Gynae Flashcards
Lichen sclerosis risk of scc
<5%
Amenorrhoea
Primary
Secondary
Primary nil Menses by age 16 in presence of secondary sex characteristics
Or nil menses or secondary sex characteristics by age 14
Secondary amenorrhoea - absent periods for at least 6/12 if prev regular periods or 12 months if okigoamenorrhoea
Type 1 amenorrhoea
Low estrogen, low fsh and no hypothalamic pituitary pathology leading to hypogonadotrophic hypogonadism
Type 2 amenorrhoea
Normal estrogen normal fsh normal prolactin - pcos
Gondal failure hormone levels
Low estrogen
High fsh
Tanner stages
Stage 1 prepubertal
Stage 2 breast bud few hairs
Stage 3 larger breast bud, central hair growth
Stage 4 mound formed, triangular hair growth
Stage 5 fully formed breast, adult pubic hair
Causes only of primary amenorrhoea
Hydrocephalus
Empty sella syndrome
Constitutional delay
Genetic disorders - androgen insensitivity syndrome, turners, rokintansky syndrome
Causes only of secondary amenorrhoea
Fragile x syndrome Sheehans Head injury Ashermans PCOS
Primary ovarian failure under what age and what blood tests?
Under 40
Two fsh >20 on two occasions
Screen for mumps, autoimmune, hiv, karyotype and baseline dexa
Turner syndrome chromosomes
45X0
Amenorrhoea with Normal low fsh Normal low LH High prolactin Testosterone normal
Hyperprolactinaemia
Fsh normal LH normal or slightly raised Prolactin normal or slightly increased Testosterone slightly increased LH:FSH ratio raised
PCOS
Secondary amenorrhoea with low normal FSH and LH with normal testosterone, prolactin and oestrogen
Hypothalamic stress weight loss
Turners syndrome
High FSH high LH Low estrogen Short stature Short 4th metacarpal Horseshoe kidney Streak like gonads
Remove testes
Induce with CHC
Constitutional delay of menses Rx
Induce puberty with 2mcg ee daily
Increase in 5mcg increments every 6/12 until 20mcg
Then go for CHC
Kallmans syndrome
Anosmia
Colour blind
Amenorrhoea primary
Rotterdam criteria for PCOS
Amenorrhoea
Hyperandrogenism or polycystic ovary (over 10 in each ovary)
Mx of PCOS
Weight loss
Induce regular bleeds
Mpa 10mg OD for 5 days every 3/12 or give CHC dianette
Rokitansky syndrome
Mullerain agenesis Vagina absent Uterus usually absent Check kidneys Normal ovaries Can do IVF with surrogate
Androgen insensitivity syndrome
46XY Gonads are testes Minimal Vulval or pubic hair development Short vagina Do get breasts
Remove testes
Can’t conceive
Testosterone >5
Risk factors for endometrial hyperplasia
Obesity
Anovulation
Estrogen secreting Tumors
Drugs eg tamoxifen HRT
Mx of endometrial hyperplasia without Atypia
Reverse RF - can observe but prefer to
Rx with progestogen IUS
TVUSS to check ovaries
2nd line Rx mpa 10mg daily
Review at 6/12 for pipelle
If persists >12/12 despite RX - hysterectomy
Atypical hyperplasia Mx
Total hyst
BSO for all
Wishing to preserve fertility and atypical hyperplasia
Ius
Exclude invasive ca with mri and Timor markers
Then TAH when no longer need fertility
Describe types of FGM
Type 1 - partial or total removal of clitoris
Type 2 partial or total removal of clitoris and labia minora
Type 3 narrowing of vagina opening by cutting and stitching labia togethe
Type 4 piercing, pricking
Mx of FGM medicolegally
If > 18 discuss with safeguarding. If children at risk then discuss with child protection or if pregnant
If under 18 - report to police by end of working day. Strategy meeting within 45 days
In early pregnancy if crl <7mm and no FH what the MX plan?
Second scan in a week
If crl >7mm and no FH what plan?
