Gynae Flashcards

Question

Vaginal ph>4.5 Offensive smelly, fishy discharge Thin white homegenous grey discharge NOT itchy

Answer 1

Bacterial vaginosis - not an STI - Often garderella vaginalis, anaerobes and mycoplasma predominate due to disturbance in normal fora 50% asymptomatic. Other have features described ``` Diagnosis requires 3/4: Microscopy: Clue cells >20% pH >4.5 KOH whiff test fishy Homogenous non clumpy vaginal discharge ``` Microscopy also shows reduced lactobacilli, reduced pus cells Conservative if asymptomatic Metronidazole 7 days

Answer 2

Protozoan trichomonas vaginalis - Curable STI Offensive odour, ITCHY, Abnormal discharge - thick, thin, frothy, yello, green, sore vulva, Dyspareuni, Dysuria MAnagement - Metronidazole 2g single dose - or 7 days 400-500mg BD

Answer 3

MEDICAL Early: Up to 9+6 - Mifepristone (antiprogesterone) oral - 48h after Misoprostol (prostaglandin analogue) Late medical: After 9+6 - In hospital if after 13/24 - KCl feticide if after 22/40 - Takes longer but same process and may need more misoprostol SURGICAL 7-15/40: LA/GA. - Suction curettage. Misoprostol used to soften cervix 15-24/40: GA. - Surgical dilation and evacuation. - Misoprostol PV or PO before on day - Forceps Anti-D for ALL within 72h Antibiotics for surgical 2 week follow up for all - 24h helpline and safety net Investigations to do prior - Pregnancy test - Determine gestation - Abdo and pelvic exam - CHLAMYDIA for all and assess risk for other (HIV, syphilis, gonorrhoea) - Hb, blood group, Rh status - Medical hx

Answer 4

MENSTRUAL DIARY FOR 2 CYCLES to be done first - Symptoms: Tension, irritable, aggression, depression, bloated, GI upsey 1) Exercise, CBT, Vit B6 Pill, clyclic or continuous Continuous or luteal (d14-28) low dose SSRI 2) Estradiol patches + micronised progesterone or LNG IUS Higher dose SSRI continuous or luteal 3) GnRH analogues + add back up HRT 4) SUrgical tx +/- HRT

Answer 5

1) Cervical - ectropion, polyps, cancer 2) Vaginal - atrophic vaginitis 3) STI?

Answer 6

1) If mid cycle - ovulation aka physiologica 2) Cervical - polyps, ectropion, 3) Endometrial - fibroids, polyps, adenomyosis, cysts, chronic pelvic infection 4) Iatrogenic - IUD, hormonal contraception

Answer 7

1) Phsyiological - pregnancy, menopause, lactation, constituitional delay 2) Pathological - Hypothalamus - Low weight/anorexia/excess exercise, rarely a tumour - Pituitary - hyperprolactinaemia, Sheehan's - Adrenal/thyroid - Hyper/hypo thyroid, CAH - Ovary - PCOS, POI, Turner's, Gonadal agenesis, Androgen insensitivity - Outflow tract - Asherman's syndrome, Imperforate hymen/septum, Absence of vagina and uterus (Rokitansky syndrome), Cervical stenosis 3) Iatrogenic - Progesterone contraceptives - GnRH analogues 4) Endocrinopathies 1st line: Pregnancy test, TFTs, LH/FSH, Prolactin, Tesosterone + SHBG 2nd line: US 3rd line: Karyotyping

Answer 8

By age 15 secondary sexual characteristics | By age 13 if no secondary sexual characteristics

Answer 9

1) Confined to vulva/perineum 2) Adjacent spread (lower urethra/vagina or anus) -ve nodes 3) +ve lymph nodes 4) Invasion of upper 2/3rds of urethra/vagina, rectum, bladder, bone or distant mets Associations - Lichen sclerosus - Paget's disease of the vulva - CIN - Smokng - Immunosuppresion Presentation Pruritus, itching, mass/ulcer, hard/large inguinal node SCC!!! Rx - Staging is surgical 1a: Wide local excision If more - also groin lymphadectomy

