Gynae Flashcards

Question

What are the normal blood test results for PCOS?

Answer 1

- Raised LH:FSH ratio - Normal/Raised testosterone - SHBG is normal/low

Answer 2

Epithelial cell tumour

Answer 3

Intramural fibroid

Answer 4

Lichen sclerosis

Answer 5

Fungal infection

Answer 6

All hormonal contraceptives

Answer 7

Hysterectomy with bilateral salpingo-oophorectomy

Answer 8

Irritant contact dermatitis

Answer 9

Imperforate hymen

Answer 10

Corpus luteal cyst

Answer 11

Assess for ketones as these would suggest ketosis/starvation

Answer 12

Thiamine to prevent Wernickes

Answer 13

- Antiphospholipid - Infection - Uterine/Cervical abnormalities

Answer 14

CIN - premalignant condition where abnormally diving cells have now invaded below the basement membrane 1 - 1/3 of epithelium 2 - 2/3 of epithelium, 3 - 3/3 of epithelium

Answer 15

Squamous cell and adenocarcinoma

Answer 16

growth of endocervical columnar epithelium outside of the external os

Answer 17

Menopausal symptoms Loss of bone mineral density

Answer 18

Small cyst ruptures on a free pedicle, restricting its blood supply causing potential ovarian necrosis

Answer 19

Derived from primitive germ cells which can differentiate into any body tissue

Answer 20

- Fixed, retroverted uterus - Tender uterus - Enlarged ovaries - Uterosacral ligament nodules - Visible lesions

Answer 21

Primary - couple have never been able to conceive Secondary - couple have achieved conception in the past

Answer 22

- Metformin - Clomiphene - Gonadotrophins

Answer 23

- Hyperandrogenism - Ovulatory dysfunction - Polycystic ovaries

Answer 24

- Day 21 progesterone - FSH/LH - Oestradiol

Answer 25

- STI/PID - Ovarian/Endometrial/Cervical cancer

Answer 26

Cervical shock leads to vasovagal which causes reflex bradycardia

Answer 27

- Inguinal lymph nodes - Lung - Bone - Liver - Peritoneum

Answer 28

- Tranexamic acid - Aspirin - Indomethacin - Mefenamic acid

Answer 29

- Ovaries - Pouch of Douglas - Uterosacral ligaments

Answer 30

- CA125 - AFP - BHCG

Answer 31

- Multiparity - Raised intrabdominal pressure - Menopause - Hysterectomy

Answer 32

- Pelvic floor excercises - Support the vaginal vault during hysterectomy

Answer 33

- Pessaries - Physio - Surgical repair

Answer 34

- PROM, renal agenesis, foetal abnormalities, IUGR

Answer 35

- Resp difficulties - Skull deformities - IUGR - Pulmonary hypoplasia - Cord compression - Shoulder dystocia - Foetal hypoxia

Answer 36

- Encourage maternal hydration - Oligoinfusion

Answer 37

7 days before next expected period

Answer 38

- If 1 missed (any time in cycle): take it and continue as normal - If 2 or more missed: take it and use condoms for 7 days - If 2 or more missed in week 1 and she has had sex this week or previous pill-free interval: + emergency contraception - If 2 or more missed in week 3: start next pack as soon as she finishes current pack

Answer 39

Cone biopsy

Answer 40

FSH - will be raised

Answer 41

- If asymptomatic: nothing - Conservative: weight loss and pelvic floor excercises - Pessary - Surgery: colporrhaphy

Answer 42

Benign smooth muscle tumour originating from the myometrium

Answer 43

Germ cell tumour

Answer 44

Potent topical steroid

Answer 45

Galactocele

Answer 46

Endometrial and ovarian cancer

Answer 47

Oral cyclical progestogen

Answer 48

post-menopausal women

Answer 49

vaginal dryness, dyspareunia and occasional spotting exam= pale and dry

Answer 50

vaginal lubricants and moisturisers if don't help then topical oestrogen creams

Answer 51

HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.

Answer 52

25-49yrs= every 3yrs 50-64yrs= every 5yrs Scotland= 25-64yrs every 5yrs

Answer 53

delayed until 3m post-partum unless missed screening or previous abnormal smears

Answer 54

women who have never been sexually active so have very low risk

Answer 55

around mid-cycle

Answer 56

when umbilical cord descends ahead of the presenting part of the fetus 1/500 deliveries

Answer 57

can lead to compression of cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death

Answer 58

- prematurity - multiparity - polyhydramnios - twin pregnancy - cephalopelvic disproportion - abnormal presentations eg. breech, transverse lie

Answer 59

at artificial rupture of the membranes

Answer 60

when fetal heart rate becomes abnormal and the cord is palpable vaginally or if the cord is visible beyond the level of the introitus

Answer 61

obstetric emergency - presenting part of fetus may be pushed back into uterus to avoid compression - if cord is past level of introitus then minimal handling and it should be kept warm and moist to avoid vasopasm - ask pt to go 'on all fours' until immediate c-section (left lateral position is alternative) - tocolytics can be used to reduce uterine contractions - retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part - c-section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.

Answer 62

opening that leads to the vaginal canal

Answer 63

minimal handling and it should be kept warm and moist to avoid vasospasm

Answer 64

go on all fours

Answer 65

tocolytics

Answer 66

retrofilling the bladder with 500-700ml saline

Answer 67

fetal mortality is low incidence has been reduced due to increase in c-sections used in breech presentations

Answer 68

implantation of a fertilised ovum outside the uterus

Answer 69

female with history of 6-8w amenorrhoea who presents with lower abdo pain and later develops vaginal bleeding

Answer 70

due to tubal spasm typically 1st symptom pain is usually constant and may be unilateral

Answer 71

less than normal period may be dark brown

Answer 72

typically 6-8w from start of last period if longer eg. 10w this suggests another cause eg. inevitable abortion

Answer 73

peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination

Answer 74

- lower abdo pain - vaginal bleeding - amenorrhoea 6-8w - shoulder tip pain +/- pain on defecation/urination - dizziness, fainting or syncope - symptoms of pregnancy eg. breast tenderness

Answer 75

- abdo tenderness - cervical excitation (aka cervical motion tenderness) - adnexal mass= DO NOT EXAMINE for adnexal mass due to increase risk of rupture of pregnancy BUT pelvic exam to check for cervical excitation is recommended

Answer 76

- stable= Ix and Mx in early preg assessment unit - unstable= refer to A&E Ix= pregnancy test positive; GOLD= transvaginal USS

Answer 77

1) expectant Mx 2) medical Mx 3) surgical Mx

Answer 78

- <35mm - unruptured - asymptomatic - no fetal heartbeat - hCG <1000 - compatible if another intrauterine pregnancy

Answer 79

- <35mm - unruptured - no signif pain - no fetal heartbeat - HCG <1500 - not suitable if intrauterine pregnancy

Answer 80

- >35mm - can be ruptured - pain - visible heartbeat - HCG >5000 - compatible with another intrauterine pregnancy

Answer 81

monitor closely over 48hrs and if B-hCG levels rise again or pt develops symptoms the intervention needed

Answer 82

methotrexate but only if pt is willing to attend follow up

Answer 83

Salpingectomy or salpingotomy

Answer 84

- Salpingectomy 1st line if not other RFs for infertility - Salpingotomy if RFs for infertile eg. contralateral tube damage - 1 in 5 who have salpingotomy also need further Tx eg. methotrexate and/or salpingectomy

Answer 85

97% are tubal, with most in ampulla more dangerous if in isthmus 3% in ovary, cervix or peritoneum trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo

Answer 86

Natural history - most common are absorption and tubal abortion: - tubal abortion - tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed - tubal rupture

Answer 87

ectopic pregnancy

Answer 88

fallopian tube others= ovary, abdomen, cervix, caesarean section scar, interstitial part of the fallopian tube, or the cornua of a unicornuate or bicornuate uterus.

Answer 89

tubal damage, maternal age over 35 years, and smoking. However, there are no identifiable risk factors in about a third of cases.

Answer 90

Tubal rupture (which may lead to maternal death, if treatment is delayed). Recurrent ectopic pregnancy. Adverse effects of treatment. Grief, anxiety, or depression.

Answer 91

Common symptoms include abdominal or pelvic pain, amenorrhoea or missed period, and vaginal bleeding. Less common symptoms include gastrointestinal symptoms, dizziness, shoulder tip pain, and urinary symptoms. Common signs include pelvic, adnexal, and abdominal tenderness. Less common signs include cervical motion tenderness, pallor, abdominal distension, shock, and hypotension.

Answer 92

Pregnancy should be confirmed (if not already done). The woman should be examined for signs of an ectopic pregnancy.

Answer 93

if there are signs of haemodynamic instability or significant concerns about the degree of pain or bleeding.

Answer 94

with a positive pregnancy test, and the following on examination: - Abdominal pain and tenderness. - Pelvic tenderness. - Cervical motion tenderness.

Answer 95

bleeding or have other symptoms and signs of early pregnancy complications if they also have any of the following: - Pain. - A pregnancy of 6 weeks' gestation or more. - A pregnancy of uncertain gestation.

Answer 96

less than 6 weeks' gestation who are bleeding but not in pain, and who have no risk factors, such as a previous ectopic pregnancy. Advise these women: - To return if bleeding continues or pain develops. - To repeat a urine pregnancy test after 7 to 10 days and to return if it is positive. - That a negative pregnancy test means that the pregnancy has miscarried.

Answer 97

transvaginal ultrasound

Answer 98

expectant management (watchful waiting), medical management (commonly with methotrexate), or surgery.

Answer 99

woman should be followed up in primary care and offered appropriate support, information, and advice.

Answer 100

condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of reproductive age have a degree of endometriosis.

Answer 101

- chronic pelvic pain - secondary dysmenorrhoea= pain typically starts days before bleeding - deep dyspareunia - subfertility - non-gynae= urinary symptoms eg. dysuria, urgency, haematuria; dyschezia (painful bowel movements) - pelvic exam= reduced organ mobility, tender nodularity in posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Answer 102

reduced organ mobility, tender nodularity in posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Answer 103

painful bowel movements

Answer 104

- no role for Ix in primary care eg. USS= if symptoms signif then refer pt for definitive diagnosis - GOLD= laparoscopy

Answer 105

laparoscopy

Answer 106

clinical features

Answer 107

no there is poor correlation

Answer 108

NSAIDs +/or paracetamol 1st line for symptomatic relief if analgesia doesn't help= COCP or progestogens eg. e.g. medroxyprogesterone acetate should be tried doesn't help/fertility priority= refer to secondary care eg. GnRH analogues or surgery

Answer 109

- GnRH analogues drug therapy doesn't seem to have impact on fertility - Surgery= laparoscopic excision or ablation of endometriosis + adhesiolysis to try and improve chance of conception; ovarian cystectomy (for endometriomas) also recommended

Answer 110

induces a 'pseudomenopause' due to low oestrogen levels

Answer 111

endometriosis

Answer 112

pelvis; on the ovaries, peritoneum, uterosacral ligaments, and pouch of Douglas. Extra-pelvic deposits, such as in the bowel and pleural cavity, are rare

Answer 113

menstruation. The hormonal changes in the menstrual cycle induce bleeding, chronic inflammation, and scar tissue formation

Answer 114

The exact cause of endometriosis is unknown. It is thought that endometriosis develops as a result of a combination of several factors, including retrograde menstruation, personal genetics, metaplasia, and environmental factors.

Answer 115

can be a chronic disease affecting women throughout their reproductive lives (and sometimes beyond). For most women, symptoms can be controlled with hormonal treatment, however, some women may have complex needs and require long-term support.

Answer 116

in women (including young women aged 17 years and younger) presenting with one or more of the following symptoms or signs: - Chronic pelvic pain (defined as a minimum of 6 months of cyclical or continuous pain). - Period-related pain (dysmenorrhoea) affecting daily activities and quality of life. - Deep pain during or after sexual intercourse. - Period-related or cyclical gastrointestinal symptoms, in particular painful bowel movements. - Period-related or cyclical urinary symptoms, particularly blood in the urine or pain passing urine. - Infertility in association with one or more of the above.

Answer 117

thorough history and examination should be undertaken to: - Identify RFs (such as early menarche, nulliparity, or family history of endometriosis). - Exclude differential diagnoses (such as other gynaecological conditions, irritable bowel syndrome, or pelvic inflammatory disease). - Identify complications (such as fertility problems or depression).

Answer 118

if suspected then transvaginal ultrasound scan should be arranged to exclude other pathology, identify endometriomas and deep endometriosis, and to guide referral and management. The possibility of endometriosis should not be excluded if the abdominal or pelvic examination or ultrasound is normal. If clinical suspicion remains or symptoms persist, referral for further assessment and investigation should be considered. Diagnosis of endometriosis can only be made definitively by laparoscopic visualization of the pelvis.

