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Gynae and Contraception Flashcards

1
Q

Cervical Cancer

A

80% SCC, 20% adeno, highest rate 25-29yrs

RF - HPV 16/18/33, smoking, HIV, COCP, ^parity, early sex, many partners, low SES, FHx

= 50% <45yrs, abnormal PV bleeding, discharge, pelvic pain, pain in sex

FIGO Staging: 1) confined to cervix, 2) beyond cervix but not to pelvic wall 3) to pelvic wall 4) beyond pelvis or involves bladder/ rectum

-> hysterectomy +/- node clearance, cone biopsy to maintain fertility, radio and chemo for 1b+

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2
Q

Cervical screening

A

25-49yrs: 3 yearly, 50-64yrs: 5 yearly

Pregnancy - delay to 3m postpartum
Virgin - can opt out

hrHPV tested first
- negative; return to normal recall
- positive; cytology

Cytology
- normal; test HPV again at 12mth, still high risk (normal cyt) test again at 24mth, colposcopy if still positive
- abnormal; colposcopy

Inadequate sample
- repeat at 3m, still inadequate then colposcopy

-> large loop excision of transformation zone, TOC pathway (repeat sample 6m after treat CIN)

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3
Q

Endometrial Cancer

A

80% adeno, oestrogen-dependent

RF - (^oes) nulliparity, early menarche, late menopause, unopposed oes, obesity, DM, PCOS, tamoxifen, HNPCC
*Protective: mp, COCP, smoking

= post-menopausal bleeding

Inv - 2WW any 55yr+ with PMB, TV US (normal thickness <4mm), hysteroscopy with biopsy

-> total abdominal hysterectomy with bilateral salpingo-oophorectomy, post-op radio

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4
Q

Endometrial Hyperplasia

A

Abnormal endometrial proliferation, 5% develop into cancer

Simple and no atypia -> high dose progestogens (IUS), repeat sample at 3m

Atypia -> hysterectomy

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5
Q

Ovarian Cancer

A

RF - FHx (BRCA1/2), age, ^ovulations (early menarche, late menopause, np), obesity, smoking, clomifene
*Protective: COCP, pregnancy, breastfeeding

= 60yrs, bloating, satiety, weight loss, pelvic pain, mass, LUTS, diarrhea, hip/ groin pain (obturator nerve compression)

Inv - risk of malignancy index (menopausal status, US, Ca125), pelvic US, CT, diagnostic laparotomy

-> surgery and platinum chemo

^Ca125 in endometriosis, fibroids, benign cysts

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6
Q

Vulval Cancer

A

90% SCC, mostly labia majora

RF - >65rys, IS, HPV, lichen sclerosis, VIN

= lump, ulcer, bleeding, itchy, inguinal nodes

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7
Q

OHSS

A

Multiple luteinised cysts in ovaries after fertility treatment, ^VEGF, ^membrane permeability and loss of intravascular fluid

RF - gonadotropin, HCG, rarely clomifene

Mild: pain, bloating
Moderate - n+v, ascites on US
Severe: clinical ascites, v protein, ^Hct, oliguria
Critical: ARDS, tense ascites, anuria, VTE

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8
Q

Trichomonas vaginalis

A

Flagellated protozoa, STI

= offensive yellow-green discharge, strawberry cervix, vulvovaginitis, urethritis in men

Inv - pH > 4.5

-> PO metronidazole 5-7d (or single dose)

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9
Q

Emergency Contracpetion

A

Levonorgestrel
-Stops ovulation and implantation
-Take <72hrs of UPSI (1.5mg, double if BMI > 26)
-If vomit <3hrs must take again
-Can start hormonal contraception straight after

Ulipristal
-Inhibits ovulation
- Take <120hrs of UPSI (30mg)
-Start hormonal contraception 5days after
-Caution in severe asthma, don’t BF for 1wk

Copper IUD
- Best, offer to all women
- Take <5d of UPSI, if later then may fit <5d post-ovulation date

