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Phase 3A medicine > Gynae FC from PPT > Flashcards

Gynae FC from PPT Flashcards

1
Q

which cell type produces oestrogen in the menstrual cycle

A

granulosa cells

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2
Q

which hormone surge acts to cause ovulation

A

LH

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3
Q

which hormone drops to cause the bleeding in the menstrual cycle and where is it produced

A
  • drop in progesterone levels cause bleeding
  • progesterone produced by the corpus luteum - corpus luteum degenerates, it stops producing progesterone, which is when the lining of the womb is shed
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4
Q

which medication can be used to postpone a period - when on holiday

A

noresthisterone - take 3 a day from 3 days before period is due and stop taking when bleeding acceptable

  • or take 2 packets of COCP back to back
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5
Q

what is the definition of primary amenorrhoea

A
  • failure to menstruate by the age of 16
  • or failure to menstruate by the age of 14 in someone with no secondary sexual characteristics
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6
Q

what are 5 causes of primary amenorrhoea

A
  1. Turner’s syndrome
  2. GU malformation - imperforate hymen
  3. hypothalamic failure - exercise, stress, anorexia
  4. constituional delay
  5. Kallmann’s syndrome
  6. sarcoidosis
  7. hyperprolactinaemia
  8. gonadal dysgenisi
  9. Swyer syndrome
  10. late onset CAH
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7
Q

what is the definition of secondary amenorrhoea

A
  • absence of periods for ≥ 6 months
  • in someone who is not pregnant
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8
Q

what are 5 causes of secondary amenorrhoea

A
  1. marathon runenrs
  2. PCOS
  3. premature ovarian failure
  4. iatrogenic
  5. pregnancy
  6. Sheehan’s syndrome
  7. Asherman’s syndrome
  8. hyperthyroidism
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9
Q

what biochemical findings would be present in someone with premature ovarian failure

A
  1. hypergonadotrophism
  2. hypooestrogenism
  3. raised FSH
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10
Q

how would you investigate primary amenorrhoea

A
  1. karyotype
  2. USS
  3. full history
  4. bloods - oestrogen, progesterone, Lh, FSH, testosterone
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11
Q

how would you investigate secondary amenorrhoea

A

full history - rule out exercise
pregnancy test
TFT
FSH and LH
mid luteal progesterone
prolactin
free androgen

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12
Q

how would you treat primary amenorrhoea

A
  • history incl family histiry
  • examination
  • treat cause - surgery, oestrogen, pituitary tumour = surgery/chemo
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13
Q

how is secondary amenorrhoea treated

A
  1. cyclic progesterone
  2. bromocriptine - treat hyperprolactinaemia
  3. GnRH replacement - if cause hypothalamic failure
  4. thyroid replacement
  5. treat underlying cause
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14
Q

what is the triad of PCOS

A

Rotterdam criteria (2/3 must be present)

  1. 12 cysts on the ovary OR an ovary >10ml
  2. signs of clinical (excess hair) or biochemcial (blood test) raised testosterone/hyperandrogenism
  3. oligo or amenorrhoea
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15
Q

how does PCOS normally present

A
  • oligomenorrhoea
  • hirsutism
  • infertility
  • associated with obesity, metabolic syndrome, T2DM, sleep apnoea
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16
Q

what investigations would you expect do for someone with PCOS

A

serum testosterone/free androgen
thyroid function
prolactin
sex hormone binding globulin
test for diabetes
USS

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17
Q

what are some long term complications of PCOS

A

gestational diabetes
T2DM
CVD
endometrial cancer

NO increased risk of ovarian or breast cancer

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18
Q

what are some differentials for PCOS

A

thyroid dysfunction
hyperprolactinaemia
CAH
androgen secreting tumours
Cushing’s syndrome

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19
Q

how is PCOS treated

A

weight loss
smoking cessation
find and treat - T2DM, HTN, dyslipidaemia and OSA

clomifene - induces ovulation
metformin
ovarian drilling - fertility
COCP w/ w/drawal bleeds
hair removal cream

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20
Q

define menorrhagia

A

heavy menstrual bleeding that occurs at expected intervals of the menstrual cycle and interferes with QoL

no measurable quantity of blood

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21
Q

what is the name for menorrhagia with no identifiable underlying cause

A

dysfunctional uterine bleeding

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22
Q

what are some causes of menorrhagia

A

MC - fibroids
bleeding disorder - present at menarche
hypothyroidism
unknown
polyps
adenomyosis
endometriosis
cancer

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23
Q

what sort of questions do you need to ask in a history for menorrhagia

A

flooding
clots
interfere with life/work
pain
symptoms of anaemia
if its always been like this

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24
Q

what investigations for menorrhagia

A

FBC
physical VE
TSH
cervical smear
STI screen
TVUS
endometrial biopsy
hysteroscopy

