Gynae Flashcards
1
Q
What hormone do the thecal cells produce and what is their action?
A
LH: produce testosterone and progesterone
2
Q
What hormone do the granulosa cells produce and what is their action?
A
FSH: converts testosterone to oestrogen
3
Q
What is the average menstrual cycle length?
A
23-35 days
4
Q
What hormonal axis is involved in menstruation?
A
HPA axis: intiially GnRH stimulates FSH and LH release which stimulates growth of follicles and Graffian follicle secretes oestrogen.
5
Q
What hormone surges in ovulation?
A
LH
6
Q
What drug can you give to postpone menstruation (what can they do if they are on the COCP?)
A
Norethisterone 3 days before period due
Run COCP packs together
7
Q
What are the two main causes of menorrhagia?
A
Fibroids (may feel a mass on examination)
Polyps
8
Q
How would you investigate menorrhagia?
A
Bloods- FBC, U&E, coag, TFTs
TVUS if mass
May need endometrial biopsy
9
Q
What are the treatment options for menorrhagia?
A
- IUS- Mirena coil
- Anti-fibrinolytics: Transexamic acid, NSAIDs eg. mefanamic acid, COCP
- Progesterones
- Surgical- ablation of endometrium
10
Q
A 16 year old comes in complaining of dysmenorrhea. When you ask more questions you find out the pain comes on at the start of menstruation and it is a crampy pain in the abdo moving to back and groin. She also feels quite nauseas with it. Is this primary or secondary dysmenorrhea and what is the treatment?
A
Primary= pain at start of menstruation
Treatment: NSAIDs eg. mefanamic acid, COCP, local application of heat
Secondary= pain preceeding menstruation and relieved by onset of menstruation
11
Q
What may cause secondary dysmenorrhea?
A
Fibroids
PID
Endometriosis
Adenomyosis
12
Q
What are some causes of irregular/inter-menstrual bleeding?
A
Anovulatory cycles eg. near puberty/later years
Fibroids
PID
Polyps
Ovarian cysts
Spotting on contraception
Cancer- ovarian, endometrial (PMB), cervical
13
Q
How would you investigate irregular/intermenstrual bleeding?
A
Bloods- FBC, U&E, clotting, TFTs
FSH, LH if suspect menopause
Ultrasound of uterus!
Biopsy- if >40, medical tx failed
14
Q
What is the first and second line treatment in irregular/intermenstrual bleeding?
A
- IUS or COCP
2. progestogens
15
Q
What are the age cut offs for primary amenorrhea?
A
Failure to start menstruating by 16 or by 14 if there are no secondary sexual characteristics eg. breast development
16
Q
What are some causes of amenorrhea (both primary and secondary)? split it up into non-pathological and pathological (split into HPA axis, Pituitary/thyroid and ovarian)
A
Non-pathological:
- Primary: Consituttional delay, drugs eg. progestogens, GnRH analogues
- Secondary: pregnancy, menopause, drugs- antipsychotics
Pathological:
- HPA axis: anorexia nervosa, stress/excessive exercise, Kallman’s syndrome- hypogonadotropic hypogonadism (all hormones low + no sense of smell)
- Pituitary/thyroid: hyperprolactinaemia (antipsychotics, prolactinoma (pit adenoma), hypothyroidism, Sheehan’s syndrome
- Ovary: primary ovarian failure (genetic cx: Turner’s syndrome), PCOS
Androgen insensitivity syndrome
17
Q
A girl presents with amenorrhea but has normal secondary sexual characteristics. She has cyclical abdominal pain. What is the likely cause?
A
Imperforate hymen
18
Q
A woman approx aged 25 years old presents with secondary amenorrhea. She used to have normal periods but now has stopped bleeding. PMH: she has had 3 abortions treated with surgical evacuation. What is the likely cause?
A
Asherman’s syndrome- scar tissue forms in canal due to excessive curettage in evacuation of retained productions.
19
Q
What investigations would you do in a patient with amenorrhea? Think about causes
A
Bedside: pregnancy test
Bloods: serum androgens (raised in PCOS), LH and FSH (FSH= low in hypothalamic causes, normal in PCOS, raised in ovarian failure), prolactin (twice), TFTs, serum testosterone
Imaging: pelvic US if suspect PCOS
20
Q
How do you treat HPA causes of amenorrhea? eg. excessive exercise, stress, anorexia
A
Normalise weight, GnRH pump
21
Q
How do you treat prolactinoma - cause of amenorrhea?
