Gynae Corrections Flashcards by Esme Cosham

Management of lichen sclerosis?

Potent topical corticosteroid e.g. dermovate

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Purpose of treatment of lichen sclerosis?

Prevent complications e.g. scarring and narrowing of vaginal opening

Reduces risk of vulval cancer

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Ovarian cancer can present with symptoms of a bowel obstruction.

What are some symptoms?

Abdo pain
Constipation
Nausea
Bilious vomiting

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What vomiting occurs with a bowel obstruction?

Bilious vomiting

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1st line investigation in suspected ovarian cancer?

Ca-125

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Management option for advanced ovarian cancer?

Surgery aiming to remove all macroscopic disease - can be done before or after chemotherapy.

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Most common type of ovarian cancer?

Serous cystadenocarcinoma

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What is management for cervical cancers that are still contained within the cervix with aim of sparing fertility?

Radical trachelectomy - removal of cervix, upper vagina and pelvic lymph nodes

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If missed two COCP pills in week 3 of the pack, what should you do?

Finish the pills in the current pack and start the new pack the next day (i.e. omit the pill-free interval)

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Can levonorgestrel and ulipristal (emergency contraception) be used more than once in the same cycle?

Yes

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How long before major surgery or surgery to the legs or surgery which involves prolonged immobilisation to the lower limb should the COCP be stopped?

4 weeks

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What happens if two COCP pills are missed between days 8-14 of the cycle?

a) is emergency contraception required?
b) is barrier contraception required?

As long as the previous 7 days of COCP have been taken correctly, no emergency contraception is needed

BUT barrier contraception required for the next 7 days

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What is the main method of action of the implant?

Inhibits ovulation

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Is ciprofloxacin a P450 inducer or inhibitor?

Inhibitor

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How is POP affected by P450 enzyme inducers or inhibitors?

Inducers –> should use barrier contraception during and for 4 weeks after cessation of treatment as can reduce levels of POP

Inhibitors –> do NOT affect effectiveness of oral POPs

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When can non-hormonal methods of contraception be stopped;
a) in woman <50
b) in women >=50

a) Stop contraception after 2 years of amenorrhoea

b) Stop contraception after 1 year of amenorrhoea

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At what age should the COCP be stopped?

At 50 - swap to non-hormonal or progestogen-only method

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At what age should the Depo-Provera (injection) be stopped?

Can be continued to 50 years

After 50 - switch to either a non-hormonal method and stop after 2 years of amenorrhoea OR switch to a progestogen-only method

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At what age should the implant, POP and IUS (i.e. Mirena) be stopped?

Can be continued beyond 50 years

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Which type of contraception can be continued >50 y/o?

Implant, POP and IUS (i.e. Mirena)

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If a patient vomits within 3 hours of taking levonorgestrel as emergency contraception, what should you do?

Take another dose ASAP

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What is the most effective method of emergency contraception?

Copper IUD

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If a woman presents >5 days after unprotected sex, when may an IUD still be fitted?

Up to 5 days after the likely ovulation date (whatever is later)

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Is the copper coil affected by BMI?

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At what BMI should the standard dose of levonorgestrel (1.5mg) be doubled?

BMI >26 (or weight >70kg)

Before trying for a baby, how long should methotrexate be stopped?

At least 6 months (and use effective contraception in this time) Both men AND women using methotrexate need to use effective contraception for at least 6 months after treatment

Which gynaecological condition is a risk factor for ecoptic pregnancy?

Endometriosis - as slows ovum's passage to uterus

If not breastfeeding, how soon after birth can the COCP be prescribed?

3 weeks due to increased VTE risk post-partum

With the COCP, if one pill is missed at any time in the cycle, what should you do?

1) take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day 2) no additional contraceptive protection needed

When taking the COCP, if 2 or more pills are missed, what should you do?

Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day The women should use condoms or abstain from sex until she has taken pills for 7 days in a row.