Answer 10

Lichen sclerosus = thin vulval epithelium with loss of collagen Autoimmune - may co-exist with vitiligo and thyroid disease. Typically postmenopausal Features - Severe pruritus - Scratching --> blled + trauma --> pain and dyspareunia - Koebner response - Pink white shiny papules which coalesce to form parchment like thin wrinkled ski with fissures (affecting labias usually) - Inflammatory adhesions --> fusion of labia and narrowing of the intaroitus Dx = clinical Management C: Moisturisers. Avoid soap. Dry pat M: Ultra potent steroid - topical clobetasol propionate 0.05% S: Rarely to divide adhesiona

Answer 11

Statutory grounds. 2 doctors to agree that 1 is met A) Continuing pregnancy risks LIFE of woman more than if terminated B) Termination necessary to prevent PERMANENT physical injury to the physical or mental health of the woman C) Pregnancy not exceeded 24/40 AND continuing would involve risk greater than terminating of injury to the physical/mental health of the woman D) Pregnancy not exceeded 24/40 AND continuing would involve risk greater than terminating of injury to the physical/mental health of the EXISTING CHILD(REN) OR FAMILY of the woman E) SERIOUS risk that child born would suffer from physical/mental abnormalities that it wold be seriously handicapped Also emergencies F) To save life of teh pregnant woman G) To prevent grave permanent injury to the physical/mental health of the woman

Answer 12

16, 18 but also 6, 11 Given to 12-13 yo girls

Answer 13

[1] Confined to cervix [2] Upper 2/3 of vagina involved but NOT pelvic side wall [3] Extension into lower vagina or pelvic wall [4] Extension to bladder, rectal mucosa or beyond pelvis PCB, Offensive blood stined discharge, IMB, PMB Later: Uraemia, haematuria. rectal bleeding, pain O/E: Ulcer may be present Squamous cell Risk factors - Immunodeficiency - Smoking - COCP - Many sexual partners - Early first intercourse Management - Stage on MRI - >4cm: Do NOT operate as relapse --> chemo/radio - <4cm: Operate - Radical abdominal hysterectomy (Removal of parametrium, LN, upper 1/3 vagina too) = Wertheim's hysterectomy - <2cm: Option to remove cervix and LN = radical trachelectomy and pelvic lymphadenopathy. ONLY if still want children and would have to be C-sections.

Answer 14

Colposcopy in 6-9 months Back to NHSCSP after 2 -ves If persists --> Tx

Answer 15

Smear in 6 months + HPV test - Negative --> discharge to NHSCSP - Positive --> Re-colposcopy For CIN2/3: Annual smears for 10y after

Answer 16

Columnar epithelium of endocervix visible as read rea around the os on the surface of cervix - Due to eversion - occurs with COCP and Pregnancy Presentation - Asymptomatic - Can cause PCB, discharge Management - Cryotherapy - Do smear and ideally colposcopy to exclude cancer - > exposed columnar epithelium more prone to infection

Answer 17

Benign tumours of endocervical epithelium Common in >40yo Presentation - Asymptomatic or PCB/PMB Management - Evulsion locally + histology

Answer 18

Associated with STI. Ulceration and infection in severe prolapse Cn be chronic --> due to inflammation/infection - Inflammatory smear - Vaginal discharhe Management - Cryotherapy +/- antibiotics

Answer 19

Nabothian's follicle = When squamous cell epithelium formed by metaplasia over columnar cells --> columnar secretions trapped --> retention cysts Management - Not required unless symptomatic

Answer 20

Benign tumours of the myometrium Risk factors - Afro-carribean - FH - Obesity - Early puberty - Increasing age - Nulliparity Protective = COCP/depot progesterone Locations - Submucosal - Intramural - Subserosal - Pedunculated

