Q

What hormone is the most accurate marker of ovarian reserve and why?

A

Anti-Mullerian hormone: released by the granulosa cells in the follicles and falls as eggs are depleted

470
Q

What other infertility investigations may be completed in secondary care?

A

USS pelvis for polycystic ovaries/ structural abnormalities
Hysterosalpingogram
Laparoscopy and dye test to look at patency of fallopian tubes/ endometriosis/ adhesions

471
Q

What is Hysterosalpingogram?

A

X-ray looking at the shape of the uterus and patency of the fallopian tubes

472
Q

What are the treatment options when anovulation is the cause of infertility?

A 
Weight loss
Clomifene (stimulates ovulation) 
Letrozole
Gonadotropins
Ovarian driling
Metformin for insulin insensitivity/ obesity in PCOS
473
Q

What is clomifene?

A

An anti-oestrogen given on days 2-6 of the menstrual cycle to stop the negative feedback of oestrogen on the hypothalamus, resulting in greater release of GnRH and therefore FSH and LH

474
Q

What is ovarian drilling?

A

Laparoscopic surgery where multiple holes are drilling into the ovaries to improve the hormonal profile

475
Q

What are management options when tubal factors are the cause of infertility?

A

Tubal cannulation
Laparoscopy to remove adhesions/ endometriosis
IVF

476
Q

What management options are used when uterine factors are the cause of infertility?

A

Surgery to correct polyps, adhesions or structural abnormalities

477
Q

How is male factor infertility assessed?

A

Semen analysis

478
Q

What instructions should men be given when providing a sperm sample?

A 
Abstain from ejaculation for at least 3 days
Avoid hot baths/ tight underwear
Attempt to catch full sample
Deliver sample within one hour
Keep sample warm
479
Q

What lifestyle factors may affect the results of semen analysis & quality/ quantity of sperm?

A 
Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine
480
Q

When is a repeat sperm sample taken with borderline and abnormal results?

A

Borderline- after 3 months

Abnormal- 2-4 weeks

481
Q

What things does semen analysis look for and what are the normal results?

A 
Semen volume (>1.5ml)
Semen pH (>7.2) 
Concentration of sperm (>15 million per ml)
Total number of sperm (>39 million) 
Motility of sperm (>40% are mobile) 
Vitality of sperm (>58% are active
Percentage of normal sperm (>4%)
482
Q

What is polyspermia?

A

High number of sperm in a semen sample (>250 million per ml)

483
Q

What is normospermia?

A

Normal characteristics of sperm in sample

484
Q

What is oligospermia?

A

Reduced number of sperm in semen sample

485
Q

How can oligospermia be classified?

A

Mild (10-15 million/ ml)
Moderate (5-10 million/ml)
Severe (<5 million/ ml)

486
Q

What is cryptozoospermia?

A

Very few sperm in the semen sample (<1 million/ml)

487
Q

What is azoospermia?

A

Abscence of sperm in the semen

488
Q

What causes pre-testicular infertility?

A

Hypogonadotrophic hypogonadism causing low levels of testosterone needed for sperm production

489
Q

What are the causes of Hypogonadotrophic hypogonadism in males?

A
  • Pituitary/ hypothalamic pathology
  • Suppression due to stress/ chronic conditions/ hyperprolactinaemia
  • Kallman syndrome
490
Q

What are the testicular causes of infertility?

A 
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
Genetic/ congenital disorders
491
Q

What are post-testicular causes of infertility?

A

Obstruction caused by:

  • Damage from trauma/ surgery/ cancer
  • Ejaculatory duct obstruction
  • Retrografe ejaculation
  • Scarring from epididymitis (chlamydia)
  • Abscence of vas deferens (Cystic fibrosis)
  • Young’s syndrome
492
Q

What initial investigations are done into male factor infertility?

A 
Semen analysis
History
Examination
Repeat sample
USS testes
493
Q

What further investigations may to considered to look into male factor infertility?

A 
Hormonal analysis (FSH/LH/ Testosterone) 
Genetic testing
Imaging
Vasography
Testicular biopsy
494
Q

What are the management options for male factor infertility?

A 
Surgical sperm retrieval 
Surgical correction
Intra-uterine insemination
Intracytoplasmic sperm injection
Donor insemination
495
Q

What is surgical sperm retrieval and when is it used?

A

When there is a blockage somewhere along the vas deferens preventing the sperm from being ejaculated, a needle and syringe is used to collect sperm directly from the epididymis

496
Q

What is intra-uterine insemination?

A

Collecting and seperating out high-quality sperm and injecting them directly into the uterus

497
Q

What is intracytoplasmic sperm injection?

A

Injecting sperm directly into the cytoplasm of an egg

498
Q

When might intrauterine insemination (IUI) be used instead of IVF?

A

Donor sperm for same-sex couples
HIV (To avoid unprotected sex)
Practical issues with vaginal sex

499
Q

What is the success rate of each cycle of IVF?

A

25-30%

500
Q

What does one cycle of IVF involve?

A

Single episode of ovarian stimulation and collection of oocytes. May produce several embryos which can be transferred seperately in multiple attempts at pregnancy

501
Q

What happens to embryos that are not used immediately?

A

They are frozen to be used at a later date

502
Q

What are the steps involved in IVF?

A 
Suppressing menstrual cycle
Ovarian stimulation
Oocyte collection
Insemination/ Intracytoplasmic sperm injection
Embryo culture
Embryo transfer
503
Q

What are the two methods of suppressing the natural menstrual cycle in IVF?

A

GnRH agonists

GnRH antagonists

504
Q

What happens if a GnRH agonist is used?

A

An injection of GnRH agonist is given in the luteal phase (day 21) to stimulate the pituitary gland to secrete large amounts of FSH and LH, which causes negative feedback to supress the natural production of GnRH and stop the menstrual cycle

505
Q

What happens for the GnRH antagonist protocol?

A

Daily subcutaneous injections of a GnRH antagonist are given starting from day 5-6 of ovarian stimulation to supress the body releasing LH and therefore supressing normal ovulation

506
Q

Why is it necessary to supress the natural menstrual cycle in IVF?