Answer 119

laparoscopic visualisation of the pelvis

Answer 120

Review to manage endometriosis-related pain with simple analgesics and/or hormonal treatment, as appropriate. Assessing the woman's individual information and support needs, taking into account her circumstances, symptoms, priorities, desire for fertility, aspects of daily living, and her physical, psychosexual, and emotional needs. Assessing for, and managing, complications of endometriosis, such as fertility problems or depression.

Answer 121

Where the diagnosis is unclear. For women with severe, persistent, or recurrent symptoms. For women with pelvic signs of endometriosis. If the initial management is not effective, not tolerated, or contraindicated (for consideration of other management options, including diagnostic laparoscopy).

Answer 122

after 3–6 months, or earlier if symptoms are troublesome. If initial hormonal treatment for endometriosis is ineffective, not tolerated, or contraindicated, refer the woman to a gynaecology service, specialist endometriosis service, or paediatric and adolescent gynaecology service

Answer 123

Deep endometriosis involving the bowel, bladder or ureter or One or more endometrioma that is larger than 3 cm.

Answer 124

BP normally falls in 1st trimester (esp diastolic), and continues to fall until 20-24w after this time the BP usually increases to pre-pregnancy levels by term

Answer 125

aspirin 75mg od from 12 weeks until the birth of the baby

Answer 126

- systolic > 140 mmHg or diastolic > 90 mmHg or - an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Answer 127

categorise into either pre-existing HTN; pregnancy induced HTN (PIH aka gestational HTN) or pre-eclampsia

Answer 128

1) pre-existing HTN 2) pregnancy induced HTN (PIH) aka gestational HTN 3) pre-eclampsia

Answer 129

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria, no oedema Occurs in 3-5% of pregnancies and is more common in older women

Answer 130

If a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review

Answer 131

ACE inhibitor or ARB for pre-existing should be stopped and start alternative eg. labetalol or nifedipine

Answer 132

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks) No proteinuria, no oedema Occurs in around 5-7% of pregnancies

Answer 133

Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life

Answer 134

Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours) Oedema may occur but is now less commonly used as a criteria Occurs in around 5% of pregnancies

Answer 135

pre-eclampsia

Answer 136

Pregnancy-induced hypertension (PIH, also known as gestational hypertension)

Answer 137

Pre-existing hypertension

Answer 138

1st line= oral labetalol 2nd= nifedipine eg. is asthmatic or methyldopa

Answer 139

diastolic blood pressure of 90–109 mmHg and/or systolic blood pressure of 140–159 mmHg.

Answer 140

diastolic blood pressure of 110 mmHg or greater and/or systolic blood pressure of 160 mmHg or greater.

Answer 141

Hypertension that is present at, or prior to the booking visit, or before 20 weeks' gestation — blood pressure tends to fall during the first and second trimesters and a woman with high blood pressure before week 20 of pregnancy can therefore be assumed to have pre-existing hypertension.

Answer 142

New hypertension presenting after 20 weeks' gestation without significant proteinuria.

Answer 143

New hypertension presenting after 20 weeks' gestation with significant proteinuria. Pre-eclampsia is a multi-system disorder which can affect the placenta, kidney, liver, brain, and other organs of the mother.

Answer 144

(Haemolysis, Elevated Liver enzymes, and Low Platelets syndrome) is a severe form of pre-eclampsia.

Answer 145

HELLP syndrome

Answer 146

Haemolysis, Elevated Liver enzymes, and Low Platelets syndrome

Answer 147

occurrence of one or more seizures in a woman with pre-eclampsia.

Answer 148

a urinary protein:creatinine ratio of at least 30 mg/mmol, or albumin:creatinine ratio of at least 8 mg/mmol. Proteinuria of at least [1+] on dipstick testing should prompt one of these additional tests.

Answer 149

aspirin 75—150 mg daily from 12 weeks' gestation until the birth of the baby.

Answer 150

Blood pressure should be taken and a dipstick urine test done for proteinuria

Answer 151

Severe headaches (increasing frequency unrelieved by regular analgesics). Visual problems, such as blurred vision, flashing lights, double vision, or floating spots. Persistent new epigastric pain or pain in the right upper quadrant. Vomiting. Breathlessness. Sudden swelling of the face, hands, or feet.

Answer 152

urgent secondary care assessment

Answer 153

postpartum monitoring and follow up

Answer 154

new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions: 1) Proteinuria, or 2) Other maternal organ dysfunction: - Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more). - Liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain). - Neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata. - Haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis. - Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth.

Answer 155

One of the following high risk factors: - A history of hypertensive disease during a previous pregnancy. - CKD - Autoimmune disease, such as SLE or antiphospholipid syndrome. - DMT1/2 - Chronic HTN Two or more of the following moderate risk factors: - First pregnancy. - Aged 40 years or older. - Pregnancy interval of more than 10 years. - BMI of 35 kg/m2 or greater at the first visit. - Family history of pre-eclampsia. Multiple pregnancy.

Answer 156

1) Refer for consultant-led care at booking for specialist input to assess and manage the obstetric risk. 2) Ensure that aspirin 75—150 mg daily is prescribed from 12 weeks' gestation until birth. This is usually arranged in secondary care, but should be initiated in primary care if the woman will not be seen by a specialist until after 12 weeks. Seek specialist advice before prescribing aspirin to girls younger than 16 years of age, and in those with thrombophilia or uncontrolled blood pressure. There is no evidence that use of low-dose aspirin in pregnancy is associated with an increased risk of congenital abnormalities or other fetal complications. 3) Offer advice about healthy lifestyle (including rest, work, exercise, and weight

Answer 157

albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women. - If using protein:creatinine ratio, use 30 mg/mmol as a threshold for significant proteinuria. - If using albumin:creatinine ratio, use 8 mg/mmol as a diagnostic threshold. - Do not use first morning urine void to quantify proteinuria in pregnant women.

Answer 158

they will be offered hospital admission for ongoing monitoring of their condition and of their baby's wellbeing. Women with less severe hypertension may be offered admission depending upon whether there are clinical concerns for the wellbeing of the woman or baby or if they are considered to be at high risk of adverse events. If there are no such concerns, the woman will be offered ongoing specialist management on an outpatient basis.

Answer 159

pre-eclampsia and should be referred for consultant-led care at booking for specialist input to assess and manage the obstetric risk.

Answer 160

Healthy lifestyle (including work, rest, exercise, healthy diet, and weight) as recommended for all pregnant women. Restriction of dietary salt.

Answer 161

ACE inhibitor, ARB. thiazide or thiazide-like diuretic

Answer 162

Sustained systolic blood pressure is less than 110 mmHg, or Sustained diastolic blood pressure is less than 70 mmHg, or The woman has symptomatic hypotension.

Answer 163

Sustained systolic blood pressure of 140 mmHg or higher, or Sustained diastolic blood pressure of 90 mmHg or higher.

Answer 164

135/85 mmHg.

Answer 165

Arrange secondary care assessment by a healthcare professional trained in the management of hypertensive disorders of pregnancy for all women with new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy. Be aware of the signs and symptoms of, and risk factors for pre-eclampsia. Advise women with new onset severe hypertension (blood pressure of 160/110 mmHg or more) that they are likely to be admitted to hospital for ongoing monitoring of their condition and of their baby's wellbeing. Women with less severe hypertension may not be routinely admitted and will instead be offered additional maternal and fetal monitoring on an outpatient basis.

Answer 166

aspirin from 12w

Answer 167

this can be a symptom of impending pre-eclampsia —if there are other symptoms of pre-eclampsia, arrange same-day obstetric assessment. If there are no other symptoms of pre-eclampsia, consider possible urinary tract infection (UTI): - If there is [1+] protein on dipstick testing and either the woman has symptoms of a UTI, or the dipstick test is positive for nitrite or for both leucocyte esterase and blood, make a working diagnosis of UTI. - Send a midstream specimen of urine (MSU) for culture and sensitivity

Answer 168

arrange urgent secondary care assessment, even if there is evidence of a possible UTI.

Answer 169

follow-up and reassess in 1 week: Advise the woman to seek immediate medical attention if she develops symptoms of pre-eclampsia in the intervening period. Dipstick the urine and measure the blood pressure. Use albumin:creatinine ratio or protein:creatinine ratio to quantify persistent ([1+] on dipstick) proteinuria. Seek specialist obstetric advice if proteinuria is significant (protein:creatinine ratio of at least 30 mg/mmol, or albumin:creatinine ratio of at least 8 mg/mmol), or if there are any other concerns or uncertainty.

Answer 170

repeat blood tests to measure platelet count, transaminases, and serum creatinine as clinically indicated, until results return to normal

Answer 171

Should have their blood pressure measured at least once between days 3–5 after birth. If blood pressure is abnormal, it should then be measured on alternate days until it normalizes. Target blood pressure is lower than 140/90 mmHg. Antihypertensive treatment should be started if blood pressure is 150/100 mmHg or higher.

Answer 172

Should continue receiving antihypertensive treatment. Should have their blood pressure measured every 1–2 days for up to 2 weeks after transfer to community, care until treatment is no longer required and there is no hypertension. If blood pressure falls below 140/90 mmHg — a reduction in treatment can be considered. If blood pressure falls below 130/80 mmHg — treatment can be reduced.

Answer 173

Be aware that methyldopa taken during pregnancy should ideally be stopped within 2 days of birth as it may increase the risk of depression. For women who are not breastfeeding or planning to breastfeed, hypertension should be managed as for a member of the general population.

Answer 174

start enalapril post-partum or If the woman is of black African or Caribbean family origin, first-line treatment with nifedipine (or amlodipine if the woman has previously used this sucessfully) if not controlled then nifedipine (or amlodipine) + enalapril ineffective then + atenolol or labetalol

Answer 175

diuretics and ARB

Answer 176

drowsiness, lethargy, pallor, cold peripheries, or poor feeding

Answer 177

All women who have had pre-eclampsia should undergo medical review of their hypertension. A urinary reagent-strip test should be carried out. Women with [1+] proteinuria should be offered a further review in primary care or by a specialist three months after delivery to assess kidney function.

Answer 178

Measure blood pressure (this will usually be done by the community midwife after hospital discharge): - Daily for the first 2 days postnatally. - At least once between days 3–5 postnatally. - As clinically indicated if the woman's antihypertensive treatment is changed postnatally. Continue antihypertensive treatment if required: Aim to keep blood pressure lower than 140/90 mmHg. Review antihypertensive treatment 2 weeks postnatally. Ensure that women with chronic hypertension are offered a medical review 6–8 weeks after the birth either in primary care, or with a specialist as appropriate.

Answer 179

Most women with gestational hypertension will be followed up by the maternity unit after delivery until their blood pressure has returned to normal, or will be referred to a specialist if blood pressure remains elevated.

Answer 180

The woman's blood pressure should be measured: - Daily for the first 2 days postnatally. - At least once between days 3–5 postnatally. - As clinically indicated if the woman's antihypertensive treatment is changed postnatally. If continued antihypertensive treatment is required: Target blood pressure is lower than 140/90 mmHg.

Answer 181

For women with gestational hypertension who did not take antihypertensive treatment and have given birth, antihypertensive treatment should be started if blood pressure is 150/100 mmHg or higher. Women who remain on antihypertensive treatment postnatally should be offered a medical review in primary care, or with their specialist 2 weeks after transfer to community care. Ensure that women with gestational hypertension are offered a medical review 6–8 weeks after the birth either in primary care, or with a specialist as appropriate.

Answer 182

Severe headaches (increasing frequency unrelieved by regular analgesics). Visual problems, such as blurred vision, flashing lights, double vision, or floating spots. Persistent new epigastric pain or pain in the right upper quadrant. Vomiting. Hypertension. Proteinuria. Breathlessness due to pulmonary oedema. Sudden swelling of the face, hands, or feet.

Answer 183

a seizure within 4 weeks of delivery.

Answer 184

emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications.

Answer 185

new-onset hypertension proteinuria oedema

Answer 186

new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: - proteinuria - other organ involvement e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Answer 187

eclampsia fetal complications prematurity liver involvement (elevated transaminases) haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure

Answer 188

other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata

Answer 189

intrauterine growth retardation prematurity

Answer 190

hypertension: typically > 160/110 mmHg and proteinuria proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Answer 191

Moderate risk factors hypertensive disease in a previous pregnancy chronic kidney disease autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension

Answer 192

first pregnancy age 40 years or older pregnancy interval of more than 10 years body mass index (BMI) of 35 kg/m² or more at first visit family history of pre-eclampsia multiple pregnancy

Answer 193

women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth: ≥ 1 high risk factors ≥ 2 moderate factors

Answer 194

arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Answer 195

oral labetalol 1st line Nifedipine (e.g. if asthmatic) and methyldopa may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 196

the period prior to the menopause where women may experience symptoms, as ovarian function starts to fail

Answer 197

12 months after the last period in women > 50 years 24 months after the last period in women < 50 years

Answer 198

permanent cessation of menstruation when women has not had a period for 12m

Answer 199

loss of follicular activity

Answer 200

clinical: not had period for 12m

Answer 201

7yrs but may resolve quicker or last longer duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.

