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GYNAE Flashcards

1
Q

What are some differentials for menorrhagia?

A

DUB, fibroids, Endometriosis, PID, IUCD & other contraception
Hypothyroidism
Bleeding disorders e.g. von Willebrands
Endometrial cancer

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2
Q

What are the red flags for vaginal bleeding? (HINT there’s 7)

A
  1. Severe pain
  2. 5-12 wk since LMP
  3. Weight loss
  4. Post-menopausal bleeding
  5. Intermenstrual bleeding
  6. Postcoital bleeding
  7. Missed cervical smears
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3
Q

What are the symptoms & signs of DUB?

A
  • anaemia (chronic IDA)
  • heavy/prolonged PV bleeding
  • menstrual irregularity
  • fatigue, dyspnoea, pallor
  • may have dysmenorrhoea
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4
Q

What are some risk factors for DUB?

A
  • extremes of reproductive age
  • PCOS
  • endocrine disorders
  • obesity
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5
Q

What is the investigations req to diagnose DUB?

A

It is a diagnosis of EXCLUSION

  1. Pregnancy test
  2. FBC (microcytic anaemia)
  3. STI screen
  4. Ferritin
  5. TFT - if suspect hypothyroidism
  6. Clotting screen
  7. Ensure cervical smear up to date
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6
Q

What is the different in management of women >45 and <45 with DUB?

A

(i) Those under 45 have such a small chance of endometrial pathology that further investigation is not required until a 3-month trial of medical management is attempted. (Totally erratic IMB or PCB should prompt search for pathology)
(ii) If over 45 or erratic IMB or PCB do:
- TVUSS: identifies fibroids and polyps. Measures endometrial thickness
- Pipelle endometrial biopsy: R/O hyperplasia or cancer
- Hysteroscopy: if over 45 and TVUSS reveals pathology

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7
Q

How is DUB managed (once pathology is ruled out)?

A

1st Line = Mirena Coil
- COCP is safe up to menopause if no CVD risk factors

If woman wants to NOT use contraception:

  • Tranexamic acid 1g TDS on days 1-4 of cycle
  • Mefenamic acid 500mg TDS days 1-5 (NSAID - if pain prominent feature)

If cycle/bleeding is irregular can use Cyclical (days 5-26) Norithestone

Surgical Options - only if family is complete:

  • Endometrial ablation
  • Hysterectomy = only definitive treatment

May also need to treat IDA with ferrous sulphate

GnRH analogues can achieve amenorrhoea by quickly inducing a menopausal state (use limited to 6-12 months due to bone loss)

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8
Q

What are the signs and symptoms of UTERINE FIBROIDS?

A

SIGNS:
- irregular, firm, central pelvic mass
- Hx of sub-fertility
SYMPTOMS:
Many are asymptomatic but menorrhagia = no. 1 symptom
- may also have pelvic pain, bloating/abdominal fullness and deep dyspareunia

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9
Q

What are some risk factors for developing uterine fibroids?

A
  1. Increased weight
  2. Aged over 40y
  3. Black ethnicity
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10
Q

What investigations are required for suspected fibroids?

A

A. TVUSS

B. Endometrial biopsy - should be normal (used to R/O endometrial cancer)

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11
Q

How are fibroids managed?

A
  1. Mirena IUS
  2. Leuroprelin for up to 3 months (GnRH analogue which shrinks fibroid)
  3. Mifepristone
  4. Naproxen PRN
  5. Myomectomy - preserves fertility
  6. Hysterectomy
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12
Q

What are red flags for heavy menstrual bleeding?

A
  1. Aged over 45y
  2. IMB
  3. PCB
  4. PMB
  5. Abnormal exam finding e.g. pelvic mass or lesion on cervix
  6. Treatment failure after 3 months
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13
Q

What are some complications which can occur as a result of uterine fibroids in situ?

A
  1. Pregnancy complications = premature labour, blocking of vaginal delivery, miscarriages
  2. Infertility
  3. Heavy bleeding - leading to anaemia
  4. Constipation
  5. Urinary outflow obstruction/UTIs
  6. Red Degeneration = haemorrhage infarct of the fibroid which usually occurs during pregnancy. Presents with abdominal pain, low grade fever and vomiting. Management is conservative
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14
Q

What are the main differentials for IMB?

