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
Q

What medical and surgical management is available for miscarriage?

A

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

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26
Q

How does overactive bladder (OAB)/urge incontinence present? How should it be managed?

A

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

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27
Q

How should any urinary incontinence be investigated?

A

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

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28
Q

What are the different types of incontinence?

A

Urge
Stress
Mixed
Overflow
Functional

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29
Q

How should stress incontinence be managed?

A

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)

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30
Q

Risk factors for urogenital prolapse?

A

increasing age
multiparity, vaginal deliveries
obesity
spina bifida

31
Q

How can urogenital prolapse be managed?

A

if asymptomatic and mild prolapse then no treatment needed
conservative: weight loss, pelvic floor muscle exercises
ring pessary
surgery

32
Q

What are the surgical intervention options for urogenital prolapse?

A

cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy

33
Q

Fibroids are benign smooth muscle tumours of the uterus. How may the present if symptomatic?

A

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
Q

What are the risk factors for developing fibroids?

A

Older, Obesity
Early menarche
Family history
Ethnicity
(African-Americans are 3x more likely to develop fibroids than Caucasians)

35
Q

How can fibroids be diagnosed and managed?

A

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
Q

DDx for fibroids?

A

Endometrial polyp
Leiomyosarcoma – malignancy of the myometrium
Adenomyosis
Ovarian tumours

37
Q

Potential complications of fibroids?

A

Iron deficiency anaemia

Compression of pelvic organs:
Recurrent urinary tract infections, Incontinence, Hydronephrosis, Urinary retention

Subfertility/infertility

Degeneration

Torsion

38
Q

Vaginal candidiasis (‘thrush’) is an extremely common condition most commonly caused by Candida albicans.

What are the risk factors?

A

diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV

39
Q

How does thrush present?

A

‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen

40
Q

How can thrush be managed?

A

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
Q

How should thrush in pregnancy be managed?

A

Only topical treatments, no oral

42
Q

What is recurrent vaginal candidiasis ? How should it be managed?

A

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
Q

How does Trichomonas vaginalis present? Mx?

A

Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix

Mx: oral metronidazole for 5-7 days

44
Q

How does bacterial vaginosis present? Mx?

A

Caused by gardnerella vaginalis

Offensive, thin, white/grey, ‘fishy’ discharge

Mx : oral metronidazole for 5-7 days

45
Q

Risk factors for Vulval carcinoma?

A

Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus

46
Q

Presentation of vulval cancer?

A

lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation

47
Q

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?

A

Risk factors
human papilloma virus 16 & 18
smoking
herpes simplex virus 2
lichen planus

Features
itching, burning
raised, well defined skin lesions

48
Q

A transvaginal ultrasound demonstrating a crown-rump length greater than 7mm with no cardiac activity suggests what?

A

a missed miscarriage

49
Q

What can be used to perform a medical abortion?

A

Oral mifepristone and vaginal misoprostol (prostaglandin)

50
Q

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?

A

Fibroma

Dermoid cyst

Follicular cyst

51
Q

What can be used to classify the severity of nausea and vomiting in pregnancy?

A

The Pregnancy-Unique Quantification of Emesis (PUQE) score

52
Q

Long-term complications of PCOS?

A

Subfertility
Diabetes mellitus
Stroke & TIA, Coronary artery disease
Obstructive sleep apnoea
Endometrial cancer

53
Q

sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity =

A

? Ruptured ovarian cyst

54
Q

Raised FSH/LH in primary amenorrhoea =

A

consider gonadal dysgenesis (e.g. Turner’s syndrome)

55
Q

For how long does a urine pregnancy test remain positive after termination of pregnancy?

A

Up to 4 weeks

A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast

56
Q

woman >50 years of age presenting with symptoms suggestive of irritable bowel syndrome in the last 12 months =

A

suspect ovarian cancer

IBS rarely presents for the first time in this group

57
Q

Risk malignancy index (RMI) prognosis in ovarian cancer is based on what 3 things?

A

US findings, menopausal status and CA125 levels

58
Q

Common misconceptions that have actually not been associated with an increased risk of miscarriage include:

A

Heavy lifting
Bumping your tummy
Having sex
Air travel
Being stressed

59
Q

What approach can you take to HRT prescribing in a woman with Mirena coil in situ?

A

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
Q

Risk of ondansetron during pregnancy ?

A

small increased risk of cleft palate/lip

61
Q

patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services =

A

consider vesicovaginal fistulae

62
Q

What HRT option is suitable for a woman who has not yet fully gone through menopause?

A

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
Q

Best preparation of HRT for someone with family hx of DVT?

A

topical

64
Q

When is expectant mx suitable for an ectopic pregnancy?

A

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
Q

management option for fibroids (as long as there is no uterine cavity distortion) causing menorrhagia?

A

treatment with an LNG-IUS

66
Q

What is Asherman’s syndrome?

A

intrauterine adhesions, may occur following dilation and curettage

67
Q

A 60-year-old obese, nulliparous woman presents with vaginal bleeding =

A

think endometrial cancer

68
Q

What are cervical polyps?

A

benign growths protruding from the inner surface of the cervix. They are typically asymptomatic, but a very small minority can undergo malignant change.

69
Q

How might cervical polyps present?

A

abnormal bleeding
increased vaginal discharge
Rarely, they grow large enough to block the cervical canal, causing infertility
visible on speculum exam

70
Q

Ix for cervical polyps?

A

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
Q

Mx of cervical polyps?

A

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
Q

Complications of polypectomy?

A

Infection
Haemorrhage
Uterine perforation (very rare)

73
Q

Define vaginismus
How is it managed?

A

automatic tightening of the vaginal muscles on penetration

psychosexual therapy and relaxation exercises