Gynaecology Flashcards

Question

When should investigations for primary amenorrhoea be undertaken?

Answer 1

**No evidence** of **pubertal changes** in a girl **aged 13**

Answer 2

* FBC and ferritin for anaemia * U&E for chronic kidney disease * Anti-TTG or anti-EMA for coeliacs disease * FSH and LH * Thyroid function tests * Insulin-like growth factor I for GH deficiency * Prolactin for hyperprolactinoma * Testosterone - raised in PCOS, Androgen insensitivity syndrome and congenital adrenal hyperplasia * Genetic testing with a microassay for Turner's syndrome

Answer 3

**Imaging** (X-ray of the wrist - assess for constitutional delay) **Pelvic ultrasound** (assess the ovaries and other pelvic organs) **MRI** of the **brain** (for pituitary pathology and olfactory bulbs in Kallman syndrome)

Answer 4

- Establish and treat the underlying cause - **Replacement hormones** where necessary - Patients with **constitutional delay in growth and development** may only require reassurance and observation - Patients with **low body weight / stress** causes require reduction in stress, CBT and healthy weight gain - Patients with **hypogonadotropism** treated with pulsatile GnRH to induce ovulation / mensturation (can induce fertility) / if pregnancy is not wanted then COOP can induce regular mensturation and prevent symptoms of oestrogen deficiency - Patients with **ovarian causes** e.g. PCOS, damage to the ovaries or absence of can have the COCP to induce regular mensturation and prevent the symptoms of oestrogen deficiency

Answer 5

No mensturation for **more than three months** after previous regular menstrual periods * 3-6 months in women with previously normal and regular menses * 6-12 months in women with previous oligomenorrhoea

Answer 6

- Pregnancy & lactation account for most cases of amenorrhoea in the reproductive years. - Menopause and premature ovarian failure - Hormonal contraception (IUS or POP) - Hypothalamic or pituitary pathology - Ovarian causes e.g. polycystic ovarian syndrome - Uterine pathology such as Asherman's syndrome - Thyroid pathology - Hyperprolactinaemia

Answer 7

Prevent pregnancy in situations where the body may not be fit for it e.g.: - **Excessive exercise** (e.g. athletes) - **Low body weight** - **Chronic disease** - **Psychological stress**

Answer 8

**Pituitary tumours** e.g. prolactin-secreting **prolactinoma** **Pituitary failure** due to trauma, radiotherapy, surgery or Sheehan syndrome

Answer 9

High prolactin levels, this acts on the **hypothalamus** to prevent the release of **GnRH**, without GnRH there is no release of LH and FSH = **hypogonadotrophic hypogonadism**

Answer 10

**Pituitary adenoma** secreting prolactin

Answer 11

CT or MRI scan of the brain

Answer 12

**Dopamine agonists** such as **bromocriptine** or **cabergoline** can be used to reduce prolactin production.

Answer 13

- Detailed history and examination to assess for causes - Hormonal blood tests - Ultrasound of the pelvis to diagnose **polycystic ovarian syndrome**

Answer 14

**Beta human chorionic gonadotrophin** (HCG) urine or blood tests for pregnancy **Luteinising hormone** and **follicle-stimulating hormone** High **FSH** suggests primary ovarian failure High LH or LH:FSH ratio suggests **polycystic ovarian syndrome** **Prolactin** can be measured to assess for **hyperprolactinaemia** followed by an **MRI** to identify a **pituitary tumour** **Thyroid stimulating hormone** (TSH) to screen for thyroid pathology, followed by **T3** and **T4** when the TSH is abnormal **Raised** TSH and **low** T3 and T4 indicates **hypothyroidism** **Low** TSH and **raised** T3 and T4 indicates **hyperthyroidism** **Raised testosterone** indicates **polycystic ovarian syndrome**, **androgen insensitivity syndrome** or **congenital adrenal hyperplasia**

Answer 15

Establishing and treating underlying cause **Replacement hormones** can induce mensturation and improve symptoms

Answer 16

Require a withdrawal bleed every 3-4 months to reduce the risk of **endometrial hyperplasia** and endometrial cancer **Medroxyprogesterone** for 14 days, or regular use of the combined oral contraceptive pill - to stimulate a withdrawal bleed

Answer 17

When the amnorrhoea lasts more than 12 months treat with: - Adequate **vitamin D** and **calcium** intake - **Hormone replacement therapy** or the **combined oral contraceptive pill**

Answer 18

Psychological, emotional and physical symptoms that occur during the **luteal phase** of the **menstural cycle** particularly in the days prior to onset of mensturation Thought to be caused by fluctuation in oestrogen & progesterone levels Exact mechanism unknown May be due to increased sensitivity to progesterone or an interaction between the sex hormones and the NTs serotonin and GABA

Answer 19

Once mensturation begins

Answer 20

* Low mood * Anxiety * Mood swings * Irritability * Bloating * Fatigue * Headaches * Breast pain * Reduced confidence * Cognitive impairment * Clumsiness * Reduced libido

Answer 21

After a hysterectomy, endometrial ablation or on the mirena coil as the ovaries continue to function and the hormonal cycle continues

Answer 22

**Premenstrual dysmorphic disorder**

Answer 23

**Symptom diary** spanning two menstrual cycles - demonstrating **cyclical symptoms** which occur just before and resolve after the onset of menstruation Adminstering **GnRH** to temporarily halt the menstrual cycle and temporarily induce the menopause, to see if symptoms improve

Answer 24

- Improve diet, exercise, alcohol, smoking, stress and sleep - COCP- using drospiernone first line as recommended by RCOG - ie Yasmin. Has mineralcorticoid effects (similar to spironolactone). Continuous use rather than cyclical use of the pill may be more effective - SSRI antidepressants - CBT - GnRH analogues to induce a menopausal state, HRT may be required to reduce adverse effects such as osteoporosis. - Hysterectomy and bilateral oophorectomy to induce menopause when symptoms are really severe & medical mx has failed.

