Gynae Flashcards

Question

What is the pathophysiology of BV?

Answer 1

- Overgrowth of anaerobic bacteria (Gardnerella vaginalis, prevotella spp, mycoplasma homonis, mobiluncus spp.) - Loss of lactobacilli --> increase PH --> increase likelihood of PC - Gardnerella normally found but commensal in 30-40% of women

Answer 2

- 50% are asymptomatic | - Offensive foul smelling discharge

Answer 3

- Diagnosis = clinical + microscopy --> offensive foul smelling discharge (no soreness or irritation), high PH - HSV - microscopy (clue cells - vaginal epithelium cells coated with lots of bacilli)

Answer 4

Amsels = 3 out of 4 - Thin, white, homogeneous discharge - Clue cells on microscopy - Vaginal PH / 4.5 (only BV and TV) - Fishy odour on adding 10% KOH Hay-Ison critera applied to gram stain: - Grade 3=BV

Answer 5

1st line - metronidazole, PO, 400mg, BD, 7 days 2nd line - intravaginal clindamycon PV cream, 5g 2%, 7 days Avoid vaginal douching, shower gel, use of shampoo in bath

Answer 6

- Associated with late miscarriage, preterm birth, PROM and postpartum endometriosis - Increase risk of acquiring transmitting STIs

Answer 7

- Flagellated Protozoan

Answer 8

It is sexually transmitted

Answer 9

- Asymptomatic in 50% Symptomatic: - Green/yellow frothy vaginal discharge - Offensive odour - Dyspareunia - Vulval itch or soreness - Lower abdo pain and dysuria

Answer 10

A strawberry cervix

Answer 11

- High vaginal swab --> direct microscopy (wet mount of vaginal fluid shows flagellated organism in the middle) - Endocervical swabs for other STIs - Culture and gram stain - HIV test, NAAT, VDRL - pH (>4.5 - only in BV and TV), Whiff test

Answer 12

- 1st line - metronidazole, PO, 400mg, BD, 7 days - 2nd line -Metronidazole, 2g, PO STAT - contact tracing, abstinence for 7 days, follow-up

Answer 13

- Pregnancy = PTL, LBW, PPROM | - Enhance HIV/STI transmission

Answer 14

- Candida albicans (90%) | - Candida globrata (5%)

Answer 15

- Candidiasis

Answer 16

- Oral (local invasion of oral tissue) | - Invasive (systematic invasion of sterile sites)

Answer 17

- Oestrogen exposure (more common in pregnancy, reproductive years) - Diabetes (poorly controlled) - Intercourse - Immunocompromised (HIV) - Recent antibiotics (ie for UTI)

Answer 18

- Vulval itching, soreness, irritation, 'cottage-cheese' like discharge

Answer 19

- No investigations usually required (pH low/normal <4.5) --> if high consider BV or TV - Diagnostic= HVS = microscopy, culture and gram stain (Speckled gram +ve spores, pseudohyphae) - Other=MSU (UTIs), HbA1c (diabetes) NB. Pseudohyphae only in C albicans.

Answer 20

- Hepatotoxicity associated with systematic azole antifungal therapy - monitor LFT - Oesophageal candidiasis or disseminated candidiasis in immunocompromised

Answer 21

1st line - clotrimazole pessary (500mg, PV, STAT) + 1% clotrimazole (BD, topical) 2nd line/severe - fluconazole (150mg, PO, STAT)

Answer 22

- Avoid tight synthetic clothing, avoid local irritants (perfume), do not wash female area with soap/shower gels (or wash >1 day), do not douche, use simple emollients to moisturise

Answer 23

> or equal to 4 proven symptomatic episodes - Check adherence, recheck initial diagnosis - Tx: induction and maintenance fluconazole

Answer 24

Only use topical treatment

Answer 25

- Condylomata acuminate | - Caused by HPV infection (HPV 6 and 11)

Answer 26

- Most are sexually active | - 10% prevalence in the sexually active population

Answer 27

- HPV vaccine 'Gardsli' - protects against stbtypes 6,11,16,18

Answer 28

90% of cutaneous warts

Answer 29

Over 70% of cervical cancers

Answer 30

- Often asymptomatic - Vaginal discharge, PCB or IMB (local trauma), pain - Genital warts on vulva, cervix, anus --> generally painless but may itch or bleed or become inflamed

Answer 31

- Often clinical diagnosis | - STI screen --> triple swab, HIV, syphillis, HBV

Answer 32

- Often no treatment required, might refer to GUM for STI risk factors - Medical (contraindicated in pregnancy): Keratinised warts - imiquimid cream Non-keratinised warts - podophyllin/tri-chloro-acetic acid - Surgical - crotherapy, laser, electroautery

Answer 33

- May be high risk HPV leading to increased risk of anogenital cancers - Disfiguring - distress or psychosexual dysfunction

Answer 34

- Chlamydia trachomatis | - Obligate intracellular gram -ve parasite (cannot see under microscope)

Answer 35

Women: Endocervixs and/or urethra Men: Urethra

Answer 36

- Asymptomatic in at least 70-80% of men | - Symptomatic (<30%) = purulent PV discharge, dyspareunia, IMB, PCB, abdo pain, dysuria

Answer 37

- If there are signs and symptoms of chlamydia, can treat on suspicion alone, unlike gonorrhoea - Direct microscopy (non-gonococcal urethritis - just neutrophils, no organisms) 1st (NAAT): - MEN: Urethral swabs or first catch urine - WOMEN: vulvovaginal swabs or first catch urine 2nd: - Culture and sensitivities

Answer 38

- Can treat suspicion before getting lab results back 1st line: Doxycycline, 100mg, BD, 7days (contraindicated in pregnancy and breastfeeding) 2nd line / pregnant/ breastfeeding - azithromycin (1g STAT)

Answer 39

- Contact tracing (6 months) - Recommend STI screen - Avoid sex until treatment has been completed - Follow up appointment by 5 weeks

Answer 40

- PID - Infertility - Ectopic - Reactive arthritis (arthritis, conjunctivitis, urethritis) - Pregnancy - Fitz-hugh-curtis (perihepatitis)

Answer 41

- Neisseria gonorrhoea | - Gram -ve intracellular diplococci

Answer 42

- Unprotected sex - Multiple partners - Presence of other STIs - HIV - Age < 25

Answer 43

- Asymptomatic in up to 50% of patients - PV discharge - IMB - PCB - Dysuria - Dyspareunia - Lower abdo pain

Answer 44

- Mucopurulent endocervical discharge | - Easily induced endocervical bleeding

Answer 45

- Cervial motion/adnexal tenderness | - Uterine tenderness

Answer 46

- Empirical treatment only if recent sexual contact with confirmed gonococcal infection - Direct microscopy (neutrophils, gram -ve diplococci) --> prescribe antibiotics 1st (NAAT): - MEN: First catch urine - WOMEN: Vulvovaginal swabs - -> prescribe antibiotics 2nd: - Culture and sensitivities - -> prescribe antibiotics

Answer 47

- After confirmation by NAAT, confirmation by culture (& sensitivities), or direct microscopy +ve) 1st line: Ceftriaxone 1g (IM)

Answer 48

- Screening for other STIs/HIV - Contact tracing - Avoid sex for 1 week - Follow-up appointment after 1 week - Cure rate = 95% with treatment

Answer 49

- PID, infertility, ectopic, conjucntivitis - Fitz-Hugh-Curtis syndrome (perihepatitis) - a PID characterised by adhesions from liver to abdominal wall - Increased HIV susceptibility - Disseminated disease in 1% - Vertical transmission - ophthalmia neonatorum - bilateral conjunctivitis

Answer 50

- A cyst of abscess of Bartholin's gland (greater vestibular glands) - Overlying superinfection by Staph or GBS - Blockage of a duct or gland in vagina has become infected

Answer 51

- Nulliparous - Pervious bartholin's cyst? - Sexually active

Answer 52

Bartholin's cyst may extend into the vaginal canal and labial cyst will remain in the labia

Answer 53

- Unilateral labial swelling, often asymptomatic/painless - Infected: Abscess with cardinal signs of infection Fever Dyspareunia Pain or sitting or walking

Answer 54

- If >40 y/o consider vulval biopsy | - If infected --> MC&S from abscess - most sterile but may help organism differentiation

Answer 55

- Conservative (if draining and patient well) - Incision and drainage + Word catheter + Flucloxicillin, OD - Marsuplalisation (forming an open pouch to stop the cyst from reforming)

Answer 56

- Rupture | - Recurrence

Answer 57

- Pelvic inflammatory disease | - Result of ascending infection of the genital tract (endometritis, salpingitis, tuboovarian abscess)

