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Gynae Passmed 2 Flashcards

1
Q

What are the 3 main categories of anovulation?

A

Class 1 : hypogonadotropic hypogonadal anovulation
- notably hypothalamic amenorrhoea

Class 2 : normogonadotropic normoestrogenic anovulation
- PCOS

Class 3 : hypergonadotropic hypoestrogenic anovulation
- premature ovarian insufficiency
- In this class, IVF with donor oocytes is usually required to conceive

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2
Q

What is the main goal of ovulation induction?

A

to induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development

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3
Q

What is the first line mx for patients with PCOS struggling with infertility?

A

Exercise and weight loss

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4
Q

What is the second-line medical therapy for patients with PCOS? What is it’s MOA? ADRs?

A

Letrozole

Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of FSH production
The rate of mono-follicular development is much higher with letrozole use compared to clomiphene

Side effects: fatigue, dizziness

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5
Q

What is the first line medical therapy for fertility in PCOS? MOA?

A

Clomiphene citrate

MOA: selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens.

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6
Q

What tx can be used for class 1 ovulatory dysfunction ? MOA?

A

Gonadotropin therapy

Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development

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7
Q

Pelvic inflammatory disease (PID) is infection and inflammation of the female pelvic organs, usually as a result of ascending infection from the endocervix.

What are the most common causative organisms?

A

Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

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8
Q

How should PID be investigated?

A

a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab (often negative)
screen for Chlamydia and Gonorrhoea

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9
Q

How should PID be managed?

A

oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole

Low threshold for tx due to risks incl infertility, chronic pelvic pain and ectopic pregnancy

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10
Q

Give some chronic causes of pelvic pain?

A

Endometriosis

IBS
abdominal pain, bloating and change in bowel habit
Features such as lethargy, nausea, backache and bladder symptoms may also be present

Ovarian cyst
Unilateral dull ache which may be intermittent or only occur during intercourse
Large cysts may cause abdominal swelling or pressure effects on the bladder

Urogenital prolapse
Seen in older women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency

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11
Q

Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction. What features may it present with?

A

subfertility and infertility
menstrual disturbances: oligomenorrhoea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)

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12
Q

How should PCOS be investigated?

A

pelvic ultrasound: multiple cysts on the ovaries

sex hormone-binding globulin (SHBG)
LH, FSH
testosterone
prolactin
TSH

SHBG is normal to low in women with PCOS
raised LH:FSH ratio is a ‘classical’ feature
testosterone may be normal or mildly elevated
prolactin may be normal or mildly elevated

check for impaired glucose tolerance

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13
Q

the Rotterdam criteria state that a diagnosis of PCOS can be made if 2 of the following 3 are present:

A

infrequent or no ovulation (usually manifested as infrequent or no menstruation)

clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of testosterone)

polycystic ovaries on ultrasound scan (≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)

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14
Q

How can hirsutism and acne be managed in PCOS?

A

COCP
if doesn’t respond to COCP then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision

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15
Q

Postcoital bleeding describes vaginal bleeding after sexual intercourse. What can cause this?

A

no identifiable pathology is found in around 50% of cases
cervical ectropion
cervicitis e.g. secondary to Chlamydia
cervical cancer
polyps
trauma

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16
Q

Postmenopausal bleeding is defined as vaginal bleeding occurring after 12 months of amenorrhoea. What can cause it?

A

vaginal atrophy
the most common cause of postmenopausal bleeding

HRT (hormone replacement therapy)
with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy

endometrial hyperplasia

endometrial cancer
although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently

cervical cancer

ovarian cancer

other uncommon causes include:
trauma
vulval / Vaginal cancer
bleeding disorders

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17
Q

Premature ovarian insufficiency is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.

What can cause it?

A

idiopathic ( most common)
bilateral oophorectomy
radiotherapy / chemotherapy
infection: e.g. mumps
autoimmune disorders
resistant ovary syndrome: due to FSH receptor abnormalities

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18
Q

How can POI be diagnosed?

A

elevated FSH levels should be demonstrated on 2 blood samples taken 4–6 weeks apart

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19
Q

How should POI be managed?

A

hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)

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20
Q

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

How can it be managed?

A

specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates

moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
e.g Yasmin

severe symptoms may benefit from an SSRI

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21
Q

Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions.

What can cause it?

A

antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders, PCOS
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking

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22
Q

What are the key points of the Abortion Act?

