gynae Flashcards
Diagnostic thresholds for gestational diabetes:
Fasting glucose
2-hour glucose
Fasting glucose > 5.6mmol/L
2-hour glucose >7.8mmol/L
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes):
(a) fasting
(b) 1 hour after meals
(c) 2 hours after meals
(a) fasting = 5.3
(b) 1 hour after meals = 7.8
(c) 2 hours after meals = 6.4
Hand foot and mouth disease
What pathogen causes it
Coxsackie A16
Rx = symptomatic only
Do not need to be off school with this
If cyclical mastitis (breast pain before period) pain has not responded to conservative measures, and is affecting the quality of life or sleep, then referral should be considered after what length of time?
And what 2 medications may help?
3 months
Bromocriptine and danazol
if guttate psoriasis covers greater than 10% of the body surface area then the patient should have what management
urgent referral for phototherapy consideration
Pregnancy induced HTN with proteinuria (>0.3g/day) = pre-eclampsia. What are the treatment options for gestational hypertension + pre-eclampsia prior to birth?
- If previously HTN - stop ACEi/ARB
- Start labetalol (first-line)
- Or nifedipine (if asthmatic) and hydralazine
- Pre-eclampsia - have aspirin 75mg OD from 12 weeks until birth of baby
Jaydess IUS coil is licensed for how many years
3 years
Mirena IUS coil is licensed for how many years
5 years
Kyleena IUS coil is licensed for how many years
5 years
Copper IUD coil is licensed for how many years
5-10 years
First line anti-emetic for hyper-emesis gravidarum
Oral cyclizine or promethazine
Hyperemesis gravidum is most common between what weeks
8-12 weeks
But may persist up to 20 weeks
What are 4 risk factors of hyperemesis gravidum
- Increased b-hCG levels - multiple pregnancies or molar pregnancy
- Nulliparity
- Obesity
- Family or personal history
What is associated with a decreased incidence of hyperemesis
Smoking
3 criteria for admission for nausea + vomiting in pregnancy
- Unable to keep down liquids/ oral antiemetics
- Ketonuria or >5% weight loss
- Comorbidity
What triad is present before the diagnosis of hyperemesis gravidarum
- 5% pre pregnancy weight loss
- Dehydration
- Electrolyte imbalance
ondansetron during the first trimester is associated with
small increased risk of baby having a cleft lip/palate
primary amenorrhoea age cut offs
failure to start period by 15 (with normal secondary sexual characteristics) or by 13 (with no secondary sexual characteristics)
secondary amenorrhoea is the cessation of menstruation for what timeframe
3-6 months with previously normal/regular periods
or 6-12 months in women with previous oligomenorrhoea
What is the most common cause of primary amenorrhoea
Gonadal dysgenesis
i.e. Turner’s syndrome
Gonadotrophins (LH/FSH) are raised in which primary amenorrhoea disease
Gonadal dysgenesis
i.e. Turner’s syndrome
gold standard investigation for endometriosis
laparoscopy
Management of endometriosis
- NSAIDs/paracetamol
- COCP or progestogens (Depo Provera)
- Secondary care can start GnRH analogues - which can induce psuedomenopause due to low oestrogen
- Surgery - laparoscopic excision
Management of menorrhagia if does not need contraception
Mefanamic acid 500mg TDS
Or Tranexamic acid 1g TDS
Or Norethisterone 5mg TDS short-term to rapidly stop menstrual bleeding
First-line for painful periods
NSAIDs
- inhibit prostaglandin synthesis
Second line = COCP
1st swab = HPV positive with normal cytology
When should the sample next be repeated?
In 12 months time
If on the repeat smear, there is HPV infection and normal cytology again, then repeat again in 12 months time.
Following a first inadequate cervical screen sample, when should another sample be taken
Within 3 months
If the repeat sample is also inadequate, the patient should be referred for colposcopy
Management of menorrhagia - requires contraception
1st line - Mirena coil
2. COCP
3. Long acting progesterones
Or Norethisterone 5mg TDS short-term to rapidly stop menstrual bleeding
Which patients with dysmenorrhoea should be referred to Gynae for investigation
ALL patients with SECONDARY dysmenorrhoea
Negative HPV smear tests return to normal recall unless what 4 things
- Test of cure pathway - if treated for CIN, they should have repeat smear in 6 months
- Untreated CIN1
- Follow-up for incompletely excised CGIN or SMILE or cervical cancer
- Follow up for borderline changes in endocervical cells
If cervical smear is HPV positive but cytology is normal, when is the test repeated?