Answer 58

``` - Chlamydia Trachomatis Other: - N Gonorrhoea - M genitalium - M hominis ```

Answer 59

- <25 y/o - Early age of first coitus - Multiple sexual partners - Recent new partner - History of STI

Answer 60

- Asymptomatic (with infertility + chronic pelvic pain) | - Acutely - bilateral lower abdo pain, PV discharge, fever, irregular PVB, dyspareunia

Answer 61

- Start with antibiotics if you suspect PID - Triple swabs: 2x endocervical and 1x HVS - Speculum: looks for signs of inflammation/discharge - Bimanual: cervical excitation, adnexal massess (tubo-ovarian abscess - confirm with TVUSS) - If febrile: blood culture, FBC, CRP

Answer 62

- Assess patient for admission: admit if pyrexial or septic If not treat then in the community. Outpatient antibiotics: - Ceftriaxone 500mg IM (single dose) - Doxycycline 100mg BD PO for 14 days - Metronidazole 400mg BD PO for 14 days Alternative (treat for 14 days): - Ofloxacin - Metronidazole Inpatient antibiotics (if pyrexcial or oral tx failed) - IV cefoxitin - IV doxycycline Alternative treatment: - IV clindamycin - IV gentamycin

Answer 63

- Infertility - Chronic pelvic pain - Ectopic pregnancy (paralyse cillia in the Fallopian tubes) - 30% require hospital admission

Answer 64

- Proliferative stage: hyperplasia of endometrium - Secretory phase: maintain endometrium - Menstrual phase (drop in progesterone): zona compacta and spongiosa shedding

Answer 65

- Responds to LH | - Produce progesterone

Answer 66

- Respond to FSH - Produce aromatase (convert androgen to oestriol) - Produce progesterone

Answer 67

- Turners syndrome - Testicular feminisation - Congenital adrenal hyperplasia - Congenital malformations of the genital tract

Answer 68

- Hypothamalic amenorrhoea (stress, excessive exercise) - PCOS - Hyperprolactinaemia - Premature ovarian failure - Thyrotoxicosis - Sheehans syndrome - Ashermans syndrome (intrauterine adhesions)

Answer 69

S/S: all other sexual characteristics developed, cyclical pelvic pain, amenorrhoea IX: USS --> haematometra

Answer 70

- b-HCG: Pregnancy - Gonadotrophins: Hypothalamic cause - Prolactin: Prolactinoma - Androgens: PCOS, CAH - Oestradiol: Pregnancy - Thyroid function: Hypothyroid

Answer 71

A diagnostic procedure obtaining a magnified view of the cervic, the lower part of the uterus and the vagina in order to examine the transformation zone and detect malignant or premalignant changes

Answer 72

Small amount of tissue removed from the cervix

Answer 73

- Severe or moderate dyskaryosis - 3x inadequate smear - Glandular neoplasia on smear - Borderline/mild dyskaryosis smear with HPV +ve test - Suspicious looking cervix

Answer 74

- Few complications for colopscopy alone - Colopscopy + excisional treatment = bleeding and infection, cervical incompetence in future pregnancies - Biopsy = rare but include excessive bleeding for more than 1 week, mild cramping, vaginal soreness, dark discharge

Answer 75

Outpatient procedure to remove or destroy endometrial layers (can prevent periods/heavy bleeding)

Answer 76

- Menorrhagia in premenopausal or perimenopausal women with normal endometrial cavities - Postmenopausal bleeding of unknown origin - Anovulatory bleeding and bleeding secondary to fibroids (intramural or submucosal <2cm for GEA, microwave ablation for submucosal up to 3cm) - higher risk of failure as does not remove fibroids - No desire for future fertility but desire to retain uterus or avoid hysterectomy

Answer 77

General= infection, bleeding, failure, damage to local structures (os, lining) Minor= cramping, nausea, frequent urination, watery discharge mixed with blood Rarely= Pulmonary oedema due to fluid used to expand uterus being absorbed into the bloodstream

Answer 78

- Biopsy of the endometrium | - Pipelle is the most widely used device - can be used without cervical dilation)

Answer 79

Over 55 and: - PMB (unexplained bleeding 12 months after LMP) - Unexplained discharge if it is new, has thrombocytosis or report haematuria - Visible heamaturia and low Hb, thrombocytosis, raised blood glucose Under 55 and: - unexplained bleeding 12 months after LMP

Answer 80

General= infection, bleeding, failure, damage to local structures (os, lining) Pipelle has blood NVP (true -ve/ total -ve)

Answer 81

Regional anaesthesia performed by injecting anaesthetic into the epidural space (diff from a spinal)

Answer 82

- Pain relief during labour - Anaesthetic for C section NB: stop any thromboprophylaxis 24 hours before epidural

Answer 83

General= infection, bleeding, failure, damage to local structures Urinary retention, shivering, pruritus, headache, (anaesthesia going to head) Hypotension, epidural haematoma, epidural meningitis, resp depression

Answer 84

Endoscopic pelvic surgical diagnostic procedure used to examine the organs inside the abdomen

Answer 85

Diagnostic: - pelvic pain, diagnose endometriosis, infertility, (dye test for tubal potency) Therapeutic: - Sterilisation, adhesiolysis, ovarian cystectomy, salpingectomy, endometrial ablation Major surgery: - Myomectomy, hysterectomy

Answer 86

General= infection, bleeding, failure, damage to local structures

Answer 87

Surgical excision of an ovarian cyst

Answer 88

- Diagnostic (and exclude an ovarian cyst) - Cyst > 7.6cm - Bilateral leisions - Removal of symptomatic cysts - Cysts that do not resolve after 2-3 months - USS finding that deviate from simple functional cyst

Answer 89

General= infection, bleeding, failure, damage to local structures

Answer 90

Surgical removal of fibroids from the uterus | the only fibroid treatment can improve pregnancy chances

Answer 91

GnRH analogues used to shrink size to reduce bleeding

Answer 92

- Hysterectomy- fibroids on the inner wall - Laparoscopy - removing 1/2 fibroids <2 inches that are growing outside the uterus - Open - large fibroids, many fibrouds, fibroids deep into the uterine wall

Answer 93

General= infection, bleeding, failure, damage to local structures Hysterectomy is large haemorrhage

Answer 94

Large loop excision of the transformation zone Use a small wire diathermy to cut away affected cervical tissue and seal the wound (examine cuttings for CIN)

Answer 95

- High grade squamous intraepithelial lesions of the cervix (CIN 2/3) - Persistent low grade squamous intraepithelial lesions of the cervix (CIN 1)

Answer 96

General= infection, bleeding, failure, damage to local structures (os, lining) --> recurrence of up to 10% Bleeding, discharge for 3-4 weeks (avoid tampons, sex, swimming until discharge has stopped)

Answer 97

Involves passing a small diameter telescope (flexible or rigid) through the cervix in inspect the uterine cavity - Flexible hysteroscope can be used in OPD setting with CO2 as filling medium - Rigid instruments use circulating fluids so can be used to visualise uterine cavity even if the women is bleeding

Answer 98

- Abnormal bleeding - PMB, IMB, PCB - Menorrhagia and or abnormal discharge - Suspected uterine malformations or suspected Ashermans

Answer 99

General= infection, bleeding, failure, damage to local structures (os, lining)

Answer 100

- Vaginal - Laparascopic assisted vaginal - Laparascopic hysterectomy

Answer 101

``` Total: uterus and cervix Cervix removed (no smears needed) ``` ``` Radial: removal of structures +/- BSO I.E Wertheim's hysterectomy Cervix removed (no smears needed) ``` Subtotal: upper part of the uterus removed Cervix NOT removed (smears needed)

Answer 102

If total or radical hysterectomy and done due to cancer/CIN, smears are still done at 6 and 18 months

Answer 103

Vaginal hysterectomy: - menstrual disorders with uterus <12w size - Microminvasive cervical carcinoma - Uterovaginal prolapse Abdominal hysterectomy: - Pfannestiel incision (midline incision if larger masses or malignancy) - Uterine, ovarian, cervical, fallopian tube carcinoma - Pelvic pain from chronic endometriosis or chronic PID where pelvis is frozen and vaginal impossible - Symptoms fibroid uterus 12w++ uterus in size

Answer 104

General= infection, bleeding, failure, damage to local structures (os, lining), GA complications, VTE

Answer 105

Augmentin (co-amoxiclav)

Answer 106

Malignancy | Uterus with 12 weeks ++ pregnancy

Answer 107

``` I = Uterus II = Uterus + cervix III = adnexa IV = distant metastasis/bladder/bowel ```

Answer 108

``` I = limited to ovaries II = pelvic extension (ie. uterus) III = abdominal extension (extra-pelvic) IV = distant metastasis ```