A
Bromocriptine/ cabergoline
22
Q
How do you treat primary ovarian failure as cause of amenorrhea?
A
No cure- hormone replacement
23
Q
What is the definition of premature menopause?
A
Menopause before the age of 40
24
Q
A 43 year old lady comes into your clinic because she has noticed her periods are not coming anymore. She also describes hot flushes and sweats every so often along with painful sex with her husband. She has also noticed some urinary symptoms , she is having to go much more often but there is no burning or stinging. What is the diagnosis and what treatment options may you offer her?
A
Menopause Treatment: Vaginal dryness: oestrogen cream SSRIs eg. fluoxetine for the vasomotor symptoms HRT
25
What test can tell you the ovarian reserve in a patient ?
Anti-mullerian hormone
26
What are the two options of HRT?
HRT: oestrogen + progesterone (if they haven't had a hysterectomy- add progesterone to reduce risk of endometrial cancer)
Cyclical : perimenopausal. take each one on diff days
Continuous combined HRT: menopausal. take both daily. don't get a withdrawal bleed
27
The lady you started on HRT calls you to ask if she still needs to use contraception, what do you tell her?
Yes- they are still fertile for 2 years
28
What does the broad ligament of the uterus contain?
```
Fallopian tubes
Ovary
Ovarian artery
Uterine artery
Round ligament of the uterus
Suspensory ligament
Ovarian ligament
```
29
What is a fibroid/leiomyomata
Benign tumour of the myometrium
30
What happens to fibroids in pregnancy and what may have to be done to deliver baby?
They grow. If they grow and obstruct- C-section to deliver baby
31
Where can fibroids be located (3 places)? Which ones are likely to pedunculate and tort?
Subserosal- into the peritoneal cavity
Inter-mural
Submucosal - into uterine cavity
Subserosal and submucosal are likely to pedunculate--> torsion
32
A woman with known fibroids comes into A&E feeling very unwell. She is in severe abdominal pain, has a high fever and is feeling very nauseas. This started about an hour ago and has been getting worse. What do you need to worry about?
Red degeneration of fibroid- vomiting, abdominal pain needing morphine and fever
33
What would you do to investigate a lady with a fibroid?
Bedside: pelvic examination- palpable mass 'knobbly'
Bloods: FBC, clotting, U&Es
Imaging: TVUS, may need MRI pelvis.
Special tests: hysteroscopy with biopsy.
34
What are the options to treat a fibroid <3cm with heavy bleeding?
1. IUS
| NSAIDs, trasexamic acid, GnRH agonists (temp, can shrink before surgery) or mifeprstone- anti progesterone
35
What are the options to treat a >3cm fibroid with heavy bleeding?
1. Ulipristal acetate- shrinks fibroids and causes amenorrhea
Surgical- myomectomy (fertility desired), uterine artery embolisation or hysterectomy (fertility not desired)
36
What is adenomyosis?
Invasion of myometrium by endometrium- it breaks through
37
What symptoms/signs might be present in a patient with adenomyosis?
Dysmenorrhea, menorrhagia
| Enlarged 'boggy' tender uterus - feel on examination
38
How would you investigate and treat someone with adenomyosis?
MRI pelvis
IUS, COCP
Hysterectomy- definitive
39
What is endometriosis?
Presence and growth of endometrial tissue outside the uterus in sites like ovaries, uterosacral ligaments, vagina which can lead to fibrosis and adhesions.
40
What is a chocolate cyst in context of endometriosis?
Blood can accumulate in the ovaries causing an ovarian cyst in patients with endometriosis which can rupture and cause acute severe pain.
41
What symptoms may a person with endometriosis present with?
```
Pelvic pain
Dysmenorrhea
Dyspareunia
Dysuria
Subfertility
```
42
What might the uterus look like if a patient with endometriosis had adhesions?
Fixed retroverted uterus
43
What is the gold standard investigation for a patient with endometriosis? What investigation might you do first?
Laparoscopy and biopsy
| TVUS
44
What are the treatment options for a patient with endometriosis and what is the problem with all these treatments?