Answer 25

**Danazole** and **tamoxifen** (initiated and monitored by a breast specialist)

Answer 26

**Spironolactone** to treaat breast swelling, water retention and bloating

Answer 27

40ml is normal \>80 ml = HMB * Changing pads every 1-2 hrs * Passing large clots * Bleeding \> 7 days

Answer 28

* Dysfunctional uterine bleeding (no identifiable cause) * Extremes of reproductive age * Fibroids * Endometriosis and adenomyosis * Pelvic inflammatory disease (infection) * Contraceptives, particularly the copper coil * Anticoagulant medications * Bleeding disorders (e.g. Von Willebrand disease) * Endocrine disorders (diabetes and hypothyroidism) * Connective tissue disorders * Endometrial hyperplasia or cancer * Polycystic ovarian syndrome

Answer 29

**Age** at **menarche** **Cycle length**, days **menstruating** and **variation** **Intermenstrual bleeding** and post coital bleeding **Contraceptive history** **Sexual** history Possibility of **pregnancy** Plans for **future pregnancies** **Cervical screening** history **Migraines** with or without aura (for the pill) **Past medical history** and past drug history **Smoking** and alcohol history **Family** history

Answer 30

- **Pelvic examination** with a **speculum** and **bimanual** (to assess for fibroids, ascites and cancers) - **FBC** for iron deficiency anaemia - OP hysteroscopy if suspecting submucosal fibroids, endometrial pathology eg hyperplasia/ cancer, persistent IMB - Pelvic/ TV USS if there is a palpable pelvic mass (possible large fibroids), pelvic pain/ tenderness o/e (possible adenomysois), examination difficult to interpret eg obesity, hysteroscopy declined - Swabs for infection if discharge/ suggestive sexual hx - Coag screen if fhx of clotting disorders - Ferritin if clinically anaemic - TFTs if additional features of hypothyroidism

Answer 31

- Exclude underlying pathology such as anaemia, fibroids, bleeding disorders and cancer - Identifiable causes should be managed initially (e.g. menorrhagia caused by a copper coil should stop when the coil is removed) - Next step is to determine if **contraception is required or acceptable** - Pt declines contraception: tranexamic acid if no associated pain or mefenamic acid with associated pian - Pt happy to use contraception: mirena coil is first line, COCP, cyclical oral progestogens

Answer 32

First generation technique = **hysteroscopy** and direct destruction of the endometrium Second generation technique = (not using hysteroscopy) e.g. passing a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining (**ballon thermal ablation**)

Answer 33

**Benign tumours** of the **smooth muscle** of the uterus

Answer 34

They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.

Answer 35

**Oestrogen** (oestrogen sensitive)

Answer 36

**Intramural** means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. **Subserosal** means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity. **Submucosal** means just below the lining of the uterus (the endometrium). **Pedunculated** means on a stalk.

Answer 37

Often a**symptomatic**, however they can present: **Heavy menstrual bleeding (menorrhagia)** is the most frequent presenting symptom **Prolonged menstruation,** lasting more than 7 days **Abdominal pain**, worse during menstruation **Bloating or feeling full** in the abdomen **Urinary or bowel symptoms** due to pelvic pressure or fullness **Deep dyspareunia** (pain during intercourse) **Reduced fertility**

Answer 38

**Abdominal examination** may reveal a **palpable pelvic mass** or an **enlarged firm non-tender uterus**

Answer 39

Hysteroscopy initially for submucosal fibroids presenting w/ HMB Pelvic / TV ultrasound is the investigation of choice for larger fibroids. MRI scanning before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Answer 40

**Less than 3cm** (same as with heavy menstrual bleeding): * Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus * Symptomatic management with NSAIDs (mefenamic acid) and tranexamic acid * Combined oral contraceptive * Cyclical oral progestogens * Injectable progestogen

Answer 41

**Endometrial ablation** **Resection** of submucosal fibroids during hysteroscopy **Hysterectomy**

Answer 42

Medical- * Referral to gynaecology for investigation and management, options: * Symptomatic management with NSAIDs and tranexamic acid * Mirena coil – depending on the size and shape of the fibroids and uterus * Combined oral contraceptive * Cyclical oral progestogens * GnRH agonists typically useful for short-term treatment Surgical- * Uterine artery embolisation- blocks the blood supply to the fibroid so it shrinks * Myomectomy- surgical removal of fibroid via laparoscopic/ laparotomy or hysteroscopically * Endometrial ablation- destroying the endometrium * Can be done hysteroscopically * Or non-hydsteroscopic- balloon thermal ablation- inserting a balloon into the endometrium and filling it with high-temperature fluid that burns the endometrial lining of the uterus * Hysterectomy

Answer 43

* Heavy menstrual bleeding, often with iron deficiency anaemia * Reduced fertility * Pregnancy complications, such as miscarriages, premature labour and obstructive delivery * Constipation * Urinary outflow obstruction and urinary tract infections * Red degeneration of the fibroid- haemorrhage into tumour- commonly occurs during pregnancy * Torsion of the fibroid, usually affecting pedunculated fibroids * Malignant change to a leiomyosarcoma is very rare (\<1%)

Answer 44

**Ischaemia, infarction** and **necrosis** of the fibroid due to disrupted blood supply More likely in **larger fibroids** (above 5cm) during the second and third trimester of pregnancy May occur to growing of fibroid during pregnancy or kinking in the blood vessel as the uterus changes shape and expands Presents with severe abdo pain, low grade fever, tachycardia, vomiting Mx- supportive, rest, fluids, analgesia

Answer 45

**Ecotopic endometerial tissue** outside of the uterus (lump of tissue = endometrioma)

Answer 46

**Not clear**, but there is a **genetic component** 1. **Retrograde menstruation:** during menstration flow is backwards through fallopian tubes and into the pelvis and peritoneum 2. **Embryonic cells** destined to become endometrial tissue may remain in **areas outside the uterus during the delelopment of the fetus** and become ectopic tissue 3. **Lymphatic system** may spread the tissue 4. **Metaplasia** may change cells outside the uterus

Answer 47

Can lead to **reduced fertility** (maybe due to adhesions around the ovaries and fallopian tubes)

Answer 48

* Cyclical abdominal or pelvic pain * Deep dyspareunia * Dysmenorrhoea * Infertility/ subfertility * Cyclical bleeding from other sites, such as haematuria * Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements) * O/E- reduced organ mobility in pelvis, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Answer 49

**Pelvic ultrasound** - for large endometriomas and chocolate cysts - if the symptoms are significant, the pt should be referred for a definitive diagnosis. USS has little role **Laparoscopic surgery** - gold standard - definitive diagnosis with **biopsy** of the lesion during laparoscopy (surgeon can remove deposits of endometriosis

Answer 50

**Stage 1:** Small superficial lesions **Stage 2:** Mild, but deeper lesions than stage 1 **Stage 3:** Deeper lesions, with lesions on the ovaries and mild adhesions **Stage 4:** Deep and large lesions affecting the ovaries with extensive adhesions