12 months
If cervical smear is HPV positive but cytology is normal, and is repeated then in 12 months with HPV negative, when is it repeated
Return to normal recall
If cervical smear is HPV positive and normal cytology, and is repeated then in 12 months with HPV positive and normal cytology, when is it repeated?
12 months
- if HPV is positive here, then to colposcopy
- if HPV is negative here, then return to normal recall
Cervical smear shows positive HPV with abnormal cytology
What is the next step?
Refer to colposcopy
When shouod individuals who’ve been treated for CIN1, CIN2, or CIN3 should be invited back after treatment for a test of cure repeat cervical sample in the community
6 months after treatment
What is the most common treatment for CIN?
Large loop excision of transformation zone
Can be done during initial colposcopy visit
Or at later date
Alternative techniques = cryotherapy
Cervical cancer can be divided into which 2 types
Squamous cell carcinoma - 80%
Adenocarcinoma - 20%
Highest risk human papillomavirus HPV strains
16, 18, 33
6 risk factors for development of cervical cancer |(other than HPV 16, 18, 33)
- smoking
- HIV
- ++ sexual partners, early first intercourse
- high parity
- low socioeconomic status
- COCP
mechanism of HPV 16 and 18 causing cervical cancer
HPV 16 produces oncogene E6 - which inhibits p53 tumour suppressor gene
HPV 18 produces oncogene E7 which inhibits RB suppressor gene
Female Genital Mutation over 18s - what to do
local safeguarding
refer to mental health services
police not needed over 18
Female Genital Mutation under 18s - what to do
call police + safeguarding
Definitive treatment of Bartholin’s abscess
marsupialisation
3 main differentials of bleeding in the first trimester
- Miscarriage
- Ectopic pregnancy
- Implantation bleeding
For immediate referral to early pregnancy unit to rule out ectopic, a woman will have a positive pregnancy test and has any 3 of which criteria
Tenderness/pain in:
Abdomen
Pelvis
Cervical motion
If a pregnant woman, >6 weeks gestation has bleeding, what is the next steps
Refer to early pregnancy assessment service
TV USS to identify foetal pole and heartbeat
If a pregnant woman, <6 weeks gestation has bleeding (and no pain, no ectopic), what is the next steps
Manage expectantly for miscarriage
Advise to return if bleeding continues or pain starts
Repeat urine pregnancy test after 7-10 days - return if positive
Negative pregnancy means miscarriage
When smear shows HPV +ve and abnormal high-grade cytology (moderate or severe dyskaryosis)
- how fast should colposcopy be offered
Within 2 weeks
When smear shows HPV +ve and abnormal borderline or LOW-grade cytology - how fast should colposcopy be offered
6 weeks
When smear results are inadequate twice (within 3 months), how fast should colposcopy be offered
6 weeks
HRT increases the risk of which two cancers
Breast cancer - reduces after 5 years of stoppingP
Endometrial cancer - reduces when given progesterone if there is a womb
Women requesting HRT who are high risk for VTE - what is appropriate management
Refer to haematology before starting any treatment!
Primary ovarian insufficiency (premature ovarian failure) shows what in:
FSH
LH
Oestradiol
FSH - raised
LH - raised
Oestradiol - low
ANY ovarian mass in a post-menopausal woman needs what type of referral?
2ww gynae
Ovarian cysts
<35 year olds
What is the management
If <5cm (small) - likely benign
Repeat ultrasound for 8-12 weeks - and referral considered if it persists
What size is considered as a ‘small’ ovarian cyst
<5cm
Ovarian hyperstimulation syndrome increases your risk of
ovarian torsion
when ovarian torsion involves fallopian tube too, what is it called
adnexal torsion
what does ultrasound show in ovarian torsion
free fluid or whirlpool sign
what investigation is both diagnostic and therapeutic in ovarian torsion
laparoscopy
ovarian torsion 4 risk factiors
- ovarian mass
- reproductive age
- pregnancy
- ovarian hyperstimulation syndrome
Around 90% of ovarian cancers are epithelial in origin. What type of epithelial ovarian cancer are they?
Serous carcinomas - 70-80%
Which 2 gene mutations are seen with ovarian cancer
BRCA1
BRCA2
Risk factors for ovarian cancer include many ovulations. This includes what in terms of menarche, menopause and number of pregnancies
Early menarche
Late menopause
Nulliparity (never pregnant) - so can continue having periods + ovulating
What is the initial test suggested by NICE to investigate ovarian cancer
CA125
If Ca125 is raised in ovarian cancer, urgent ultrasound scan abdo pelvis should be ordered.
