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Y4 medicine > Gynae > Flashcards

Gynae Flashcards

1
Q

what is PCOS?

A

polycystic ovarian syndrome
endocrine condition characterised by menstrual dysfunction and features of hyperandrogenism

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2
Q

clinical features os PCOS?

A
  • acne
  • hirsutism
  • depression/anxiety
  • irregular periods (oligomenorrhea) or amenorrhea
  • anovulatory infertility
  • obesity u
  • acanthosis nigricans
  • sleep apnoea
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3
Q

what hormone changes do you see in PCOS?

A
  • elevated LH hormone
  • elevated testosterone
  • insulin resistance
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4
Q

Ix for PCOS?

A

bloods:
- high testoterone
- elevated LH
- low/normal Sex hormone-binding globulin

  • prolactin (elevated in hyperprolactinaemia - DD)
  • TFTs (to exclude thyroid problems)
  • 17-hydroxyprogesterone (elevated in congenital adrenal hyperplasia)

imaging: Transvaginal USS shows cysts

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5
Q

diagnostic criteria for PCos?

A

rotterdam criteria: 2/3 must be present to diagnose

  1. Polycystic ovaries (12 or more follicles on one ovary or increased ovarian volume)
  2. Oligo-anovulation or anovulation
  3. Clinical and/or biochemical signs of hyperandrogenism
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6
Q

management for PCOS?

A

conservative: weight loss (dietary advice and exercise) and hair removal processes, quit smoking

oligo/amenorrhoea and pre-menopausal oestrogen levels lead to endometrial hyperplasia and possibly an increased risk of endometrial carcinoma - therefore need a induced bleed by cyclical progestogen or can go on COCP or IUS

inducing fertility: Letrozole or clomiphene

metformin if needed for insulin resistance

acne treatment

counselling or therapy for anxiety/depression

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7
Q

what is endometriosis?

A

cells similar to the lining of the uterus, or endometrium, grow outside the uterus e.g. ovaries or fallopian tubes leading to inflammation, bleeding and scarring

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8
Q

what is adenomyosis?

A

a condition where endometrial tissue grows in the myometrium (muscle layer) of uterus

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9
Q

what is an endometrioma?

A

Cystic structures developing on the ovaries in endometriosis. They are frequently referred to as chocolate cysts due to the appearance of the contained, old and altered blood

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10
Q

name some risk factors for developing endometriosis?

A

Early menarche
Late menopause
Nulliparity
Delayed childbearing
Short menstrual cycle
FHx
White ethnicity

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11
Q

name some clinical features of endometriosis?

A

Chronic pelvic pain
Dysmenorrhoea
Irregular periods
Dyspareunia - pain during intercourse
Dyschezia - pain on passing faeces (often cyclical)
Bloating, nausea (often cyclical)
LUTS (often cyclical)
Infertility/sub-fertility

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12
Q

what investigations are done in endometriosis diagnosis?

A
  • laparascopy = gold standard
  • USS (transvaginal)
  • MRI (last resorT)
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13
Q

management of endometriosis? (pharm)

A
  • pain relieF: paracetamol or NSAIDs
  • hormonal: COCP, POP, implant, mirena coil
  • GnRH analogues
  • mefenamic acid/ transexamic acid
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14
Q

surgical management of endometriosis?

A
  • excision or ablation via laparoscopy
  • endometriosis affecting the bowel, bladder or ureter, 3 months of GNRH agonists may be given pre-operatively
  • ovarian cystectomy with excision of the cyst wall for endometriomas affecting fertility
  • hysterectomy as last resort (TAH + BSO)
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15
Q

what are uterine fibroids?

A

benign tumours that arise from myometrium (usualy arise at child bearign age)

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16
Q

clinical features of uterine fibroids

A

usually asymptomatic

  • pelvic pain
  • Menorrhagia
  • Abdominal swelling
  • Dyspareunia
  • Dysmenorrhoea
  • Urinary/bowel symptoms
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17
Q

risk factors for fibroids?

A

Early age of puberty
Increasing age
Obesity
Ethnicity (e.g. black females)

(pregnancy can reduce the risk)

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18
Q

how do you diagnosis fibroids (what Ix)?

A

first line: USS transvaginal

(Full blood count: assessment of anaemia
Pelvic MRI +/- hysteroscopy: if concern about intramucosal fibroids or malignancy)

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19
Q

managment of fibroids>/

A

menorrhagia treatment - mirena coil (or COCP, POP, transexamic acid)
NSAIDs

surgical intervention with myomectomy (if >3cm and symptomatic) or hysterectomy can be considered

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20
Q

complications of fibroids?

A

Pregnancy-related complications:
- Infertility (distortion of uterine cavity)
- Placental abruption
- Intrauterine growth restriction
- Preterm labour

Non-pregnancy-related complications
- Prolapsed fibroid
- Anaemia (due to menorrhagia)
- Endocrine effects (polycythaemia, hypercalcaemia, hyperprolactinaemia)

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21
Q

name some risk factors for stress incontinence

A
  • age
  • obesity
  • pregnancy and vaginal delivery
  • constipation
  • FHx
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22
Q

4 types of incontinence?

A

stress incontinence: leakage with increased intraabdo pressure
overflow incontinence: BOO or detrusor inactivity
urge incontinence: OAB
mixed incontinence: stress and urge incontinence

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23
Q

what bedside tests and investigations to diagnosis incontinence?

A
  • Hx
  • abdo examination
  • pelvic exam
  • Urine dipstick +/- MSU - look for infection
  • Bladder scan - look for retention
  • Bladder diaries
  • Quality of life assessments

not routinely done:
(Cytometry is a urodynamic test that involves the insertion of a urinary catheter and the gradual filling of the bladder. A rectal probe is used at the same time to measure pressure as the bladder fills and then during voiding)

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24
Q

management of stress incontinence?

