gynae Flashcards
what is a krunkenburg tumour
development of mets to the ovary
what to do when having surgery if on the pill
stop 4 wks before
first line for urge incontinence
bladder retraining for a min of 6 wks (gradually increasing the time between voiding)
first line for stress incontinence
pelvic floor muscle training
8 contractions 3x/day for at least 3 mths
first-line in the management of nausea & vomiting in pregnancy/hyperemesis gravidarum
antihistamines - oral cyclizine or promethazine
ondansetron is second line
RFs of Hyperemesis gravidarum
increased levels of beta-hCG
- multiple pregnancies
- trophoblastic disease
nulliparity
obesity
family or personal history of NVP
Referral criteria for nausea and vomiting in pregnancy
Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
dx of Hyperemesis gravidarum
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
cervical smear: what to do if the sample is Positive hrHPV
samples are examined cytologically
cervical smear: what to do if the sample is Positive hrHPV and abnormal cytology
colposcopy
cervical smear: what to do if the sample is Positive hrHPV and normal cytology
repeat test at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
(ie test HPV 3x b4 colposcopy)
what to do if cervical smear sample is inadequate
repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy
medical mx of abortion
mifepristone (an anti-progestogen)
followed by misoprostol (a prostaglandin) 48 hrs later
take a multi-level preg test after 2 wks to check (Quantitative hCG measurement )
causes of primary amenorrhoea
gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
causes of secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
what is gonadal dysgenesis + what might be the examination findings
congenital condition in which the gonads are atypically developed, and may be functionless
e.g. turners syndrome
Due to the abnormal gonads, androgens are not produced in response to FSH and LH from the anterior pituitary gland. -> absent 2ndary sex characteristics
FSH + LH remain high as no -ve feedback
ix for ectopic preg
transvaginal ultrasound
when to do expectant mx for ectopic
size < 35mm
unruptured
asx
no fetal heartbeat
hCG <1,000IU/L
Compatible if another intrauterine pregnancy
what does expectant mx for ectopic involve
closely monitoring the px over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed
when to do medical mx for ectopic
Size <35mm
unruptured
no signif pain
no fetal heartbeat
hCG <1,500IU/L
Not suitable if intrauterine pregnancy
what does medical mx for ectopic involve
methotrexate
needs to attend follow up
when to do surgical mx for ectopic
Size >35mm
can be ruptured
pain
visible fetal heartbeat
hCG >5,000IU/L
Compatible with another intrauterine pregnancy
what does surgical mx for ectopic involve
Salpingectomy is first-line for women with no other risk factors for infertility (full fallopian tube out)
Salpingotomy (tube not acc removed, opening made) should be considered for women with risk factors for infertility such as contralateral tube damage
PCOS test results
raised LH:FSH ratio
testosterone may be normal or mildly elevated
SHBG is normal to low
rotterdam criteria for PCOS
two out of three of the following:
Oligo and/or anovulation
Clinical and/or biochemical signs of hyperandrogenism
Polycystic ovaries
risk factors for endometrial cancer
excess oestrogen
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
metabolic syndrome
- obesity
- diabetes mellitus
- polycystic ovarian syndrome
tamoxifen
hereditary non-polyposis colorectal carcinoma
protective factors for endometrial cancer
multiparity
combined oral contraceptive pill
smoking (the reasons for this are unclear)
how long should women take HRT for premature menopause
until the age of 50
presentation of intraductal papilloma
clear or blood-stained nipple discharge
tenderness or pain
palpable lump (maybe)
what is intraductal papilloma
warty lesion that grows within one of the ducts in the breast - benign tumour
what is a fibroadenoma
common benign tumours of stromal/epithelial breast duct tissue
features of fibroadenoma
Painless
Smooth
Round
Well circumscribed (well-defined borders)
Firm
Mobile (moves freely under the skin and above the chest wall)
Usually up to 3cm diameter
more common ages 20-40
what to do in fibroadenomas >3cm
surgical excision
what is Mammary duct ectasia
dilation of the breast ducts, often resulting in blockage
features of Mammary duct ectasia
Most common in menopausal women
Discharge typically thick and green in colour
Most common in smokers
clinical features of breast cancer
Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
two week wait referral for suspected breast cancer for:
An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
what forms part of a triple assessment
Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Histology (fine needle aspiration or core biopsy)
what pill to use in PCOS + why
COCP - co-cyprindrol
- reduceS hirsutism, acne and regulates periods
what to do in PCOS if wanting preg
weight loss
clomifene - induces ovulation
- Try metformin with it
Laparoscopic ovarian drilling
IVF
most common ovarian cyst
follicular
what is a follicular cyst
type of functional cyst
non-rupture of the dominant follicle
usually regresses after several menstrual cycles
what is a corpus luteum cyst
type of functional cyst
when it does not break down in a cycle w no preg and fills with blood/fluid
may cause pelvic discomfort, pain or delayed menstruation
what is a dermoid cyst
most common benign ovarian tumour
mature cystic teratomas (come from germ cells + contain various tissue types)
assoc w ovarian torsion
what do you see on imaging with a dermoid cyst
rokitansky protuberance
what is a serous cystadenoma
most common benign epithelial tumour
what is the triad in Meig’s syndrome
Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites
Typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.