A
  1. Ectopic pregnancy
  2. Spontaneous abortion/miscarriage
  3. STI
  4. Normal spotting as part of ovulation on day 14 of cycle
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15
Q

Define Threatened Miscarriage.

A

Painless vaginal bleeding before 24w (usually 6-9 wks)

  • Bleeding often less than menstruation
  • Cervical os is CLOSED
  • complicates up to 25% pregnancies
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16
Q

Define Missed (Delayed) Miscarriage.

A

Loss of gestational sac before 20wk gestation without symptoms of expulsion

  • Mothers have light vaginal bleeding and symptoms of pregnancy disappear
  • Pain is usually NOT a feature
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17
Q

Define Inevitable Miscarriage.

A

Heavy bleeding with clots and pain

Cervical os is OPEN

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18
Q

Define Incomplete Miscarriage.

A

Not all products of conception are expelled

  • Pain and PV bleeding
  • Cervical os is OPEN
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19
Q

Define Complete Miscarriage.

A

Bleeding and pain cease

Cervical os is CLOSED

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20
Q

What initial assessment is required in a women presenting with a suspected miscarriage?

A
  1. Full medical + gynae Hx
    - LMP
    - Date of 1st +ve pregnancy test
    - PV bleeding + its severity
    - Pain (referred, shoulder tip, rectal)
  2. Examination
    - Vital signs
    - Signs of hypovolaemic shock
    - Abdominal exam
    - Speculum exam
    - Digital vaginal exam
  3. TVUSS - diagnoses
    - Crown-rump length of embryo 7mm or more with NO FHR. If smaller than 7mm then need to rescan in 7-days as too small to make decision
    - Mean sac diameter is 25mm or less with NO yolk sac or embryo
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21
Q

How is a miscarriage managed?

A
  1. EXPECTANT
    - For those with incomplete miscarriage.
    - Need USS every 2 weeks, can take up to 6 weeks
    - Should be offered surgical evacuation if expectant management unsuccessful
    - ADV = avoids hospital, natural process
    - DIS = uncertainty, coping with pain/bleeding at home, may be distressing
  2. MEDICAL - Misoprostol given oral or vaginal, with Mifepristone given 24-48hr prior
    - Bleeding can continue for 3 weeks and expulsion may be associated with pain and heavy bleeding.
    - 24hr telephone service + facilities for emergency admission should be available
  3. SURGICAL - suction curretage
    - Performed in those with excessive/persistent bleeding or request it
    - ADV = shorter process
    - DIS = risk of infection, uterine perforation/adhesions, retained products, GA risk, hysterectomy req in 1/30,000
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22
Q

What are some risk factors for cervical carcinoma?

A
  1. HPV infection
  2. Early sexual activity with many partners
  3. Smoking
  4. HIV/Immunocompromised
  5. Use of COCP
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23
Q

What are the clinical features seen in someone presenting with suspected cervical cancer?

A

Often found incidentally on cervical smear

  • PCB in about 40%
  • IMB
  • Increased or altered vaginal discharge

Signs of advanced disease = pelvic pain, leg pain, PR bleed, haematuria, altered bowels, urinary symptoms

Common sites of mets = lung, liver, bones

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24
Q

What investigations should be performed in suspected cervical carcinoma/CIN?

A

Send for urgent colposcopy if cancer suspected!

  1. Speculum + Bimanual
  2. Pregnancy test
  3. Triple swabs: R/O STI
  4. Colposcopy with punch biopsy
  5. TVUSS if post-menopausal to R/O endometrial cancer
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25
Q

How is cervical cancer/CIN managed?

A

CIN 1 = will regress spontaneously in 50-60% within 2y. So can conservatively monitor with colposcopy/cytology every 6months, LLETZ if persistent.

CIN3 or above = LLETZ required

Stage 1a1 = LLETZ
Stage 1a2 = Hysterectomy + B/L pelvic lymph node dissection
Stage 2b1 = inoperable, chemo only

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26
Q

What follow-up is required post-LLETZ?