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25
Q

how do you medically treat menorrhagia

A

reassure
mirena coil - 1st line
tranexamic acid - antifibrinolytic
NSAIDs - mefanamic acid

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26
Q

surgical options for menorrhagia treatment

A

endometrial ablation - ONLY IF COMPLETED FAMILY
uterine artery embolisation
hysterectomy - last resort

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27
Q

define dysmenorrhoea

A

painful periods

+/- N + V

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28
Q

what are some causes of primary and secondary dysmenorrhoea

A

primary - unknown, no underlying physical cause

secondary:
- endometriosis
- adenomyosis
- fibroids
- PID
- cancer

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29
Q

how should dysmenorrhoea be investigated

A

clinical assessment

USS
endometrial biopsy
laparoscopy
STI screen

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30
Q

how is primary dysmenorrhoea treated

A

NSAIDS - mefanemic acid given during menstruation
paracetamol
COCP
smooth muscle anti-spasmodics - hyoscine butylbromide

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31
Q

how is secondary dusmenorrhoea treated

A

NSAIDS - mefanemic acid
paracetamol
treat underlying cause - fibroids
mirena

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32
Q

what is the main diagnosis to rule out when someone presents with post coital bleeding and what are some other causes

A

cervical cancer **

other:
polyps, cervical trauma, cervicitis, vaginitis, chlamydia

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33
Q

what is the main diagnosis to rule out when someone presents with post-menopausal bleeding and what are some other causes

A

endometrial cancer until proven otherwise***

other:
vaginitis, foreign bodies, carcinoma of cervix or vulva, polyps, oestrogen w/drawal

clarify it isn’t rectal bleeding

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34
Q

what is the average age of onset of menopause

A

51

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35
Q

how is menopause diagnosed

A

retrospective diagnosis
after 12 months of amenorrhoea

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36
Q

what are the symptoms of the peri-menopause

A

irregular periods
vasomotor symptoms - hot flushes, night sweats, impact on sleep and mood
mood swings
decreased sexual desire
joint aches and muscle pains
vaginal dryness
headache and dry skin
loss of energy

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37
Q

before what age is menopause deemed premature

A

before the age of 40

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38
Q

what are the long term complications of the menopause

A

osteoporosis (oestrogen inhibits oesteoclasts, so when it drops they become hyperactive)
CVD
dementia

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39
Q

how is the menopause managed

A

lifestyle - reduce risk factors - smoking, heart disease, alcohol, diabetes
hormonal treatments - HRT, vaginal oestrogen
non-hormonal - clonidine, alpha receptor agonist
CBT

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40
Q

what are the benefits and risks of HRT

A

benefits:
- relief of symptoms
- bone mineral density protected
- possibly prevent long term morbidity

risks:
- breast ca
- VTE
- CVD
- stroke

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41
Q

how is the risk of endometrial cancer from HRT reduced

A

progesterone alongside oestrogen replacement

  • stops oestrogen causing excessive proliferation of the endometrium by allowing shedding
  • not necessary if - they have had hysterectomy or have mirena
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42
Q

which route of HRT hives the highest increased risk of DVT and how is it reduced

A

oral HRT
- reduced by giving transdermal patch instead
- transdermal always offered in people with BMI >30

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43
Q

how is the risk of CVD managed in someone with HRT

A

aim to manage and optimise RF before comencing on HRT - HTN, diabetes, cholesterol etc

  • if someone has prev had a stroke or MI = NOT HAVE HRT AT ALL
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44
Q

what are the different preparation of HRT available

A

pessary
cream applied with applicator for local vaginal symptoms - bleeding, pain, UTI
patch
oral tablet

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45
Q

what are some indications for a transdermal HRT patch

A

patient choice
gastric upset - malabsorption like Crohn’s
increased risk of VTE

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46
Q

what are some common side effects of transdermal HRT patch

A

skin irritation

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47
Q

what is the difference between the hormone levels in HRT and OCP

A

COCP give supraphysiological dose of oestrogen

HRT only gives a physiological dose of oestrogen - body used to this

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48
Q

what is the definition of premature ovarian failure

A

when periods stop <40 years of age

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49
Q

what are the causes of premature ovarian failure

A

idiopathic
iatrogenic - chemo, radio, surgery

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50
Q

how does premature ovarian failure present

A

infertility
amenorrhoea

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51
Q

what are the diagnostic criteria for premature ovarian failure

A

age <40
FSH > 25 in 2 samples > 4 weeks apart
plus 4 months of amenorrhoea

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52
Q

how is premature ovarian failure treated

A

oestrogen replacement - HRT, COCP, encourage until 50
androgen replacement - testosterone gel
fertility - donor egg