```
Options:
NSAIDs
COCP
IUS
Progestogens orally/IM eg. dEpo
GnRH analogues eg. goserilin
```
Problem with all these: fertility- these are all contraceptives
Fertility problems: IVF
45
What symptoms may a person with polyps present?
PV bleeding- menorrhagia, inter-menstrual bleeding
| infertility
46
What are some risk factors for polyps?
Obesity, HTN, HRT, tamoxifen (breast cancer)
47
How do you treat polyps?
Curretage via hysteroscopy
48
A post-menopausal lady has presented with vaginal bleeding. She has a PMH of T2DM and HTN and is slightly obese. The vaginal bleeding started 2 weeks ago and has not settled since so she has come seen you. Do you investigate her?
YES - post-menopausal bleeding can be indicative of endometrial cancer
49
What are some risk factors for endometrial cancer?
Unopposed oestrogen is the cause!
| RF: post-menopausal, obesity, T2DM, hypertension, PCOS, tamoxifen, LATE menopause, oestrogen therapy
50
What is the commonest histology of endometrial cancer?
adenocarcinoma
51
Which nodes to endometrial cancer metastasise first?
Para-aortic lymph nodes
52
What investigations would you do in a patient with suspected endometrial cancer?
Bloods
TVUS
Biopsy
MRI/CT- mets
53
What are the treatment options for stage 1,2 or 3 endometrial cancer?
Stage 1: hysterectomy with bilateral salpingoophrectomy
Stage 2: radical hysterectomy + pelvic node clearance
+/- chemo/radio
Stage 3: palliative - debunking surgery + radiotherapy to decrease bleeding
54
What is the histology of ectocervix and endocervix and what is the significance of where they meet?
Endocervix: columnar glandular
Ectocervix: stratified squamous epithelium
Meet at sqaumo-columnar junction - transitional zone and increased risk of malignancy here.
55
What does a cervical ectropion look like?
Red area where red endocervix extends out onto pale ectocervix
56
What are the two main risk factors for cervical ectropion?
COCP
| pregnancy/puberty
57
A young girl aged 25 years old presents to the GP with some vaginal bleeding after sex and a bit of discharge. She has no other symptoms or red flags and her recent smear (1 month ago) was normal. PMH: COCP. What is the likely diagnosis?
Cervical ectropion
58
What is a complication of cervical ectropion?
Chronic cervicitis- ectropion can get infected and get increased discharge. Treat with antibiotics if needed + cryotherapy
59
How would you treat a cervical polyp?
Avulsion with forceps
60
What is a Nabothian follicle?
Metaplasia of ectocervix over endocervix- of the glandular cells --> MUCUS CYSTS
61
What would a Nabothian folllicle look like?
White cysts on cervix
62
What is cervical intraepithelial neoplasia?
Dyskaryotic cells in squamous epithelium - either stage 1 in lower 1/3, stage 2 in lower 2/3 or stage 3 in full thickness.
63
How is cervical intraepithelial neoplasia picked up?
Routine smears
64
A lady comes for her smear check and there are no dyskaryotic cells found. Can she go back to routine screening or does she need HPV testing?
Routine screening
65
A lady comes for her smear check and MILD/BORDERLINE dyskaryotic cells are found. What is the next step?
Testing for HPV
66
A lady with MILD/BORDERLINE dyskaryotic cells found on smear check is HPV +, what is the next step?
Colposcopy
67
A lady comes from her smear check and MODERATE-SEVRE dyskaryotic cells are found. What is the next step?
Straight to colposcopy.
68
What are risk factors for cervical intraepithelial neoplasia
HPV (16,18), multiple partners, smoking, COCP
69
What is the treatment for cervical intraepithelial neoplasia?
LLETZ- large loop excision of the transitional zone (loop diathermy, loop excision)
70
What is the most common histology of cervical cancer?
Squamous cell carcinoma
71
What lymph nodes does cervical cancer metastasise too?
Pelvic nodes
72
What symptoms may someone with cervical cancer present with?
Post coital bleeding
Inter-menstrual/post-menopaulsa bleeding
Offensive discharge
73
What investigations do you want to do in a patient with suspected cervical cancer?
Bedside: pregnancy test, PV- may bleed on contact
Bloods- FBC, U&Es, LFTs
Imaging and special tests: Colposcopy + biopsy tumour and MRI pelvis for staging
74
What is the mainstay of treatment for cervical cancers with no lymph node involvement? What other option is there?