Answer 51

**Analgesia as required** for pain (NSAIDs and paracetamol first line) If analgesia doesn't help then hormonal treatments such as COCP or progestogens eg medroxyprogesterone acetate should be tried If analgesia/ hormonal treatments don't improve or fertility is a priority- refer to secondary care * GnRH analogues- improve symptoms due to low oestrogen, however no effect on fertility * Laparoscopic excision or laser treatment of endometriotic ovarian cysts may improve fertility

Answer 52

**Combined oral contractive pill,** which can be used back to back without a pill-free period if helpful **Progesterone only pill** **Medroxyprogesterone acetate injection** (e.g. Depo-Provera) **Nexplanon implant** **Mirena coil** **GnRH agonists**

Answer 53

**Laparoscopic surgery** to **excise** or **ablate** the endometrial tissue and remove adhesions (adhesiolysis) ## Footnote **Hysterectomy**

Answer 54

**Cyclical pain** - COCP, oral progesterone-only pill, progestin depot injection, progestin implant (nexplanon) **stop ovulation** and **reduce endometrial thickening** **GnRH agonists** - induce **menopause-like state** using GnRH agonists e.g. **goserelin** (zoladex) or **leuprorelin** (prostap) (risk of **osteoporosis**) **Laparoscopic surgery** - excise or ablate the ectopic endometrial tissue, where there is chronic pelvic pain due to **adhesions** surgery can dissect these **Hysterectomy and bilateral salpingo-opherectomy** - final surgical option, removing ovaries induces menopause, stopping ectopic endometrial tissue responding to menstrual cycle **Infertility** - treated by removing as much of the endometriosis as possible

Answer 55

**Endometrial tissue** inside the **myometrium** (muscle layer of uterus) It is more common in multiparous women towards the end of their reproductive years.

Answer 56

* Dysmenorrhoea * Dyspareunia * Menorrhagia * Enlarged, boggy uterus

Answer 57

**Enlarged and tender uterus** **Feels more soft** than a uterus containing fibroids

Answer 58

**Transvaginal ultrasound** of the pelvis (first-line) **MRI** and **transabdominal ultrasound** alternatives where TV is nor suitable **Gold standard** is to perform a **histological examination** of the uterus after a hysterectomy (not always suitable for obvious reasons)

Answer 59

Depends on **symptoms**, **age** and **plans for pregnancy**: - Non-contraceptive: **tranexamic acid** (antifibrinolytic - used when no pain), **mefenamic acid** (NSAID - reduces bleeding and pain - Contraceptive: **Mirena coil** (first line), **COCP**, **cyclical oral progestogens** (progesterone only medication e.g. the pill, implant or depot injection may also be helpful) - GnRH analogues to induce menopause-like state - Hysterectomy - Uterine artery embolisation - Endometrial ablation

Answer 60

* Infertility * Miscarriage * Preterm birth * Small for gestational age * Preterm premature rupture of membranes * Malpresentation * Need for caesarean section * Postpartum haemorrhage

Answer 61

Retrospectively - after woman has **no periods for 12 months**

Answer 62

**51 years old**

Answer 63

Period from 12 months after the final period ~51 years of age

Answer 64

Time around menopause, **vasomotor symptoms** and **irregular periods** Including time leading up and 12 months after menopause Women **older that 45**

Answer 65

Menopause **before the age of 40** - result of **premature ovarian insufficiency**

Answer 66

Lack of **ovarian follicular function**: - **Oestrogen** and **progesterone** levels are low - **LH** and **FSH** levels are **high** in response to an **absence** of negative feedback from oestrogen

Answer 67

In ovaries **primordial follicles** mature into **primary and secondary follicles** (independent of the menstrual cycle) at start of menstrual cycle **FSH** stimulates the development of **secondary follicles** - as these grow **granulosa cells** which surround them secrete increasing amounts of **oestrogen** **Menopause begins** in the decline of the development of follicles - reducing oestrogen levels - increasing LH and FSH **Anovulation results** and without oestrogen the endometrium doesnt develop = **amenorrhoea** **Low levels of oestrogen** cause **perimenopausal symptoms**

Answer 68

* Hot flushes * Emotional lability or low mood * Premenstrual syndrome * Irregular periods * Joint pains * Heavier or lighter periods * Vaginal dryness and atrophy * Reduced libido

Answer 69

* Cardiovascular disease and stroke * Osteoporosis * Pelvic organ prolapse * Urinary incontinence

Answer 70

**Perimenopause / menopause** diagnosis can be made in women **over 45 years old** with typical symptoms **FSH** blood test is recommended in women under 40 with premature menopause / women aged 40-45 with menopausal symptoms/ change in menstrual cycle

Answer 71

- Two years after LMP in women \< 50 - One year after LMP in women \> 50

Answer 72

**No**, they may suppress and mask the symptoms

Answer 73

Barrier methods Mirena or copper coil Progesterone only pill Progesterone implant Progesterone depot injection (under 45 years) Sterilisation

Answer 74

UKMEC2- benefits generally outweigh the risks

Answer 75

Those containing **norethisterone or levonorgestrel** due to the relatively lower risk of VTE

Answer 76

**Weight gain** **Osteoporosis** (so, unsuitable for women over 45)

Answer 77

**No treatment** Hormone replacement therapy (**HRT**) **Tibolone**, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) **Clonidine**, which act as agonists of alpha-adrenergic and imidazoline receptors Cognitive behavioural therapy (**CBT**) **SSRI** antidepressants, such as fluoxetine or citalopram **Testosterone** can be used to treat **reduced libido** (usually as a gel or cream) **Vaginal oestrogen cream** or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) **Vaginal moisturisers**, such as Sylk, Replens and YES

Answer 78

**Hypergonadotrophic hypogonadism** - lack of negative feedback on the pituitary gland resulting in an excess or gonadotrophins: ## Footnote **Raised LH and FSH** **Low oestradiol levels**

Answer 79

**Idiopathic** (the cause is unknown in more than 50% of cases; may be fhx ) **Iatrogenic**, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. bilateral oophorectomy) **Autoimmune,** possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease **Genetic,** with a positive family history or conditions such as Turner’s syndrome **Infections** such as mumps, tuberculosis or cytomegalovirus

Answer 80

Irregular menstrul periods, lack of menstrual periods (secondary amenorrhea), symptoms of low oestrogen levels such as hot flushes, night sweats and vaginal dryness Raised FSH, LH levels Low oestradiol