Answer 109

``` I = cervix II = invade beyond cervix, not into pelvic wall or lower 1/3rd vagina III = extend to pelvic wall +/- lower 1/3rd of the vagina +/- hydronephrosis IV = extend to pelvic wall + involve the mucosa of bladder or rectum ```

Answer 110

Follucilar (most common) - Cyst: >3cm (>5cm risk of torsion) - USS: thin walled, unilocular, anechoic Corpus luteal: - Occur after ovulation, may rupture at the end of the menstrual cycle - USS: diffusely thick walls, <3cm, lacey pattern Theca lutein: - Associated with pregnancy (high circulating ganadotrophins eg. hCG) - USS: bilaterally enlarged, multicystic ovaries, thin-walled and anechoic - Features: Can cause hypertension, often bilateral and resolve spontaneously

Answer 111

Tubo-ovarian abscess: - Features of PID - Tender to adnexal mass - USS: Ovary and tube cannot be distinguished from mass Endomatrioma: - Chocolate cyst - Associated with endometriosis - USS: unilocular with ground- glass echos (50% cases)

Answer 112

Dermoid - Mature: benign, solid or cystic - USS: unilocular, diffusely or partially echogenic, may contain teeth, no internal vascularity - Immature: contains embryonic elements, malignant

Answer 113

Thecoma: - Benign, may produce oestrogens (and, rarely, androgens) - USS: variable - echogenic mass, hyperechoic and anechoic Fibroma: - Benign, no endocrine production - USS: solid, hyperechoic mass Granulosa cell: - Produce oestrogen - USS: variable - may appear solid or cystic

Answer 114

Brenner's tumour: - Small - Contain urothelial-like epithelium - USS: hyperachoic, occasionally calcifications may be seen Mucinous Cystsdenoma: - Usually LARGE - USS: multiloculated, many thin seperations, low echogenicity due to mucin Serous cystadenoma (most common ovarian neoplasm) - Usually unilocular - Often bilateral - USS: unilocular, anechoic, no flow on colour Doppler

Answer 115

- Malignant neoplasm of the vulva | - Majority are squamous cell carcinomas

Answer 116

Usual type: - (warty/basaloid SCC) --> VIN (HPV type 16), immunosupression, smoking Differential type: - (Keratenised SCC) --> lichen sclerosis

Answer 117

Progression of certain vulval dermatoses, progression of VIN - VIN splits into 1,2 and 3 (how deep the cancer goes) - VIN classified by low-grade squamous, high-grade and differentiated ``` LSIL = low grade squamous HSIL = high grade squamous dVIN = differentiated VIN (keratinised) ```

Answer 118

- Tissue diagnosis: full thickness biopsy, sentinel node biopsy - Cervical smear: exclude CIN if VIN-associated - Imaging: CT or MRI to assess lymphadenopathy - Other: staging by cytoscopy, proctoscopy

Answer 119

- Vulvectomy + bilateral inguinal lymphadenectomy 1a --> wide local insicion +/- neoadjuvant chemo = radical surgical excision with 10mm clear margin >1a --> radical vulvectomy + bilateral inguinal lymphadenectomy - a dye and radioactive nucleotide can be injected into the vulval tumour to identify the sentinel node - if removed, groin lymphadenopathy is a very morbid procedure with complications including wound healing problems, infection, VTE and chronic lymphoedema

Answer 120

- Vulvectomy + bilateral inguinal lymphadenectomy 1a --> wide local insicion +- neoadjuvant chemo = radical surgical excision with 10mm clear margin >1a --> radical vulvectomy + bilateral inguinal lymphadenectomy - a dye and radioactive nucleotide can be injected into the vulval tumour to identify the sentinel node - if removed, groin lymphadenopathy is a very morbid procedure with complications including wound healing problems, infection, VTE and chronic lymphoedema unsuitable for surgery --> radiotherapy

Answer 121

Septicaemia from toxin (TSST 1) produced by staph and strep bacteria - Staph: endotoxins (TSS toxin 1) - Strep: inflammatory cascade initiation

Answer 122

Multi-system inflammatory response to bacterial endotoxins

Answer 123

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

Answer 124

- Fever - D&V - Myalgia - Sore throat - Shock - Diffuse red macular rash - Headache - Desquamation of palms and soles

Answer 125

1. Bloods- FBC (raised WBC, low platelets), U&Es (impaired renal function), LFT, raised CK, raised CRP 2. Microbiology - HVS, blood culture, culture of tampon

Answer 126

- ABCs and remove tampons | - Antibiotics (broad-spectrum IV)

Answer 127

- Septic shock, MOF, DIC, ARDS, death

Answer 128

- Uterine prolapse = prolapse of uterus into the vagina - Cystocele = prolapse of anterior vaginal wall involving the bladder - Rectocele = prolapse of lower posterior vaginal wall involving the anterior wall of the rectum - Enterocele = prolapse of the upper vaginal wall containing loops of small bowel - Vault prolapse = prolapse of vaginal vault after hysterectomy

Answer 129

Weak pelvic floor muscles

Answer 130

- Increasing age - Parity - Menopause - obesity - pelvic surgery - chronic cough - occupations associated with heavy lifting - high impact sports - constipation - pelvic mass - FHx - spinal cord injury/mascular atrophy

Answer 131

- Feelings of heaviness of descent PV - Recurrent UTI - Urinary symptoms if cystocele - Back pain - Dyspareunia - Constipation or faecal incontinence if rectocele

Answer 132

- Speculum (grade and severity) - Urodynamics (incontinence) - MC&S (urine infections)

Answer 133

1st line: conservative - weight loss - minimise weightlifting - stop smoking 2nd line: - Pelvic floor exercises - Topical oestrogen in elderly patients - Pessary 3rd line: - Surgical options - depends on what organs have been prolapsed 1. Uterine prolapse (depends on whether the patient wants to preserve the uterus or not) 2. Vault prolapse - 1st line: sacrocolpopexy (abdonimal or laparoscopic) with mesh - Other: vaginal sacrospinous fixation with sutures (risk of sciatic nerve damage) 3. Anterior prolapse (cystocele) or posterior prolapse (rectocele) - 1st line: anterior/posterior colporrhaphy (without mesh)

Answer 134

Ring: common type, soft, does not prevent sex Shelf: common type, hard, more support than a ring, DOES prevent sex Gelhorn: similar to shelf but are soft instead of hard, DOES prevent sex Gehrung: disk-shaped and used for more serious prolapse (easier to remove) Cube: for very advanced prolapse - uses suction to keep things in place

Answer 135

1. POP-Q (measures different anatomical landmarks in relation to the hymen) - NICE recommended - These positions are recorded as co-ordinates relative to the physiological position of the pelvic organs. The hymen is used as a reference point. - Distal to the hymen is a +ve number and proximal is a -ve number 2. Shaw's (more commonly used, looks at the extent of descent of prolapse) - 1st degree: descent to the introitus - 2nd: extends to the introitus but decreased past the introitus on straining - 3rd degree: prolapse descends throught the introitus 3. Baden-walker (Like Shaw's but uses the hymen as a reference point)

Answer 136

Commonly caused by vulvoganitis (vulvovaginal candidiasis, atrophic vaginitis, vulvar vestibulitis and contact dermatitis) --> infection, eczema, contact dermatitis

Answer 137

Vulvovaginal candidiasis: - vulvar pruritis - burning - erythema - oedema of the vestibule and labia - thick curd like PVD - Chronic: grey-sheen of epithelia cells, severe pruritus, irritation and pain, lichenification of vulva Atrophic vaginitis: - soreness - dyspareunia - burning leucorrhoae (white mucous discharge) - occasional spotting Vulvar vestibulitis: - primary: introital dyspareunia - Secondary: introital dyspareunia that develops after period of comfortable sexual relations - pain - soreness - burning - rawness Contact dermatitis: - pruritis - can get burning - pain - red - ulcerative skin following contact

Answer 138

- Vulvovaginal candidiasis: wet-mount test or KOH preparation - Atrophic vaginitis: vaginal PH and wet-mount test (often shows white blood cells and paucity of lactobacillus)

Answer 139

Vulvovaginal candidiasis: - Ketaconazole (400mg/day) or fluconazole (100mg/week) for 6 weeks - Clotrimazole 500mg suppositories once per week Atrophic vaginitis: - topical vaginal oestrogen or HRT Vulvar vestibulitis: - pain management with sex therapy - behaviour modification - topical steroid - anaesthetic - petroleum jelly - anti-inflammatories - surgical excision at last resort Contact dermatitis: - remove itching agent - MILD = 1% hydrocortisone - MODERATE = betamethasone - Triamcinolone ointment applied BD - Wet compresses of aluminium acetate for several lesions - seborrhoeic dermatitis, consider ketoconazole shampoo body wash

Answer 140

Atrophic vaginitis: - super infection due to raised vaginal PH Candida: - disruption to social and sexual life

Answer 141

Complication of ovarian cysts of tumours - dermoid cysts are most likely to undergo torsion, whereas endometriomas are least likely - Any ovarian cyst >5cm diameter is at risk of torsion

Answer 142

- Ovarian cysts or tumours - Long ovarian ligaments - Pregnancy - Tubal ligation

Answer 143

- Severe right/left illiac fossa pain | - Vomitting

Answer 144

- Pregnancy test - FBC (might show high WCC) - Speculum if PID is a differential - Bimanual examination (adnexal mass) - Urinalysis (rule out ureteric colic) USS with dopplers: - Doppler may be false -ve due to dual blood supply to the ovary (ovarian artery and uterine artery) - Ovarian necrosis may cause lactic acidosis USS --> whirlpool sign

Answer 145

1st line: laparoscopic detorsion +/- cystectomy 2nd line: salpingo-oophrectomy

Answer 146

Increased pressure on the bladder --> incontinence (small losses)

Answer 147

Strong urge to urinate and often don't get to the toilet in time --> incontinence (big losses)

Answer 148

>2 types (often stress and urge together)

Answer 149

Difficulty emptying bladder --> filling --> incontinence

Answer 150

Cannot get to the toilet in time due to mobility issues

Answer 151

- Speculum exam --> can exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (Kegel exercises) --> ask patient to cough (Vasalva) during exam to check for fluid leakage 1st: - Urine dipstick - Urine MC&S (rule out DM or UTI) - bladder diaries (min 3 days) 2nd: - urodynamic testing (if mixed incontinence) 3 pressures measured from inside rectum and urethra - bladder pressure = detrusor + IAP - Detrusor = bladder - IAP

Answer 152

Men - hold 400ml and void at a rate of 10-15mL/s | Women - hold 500ml and void at a rate of 15-20mL/s

Answer 153

- Age - Children - Traumatic delivery - Pelvic surgery - Obesity

Answer 154

- Age - Obesity - Smoking - FHx - DM

Answer 155

Check need for referral to specialist (ie. trigone tumour --> need to be checked) 1st line: - lifestyle advice, WL (BMI>30), pelvic floor exercises (8 contractions, TDS, 3 months) 2nd line: (surgical treatment) or SNRI duloxetine - Burch colposupression --> stitching the neck of the bladder higher (coopers ligaments) - Autologous rectus facial sling --> a sling placed around the neck of the bladder - Bulking agents --> put bulking agents into urethral wall to provide more force

Answer 156

Check need for referral to specialist (ie. trigone tumour --> need to be checked) 1st Line: lifestyle advice, bladder training: - Bladder training (6 weeks) --> progressive hold off going to the toilet for up to 25 minutes - Avoid fizzy drinks (carbonic acid can stimulate detrusor muscles) - Control diabetes (avoid diabetic nepropathy) 2nd line: antimuscarinics (oxybutynin, tolterodine), ADH analogues (desmopressin) - Antimuscarinics (oxybutynin, tolterodine, darifenacin) - DO NOT give a patient with closed angle glaucoma - oxybutynin (increased risk of falls do not give elderly) - darifenacin = M3 receptor antagonist 3rd line: - mirabegron (beta-3 agonist) - used if concerns about during anticholinergics in older, frail women 4th line: - botox injection - sacral nerve stimulation - cystoplasty - urinary diversion