Cone biopsy
Radical hysterectomy with pelvic node clearance
Radical trachelectomy with lymph node clearance- conserve fertility
75
What happens to the corpus luteum in the ovary in normal menstruation v pregnancy?
Menstruation: corpus luteum dies in absence of fertilisation
Pregnancy: corpus luteum secretes progesterone and oestrogen to maintain uterine endothelium
76
Sarah is a 23 year old woman who has come to the GP because she is concerned that she has started growing facial hair. This has started since she came off her COCP 8 months ago. On questioning, she has not had a period in this time.
PMHx: BMI 30
What is the diagnosis and what criteria can be used?
PCOS
| Rotterdam criteria
77
What is the triad of symptoms in PCOS? And what causes this?
Polycystic ovaries + hirsutism + oligo/amenorrhea
Raised LH and insulin levels --> increased peripheral and ovarian androgen production --> hirsutism and polycystic ovaries and anovulation
Other sx: obesity, acne
78
What tests may you do in a patient with suspected PCOS?
Bloods: FBC, U&E, LFTs, LIPIDS, GLUCOSE. FSH= normal, LH= high, testosterone= high, prolactin= normal, TSH= normal.
Imaging: TVUS: >12 follicles in one ovary
79
Sarah is a 23 year old woman who has come to the GP because she is concerned that she has started growing facial hair. This has started since she came off her COCP 8 months ago. On questioning, she has not had a period in this time.
PMHx: BMI 30
Given the likely diagnosis, how are you going to treat her? (she is currently not trying for children)
Conservative: weight loss, exercise, smoking cessation
Metformin - improves insulin sensitivity
COCP - regulates menstruation
Anti-androgens: spironolactone, finasteride
80
Sarah has been diagnosed with PCOS recently and started on treatment. Sarah decides to go back onto a COCP and try to increase her exercise levels to lose weight.
3 years later she returns to the GP. Her BMI is now 24. She stopped taking the COCP 2 years ago as her and her partner decided to try for a baby. She is struggling to conceive and wants to know if there is anything you could do. What are the options for treatment of her PCOS now that she wants help with the infertility?
1 or 2. Clomiphene: anti-oestrogen. risk of multiple births
1 or 2. Aromatase inhibitor: letrozole.
3 or 4. Gonadotrophins
3 or 4. Ovarian drilling- to decrease androgen production
Need OGTT when pregnant- risk of gestational diabetes
81
What are some symptoms and signs a patient with an ovarian cyst can present with?
```
Dull ache in lower abdo/back
Dyspareunia
Abdominal distension if big
Urinary symptoms if pressing on bladder- urinary frequency
O/E: pelvic mass, tender
```
82
What is a functional ovarian cyst?
Normal in menstruating women. Don't usually cause symptoms.
83
What is a endometrioma/chocolate ovarian cyst?
Cysts full of accumulated blood in patients with endometriosis.
84
What is a serous cystadenoma and what is the complication of a mucous cystadenoma?
Serous cyst adenoma: very common, looks solid.
| Mucous- mucin filled. Complication: pseudomyxoma peritoni- mucous cells spread into the abdomen
85
What investigations would you do in a patient with suspected ovarian cysts?
Bedside: pregnancy test, urinalysis
Bloods: FBC, U&E, LFTs
Imaging: TVUS. If not clear: MRI
86
Andrea presents with a sudden onset, colicky lower abdominal pain. She has vomited twice.
An ultrasound scan shows the ‘whirl pool sign’.
What is the diagnosis? What does it mean if the pain improves?
Ovarian torsion
| It means the ovary is dying
87
What investigations would you do in a patient if you suspected ovarian torsion?
Bedside: pregnanyc test
Bloods: FBC, U&E, LFTS
Imagine: Ultrasound (transvaginal) - whirlpool sign
88
How do you treat ovarian torsion?
Detorsion- laparoscopically and may do oophrepexy- fix ovary to wall
If ovary unviable: salpingo-oophrectomy.
89
A 58 year old woman has presented with non-specific GI pains. She has been suffering from abdomen bloating and pain along with early satiety for a long time and has been investigated for many gastro conditions with no diagnosis. She hasn't got any children and you learn she had her first period aged 12 (early). What is the likely diagnosis and what test would you want to do immediately?
Ovarian cancer
| CA-125.
