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O&G > Gynae 7 > Flashcards

Gynae 7 Flashcards

1
Q

What is PMS?

A

Distressing emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle (in the absence of disease)

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2
Q

What are the RFs for PMS?

A

obesity, lack of exercise, dietary, smoking, FHX

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3
Q

What are the S/S of PMS?

A
  • Mood swings
  • Anxiety
  • Headache
  • Poor concentration
  • Lack of energy
  • Changes in appetite
  • Disturbed sleep
  • Bloating
  • Breast tenderness
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4
Q

What are the investigations for PMS?

A

diagnosis requires a symptom diary over 2 cycles

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5
Q

What is the management of PMS?

A

All PMS > conservative lifestyle measures, painkillers:

  • Regular meals, exercise, sleep
  • Stress reduction, smoking cessation, alcohol restriction
  • Painkillers (NSAIDs, paracetamol)

Moderate (some impact on personal, social and professional) = COCP± CBT:

  • COCP – cyclical or continuous
  • Paracetamol or NSAIDs
  • Referral for CBT
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6
Q

What is Premenstrual Dysphoric Disorder?

A

Severe PMS: Withdrawal from social and professional activities, prevents normal functioning

Management = SSRI± CBT:

  • SSRI (continuous or just during the luteal phase > initially trial for 3 months)
  • Alternatives: GnRH analogues, transdermal oestrogen, surgery
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7
Q

What is pruritus vulvae?

A

Itching / irritation of the vulva

Causes:

  • Infection (vulvovaginitis) e.g. candidiasis, BV
  • Atrophic vaginitis
  • Eczema, contact dermatitis, psoriasis
  • Vulvar vestibulitis
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8
Q

What are the S/S of pruritis vulvae?

A

Vulvovaginal candidiasis:

  • Vulvar pruritus, burning, erythema and oedema of the vestibule and labia, thick white curd-like PVD
  • Chronic – grey-sheen of epithelial cells, severe pruritus, irritation and pain, lichenification of vulva

Atrophic vaginitis:

  • Soreness, dyspareunia, burning leucorrhoea (white mucous discharge), occasional spotting

Vulvar vestibulitis:

  • Primary (20%) – introital dyspareunia
  • Secondary – introital dyspareunia that develops after period of comfortable sexual relations, etc.
  • Pain, soreness, burning, rawness

Contact dermatitis:

  • Pruritus, can get burning, pain, red, ulcerative skin following contact
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9
Q

What are the investigations for pruritis vulvae?

A

Vulvovaginal candidiasis = wet-mount test or KOH preparation

Atrophic vaginitis = vaginal pH and wet-mount test (often shows white blood cells and paucity of lactobacillus)

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10
Q

What is the management of pruritis vulvae?

A

Vulvovaginal candidiasis:

  • Ketoconazole (400mg/day) or fluconazole (100mg/week) for 6 weeks
  • Clotrimazole 500mg suppositories once per week

Atrophic vaginitis:

  • Topical vaginal oestrogen or HRT

Vulvar vestibulitis:

  • Pain management with sex therapy, behaviour modification, topical steroid, anaesthetic, petroleum jelly, anti-inflammatories.
  • Surgical excision as last resort – success rate of 60-80%

Contact dermatitis:

  • Remove itching agent
  • Mild CD = 1% hydrocortisone creams
  • Moderate CD = betamethasone
  • Triamcinolone ointment applied BD
  • Wet compresses of aluminium acetate for severe lesions
  • If seborrhoeic dermatitis, consider ketoconazole shampoo body wash
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11
Q

What are the complications of pruritis vulvae?

A

Atrophic vaginitis – super infection due to raised vaginal pH

Candida – disruption to social and sexual life

Prognosis:

  • Atrophic vaginitis – substantial relief with treatment
  • Candida – good with treatment but frequent recurring attacks in 5%
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12
Q

What is sub-fertility?

A

A woman of reproductive age that has not conceived after 1 year of regular, unprotected sexual intercourse

  • Chances of getting pregnant 19-26yo = 98% over 24 months (twice weekly unprotected sexual intercourse)
  • Sub-fertility affects 1 in 6 couples (incidence increases with maternal age)
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13
Q

Who is likely responsible for sub-fertility?