A

If the gonadotropins weren’t supressed, ovulation would occur and follicles would be released before it is possible to collect them

507
Q

What does ovarian stimulation involve?

A

Using medications to promote the development of multiple follicles in the ovaries:

  1. Sub-cut FSH injections from day 2-12
  2. Monitoring the development of follicles with TVUS
  3. Trigger injection: When there are enough follicles of adequate size, stop FSH and hCG injection given to stimulate final maturation of follicles.
508
Q

How are oocytes collected?

A

Under sedation with the guidance of TVUS. Needle inserted through vaginal wall into each ovary to aspirate follicular fluid which contains the mature oocytes.

509
Q

How are oocytes then inseminated?

A

Male produces semen sample and sperm and egg mixed in culture medium

510
Q

Why do thousands of sperm need to be combined with each oocyte?

A

To produce enough enzymes for a sperm to penetrate the corona radiata and zona pellucide

511
Q

What happens once the oocyte has been inseminated?

A

The fertilised eggs are left in an incubator for 2-5 and observed until the reach the blastocyst stage of development when the highest quality embryos are selected for transfer/

512
Q

How are embryos transferred?

A

Catheter placed into the uterus. Single embryo is injected and the catheter is removed.

513
Q

How long after egg collection is a pregnancy test performed?

A

Around day 16

514
Q

What needs to be given from the time of oocyte collection until 8-10 weeks gestation and why?

A

Progesterone suppositories to mimic the progesterone that would be released from the corpus luteum in a normal pregnancy

515
Q

What are the main complications of IVF?

A 
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome 
Pain/ bleeding/ infection during egg collection
516
Q

What is OHSS?

A

Ovarian hyperstimulation syndrome

517
Q

What triggers OHSS?

A

The hCG trigger injection given 36 hours before oocyte collection–> HCG stimulates the release of vascular endothelial growth factor (VEGF) which increases vascular permiability and causes the ovaries to swell

518
Q

What are the risk factors for OHSS?

A 
Younger age
Low BMI
Raised anti-Mullerian hormone
Higher antral follicle count
PCOS
Raised oestrogen levels
519
Q

How is OHSS prevented?

A

During gonadotropic stimulation, they are monitored with serum oestrogen levels and USS

520
Q

How may OHSS present?

A 
Abdominal pain/ bloating
N&V
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from ruptured follicles
Prothrombotic state
521
Q

How is the severity of OHSS determined?

A

Based on clinical features:
Mild= abdo pain/ bloating
Moderate= N&V/ ascites
Severes= Ascites, oliguria, low albumin, high potassium
Critical= tense ascites, anuria, thromboembolism, acute respiratory distress

522
Q

How is OHSS managed?

A 
Supportive: 
Oral fluids
Monitor urine output
LMWH
Ascitic fluid removal
IV colloids
523
Q

What are the key methods of contraception?

A 
Natural family planning
Barrier methods
COPC
POP
Copper coil
Mirena coil 
Implant
Progesterone injection
Surgery (sterilisation/ vasectomy
Emergency contraception
524
Q

What are the 4 levels used to assess the risk of different contraceptions in individuals?

A 
UKMEC1= No restriction 
UKMEC2= Benefits outweigh risk
UKMEC3= Risks outweigh benefits
UKMEC4= Unacceptable risk
525
Q

Which are the most reliable methods of contraception with typical use?

A

Surgery
Coils
Progesterone implant

526
Q

What contraception should be avoided in women with breast cancer?

A

Hormonal contraception: use copper coil or barrier methods

527
Q

What contraception should be avoided in women with cervical or endometrial cancer?

A

IUD

528
Q

What contraception should be avoided in women with Wilson’s disease?

A

Copper coil

529
Q

What specific risk factors would cause you to avoid the COCP?

A 
Uncontrolled hypertension
Migraine with aura
History of VTE
>35 and smoking >15 per day
Major surgery with prolonged immobility
Vascular disease/ stroke
Ischaemic heart disease/  cardiomyopathy /atrial fibrillation
Liver cirrhosis/ tumours
SLE/ Antiphospholipid syndrome
530
Q

How long after the last period should post menopausal be on contraception?

A

2 years if <50

1 year if >50

531
Q

Why should the progesterone injection not be given to women over 50?

A

It increases the risk of osteoporosis

532
Q

What are the different barrier methods of contraception?

A

Condoms
Diaphragms/ cervical caps
Dental dams

533
Q

How effective are condoms?

A

98% with perfect use

82% with typical use

534
Q

What should be avoided when using condoms?

A

Oil-based condoms as they can damage the latex

535
Q

How should diaphragms be used?

A

Silicone cup fitted over cervix before having sex and left for at least 6 hours afterwards. Should be used with spermicide gel

536
Q

What are dental dams used for?

A

During oral sex to provide a barrier between the mouth and vulva, vagina and anus to prevent infection

537
Q

How effective is the COCP?

A

99% with perfect use

91% with typical use

538
Q

How does the COCP prevent pregnancy?

A
  1. Prevents ovulation
  2. Progesterone thickens cervical mucus
  3. Progesterone inhibits proliferation of endometrium reducing risk of successful implantation
539
Q

How does the COCP prevent ovulation?

A

Negative feedback effect on hypothalamus and anterior pituitary suppresses the release of GnRH, LH and FSH, preventing ovulation

540
Q

What happens to the endometrium when taking the combined pill?

A

It is maintained in a stable state

541
Q

What happens to the endometrium when the pill is stopped?

A

It breaks down and sheds, leading to a withdrawal bleed

542
Q

What are the two types of COCP?

A

Monophasic pills

Multiphasic pills

543
Q

What are monphasic pills?

A

Contain the same amount of hormone in each pill

544
Q

What are multiphasic pills?

A

Contain varying amounts of hormone to match normal cyclical changes more closely

545
Q

What is the first line COPC and why?

A

Microgynon (monophasic with 7 inactive pills)

Lower risk of VTE

546
Q

What type of oestrogen and progesterone do the first line COCP’s contain?

A 
Oestrogen= ethinylestradiol 
Progesterone= Levonorgestrel or norethisterone
547
Q

What type of COCP’s are first line for PMS and why ?

