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Year 5 (Alex) > Gynae > Flashcards

Gynae Flashcards

1
Q

Menstrual cycle - HPO axis

A

*Effect of oestrogen on pituitary hormones switches when concentration increases beyond a threshold

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2
Q

What are the 2 phases of the menstrual cycle?

A

Follicular phase and luteal phase

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3
Q

How long does follicular phase last?

A

From day 1 of menstrual cycle up to ovulation (approx 14 days)

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4
Q

What happens during follicular phase?

A

LH and FSH stimulates growth of follicles in the ovaries.

Follicular growth produces oestrogen -> oestrogen builds endometrium

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5
Q

What are the LH and FSH levels during follicular phase?

A

Oestrogen release from follicle is gradually increasing - whilst it is still low, LH and FSH production is inhibited thus decrease

Once oestrogen past critical threshold, positive feedback effect and surge in LH and FSH (LH much higher)

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6
Q

What does surge in LH trigger?

A

Ovulation

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7
Q

What happens in ovulation?

A

A maure egg is released from the ovary

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8
Q

What happens during luteal phase?

A

Follicle that has released its egg becomes corpus luteum –> progesterone release

Progesterone maintains endometrial lining

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9
Q

Why does endometrial lining break down?

A

No implantation + corpus luteum is out of progesterone (has enough for 14 days)

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10
Q

Differentials for bleeding + abdo pain in early pregnancy

A
  • Ectopic pregnancy
  • Miscarriage
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11
Q

Ectopic pregnancy

A

Implantation of a conceptus outside uterine cavity

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12
Q

Ectopic pregnancy clinical features

A
  • Lower abdo pain (often to one side)
  • PV bleeding
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13
Q

Ectopic pregnancy RFs

A
  • Previous abdo/pelvic surgery (adhesions)
  • IUD
  • PID
  • Assisted conception
  • Progesterone only pill
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14
Q

Ectopic pregnancy Ix

A
  • Urien B-hCG
  • TV USS (empty uterus, free fluid in pouch of Douglas)
  • Serum B-hCG
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15
Q

Ectopic pregnancy Mx - 3 categories

A

Expectant

Medical

Surgical

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16
Q

When to consider expectant management for ectopic pregnancy?

A
  • Clinically stable
  • Pain free
  • Ectopic ≤ 35mm w/o heartbeat
  • Serum hCG ≤ 1000IU/L
  • Able to return for follow up
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17
Q

Expectant mx for ectopic pregnancy

A
  • Repeat serum hCG on days 2, 4, 7
    • Ensure downtrending - ≥15% drop on e/ occasion
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18
Q

When to consider medical management for ectopic pregnancy?

A
  • Significant pain
  • Ectopic ≤ 35mm w/o heartbeat
  • Serum hCG ≤ 1500IU/L
  • No intrauterine pregnancy
  • Able to return to follow up
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19
Q

Medical Mx ectopic pregnancy

A

IM Methotrexate

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20
Q

Management of ectopic pregnancy

hCG 1500-5000 w/o heartbeat

A

Offer either medical or surgical

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21
Q

When to consider surgical mx for ectopic pregnancy?

A
  • Significant pain
  • Ectopic >35mm
  • Ectopic with hearbeat
  • hCG ≥ 5000IU/L
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22
Q

Surgical Mx of Ectopic pregnancy

A

Salpingectomy

(affected fallopian tube removed)

+ anti D prophylaxis for anti D-ve mums

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23
Q

How long after methotrexate should you wait to conceive?

A

At least 3/12

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24
Q

Ruptured ectopic pregnancy Mx

A

Definitive:
Diagnostic laparoscopy w/ views towards laparoscopic salpingectomy

  • Admit pt to ward
  • Escalate to gynae seniors
  • A to E approach (2x large bore cannulae + G&S +/- IV Hartmanns)
  • Consent pt for surgery
  • Speak to ER theatre team
  • On call anaesthetist to see pt
  • Prep pt for surgery (NBM, cross match 4 units blood)
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25
Q

Miscarriage

A

Pregnancy ending spontaneously before 24 weeks gestation

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26
Q

What are the 5 types of miscarriage?

A
  • Threatened
  • Inevitable
  • Incomplete
  • Complete
  • Missed
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27
Q

What are the USS and clinical findings of each of a threatened miscarriage?

A

USS

  • Intrauterine pregnancy with heartbeat

Clinical

  • Vaginal bleeding
  • Abdominal pain
  • Closed os
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28
Q

What are the USS and clinical findings of each of an inevitable miscarriage?