Answer 202

- Lifestyle modifications - Hormone replacement therapy (HRT) - Non-hormone replacement therapy

Answer 203

Hot flushes= regular exercise, weight loss, reduce stress Sleep disturbance= avoid late evening exercise and good sleep hygiene Mood= sleep, regular exercise and relaxation Cognitive symptoms= regular exercise and sleep hygiene

Answer 204

- Current or past breast cancer - Any oestrogen-sensitive cancer - Undiagnosed vaginal bleeding - Untreated endometrial hyperplasia

Answer 205

unopposed oestrogens as this will increase her risk of endometrial cancer. Therefore oral or transdermal combined HRT is given.

Answer 206

oestrogen alone can be given either orally or in a transdermal patch.

Answer 207

VTE= a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT. Stroke= slightly increased risk with oral oestrogen HRT. Coronary heart disease= combined HRT may be associated with a slight increase in risk. Breast cancer= there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised. Ovarian cancer= increased risk with all HRT.

Answer 208

fluoxetine, citalopram or venlafaxine

Answer 209

vaginal lubricant or moisturiser

Answer 210

self-help groups, cognitive behaviour therapy or antidepressants

Answer 211

if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

Answer 212

may need long term

Answer 213

When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.

Answer 214

if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.

Answer 215

BMI >30 at 1st antenatal visit

Answer 216

miscarriage venous thromboembolism gestational diabetes pre-eclampsia dysfunctional labour, induced labour postpartum haemorrhage wound infections higher c-section rate

Answer 217

congenital anomaly prematurity macrosomia stillbirth increased risk of developing obesity and metabolic disorders in childhood neonatal death

Answer 218

how this poses a risk, both to their health and the health of the unborn child. Explain that they should not try to reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy

Answer 219

5mg not 400mcg

Answer 220

- 5mg folic acid - screen for gestational diabetes with OGTT at 24-28w - if BMI >=35 then give birth in consultant led obstetric unit - if BMI >=40 then antenatal consultation with obstetric anaesthetist and a plan made

Answer 221

placenta lying wholly or partly in the lower uterine segment

Answer 222

5% but incidence at delivery is only 0.5%, therefore most placentas rise away from the cervix

Answer 223

multiparity multiple pregnancy embryos are more likely to implant on a lower segment scar from previous caesarean section

Answer 224

shock in proportion to visible loss NO PAIN uterus not tender lie and presentation may be abnormal fetal heart usually normal coagulation problems rare small bleeds before large

Answer 225

digital vaginal examination should NOT be performed before an ultrasound as it may provoke a severe haemorrhage often picked up on the routine 20 week abdominal USS the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

Answer 226

I - placenta reaches lower segment but not the internal os II - placenta reaches internal os but doesn't cover it III - placenta covers the internal os before dilation but not when dilated IV ('major') - placenta completely covers the internal os

Answer 227

rescan at 32 weeks no need to limit activity or intercourse unless they bleed if still present at 32 weeks and grade I/II then scan every 2 weeks

Answer 228

final ultrasound at 36-37 weeks to determine the method of delivery

Answer 229

elective caesarean section for grades III/IV between 37-38 weeks if grade I then a trial of vaginal delivery may be offered

Answer 230

an emergency caesarean section should be performed due to the risk of post-partum haemorrhage

Answer 231

admit ABC approach to stabilise the woman if not able to stabilise → emergency caesarean section if in labour or term reached → emergency caesarean section

Answer 232

death is now extremely rare major cause of death in women with placenta praevia is now PPH

Answer 233

separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space occurs in approximately 1/200 pregnancies

Answer 234

not known but associated factors: proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age

Answer 235

shock out of keeping with visible loss pain constant tender, tense uterus normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria

Answer 236

fetal distress: immediate caesarean no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Answer 237

fetal distress: immediate caesarean no fetal distress: deliver vaginally

Answer 238

induce vaginal delivery

Answer 239

Maternal: - shock - DIC - renal failure - PPH Fetal: - IUGR - hypoxia - death

Answer 240

associated with high perinatal mortality rate responsible for 15% of perinatal deaths

Answer 241

blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.

Answer 242

occurs within 24 hours. It affects around 5-7% of deliveries.

Answer 243

4 Ts: Tone (uterine atony): the vast majority of cases Trauma (e.g. perineal tear) Tissue (retained placenta) Thrombin (e.g. clotting/bleeding disorder)

Answer 244

previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia, placenta accreta macrosomia the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor

Answer 245

life-threatening emergency - senior members of staff should be involved immediately ABC approach= - two peripheral cannulae, 14 gauge - lie the woman flat - bloods including group and save - commence warmed crystalloid infusion mechanical= - palpate the uterine fundus and rub it to stimulate contractions ('rubbing up the fundus') - catheterisation to prevent bladder distension and monitor urine output medical= - IV oxytocin: slow IV injection followed by an IV infusion - ergometrine slow IV or IM (unless there is a history of hypertension) - carboprost IM (unless there is a history of asthma) - misoprostol sublingual - there is also interest in the role tranexamic acid may play in PPH surgical= if medical options fail to control the bleeding then surgical options will need to be urgently considered

Answer 246

two peripheral cannulae, 14 gauge lie the woman flat bloods including group and save commence warmed crystalloid infusion

Answer 247

palpate the uterine fundus and rub it to stimulate contractions ('rubbing up the fundus') catheterisation to prevent bladder distension and monitor urine output

Answer 248

IV oxytocin: slow IV injection followed by an IV infusion ergometrine slow IV or IM (unless there is a history of hypertension) carboprost IM (unless there is a history of asthma) misoprostol sublingual there is also interest in the role tranexamic acid may play in PPH

Answer 249

intrauterine balloon tamponade is an appropriate first-line 'surgical' intervention for most women where uterine atony is the only or main cause of haemorrhage other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Answer 250

IV oxytocin: slow IV injection followed by an IV infusion ergometrine slow IV or IM (unless there is a history of hypertension) carboprost IM (unless there is a history of asthma)

Answer 251

occurs between 24 hours - 12 weeks.

Answer 252

It is typically due to retained placental tissue or endometritis.

Answer 253

Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. 87.5% have gestational diabetes 7.5% have type 1 diabetes 5% have type 2 diabetes

Answer 254

HTN then gestational diabetes

Answer 255

BMI of > 30 kg/m² previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 256

oral glucose tolerance test (OGTT)

Answer 257

pt with previous gestational diabetes= OGTT asap after booking and at 24-28w if 1st test is normal any other RFs= OFTT at 24-28w

Answer 258

early self-monitoring of blood glucose

Answer 259

either: fasting glucose is >= 5.6 mmol/L 2-hour glucose is >= 7.8 mmol/L

Answer 260

in a joint diabetes and antenatal clinic within a week

Answer 261

- diabetes and antenatal clinic within 1w - self-monitoring of blood glucose - advice about diet (foods with low glycaemic index) and exercise - fasting glucose <7 at diagnosis= trial diet and exercise - if not met within 1-2w then start metformin - still not met= + short acting insulin - fasting glucose >=7 at diagnosis= start insulin - glucose 6-6.9 and evidence of Cx eg. macrosomia or hydramnios= insulin - glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Answer 262

- trial diet and exercise - if not met within 1-2w then start metformin - still not met= + short acting insulin

Answer 263

start insulin

Answer 264

cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Answer 265

weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy

Answer 266

Time Target Fasting= 5.3 mmol/l 1 hour after meals= 7.8 mmol/l or 2 hour after meals= 6.4 mmol/l

Answer 267

in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is risk of serious physical or mental injury to the woman.

Answer 268

two registered medical practitioners must sign a legal document (in an emergency only one is needed) only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

Answer 269

to women who is rhesus D negative and are having an abortion after 10+0 weeks gestation

Answer 270

can be done at home depending on gestation

Answer 271

hrs to days to complete can be unpredictable

Answer 272

mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions

Answer 273

pregnancy test is required in 2 weeks to confirm that the pregnancy has ended. This should detect the level of hCG (rather than just be positive or negative) and is termed a multi-level pregnancy test

Answer 274

use of transcervical procedures to end a pregnancy, including manual vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E) cervical priming with misoprostol +/- mifepristone is used before procedures women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity

Answer 275

after 9 weeks medical abortions become less common. Factors include increased likelihood of women seeing products of conception pass and decreased success rate before 10 weeks medical abortions are usually done at home

Answer 276

Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith: - that the pregnancy has not exceeded its 24th week and that 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; or - that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or - that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or - that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Answer 277

medical and surgical

Answer 278

the use of medications (mifepristone followed by misoprostol) to end a pregnancy.

Answer 279

the use of transcervical procedures (manual vacuum aspiration, electric vacuum aspiration, or dilatation and evacuation) to end a pregnancy.

Answer 280

The pregnancy has not exceeded its 24th week and 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 person or any existing children of their family. The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant person. Continuing the pregnancy would involve risk to the life of the pregnant person, greater than if the pregnancy were terminated. There is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Answer 281

people can self-refer directly to an abortion care provider or be referred by a GP, sexual health clinic, or specialist clinic (such as Brook service)

Answer 282

benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.

Answer 283

more common in Afro-Caribbean women rare before puberty, develop in response to oestrogen

Answer 284

may be asymptomatic 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

Answer 285

transvaginal USS

Answer 286

no treatment is needed other than periodic review to monitor size and growth

Answer 287

- 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

Answer 288

GnRH agonists may reduce the size of the fibroid but are typically used more for short-term

Answer 289

treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density

Answer 290

myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically hysteroscopic endometrial ablation hysterectomy

Answer 291

- medical - surgical= myomectomy - uterine artery embolization= if there are symptomatic fibroids and a woman wishes to avoid surgery

Answer 292

generally regress after menopause

Answer 293

subfertility and iron-deficiency anaemia red degeneration - haemorrhage into tumour - commonly occurs during pregnancy

Answer 294

(leiomyomas) are benign tumours which are caused by proliferation of a mixture of smooth muscle cells and fibroblasts, which form hard, round, whorled tumours in the myometrium.

Answer 295

They can be single, multiple, of variable size, and may develop anywhere within the myometrium (subserosal, intramural, or submucosal).

Answer 296

women of reproductive age and regress after the menopause.

Answer 297

asymptomatic and may be found incidentally on pelvic examination or ultrasound scan.

Answer 298

increasing age (until the menopause); early menarche; older age at first pregnancy; comorbidities such as obesity and hypertension; black and Asian ethnicity; family history

Answer 299

iron deficiency anaemia from heavy menstrual bleeding; bladder and bowel compressive symptoms (especially with large fibroids); subfertility or infertility; obstetric complications; tortion (of a pedunculated fibroid)

Answer 300

Heavy menstrual bleeding and/or dysmenorrhoea. Pelvic pain, pressure, or discomfort; dyspareunia. Abdominal discomfort or bloating; back pain. Urinary symptoms, such as frequency, urgency, urinary incontinence, or retention; urinary tract infections (UTIs). Bowel symptoms, such as bloating, constipation, and/or painful defecation. Subfertility or infertility (particularly if there are submucosal fibroids).

Answer 301

A firm, enlarged, and irregularly shaped non-tender uterus on pelvic examination. A central irregular abdominal mass (if a large fibroid).

Answer 302

Asking about symptoms including severity, duration, and impact on daily functioning and quality of life; previous fertility issues and hopes for future fertility; risk factors; and any previous treatments. Performing an abdominal and bimanual pelvic examination to assess for pelvic tenderness and any mass(es). Arranging a routine pelvic ultrasound scan to determine the number, size, and location of fibroid(s). Checking a FBC to assess for iron deficiency anaemia if there is a history of heavy menstrual bleeding and/or symptoms of anaemia.

Answer 303

if there are any clinical or radiological features suggesting a gynaecological or other malignancy

Answer 304

if she has an uncertain diagnosis; severe or refractory symptoms; confirmed fibroids measuring 3 cm or more in diameter or suspected submucosal fibroids; suspected fertility or obstetric issues; rapid or unexpected growth of fibroids after the menopause.

Answer 305

Reassurance that no treatment is routinely needed

Answer 306

clinical routine pelvic ultrasound scan (transabdominal and transvaginal, if needed) to determine the number, size, and location of fibroid(s), particularly if there are any of the following: - The uterus is palpable abdominally. - History or examination suggests a pelvic mass. - Examination is inconclusive or difficult, for example, if a woman is obese.