When taking the COCP, if 2 or more pills are missed in week 1, what should you do?

emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1

When taking the COCP, if 2 or more pills are missed in week 2 (days 8-14), what should you do?

after seven consecutive days of taking the COC there is no need for emergency contraception

When taking the COCP, if 2 or more pills are missed in week 3 (days 15-121), what should you do?

Should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

When can the COCP be given during breastfeeding?

If 6 weeks postpartum

Which POP has a 12 hour missed pill window?

Desogestrel

How does ulipristal affect hormonal contraception?

Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period

When switching from an IUD to COCP, when is no additional contraception needed?

if removed day 1-5 of cycle

For patients assigned female at birth receiving testosterone therapy, which contraceptive methods are not recommended?

contraceptives containing oestrogen as they can antagonize the effect of testosterone therapy

Is the nexplanon implant affected by enzyme inducers?

Yes

Is the Depo-Provera injection affected by enzyme inducers?

What lobe does HSV encephalitis typically affect?

Temporal lobes Note - questions may give the result of imaging or describe temporal lobe signs e.g. aphasia, rising feeling in stomach (aura) before seizure.

Features of HSV encephalitis?

- fever - headache - seizures - vomiting - psychiatric symptoms - focal symptoms e.g. aphasia

Which HSV is responsible for 95% of cases of HSV encephalitis in adults?

HSV-1

Management of HSV encephalitis?

IV aciclovir

What is a key investigation in cases of erythema nodosum?

CXR as sarcoidosis and tuberculosis are 2 important causes of erythema nodosum

Give some causes of erythema nodosum

- TB - sarcoidosis - IBD - pregnancy

What is recommended for recurrent vaginal candidiasis?

Oral fluconazole

What HPV strains cause genital warts?

6 & 11

What infection is implicated in the pathogenesis of Burkitt's lymphoma?

EBV infection

Microscopy findings in Burkitt's lymphoma?

'starry sky' appearance: lymphocyte sheets interspersed with macrophages containing dead apoptotic tumour cells

Triad of features of disseminated gonococcal infection?

1) tenosynovitis 2) migratory polyarthritis 3) dermatitis this is known as 'arthritis-dermatitis'

Diarrhoea is common in patients with HIV. What is the most common infective cause of diarrhoea in HIV patients?

Cryptosporidium (a protozoa)

What may a modified Ziehl-Neelsen stain (acid-fast stain) of the stool in cryptosporidium infection reveal?

characteristic red cysts of Cryptosporidium

What is the mainstay of treatment of Cryptosporidium diarrhoea?

Supportive

What is the most common presenting symptom of syphilis?

a chancre, a painless ulcer at the site of sexual contact

What should all men presenting with ED have checked?

Their morning testosterone

What does Pneumocystis pneumonia (PCP) cause on exercise?

Desaturation

CXR findings in PCP?

- patchy opacities - bilateral hilar enlargement

What is 1st line treatment of PCP?

Co-trimoxazole (trimethoprim + sulfamethoxazole)

What test should all patients with TB be offered?

HIV test: as TB is classified as one of the 'AIDS-defining' illnesses

1st line management of trichomonas vaginalis?

Oral metronidazole

1st line investigation to look for source of infection in discitis due to Staphylococcus?

Echocardiogram (to look for endocarditis)

What is the LARC of choice in young people?

Progesterone only implant (Nexplanon)

Sex under what age should automatically trigger child protection measures?

children under the age of 13 years - considered unable to consent for sexual intercourse

What timeframe differs emergency contraception vs abortion?

<5 days is post-coital contraception (i.e. emergency contraception)

How long is effective contraception required for after methotrexate treatment in men or women?

During treatment and for at least 6 months afterwards

What type of childhood epilepsy syndrome is classically associated with seizures in the morning/following sleep deprivation?

Juvenile myoclonic epilepsy - generalised tonic-clonic seizures (GTCS) and myoclonic episodes

Which contraceptive method (aside from coils) is not affected by enzyme inducers/inhibitors?

depot

What investigations may be performed in menorrhagia?