A
  • Female problem = 30-40%
  • Unexplained = 30%
  • Male problem = 25-30%
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14
Q

What are the female causes of sub-fertility?

A

Ovulatory disorders

Hypothalamic-pituitary failure
Low gonadotrophins and low oestrogen

  • Low weight, excessive exercise, Kallman’s syndrome, Sheehan’s syndrome

Hypothalamic-pituitary-ovarian dysfunction
Normal gonadotrophins, normal oestrogen

  • PCOS

Ovarian Failure
High gonadotrophins, low oestrogen

  • POI

Also

Prolactinaemia, Thyroid Disease

  • Prolactinoma, primary hypothyroidism, chronic renal failure, drugs

Tubal disorders

  • Block (infections, adhesions, endometriosis)
  • Congenital
  • Salpingectomy

Cervical and uterine factors

  • Uterine abnormalities
  • Fibroids

Genetic / developmental:

  • Chromosomal abnormalities (Turner’s)
  • Genetic issues (CF)

Lifestyle / functional:

  • Smoking
  • Method of sex
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15
Q

What are the male causes of sub-fertility?

A
  • Structural (cryptorchidism, absence of vas deferens in CF, varicocele)
  • Hypothalamic/Pituitary (hypothalamic hypogonadism, hyperprolactinaemia)
  • Functional (erectile dysfunction)
  • Pharmacological (recreational drugs)
  • Infectious (epididymitis, mumps orchitis)
  • Lifestyle (ETOH, smoking, BMI >30)
  • Genetic (Klinefelter’s XXY, Kallman’s, testicular feminisation)
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16
Q

What are the investigations for sub-fertility?

A

1st line basic tests:
Male:

  • Semen analysis (2 tests, 3m apart)
  • Chlamydia screen

Female:

  • Day 21 progesterone (confirm ovulation) = >30 indicated ovulation
  • If POI, you cannot do this as there are no periods to base the measurement off
  • Chlamydia screen
  • Other = FBC, prolactin, TFTs, LH/FSH (irregular cycles), oestradiol

Ovarian reserve measure (≥1 of 3 results measures around day 3 of the cycle):

  • FSH = raised; inaccurate during the luteal phase (being supressed by progesterone)
  • Anti-Mullerian hormone (AMH) = low; does not change with cycles so taken anytime
  • TVUSS = Antral Follicle Count (AFC: <4 = poor response; 16+ = good response)

Tubal assessment:

  • No co-morbidities = hysterosalpingography (HSG) - assess patency
  • Co-morbidities (hx of PID, ectopics, endometriosis) = laparoscopy and dye
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17
Q

What is the initial management of sub-fertility?

A

1st line: wait for regular intercourse to be established for at least 12 months (every 2-3 days)

  • Key Information: BMI 20-25, folic acid, regular intercourse (every 2-3 days), smoking/drinking advice
  • Ix = perform investigations after 12 months…

2nd line: unexplained sub-fertility, mild endometriosis, or ‘male factor’ sub-fertility

  • Try for another 12m
  • After this, you can consider IVF
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18
Q

What is the medical management for subfertility?

A

Ovulation induction > anovulation (PCOS, idiopathic):

  • 1st line: clomiphene (blocks oestrogen-R > increased LH/FSH release)
  • 2nd line: FSH and LH injections
  • 3rd line: pulsatile GnRH or DA agonists
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19
Q

What is the surgical management for subfertility?

A
  • Operative laparoscopy = adhesions, ovarian cyst, endometriosis
  • Myomectomy = fibroids
  • Tubal surgery = blocked tubes amenable to repair
  • Laparoscopic ovarian drilling = PCOS (unresponsive to medical management) > removes endometrium > reduce amount of androgen-producing tissue
20
Q

What are some types of assisted conception?