Answer 307

Malignant= ovarian ca; endometrial ca; GI malignancy Benign= endometrial polyp or hyperplasia; adenomyosis or endometriosis; urinary retention; pregnancy; ectopic pregnancy

Answer 308

both the mother and also the fetus, a syndrome now termed fetal varicella syndrome

Answer 309

5 times greater risk of pneumonitis

Answer 310

risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation small number of cases occurring between 20-28 weeks gestation and none following 28 weeks features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

Answer 311

skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

Answer 312

- fetal varicella syndrome - shingles in infancy= 1-2% risk if maternal exposure in the second or third trimester - severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 313

chickenpox= if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 314

maternal blood should be urgently checked for varicella antibodies

Answer 315

oral aciclovir (or valaciclovir) given at day 7 to day 14 after exposure, not immediately

Answer 316

at day 7 to day 14 after exposure, not immediately

Answer 317

in a study the incidence and severity of varicella infection was significantly higher in those given aciclovir immediately (10/13 (77%) who received aciclovir immediately developed clinical varicella compared with 3/14 (21%) who started aciclovir at day 7)'

Answer 318

if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash if the woman is < 20 weeks the aciclovir should be 'considered with caution'

Answer 319

specialist advice

Answer 320

aciclovir in pregnancy

Answer 321

Respiratory symptoms. Neurological symptoms. Haemorrhagic rash or bleeding. Severe disease (for example dense rash with or without numerous mucosal lesions). Significant immunosuppression (including recent use of systemic corticosteroids).

Answer 322

Pregnancy approaching term. Previous obstetric complications or risk factors. Smoking. Chronic lung disease. Social risk factors. Close monitoring in the community is not possible.

Answer 323

Close monitoring is needed — review daily, or earlier if her condition deteriorates and have a low threshold for considering admission. Where close monitoring in the community is not possible, admission should be considered. If there is deterioration, fever persists, or cropping of the rash continues after 6 days, refer for urgent hospital assessment. If a high temperature develops (particularly after initial improvement) with redness and pain surrounding the chickenpox lesions, consider bacterial superinfection and manage accordingly.

Answer 324

from 24 hours before the rash appears, but infectivity continues until all the lesions have crusted over (commonly about 5 days after the onset of the rash) During this time, advise a pregnant woman with chickenpox to avoid contact with: - People who are immunocompromised (for example those receiving cancer treatment or high doses of oral steroids, or those with conditions that reduce immunity). - Other pregnant women. - Infants aged 4 weeks or less.

Answer 325

Topical calamine lotion. Chlorphenamine is NOT recommended for the management of the itch of chickenpox in pregnancy.

Answer 326

paracetamol NOT NSAIDs

Answer 327

varicella-zoster immunoglobulin G (IgG) antibodies

Answer 328

If the test shows varicella-zoster immunoglobulin G antibodies (evidence of immunity from past infection or immunization), the woman can be reassured that she is immune. If the woman's antibody status is negative, urgently discuss with a specialist the need for prophylaxis (antiviral treatment)

Answer 329

low molecular weight heparin throughout the antenatal period and also input from experts.

Answer 330

antenatal prophylactic low molecular weight heparin.

Answer 331

Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy

Answer 332

immediate treatment with low molecular weight heparin continued until six weeks postnatal

Answer 333

low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.

Answer 334

continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.

Answer 335

alteparin sodium, enoxaparin

Answer 336

DOAC and warfarin should be AVOIDED

Answer 337

- ectopic pregnancy - miscarriage

Answer 338

- labour - placental abruption - Symphysis pubis dysfunction - Pre-eclampsia/HELLP syndrome - uterine rupture

Answer 339

- appendicitis - UTI

Answer 340

ectopic pregnancy

Answer 341

(anything slowing the ovum's passage to the uterus): - damage to tubes (salpingitis, surgery) - previous ectopic - IVF (3% of pregnancies are ectopic)

Answer 342

threatened missed (delayed) inevitable incomplete

Answer 343

painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks cervical os is closed complicates up to 25% of all pregnancies

Answer 344

a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'

Answer 345

cervical os is open heavy bleeding with clots and pain

Answer 346

not all products of conception have been expelled

Answer 347

Regular tightening of the abdomen which may be painful in the later stages

Answer 348

Ligament laxity increases in response to hormonal changes of pregnancy Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen

Answer 349

Associated with hypertension, proteinuria. Patients with HELLP also have haemolysis, elevated liver enzymes and a low platelet count. The pain is typically epigastric or in the RUQ

Answer 350

Ruptures usually occur during labour but occur in third trimester Risk factors: previous caesarean section Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree

Answer 351

Occurs in 1:1,000-2:1,000 pregnancies, making it the most common non-obstetric surgical emergency Higher morbidity and mortality in pregnancy Location of pain changes depending on gestation, moving up from the RLQ in the first trimester to the umbilicus in the second and the RUQ in the third

Answer 352

1 in 25 women develop in UTI in pregnancy Associated with an increased risk of pre-term delivery and IUGR

Answer 353

all female patients should also undergo a bimanual vaginal examination, urine pregnancy test and consideration given to abdominal and pelvic ultrasound scanning. When diagnostic doubt persists a laparoscopy provides a reliable method of assessing suspected tubulo-ovarian pathology.

Answer 354

- Mittelschmerz - Endometriosis - Ovarian torsion - Ectopic gestation - PID

Answer 355

Usually mid cycle pain. Often sharp onset. Little systemic disturbance. May have recurrent episodes. Usually settles over 24-48 hours. Full blood count- usually normal Ultrasound- may show small quantity of free fluid Tx= Conservative

Answer 356

25% asymptomatic, in a further 25% associated with other pelvic organ pathology. Remaining 50% may have menstrual irregularity, infertility, pain and deep dyspareurina. Complex disease may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction. Intra-abdominal bleeding may produce localised peritoneal inflammation. Recurrent episodes are common. Ultrasound- may show free fluid Laparoscopy will usually show lesions Usually managed medically, complex disease will often require surgery and some patients will even require formal colonic and rectal resections if these areas are involved

Answer 357

Usually sudden onset of deep seated colicky abdominal pain. Associated with vomiting and distress. Vaginal examination may reveal adnexial tenderness. Ultrasound may show free fluid Laparoscopy is usually both diagnostic and therapeutic Mx= Laparoscopy

Answer 358

Symptoms of pregnancy without evidence of intra uterine gestation. Present as an emergency with evidence of rupture or impending rupture. Open tubular ruptures may have sudden onset of abdominal pain and circulatory collapse, in other the symptoms may be more prolonged and less marked. Small amount of vaginal discharge is common. There is usually adnexial tenderness. Ultrasound showing no intra uterine pregnancy and beta HCG that is elevated May show intra abdominal free fluid Mx= Laparoscopy or laparotomy is haemodynamically unstable. A salphingectomy is usually performed.

Answer 359

Bilateral lower abdominal pain associated with vaginal discharge. Dysuria may also be present. Peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh Curtis Syndrome) may produce right upper quadrant discomfort. Fever >38o Full blood count- Leucocytosis Pregnancy test negative (Although infection and pregnancy may co-exist) Amylase - usually normal or slightly raised High vaginal and urethral swabs Usually medical management

Answer 360

Intestinal obstruction

Answer 361

urinary retention

Answer 362

ovarian ca

Answer 363

return to normal recall, unless: - the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community - the untreated CIN1 pathway - follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer - follow-up for borderline changes in endocervical cells

Answer 364

colposcopy

Answer 365

includes the following results: borderline changes in squamous or endocervical cells. low-grade dyskaryosis. high-grade dyskaryosis (moderate). high-grade dyskaryosis (severe). invasive squamous cell carcinoma. glandular neoplasia

Answer 366

the test is repeated 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

Answer 367

repeat the sample in 3 months if two consecutive inadequate samples then → colposcopy

Answer 368

individuals who've been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.

Answer 369

Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic. Alternative techniques include cryotherapy.

Answer 370

First choice is nitrofurantion 100 mg modified-release twice daily for 7 days (avoid in third trimester). Second choice is either cefalexin 500 mg twice a day for 7 days or amoxicillin 500 mg 3 times a day for 7 days.

Answer 371

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

Answer 372

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

Answer 373

- 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

Answer 374

functional hypothalamic amenorrhoea

Answer 375

gonadal dysgenesis (e.g. Turner's syndrome)

Answer 376

- hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise) - polycystic ovarian syndrome (PCOS) - hyperprolactinaemia - premature ovarian failure - thyrotoxicosis (hypothyroidism may also cause amenorrhoea) - Sheehan's syndrome - Asherman's syndrome (intrauterine adhesions)

Answer 377

hypothalamic amenorrhoea

Answer 378

exclude pregnancy with urinary or serum bHCG FBC, U&E, coeliac screen, TFTs gonadotrophins= low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure); raised if gonadal dysgenesis (e.g. Turner's syndrome) prolactin androgen levels= raised levels may be seen in PCOS oestradiol

Answer 379

hypothalamic cause

Answer 380

ovarian problem (e.g. Premature ovarian failure) or gonadal dysgenesis (e.g. Turner's syndrome)

Answer 381

investigate and treat any underlying cause with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner's syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)

Answer 382

exclude pregnancy, lactation, and menopause (in women 40 years of age or older) treat the underlying cause

Answer 383

failure to establish menstruation by the expected age, variably considered to be 15 or 16 years of age in girls with normal secondary sexual characteristics (such as breast development), or 13 or 14 years of age in girls with no secondary sexual characteristics.

Answer 384

physiological states; outflow tract obstruction; genetic and congenital conditions; disorders of the ovaries, hypothalamus, or pituitary gland; and disorders of other endocrine glands

Answer 385

anatomical abnormalities due to genetic or congenital conditions, functional hypothalamic amenorrhoea (related to eating disorders, stress, weight loss, and excessive exercise) and polycystic ovary syndrome (PCOS)

Answer 386

polycystic ovary syndrome, functional hypothalamic amenorrhoea, premature ovarian insufficiency, and hyperprolactinaemia

Answer 387

Ultrasound. Serum prolactin. Thyroid-stimulating hormone. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Oestradiol. Total testosterone (if there are features of androgen excess).

Answer 388

Elevated FSH and LH levels (and younger than 40 years of age). Recent history of uterine or cervical surgery, or severe pelvic infection. Infertility. Suspected PCOS where the diagnosis is unclear or where there are complications that cannot be managed in primary care.

Answer 389

Hyperprolactinaemia. Low FSH and LH. An increased testosterone level not explained by PCOS. Features of Cushing's syndrome or late-onset congenital adrenal hyperplasia.

Answer 390

primary care if appropriate

Answer 391

endocrinologist has assessed and excluded other hypothalamic or pituitary causes (such as a tumour). However, if an eating disorder is suspected, a prompt referral should be made to an age-appropriate community eating disorders service.

Answer 392

Girls who have not established menstruation by the age of 13 years and have no secondary sexual characteristics (such as breast development). Girls who have not established menstruation by the age of 15 years and have normal secondary sexual characteristics. Girls who have not established menstruation within 3 years of the start of breast development (thelarche), or within 5 years if breast budding occurred before the age of 10.

Answer 393

normal secondary sexual characteristics= outflow obstruction (for example, imperforate hymen or transverse vaginal septum) and polycystic ovary syndrome (PCOS). no secondary sexual characteristics= Turner's syndrome (46XO; 'streak' ovaries only) and gonadal agenesis (46XX or 46XY).

Answer 394

could be caused by androgen insensitivity syndrome.

Answer 395

usually magnetic resonance imaging [MRI] of the pituitary fossa is required pituitary adenoma, empty sella syndrome, hypothyroidism, and drugs (including antipsychotics [particularly risperidone], antidepressants [particularly selective serotonin reuptake inhibitors], and antiemetics [such as metoclopramide or domperidone]).

Answer 396

stress and medications (such as antipsychotics).

Answer 397

Pregnancy and breastfeeding. Needle phobia or traumatic venesection (can double or occasionally quadruple basal prolactin concentrations). Vigorous exercise within 30 minutes of the blood sample being taken. PCOS (in 10–20% of people; rarely above 1000 mIU/L). Renal impairment (occasionally associated with mild hyperprolactinaemia; typically less than 2000 mIU/L). Hypothyroidism (uncommon, often still within the reference range and only rarely above 1200 mIU/L).

Answer 398

?pituitary adenomas.

Answer 399

?outflow obstruction (although they can be normal in other common causes such as functional hypothalamic amenorrhoea and PCOS).

Answer 400

karyotyping in secondary care may be necessary. - Short stature and high FSH and LH levels suggest Turner's syndrome. - Short stature and low FSH and LH levels suggest an intracranial lesion, for example, hydrocephalus. - Normal height and high FSH and LH levels suggest ovarian failure (normal karyotype) or 46XY (abnormal karyotype). - Normal height and low FSH and LH levels suggest constitutional delay, weight loss, anorexia nervosa, or excessive exercise.

Answer 401

(refer to local laboratory reference range) warrant investigation to exclude androgen insensitivity (46XY genotype, female phenotype), late-onset congenital adrenal hyperplasia, Cushing's syndrome, or an androgen-secreting tumour.

Answer 402

may be seen in PCOS.