A

(i) LOW GRADE = follow up with cytology + HPV testing at 6months. If negative then repeat in 3y.
(ii) HIGH-GRADE = follow up cytology + test of cure hrHPV at 6 months. If negative smear in 3y.

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27
Q

What are risk factors for cervical ectropion?

A

High levels of oestrogen induce cervical ectropion:

  • COCP
  • Pregnancy
  • Adolescence
  • Menstruating age
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28
Q

What are the symptoms + signs of cervical ectropion?

A

SYMPTOMS:
- PCB, IMB, excessive non-purulent discharge
SIGNS:
- O/E may be a red looking area around the os, which should not be confused with other conditions such as cervicitis.

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29
Q

What investigations are required for a diagnosis of cervical ectropion?

A

Diagnosed clinically, but other DDx must be R/O:

  • pregnancy test
  • triple swabs
  • cervical smear
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30
Q

How is cervical ectropion managed?

A

Usually no treatment is required, but if it is particularly troublesome, then you could try cessation of the COCP, or in serious cases, ablation therapy may be used.

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31
Q

What are cervical polyps?

A

Benign growths protruding from inner surface of cervix

Typically asymptomatic, but a very small minority can undergo malignant change

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32
Q

What are the typical clinical features of cervical polyps?

A

Typically asymptomatic

  • abnormal bleeding = PCB, IMB, PMB, menorrhagia
  • large polyps may cause infertility
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33
Q

What investigations are required to diagnose cervical polyps?

A

Can only definitively be made after histology done after removal
A. Triple swabs
B. Cervical smear

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34
Q

How are cervical polyps managed?

A

Should be REMOVED due to small risk of malignant transformation
- the excised polyp is sent for histology for definitive diagnosis

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35
Q

What are the most common DDx for post-coital bleeding? (Hint there are 3 main ones)

A
  1. CERVICAL CARCINOMA
    - infection with HPV 16 or 18
    - Can also present as IMB
  2. CERVICAL ECTROPION
    - squamocolumnar junctions extends under normal hormonal influence
  3. CERVICAL POLPY
    - May bleed on contact
    - Can also present as IMB
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36
Q

What is CIN? What are Risk factors for it?

A

It is a precancerous formation of cervical epithelium for which HPV infection is necessary pre-requisite

Risk Factors = Persistent high risk HPV infection, Multiple partners, Smoking, Immunocompromised, COCP (as not using barrier methods)

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37
Q

What screening is currently performed in the UK to screen for CIN and cervical carcinoma?

A

Every 3 years for women 25-49y. Every 5y from 50-64y.
- If not sexually active then not required to partake
Smear performed to test for hrHPV types:
(i) Negative hrHPV = return to normal recall
(ii) Positive hrHPV = examine samples cytologically.
- If cytology abnormal = COLPOSCOPY
- if cytology normal, repeat hrHPV in 12 months. If still the same then repeat in another 12 months. After this still hrHPV +ve and cytology normal then do colposcopy
(iii) If sample ‘inadequate’:
- repeat in 3 months
- if 2 inadequate samples then perform colposcopy

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38
Q

What does CIN look like on colposcopy? (Types I to III)

A
  • Aceto-white epithelium
  • Vascular abnormalities
  • Bizarre/abnormal vessels

CIN I = bottom 1/3rd
CIN II = bottom 2/3rd
CIN III = full thickness

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39
Q

How is CIN managed?

A

(i) Low Grade = CIN I
- 50-60% regress after 2y
- conservative monitoring with colposcopy/cytology every 6-months
- LLETZ if persistent

(ii) High Grade - CIN II + III
- LLETZ

Follow up = test of cure smear @ 3-6 months

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40
Q

What are the (i) short term and (ii) long term complications of a LLETZ procedure?

A

(i) haemorrhage, infection, vaso-vagal reaction, anxiety

ii) cervical stenosis, cervical incompetence (premature delivery

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41
Q

What are the main differentials for post-menopausal bleeding?