Answer 81

**Women younger than 40** years old with **typical menopausal symptoms** plus **elevated FSH** **FSH elevation** needs to be on two consecutive samples separated by more than 4 weeks (results are difficult to interpret in women taking hormonal contraception)

Answer 82

- CVD - Stroke - Osteoporosis - Cognitive impairment - Dementia - Parkinsonism

Answer 83

**Hormone replacement therapy** - reducing risk of CVD, osteoporosis, cognitive and psychological risks * **Traditional HRT** (associated with a lower BP compared to COCP) * **COCP** (less stigma for younger women) **Contraception** - as pregnancy is still possible

Answer 84

**Lifestyle changes such as improving the diet**, **exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress** Cognitive behavioural therapy (**CBT**) **Clonidine**, which is an agonist of alpha-adrenergic and imidazoline receptors **SSRI antidepressants (e.g. fluoxetine)** **Venlafaxine,** which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) **Gabapentin**

Answer 85

**Agonist** of **alpha-2 adrenic receptors** and **imidazoline receptors** in the brain **Lower BP** and **reduced HR** Useful for **vasomotor symptoms** and **hot flushes** particularly when there are contraindications to HRT

Answer 86

**Dry mouth** **Headaches** **Dizziness** **Fatigue** (sudden withdrawal can cause rapid increase in BP and agitation)

Answer 87

**Replacing hormones in premature ovarian insufficiency,** even without symptoms **Reducing vasomotor symptoms** such as hot flushes and night sweats **Improving symptoms such as low mood**, decreased libido, poor sleep and joint pain **Reducing the risk of osteoporosis in women under 60 years**

Answer 88

**More significant in older women** and increase with longer duration of treatment: - Increased risk of **breast/endometrial cancer** - Increased risk of **VTE** (2-3 times background risk) - Increased risk of **stroke** and **coronary artery disease** - Inconclusive evidence about **ovarian cancer**

Answer 89

- Adding **progesterone** in women with a uterus to **reduce risk of endometrial cancer** - Using **patches** instead of **pills** to reduce the risk of VTE - Using **local progestogens** (e.g. mirena coil) to reduce the risk of **breast cancer** and **CVD**

Answer 90

* Current, past, suspected breast cancer * Known or suspected oestrogen-dependent cancer * Undiagnosed vaginal bleeding * Untreated endometrial hyperplasia * Previous idiopathic or current VTE Active or recent arterial thromboembolic disease eg angina or MI * Active liver disease with abnormal LFTs * Pregnancy * Thrombophilic disorder

Answer 91

* Local or systemic symptoms? * Local → topical oestrogen creams/ tablets * Systemic → Uterus or no uterus? * No uterus → continuous oestrogen-only HRT * Uterus → have they had a period in the last 12 months? * Yes → cyclical combined * Can be switched to continuous after 12 months for women \> 50, after 24 months in women \< 50 * No uterus → continuous combined

Answer 92

**At least 12 months** of treatment in women over 50 **At least 24 months** in women under 50

Answer 93

* Multiple ovarian cysts * Infertilify * Oligomenorrhoea * Hyperandrogenism (olgomenorrhoea, hirsutism, acne) * Insulin resistance * Obesity * Hair loss in male pattern * Acanthosis nigricans * CVD * Hypercholesterolaemia * Endometrial hyperplasia and cancer * OSA * Depression, anxiety * Sexual problems

Answer 94

1. Anovulation refers to the absence of ovulation 2. Oligoovulation refers to irregular, infrequent ovulation 3. Amenorrhoea refers to the absence of menstrual periods 4. Oligomenorrhoea refers to irregular, infrequent menstrual periods 5. Androgens are male sex hormones, such as testosterone 6. Hyperandrogenism refers to the effects of high levels of androgens 7. Hirsutism refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair 8. Insulin resistance refers to a lack of response to the hormone insulin, resulting in high blood sugar levels

Answer 95

**Rotterdam criteria -** At least 2 of the 3 key features: * **Oligoovulation / anovulation** - presenting with irregular / absent periods * **Hyperandrogenism** - hirsutism and acne * **Polycystic ovaries** on ultrasound (or ovarian volume of \> 10cm^3)

Answer 96

* Metabolic disorders, such as impaired glucose tolerance and type 2 diabetes. * Cardiovascular disease. * Infertility. * Pregnancy complications, such as pre-eclampsia and gestational diabetes. * Endometrial cancer. * Psychological disorders, such as anxiety and depression. * Obstructive sleep apnoea.

Answer 97

Thickened, rough skin, typically found on the **axilla** and on the **elbows,** has a **velvety texture** occurs with **insulin resistance**

Answer 98

* Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids * Ovarian or adrenal tumours that secrete androgens * Cushing’s syndrome * Congenital adrenal hyperplasia

Answer 99

* Pancreas produces more insulin which promotes the release of androgens from the ovaries and adrenal glands - causing higher levels of testosterone * Insulin suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens, supressing them - thus less SHBG promotes hyperandrogenism in women with PCOS * Diet, exercise and weight loss help to reduce insulin resistance

Answer 100

* Testosterone * Sex hormone-binding globulin * Luteinizing hormone * Follicle-stimulating hormone * Prolactin (may be mildly elevated in PCOS) * Thyroid-stimulating hormone

Answer 101

* **Raised luteinising hormone** * **Raised LH to FSH ratio** (high LH compared with FSH) * **Raised testosterone** * **Raised insulin** * **Normal or raised oestrogen levels**

Answer 102

**Transvaginal ultrasound** (gold standard) - follicles may be arranged around the periphery of the ovary, giving a "string of pearls" appearance. Diagnostic criteria: * 12/ more developing follicles * Ovarian volume of more than 10cm3

Answer 103

**2-hour 75g oral glucose tolerance test** (OGTT): Morning prior to having breakfast, take baseline **fasting plasma glucose,** then 75g glucose drink, then measure plasma glucose 2 hours later Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink) Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l Diabetes – plasma glucose at 2 hours above 11.1 mmol/l

Answer 104

* Weight loss * Low glycaemic index, calorie-controlled diet * Exercise * Smoking cessation * Antihypertensive medications where required * Statins where indicated (QRISK \>10%)

Answer 105

* Endometrial hyperplasia and cancer * Infertility * Hirsutism * Acne * Obstructive sleep apnoea * Depression and anxiety