Can rescan in a week or second sonographer to confirm
If GS over 25mm and nil pole
Second sonographer to confirm
Rfs for ectopic
Smoking Prev ectopic Tubal surgery PID >35 IVF IUD
PUL Mx of 48hours hcgs
If >63% increase then likely intrauterine. Rescan when hcg >1500
If descrease over 50% likely failing pregnancy and do PT
If between the two - potential ectopic
Mx of miscarriage
Expectant mx first line for 2 weeks
Medical mx vaginal miso 800mcg
Surgical Mx
Ectopic mx for expectant
If clinical stable Pain free Tubal ectopic not over 35mm No FH Hcg less than 1000
Hcg on d2, 4 and 7 and should drop by 15%
Ectopic medical mx
No significant pain Unruptured Less than 35mm No FH Hcg less than 1500
Hcg d4 and d7
Can consider up to 5000 but chance of intervention increased
When surgical mx of ectopic 1st line
Significant pain
Mass over 35mm
FH
Hcg >5000
How to calculate % change
New number minus old number
Divided by old number
X100
Dose of methotrexate
50mg/m2
Transient pain 3-10 days post
Complete mole
Empty egg fertilised by one sperm
46XX androgenetic
Snow storm on USS with nil embryo
Partial mole
Two sperm fertilise one egg
Most triploid
69XXY or 69 XYY
Uss- embryo but looks like m/c with cysts
Thecal luteal cysts
Follow up for molar
If hcg normal within 8 weeks of evac - 6/12 from evac
If not normal at 8 weeks then 6/12 from when normal
Ix of HMB
If low risk start medical mx
Is suspect fibroids etc or Sx imb- OP hyst and pipelle
Mx of HMB if nil pathology
Fibroids less than 3cm
IUS
If declines then txa, nsaids, CHC
GNRHa
If declines medical
Surgical - ablation or hysterectomy
Mx of fibroids >3cm
Medical - txa, nsaids, esmeya, ius, CHC zoladex
Surgical - myomectomy, uae hysterectomy
Esmya side effects and monitoring
Can cause liver damage
LFTs for first 2 courses
Dose 5mg OD for up to 3/12
Max 4 courses
Should be fibroids >3cm and hb less than 102
Palm coein for causes of AUB
Polyp Adenomyosis Leiomyoma Malignancy Coag Ovulating disorder Endometrial Iatrogenic Not yet classified
Ablation
Up to 14cm cavity length
Not fibroids >3cm
No cavity distortion
Myometrium at least 10mm
Pipelle and hyst pre procedure
When to offer risk reducing bso
Brca 1 or 2
15-60% risk of ovarian ca
Risk reducing bso after family complete
Rx of LS
Dermovate 0.05%
Cin by grades
Cin 1 basal third
CIN 2 basal 2/3rds
CIN 3 entire epithelium
Cervical screening per age
25-49 every 3 years
50-64 every 5 years
When to screen women over 65 for cervical screen
If recent smear abnormal
Nil test since 50
If inadequate sample or postnatal when to perform smear?
3/12
When no longer near a smear?
Total hysterectomy
Congenital abcense
Radical trachelectomy
Pathway through colp and outcome
If borderline or mild dyskaryosis and hpv neg then normal recall
If hpv positive and colp normal - smear and colp 1 year
If low grade disease and punch biopsy shows cin 1 - smear in one year
Cin2/3 lletz and smear in 6/12
If severe mod and high grade disease - lletz 6/12 toc and if hpv neg - routine recall
Dose of folic acid and which conditions to give higher dose in!