A
  1. Endometrial carcinoma
  2. Atrophic vaginitis
  3. Endometrial hyperplasia
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42
Q

What are the risk factors for endometrial carcinoma?

A
  • Increasing age
  • Obesity
  • Tamoxifen
  • PCOS
  • Unopposed oestrogen exposure = early menopause, late menarche, HRT or COCP use, nulliparity
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43
Q

What are the symptoms + signs of endometrial carcinoma?

A

Presents as PMB or IMB, can have increased vaginal discharge

Signs of advanced disease = abdominopelvic mass, leg swelling, haematuria, PR bleeding, weight loss

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44
Q

What investigations are performed in suspected endometrial carcinoma?

A

A. TVUSS - endometrial thickness over 5mm is abnormal
B. Pipelle biopsy
C. Hysteroscopy + curretage biopsy
D. Determine spread + fitness for surgery = CT/MRI, Bloods (FBC, U+E, glucose), CXR, ECG

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45
Q

What is the management for endometrial carcinoma? (There are 3 stages!)

A

Stage 1 = total abdominal hysterectomy + bilateral salpingo-oophrectomy

Stage 2 = exploratory laparotomy + adjuvant chemotherapy

Stage 3 = Maximal de-bulking surgery + adjuvant chemo

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46
Q

What is endometrial hyperplasia? What is the risk associated with it?

A

Abnormal proliferation of endometrium in excess of normal proliferation that occurs during menstrual cycle
- due to unopposed oestrogen levels

A minority of patients with hyperplasia may develop endometrial cancer

47
Q

How does endometrial hyperplasia present? What is the one important investigation required?

A

Abnormal vaginal bleeding

TVUSS required. Diagnosed on biopsy/curettage

48
Q

How is endometrial hyperplasia managed?

A

Simple without atypia = high dose progesterone (Porgestin), with repeat sampling in 3-4wks
- levonogestrel IUS may be used

With atypia = hysterectomy usually advised

49
Q

What is atrophic vaginitis? How does it present?

A

Inflammation of vagina as a result of tissue thickening secondary to oestrogen depletion (v. common in post-menopausal women)

Presents with dry itchy vagina with subsequent dyspareunia. Also can have PMB, urinary urge incontinence and can have recurrent UTIs

50
Q

How is atrophic vaginitis managed?

A

Vaginal lubricants and moisturisers

If these don’t help, topical oestrogen cream can be used

51
Q

What is the definition of subfertility?

A

The unwanted delay of 2 years in achieving conception despite regular unprotected sexual intercourse

52
Q

What are the 5 common causes/systems causing subfertility?

A
  1. Sperm problems (30%)
  2. Ovulation problems (25%) e.g. PCOS, premature ovarian failure
  3. Tubal problems (15%) e.g. Hx of ectopic, PID, Endometriosis
  4. Uterine problems (10%) e.g. fibroids
  5. Unexplained (15%)
53
Q

What is AMH? When is it best measured?

A

Anti-Mullerian Hormone

  • produced by pre-antral and small antral follicles
  • excellent indicator of oocyte reserve
  • can be measured at ANY time in cycle
  • Low response = less than 5.4 pmol/L
  • High response = over 25 pmol/L
54
Q

What is AFH? When is it best measured?

A 
Antral Follicle Count
- measured at ANY time in cycle
- performed using TVUSS 
Low response = less than 4
High response = more than 16
(small follicles 2-5mm)
55
Q

What Qs do you have to ask yourself when investigating infertility?

A
  1. OVULATION
    - Is the woman ovulating? If anovulation - WHY?
  2. OVARIAN RESERVE
    - Good? Satisfactory? Poor? Diminished?
  3. TUBES + TRANSPORT
    - Problem with the tubes?
  4. SPERM
    - sperm present in ejaculate? If not present or reduced number - WHY?
56
Q

What investigations should you perform in a female with a REGULAR cycle + subfertility?

A
  1. FSH, LH, oestradiol on day 1-5 of cycle to assess ovarian reserve
  2. Progesterone 7 days before menses to confirm ovulation
57
Q

What investigations should you perform in a female with a IRREGULAR cycle or AMENORRHOEA + subfertility?

