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Phase 4 Question Knowledge > Gynae > Flashcards

Gynae Flashcards

1
Q

Bartholin’s cyst / abscess

A

Fluid filled sac in one of Bartholin’s glands

Gland blocked - mucus build up - cyst

Infected - abscess - E coli, MRSA, STIs

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2
Q

Bartholin’s cyst / abscess Px

A

Cyst
- soft, fluctuant, non-tender mass
- vulvar pain walking / sitting
- superficial dyspareunia
- sudden relief (rupture)

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3
Q

Bartholin’s cyst / abscess Ix

A

Clinical dx

> 40yo biopsy - r/o cancer

Endocervical + high vagina; swabs - STI

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4
Q

Bartholin’s cyst / abscess Mx

A

Small - warm baths may stimulate rupture

Word catheter - incise, insert catheter, leave for 4-6wks, tract forms (not for deep cysts)

Marsupialisation - cut into, suture up - under GA

Also silver nitrate cautery, needle aspiration, CO2 laser

Abscess - abx

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5
Q

Stress incontinence

A

Involuntary leakage of urine with increased intra-abdo pressure

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6
Q

Stress incontinence Px

A

Urine leakage on exertion

Coughing, sneezing, exercise

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7
Q

Stress incontinence Ix

A

R/o UTI - urine dip + culture

Freq/vol chart

Urodynamic studies - r/o detrusor overactivity

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8
Q

Stress incontinence Mx

A

Wt loss, reduce caffeine, stop smoking

Pelvic floor muscle training

Surgical- Tension free vaginal tape

Duloxetine - enhanced contraction of urethral sphincter- if women decline surgical procedure

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9
Q

Urge incontinence

A

Overactive bladder - freq, urg, nocturia - detrusor overactivity

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10
Q

Urge incontinence Px

A

Urgency, frequency, nocturia

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11
Q

Urge incontinence Ix

A

R/o UTI
Freq/vol chart - shows increased freq
Urodynamic studies

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12
Q

Urge incontinence Mx

A

reduce fluids, caffeine

Bladder retraining

Anticholinergics - oxybutynin / solifenacin / tolterodine

Mirabegron

Botox

Surgical mx (detrusor myomectomy) if debilitating sx

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13
Q

Pelvic organ prolapse

A

Descent of pelvic organs into vagina - from weakness / lengthening of ligaments / muscles

Uterine prolapse - uterus descends

Vault prolapse - post-hysterectomy - top of vagina descends

Rectocele - defect in posterior vaginal wall - rectum prolapses

Cystocele - defect in anterior vaginal wall - bladder prolapses

urethrocele - urethra prolapses

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14
Q

Pelvic organ prolapse Px

A

Dragging sensation, something coming down

Urinary sx - incontinence, urgency, freq, weak stream, retention

Bowel sx - incontinence, constipation, urgency

Sexual dysfunction - pain, altered sensation

Lump / mass in vagina

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15
Q

Pelvic organ prolapse exam

A

Use Sim’s speculum, empty bladder / bowel first

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16
Q

Pelvic organ prolapse Mx

A

Pelvic floor exercises, wt loss…

Pessaries

Surgery

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17
Q

Lichen sclerosus

A

Chronic inflammation (?autoimmune) of genitalia usually

more common in elderly F

Atrophy of epidermis + white plaques

Increased vulvar SCC risk

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18
Q

Lichen sclerosus Px

A

White patches
Scarring
Itch
Dyspareunia, dysuria
Sx worse with friction (Koebner)

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19
Q

Lichen sclerosus Ix

A

Clinical
Biopsy if atypical, ?malignancy, no tx response

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20
Q

Lichen sclerosus Mx

A

Topical steroids - clobetasol

Emollients

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21
Q

Ovarian cysts

A

Fluid filled sac in ovary

Common, benign mostly

Simple - fluid only
Non-neoplastic - no malignant potential
Neoplastic - malignant potential

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22
Q

Ovarian cysts / tumours RFs

A

Nulliparity (more ovulations), early menarche, late menopause, smoking, obesity, HRT with oestrogen only

BRCA 1+2 - breast, ovarian ca
HNPCC - colorectal, endometrial, ovarian ca

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23
Q

Ovarian cysts / tumour protective factors

A

Multiparity, combined contraception, breastfeeding

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24
Q

Ovarian cysts Px

A
  • Asym
  • Chronic pain - frequency, constipation, bloating, dyspareunia
  • Acute pain - bleed / rupture / torsion
  • PV bleed
  • Wt loss - cancer
  • Abdo mass, ascites
  • Adnexal masses, cervical excitation
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25
Q