A

Those containing drosipernone (e.g. Yasmin) as it has anti-mineralocorticoid and anti-androgen activity so can help with bloating, water retention and mood changes

548
Q

What type of COCP’s are first line for acne and hirsutism and why?

A

Those containing cyproterone acetate (e.g. Dianette) as it has anti-androgen effects

549
Q

What are the 3 most common regimes used when taking the COCP?

A
  1. 21 days on, 7 days off
  2. 63 days on (3 packs) and 7 days off
  3. Continuous use
550
Q

What are the main side effects of taking the COCP?

A
  • Unscheduled bleeding
  • Breast pain/ tenderness
  • Mood changes/ depression
  • Headaches
  • Hypertension
551
Q

What are the main risks of taking the COCP?

A
  • VTE
  • Increased risk of breast/ cervical cancer
  • MI/ stroke
552
Q

What are the benefits of taking the COCP?

A
  • Contraception
  • Rapid return of fertility after stopping
  • Improvement in PMS, menorrhagia, dysmenorrhoea
  • Reduced risk of endometrial, ovarian and colon cancer
  • Reduced risk of benign ovarian cysts
553
Q

What are the contraindications to taking the COCP? (UKMEC 4)

A
  • Uncontrolled hypertension
  • Migraine with aura
  • History of VTE
  • > 35 smoking >15 cigarettes a day
  • Major surgery with prolonged immobility
  • Vascular disease/ stroke
  • IHD/ Cardiomyopathy/ AF
  • Liver cirrhosis/ Liver tumours
  • SLE/ Antiphospholipid syndrome
554
Q

What factor makes the risk of taking the COCP UKMEC3?

A

BMI > 35

555
Q

At what stage in the cycle should the COCP be started and why?

A

Day 1 of cycle as this offers protection straight away

556
Q

What should be used if the COCP is started after day 5 of the cycle?

A

Extra contraception for 7 days

557
Q

What should happen if switching between COCPs?

A

Finish one pack then immediately start the new one without a pill free period

558
Q

What should happen if switching from a POP to a COCP?

A

7 days of contraception used

559
Q

What should be discussed when prescribing the COCP?

A 
Different options including LARC
Contraindications
Adverse effects
Instructions 
Factors that impact efficacy
STI protection
Safeguarding concerns
560
Q

What contraindications should be screened for when prescribing the pill?

A 
Age
BMI
BP
Smoking status
PMH (migraine, VTE, Cancer, Cardiovascular disease, SLE) 
FH (VTE, breast cancer)
561
Q

What is classified as missing one pill?

A

More than 24 hours late (48 hours since last pill taken)

562
Q

What should the woman do if one pill is missed?

A
  • Take missed pill ASAP (even if that means 2 in one day)

- No extra protection required

563
Q

What should the woman do if more than one pill is missed?

A
  • Take most recent missed pill ASAP

- Additional contraception until have taken pill for 7 days straight

564
Q

What should the woman do if she missed more than one pill during day 1-7 in the packet?

A

Need emergency contraception of had unprotected sex

565
Q

What should the woman do if she missed more than one pill during day 8-14 in the packet?

A

If day 1-7 was fully compliant need no emergency contraception

566
Q

What should the woman do if she missed more than one pill during day 15-21 in the packet?

A

No emergency contraception needed if days 1-14 were fully compliant but should go back-back with next pack of pills

567
Q

In theory, in what cycle of pill usage will women be protected if taken perfectly?

A

7 days on, 7 days off

568
Q

What can reduce the effectiveness of the pill?

A

Vomiting
Diarrhoea
Certain medications

569
Q

When should the COCP be stopped?

A

4 weeks before a major operation or any procedure that requires the lower limb to be immobilised
Age 50

570
Q

How is the POP taken?

A

Continuously

571
Q

How effective is the POP?

A

99% with effective use

91% with perfect use

572
Q

Des the COCP or POP have more contraindications/ risks?

A

POP has far fewer contraindications & risks

573
Q

What are the 2 types of POP?

A

Traditional (e.g. Norgeston, Noriday)

Desogestrerl-only pill

574
Q

When is considered a ‘missed pill’ when taking the traditional progesterone-only pill?

A

If it is >3 hours late

575
Q

When is considered a missed pill when taking the desogestrel-only pill?

A

> 12 hours late

576
Q

How does the traditional progesterone-only pill work?

A

Thickens cervical mucus
Alters endometrium to make implantation less successful
Reduces ciliary action in fallopian tubes

577
Q

How does the Desogestrel pill work?

A

Inhibits ovulation

578
Q

At what points in the cycle does starting the POP mean the woman is protected immediately?

A

Day 1-5

579
Q

For how long is additional contraception required if the POP is started at other times in the cycle and why?

A

48 hours (takes 48 hours for cervical mucus to thicken enough to prevent sperm entering uterus)

580
Q

How long does it take for the POP vs the COCP to become effective and why?

A

POP- 48 hours for cervical mucus to thicken enough to prevent sperm entering uterus
COCP- 7 days to inhibit ovulation

581
Q

Can the POP/ COCP be taken even if there is a risk of pregnancy?

A

POP- Yes

COCP- Must rule out pregnancy first

582
Q

What should happen when switching between POPs?

A

No extra protection required

583
Q

What should happen when switching from a COCP to a POP?

A

Should aim to change on day 1-7 after finishing COCP pack with no extra protection required.
If switching immediately, need to use contraception for first 48 hours of POP

584
Q

What are the main adverse effects of the POP?

A

Unscheduled bleeding
Breast tenderness
Headaches
Acne

585
Q

After how long does unscheduled bleeding usually settle?

A

3 months (should investigate for other causes after this)

586
Q

What changes to bleeding schedule may the POP have and how many women do these effect?

A

20% No bleeding
40% regular bleeding
40% irregular, prolonged or troublesome bleeding

587
Q

What can the POP make you more at risk of?

A

Ovarian cysts
Ectopic pregnancy
Breast cancer

588
Q

What should happen if a POP is missed?

A

Take the pill ASAP and continue the next pill at the usual time, with extra contraception for 48 hours

589
Q

What is the Progesterone-only injection also known as?