A

non pharm:
- reduce caffeine intak e
- reduce fluid intake (to 1.5-2L)
- stop smoking
- lose weight
- pelvic floor training (8 contractions, 3 times a day)

pharm: duloxetine

surgical: colosupsension or autologous rectal fascial sling
(other options: intramural bulking agent or a retropubic mid-urethral mesh sling)

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25
Q

managament of urge incontinence?

A

non pharm:
- reduce caffeine intak e
- reduce fluid intake (to 1.5-2L)
- stop smoking
- lose weight
- bladder diary and training (at least 6 weeks)

pharm: oxybutynin

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26
Q

management of overflow incontinence?

A
  • referral to find out the obstructive cause
  • may need long term catherisation (intermittent, indwelling or suprapubic) if cannot be corrected and retention is leading to UTIs or renal impairment
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27
Q

what are the two different types of endometrial cancer?

A

endometrioid: 75-80% Earlier presentation and better prognosis. Stimulated by oestrogen. Typically follows period of endometrial hyperplasia

non-endometrioid: 10-20% Multiple subtypes of tumour (e.g. serous, clear cell, mucinous)

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28
Q

risk factors for endometrial cancer?

A
  • obesity (due to increased adipose tissue which leads to increased oestrogen)
  • Unopposed oestrogen therapy (HRT)
  • Increasing age
  • Tamoxifen therapy
  • Early menarche & late menopause: increased time expose to oestrogen
  • Nulliparity: never borne a child
  • PCOS: chronic anovulation
  • Genetic risk (e.g. Lynch syndrome)
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29
Q

what is lynch syndrome

A

inherited cancer syndrome - can lead to early onset EC and colorectal cancer

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30
Q

clinical features of endometrial canceR?

A
  • Postmenopausal bleeding
  • Abnormal uterine bleeding: intermenstrual, frequent, heavy or prolonged
  • weight loss, anorexia, lethargy
  • may see abnormal tissue on cervical speculum examination
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31
Q

what is post menopausal bleeding defined as?

A

abnormal vaginal bleeding ≥12 months after the last menstrual period in patients not on HRT

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32
Q

what clinical features warrant a two wk wait referral for Endometrial cancer ?

A

> 55 yrs and post menopausal bleeding

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33
Q

what examinations and investigations are done in suspected endometrial cancer?

A

abdominal, pelvic and speculum exminations
USS transvaginal (if ≥ 4 mm endometrial thickness then take biopsy!)
Pipelle biopsy or Hysteroscopy and biopsy (done under regional or general - for pts who can’t handle pipelle)

other: CT for advanced disease or MRI for better imagin of local disease

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34
Q

5 year survival rate for endometrial cancer?

A

75%

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35
Q

management for endometrial cancer?

A
  • Surgical: total hysterectomy +/- bilateral salpingoopherectomy (removal or ovaries and fallopian tubes). first-line option in early stage. +/-lymph node dissection.
  • Chemoradiotherapy: may be combined with surgery. mostly given pre-op but can be given post-op
  • Unfit for surgery: options can include vaginal hysterectomy (regional anesthetic), pelvic radiotherapy or hormonal therapy with progestogens or aromatase inhibitors.
  • Fertility-sparing: <5% of EC occur in women under 45 years. Progestogens in selected patients
  • Other: immunotherapies + biological therapies.
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36
Q

which virus is cervical cancer related to?

A

HPV (16 and 18)

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37
Q

what is the transformation zone of the cervix and how can it lead to cervical cancer?

A

ectropian occurs which is the eversion of endocervical columnar epithelium onto the ectocervix
columnar epithelium is replaced with squamous epithelium = sqaumous metaplasia and higher risk of cancers

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38
Q

what does the position of the squamocolumnar epithelium depend on

A

age
menstrual status
pregnancy status
hormonal contraceptives)

formation of the trasnformation zone is a normal physiological process

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39
Q

what are teh strains of virus that cuase genital warts?

A

HPV 6 and 8

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40
Q

risk factors for cervical cancer?

A

Missed screening
young age first intercourse
multiple sexual partners
exposure to HPV (no barrier contraception)
Smoking
High parity (> 5)
FHx
COCP long term use
Immunosuppression (HIV e.g. /AIDS)

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41
Q

what are the different types of cerivcal cancer

A
  • SCC
  • adenocarcinoma
    (rare - small cell cancer and lymphoma)
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42
Q

what is the most common type of cervical cancer

A
  • squamous cell carcinoma (70-80%)
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43
Q

clincial features of cervical cancer?

A

can be asymptomatic and picked up on screening

  • intermenstrual bleeding
  • postcoital bleeding
  • Post-menopausal bleeding
  • Malodorous discharge
  • Blood-stained discharge
  • Pelvic pain
  • Dyspareunia
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44
Q

what investigations are done for cervical cancer?

A

bloods: FBC, U+Es, LFTs

Colposcopy +/- biopsy = gold standard

CT, MRI and PET- to see mets and disease extent

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45
Q

what is the name of the staging done in cervical cancer?

A

FIGO staging

stage 1: confined to cervix 80%
stage 2: beyond cervic but not pelvic side wall or lower 1/3 of vagina 65%
staeg 3: pelvic spread, reaches side wall or lower 1/3 vagina 40%
stage 4: adjacent organ spread or distant mets 20%

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46
Q

managment for cervical cancer?

A

surgery:
1. large loop excision of transformation zone OR simple hysterectomy
2. radical hysterectomy with lymphadenectomy

**for premenopausal ovarian conservation and fertility sparing treatments discussed

with disease > 4cm, chemoradiation is the treatment of choice

with mets: combo chemo, single-agent therapy and palliative radiotherapy

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47
Q

what are the key preventions of cervical cancer?