Ovarian cysts Ix

A

CA125

USS

Calculate risk of malignancy index (RMI) - menopausal status + US findings + CA125 level

<40yo - bloods for ?germ cell tumour - LDH, alpha-fetoprotein, hCG

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26
Q

Ovarian cyst Mx

A

Pre-menopause
- Monitor with rpt US / CA125
- Persistent / >5cm - laparoscopic cystectomy / oophorectomy

Post-menopause
- RMI <25, <5cm - 1yr follow up with USS + CA125
- RMI 25-250 - oophorectomy / hysterectomy / omentectomy / lymphadenectomy
- RMI >250 - staging laparotomy

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27
Q

Meig’s syndrome

A

Benign ovarian fibroma (mass) + pleural effusion + ascites

Typically older women

Remove tumour - effusion + ascites resolve

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28
Q

Ovarian cancer

A

Malignant tumour of ovary

Can be surface derived, germ cell, sex-cord stromal, mets

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29
Q

Ovarian cancer Px

A

Abdo / pelvic pain
Abdo distension / bloating
Urinary sx - urgency
Diarrhoea
Early satiety, weight loss, anorexia
Abdo mass

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30
Q

Ovarian cancer Ix

A

Bloods, inc CA125, (aFP + hCG if <40yo)

Abdo / pelvic USS

CT / CXR - staging

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31
Q

FIGO staging Ovarian cancer

A

1 - ovary
2 - spread to pelvis
3 - spread to abdo
4 - spread past abdo

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32
Q

Ovarian cancer Mx

A

Surgery - staging laparotomy

Chemo

Follow up for 5yrs

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33
Q

PCOS

A

Excess androgens + multiple immature follicles (cysts) in ovaries

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34
Q

PCOS Patho

A
  • Multifactorial cause
  • Excess LH (from ant pit) -> ovaries produce excess androgens
  • Insulin resistance - high insulin - supresses hepatic production of sex hormone binding globulin (SHBG) - higher levels of free androgens
  • androgens suppress LH surge + ovulation
  • follicles develop in ovary, arrested at early stage - remain as cysts
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35
Q

PCOS Px

A
  • Oligomenorrhoea, amenorrhoea
  • Infertility
  • Hirsutism
  • Obesity
  • Chronic pelvic pain
  • Depression
  • Acne, acanthosis nigricans, male pattern hair loss, HTN
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36
Q

PCOS DDx

A

Hypothyroid

Hyperprolactinaemia

Cushing’s

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37
Q

PCOS Dx - Rotterdam Criteria

A

Dx if 2/3 of:
- Oligo +/-anovulation
- clinical / biochemical signs of hyperandrogenism
- polycystic ovaries on imaging

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38
Q

PCOS Ix

A
  • Testosterone raised, SHBG low, LH raised, FSH normal, progesterone low
  • LH:FSH raised
  • TFTs, serum prolactin
  • Pelvic USS - peripheral ovarian follicles - string of pearls appearance
  • OGTT
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39
Q

PCOS Mx

A

Oligomenorrhoea
- With anovulation - low progesterone -> unopposed oestrogen => endometrial hyperplasia + malignancy risk - need to induce bleeds to prevent this:
- cOCP
- Dydrogesterone (progesterone analogue)

Infertility
- Clomifene +/- metformin -> induce ovulation
- Laparoscopic ovarian drilling
- Gonadotrophins

Hirsutism
- Cosmetic
- Anti-androgens - cyproterone, spironolactone, finasteride
- Eflornithine - cream for facial hair

Obesity
- Diet, exercise
- Orlistat

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40
Q

Adenomyosis

A

Growth of endometrial tissue in myometrium - benign

tends to be multiparous, older women

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41
Q

Adenomyosis Px

A
  • Dysmenorrhoea - cyclical -> daily
  • Menorrhagia
  • Deep dyspareunia
  • Irregular bleeding
  • Symmetrically enlarged, boggy uterus
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42
Q

Adenomyosis Ix

A

TVUS

MRI

Histology after hysterectomy - definitive

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43
Q

Adenomyosis Mx

A

NSAIDs, TXA + mefenamic acid for sx

Hormone therapy for cycle control - cOCP, progestogens, GnRH agonist, aromatase inhibitor