A
  1. FSH, LH (early follicular) to assess pituitary function + possible PCOS indicator
  2. Oestrogen at any time (assess ovarian function)
  3. Prolactin, free testosterone at any time to explore causes of oligomenorrhoea/amenorrhoea
58
Q

What are the main investigations which should be performed for infertility?

A

A. BMI - may indicate PCOS
B. Semen analysis
C. LH + FSH on days 2-5
D. Day 21 progesterone
E. AMH
F. Rubella serology at any time
G. Cervical smear - to ensure no cervical pathology before pregnancy
H. TVUSS - to assess uterus and ovaries
I. Women with NO co-morbidities should be offered hysterosalpingography (HSG) to screen for tubal occlusion
- if co-morbidities then offer laparoscopy + dye

59
Q

With males how many semen samples are required? What should you tell them beforehand?

A

2

  • they should be abstinent for 2-5 days
  • if sample is abnormal, the second sample should be repeated after 3 months time
60
Q

What conditions can cause damage to the fallopian tube?

A
  1. Endometriosis
  2. Infection e.g. chlamydia or gonorrhoea
  3. Prev surgery causing peri-tubal adhesions
61
Q

Explain the Rotterdam Criteria for diagnosis of PCOS.

A

Requires presence of 2 of the following:

  1. Irregular/absent ovulations (cycle >42 days)
  2. Clinical signs of hyperandrogenism e.g. acne, hirsutism, alopecia
  3. Polycystic ovaries on USS 12 or more antral follicles per ovary or ovarian volume greater than 10ml
62
Q

What is the aetiology behind PCOS?

A

Hypersecretion of LH in 60%

  • leads to elevated LH:FSH ratio which implicates the following:
  • insulin resistance with compensatory hyperinsulinaemia
  • Genetic
  • Hyperandrogenism
  • Obesity (BMI over 30, central obesity, worsens insulin resistance)
63
Q

What are the clinical features patients will present with in PCOS?

A
  • weight gain
  • hirsutism
  • infrequent/absent ovulations
  • acanthosis nigricans
  • impaired glucose tolerance test
64
Q

What are the long term consequences of PCOS?

A
  1. IHD - obesity, insulin resistance + dyslipidaemia are all risk factors
  2. T2DM + GDM in pregnancy
  3. Endometrial hyperplasia or carcinoma - due to long periods of secondary amenorrhoea (causing unopposed oestrogen production)
65
Q

What investigations should be performed in a patient with suspected PCOS?

A

A. Basal (day 2-5) LH, FSH, TFT, prolactin, testosterone
- raised LH
- LH:FSH ratio raised
- Raised testosterone
B. USS
C. Exclude other causes of secondary amenorrhoea

66
Q

How is PCOS managed?

A
  1. Lifestyle = weight loss, diet, exercise
  2. Improve menstrual regularity = weight loss, COCP, Metformin
  3. Control hyperandrogenism symptoms = co-cyprindiol (Dianette), spironolactone, finasteride can be used under specialist supervision
  4. Address subfertility = weight loss, clomifene to induce ovulation, metformin, ovarian diathermy, IVF
  5. Psychological support
67
Q

What are some causes of premature ovarian failure?

A
  • Idiopathic
  • Chemotherapy
  • Autoimmune
  • Radiation
  • Turner’s syndrome
68
Q

What are the typical clinical features of premature ovarian failure?

A

Climacteric symptoms = hot flushes, night sweats
Infertility
Secondary amenorrhoea
Raised LH + FSH

69
Q

What investigations should be performed in suspected premature ovarian failure?

A

A. Gonadotropin levels - raised LH + FSH
B. Oestradiol - low
C. AMH - confirms lack of oocytes

70
Q

How is premature ovarian failure managed?

A
  1. HRT to protect from osteoporosis

2. Donor eggs

71
Q

What are some possible causes of unexplained infertility?

