Gynae / GUM Flashcards
Symptoms of candidal vulvovaginitis
Soreness
Itching
Red skin - possible peeling, pustules or papules
White discharge
When to refer candidal vulvovaginitis
Unclear diagnosis
No improvement despite tx
Immunocompromised patient
Systemic tx needed
Tx of candidal vulvovaginitis
first line = Fluconazole capsule 150mg, single dose, orally
If oral treatment unsuitable / CI
Clotrimazole pessary 500mg STAT PV
Which COCP may also help with acne
Dianette - shouldn’t be used only for contraception
Yasmin
What syndrome is caused by 45XO
Turners syndrome - absence of one X chromosome in a female
What is the SRY gene
Sex determining region of the Y chromosome
Clinical features of Turners Syndrome
Female
Short stature
Webbed neck
Wide carrying angle of elbow
Associated medical conditions of Turners Syndrome include
Coarctation of the aorta IBD Sensorineural and conduction deafness Renal anomalies Endocrine dysfunction - autoimmune thyroid disease
What patients have streak ovaries
Turners Syndrome
How does Turners Syndrome get detected
At birth - clinical appearance
Childhood - short stature
Adolescence - delayed puberty
Is pregnancy possible in Turners Syndrome
Yes - usually requires egg donation
What is XY gonadal dysgenesis
XY karyotype but gonads don’t develop in testis
Phenotypically Female
Genotypically Male
Pregnancy may be possible with egg donation
What is 46XY disorder of sex development
Complete androgen insensitivity syndrome.
Testes form due to SRY gene action.
Testes secrete AMH –> regression of Müllerian ducts.
Phenotypically F - F external genitalia - no uterus.
Breast development, minimal public hair.
Short vagina
Genital effects of congenital adrenal hyperplasia
Virilization of F foetus
Enlarged clitoris
Labia fused + scrotal in appearance
What is Mayer-Rokitansky-Kuster-Hauser syndrome
Müllerian agenesis - absent / rudimentary uterus + upper vagina.
Primary amenorrhea after normal pubertal development.
What age defines precocious puberty
Before 8 in F
Before 9 in M
2 categories of precocious puberty
Central (gonadotropin dependent - 75% cause unknown.)
Peripheral (always pathological)
Causes of central precocious puberty
75% unknown
25% due to CNS malformation or brain tumour
Causes of peripheral precocious puberty
Always pathological
Oestrogen secretion - e.g. Hormone producing tumour, exogenous ingestion
Age definition of delayed puberty
No secondary sexual characteristics by age 14
Due to - hypogonadotrophic hypogonadism
- hypergonadotrophic hypogonadism
What causes hypogonadotrophic hypogonadism
Constitutional Anorexia nervosa Excessive exercise Diabetes Renal failure (Pituitary tumour, kalman's syndrome) - rare
What causes hypergonadotrophic hypogonadism
Turner syndrome
XX gonadal dysgenesis
Premature ovarian failure
Following chemo or radio therapy for child cancers.
What does gonadotropin releasing hormone do
Controls pituitary hormone secretion
GnRH secreted in a pulsatile way to stimulate LH and FSH
GnRH at constant high dose reduces LH and FSH secretion.
What are buserelin and goserelin
GnRH agonists
What is the effect of oestrogen on LH
Low oestrogen inhibits LH production.
High oestrogen increases LH production.
Effect of progesterone on LH and FSH
Low progesterone levels increase LH and FSH productions.
High progesterone levels decrease LH and FSH productions.