A
  1. HPV vaccine (first dose age 12/13 and second is 6 months later)
  2. screening
  3. safe sex
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48
Q

what are the two different types of ovarian cancer and which one is most common?

A

epithelial ovarian carcinoma (90%)
non epithelial ovarian carcinoma (10%)

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49
Q

name the different types of epithelial ovarian carcinoma

A

serous (60-70%)
endometrioid
clear cell
mucinous
transitional cell
undifferentiated

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50
Q

name the different types of non epithelial ovarian carcinoma

A

germ cell
sex cord and stromal tumours
carcinosarcoma
small cell cancer

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51
Q

what are the risk factors for ovarian cancer?

A

Age
Smoking
Obesity
Endometriosis (disputed )
Asbestos
nulliparity
early menarche
late menopause
IVF
HRT
FHx (BRCA1/2 or lynch syndrome)

(risk reduced with more pregnancies, breastfeeding and the COCP)

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52
Q

clinical features of ovarian cancer?

A
  • Abdominal distension
  • Early satiety (feeling full earlier than normal)
  • Anorexia
  • Change in bowel habit
  • Abnormal or postmenopausal bleeding
  • Pelvic or abdominal pain
  • Urinary urgency
  • Urinary frequency
  • Weight loss
  • Ascites
  • Pelvic mass

** can prevent in advanced disease or symptoms may be mistaken for IBS, can present as a paraneoplastic syndrome or bowel obstruction due to ovarian adhesions

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53
Q

what tumour marker is used in the diagnosis of ovarian cancer?

A

CA-125 (raised in 80% of pts)

altho non specific therefore can be raised in pancreas, breast, lung, colon and endometrium cancer
or benign disease - PID, endometriosis, liver disease and 1st trimester of pregnancy

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54
Q

what investigations are done if ovarian cancer is suspected?

A

pelvic examination + FBC, U+Es, LFTs
USS + Ca125 marker testing for risk of malignancy index
AFP and hCG can be used for <40yo to test for non-epithelial ovarian cancers
CT scans (+ CXR) for staging
histological sample obtained via surgery after MDT discussion for diagnosis

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55
Q

what is the risk of malignancy index in ovarian cancer?

A

USS x Menopausal status x CA125 = RMI

premenopausal = 1
post menopausal = 3
USS graded: 0 if nothign present, 1 if one feature present, 3 if >=2 features present:
- multilocular cysts
- solid areas
- mets
- ascites
- bilateral lesions

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56
Q

what staging is used for ovarian cancer?

A

FIGO staging

stage 1: limtied to ovary/ovaries 90%
stage 2: spread to pelvic organs 60%
stage 3: spread to rest of peritoneal cavity, omentum, +ve lymph nodes30%
stage 4: distant mets, liver parenchyma, lung 5%

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57
Q

management of ovarian cancer?

A

surgery: can be used to confirm diagnosis, stage disease and remove tumour bulk all in one

Adjuvant chemotherapy: Carboplatin monotherapy or Carboplatin & Paclitaxel

in advanced disease - may need neoadjuvant chemotherapy

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58
Q

causes for menorrhagia? use pneumonia ‘PERIODS’

A

P: Polyps & PID
E: Endometriosis & Endometrial carcinoma
R: Really bad hypothyroidism
I: IUD
O: pcOs
D: Dysfunctional uterine bleeding
S: Submucosal fibroids

+ anticoagulants, coagulations disorders (platelets disorders, von willebrands), liver/renal disease

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59
Q

how to diagnose menorrhagi?

A

clinically it is said to be > 80ml blood loss
altho
diagnosis shld be agreement between patient and clinician that menstrual bleeding experienced is heavy (ask about QoL (accidents, distrupted sleep, unable to do sports) and anaemia features can help)
aroudn 40-60% of cases have no underlying cause (DUB)

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60
Q

what investigations can be done when a patient comes in with menorrhagia?

A
  • FBC (iron deficiency anaemia)
  • pregnancy test

referral to secondary care if suspected underlying malignancy (high risk) - can have USS and hysteroscopy + biopsy

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61
Q

managment of menorrhagia in primary care?

A

1st line: IUS
2nd line: tranexamic acid (only taken on days periods are heavy), NSAIDs, COCP
3rd line: POP, contraceptive injection, implant

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62
Q

what other red flag symptoms alongside menorrhagia wld warrant a referral to secondary care?

A
  • Persistent intermenstrual or post-coital bleeding
  • Unexplained vulval lump or vulval ulceration and bleeding
  • Palpable abdo mass that is not a fibroid
  • Clinical features of cervical cancer
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63
Q

management of menorrhagia in secondary care?

A

pharm: GnRH analogues
surgical: endometrial ablation, hysterectomy. Uterine artery embolization and myomectomy (for fibroids)

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64
Q

what are the most common types of vulval cancer?

A

SCC

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65
Q

what virus is linked to vulval cancer?

A

HPV virus

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66
Q

what is vulval intraepithelial neoplasia?

A

VIN is the precursor to vulval cancer
can present with itching/burning/pain

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67
Q

risk factors for vulval cancer?

A

HPV infection (50% caused by HPV) , lichen sclerosus and immunosuppression, chornic vulval irritation, smoking

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68
Q

name the clinical features for vulval cancer?

A
  • vulval lump, ulceration or bleeding
  • irregular fungating mass, irregular ulcer, or enlarged groin nodes

*mostly seen in elderly women

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69
Q

Ix to diagnose vulval cancer?

A
  • physical examination
  • biopsy
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70
Q

management ofr vulval cancer?

A

Surgical resection (+ radiotherapy/chemotherapy)

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71
Q

what is lichen sclerosus?

A

chronic progressive skin disorder that affects genital and perianal area

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72
Q

clinical features of lichen sclerosus?

