Gynae Flashcards
what is the average age of menarche?
12 years (8-16)
what is mittelzchmerz?
peri-ovulatory, unilateral pelvic pain
what causes ovulation?
LH surge
is oestrogen higher in the proliferative or luteal phase?
proliferative/ follicular
which phase of the menstrual phase is progesterone highest in?
luteal phase as is released by corpus luteum
how long does the corpus luteum survive?
14 days
what does the hypothalamus release?
gonadotropin releasing hormone
what does the anterior pituitary release?
FSH and LH
feedback mechanisms in the menstrual cycle
FSH stimulates release of oestrogen
oestrogen provides -ve feedback so decreases FSH and +ve feedback to increase LH
LH stimulates release of progesterone
progesterone has -ve feedback on pituitary so decreases LH
causes of abnormal bleed mnemonic
PALM (strutctural) COEIN Polyp/ pregnancy Adenomyosis Leiomyoma Malignancy endometrial/ cervical Coagulopathy Ovulation (disorders of)- PCOS, hypothyroid Endometrial- fibroids/ endometriosis Iatrogenic (POP/IUCD etc) Not yet classified
what is PCOS?
unexplained chronic hyperandronergic anovulation
what are signs of PCOS?
hirstutism
male pattern balding
acne
insulin resistance (obesity, cenrtal fat distribution, acanthosis nigricans)
what criteria can be used to assess PCOS?
Rotterdam criteria; 2/3 of:
polycystic ovaries on USS
oligo/ anovulation
signs of excess androgens
how is the pituitary axis affected in PCOS?
increased oestrogen from peripheral adipose-> stimulates more LH from anterior pituitary-> androgen production-> converted to oestrogens peripherally…
what are the long term risks of PCOS?
infertility
CVD
DM2
endometrial carcinoma
what is the treatment of PCOS?
contraception
if trying to conceive- metformin, clomiphene citrate
what is the average age of menopause?
51, premature <40
what happens to the hormones during menopause?
oestrogen and progesterone decrease
therefore LH/ FSH increase
what is the perimenopausal period known as
climacteric
what symptoms suggest a woman is perimenopausal?
weight gain (especially abdo/ buttocks) menstrual irregularity vasomotor- night sweats, hot flushes, palpitations mood swings vaginal atrophy
what are post-menopausal women at increased risk of?
osteoporosis
what is menopause?
amenorrhoea for at least 12 months
how are menopausal women treated?
HRT- sequential if menstruating, continuous combined if not. unopposed oestrogen if had hysterectomy
bisphosphonates if indicated by DEXA
what are the side effects of HRT?
Increased risk of VTE increased risk of breast/ cervical cancer CVD risk Breast tenderness PV bleed headaches
when could oestrogen only therapy be a possibility?
if the woman has had a hysterectomy
what are the most common features of endometriosis?
infertility
deep dyspareunia
secondary dysmenorrhoea
pelvic pain- typically starts 2 weeks pre-bleed and bleed helps relieve it
what are risk factors for endometriosis?
early menarche/ late menopause
no kids
family history
what is the gold standard for diagnosis of endmetriosis?
laparoscopy
what can be used for effective pain relief in endometriosis?
mefanamic acid (NSAID)
what treatments can be used to stop complications of endometriosis?
tricycling COCP (take 3 packets back to back) progestagens anti-progestagins laparoscopic ablation/ excision hysterectomy
what are risk factors for an ectopic pregnancy?
PID tubal surgery eg previous ectopic/ pelvic surgery IUCD IVF if conceives on POP
what are common locations for an ectopic?
tubal- ampulla/ isthmus/ cornual)
cervical
ovarian
other than abdominal pain/ PV bleed, what would make you suspicious of an ectopic?
shoulder tip pain
how would the results of 2 BhCG tests help you distinguish between an ectopic and an IUP?
take 2 samples 48 hours apart
if doubles = IUP
if decreases = miscarriage
if stays the same/ increases but not doubled = ectopic
when is the medical treatment of an ectopic appropriate?
if BhCG <1500u/L no significant pain mass <35mm no foetal heart beat no IUP
what is the medical treatment for an ectopic?
methotrexate IM, advise may require surgical treatment also
how often should you check BhCG after medical treatment of an ectopic?
day 4 and 7, then weekly until negative. may take 4-6 weeks to resolve
what is the surgical management of an ectopic?
salpingectomy/ salpingotomy if damage to other tube. give anti-D prophylaxis
repeat PT after 3 weeks
criteria for PID
Lower abdo pain +
1 of; pyrexia >38/ ESR>15/ Luecocytosis+
1 of; adnexal pain/ adnexal mass/ CMT
what pain is common in PID?
deep dyspareunia
treatment for PID?