A

Depot medroxyprogesterone acetate (DMPA)

590
Q

How frequently is the progesterone-only injection given?

A

12-13 week intervals

591
Q

How is the progesterone-only injection given?

A

IM or Sub-cut injection of medroxyprogesterone acetate

592
Q

How effective is the progesterone-only injection?

A

99% with perfect use

94% with imperfect use (forgetting to book injection)

593
Q

How long can it take for fertility to return after stopping injections?

A

Up to 12 months

594
Q

What are the two versions of progesterone-only injection used in the UK?

A 
Depo-Provera (IM) 
Sayana Press (self-injected sub cut)
595
Q

What are the UKMEC 4 and UKMEC 3 contraindications to the progesterone-only injection?

A 
UKMEC4: Active breast cancer
UKMEC3: Ischaemic heart disease/ stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
596
Q

What is the main risk factor of the progesterone-only injection and therefore in which women should this be considered?

A

Osteoporosis

Older women and patients on steroids (for asthma/ inflammatory conditions)

597
Q

What is the mechanism of action of the progesterone-only injection?

A

Inhibits ovulation by inhibiting FSH secretion by the pituitary gland
(Also thickens cervical mucus and alters the endometrium to make implantation less successful)

598
Q

When should the progesterone-only injection be given to offer immediate protection?

A

Day 1-5

599
Q

If the progesterone-only injection is given after day 5 of the menstrual cycle, how long should additional contraception be used?

A

7 days

600
Q

What are the main sides effects of the progesterone-only injection?

A 
Changes to bleeding schedule (may become highly irregular but usually stops altogether after 1 year) 
Weight gain
Acne
Reduced libido
Mood changes
Headaches
Flushes
Hair loss
Skin reactions at injection site
601
Q

What is the biggest risk of the progesterone-only injection and why?

A

Osteoporosis –> Oestrogen helps maintain bone mineral density in women so suppressing the development of the follicles reduces the amount of oestrogen produced

602
Q

Which two side effects are unique to the progesterone-only injection?

A

Weight gain

Osteoporosis

603
Q

What are the benefits of the progesterone-only injection?

A

Improves dysmenorrhoea
Improves endometriosis symptoms
Reduces risk of endometrial and ovarian cancer
Reduces the severity of sickle cell crisis

604
Q

Where the the progestogen-only implant placed?

A

Upper arm, beneath skin and above subcutaneous fat

605
Q

How long does the progestogen-only implant last before it needs replacing?

A

3 years

606
Q

How effective is the progestogen-only implant ?

A

99%

607
Q

What is the only contraindication for the progestogen-only implant?

A

Active breast cancer

608
Q

What is the name of the implant used in the UK and what does it contain?

A

Nexplanon, contains 68mg of etonogestrel

609
Q

How does the progestogen-only implant work?

A

Inhibits ovulation
Thickens cervical mucus
Makes endometrium less accepting of implantation

610
Q

What point of the cycle does inserting the implant offer immediate protection and what should happen if its inserted after this?

A

Day 1-5= immediate protection

After this, need 7 days extra contraception

611
Q

What are the benefits of the implant ?

A 
Effective contraception
Can improve dysmenorrhoea
Can make periods lighter/ stop
No need to remember to take pills
Doesn't cause weight gain
No effect on bone mineral density
No increase in thrombosis risk
612
Q

What are the drawbacks of the implant?

A

Requires minor operation which may have complications
Can worsen acne
No STI protection
May cause problematic bleeding
Can become impalpable or deeply implanted

613
Q

What changes to bleeding pattern may occur with the implant and how many women does this effect?

A

1/3 infrequent bleeding
1/3 frequent or prolonged bleeding
1/5 no bleeding

614
Q

What should be given to help ease problematic bleeding when using a progesterone-only form of contraception?

A

COCP for 3 months to help settle the bleeding

615
Q

What is LARC?

A

Long-acting reversible contraception

616
Q

What are the two types of IUD?

A

Copper coil

Levonorgestrel intrauterine system (LNG-IUS) - Mirena

617
Q

How effective are coils?

A

99%

618
Q

How soon after removal of coils does fertility return?

A

Immediately

619
Q

What do IUD and IUS refer to?

A 
IUD= Copper coil
IUS= Mirena coil
620
Q

What are the contraindications to coils?

A 
PID/ Infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (fibroids)
621
Q

What should be screened for before coil insertion?

A

Chlamydia

Gonorrhoea

622
Q

What happens during coil insertion?

A

Bimanual examination to check size/ position of uterus
Speculum insertion to fit device
Forceps stabilise cervix while device is inserted
Record BP and HR during

623
Q

How long after coil insertion should women be seen and why?

A

3-6 weeks to check the threads and ensure coil is in place

624
Q

What are the risks associated with coil insertion?

A 
Bleeding
Pain on insertion
Vasovagal reactions
Uterine perforation
PID
Expulsion
625
Q

What needs to happen before the coil can be removed?

A

Women need to abstain from sex/ use condoms for 7 days

626
Q

What needs to be excluded when coil threads can’t be seen or palpated?

A

Expulsion
Pregnancy
Uterine perforation

627
Q

What investigations would be carried out if coil threads can’t be seen/ palpated?

A

USS
Abdo/ pelvic xray
Hysteroscopy or laparoscopic surgery may be required

628
Q

For how long can the copper coil be inserted?

A

5-10 years

629
Q

When is the copper coil contraindicated?

A

Wilson’s disease

630
Q

How does the copper coil work?

A

Copper is toxic to the ovum and sperm

Alters endometrium to make it less accepting of implantation

631
Q

What are the benefits of the IUD?

A

Reliable contraception
Effective immediately at any time of cycle
Contains no hormones so no risk of VTE/ cancer

632
Q

What are the drawbacks of the IUD?

A 
Risks of procedure
Can cause heavy/ intermenstrual bleeding
May have pelvic pain
No protection against STI's 
Increased risk of ectopic pregnancies
5% fall out
633
Q

What are the 4 types of IUS?

A

Mirena
Levosert
Kyleena
Jaydess

634
Q

How long can the mirena coil be inserted?