Hysterectomy - curative

Uterine artery embolisation - short term to preserve fertility (block blood supply to adenomyosis)

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44
Q

Endometrial cancer

A

Tumour of endometrium

Mostly adenocarcinoma

From unopposed oestrogen (no progesterone)

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45
Q

Endometrial cancer RFs

A

Obesity, nulliparity, early menarche, late menopause

Unopposed oestrogen (so add progesterone to HRT to prevent)

DM, tamoxifen, PCOS

HNPCC- hereditary non-polyposis colorectal carcinoma- also known as lynch syndrome

cOCP + smoking + multiparity - protective

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46
Q

Endometrial cancer Px

A

PMB - post-menopausal bleeding

Intermenstrual bleeding (IMB) (pre-menopause)

Pain, discharge

Abdo pelvic masses, vaginal atrophy

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47
Q

Endometrial cancer Ix

A

All women >55 with postmenopausal bleeding should be referred

TVUS - endometrial thickness should be <4mm

Pipelle biopsy

Hysteroscopy, endometrial biopsy

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48
Q

FIGO endometrial cancer staging

A

1 - in uterus
2 - spread to cervix
3 - spread to pelvis
4 - bladder/bowel/further

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49
Q

Endometrial cancer Mx

A

Hysterectomy + bl salpingo-oophorectomy

Chemo / radio if mets

Progesterone therapy - if frail / not fit for surgery

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50
Q

Endometrial hyperplasia

A

Abnormal PV bleed - eg IMB

Progestogens (eg Mirena), rpt sample 3-4mo

Surgery if atypical hyperplasia - dilatation + curettage

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51
Q

Endometriosis

A

Growth of endometrial tissue outside uterus

Tissue is sensitive to oestrogen - cyclical sx

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52
Q

Endometriosis Px

A
  • Cyclical pelvic pain - at menstruation
  • secondary dysmenorrhoea - pain days after bleeding
  • Deep dyspareunia
  • Subfertility
  • Non-gynae sx - dysuria, urgency, haematuria, dyschezia…

Pelvic exam
- fixed retroverted uterus, tender nodularity in posterior fornix, visible lesions

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53
Q

Endometriosis Ix

A

Laparoscopy

US not useful

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54
Q

Endometriosis Mx

A

NSAIDs +/- paracetamol

cOCP, progesterones

GnRH analogues - reduce oestrogen, induce pseudomenopause

Surgical laparoscopic excision, laser tx, hysterectomy

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55
Q

Uterine fibroids

A

Benign smooth muscle tumours of uterus - leiomyomas

Intramural, submucosal, subserosal

RFs - Afro-Carribean, obesity, early menarche, FHx

Develop in response to oestrogen

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56
Q

Fibroids Px

A
  • Asym
  • Heavy menstrual bleeding (HMB), anaemia
  • Lower abdo pain
  • Bloating
  • Urinary frequency
  • Subfertility
  • Polycythaemia rarely
  • Solid mass / enlarged uterus on examination
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57
Q

Fibroids Ix

A

TVUS

Hysteroscopy

MRI (if ?malignancy)

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58
Q

Fibroids Mx

A

Medical
- TXA, mefenamic acid
- Hormonal contraception - control HMB
- GnRH analogue - suppress ovulation

Surgical
- Endometrial ablation
- Fibroid resection
- Myomectomy
- Uterine artery embolisation
- Hysterectomy

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59
Q

Fibroids Cx

A

Regress after menopause

Red degeneration
- Ischaemia, infarction, necrosis of fibroid - disrupted blood supply
- Abdo pain, fever, tachycardia, vomiting
- Supportive mx

60
Q

Heavy menstrual bleeding (HMB)

A

Excessive menstrual blood loss which interferes with QoL

61
Q

Abnormal uterine bleeding (AUB) causes

A

PALM - structural
- Polyp - endometrial / cervical
- Adenomyosis
- Leiomyoma (fibroid)
- Malignancy, hyperplasia

COEIN - non-structural
- Coagulopathy
- Ovulatory dysfunction - PCOS, hyperthyroid, anorexia, athletes
- Endometrial
- Iatrogenic - hormonal contraception, HRT, post-surgery
- Not yet classified - PID, endometriosis, trauma, FB

HMB
- miscarriage / ectopic
- as above

62
Q

HMB Px

A

Excessive PV bleed at menstruation
Fatigue
COB

?pallor, assess for inflamed cervix, pelvic masses….