A

USS

  • Intrauterine pregnancy without heartbeat

Clinical

  • Vaginal bleeding
  • Abdominal pain
  • Open cervical os
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29
Q

What are the USS and clinical findings of each of an incomplete miscarriage?

A

USS

  • Retained products of conception

Clinical

  • Vaginal bleeding
  • Abdominal pain
  • Open os
  • Visible products of conception
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30
Q

What are the USS and clinical findings of each of a complete miscarriage?

A

USS

  • Empty uterus
  • Needs to have previously been visualised on USS

Clinical

  • Resolved PV bleed
  • Closed os
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31
Q

What are the USS and clinical findings of each of a missed miscarriage?

A

USS

  • Intrauterine pregnancy without heartbeat

Clinical

  • Asymptomatic
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32
Q

Miscarriage Ix

A

Bedside

  • Urinary pregnancy test
  • Speculum + bimanual
  • TVUSS
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33
Q

Threatened miscarriage Mx

A

Monitoring

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34
Q

Miscarriage Mx (3)

A

Expectant, medical, surgical

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35
Q

Miscarriage expectant mx

A
  • Wait for bleeding and pain to resolve in 7-14 days
  • Pregnancy test after 3 weeks

Rescan if pain and bleeding -

  • Not started
  • Persisting/worsening
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36
Q

Miscarriage medical mx

A
  • Vaginal misoprostol
  • Pain relief
  • Anti-emetics

+ Pregnancy test after 3 weeks

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37
Q

Medical miscarriage safety netting

A
  • Vaginal bleeding
  • Pain
  • Diarrhoea
  • Vomiting
  • 10% failure rate
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38
Q

Miscarriage surgical Mx

A
  • Manual vacuum aspiration
    • Local anaesthetic
  • Surgical mx in theatre
    • GA
    • More advanced misc!
      • offer Anti D prophylaxis
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39
Q

Recurrent miscarriage

A

3 or more consecutive miscarriages

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40
Q

Increased risk of miscarriages

A
  • Thyroid disease
  • Uterine anomaly
    • e.g., fibroid
  • Chromosomal abnormality
  • Blood clotting disorder
    • Antiphospholipid syndrome
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41
Q

Recurrent miscarriage Ix

A

Bedside

  • TVUSS

Bloods

  • TFTs
  • Thrombophilia screen
  • Antiphospholipid syndrome screen
  • Cytogenetic analysis
    • Individual and partner
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42
Q

Antiphospholipid syndrome triad

A
  • Recurrent miscarriage
  • Venous thromboembolism
  • Thrombocytopaenia (low platelets)
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43
Q

What are the 2 blood tests done in antiphospholipid syndrome screen?

A

Lupus anticoagulant

Anticardiolipin antipodies

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44
Q

Antiphospholipid syndrome Mx

A
  • Low dose aspirin
  • LMWH in future pregnancies
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45
Q

Termination of pregnancy options

A

Medical

Surgical

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46
Q

What time frame (gestation) can medical TOP be considered?

A

Before 24 weeks (from last menstrual period)

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47
Q

Medical mx for TOP

A

<10 weeks - can be done at home
10-12 weeks - either :)
13-23+6 in clinic

  1. Mifepristone, then
  2. Misoprostol
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48
Q

How does Mifepristone work?

A

Anti-progestogen - precipitate break down of endometrial lining and conceptus to come out with it

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49
Q

How does misoprostol work?

A

Prostaglandin analogue stimulates uterine contractions

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50
Q

When can feticide be considered in TOP?

A

From 21+6 weeks to ensure no signs of life once born

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51
Q

Surgical mx of TOP

A

<14 weeks

  • Suction curettage
    • Can be done under GA
    • Insertion of vacuum tube via cervix + curettage to remove any remaining pregnancy tissue

14 - 23+6 weeks

  • Dilation & evacuation
    • GA in theatre
    • Similar to suction curettage but use of forceps to remove larger tissue
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52
Q

Gestational trophoblastic disease / molar pregnancy

A

Spectrum of tumours and tumour-like conditions characterised by proliferation of pregnancy-associated trophoblastic tissue

/ pt:

A molar pregnancy is when there’s a problem with a fertilised egg, which means a baby and a placenta do not develop the way they should after conception. A molar pregnancy is not viable.