90
What are the risk factors for ovarian cancer?
```
Related to increased ovulations
Early menarche
Late menopause
Nulliparity
Long term HRT
BRCA Gene 1 &2
```
91
What are the signs & symptoms of ovarian cancer?
```
Abdo bloating, distension
Abdo pain
Early satiety
Loss of appetite
Urinary symptoms - frequency, urgency
Palpable abdo/ pelvic mass
May have ascites
```
92
What investigations would you do in a patient with suspected ovarian cancer?
Bedside: pregnancy test, urinalysis (if urinary sx)
Bloods: FBC, U&E, LFTs, CA-125!
Imaging: Pelvic US!, CT of pelvic abdo- staging
Risk of malignancy index: USS x CA125 x menopausal status
93
Can you be screened for ovarian cancer?
No programme at the mo. Can have yearly Ca-125 & US if family history.
94
How do you treat ovarian cancer?
Surgery: hysterectomy (can be spared if young woman/lower risk) + bilateral salping-oophrectomy + lymph node clearance + omentectomy
Adjuvant chemo if higher risk disease
95
A patient comes into clinic presenting with vulval itching. This is particularly present at night. She says its the 'flaps' that are the itchiest. She has a PMH of eczema. On examination you see an inflamed labia majora. What is the likely diagnosis and what treatment will you tell her?
Lichen simplex- vulval dermatitis.
Treatment: no harsh soaps, clean gently, loose clothing and cotton underwear, steroid cream eg. betamethasone, antihistamines
96
A patient comes into clinic describing painful patches on her vulva. They are not itchy. On examination you see purple papules on her vulva. What is the likely diagnosis and how will you treat?
Lichen Planus- 'purple' 'papules' 'pain'
| Treat with steroid creams
97
A patient comes into clinic with intense vulval itching. On examination you see white flat fissured skin that looks and feels like parchment. PMH: Crohn's disease. What is the likely diagnosis and what treatment?
Lichen sclerosis - AI
| Treatment: steroid creams eg. clobetasol or tacrolimus 2nd line.
98
Is there a risk of vulval cancer with lichen sclerosis?
Yes- small %. may need biopsy.
99
What causes a Bartholin cyst and how is it treated?
Bartholin's glands behind labia minor get blocked. Cyst= painless. Treated with conservative measures or marsupilisation or incision and drainage (if abscess)
100
Vulval intraepithelial neoplasia has a usual type and differentiated type? How do they differentiate in terms of common/uncommon, age affected, what are they each associated with?
Usual: common, younger people, associated with HPV, smoking
Differentiated: rarer, older people, associated with lichen sclerosis
101
Are Vulval intraepithelial neoplasia nodules/patches likely to be ulcerated?
No - if ulcerated- likely to be carcinoma
102
How do you treat Vulval intraepithelial neoplasia?
Local surgical excision AND/OR imiquimod cream
103
What is the most common histological cancer of vulva?
Squamous cell carcinoma
104
What symptoms may a person with vulval cancer present with?
Mass (ulcerated) on labia/vulva
| Pain, bleeding, discharge
105
What are the options for treatment of vulval cancer?
Wide local excision and add lymphadenectomy of inguinal nodes if over stage 1 (spread past vulva)
106
Is vaginal carcinoma more commonly caused by a primary cancer or metastases?
Mets from cervix/endometrial/vulval cancer
107
June is 26. She presents with lower abdominal pain, abnormal vaginal discharge and has a fever. She has multiple sexual partners and was diagnosed with chlamydia last week. She has a mirena coil in situ. What is the diagnosis and what are the causes?
Pelvic inflammatory disease.
Causes: STIs- chlamydia!, post-partum infection, instruments- hysteroscopy, IUD. Can sometimes descend from other organs e.g. appendicitis.
108
What are some symptoms of PID?
```
Can be asymptomatic
Lower abdominal pain
Deep dyspareunia
Bleeding- intermenstrual, post-coital, dysmenorrhea
Vaginal discharge
May have fever - absent if chronic
```
109
What may you find on examination of cervix in PID?
Cervical excitation - v painful on palpation of cervix
110
What investigations would you do in a patient with suspected PID?
Bedside: pregnancy test, endocervical swabs for chlamydia/gonorrhea
Bloods: FBC, U&E, LFTs, CRP, blood cultures if sepsis suspected
Imaging: TVUS if suspect tuba-ovarian abscess (complication)
Special tests: laparoscopy only if diagnosis uncertain/Abx don't work
111
What is PID?
