gynae Flashcards
Ladies presenting from which countries should you consider FGM?
Somalia, Sudan, Kenya, Eritrea, Ethiopia and the Yemen, Malia, Guinea and Egypt
How is FGM classified?
Type 1 - clitoroidectomy - partial or total removal of clitoris and/or prepuce
Type 2 - partial/total removal of clitoris and labia minor ± excision of labia majora.
Type 3 - infibulation - narrowing of vaginal orifice by creation of a seal through cutting and appositioning of labia minora/majora, ± clitoroidectomy.
Type 4 - any other harmful procedures to female genitalia for non-medical reasons e.g. pricking, piercing, cauterisation, incision and scraping
Acute complications of FGM
haemorrhage, pain, urinary retention, sepsis, HIV, tetanus, death
Long-term sequelae of FGM
Chronic pain, apareunia, dyspareunia, anorgasmia, sexual dysfunction, keloid scar, UTIs, micturition difficulty, sub fertility, psychological/emotional trauma.
Describe the sequence of events in female puberty
Breast bud development -> pubic hair -> axillary hair -> menarche
Briefly describe the hormonal changes through the ovarian cycle
Follicles start developing independently, low steroid/inhibin = little negative feedback on HPG axis -> increasing FSH and LH -> follicle growth + oestrogen production.
Rising oestrogen -> -ve feedback HPG axis -> reduced FSH -> one follicle survives, others polar bodies.
Oestrogen increases sufficient to cause +ve feedback HPG -> LH surge (FSH suppressed by Inhibin) -> ovulation.
Luteineised follicle secretes oestrogen + progesterone, restoring -ve feedback HPG. End of cycle = corpus luteum regresses to reset the cycle (no fertilisation) or is maintained by the syncytiotrophoblast of the embryo which secretes hCG, it is supported by placental hCG which controls HPG axis around 4months.
With respect to the uterine cycle, length of cycle varies due to variation in….?
Follicular phase, luteal phase remains constant hence you measure LH 14 days before end of cycle to catch ovulation.
A 23 year old woman attends her GP, she is soon to go on a beach holiday and has heard of a pill that can delay her menstruation to avoid it coinciding with the holiday. What treatment options are there for delaying menstruation?
take norethisterone 5mg TDS 3 days before expected period. If overweight/smoker/35+/risk of VTE use medroxyprogesterone acetate.
What is oligomenorrhoea and at what age is it more likely?
Infrequent periods - cycles lasting over 35 days and/or fewer than 9 periods per year, extremes of reproductive age
How is amenorrhoea classified?
Primary - failure to commence menses
Secondary - cessation of periods for >6 months after menarche in the absence of pregnancy.
How would you investigate oligomenorrhoea/amenorrhoea?
Pregnancy test!
FSH - raised if POF, low/normal in hypothalamic-pituitary cause
LH - raised in POF/PCOS; low/normal in hypothalamic-pituitary cause
oestradiol - low in hypothalamic and POF
testosterone - raised in PCOS
prolactin - raised in prolactinoma, stress, hypothyroid
TFT if clinically suggestive?
Common causes of oligomenorrhoea
PCOS, hormonal/contraceptive treatments, perimenopause, thyroid dysfunction, diabetes, ED, excessive exercise, medications (anti-psychotics/AEDs)
Common causes of amenorrhoea
Hypothalamic (low GnRH, low FSH/LH) - ED, exercise, severe chronic disease (thyroid, psychiatric disorder, sarcoidosis), Kalllman syndrome.
Pituitary - prolonged use of contraception (esp Depo-Provera can take 18m as pituitary downregulated), prolactinoma, other pituitary tumour (acromegaly, Cushings), Sheehans syndrome.
Ovarian - PCOS (though more commonly oligomenorrhoea), Turners Synd, POF
Consider - adrenal (CAH), genital tract abnormality (Ashermans syndrome, imperforate hymen, septum)
How is premature ovarian failure managed?
Cyclic HRT - oestrogen (+ progesterone if she has a uterus)
DEXA scan - vitamin D and calcium
Define premature ovarian failure
Onset of menopausal symptoms and elevated gonadotrophins (LH and FSH) before the age of 40. Usually idiopathic but can occur secondary to chemo, radiation, autoimmune.
Define polycystic ovary syndrome
Endocrine disorder affecting 5-10% pre-menopausal women, characterised by oligo/a-menorrhoea, excess androgen production and presence of multiple immature follicles ‘cysts’ within the ovary as seen on imaging.
What is the underlying aetiology in PCOS?
increased frequency of GnRH pulse -> increased LH levels which promotes androgen production and insulin resistance which suppresses hepatic SHBG production causing increased free androgens.
Increased androgens prevent LH surge sufficient to cause ovulation so follicles within the ovary remain arrested early in development hence seen as ‘cysts’ on imaging.
Clinical features of PCOS
Oligo/a-menorrhoea, obesity, subfertility, acne, hirsutism, chronic pelvic pain, depression, acanthosis nigricans, male-pattern hair loss, hypertension
A 23 year old female visits her GP complaining of infrequent periods - her cycle usually lasts 37-39 days and in the last year she has had 8 periods. You also note she is rather hirsute and her BMI at last checking was 31.
What is your differential ddx?
PCOS - oligomenorrhoea, hirsute, obese
hypothyroidism - obesity, insulin resistance, oligomenorrhoea
Cushings - obesity, acne, htn, insulin resistance
hyperprolactinaemia - oligo/amenorrhoea, acne, hirsute.
How is PCOS diagnosed?
By fulfilling 2 out of 3 of the Rotterdam criteria:
oligo/a-menorrhoea
clinical/biochemical sx hyperandrogenism
polycystic ovaries seen on US (>12follicles in one ovary, or ovary vol >10cm3).
What investigations would you perform in someone with clinical picture suggestive of PCOS and when?