63
Q

HMB Ix

A
  • Pregnancy test
  • Bloods - FBC, TFT, hormones (PCOS), coag, vWF…
  • TVUS
  • Cervical smear
  • Swabs - infection - high cervical + endometrial
  • Pipelle endometrial biopsy - if persistent bleed, >45yo
  • Hysteroscopy + biopsy
64
Q

HMB Mx

A
  1. Mirena - thin endometrium, shrink fibroids
  2. TXA / mefenamic acid / cOCP
  3. Progesterone only - POP, depo, implant - oral on d5-26 of cycle, not acting as contraception

Surgical
- endometrial ablation (if no longer wanting to conceive)
- hysterectomy

65
Q

Primary dysmenorrhoea

A

Painful periods / lower abdo pain, no underlying pathology

Prostaglandins -> spiral artery vasospasm, myometrial contractions => pain

66
Q

Secondary dysmenorrhoea

A

Painful periods associated with pathology

Endometriosis, adenomyosis, PID, intrauterine devices, fibroids

67
Q

Primary dysmenorrhoea Px

A

Lower abdo / pelvic pain - starts just before period

Malaise, N+V, diarrhoea, dizzy

Examination unremarkable

68
Q

Primary dysmenorrhoea Ix

A

R/o pathology - eg swabs for infection, TVUS

69
Q

Primary dysmenorrhoea Mx

A

Stop smoking, analgesia

Monophasic cOCP

Mirena

Water bottles, heat patch

TENS - transcutaneous electrical nerve stimulation

70
Q

Post-coital bleeding causes

A

50% no pathology
Cervical ectropion (more common on cOCP)
Cervicitis - infections
Cancer
Polyps
Trauma

71
Q

Post-menopausal bleeding (PMB)

A

PV bleed after >12mo amenorrhoea

72
Q

PMB causes

A
  • Vaginal atrophy
  • endometrial hyperplasia
  • endometrial / cervical / ovarian / vaginal / vulval cancer
  • Trauma
73
Q

PMB Ix

A
  • PMB >55yo -> TVUS <2wks for ?endometrial cancer (<5mm thickness acceptable)
  • Hysteroscopy + biopsy if uncertain / anything found
74
Q

PMB Mx

A

Tx cancer
Change HRT
Tx vaginal atrophy

75
Q

Cervical polyps

A

Benign growths on inner surface of cervix, malignant potential

76
Q

Cervical polyps Px

A

Asym
PV bleed, discharge
Rarely block os - infertility
May project through os - see on speculum

77
Q

Cervical polyps Ix

A

Triple swabs - r/o infection - endocervical + high vaginal

Cervical smear - r/o CIN

Biopsy - definitive

78
Q

Cervical polyps Mx

A

Remove - polypectomy forceps / in colposcopy clinic

79
Q

Cervical ectropion

A

Eversion of endocervix - columnar epithelium (bleeds easily)

Commonly seen when taking oestrogen contraceptives

80
Q

Cervical ectropion Px

A

Asym
PV bleed - post-coital, IMB
Discharge
Speculum - red appearance

81
Q

Cervical ectropion Ix

A

Clinical dx

pregnancy test, triple swabs, cervical smear

82
Q

Cervical ectropion Mx

A

No tx unless sx
Stop cOCP
Ablation of tissue

83
Q

Cervical cancer

A

Cancer of cervix

70% SCC, 15% ACC, 15% mixed

Develops from cervical intraepithelial neoplasia (CIN)

Majority caused by HPV

Mets to lung, liver, bone, bowel

84
Q

Cervical intraepithelial neoplasia (CIN)

A

Dyskaryosis - cell mutations in transformational zone of cervix, (cells already transforming from squamous -> columnar)

Tx - large loop excision of transformational zone (LLETZ)

85
Q

HPV in cervical cancer

A

HPV 16 + 18 high risk, 6 + 11 low risk

Vaccinate to prevent

86
Q

Cervical cancer RFs

A

HPV
Smoking
STIs
>8yrs cOCP use
Immunodeficiency

87
Q

Cervical screening

A

Speculum, brush transformational zone, send for HPV screen, liquid based cytology for dyskaryosis