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10
Q

COCP

A

Started in first 5 days of cycle = immediate protection (If not, 7 days of condoms)

MOA - inhibits ovulation

+fertility returns when stopped, v risk of ovarian and endometrial cancer, v CRC, v PID, lighter period

-blood clots, heart attacks, strokes, breast and cervical cancer, affected by Abx (rifampicin)

*sex in pill free period is only safe if start next pack on time

Contra
UKMEC 3 - BMI>35, >35yrs + smoking <15, VTE in first degree <45yrs, HTN, immobility, BRCA, gallbladder disease, DM for >20yrs
UKMEC 4 - >35yrs + smoking >15, migraine with aura, VTE, IHD, BF <6wks postpartum, major surgery, APLS, current breast cancer

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11
Q

COCP: Missed Pill

A

Missed if 24 hours late

2) 1) take last pill asap, no barrier needed

2+) take last pill asap, barrier until 7 in a row
Week 1 - emergency contraception if sex in pill free/ first week
Week 2 - no additional need
Week 3 - finish pills in pack and start next, omit pill free interval

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12
Q

Implant

A

Nexplanon, subdermal implant, lasts 3yrs, most effective contraception

MOA - inhibits ovulation, thicken mucus

Inserted in first 5 days of cycle = immediate protection (If not, 7 days of condoms)

SE: irregular/ heavy bleeding (? +COCP), headache, nausea, breast pain, reduced by antiepileptic/ rifampicin

Contra
UKMEC 3 - IHD, vaginal bleeding, past breast cancer, severe liver disease
UKMEC 4 - current breast cancer

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13
Q

POP

A

Same time every day no pill free period

MOA - thickens cervical mucus

Started in first 5 days of cycle = immediate protection (If not, 2 days of condoms)

+antibiotics don’t affect it

-irregular bleeding, d+v, breast cancer, ovarian cysts

Contra - severe liver disease, breast cancer, preg

Missed pill
<3hrs late (12 for desogestrel): cont as normal
>3hrs late: take it asap, 2 days barrier

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14
Q

Injectable Contraception

A

Depo provera, medroxyprogesterone acetate, IM 12wkly (<14 without barrier)

MOA - inhibits ovulation

SE: cannot be reversed once given, delay in fertility <12m, irregular bleeding, weight gain, OP

Contra - current breast cancer

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15
Q

IUD and IUS

A

IUD
- v sperm motility and survival
- works immediately
- last 5 or 10yrs

IUS
- v endometrial proliferation, thickens mucus
- reliable after 7 days
- Mirena 5yrs (4 as HRT), jaydess 3yrs

SE: heavier longer periods (IUD), uterine perf (^if BF), ectopic, PID in first 20d, expulsion

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16
Q

Bacterial Vaginosis

A

Overgrowth of anaerobes e.g., Gardnerella Vaginalis, fall in lactobacilli (produce lactic acid) so pH rises

= fishy, thin white discharge

Inv - pH > 4.5, microscopy (clue cells), whiff test

-> symptomatic only, PO metro (5-7d or single) or topical metro/ clindamycin

Comp - prem, v BW, CA if pregnant

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17
Q

Adenomyosis

A

Endometrial tissue within the myometrium

RF - multiparous, later in reproductive years

= painful heavy periods, large boggy uterus

Inv - TV US

-> GnRH agonists, uterine artery embolisation, hysterectomy definitive, TX for heavy bleeding

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18
Q

Amenorrhoea

A

Primary: no period by 15yrs (normal 2nd characteristics) or 13yrs (no 2nd)

Secondary: cessation of periods for 3-6m if previously regular, or 6-12m if irregular

Inv - excl pregnancy, FBC, U&E, TFTs, coeliac screen, gonadotrophins (low = hypothlamic, raised = ovarian problem/ gonadal dysgenesis), prolactin, androgen, oestrodiol