A

two registered medical practitioners must sign a legal document (in an emergency only one is needed)

only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

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23
Q

What should be done for women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation?

A

anti-D prophylaxis should be given

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24
Q

What surgical options are available for termination of pregnancy?

A

vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)

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25
What medical and surgical management is available for miscarriage?
Medical: Vaginal misoprostol alone Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue Surgical : vacuum aspiration (suction curettage) or surgical management in theatre
26
How does overactive bladder (OAB)/urge incontinence present? How should it be managed?
due to detrusor overactivity the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying Mx: bladder retraining (lasts for a minimum of 6 weeks) bladder stabilising drugs (antimuscarinics) oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation) oxybutynin should be avoided in 'frail older women' mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients surgery: sacral nerve augmentation, botox injections
27
How should any urinary incontinence be investigated?
bladder diaries should be completed for a minimum of 3 days vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises) urine dipstick and culture urodynamic studies
28
What are the different types of incontinence?
Urge Stress Mixed Overflow Functional
29
How should stress incontinence be managed?
pelvic floor muscle training NICE recommend at least 8 contractions 3 x / day for a minimum of 3 months duloxetine : noradrenaline and serotonin reuptake inhibitor increased conc of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter surgical procedures: e.g. retropubic mid-urethral tape procedures, rectus fascial sling, bulking agent injection (Bulkamid)
30
Risk factors for urogenital prolapse?
increasing age multiparity, vaginal deliveries obesity spina bifida
31
How can urogenital prolapse be managed?
if asymptomatic and mild prolapse then no treatment needed conservative: weight loss, pelvic floor muscle exercises ring pessary surgery
32
What are the surgical intervention options for urogenital prolapse?
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension uterine prolapse: hysterectomy, sacrohysteropexy rectocele: posterior colporrhaphy
33
Fibroids are benign smooth muscle tumours of the uterus. How may the present if symptomatic?
more common in Afro-Caribbean women may be asymptomatic menorrhagia (may result in iron-deficiency anaemia) bulk-related symptoms: lower abdominal pain: cramping pains, often during menstruation bloating urinary symptoms, e.g. frequency, may occur with larger fibroids subfertility
34
What are the risk factors for developing fibroids?
Older, Obesity Early menarche Family history Ethnicity (African-Americans are 3x more likely to develop fibroids than Caucasians)
35
How can fibroids be diagnosed and managed?
Diagnosis : transvaginal USS Mx: If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried to reduce sxs (e.g. IUS, tranexamic acid, COCP) GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment due to side-effects (e.g. osteoporosis) myomectomy hysteroscopic endometrial ablation hysterectomy uterine artery embolization Can just be monitored if asymptomatic - usually regress after menopause
36
DDx for fibroids?
Endometrial polyp Leiomyosarcoma – malignancy of the myometrium Adenomyosis Ovarian tumours
37
Potential complications of fibroids?
Iron deficiency anaemia Compression of pelvic organs: Recurrent urinary tract infections, Incontinence, Hydronephrosis, Urinary retention Subfertility/infertility Degeneration Torsion
38
Vaginal candidiasis ('thrush') is an extremely common condition most commonly caused by Candida albicans. What are the risk factors?
diabetes mellitus drugs: antibiotics, steroids pregnancy immunosuppression: HIV
39
How does thrush present?
'cottage cheese', non-offensive discharge vulvitis: superficial dyspareunia, dysuria itch vulval erythema, fissuring, satellite lesions may be seen
40
How can thrush be managed?
oral fluconazole 150 mg as a single dose first-line clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
41
How should thrush in pregnancy be managed?
Only topical treatments, no oral
42
What is recurrent vaginal candidiasis ? How should it be managed?
4 or more episodes per year compliance with previous treatment should be checked confirm the diagnosis of candidiasis high vaginal swab for microscopy and culture consider a blood glucose test to exclude diabetes exclude differential diagnoses such as lichen sclerosus consider the use of an induction-maintenance regime induction: oral fluconazole every 3 days for 3 doses maintenance: oral fluconazole weekly for 6 months
43