Answer 403

hyperprolactinaemia

Answer 404

premature ovarian insufficiency

Answer 405

Functional hypothalamic (for example weight loss, excessive exercise, or stress)

Answer 406

presence of 20 or more follicles in at least one ovary

Answer 407

High levels of total testosterone (refer to local laboratory reference ranges) warrant investigation to exclude other causes, such as Cushing's syndrome, late-onset congenital adrenal hyperplasia, or an androgen-secreting tumour. A moderately increased testosterone level or free androgen index may be seen in PCOS.

Answer 408

suggest premature ovarian insufficiency (POI) in women younger than 40 years of age. Diagnosis of POI is confirmed by oligo/amenorrhoea for at least 4 months and elevated FSH (>25 IU/l) on two occasions at least 4 weeks apart.

Answer 409

suggest hypothalamic causes (weight loss, excessive exercise, stress, or rarely, a hypothalamic or pituitary tumour).

Answer 410

BMI Cushing's syndrome (striae, buffalo hump, significant central obesity, easy bruising, hypertension, and proximal muscle weakness). Thyroid disease. Excess androgens (hirsutism and acne) or virilization (hirsutism, acne, deep voice, temporal balding, increase in muscle bulk, breast atrophy, and clitoromegaly). Adrenal insufficiency (orthostatic hypotension, pigment changes, and decreased axillary or pubic hair). Decreased endogenous oestrogen (reddened or thin vaginal mucosa). If appropriate, examine for galactorrhoea (suggesting raised prolactin levels). Assess visual fields (if a pituitary tumour is suspected).

Answer 411

condoms (male and female) diaphragms & cervical caps

Answer 412

percentage of women experiencing an unintended pregnancy within the first year of use

Answer 413

perfect use - 98%, typical use - 80%

Answer 414

95%, typical use - 80%

Answer 415

if used with spermicide then 92-96%

Answer 416

oil based lubricants

Answer 417

polyurethane condoms

Answer 418

highly effective (failure rate < 1 per 100 woman years) doesn't interfere with sex contraceptive effects reversible upon stopping usually makes periods regular, lighter and less painful reduced risk of ovarian, endometrial - this effect may last for several decades after cessation reduced risk of colorectal cancer may protect against pelvic inflammatory disease may reduce ovarian cysts, benign breast disease, acne vulgaris

Answer 419

people may forget to take it offers no protection against sexually transmitted infections increased risk of venous thromboembolic disease increased risk of breast and cervical cancer increased risk of stroke and ischaemic heart disease (especially in smokers) temporary side-effects such as headache, nausea, breast tenderness may be seen

Answer 420

not found to but some users do report to

Answer 421

by amount of oestrogen and progestogen and by presentation eg. everyday pill/phasic presentation, patches etc

Answer 422

consider using a pill containing 30 mcg ethinyloestradiol with levonorgestrel/norethisterone (e.g. Microgynon 30 - ethinylestradiol 30 mcg with levonorgestrel 150 mcg)

Answer 423

work slightly differently compared to traditional pills - Qlaira and Yaz.

Answer 424

combination of estradiol valerate (as opposed to the usual ethinylestradiol) and dienogest. It has a quadraphasic dosage regimen which is designed to give optimal cycle control. Users take a pill everyday of a 28 day cycle, with 26 of the pills containing estradiol +/- dienogest and 2 of the pills being inactive. During the cycle the dose of estradiol is gradually reduced and that of dienogest is increased

Answer 425

day 1-2= 3mg E and no D 3-7= 2mg E and 2mg D 8-24= 2mg E and 3mg D 25-26= 1mg E and no D 27-18= no E or D

Answer 426

give women a more 'natural' cycle with more constant oestrogen levels. The efficacy is similar to that of other COCPs with a Pearl Index of 0.4 failures per 100 women-years in subjects aged 18-35 years

Answer 427

cost: currently £8.39 per month, which is considerably more than some standard COCPs which can cost < 70p per month limited safety data to date. For the time being the FSRH suggest using standard COCP UKMEC critera there are different missed pill rules

Answer 428

If a pill is taken 12 hours late it is classed as 'missed' (compared to 24 hours for standard COCPs). If a woman has missed more than 2 pills emergency contraception may be needed

Answer 429

Day 1-17= Take missed pill immediately and the next tablet at the usual time (even if means taking two on same day). Continue with the tablet taking in the normal way Abstain or use an additional contraceptive method for 9 days 18-24= Discard the rest of the packet. Start taking the Day 1 pill from a new packet immediately and continue taking these pills at the correct time. Abstain or use an additional contraceptive method for 9 days 25-26= Take the missed tablet immediately and the next tablet at the usual time (even if it means taking two tablets on the same day). Additional contraception is not necessary. 27-28= Discard the forgotten table and continue tablet taking in the normal way. Additional contraception is not necessary.

Answer 430

product combining 20mcg ethinylestradiol with 3mg drospirenone is soon to be launched in the UK. In the US and Europe it is branded as Yaz and has an interesting 24/4 regime, as opposed to the normal 21/7 cycle. The idea is that a shorter pill-free interval is both better for patients with troublesome premenstrual symptoms and is also more effective at preventing ovulation. Studies have shown Yaz causes less pre-menstrual syndrome and blood loss reduced by 50-60%.

Answer 431

UKMEC recommendations on contraceptions made by the Faculty of Sexual and Reproductive Health (FSRH)

Answer 432

1 (no risk), 2, 3 and 4

Answer 433

advantages generally outweigh the disadvantages

Answer 434

disadvantages generally outweigh the advantages

Answer 435

represents an unacceptable health risk

Answer 436

CVD disease

Answer 437

age <35yrs + smoke

Answer 438

age > 35 years and smoking < 15 cigarettes/day

Answer 439

age > 35 years and smoking > 15 cigarettes/day

Answer 440

no increased CVD risk with progesterone only so UKMEC 1 regardless of age/smoking

Answer 441

UKMEC 2: BMI 30-34 kg/m² UKMEC 3: BMI >= 35 kg/m² All other methods of contraception have a UKMEC of 1.

Answer 442

COCP contraindicated (i.e. UKMEC 4) in patients with a history of migraine with aura. For patients who have migraines without aura the recommendation by the FSRH is that the COCP is UKMEC 3 for continued prescribing and UKMEC 2 for initiation. Progestogen only methods such as the progestogen-only pill (POP), implant and injection are UKMEC 2 and are hence better choices.

Answer 443

the effect of the contraceptive on the effectiveness of the anti-epileptic medication the effect of the anti-epileptic on the effectiveness of the contraceptive the potential teratogenic effects of the anti-epileptic if the woman becomes pregnant

Answer 444

consistent use of condoms + other form of contraception

Answer 445

UKMEC 3: the COCP and POP UKMEC 2: implant UKMEC 1: Depo-Provera, IUD, IUS

Answer 446

UKMEC 3: the COCP UKMEC 1: POP, implant, Depo-Provera, IUD, IUS

Answer 447

minimum of 30 µg of ethinylestradiol.

Answer 448

The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale.

Answer 449

condition for which there is no restriction for the use of the contraceptive method

Answer 450

more than 35 years old and smoking less than 15 cigarettes/day BMI > 35 kg/m^2* family history of thromboembolic disease in first degree relatives < 45 years controlled hypertension immobility e.g. wheel chair use carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2) current gallbladder disease

Answer 451

more than 35 years old and smoking more than 15 cigarettes/day migraine with aura history of thromboembolic disease or thrombogenic mutation history of stroke or ischaemic heart disease breast feeding < 6 weeks post-partum uncontrolled hypertension current breast cancer major surgery with prolonged immobilisation positive antiphospholipid antibodies (e.g. in SLE)

Answer 452

diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity

Answer 453

breast feeding 6 weeks - 6 months postpartum was changed from UKMEC 3 → 2

Answer 454

- potential harms and benefits - advice on taking the pill - discussion on situations where efficacy may be reduced - discussion on STIs - concurrent Abx use

Answer 455

the COC is > 99% effective if taken correctly small risk of blood clots very small risk of heart attacks and strokes increased risk of breast cancer and cervical cancer

Answer 456

Should be taken at same time every day. 'Tailored' regimes should now be discussed with women. This is because there is no medical benefit from having a withdrawal bleed. Options include never having a pill-free interval or 'tricycling' - taking three 21 day packs back-to-back before having a 4 or 7 day break.

Answer 457

if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days

Answer 458

only if the next pack is started on time

Answer 459

if vomiting within 2 hours of taking COC pill medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat) if taking liver enzyme-inducing drugs

Answer 460

no only enzyme inducing Abx eg. rifampicin

Answer 461

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

Answer 462

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.

Answer 463

emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1

Answer 464

after seven consecutive days of taking the COC there is no need for emergency contraception (theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off)

Answer 465

she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Answer 466

7 days on, 7 days off

Answer 467

main: stops ovulation also: thickens cervical mucus (reducing chance of semen entering uterus) and thins endometrial lining (reducing chance of implantation)

Answer 468

no All methods are UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years).

Answer 469

COCP use in the perimenopausal period may help to maintain bone mineral density COCP use may help reduce menopausal symptoms a pill containing < 30 µg ethinylestradiol may be more suitable for women > 40 years

Answer 470

women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years use is associated with a small loss in bone mineral density which is usually recovered after discontinuation

Answer 471

stop after 2yrs of amenorrhoea

Answer 472

stop after 1yr of amenorrhoea

Answer 473

can be continued to 50yrs

Answer 474

switch to non-hormonal or progestogen only method

Answer 475

can be continued to 50yrs

Answer 476

Switch to either a non-hormonal method and stop after 2 years of amenorrhoea OR switch to a progestogen-only method and follow advice (to do with HRT)

Answer 477

can be continued beyond 50yrs

Answer 478

continue if amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years If not amenorrhoeic consider investigating abnormal bleeding pattern

Answer 479

HRT cannot be relied upon for contraception so a separate method of contraception is needed. POP may be be used with in conjunction with HRT as long as the HRT has a progestogen component (i.e. the POP cannot be relied upon to 'protect' the endometrium). In contrast the IUS is licensed to provide the progestogen component of HRT.

Answer 480

barrier methods daily methods long-acting methods of reversible contraception (LARCs)

Answer 481

COCP and progesterone only pill (POP)

Answer 482

implantable contraceptives injectable contraceptives intrauterine system (IUS): progesterone releasing coil intrauterine device (IUD): copper coil

Answer 483

Physical barrier Relatively low success rate, particularly when used by young people Help protects against STIs

Answer 484

Inhibits ovulation Increases risk of venous thromboembolism Increases risk of breast and cervical cancer

Answer 485

Thickens cervical mucus Irregular bleeding a common side-effect

Answer 486

Primary: Inhibits ovulation Also: thickens cervical mucus Lasts 12 weeks

Answer 487

Primary: Inhibits ovulation Also: thickens cervical mucus Irregular bleeding a common side-effect Last 3 years

Answer 488

Decreases sperm motility and survival

Answer 489

Primary: Prevents endometrial proliferation Also: Thickens cervical mucus Irregular bleeding a common side-effect

Answer 490

primary: inhibits ovulation (as well as thickens cervical mucus)

Answer 491

inhibits ovulation

Answer 492

inhibits ovulation

Answer 493

Primary: Toxic to sperm and ovum Also: Inhibits implantation

Answer 494

UKMEC 2: BMI 30-34 kg/m² UKMEC 3: BMI >= 35 kg/m²

Answer 495

all except COCP (and patch less effective if >90%)

Answer 496

cannot have oral contraception ever again due to lack of efficacy, including emergency contraception.

Answer 497

starting contraception at any time other than the start of the menstrual cycle.

Answer 498

no intercourse since the start of the last menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease. correct and reliable contraception use within 5 days onset of a normal menstrual period < 21 days post-partum (non-breastfeeding) fully breastfeeding, amenorrheic, <6 months post-partum within the first 5 days after an abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease not had intercourse for >21 days and urine pregnancy test is negative

Answer 499

days 1-5 of the menstrual cycle and days 1-7 for the levonorgestrel intrauterine system.

Answer 500

6 onwards then an additional 7 days of extra precautions are required.

Answer 501

emergency contraception

Answer 502

Levonorgestrel Ulipristal acetate Copper IUD

Answer 503

UPSI within 72hrs (3d) and copper IUD unsuitable or declied

Answer 504

immediately

Answer 505

UPSI within 120hrs (5d) and copper IUD unsuitable or declined

Answer 506

Unprotected sex within the last 5 days / within 5 days of the earliest estimated date of ovulation

Answer 507

immediately effective for ongoing contraception

Answer 508

copper IUD

Answer 509

someone whose gender identity is not congruent with the sex they were assigned at birth

Answer 510

someone who was assigned the sex of male but identifies as a woman

Answer 511

assigned the sex of female but identifies as a man

Answer 512

describes any gender identity which does not fit the male and female binary.