A
  • Intrauterine insemination (IUI)
  • In vitro fertilisation (IVF)
  • Intracytoplasmic sperm injection (ICSI)
  • Donor insemination
  • IVF with donor egg
21
Q

Describe intrauterine insemination (IUI)

A

Fertility treatment that involves placing sperm directly into the uterus at the time of ovulation to increase the chance of fertilisation
Unexplained infertility, male factor infertility, cervical factor infertility

  • Prior to procedure, sperm is washed and concentrated to increase number of motile sperm
  • Sperm is inserted using a catheter
  • IUI is timed to coincide with ovulation
22
Q

Describe IVF

A

Eggs are retrieved from a woman’s ovaries and fertilised with sperm in a Petri dish. Resulting embryos are transferred into the woman’s uterus
Blocked tubes, male factor, idiopathic, unsuccessful OI or intrauterine insemination

NICE guidance:
Women <40 offered 3 cycles of IVF if…

  • Subfertility for 2 years
  • Not pregnant after 12 cycles of artificial/intrauterine insemination

Women 40-42 offered 1 cycle of IVF if…

  • Subfertility for 2 years and/or not pregnant after 12 cycles of AI
  • Never had IVF
  • No evidence of low ovarian reserve
  • Informed about additional implications of IVF at this age
23
Q

Describe intracytoplasmic sperm injection (ICSI)

A

Specialised form of IVF used to treat severe male factor infertility
Oligospermia, poor fertilisation (DM, erectile dysfunction)

  • Single sperm injected directly into egg using a microinjection needle
  • Fertilised egg then transferred into woman’s uterus
  • Most common treatment for male infertility
24
Q

When is donor insemination / donor IVF used?

A

Donor insemination ± LH/FSH:

  • Azoospermia, single women, same sex couples, infectious disease

Donor egg with IVF:

  • POI, bilateral oophorectomy, gonadal dysgenesis, high-risk generic disorder
25
Q

What is toxic shock syndrome?

A

Septicaemia from toxin (TSST 1) produced by staphylococcus and streptococcus bacteria

  • Staphylococcus = exotoxins (e.g. TSS toxin 1)
  • Streptococcus = inflammatory cascade initiation
26
Q

What is the aetiology of toxic shock syndrome?

A

multisystem inflammatory response to bacterial exotoxins

27
Q

What are the RFs for toxic shock syndrome?

A

tampons of higher absorbency, infrequent change of tampons, overnight tampon use

28
Q

What are the S/S of toxic shock syndrome?

A
  • Fever (usually >39C)
  • Myalgia
  • Diffuse red macular rash
  • D&V
  • Sore throat
  • Headache
  • Desquamation of palms and soles
  • Shock
29
Q

What are the investigations for toxic shock syndrome?

A
  • Bloods – FBC (raised WCC, low platelets), U&Es (impaired renal function), LFT, raised CK, raised CRP
  • Microbiology – HVS, blood culture, culture of tampon
30
Q

What is the management of toxic shock syndrome?

A
  • ABCs and remove tampon
  • Antibiotics (broad-spectrum IV)
31
Q

What are the complications of toxic shock syndrome?

A
  • Septic shock, MOF, DIC, ARDS, death
  • Prognosis - Mortality is 5-15%
32
Q

What are the types of urogenital prolapse?

A
  • Uterine prolapse – prolapse of uterus into the vagina
  • Cystocele – prolapse anterior vaginal wall involving the bladder
  • Rectocele – prolapse of lower posterior vaginal wall involving the anterior wall of the rectum
  • Enterocele – prolapse of the upper posterior vaginal wall containing loops of small bowel
  • Vault prolapse – prolapse of the vaginal vault after hysterectomy
33
Q

What is urogenital prolapse?

A

Descent of the pelvic organs

34
Q

What is the aetiology of urogenital prolapse?

A

weakness of pelvic floor muscles

35
Q

What are the RFs for urogenital prolapse?

A
  • Increasing age
  • Parity
  • Menopause
  • Obesity
  • Pelvic surgery
  • Chronic cough (e.g. smoking)
  • Occupations associated with heavy lifting
  • High-impact sports
  • Constipation
  • Pelvic mass
  • FHx
  • Spinal cord injury/muscular atrophy

> > Affects 30-50% of women aged >50 years

36
Q

What are the S/S of urogenital prolapse?

A

Can be asx

  • Feelings of heaviness / dragging sensation
  • Worse when active / at end of end
  • Back pain - dragging
  • Recurrent UTI
  • Dyspareunia
  • Urinary symptoms if cystocele - difficulty emptying, retention
  • Constipation or faecal incontinence if rectocele
37
Q

What are the grading systems for urogenital prolapse?