Answer 21

SM and fibrous element - Harrd whirled (in transverse section) round tumours in the myometrium 50% asymptomatic. Symptoms related to location Menorrhagia in 30% - Submucosal/polypod: IMB Pain - Dysmenorrhoea - Pain if torsion, red degeneration or sacramatous change Other symtoms - Pressure: Urinary freq, urgency, incontinence, retenton - Impaired fertility: Distortion of cavity (intramural), prevent implantation (submucosal), obstruction of tubal ostia

Answer 22

Regress at menopause (unless HRT) Slow enlargement. Calcification Pedunculate fibroid --> torsion --> pain Degeneration = inadequate blood supply - Red: Acute disrupted blood suppply e.g. pregnancy -> PAIN, tenderness, haemorrhage and necrosis - Hyaline/cystic: More gradual outgrowing of blood supply and progresses to central necrosis, leaving cystic spaces iat the centre = soft and partially liquified Pregnancy - Premature labour - Malpresentation - Transverse lie - Obstructed labour - PPH - Red degeneration

Answer 23

C: If asymptomatic/slow growing. Annual monitoring of size and growth. Closer eye on big ones as higher malignant potential M - Menorrhagia: Transexamic acid, NSAIDs, Progestogens, IUS (only if cavity not distorted) - GnRH --> temporary amenorrhoea and fibroid shrinkage but restriced to 6/12 as bone density effect. Can be used near menopause or pre-surgery to shrink S - Hysteroscopy (IF <3cm and SUBMUCOSAL). Pretreat with GnRH agonists 1-2 months prior = safer and easier - Myomectomy (open or lap). If medical not good enough but need to preserve fertility. If open (GnRH) otherwise don't give - -> Adhesions form (Asherman's syndrome) - can reduce fertility + risk of rupture in labour --> opt for C-section? Other - UAE - Ablation (Radiofrequency) - MRI focused ultrasound

Answer 24

Presence of endometrium and underlying stroma within myometrium Pathology - Endometrium grows into myometrium (variable extent) - Severe - pockets of menstrual blood seen in myometrium - Can show atypia or invasion Hx: Painful, regular and heavy menstruation. Ex: Mildly enlarged, tender uterus IX: MRI!!! Management - IUS, COCP, NSAIDs - Hysterectomy may be required - GnRH may be used to determine if symptoms would improve with hysterectomy

Answer 25

2 uterine cavities, 2 cervix - Didelphys Normal external uterine surface but two endometrial cavities - Septate Abnormal, indented external uterine surface and two endometrial cavities - Bicornuate Only one half of the uterus has developed - Unicornuate These can all cause pregancy problems - Malpresentation - Transverse lie - Preterm labour - Recurrent miscarriage - Retained placenta

Answer 26

[1] Confined to uterus: < 1/2 myometrium(a) [2] As above but in cervix too [3] Extension through uterus : Vaginal (b), parametrial (b), pelvic node(ci), para-aortic node (cii) [4] Further spread to bowel/bladder (a) /distant mets(c)

Answer 27

Risk factors - Unnoposed oestrogen: PCOS, obesity, nulliparous, early menarche, late menopause, tamofixen, Lynch II (endometrial, ovarian, colorectal) Protective: COCP, Pregnancy, Smoking Presentation - PMB - IMB - Recent onsent menorrhagia - IMB Early presentation due to bleeding

Answer 28

Normal examinations US - >4mm post menopausal, >16 pre-menopausal need pipelle biopsy - If post menopausal and >11 or polyp --> hysteroscopy MRI to stage Management - Hysterectomy + BSO - Limited role for radiotherapy: reserved for recurrence or post surgery if high risk

Answer 29

Atypia --> Total hysterectomy +/- BSO Without atypia or if fertility required --> Observe, LNG-IUS (1st line), Oral progesterone (2nd line) - Regression: Continue IUS for 5 years, oral progesterone 6 months - Persistence of atypia: Total hysterectomy +/- BSO - Persistence of no atypia: Total hysterectomy +/- BSO if medical failed - Progression: Total hysterectomy +/- BSO - If cancer - manage as guidelines