Answer 157

Refer to specialist urogynaecologist 1st line: timed voiding

Answer 158

Dribbling incontinence after having a child with a prolonged labour urinary dye studies

Answer 159

2 or more of the following - Oligo/anovulation (>2 years) - Clinical or biochemical features of hyperandrogenism - Polycystic ovaries on USS

Answer 160

- Family history | - Obesity

Answer 161

- Hirsutism - Sub-fertility - Amenorrhoea - Weight gain - Acne - Insulin resistance (acanthosis nigricans)

Answer 162

TVUSS --> polycystic ovaries (Pear necklace sign) LH>FSH index --> 2/3:1 Other: testosterone, SHBG, TSH DM monitoring: - OGTT at diagnosis for BMI>25, non-caucasian ethnicity, any BMI and >40yo, FHx, DM, GDM Hx Annual OGTT for: - IFG (fasting 6.1-6.9 mmol/L) - IGT (OGTT 7.8-11.1 mmol/L) CVD monitoring (assess risk with QRISK2): - Lipid profile - Blood pressure - Diet, exercise, smoking and weight loss

Answer 163

Oligomenorrhoea (>3m) --> refer for TVUSS to assess endometrial thickness - Weight reduction - COCP (indication: contraception and hyperandrogenism) - Cyclical progesterone (indication: contraception) - LNG-IUS (indication: contraception)

Answer 164

- Weight reduction - 1st line: COCP (indication: contraception and hyperandrogenism) Increases SHBG to relieve androgenic symptoms (co-cyprindiol better) - Co-cyprindoil (indication: contraception and hyperandrogenism) COCP and enhanced anti-androgenic activity. Cyproterone acetate and ethinylestradiol - Topical eflornithine cream (indication hyperandrogenism)

Answer 165

1st line: weight loss 2nd line: clomiphene --> clomiphene and metformin (after 3 failed clomiphene cycles) Induces ovulation if subfertility is an issue Increased risk of multiple pregnancy SERM (blocks ER in hypothalamus --> reduce -ve feedback --> more GnRH pulsatile release) 3rd line: - Gonadotrophins - IVF Surgery: - laparascopic ovarian drilling (destroy ovarian stroma and prompt cycles)

Answer 166

- Metabolic syndrome (DM and heart disease) - CVD - Sleep apnoea - Endometrial cancer (if >7mm may be pathalogical) - Subfertility - Recommend withdrawal bleeding every 3-4 months

Answer 167

Ovarian hyperstimulation syndrome - Multi luteinized cysts - loss of oestrogen (VEGF) - Pain + bloating

Answer 168

Secondary amenorrhoea before the age of 40 years old

Answer 169

- Iatrogenic (oophorectomy) | - Unknown (Addison's - steroid cell autoantibodies cross-react with granulosa cells and theca interna)

Answer 170

Menopause signs and symptoms

Answer 171

- Diagnosis = = 40 years old, 2x FSH results >30 (these should be repeated 4-6 weeks apart) + menopause symptoms - Oestrogen Low - LH/FSH high - Antral follicle count, AMH levels (test ovarian reserve)

Answer 172

Fertility management: - Donor Oocyte IVF - Surrogacy and adoption are other options - only 5-10% POI women can get pregnant without fertility treatment

Answer 173

Osteoporosis: Regular DEXA scans, all should get HRT Other: hypothyroid, sexual dysfunction, insomnia (vasomotor symptoms), stroke, heart disease

Answer 174

- Distressing symptoms occurring in the luteal phase of the menstrual cycle (in the absence of disease)

Answer 175

Unknown, likely due to the cyclical effect of oestradiol and progesterone on neurotransmitters (serotonin and GABA)

Answer 176

- Obesity - Lack of exercise - Dietary - Smoking - FHx

Answer 177

- Mood swings - Anxiety - Headache - Poor concentration - Lack of energy - Changes in appetite - Disturbed sleep - Bloating - Breast tenderness

Answer 178

Diagnosis requires a symptom diary over 2 cycles

Answer 179

ALL PMS: - Conservative lifestyle measures, painkillers - regular meals, exercise, sleep - stress reduction, smoking cessation, alcohol restriction - Painkillers (NSAIDs, paracetamol) Moderate: (some impact on personal, social and professional life) - COCP (cyclical or continuous) +/- CBT - Paracetamol or NSAIDs - Referral to CBT Severe: (withdrawal from social and professional activities, prevents normal functioning) - SSRI (continuous or just during the luteal phase, try initially for 3 months) +/- CBT - Alternatives: GnRH analogues, transdermal oestrogen, surgery

Answer 180

Syphilis is a systemic infection caused by the gram -ve spirochete (Treponema pallidum)

Answer 181

- Sexual contact - Blood bourne - Vertical

Answer 182

- Young age - African american - Use of illicit drugs - Infection with other STIs - Sex worker

Answer 183

Primary (3-4 weeks): - painless chancres +/- local lymphadenopathy - resolves in 3-8 weeks Secondary (4-10 weeks after chancre): - rough papulonodular rash (hands, feet, trunk) - uveitis - condylomata lata - lymphadenopathy + systematic symptoms - Snail tack oral ulcers - Resolves in 2-12 weeks

Answer 184

No symptoms, detected on routine tests - Early latent: (<2 years after infection - exposure to or symptoms of 1st/2nd in <2 year) - Late latent: (>2 years after infection - exposure to or symptoms of 1st/2nd in >2 year)

Answer 185

- 1 to 20 years - Gummatous syphilis (erosive skin and bone lesions) - Cardiovascular syphilis (aortic, aortic regurgitation - early diastolic decrescendo, heart failure) - Neurosyphilis Neurosyphilis: - meningovascular --> ischaemia, insomnia, emotionally labile - general paresis --> dementia - tabes dorsalis --> sensory problems, lightning pains, absent reflexes (affects the dorsal column)

Answer 186

Microbiology: dark-ground (from chancre with dark field illuminations), PCR Serology: - routine antenatal screening offered to all pregnant women --> detects treponemal antibodies - takes 3/12 weeks for syphilis to become positive in serology Non-treponemal tests - high false positive rate due to cross-reactivity: - RPR (rapid plasmin reagin) --> how many dilutes to lose the reagin - If positive, must be followed by a more specific treponemal test Treponemal tests: - EIA - very sensitive and specific - TPHA/TPPA (treponemal pallidum haemagglutinin assay) - FTA-ABS (flourescent treponemal antibody absorption) Neurosyphilis: - CT/MRI head - LP (raised WCC, raised protein) - TPPA >1:320

Answer 187

Early: (1st, 2nd, early latent) - Benzathine-Pen IM STAT or - Doxycyclin (BD, 14/7) Late: (late-latent, non-neuro 3rd) - Benzathine-Pen IM OW, 3/52 or - Doxycyclin (BD, 28/7) Neurosyphillis: - Penicillin (IV, 4-hourly, 14/7) or - Doxycycline (BD, 28/7) Prednisolone (OD, 3/7) started 24 hours before treatment to avoid Jarish-Harxheimer reaction

Answer 188

- Release of pro-inflammatory cytokines in response to dying organisms S/S: 24-hours of febrile myalgia, rare/serious consequences, admit mother >22w when treating

Answer 189

- Partner notification | - Repeat bloods at 3/12 (4-fold drop in RPR)

Answer 190

Congenital syphilis: - rash on soles of feet and hands +/- bone lesions Risks in pregnancy: (benzathine penicillin greatly improves foetus outcomes) - FGR - Foetal hydrops - Congenital syphilis - Stillbirth - Preterm birth - Neonatal death

Answer 191

Type 1 - clitoridectomy - removing part of the clitoris Type 2 - Excision - removing part of all of the clitoris, labia minora +/- major Type 3 - infibulation - narrowing vaginal opening by creating a seal by cutting and repositioning the labia Type 4 - any other procedure to the genitals including pricking, piercing, cutting, scraping, burning

Answer 192

- Constant pain - incontinence - Dyspareunia - Depression, flashbacks, self-harm - Bleeding, cysts, abscesses

Answer 193

Deinfibulation: - offered to those unable to have sex, pass urine, or pregnant women at risk during delivery Must record in notes If under 18, record in notes and report to the police and social services If over 18, record in notes, no obligatory duty to report though

Answer 194

- Repeated infections --> infertility - Life-threatening complications during labour, childbirth - Short-term - haemorrhage, urinary retention, genital swelling, menstrual difficulties, infertility, HIV, HBV

Answer 195

Benign tumour (leiomyomas) arising from the myometrium

Answer 196

- Submucosal (within cavity) - Intramural - Subserosal (can undergo secondary changes)

Answer 197

- Hyaline degeneration - fibroids outgrow their blood supply. Hyaline degeneration involves the presence of homogeneous eosinophilic bands or plaques in the extracellular space, which represent the accumulation of proteinaceous tissue - Calcification - postmenopausal - Red degeneration - coagulation necrosis in pregnancy, cystic changes

Answer 198

Hormone dependant (contain lots of oestrogen and progesterone receptors) - Enlarge in pregnancy (due to oestrogen) - Shrink in menopause

Answer 199

1/3 women of reproductive age

Answer 200

- Asymptomatic (O/E: palpable pelvic masses, uterine enlargement) - Symptoms: DUB, miscarriage, sub-fertility - Signs: abdo swelling, pressure symptoms on bowel or bladder

Answer 201

1st line: TVUSS (>4mm when not expected, do a hysteroscopy)

Answer 202

B - Black women (plus FHx) O - Obesity N - Nulliparity E - Expecting (pregnancy) S - Smoking M - Multiparity (grand) C - COCP BONE - Risk SMC - protective

Answer 203

If no identified pathology, fibroids <3cm, suspected/diagnosed adenomyosis --> DUB management Fibroids >3cm: 1st line non-hormonal (not contraceptive) - Tranexamic acid, 1g, TDS (contraindications: renal impairment, thrombotic disease) - Mefenamic acid/NSAIDS (Contraindications: IBS) 1st line hormonal (contraceptive): - COCP - Cyclical oral progestogens Surgical/radiological treatment: Injectable GnRH Agonist (short-term usually prior to surgery): - Shrinks fibroids - Induces a menopausal state (shuts down ovarian oestrodiol production) - Side effects (menopausal) Ulipristal acetate (short-term, selective progesterone receptor modulator), OD - Shrinks fibroids, reduce bleeding (use for 6/12) - As effective as GnRH agonists BUT no menopausal state induced - Not yet widely accepted into clinical practice - Long term use associated with live injury

Answer 204

Hysteroscopic (TCRF): - Indication: small submucosal or polypoid Myomectomy: (best for improving fertility) - Open or laparoscopic - Power morcellation is used to shrink the fibroids for renewal Side effects: - Uncontrolled life-threatning bleed - More likely to need C section in the future as they have to make an incision into the uterus --> risk of uterine rupture Hysterectomy Endometrial ablation: - removed fertility - must use contraception

Answer 205

Uterine artery ablation: - May preserve fertility (may also make ovaries fail) - Embolise both uterine arteries --> infarct/degenerate fibroids - Patients need admission to deal with pain (opiate analgesia) - As effective as myomectomy for alleviating fibroid DUB and pressure symptoms Complications: - Fever - infection - fibroid expulsion - potential ovarian failure (need to council)

Answer 206

Pregnancy: - red degeneration - miscarriage - malpresentation - transverse lie - PTL - PPH

Answer 207

low fever pain vomitting

Answer 208

Conservative | Resolve in 4-7 days

Answer 209

Regress and calcify

Answer 210

Very rare cancer: smooth muscle cancer of the uterus Associated with Gardner's syndrome (subtype of FAP with extra-colonic polyps)

Answer 211

Normal epithelium of the cervix is endocervix (columnar) --> transformation zone --> ectocervix (squamous)

Answer 212

Ectropion = ectocervical migration of columnar epithelium (linked to oestrogen - pregnancy, COCP)

Answer 213

Present with IMB, PCB, increased discharge

Answer 214

- Reassure - Cauterisation - Cryotherapy - Move more oestrogen based contraceptives

Answer 215

Overgrowth of endocervical columnar epithelium, benign, solitary (can be linked to oestrogen)

Answer 216

Asymptomatic or small bleeding and discharge If at cervix, PCB might be more apparent

Answer 217

Reassurance: - Generally advised to remove (twist off if small or surgery) - Send for histology

Answer 218

