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Phase 3a topics > Gynae > Flashcards

Gynae Flashcards

1
Q

whirlpool sign

A

ovarian torsion

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2
Q

masses in the uterine wall

A

fibroids

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3
Q

Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
Prolonged menstruation, lasting more than 7 days
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility
Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.

A

fibroids

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4
Q

Investigations for fibroids

A

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding.

transvaginal ultrasound is the investigation of choice for larger fibroids.

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5
Q

Management of menorrhagia with no identified pathology, fibroids <3cm, or a suspected or confirmed diagnosis of adenomyosis

A
  1. mirena coil
  2. non-hormonal options: tranexamic acid, NSAIDs such as mefanamic acid (if dysmenorrhoea too)
  3. hormonal options: COCP, cyclical progestogens
  4. surgical
    - endometrial ablasion
    - hysterectomy
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6
Q

management of menorrhagia with fibroids > 3cm in diameter

A
  1. mirena coil (fibroids must be less than 3cm with no distortion of the uterus)
  2. non-hormonal options: tranexamic acid, NSAIDs
  3. hormonal options: COCP, cyclical progestogens fibroids must be less than 3cm with no distortion of the uterus
  4. Surgical options:
    - uterine artery embolisation
    - myomectomy (if want to maintain fertility)
    - hysterectomy
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7
Q

what drugs can shrink fibroids eg before surgery

A

GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.

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8
Q

complications of fibroids

A
  • sub-fertility
  • anaemia
  • red-degenration during pregnancy
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9
Q

pregnant lady with severe abdo pain, low grade fever, history of fibroids

A

red degeneration of fibroids

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10
Q

Initial investigations menorrhagia

A
  • fbc
  • transvaginal USS

NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.

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11
Q

a benign ovarian tumour
ascites
pleural effusion

A

Meig’s syndrome

It is a rare condition usually occurring in woman over the age of 40 years and the ovarian tumour is generally a fibroma. It is managed by the surgical removal of the tumour, however the ascites and pleural effusion may need to be drained first to allow symptomatic relief and improve pulmonary function before the anaesthetic. It has excellent prognosis due to the benign nature of the tumour.

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12
Q

“string of pearls”

A

multiple ovarian cysts

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13
Q

Presentation of ovarian cysts

A

Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans.

Occasionally, ovarian cysts can cause vague symptoms of:
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)
Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.

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14
Q

Most common type of ovarian cyst

A

Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist.

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15
Q

What type of ovarian cyst may cause pelvic discomfort, pain or delayed menstruation

A

corpus luteum cyst

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16
Q

What type of ovarian cysts can become huge and take up lots of space in abdomen

A

Mucinous Cystadenoma

benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen.

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17
Q

What type of cysts are particualrly associated with torsion

A

teratomas

Dermoid Cysts / Germ Cell Tumours

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18
Q

What tests do you need to do after an ovarian cyst has been identified? younger women vs oldeR?

A

Younger women:
Premenopause with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations.
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)

Older women/complex on scan/>5cm:
CA-125
The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level

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19
Q

2ww for ovarian cancer

A

complex cysts or raised CA125

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20
Q

Management of ovarian cysts - premenopause vs postmenopause

A

Premenopause:
- simple and < 5cm: no follow up
- 5-7cm: routine gynae rf, uss each year
- >7cm: MRI to see character, surgical rf

Postmenopause:
correlation with CA-125 to consider 2ww
- simple and < 5cm: uss every 4-6 months
- perisistent/enlarging: laparoscopy

Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).

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21
Q

has an ovarian cyst, acute onset pain

A

consider:
Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum

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22
Q

what type of cyst causes meig’s syndrome

A

Ovarian fibroma (a type of benign ovarian tumour)

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23
Q

Risk of malignancy index for ovarian cancer

A

Risk malignancy index (RMI) prognosis in ovarian cancer is based on

US findings,
menopausal status and
CA125 levels

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24
Q

A 29-year-old nulliparous female presents to gynaecology clinic with a history of worsening menstrual pain for three years. There is no relief from ibuprofen. She is sexually active with her husband and reports pain during intercourse. Dysuria and urgency in urination are also present. She has been trying to conceive for the past two years, but failed. On examination, her uterus is of normal size. Rectovaginal exam reveals uterosacral nodularity and tenderness.