24.5yo - first invitation

25-49yo - 3yrly screening

50-64yo - 5yrly screening

> 65yo - if recent smear / no screening since 50yo

88
Q

Cervical screening results

A

HPV -ve - continue as routine

HPV +ve, normal smear - rpt smear 12mo - if still HPV +ve + normal smear - rpt again in 12mo - if still HPV +ve normal smear at 24mo - colposcopy - if HPV -ve at 24mo test - back to routine

If HPV +ve, abnormal smear - colposcopy

If inadequate smear - rpt 3mo - if still inadequate - colposcopy

Include transgender men / non-binary individuals in screening

Pregnant women - delay screening until 12wks post-partum

89
Q

Cervical cancer Px

A
  • Asym
  • Abnormal PV bleed
  • PV discharge
  • Dyspareunia
  • Pelvic pain
  • Wt loss
  • Local invasion - oedema, loin pain, PR bleed, radiculopathy, haematuria, urinary retention
  • Pelvic mass on bimanual
90
Q

Cervical cancer Ix

A
  • Colposcopy - magnify cervix, take biopsy
  • Premenopause - Ix + Tx for chlamydia - if sx ongoing, for colposcopy
  • Post-menopause - urgent colposcopy + biopsy

CT / MRI / PET

Examination / biopsy under GA

91
Q

Cervical cancer FIGO staging

A

0 - in situ
1 - cervix
2 - pelvis
3 - vagina
4 - bladder, rectum, mets

92
Q

Cervical cancer Mx

A

Surgery
- Trachelectomy - remove cervix + upper vagina - preserve fertility
- Laparoscopic hysterectomy + pelvic lymphadenectomy
- Remove all organs

Radiotherapy

Chemotherapy

93
Q

Vulval carcinoma

A

Rare, 90% SCC, rest BCC…

RFs - HPV, lichen sclerosis, lichen planus, smoking…

94
Q

Vulval carcinoma Px

A

Pruritis, burning, soreness, bleed, pain, lump

Unifocal lesion on labia majora / clitoris / perineum

95
Q

Vulval carcinoma Ix

A

Biopsy

Staging
1 - vulva
2 - vagina (lower 1/3) / urethra / anus
3 - upper 2/3 vagina / bladder / rectal / lymph nodes
4 - distant mets

96
Q

Vulval carcinoma Mx

A

Surgical resection +/- lymphadenectomy

Small - wide local excision

Advanced - radical vulvectomy

97
Q

Ovarian torsion

A

Ovary twists - compromise blood supply - ischaemia, necrosis

Adnexal torsion - involves fallopian tube

Often mass present

98
Q

Ovarian torsion Px

A

Sudden onset colicky abdo / pelvic pain, unilateral

N+V, distress

Fever (minority)

Adnexal tenderness on VE, palpable mass

99
Q

Ovarian torsion Ix

A

Bloods - bhCG, abdo bloods

USS - free fluid / whirlpool sign

100
Q

Ovarian torsion Mx

A

Laparoscopy - dx and tx

Detorsion +/- oophorectomy

101
Q

PID

A

Infection / inflammation of female pelvic organs - uterus, fallopian tubes, ovaries, peritoneum

102
Q

PID causes

A

Chlamydia- most common
Gonorrhoea
Mycoplasma genitalium / hominis

103
Q

PID Px

A
  • Lower abdo / pelvic pain
  • Fever
  • Deep dyspareunia
  • Dysuria
  • Abnormal PV bleed
  • Dysmenorrhoea
  • PV discharge
  • Cervical motion tenderness
104
Q

PID Ix

A

Pregnancy test - r/o ectopic

High vaginal swab

Chlamydia / gonorrhoea screen

105
Q

PID Mx

A
  • IM ceftriaxone stat + oral doxycycline 14d + oral metronidazole 14d

OR oral ofloxacin + oral metronidazole

Admit if septic, consider removal of coils

Drain any abscess

106
Q

PID Cx

A

Perihepatitis - Fitz-Hugh Curtis syndrome
- inflammation of liver capsule from infection spread, adhesions form - RUQ pain

Infertility

Chronic pelvic pain

Ectopic

107
Q

Primary amenorrhoea

A

Failure to establish menstruation
- by 15yo if secondary sexual characteristics
- by 13yo if none

108
Q

Secondary amenorrhoea

A

Cessation of menses where previously normal
- 3-6mo if previously normal
- 6-12mo if previous oligomenorrhoea