``` TVUSS Outpatient hysteroscopy (OPH) and saline infusion sonography (SIS) are the most accurate ```

Answer 219

- May resolve spontaneously (if small) - Polypectomy to alleviate DUB symptoms, optimise fertility and exclude hyperplasia/cancer - Day case under GA or under LA in OPD

Answer 220

Low-risk subtypes (6 & 11): - benign genital warts High-risk subtypes (16 & 18): - CIN, VIN, VAIN - implicated in 70% of cervical cancers

Answer 221

Transmission is by physical or sexual contact but occasional vertical

Answer 222

- Smoking - Multiple sexual partners - Unprotected intercourse - Immunosuppression

Answer 223

50% of sexually active adults have HPV

Answer 224

- Asymptomatic - Genital warts on vulva, cervix, and anus (painless, may itch/bleed +/- inflamed) - pink/red/brown warty papules (single or multiple) - Four types - small popular, cauliflower, keratotic, flat papules/plaques (usually cervix)

Answer 225

Clinical diagnosis - (dermatoscope) Histology - (biopsy) Cytology - (smear)

Answer 226

Medical: imiquimod cream or podophyllin/trichloroacetic acid (both contraindicated in pregnancy) Surgical: cryotherapy, laser, electrocautery Prevention - HPV vaccines

Answer 227

- Clusters of shiny, raised, purple-red blotches on your arms, legs or body - May see fine white lines on the blotches - White patches on your gums, tongue or the insides of your cheeks - Sore patches on the vulva or ring-shaped purple/white patches on the penis

Answer 228

Clinical diagnosis

Answer 229

1st line: High-dose topical steroids (clobetasol) 2nd line: topical calcineurin inhibitor (tacrolimus) If vaginal stenosis, dilatation with manual measures should be attempted in the first instance

Answer 230

Chronic inflammatory skin condition, usually affective genital skin (vulva and perineum) - not contagoius - occurs at extremes of age: <10, >60

Answer 231

Unknown but associated with autoimmunity and genetics - Autoimmune - hypothyroid, graves disease, T1DM - Genetic

Answer 232

- White polygonal papules - Hypopigmentation + atrophy - White/shiny vulva (Figure of 8 pattern) - Pruritis - May be raised or thickened - Dyspareunia (due to tightened skin) - Dysuria (due to tightened skin) - Can be on wrists, upper trunk, around breast, neck, armpits