A

POP-Q

  • NICE recommended
  • Positions are recorded as co-ordinates relative to the physiological position of the pelvic organs. The hymen is used as the reference point
  • Distal to the hymen is a +ve number and proximal is a -ve number

Shaw’s (more commonly used, looks at extent of descent of prolapse)

  • First degree – descent to the introitus
  • Second degree – extends to the introitus but descend past the introitus on straining
  • Third degree – prolapse descends through the introitus

Baden-Walker (like Shaw’s but uses the hymen as a reference point)

38
Q

What are the investigations for urogenital prolapse?

A

Clinical diagnosis unless other sx present

  • Simms Speculum (grade and severity) - patient on side (left lateral position) ask to strain, examine that side then repeat - loss of rugae in vaginal mucosa, decreased secretions, thin perineal skin, easy perineal tearing
  • Bimanual - ask patient to cough, assess
  • Urodynamics (incontinence)
  • MC&S (urine infections)
  • Bladder USS
  • Post void residual
39
Q

What is the management of urogenital prolapse?

A

1st line = conservative:

  • Weight loss, minimise weightlifting, stop smoking

2nd line:

  • Pelvic floor exercises (i.e. stress incontinence and urogenital prolapse)
  • Topical oestrogen in elderly patients
  • Pessary
    Types
  • Ring – common type – soft – do NOT prevent sex - can take them in/out their self
  • Shelf – common type – hard – more support than a ring – DO prevent sex
  • Gellhorn – similar to a shelf but are soft instead of hard – DO prevent sex
  • Gehrung – disk-shaped and used for more serious prolapse (easier to remove)
  • Cube – for very advanced prolapse – uses suction to keep things in place

3rd line = surgical options

  • Anterior / posterior colporrhaphy - repair of defect
  • Vaginal hysterectomy, +/- vaginal sacrospinous fixation
  • Vaginal sacrospinous hysteropexy with sutures
  • Manchester repair - cervix is shortened / amputated
  • Colpocleisis - closure of vagina
40
Q

What is the management of a vault prolapse?

A
  • 1st line: Sacrocolpopexy (abdominal or laparoscopic) with mesh
  • Other: vaginal sacrospinous fixation with sutures (risk: sciatic nerve damage)
41
Q

What is vulval cancer?

A

Malignant neoplasm of the vulva

  • Majority SSC (SCC (95%)&raquo_space;> melanoma, BCC > adenocarcinoma)
42
Q

What are RFs for vulval cancer?

A
  • Usual type (warty/basaloid SCC) > VIN (HPV type 16), immunosuppression, smoking
  • Differentiated type (keratinised SCC) > lichen sclerosis
43
Q

What is the aetiology of vulval cancer?

A

Progression of certain vulval dermatoses, progression of VIN

44
Q

What are the S/S of vulval cancer?

A
  • Vulval swelling/ulcer, pruritus, pain, bleeding, discharge
  • Nodule or ulcer visible on vulva – commonly labia majora
  • Inguinal lymphadenopathy
45
Q

What are the investigations for vulval cancer?

A

Tissue diagnosis

  • Full thickness biopsy
  • Sentinel node biopsy
  • > Vaginal carcinomas are rare

Cervical smear:

  • Exclude CIN if VIN-associated
  • > Clear Cell adenocarcinoma

Imaging:

  • CT or MRI to assess lymphadenopathy
  • > Primary vaginal adenocarcinoma

Other:

  • Staging by cystoscopy, proctoscopy
46
Q

What is the management for vulval cancer?

A

1a = wide local excision ± neoadjuvant chemotherapy

  • Radical surgical excision with 10mm clear margin

>1a = radical vulvectomy + bilateral inguinal lymphadenectomy (15% are +ve for inguinal metastasis)

  • A dye and radioactive nucleotide can be injected into the vulval tumour to identify the sentinel node
  • If removed, groin lymphadenectomy is a very morbid procedure with complications including wound healing problems, infection, VTE and chronic lymphoedema

Unsuitable for surgery = radiotherapy

47
Q

What are the complications of pessary’s?

A
  • Vaginal ulceration
  • They may fall out
  • Discomfort
  • Incontinence, retention

O&G (17 decks)

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