A

Pruritus
Soreness or irritation
Dysuria
Dyspareunia
Anal symptoms: bleeding, fissures, painful defecation, pruritus ani.
Painful erections (men)

White atrophic plaques
Haemorrhagic lesions (i.e. blood blister)
Bullae (fluid filled lesion >5mm)
Ulcers
Lichenification
Adhesions and scarring
Phimosis
Meatal stenosis (in men)

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73
Q

what is extragenital lichen sclerosus?

A

can occur in 15% of cases
occurs on thighs, breasts, wrists, shoulders, back, neck.
Appearance (white skin): typically white papules or atrophic papules
Appearance (dark skin): hypo- or hyperpigmentatory papules

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74
Q

causes of lichen sclerosus?

A

exact cause unknown

  • genetic
  • infection
  • hormonal (low oestrogen)
  • immunlogical
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75
Q

diagnosis of lichen scleorsus/?

A

diagnosis made on characteristic appaerance then ocnfimred by punch biopsy done
pt can also be assessed for other autoimmune conditions

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76
Q

what is the malignancy risk associated with lichen sclerosus

A
  • can increase chances of vulval and penile cancer

Women with lichen sclerosus should have the area of skin examined at least annually and non-resolving lesions biopsied, particularly hyperkeratotic areas

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77
Q

management of lichen sclerosus?

A

conservative: good hygeine, non soap cleaners, loose clothing, avoid scratching/rubbing

pharm: emollients, topical corticosteroids, intralesional corticosteroids (injections), topical calcineurin inhibitors, oral/topical retinoids, phototherapy or oestrogen pessaries/creams (in post menopausal)

surgical: can be done if malignancy suspected or extreme scarring, circumcision in men very useful ig phimosis present

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78
Q

what is FGM?

A

female gential mutilation is partial or total removal of external female genitalia for non medical reasons

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79
Q

what are teh different types of FGM?

A

Type 1:
Partial or total removal of the clitoral glans and/or the prepuce/hood

Type 2:
Partial or total removal of the clitoris and labia minora +/- removal of the labia majora

Type 3:
Infibulation: the narrowing of the vaginal opening through the creation of a covering seal.
– This is formed by cutting and repositioning the labia minor or majora, sometimes through stitching.
– May be with or without removal of the clitoral glans and hood/prepuce.

Type 4:
All other harmful procedures to the female genitalia for non-medical purposes (e.g. pricking, piercing, incising)

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80
Q

complications of FGM?

A

– Pain, bleeding, infection and scar tissue formation
– Vaginal problems –> discharge, pruritis, infections
– Menstrual problems –> dysmenorrhoea
– Sexual problems –> dyspareunia, reduced satisfaction
– Urinary problems -> dysuria, UTIs
– Childbirth complications
– psychological problems -> depression, anxiety, PTSD

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81
Q

role of a doctor in reporting FGM?

A

under FGM act 2003 if a age is <18yo and confirmed FGM - report to police within one month

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82
Q

what factors affect menstrual blood loss (menorrhagia specifically)

A
  • higher parity = more likely to have menorrhagia
  • gentetic correlation
  • 4th decade of life, more likely to have menorrhagia
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83
Q

define metrorrhagia

A

heavy irregular bleeding! - no cycle

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84
Q

definition of amenorrhea

A

no bleeding for 6 months or more

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85
Q

what is dysfunctional uterine bleeding an how can you make a diagnosis?

A

it is primary menorrhagia
no underlying causes of menorrhagia and can onyl be diagnosed when you have excluded all causes of menorrhagia
- 60% of menorrhagia is DUB

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86
Q

short term emergency control for heavy menstrual bleeding?

A
  • norethisterone: 5mg po tds for up to 7 days. can be used in a 3 weeks on, 1 week off pattern for 3-4 terms (if patient waiting for surgery) but not long term use!
  • GnRH analgoues: monthly injection (often used in fibroids for correction of anaemia)
87
Q

SE of tranexamic acid?

A
  • Nausea
    0 dizziness
  • tinnitus
  • rash
  • abdo cramping
88
Q

definition of oligomenorrhea?

A
  • infrequent periods

> 5wks apart but less than 6 months apart

89
Q

definition of primary and secondary amenorrhea?

A

primary - no menarche by age of 16
secondary - no periods in 3/12 if previously had regualr cycle, no periods in 6/12 if previously had oligomenorrhea

90
Q

causes for oligomenorrhea?

A
  • constitutional - no pathology
  • anovulation: PCOS, thyroid disease, prolactinoma, CAH
91
Q

cuases of primary amenorrhea?

A
  • delayed puberty
  • imperforate hymen/transverse septum
  • absent vagina
  • mullerian agenesis
  • gonadal dysgenesis (turners)
  • PCOS
  • CAH
92
Q

causes of secondary amenorrhea?

A
  • pregnancy
  • PCOS
  • premature menopause
  • prolactinoma
  • thyroid disease
  • cushings
  • eating disorder
  • exercise induced / stress induced
  • asherman syndrome
  • sheehan syndrome
93
Q

what tests are doen to investigate amenorrhea?

A

bloods:
pregnancy test
TSH
prolactin
LH, FSH

if LH + FSH normal then perform pelvic USS (to check if uterus absent or present, PCOS, adhesions)

94
Q

what would low and high values of FSH in amenorrhea suggest a diagnosis of?

A

FSH low: constitutional delay, eating disorder, exercise or stress induced, chronic illness (+ sheehans in secondary)

FSH high: check karotype: if 46 XX then preamture menopause or primary ovarian failure, if 45 XO then turners)

95
Q

what is the endometrial cancer pre malignant cpndition?

A

endometrial hyperplasia, 20% will develop Ca within 10yrs

96
Q

what is the endometrial FIGO staging?