Bloods - (FSH and LH best taken day 1-3):
- FSH - normal/low
- LH - raised (classically LH:FSH 3:1)
- Progesterone - low (corrected for time in cycle)
- Testosterone - high
- SHBG - low
may be worth testing for diabetes simultaneously
(if ?diagnosis - TSH, prolactin)
US ovary - 12+ cysts in one/ovarian vol >10cm3
What are the general themes of managing PCOS?
Rx underlying diabetes/htn. If overweight advise diet and exercise to lose weight will help all facets of mx! oligo/a-menorrhoea infertility obesity hirsutism
A 35 year old female attends GP clinic as following subfertility investigations she was found to have PCOS. How would you counsel her on improving fertility with PCOS?
If overweight lifestyle changes - achieving BMI <30 can be enough to trigger ovulation on its own.
Drug rx - Clomifene citrate and/or metformin
- clomifene stimulates ovulation, can only be given for 6months due to risk of ovarian hyper stimulation/ca, also risk of multiple pregnancy
- not responding = ?ovarian drilling
A 17 year old girl is newly diagnosed with PCOS and attends your clinic to discuss management. The main symptom of her PCOS is oligomenorrhoea. However, she says she is quite happy to have periods less frequently anyway so does not see the need for treatment. What would you advise?
She is unlikely to be ovulating in her current state, anovulation means progesterone production is suppressed, leaving oestrogen unopposed. Unopposed oestrogen promotes endometrial hyperplasia, which increases risk of endometrial cancer. For that reason it is advisable to have 3+ periods per year. So would advise use of COCP, levonorgestrel-IUS, cyclical progesterone such as medroxyprogesterone. OCs also have the benefit of treating hirsutism and acne.
A 21 year old comes to your clinic distressed as she is growing more dark hair on her face. You believe this to be hirsutism associated with her previously diagnosed PCOS. How would you manage this?
Advise weightloss if she is overweight
Discuss use of cosmetic rx
Start COCP, if 6/12 no improvement add anti-androgen spironolactone.
List some of the long-term consequences of PCOS
Increased risk of DM2 and gestational diabetes (OGTT pre-conception ideally/before 20 weeks, then again at 24-28wks), cardiovascular disease, endometrial cancer, OSA.
What is menorrhagia?
excessive menstrual bleeding which interferes with a womans quality of life. Refers to bleeding not related to pregnancy, and only that during reproductive years.
used to be >80ml/cycle but hard to measure and irrelevant to QOL impact
List the causes of heavy menstrual bleeding
PALM (structural) COEIN (non-structural) Polyps Adenomyosis Leiomyoma (fibroids) Malignancy and hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
What are the 2 main risk factors for heavy menstrual bleeding?
Extremes of reproductive age (at menarche and approaching menopause) and obesity; risk factors relating to specific cause e.g. Adenomyosis and previous C-section
Main features of HMB
Menstrual bleeding deemed excessive by the woman, fatigue, SOB (if anaemic)
What should you establish in woman p/c HMB HPC
Cycle duration, frequency, date LMP? flooding/clots, how many menstrual products are you using per day? When was last smear? PMH (inc pregnancy)? PSH? DHx (including contraceptions, anything taken to stop bleeding)?
List potential findings seen by clinical examination of a woman with HMB
General - sx anaemia e.g. pallor, SOB, palpitations
bimanual examination - enlarged uterus (irregular - ?fibroids), tender uterus or CMT (adenomyosis/endometriosis)
Speculum - cervical inflammation, polyp or tumour, vaginal tumour.
How would you investigate a woman with HMB?
Urine pregnancy test!
Dictated by ddx
Bloods - FBC (anaemia), TFT (?hypothyroid), other hormones (not routine but could consider if ?PCOS etc), coagulation screen and vWD testing (features hx suggestive)
? infection - cervical smear if not up to date, high vaginal and endocervical swabs
Imaging - TVUS - inconclusive/+ = hysteroscopy and endometrial bx
A 37 year old woman presents to clinic with heavy periods during which she experiences flooding. She reports no pain, no changes in her discharge or itching, her smear is up to date and normal, and her LMP was 2 weeks ago. She is G4P4. O/E bimanual examination is unremarkable but on speculum a fleshy pink protuberance can be seen at the 2 o’clock position.
What is her likely diagnosis? How would you investigate and manage this?
HMB 2ndary to cervical polyp
Ix - pregnancy test to rule out, polypectomy and histological examination, FBC to check for anaemia.
a 43 year old woman presents to clinic with HMB that is reducing her QOL as they are painful and she has experienced floods, passes clots and has to change her sanitary products regularly. She is G2P1, LMP 3 weeks ago (cycle getting longer, now ~33 days; period lasts 5 days), cervical smear is up to date. O/E she has a boggy enlarged uterus which is tender to the touch.
What is the likely diagnosis? How would you investigate and treat this lady?
Adenomyosis - dysmenorrhoea and HMB, O/E tender boggy enlarged uterus, a woman approaching menopause
Ix - FBC (check for subsequent anaemia), TVUS.
Mx - medications to reduce bleeding e.g. tranexamic acid, hormonal contraception (IUS), GnRH agonist to shrink lining, hysterectomy
what is the most common cause of HMB?
abnormal uterine bleeding - idiopathic, with no apparent structural/infective/endocrine/haematological pathology.
How would you manage HMB?
Depends on wishes for fertility
- Medical = LNG-IUS (mirena licensed for 5yrs rx, also acts as contraceptive, thins endometrium and can shrink fibroids), COCP, Progesterone only (oral NET taken day 5-26 is not a contraceptive, depot or implant are long acting contraceptives). If preserving fertility can offer tranexamic/mefanemic acid (mef = NSAID analgesic)
- surgery (neither suitable if planning family) = endometrial ablation (risk ectopics, still use contraception), hysterectomy (only definitive rx)
How would you investigate and manage HMB associated with fibroids?
Ix - TVUS
Mx - 1st line LNG-IUS (alt COCP, tranexamic acid). GnRh agonists can be used for short term rx to reduce size. Surgery - endometrial ablation, hysterectomy, myomectomy and uterine artery embolisation.