Causes of heavy menstrual bleeding
Fibroids Endometrial polyps Coagulation disorders PID thyroid disease Drug tx - warfarin Copper coil Endometrial ca Cervical ca
What is the new name for dysfuntional uterine bleeding
Bleeding of endometrial origin
Diagnosis of exclusion
Investigation for heavy menstrual bleeding
FBC - anaemia Coagulation screen Pelvic USS - fibroid, endometrial polyp, cancer Vaginal / endocervical swabs - PID Endometrial biopsy - endometrial cancer TFTs
Management of heavy menstrual bleeding
Mefenamic acid (NSAID) Tranexamic acid COCP Norethisterone - taken from day 6 to 26 Mirena coil GnRH agonists - short term Endometrial ablation Hysterectomy
What is endometrial ablation / how is it done
Day case
Through the vagina and cervix
Hysteroscopy before + after
Full thickness of endometrium abated
Causes of dysmenorrhea
No cause found Endometriosis Adenomyosis PID Cervical stenosis Haematometra
Diagnosis of endometriosis
Laparoscopy
Treatment of endometriosis
COCP (continuously is best)
Mirena
Surgical laser ablation, diathermy or excision
Complication of endometriosis
Adhesions
‘Chocolate’ ovarian cysts = endometriomas
Infertility
What is adenomyosis
Ectopic endometrial tissue within myometrium
Management of dysmenorrhea
NSAIDS - ibruprofen, mefenamic acid COCP Mirena Low fat diet Exercise GnRH anaologues Heat
Causes of dyspareunia
PID Endometriosis Ovarian cysts STIS Thrush / genital skin conditions (superficial dyspareunia) Vaginal atrophy / lack of lubrication UTIs
Define primary amenorrhea
Failure to menstruate by age 16
Define secondary amenorrhea
Absence of menstruation for >6m that isn’t due to pregnancy, lactation or menopause
Causes of secondary amenorrhea
Obesity BMI <18.5 Excessive exercise Severe anxiety Pituitary tumour Chemotherapy Antipsychotic drugs Thyroid overactivity PCOS POI Ashermans syndrome
Causes of primary amenorrhea
Anatomical - cervical stenosis - imperforate hymen - Müllerian agenesis - transverse vaginal septum Hypothalamic-pituitary dysfunction - Anorexia - Chronic illness - excessive exercise - head injury Ovarian failure - Turners syndrome - POF - chemotherapy - pelvic irradiation Hypothyroidism Hyperthyroidism
Investigation of amenorrhea
Pregnancy test Blood - LH, FSH, Testosterone Prolactin level TFT USS of ovaries Hysteroscopy if ashermans / cervical stenosis
Clinical manifestations of PCOS
Menstrual irregularity - oligomenorrhoea / amenorrhea Hirsutism Subfertility Recurrent miscarriage (50%) Obesity High LH insulin resistance Acanthosis nigricans
Diagnosis of PCOS
2+ of:
- amenorrhea / oligomenorrhoea
- hyperandrogenism
- polycystic ovaries on USS
Management of PCOS
COCP Cyclical oral progesterone Metformin Clomiphene Weight reduction Exercise
Management of hirsutism
Eflornithine cream Cyproterone acetate (Dianette) Metformin GnRH analogues Laser / electrolysis
Causes of post menopausal bleeding
Atrophic vaginitis Endometrial polyps Endometrial hyperplasia Endometrial carcinoma Cervical carcinoma
Investigation of post menopausal bleeding
TV USS of endometrial thickness (<3mm)
Endometrial biopsy
Hysteroscopy (+curettage of polyps)
Management of atrophic vaginitis
Topical oestrogen cream Oestrogen pessaries Oestrogen ring pessaries Vaginal moisturisers - daily use Vaginal lubricants for SI
Management of simple or complex endometrial hyperplasia
Oral progesterone
Mirena
Management of atypical endometrial hyperplasia
Total abdominal hysterectomy - risk of progression to malignancy
Management of endometrial cancer
Total abdominal hysterectomy + BSO + washing +/- adjuvant therapy
Management of pre-menstrual syndrome
Stress reduction Exercise Alcohol and caffeine reduction COCP / oestrogen patches / mirena SSRIs CBT GnRH analogues Hysterectomy + BSO
Types of candida species
Candida albicans Candida tropicalis Candida glabrata Candida krusei Candida parasilosis
Common species involved in bacterial vaginosis
Gardnerella vaginalis
Mycoplasma hominis
Bacteroides
Mobilincus
Which STI is a flagellate Protozoan