A

stage 1: limited to myometrium 80%
stage 2: cervical spread 60%
stage 3: uterine serosa, ovaries/tubes, vagina, pelvic/paraaortic lymph nodes 40%
stage 4: bladder/bowel involvement, distant mets 20%

97
Q

what is teh pre cancerous form of cervical cancer?

A

CIN 1/2/3 (cervical intraepithelial neoplasia) that occurs at tranformation zone
can be asymptomatic

98
Q

what is colposcopy?

A

low power binocular microscopy of cervix
to look for features suggestive of CIN or invasion (abnormal vascular pattern or abnormal staining of tissue)

99
Q

Tx for CIN?

A

see and treat concept
excisional: LLETZ (large loop excision of the TZ), cold knife cone
destructive: cryocautery, diathermy, laser vaporisation

following colposcopy, follow up depends on results, but may be 6 monthly, yearly for 10 yrs

100
Q

what is the treatment for VIN?

A

conservative: antihistamine
medical: imiquimod
surgical: excision

101
Q

what is teh definition of chronic pelvic pain?

A

intermittent or constant pain in lower abdo/pelvis that has lasted at least 6 months

102
Q

what can be seen on viewing inside the uterine cavity in endometriosis ?

A
  • powder burn deposits
  • red flame lesions
  • scarring
  • peritoneal defects
103
Q

causes of pelvic pain?

A
  • endometriosis and adenomyosis
  • PID
  • MSK
  • nerve entrapment
  • adhesions
  • social and psychological factors
  • IBS
  • interstitial cystitis
104
Q

how are adhesions treated?

A

division of vascular adhesions laparoscopily - may provide relief temporarily but then can reccur

105
Q

what is residual ovarian syndrome?

A

when remnants of ovarian tissue still remains after hysterectomy and cause chronic pelvic pain

106
Q

how to treat residual ovarian syndrome?

A

GnRH analogues may improve symptoms
if not they surgery to remove left over ovarian tissue but it is risky due to increased adhesions

107
Q

what is the rome III criteria for the diagnosis of IBS?

A
  1. continous or recurrent abdo pain or discomfort on @ least 3 days a month in last 3 months
  2. onset at least 6 months previously
  3. +two of following:
    - improvment with defaecation
    - onset associated with change in frquency of stool
    - onset associated with change in form of stool
108
Q

what is the treatment of IBS?

A

antispasmodic (mebeverine hydrochloride)

109
Q

what are the sources of MSK pain in the pelvis?

A
  • joints in pelvis
  • damage to muscles in abdo wall or pelvic floor
  • pelvic organ prolapse
  • localised area of deep tenderness - chronic muscle contraction
110
Q

what examinations woudl you do if a pt has pelvic pain?

A

abdo exam
speculum and pelvic examination
check focal tenderness
trigger points - abdo wall and/or pelvic floor
enlargement, distortion or tethering or prolapse
check sacroiliac joints or symphysis pubic

111
Q

invesigations

A
  • STI screening (for PID)
  • transvaginal US = identify and assess adenexal masses
  • transvaginal US + MRI - adenomyosis and endometriosis
  • laparoscopy
112
Q

how do you treat cyclical pain?

A

therapeutic trial using hromonal treatment for period of 3-6 months before having diagnostic laparoscopy

113
Q

definition of infertility?

A

defined as the inability to coneive after 12 months of refular unprtected sex

114
Q

difference ebtween primary and secondary infertility?

A

primary -> no pregancy before
secondary -> mother has had child before

115
Q

cuases of ifnertility?

A
  • ovulation defects (25%)
  • male factor (30%)
  • tubal disease (20%)
  • unexplained infertility (25%)
  • endometriosis
  • uterine factors
  • other
116
Q

causes of anovulation in women/

A

PCOS
weight related
ovarian fialure
hyperprolactineamia

117
Q

what type of tubal disease can reduce infertility

A

PID
pelvic surgery
endometriosis

118
Q

how do increase fertility in women who has endometriosis?

A

no evidence that medical management helps

rle of surgegry - ablation, cystectomy

assisted reproducitve techniques needed

119
Q

what examinations are important if a woman is suspected to have ifnertility?

A
  • BMI
  • body hair distribution (hyperandrogenaemia)
  • galactorrhea
  • secondary sexual characetristics (primary of secondary amnorrhea)
  • pelvic - structural abormalities, (fixed or tender uterus)
120
Q

what examinations are needed to check for male infertility?

A
  • scrotum - check varicocele
  • testicular size and position - check undescended testes
  • check prostate - chronic infection
121
Q

what factors coudl affect male fertility?

A
  • general health
  • alcohol/smoking
  • previous surgery
  • previous ifnection
  • sexual dysfunction - erectile/ejaculatory
122
Q

baseline investigations to check for female infertility?

A
  • follicular phase LH, FSH
  • luteral phase progesteron e
  • rubella status
  • tests of tubal patency
  • cervical screening
  • chlamydia

+/-:
- pelvic USS
- hysteroscopy
- prolactin/TFTs
- testosterone/SHBG
- HIV, Hep B, C

123
Q

how do you test for tubal patency

A
  • hysterosalphingography (HSG)
  • diagnostic laparoscopy and dye
124
Q

what baseline investigation is done to test for male infertility?

A

male semen analysis x2

+/-:
- FHS/LH/testosterone
- USS - seminal vesicle and prostate

125
Q

what treatment can be used if a women has anovulatory infertility?

A

clomiphene citrate
gonadotrophins/pulsatiel GnRH

126
Q

what can be used if a patient has infertility due to hyperprolactinameia?

A

dopamine agonists

127
Q

TRETAMENT FRO INFERILITY DUE TO TUBAL DISEASE?

A
  • SURGERY - tubal reconstructive surgery (not commonly offered)
  • IVF
128
Q

when is intra uterine insemination offered?