A

5 years (4 years as HRT)

635
Q

For what reasons can the mirena coil be used?

A

Contraception
Menorrhagia
HRT

636
Q

How does the mirena coil work?

A

Releases progesterone (levonorgestrel) into local area to thicken mucus, alter endometrium and inhibit ovulation in some women/

637
Q

Up to what day of the menstrual cycle can the LNG-IUS be inserted without the need for additional contraception?

A

Day 7

638
Q

What are the benefits of the LNG-IUS?

A 
Can make periods lighter/ stop
May improve dysmenorrhoea or pelvic pain
No effect on bone mineral density
No increase in thrombosis risk
No restrictions for obese patients
Has additional uses
639
Q

What are the drawbacks of the LNG-IUS?

A 
Risks of procedure
Can cause spotting/ irregular bleeding
May cause pelvic pain
No protection against STI's
Increased risk of ectopic pregnancies
Increased risk of ovarian cysts
Systemic absorption may cause side effects
5% fall out
640
Q

How long does irregular bleeding usually go on for when the LNG-IUS is inserted?

A

Around 6 months

641
Q

What may be found incidentally during a smear test in women with an IUD?

A

Actinomyces-like organisms (don’t require treatment)

642
Q

What are the 3 options for emergency contraception?

A

Levonorgestrel
Ulipristal
Copper coil

643
Q

What is UPSI?

A

Unprotected sexual intercourse

644
Q

How long after intercourse should Levonorgestrel be taken?

A

Within 72 hours

645
Q

How long after intercourse should Ulipristal be taken?

A

Within 120 hours

646
Q

How long after intercourse can the coil be inserted as emergency contraception?

A

Within 5 days of UPSI or within 5 days of estimated date of ovulation

647
Q

What is the most effective form of emergency contraception?

A

Copper coil

648
Q

What can the two oral methods of contraception be affected by?

A

BMI
Enzyme-inducing drugs
Malabsorption

649
Q

Why is the copper coil the most effective form of contraception?

A

It is toxic to the ovum and sperm, and inhibits implantation

650
Q

What may copper coil insertion cause?

A

Pelvic inflammatory disease

651
Q

For how long should the coil be kept in if used as emergency contraception?

A

Until at least the next period (though can be kept in as long-term contraception)

652
Q

What is Levonorgestrel?

A

A type of progesterone (used in the IUS or as emergency contraception)

653
Q

What dose of Levonorgestrel is used as emergency contraception?

A

1.5mg as single dose

3mg in women >70kg or BMI>26

654
Q

What is the common side effects of taking Levonorgestrel as emergency contraception?

A

Nausea and vomiting (need to take another dose if vomit within 3 hours)

655
Q

What is Ulipristal?

A

A selective progesterone receptor modulator used as emergency contraception

656
Q

What is Ulipristal better known as?

A

EllaOne

657
Q

What are the notable restrictions to taking Ulipristal?

A

Avoid breastfeeding for 1 week

Should be avoided in those with severe asthma

658
Q

What is the female sterilisation procedure?

A

Tubal occlusion

659
Q

What happens during tubal occlusion?

A

Clips are used to occlude the fallopian tubes using laparoscopy under general anaesthesia

660
Q

What other options are there for female sterilisation?

A

Tube tying, cutting or removal

661
Q

What is the male sterilisation procedure?

A

Vasectomy

662
Q

What does a vasectomy involve?

A

Cutting the vas deferens, to prevent the sperm travelling from the testes to join the ejaculated fluid

663
Q

What must happen after a vasectomy before it can be relied upon as contraception?

A

Semen testing 12 weeks after to confirm absence of semen

664
Q

When can children under 16 make decisions about their own treatment?

A

When they are deemed to have Gillick competence

665
Q

What is Gillick competence?

A

Judging whether the understanding/ intelligence of a child is sufficient to consent to treatment.

666
Q

What are the Frazer guidelines?

A

Specific guidelines for providing contraception to patients under 16 without parental input/ consent

667
Q

What criteria is included in the Frazer guideline?

A
  1. Mature/ intelligent enough to understand treatment
  2. Can’t be persuaded to discuss with parents
  3. Likely to have intercourse regardless
  4. Physical/ mental health will suffer without treatment
  5. It’s in their best interests
668
Q

What is bacterial vaginosis?

A

(BV) Overgrowth of anaerobic bacteria in the vagina

669
Q

What causes bacterial vaginosis?

A

Loss of lactobacilli (friendly bacteria) in the vagina

670
Q

What is the main component of healthy vaginal bacterial flora?

A

Lactobacilli

671
Q

What is the action of Lactobacilli?

A

Produce lactic acid that keeps the vaginal pH low (<4.5) and prevents other bacteria from overgrowing

672
Q

Why does an absence of lactobacilli enable anaerobic bacteria to multiply in the vagina?

A

Lactobacilli produce lactic acid which creates an acidic environment, so when there are reduced numbers the pH rises and the alkaline environment enables anaerobic bacteria to multiply

673
Q

What can BV increase the risk of in women?

A

Developing STI’s

674
Q

What are some examples of anaerobic bacteria associated with BV?

A

Gardnerella vaginalis
Mycoplasma hominis
Prevotella

675
Q

What are the main risk factors for developing bacterial vaginosis?

A 
Multiple sexual partners
Excessive vaginal cleaning
Recent antibiotics
Smoking
Copper coil
676
Q

Is BV sexually transmitted?

A

No

677
Q

What factors can reduce your risk of BV?

A

COCP

Using condoms effectively

678
Q

How does bacterial vaginosis present?

A

Fishy-smelling watery grey/ white discharge

679
Q

How is BV investigated?

A
  • Speculum examination to confirm typical discharge
  • Vaginal pH test with swab and pH paper
  • High vaginal swab to rule out other causes
680
Q

What does BV look like on microsopy?

A

‘Clue cells’- Epithelial cells from the cervix that have bacteria stuck inside them

681
Q

How is BV managed?

A 
If asymptomatic needs no treatment, and may resolve itself.
Metronidazole antibiotic (orally or by vaginal gel) 
Provide advice on how to avoid in future (e.g. cleaning)
682
Q

What should be avoided when taking Metronidazole?