A 34 year old woman comes to discuss her treatment options for HMB due to uterine fibroids. A large fibroid was discovered on TVUS after investigations into subfertility. She is very concerned that there will be nothing she can do as she still wishes to add to her family. What treatment would be suitable for her?
Only effective treatment for large fibroids causing subfertility is myomectomy.
LNG-IUS and tranexamic acid etc would help HMB but not fertility, medical rx also less likely to work in large fibroids.
GnRH agonists may reduce size of fibroids but if planning to get pregnant soon would not be suitable as will suppress fertility.
Hysterectomy and endometrial ablation are not suitable for women who wish to get pregnant in future
Fibroids are more likely to cause subfertility if submucosal or >6cm intramural.
What is a uterine fibroid? How are they classified?
Leiomyoma, benign smooth muscle tumour. Most common benign tumour in women.
Subserosal - protrudes into and distorts the outside surface of the uterus, can be pedunculate.
Submucosal - develops immediately underneath endometrium protruding into cavity.
Intramural - most common, confined to myometrium
Risk factors for developing fibroids
Obesity, age, early menarche, family hx (1st degree relative), African-American
How do uterine fibroids usually present?
Usually asymptomatic, incidental finding.
Can present with HMB, pressure sx (e.g. urinary frequency or retention) ± abdominal distension, subfertility. Rarely acute pelvic pain - may occur in Pregnancy with red degeneration of fibroid.
What medications can be used to shrink uterine fibroids pre-operatively?
GnRH analogue - Zolidex - use for 6months max risk osteoporosis, induces temporary menopausal state, reduces fibroid size and lowers risk complications
Selective progesterone receptor modulators - Ulipristal - reduces size of fibroid and menorrhagia, can be used pre-op or as an alternative to surgery.
A 19 year old woman asks to be fitted with a levonorgestrel IUS as she has heard it stops periods. Is this correct? what is its effect on periods?
Levonorgestrel IUS reduces bleeding, with 30% women amenorrhoeic after 12 months of use. However a side effect to note is that it can make your bleeding irregular for the first 4-6/12 of use.
Define the menopause
The end of female reproductive life, a physiological process which begins as peri menopause around the age of 45 and progresses until final menarche and end of fertility (UK average 51). It is diagnosed after 12 months of amenorrhoea
Describe the characteristic hormone changes seen in menopause
Decreasing oestrogen -> anovulatory cycles and raised FSH and LH (esp FSH)
List symptoms of the menopause and peri-menopause.
Vasomotor - hot flushes (peripheral vasodilation and transient rise in temperature, usually start on face and spread to neck and chest), night sweats.
Urogenital - vaginal atrophy and dryness -> dyspareunia, urinary incontinence and UTIs (urethra and bladder share embryological origin with vagina and uterus so also atrophy)
Irregular PV bleeds - menstrual cycles change length, and oestrogen breakthrough bleeding as a result of anovulatory cycles (IMB).
Difficulty sleeping, loss of libido, problems with mood/concentration/memory, headaches.
Why does the risk of osteoporosis increase post-menopause?
Oestrogen supports bone density and mass, as it reduces osteoclast activity. Reduced oestrogen -> unsuppressed osteoclast activity.
How should contraception be managed in women who are menopausal/perimenopausal?
Still continue with contraception until 12 months of amenorrhoea if >50, 24 months of amenorrhoea if <50.
List contraindications for HRT
Current/past breast cancer
Oestrogen-sensitive cancer
Undiagnosed PV bleed
Untreated endometrial hyperplasia
Previous idiopathic/current VTE unless already on anti-coagulant
untreated htn
active/recent thromboembolic disease e.g. MI
A 54 year old lady visits the GP to discuss starting HRT as she is troubled by intense hot-flushes and night sweats. Gynae hx - LMP 14/12 ago, G3P3, smear up to date, no sig PMH/DHx/PSH.
What HRT regimen would you recommend
Continuous Combined
Assume this lady has a uterus (no significant PSH indicates no hysterectomy) - so oestrogen and progesterone regimen needed.
>50 and amenorrhoeic for >12months so continuous combined HRT. Can discuss with her the route/formulation she prefers.
A 49 year old lady visits the GP to discuss starting HRT. Her LMP was 18 months ago, she has no sig PMH/PSH/DHx.
What HRT would you advise?
Continuous combined + contraception
No sig PSH/PMH - assume she has a uterus so combined regimen
>12 months amenorrhoea = continuous combined regimen.
Under 50 and <24m amenorrhoea = advise on need for continued contraception use - could use a LNG-IUS for both contraception and HRT, otherwise use non-hormonal contraception.
A 51 year old lady visits the GP to discuss starting HRT. Her LMP was 10 months ago, she has no sig PMH/PSH/DHx
What HRT would you advise?
Combined Cyclical (aka sequential) + contraception
Assumed no hysterectomy = need combined regimen
Perimenopausal lady - <12months amenorrhoea so need daily oestrogen with cyclical progestogens to allow for withdrawal bleeds that are regular and minimise risk enndometrial ca.
Cyclical progestogens include norethisterone or utrogestan
Contraceptives - use progesterone-only implant/injection/pill or non-hormonal contraception.
A 55 year old lady visits the GP to discuss starting HRT. Her LMP was 23 months ago. PSH - total abdo hysterectomy 1yr ago.
What HRT would you advise?
oestrogen only HRT, usually taken continuously
What are the benefits of HRT?
Reduce vasomotor symptoms of menopause (hot flush night sweats), mood swings, vaginal dryness and loss of libido.
Reduce risk osteoporosis
What are the side effects of HRT? How would you counsel a patient on them?
Advise that they are usually worst in first month or two,, settle by 3 months, and that there are many alternative routes or types of each hormone to try.
Oestrogen - nausea, bloating, breast tenderness, fluid retention, headaches, leg cramps, dyspepsia
Progestogen - acne, depression, mood swings, PV bleeding, also migraine/headache/breat tenderness/fluid retention.