A

endometriosis

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25
Q

Presentation endometriosis

A

Endometriosis can be asymptomatic in some cases, or present with a number of symptoms:
Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria

There can also be cyclical symptoms relating to other areas affected by the endometriosis:
Urinary symptoms
Bowel symptoms

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26
Q

examination of endometriosis may reveal:

A

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix

A fixed cervix on bimanual examination

Tenderness in the vagina, cervix and adnexa

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27
Q

Gold standard invetsigation for endometriosis

A

Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.

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28
Q

Are USS useful in endometriosis

A

Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy.

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29
Q

Management endometriosis

A
  1. NSAIDs - ibruprofen, mefanamic acid, paracetamol
  2. COCP or progestogens e.g. medroxyprogesterone acetate

Medical (symptom management):
- COCP
- POP
- mirena coil
- Implant
- injection

Secondary care:
Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
Surgical:
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis)
- Hysterectomy and bilateral salpingo-opherectomy

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30
Q

postmenopausal women with symptoms of:
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding (spotting)

o/e
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair

A

atrophic vaginitis

diagnosis of exclusion so may need to do TVUSS etc.

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31
Q

Management of atrophic vaginitis

A
  1. creams/lubricants
  2. topical oestrogen
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32
Q

When is urodynamic testing appropriate for urinary incontinence

A

Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.

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33
Q

Management of stress incontinence

A
  1. Avoid caffiene, alcohol, fluid restriction/excess
  2. Pelvic floor exercises supervised for 3 months
  3. Duloxetine where surgery not wanted
  4. Surgery such as Tension-free vaginal tape (TVT)
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34
Q

Management of urge incontinence

A
  1. Bladder retraining for 6 weeks
  2. Anticholinergic drugs such as oxybutynin, tolterodine and solifenacin
  3. Mirabegron (a beta-3 agonist) is used in ‘frail elderly women’ as anticholinergic side effects of above may not be tolerated but avoided in uncontrolled HTN
  4. Invasive: botox, nerve stimulation, augmentation etc
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35
Q

Type 1 FGM

A

Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

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36
Q

Type 2 FGM

A

Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

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37
Q

Type 3 FGM

A

Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

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38
Q

Type 4 FGM

A

All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

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39
Q

What are women with PCOS at particular risk of when undergoing IVF?

A

ovarian hyperstimulation syndrome

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40
Q

Rotterdam critera

A

The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features:

Oligoovulation or anovulation, presenting with irregular or absent menstrual periods (generally defined as fewer than six to nine menstrual cycles per year)

Hyperandrogenism, characterised by hirsutism and acne

Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

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41
Q

Invetsigations PCOS

A

pelvic ultrasound: transvaginal

FSH, LH, prolactin, TSH, and testosterone are useful investigations

(raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes)

2-hour 75g oral glucose tolerance test (OGTT)

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42
Q

General management PCOS

A

weight loss, orlistat if bmi>30

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43
Q

Managing Hirsutism PCOS

A

weight loss
Co-cyprindiol (Dianette) for 3 months*
Topical eflornithine

Specialist:
Electrolysis
Laser hair removal
Spironolactone (mineralocorticoid antagonist with anti-androgen effects)
Finasteride (5α-reductase inhibitor that decreases testosterone production)
Flutamide (non-steroidal anti-androgen)
Cyproterone acetate (anti-androgen and progestin)

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44
Q

Management acne PCOS

A

Co-cyprindiol (Dianette) for 3 months*

Topical adapalene (a retinoid)
Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
Topical azelaic acid 20%
Oral tetracycline antibiotics (e.g. lymecycline)

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45
Q

Managing infertility PCOS

A

weight loss

Clomifene (causes ovulation, selective estrogen receptor modulator (SERM).)

metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins

Laparoscopic ovarian drilling

In vitro fertilisation (IVF)

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46
Q

reducing risk of endometrial cancer pcos

A

Mirena coil for continuous endometrial protection

Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill

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47
Q

PCOS blood results

A

high LH
high LH:FSH ratio

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48
Q

turners blood results

A

high LH and FSH

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49
Q

management turner syndrome

A

Growth hormone therapy can be used to prevent short stature

Oestrogen and progesterone replacement can help establish female secondary sex characteristics, regulate the menstrual cycle and prevent osteoporosis
Fertility treatment can increase the chances of becoming pregnant

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50
Q

inheritance androgen insensitivity syndrome?