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53
Q

Molar pregnancy presentation

A
  • Irregular PV bleeding
  • Hyperemesis gravidarum
    • HUGE amount of hCG produced
  • Large for date uterus
    • Mass growing way quicker than usual preg would
  • HTN
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54
Q

Complete mole aetiology

A

2 sperm (23X x2), or 1 sperm (23X) fuse with an empty egg (containing no genetic material)

If 1 sperm, then it duplicates itself -> overall 46 XX fertilised egg -> all the genetic material purely male -> overdose male chromosomes -> excessive growth

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55
Q

Partial mole aetiology

A

2 normal sperm (23X x2) or 1 sperm with full set of chromosomes (46XY) fuses with normal egg (23X)

–> 69XXY

Huge abundance of chromosomes in fertilised egg –> overdose of chromosomal material from male partner –> excessive growth

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56
Q

Molar pregnancy Ix

A

Bedside

  • Urinary pregnancy test

Bloods

  • Serum hCG
    • out of proportion w gestation
  • FBC + G&S
    • Likely need surgical intervention
  • TFT
    • excess bHCG can affect thyroids

Imaging

  • TVUSS
    • Bunch of grapes/
    • Snowstorm appearance - complete
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57
Q

Molar pregnancy mx

A
  • Suction curettage
  • GTD centre follow up
    • Serial quantitative beta-HCG

If gestational trophoblastic neoplasia

  • Chemotherapy at GTD centre
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58
Q

Heavy menstrual bleeding Ddx

A
  • Endometriosis
  • Adenomyosis
  • Fibroids
  • IUD
  • Endometrial hyperplasia
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59
Q

Menorrhagia Ix

A

TVUSS

*Diagnostic laparoscopy

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60
Q

Endometriosis

A

Endometrial tissue outside the uterine cavity

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61
Q

Endometriosis presentation

A
  • Cyclical (or chronic) pelvic pain
  • Dysemnorrhea
  • Deep dyspareunia
  • IMB
  • Haematuria
  • Painful bowel movement
  • Chronic fatigue
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62
Q

Endometriosis Ix

A
  • USS
  • Diagnostic laparoscopy
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63
Q

Endometriosis Mx

A

Medical

  • NSAIDs
    • Mefenamic acid
  • COCP/IUS
  • GnRH agonists
    • Goserelin

Surgical

  • Ablation or excision
    • Fertility-sparing
  • Hysterectomy with bilateral salpingo-oophorectomy

www.endo.org.uk - Endometriosis UK

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64
Q

Adenomyosis

A

Endometrial tissue is found deep within myometrium

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65
Q

Adenomyosis Mx

A

Medical

  • Tranexamic acid
  • NSAID
    • Mefenamic acid
  • ​​IUS

Surgical

  • Uterine artery ablation
  • Endometrial ablation
  • Hysterectomy
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66
Q

Fibroids

A

Benign tumour of the uterine smooth muscle (myometrium)

  • oestrogen sensitive
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67
Q

Fibroid presentation

A
  • Menorrhagia
  • Urinary frequency
  • Back pain
  • Bloating
  • ±pelvic mass o/e
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68
Q

What are the different types of fibroids?

A
  • Submucosal
  • Intramural
  • Subserosal
  • Pedunculated
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69
Q

Fibroids Mx

A

Fibroid <3cm

  • 1st line: LNG-IUS
    • reduces menstrual blood loss, some studies showed a reduction in uterine fibroids size
  • 2nd line
    • Non-hormonal: Tranexamic acid (if no dysmen), or mefenamic acid (if dysmen)
    • Hormonal: Other contraception
  • 3rd line -> Specialty referral
    • Endometrial ablation
    • Hysterectomy

Fibroid ≥3cm

  • Specialist referral
  • Whilst ^ awaiting: Tranexamic acid ± mefenamic acid

In 2ndry care

  • Pharmacological treatment — hormonal (LNG-IUS, CHC, or cyclical oral progestogens) or non-hormonal (NSAIDs or tranexamic acid)
  • Uterine artery embolization.
  • Surgery - transcervical resection of fibroids, myomectomy, hysterectomy, or endometrial ablation
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70
Q

Causes of irregular periods

A
  • Raised prolactin
  • Disturbed thyroid function
  • Severe anaemia
  • Contraception
  • PCOS
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71
Q

What criteria is used to define PCOS?

A

Rotterdam criteria

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72
Q

What is needed to diagnose PCOS?