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53
Q

define miscarriage

A

the loss of pregnancy before 24 weeks gestation

(after 24 = still birth)

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54
Q

what proportions of pregnancies miscarry

A

15-20%
usually in first trimester

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55
Q

what parental ages pose the highest risk of miscarriage

A

maternal age >35
paternal age >40

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56
Q

what are 5 risk factors that increase risk of miscarriage

A
  1. increased maternal age
  2. smoking in pregnancy
  3. alcohol and drugs
  4. high caffeine intake
  5. obesity
  6. infections and food poisoning
  7. medicines like ibuprofen
  8. health conditions - thyroid, severe HTN
  9. cervical incompetency
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57
Q

what factors are not associated with miscarriage but some people believe them to be

A

heavy lifting
bumping tummy
having sex
ait travel
being stressed

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58
Q

what are 5 common causes for one-off miscarriages

A
  1. unknown
  2. chromosomal abnormalities
  3. abnormal fetal development
  4. maternal illness
  5. infection
  6. trauma
  7. cervical weakness
  8. chronic maternal disease (SLE)
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59
Q

what is the definition of recurrent miscarriage

A

the loss of >3 consecutive pregnancies before 24 weeks with the same biological father

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60
Q

what are 3 causes of recurrent miscarriage

A

antiphospholipid syndrome
uterine abnormalities
thrombophilia - Factor V leiden, protein C or protein S deficiency
parental chromosomal abnormality - unbalanced Robertsonian translocation
infection - BV associated with 2nd trimester loss

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61
Q

what are the signs and symptoms of a threatened miscarriage

A

mild:
- mild abdo pain
- mild vaginal bleeding

CERVICAL OS IS CLOSED

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62
Q

what are the signs and symptoms of an inevitable miscarriage

A

severe abdo pain
vaginal bleeding
CERVICAL OS IS OPEN
can get a finger in the os

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63
Q

what are some other classifications of miscarriage

A

incomplete miscarriage - most of the products have already been passed but process still happening

missed miscarriage - fetus dies and remain in utero, os is closed, may be completeley asymptomatic - confirmed by USS

pregnancy of uncertain viability - small sac with no visible heart beat - rescan 10-14 days

complete - os closed, empty uterus

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64
Q

how is a miscarriage managed

A

A-E appraoch to bleeding
epectant management (conservative)

inevitable and incomplete miscarriage - misoprostol or surgical evac

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65
Q

what are the 3 main causes of PV bleeding in early pregnancy

A

ectopic pregnancy
miscarriage
molar pregnancy

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66
Q

what is the definition of an ectopic pregnancy

A

implantation of a fertilised ovum outside the uterine cavity

97% occur in fallopian tubes

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67
Q

what are 5 risk factors for ectopic pregnancies

A

1, damage to tubes - PID or surgery
2. previous ectopic
3. endometriosis
4. copper coil
5. IVF
6. smoking
7. past infection of tubes or appendicitis

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68
Q

what are some features of ectopic pregnancy

A

EXAM - LMP 8 weeks ago

vaginal bleeding
pain - generalised abdo or confined to an iliac fossa
shoulder tip pain from haemoperitoneum

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69
Q

how would you investigate someone with a suspected ectopic pregnancy

A

USS - intrauterine, fetal heart beat

serial HCG measurements

pelvic exam - cervical excitation/motion tenderness on speculum

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70
Q

how should an ectopic pregnancy be managed

A

A-E for bleeding

surgical - salpingectomy (only if one fallopian still viable) if not - salpingotomy

medical - methotrexate if BHCG is low

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71
Q

what are some clinical features of a molar pregnancy

A

vaginal bleeding
pain
uterus larger than it should be for dates
very very high BHCG
clinical hyperthyroidism
severe morning sickness

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72
Q

how is molar pregnancy managed

A

removal by suction

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73
Q

what is lichen sclerosus and how is it treated

A

not an STI
creates patchy white thin skin around vulval area
possibly autoimmune

observe if no response to treatment - can be pre-malignant

topical steroid cream or topical tacrolimus

kids - 50% resolve by menarche

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74
Q

what is the pre-malignant stage of cervical cancer that can be picked up in screening

A

cervical intra-epithelial neoplasia

pre-invasive
60% regress to normal w/in 2 years
many develop squamous carcinoma of cervix

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75
Q

what should be done in an abnormal smear

A

refer to colposcopy
if abnormal cytology or HPV +ve

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76
Q

when are women offered cervical screening

A

sexually active women agedd 25-64

every 3 years from 25-50

every 5 years from 50-64

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77
Q

what proportion of cervical abnormalities are picked up by screening

A

95%

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78
Q

what are some risk factors for CIN

A

HPV infection
multiple partners
smoking
immune compromisation

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79
Q

how is CIN managed

A

HPV vaccine
colposcopy - further asses abnormal smear
large loop excision of transformation zone