A

Alcohol (can cause N&V, flushing etc)

683
Q

What are the potential complications of BV?

A

Increases risk of catching STI’s

Can cause pregnancy complications

684
Q

What is vaginal candidiasis more commonly known as?

A

Thrush (or candida)

685
Q

What is the most common cause of vaginal candidiasis?

A

Candida albicans (type of fungus/ yeast)

686
Q

What happens after the candida colonises the vagina?

A

It may not cause symtoms until the right environment occurs

687
Q

What changes to environment can cause candida to progress to infection?

A

During pregnancy

After treatment with broad-spectrum antibiotics

688
Q

What are the risk factors for developing vaginal candidiasis?

A

Increased oestrogen (e.g. pregnancy)
Poorly controlled diabetes
Immunosuppression
Broad-spectrum antibiotics

689
Q

What are the symptoms of vaginal candidiasis?

A

Thick, white discharge (no odour)

Vulval/ vaginal itching/ irritation/ discomfort

690
Q

How is vaginal candidiasis investigated?

A

(Treatment often started based on presentation)
Test vaginal pH
Charcoal swab with microscopy can confirm dignosis

691
Q

What are the treatment options for candidiasis?

A

Antifungals:

  • Cream
  • Pessary
  • Oral tablets
692
Q

What is the usual antifungal medication used to treat vaginal candidiasis?

A

Clotrimazole

693
Q

What OTC treatment is often used to treat thrush?

A

Canesten Duo (contains fluconazole tablet and clotrimazole cream)

694
Q

What should women be advised when using antifungal creams/ pessaries?

A

That they can damage latex condoms so should use alternative contraceptions for at least 5 days after use

695
Q

What is the most common STI in the UK?

A

Chlamydia

696
Q

What kind of organism is chlamydia trachomatis?

A

Gram-negative bacteria

697
Q

How does chlamydia spread in the body?

A

It is an intracellular organism that enters and replicated in cells before rupturing and spreading to other cells

698
Q

What are the risk factors for catching chlamydia?

A

Young
Sexually active
Having multiple partners

699
Q

What percentage of chlamydia cases are asymptomatic?

A

50% in men

75% in women

700
Q

What does the National Chlamydia Screening Programme aim for?

A

To screen every sexually active person <25 for chlamydia annually or when changing sexual partners
To re-test positive cases after 3 months

701
Q

What is tested on an STI screen (as a minimum)?

A

Chlamydia
Gonorrhoea
Syphilis
HIV

702
Q

What are the two types of swab used in sexual health testing?

A

Charcoal swabs

Nucleic acid amplification test (NAAT) swabs

703
Q

What do charcoal swabs allow to be tested for?

A

Microscopy
Culture
Sensitivities

704
Q

What type of swabbing can charcoal swabs be used for?

A

Endocervical swabs

High vaginal swabs

705
Q

What conditions can charcoal swabs confirm?

A

BV
Candidasis
Gonorrhoeae
Trichomonas vaginalis

706
Q

What does NAAT look for?

A

The DNA/ RNA of an organism

707
Q

What conditions can NAAT confirm?

A

Chlamydia

Gonorrhoea

708
Q

What type of swabbing can be done with NAAT swab?

A

Vulvovaginal swab
Endocervical swab
First-catch urine sample
(Rectal and pharyngeal)

709
Q

If gonorrhoea is proven on a NAAT, what needs to happen?

A

An endocervical charcoal swab must be done to look for microscopy, culture and sensitivities

710
Q

If chlamydia is symptomatic, how might it present in women?

A 
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding
Painful sex
Painful urination
711
Q

If chlamydia is symptomatic, how might it present in men?

A

Urethral discharge/ discomfort
Painful urination
Epididymo-orchitis
Reactive arthritis

712
Q

What should be considered if sexually active patients are presenting with anorectal symptoms (discomfort, discharge, bleeding, change in bowel habits)?

A

Rectal chlamydia or lymphogranuloma venereum

713
Q

What may be found on examination of chlamydia?

A

Pelvic/ abdominal tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge

714
Q

How is chlamydia diagnosed?

A

NAAT:

Vulvovaginal/ endocervical/ urethral/ rectal/ pharyngeal swab or first-catch urine sample

715
Q

What is the first-line treatment for uncomplicated chlamydia?

A

Doxycycline 100mg

Twice a day for 7 days

716
Q

When would doxycycline be contraindicated as chlamydia treatment?

A

In pregnancy and breastfeeding

717
Q

What should happen when someone is being treated for chlamydia?

A
  • They should abstain from sex until treatment is complete

- They should be referred to GUM for contact tracing

718
Q

What are the main complications of infection with chlamydia?

A 
PID
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lyphogranuloma venereum 
Reactive arthritis
719
Q

What are the pregnancy complications of chlamydia?

A 
Preterm delivery
PROM
Low birth weight
Postpartum endometritis
Neonatal infection
720
Q

What is lymphogranuloma venereum?

A

Condition that affects the lymphoid tissue around site of chlamydia infection

721
Q

What are the 3 stages of lymphogranuloma venereum?

A 
Primary= Painless ulcer
Secondary= Lymphadenitis
Tertiary= Inflammation of rectum and anus (may cause tenesmus)
722
Q

What is tenesmus?

A

The feeling of needing to empty the bowels when they are empty

723
Q

How is lymphogranuloma venereum treated?

A

21 days Doxycycline

724
Q

What is chlamydial conjunctivitis?

A

Chlamydia infection of the conjunctiva of the eye (usually happens when genital fluid comes in contact with the eye)

725
Q

What kind of organism is gonorrhoea?

A

Gram-negatie diplococcus bacteria

726
Q

How does gonorrhoea cause infection?

A

Infects mucous membranes with a columnar epithelium (e.g. endocervix) and then spreads via contact with the mucous secretions from these infected areas

727
Q

What is the concern with gonorrhoea treatment?

A

There is a high level of antibiotic resistance and the traditional things used to treat it can no longer be used

728
Q

What percentage of presentations are symptomatic with gonorrhoea?