0.4mg for low risk
5mg for high risk
Prev neural tube defect
Diabetic
On antiepileptics
BMI>30
Type 1 ovulating disorders and fertility
Low LH and FSH
Signs of low estrogen
Nil progestogen withdrawal bleed
Rx underlying cause
Will need gnrh ovulation induction
Rx for fertility in PCOS
Optimise health
Then induce ovulation with clomifene
Monitor with uss and progesterone to avoid over recruitment
If clomifene resistant then ovarian drilling
Can induce with gnrh
Define oligospermia
Asthenospermia
Teratozoospermia
Azoospermia
Oligo- reduces concentration <15 million
Astheno- reduces motility <32%
Tertato- reduce normal shape <4%
Azoo- no sperm
Causes of male factor problems
Unknown Tumors Steroids for beef caking Chronic illness Obesity
Kallmans, caricocoele, infection, drugs, smoking
Normal semen analysis Volume Sperm number Concentration Total motility Progressive motility Normal sperm
Volume 1.5ml Total sperm no 39million Concentration 15million Total motility 40% Progressive motility 32% Normal speed 4%
Ovarian reserve
Amh > 25 good low if under 5.5
Total antral follicle count 4-16
Indications of assisted reproduction
Tubal damage if severe and nil conceive 6/12 post tubal surgery
Endometriosis I’d mod to severe and 12/12 post ablative surgery
Male factor if significant
Pcos failed with clomifene
Unexplained fertility if over 2 years and lifestyle not worked
Cycles offered on nhs of ivf
3 cycles to women under 40 who have tried for 2 years
Can offer investigations after 1 year of trying
Fertility Rx and 40-42 yers old
1 cycle ivf as long as nil previous. Not low ovarian reserve
Mx of overactive bladder, urgency symptoms
Lifestyle change Bladder diary and void chart Restrict fluid intake Bladder train for 6 weeks If urogenital atrophy add oestrogen pessary Give solifenacin
If still Sx then urodynamics
If destructor overactivity then do Botox
If not then detrusor myectomy
Mx of stress incontinence
Physio exercises 3/12
Weight loss
Can trial duloxetine
Or offer surgery
TVT
Burch colposuspension
Grading a prolapse
Grade 1 half way down vagina
Grade 2 to hymenal ring
Grade 3 not max decent
Grade 4 maximal decent
HRT regime
Sequential combined - estrogen daily then 14/7 progestogen every cycle to induce bleed
Continuous combined continual regime
Preparations of HRT
Transdermal or tablet micronised estradiol
Progestogen micronised pessary or capsule
Or mpa tablet as less androgenic
Risks of HRT
Breast ca - increases risk. Not in first 3 years. After this 8 extra cases per 1000.
VTE - increases by oral, not increased by transdermal . Two fold increase
CV risk- between 50-59 protective role but over 60 estrogen increases stroke risk
Diagnosing PMS
Diary for 2 cycles
Gnrh analogues for 3/12 if diary inconclusive
Complimentary therapies in PMS
Saffron
Calcium and vit D
Vitex agnus
B6
Rx algorithm for PMS
1st line exercise CBT vit b6
CHC Yasmin or SSRI 10mg cotalopram
2nd line - estradiol patches (100mcg) plus micronised progestogen 100mg for 10/7 or mirena
Higher dose SSRI 20-40
3rd line - GNRH analogues plus add back HRT 100mcg estradiol patch plus micronised progestogen 100mg/day
4th line surgery and then HRT
Pre top what needs to be tested
Rhesus Hb VTE risk Smear check Uss Abx Medical Hx Sti screen Contraception
When to give fetecide for TOP
Over 21+6
Surgical TOP and method depending on gestation
<14 weeks vacuum aspiration
14-16 weeks vacuum aspiration with large bore cannula
Over 14 weeks dilataion and evacuation under uss
Miso pre stop regime
400mcg 3 hours pre op
> 14 weeks oncogenic dilators better but miso ok up to 18/40
Medical TOP regime
Early medical up to 9 weeks- mifepristone 200mg then miso 800mcg. If nil give one further dose 400mcg
9-13 weeks mife 200mg then miso 800mcg. Max 4 further doses of 400 at 3 hourly intervals
13-24 weeks mife 200mg then 800mcg then miso 400 3 hourly for max 4 further doses. If nil then repeat mife 3hours post last miso and restart miso 12 hours later
Advice post top
Leaflet Sx ongoing pregnancy What to expect with bleeding When to present 24hours phone number Nil pt post surgical Pt post medical
What is the hsa1?
Form needing two docs and circling reason for top
Must be kept for 3 years
Hsa4 what is it?
Form saying place and details of
TOp
Must send to chief medical officer within 14/7
Only doctors terminating pregnancy can complete
Abortion grounds letters
A- risk to life of pregnant woman
B- permenant grave injury of physical of mental health to woman
C- not over 24 weeks and continuing would risk physical or mental health of woman
D- not over 24 weeks and risk health of existing children
e - risk to unborn child of physical or mental abnomalitie
F- save life of preggers woman
G - prevent permanat grave injury to preggers woman in an emergency
Fraser criteria
Under 16 year old understand the advice Can’t be persuaded to tell parents Likely to keep having sex Mental or physical health may suffer without it Best interests to give
Forensic timescales
Digital penetration 12hours Kissing licking 48hours Oral penetration 48hours Anal penetration 3 days Vaginal penetration 7 days Blood within 3 days and urine within 4 days
Hair analysis up to 6/12
Crl and weeks approx
6/40 5 7/40 10mm 8/40 15mm 9/40 20mm 10/40 30mm 11/40 40mm 12/40 55mm
> 13/40 head circumferenxe