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80
Q

what is the cell type usually seen in cervical cancer

A

squamous cell carcinoma

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81
Q

whats staging tool is used to stage cervical cancer

A

FIGO stagiing - 1/2/3/4

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82
Q

what is stage 1 cervical cancer

A

confined to cervix

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83
Q

what is stage 2 cervical cancer

A

spread into top part of vagina

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84
Q

what is stage 3 cervical cancer

A

spread into other nearby organs such as the ureter

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85
Q

what is stage 4 cervical cancer

A

distant mets

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86
Q

what are some risk factors for cervical cancer

A

HPV infection
early stage intercourse (<16)
STIs
cigarette smoking - HPV persistence
previous CIN/abnormal smear
multiparity
history of other genital tract neoplasia

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87
Q

what are the harmful forms of HPV most associated with cervical cancer

A

HPV 16 and 18

88
Q

which oncoproteins do these HPV subtypes contain and why does this cause cancer

A

contain E6 and E7 oncoproteins

  • E6 - prevents p53 tumour suppressor gene working
    -E7 attacks retinoblastoma tumour suppressor gene

leads to overstimulation of growth of the cells of the cervix

89
Q

what are the symptoms of cervical cancer

A

often asymptomatic and caught with smear
POST COITAL BLEEDING
PMB
water vaginal discharge

advanced:
- heavy vaginal bleeding
ureteric obstruction
weight loss
bowel disturbance
vesico-vaginal fistula
pain

90
Q

how do you investigate someone with suspected cervical cancer

A

history - last smear and result
physical exam - VE and speculum
punch biopsy for histology
CT abdo and pelvis - stage
MRI pelvis - identify and stage lymph nodes

91
Q

how is cervical cancer treated

A

LARGE LOOP EXCISION OF THE TRANSFORMATION ZONE

  • knife cone biopsy +/- pelvic lymph nodes
  • simple hysterectomy
  • cervicetomy/tracelestomy
  • radiacl hysterectomy and pelvic lymph nodes
  • chemo/rafio if too large for surgery (impacts fertility)
92
Q

which histological cell types is usually seen in endometrial cancer

A

adenocarcinoma

93
Q

what are the different stages of endometrial cancer

A

staged with FIGO

stage 1 - confined to endometrium and uterus
stage 2 - grown into cervix
stage 3 - into ovaries, vagina and surroudning lymph nodes
stage 4 - distant spread

94
Q

who is more at risk of endometrial cancer

A

post-menopausal women

95
Q

what causes endometrial cancer

A

unopposed oestrogen

  • obesity
  • early menarche
  • late menarche
  • mulliparity
  • PCOS
  • lynch syndrome
  • HRT
96
Q

what are some risk factors for endometrial cancer

A

obesity - adipose tissue released oestrogen

post-menopause - loss of progesterone to unopposed oestrogebn

97
Q

what are some protective factors against endometrial cancer

A

parity - high progesterone and low oestrogen
combined COCP

98
Q

how does endometrial cancer present

A

post-menopausal bleeding

pre-menopausal - heavy/irregular periods, PV discharge, pyrometra

99
Q

what investigations should be done for someone presenting with suspected endometrial cancer

A

transvaginal USS
endometrial biopsy
hysterectomy
MRI

100
Q

how is endometrial cancer treated

A

surgery - total abdo hysterectomy +/- lymph nodes
radiotherapy - adjuvant
progesterone therapy
good prognosis - 5 year survival for stage 1 = 80%

101
Q

what histological cell type would be seen in vulval cancer and what causes it

A

squamous cell

younger women - HPV
older women - lichen slerosus

102
Q

how does vulval cancer present

A

vulval itching
vulval soreness
persistent lump
bleeding
pain on passing urine
past history of VIN or lichen slerosus

103
Q

what cell type is mainly seen in ovarian cancer

A

epithelial cell tumours

other:
granulosa, cell (teratomas) or secondary - upper GI cancers

104
Q

what are some causes of ovarian cancer

A

gene mutation - BRCA 1 and 2, HNPCC (lynch)

ovulation - more you do = higher risk (early menarche, late menopause, nullparity, never taken pill)

105
Q

what are the main risk factors for ovarian cancer

A

nulliparity
early menarche and/or late menopause
family history - genes

106
Q

what are some protective factors against ovarian cancer

A

pregnancy
breastfeeding
COCP
tubal ligation (prevents ovulation)