Answer 106

**Weight loss** - result in ovulation, restoration of fertility, improve insulin resistance, reduce hirsutism, reduce the risks of associated conditions. **Orlistat** may be used to help in women with a BMI about 30 **Orlistat is a lipase inhibitor** (preventing absorption of fat in the intestines)

Answer 107

* Obesity * Diabetes * Insulin resistance * Amenorrhoea

Answer 108

Normally **corpus luteum** releases **progesterone** after ovulation - women with PCOS ovulate infrequently - less progesterone Oestrogen is "unopposed" and continues to **proliferate** the endometrial lining - causing **endometrial hyperplasia**

Answer 109

**Pelvic ultrasound** to assess **endometrial thickness** **Cyclical progestogens** should be used to induce a period **prior to the ultrasound** scan If **endometrial thickness** is more than 10mm, need to be referred for a biopsy to exclude endometrial hyperplasia / cancer

Answer 110

**Mirena coil** for continuous endometrial protection **Inducing a withdrawal bleed** (every 3-4 months) with: * Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) * COCP

Answer 111

**Weight loss**, can restore regular ovulation **Clomifene** **Laparoscopic ovarian drilling** **In vitro fertilisation** (IVF)

Answer 112

**Weight loss** or hair removal e.g. waxing, shaving and plucking **Co-cyprindiol** is a **COCP** liscensed for the treatment of **hirsutism** and **acne** (anti-androgenic effect) - BUT significant risk of VTE, co-cyprindiol is usually stopped after 3 months of use **Topical eflornithine** - used to treat facial hirsutism - takes 6-8 weeks to see improvement (hirsutism will return in 2 months of stopping eflornithine) Other options initiated by specialist- spironolactone, finasteride (reduces testosterone production), flutamide (non-steroidal anti-androgen), cyproterone acetate (anti-androgen and progestin)

Answer 113

**COCP** (first line) - co-cyprindiol has anti-androgen effects (high risk of VTE) Other standard acne treatments: * **Topical adapalene** (a retinoid) * **Topical antibiotics** (e.g. clindamycin 1% with benzoyl peroxide 5%) * **Topical azelaic acid** 20% * **Oral tetracycline antibiotics** (e.g. lymecycline)

Answer 114

**Cyst** = fluid filled sac **Functional ovarian cysts** = related to fluctuating hormones of menstrual cycle, very common in **premenopausal women** (vast majority are benign) Cysts in post menopausal women are more concerning for malignancy

Answer 115

**Pelvic pain** **Bloating** **Fullness** in the abdomen **A palpable pelvic mass** (particularly with very large cysts such as **mucinous cystadenomas**)

Answer 116

Ovarian torsion Haemorrhage Rupture of cyst

Answer 117

Follicular cysts * commonest type of ovarian cyst * due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle * commonly regress after several menstrual cycles Corpus luteum cyst * during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst * more likely to present with intraperitoneal bleeding than follicular cysts * may occur during early pregnancy

Answer 118

1. **Serous cystadenoma** = the most common benign tumour of epithelial cells which bears a resemblance to the most common type of ovarian cancer (serous carcinoma). Bilateral in ~20% 2. **Mucinous cystadenoma** = 2nd most common benign tumour of epithelial cells, can become huge, if ruptures may cause pseudomyxoma peritonei 3. **Endometrioma** = lumps of endometrial tissue within the ovary, occur in patients with endometriosis 4. **Dermoid cyst / germ cell tumour** = benign ovarian tumours, **teratomas** meaning they come from the **germ cells,** usually lined with epithelial tissue hence may contain various tissue types e.g. skin, teeth, hair and bone - associated with **ovarian torsion.** Median age of diagnosis is age 30. Bilateral in 10-20% 5. **Sex cord-stromal tumours**= rare tumours that can be **benign** or **malignant** - arise from stroma (connective tissue) or sex cords (embryonic structures associated with the follicles) e.g. **Sertoli-Leydig cell tumours** and **granulosa cell tumours**

Answer 119

* Age * Postmenopause * Increased number of ovulations * Obesity * Hormone replacement therapy * Smoking * Breastfeeding (protective) * Family history and BRCA1 and BRCA2 genes

Answer 120

**Later onset of periods** (menarche) **Early menopause** **Any pregnancies** Use of the **combined contraceptive pill**

Answer 121

**Premenopausal women** with a **simple ovarian cyst** less than 5cm on **ultrasound** do not need further investigations **CA125** is the tumour market for epithelial cell ovarian cancer (forms part of the risk malignancy index) **Women under 40 years** with a complex ovarian mass require tumour markers for a possible **germ cell tumour**: * **Lactate dehydrogenase** (LDH) * **Alpha-fetoprotein** (alpha-FP) * **Human chorionic gonadotrophin** (HCG)

Answer 122

* Endometriosis * Fibroids * Adenomyosis * Pelvic infection * Liver disease * Pregnancy

Answer 123

Estimates the risk of an **ovarian mass being malignant**: * Menopausal status * Ultrasound findings * CA125 level

Answer 124

**Possible ovarian cancer**: 2WW referral to a gynae oncology specialist **Possible dermoid cysts**: referral to a gynaecologist for further investigations **Simple ovarian cysts** in **premenopausal women**: * Less than 5cm cysts will almost always resolve in 3 cycles- repeat USS for 8-12 weeks and referral considered if persists * 5cm-7cm: resuire routine referral to gynar and yearly ultrasound * \> 7cm consider an MRI scan or surgical evaluation (difficult to characterise with ultrasound)

Answer 125

In post-menopausal women, by definition physiological cysts are unlikely Hence refer all to gynae for assessment regardless of nature/ size Require correlation with the CA125 (2WW referral if raised) Simple cysts under 5cm with normal CA125 may be **monitored with ultrasound every 4-6 months**

Answer 126

**Surgical intervention** (usually with **laparoscopy**) **Ovarian cystectomy** (removing cyst) **Oophorectomy** (removing the affected ovary)

Answer 127

**Torsion** **Haemorrhage** into the cyst **Rupture**, with bleeding into the peritoneum

Answer 128

Triad: **- Ovarian fibroma** (benign ovarian tumour) **- Pleural effusion** **- Ascites** Typically occurs in older women - removal results in complete resolution of effusion and ascites

Answer 129

* Ovarian mass * Pregnancy * Being of a reproductive age- younger girls before menarche as they have longer infundibulopelvic ligaments that twist easily * Ovarian hyperstimulation syndrome