when do you need post-partum contraception
21 days after birth
when can you insert IUD after childbirth
within 48 hrs
or
after 4 weeks
candida pres
cottage cheese discharge
vulvitis
itch
tx candida
oral fluconazole single dose
CI in preg
- use detrimazole pessary
trichomonas vaginalis pres
offensive yellow/green frothy discharge
vulvovaginitis
strawberry cervix
trichomonas vaginalis tx
oral metronidazole
bacterial vaginosis pres
offensive thin white/grey fishy discharge
bacterial vaginosis tx
oral metronidazole
gonorrhoea tx
IM ceftriaxone
what increases your risk of breast cancer
anything that increases oestrogen exposure
- early onset periods
- late menopause
- combined HRT
- COCP
- smoking
- obesity
- more dense breast tissue
- FHx
risk factors for cervical cancer
COCP
multiparity
HPV 16, 18, 33
smoking
early sex, increased no of sexual partners
FHx
non attendance to screening
risk factors for ovarian cancer
increased amount of ovulations
age
early onset periods
late menopause
no pregnancies
SO COCP, breastfeeding and pregnancy are protective
BRCA 1 + 2 genes
smoking
obesity
clomifene use
presentation of PID
pelvic pain
abnormal bleeding
dyspareunia
dysuria
fever
cervical excitation
purulent discharge
ix PID
a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab
these are often negative
screen for Chlamydia and Gonorrhoea
mx PID
or intramuscular ceftriaxone (for ghonorrhoea) + oral doxycycline 100mg 2x daily 14 days (for chlamydia) + oral metronidazole 400mg 2x daily 14 days
what is a chronic manifestation of PID
Fitz-Hugh Curtis Syndrome
- inflam of liver capsule w adhesion formation
RUQ pain
chlamydia presentation
asymptomatic in around 70% of women and 50% of men
women: cervicitis (discharge - strong odour, bleeding - intermenstrual or post coital), dysuria, pelvic pain
men: urethral discharge, dysuria, reactive arthritis
chlamydia ix
nuclear acid amplification tests (NAATs)
for women: the vulvovaginal swab is first-line
for men: first catch urine test is first-line
gonorrhoea presentation
90% of men and 50% of women are symptomatic
women: odourless purulent discharge (green/yellow), dysuria, pelvic pain
men: odourless purulent discharge (green/yellow), dysuria, testicular pain or swelling (epididymo-orchitis)
rectal infection
pharyngeal infection
gonorrhoea bacteria
gram -ve diplococcus
chlamydia tx
doxycycline 100mg twice a day for 7 days
CI in preg + breastfeeding
azithromycin 1g stat
order of preference of where to take a NAAT sample
women: endocervical, vulvovaginal, and then first catch urine
men: first-catch urine sample/urethral swab
Rectal and pharyngeal NAAT swabs can also be taken to diagnose chlamydia in the rectum and throat
gonorrhoea ix
NAAT
- endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample. Rectal and pharyngeal swab are recommended in all men who have sex with men (MSM), and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas
standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics
which STIs need a test of cure
gonorrhoea due to high abx resistance
72 hours after treatment for culture
7 days after treatment for RNA NAAT
14 days after treatment for DNA NAAT
why do you get overactive bladder/urger incontinence
overactive detrusor muscle
causes urger to urinate followed by uncontrollable leakage
why do you get stress incontinence
weak pelvic floor muscles and sphincter muscles
causes urinary leakage when laughing, coughing or surprised
what is overflow incontinence
can occur when there is chronic urinary retention due to an obstruction to the outflow of urine
incontinence occurs without the urge to pass urine
more common in men
what to do in women w overflow incontinence
refer for urodynamic testing and specialist management
what to do for all types on incontinence
3 day bladder diary
vaginal exam (to exc prolapse + see ability for kegels)
urine dipstick + culture - to rule out UTI + DM (do urinalysis is >65)
meds to use in overactive bladder/urge incontinence
anticholinergic meds - OXYBUTYNIN, tolterodine, solifenacin
Mirabegron as an alt (less anticholinergic burden) - B-3 agonist
when is oxybutynin CI
elderly/frail
glaucoma
when is mirabegron CI
uncontrolled HTN
need to monitor BP during tx
anticholinergic SEs
dry mouth, dry eyes, urinary retention, constipation and postural hypotension
can’t see, can’t pee can’t shit, can’t spit
they can also lead to a cognitive decline, memory problems and worsening of dementia
further mx in stress incontinence
Surgery - Tension-free vaginal tape (TVT) etc
DULOXETINE (SNRI) if surgery no approp/declined
when to suspect a vesicovagal fistulae
in px w continuous dribbling incontinence after prolonged labour + country w poor obstetric services
ix vesicovagal fistulae
urinary dye studies
when to ix infertility
after 1 yr of trying
how to ix infertility
semen analysis
measure serum progesterone 7 days prior to expected next period (ie on day 21 on a typical 28 day cycle)
serum progesterone results when testing infertility
<16 = repeat, if consistent -> specialist
16-30 = repeat
>30 = indicates ovulation
key counselling pts when trying to conceive
folic acid
BMI 20-25
sex every 2-3 days
smoking + drinking advice
PMS mx
General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
Combined contraceptive pill (COCP) - new gen containing drospirenone eg yasmin
SSRI antidepressants
