Gynae and Breast

Question 1

Heavy menstrual bleeding differentials

Answer 1

Dysfunctional uterine bleeding if no cause is found.
Iatrogenic (e.g. IUD), psychosomatic disturbance.
Fibroids, endometrial hyperplasia, cancer, endometriosis, PID.
Hypothyroidism, blood clotting disorders.

Question 2

Heavy menstrual bleedings red flags

Answer 2

Pelvic pain
Intermenstrual bleeding
Post coital bleeding

Question 3

Menorrhagia Ix

Answer 3

FBC, COAG, TFT

USS Pelvis or Transvaginal

Hysteroscopy - via Gynae referral

Question 4

Focused Hx for Gynae

Answer 4

last menstrual period, cycle, post-coital bleeding, intermenstrual
bleeding, discharge, smears, parity and operations.

Question 5

Menorrhagia Mx

Answer 5

1st - Mirena Coil (levonorgestrel intrauterine system LNG IUS) (if no fibroids (<3cm) or uterine abnormality)

Non hormonal - Tranexamic acid (SE: headache, GI upset)

Hormonal - IUS, COCP, cyclical norethisterone

Surgical - ablation, hysterectomy

Short term relief - Consider Medroxyprogesterone (Provera) > Norethisterone - as lower VTE risk.

Question 6

Polycystic ovary syndrome Fx

Answer 6

Two of three:
- hyperandrogenism - hirsutism, acne, biochemical tests (high testosterone)
- Oligo or amenorrhea
- ovarian cysts on USS

Question 7

PCOS differentials

Answer 7

Hypogonadotropic hypogonadism - Low LH and FSH

Premature ovarian failure - High LH and FSH

Hypothyroid - High TSH and low T4

Hyperprolactinaemia

Question 8

PCOS Mx

Answer 8

Oligomenorrhea - cyclical progesterone or COCP - induce withdrawal bleed to prevent endometrial hyperplasia

Acne - co-cyprindiol

Hirsutism - Bleach and electrolysis.
Efornithine cream (SE skin irritation)

Question 9

PCOS complications

Answer 9

Infertility
CVD
Diabetes
High cholesterol
Obesity

Question 10

Ovarian Ca Ix
- When to request Ca 125

Answer 10

• Refer all below for Ca 125
  >50 AND (one of following)
  bloating
  abdominal/ pelvic pain
  urinary frequency/ urgency
  symptoms more than 12x /month
• If Ca 125 POS - for USS Abdomen pelvis (2WW)
• If USS Pos - Gynae refer 2WW

Question 11

PMB Ix

Answer 11

> 55yo = 2WW

<55yo = consider referral/ USS first

Question 12

Gynaecomastia DDx

Answer 12

Idiopathic

Physiological - In teens and elderly.

Infection - Mumps.

Tumours - Lung (there may be an increased β-hCG) and testicular.

Systemic disease - Liver, thyrotoxicosis.

Iatrogenic - Drugs, steroids, PPIs, TCAs.

Hormonal - Hyperprolactinaemia, hypogonadism.

Alcohol

Question 13

HRT Risks

Answer 13

VTE - transdermal preparations are better than oral

Stroke - Oral oestrogen increased risk of stroke

Breast Ca - Combined preparations are increased risk of breast ca

Question 14

HRT Mx

Answer 14

Hysterectomy? - Oestrogen only

Still having periods (perimenopausal) - cyclical HRT

Stopped periods >1 year (post menopausal) - continuous combined HRT

FU 3 then 6 monthly
SE: Skin irritation from patches, leg cramps, breast pain

Question 15

Contraindications to topical oestrogen

Answer 15

breast ca
undiagnosed vaginal bleeding

Question 16

Endometriosis Fx

Answer 16

Cyclical pelvic pain
Pre/ post menstrual spotting
dysmenorrhea, menorrhagia, dyspareunia

complications: infertility

Question 17

Endometriosis Ix

Answer 17

Laparoscopy or MRI

Refer to Gynae if suspected due to uncertainty of diagnosis