Answer 233

Clinical diagnosis

Answer 234

- Good skin care - 1st line (3 months): clobetasol propionate (strong steroid ointment) - 2nd line: tacrolimus (topical calcineurin inhibitor) + biopsy (as steroid resistant)

Answer 235

- Never can be completely cured | - Squamous cell cancer

Answer 236

- Intermittent pain - During and before feeding - Blanching followed by cyanosis and erythema of the nipple

Answer 237

- Occurs in the first few days of birth - Affects both breasts - Pain often before breast feeding, which can relieve it

Answer 238

- Breast infection --> staph aureus is the most common - Affects in 1/10 breastfeeding women due to backup of milk in ducts - Associated with nipple injury and smoking

Answer 239

- Coryzal symptoms - aches, chills, fever - Nipple discharge - Red, tender breast with possible abscess

Answer 240

Clinical diagnosis

Answer 241

Consider admission if: - sepsis, - rapid progression - haemodynamically unstable - immunocompromised Abscess: USS diagnosis - Incision and drainage - culture of fluid Non-severe or lactational: - simple analgesia - supportive care (warm compression) - continue breastfeeding Non-lactational or severe: - infected nipple fissure - not improved after 12-24 hours - breast milk culture +ve - 1st line: flucloxacillin 50-mg QDS, oral, 10-14 days - 2nd line (failure to settle after 48 hours): co-amoxiclav - MRSA: trimethoprim 160-800mg BD PO

Answer 242

- Sepsis, scarring, functional mastectomy, breast hyperplasia - Most have resolution of mastitis after 2-3 days of antibiotic therapy

Answer 243

- Absence of menses for >12 months (retrospective diagnosis) - Average age 50 +/- 2 - If less than 45, consider investigating - if <40, premature ovarian insufficiency

Answer 244

Depletion of the oocytes --> reduction in ovarian production of progesterone, oestrodiol and testosterone

Answer 245

- Presistent amenorrhoea - often initial oligomenorrhoea/irregular shortened cycles - Vasomotor symptoms - hot flushes, night sweats, palpitations, headaches - Urogenital - vaginal dryness, dyspareunia, frequency, dysuria, recurrent UIT - Psychological - poor concentration, lethargy, mood disturbances, reduced libido (present first)

Answer 246

- Pregnancy test - FH:LSH = high (unopposed) - serum oestrodoil = low (no oocytes to produce) - Prolactin - TFTs - TVUSS (endometrial/ovarian cancer --> bleeding= endometrial; no bleeding and mass = ovarian)

Answer 247

Uterus = combines with progesterone to protect against endometrial carcinoma No uterus = systemic oestrogen (think about contraindications eg. DVT)

Answer 248

Systemic - oral, implant Transdermal - hx of DVT/stroke Topical - hx of DVT/stroke

Answer 249

1. Thecal Cells (ovaries and eggs) 2. Androgens (oestrogen) 3. Endometrial growth 4. Corpus luteum 4. Progesterone 5. Secretory changes (maintains endometrium) 6. Drops 7. Menses

Answer 250

Lifestyle changes - exercise, alcohol, caffeine, weight loss, stress reduction - Hot flushes (regular exercise, WL, reduce stress) - Sleep disturbances (sleep hygiene, no late evening exercise) - Mood (sleep hygiene, regular exercise, relaxation techniques) - Cognitive symptoms (sleep hygiene, regular exercise)

Answer 251

HRT: Oestrogen alone (Elleste Solo) = only in post-hysterectomy - OD, oral, oestrogen (standard therapy) - Transdermal oestrogen patch (BMI>30, due to lower VTE risk) - You can only have oestrogen only preperation combined with an LNG-IUS (Mirena) Oestrogen with progesterone (Elleste Duet) = progesterone protects endometrium - oral, transdermal (less clot risk), vaginal creams/gel (less clot risk), implant - adding progesterone increases the risk of breast cancer Cyclical/sequential pattern/SCT (peri-menopausal): - Monthly: oestrogen everyday of month + progesterone for the last 14 days - Indication = regular periods and menopause symptoms - 3 months: oestrogen everyday for 3 months + progesterone for the last 14 days - Indication = irregular periods and menopause symptoms (common cause of IMB = endometrial polyps) Continuous/CCT (post-menopausal so no period for >1 year) - oestrogen and progesterone everyday

Answer 252

- Improved menopause symptoms (vasomotor, sleep and genital symptoms like dryness and dyspareunia) - Prevention of osteoporosis

Answer 253

Cancer: - Oestrogen-only = breast and endometrial cancer - Combines = breast cancer VTE: - 2-4x higher

Answer 254

Should pass in a few weeks of starting HRT: - Oestrogenic: breast tenderness, nausea, headaches - Progestogenic: fluid retention, mood swings, depression - Unscheduled vaginal bleeding (common in the first 3 months of HRT, investigate if it continues >6 months) Sequential > continuous

Answer 255

- Undiagnosed vaginal bleeding - Pregnancy - Breast cancer - Sever liver disease - History of VTE - Current thrombophilia (AT-III, FV leiden)

Answer 256

Vasomotor symptoms: - 1st line: (SSRI) - fluoxetine - 2nd line: citalopram, venlafaxine - 3rd line: gabapentin - Alpha agonist (clonidine) are licenced but there are lots of anti-ACh side effects Vaginal dryness: - Lubricants Osteoporosis treatments: - Bisphosphonates

Answer 257

Until >1 year amenorrhoeic if >50 Until >2 years amenorrhoeic if <50

Answer 258

Premalignant cellular atypia with squamous epithelium of the cervix (FIGO stage 0) - before cervical cancer - HPY 16 and 18 is indicated in 95% of the cases

Answer 259

Smoking Multiple sexual partners Early age of first intercourse HIV

Answer 260

``` National vaccine for girls and boys age 12-13 Quadrivalent vaccine (Gardisil) against HPV 6,11,16 and 18 ```

Answer 261

Invited less than 6 months before 25 ``` 25-49 = every 3 years 50-64 = every 5 years 65+ = only if one of your last 3 tests was abnormal ``` ``` High-risk = every 1 year Pregnancy = delayed until >3 months post-partum ```

Answer 262

Inflammation Age-related atrophic change Blood on smear

Answer 263

- Increase nuclear to cytoplasmic ration - Increase nuclear size - Decrease cytoplasm - Abnormal nuclear shape - poikilocytosis - increase nuclear density - koikilocytosis

Answer 264

CIN 1 (low grade) = mild dysplasia confined to lower 1/3 of epithelium CIN 2 (high grade) = moderate dysplasia affecting 2/3 of epithelial sickness CIN 3 (high grade) = severe dysplasia extending to upper 1/3 of epithelium (risk of Stage 1a FIGO)

Answer 265

Symptoms of cervical cancer (PV bleeding - IMB, PCB, PMB)

Answer 266

16 18 (33)

Answer 267

Boderline/mild/ CIN 1 --> HPV test (+ve colposcopy, -ve routine call) Moderate/ CIN 2 --> urgent colposcopy (<2 weeks) Severe/ CIN 3 --> urgent colposcopy (<2 weeks) Suspected invasive cancer --> urgent colposcopy (<2 weeks) Inadequate sample --> repeat 3x, refer to colposcopy

Answer 268

Conservative for CIN 1 --> smear in 12 months LLETZ/ Loop diathermy - involves removal of abnormal cells during a thin wire loop that is heated by electric current under LA - SE: cervical stenosis, cervical incontinence, pyometra, smear follow up difficulties - Risks: increase risk of miscarriage due to bigger lumen of the cervix so harder to follow close Cone biopsy: - used less frequently and under GA - Only performed in a large area of tissue need to be removed Other: - cryotherapy - laser treatment - cold coagulation - hysterectomy If hysterectomy for CIN --> a vault smear must be done at 6m and 18m Follow up-to cure (6 months later = smear and HPV test) - Negative: routine recall - Positive: repeat colposcopy to identify residual/untreated CIN

Answer 269

Miscarriage and PTL | CIN can progress to cervical carcinoma (but may also regress spontaneously, esp when young)

Answer 270

80% squamous and 20% adenocarcinoma - SCC from CIN - Adenocarcinoma from cGin

Answer 271

HPV 16,18 in >70% of the cases - FIGO staging system - Age 45-50 y/o

Answer 272

``` Major = HPV Minor = smoking, early first intercourse, many sexual partners, immunosupression ```

Answer 273

- PV discharge (offensive or bloodstained) = PCM, PMB, IMB - Dyspareunia (deep_ - Symptoms of las metastasis (SOB, DIC) and FLAWS

Answer 274

Illiac lymph nodes (not para-aortic)

Answer 275

- Cervical screening pathway - MRI>CT-CAP = cervical cancer - CT-CAP > MRI = ovarian cancer, endomatrial cancer - Blood: FBC (anaemia), U&E (obstructive picture), LFTs (metastasis), clotting and G&S