109
Q

Oligomenorrhoea

A

Irregular periods

110
Q

Primary amenorrhoea causes

A

Turner’s
testicular feminisation
anatomical abnormality
anorexia
exercise
CAH
imperforate hymen
AIS
Kallman
thyroid

111
Q

Secondary amenorrhoea causes

A

Stress
exercise
PCOS
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis
Sheehan’s
Ashermann’s
pregnancy

112
Q

Oligomenorrhoea causes

A

PCOS, contraception, perimenopause, thyroid disease, DM, anorexia, exercise, meds

113
Q

Amenorrhoea Ix

A
  • Pregnancy test
  • FBC, U/E, coeliac, TFTs, prolactin, FSH, LH, oestradiol, progesterone, testosterone, 17-hydroxyprogesterone
  • Low FSH / LH - hypothalamic problem
  • Raised - ovarian problem (eg Turners)
  • Karyotype - if ?genetic
  • USS - ovaries, pelvic anatomy
  • Progesterone challenge test - elicit withdrawal bleed - if bleed, suggests enough oestrogen, but not ovulating (eg PCOS) - no bleed, low oestrogen / outflow obstruction
114
Q

Amenorrhoea Mx

A

Tx cause

Contraception to regulate periods

HRT if ovarian insufficiency

115
Q

Premenstrual syndrome (PMS)

A

Emotional / physical sx during luteal phase of menstrual cycle

116
Q

PMS Px

A

Anxiety, stress, fatigue, mood swings, bloating, breast pain, headaches

117
Q

PMS Ix

A

Sx diary - cyclical

118
Q

PMS Mx

A

Stop smoking, exercise, sleep well, regular small balanced meals

Paracetamol / ibuprofen

COCP - Yasmin brand

SSRI if severe - continuous / during luteal only

CBT

119
Q

Premature ovarian insufficiency (POI)

A

Menopause onset + elevated gonadotrophins <40yo

120
Q

POI causes

A

Idiopathic
Bl oophorectomy
Radio / chemo
Infection, eg mumps
Autoimmune
Resistant ovary syndrome - FSH receptor pathology

121
Q

POI Px

A

Menopause - hot flushes, night sweats, vaginal dryness, infertility

Secondary amenorrhoea / oligomenorrhoea

122
Q

POI Ix

A

Bloods
- Raised FSH, raised LH, low oestradiol

Raised FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart

123
Q

POI Mx

A

HRT

Offer cOCP until age of menopause

124
Q

Bicornuate uterus

A

2 horns to uterus - heart shaped

Dx on US

Risk of miscarriage, premature birth, malpresentation

125
Q

Imperforate hymen

A

Hymen at vaginal entrance formed, not open

Cyclical pelvic pain, no PV bleed

Surgical incision to tx

126
Q

Transverse vaginal septae

A

Septum across vagina
- perforate - with hole, difficulty with intercourse
- imperforate - sealed + cyclical pelvic pain without blood

Dx on US / exam

Tx - surgery

127
Q

Vaginal hypoplasia + agenesis

A

Hypoplasia - abnormally small vagina

Agenesis - absent vagina

Ovaries usually unaffected

Mx - vaginal dilator / surgery

128
Q

Asherman’s syndrome

A

Adhesions in uterus after damage - eg surgery, miscarriage

129
Q

Asherman’s syndrome Px

A
  • Recent surgery, endometritis etc
  • secondary amenorrhoea
  • lighter periods
  • dysmenorrhoea
  • infertility
130
Q

Asherman’s syndrome Ix

A

Hysteroscopy - gold std

Hysterosalpingography - contrast injected into uterus, see in XR

Sonohysterography - fill uterus with fluid, scan on USS

MRI

131
Q

Asherman’s syndrome Mx

A

Dissect adhesions in hsyteroscopy

132
Q

FGM

A

partial / total removal of external genitalia or injury to female genital organs for non-medical reasons

Type 1
Partial / total removal of clitoris +/- prepuce

Type 2
as above + labia minora +/- majora

Type 3
as above + narrowing of vaginal orifice

Type 4
All other harmful procedures - eg scraping, cautery

Mx
- <18yo - report to police
- >18yo - report if F relatives at risk, risk to unborn child
- De-infibulation surgery - for type 3

133
Q

Infertility

A

Start Ix after 12mo unprotected sex trying to conceive (6mo if >35)

Causes
problems with sperm, ovulation, tubes, uterus….