A

x linked

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51
Q

blood results androgen insensitivity syndrome

A

High LH, High/normal testosterone

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52
Q

diagnostic invetsigation androgen insensitivity

A

buccal smear or chromosomal analysis to reveal 46XY genotype

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53
Q

Presentation of CAH neonate? why?

A

Hyponautramia, shocked, hyperkalaemia
Poor feeding
Vomiting
Dehydration
Arrhythmias

as aldosterone is low so not adequate resorption of sodium and water/excretion of potassium

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54
Q

most common cause CAH?

others?

A

21-hydroxylase deficiency

11-beta hydroxylase deficiency (5%)
17-hydroxylase deficiency (very rare)

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55
Q

inheritance CAH

A

autosomal recessive

56
Q

Management CAH

A

Hydrocortisone- Cortisol replacement

Fludrocortisone - Aldosterone replacement

Female patients with “virilised” genitals may require corrective surgery

57
Q

Pathophysiology CAH

A

21-hydroxylase deficiency (90%) (responsible for biosynthesis of aldosterone + cortisol)

21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol. Progesterone is also used to create testosterone, but this conversion does not rely on the 21-hydroxylase enzyme. In CAH, there is a defect in the 21-hydroxylase enzyme. Therefore, because there is extra progesterone floating about that cannot be converted to aldosterone or cortisol, it gets converted to testosterone instead. The result is a patient with low aldosterone, low cortisol and abnormally high testosterone.

High progesterone also seems to inhibit menstruation and so leads to primary or secondary amenorrhoea.

58
Q

Most common cause of secondary amenorrhoea

A

pregnancy

59
Q

what is hypothalamic amenorrhoea

A

The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea. The hypothalamus responds this way to prevent pregnancy in situations where the body may not be fit for it, for example:

Excessive exercise (e.g. athletes)
Low body weight and eating disorders
Chronic disease
Psychological stress

60
Q

what type of amenorrhoea would prolactin secreting pituitary tumour cause

A

High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH. This causes hypogonadotropic hypogonadism.

eg pituitary adenoma

61
Q

what is sheehans syndrome

A

Sheehan’s syndrome (SS) is postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with SS have varying degrees of anterior pituitary hormone deficiency.

Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.

Features may include:
agalactorrhoea
amenorrhoea
symptoms of hypothyroidism
symptoms of hypoadrenalism

62
Q

definition secondary amenorrhoea

A

Cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhea

63
Q

define premature ovarian insufficiency

A

menopause before the age of 40 years

64
Q

blood results premature ovarian insufficiency

A

Raised LH and FSH levels (gonadotropins)
Low oestradiol levels

hypergonadotrophic hypogonadism

65
Q

diagnosis of premature ovarian insufficiency

A

FSH level persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis.

menopause symptoms

66
Q

Management of premature ovarian insufficiency

A

Traditional hormone replacement therapy
Combined oral contraceptive pill
Adequate vitamin D and calcium intake

67
Q

Diagnosing menopause

A

A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations.

NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in:
Women under 40 years with suspected premature menopause
Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

68
Q

Ashermans presentation

A

presents following recent dilatation and curettage, uterine surgery or endometritis with:
Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)

69
Q

Ashermans diagnosis and management

A

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions

reoccurence is common

70
Q

When should you refer someone to gynae with dysmenorrhoea

A

when it is secondary (not developed in 1-2 years after menarche)

71
Q

Management of priamary dysmenorrhoea

A

NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women
2. COCP

72
Q

Digital vaginal examination reveals nodularity and marked tenderness in the posterior fornix of the cervix. Bimanual examination reveals a fixed, retroverted uterus.