Above what level does it need to be raised above?
> 35
Management of ovarian cancer
Surgery and platinum based chemotherapy
which type of incontinence is worse with laughing/coughing
stress incontinence
which incontinence is due to detrusor overactivity - the urge to urinate is followed by leakage
overactive bladder (OAB) /urge incontinence
which urine incontinence is due to bladder outlet obstruction e.g. prostate
overflow incontinence
functional incontinence is secondary to
comorbid physical conditions so a patient cannot get to a bathroom
e.g. dementia, decreased mobility
initial investigation for urine incontinence includes bladder diary to be kept for at least how many days
3 days
management of urge incontinence (overactive bladder)
- bladder retraining - at least 6 weeks
- bladder stabilising drugs:
- antimuscarinics 1st line e.g. IR oxybutynin, IR tolterodine, or darifenacin (once daily)
- 2nd line = mirabegron. this is used in older frail patients to avoid falls/side effects
management of stress incontinence
- pelvic floor muscle training - at least 8 contractions done 3 times a day for at least 3 months
- surgery - retropubic urethral tape
- duloxetine if surgery declined
what is the role and mechanism of duloxetine in stress incontinence
- combined NA and serotonin reuptake inhibitor
- given if surgery declined
- increases NA and serotonin in the pudendal nerve, stimulates urethral muscles in the sphincter to contract more
Women need to use contraception up until what ages with regards to the menopause
Women <50 years - 24 months after last period
Women >50 years - 12 months after last period
Who has the rights to child - surrogate vs genetic parents
surrogate!!
What are the routine recall ages and timeframes for cervical smear
25-49 = every 3 years
50-65 = every 5 years
what are uterine fibroids
benign smooth muscle tumours of the uterus
treatment of fibroids
Medical: GnRH agonists (reduce size)
Surgical: myomectomy, ablation, hysterectomy or uterine artery embolisation
What do NICE recommend for initial primary care investigations for males with infertility
Semen analysis
Chlamydia testing
What is tested for in women to assess for infertility
Serum progesterone - 7 days before next period
e.g. for 28 day cycle, day 21 prog is tested
Interpretation of serum progesterone levels (take 7 days prior to next expected period) in female infertility:
<16
16-30
>30
<16 - refer to specialist
16-30 - repeat
>30 - normal, ovulation
Four key counselling points on infertility
- folic acid
- aim for BMI 20-25
- advise regular intercourse every 2-3 days
- smoking/drinking advice
Endometrial cancer risk is increased by…
- Excess oestrogen (nulliparity, early menarche, late menopause, unopposed oestrogen)
- Metabolic syndrome - obesity, DM, PCOS
- Tamoxifen
- HNPCC
Investigations that occur for suspected endometrial cancer
- First line TV USS - normal endometrial thickness <4mm has a high negative predictive value
- Hysteroscopy with endometrial biopsy
First line investigation for suspected endometrial cancer is TVUSS. What is the threshold for endometrial thickness size
<4mm
this has high negative predictive value
What is the age criteria for women who have postmenopausal bleeding for 2ww gynae
> 55 years with post-menopausal bleeding
what is the commonest type of ovarian cyst
follicular cyst
dermoid cysts are also called
mature cystic teratomas
What are the three main types of categories of ovarian cysts and subtypes
- Physiological (functional) cysts - follicular cysts, corpus luteum cyst
- Benign germ cell tumours - dermoid cyst (teratomas)
- Benign epithelial tumours - serous cystadenoma, mucinous cystadenoma
What ovarian cyst if ruptures may cause pseudomyxoma peritonei
Mucinous cystadenoma - this is a type of benign epithelial tumour
What type of HRT has the highest risk of VTE
COMBINED oestrogen + progesterone tablets
Management of PMS - mild symptoms
Lifestyle advice
Regular and frequent (2-3 hourly) small, balanced meals rich in complex carbohydrates
Management of PMS - moderate and severe symptoms
Moderate - COCP
Severe - SSRI continuous or during LUTEAL phase
for severe PMS symptoms, it is advised to try low dose SSRI at what time frame?