General advice
400mcg folic acid OD, healthy BMI, avoid smoking / drinking, reduce stress, intercourse every 2-3d, avoid timing sex

134
Q

Infertility Ix

A
  • BMI
  • STI screen
  • Semen analysis
  • Rubella immunity in mum

Female hormone testing
- On d2-5 of cycle - LH (high - PCOS), FSH (high - low no. of follicles)
- Serum progesterone d21 (7d before cycle end) - should rise (ovulation)
- Anti-mullerian hormone (high - good ovarian reserve)
- TFTs
- Prolactin - if galactorrhoea / amenorrhoea

Secondary care
- US pelvis
- hysterosalpingogram
- laparoscopy / dye test

135
Q

Infertility Mx

A

Anovulation
- Wt loss
- Clomifene
- Letrozole
- Gonadotrophins
- Ovarian drilling - PCOS
- Metformin - PCOS

Tubal
- Tubal cannulation
- laparoscopy to remove adhesions…
- IVF

Uterine
- Surgery - correct abnormalities

136
Q

Male factor infertility causes

A

Pre-testicular
- Pituitary / hypothalamus issues
- Stress
- increased prolactin
- Kallman
- Low LH / FSH

Testicular
- Mumps
- undescended
- trauma
- radio / chemo
- cancer
- Klinefelter

Post-testicular
- Damage
- ejaculatory duct obstruction
- retrograde ejaculation
- scarring
- no vas deferens (CF)
- young’s syndrome

137
Q

Semen analysis sample

A

Avoid ejaculation for 3-7d, avoid hot baths, deliver to lab <1hr, keep warm

Rpt in 3mo if abnormal

Look at sperm count etc

138
Q

Male factor infertility Ix

A
  • Abnormal semen - urology referral
  • hormone testing - LH, FSH, testosterone
  • genetic testing
  • transrectal US / MRI
  • vasography - inject contrast into vas deferens, XR
  • testicular biopsy
139
Q

Male factor infertility Mx

A
  • surgical sperm retrieval
  • surgical correction of vas deferens
  • intrauterine insemination
  • intracytoplasmic sperm injection
  • donor insemination
140
Q

Ovarian hyperstimulation syndrome (OHSS)

A

Seen with gonadotrophin / hCG tx

Multiple luteinised cysts in ovaries -> high oestrogen, progesterone, VEGF -> fluid loss -> oedema, ascites, hypovolaemia, RAAS

Px
Low BP, diarrhoea, N+V, pleural effusion, renal failure, ascites, VTEs

Mx
Oral fluids, UO monitoring, paracentesis, IV human albumin solution, ICU tx

Prevention
monitor serum oestrogen during tx, US monitor follicles, lower hCG / gonadotrophin dose

141
Q

Menopause

A

Permanent cessation of menstruation - no periods for 12mo - avg age 51yo

Take contraception for 12mo after LMP if >50yo, 24mo if <50yo

142
Q

Menopause Px

A
  • menstrual cycle length changes
  • PV bleeds
  • hot flushes, night sweats
  • vaginal dryness + atrophy
  • urinary frequency
  • anxiety / depression
  • brain fog
  • reduced libido, fatigue

Sx can last 7yrs
long term - osteoporosis, IHD

143
Q

Menopause Ix

A

Clinical dx

Consider serum FSH (raised) if atypical sx >45yo, 40-45yo with sx, or ?POI <40yo

144
Q

Menopause Mx

A
  • Exercise, wt loss
  • HRT
  • vasomotor sx - fluoxetine, citalopram, venlafaxine, clonidine
  • vaginal lubrication
  • vaginal oestrogen for atrophy (atrophic vaginitis - dry, pain, spotting)
  • vit D supplements post-menopause
  • 2-5yrs tx, gradually reduce HRT when stopping
145
Q

HRT

A
  • Oral / transdermal patch
  • If uterus present - give combined HRT (oestrogen + progesterone) - unopposed oestrogens cause endometrial cancer
  • If still having periods - give cyclical HRT
  • If no periods for >12mo - give continuous HRT

S/Es
- Nausea, breast tenderness, fluid retention, wt gain

CI’s
- current / past breast CA
- oestrogen-sensitive CA
- endometrial hyperplasia

Risks
- VTE, stroke, coronary heart disease, breast CA, ovarian CA

Phase 4 Question Knowledge (30 decks)

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