A 56 year old patient c/o hot flushes which are severe and interfering with her work. She is reluctant to try HRT due to the side effect profile, and her being relatively well otherwise. What could you offer instead?
fluoxetin/citalopram/venlafaxine for vasomotor sx
How does premature ovarian failure differ to premature menopause?
POF tends to be seen in women <40, premature menopause <45
POF - still might have periods though they are irregular, may still be ovulating and it is still possible to fall pregnant though less likely than in someone without POF. Premature menopause is amenorrhoea for 12 months and anovulation, they are no longer fertile.
A 19 year old woman attends the EPAU having recently taken a home pregnancy test which was positive. She does not wish to continue the pregnancy (7+3/40) and attends for a TOP. Which method of TOP is she likely to have?
Medical TOP usually offered if between 6 and 9 weeks.
What does a medical TOP involve?
PO mifepristone (an anti-progestogen), 48h later given sublingual/buccal/PV misoprostol (prostaglandin)
What forms of surgical TOP are available and for which gestation is each more commonly used?
Surgical dilatation and suction of uterine contents - up to 14wks gestation
Surgical dilatation and evacuation of uterine contents - after 14 weeks gestation
What complications of TOP should you advise a patient of?
failure of TOP retained products of conception infection bleeding cervical trauma uterine perforation/rupture
Describe some of the after care a TOP patient should receive
After abortion may have abdominal cramps and some PV bleeding which should self-resolve in 1-2 weeks
Fertility returns immediately so should discuss contraception
Pregnancy test in 3wks still positive = return ?RPOC
Anti-D should be admitted to a Rh- woman having a surgical TOP >12/40.
Define miscarriage
Expulsion of products of conception before 24 weeks gestation
How does a threatened miscarriage present?
Painless PV bleed, cervical os closed. Typically small amount of blood 6-9 weeks.
How does a missed miscarriage present?
foetus dies but remains in utero. May be asymptomatic or only disappearance of sx of pregnancy, or PV bleed, pain. Cervical os closed. Confirmed by TVUS CRL>7mm without heartbeat.
How is an anembryonic pregnancy diagnosed?
US shows gestational sac >25mm without an embryonic or foetal pole
How does an inevitable miscarriage present?
heavy PV bleeding, clots, pain, cervical os open
How does incomplete miscarriage present?
PV bleeding, pain, not all products of conception have been expelled some still in the canal, cervical os open.
Risk factors for miscarriage
Maternal age (>30-35), previous miscarriage, obesity, smoking, uterine abnormality/surgery, parental chromosomal abnormality, antiphospholipid syndrome, coagulopathies
Differential diagnosis in woman with pain, PV bleed and a positive pregnancy test?
Miscarriage, ectopic pregnancy, cervical/uterine malignancy
How would you manage a woman with suspected miscarriage?
Refer to Early Pregnancy Assessment Unit
TVUS - for definitive dx
Bloods - FBC, blood group and Rhesus status, triple swabs and CRP if pyrexial, b-hCG for serial measurements if ?ectopic
A woman presents to EPAU at 8/40 with heavy PV bleeding and pain, on speculum examination cervical os is open.
What is the diagnosis and how should this be managed?
Inevitable miscarriage
<12 weeks so no need for anti-D
Expectant, medical or manual vacuum aspiration (<12)
A woman presents to EPAU at 13/40 with heavy PV bleeding and pain, on speculum examination cervical os is open and products of conception can be seen in the cervical canal.
What is the diagnosis and how should this be managed?
Incomplete miscarriage
> 12wks so if Rh- administer anti-D
Expectant, medical or surgical mx (prev ERPC)
A woman presents to EPAU at 6/40 having passed a ‘teaspoon-ish’ quantity of blood from her vagina, on speculum examination cervical os is closed. TVUS detects a foetal heartbeat.
What is the diagnosis and how should this be managed?
Threatened miscarriage
<12wks so no need for anti-D
Reassure, redirect back to GP/midwife, safety net sx such as heavier bleeding, clots, pain.
A woman presents to EPAU at 6/40 with painless PV bleeding, on speculum examination cervical os is closed. TVUS = CRL 6mm, no heartbeat.
What is the diagnosis and how should this be managed?
CRL <7mm so cannot accurately comment on heartbeat, re-scan in 1 week.
A woman presents to EPAU at 13/40 with painless PV bleeding, speculum = cervical os is closed. TVUS = CRL 12mm, no heartbeat. What is the diagnosis and how should this be managed?
Missed miscarriage
If Rh- administer anti-D as >12 weeks
Conservative/medical/surgical mx (>12)
What does medical management of miscarriage involve? What follow up would you offer?
vaginal misoprostol (+analgesia, anti-emetics)
stimulate cervical ripening and myometrial contractions
s/e - diarrhoea, vomiting, heavy bleeding and pain, chance it may not work and she requires surgery
pregnancy test in 3 weeks time
What does expectant management of miscarriage involve? What follow up is offered?
Waiting for miscarriage to complete naturally, without medical intervention.
>12weeks = offer anti-D to Rh- women.
follow up = scan in 2 weeks/pregnancy test in 3 weeks
How is a miscarriage managed surgically?
Anti-D to Rhesus- women
<12 weeks - manual vacuum aspiration under LA
>12 weeks - surgical management of miscarriage under GA (prevents ERCP)
Define recurrent miscarriage, and give examples of causes of this condition?
3+ consecutive miscarriages which occur spontaneously before 24 weeks
Antiphospholipid syndrome or inherited thrombophilia
Endocrine - uncontrolled and severe diabetes/thyroid/PCOS
Genetics - parental chromosomal rearrangement/foetal chromosomal abnormality
Anatomical abnormalities - uterine malformation (e.g. septate/bicornuate uterus), cervical weakness, acquired uterine abnormality e.g. adhesions and fibroids
Define ectopic pregnancy
Any pregnancy whereby the fertilised ovum implants outside the uterine cavity - Fallopian tube, ovary, cervix, peritoneal cavity.
Where are ectopic pregnancies most likely to be found and where are they most dangerous?