Answer 130

**Sudden onset deep- seated severe unilateral pain** - constant / colicky- gets worse - associated with N&V **Pain is not always severe** (can twist and untwist) **Localised tenderness** (may be a palpable mass) Vaginal examination may reveal adnexial tenderness Fever may be seen secondary to adnexal necrosis USS- free fluid or whirlpool sign

Answer 131

**Pelvic ultrasound** - TV is ideal but transabdominal will do **"Whirlpool sign", free fluid** in pelvis and **oedema** of the ovary may be seen **Doppler studies** may show a lack of blood flow **Definitive diagnosis** = **laparoscopic surgery**

Answer 132

Admission under gynaecology Require **laparoscopic** **surgery** to either: - **Untwist** the ovary and fix it in place (detorsion) - **Remove** the affected ovary (oophorectomy) Decision is made during surgery **based on visual inspection**

Answer 133

If only ovary - can lead to infertility and menopause Necrotic ovary which isnt removed can become **infected**, develop an **abscess** and lead to **sepsis** May **rupture** resulting in **peritonitis** and **adhesions**

Answer 134

**Adhesion** (aka **synechiae**) form within the uterus following damage to the endometrium basal layer, the damaged tissue may heal abnormally creating scar tissue (adhesions) connecting areas of the uterus which are usually not connected * Pregnancy-related dilatation and currettage procedure- eg during treatment of retained products of conception- removal of placental tissue after birth * Uterine surgery eg myomectomy * Pelvic infection eg endometritis

Answer 135

Following recent dilatation and curettage: **Secondary amenorrhoea** (absent periods) Significantly **lighter periods** **Dysmenorrhoea** (painful periods)

Answer 136

**Hysteroscopy** - gold standard - can dissect and treat adhesions **Hysterosalpingography** - contrast is injected into the uterus and imaged with xrays **Sonohysterography** - uterus is filled with fluid and pelvic ultrasound **MRI** Mx- disseciton of adhesions during hysteroscopy. Reoccurance is common.

Answer 137

**Columnar epithelium** of the **endocervix** (the canal of the cervix) has extended out to the **ectocervix** (outer area od the cervix) Cells of the **endocervix** are more fragile and prone to trauma - more likely to bleed with **sexual intercourse** - often presents with **post-coital bleeding** Often associated with high oestrogen levels- common in younger women, COCP, pregnancy

Answer 138

Border between the **columnar epithelium** of the **endocervix** (the canal) and the **stratified squamous epithelium** of the **ectocervix** (the outer area of the cervix)

Answer 139

Mainly **asymptomatic** - found incidentally suring speculum examination * Increased **vaginal discharge** * **Vaginal bleeding** * **Dyspareunia** (pain during sex) * Postcoital bleeding Examination reveals well-demarcated border between the redder, velvety columnar epithelium extending from the os and the pale pink squamous epithelium of the endocervix. This border is the transformation zone.

Answer 140

Asymptomatic requires **no treatment** - typically resolves as patient gets older, stops the pill or is no longer pregnant (not a contraindication to the COCP) **Problematic bleeding** - treated with **cauterisation** of the ectropion using **silver nitrate** or **cold coagulation** during colposcopy

Answer 141

**Fluid filled cysts** seen on **surface of cervix** (also called nabothian follicles or mucinous retention cysts) **Up to 1cm in size** - harmless and unrelated to cancer When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium of the endocervix then the mucus becomes trapped and forms a cyst Happens: after childbirth, minor trauma to the cervix or cervicitis secondary to infection

Answer 142

Incidentally on speculum - smooth rounded bumps near the os Whitish or yellow appearance No treatment required If uncertain of diagnosis, refer to colposcopy for further examination

Answer 143

Women who have had a **hysterectomy** Top of **vagina (the vault)** descends into the **vagina** *Vaginal vault prolapse occurs when the upper portion of the vagina loses its normal shape and sags or drops down into the vaginal canal or outside of the vagina. *

Answer 144

Rectum prolapses into the vagina due to a defect in the **posterior vaginal wall** - associated with constipation

Answer 145

Dur to a defect in the **anterior vaginal wall** allowing the bladder to **prolapse backwards** into the vagina (prolapse of the urethra is called a **urethrocele**, or both **cystourethrocele**)

Answer 146

* Multiple vaginal deliveries * Instrumental, prolonged or traumatic delivery * Advanced age and postmenopause status * Obesity * Chronic respiratory disease causing coughing * Chronic constipation causing straining * Spina bifida

Answer 147

* Feeling of "something coming down" in the vagina * Dragging or heavy sensation in pelvis * Urinary symptoms e.g. incontinence, urgency, frequency, weak stream, retention * Bowel symptoms e.g. constipation, incontinence and urgency * Sexual dysfunction e.g. pain, altered sensation and reduced enjoyment

Answer 148

Patient should **empty bladder and bowel** before examination of prolapse A **Sim's speculum** is a U-shaped, single bladed speculum used to support the anterior wall to examine for a rectocoele and the posterior wall for a cystocele Woman **asked to cough**

Answer 149

**Grade 0**: Normal **Grade 1:** The lowest part is more than 1cm above the introitus **Grade 2:** The lowest part is within 1cm of the introitus (above or below) **Grade 3**: The lowest part is more than 1cm below the introitus, but not fully descended **Grade 4:** Full descent with eversion of the vagina Prolapse extending beyond the introitus = **uterine procidentia**

Answer 150

**Conservative** = physio (pelvic floor exercises), weight loss, reduced coffee intake, incontinence pads, treat related symptoms e.g. stress incontinence with anticholinergic medications, vaginal oestrogen cream **Vaginal pessary** = placed into vagina for support, many types (**ring** sit around cervix, **shelf** and **gellhorn** pessaries are a flat disc with a stem, **cube** are cube shaped, **donut** are a thick ring, **hodge**), oestrogen cream can help protect against irritation **Surgey** = **mesh repairs** (now avoided entirely - over a lot of controversy)

Answer 151

**Pain, bleeding, infection, DVT and risk of anaesthetic** **Damage** to **bladder** **Recurrence** of the prolapse **Altered** experience of **sex**

Answer 152

Chronic pain Altered sensation Dyspareunia (painful sex) for the woman / partner Abnormal bleeding Urinary / bowel problems