How does Trichomonas vaginalis present? Mx?
Offensive, yellow/green, frothy discharge Vulvovaginitis Strawberry cervix Mx: oral metronidazole for 5-7 days
44
How does bacterial vaginosis present? Mx?
Caused by gardnerella vaginalis Offensive, thin, white/grey, 'fishy' discharge Mx : oral metronidazole for 5-7 days
45
Risk factors for Vulval carcinoma?
Human papilloma virus (HPV) infection Vulval intraepithelial neoplasia (VIN) Immunosuppression Lichen sclerosus
46
Presentation of vulval cancer?
lump or ulcer on the labia majora inguinal lymphadenopathy may be associated with itching, irritation
47
Vulval intraepithelial neoplasia (VIN) is a pre-cancerous skin lesion of the vulva, and may result in squamous skin cancer if untreated. What are the risk factors? How does it present?
Risk factors human papilloma virus 16 & 18 smoking herpes simplex virus 2 lichen planus Features itching, burning raised, well defined skin lesions
48
A transvaginal ultrasound demonstrating a crown-rump length greater than 7mm with no cardiac activity suggests what?
a missed miscarriage
49
What can be used to perform a medical abortion?
Oral mifepristone and vaginal misoprostol (prostaglandin)
50
Most common type of ovarian pathology associated with Meigs' syndrome? Most common benign ovarian tumour in women under the age of 25 years? The most common cause of ovarian enlargement in women of a reproductive age?
Fibroma Dermoid cyst Follicular cyst
51
What can be used to classify the severity of nausea and vomiting in pregnancy?
The Pregnancy-Unique Quantification of Emesis (PUQE) score
52
Long-term complications of PCOS?
Subfertility Diabetes mellitus Stroke & TIA, Coronary artery disease Obstructive sleep apnoea Endometrial cancer
53
sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity =
? Ruptured ovarian cyst
54
Raised FSH/LH in primary amenorrhoea =
consider gonadal dysgenesis (e.g. Turner's syndrome)
55
For how long does a urine pregnancy test remain positive after termination of pregnancy?
Up to 4 weeks A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
56
woman >50 years of age presenting with symptoms suggestive of irritable bowel syndrome in the last 12 months =
suspect ovarian cancer IBS rarely presents for the first time in this group
57
Risk malignancy index (RMI) prognosis in ovarian cancer is based on what 3 things?
US findings, menopausal status and CA125 levels
58
Common misconceptions that have actually not been associated with an increased risk of miscarriage include:
Heavy lifting Bumping your tummy Having sex Air travel Being stressed
59
What approach can you take to HRT prescribing in a woman with Mirena coil in situ?
The Mirena IUS is licensed for use as the progesterone component of HRT for 4 years, so you can safely prescribe estradiol alone in a woman with a uterus
60
Risk of ondansetron during pregnancy ?
small increased risk of cleft palate/lip
61
patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services =
consider vesicovaginal fistulae
62
What HRT option is suitable for a woman who has not yet fully gone through menopause?
a cyclical regime should be used (oestrogen daily, but progesterone used for a few weeks in the cycle) once amenorrhea for >1 year = continuous regime can be used (oestrogen and progesterone daily)
63
Best preparation of HRT for someone with family hx of DVT?
topical
64
When is expectant mx suitable for an ectopic pregnancy?
1) An unruptured embryo 2) <35mm in size 3) Have no heartbeat 4) Be asymptomatic 5) Have a B-hCG level of <1,000IU/L and declining
65
management option for fibroids (as long as there is no uterine cavity distortion) causing menorrhagia?
treatment with an LNG-IUS
66
What is Asherman's syndrome?
intrauterine adhesions, may occur following dilation and curettage
67
A 60-year-old obese, nulliparous woman presents with vaginal bleeding =
think endometrial cancer
68
What are cervical polyps?
benign growths protruding from the inner surface of the cervix. They are typically asymptomatic, but a very small minority can undergo malignant change.
69
How might cervical polyps present?
abnormal bleeding increased vaginal discharge Rarely, they grow large enough to block the cervical canal, causing infertility visible on speculum exam
70
Ix for cervical polyps?
Triple swabs – if there is any suggestion of infection (such as purulent discharge), endocervical and high vaginal swabs should be taken. Cervical smear – to rule out cervical intraepithelial neoplasia (CIN)
71
Mx of cervical polyps?
Small polyps can be removed in the primary care setting. The polyp is grasped with polypectomy forceps, and twisted several times. larger polyps removed in colposcopy clinic all sent for histological examination
72
Complications of polypectomy?
Infection Haemorrhage Uterine perforation (very rare)
73
Define vaginismus How is it managed?
automatic tightening of the vaginal muscles on penetration psychosexual therapy and relaxation exercises

Y4 Reproductive Health (13 decks)

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