Answer 30

Follicular - Commonest due to non-rupture of dominant follicle or failure of atresia in non-dominant follice Corpus luteum - When corpus luteum doesn't break down in absence of pregnancy. - May be full with blood/fluid - More likely to have intraperitoneal bleeding

Answer 31

For cyst 1cm or more- calculate RMI ``` <200 = low risk of malignancy. If all apply: asymptomatic, simple, <5cm, unilocular, unilateral - consider conservative and repeat RMI in 4-6 months - Resolve --> discharge - Persist --> repeat in 4-6months again - Change --> consider intervention ``` <200 = low risk of malignancy One or more of: asymptomatic, simple, <5cm, unilocular, unilateral - consider conservative and repeat RMI in 4-6 months - Consider surgery: BSO RMI >200 = increased risk of malignancy - CT scan (abdo and pelvis) - Refer to MDT gynae to decide if 1) Laparotomy (full staging) or 2) Laparotomy with Pelvic clearance (TAH +BSO + Omentectomy + Peritoneal cytology)

Answer 32

RMI. If growing: Rx Lap cystectomy <50mm + simple = no F/U as resolve within 3 cycles 50-70mm - F/U = annual US >70mm - MRI? Surgery?

Answer 33

Firstly it's TUBULO OVARIAN CANCER [1] Confined to ovaries [2] 1 or both ovaries. Extends to pelvis: uterus, tubes, intraperitoneal tissue [3] Extends beyond pelvis but confined to abdomen [4] Disease beyond abdomen e.g. lungs, liver RMI = Ca-125 x U x M

Answer 34

Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise. Nausea and vomiting are common Unilateral, tender adnexal mass on examination

Answer 35

Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy

Answer 36

Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women ``` Causes antiphospholipid syndrome endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome uterine abnormality: e.g. uterine septum parental chromosomal abnormalities smoking ```

Answer 37

Mild: bdominal pain, Abdominal bloating Mod: As for mild +Nausea and vomiting + Ultrasound evidence of ascites Severe: As for moderat, Clinical evidence of ascite, Oliguri, Haematocrit > 45%, Hypoproteinaemia Critical As for severe, Thromboembolism, Acute respiratory distress syndrome, Anuria, Tense ascites

Answer 38

Candidiasis Management Local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat) Oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat If pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Answer 39

Management if asymptomatic and mild prolapse then no treatment needed conservative: weight loss, pelvic floor muscle exercises ring pessary surgery Surgical options cystocele/cystourethrocele: anterior colporrhaphy, colposuspension uterine prolapse: hysterectomy, sacrohysteropexy rectocele: posterior colporrhaphy Usually 4 days in hospital 6 weeks before sex, tampons, swim, exercice + follow up AVOID CONSTIPATION - lots of water, fruit, veg

Answer 40

Long term complications of vaginal hysterectomy with antero-posterior repair include enterocoele and vaginal vault prolapse. Urinary retention may occur acutely following hysterectomy, but it is not usually a chronic complication.

Answer 41

Bleeding from the genital tract after 24 weeks gestation <50ml = Minor 50-1000ml + No shock = Major >1000 +/- shock = MAssive Stage one blood loss less than 15%. Everything normal Stage two: +15 to 30%. Slightly anxious. RR 20-30; HR 100-120, BP systolic increase Stage 3:30 to 40% blood loss. Confused. RR >30. HR 120-140. SBP <100 Stage four: greater than 40% blood loss. Loss of consciousness/coma. Extreme tachypnoea. HR >140. Systolic BP <70