Trichomonas vaginalis
Symptoms of Trichomonas vaginalis
Vulval soreness + itching
Foul smelling discharge - may be frothy / green
Dysuria
Abdo discomfort
Strawberry cervix (punctate haemorrhages)
Diagnosis of Trichomonas vaginalis
Microscopy of vaginal discharge
and TV NAATs
Treatment of Trichomonas vaginalis
Metronidazole 400mg BD for 5-7 days Or Metronidazole 2 g STAT PO OR PV metronidazole gel (0.75%) OD 5 days OR PV clindamycin cream (2%) OD 7 days Tx both partners
Symptoms of bacterial vaginosis
Malodorous fishy discharge
Assymptomatic carriers
More prominent during menstruation
Cream / grey discharge - commonly adheres to wall of vagina
What do clue cells suggest
Bacterial vaginosis
Clue cell = epithelial cell covered in bacteria
Management of bacterial vaginosis
Metronidazole 400mg BD for 5-7 days Or Metronidazole 2 g STAT PO OR PV metronidazole gel (0.75%) OD 5 days OR PV clindamycin cream (2%) OD 7 days
Problems with bacterial vaginosis in pregnancy
In 1st T can –> second trimester miscarriages or preterm labour
Tx with metronidazole
Which STI is a gram -ve diplococcus
Neisseria gonorrhoea
Symptoms of gonorrhoea
Asymptomatic Increased vaginal discharge Abdo / pelivic pain Dysuria Urethral discharge Proctitis / rectal bleeding Cervical bleeding on contact Cervical excitation
Causes of cervical excitation
Ectopic pregnancy
PID
gonorrhoea
Treatment of gonorrhoea
Monotherapy - ceftriaxone 1g intramuscularly
2019 guidelines
Which STI is an obligate intracellular pathogen
Chlamydia
Symptoms / signs of chlamydia infection
Asymptomatic Vaginal discharge Lower abdo pain Intermenstrual bleeding Cervical discharge Post-coital (contact) bleeding Dysuria Urethral discharge
Complications of chlamydia
PID endometritis salpingitis tubal infertility Ectopic pregnancy Fitz-Hugh-Curtis syndrome =peri-hepatitis Neonatal or adult conjunctivitis Neonatal pneumonia conjunctivitis Sexually acquired reactive arthritis Epididymo-orchitis
Treatment of chlamydia
First line = Doxycycline 100mg oral BD 7d (contraindicated in pregnancy)
Second line = Azithromycin 1g STAT PO, followed by 500mg OD PO 2/7
Alternative regimens:
Erythromycin 500mg BD 10–14 days
Ofloxacin 200mg BD or 400mg OD 7days
What is PID
Inflammation and infection arising from endocervix
Leading to endometritis, salpingitis, oophoritis and pelvic peritonitis.
Often due to chalmydia, gonorrhoea or BV
Symptoms / signs of PID
Abdo / pelvic pain Dyspareunia Pyrexia >38 Heavy bleeding Intermenstrual bleeding Pelvic tenderness and cervical excitation on examination Tubal damage
Outpatient treatment of PID
Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7
When is hospitalisation indicated for PID
Severe infection Adnexal mass ? Abscess Sepsis Poor response to tx Severe pain requiring strong analgesics
Symptoms of herpes simplex
Painful vesicles Ulcerations Urine retention May be asymptomatic systemic symptoms - fever + myalgia (more common with primary HSV)
Treatment of herpes simplex
preferred regimens = Aciclovir 400 mg TDS for 5/7
OR Valaciclovir 500 mg BD 5/7
Alternative regimens:
Aciclovir 200 mg five x day for 5/7
Famciclovir 250 mg TDS for 5/7
What virus causes genital warts
HPV 6 + 11
Treatment of genital warts
Podophyllin - BD application 3 days, followed by 4 days rest, for 4-5 cycles Imiquimod Cryotherapy - liquid nitrogen Hyfrecation / excision (Catephen) (TCA- specialist clinic only) (5-Fluorouracil 5% cream - not routinely advised) (Interferons- expert advice)
What causes Syphillis
Treponema pallidum
Symptoms of primary syphilis
Painless ulcer on vulva / cervix
Englarged groin / inguinal lymph nodes
Symptoms of secondary syphilis
Maculopapular rash on palms and soles
Mucous membrane ulcer
Treatment of early syphilis
Benzathine penicillin G IM 2.4 MU IM single dose
Symptoms of generalised syphilis
Lymphadenopathy
Arthritis
Symptoms of neuro Syphilis
Meningitis
Stroke
Tabes dorsalis
Symptoms of congenital Syphilis
Intrauterine death
Interstitial keratitis
VIII nerve deafness