Answer 276

MDT approach Stage Ia1 (microinvasive) - conservative - LLETZ, cone biopsy (followed by smear pathway) Stage Ia2 to IIa (early stage): - Fertility sparing = radical trachelectomy (remove cervix) + bilateral pelvic node dissection - Tumour = 4cm = radical hysterectomy + bilateral pelvic node dissection (Wertheim's) - Tumour >/= 4cm = Chemoradiation Stage IIb to IVa (locally advanced disease) - Chemoradiation Stage IVb (metastatic disease) - Combo chemo - Single-agent therapy and palliative care Radiotherapy +/- chemo (cisplastin based therapy): - External beam radiotherapy (10 minutes delivery, completed over 4 weeks) - Internal radiotherapy (brachytherapy, rods of radioactive selenium is inserted into the affected area)

Answer 277

Abnormal uterine bleeding in the absence of organic pathology - Hormonal influences in anvoluntary and ovulatory cycles (Ovulatory/Endometrial dysfunction)

Answer 278

Extremes of reproductive age | Obesity

Answer 279

Anvoluntary (90%) = failure of follicular developement --> no increase in progesterone --> cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelia due to unopposed oestrogen stimulation Ovulatory (10%) = prolonged progesterone secretion --> irregular shedding

Answer 280

What the individual women believes is heavy periods, no need to quantify it. Used to be 80ml

Answer 281

What the individual women believes is heavy periods, no need to quantify it. Used to be 80ml

Answer 282

Diagnosis of exclusion: - Bleeding (menorrhagia, IMB, dysmenorrhoea) - Anaemia signs and symptoms S/S of the cause: - relation to menstrual cycle - fertility issues - compression symptoms - cervical screen history - DHx, FHx, sexual history - Coag disorders (von Williebrand disease)

Answer 283

``` Pathology: PALM Polyps Adenomyosis Leiomyoma Malignancy ``` ``` Endocrine: Coagulopathy - von Williebrand disease Ovulation - PCO, hypothryroid Endometriosis Iatrogenic Not classified ```

Answer 284

Examine with speculum and bimanual 1st line: - FBC (anaemia) - TFT (hypothyroid) - Clotting screen (if primary menorrhagia or FHx) 2nd line: - TVUSS (PCOS, fibroids, malignancy) 3rd line: - OPD hysteroscopy - laparoscopy +/- biopsy (endometriosis)

Answer 285

If no identified pathology, fibroids <3cm, suspected/diagnosed adenomyosis 1st line: - contraception required (hormonal) - LNG-IUS (may not be possible with large fibroids distorting the uterus) 2nd line: (fertility required, 1st line declined/unsuitable) - BLEED = tranexamic acid, 1g, TDS (contraindications: renal impairment, thrombotic disease) - PAIN = mefanamic acid (NSAIDs, contraindication: IBD) 2nd line: (contraception required, 1st line declined/unsuitable) - 1st: COCP - 2nd: cyclical progesterone (Norethisterone 5mg TDS for 20 days to arrest bleeding acutely) Surgical: - Endometrial ablation (will need continued contraception) - Hysterectomy

Answer 286

From excess endometrial growth which usually occurs after the menopause and can progress to cancer: - EH without atypia (cells are normal) - EH with atypia (cells are abnormal)

Answer 287

(Oestrogen) - Increasing age - Oestrogen (early menarche, late menopaus, nulliparous, tamoxifen, HRT) - Sex cord stromal ovarian tumours are functional (granulosa cell tumours --> oestrogen --> EH) - High insulin (T2DM, PCOS) - Obesity, smoking - FHx ovarian, bowel (HNPCC, Lynch syndrome) or uterine cancer

Answer 288

PV bleeding - usually PMB

Answer 289

1st line: TVUSS (if PMB, otherwise must be matched with ovulatory cycle) - <4mm = endometrial cancer unlikely - >4mm = 2nd line investigations (hysteroscopy +/- biopsy) 2nd line: (Gold standard) Hysteroscopy - outpatient under LA +/- pipelle biopsy - Complex hyperplasia with atypia is a premalignant condition that often co-exsists with low grade endometrioid tumours on the endometrium - Sonohysterography = replacing hysteroscopy as a method of visualisation

Answer 290

<5% risk of becoming malignant in 20 years - Reverse risk factors - Endometrial surveillance every 6 months (biopsies recommended in high-risk women) 1st line: Progesterones - LNG-IUS (5 years) - Oral (continuous progestogens should be used rather than cyclical), continue for min 6 months to induce histological regression 2nd line: - hysteroscopy is an option

Answer 291

Fertility non-sparing = total hysterectomy (+ BSO if post-menopausal) Fertility sparing: - LNG-IUS - Oral progestogens - (routine endometrial surveillance with biopsies every 3 months)

Answer 292

- Malignancy arising from endometrial tissue - 2nd most common gynae malignancy in the UK - Uncommon in <40 y/o (mean age 54 y/o)

Answer 293

- Unclear | - Involves unopposed oestrogen stimulation of endometrium (exogenous or endogenous)

Answer 294

Same as endometrial hyperplasia

Answer 295

Adenocarcinoma

Answer 296

- 85% - SEM = secretory, endometrioid, mucinous carcinoma - Younger patients, oestrogen dependant, superficially invade, low grade - >/= 4 mutations must accumulate to cause: PTEN, PI3KCA, k-ras, ctnnb1, fgfr2, p53

Answer 297

- 15% - SC = uterine pappilary serous carinoma (UPSC), clear cell carcinoma - Older patients, less oestrogen dependant, deeper invasion, higher grade Mutations associated: - Serous Carcinoma P53, PI3KCA, Her-2 amplification - Clear cell carcinoma PTEN, CTNNB1, Her-2 amplification

Answer 298

- Most people present in stage 1 (PV bleeding) --> surgery is enough to treat - PV bleeding - Bulky uterus - Metastasis to para aortic LNs

Answer 299

1st: TVUSS (if PMB, otherwise must be matched with ovulatory cycle) - <4mm = endometrial cancer unlikely - >4mm = 2nd line investigations: hysteroscopy +/ biopsy 2nd line: Hysteroscopy (performed as outpatients under LA) +/ biopsy - Complex hyperplasia with atypia is a premalignant condition that often co-exsists with low grade endometroid tumours of the endometrium

Answer 300

FIGO staging (CT-CAP>MRI) Stage 1 - requires all - total abdo hysterectomy (TAH) - bilateral salpingoophorectomy (BSO) - Peritoneal washings Stage 2+: - Radical hysterectomy (including cervix) - Radiotheraoy adjunct Chemo is of limited use and used if a cancer is not amenable to radiotherapy Hormone treatments: - High-dose oral or intrauterine progestins (LNG-IUS) - Indication: women with complex atypical hyperplasia + low grade stage 1A endometrial tumours - Relapse rates high but may be suitable for those not fit for surgery or for fertility reasons

Answer 301

5-year survival rate = 80% | dependant on type, stage and grade

Answer 302

- Age - Grade 3 tumours - T2 Histology - Distant metastasis - Deep invasion - Nodal involvement - Lymphovascular space invasion Hormone receptor expression may influence a better prognosis/treatment (HER-2)

Answer 303

``` I = limited to the uterus II = spread to cervix III = spread adjacent IV = distant spread ```

Answer 304

Fluid-filled sac in ovarian tissue

Answer 305

- 8% in premenopausal women have large cysts | - 90% of ovarian tumours are benign

Answer 306

- PCOS - Endometriosis - Pregnancy

Answer 307

Physiological/functional: - Follicular cysts (most common) - Corpus luteal cysts Benign germ cell: - Dermoid cysts/ Mature cystic teratoma Benign epithelia: - Serous cystadenoma - Mucinous Cystadenoma

Answer 308

Follicular (failure rupture of dominant graafian follicle or nondominant follicles to degenerate): - Lined with granulosa cells - May occasinally continue to produce oestrogen and lead to EH Luteal (following rupture, follicle reseals, distends with fluid) - normal in early pregnancy: - Lined with luteal cells Haemorrhagic (bleeding into functional cysts)

Answer 309

Dermoid cysts/ Mature cystic teratoma (most common benign tumour in those <30y/o) - lined with epithelial cells - Often asymptomatic but most likely to tort - Rokitansky protuberance = single or multiple white shiny masses that protrude out

Answer 310

Serous cystadenoma ``` Mucinous Cystadenoma (typically very large) - If ruptures can cause pseudomyxoma peritonei (mucin in the abdomen) ```

Answer 311

- Lower abdo pain - Swelling with pressure symptoms (urinary symptoms) - Deep dyspareunia - Acute abdomen (torsion/haemorrhagic) - severe right or left illiac fossa pain (+/- vomiting in torsion)