Answer 42

``` Multiple pregnancy Previous C-section Multi Paris Aged 40 Smoking IVF ``` Painless bleed. Breach or transverse presentation comment. Vagina exam can cause bleeding. 20 week picked up. Only 10% go on to have later TVUS - 32 weeks and measure cervical length. If still low - repeat at 36 weeks. If still low recommend C-section TVUS Major placenta praevia - admit at 34 weeks Uncomplicated - deliver 36+0 - 37+0 Complicated (vaginal bleeding or risk for preterm) -> plan for 34+0 to 36+0

Answer 43

Uterus surgery e.g. C section on myomectomy Repeated surgical T a P Perforation of the uterus Occurs in 10% of women who have placenta previa and previous C-section scar Can suspect on ultrasound but diagnosis is at time of Caesarean May plan early C-section 35-37 weeks - May require hysterectomy to stop bleed - can consider plan

Answer 44

``` Risk factors – previous abruption – pre-eclampsia – IUGR – hypertension – maternal smoking – maternal cocaine use – sudden reduction in uterine volume ``` ``` Presentation – painful bleed (MAY BE CONCEALED) – constant severe sudden pain (blood behind placenta and in myometrium) – dark blood – signs of shock ``` TENDER WOODY HARD UTERUS CTG changes

Answer 45

Blood vesels unprotected between baby and placenta and near cervix - delicate and prone to rupture Vaginal bleed AFTER rupture of membranes followed by FETAL DISTRESS Risk factors - Multiparous - IVF - low lying placenta Management - YIKE - C-section in 5 Should be planned C-section 34-36 weeks