IM ceftriaxone 500mg then PO doxycycline and metronidazole for 14 days
after how many consecutive miscarriages would you start investigations?
3
investigations for abnormal bleeding?
bloods- FBC, TFT, coag screen
USS
may require hysteroscopy and biopsy
treatment for abnormal bleeds?
Medical- COCP, mefenamic/ tranexamic acid, mirena coil for fibroids,
surgical depending on cause
STI tests for women with symptoms?
vvs for chlamydia and gonorrhoea NAAT
HVS for TV, BV, candida
endocervical swab for gonorrhoea culture
bloods for HIV and syphilis
STI tests for asymptomatic women?
vvs for chlamydia and gonorrhoea NAAT
bloods for HIV and syphilis
STI tests for men with symptoms?
1st pass urine for chlamydia and gonorrhoea NAAT
urethral swab for gonorrhoea culture
blood for HIV and syphilis
if MSM: also do rectal + pharyngeal swab for NAAT and culture and offer hep B vaccine
STI tests for men without symptoms?
1st pass urine for chlamydia and gonorrhoea NAAT
blood for HIV and syphilis
vaginal discharge with contact bleed and “cobblestone cervix” on speculum
chlamydia, treat with azithromyicin 1g single dose
green/ yellow PV discharge, IMB, dysuria
gonorrhoea
pH suggestive of BV
> 4.5
Treatment for BV
PO metronidazole
white cheesy discharge
candida, treat with topical clotrimazole/ pessary
treatment for gonorrhoea
once only:
IM cefetriaxone 500mg
PO azithromycin 1g
gonorrhoea in pregnancy concerns?
causes blindness in foetus
what causes chlamydia
chlamydia trichomatis
complications of chlamydia in pregnancy?
PROM/ pre-term delivery
low foetal birth weight
neonatal ophthalmic infection
neonatal pneumonitis
what organism causes gonorrhoea?
Neisseria gonorrhoeae
which organism causes syphilis?
Treponema pallidum
how is syphilis spread?
skin abrasions/ intact mucous membranes
how long is the incubation period of syphilis?
3 weeks until primary local infection, 6-12 weeks for generalised secondary infection
how does primary syphilis present?
chancre- small painless papule which ulcerates and may discharge clear fluid, heals in 2-6 weeks
how does secondary syphilis present?
6 weeks after chancre
systemic symptoms (malaise/ fever etc)
generalised polymorphic rash on palms/ soles/ face
lymphadenopathy
what percentage of untreated primary syphilie develops into secondary?
25%
what percentage of untreated secondary syphilis develops into latent asymptomatic syphilis?
80%
what are the neuro manifestations of tertiary syphilis
tabes dorsalis- 15 to 25 years after primary infection, locomotor ataxia
dementia
what are the cardiovascular manifestations of tertiary syphilis?
aortitis-> aortic regurgitation, aneurysm
what are gumma?
tertiary syphilis-> soft locally-destructive non-cancerous growths
what is the treatment for syphilis?
benzathine penecillin
what are non-infective differentials for PV discharge?
physiological
pregnancy
retained FB
chemical irritants
what causes trichomonas?
protozoan infection
what colour is the discharge in trichomonas?
yellow and frothy
treatment for trichomonas?
one off metronidazole
what is balanitis?
infection of the glans penis
causes of balanitis?
intertrigo (rubbing) candida bacterial: staph/ group B strep viral lichen planus/ lichen sclerosis contact allergy eczema/ psoriasis
how would candidial balanitis present?
red papules + superficial erosions and white plaques
what condition should you consider checking for if someone presents with candidial balanitis?
DM
how would balanitis due to lichen sclerosis present?
pale atrophic skin, telangectasia
why should balanitis due to lichen sclerosis have biopsy + long-term follow up?
risk of malignancy
treatment for scabies balanitis?
topical permethrin
treament for balanitis due to lichen sclerosis?
topical steroids
treatment for candidal balanitis?
canestan
treatment for eczema/ psoriasis balanitis?
topical betnovate
which type of HSV causes genital lesions
mostly 2 but now 1 as well (increase in oral sex)
how would HSV infection present?
painful shallow ulcer
what is the incubation period of HSV?