107
Q

how does ovarian cancer present

A

bloating/IBS like symptoms
abdo pain/discomfort
change in bowel habit

urinary frequency - bladder pressure
bowel obstruction
asymptomatic until late

108
Q

how do you investigate ovarian cancer

A

Ca125 levels
transabdo USS
whether they are pre or post menopause

combine USS, menopause status and Ca125 levels to determine malignancy index

109
Q

what are the USS findings suggestive of ovarian malignancy

A
  1. bilateral
  2. multiocular
  3. ascites
  4. solid areas
  5. mets

one point scored for each

110
Q

what score on the risk of malignancy index warrants a referral to gynae

A

250 or above

111
Q

how is ovarian cancer treated

A

surgery
chemo
biologics

holistically

112
Q

define endometriosis

A

presence of endometrial tissue outside the uterus

113
Q

what ares some sites that endometriosis can occur and what symptoms can this cause

A

pouch of douglas - rectal bleeding during period

lungs or pharynx - coughing up blood during period

nose - nosebleeds during period

umbilicus

points of previous scarring - gets big and painful when on period (appendix scar)

endometrioma - bleeding into ovaries

?lacrimal glands, bloody tears?

114
Q

what are the 3 theories of how endometriosis develops

A
  1. sampson’s - retrograde menstruation
  2. meyer’s - metaplasia of mesothelial cells
  3. Halban’s - via the blood or lymphatic system
115
Q

what are the symptoms of endometriosis

A

PAIN
SUB-FERTILITY

heavy bleeding
bleeding from other places during pregnancy

116
Q

what are the features of the pain in endometriosis

A

worse 2-3 days before period
gets better after period
cyclical pain
deep dyspareunia
dysuria

pain on defecation - pouch of Douglas involvement

improves when pregnant - low oestrogen

117
Q

why does endometriosis cause sub-fertility

A

areas of endometriosis release cytokines and harmful chemicals which can damage areas of reproductive tract

damage can cause - reduced fallopian tube motility, scarring, bleeding, toxicity to oocyte, adhesions and ovarian dysfunction

118
Q

what is the main differential for endometriosis

A

adenomyosis - areas of endometrial tissue are localised to myometrium

119
Q

what is the gold standard diagnosis for endometriosis

A

laparoscopy

120
Q

what are the 2 generic approaches to treatment for endometriosis

A
  1. abolish cyclicity
  2. invoke glandular atrophy
  3. in addition - pain releif - mefenamic acid, paracetamol
121
Q

what are some treatment options for endometriosis that work by abolishing cyclicity

A

COCP - triphasing - young women who don’t want pregnancy

GnRH agonists - induced menopause, reversible, need HRT also

122
Q

what are some endometriosis treatments which work by invoking glandular atrophy

A

use of progesterone
- POP - stops bleeding, can = PMS Sx
- Depot provera
- mirena

*don’t want pregnancy

123
Q

how can endometriosis be treated in ladies who wish to get pregnant

A

ablation - burning away of endometriotic tissue

excision - cutting away of endometriotic tissue

124
Q

what are some surgical options for endometriosis in a woman who has completed their family

A

oophorectomy - no ovaries => no oestrogen => no cycle => no endometriosis

hysterectomy

low dose HRT after to help menopause symptoms

125
Q

what is adenomyosis and who is it most commonly seen in

A

excess endometrial tissue in the myometrium

older women who have had lots of children

126
Q

what causes adenomyosis

A

unknown

127
Q

how does adenomyosis present

A

cyclic pain - worse when period starts

can last for 2 weeks after period stops (longer pain with endometriosis)

dysmenorrhoea
dyspareunia

128
Q

what is the gold standard diagnosis for adenomyosis

A

MRI scan

129
Q

how is adenomyosis treated

A

often hysterectomy - completed family

130
Q

what are fibroids

A

benign smooth muscle tumours of the uterus - uterine leiomyomas

very common (20% of reproductive age)

131
Q

what causes fibroids

A

unknown

oestrogen dependent - shrink after menopause

associated with mutation in gene for fumarate hydratase

132
Q

what are the risk factors for fibroids

A

increasing age (until menopause)

afro-carribean

family history

early puberty

obesity

133
Q

how do fibroids present

A

menorrhagia
dysmenorrhoea
fertility problems
miscarriage
pain
mass
pressure symptoms - frequency, varicose veins
bloating/constipation - IBS Sx

may be incidentally found and asx

134
Q

how are fibroids investigated

A

abdominal examination
bimanual pelvic examination
TVUS
Trans abdo USS
hysteroscopy

135
Q

what would be felt on pelvic exam in someone with fibroids

A

bulky, NON-tender uterus

136
Q

how are fibroids managed

A

<3cm - IUS, tranexamic acid, NSAIDs (mefenamic acid) or COCP

> 3cm - trans-cervical resection of fibroids, myomectomy, hysterectomy, uterine artery embolisation