Answer 46

``` Risk factors Previous Caesarean or surgery – oxytocin – very to recognise obstructed labour – congenital abnormalities of the uterus ``` Features – vagina bleed, Abdominal pain, maternal shock, vital parts easily palpable, lots of station of presenting part, CTG abnormalities Management – FBC, crossmatch, maternal resuscitation – urgent see section

Answer 47

History – pain – risk factors for abruption and placenta praevia – fetal movements and also Tate heart Examination – abdominal palpation – speculum – Vagina examination: only after ultrasound to exclude previa Investigations – bloods: FBC, coagulation, crossmatch, using these, LFT, Kleihauser Ultrasound: exclude placenta previa Fetal investigation: CTG and ultrasound

Answer 48

Non-hormonal 40-50yo: stop after 2 yrs of amenorrhoea >50yo: After 1yr amenorrhoea Combined pill 40-50yo: Can continue >50yo: Stop at 50 and switch to non-hormonal or POP/IMP/LNG-IUS Progesterone injection 40-50yo: Can continue >50yo: Switch to other method: non-hormonal or POP/IMP/LNG-IUS POP/IMP/LNG-IUS 40-50yo: Can continue beyond 50 >50yo: Stop at 55 (natural fertility gone). If over 50 with amenorrhoea and want to stop, can check if FSH >30 and then discontinue after 1 more year NBL LNG-IUS inserted >/=45yo can stay in situ until 55 if used as contraction or menorrhagia

Answer 49

ALL ok with sequential HRT EXCEPT COCP

Answer 50

LNG-IUS can be used for endometrial protection with oestrogen (Mirena only) - Does need changing regularly Others are not recommended

Answer 51

COCP - NOT IN FIRST 6 weeks - Then ok but does reduce lactation - D21 = immediate protection; after that need 7 days extra measures POP - any time - little does enter breast milk but not harmful - After d21 needs 2 days extra measures IUS - Insert in 1st 48h or after 4 weeks

Answer 52

Vaginal ring as is combined

Answer 53

2 week wait cancer pathway | [1st line] TVUS

Answer 54

REFER ALL TO GYNAE IIREGARDLESS OF US RESULT

Answer 55

Previous baby with early- or late-onset GBS disease Preterm labour regardless of their GBS status women with a pyrexia during labour (>38ºC) should also be given intravenous antibiotics

Answer 56

Down's syndrome congenital heart defects abdominal wall defects

Answer 57

1: Tocolytics should be used to reduce cord compression and allow Caesarean delivery 2: Correct, to avoid compression 3: The patient is advised to go onto all fours 4: The cord should not be pushed back into the uterus 5: Immediate Caesarean section is the delivery method of choice

Answer 58

Bradycardia or a single prolonged deceleration with baseline below 100/min for >3 minutes

Answer 59

Heart rate - >180 BPM or <100 BPM Variability - Less than 5 for over 90 minutes Decelerations - Non-reassuring variable decelerations for over 30 minutes since starting conservative measures to improve occuring with over 50% of contractions OR late decelerations present for over 30 minutes not improving with conservative measures occurring with over 50% of contractions OR bradycardia or a single prolonged deceleration lasting 3 minutes or more.

Answer 60

Hyperandrogenism Ologies/anovulation Polycystic ovaries on scan = 12 or more follicles, 2-9cm OR ovary >10cm3 2 = diagnosis 3 if <18

Answer 61

Hyperangdrogenism - acne - hirsuitism - slope is Irregular menstruatio Infertility Obesity Late sequelae - T2DM - HTN - CVD - Endometrial cancer

Answer 62

[1] metabolic syndrome - ogtt if bmi > 30 - risks of DM, impaired glucose tolerance, IHD, stroke [2] endometrial hyperplasia - unopposed oestrogen as anovulatory (no progesterone) - offer cyclic hormone at least 3 bleeds a year [3] subfertility - reduce BMI first - induce ovulation BUT CHECK semen first — clomiphene, ovarian drilling, metformin ``` [4] hisruitism monitor with ferryman and gallwey score - options: COCP, Disney, Yasmin - topical eflornithin - sprionalactobw Physical options not on nhs - acne: benzyl peroxide ```

Answer 63

Diagnosis = FSH > 30-40 4-6 weeks apart ``` Pregnancy test LH Oestradiol Progesterone Testostosterone TFTs Prolactin USS (if considering PCOS) Can consider karyotyping - Turner, Fragile X ``` Management - Secondary care as young - gynaecologist - DEXA scan - Fertility - IVF with donor oocytes, adoption. 5-10% can get pregnant without help from fertility treatment! - PSYCHOLOGICAL SUPPORT - Review in 3 months Need HRT or COCP until natural age of menopause + physiological support (HRT is not enough contraception) Don’t do lab tests if >45 for menoupause (<40 is POI remember)

Answer 64

Adrenal insufficiency Hypothyroid FH indicates constitutional or genetic

Answer 65

Benefits - alleviates vasomotor, vagunak dryness and urinary symptoms, libido - reduces fracture risk - reduces colon cancer Risks Combined has breast cancer risk. But falls after 5y of stopping and NOT in POI VTE and gallbladder disease - NOT with transdermal patches and gels Contraindications - past, present or suspected breast cancer - known oestrogen sensitive cancer (endometrial) - undiagnosed vaginal bleeding - I treated endometrial hyperlasia - VTE - Untreated HTN - liver disease