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19
Q

Causes of Amenorrhoea

A

Primary:
Gonadal dysgenesis (Turner’s)
Imperforate hymen
Anorexia (functional hypothalamic)
Congenital adrenal hyperplasia

Secondary:
Excessive exercise/ stress (hypothalamic)
PCOS
High prolactin, high thyroid
Premature ovarian failure
Sheehan’s
Ashermann’s (IU adhesions)

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20
Q

Cervical Ectropion

A

Larger area of columnar epithelium on the ectocervix (transformation zone, squamous - columnar)

RF - ^oestrogen e.g., COCP, pregnancy

= discharge, post-coital bleeding

-> ablation (cold coag) if troublesome symptoms

21
Q

Dysmenorrhoea

A

Excessive pain during periods

Primary
50% of women, no pathology
= pain alongside period, suprapubic cramping
-> NSAIDs (mefenamic, ibuprofen), COCP 2nd

Secondary
Develops years after menarche
Causes - endometriosis, adeno, PIDs, IUD, fibroid
= pain starts 3-4 days before period
-> refer to gynae

22
Q

Endometriosis

A

Growth of ectopic endometrial tissue outside the uterine cavity

Causes - unknown, retrograde flow or embryonic cells outside of uterus during development?

= chronic pelvic pain, 2nd dysmenorrhea, subfertility, deep pain in sex, LUTS, painful stool
*Exam; tender nodular posterior fornix, reduced organ mobility

Inv - laparoscopy

-> NSAIDs +/- paracetamol, COCP or injection 2nd, refer to hosp, GnRH analogues (pseudo-menopause), lap excision and adhesiolysis if want to conceive

23
Q

Fibroid Degeneration

A

Uterine fibroids are sensitive to oestrogen so grow during pregnancy, eventually outgrow their blood supply

= T1/2, low grade fever, pain, vomiting

-> rest, pain relief, resolves <1wk

24
Q

Menorrhagia

A

No set amount, what is excessive for her

Causes - dysfunctional uterine bleeding (50%), anovulatory cycles, fibroids, hypothyroid, IUD, PIDs, vWD

Inv - all get FBC, TV US

-> if requires contraception use IUS, not then mefenamic or tranexamic acid

25
Q

HRT: Side Effects

A

Small dose of oestrogen (+ progesterone if uterus) to alleviate menopausal symptoms

SE: nausea, tender breasts, fluid retention, weight gain, stroke, IHD (if >10yrs since menopause)

Progestogen = VTE, breast cancer (normal 5yrs after stopping)
Oestrogen = endometrial cancer

Contra - breast cancer, any oestrogen-sensitive cancer, bleeding, endometrial hyperplasia

26
Q

Infertility

A

1 in 7 couples, 84% should conceive in 1yr

Inv - semen analysis, day 21/ 7d before period serum progesterone (normal >30, repeat 16-30, refer <16)

-> folic acid, BMI 20-25, sex every 2-3d

27
Q

Menopause

A

51yrs average, symptoms for 5 years, due to low oestrogen

= change in period length, hot flush, night swets, dryness, atrophy, urinary frequency, anxiety, depression, STM issue, OP, IHD

-> contraception for 12m after LMP if >50yrs or 24m <50yrs, exercise and weight loss, sleep hygiene, HRT

28
Q

Miscarriage

A

<24wks, usually 6-9wks

Threatened: painless bleed, os closed
Inevitable: heavy bleeding, pain, os open

Missed: dead fetus in sac, light bleed, os closed
-> expect, if not then PO mifepristone, PO/PV misoprostol at 48hrs

Incomplete: not expelled, pain, bleeding, os open
-> expect, if not then single dose misoprostol

29
Q

Types of Ovarian Cysts

A

Physiological (functional) Cysts
- Follicular: most common, dominant follicle didn’t rupture, regress in mths
- Corpus luteum: hasn’t broken down, fills with blood or fluid

