Gynae and Contraception Flashcards
Cervical Cancer
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+
Cervical screening
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)
Endometrial Cancer
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
Endometrial Hyperplasia
Abnormal endometrial proliferation, 5% develop into cancer
Simple and no atypia -> high dose progestogens (IUS), repeat sample at 3m
Atypia -> hysterectomy
Ovarian Cancer
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
Vulval Cancer
90% SCC, mostly labia majora
RF - >65rys, IS, HPV, lichen sclerosis, VIN
= lump, ulcer, bleeding, itchy, inguinal nodes
OHSS
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
Trichomonas vaginalis
Flagellated protozoa, STI
= offensive yellow-green discharge, strawberry cervix, vulvovaginitis, urethritis in men
Inv - pH > 4.5
-> PO metronidazole 5-7d (or single dose)
Emergency Contracpetion
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
COCP
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
COCP: Missed Pill
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
Implant
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
POP
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
Injectable Contraception
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
IUD and IUS
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
Bacterial Vaginosis
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
Adenomyosis
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
Amenorrhoea
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
Causes of Amenorrhoea
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)
Cervical Ectropion
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
Dysmenorrhoea
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
Endometriosis
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
Fibroid Degeneration
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
Menorrhagia
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
HRT: Side Effects
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
Infertility
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
Menopause
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
Miscarriage
<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
Types of Ovarian Cysts
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
Ovarian Torsion
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
PID
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
PCOS
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)
PCOS: Management
-> weight loss, COCP (regulate period, hirsutism), top eflornithine 2nd for hirsutism, clomifene for fertility, may add metformin
PMB Causes
Vaginal atrophy - most common, thin/ dry/ inflamed walls -> topical oestrogen
HRT
Trauma
Endometrial hyperplasia
Endometrial, cervical, ovarian, vulval cancer
Premature ovarian Insufficiency
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
Premenstrual syndrome
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
Abortion
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
Urinary Incontinence
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
Urogenital Prolapse
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)
Uterine Fibroids
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
Candidiasis
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)
Chlamydia
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
Mycoplasma Genitalium
Common cause of non-gonococcal urethritis
Same treatment and investigation as chlamydia
-> test for macrolide resistance, do test of cure
Contraception >40yrs
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
Contraception transgender or non binary
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
Contraception young people
Nexplanon best
Avoid Depo due to v bone mineral density
IUS/ IUD are UKMEC2 <20yrs
Postpartum Contraception
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
Ectopic Pregnancy
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
Ectopic: Management
-> 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)