Infection of the upper genital tract- uterus, ovarian, fallopian tubes
112
How do you treat PID?
Doxycycline PO + metronidazole PO (14d) + ceftriaxone IM (IV if in hospital)
113
What are some complications of PID?
```
Tuba-Ovarian abscess
Chronic/recurrent PID- hard to treat (pelvic adhesions, Fallopian tube blockage)
Fitz-Hugh-Curtis: perihepatic adhesions
Subfertility
Ectopic pregnancy
```
114
What happens in a prolapse?
Weakness in supporting structures allows pelvic organs eg. bladder/uterus/rectum to fall and protrude within vagina
115
What are some causes of prolapse?
```
Congenital
Prolonged vaginal labour
Instrumental delivery
Menopause
Increased intra-ado pressure- chronic cough, obesity, constipation
```
116
What happens in a urethrocele?
Weakness of tissues holding urethra in place causes it to prolapse into the lower anterior wall of vagina
117
What happens in a cystocele? What symptoms may you get?
Weakness of tissues holding bladder in place causes it to prolapse into the upper anterior wall of vagina.
Sx: stress incontinence, incomplete bladder emptying
118
What happens in a enterocoele?
Small bowel descends and pushes into wall of vagina --> pouch of small bowel
119
What happens in a rectocele? What symptom may it cause?
Weakness of muscles of rectum causes it to prolapse into the lower posterior wall of vagina.
Sx: difficulty defecating
120
What is the main symptom patients with a prolapse suffer with?
Dragging sensation
| Feeling a lump coming down
121
What are the options for treatment of prolapse?
Conservative: weight loss, pelvic floor exercises, stop smoking/straining.
Medical: pessary- acts as an artificial pelvic floor, common= ring pessary. SE: sexual dysfunction.
Surgical: hysterectomy (can lead to vaginal vault prolapse), hysteropexy- uterus and cervix attached to sacrum with mesh
122
What happens in a vaginal vault prolapse
Internal end/top of vagina falls into the lower end
123
What are the two main causes of a vaginal vault prolapse?
Post-hysterectomy - no uterus to support internal/top of vagina
Uterine prolapse
124
What are the two surgical options for treatment of vaginal vault prolapse?
Sacroclopopexy: fix vaginal vault to sacrum using mesh
| Sacrospinous fixation: suspends vault to sacrospinous ligament
125
What is the definition of infertility?
Failure to conceive after 1 year.
126
A male-female couple comes into infertility clinic after failing to conceive for 12 months. Are you going to investigate them?
Yes because failure to conceive after 1 year
127
A male-female couple come to infertility clinic after failure to conceive for 9 months. Are you going to investigate them?
No
128
A male-female couple come to infertility clinic after failure to conceive for 9 months. She is 37 years old and they have both had previous STIs and she has struggled with oligmenorrhea for years. Are you going to investigate them?
Yes- although less than 1 year- she is over 25, previous STIs and she has bleeding irregularities.
129
What are some causes of infertility?
```
unexplained
male factors
PCOS
Ovarian failure (genetic= Turner's)
Surgery or chemotherapy to pelvis
Excessive exercise, stress, low weight.
Sheehan's- FSH and LH hormone replacement
PID - chronic
Endometriosis
```
130
What investigations would you like to do in a couple who has presented to clinic with failure to conceive for >1 year?
Bedside: smear if not up to date, vaginal swabs for STI
Bloods: 21 day progesterone (>30), FSH &LH, progesterone, FBC, U&Es, TSH, prolactin,
Semen analysis on man
Imaging: check tubes: low risk: TVUS (rule out PCOS, fibroids, endometriosis), HSG (x ray of tubes), HyCoSy (US contrast of tubes).
high risk: laparoscopy and dye (STI, prev surgery, PID)
131
What is the first line treatment for infertility?
Conservative: lose weight, stop smoking, healthy diet, stop alcohol & recreational drugs, Aim to have sex every 2-3 days.
132
What is the medical management for female infertility? (cx: excessive exercise, weight loss, Sheehan's, early menopause, PCOS)
Excessive exercise, weight loss: Tx: GnRH agonists, normalise weight.