A
  • Oligo/anovulation
    • >2 years
  • Hyperandrogenism
    • Clinical: weight gain, hirutism, acne
    • Biochemical: Increased testosterone
  • Polycystic ovaries on USS
    • (≥12 in one ovary measuring 2-9mm)
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73
Q

PCOS Ix

A

Bloods

  • LH (often raised) and FSH (often normal - raised in ova failure, low in hypothalamic disease)
    • High LH:FSH
  • Total testosterone
    • Normal/elevated
      • Calculate free androgen index from total testosterone - physiologically active testosterone: normal to raised
  • Sex hormone binding globulin (SHBG)
    • low
  • Prolactin
    • Rule out hyperprolactinaemia
  • TFTs
    • Rule out thyroid dysfunction
  • Cortisol
    • Rule out cushings

Imaging

  • TVUSS
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74
Q

PCOS Mx

A

Symptomatic

  • Weight loss
  • Acne
    • COCP
    • ±Topical retinoid
    • Co-cyprindiol
  • Hirsutism
    • COCP
    • Facial hirsutism: topical eflornithine

Menstruation

  • Prolonged amenorrhea (less than one period every three months)
    • progestogen (such as medroxyprogesterone) to induce withdrawal bleed, then
    • Refer for a transvaginal ultrasound to assess endometrial thickness
      • If abnormal, biopsy referral
      • If normal –>
  • COCP
  • IUS/IUD

Subfertility

  • Weight loss
  • Smoking cessation
  • Clomiphene
    • Stimulates ovulation
  • Metformin
    • Stimulates ovulation
      • 2nd line in clomiphene resistance
  • Laparoscopic ovarian drilling
    • May help release some eggs

Moreover

  • Offer screening for impaired glucose tolerance and type 2 diabetes
  • Offer screening for CVD RFs: HTN, lipid levels
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75
Q

Infertility Ix

A

Bedside

  • General exam: hirsutismm, acne (PCOS)
  • Abdo exam: mass (ova cyst)
  • Pelvic exa, (PID, endometriosis)
  • BMI

Bloods

  • FBC (IDA)
  • Mid luteal phase progesterone (high in fertile individuals)
    • To confirm ovulation
  • Chlamydia screen

If irreg cycles: gonadotrophin (FSH & LH)

  • TFTs (thyroid dysfunction)
  • Prolactin (hypeerprolactinaemia)
  • AMH (not on NHS)

Imaging

  • TVUSS

Others

  • Semen analysis
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76
Q

Primary amenorrhea Mx

A
  • Refer to 2ndry care to rule out causes
    • Gynae
    • Endo if hyperprolactinaemia, thyroid disease, or features of androgen excess
  • Manage amenorrhoea caused by weight loss, excessive exercise, stress, chronic illness
    • Reduce exercise, incr calorie intake
    • Dietitian
    • Psych (if ED)
    • CBT
  • Osteoporosis risk mx
    • Vit D + Ca
    • Consider HRT if amenorrhea persists >12 months
      Healthy lifestyle + weight bearing exercise
77
Q

Premature ovarian failure

A

Occurrence of menopause under the age of 40. 1% of women.

78
Q

Premature ovarian failure Ix

A

DIAGNOSIS: 2x FSH results >30 (4-6 weeks apart)

  • Day 2 FSH, LH, Oestradiol
    • FSH & LH raised
      • ​FSH very high as your body produces high levels to try to stimulate your ovaries
    • Oestrogen low
  • Testosterone level
    • Rule out PCOS
  • TFTs
    • Rule out thyroid dysfunction
  • Prolactin
    • Rule out prolactinaemia
  • Antral follicle count or anti-mullerian hormone (test of Ovarian reserve - produced by ovaries and levels drop nearer to menopause)
  • Semen analysis
79
Q

Premature ovarian insufficiency Mx

A

Definitive

  • COCP (if needing contraception), or
  • Combined progesterone and oestrogen cyclical HRT

Additional

  • ±ca and vit D

Having children

  • Permanent early menopause will affect your ability to have children naturally.
  • 1 in 10 POI w/o known cause still get pregnant
  • You may still be able to have children by using IVF and donated eggs from another woman, or using your own eggs if you had some stored.
  • Surrogacy (surrogacy UK) and adoption (Adoption UK) may also be options for you.

The Daisy Network – a support group for women with premature ovarian failure

80
Q

Premature ovarian insufficiency

Consequences

A
  • Increased risk hypothyroid disease
  • Osteoporosis
  • Sexual dysfunction (due to dyspareunia from vaginal dryness)
  • Insomnia (due to hot flushes)
81
Q

Premature ovarian failure

Advice for assisted conception

A

Donor oocyte IVF

82
Q

Lifestyle + Non-hormonal/symptomatic menopause Mx

A

Lifestyle

  • Regular exercise + weight loss (if applicable)
  • Wearing lighter clothing/layers of clothing
  • Turning down central heating/sleeping in a cooler room
  • Using fans
  • Reducing stress
  • Avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol)

Non hormonal/symptom Mx

  • Vasor motor syx
    • SSRIs, e.g.. fluoxetine, citalopram
    • Clonidine (an alpha-2 adrenergic receptor agonist)
  • Mood disorder
    • Self help
    • CBT
  • Dyspareunia
    • Lubrication

R/v after 3 months then annually thereafter

83
Q

What are the 2 formulations of HRT?