A

endo

73
Q

define priamary amenorrhoea

A

primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics

74
Q

lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation

A

vulval carcinoma

75
Q

sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity

A

ruptured ovarian cyst

76
Q

Rokitansky’s protuberance

A

teratoma

77
Q

On examination the abdomen is non-tender and the uterus feels bulky.

A

fibroids

78
Q

In what patients should oxybutinin be avoided

A

frail older women due to increased risk of falls

79
Q

intense pain. She has a past medical history of endometriosis, and it is one week since her last period. On ultrasound scan there is free fluid in the pelvis

A

ruptured endometrioma

80
Q

inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.

A

Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease

Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

81
Q

continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services? diagnosis? investigation?

A

vesicovaginal fistula

Urinary dye studies

82
Q

types of fibroids

A

Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.

Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.

Submucosal means just below the lining of the uterus (the endometrium).

Pedunculated means on a stalk

83
Q

When do you initiate investigations for infertility

A

After 12 months of trying

After 6 months if >35

84
Q

Advice for couples trying to conceive

A

The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse

85
Q

Initial investigations infertility

A

BMI
chlamydia screening
Semen analysis
Female hormone testing: FSH, LH, Progesterone, AMH, prolactin
Rubella immunity testing

86
Q

When is LH and FSH tested - fertility

A

day 2 to 5 of the cycle

87
Q

When is progesterone measured - fertility

A

7 days before end of cycle

88
Q

What does FSH indicate - fertility

A

High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.

89
Q

What does LH indicate- fertility?

A

high could indicate PCOS

90
Q

what does progesterone indicate - fertility

A

A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.

91
Q

What does AMH indicate- fertility

A

It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.

92
Q

Secondary care investigations fertility

A

Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus

Hysterosalpingogram to look at the patency of the fallopian tubes

Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis

93
Q

Management of anovulation

A

Weight loss for overweight patients with PCOS can restore ovulation

Clomifene may be used to stimulate ovulation

Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)

Gonadotropins may be used to stimulate ovulation in women resistant to clomifene

Ovarian drilling may be used in polycystic ovarian syndrome

Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)

94
Q

How does clomifene work

A

Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.

95
Q

Define oligospermia

A

Mild oligospermia (10 to 15 million / ml)
Moderate oligospermia (5 to 10 million / ml)
Severe oligospermia (less than 5 million / ml)

96
Q

Instructions for providing a sperm sample

A

Abstain from ejaculation for at least 3 days and at most 7 days
Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep the sample warm (e.g. in underwear) before delivery

97
Q

Pre-testicular causes of male factor infertility

A

Testosterone is necessary for sperm creation. The hypothalamo-pituitary-gonadal axis controls testosterone. Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone), can be due to:

Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome

98
Q

Testicular causes of male factor infertility

A

Testicular damage from:

Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer

Genetic or congenital disorders that result in defective or absent sperm production, such as:

Klinefelter syndrome
Y chromosome deletions
Sertoli cell-only syndrome
Anorchia (absent testes)

99
Q

Post testicular causes of male factor infertility

A

Obstruction preventing sperm being ejaculated can be caused by:

Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens (may be associated with cystic fibrosis)
Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

100
Q

Further investigations after abnormal semen sample identified

A

Hormonal analysis with LH, FSH and testosterone levels
Genetic testing
Further imaging, such as transrectal ultrasound or MRI
Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
Testicular biopsy

Repeat in 3 months

101
Q

success rate of IVF

A

Each attempt has a roughly 25 – 30% success rate at producing a live birth

102
Q

complications IVF

A

Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome

103
Q

Basic IVF process

A
  1. supression of menstrua cycle with GnRH agonists or antagonists
  2. ovarian stimulation with FSH
  3. hCG trigger injection
  4. oocyte collection
  5. oocyte insemination
  6. culture
  7. transfer
  8. pregnancy test after 26 days
104
Q

Pathophysiology of ovarian hyperstimulation syndrome

A

bHCG injections –> stimulation of granulosa cells –> increase in vascular endothelial growth factor (VEGF) –> increased vascualr permeability –> oedema/ascites/hypovolemia

also renin high due to RAAS activation

105
Q

what indicates higher risk for OHSS

A

Serum oestrogen levels (higher levels indicate a higher risk)

Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk)

106
Q

Features OHSS

A

Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)

107
Q

Management OHSS

A

Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution)

108
Q

What blood test may be useful in monitoring the amount of fluid in intravascualr space - OHSS

A

Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.