Cognitive behavioural therapy (CBT)
HRT
uterus + post-menopause (12 mths w/o periods)
continuous combined
oral / patch
HRT
uterus + perimenopause
sequential (cyclical progesterone + reg breakthrough bleeds)
oral / patch
HRT
hysterectomy (no uterus) / mirena in situ
estradiol / conjugated equine oestrogens
oral / patch
the mirena is liscenced for use as the progesterone component of HRT for 4 yrs
comps of oestrogen + progesterone HRT
increased risk of breast cancer (increases w duration of use, decreases when stopped)
increased risk of VTE (transdermal does not)
- if px has increased risk of this anyway refer to haematology 1st
comps of oestrogen only HRT
increased risk of endometrial cancer
DO NOT GIVE TO WOMEN W UTERUS
comps of all HRT
increased risk of stroke
increased risk of IHD if 10 + yrs after menopause
Non-Hormonal Treatments for Menopausal Symptoms
Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress
CBT
Clonidine, which is an agonist of alpha-adrenergic and imidazoline receptors - lowers BP + reduces HR - helpful for vasomotor symptoms and hot flushes
SSRIs (e.g. fluoxetine)
Venlafaxine (SNRI)
Gabapentin
Indications for HRT
Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60 years
CI ulipristal acetate (ellaone)
severe asthma
how soon after unprotected sex for
levonorgestrel
ulipristal acetate (ellaone)
72 hrs (double dose if BMI > 26, weight > 70)
120 hrs
when can you start hormonal contraceptive after emergency one w
levonorgestrel
ulipristal acetate (ellaone)
immediately
5 days
2 types of endometrial hyperplasia
precancerous condition involving thickening of the endometrium (5% go to cancer most return to normal):
Hyperplasia without atypia
Atypical hyperplasia (higher risk of malignancy)
how to tx endometrial hyperplasia
using progestogens, with either:
Intrauterine system (e.g. Mirena coil)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
repeat sampling in 3-4 mths
endometrial cancer presentation
POSTMENOPAUSAL BLEEDING
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
referral criteria for endometrial cancer
The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is:
Postmenopausal bleeding (more than 12 months after the last menstrual period)
Referral for a transvaginal ultrasound in women over 55 years with:
Unexplained vaginal discharge
Visible haematuria plus raised platelets, anaemia or elevated glucose levels
ix endometrial cancer
Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy
stages of endometrial cancer
International Federation of Gynaecology and Obstetrics (FIGO) staging system
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
mx endometrial cancer
total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH and BSO (removal of uterus, cervix and adnexa))
for stage 1 + 2
Other treatment options depending on the individual presentation include:
A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
UKMEC4 conditions for COCP (unacceptable risk)
> 35 yrs + 15 cigs/day
migraines w aura
hx of thromboembolic dis/mutation
hx of stroke/IHD
breastfeeding < 6 wks post partum
uncontrolled HTN
breast cancer
major surgery w prolonged immobilisation
+ve antiphospholipid antibodies (eg SLE)
UKMEC3 conditions for COCP (risks>advs)
> 35 <15 cigs / day
BMI > 35
FHx thromboembolism dis
controlled HTN
immobility (wheelchair)
BRCA1/BRCA2 mutation
POP + abx
no change
**unless the antibiotic alters the P450 enzyme system, for example, rifampicin
starting POP
if commenced up to + inc day 5 = immediate protection
day 6+ = additional contraceptive for the first 2 days
if switching from COCP = immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
taking POP
should be taken at the same time every day, without a pill-free break
missed pills POP
if < 3 hours* late: continue as normal
*for Cerazette (desogestrel) a 12 hour period is allowed
if > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
vaginal atrophy
the thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding
what is used to rehydrate if admitted w hyperemesis gravidarum
normal saline with added potassium is used to rehydrate
limit for abortion
24 wks
surgical abortion options
vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)
cervical priming with misoprostol +/- mifepristone b4
an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
choice of abortion procedure
women are offered a choice between medical or surgical abortion up to and including 23+6 weeks’ gestation
likelihood of women seeing products of conception pass and decreased success rate
before 10 weeks medical abortions are usually done at home
abortion act
2 registered medical practitioners are of the opinion:
- the pregnancy has not exceeded its 24th week + the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
- the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
- the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated
- substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
electrolyte imbalance w vomiting
hypokalaemia
RFs for ectopic preg
(anything slowing the ovum’s passage to the uterus)
damage to tubes (pelvic inflammatory disease, surgery)
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF (3% of pregnancies are ectopic)
1 missed COCP
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
2+ missed COCP
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
2+ missed COCP in week 1
emergency contra?
emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
2+ missed COCP in week 2
emergency contra?
after seven consecutive days of taking the COC there is no need for emergency contraception
2+ missed COCP in week 3
interval?
she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
most common type of ovarian cancer
Epithelial Cell Tumours
- eg. serous tumour
protective factors ovarian cancer
Factors that stop ovulation or reduce the number of lifetime ovulations
Combined contraceptive pill
Breastfeeding
Pregnancy
ovarian cancer presentation
non-spec sx, often dx late
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
An ovarian mass may press on the obturator nerve and cause referred hip or groin pain.
referral criteria for ovarian cancer
Refer directly on a 2-week-wait referral if a physical examination reveals:
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
Carry out further investigations before referral in women presenting with symptoms of possible ovarian cancer:
which ix
who to refer
CA125
uss?
women over 50 years presenting with:
New symptoms of IBS / change in bowel habit
Abdominal bloating
Early satiety
Pelvic pain
Urinary frequency or urgency
Weight loss
ix ovarian cancer
CA125 blood test (>35 IU/mL is significant)
Pelvic ultrasound
CT scan to establish the diagnosis and stage the cancer
Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
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
Women under 40 years with a complex ovarian mass
require tumour markers for a possible germ cell tumour:
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
postmenopausal women w cysts
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
premenopausal women w cysts
If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
how many women who undergo a salpingotomy for an ectopic pregnancy require further treatment
20%
what is adenomyosis
endometrial tissue within the myometrium
more common in later repro yrs + women who are multiparous
features of adenomyosis
dysmenorrhoea
pain during sex
menorrhagia
enlarged, boggy uterus
ix adenomyosis
- transvaginal ultrasound
MRI
mx adenomyosis
symptomatic treatment
- tranexamic acid to manage menorrhagia
- mefenamic acid to manage menorrhagia + dysmenorrhoea
hormone contraception
GnRH agonists
endo ablation
uterine artery embolisation
hysterectomy
- considered the ‘definitive’ treatment
causes of recurrent miscarriage
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
most effective emergency contraception
copper intra-uterine device
features of fibroids
may be asx
menorrhagia
may result in iron-deficiency anaemia
bulk-related symptoms
- lower abdominal pain: cramping pains, often during menstruation
- bloating
- urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
rare features:
- polycythaemia secondary to autonomous production of erythropoietin
what are fibroids
benign smooth muscle tumours of the uterus. T
hey are thought to occur in around 20% of white and around 50% of black women in the later reproductive years
dx fibroids
transvaginal ultrasound
mx fibroids
asx = none
menorrhagia =
levonorgestrel intrauterine system (LNG-IUS)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity
NSAIDs e.g. mefenamic acid
tranexamic acid
combined oral contraceptive pill
oral progestogen
injectable progestogen
to shrink / remove =
Indications for early referral to fertility specialist
> 35
Has a menstrual disorder
Previous surgery
Previous STI/PID
mastitis mx
normal
+ if worse
ctu breastfeeding
analgesia
warm compresses
if systemically unwell/nipple fissure present/sx do not improve after 12-24 hours of effective milk removal/culture indicates infection
- oral flucloxacillin for 10-14 days
most common cause of infective mastitis
s aureus
mastitis presentation
typically assoc w breast feeding
painful, tender, red hot breast
fever, and general malaise may be present
tx periductal mastitis
co-amoxiclav
characteristics of periductal mastitis
smokers
freq infections