97% tubal - mostly in the ampulla
greatest chance of tubal rupture in the isthmus
Risk factors for ectopic pregnancy
Tubal damage - PID, prev surgery Contraception - IUCD, IUS, POP, progesterone implant, tubal ligation or occlusion Previous ectopic Endometriosis IVF
Clinical features of an ectopic pregnancy
Lower abdo/pelvic pain, PV bleed/discharge, hx recent amenorrhoea, rupture - peritonism, shoulder tip pain (diaphragm irritation), haemodynamic instability
O/E abdo tenderness, CMT
Ddx for a woman presenting with PV bleed/discharge and lower abdominal pain
Ectopic pregnancy
Miscarriage
Infection/inflamm - acute PID, UTI, appendicitis, diverticulitis
Ovarian cyst rupture/torsion/haemorrhage
A woman presents to A&E with severe lower abdominal pain, PV bleeding and abdominal guarding. LMP 6/52 ago. What investigations would you perform?
Urine pregnancy test
TVUS
TVUS cannot identify a pregnancy though her pregnancy test is positive. What is your differential?
Ectopic pregnancy
miscarriage
very early uterine pregnancy
The patient is diagnosed with ‘pregnancy of unknown location’, her initial serum b-hCG is back and is 2000iu/l. How does this impact management?
> 1500 = Ectopic pregnancy until proven otherwise, diagnostic laparoscopy
How can you manage a ‘pregnancy of unknown location’ with an initial serum bhCG of 1200?
If patient is stable can wait 48h and repeat for a serial bhCG, if a miscarriage would expect this number to half, if ectopic/viable would expect it to double, can rescan to check if it is intrauterine or ectopic and should be able to see it at this stage
How would you manage a confirmed ectopic pregnancy?
Admit to hospital
A-E assessment to assess resuscitation needs if haemodynamically unstable
Definitive management can be expectant (unlikely), medical or surgical.
What is medical management of an ectopic pregnancy and who is suitable for it?
IM methotrexate - ectopic mass <35mm, not ruptured, no pain, no foetal heartbeat, serum bhCG <1500, no intrauterine pregnancy.
How would you counsel a patient on medical management of ectopic pregnancy?
Methotrexate requires follow up on day 4, 7 and then weekly to check bhCG levels are falling and may require second dose if it doesn’t drop >15% day 4-7. Rarely people require surgery if it doesn’t work.
S/E - stomatitis, diarrhoea, dysphagia, mucositis and myelosuppression. Also should be advised to use contraception for 3/12 and prenatal 5mg folic acid.
What is surgical management of an ectopic pregnancy and who is suitable for it?
Laparascopic salpingectomy (or salpingotomy if other tube is damaged/absent to preserve fertility) Indications - ectopic mass >35mm, ruptured, painful, foetal heartbeat, bhCG>1500, compatible with uterine pregnancy.
How would you counsel a patient on surgical management of ectopic pregnancy?
Risks - infection, bruising, bleeding, UTI, abdo/shoulder tip pain, damage to nearby structures (bladder, bowel, blood vessels, uterus) requiring immediate repair, wound hernia, risks of general anaesthesia.
Will be given anti-D if Rh-. Salpingectomy does eliminate a Fallopian tube reducing fertility, but can still get pregnant if the other is intact and there is less chance of ectopic than in Salpingotomy.
List 3 examples of gestational trophoblastic disease
Partial and complete hydatidiform moles, choriocarcinoma, invasive mole, epithelioid/placental trophoblastic tumour.
Who is at risk of gestational trophoblastic disease?
Maternal age <20/>35
Use of COCP
Previous miscarriage
Previous GTD
Describe the pathophysiology of a complete hydatidiform mole
An empty ovum without chromosomes is fertilised by a haploid sperm which then duplicates its DNA (or less commonly is fertilised by 2 sperm) leading to 46 chromosomes of paternal origin only.
Describe the pathophysiology of a partial hydatidiform mole
A normal haploid ovum is fertilised by 2 sperm leading to triploid DNA (69 XXX or XXY). Can have a viable foetus if mosaicism gives rise to normal karyotype foetus and triploid placenta
What is an invasive hydatidiform mole?
Hydatidiform moles are usually benign but can become malignant and invade myometrium, disseminating around the body.
What is a choriocarcinoma?
Malignant form of GTD, it is a malignancy of trophoblastic cells of the placenta which characteristically metastasise to the lung. It commonly, though not exclusively, co-exists with hydatidiform mole
How might a hydatidiform mole present? Symptoms and signs on clinical examination.
PV bleed, abdominal pain, exaggerated symptoms of pregnancy e.g. hyperemesis, anaemia, hyperthyroidism (bhCG can mimic TSH). O/E uterus may be larger than expected for generation, soft and boggy.
What investigations would you order in ?hydatidiform mole and what might you expect to see?
Positive urinary pregnancy test
Serum bhCG - very high
Pelvic USS - complete mole classically ‘snowstorm’ appearance, central heterogenous mass with multiple surrounding cystic areas and vesicles.
How would you manage a hydatidiform mole?
Urgent referral to specialist centre
Surgery - evacuation of uterus (suction curettage) + histology to confirm dx ± follow-up treatments including chemo.
Anti-D if Rh-
Effective contraception to prevent pregnancy until follow up treatment finishes 6-12/12 - barrier contraception until hCG normalises
How does lichen sclerosus present? How would you treat it?
Itchy white plaques on the vulva, caused by atrophy of epidermis in elderly. Mx topical steroids and emollients, follow up risk of vulva ca.
How does vulva cancer present?
Lump/ulcer on labia majora ± irritation/itching
What is a bartholins abscess? How would you manage it?
Infection and inflammation of the Bartholins gland, a pair of glands located next to the entrance to the vagina, normally about the size of a pea.
Swollen hot red labium + painful abscess (can’t sit down)
Rx marsupialisation to incise and drain
What is cervical ectropion? How might it present?
Stratified squamous of the ectocervical epithelium is replaced by columnar epithelium of endocervical epithelium. O/E red ring around cervix. PV bleed, PCB.