109
Q

What is adenomyosis

A

endometrial tissue inside the myometrium

110
Q

What age/patient does adenomyosis present in?

A

more common in later reproductive years and those that have had several pregnancies (multiparous)

111
Q

Presentation adenomyosis

A

Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
It may also present with infertility or pregnancy-related complications

112
Q

Pathophysiology cervical ectropion

A

Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix).

Think N : canal , endocervix, columnar

113
Q

Associations cervical ectropion

A

associated with higher oestrogen levels, and therefore, is more common in younger women, the combined contraceptive pill and pregnancy.

114
Q

Presentation ectropion

A

post coital bleeding, increased vaginal discharge, vaginal bleeding or dyspareunia

115
Q

Management ectopion

A

Asymptomatic: no treatment

Symptomatic: cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy

116
Q

Presentation nabothian cysts

A

smooth rounded bumps on the cervix, usually near to os (opening). They can range in size from 2mm to 30mm, and have a whitish or yellow appearance.

117
Q

Investigations and management ovarian torsion

A

TVUSS
Treatment and definitive diagnosis by laparoscopic surgery

Un-twist the ovary and fix it in place (detorsion)
Remove the affected ovary (oophorectomy)

118
Q

Grading of pelvic organ prolapse

A

Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.

119
Q

woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms:
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures

A

lichen sclerosus

120
Q

Management lichen sclerosus

A

Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy.

121
Q

Complication lichen sclerosus

A

5% risk of developing squamous cell carcinoma of the vulva.

122
Q

Management bartholin cyst

A

usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. Incision is generally avoided, as the cyst will often reoccur. A biopsy may be required if vulval malignancy needs to be excluded (particularly in women over 40 years).

123
Q

Most common infective cause bartholin abscess

A

e-coli

but may do swabs for chlamydia and gonorrhoea too

124
Q

Management bartholin abscess

A

abx
surgical:
Word catheter (Bartholin’s gland balloon) – requires local anaesthetic
Marsupialisation – requires general anaesthetic

125
Q

GnRH agonists? examples and pharmacology

A

GnRH agonists (zoladex) Leuprolide, goserelin, triptorelin and histrelin if secondary to fibroids as shrinks it!

GnRH agonists initially cause an increase in gonadotropin secretion that is followed 2–3 weeks later by marked inhibition. This action is due to the development of desensitization of the gonadotroph GnRH receptor, resulting in the suppression of LH and FSH secretion.

126
Q

Most common cause PID

A

Chlamydia trachomatis

127
Q

enlarged, boggy uterus

A

adenomyosis

128
Q

Best investigation adenomyosis

A

MRI pelvis,

definitive diagnosis is biopsy from hysterectomy

129
Q

Most likely place endometriosis

A

pouch of douglas

130
Q

Abx for PID

A

ceftriaxone
doxycycline
metronidazole

131
Q

Medication to delay period eg going on holiday

A

norithisterone

132
Q

Most common benign ovarian tumour in women under the age of 25 years

A

teratoma

133
Q

Components of bishop score

A

Cervical position (posterior/intermediate/anterior)
Cervical consistency (firm/intermediate/soft)
Cervical effacement (0-30%/40-50%/60-70%/80%)
Cervical dilation (<1 cm/1-2 cm/3-4 cm/>5 cm)
Foetal station (-3/-2/-1, 0/+1,+2)

134
Q

types of epithelial ovarian tumours

A

Arise from the ovarian surface epithelium

Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%

Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei

135
Q

management of uterine prolapse

A

Management
if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery

Surgical options
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy

136
Q

Management endometriosis

A

Any of
1. paracetamol and/or NSAID for 3 months
2. hormonal contraception eg COCP or progestogen
3. refer to gynae

secondary care:
- GnRH analogues
- Laparascopic surgery

137
Q

why does breast development occur androgen insensitivity?

A

Breast development still occurs because testosterone can be converted to oestrogen in the periphery to drive breast development, but it is not present in the reproductive system.

Phase 3a topics (39 decks)

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