A

90% men

50% women

729
Q

How may gonorrhoea present in women?

A

Odourless purulent discharge (may be green/ yellow)
Dysuria
Pelvic pain

730
Q

How may gonorrhoea present in men?

A

Odourless purulent discharge (may be green/ yellow)
Dysuria
Testicular pain/ swelling

731
Q

How is gonorrhoea diagnosed?

A

NAAT to detect the RNA or DNA

Charcoal swab for microscopy, culture and antibiotic sensitivities to guide antibiotic treatment

732
Q

What is the first-line treatment for uncomplicated gonorrhoeal infections if sensitivities are not known?

A

Single dose of IM Ceftriaxone 1g

733
Q

What is the first-line treatment for uncomplicated gonorrhoeal infections if sensitivities are known?

A

Single dose of oral Ciprofloxacin 500mg

734
Q

After how long should patients treated for gonorrhoea have a test of cure?

A

72 hours after treatment for culture
7 days after treatment for RNA NAT
14 days after for DNA NAAT

735
Q

What are the complications of gonorrhoea?

A 
PID
Chronic pelvic pain
Infertility
Epididymo-orchitis
Prostatitis
Conjunctivitis
Urethral strictures
Disseminated gonococcal nfection
Skin lesions
736
Q

What is a key complication of neonatal gonorrhoea passed down from the mother?

A

Ophthalmia neonatorum (gonococcal conjunctivitis)- medical emergency associated with sepsis and blindness

737
Q

What is disseminated gonococcal infection?

A

Complication of untreated gonococcal infection where bacteria spreads to skin and joints

738
Q

What is PID?

A

Pelvic inflammatory disease

739
Q

What causes PID?

A

Infection spreading up through the cervix

740
Q

What are the kay complications of PID?

A

Tubular infertility

Chronic pelvic pain

741
Q

What are the 3 most common causes of PID?

A

Gonorrhoea
Chlamydia
Mycoplasma genitalium

742
Q

What are non-sexually transmitted causes of PID?

A

Gardnerella vaginalis
Haemophilus influenzae
E. coli (UTI)

743
Q

What are the risk factors for PID?

A

Same as any other STI:

  • Not using barrier contraception
  • Multiple partners
  • Young age
  • Existing STI’s
  • Previous PID
  • IUD
744
Q

How may PID present?

A 
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding
Dyspareunia
Fever
Dysuria
745
Q

What may examination of PID reveal?

A

Pelvic tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge

746
Q

How is PID investigated?

A

NAAT swabs for gonorrhoea, chlamydia and Mycoplasma genitalium
HIV test
Syphilis test
High vaginal swab for bacterial vaginosis, candidiasis and trichomoniasis
Microscopy to look for pus cells
Inflammatory markers

747
Q

How is PID managed?

A

Refer to GUM for contact tracing

Empirial antibiotics started before confirmation, followed by necessary local antibiotic regime

748
Q

What is a typical regime for the treatment of PID ?

A
  1. Single dose of IM ceftriaxone (for gonorrhoea)
  2. 14 Dyas Doxyccycline (for chlamydia/ mycoplasma genitalium)
  3. 14 days Metronidazole (for garnerella vaginalis)
749
Q

What are the complications of PID?

A 
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis Syndrome
750
Q

What is Fitz-Hugh-Curtis Syndrome?

A

Complication of PID that causes inflammation of the liver capsule, leading to adhesions between the liver and peritoneum.

751
Q

What is Trichomonas vaginalis?

A

A type of parasite spread through sexual intercourse

752
Q

What type of organism is trichomonas vaginalis?

A

Protozoan, single-celled organism with flagella (parasite)

753
Q

Where does trichomonas live in infected men/ women?

A 
Men= Urethra
Women= Vagina
754
Q

What can Trichomonas vaginalis increase the risk of?

A 
Contracting HIV
Bacterial vaginosis
Cervical cancer
PID
Pregnancy-related complications
755
Q

How does Trichomonas vaginalis present?

A 
50 % asymptomatic 
50% non specific syptoms: 
- Vaginal discharge
-Itching
-Dysuria
-Dyspareunia
-Balanitis
756
Q

What is the typical description of discharge with Trichomonas vaginalis?

A

Frothy, yellow- green discharge with fishy smell

757
Q

What may examination reveal with Trichomonas vaginalis?

A

‘Strawberry cervix’ (inflammation with tiny haemorrhages)

Raised vaginal pH

758
Q

How can Trichomonas vaginalis be diagnosed?

A

Standard charcoal swab with microscopy

759
Q

How is Trichomonas vaginalis managed?

A

GUM referral

Treat with Metronidazole

760
Q

What is Mycoplasma genitalium?

A

STI that causes non-gonococcal urethritis

761
Q

What is the key feature of Mycoplasma genitalium?

A

Urethritis

762
Q

How does MG present?

A

Most are asymptomatic

May present similarly to chlamydia

763
Q

How is MG diagnosed?

A

NAAT from first urine sample (men) or vaginal swab (women)

764
Q

How is MG treated?

A

Doxycycline for 7 days followed by Azithromycin

765
Q

What is HSV?

A

The herpes simplex virus

766
Q

What is HSV most commonly responsible for?

A 
Cold sores (herpes labialis) 
Genital herpes
767
Q

What are the two most common strains of herpes?

A

HSV-1

HSV-2

768
Q

What happens after initial infection with herpes?

A

The virus becomes latent in the associated sensory nerve ganglia

769
Q

Which nerve ganglia does the herpes virus usually live in with cold sores?

A

Trigeminal nerve ganglion

770
Q

Which nerve ganglia does the herpes virus usually live in with genital herpes?

A

Sacral nerve ganglia

771
Q

What else can the HSV cause?

A

Apthous ulcers
Herpes keratitis
Herpetic whitlow

772
Q

How is HSV spread?

A

Direct contact with affected mucous membranes or viral shedding in mucous secretions

773
Q

When is asymptomatic viral shedding most common?

A

In the first 12 months of infection

774
Q

What is HSV-1 most associated with?

A

Cold sores

775
Q

When is HSV-1 usually contracted?