A
  • Oestrogen only
  • Combined (O+P)
84
Q

When would you use E only HRT?

A

Women without a womb

(Increased risk endometrial Ca)

85
Q

Continuous v cyclical combined HRT

A
  • If pt has intermittent periods = Cyclical
  • No periods for >12/12 = continuous
86
Q

Pros of HRT

A
  • Improved vasomotor syx
  • Prevent osteoporosis
  • Improved genital syx
87
Q

Cons of using HRT

A
  • Increased risk breast Ca
    • O+P
  • Increased risk CVD
  • Increased risk VTE
88
Q

SE of HRT PILL v patch

A

Pill incr risk VTE

89
Q

Emergency contraception

  1. 3 types
  2. How long each can be used for
  3. Efficacy
  4. Any caveats/ special notes
A
  • IUD Copper coil
  1. Up to 5 days/120h after UPSI or expected ovulation date
  2. 99%
  • Ulipristal actetate/ Ellaone 30mg
  1. Up to 5 days/120h after UPSI
  2. 85%
  3. Repeat if vomit within 3h + caution for asthmatics
  • Levonorgesterel / Levonelle 1500mcg
    1. Up to 3 days/72h after UPSI
    2. 95% within 24h then 58% up till 72h
    3. Double dose if >70kg or BMI >26 + repeat if vomit within 2h
90
Q

How does the COCP work?

A

Prevents ovulation

91
Q

How does COCP affect periods?

A

Makes them lighter

92
Q

Return to fertility on COCP

A

Upon stopping

93
Q

Absolute contraindications for COCP

A
  • Breast cancer
  • Migraine w aura
  • VTE
  • ≥35 and ≥15 cigarettes a day
94
Q

How does POP work?

A

Thickens cervical mucus

95
Q

POP affect on periods

A

May get irreg bleeding

96
Q

What are the different types of LARC?

A
  • Coil
    • IUS
    • IUD
  • Implant
  • Depot injection
97
Q

What hormone does the IUS have?

A

Levonorgestrel

98
Q

How long does the IUS last?

A

3-5 years

99
Q

How does the IUS work?

A

Prevents fertilisation

thickens the mucus from the cervix (opening of the womb), making it harder for sperm to move through

100
Q

How does IUS affect periods?

A

Lighter periods -> amenorrhoea

101
Q

How long does the IUD work?

A

5-10 years

102
Q

How does the IUD work?

A

Sterile inflammation

(release copper ions, which are toxic to sperm.)

103
Q

How does IUD affect periods?

A

Heavier + more painful

104
Q

What type of hormone is used in depot injection?

A

Depo-provera = medroxyprogesterone acetate (progestin)

105
Q

How long does the implant last?

A

3 years

106
Q

What type of hormone(s) is/are in the implant? How does the implant work?

A

Progesterone only. Prevents ovulation (and fertilisation - thickens cervical mucus)

107
Q

Implant SE

A

Irregular bleeding

108
Q

How does the implant effect periods?

A

Irregular periods

109
Q

Return to fertility on implant

A

Rapid

110
Q

How long does depot last?

A

12-14 weeks (3 months ish)

111
Q

Main side effect of depot

A

Weight gain

112
Q

Return to fertility on depot

A

Delayed

113
Q

How does patch application work?

A

Weekly patches applied for 3 weeks, with 1 week off (withdrawal bleed)

114
Q

Problems with patch

A

Adherence (to skin)

Skin sensitivity

115
Q

Ovarian Ca Presentation

A
  • Abdominal bloating
  • Loss of appetite
  • Pelvic/abdo pain
  • Constipation/diarrhoea
  • Urinary problems
  • PMB
  • Pelvic mass
  • Ascites
116
Q

Ovarian Ca RFs

A
  • Age
  • FHx
  • Many ovulations (early menarche, late menopause, nulliparity)
  • Smoking
  • Obesity
117
Q

Ovarian Ca Ix

A
  • Abdo exam
  • TVUSS
  • Ca125
  • CT/MRI
    • For staging
118
Q

Ovarian Ca Mx

A
  • Total hysterectomy with bilateral salpingo-oophorectomy
    • Platinum based chemo
  • F/u
119
Q

Which ovarian mass has solid components on USS?