A
  1. Subtle abnormalities in oocyte/sperm function
    (If failed IVF, use ICSI in next cycles)
  2. Defective endometrial receptivity - think if recurrent early pregnancy losses
  3. Subclinical endometriosis
  4. Nutritional deficiencies - zinc + Mg in women, Zinc selenium + Vit E in males
  5. Coeliac disease
  6. Immunological factors e.g. antiphospholipid, antinuclear, antithyroid etc.
  7. Poor ovarian reserve
72
Q

What factors tend to (i) improve fertility and (ii) reduce fertility?

A

(i) Female under 30y, previously conceived, less than 3y infertility, unprotected sex at ovulation, BMI 20-30, non-smoker, limited alcohol, no recreational drug use
(ii) Female over 35y, not previously conceived, more than 3y infertility, no sex during ovulation, BMI under 20 or over 30, one/both parties smoke, excessive alcohol, recreational drug use

73
Q

What advice should you give to patients pre-conception?

A
  1. Optimise pre-existing medical conditions
  2. Female BMI 19-30
  3. Both parties stop smoking + recreational drugs
  4. Limit alcohol intake
  5. Advise intercourse at least every 2 days from about 6 days before predicted ovulation until 2 days after
  6. Female take folic acid 0.4mg/day (5mg if diabetes, epilepsy or prev NTD)
  7. Cervical smear up to date
  8. Rubella immunisation - take full immunisation hx
74
Q

What is the typical clinical presentation of a patient with endometriosis?

A

Many are asymptomatic BUT it is a cause of subfertility

  • Pain (usually chronic pelvic pain) = cyclical or constant, severe dysmenorrhoea, dyschezia + cyclical pararectal bleeding
  • Deep dyspareunia
  • Dysuria
  • Chronic fatigue
  • May have strong FHx of endometriosis
75
Q

What signs will be present on examination of a pt with endometriosis?

A
  1. ABDO EXAM
    - tenderness without rebound or guarding
    - no palpable masses
  2. BIMANUAL EXAM
    - adnexal masses or tenderness
    - nodules/tender in posterior vaginal fornix
    - rectovaginal nodes
  3. SPECULUM EXAM if indicated
76
Q

How do you investigate + diagnose endometriosis?

A

Gold standard = Laparoscopy with biopsy

  • FBC: anaemia may be present
  • Urine dip if suspect haematuria
  • TVUSS to exclude other causes

Many cases diagnosed clinically on basis of significant cyclical abdominal pain

77
Q

How is endometriosis managed?

A

Start with non-surgical options. If pt does not respond in 3-6 months consider gynae referral for surgical management.
1st Line = NSAIDs + Paracetamol
2nd Line = COCP or progesterones or mirena IUS. Aim is to prevent ovulation and prevent build-up and breakdown of endometrial tissue
Referral to secondary care:
- GnRH analogues can induce a pseudomenopause
- Incision or ablation of adhesions via laparotomy
- As a last resort = hysterectomy + B/L salpingo-oophrectomy

78
Q

What is the definition of secondary amenorrhoea?

A

absence of menses for at least 6 months in women with previously normal and regular menses
or 12 months in women with previous oligomenorrhoea

79
Q

What are the causes of secondary amenorrhoea?

A
  1. Physiological e.g. pregnancy, lactation, menopause
  2. Iatrogenic = after stopping COCP or POP, antipsychotics, metoclopramide, methyldopa, opioids
  3. Hypothalamic dysfunction = chronic illness, excessive exercise, anorexia/underweight, stress
  4. Pituitary causes = pituitary tumours, or necrosis (Sheehan’s)
  5. Ovarian causes = premature ovarian failure, irradiation of pelvis, PCOS
  6. Uterine causes = cervical stenosis, Asherman’s syndrome
  7. Endocrine causes = Cushing’s syndrome, Hyper- or hypo-thyroidism
80
Q

What examinations should be performed in a female with secondary amenorrhoea?

A

BMI
PCOS - hirsuitusm, acne, weight gain
Thyroid - weight gain, lethargy, thin hair, cold intolerance
Breast - galactorrhoea
Visual fields - bitemporal hemianopia (pituitary tumour)

81
Q

What investigations should be performed in a female presenting with secondary amenorrhoea?