Sheehan's: FSH and LH hormone replacement
Early menopause: donor egg
PCOS:
Letrozole - lower rates of multiple pregnancy.
Clomiphene - antioestrogene. SE: multiple pregnancy
Ovarian drilling- to induce ovulation
Gonadotrophins if above not working
133
How would you treat endometriosis causing infertility ?
Surgery- laparoscopic ablation (treatments for endometriosis are contraceptive based eg. COCP, IUS, GnRH agonists)
134
What are some indications for IVF?
```
Male infertility
Not responding to medical treatments
Tubal disease
>2 years with no cause
High maternal age
```
135
What are some risks of IVF?
Multiple pregnancy
Miscarriage
Ectopic pregnancy
Ovarian hyperstimulation syndrome - due to induction. ovaries swell and become painful.
136
What are some causes of male sub/infertility?
```
Semen abnormality (most common): idiopathic- low sperm count, low sperm movement. Drugs, alcohol, testicular cancer, varicocele
Absence of sperm in semen: hypogonadotropic hypogonadism (decreased FSH, LH, testosterone), anabolic steroids (low FSH, LH, high testosterone), crypto-orchidist, Kleinfelters, vasectomy
Coital problems: ED- normal sperm function, phimosis, hypospadias, retrograde ejaculation
```
137
What investigations may you do on with a man who has sub fertility?
Semen analysis- count, morphology, motility
Bloods- FSH, LH, testosterone
Karyotype - Kleinfelters
138
What are the options for fertility treatment if male infertility is the cause ? mild, moderate, severe
Mild: intra-uterine insemination - inject sperm into uterus
Moderate: IVF
Severe: intracytoplasmic sperm injections- inject sperm into egg directly.
139
How do you treat vaginal candida?
Clotrimoxazole pessary + cream if vulval symptoms OR flucozonole tablet
140
A patient presents with increased vaginal discharge. She describes it as a grey colour and smells fishy. There is no itching present. Likely diagnosis and what would you see on microscopy?
```
Bacterial vaginosis (Gardnerella)
Microscopy- clue cells
```
141
How do you treat bacterial vaginosis?
Oral metronidazole (or cream) or clindamycin cream
142
What investigations would you do a patient you suspect has gonorrhoea or chlamydia? men and women
Endocervcial/vulvovaginal swabs for PCR/NAAT
Pregnancy test
Men: first void urine test
143
What are some complications of chlamydia?
Reactive arthritis: arthritis, urethritis, conjunctivitis
Fitz-Hugh-Curits: hepatic adhesions
PID
Tubal infertity
144
What does chlamydia look like under microscopy compared to gonorrhoea?
Chlamydia: gram -ve rods
Gonorrhea: gram -ve diploccocus
145
How do you treat chlamydia?
Doxycycline for 7 days (CI pregnancy)
| OR azithromycin single dose
146
What are some complications of gonorrhoea?
PID, cervicitis, Bartholinitis, tubal infertility
147
How do you treat gonorrhea?
Ceftriaxone IM + azithromycin PO stat both
148
A lady presents to the GUM clinic complaining of greeny-grey discharge. She says it smells awful and can be frothy. She also has significant vulval itching and pain. What is the likely diagnosis and treatment?
Trichomonas vaginalis- protozoan infection
| Oral metranidazole
149
In trichomonas vaginalis- what would you see on examination of cervix and what would you see on microscopy?
Cervix: strawberry lesions
Microscopy: protozoa- motile flagellates
150
What is the most common cause of genital warts?
HPV 6 and 11
151
What is the treatment for genital warts?
Phodophyllotoxin cream or imiquimod cream. Or cryotherapy
152
What causes herpes?
Herpes simplex virus 1 and 2
153
What symptoms may a patient get with herpes?
Small painful vesicles on genitals, lymphadenopathy, gingovostomatitis, dysuria
154
How do you investigate and treat herpes?
Ix: viral swabs of ulcers/vesicles for PCR
Tx: acyclovir PO
155
How would management of herpes change in a pregnant lady?
Aciclovir still given PO
Can have normal birth if no active lesions/symptoms at term
Only C-section: if developed herpes in 3rd trimester
156
What is the cause of syphillis?
Treponoma pallidum
157
What are the symptoms of syphillis- primary, secondary and tertiary?