Benign Germ Cell Tumour
- Dermoid cyst (teratoma): most common benign tumour <30yrs, hair/ teeth (Rotikansky protuberance), ^torsion

Benign Epithelial Tumour
- Serous cystadenoma
- Mucinous cystadenoma: large, pseudomyxoma peritonei

Inv - biopsy any complex (multi-loculated) or post-menopausal to excl. cancer

30
Q

Ovarian Torsion

A

Torsion of the ovary around its supporting ligaments, may compromise blood supply

RF - ovarian mass, reproductive age, pregnancy, OHSS

= sudden severe abdo pain, n+v, distress, fever, adnexial tenderness

Inv - US (whirlpool sign)

-> laparoscopy

31
Q

PID

A

Infection and inflammation of the female pelvic organs

Causes - ascending infection from ectocervix e.g., chlamydia, gonorrhea, mycoplasma

= lower abdo pain, fever, deep pain in sex, discharge, cervical excitation

Inv - exclude pregnancy, high swab (often neg), STI screen

-> low threshold, IM ceftriaxone + 14d doxy + metro, or ofloxacin + metro, consider removing IUD

Comp - Fitz Hugh Curtis (perihepatitis, RUQ pain), infertility, ectopic, chronic pain

32
Q

PCOS

A

High insulin and high LH

= subfertility, oligomenorrhea, hirsutism, acne, acanthosis nigricans, obesity

Inv - ^LH:FSH, TFTs, prolactin, T, v SHBG, IGT, pelvic US

Rotterdam criteria (2 of 3)
- infrequent or anovulation
- clinical or biochemical signs of high androgens
- PCO on US (12+ follicles)

33
Q

PCOS: Management

A

-> weight loss, COCP (regulate period, hirsutism), top eflornithine 2nd for hirsutism, clomifene for fertility, may add metformin

34
Q

PMB Causes

A

Vaginal atrophy - most common, thin/ dry/ inflamed walls -> topical oestrogen
HRT
Trauma
Endometrial hyperplasia
Endometrial, cervical, ovarian, vulval cancer

35
Q

Premature ovarian Insufficiency

A

Onset of menopause <40yrs

Causes - idiopathic (FHx), radio, chemo, bilateral oophorectomy, mumps, AI disorders

Inv - ^FSH (2 samples, 4-6wks apart), ^LH, v oestradiol

-> HRT or COCP until 51yrs

36
Q

Premenstrual syndrome

A

Emotional and physical symptoms during the luteal phase

= anxiety, stress, fatigue, mood swings, bloating, breast pain

-> lifestyle (regular, frequent, balanced meals, complex carbs), COCP, SSRI if severe

37
Q

Abortion

A

Two registered practitioners must sign, one
performs, <24wks only (unless risk)

Medical (<10wks, at home)
-> mifepristone (anti progestogen), misoprostol (PG) 48hrs after, multi-level pregnancy test in 2wks (hCG)

Surgical
-> Manual/ electric vacuum aspiration, dilatation and evacuation (may prime cervix with medical)

*Anti-D if RhD negative have abortion >10wks

38
Q

Urinary Incontinence

A

RF - age, prev pregnancy/ childbirth, fat, hysterectomy, FHx

Overactive bladder/ urge - detrusor overactivity
-> 6wk bladder retraining, oxybutynin/ tolterodine/ darifenacin

Stress - leaking when laughing or coughing
-> 3m pelvic floor training, retropubic mid-urethral tape, duloxetine (SNRI) if no surgery

Mixed - both of the above
Overflow - due to bladder outlet obstruction

39
Q

Urogenital Prolapse

A

Descent of pelvic organs causing protrusion on the vaginal walls

Cystocele, uterine, rectocele etc.