137
Q

what are endometrial polyps

A

benign growths of the endometrium

some can be cancerous or pre-cancerous

138
Q

what are some risk factors for endometrial polyps

A

benign peri or post menopausal

HTN

obesity

taking tamoxifen (breast cancer chemo)

139
Q

how do polyps present

A

irregular menstrual bleeding
menorrhagia
inter-menstrual bleeding
post-menopausal bleeding

infertility in younger Pts - compete with fetus for space

140
Q

what is the main differential for polyps

A

fibroids

141
Q

how are polyps investigated

A

USS - trans vaginal and abdo

hysteroscopy

endometrial biopsy

142
Q

how are polyps treated

A

can be left alone - monitor and biopsy if malignancy concern

GnRH analogues (oestrogen sensitive)

polypectomy - hysteroscopically

hysterectomy

143
Q

what are the main types of benign ovarian tumours

A
  1. functional cysts
  2. mucinous cystadenomas
  3. seroud cystadenomas
  4. dermoid cyst ‘mature cystic teratoma’
144
Q

features of functional cysts, mucinous cystademonas, serous cystadenomas, dermoid cysts

A
  1. FC - enlarged persisten follicle, resolves after 2/3 cycles, may cause pain or peritonitis if bleed, COCP inhibits
  2. mucinous cystademonas - massive, unilateral, solid, common, 15% malignant, mucus ascites if rupture
  3. serous cystadenomas - MC epithelial tumour, bilateraly, 25% malignant
  4. dermoid cyst - contain skin/hair/teeth, MC cysts in <30 y/o, torsion most likely
145
Q

how do benign ovarian tumours present

A

ASx - incidental findings

chronic pain - dull ache, dyspareunia, cyclical pain, pressure effects

acute pain - unilateral - if bleeding, torsion, or rupture

irregular vaginal bleeding

hormonal effects

abdo swelling or mass - ascites may = malignancy or rupture mucinous cystadenoma

146
Q

how should benign ovarian tumours be investigated

A

FBC
Ca125 (if >40)
> 40 other tumour markers - AFP, CEA, HCG
TVUD, TAUS
consider MRI, mass >7
MRI and CT for staging malignancy

147
Q

how should benign ovarian tumours be treated

A

A-E

pre-menopausal - preserve fertility and exclude malignancy. no malignancy = leave, if cyst >5cm or Sx - laparscopic ovarian cystectomy

post-menopausal - calculate risk of malignancy index, leave alone if <5cm, watch and wait, remove if >5cm or Sx - bilateral oophorectomy

148
Q

what are some risk factors for ovarian torsion

A

pregnancy
malformations
tumours
previous surgery

149
Q

how does ovarian torsion prevent

A

acute unilateral abdo pain (often during exercise)

radiates - back, thigh, pelvis

N + V

fever = necrotic

150
Q

how do you investigate ovarian torison

A

rule out ectopic - pregnancy test

USS with colour doppler = GS

151
Q

how is ovarian torsion managed

A

laparoscopy

plus analgesia and fluid resus

152
Q

how does a ruptured ovarian cyst present

A

acute abdo pain (often during exercise)

PV bleed

N+V

circulatory collapse +/- weakness, syncope

fever/sepsis

153
Q

how should a ruptured ovarian cyst be investigated

A

rule out ectopic - urinary HCG

USS

laparoscopy - GS

154
Q

how should someone with a ruptured ovarian cyst be managed

A

A-E

stable - analgesia and supportive (fluid, painkiller)

unstable/bleeding - surgery - laparotomy may be needed

155
Q

what is pelvic inflammatory disease

A

a chronic infection of the upper genital tract

156
Q

what causes PID

A

STI - 25% chlamydia and gonorrhoea

uterine instrumentation - hysteroscopy, insertion of IUCD, TOP

post-partum (retained tissue)

descend from other organs - appendicitis

157
Q

what are the risk factors for PID

A

age <25

history of STI

new and multiple sexual partners

158
Q

what are some protective factors against PID

A

barrier contraception

Mirena

COCP

159
Q

what are the symptoms of PID

A

lower abdo pain
may be unilateral or bi
may be constant or intermittent - but normally chronic
deep dyspareunia
vaginal discharge
IMB
PCB
dysmenorrhoea
fever

160
Q

how would you investigate someone with suspected PID

A

history
exam - VE and speculum
Full STI screen - high and low vaginal swabs, endocervical swabs, urine sample
TVUS if abscess suspected
FBC, CRP, culture - acutely unwell

161
Q

what are some signs you’d see on examination in someone with PID

A

cervical excitation (motion tenderness) on VE

vaginal discharge
adnexal tenderness

162
Q

what are some complications of PID

A

tubo-ovarian abscess
Fitz-Hugh Curtis syndrome - liver capsule inflammation
recurrent PID
ectopic pregnancy
subfertility from tubal blockage