Primary: painless ulcer- chancre
Secondary: rash, flu like symptoms, warty genital growths
Tertiary: years later- neurosyphilis, cardiovascular syphillis
158
What investigations and treatment will you do in a patient with suspected syphillis?
Ix: antibodies for treponema eg. treponema enzyme immunosassay
Tx: IM benzathine ben pen
159
What system of nerves are involved in voiding urine? PNS or SNS?
Parasympathetic (relax to pee), S2,3,4 - pelvic splanchnic
160
What system of nerves are involved in keeping urine in? PNS or SNS?
Sympathetic (constrict detrusor): T10, T11, T12, L1, L2 - hypogastric nerve
161
What system of nerves innervate external sphincter to provide voluntary control over micturition?
Somatic: S2,3,4- pudendal nerve
162
What are some causes of stress incontinence?
```
Due to urethral sphincter weakness
Pregnancy + vaginal delivery
Instrumental delivery
Obesity
Post-menopausal
Previous hysterectomy
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163
An overweight patient comes in to see you because she is struggling with incontinence. She says it's only when she is coughing or sneezing. She has had 3 previous vaginal deliveries, one of which required forceps. What is the first line treatment options you are going to tell her
1. Lose weight, stop smoking, chronic causes- constipation, chronic cough.
2. Pelvic floor exercises for at least 3m
164
An overweight patient comes in to see you because she is struggling with incontinence. She says it's only when she is coughing or sneezing. She has had 3 previous vaginal deliveries, one of which required forceps. She has tried pelvic floor exercises for 6 months and has lost a lot of weight with no success. What is the next treatment you will offer?
Medication- pseudoephedrine or surgery- mesh tapes, intraurethral bulking agents
Duloxetine no longer first line.
165
What is the cause of urge incontinence?
Detrusor overactivity - idiopathic or secondary to pelvic surgery
166
What is the best investigation for urge incontinence?
Urodynamic studies show involuntary detrusor contractions
167
What are the treatment options for urge incontinence? What can you try in post-menopausal women?
1. Bladder training - 6w minimm
2. Oxybutinin (anticholinergic SE)
3. Bot tox to relax detrusor
4. Sacral/tibial nerve stimulation
Post-menopausal women: oestrogen intravaginally- to help with vaginal atrophy
168
How does the COCP work? (3)
1. Acts on HPO axis to decrease FSH, LH so stops ovulation
2. Thickens cervical mucus to prevent sperm penetration
3. Decreased endometrial receptivity to implant
169
What are the advantages and disadvantages of COCP?
Adv: very effective, decreased risk of endometrial and ovarian cancer, decreased risk of PID
Disadv: increased risk of DVT, stroke, MI, breast/cervcial cancer, migraines
170
How does the POP work? (2)
1. Thickens cervical mucus
| 2. Makes endometrium unsuitable for implantation
171
What are the advantages and disadvantages of POP?
Adv: Easy to use, fewer CV than COCP, fewer CI
Disadv: vaginal spotting/amenorrhea, weight gain
172
How does the POI- Depot injection work? (1)
1. Suppresses ovulation mainly. Also thickens mucus.
173
What are the advantages and disadvantages of POI-depot injection?
Adv: easy to use/don't have to remember pill, good for breastfeeding, amenorrhea is common- can be useful for heavy periods/painful
Disadv: not rapidly reversible eg. trying for baby, small decrease in bone density, weight gain
174
How does the Progesterone implant work? (1)
Suppresses ovulation. Also thickens mucus.
175
What are the advantages and disadvantages of prog implant?
Adv: very effective immediately, lasts long term, convenient, decreases menstrual problems
Disadv: irregular bleeding initially, weight gain, mood changes
176
How does the IUCD (copper coil) work?
Copper is toxic to sperm
177
What are the advantages and disadvantages of Copper coil?
Adv: long term, highly effective, no hormones, used in emergency
Disadv: insertion can be painful, increased blood loss/pain in periods at start, can perforate wall, can displace
178
How does the IUS (Mirena) work? (2)
Decreases endometrial growth to stop implantation
| Thickens cervical mucus
179
What are the advantages and disadvantages of IUS?
Adv: very effective, quickly reversible, decreases blood loss and dysmenorrhea, decreased risk of PID (v copper coil)
Disadv: insertion unpleasant, device can perforate uterus wall, can displace, menstrual irregularities, weight gain