Answer 66

MCDA from 36 DCDA from 37 NO LATER THAN 38

Answer 67

AC, HC, FL SGA based on AC or EFW < 10th centile - need serial growth scans and UA Doppler Delivery by 37 weeks usually

Answer 68

GDM by 40 weeks T1/2 between 37+0 and 38+ 6

Answer 69

GDM by 40 weeks T1/2 between 37+0 and 38+ 6

Answer 70

Simply put POI means that the ovaries aren’t working properly. They stop producing eggs years before they should (i.e. before 40yrs) and they also stop produce the hormones estrogen and progesterone, which have important roles in women’s health and well-being. POI can occur for several reasons. Unfortunately, there is still a lot that we don’t understand about POI and in the majority of women (90%), no underlying cause will be found. However it doesn’t affect the treatment you should be offered POI is different to menopause that occurs at around the average age (51 years). Not only does it occur at a very young age, but the ovaries often don’t completely fail. This means that ovarian function can fluctuate over time, occasionally resulting in a period, ovulation or even pregnancy, several years after diagnosis. Because of this intermittent temporary return of ovarian function, approximately 5-10% of women with POI may still conceive. Oestrogen is the principal female sex hormone produced by the ovaries and is vital for the growth of eggs and for the reproductive process. It is also plays a role throughout the body in maintaining cardiovascular, brain and bone health, along with many other tissues in the body. Progesterone is a female hormone produced by the ovaries. One of its many functions is to help to maintain pregnancy.

Answer 71

Conservative: Regular aerobic exercises e.g. running, swimming Low intensity exercises/reduce caffeine and alcohol intake = reduce hot flushes Support - daisy network CBT (2nd line = venlafaxine SNRI) Medical: In women with POI, the ovaries will stop producing hormones (estrogen, progesterone, testosterone), which are needed for a healthy body. HRT aims to restore the levels of these hormones in your body to a similar level as women of the same age without POI. The combined oral contraceptive pill may be appropriate for some women but effects on the bones are less favourable. Fertility reduced as ovarian function impaired SEX LIFE: Your doctor should discuss the impact on your sex life with you, and can recommend the use of hormone replacement therapy, estrogen creams, testosterone or lubricants. BONES, HEART, BRAIN: Hormones, especially estrogen, are important for the normal functioning of a (young) woman’s body. Reduced estrogen levels do not only result in menopausal symptoms, but can also affect the health of your bones, heart and brain It is important to continue treatment until at least the age of natural menopause, to give you some protection from osteoporosis and other conditions that can develop after menopause Helps with the symptoms of menopause (vasomotor, psyc, reduced libido, bone, vaginal and bladder The risk of conditions such as cardiovascular disease and breast cancer rises with age and is very low in women under 40 (risk not there for POI) Any increase in risk of ca = related to duration and reduces after stopping Both HRT and the combined contraceptive pill are good for bone health HRT may be better for your blood pressure than the combined contraceptive pill including tablets, skin patches, gels and vaginal creams, pessaries or rings Review the woman at 3 months, then annually thereafter unless there are clinical indications for an earlier review (such as treatment ineffectiveness or adverse effects)

Answer 72

VASOMOTOR - Hot flushes – Night sweats – headache Sleep disturbance (fatigue and irritable ability) – hair loss, thinking of skin, aches and pains – usually <5 years PSYCHOLOGICAL – Memory problems – mood swings/panic attacks/depression/anxiety CVD – Low oestrogen associated with increased cardiovascular tax – increasing weight and changing body fat distribution – hypertension, atherosclerosis –? Dementia UROGENITAL – Dyspareunia, itching, burning and dryness – urinary frequency, urgency, not sharia and recurrent infection SEXUAL – Lots of libido, dyspareunia – most likely due to loss of testosterone OSTEOPOROSIS – Increase fracture risk due to reduced bone mass density

Answer 73

SERM – Combines Oestrogen, progestogen with weak androgenic activity – Useful for sexual function and facing motor symptoms in menopause – less effective than combined HRT – small risk of stroke, Endometrial cancer and breast cancer

Answer 74

"Safe procedure that many women undergo (1/3 by 45) for many different. Major complications are uncommon at any stage of pegnancy but the earlier you have it, the safer it is. You have a choice of different methods which we can definitely discuss but could I ask you some questions before we get to that?" ``` – How do you know you're pregnant? – Do you member when your last menstrual period was common? (Cycle questions) – ever been pregnant before? – Why termination? – Spoken to partner/potential father? – Spoken to anyone else? ``` We ca talk aboy the options and then if you need more time or perhaps counselling that's absolutely fine. YOu have the right to delay/cancel appointments and change your mind at any time" Investigations - Pregnancy test - Determine gestation from LMP/ US if unclear - Abdo and pelvic exam (smear if due) - Hb, blood group, Rh status (All need anti d within 72h of TOP if -ve) - Infection screen: Chlamydia + risk assess for others