A

Germ cell tumour

120
Q

Post menopausal bleed Ddx

A
  • Endometrial ca
  • Hyperplasia w/o malignancy
  • Benign endometrial polyps
  • Cervical polyps
  • Vaginal atrophy
  • Vulval atrophy
121
Q

Endometrial Ca Presentation

A
  • Post menopausal bleeding
122
Q

Endometrial ca RF

A
  • Obesity
    • More oestrogen released from subcutaneous fat
  • Oestrogen-only HRT
  • Tamoxifen
    • Oestrogenic effect on uterus
  • Nulliparous
  • PCOS
123
Q

Endometrial Ca Ix

A
  • TVUSS
    • Normal endometrial lining <4mm post menopause, <10mm pre men
  • Pipelle biopsy
    • Hysteroscopy if cant be performed
  • CT/MRI
    • Staging
124
Q

Endometrial Ca Mx

A

Low grade tumour/atypical endothelial hyperplasia (not quite malignant)

  • High dose progestogen

Otherwise

  • Total hysterectomy with BSO
125
Q

Cervical Ca Presentation

A
  • Post coital bleeding
  • Intermentsrual bleeding
126
Q

Cervical Ca RFs

A
  • HIV
  • Prev HPV
  • Smoking
  • Multiple sexual partners
  • Prolonged use of COCP
127
Q

Cervical Ca screening - which HPVs are looked for?

A

HPV 16/18

128
Q

How does cervical screening work?

A

Smear taken -> test sample for HPV 16/18

If +ve, looked at under microscope for cytology -cervical intra-epithelial neoplasia (CIN)

129
Q

Cervical Ca screening outcomes

A

Inadequate smear: Repeat in 3/12 -> inadequate smear -> colposcopy

HPV -ve: Routine recall (3 years)

HPV +ve & cytology normal: 1 year recall

HPV+ve & abnormal cytology (dyskariosis): colposcopy & biopsy

130
Q

What is the cervical screening schedule?

A

25 - 49: Every 3 years

50 - 64: Every 5 years

65 and above: Only if 1 of last 3 tests were abnormal

131
Q

Cervical ca screening biopsy results and mx

1) Normal
2) CIN1
3) CIN 2
4) CIN 3
5) CGIN

(Cervical Glandular Intra-epithelial Neoplasia)

A
  1. Routine recall
  2. 12 month recall
      1. Removal of cells - LLETZ (large loop excision of the transformation zone) + cervical screening (test of cure) after 6/12
132
Q

!Cervical Ca vax

A

For Human papillomavirus (HPV) - Gardasil

6, 11, 16, 18

HP6+11= genital warts

16+18 = cervical ca

Offered to all y9 school children (12-13)

133
Q

Cervical ca Ix

A
  • Vaginal + sepc exam
  • Cervical smear
    • only if overdue
  • Vaginal swabs
  • Biopsy
    • Colposcopy
134
Q

Cervical ca Mx

A

Depends on staging

  • Surgical
    • hysterectomy
    • cone biopsy w negative markers
  • Radiotherapy
  • Chemotherapy
    • cisplatin
135
Q

Pelvic inflammatory disease

A

Ascending infection of the female reproductive tract

136
Q

PID Ix

A

Bedside

  • Bimanial + speculum
    • Cervical excitation
  • Endocervical swab
    • For chlamydia and gonorrhoea
  • High vaginal swab
    • Anaerobes

Bloods

  • FBC -> WBC
  • CRP
  • Blood culture

Imaging

  • TVUSS
    • Check for development of tubo-ovarian abscess
137
Q

PID Mx

A

! IM Ceftriaxone 500mg STAT + PO Doxycycline 100mg BD 14 days + PO Metronidazole 400mg BD 14 days

(If pen allergic: PO Ofloxacin + Metronidazole 14 days)

  • Consider IUD removal
  • STI screen
  • Contact tracing
  • Counsel about subfertility
138
Q

Vaginal d/c

A
  • Cottage cheese w/o foul smell + itchy vulva -> Candida albicans (thrush)
  • Fish-grey d/c -> bacterial vaginosis
  • Yellow-green w/ pain -> trichomonas vaginalis
  • White/yellow/grey foul -> Chlamydia trachomatis
139
Q

Most common reason for foul vaginal d/c in children?