A

not possible vaginal sex (due to physical or psychosexual problem)
specific condition - if 1 has HIV
same sex relationshup

129
Q

how to treat male infertility?

A

IVF
intracytoplasmic sperm injection (ICSI)
donor sperm

130
Q

what hormone changes occur durig menopuase

A

pituitary keep releasing LH and FSH to stimulate ovaries. but not enough oocytes so reduced production of oestrogen and progesterone
= -ve feedback to hypothalamus = increased stimulation of pituitary = raised LH and FSH

131
Q

what is perimenopause?

A

the time when women are havign symptoms of menopause before their final period

132
Q

symptoms of menopause?

A
  • hot flushes
  • nigth swetas
  • vaginal dryness
  • low mood and or feeling anxious
  • joint and muscle pain
  • loss of interest in having sex
  • space, irregular, erratic bleeding before final period - should be investigated
133
Q

benefits of HRT?

A
  • treated hot flushes and low mood
  • reduced vaginal dryness and increases sexual desire
  • prevents osteoprosis
  • reduced urinary symptoms and risk of urine infections
134
Q

side effecs of hormone therapy

A
  • headaches
  • breast tenderness
  • bloating
  • muscle cramps
  • irregular bleeding
135
Q

what are the risk sof HRT?

A

oral HRt can slightly increase risk of stroke
risk of stroke is very low
HRT (with oestrogn and progesterone) can slightly increased risk of breast cancer

136
Q

what are teh different types of HRT and when are they used?

A

sequential HRT - perimenopausal phase
continuous combined HRT - not had period for 12 months
tibolone - own class of HRT
vaginal oestrgoen - vaginal pesseries or creams that help wth vaginal and urinary symptoms

137
Q

what other treatment cna be given alternatively to HRT?

A
  • clonidine
  • gabapentin
  • SSRI
138
Q

what examinations are important when derterminign urinary incontinence?

A
  • obesity
  • abdo exam - scars, masses
  • vaginal exma - visible incontinence when coughing
  • prolapse
  • pelvic floor tone - digital vaginal examination and ask pt to contract
  • central nervous system
139
Q

investigations doen for urinary incontinence ?

A
  • urinalysis
  • bladder diaries
  • pelvic floor muscles test (PV)
  • cystometry
  • US/IVP (IV pyelogram) for renal tract abnormalities (heamaturia, pain, UTIs) if needed
  • cystoscopy (if needed)
140
Q

what is cystometry?

A

functional test of bladder capacity, flow rate and voiding function and demonstrate leakage with intravesical pressure

141
Q

name some causes of stress incontinence in women?

A
  • incompetent urethral sphincter (childbirth, menopause, prolapse, chronic cough)
  • positional displacement
  • intrinsic weakness
142
Q

what findings would you see on cystometry with stress incontinence?

A
  • normal capacity bladder
  • leakage in absence of detrusor pressure rise
  • provoked by cough test
  • small to moderate loss
143
Q

cuases of detrusor overacitvity ?

A
  • often occurs in pts with history of chidlhood UTIs
  • may occur as a new problem following incontinence surgery
144
Q

what findings in cystometry would you have when a patient has detrusor overactivity?

A
  • reduced capacity baldder
  • leakage with detrusor pressure rise
  • often large loss
  • triggers include runnign water, washing hands etc
145
Q

treatment of stress incontinence?

A

conservative: max 2L fluid intake, decaff drinks, stop smoking, alcohol, physio (pelvic floor training)

medication: duloxetine 40mg

surgery: colposuspension, tension free vaginal tape (mesh)

146
Q

treatment of detrusor overacitivty?

A

conservative : bladder drill, diaries, timers
(+physio for pelvic floor training)

electrical stimulation: electrical stimulation to pudendal nerves via vagina

pharm: anticholinergic drugs (oxybutynin, tolteradine, solifenacin)
+ beta agonist (mirabegnon)

botulinum toxin injection

surgery: clam enterocystoplasty(requires self catherisation) or urinary diversion (ileostomy)

147
Q

what is mixed incontinence?

A

stress incontinence and detrusor overactivity

148
Q

what are teh three stages of uterine prolapse?

A

stage 1: prolpase of uterus into vagin a
stage 2: prolapse of uterus and reaches vaginal opening
stage3: complete prolpase of uterus and vagin aoutsdie teh body

149
Q

what are predisposing factors to prolapse of uterus or vagina?

A
  • age
  • menopause
  • parity
  • connective tissue disease
  • obesity
  • smoking
150
Q

symptoms of uterine or vaginal prolapse?

A
  • backache or abdo pain
  • ‘something coming down’
  • urinary incontinence
  • faecal incontincence
  • difficulty with micturition or defeaection
  • bleeding /discharge
  • apareunia
151
Q

treatment ofo varingal or uterine prolapse?

A
  • nothing!
  • pessaries to reduce prolapse
  • surgery: remove lump, restore organs to correct place, correct incontinence, preserve sexual function
152
Q

complications for surgery to treat uterine/vaginal prolpase?

A
  • recurrent prolapse
  • heamorrhage and vault heamatoma
  • vault infection
  • DVT
  • new incontincen
  • ureteric or bladder injury
153
Q

what is conscientious objection

A

doctor does not wish to provide, or participate in a legal, and clinically appropriate treatment or procedure because it conflicts with their personal beliefs or values e.g. termination of late pregnancy

154
Q

what two areas do healthcares have the righ tto conscientious objection?

A
  • termination of pregnancy
  • fertility treatment
155
Q

definition of abortion and the two types of abortion?

A

removal or expulsion of an embryo of retus from uterus before viability

  • spiantenous: miscarriage
  • induced : termination
156
Q

when can abortion be carried out?