A
  1. R/O pregnancy
  2. Pelvic USS
  3. Serum prolactin (if raised perform pituitary fossa MRI)
  4. TFTs
  5. LH + TSH
  6. Total cholesterol - PCOS
  7. Testosterone (raised in PCOS)
82
Q

When a patient presents with vaginal discharge, what sort of thing do you want to ask in the history?

A
  • Colour
  • Consistency
  • Blood
  • Duration
  • Timing: cyclical or constant
  • Odour
  • Relationship with menstrual cycle
  • Associated symptoms: itching, burning, dysuria, dyspareunia
  • Precipitating factors: pregnant, pill, sexual arousal
  • PMH: STIs, DM, immunocompromised
  • Sexual + Menstrual history
  • Allergies
83
Q

What examination(s) should be performed in a female presenting with vaginal discharge?

A
  1. External genitalia
    - For vulvitis, obvious discharge, ulcers etc.
  2. Speculum examination
    - Vagina, cervix, foreign bodies, amount/colour/consistency of discharge
  3. Bimanual exam
    - masses, adnexal tenderness, cervical excitation
84
Q

What investigations should be performed?

A
  1. Endocervical or vulvovaginal swabs for gonorrhoea + chlamydia
  2. High vaginal swabs for BV, trichomonas and thrush
  3. Vaginal pH
  4. Saline wet mount + gram stain
  5. Colposcopy if abnormal cervical appearance on speculum exam
85
Q

What are some common differentials for vaginal discharge?

A
  1. Infective (non-STI)
    - BV or Candida albicans (thrush)
  2. Infective (STI)
    - Chlamydia, N.Gonorrhoea, Trichomonas vaginalis, HSV
  3. Non-Infective
    - Foreign bodies, cervical polyps + ectropion, malignancy, fistulae
  4. Physiological
    - oestrogen related, cycle related, sexual excitement
86
Q

What are some predisposing factors to vaginal thrush?

A
  • DM
  • Drugs e.g. Abx, steroids
  • Pregnancy
  • HIV/Immunosuppression
87
Q

What are the clinical features of thrush?

A
  • Cottage cheese non-offensive discharge
  • Vulvitis = dyspareunia (superficial), dysuria
  • Itch
  • Vulvar erythema, fissuring, satellite lesions may be seen
88
Q

What investigation is required for diagnosing thrush?

A

High vaginal swab

- not indicated if clinical features consistent with candidiasis

89
Q

What is the management for vaginal candidiasis?

A
  1. Local = Clotrimazole 500mg PV STAT (if pregnant only local treatment used)
  2. Oral = itraconazole 200mg DB for 1 day or Fluconazole 150mg PO stat
90
Q

What is Amstel’s diagnostic criteria for BV?

A

Need 3 out of 4 to diagnose:

  1. Thin, white discharge (also grey)
  2. Positive whiff test = offensive fishy smell
  3. Clue cells on microscopy
  4. Vaginal pH greater than 4.5
91
Q

What is the one investigation to diagnose BV?

A

High vaginal swab

92
Q

What is the management of bacterial vaginosis?

A
  1. Oral metronidazole for 5-7 days.

2. Topical clindamycin or metronidazole

93
Q

How can BV infection affect pregnancy?

A

Increased risk of pre-term labour, low birth weight, chorioamnionitis + late miscarriage

94
Q

What are the clinical features of trichomonas vaginalis?

A
  • Vaginal discharge = offensive, green + frothy
  • Vulvovaginitis
  • Strawberry cervix
  • pH greater than 4.5
  • Usually asymptomatic in men but may cause urethitis
95
Q

What investigations are required to diagnose trichomonas?

A
  1. High vaginal swab

2. Microscopy of a wet mount shows motile trophozites

96
Q

How is trichomonas managed?

A

Oral metronidazole for 5-7days (or 2g STAT)

97
Q

What are the symptoms of chlamydia?

A

70% are asymptomatic

  • dysuria
  • vaginal discharge
  • irregular bleeding
  • pelvic pain + deep dyspareunia
98
Q

What investigation is required to diagnose chlamydia?