Answer 513

Condoms and dental dams are recommended to all individuals at risk of sexually transmitted infections. Condoms may be considered as a contraceptive choice, but efficacy in prevention of pregnancy may be considered sub-optimal, with a failure rate quoted as 18% with typical use (2% failure rate with perfect use).

Answer 514

for all sexually active individuals with uterus

Answer 515

all sexually active individuals

Answer 516

hep A and B and offered vaccinations

Answer 517

availability of pre-exposure prophlyaxis (PrEP) and post-exposure prophylaxis (PEP) as required

Answer 518

may already have hysterectomy or bilateral orchiectomy if not then fallopian tube occlusion or vasectomy

Answer 519

Testosterone therapy does not provide protection against pregnancy and if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects. Regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy. Progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and the intrauterine system and injections may also suspend menstruation. Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding, which may be unacceptable to patients.

Answer 520

Either of the available oral emergency contraceptive options may be considered as it is believed that neither oral formulation interacts with testosterone therapy. In addition, the non-hormonal intrauterine device may be considered, however, this may have unacceptable side effects in some patients.

Answer 521

oestradiol, gonadotrophin-releasing hormone analogs, finasteride or cyproterone acetate, there may be a reduction or cessation of sperm production, however, the variability of the effects of such therapy is such that they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients assigned male at birth engaging in vaginal sex wishing to avoid the risk of pregnancy.

Answer 522

child protection measures

Answer 523

if doctor feels they are 'competent' assessed using the Fraser guidelines

Answer 524

the young person understands the professional's advice the young person cannot be persuaded to inform their parents the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent

Answer 525

2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI)

Answer 526

long-acting reversible contraceptive methods (LARCs) have advantages in young people as this age group may often be less reliable in remembering to take medication however, there are some concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice the progesterone-only implant (Nexplanon) is therefore the LARC of choice is young people

Answer 527

acts both to stop ovulation and inhibit implantation

Answer 528

1.5mg (a progesterone)

Answer 529

if BMI >26 or weight over 70kg or if taking enzyme-inducing drugs (although a copper IUD as emergency contraception is preferable in this situation)

Answer 530

if vomit within 3hrs of taking

Answer 531

immediately

Answer 532

inhibition of ovulation

Answer 533

Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period

Answer 534

pts with severe asthma

Answer 535

ulipristal= delay for 1w after taking levonorgestrel= no restrictions

Answer 536

copper IUD

Answer 537

if the criteria for insertion of a copper IUD are not met or is not acceptable to the woman, oral emergency contraception should be considered in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are

Answer 538

within 5 days of UPSI, or if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date

Answer 539

inhibit fertilisation or implantation

Answer 540

prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection

Answer 541

copper IUD= 99% levnorgestrel= 84%

Answer 542

may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

Answer 543

the applicator has been redesigned to try and prevent 'deep' insertions (i.e. subcutaneous/intramuscular) it is radiopaque and therefore easier to locate if impalpable

Answer 544

Both versions slowly releases the progestogen hormone etonogestrel. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.

Answer 545

They are typically inserted in the proximal non-dominant arm, just overlying the tricep.

Answer 546

Implantable contraceptive (Nexplanon) highly effective: failure rate 0.07/100 women-years

Answer 547

yes as doesnt contin oestrogen

Answer 548

immediately

Answer 549

the need for a trained professional to insert and remove device additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman's menstrual cycle

Answer 550

irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues 'progestogen effects': headache, nausea, breast pain

Answer 551

headache, nausea, breast pain

Answer 552

enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment

Answer 553

UKMEC 3: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer UKMEC 4: current breast cancer

Answer 554

Depo Provera

Answer 555

medroxyprogesterone acetate 150mg

Answer 556

IM injection every 12w can be given up to 14w after last dose without need for extra precautions (BNF says do preg test if given after 12w and 5d)

Answer 557

another form of injectable contraceptive given every 8w but rarely used

Answer 558

main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.

Answer 559

injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)

Answer 560

Depo Provera (injectable contraceptive)

Answer 561

irregular bleeding weight gain may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable not quickly reversible and fertility may return after a varying time

Answer 562

Depo Provera (injectable contraceptive)?

Answer 563

current breast ca (UKMEC 4) and past breast ca is UKMEC 3

Answer 564

copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirenaµ)

Answer 565

contraception and in Mx of menorrhagia

Answer 566

prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)

Answer 567

levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening

Answer 568

majority of IUDs with copper on the stem only are effective for 5 years, whereas some of the IUDs that have copper on the stem and the arms of the T may be effective for up to 10 years

Answer 569

the most common IUS (i.e. Mirenaµ - levonorgestrel 20 mcg/24 hrs) is effective for 5 years if used as endometrial protection for women taking oestrogen-only hormone replacement therapy they are only licensed for 4 years

Answer 570

immediately following insertion

Answer 571

7d after insertion

Answer 572

IUDs make periods heavier, longer and more painful the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic uterine perforation: up to 2 per 1000 insertions and higher in breastfeeding women the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months

Answer 573

The Jaydessµ IUS is licensed for 3 years. It has a smaller frame, narrower inserter tube and less levonorgestrel (LNG) than the Mirenaµ coil (13.5 mg compared to 52 mg). This results in lower serum levels of LNG. The Kyleenaµ IUS has 19.5mg LNG and is also smaller than the Mirenaµ but is licensed for 5 years. It also results in lower serum levels of LNG. The rate of amenorrhoea is less with Kyleenaµ compared to Mirenaµ.

Answer 574

between 48 hours and 4 weeks postpartum (increased risk of perforation) initiation of method in women with ovarian cancer

Answer 575

pregnancy current pelvic infection, puerperal sepsis, immediate post-septic abortion unexplained vaginal bleeding which is suspicious uterine fibroids or uterine anatomical abnormalities distorting the uterine cavity

Answer 576

UKMEC 1 (used to be 3)

Answer 577

Chlamydia trachomatis in women at risk of STIs Neisseria gonorrhoeae in women at risk of STIs, in areas where it is prevalent any STIs in women who request it

Answer 578

prophylactic antibiotics

Answer 579

after day 21

Answer 580

any time additonal contracpetion for 2d after starting if after day 21

Answer 581

small amount of progestogen enters breast milk but this is not harmful to the infant

Answer 582

if breastfeeding or <6w post-partum

Answer 583

increased risk of VTE

Answer 584

can reduce breast milk production

Answer 585

within 48 hours of childbirth or after 4 weeks

Answer 586

98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum

Answer 587

preterm birth, low birth weight and small for gestational age babies.

Answer 588

drugs galactosaemia viral infections

Answer 589

antibiotics: penicillins, cephalosporins, trimethoprim endocrine: glucocorticoids (avoid high doses), levothyroxine epilepsy: sodium valproate, carbamazepine asthma: salbutamol, theophyllines psychiatric drugs: tricyclic antidepressants, antipsychotics (AVOID CLOZAPINE) hypertension: beta-blockers, hydralazine anticoagulants: warfarin, heparin digoxin

Answer 590

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone clozapine

Answer 591

stop the lactation reflex i.e. stop suckling/expressing supportive measures: well-supported bra and analgesia cabergoline is the medication of choice if required

Answer 592

cabergoline

Answer 593

involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

Answer 594

nausea breast tenderness fluid retention and weight gain

Answer 595

increased risk of... - breast ca - endometrial ca - VTE - stroke - ischaemic heart disease if taken more than 10yrs after menopause

Answer 596

progesterone

Answer 597

stopped and by 5 years it reaches the same level as in women who have never taken HRT

Answer 598

women with uterus

Answer 599

oestrogen by itself should not be given as HRT to women with a womb reduced by the addition of a progestogen but not eliminated completely he additional risk is eliminated if a progestogen is given continuously

Answer 600

addition of a progestogen

Answer 601

transdermal oral increases VTE risk

Answer 602

referred to haematology before starting any treatment (even transdermal)

Answer 603

complementary or alternative medicines to try and alleviate their symptoms

Answer 604

Herbal medicine from a North American plant Actaea racemosa The Medicines and Healthcare products Regulatory Agency (MHRA) has given a preparation of Black Cohosh called Menoherb a Traditional Herbal Registration for the relief of menopausal symptoms The most important adverse effect to inform women about is the risk of liver toxicity The results of randomised controlled trials have been mixed

Answer 605

risk of liver toxicity

Answer 606

may potentiate seizures

Answer 607

may cause sleep problems and nausea

Answer 608

Contains a type of phytoestrogens Theoretical risk of endometrial hyperplasia and stimulating hormone-sensitive cancers

Answer 609

Type of Chinese medicine May cause photosensitivity and interfere with warfarin metabolism

Answer 610

Elleste-duet (pill) or Evorel Sequi (patch) (estradiol + northisterone)

Answer 611

Elleste-duet Conti (pill) or Evorel Conti (estradiol + northisterone)

Answer 612

Elleste-Solo (pill) or Evorel Solo (patch) (estradiol)

Answer 613

in the climacteric perioid

Answer 614

reduced levels of female hormones, principally oestrogen

Answer 615

change in length of menstrual cycles dysfunctional uterine bleeding may occur

Answer 616

change in periods vasomotor symptoms (80%) urogenital changes (35%) psychological longer term Cx

Answer 617

affects around 80% of women. Usually occur daily and may continue for up to 5 years hot flushes night sweats

Answer 618

vaginal dryness and atrophy urinary frequency

Answer 619

anxiety and depression may be seen - around 10% of women short-term memory impairment

Answer 620

osteoporosis increased risk of ischaemic heart disease

Answer 621

Enabling an informed choice of preparation, based on age, symptoms, and co-morbidities, including discussion of risks, benefits, adverse effects, and contraindications. Prescribing the lowest dose for the shortest possible duration. Offering an oestrogen plus progestogen preparation for women with a uterus, or oestrogen-only preparation for women without a uterus. Offering low-dose vaginal oestrogen first-line for urogenital symptoms. Arranging regular review to assess the efficacy and tolerability of treatment(s), adjusting the dose or preparation if needed, and advice on stopping HRT.

Answer 622

Offering antidepressants, clonidine, gabapentin, and/or cognitive behavioural therapy (CBT) for vasomotor symptoms, depending on her wishes and local service provision. Offering self-help resources and CBT for mood disorders and problems with sleep. Vaginal moisturizers and/or lubricants for urogenital symptoms. Arranging regular review to assess the efficacy and tolerability of treatment(s).

Answer 623

Are ongoing symptoms despite treatment. Are persistent, troublesome adverse effects. Is uncertainty about the most suitable treatment option. Is uncertainty about the diagnosis or management of POI. Is a need for psychological treatment for people who have experienced an early menopause.

Answer 624

the menstrual cycle length may shorten to 2–3 weeks or lengthen to many months. The amount of menstrual blood loss may change, and commonly increases slightly.

Answer 625

A sudden feeling of heat in the upper body (face, neck, and chest) that spreads upwards and downwards. In some cases, this becomes generalized, typically lasting 2–4 minutes, and can be associated with excessive sweating, palpitations, or anxiety. They can be embarrassing and distressing, and triggers may include spicy food and alcohol.

Answer 626

hormonal contraception or HRT

Answer 627

continue contraception and the FSH level should be rechecked in 1 year.

Answer 628

elevated FSH level on two blood samples taken 4–6 weeks apart.

Answer 629

no, usually clinical

Answer 630

low dose vaginal oestrogen for as long as needed

Answer 631

clonidine (alpha-2 adrenergic receptor agonist) or SSRI

Answer 632

gradually reduce over 3-6m or stop suddenly depending on preference

Answer 633

transdermal over oral

Answer 634

- VTE (oral>transdermal) - small increased risk stroke if oral and if higher oestrogen & longer duration but not if <60 - increased risk of breast ca with combined

Answer 635

- fragility fractures decreased - may improve muscle mass and strength

Answer 636

excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.

Answer 637

no underlying pelvic pathology

Answer 638

up to 50% of menstruating women and usually appears within 1-2 years of the menarche.

Answer 639

Excessive endometrial prostaglandin production

Answer 640

pain typically starts just before or within a few hours of the period starting suprapubic cramping pains which may radiate to the back or down the thigh

Answer 641

1st line= NSAIDs eg. mefenamic acid or ibuprofen work in up to 80% 2nd= COCP

Answer 642

inhibit prostaglandin production

Answer 643

typically develops many years after the menarche and is the result of an underlying pathology

Answer 644

usually starts 3-4 days before the onset of the period

Answer 645

endometriosis adenomyosis pelvic inflammatory disease copper IUD fibroids

Answer 646

refer all patients with secondary dysmenorrhoea to gynaecology for investigation.

Answer 647

Primary= typically starts just before or within a few hours of the period starting Secondary= usually starts 3-4 days before the onset of the period.

Answer 648

occurs in the absence of any identifiable underlying pelvic pathology. It is thought to be caused by the production of uterine prostaglandins during menstruation, which causes uterine contractions and pain.