A

In childhood (before 5)

776
Q

When does HSV-1 usually reactivate?

A

In times of stress

777
Q

What is HSV-2 most associated with?

A

Genital herpes

778
Q

What are the main symptoms of initial genital herpes infection?

A 
May be asymptomatic
Ulcers or lesions to the genitals
Neuropathic pain
Flu-like symptoms
Dysuria
Inguinal lymphadenopathy
779
Q

How long do symptoms last with initial infection and do they get better or worse with recurrent infections?

A

3 weeks

Milder and more quickly resolved with recurrent infections

780
Q

How is herpes diagnosed?

A

History to try to establish source of infection
Clinical diagnosis with history/ examination findings
May do viral PCR from lesion to confirm

781
Q

How is herpes managed?

A

Aciclovir

Symptomatic management

782
Q

What is the main complication of genital herpes during pregnancy?

A

Risk of neonatal herpes simplex infection contraction during labour or delivery

783
Q

How is primary genital herpes contracted before 28 weeks gestation managed?

A

Aciclovir followed by prophylactic aciclovir starting from 36 weeks
(may need C-section is symptoms are present)

784
Q

How is primary genital herpes contracted after 28 weeks gestation managed?

A

Aciclovir followed immediately by regular prophylactic aciclovir
C-section

785
Q

How is recurrent genital herpes managed in pregnancy?

A

Consider prophylactic aciclovir from 36 weeks

786
Q

What causes Syphilis?

A

Treponema pallidum bacteria

787
Q

What is the incubation period between infection and symptoms with syphilis?

A

21 days

788
Q

How can syphilis be contracted?

A

Through oral, vaginal or anal sex
Vertical transmission
IV drug use
Blood transfusions/ transplants

789
Q

What are the 5 stages of syphilis?

A 
Primary
Secondary
Latent
Tertiary
Neurosyphilis
790
Q

What is primary syphilis?

A

A painless ulcer (chancre) at the original site of infection

791
Q

What is secondary syphilis?

A

Systemic symptoms that resolve after 3-12 weeks

792
Q

What is latent syphilis?

A

When symptoms disappear and the patient becomes asymptomatic despite being infected.

793
Q

After how long does it become late latent syphilis instead of early latent syphilis?

A

After 2 years

794
Q

What is tertiary syphilis?

A

When many years after initial infection, syphilis may affect many organs of the body

795
Q

What is neurosyphilis?

A

When the infection involves the CNS and presents with neurological symptoms

796
Q

How does primary syphilis present?

A

Painless genital ulcer that resolves in 3-8 weeks

Local lymphadenopathy

797
Q

How does secondary syphilis present?

A 
Maculopapular rash
Condylomata lata (wart) 
Low-grade fever
Lymphadenopathy
Alopecia
Oral lesions
798
Q

How may tertiary syphilis present?

A

Gummatous lesions
Aortic aneurysms
Neurosyphilis

799
Q

How may neurosyphilis present?

A 
Headache
Altered behavious
Dementia
Tabes dorsalis
Ocular syphilis
Paralysis
Sensory impairment
800
Q

What is the specific finding found in neurosyphilis?

A

Argyll-Robertson pupil: constricted pupil that accommodates when focusing on a near object but does not react to light

801
Q

How is syphilis

diagnosed?

A

Antibodies for antibodies to T. pallidum

802
Q

How is syphilis managed?

A

GUM

Single deep IM dose of penicillin

803
Q

What comes first, HIV or AIDS?

A

AIDS= acquired immunodeficiency syndrome that comes as HIV progresses

804
Q

What type of organism is HIV?

A

RNA retrovirus

805
Q

What is the mechanism of HIV?

A

Enters and destroys CD4-T helper cells

806
Q

How is HIV transmitted?

A

Unprotected sex
Vertical transmission
Exposure to infected blood or bodiliy fluids

807
Q

What is the course of HIV?

A

Inital flu-like infection, then asymptomatic until progresses to immunodeficiency

808
Q

What causes AIDS-defining illnesses?

A

When the CD4 count drops to a level that allows for opportunistic infections

809
Q

What are some examples of AIDS- defining illnesses?

A 
Kaposi's sarcoma
PCP (pneumonia) 
Cytomegalovirus
Candidiasis
Lymphomas
Tuberculosis
810
Q

For up to how long after infection can HIV antibody tests remain negative and why?

A

Up to 3 months as it taes this long to develop antibodies to the virus

811
Q

Who should be screened for HIV?

A

Practically everyone admitted to hospital and especially those with risk factors

812
Q

How is HIV screened for?

A

Antibody blood test

813
Q

How is HIV monitored?

A

CD4 count

814
Q

What is the normal CD4 rage?

A

500-1200 cells

815
Q

What range of CD4 cells indicated end-stage HIV?

A

<200 cells

816
Q

How can you assess the HIV viral load?

A

PCR testing for HIV RNA

817
Q

How is HIV treated?

A

ART

818
Q

What is ART?

A

Antiretroviral therapy

819
Q

What does ART involve?

A

Tailored treatment that aims to achieve normal CD4 count and undetectable viral load

820
Q

What is HAART?

A

Highly active anti-retrovirus therapy medication

821
Q

What are the medications used in HAART therapy?

A

Protease inhibitors
Integrase inhibitors
Nucleoside reverse transcriptase inhibitors
Non-nucleoside reverse transcriptase inhibitors
Entry inhibitors

822
Q

What additional management should be used to treat those with HIV?

A

Prophylactic septrin to protect against PCP
Monitoring of cardiovascular health
Yearly cervical smears
Vaccinations

823
Q

How can you prevent HIV transmission during birth if there is a high viral load?

A

C-section and IV zidovudine

Baby given Zidovudine for 4 weeks

824
Q

Should mothers with HIV breastfeed?

A

NO

825
Q

What can be used to prevent HIV developing?

A

PEP (post-exposure prophylaxis)

826
Q

How soon after potential exposure should PEP e given?

A

<72 hours

827
Q

What does PEP involve?

A

A combination of ART therapy ( Truvafa and raltegravir for 28 days)

Obs & Gynae (4 decks)

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