RF - age, weight, mp, obesity, spina bifida

= sensation of dragging/ pressure, incontinence, frequency, urgency

-> treat symptomatic, weight loss, pelvic floor exercises, ring pessary, surgery (colporrhaphy, hysterectomy)

40
Q

Uterine Fibroids

A

Benign smooth muscle tumours of the uterus

RF - black, later reproductive years

= lower abdo pain, heavy periods, urinary symptoms, bloating, sub-fertility, polycythaemia

Inv - TV US

-> monitor growth, treat if symptoms, IUS or mefenamic acid for bleeding, GnRH agonist to shrink (menopause symp, v bone density), surgery (myomectomy, hysteroscopic endometrial ablation, hysterectomy), uterine artery embolization

Prog - regress after menopause

41
Q

Candidiasis

A

Thrush, candidia albicans

RF - DM, Abx, steroids, pregnancy, HIV

= cottage cheese discharge, no smell, itchy, red, dysuria

Inv - clinical, high vaginal swab, glucose

-> PO fluconazole single dose, clotrimazole pessary if preg

Recurrent - 4+ in 1yr, check compliance, high swab (M&C), glucose
-> induction-maintenance (PO fluconazole 6m)

42
Q

Chlamydia

A

Most common STI in UK (1 in 10 F), intracellular pathogen, chlamydia trachomatis

Screening open to all 15-24yrs

= aymp, dysuria, cervicitis, urethral discharge (m)

Inv - NAAT to diagnose (urine for M, vulvovaginal swab for F) 2wks post-exposure

-> 7d doxycycline, if pregnant use stat azithromycin/ erythromycin/ amoxicillin, partner notification (past 6mths)

Comp - epididymitis, PID, endometritis, ^ectopic, infertility, reactive arthritis

43
Q

Mycoplasma Genitalium

A

Common cause of non-gonococcal urethritis

Same treatment and investigation as chlamydia

-> test for macrolide resistance, do test of cure

44
Q

Contraception >40yrs

A

Non-hormonal
- stop <50yrs if 2yr no period or >50yrs if 1yr no period

COCP
- UKMEC2 40yrs+
- continue to 50 years then switch to POP or non hormonal

Depo
- UKMEC2 >45yrs
- continue to 50yrs then switch to POP or non hormonal

Implant / POP / IUS
- stop taking at 55yrs or if amenorrhoeic with FSH>30

WOMEN WITH GASTRIC SLEEVE OR BYPASS CANNOT HAVE ORAL METHODS EVER

45
Q

Contraception transgender or non binary

A

If assigned female at birth and have uterus
- Testosterone is not a contraceptive
- Do not use any with oestrogen in (progesterone okay)

Assigned male at birth
- Condoms needed

46
Q

Contraception young people

A

Nexplanon best
Avoid Depo due to v bone mineral density
IUS/ IUD are UKMEC2 <20yrs

47
Q

Postpartum Contraception

A

Need it after day 21

POP - can start at any time
- 2 days barrier if after day 21

COCP - do not use <21d due to VTE, UKMEC4 if BF <6wks, UKMEC2 if BF 6wk-6m
- 7 days barrier after day 21

IUD/S - insert <48hrs or >4wks postpartum

LAM - 98% effective in first 6m if full breastfeeding and no periods

48
Q

Ectopic Pregnancy

A

Implantation of a fertilised ovum outside the uterus, 97% tubal (^ampulla), isthmus most dangerous

RF - tubal damage (PID/ surgery), prev ectopic, endometriosis, POP, IUD, IVF

= 6-8wks, lower abdo pain, dark bleeding, shoulder pain, dizzy, cervical excitation, adnexal mass

Inv - preg test, NO DVE (rupture), hCG>150, TV US

49
Q

Ectopic: Management

A

-> EPAU

Expectant - <35mm, not ruptured, no symptoms, no heartbeat, hCG <1000
-> monitor 48hrs, hCG levels

Medical - <35mm, not ruptured, no sig pain, no heartbeat, hCG <1500
-> methotrexate, must attend follow-up

Surgical - >35mm, rupture, pain, visible heartbeat, hCG >5000
-> salpingectomy, salpingotomy if RF for infertility (1 in 5 unsuccessful)

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