Answer 649

caused by an underlying pelvic pathology (such as endometriosis, fibroids, or pelvic inflammatory disease [PID]) or by intrauterine device (IUD) insertion.

Answer 650

earlier age at menarche, heavy menstrual flow, nulliparity, and family history of dysmenorrhoea.

Answer 651

exclude secondary causes

Answer 652

usually starts 6–12 months after the menarche once cycles are regular. The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses. The pain is usually lower abdominal but may radiate to the back and inner thigh. It may be accompanied by non-gynaecological symptoms, such as vomiting, nausea, diarrhoea, fatigue, irritability, dizziness, headache, and lower back pain. Pelvic examination is normal.

Answer 653

starts after several years of painless periods. The pain is not consistently related to menstruation and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation. Other gynaecological symptoms (such as dyspareunia) are often present. Pelvic examination may be abnormal, but normal findings do not exclude secondary dysmenorrhoea.

Answer 654

Positive pregnancy test with vaginal bleeding. Ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids). Abnormal cervix on examination. Persistent intermenstrual or postcoital bleeding without associated features of PID, such as pelvic pain, deep dyspareunia, and abnormal vaginal or cervical discharge.

Answer 655

If symptoms are severe and have not responded to initial treatment within 3–6 months or if there is doubt about the diagnosis.

Answer 656

heavy bleedings - what the women considers to be excessive

Answer 657

- FBC in all women - Routine transvaginal USS if symptoms suggest structural or histological abnormality (eg. intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) or if abnormal pelvic exam findings

Answer 658

either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period if no improvement then try other drug whilst awaiting referral

Answer 659

if pt requires contraception or not

Answer 660

- 1st line= IUS (mirena) - COCP - long-acting progestogens

Answer 661

norethisterone 5mg tds

Answer 662

excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life. It can occur alone or in combination with other symptoms.

Answer 663

no underlying cause found

Answer 664

unknown, uterine fibroid, uterine cancer, endometriosis, systemic disorders (such as coagulation disorders and hypothyroidism), and medications (such as anticoagulants).

Answer 665

An LNG-IUS should be offered. If this is declined or unsuitable, other pharmacological treatments should be considered, such as tranexamic acid, a nonsteroidal anti-inflammatory drug (NSAID), or hormonal treatments (combined hormonal contraception or cyclical oral progestogens). If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, referral to a specialist should be considered for further investigations and consideration of alternative treatment options.

Answer 666

specialist referral should be considered for additional investigations and consideration of treatment options. If pharmacological treatment is needed while the woman is awaiting treatment or referral, tranexamic acid and/or an NSAID should be offered.

Answer 667

Physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously due to uterine fibroids). The woman has a pelvic mass associated with any other features of cancer (such as unexplained bleeding or weight loss). There are complications, such as compressive symptoms from large fibroids (for example, dyspareunia, pelvic pain or discomfort, constipation, or urinary symptoms). The woman has iron deficiency anaemia that has failed to respond to treatment and other causes have been excluded.

Answer 668

'middle pain' and refers to abdominal pain associated with ovulation. This mid-cyclical pain is experienced by 20% of women.

Answer 669

That it occurs due to a leakage of follicular fluid containing prostaglandins at the time of ovulation, which causes the pain. Another explanation is that the growth of the follicle stretches the surface of the ovary, causing pain.

Answer 670

Sudden onset of pain in either iliac fossa which then manifests as a generalised pelvic pain. Typically, the pain is not severe and varies in duration, lasting from minutes to hours. It is self-limiting and resolves within 24 hours of onset. Pain may switch side from month to month, depending on the site of ovulation

Answer 671

There is no specific test to confirm Mittelschmerz and it diagnosed clinically, after taking a full history and examination to exclude other conditions No abnormal signs on abdominal or pelvic examination.

Answer 672

not harmful and can be controlled with simple analgesia

Answer 673

polycystic ovary syndrome

Answer 674

complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age

Answer 675

not fully understood Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.

Answer 676

subfertility and infertility menstrual disturbances: oligomenorrhoea and amenorrhoea hirsutism, acne (due to hyperandrogenism) obesity acanthosis nigricans (due to insulin resistance)

Answer 677

- pelvic USS= multiple cysts on ovaries - FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG) - check for impaired glucose tolerance

Answer 678

FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)

Answer 679

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 SHBG is normal to low in women with PCOS

Answer 680

consider other causes

Answer 681

after performing Ix to exclude other conditions

Answer 682

Rotterdam criteria

Answer 683

- infrequent or no ovulation (usually manifested as infrequent or no menstruation; oligomenorrhea) - clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone) - polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)

Answer 684

hirsutism, acne, or elevated levels of total or free testosterone

Answer 685

presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³

Answer 686

- weight loss if relevant - COCP may help regulate her cycle if require contraception - hirsutism & acne= COCP or topical eflornithine if no response - infertility Mx

Answer 687

COCP= options incl third generation COCP which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of VTE if doesn't respond to COCP then topical eflornithine may be tried spironolactone, flutamide and finasteride may be used under specialist supervision

Answer 688

- weight reduction in relevant - specialist Mx= metformin, clomifene or combination; gonadotrophins may be used

Answer 689

work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion There is a potential risk of multiple pregnancies with anti-oestrogen therapies.

Answer 690

heterogeneous endocrine disorder that appears to emerge at puberty

Answer 691

hyperandrogenism (with clinical features such as acne and hirsutism), ovulation disorder (usually manifested as infrequent or no menstruation), and polycystic ovarian morphology on ultrasound.

Answer 692

Infertility. Cardiovascular disease (CVD). Metabolic disorders, such as impaired glucose tolerance and type 2 diabetes. Obstructive sleep apnoea. Psychological disorders, such as anxiety and depression. Pregnancy complications, such as pre-eclampsia and gestational diabetes. Endometrial cancer. Non-alcoholic fatty liver disease.

Answer 693

20 or more follicles in at least one ovary

Answer 694

Free androgen index should be calculated to assess the amount of physiologically active testosterone present. Luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone levels should be measured to rule out other causes of oligomenorrhoea and amenorrhoea (such as premature ovarian failure, hypothyroidism, and hyperprolactinaemia). Referral for an ultrasound scan is required in adult women (unless the diagnosis of PCOS is obvious on clinical and biochemical grounds). An ultrasound scan should not be used for the diagnosis of PCOS in adolescents due to the high incidence of multi-follicular ovaries in this life stage. Polycystic ovaries on ultrasound is defined as the presence of 20 or more follicles in at least one ovary.

Answer 695

- Clinical and/or biochemical signs of hyperandrogenism. - Ovulatory dysfunction. - Polycystic ovarian morphology on ultrasound.

Answer 696

tighter criteria requiring both hyperandrogenism and irregular menstrual cycles is recommended due to the overlap with normal pubertal reproductive physiology.

Answer 697

Managing the clinical features of PCOS. Screening for cardiovascular risk factors and advising on healthy lifestyle measures to reduce CVD risk. Where appropriate, weight loss should be advised. Assessing for (and managing) other possible complications of PCOS. Providing sources of additional information and support.

Answer 698

at 'increased risk' of PCOS and reassessed at or before full reproductive maturity (8 years post-menarche). This includes those with PCOS features before combined oral contraceptive pill commencement, those with persisting features, and those with significant weight gain in adolescence.

Answer 699

Normal in the first year post-menarche as part of the pubertal transition. More than 1 year to less than 3 years of irregular cycles (more than 45 days or less than 21 days) after the onset of menarche. More than 3 years of irregular cycles (more than 35 days or less than 21 days, or less than 8 cycles every year) post menarche to perimenopause. More than 1 year of irregular cycles (more than 90 days for any one cycle) post menarche. Primary amenorrhea by age 15 years or more than 3 years of irregular cycles post thelarche (breast development).

Answer 700

if BMI 25 or more for weight loss

Answer 701

GI symptoms and reduced vit B12

Answer 702

weight change and excess weight. Monitoring could be at each visit or at a minimum of 6–12 monthly, with frequency, planned and agreed with the woman.

Answer 703

Reduce hyperinsulinism and hyperandrogenism. Reduce the risk of type 2 diabetes and CVD. Result in menstrual regularity. Improve the chance of pregnancy (if it is desired).

Answer 704

2-hour post 75 g oral glucose tolerance test (OGTT), fasting plasma glucose, or HbA1c to assess glycaemic status.

Answer 705

premenstrual syndrome

Answer 706

emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.

Answer 707

in the presence of ovulatory menstrual cycles - it doesn't occur prior to puberty, during pregnancy or after the menopause.

Answer 708

anxiety stress fatigue mood swings

Answer 709

bloating breast pain

Answer 710

lifestyle advice apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates

Answer 711

new-generation combined oral contraceptive pill (COCP) examples include Yasminµ (drospirenone 3 mg and ethinylestradiol 0.030 mg)

Answer 712

selective serotonin reuptake inhibitor (SSRI) this may be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length)

Answer 713

Menstrual phase= days 1-5 Follicular phase= 6-14d Ovulatory phase= day 14 Luteal phase= 15-28d

Answer 714

psychological, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle (the time between ovulation and onset of menstruation). Psychological symptoms include depression, anxiety, irritability, loss of confidence, and mood swings. Physical symptoms include bloating and breast pain. Behavioural symptoms include reduced cognitive ability and aggression.

Answer 715

timing (rather than the types) of symptoms and the degree of impact on daily activity.

Answer 716

significant impairment to the woman during the luteal phase of the menstrual cycle.

Answer 717

a severe form of PMS defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as occurring when a woman suffers from at least five out of 11 distinct premenstrual symptoms, one of which must be related to mood, and which cause significant distress or impaired functioning.

Answer 718

record a daily symptom diary for two or three cycles.

Answer 719

The diary shows a prominence of symptoms during the luteal phase of the menstrual cycle, which resolve with the onset of menses or soon after, followed by a symptom-free week. Symptoms are severe enough to affect daily functioning or interfere with the woman's work, school, performance, or interpersonal relationships. There is an absence of other conditions that could explain the symptoms, such as depression, hypothyroidism, anaemia, irritable bowel syndrome, and endometriosis.

Answer 720

severity, impact and type of symptoms, the woman's treatment preferences and goals, and any plans to become pregnant.

Answer 721

lifestyle advice (including advice on diet, regular exercise, smoking cessation, alcohol restriction, regular sleep, stress reduction, and complementary treatments and/or dietary supplements), a non-steroidal anti-inflammatory drug (NSAID) for pain as required (if relevant and not contraindicated), and patient information on PMS.

Answer 722

A drospirenone-containing combined oral contraceptive pill, particularly where contraception is desired (off-label use if not required for contraception). Cognitive behavioural therapy. A selective serotonin reuptake inhibitor (SSRI) (off-label use), particularly where symptoms are severe or affective symptoms are predominant.

Answer 723

woman must have a minimum of five of the eleven listed symptoms, with a minimum of one being related to mood, during most menstrual cycles over the last year. The symptoms must be present in the final week before menstruation and start to improve within a few days of its onset, and be minimal or absent in the week after.

Answer 724

At least one of the following symptoms must be present: - Marked mood lability/mood swings. - Marked depressed mood, feelings of hopelessness or self-deprecating thoughts. - Marked irritability or anger or increased interpersonal conflicts. - Marked anxiety or tension. Additionally there must be further symptoms, reaching a total of five between the two lists: - Reduced interest in usual activities. - Difficulty concentrating. - Lethargy, easily tired, or lack of energy. - Marked changes in appetite. - Sleep changes (hypersomnia or insomnia). - A sense of feeling overwhelmed or out of control. - Physical symptoms, such as breast tenderness or swelling, joint or muscle pain, bloating, or weight gain. These symptoms must cause significant distress or interference with usual activities or relationships. The symptoms do not represent an exacerbation of another mental health disorder, and cannot be attributable to a substance or another medical condition. There should be confirmation by using a symptom diary for at least two cycles.

Answer 725

descent of one of the pelvic organs resulting in protrusion on the vaginal walls. It probably affects around 40% of postmenopausal women

Answer 726

cystocele, cystourethrocele rectocele uterine prolapse less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)

Answer 727

increasing age multiparity, vaginal deliveries obesity spina bifida

Answer 728

sensation of pressure, heaviness, 'bearing-down' urinary symptoms: incontinence, frequency, urgency

Answer 729

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

Answer 730

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

Answer 731

physiological Candida Trichomonas vaginalis bacterial vaginosis

Answer 732

Gonorrhoea Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms ectropion foreign body cervical cancer

Answer 733

post-menopausal

Answer 734

Vaginal dryness, dyspareunia and occasional spotting. On examination, the vagina may appear pale and dry.

Answer 735

vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.