Abnormal teeth
Symptoms of genital TB
Amenorrhoea
Infertility
Acute / chronic pelvic pain
Frozen pelvis due to adhesions
What does haemophilus ducreyi cause
Chancroid
Symptoms of Chancroid
Painful shallow multiple ulcers
Regional lymphadenopathy + suppuration
What causes granuloma inguinale
Klebsiella granulomatosis
Typical failure rate of COCP per 100 women years
9 %
Typical Failure rate of POP per 100 women years
9%
Failure rate of mirena per 100 women years
0.5%
Failure rate of depo prova per 100 women years
0.1-2%
Typical Failure rate of condom per 100 women years
17-21%
Mechanism of action of COCP
Inhibition of ovulation
Atrophic endometrium
Thickened cervical mucus
Absolute CI to COCP use
0 to <6 weeks postpartum + breastfeeding
0 to <3 weeks postpartum + other VTE risk
Age ≥35 years + 15 cigarettes / day
Hypertension ≥160 / 100
Vascular disease / impaired cardiac function
Hx of DVT / PE / stroke / IHD
Major surgery with prolonged immobilisation
Migraine with aura
Current breast cancer
Viral hepatitis / decompensated cirrhosis / liver tumours
Thrombogenic mutations / Positive antiphospholipid antibodies
SE of COCP
altered mood - no causal relationship with depression Mood swings Headache Loss of libido Nausea percieved weight gain - no causal relationship Bloatedness Breakthrough bleeding Vaginal discharge Breast pain
Benefits of COCP
Lighter less painful periods Regular bleeds Improved pre-menstrual syndrome Reduced risk of PID Protect against ovarian and endometrial cancer
Mechanism of action of progesterone methods
Thickened cervical mucus
Thin endometrium
Common SE of progesterone only methods
Irregular / absent menstrual bleeding
Simple ovarian cysts
Breast tenderness
Acne
Risk of depo provera
Loss of bone mineral density
Weight gain (2-3kg in 1st yr)
Delay in return of fertility
Irregular / absent menstruation
Mechanism of action of copper IUD
Toxic to egg and sperm
SE of copper IUD
Heavier periods
Increased menstrual pain
Increased spotting
Duration of action of depo, implant, mirena, copper coil
Depo = 12 weeks
Implant = 3 years
Mirena = 5 years
Copper coil = 10 years
CI to intrauterine contraception
Current STI PID malignant trophoblastic disease Unexplained vaginal bleeding Endometrial cancer Cervical cancer Malformation of uterus Copper allergy
Techniques to calculate the fertile period
Change in basal body temp
Change in cervical mucus
Track cycle days
Combination of above
Types of emergency contraception
Levonelle
EllaOne
Copper IUD
Early medical termination - drugs used + gestation
Mifepristone oral + misoprostal
4 - 9weeks
Later medical termination - drugs used + gestation
Mifepristone oral + misoprostal pessary every 3-6 hours
+ analgesia
12 - 24weeks
surgical termination - technique used + gestation
Suction 4-6 weeks
Suction under GA 6-14 weeks
Dilation and evacuation 12-24weeks
Possible Complications of termination
Incomplete abortion Endometritis and resultant tubal damage Uterine perforation cervical trauma Psychological SE
Factors decreasing fertility
Increasing age Smoking Less frequent sex Alcohol Obesity NSAIDs Chemotherapy
Presentation of ectopic pregnancy
\+ve pregnancy test Abdo / adnexal pain Vaginal bleeding Cervical excitation fainting
Investigation of ectopic pregnancy
obs - BP, HR, RR, temp Hb Group + save Beta-HCG TVUSS
Management of ectopic pregnancy
IM methotrexate
laparoscopy - salpingectomy / salpingotomy
Define threatened miscarriage
Vaginal bleeding
Os closed
Define inevitable miscarriage
Vaginal bleeding
Os open
Define incomplete miscarriage
Vaginal bleeding
Os open, products of conception in os
Define complete miscarriage
Pain and bleeding resolved
os closed
No retained products on USS
Define missed miscarriage
Fetal pole present on USS - no heart beat
Or Gestational sac present but no fetal pole
No pain or bleeding
Management of miscarriage
Expectant
Medical - misoprostal
Surgical - SMOM
Define cervical ectropion
Benign condition
Columnar epithelium on vaginal aspect of cervix.