A

Vulvovaginitis

140
Q

HSV presentation

A
  • White lesion on labia
  • painful urination
141
Q

HSV Mx

A

Lesion

  • Topical aciclovir

Suppression

  • Oral aciclovir
142
Q

Trichomonas vaginalis presentation

A

frothy yellow/green d/c + dyspareunia and strawberry cervic

143
Q

Syphilis Presentation

A

Primary syphilis

  • Chancre - painless lesions on genitals or mouth
  • Lymphadenopathy
144
Q

2 main types of urinary incontinence

A
  1. Urge incontinence
  2. Stress incontinence
    • Bladder unable to close itself fully so when incr intra-abdo pressure, you get leakage
145
Q

Urge incontinence Mx

A
  1. Discuss diet + fluid intake + bladder retraining (6 weeks)
  2. Anticholinergics
    • Tolterodine
      • This over oxybutynin in frail elderly
    • Oxybutynin
  3. Beta 3 agonist
    • Mirabegranon
  4. Surgical
    • Botox injection
    • Percutaneous nerve stimulation
    • Sacral nerve stimulation
146
Q

Stress incontinece Mx

A

Lifestyle changes

  • Reducing caffeine intake — this may improve symptoms of urgency and frequency but not incontinence.
  • Fluid intake — advise the woman to avoid drinking either excessive amounts, or reduced amounts, of fluid each day.
  • Weight loss if the woman’s body mass index is 30 kg/m2 or greater. For more information, see the CKS topic on Obesity.
  • Smoking if this is appropriate — for more information, see the CKS topic on Smoking cessation.
  1. Pelvic floor excercises (min 3 months)
    - at least 8 contractions x 3/day
    - squeezy app
  2. Duloxetine
    • Only 2nd line if pt doesn’t want surgical mx
    • Awful side effects :(
  3. Surgical procedures
    • Intramural urethral bulking agent
    • Autologous rectus fascial sling
    • Burch colposuspension
147
Q

What is the cause of constant urinary dribbling?

A

vesicovaginal fistula

148
Q

Urinary incontinence Ix

A
  • Bladder diary
    • Min 3 days
  • Urodynamic testing
149
Q

Urodynamics - what does unprovoked pressure peaks with urinary leakage indicate?

A

Overactive bladder secondary to detrusor overactivity

150
Q

Pelvic organ prolapse Mx

A

Conservative

  • Losing weight if BMI>30
  • Minimise heavy lifting
  • Preventing/treating constipation
  • Pelvic floor muscle training

Medical

  • Pessary

Surgical

Urocele

  • Anterior wall repair

Vault prolapse

  • sacrocolpoplexy

Uterine prolapse

  • Vaginal hysterectomy

Rectocele

  • Posterior wall repair
151
Q

What scoring system is used to assess severity of pelvic organ prolapse?

A

POP Q

152
Q

Turner’s syndrome presentation

A

Teenager presenting

  • Short
  • No signs development of secondary sexual characteristics
  • Widely spaced nipples
  • Systolic murmur under L clavicle
153
Q

Turner’s syndrome/primary amenorrhoea Ix

A
  • FSH/LH
    • Raised due to negative feedback to try compensate for lack of oestrogen/progesterone
154
Q

Which Ix confirms Tuner’s?

A

Karotyping

155
Q

Imperforate hymen presentation

A
  • Cyclical pain
  • Developed 2ndry sexual characteristics
156
Q

What to do if you come across FGM?

A

Under 18 - police

18 and over - safeguarding lead

157
Q

Most common cause Azoospermia

A

Mumps orchitis

158
Q

Azoospermia Mx for getting pregnant

A

ICSI - Intracytoplasmic sperm injection

(Type of IVF)

159
Q

Blocked fallopian tubes Mx for getting pregnant

A

IVF

160
Q

Ovarian cyst mx

A
  • Women with small (less than 50 mm diameter) simple ovarian cysts
  • Women with simple ovarian cysts of 50–70 mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.
  • If surgery, lap removal
161
Q

What size is classed as a small ovarian cyst?

A

<50mm

162
Q

What is the management for a small simple ovarian cyst?

A

Generally do not require follow-up as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles.

163
Q

>70mm simple ovarian cyst Mx

A

Surgical intervention - laparoscopic removal

164
Q

Which ovarian cyst contains hair and teeth?

A

(Mature cystic) Teratoma

165
Q

Which ovarian cyst shows ground glass appearance on USS?