A

in first 24 weeks of pregnancy (based on abortion act 1967)

157
Q

how do you medically terminate a pregnancy?

A

medical: mifepristone 200mg (antiprogesterone) and a prostaglandin (e.g. misoprostol 800mg) which helps uterine contractions

with or without fetocide

158
Q

how do you surgically terminate a pregnancy?

A
  • suction evacuation (1st trimester)
  • dilatation and evacuation (2nd trimester)
159
Q

benefits to medical abortion over surgical?

A
  • avoids surgery (e.g if have contraindications liek fibroids and obesity)
  • medical mimics miscarriage
  • medical is controlled by woman and may take place at home
160
Q

advantages to surgical abortion over medical ?

A
  • can take hours to days for medical abortion to complete - surgical is quick
  • women may experience bleeding or cramping (+N+V) with medical
  • may require several hospital visits with medical
  • when undergoing surgical you can perform coil insertion or sterilisation at the same time
161
Q

how to help dilate the cervix during surigcal termination?

A

prostoglandins e.g. misoprostol given to dilate cervix

162
Q

what are teh complications of termination of pregnancy?

A
  • failure to end pregnancy
  • need for fruther intervention e.g. surigcal intervention following failed medical abortion
  • heamorrhage
  • uterine rupture

with srgeyr:
- cervical trauma
- uterine perforation
- upper genital tract infection

163
Q

what are some important features of safe abortion care?

A
  • referral to counseller
  • vulnerbale? domestic violence? udnerage?
  • future contraception?
  • blood group (see if woman needs anti-d)
  • std screening
  • give pt time to think
  • gain consent and capacity
  • offer most appropriate method

** teo doctors must agree, independently

164
Q

what info is important to provide to pt after termination of pregnancy?

A
  • how much bleeding to expect over nect few dyas/wks
  • how to recognise important complications, including signs of ongoing pregnancy
  • when they can resume normal activties e.g. sex
  • how and where to seek help if required
  • administer anti D if required
165
Q

what exmaination woudl you want to do on a patient you suspect has an ectopic pregnancy?

A
  • general examination (pale, pain, clammy)
  • abdo exam (distention, scars)
  • speculum examination (internal os opened?)
  • bimanual exmiantion (enlarged uterus?)
166
Q

what investigations woudl you want to do on a patient you suspect has an ectopic pregnancy?

A
  • urine preg test
  • USS - TA or TV
  • serum betahCG if other investigations are unknown
  • G+S - blood group + Rh status
167
Q

how can rate of change in serial hCG values be used to distinguish between intra uterine and ectopic pregnancies?

A

a hCG that rises <35% every 2 days = consistent w ectopic

168
Q

what are teh clinical features of a threatened miscarriage?

A

bleeding and or pain up to 24/40 with a viable ongoing pregnancy
cervix not dilated

169
Q

definitioin of an inevitable miscarriage

A

cervix is open (internal os)
products on conception not yet passed but inevitably will

170
Q

definiton of incomplete miscarriage

A

soem products of conception have been passed
soem tissues and blood clot remian within the uterus
cervix stays open

171
Q

definition of septic miscarriage

A

if products of conception is infected
need IV ABx and surigcal removal of ifnected tissues

172
Q

definition of complete miscarriage?

A

all products of conception have been passed
complete sac may be indentifiable
bleeding and pain reducing
cervix now closed

173
Q

most common cuases of miscarriage

A
  • chromosomal abnormalities
  • congenital abnormalities
  • maternal disease - poorly controlled diabetes, acute illness/infection, uterine anomalies, thrombophilia/antiphospholipid syndrome
174
Q

risk factors for miscarriage?

A
  • advanced maternal age
  • previous miscarriage
  • smoking
  • alcohol and drug use
  • folate deficiency
  • consanguinity (FHx)
175
Q

conservative managment for miscarriage?

A
  • wait for over 2 wks for POC to pass naturally
176
Q

advantages and disadvantages of conservative management?

A

advantages:
- avoids risks of surgery / medication
- can be at home

disadvantages:
- pain and bleeding can be unpredictable
- worries re: b eing at hom e
- takes longer
- may be unsuccessful

177
Q

what is the medical managment for miscarriage?

A
  • misoprostol (prostaglandin) - stimulates uterine contractions
178
Q

advantages and disadvnatages of medical managament for miscarriage?

A
  • avoids surgery
  • high pt satisfaction if successful
  • can be done at outpt

disadvantages:
- pain and bleeding may be unpleasant
- s/e of drugs
- need to emergency surgical managment (<5%)

179
Q

what is teh surgical management for miscarriage?

A
  • use fo suction curette to empty uterus
  • 5 min precodure under GA
  • day case
  • return to normal physically 24 hrs
  • bleeding 1-2 wks
180
Q

advnatges and disadvantages of surgical managment of a miscarriage ?

A

advant:
- planned procedure
- closure

disadvan:
- perforation - bowel bladder damage
- damage to cervix
- cervical weakness
- anaesthetic risk
- ashermans syndrome

181
Q

deifniton of recurrent miscarriage?

A

loss of 3 or more consecutive pregnancies with same partner

182
Q

at what serum beta hCG level woudl you start to see the uterien pregnancy on US?

A

> 1500mIU/mL

183
Q

risk factors for ectopic?

A
  • previous ectopic pregnancy
  • tubal surgery (sterilisation or reversal)
  • tubal pathology
  • previous PID/endometriosis
  • pregnancy with Cu IUCD
  • POP
184
Q

clinical features of an ectopic pregnancy?

A
  • unilateral pain RIF/LIF
  • irregualr PV spotting /bleedin g
  • fainting, dizziness, collapse
  • shoudler tip pain
  • GI symptoms (N+V)
185
Q

when can expectant managemnt of an ectopic be offered to a patient?