Answer 312

- Pregnancy test - TVUSS (outcome dependant on menopause symptoms) Pre-menopausal: - simple --> manage depending on size - complex (< 40 y/o) --> LDH, aFP, B-HcG levels Post-menopausal: - simple or complex --> CA-125 level --> RMI calculation

Answer 313

USS score Menopause status CA-125 score

Answer 314

Simple/unilocular cyst: - <5cm - no follow up required - 5-7cm - repeat USS yearly - >7cm - MRI +/- surgery Indications for watchful waiting: - Unilateral - Unilocular (no solid parts) - Pre-MP (3-10cm) - Post-MP (2-6cm) - Normal Ca-125 - No free fluid If recurrent or unresolved --> medical (COCP - prevent ovulation will prevent recurrent cysts) If recurrent, sustained >5cm, suspicious/multiloculated --> surgical (laparoscopic cystectomy, usually curative)

Answer 315

RMI calculated and management based on this: RMI <200: - All of asymptomatic, simple cysts, <5cm, unilocular, unilateral --> repeat USS, Ca-125 in 4-6cm --> (1) resolved (2) unchanged --> repeat USS, Ca-125 in 4-6cm (3) Changed --> laparoscopic cystectomy - Any of symptomatic, non-simple features, >5cm, miltilocular, bilateral --> BSO RMI >200 --> CT-AP --> MDT management: - TAH, BSO +/- omentectomy

Answer 316

Serous epithelial ovarian cancer

Answer 317

Mucinous epithelial ovarian cancer | Pancreatic cancer

Answer 318

Bowel cancer

Answer 319

Granulosa cell tumours

Answer 320

Liver cancer Endodermal yolk sac tumour Teratoma

Answer 321

Breast cancer (receptor)

Answer 322

Dysgerminoma

Answer 323

Dysgerminoma | Choriocarcinoma

Answer 324

Makes up 5% of female cancers | 5th most common malignancy in females

Answer 325

- Pregnancy | - COCP

Answer 326

- Pregnancy/breastfeeding - COCP - hysterectomy

Answer 327

- Lynch syndrome (AD HNPCC, MLH1, MSH2) - Breast cancer (BRCA1/2) - Many genetic associations exist (p53 - serous, BRAF, K-ras)

Answer 328

- 70% epithelial origin (most are benign, however, if malignant likely to be epithelial)

Answer 329

- 70% - Post menopausal women - Present late with bad diagnosis - Endometriosis associated with clear cell (>20%) > endometrioid (10-20%) ovarian cancer - Endometrioid ovarian carcinoma often found alongside endometroid endometrial carcinoma

Answer 330

- 15-20% - young women 20s and old women 70s - Mature teratomas = benign - immature = malignant

Answer 331

- 15-20% - young women 20s and old women 70s - Mature teratomas = benign - immature = malignant

Answer 332

- 5-10% | - All ages but more common in post menopausal

Answer 333

Leydig cell tumours that secrete androgens

Answer 334

Triad of: - benign ovarian fibroma - ascites - right-sided pleural effusion

Answer 335

- Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited condition that puts people at an increased risk for developing hamartomatous polyps in the digestive tract, as well as cancers of the breast, colon and rectum, pancreas, stomach, testicles, ovaries, lung, cervix, and other types - granulosa cell tumours (sex cord turmous)

Answer 336

- Gorlin syndrome, also known as nevoid basal cell carcinoma syndrome, is a condition that affects many areas of the body and increases the risk of developing various cancerous and noncancerous tumors. Ovarian fibromas, often calcified and bilateral, develop in 15 to 25 percent of women with Gorlin syn-drome. - Fibroma

Answer 337

Mucinous = resemble gastric or cervical epithelium Serous = Psammoma bodies

Answer 338

- From endometriosis - If ruptures can cause acute pain - Rule out ectopic from LMP

Answer 339

- 5% | - Spread to breast, colon, endometrium, gastric, cervical cancers

Answer 340

- Bilateral metastasis from breast/gastric cancer, malignancy in the ovary that metastasized from a primary site - Mucin-producing signet ring cell

Answer 341

Stage 1 - confined to ovary Stage 2 - outside ovary but within pelvis Stage 3 - Outside pelvic but within abdomen Stage 4 - Distant metastasis

Answer 342

Late presentation: 75% present in stage 3 - vague symptoms - bloating - B symptoms - No PV bleeding

Answer 343

Ovarian = adnexal mass with no PV bleeding Endometrial = uterine mass and PMB

Answer 344

1st: - Tumour markers (CA125); if >35 IU/ml --> 2ww referral to O&G for TVUSS - Raised in >80% of epithelial cancers - CA125 also raised in pregnancy, endometriosis and alcoholic liver disease 1st: - TVUSS - Characterise: size, consistency, presence of solid elements, bilateral or not, presence of ascites, extraovarian disease (peritoneal thickening and omental deposits) 1st: - Risk of malignancy index (RMI), calculated from: - Features: menopausal status, USS features, CA125 - Score >250 is considered high-risk (<25 low risk) Staging: - CT-PAP > MRI

Answer 345

Surgery +/- chemo (2nd line = just chemo) Neoadjucant (before surgery) or 2nd line adjuvant = chemo (in OPD, 3 weeks apart for 6 cycles): - Type: platinum compounds with paclitaxel Follow up with: - CT scan to assess response to treatment - CA-125 measurement (tends to rise prior to onset of clinical evidence of disease recurrence) Platinum compounds (cross-linkage of DNA leading to cell cycle arrest) - Carboplatin (most commonly used as less nephrotoxic and less nausea than cisplatin) - More effective in ovarian cancer - Dose calculated in line with patient's GFR Paclitaxel (microtubular damage --> prevents cell division): - Pre-emptive steroids given to reduce hypersensitivity reactions and side effects (eg. peripheral neuropathy, neutropenia and myalgia) - Causes total loss of body hair Bevacizumab (monoclonal antibody against VEGF and inhibits angiogenesis) - not routinely prescribed in ovarian cancer due to cost - Available for the treatment of recurrent disease Surgery = Laparotomy (TAH + BSO + extra debulking) - Consider fertility sparing surgery in young women (ie. germ cell tumours) - Chemotherapy is not useful in sex cord stromal tumours, surgery is the mainstay

Answer 346

- Presence and growth of endometrial tissue outside the uterus - Affects 1 in 10 women of reproductive age, mainly 30-45 y/o

Answer 347

- Early menarche - FHx - Prolonged menstruation - Short menstrual cycles - Nulliparity

Answer 348

- Retrograde menstruation and implantation may be the cause of endometriosis

Answer 349

Clear cell ovarian carcinoma > endometroid ovarian carcinoma

Answer 350

- Cyclical or chronic pelvic pain occurring before or during menstruation - Deep dyspareunia - Dyschezia (pain on defecation) - Subfertility Extra-uterine endometriosis: - Rectal pain - Bleeding

Answer 351

Bimanual and speculum: - reduced mobility - tender nodularity in posterior vaginal fornix - visible vaginal endometriotic lesions - fixed retroverted uterus = ectopic tissue on utero-sacral ligament TVUSS (may show endometrioma, may show nothing): other may include HSG or HyCoSy -Association to clear cell (20%) and endometroid (20%) ovarian cancer Diagnostic laparoscopy (GOLD-STANDARD): - Red vesicles or punctate marks on peritoneum = active lesions - White scars/brown spots = less active endometriosis

Answer 352

Medical treatment of presumed endometriosis can begin in clinical examinations/TVUSS normal (without need for laparoscopy) however, if no symptom relief in 3-6m, a diagnostic laparoscopy should be undertaken:

Answer 353

Medical treatment of presumed endometriosis can begin in clinical examinations?TVUSS normal (without need for laparoscopy) however, if no symptom relief in 3-6m, a diagnostic laparoscopy should be undertaken: 1st line (3 months): - Paracetamol +/- NSAIDS (inhibit PG synthesis = main reason for pain) - Avoid opiates due to pre-existing constipation - Adjunct: Tranexamic acid 1st line (3 months): - COCP, progesterone (POP, implant, injectables or LNG-IUS) - COCP can provide cycle control and contraception whilst alleviating symptoms of endometriosis - Progesterone used to induce amenorrhoea in those where COCP contraindicated 2nd line (surgical): - Laparoscopic ablation (mild endometriosis superficially) - Recurrence is high at 30% so supplement with medical therapy (COCP) - Superficial peritoneal endometriosis can be easily ablated - Hysterectomy with BSO (radical surgery) - GnRH analogues (eg. leuprorelin) can induce a 'preudo-menopause' - Used to shrink endometriosis in the approach to surgery - Inhibits oestrogen release (do not use longer than 6 months due to osteoporosis risk) - Menopause like side effects (hot flushes, night sweats) Subfertility: - laparoscopic ablation +/- endometrioma cystectomy (no hormone treatment if trying to conceive)