Continuous
Or LUTEAL phase (days 15-28 of cycle)
PCOS diagnosis needs 2 out of 3 features which are:
- Oligomenorrhoea
- Clinical or biochem signs of hyperandrogenism
- Polycystic ovaries on USS (>12 follicles over 9mm or increased ovarian volume >10cm3)
How may the hormone profile be with someone who has PCOS?
- LH:FSH ratio
- Prolactin
- Testosterone
- SHBG
LH:FSH ratio - high
Prolactin - normal/mildly high
Testosterone - normal/mildly high
SHBG - normal to low
Infertility in PCOS - what is used first line
Clomifene
Cervical screening in pregnancy is delayed until when
3 months post-partum unless missed screening or previous abnormal smears
BASHH define recurrent vaginal candidiasis as how many episodes or more per year
4 or more per year
What is the most common benign ovarian tumour in a woman under tha age of 30 years old
Dermoid cyst (teratoma)
What is the most common type of ovarian pathology associated with Meigs’ syndrome
Fibroma
- associated with ascites and pleural effusion
What is the most common cause of ovarian enlargement in women of a reproductive age
Follicular cyst
For ectopic pregnancy, what do NICE advise NOT TO EXAMINE FOR?
Adnexal mass
Due to risk of rupturing pregnancy
They do recommend cervical excitation (i.e. cervical motion tenderness) examination
What % of infertility in couples is due to male infertility
30%
What is the most common cause of RECURRENT first trimester spontaneous miscarriage?
antiphospholipid syndrome
is migraine with aura a contraindication for HRT
no
Most women with VIN present with
burning
itching
or vulval skin lesions
Vulval intraepithelial neoplasia (VIN) is a pre-cancerous skin lesion of the vulva, and may result in what if it is left untreated
Squamous skin cancer
What are 4 risk factors for vulval intraepithelial neoplasia
- HPV 16 and 18
- Smoking
- HSV 2
- Lichen planus
What is the most common ovarian cancer
Serous carcinoma
What are sometimes referred to as chocolate cysts due to their external appearance
Endometriotic cyst
Treatment of pelvic inflammatory disease
Oral oflaxacin + oral metronidazole OR
IM ceftriaxone + oral doxycycline + oral metronidazole
Threatened miscarriage
- bleeding?
- cervical os?
- pain?
- bleeding - yes but small
- cervical os - closed
- pain - painless bleeding
Missed (delayed) miscarriage
- bleeding?
- cervical os?
- pain?
- scan findings?
- bleeding - light
- cervical os - closed
- pain - painless
- scan findings - no fetal pole. when gestational sac is >25mm and no fetal part, it can be called blighted ovum or anembryonic pregnancy
Inevitable miscarriage
- bleeding?
- cervical os?
- pain?
- scan findings?
- bleeding - heavy, clots
- cervical os - open
- pain present
Incomplete miscarriage
- bleeding ++ with pain
- cervical os - open
NOT ALL PRODUCTS OF CONCEPTION HAVE BEEN EXPELLED
In women with PCOS, intervals between menstruation of more than 3 months (or fewer than 4 per year) increase the risk of
Endometrial hyperplasia and carcinoma
therefore inducing a bleed every 3-4 months is recommended - this prevents proliferation of endometrium
How often should a withdrawal bleed be induced in patients with PCOS
every 3-4 months
- this prevents proliferation of endometrium and decreases risk of endometrial hyperplasia or carcinoma
What is the most appropriate advice to give regarding semen collection
abstain for 3-5 days before giving sample and then deliver sample to lab within 1 hour
Which HRT is unsuitable for use within 12 months of last menstrual period as it can cause irregular bleeding
Tibolone
clonidine can be used in the menopause to decrease hot flushes and night sweat vasomotor symptoms. what are two side effects that are common
dry mouth
dizziness
Premature ovarian insufficiency should not be diagnosed on the basis of one raised FSH level - when should a further sample be taken?
In 4-6 weeks
HRT: adding a progestogen increases the risk of what cancer
breast cancer
what is the relationship between the menstrual cycle and body temperature
body temp rises following ovulation
If a semen test is abnormal, when should it be repeated
3 months
Older woman with labial lump and inguinal lymphadenopathy. What should be ruled out?
Vulval carcinoma
The most common cause of puritus vulvae is
contact dermatitis
What hormone surge causes ovulation
LH surge
How can the menstrual cycle be divided into phases
Menstruation - day 1-4
Follicular (proliferative) phase - day 5-13
Ovulation - day 14
Luteal (secretory) phase - 15-28