A
  • asymptomatic
  • no evidence of rupture
  • <3cm
  • hCG <1500 and falling
186
Q

when shoudl you offer medical management to a pt w an ectopic pregnancy?

A
  • <3.5cm
  • hCG<5000
  • no symptoms or free fluid
187
Q

what is the medical management of an ectopic pregnancy?

A
  • methotrexate
188
Q

what is the surgical treatment for ectopic pregnancy ?

A
  • laparoscopic / laparotomy
  • salpingectomy / salpingotomy
189
Q

when woudl you perform surgical treatment fro an ectopic pregnancy

A
  • clinically unwell
  • free fluid in abdomen
  • medical criteria not met
190
Q

what is gestational trophoblastic disease?

A

group of rare disease in which abnormal trophoblast cells grow inside the uterus after conception -> tumour develops inside uterus from tissue

191
Q

clinical features of trophoblastic disease?

A
  • asymptomatic (USS diagnosis - 50%)
  • bleeding/heamorrhage
  • severe N+V
  • severe very early PET (pre-eclampsia)
  • uterus large for dates
192
Q

how is gestational trophoblastic disease diagnosed?

A
  • suspected on USS
  • confirmed on histolgoy
193
Q

managment of gestational trophoblastic disease

A
  • surgical evacuation of retained products of conception (SERPC)
    follow up of serum and urine serial betahCG
194
Q

what is hyperemesis gravidarum?

A

excessive N+V durign early pregnancy

195
Q

clinical features of true hyperemesis gravidarum?

A
  • severe dehydration
  • deranged bloods
  • marked ketosis
  • weight loss
  • nutritional deficiency
    (- complications of all of above)
196
Q

what investigations are importatn when a pt presents with hyperemesiz gravidarum

A
  • urine: betahCG, ketones, infection markers
  • fbc: heamotocrit
  • U+Es (esp K+)
  • LFT adn amylase
  • TFTs
  • USS: exclude GTD/multiple pregnancy
197
Q

managment of hyperemesis gravidarum?

A
  • rehydration
  • replace K+
  • thiamine replacemnt and folic acid
  • antiemetics e.g. metoclopramide: parenteral route initially
  • ranitidine (esp if malary weiss tear)
  • consider throbophylaxis
  • rarely: steroids to stimulate appetite
198
Q

name some non pregnant cuases of acute pelvic pain?

A
  • ovarian cyst torsion
  • degeneration of fibroids
  • flare up of PID
  • heamatocolpos
  • heamatometra/pyometra
  • endometriosis
199
Q

name some gynae causes of pain in pregnancy?

A
  • torsion of ovarian cyst
  • degeneration of fibroids
  • flare up of pre existing PID
200
Q

other non gynae cuases fo acute pelvic pain?

A
  • constipation
  • uti
  • diverticulitis
  • IBS
  • interstitial cystitis
  • sickle cell cystitis
  • porphyria
  • acute appendicitis
  • ureteric calculi
  • cholecystitis
  • peptic ulcer
  • pancreatitis
  • intestinal obstruction
  • ruptured liver/spleen
  • GI cancers
201
Q

clinical features of ovarian torsion?

A
  • pelvic or abdo pain radiation to loin or thigh (fluctuating)
  • nausea
  • vomiting
  • pyrexia
  • tachy
  • abdo tenderness, guarding, re bound
  • cervical excitation, adnexal tenderness, adnexal mass
202
Q

what is teh presenation on USS of a ovarian torsion

A
  • dense stroma
  • reduce blood flow through ovary
203
Q

investigation for suspected ovarian torsion?

A
  • US pelvis
  • tumour markers to rule out cancerous lumps
  • raise CRP and WCC
204
Q

treatment for ovarian torsion

A
  • admit
  • IV fluids
  • pain relief
  • surgery
205
Q

what is the management of degeneration of fibroids?

A
  • pain relief
  • hydration
  • ABx
  • emergency surgery if pendunculated fibroid torsion
  • suspicious of sarcoma - hysterectomy (after necessary imaging/investigations)
206
Q

organisms that cuase PID ?

A

chlamydia and gonorrhoea (most)
E.coli
(30-40% are polymicrobial)

** appendicitis, diverticulitis or pyelonephritis may be cuased by direct or heamatogenous spread of infection

207
Q

risk factors for PID?

A
  • non use of barrier contraception
  • previous episodes of PID
  • earlier age of first intercourse
  • multiple sexual partners
  • diabetes
  • immunocompromised
  • co-existing endometriosis
  • reported in not sexually active women
208
Q

clinical features of PID?

A
  • lower abdo pain
    pyrexia
  • vagiinal discharge - yellow or green
  • dyspareunia
  • IMB and PCB
  • cervical excitation
209
Q

what investigations need to be done if PID suspected?

A
  • preggo test
  • FBC, CRP, WCC
  • MSU
  • triple swabs
  • US - pelvis/abdo
  • xray
  • diagnostic laparoscopy
  • HVS and ECS
210
Q

managemnt of PID?

A
  • admit and commence IV ABx
  • manage sepsis if signs of it
  • daily FBC and CRP
  • 4 hrly obs
211
Q

what ABx do you give in outpatients to pts with PID?

A

IM ceftriaxone 1g followed by doxycyccine 100mg x2 a day + metronidazole 400mg x2 a day for 14 days

212
Q

what ABx do you give to inpatient pts with PID?

A

IV ceftriaxone 1g daily plus IV doxycycline 100mg twice daily
followed by oral doxycycline 100mg twice daily plus oral metrondiazole 400mg twice daily for 14 days

213
Q

what surgical management is done in PID

A

laparoscopy or laparotomy for drainage + washout

214
Q

first line Mx for fibroids <3cm?

A

IUS mirena coil

Y4 medicine (17 decks)

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