2 days- 2 weeks
treatment of recurrence of HSV?
acyclovir, avoid sex, analgesia
frequency of recurrence of HSV?
Median 4/ year
what causes genital warts?
HPV 6 and 11
which types of HPV are associated with and increased risk of cancer?
HPV 16/ 18
which types of cancer are increased in people infected with HPV 16/ 18?
cervical, vaginal, penile, anal and oral
what are the treatment options for genital warts?
often self resolve in 6 months (may recur)
medical: podophyllotoxin/ imiquimod 5%
surgical: ablation/ cryotherapy/ excision
what ages are prone to testicular torsion?
neonates and post-puberty
which testes is more prone to torsion?
left
what deformity increases the risk of testicular torsion?
Bell-Clapper
would lifting the tests increase or decrease the pain in torsion?
increase, decreases in epididymitis
what is the cremasteric reflex and when would it be absent?
stroking of inner thigh causes raising of testes, absent in torsion
what age to testes descend?
34 weeks in utero
at what age are testes checked in neonates?
just born, 6 weeks and 18 months
when would you operate on an undescended testicle
1-2 years orchidopexy as can still descend until then
what organisms are most common causative organisms of prostatitis?
gram negative
then STI
How is prostatitis diagnosed?
urine culture
what is the treatment for prostatitis
fluoroquinolones eg ciprofloxacin
at what age does a physiological phymosis start to resolve
2, 95% resolved by 16 years
what would indicate a pathalogical phymosis
haematuria, urinary obstruction, painful erection. recurrent UTIs can occur in physiological phymosis
what are medical treatments for phymosis?
topical steroids onto preputial ring
what is phymosis a risk factor for?
penile cancer
what are surgical options for treating phymosis?
dorsal incision/ circumcisison
what is paraphymosis?
retracted prepuce causes swelling and inability to replace, emergency
what may aid the replacement of a paraphymosis?
compression with saline soaked swab/ 50% dextrose
ice
ask patient to squeeze glans for up to 30 minutes
what are some causes of erectile dysfunction?
Vascular: CVD, trauma, surgery
Neuro: central/ peripheral
Hormonal: hypogonadism, exogenous anabolic steroids
Anatomical
Drugs: psych drugs, BB, anti-HTN, prostate cancer tx
psychogenic: general/ situational
what else should be investigated in someone presenting with erectile dysfunction?
CVD risk factors
what class of drug is viagra
phosphodiesterase type 5 inhibitor
what is viagra’s drug name
sildenafil
when is viagra contraindicated?
if on nitrates as increased risk of stroke/ MI
what is the most common cause of epididymo-orchitis in under 35s?
STI
what is the most common cause of epididymo-orchitis in over 35s?
UTIs
scrotal pain and swelling which is improved by elevation?
epididymo-orchitis
what are the classifications of urethritis?
gonococcal/ non-gonococcal/ persistent/ recurrent
what is the most common cause of urethritis?
non-gonococcal e.g. chlamydia
what causes an increase in alpha feto-protein
yolk sac tumours
what is the most common form of testicular tumour?
seminoma
what causes an increase in BhCG?
seminoma/ teratoma
if carrying out an orchidectomy for testicular cancer what should you consider before?
sperm collection and storage
who should be offered genetic testing for breast cancer?
manchester scoring system
men
young women with triple negative
women with other cancers, e.g. ovarian
where is breast cancer most commonly found?
left breast, outer upper quadrant
what type of breast cancer is most common?
ductal carcinoma
are most breast cancers oestrogen receptor + or -
+ve, better prognosis
what is the HER2 receptor
growth factor receptor, if positive worse prognosis but can be treated with herceptin (trastuzamab)
when would neoadjuvant chemo be useful for breast cancer?
for breast conservation or if HER2 positive/ triple negative as better response
why would adjuvant chemotherapy be used in breast cancer?
for micrometastatic disease
how is a fibroadenoma differentiated from a cancer?
mobile, younger woman (peak early 20s)
what age is the cut off for 2 week wait referral for a breast lump?
30 (over 30 2ww, under 30 non-urgent)
what factors increase the risk of a breast abscess?
breast feeding
immunocompromise/ DM
nipple piercing
what should be excluded in mastitis or breast abscess
inflammatory breast cancer
how should a breast abscess be treated?
incision and drainage, send swab for culture, Abx eg fluclox?