Answer 75

AFTER - Anti-D if Rh-ve - Advice: 24h helpline - F/U in 2 weeks - Further counselling if you want (Marie stokes or for <25yos -Brooks Advisory centre) - Contraception - Avoid SI and tampons until bleed free for 1 week - SAFETY NET: Smelly, no period in 6 weeks, heavy bleed, pain - Will not affect future chances of becoming pregant if no complications or increase risk of miscarriage, ectopic or low placenta but may have a higher risk of a premature birth

Answer 76

Anterior vagina wall prolapse: – urethrocole: prolapse of lower anterior vagina wall, involving urethra only – cystocele: prolapse of upper anterior wall of vagina, involving bladder – cystourethrocele: bladder and urethra Posterior vagina wall prolapse: – rectocele: prolapse of lower posterior vagina wall, involving anterior wall affected – Enterocele: prolapse of upper posterior wall of the vagina, usually containing loops of small-bowel Apical prolapse = prolapse of uterus, cervix and upper vagina – uterovaginal: uterine descent within inversion of vagina apex – vault: post hysterectomy inversion of vagina apex

Answer 77

Descent of the uterus and/or vagina walls beyond normal anatomical confines, due to weakness in the supporting structures "the organs within a woman's pelvis are normally held in place by ligaments and muscles known as the pelvic floor. If this support structures are weakened by overstretching, the pelvic organs can build from their natural positions into the vagina. When this happens it is known as pelvic organ products" Using the POP-Q system and Pelvic floor bother questionnaire - Stages 0-4 -

Answer 78

Vagina delivery in pregnancy – very common – vagina delivery causes injuries and dinner dinner Bashan of the pelvic floor – rest increased to large infants, not pregnancies, prolonged second stage and instrumental delivery Congenital factors – abnormal collagen Metabolism e.g. and has done lost syndrome Menopause – deterioration of collagenous connective tissue after Easter withdrawal ``` Raised intra domino pressure – beastie Cough – constipation – heavy lifting – pelvic mass ``` Iatrogenic factors – Pelvic surgery e.g. hysterectomy – continence procedures

Answer 79

This involves inserting a plastic tube into the vagina to allow me to visualise the neck of the womb and the vaginal walls. I'll then take a sample of cells from the neck of the womb using a small plastic thin brush. This shouldn't be painful but may be slightly uncomfortable. We can stop at any point if you say so. After the procedure, you may experience some light vaginal bleeding. I will have a chaperone present. Does that all make sense? Any questions? Happy to continue? Can go behind the curtain, undress from the waist down including your underwear, lie down and place the sheet provided over you. Let me know when you're ready. I'll just get my thing ready Bend your knees and bring your ankles as far up to your bottom as possible. Now drop your knees out wit your feet touching. Will start by having a look. If you just relax, i'm going to put the speculum in now. Visualise. Brush - clockwise 5 times in external os

Answer 80

Been asked to perform an internal vaginal examination. This will involve me putting 2 fingers into the vagina and a hand onto the abdomen and allow me to assess the vagina, the abdomen and the ovaries. It shouldn't be painful but may be uncomfortable. If you want to stop at any point we can. Will have a chaperone. Any questions? Shall we continue? Can go behind the curtain, undress from the waist down including your underwear, lie down and place the sheet provided over you. Let me know when you're ready. I'll just get my thing ready Bend your knees and bring your ankles as far up to your bottom as possible. Now drop your knees out wit your feet touching.

Answer 81

1 in 50. 20-30 yo sexually active women ``` Cyst = swelling Abscess = pain, hot, swollen ``` Options: [1] Antibiotics [2] Word balloon catheter - sits in place for 3 weeks to drain the abscess and allow it to heal, will take it out [3] Marsupilisation - day surgery case, GA. 15 mins. a small cut in the abscess and gland to release the fluid, sewing the edges to the surrounding skin. This is done to keep the cut open so it can heal and for the contents of the abscess to drain out. This prevents another abscess from forming later. The small cut willcompletely heal by itself eventually [4] Excision (for >40yo): Day surgery, GA. If recurrent. Gladn removed Surgery day cases 24h to get back to work. Antibiotics and painkillers for all. Avoid sexual intercourse for 2 weeks to allow healing.