1) FBC 2) Consider transvaginal US if symptoms suggest structural or histological abnormality e.g. IMB, PCB, pelvic pain

1st line for menorrhagia in patients who do not require contraception?

Either mefenamic acid or tranexamic acid (both started on 1st day of period)

1st line for menorrhagia in patients who do require contraception?

Mirena coil

What is PMS?

Premenstrual syndrome (PMS) describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.

What phase of the menstrual cycle do women experience PMS?

Luteal phase

1st line management of mild symptoms of PMS?

Lifestyle: - sleep, exercise, smoking and alcohol - regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates

1st line management of moderate symptoms of PMS?

Consider COCP (with drospirenone)

1st line management of severe symptoms of PMS?

Consider SSRI - this may be taken continuously or just during the luteal phase (days 15-28)

What is UKMEC for COCP for patients in wheelchair?

UKMEC 3

What is the UKMEC for positive antiphospholipid antibodies for the COCP?

UKMEC 4

What cancers does the COCP increase and decrease the risk of?

Increase - breast & cervical Decrease - ovarian & endometrial

What is a rare but recognised side effect of lamotrigine?

Stevens-Johnson syndrome --> warn patients to look out for a rash

What drug can lead to false negative results on the urea breath test?

Abx used to treat H. pylori e.g. amoxicillin It is recommended that patients should not have taken any antibiotics within four weeks prior to the test to ensure accurate results.

What is Medroxyprogesterone acetate?

A progestogen

If a woman does not plan to breastfeed her baby, how soon after delivery can she start the COCP?

3 weeks

Why should COCP not be used in the first 21 days post-partum?

Due to increased VTE risk

How soon after surgery can the COCP be restarted?

2 weeks after

For an ectopic pregnancy requiring surgical management, what is the 1st line option for women with no other risk factors for infertility?

Salpingectomy

What is the most common cause of pruritus vulvae?

irritant contact dermatitis (e.g. latex condoms, lubricants)

Investigation pathway in post-menopausal bleeding?

1) If ≥55 y/o with PMB --> refer under 2 week wait 2) 1st line investigation --> transvaginal US to assess endometrial thickness 3) If endometrial thickness is ≥4 mm --> hysteroscopy with endometrial biopsy 4) If endometrial thickness is <4 mm --> high negative predictive value

What endometrial thickness is a high negative predictive value for endometrial cancer in PMB?

<4mm

If a cervical smear sample is 'anadequate', what is the next step?

Repeat the sample in 3 months.

If two consecutive cervical smear samples are inadequate, what is next step?

Refer for colposcopy

Management of FGM in girls <18?

Report to police

When should admission to hospital be considered for N&V in pregnancy?

1) ketonuria and/or 2) weight loss despite use of oral anitemetics

What does added progesterone in HRT increase the risk of?

Breast cancer

What management option can women with stage IA cervical cancer be considered for if they wish to maintain their fertility?

Cone biopsy with negative margins. Close follow up required.

In early pregnancy, what type of ovarian cysts are common?

Corpus luteum cysts. These usually resolve from the second trimester on wards.

What lifestyle factor is associated with a decreased incidence of hyperemesis?

Smoking

What are the 1st and 2nd line antiemetics for N&V in pregnancy?

1st line --> cyclizine, promethazine, prochlorperazine or chlorpromazine 2nd line --> metoclopramide or domperidone

What caution is there surrounding metoclopramide for N&V in pregnancy?

Metoclopramide should not be used for >5 days as may cause EPSEs

What fluids are women who have been admitted with hyperemesis gravidarum generally given?

IV normal saline with added potassium (as hypokalaemia is common).

What condition should you consider: female aged >30y/o with dysmenorrhoea, menorrhagia and an enlarged & boggy uterus?

Adenomyosis

What is required for diagnosis of premature ovarian insufficiency?

2x raised FSH levels taken 4 weeks apart

What score can be used to classify the severity of N&V in pregnancy?

The Pregnancy-Unique Quantification of Emesis (PUQE) score

What is the most common cause of PID in the UK?

Chlamydia