A

Endometrioma/chocolate cysts

166
Q

Recovery time post-hysterectomy

A
  • Vaginal or laparoscopic hysterectomy: 1- 4 days inpt
  • Abdominal hysterectomy: up to 5 days inpt
  • GP r/v 4-6 weeks
    • hosp if complicates
  • 6 to 8 weeks to fully recover after abdominal hysterectomy
167
Q

PMS Mx

A

+ r/v after 2/12 + keeping syx diary

Mild

  • Lifestyle advice
    • Regular, frequent, small meals rich in complex carbs
    • Reg exercise
    • Reg sleep
    • Stress reduction
    • Alcohol reduction
    • Smoking cessation
  • Paracetamol or NSAIDs for pain

Moderate

  • Combined oral contraceptive pill
  • CBT referral

Severe

  • SSRI
168
Q

Why are COCPs used for PMS?

A

they suppress ovulation, which is thought to contribute to PMS

169
Q

Contraception prior to sterilisation

A

Use until the day of operation and up until next period after surgery

170
Q

What is a nodule on the uterosacral ligament indicative of?

A

Endometriosis

171
Q

What does high vaginal swab (HVS) test for?

A

BV + candidiasis

172
Q

What do endocervical swabs test for?

A

Gonorrohoea and chlamydia

173
Q

Bartholin’s cyst presentation

A

painless fluid-filled lump near the opening of the vagina

174
Q

Bartholin’s abscess presentation

A

acutely painful large swelling near the opening of the vagina

175
Q

Atrophic vaginitis presentation

A
  • Vaginal dryness
  • Vaginal burning (inflammation)
  • Postcoital bleed
  • Dyspareunia
  • Dysuria
  • Urinary frequency
  • Urinary incontinence

vulvar and vaginal tissues are red, thin, friable, with a loss of rugae and loss of normal anatomy

176
Q

Lichen sclerosus

A

Patches on the skin that are usually:

  • itchy
  • white
  • smooth or crinkled
  • easily damaged – they may bleed or hurt if rubbed or scratched

vulvar tissue is usually thin and white but may be red and inflamed

177
Q

How long after simple lap surgery can a pt go home?

A

4hrs

178
Q

Bulky uterus ddx

A
  • Fibroid
    • Menorrhagia
  • Adenomyosis
    • Dysmenorrhea +menorrhagia
179
Q

Asherman’s syndrome

A

Characterised by uterine adhesions

180
Q

What are the 4 types of Female Genital Mutilation (FGM)?

A

Type 1 - clitoridectomy (partial or total)

Type 2 - clitoridectomy (partial or total) + removal of labia minora +/- removal of labia majoria

Type 3 - infibulation - narrowing of vaginal opening either by stitching or by using labia to form a seal

Type 4 - any other type, e.g., piercing, stabbing, burning, etc.

181
Q

Bartholin cyst and abscess Mx

A

Asymptomatic cyst

  • Warm compress/siltz bath
  • ±Antibiotic cover

Abscess

  • Marsupialisation
    • The cyst is first opened with a cut and the fluid is drained out. The edges of the skin are then stitched to create a small “kangaroo pouch”, which allows any further fluid to drain out.
    • Takes 10-15mins
    • GA usually
182
Q

Uterine artery embolisation explanation

A

Involves injecting (cannulating the femoral artery) small particles into the blood vessels which supply blood to the uterus/womb. The aim is to block the blood supply to the fibroids/adenomyosis to relieve symptoms and reduce their size.

may potentially allow them to retain their fertility.

183
Q

Myomectomy

A

surgery to remove the fibroids from the wall of your womb - usually approached from the abdomen

may potentially allow them to retain their fertility.

184
Q

Endometrial ablation explanation

A

Endometrial ablation is a procedure to remove a thin layer of tissue (endometrium) that lines the uterus. But it is only done on women who do not plan to have any children in the future - use of contraception.

185
Q

How does the LNG IUS work?

A

The LNG-IUS works primarily by thickening the cervical mucus and changing the endometrial lining. Thick cervical mucus obstructs the passage of sperm through the cervix. High concentrations of progestins are produced in the endometrium; this progestin-dominant effect allows the endometrium to remain thin and nonproliferate.

(Feedback loop where high levels prog is inhibitory for GnRH and LH/FSH prod = no/low oestr and prog prod - tho prog is released from external source. Oest needed for build up of wall)

186
Q

What can premature ovarian insufficiency be caused by?

A
  • chromosome abnormalities – such as in women with Turner syndrome
  • an autoimmune disease – where the immune system starts attacking body tissues
  • Ca trx
  • certain infections, such as tuberculosis, malaria and mumps – but this is very rare
187
Q

BV Mx

A

PO metronidazole

188
Q

Fibroids Complx

A
  • Red degeneration
    • Insufficient blood supply can cause haemorrhage and necrosis often during pregnancy
  • Torsion of pedunculated fibroid

Year 5 (Alex) (4 decks)

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