A

Vulvovaginal + endocervical swab for NAAT

99
Q

How is chlamydia managed?

A
  1. Azithromycin 1g STAT
  2. Doxycycline 100mg BD for 7-days
  3. Contact tracing + treatment of partners
100
Q

What complications can occur as a result of chlamydial infection?

A
  1. PID
  2. Perihepatitis (Fitz-Hugh Curtis Syndrome)
  3. Reactive arthritis (more common in men)
  4. Tubal infertility
  5. Risk of ectopic pregnancy
101
Q

How are pregnant women with chlamydia managed? What are they at risk of?

A

Erythromycin 500mg BD for 10-14 days

  • PROM
  • premature delivery
  • neonatal conjunctivitis
  • neonatal pneumonia
102
Q

What are the clinical features of gonorrhoea?

A

Usually asymptomatic

  • odourless green vaginal discharge
  • lower abdominal pain
  • dysuria
  • IMB, PCB
103
Q

What investigations are required in suspected gonorrhoea?

A
  1. Endocervical swab for NAAT

2. Culture for sensitivity before commencing Abx

104
Q

How is Gonorrhoea managed?

A

1g Ceftriaxone IM STAT
- if needle phobic use Cefixime PO 400mg and Azithromycin 1g PO STAT

Test of cure at least 72h after treatment

105
Q

What are some complications of Gonococcal infection?

A
  • PID
  • Bartholins/Skenes abscess
  • Fever, pustular rash, migratory polyarthralgia, septic arthritis
  • Tubal infertility
  • Risk of ectopic pregnancy
106
Q

What 2 organisms are commonly the causes of PID?

A
  • chlamydia trachomatis

- N. gonorrhoea

107
Q

What are the clinical features of pelvic inflammatory disease?

A
  • Pelvic pain/lower abdominal pain
  • Fever
  • Dysuria
  • Deep dyspareunia
  • Vaginal discharge
  • Abnormal bleeding (IMB/PCB)
  • Menorrhagia
  • Cervical excitation
108
Q

How is pelvic inflammatory disease managed?

A
  1. Abx as per local guidance
  2. NICE suggest:
    - oral ofloxacin 400mg BD + oral metronidazole 400mg BD for 14 days
    - IM ceftriaxone 500mg STAT with oral doxycycline 100mg BD with oral metronidazole 400mg BD for 14 days
  3. Treat based on clinical diagnosis (no need to wait for microbiology)
  4. Consider removing any IUS or IUD in situ
  5. Refer to GUM clinic
109
Q

What is Fitz-Hugh Curtis Syndrome? What symptom does it cause?

A

It is where PID causes inflammation of the liver capsule, leaving to adhesions between the liver + peritoneum

  • causes RUQ pain that is referred to the R shoulder tip - if there is diaphragmatic irritation
110
Q

What does the RMI for ovarian cancer consist of?

A

U x M x Ca125
U = features of malignancy on USS
M = menopausal status

111
Q

How is ovarian cancer managed?

A

High risk RMI required full staging laparotomy (de-bulking surgery)
- bulky stage 3 or 4 (out of pelvis), may need neoadjuvant chemo prior to de-bulking. 3 cycles before + 3 after.

112
Q

What cancer(s) are you at risk of with HNPCC?

A

Colorectal
Uterine
Ovarian

113
Q

What are the 4 main types of prolapse?

A
  1. Uterine = uterus descends into vagina
  2. Vault prolapse = happens in women who’ve had hysterectomy. Top of vagina descends into vagina itself
  3. Rectocele = rectum prolapses forwards into posterior vaginal wall (constipation + urinary retention)
  4. Cystocele = bladder prolapses backwards into vagina. Urinary symptoms present
114
Q

How do you manage a prolapse?

A

CONSERVATIVE:
- physio: pelvic floor exercises
- weight loss
- reduce caffeine + use incontinence pads
- treat related symptoms e.g. chronic cough/constipation
PESSARIES
- ring, donut, cube, shelf
- oestrogen cream will help protect vaginal walls from irritation of pessary
SURGERY

FINALS (14 decks)

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