What is the cervical screening programme in England?
25-49 every 3 yrs. 50-64 every 5yrs. Delay for 3m until post partum
How do HPV 16 and 18 cause cervical cancer?
HPV 16 produces E6 oncogene which inhibits p53
HPV 18 produces E7 oncogene which inhibits RB TSG
What would your next step be in managing a woman diagnosed with mild dyskaryosis on smear?
HPV testing. If positive refer to colposcopy. If negative return to routine recall
What would your next step be in managing a woman diagnosed with moderate or severe dyskaryosis on smear?
Refer for immediate colposcopy (within 2wks)
How is CIN treated?
CIN 1 may spontaneously regress can repeat smear in 1yr or can treat as CIN 2/3. Large Loop Excision of the Transformation Zone (LLETZ) using loop diathermy and test of cure cytology in 6months
How would you manage cervical cancer?
Hysterectomy ± LN clearance
1a and wish to maintain fertility = cone bx with negative margins and close follow up.
Later stage radio+ chemotherapy
How does endometrial cancer present? Risk factors?
PMB - PMB must rule out endometrial cancer. Nulliparity, early menarche, late menopause, obesity, PCOS, tamoxifen, HNPCC
How would you investigate endometrial ca?
55+ PMB 2WW referral.
TVUS - endometrial thickness >4mm then proceed to hysteroscopy and endometrial bx.
Rx endometrial ca
localised disease TAH+BSO
High risk disease - + post op radiotherapy
Not fit for surgery - progestogen therapy
What feature would make you bx an ovarian cyst?
Complex cyst e..g. multiloculated
What are the 2 types of benign physiological ovarian cysts?
Follicular cyst
Corpus luteum cyst
What type of ovarian cyst may contain skin appendages, and what type of tumour is this?
Dermoid cyst
Benign germ cell tumour
How would you investigate an ovarian cyst in a postmenopausal woman?
Ca125 and TVUSS
How is risk malignancy index calculated?
RMI = CA125 (actual value) x USS score (0 = 0 points, 1 = 1 points, 2-5 features =3) x Menopausal status (pre=1, post=3)
What is the most common cellular type/origin of ovarian cancer?
90% epithelial, 70-80% of which are serous carcinomas
Sx of ovarian ca
Vague often presents late - can be mistaken for IBS, diverticulitis
Abdo/pelvic pain, change in bowel habit, bloating, UEW, early satiety, fatigue, urrinary sx, PV bleeding.
How would you investigate ovarian ca?
CA125 and refer to gynaecology for pelvic/abdo USS, diagnostic laparotomy.
How is ovarian ca managed
Surgery (usually TAH+BSO, can preserve uterus and other ovary if young and early disease) + platinum based chemo
Causes of PV discharge?
Physiological Bacterial vaginosis Candida Trichomoniasis Less common - Chlamydia, Gonorrhoea, Ectropion, Foreign body, Cervical ca.
What causes bacterial vaginosis?
Overgrowth of anaerobes, especially gardnerella vaginalis, which reduces the number of lactic acid producing lactobacilli causing raised pH of vagina.
Sx and investigative findings of bacterial vaginosis
Thin, offensive, fishy discharge. pH >4.5, clue cells on microscopy, positive whiff test.
Management of bacterial vaginosis?
PO metronidazole 5-7/7
Risk factors for candidiasis
diabetes, abx/steroid use, pregnancy, immunosuppression and HIV
Sx of candidiasis
Thick white non-offensive discharge, itch, vulvitis (dysuria/dyspareunia), vulvar erythema/fissuring/satellite lesions.
Mx of candidiasis?
PV clotrimazole pessary + PO itraconazole (do not use PO in pregnancy)
What is recurrent candidiasis
4+ episodes per year
What causes trichomoniasis?
Trichomonas vaginalis - flagellated protozoan parasite, STI.
Sx of trichomoniasis? Mx?
Strawberry cervix, thin offensive discharge ‘green frothy’., vulvovaginitis, pH>4.5. PO metronidazole 5-7d
Symptoms of chlamydia
Men - urethral discharge + dysuria
Women - cervicitis (discharge, bleeding) + dysuria
Ix of chlamydia
Vulvovaginal swab / first void urine sample for NAAT 2 weeks after possible exposure
Mx of chlamydia
Contact testing (men - partners in prev 4 weeks, woman - partners in prev 6months/last partner) PO doxycycline 7/7
Complications of chlamydia
PID, endometritis, infertility, increased risk of ectopic pregnancy, Fitz Hugh Curtis syndrome
epididymitis
Sx of gonorrhoea
Men - urethral discharge + dysuria
Women - cervicitis (discharge, bleeding)
Complications of gonorrhoea
Epididiymitis, urethral strictures, salpingitis, disseminated infection
Ix of gonorrhoea
NAAT vulvovaginal/urethral swabs (test for chlamydia too as co-infection common)
Rx gonorrhoea
IM ceftriaxone stat
What is PID?
Infection and inflammation of female pelvic organs including uterus, fallopian tubes, ovaries, adjacent peritoneum. usually result of ascending infection from endocervix.
Most common causes of PID
Chlamydia
Other infections inc gonorrhoea, mycoplasmas
Less commonly insertion of IUCD, TOP
Sx of PID
lower abdo pain, pyrexia, deep dyspareunia, dysuria/menstrual irregularities, discharge, cervical motion tenderness
Ix of PID
Pregnancy test to exclude ectopic
High vaginal swabs for BV, trichomoniasis
vulvovaginal swabs for chlamydia and gonorrhoea NAAT
Mx of PID
Low threshold for rx due to complications and difficult dx
IM ceftriaxone STAT + PO doxycycline + PO metronidazole (for total 14d). If complicated PID e.g. sepsis or abscess admit for IV ceftriaxone (other medications as normal)
What is endometriosis?
Hormonally (mainly oestrogen) driven growth of ectopic endometrial tissue outside the uterine cavity - commonly uterine muscle (adenomyosis), ovaries, Fallopian tubes, vaginal fornices, uterosacral ligaments.