Transforms to squamous epithelium
Define nabothian follicle
Mucus filled cyst within the ectocervix - not significant - no tx needed
Causes of cervical ectropion
Puberty
Pill
Pregnancy
Causes of cervical stenosis
Usually iatrogenic
Cervical cone biopsy / LLETZ
Endometrial ablation devices
What is asherman’s syndrome
Endometrial cavity fibrosis and adhesion
What is a uterine fibroid
Benign tumour of uterine smooth muscle = leiomyoma
Risk factors for uterine fibroids
Nulliparity
Obesity
Family history
African origin
Symptoms of uterine fibroids
Pelvic mass
Menstrual disturbance
Pressure symptoms - urinary frequency
Management of fibroids
Conservative Medical tx for heavy menstrual bleeding Uterine artery embolisation Myomectomy Hysterectomy
Cell types of endo and ecto cervix
Endocervix = canal = columnar glandular epithelium Ectocervix = external = squamous epithelium
Symptoms and causes of acute cervicitis
Irritation, mucus/pus discharge Dyspaerunia Post coital bleeding Inter-menstrual bleeding STIs
Cell type of cervical polyp
Endocervical = columnar (glandular) epithelium
symptoms of cervical polyp
Asymptomatic
Intermenstrual bleeding
Post coital bleeding
Rarely >1cm
What is cervical dysplasia
Cervical intraepithelial neoplasia.
Atypical cells in the squamous epithelium
If untreated what % of CIN develop cancer over 10 years
1/3 with CIN II or III
CIN Commonly regresses - can progress to CIN II or III
What age is CIN most common
90% <45yo
Peak incidence 25-29
Aetiology of cervical cancers
HPV 16, 18, 31, and 33 most common.
HPV vaccine is for 16 and 18
Oral contraceptives (all COC, POP, depot)
Smoking
Biggest risk factor for the development of cervical cancer
Non-attendance for cervical screening
Who is invited for cervical screening + how often
25-64
Every 3 years until 50 then 5 yearly until 65.
Annually if HOV +ve
Describe colposcopy
Speculum ex + microscope magnification 10-20x
Acetic acid stain + iodine
+ biopsy
What is a LLETZ procedure + what’s it for
Large loop excision of the transformation zone
For CIN II or III
Possible complications of LLETZ
Haemorrhage
Cervical stenosis
Slight increased risk of preterm delivery
Peak incidence of cervical carcinoma
2 peaks -30s and 80s
Types of cervical carcinoma
90% squamous malignancies
10% adenocarcinomas (worse prognosis)
What organism causes chancroid
Hawmophilus ducreyi
Presentation of chancroid (STI)
Ulcerative
Small papule, ulcerates
Forms a single or multiple painful superficial ulcers
Inflammation can lead to phimosis
Enlargement and suppuration of inguinal LN may occur –> bubo formation
Features of acute PID
Pelvic pain
Pyrexia
Cervical excitation
Adnexal tenderness
Presentation of bacterial vaginosis
Creamy-grey discharge
Fishy odour
No itch
What do clue cells on microscopy indicate
Bacterial vaginosis
What is Stress incontinence
Involuntary leakage of urine on effort / exertion /sneezing / coughing.
Due to an incompetent sphincter.
May be associated with genitourinary prolapse.
What is Urge incontinence
Involuntary urine leakage
Accompanied by/ immediately preceded by urgency.
Due to detrusor instability or hyperreflexia leading to involuntary detrusor contraction.
What is Mixed incontinence
Involuntary leakage of urine associated with urgency and exertion/effort/sneezing/ coughing.
What is Overactive bladder syndrome (OAB)
Urgency with or without urge incontinence
+ usually frequency and nocturia.
+/- Incontinence
What is Overflow incontinence
Due to chronic bladder outflow obstruction.
Often due to prostate disease in M.
Can be due to a neurogenic bladder.
What is True incontinence
continuous urine leakage
May be due to a ureto/urethro/bladder-vaginal fistula
Treatment of PCOS
COCP
Metformin
What is tranexamic acid
Anti-fibrinolytic
Cause of a single painless ulcer on genital area
Primary Syphilis
Multiple painless maculopapular ulcers with lymphadenopathy following a primary genital answer is due to what
Secondary syphilis