163
Q

how is PID managed

A

contact tracing
ABx - ceftriaxone, dosycycline, metronidazole, azithromycin
very unwell - admit for ABx

164
Q

what ASx screening is offered in GUM clinics

A

female - self take vulvo-vaginal swab (gonorrhoea and chlamydia) NAAT, bloods for HIV and STIs

hetero male - first void urine, bloods

MSM - first void urine (chlamydia and gonorrhoea), pharyngeal swab, rectal swabs, bloods - STI, HIV, Hep B

165
Q

what tests are available at GUM for people with symptoms

A

vulvovaginal swab
high vaginal swab
urethral swabs for men
first void urine for men
dipstick urinalysis (pus cells)
bloods
rectal and pharyngeal swabs and cultures for MSM

166
Q

what are some symptoms that female with STI problems will present with

A

vaginal discharge
vulval discomfort/soreness, itching and pain
superficial dyspareunia
chronic pelvic pain
vulval lumps and ulcers
IMP
PCB

167
Q

what are some symptoms of STIs that males may present with

A

pain/burning during micturition
pain/discomfort in the urethra
urerthral discharge
genital ulcers, sores or blisters
syphillis - primary shankra
genital lumps
rash on penis/genital area
testicular pain/swelling - orchiditis

168
Q

what is the importance of contact tracing

A

prevent re-infection of index patient

identify and treat asymptomatic infected individuals as a public health measure - prevent disease from spreading further

169
Q

what is the definition of incontinence

A

involuntary leakage of urine at a time which is not socially acceptable

170
Q

what proprotion of women experience urinary incontinece

A

20% of adult women

171
Q

what are the different subtypes of incontinence

A

overactive bladder (detrusor overactivity) - involuntary bladder contractions

stress incontinence - sphincter weakness

neurlogical - nerve damage/MS

overflow incontinence - retention/prostate enlargement

functional

mixed incontinence

172
Q

what are some risk factors for urinary incontinence

A

age
increasing parity
obesity
smoking
previous surgery

173
Q

what are some causes of urinary incontinence

A

nerve damage from previous surgery

childbirth

diabetes - neuropathy of bladder control, polyuria, polydipsia, renal impairment, nephropathy

recurrent UTI - frequency

174
Q

what is the clincial presentation of an overactive bladder

A

urgency
urge incontinence
frequency
nocturia
nocturnal enuresis
‘key in door’ and ‘hand wash’
intercourse

175
Q

how does stress incontinence present

A

involuntary leakage when:

cough
laugh
lifting
exercise
movement

176
Q

what is the first line investigation for incontinence

A

HISTORY
bladder diary (Freq volume chart) - when, how much and fluid intake

177
Q

what other investigations can you do for incontinence

A

MSU
residual urine measuements - in/out catheter
ePAQ questionnaire
urodynamics
cystogram

178
Q

what conservative/lifestyle measures can help someone with incontinence

A

weigth loss
smoking cessation
reduced caffeine intake
avoidance of straining and constipation

179
Q

what is the first line treatment for overactive bladder

A

bladder training
can also use pads to absorb any leaked urine

180
Q

what is the first line treatment for stress incontinence

A

pelvic floor exercises

181
Q

what medications can be used in overactive bladder

A

anticholinergics:
- oxybutin
- solifenacin
- parasympathetic - pissing - decreasing need to urinate

mirabegron
- beta-3-adrenergic receptor agonist (sympathetic storage)
- relaxes detrusor and increases bladder capacity

botox injection - paralyses detrusor to stop it from being overactive

182
Q

what are the side effects of anti-cholinergics

A

dry mouth
blurred vision
drowsiness
constipation
tachycardia

183
Q

what are some surgical options for managing overactive bladder

A

augmentation cystoplasty
indwelling catheters
bypass (urostomy)

184
Q

what are the treatment options for stress incontinence

A

60% cured by PT and conservative measures - pelvic floor exercise, pads, pessaries, skin care, odor control

surgery - sling, suspension - supports urethra to increase urethral resistance

185
Q

what are the different types of prolapse can occur

A

cystocele - anterior of vagina and bladder = frequency and dysuria

rectocele - lower posterior vagina and rectum = finger in vagina to aid defecation

enterocele - upper posterior wall of vagina and intestine

uterine prolapse - protrusion of uterus down vagina

vault prolapse - total hysterectomy

186
Q

what is the pathological reason behind prolapse and what are the risk factors

A

cause - weakness of ligaments and pelvic floor

risk factors - age, obesity, childbirth, previous surgery

187
Q

what are the symptoms of prolapse

A

something coming down - dragging
pain
lump
discomfort
incontinence
sexual dysfunction
unable to go toilet