Answer 153

Urge: **Overactive bladder** caused by overactivity of the detrusor muscle of the bladder Stress: pelvic floor muscles are weak, canals (urethral/ vaginal/ rectal) become lax, weak sphincter muscles, allows urine to leak when there is increased pressure on the bladder eg when laughing, coughing or surprised Mixed: urge and stress Overflow: when the bladder becomes dilated or flaccid with minimal or no tone/function. Can occur with anticholinergics, fibroids, pelvic tumours, neuro conditions eg MS, diabetic neuropathy, spinal cord injury

Answer 154

* Increased age * Post menopausal * High BMI * Previous pregnancies and vaginal deliveries * Pelvic organ prolapse * Pelvic floor surgery * Neuro conditions e.g. MS * Cognitive impairment / dementia * FHx

Answer 155

Caffeine consumption Alcohol consumption Medications BMI

Answer 156

**0:** No contraction **1:** Faint contraction **2:** Weak contraction **3:** Moderate contraction with some resistance **4:** Good contraction with resistance **5:** Strong contraction, a firm squeeze and drawing inwards

Answer 157

**Bladder diary** tracking fluid intake and episodes of urination and incontinence over 3 days (mix of work and leisure days) **Urine dipstick** for infection, microscopic haematuria and other pathology **Post-void residual bladder volume** measured using a bladder scan to assess for incomplete emptying **Urodynamic testing** for urge incontinence patients not responding to first line medical treatments, difficulties urinating, urinary retention, previous surgery, unclear diagnosis

Answer 158

Patients **stop any anticholinergic** medication (and other bladder meds) **5 days before** Thin catheter (that **measures pressure**) is inserted into the bladder and rectum, **bladder is filled with liquid** and various outcome measures are taken: **Cystometry** measures the **detrusor muscle contraction** **Uroflowmetry** measures the **flow rate** **Leak point pressure** is the **point at which the bladder pressure results in leakage** (after coughing - for stress incontinence) **Post void residual bladder volume** for incomplete emptying of bladder **Video urodynamic testing** - filling the bladder with contrast and taking x-rays images as the bladder is emptied (this is not routine)

Answer 159

**Avoid caffeine, diuretics and overfilling** of the bladder **Avoid excessive / restrictive** fluid intake **Weight loss** (if appropriate) **Supervised pelvic floor exercise** for at least 3 months before considering surgery (8 contractions 3 times daily) **Surgery** **Duloxetine** is a SNRI antidepressant used second line where surgery is less preferred * a combined noradrenaline and serotonin reuptake inhibitor * mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced

Answer 160

**Tension-free vaginal tape** (TVT) - procedure involving a mesh sling looped under the urethra and up behind the pubic symphysis to abdo wall (supporting urethra) **Autologous** **sling procedure** (similar to TVT procedure but strip of fascia from abdo wall is used rather than tape) **Colposuspension** involves using stitches connecting the anterior vaginal wall and the pubic symphysis around the urethra - for support **Intramural urethral bulking** - injections around the urethra to reduce diameter and add support

Answer 161

Operation to create an **artificial urinary sphincter** - using a pump inserted into the labia which inflates and deflates a cuff around the urethra

Answer 162

**Bladder retraining** - gradually increasing time between voiding (for at least 6 weeks) Bladder stabilising drugs: antimuscarinics are first-line * NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation) * Immediate release oxybutynin should, however, be avoided in 'frail older women' **Mirabegron** (a beta-3 agonist): alternative to anticholinergic medication, may be useful if there is concern about anticholinergic side-effects in frail elderly patients **Invasive procedures** where medical treatment fails

Answer 163

Dry mouth Dry eyes Urinary retention Constipation Postural hypotension **Coginitive decline** **Memory problems** Worsening of dementia

Answer 164

**Botulinum toxin type A** injection into the bladder wall **Percutaneous sacral nerve stimulation** involves implanting a device in the back that stimulates the sacral nerves **Augmentation cystoplasty** involves using bowel tissue to enlarge the bladder **Urinary diversion** involves redirecting urinary flow to a urostomy on the abdomen

Answer 165

**Dryness** and **atrophy** of the vaginal mucosa due to a lack of oestorgen occuring in women entering the menopause

Answer 166

**Vaginal lubricants** e.g. sylk, replens and YES **Topical oestrogen** Estriol cream, applied using an applicator (syringe) at bedtime Estriol pessaries, inserted at bedtime Estradiol tablets (Vagifem), once daily Estradiol ring (Estring), replaced every three months

Answer 167

**Pair of glands** located either side of the posterior part of the **vaginal introitus** (vaginal opening) - usually pea sized and not palpable - produce mucus for lubrication

Answer 168

When the ducts become blocked - glands swell and become tender causing a **cyst** (unilateral and fluid filled up to 4cm) this can then become **infected** forming an **abscess** which will be **hot, red,** and potentially **draining pus**

Answer 169

Good hygiene Analgesia Warm compresses **Biopsy** (if vulval malignancy needs to be excluded)

Answer 170

**Antibiotics** Swab of pus for organism and sensitivities (E. Coli most common, send swabs for chlamydia and gonorrhoea too) **Surgical intervention** = Word catheter / Marsupilisation

Answer 171

**Chronic inflammation** of the skin which causes patches of white shiny areas on **labia, perineum** and **perianal** skin in women (can affect men on **foreskin** and **glans** of the penis) Lichen sclerosus leads to atrophy of the epidermis with white plaques forming Features * white patches that may scar * itch is prominent * may result in pain during intercourse or urination

Answer 172

**Autoimmune condition** associated with other sutoimmune diseases e.g. **type 1 diabetes**, **alopecia**, **hypothyroid** and **vitiligo**

Answer 173

Chronic inflammation and irritation caused by repeated scratching of an area of skin **Excoriations**, **plaques**, **scaling** and **thickened skin**

Answer 174

Autoimmune condition which causes **chronic inflammation** with shiny, purplish, flat-topped raised aread with white lines across the surface called **Wicham's striae**

Answer 175

Where symptoms of lichen sclerosus is **made worse with friction to the skin** e.g. wearing tight underwear, scratching

Answer 176

"porcelain-white" in colour Shiny Tight Thin Slightly raised Papules / plaques

Answer 177

Chronic disease, symptomatic treatment: * **potent topical steroids** clobebasol propionate **(dermovate) 0.05%** * Steroids once a day for 4 weeks until condition controlled * **Emollients** used regularly

Answer 178

**Squamous cell carcinoma of the vulva** Other complications: * Pain and discomfort * Sexual dysfuction * Bleeding * Narrowing of the vaginal / urethral openings

Answer 179

Surgically changing the genitals of a female for non medical reasons - form of **child abuse** and **safeguarding issue**

Answer 180

**Type 1:** Removal of part or all of the clitoris. **Type 2:** Removal of part or all of the clitoris and labia minora. The labia majora may also be removed. **Type 3:** Narrowing or closing the vaginal orifice (infibulation). **Type 4:** All other unnecessary procedures to the female genitalia.