How does endometriosis present?
Pelvic pain - can be cyclical (responding to hormonal changes of menstrual cycle) or chronic (adhesions formed due to chronic inflammation), severe dysmenorrhoea, deep dyspareunia (involvement of uterosacral ligaments)
Subfertility
Non gynaecology sx - urinary (urgency, dysuria, haematuria), dyschezia, cyclical rectal bleeding
Possible examination findings of a woman with endometriosis?
May be normal if minimal disease
Fixed retroverted uterus, tenderness in posterior vaginal fornix, adnexal masses
How would you investigate endometriosis?
Gold standard = laparoscopy (with a pre-surgery USS)
What findings might you expect in laparoscopy for endometriosis?
Chocolate cysts (endometriomas), adhesions, peritoneal deposits.
How would you manage endometriosis?
Analgesia - start with NSAIDs and paracetamol
Hormonal rx - COCP, progestogens (PO, IM, SC, IUS), 6/12 of GnRH analogues (goserelin)
Not working/fertility a priority - surgical rx with laparoscopic excision or laser ablation of endometriotic ovarian cysts.
Define urogenital prolapse
Weakness of the supporting structures causing descent of pelvic organs with protrusion onto the vaginal walls
What types of urogenital prolapse are there?
Cystocoele/cystourethrocoele
Rectocoele
Uterine prolapse
Less common - Urethrocoele, Enterocoele
Risk factors for urogenital prolapse?
Age, postmenopausal, obesity, chronic cough/constipation, multiparity, vaginal deliveries, spina bifida.
Sx of prolapse
Discomfort, sensation of heaviness, pressure, dragging or ‘bearing down’ in the pelvis
Cystocoele - urinary sx (urgency, frequency, incomplete emptying, retention if urethra is kinked)
Rectocoele - constipation or difficulty defecating
Grading of prolapse
0 = normal 1 = lowest part of the prolapse is >1cm above the introitus 2 = lowest part of prolapse is <1cm above/below introitus 3 = lowest part of the prolapse is >1cm below introitus but not fully descended 4 = complete prolapse with eversion of vagina
Mx of prolapse
Conservative - weightloss, stop smoking, pelvic floor exercises
Vaginal pessary - ring, shelf, cube etc. Change every 4-6months and apply topical oestrogen if postmenopausal to prevent vaginal erosions. S/E infection, erosions, ulcers
Surgery - complications inc infection, bleeding, DVTs, anaesthetic risk, damage to other pelvic organs and new/worsening sx, dyspareunia, recurrence of prolapse
- Cystocoele - anterior colporrhapy/colposuspension
- Rectocoele - posterior colporrhapy
- Uterine prolapse - hysterectomy/hysteropexy
How long would you expect a couple to try before conceiving?
> 80% couples conceive within 1yr if woman is under 40, they do not use contraception and they are having regular vaginal intercourse (at least twice a week)
Of the remaining ~20%, half will conceive in the 2nd year (overall rate 90%)
Define primary infertility
Couple that has never conceived a pregnancy, after 1 yr of trying
Define secondary infertility
Couple that either one, or both, partners have previously conceived/induced a pregnancy, but have not been able to conceive after a year of regular unprotected sex. Pregnancies include any TOP or ectopics/miscarriage.
How long should a couple have been trying to conceive before you investigate/refer?
1 yr of unprotected vaginal sex at least twice a week, without use of contraception - investigate/refer earlier if known clinical case of infertility e.g. prev cancer treatment, hx scrotal problems, oligo/a-menorrhoea, or if woman is over 35.
Causes of infertility
Female - ovulatory failure (PCOS, POF, surgery/chemo, weight, excessive exercise), tubal damage (PID, tubal endometriosis), uterine anomalies (large fibroids), cervical anomalies, hypogonadotrophic hypogonadism.
Male - sperm disorder (reduced sperm count, impaired mobility/volume), varicocele causing scrotal hyperthermia, testicular damage (mumps), Kallman syndrome
investigations of infertility
Woman - mid-luteal progesterone (7d before end of cycle - usually day 21), day 2-4 LH/FSH/oestradiol/testosterone
- TFTs, PRL if clinically indicated
Man - semen analysis (abnormal - repeat confirmatory test in 3/12)
If all normal - assess uterus and tubal patency with hysterosalpingography/laparoscopy and dye
What initial (conservative) advice would you give in management of infertility
weightloss/gain as appropriate, smoking cessation, cutting down alcohol, exercise, rx underlying medical diseases, regular UPSI, 400mcg folic acid OD 3/12 before conception
How would you manage a couple with infertility due to anovulation?
optimise weight, clomifene citrate 6/12 (SERM, s/e hot flushes, abdo distension/pain, N+V), ± metformin, laparoscopic drilling.
POF - requires IVF usually
How would you manage a couple with infertility due to tubal damage?
Surgery - salpingolysis/salpingostomy
How would you manage a couple with infertility due to male factors?
if hypogonadotrophic hypogonadism then gonadotrophin, obstructive azoospermia requires surgical correction, IVF
Sx of ovarian hyper stimulation synd and who is at risk of it?
abdo pain and bloating, N+V, ascites, oliguria, haematuria, hypoproteinaemia, VTE, ARDS. Hx OHSS, young age, low BMI, PCOS, seen in infertility rx usually gonadotrophin/hcg, rarely clomifene
Which methods of contraception inhibit ovulation as their primary/only MoA?
COCP
Desogestrel POP
Implant etonogestrel
Injectable MPA
Which methods of contraception thicken cervical mucus as their MoA?
POP (except desogestrel)
Which methods of contraception reduce sperm motility and survival to prevent pregnancy?
Copper IUCD
Which methods of contraception reduce endometrial proliferation (and thicken cervical mucus) to prevent pregnancy?
LNG-IUS
Advantages and disadvantages of copper coil?