188
Q

how should a prolapse be investigated

A

speculum

189
Q

how is a prolapse managed

A

conservative - reassure, pelvic floor exercise

pessary - ring, shelf, gelhorn

surgery if all else fails

190
Q

what is the definition of subfertility

A

failure to conceive after 1 year of regular unprotected sex (2-3 times a week)

191
Q

what are the causes of infertility

A

unexplained - 25%
male factors - 30%
ovulatory disorders - 25%
tubal damage - 20%
uterine disorders - 10%

in 40% factors due to both partners

192
Q

what are some risk factors for subfertiity

A

increasing age
extremes of weight

193
Q

what are some ovarian factors in females that cause sub-fertility

A

PCOS
pituitary tumours
Sheehan’s syndrome
hyperprolactinaemia
premature ovarian failure
Turner’s syndrome
hypothyroidism
previous chemo or radio

194
Q

what are some tubal/uterine causes of subfertility in women

A

PID
sterilisation
Asherman’s syndrome (adhesions)
fibroids
polyps
endometriosis
uterine malformations

195
Q

how should sub-fertility be investigated

A

see both partners
ovulatory tests - mid luteal progesterone levels
ovarian reserve testing
semen analysis - count, motility, morphology

other for women: prolactin, thyroid, free androgen, USS of uterus and tubes, karyotype

196
Q

what are some causes of male infertility

A

use of anabolic steroids
high prolactin
CF
history of undescenced testes
childhood measles
working with a lot of heat - chefs

197
Q

how should male infertility be investigated

A

semen analysis - sperm coutn, motility, morphology

imaging - vasogram, USS, urology

CF screen

karyotype

198
Q

how should sub-fertility be managed

A

keep trying for a year
inform effect of age
intercourse 2-3x a week, folic acid, smear, rubella, stop smoking, BMI normal, no alcohol or drugs

199
Q

what are the criteria for an early referral to specialist sub-fertility centres

A

female:
age >35
menstrual disorder
previous abdo/pelvic surgery
PID

male:
previous genital patho or urogenital surgery
previous STI
systemic illness

200
Q

what are some lifestyle measures to optimise male fertility

A

avoid extreme heat near genitals
looser pants
stop smoking
moderate alcohol
avoid harmful chemical in occupation
diet/supplements - folic acid
weigth optimisation

201
Q

what are some treatments for male infertility

A

mild - intrauterin insemination
moderate - IVF
severe - ICSI (intracytoplasmic sperm injection)

azoospermia - surgical sperm recover or donor

hormonal - bromocriptine

ensure no anabolic steroids

202
Q

infertility treatment for women

A

induce ovulation
treat tubal disease
IVF
endometriosis - surgical ablation/excision

203
Q

what are some methods of assissted conception

A

ovulation induction
stimulated intrauterine insemination
IVF
ICSI
donor insemination
donor egg
donor embryo
host surrogacy

204
Q

what are some risks/complications of IVF

A

multiple pregnancy
miscarriage
ectopic
ovarian hyper stimulation syndrome
bleeding and infection at egg collection

205
Q

what are some patient factors which affect the success of IVF

A

age
cause of infertility
previous pregnancies - increase
duration of infertility
number of previous attempts
medical conditions
environmental factors

206
Q

what is the definition of FGM

A

all procedures involving partial or total removal of female external genitalia or injury to female organs for non-medical reasons

involves damaging or removing normal, healthy female genital tissue and hence interferes with function

207
Q

what are the 4 different types of FGM

A

clitoridectomy

excision (clitoris, labia minora +/- majora)

infibulation - narrowing orifice with stitches

all other harmful procedures to female genitalia

208
Q

what are some ‘reasons’ given for FGM in certain cultures

A

brings status and respect
preserves virginity
part of being a woman
rite of passage
upholding family honour
cleanses and purifies a girl
fulfils a religious need
makes girl acceptable for marriage
sense of belonging to community

209
Q

what are some dangers of FGM

A

blood borne virus - non sterile equipment

haemorrhage

infection and sepsis

210
Q

how many women in UK (age 15-49) have been subject to FGM

A

103,000

211
Q

what are legal standings on FGM in UK

A

illegal to do any sort of FGM in UK

illegal to assist in carrying out ( including booking flights, taking them or knowing etc)

if a child is seen with it must report to police

212
Q

what are some gynae complications of FGM

A

sexual dysfunction with anorgasmia
chronic pain
keloid scar formation
dysmenorrhoea
haematocolpos - period blood backs up
urinary outflow obstruction
recurrent UTI
difficulty conceiving - sex can be hard
PTSD

213
Q
A
214
Q

what are the responsibilities of doctors with regards to FGM

A

report all cases of FGM in medical notes (if adult)

call police if child

ensure families know FGM is illegal so they don’t keep doing it to children

215
Q
A

Phase 3A medicine (5 decks)

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