Answer 736

an underlying cause

Answer 737

skin condition characterized by the sensation of perianal itching or burning

Answer 738

irritant contact dermatitis (e.g. latex condoms, lubricants): most common cause atopic dermatitis seborrhoeic dermatitis lichen planus lichen sclerosus psoriasis: seen in around a third of patients with psoriasis

Answer 739

women who suffer from this should be advised to take showers rather than taking baths they should also be advised to clean the vulval area with an emollient such as Epaderm or Diprobase clean only once a day as repeated cleaning can aggravate the symptoms most of the underlying conditions will respond to topical steroids combined steroid-antifungal may be tried if seborrhoeic dermatitis is suspected

Answer 740

inflammatory condition that usually affects the genitalia and is more common in elderly females

Answer 741

atrophy of the epidermis with white plaques forming

Answer 742

white patches that may scar itch is prominent may result in pain during intercourse or urination

Answer 743

clinical grounds but a biopsy may be performed if atypical features are present

Answer 744

topical steroids and emollients

Answer 745

increased risk of vulval ca

Answer 746

if the woman fails to respond to treatment or there is clinical suspicion of VIN or cancer.

Answer 747

(i) there is a suspicion of neoplastic change, i.e. a persistent area of hyperkeratosis, erosion or erythema, or new warty or papular lesions; (ii) the disease fails to respond to adequate treatment; (iii) there is extragenital LS, with features suggesting an overlap with morphoea; (iv) there are pigmented areas, in order to exclude an abnormal melanocytic proliferation; and (v) second-line therapy is to be used.

Answer 748

pre-cancerous skin lesion of the vulva, and may result in squamous skin cancer if untreated. The average age of an affected woman is around 50 years

Answer 749

human papilloma virus 16 & 18 smoking herpes simplex virus 2 lichen sclerosus

Answer 750

itching, burning raised, well-defined skin lesions

Answer 751

biopsy: punch biopsy or excisional biopsy for histological diagnosis HPV Testing: PCR or in situ hybridisation for high-risk HPV DNA

Answer 752

topical therapies: - imiquimod= Immune response modifier - 5-Fluorouracil: Topical chemotherapeutic agent surgical Interventions: - aimed at complete removal of dysplastic areas while preserving normal anatomy and function as much as possible. - techniques include wide local excision, laser ablation, or more radical approaches like partial vulvectomy in cases of extensive disease.

Answer 753

- imiquimod= Immune response modifier - 5-Fluorouracil: Topical chemotherapeutic agent

Answer 754

aimed at complete removal of dysplastic areas while preserving normal anatomy and function as much as possible. techniques include wide local excision, laser ablation, or more radical approaches like partial vulvectomy in cases of extensive disease.

Answer 755

regular monitoring with repeat colposcopy and biopsy if recurrence or progression is suspected.

Answer 756

considered a permanent method of contraception. The operation to sterilize a man is called a vasectomy. The operation to sterilize a woman is called tubal occlusion.

Answer 757

Fertility awareness methods (FAM). Lactational amenorrhoea methods (LAM).

Answer 758

Fertility awareness methods (FAM). Basal body (waking) temperature — a slight rise in temperature that persists for 3 days indicates that the fertile time has ended. Cervical secretions — an increase in the volume of wet, slippery, and clear cervical secretions indicates that ovulation is approaching. Changes in the cervix — the fertile window starts at the first sign of the cervix changing from being low and firm, and the cervical os closed, to the cervix being high and soft and the cervical os open. Length of menstrual cycle — involves calculating the length of the menstrual cycle and using this to estimate the time of ovulation and the fertile days of the menstrual cycle.

Answer 759

Lactational amenorrhoea methods involves breastfeeding after childbirth to prevent pregnancy (breastfeeding delays the return of ovulation by disrupting gonadotrophin release). The following conditions must all be met before LAM can be used: Complete amenorrhoea. Fully or nearly fully breastfeeding (that is, the baby is getting 85% or more of its feeds as breast milk). Less than 6 months postpartum.

Answer 760

An assessment should be done to confirm the suitability of the method. As part of the assessment, the World Health Organization Medical Eligibility Criteria for Contraceptive Use should be applied to assess her eligibility for use of the method. Verbal and written information should be provided on how the method works, as well as the efficacy, advantages, and disadvantages of the methods. Women wishing to use fertility indicators for contraceptive purposes should receive support and instruction on the method from a trained practitioner. Advice should be offered on other methods of contraception, such as long-acting reversible contraception (LARC), and their comparative efficacy. In women for whom pregnancy poses a significant health risk, the reliance on fertility indicators for the prevention of pregnancy is not recommended. Contraceptive options should be discussed with the woman and, where necessary, specialists involved in the management of her condition. Women taking drugs that are known to have a teratogenic effect should not rely solely on fertility indicators for the prevention of pregnancy.

Answer 761

characterized by the presence of endometrial tissue within the myometrium. It is more common in multiparous women towards the end of their reproductive years.

Answer 762

dysmenorrhoea menorrhagia enlarged, boggy uterus

Answer 763

adenomyosis

Answer 764

transvaginal ultrasound as the first-line investigation MRI is an alternative

Answer 765

symptomatic= tranexamic acid to manage menorrhagia GnRH agonists uterine artery embolisation hysterectomy= considered the 'definitive' treatment

Answer 766

hysterectomy

Answer 767

X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype.

Answer 768

testicular feminisation syndrome

Answer 769

'primary amenorrhoea' little or no axillary and pubic hair undescended testes causing groin swellings breast development may occur as a result of the conversion of testosterone to oestradiol

Answer 770

androgen insensitivity syndrome

Answer 771

buccal smear or chromosomal analysis to reveal 46XY genotype after puberty, testosterone concentrations are in the high-normal to slightly elevated reference range for postpubertal boys

Answer 772

counselling - raise the child as female bilateral orchidectomy (increased risk of testicular cancer due to undescended testes) oestrogen therapy

Answer 773

androgen insensitivity syndrome

Answer 774

party carrying the foetus is not genetically related to the implanted foetus

Answer 775

which the surrogate's egg is fertilised via IVF and then re-implanted

Answer 776

the women giving birth

Answer 777

refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.

Answer 778

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

Answer 779

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

Answer 780

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).

Answer 781

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

Answer 782

partial or complete torsion of the ovary on it's supporting ligaments that may in turn compromise the blood supply.

Answer 783

adnexal torsion

Answer 784

ovarian mass: present in around 90% of cases of torsion being of a reproductive age pregnancy ovarian hyperstimulation syndrome

Answer 785

Usually the sudden onset of deep-seated colicky abdominal pain. Associated with vomiting and distress fever may be seen in a minority (possibly secondary to adnexal necrosis) Vaginal examination may reveal adnexial tenderness

Answer 786

Ultrasound may show free fluid or a whirlpool sign. Laparoscopy is usually both diagnostic and therapeutic.

Answer 787

surface derived tumours germ cell tumours sex cord-stromal tumours metastasis

Answer 788

malignant tumours

Answer 789

Serous cystadenoma Serous cystadenocarcinoma Mucinous cystadenoma Mucinous cystadenocarcinoma Brenner tumour

Answer 790

Benign Most common benign ovarian tumour, often bilateral Cyst lined by ciliated cells (similar to Fallopian tube)

Answer 791

Malignant Often bilateral Psammoma bodies seen (collection of calcium)

Answer 792

Benign Cyst lined by mucous-secreting epithelium (similar to endocervix)

Answer 793

Malignant May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)

Answer 794

Benign Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have 'coffee bean' nuclei.

Answer 795

adolescent girls and are account for 15-20% of tumours. Similar cancer types to those seen in the testicle.

Answer 796

Teratoma Dysgerminoma Yolk sac tumour Choriocarcinoma

Answer 797

Mature teratoma (dermoid cyst) - most common: benign Immature teratoma: malignant Account for 90% of germ cell tumours Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue

Answer 798

Malignant Most common malignant germ cell tumour Histological appearance similar to that of testicular seminoma Associated with Turner's syndrome Typically secrete hCG and LDH

Answer 799

Malignant Typically secrete AFP Schiller-Duval bodies on histology are pathognomonic

Answer 800

Malignant Rare tumour that is part of the spectrum gestational trophoblastic disease Typically have increased hCG levels Often characterised by early haematogenous spread to the lungs

Answer 801

hormones Represent around 3-5% of ovarian tumours.

Answer 802

Granulosa cell tumour Sertoli-Leydig cell tumour Fibroma

Answer 803

Malignant Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults. Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)

Answer 804

Benign Produces androgens → masculinizing effects Associated with Peutz-Jegher syndrome

Answer 805

Benign Associated with Meigs' syndrome (ascites, pleural effusion) Solid tumour consisting of bundles of spindle-shaped fibroblasts Typically occur around the menopause, classically causing a pulling sensation in the pelvis

Answer 806

Fibroma (sex cord-stromal tumours)

Answer 807

Krukenberg tumour

Answer 808

Malignant Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma

Answer 809

early follicular phase requires an increase in gonadotropin-releasing hormone (GnRH) pulse frequency which increases the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH), to allow for stimulation and development of multiple ovarian follicles, and usually only one of which will become the dominant ovulatory follicle in that menstrual cycle.

Answer 810

mid-follicular phase, FSH gradually stimulates estradiol production, following which estradiol itself produces a negative feedback loop on the hypothalamus and pituitary gland to suppress FSH and LH concentrations.

Answer 811

In the luteal phase, there is a unique switch from negative to positive feedback of estradiol, resulting in a surge of LH secretion and this leads to subsequent follicular rupture and ovulation.

Answer 812

It is the unique balance of hormones and their feedback loops which leads to normal ovulation with each menstrual cycle, however with each class of ovulatory dysfunction, there is an alteration in this fine balance which may lead to irregular or complete anovulation.

Answer 813

Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women) Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases) Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive

Answer 814

when the ovaries do not release an egg during a menstrual cycle

Answer 815

It is ideal to start with the least invasive and simplest management option first, and work the way up to more complicated and intensive treatment For most women, it is the goal to induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development, and this is to ultimately lead to a singleton pregnancy, which tends to be far lower risk and therefore preferable

Answer 816

- exercise and weight loss - letrozole - Clomiphene citrate - gonadotropin therapy

Answer 817

Typically this is the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss Therefore, particularly for overweight or obese women with polycystic ovarian syndrome, this should be trialled solely first, and then artificial ovulation induction be considered

Answer 818

now considered the first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction Side effects: fatigue (20%), dizziness (10%)

Answer 819

While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead Mechanism of action: clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development Side effects: hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%)

Answer 820

This tends to be the treatment used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development

Answer 821

Ovarian hyperstimulation syndrome (OHSS)

Answer 822

ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications

Answer 823

Hypovolaemic shock Acute renal failure Venous or arterial thromboembolism

Answer 824

rare side effect which varies in severity, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction

Answer 825

depends on severity Fluid and electrolyte replacement Anti-coagulation therapy Abdominal ascitic paracentesis Pregnancy termination to prevent further hormonal imbalances

Answer 826

vaginal bleeding after sex

Answer 827

no identifiable pathology is found in around 50% of cases cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill cervicitis e.g. secondary to Chlamydia cervical cancer polyps trauma

Answer 828

post menstrual= ?endometrial ca post coital= ? cervical ca

Answer 829

vaginal bleeding occurring after 12 months of amenorrhoea. Whilst the majority of women do not have an underlying malignancy it is important to exclude this in all women.

Answer 830

vaginal atrophy= the most common cause of postmenopausal bleeding 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 HRT (hormone replacement therapy)= periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding endometrial hyperplasia= an abnormal thickening of the endometrium and a precursor for endometrial carcinoma risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes endometrial cancer= although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently cervical cancer= it is important to obtain a full record of prior cervical screening programme attendance ovarian cancer= can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours vaginal cancer= uncommon but can present with postmenopausal bleeding other uncommon causes include= trauma vulval cancer bleeding disorders

Answer 831

within two weeks by ultrasound for endometrial cancer= transvaginal ultrasound: - endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm - however, it may miss some pathology and if clinical suspicion is high, further testing is required

Answer 832

endometrial ca

Answer 833

NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer for those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer

Answer 834

Tx by cause once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding - vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used - if a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this - in the case of endometrial hyperplasia, usually dilatation and curettage is performed to remove the excess endometrial tissue

Answer 835

nset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.

Answer 836

idiopathic: - the most common cause - there may be a family history bilateral oophorectomy: - having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause radiotherapy chemotherapy infection: e.g. mumps autoimmune disorders resistant ovary syndrome= due to FSH receptor abnormalities

Answer 837

climacteric symptoms: hot flushes, night sweats infertility secondary amenorrhoea raised FSH, LH levels e.g. FSH > 30 IU/L elevated FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart low oestradiol e.g. < 100 pmol/l

Answer 838

raised FSH, LH levels e.g. FSH > 30 IU/L elevated FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart low oestradiol e.g. < 100 pmol/l

Answer 839

on 2 blood samples taken 4-6 weeks apart

Answer 840

hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years) it should be noted that HRT does not provide contraception, in case spontaneous ovarian activity resumes