Gynae Flashcards
1
Q
Lichen sclerosis risk of scc
A
<5%
2
Q
Amenorrhoea
Primary
Secondary
A
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
3
Q
Type 1 amenorrhoea
A
Low estrogen, low fsh and no hypothalamic pituitary pathology leading to hypogonadotrophic hypogonadism
4
Q
Type 2 amenorrhoea
A
Normal estrogen normal fsh normal prolactin - pcos
5
Q
Gondal failure hormone levels
A
Low estrogen
High fsh
6
Q
Tanner stages
A
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
7
Q
Causes only of primary amenorrhoea
A
Hydrocephalus
Empty sella syndrome
Constitutional delay
Genetic disorders - androgen insensitivity syndrome, turners, rokintansky syndrome
8
Q
Causes only of secondary amenorrhoea
A
Fragile x syndrome Sheehans Head injury Ashermans PCOS
9
Q
Primary ovarian failure under what age and what blood tests?
A
Under 40
Two fsh >20 on two occasions
Screen for mumps, autoimmune, hiv, karyotype and baseline dexa
10
Q
Turner syndrome chromosomes
A
45X0
11
Q
Amenorrhoea with Normal low fsh Normal low LH High prolactin Testosterone normal
A
Hyperprolactinaemia
12
Q
Fsh normal LH normal or slightly raised Prolactin normal or slightly increased Testosterone slightly increased LH:FSH ratio raised
A
PCOS
13
Q
Secondary amenorrhoea with low normal FSH and LH with normal testosterone, prolactin and oestrogen
A
Hypothalamic stress weight loss
14
Q
Turners syndrome
A
High FSH high LH Low estrogen Short stature Short 4th metacarpal Horseshoe kidney Streak like gonads
Remove testes
Induce with CHC
15
Q
Constitutional delay of menses Rx
A
Induce puberty with 2mcg ee daily
Increase in 5mcg increments every 6/12 until 20mcg
Then go for CHC
16
Q
Kallmans syndrome
A
Anosmia
Colour blind
Amenorrhoea primary
17
Q
Rotterdam criteria for PCOS
A
Amenorrhoea
Hyperandrogenism or polycystic ovary (over 10 in each ovary)
18
Q
Mx of PCOS
A
Weight loss
Induce regular bleeds
Mpa 10mg OD for 5 days every 3/12 or give CHC dianette
19
Q
Rokitansky syndrome
A
Mullerain agenesis Vagina absent Uterus usually absent Check kidneys Normal ovaries Can do IVF with surrogate
20
Q
Androgen insensitivity syndrome
A
46XY Gonads are testes Minimal Vulval or pubic hair development Short vagina Do get breasts
Remove testes
Can’t conceive
Testosterone >5
21
Q
Risk factors for endometrial hyperplasia
A
Obesity
Anovulation
Estrogen secreting Tumors
Drugs eg tamoxifen HRT
22
Q
Mx of endometrial hyperplasia without Atypia
A
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
23
Q
Atypical hyperplasia Mx
A
Total hyst
BSO for all
24
Q
Wishing to preserve fertility and atypical hyperplasia
A
Ius
Exclude invasive ca with mri and Timor markers
Then TAH when no longer need fertility
25
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
26
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
27
In early pregnancy if crl <7mm and no FH what the MX plan?
Second scan in a week
28
If crl >7mm and no FH what plan?
Can rescan in a week or second sonographer to confirm
29
If GS over 25mm and nil pole
Second sonographer to confirm
30
Rfs for ectopic
```
Smoking
Prev ectopic
Tubal surgery
PID
>35
IVF
IUD
```
31
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
32
Mx of miscarriage
Expectant mx first line for 2 weeks
Medical mx vaginal miso 800mcg
Surgical Mx
33
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%
34
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
35
When surgical mx of ectopic 1st line
Significant pain
Mass over 35mm
FH
Hcg >5000
36
How to calculate % change
New number minus old number
Divided by old number
X100
37
Dose of methotrexate
50mg/m2
| Transient pain 3-10 days post
38
Complete mole
Empty egg fertilised by one sperm
46XX androgenetic
Snow storm on USS with nil embryo
39
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
40
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
41
Ix of HMB
If low risk start medical mx
| Is suspect fibroids etc or Sx imb- OP hyst and pipelle
42
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
43
Mx of fibroids >3cm
Medical - txa, nsaids, esmeya, ius, CHC zoladex
Surgical - myomectomy, uae hysterectomy
44
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
45
Palm coein for causes of AUB
```
Polyp
Adenomyosis
Leiomyoma
Malignancy
Coag
Ovulating disorder
Endometrial
Iatrogenic
Not yet classified
```
46
Ablation
Up to 14cm cavity length
Not fibroids >3cm
No cavity distortion
Myometrium at least 10mm
Pipelle and hyst pre procedure
47
When to offer risk reducing bso
Brca 1 or 2
15-60% risk of ovarian ca
Risk reducing bso after family complete
48
Rx of LS
Dermovate 0.05%
49
Cin by grades
Cin 1 basal third
CIN 2 basal 2/3rds
CIN 3 entire epithelium
50
Cervical screening per age
25-49 every 3 years
| 50-64 every 5 years
51
When to screen women over 65 for cervical screen
If recent smear abnormal
| Nil test since 50
52
If inadequate sample or postnatal when to perform smear?
3/12
53
When no longer near a smear?
Total hysterectomy
Congenital abcense
Radical trachelectomy
54
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
55
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
56
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
57
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
58
Define oligospermia
Asthenospermia
Teratozoospermia
Azoospermia
Oligo- reduces concentration <15 million
Astheno- reduces motility <32%
Tertato- reduce normal shape <4%
Azoo- no sperm
59
Causes of male factor problems
```
Unknown
Tumors
Steroids for beef caking
Chronic illness
Obesity
```
Kallmans, caricocoele, infection, drugs, smoking
60
```
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%
```
61
Ovarian reserve
Amh > 25 good low if under 5.5
Total antral follicle count 4-16
62
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
63
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
64
Fertility Rx and 40-42 yers old
1 cycle ivf as long as nil previous. Not low ovarian reserve
65
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
66
Mx of stress incontinence
Physio exercises 3/12
Weight loss
Can trial duloxetine
Or offer surgery
TVT
Burch colposuspension
67
Grading a prolapse
Grade 1 half way down vagina
Grade 2 to hymenal ring
Grade 3 not max decent
Grade 4 maximal decent
68
HRT regime
Sequential combined - estrogen daily then 14/7 progestogen every cycle to induce bleed
Continuous combined continual regime
69
Preparations of HRT
Transdermal or tablet micronised estradiol
Progestogen micronised pessary or capsule
Or mpa tablet as less androgenic
70
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
71
Diagnosing PMS
Diary for 2 cycles
| Gnrh analogues for 3/12 if diary inconclusive
72
Complimentary therapies in PMS
Saffron
Calcium and vit D
Vitex agnus
B6
73
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
74
Pre top what needs to be tested
```
Rhesus
Hb
VTE risk
Smear check
Uss
Abx
Medical Hx
Sti screen
Contraception
```
75
When to give fetecide for TOP
Over 21+6
76
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
77
Miso pre stop regime
400mcg 3 hours pre op
> 14 weeks oncogenic dilators better but miso ok up to 18/40
78
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
79
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
```
80
What is the hsa1?
Form needing two docs and circling reason for top
| Must be kept for 3 years
81
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
82
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
83
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
```
84
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
85
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