Adv - immediately effective upon insertion, lasts 5-10yrs depending on brand, suitable for those in whom combined hormonal contraception CI, very effective
Dis - uncomfortable insertion, risk of expulsion esp in first 3/12 in nulliparous women, periods can be heavier longer and more painful, increased risk of PID (slight)/perforation on insertion/ectopics
Counsel patient on the LNG-IUS
Small plastic shaped device placed in the uterus, releases LNG continuously, lasts 3-5yrs depending on brand, effective immediately if started in first 7d cycle otherwise extra precautions for 7d. Risks - pain on insertion, perforation rarely, risk PID/ectopic/expulsion. S/E = initially irregular bleeding - increased number of bleeding days due to spotting (usually light bleeding 1 day of the month by 1 year), s/e of progesterone is less than in pill due to low systemic dose but can include acne, headache, nausea, depression
CIs to IUCD (IUS and Copper)
pregnancy
current STI/pelvic infection
cervical/uterine malignancy
What are the 3 methods of emergency contraception? For each, give the timeframe after UPSI for which they are effective
Levonorgestrel - up to 72h
Ullipristal acetate - up to 120h
Copper IUCD - up to 5 days after UPSI, or if outside that can insert up to 5d after ovulation but is less effective.
How does ullipristal acetate (EllaOne) use impact hormonal contraception use?
Can reduce efficacy of hormonal contraception so restart 5 days after, use barrier methods prior to restarting and while re-establishing contraception
How long before COCP can be relied on for contraception if starting on menstrual cycle day:
A) 5
B) 10
A) immediately if started in first 5 days
B) 7d
Risks associated with COCP use
Breast and cervical cancer (though protective against endometrial, ovarian and colorectal), VTE, stroke, IHD
CIs to COCP use
Absolute - migraine with aura, 35+ smoking 15+/day, hx VTE/CVA/IHD, breastfeeding <6wk post partum, current breast ca, uncontrolled htn, major surgery with prolonged immobilisation.
Relative - 35+ smoker, BMI >35, htn, immobility, BRCA1/2
How would you counsel a patient on COCP going for elective major surgery?
Stop 4 weeks before, restart at first menses occurring at least 2 weeks after full mobilisation post-op
Missed pill rules in COCP
1 pill - take ASAP, continue as normal
2+ pills missed - take last dose even if taking 2 in a day, condoms until 7d pills.
If they have had sex in intermittent period and missed pill was in:
- Week 1 (sex between pills or in pill free interval) = emergency contraception
- Week 2 - should be protected by prev and forthcoming week
- Week 3 - omit pill-free interval
S/E of combined hormonal contraception inc COCP
Oestrogen - breast tenderness, bloating, nausea, fluid retention, migraine
Progestogenic - breast tenderness, headache, increased appetite, low mood and libido, acne.
Breakthrough bleeding - common in first 6 months but if persists for over 3 months then investigate
Which of the contraceptives is the only one proven to cause weight gain?
Depo-provers (injectable MPA)
Counsel a patient on the implant
Contraceptive small plastic rod inserted just under the skin of your non-dominant arm around the inside bicep which releases progesterone to prevent ovulation, it lasts for 3yrs and is effective immediately if inserted day 1-5 (otherwise 7d contraception).
S/E irregular heavy bleeding, progesterone s/e - headaches, nausea, breast tenderness etc.
Counsel a patient on the injectable contraceptive
E.g. depo-provera; IM injection into your buttock or thigh every 12 weeks of medroxyprogesterone acetate. Adverse effects = weight gain, irregular bleeding, ?risk osteoporosis (avoid in under 20), delayed return to fertility (can be up to 12m). Effective immediately if in first 7d, otherwise use additional contraception.
Counsel a patient on the progesterone only pill - when to take it, when it is effective, side effects, and missed pill rules
Pill must be taken at the same time everyday, max 3h late or else not covered (except desogestrel - 12h); no pill free intervals. Effective immediately day 1-5 or else 2d contraceptive cover. S/E - breast tenderness, headache, nausea, acne. If you miss a pill (>3h/12h late) take ASAP and use extra precautions until re-established for 48h
What contraception method should someone on lamotrigine use?
Progesterone only method or copper IUD
What contraception method should someone on carbamazepine/phenytoin/barbiturates/topiramate use?
Depo-provers, IUS, IUD; maybe implant; avoid COCP/POP
Counsel a patient on post partum contraception
Require contraception day 21.
COCP - if breastfeeding cannot take until 6wks post partum, even still UKMEC2 til 6m, can reduce breastmilk production. Not breastfeeding = start day21
POP - insert day 21 effective immediately, if after cover for 2d, suitable for breastfeeding.
When can a copper coil be inserted post partum?
within 48h or after 4 weeks to reduce risk perforation
What is SUI?
Involuntary leakage of urine due to raised intra-abdominal pressure, in the absence of detrusor contraction. Typically seen after childbirth or can be postmenopause/surgery/irradiation. May have cystocoele
What is UUI?
Involuntary Leakage of urine due to detrusor overactivity, symptoms of urgency, usually with frequency and nocturia, in the absence of UTI or any other obvious pathology. Commonly seen in neurological pathology e.g. MS, spina bifida, post-pelvic or incontinence surgery, can be idiopathic.
How would you investigate urinary incontinence?
Dipstick and culture for UTI
Bladder diary for at least 3 days, pelvic exam to exclude prolapse and ability to contract pelvic floor muscles, urodynamic studies, post void bladder scan if ?overflow.
How would you manage stress urinary incontinence?
weightloss if appropriate, pelvic floor exercises for at least 3/12 ± physio led. Surgery - autologous rectal fascia sling, colposuspension (prev tension free vaginal tape but mesh scandal not advised). Surgery complications - bleeding, infection, anaesthetic risks, VTE, damage to bladder/bowel/ureter/nerves, new retention or urgency sx, prolapse, pelvic/abdo/wound pain
How would you manage urge urinary incontinence?
Conservative - reduce caffeine intake, appropriate fluid intake. Bladder retraining for at least 6 weeks.
Medical - antimuscarinics e.g. tolterodine, oxybutynin (avoid IR oxybutynin in frail elderly); B3 agonist mirabegron