Answer 181

**Pain** **Bleeding** **Infection** **Swelling** Urinary retention Urethral damage and incontinence

Answer 182

Vaginal infections (e.g. BV) UTIs **Dysmenorrhoea** **Dyspareunia** Infertility Psychological issues (e.g. depression) Reduced engagement with screening

Answer 183

- Educate that **its illegal** - Report all **FGM** under 18 to police (and social services, paediatrics, specialist gynae services, counselling) - **Consider reporting** in over 18s using risk assessment tool, consider relatives at risk, unborn child at risk? - **De-infibulation** - to correct narrowing or closure (re-infibulation is illegal)

Answer 184

**Paramesonephric ducts** (Mullerian ducts)

Answer 185

**Anti-Mullerian hormone**

Answer 186

Where there are **"two horns" to the uterus**, giving it a heart shaped appearance (diagnosed on pelvic ultrasound) Typical complications- miscarriage, premature birth, malpresentation No specific mx

Answer 187

Hymen is **fully formed** without an opening (discovered when menstration starts - menses trapped = cyclical pain and cramping, no bleeding) Diagnosed on examination, treated with surgical incision

Answer 188

Error in development where a **septum** (wall) forms **across the vagina** - can either be **perforate** (with a hole) or **imperforate** (completely sealed) **Perforate** = still menstruate but difficulty with intercourse/tampon **Imperforate** = present similarly to an imperforate hymen with cyclical pelvic symptoms Can cause **infertility**

Answer 189

**Examination** **Ultrasound** **MRI** **Treat** with **surgical correction** (complication = vaginal stenosis / recurrence of septae)

Answer 190

Abnormally **small vagina** mx- vaginal dilator over a prolonged period of time

Answer 191

Absent vagina

Answer 192

Failure of the **Mullerian ducts** to properly develop (may have absent uterus and cervix)

Answer 193

**X-linked recessive** (caused by mutation in the **androgen receptor gene** on the **X chromosome**)

Answer 194

**Genetically male** with **XY sex chromosome** Absent response to testosterone and conversion of androgens to oestrogen results in **female phonetype externally** - male sexual characteristics don't develop, patients have normal female external genitalia and breast tissue

Answer 195

**Testes** in the abdomen or inguinal canal with **absence** of a **uterus**, **upper vagina**, **cervix**, **fallopian tube** and **ovaries** (these organs don't develop as the **testes** produce **anti-Mullerian hormone**)

Answer 196

Lack of pubic hair / facial hair and male type muscle development Slightly **taller than the average female, infertile, increased risk of testicular cancer** unless testes are removed

Answer 197

**Ambiguous signs** cells have a partial response to androgens, micropenis, clitoromegaly, bifid scrotum, hypospadias, diminished male characteristics

Answer 198

**Infancy** with **inguinal hernias** containing **testes** Alternatively, in **puberty** with **primary amenorrhoea**

Answer 199

Raised LH Normal / raised FSH Normal / raised testosterone levels (for a male) Raised oestrogen levels (for a male)

Answer 200

**Bilateral orchidectomy** (removal of the testes) to avoid testicular tumours **Oestrogen therapy** **Vaginal dilators** / **vaginal surgery** to create length (management involves paediatrics, gynae, urology, endocrinology, clinical psychology) Generally patients are **raised as female** but this is sensitive and tailored to the individual, offered support and counselling

Answer 201

* Systemic oestrogen * Natural oestrogens- conjugated oestrogen, estradiol, estrone, estriol are used * Synthetic oestrogens- mestranol or ethinylestradiol generally not used except in women in POI due to the greater metabolic effect * Progestogen * Almost all synthetic * C19 progestogens: derived from testosterone- norethisterone, levonorgestrel (good for reduced libido) * C21 progestogens: dydrogesterone, medroxyprogesterone (good for mood, depression, acne) * Given cyclically to women who have had a period in last 12 months to induce a withdrawal bleed * Mirena coil: LNG-IUS is an alternative route of delivery of progestogen and provides endometrial protection locally (good for contraception too)

Answer 202

* Combined HRT can be prescribed as a: * Monthly cyclical regimen- oestrogen daily and progestogen given at the end of the cycle for 10-14 days * 3 monthly cyclical regimen- oestrogen daily and progestogen given for 14 days every 13 weeks * Continuous combined regimen- oestrogen and progestogen daily * Peri-menopausal women: monthly or 3 monthly regimen * Absence of bleeding reflects atrophic endometrium * Post-menopausal: monthly or 3 monthly cyclical or continuous combined may be used * Vaginal oestrogen therapy regiments eg 1 vaginal tablet daily for 2 weeks then 1 twice weekly

Answer 203

* Reduce risk of endometrial hyperplasia and cancer * Continuous provides better protection than cyclical

Answer 204

* Oestrogen related * Fluid retention * Bloating * Breast tenderness or enlargement * Nausea * Headaches * Leg cramps * Dyspepsia * Progestogen-related * Fluid retention * Breast tenderness * Headaches or migraine * Mood swings/ PMS symptoms/ depression * Acne vulgaris * Lower abdo/ back pain * Vaginal bleeding

Answer 205

* Vaginal bleeding * Unscheduled bleeding is common within first 3 months of treatment * Monthly cyclical regiments produce withdrawal bleeding towards end of the progestogen phase * Continuous combined HRT produces irregular breakthrough bleeding or spotting in first 4-6 months of treatment * If beyond 6 months, exclude endometrial pathology * If serious gynae pathology has been exclude, alter the progestogen part of the regimen and this may improve bleeding problems- eg increase duration/ dose or switch to LNG-IUS combined with oral/ transdermal oestrogen preparation

Answer 206

* Synthetic steroid, stimulates oestrogen, progesterone and androgen receptors * Used as a form of continuous combined HRT

Answer 207

Clinicians may consider offering screening for gestational diabetes to women who have been diagnosed as having PCOS before pregnancy. This should be performed at 24–28 weeks of gestation, with referral to a specialist obstetric diabetic service if abnormalities are detected.

Answer 208

Women presenting with PCOS who are overweight (body mass index [BMI] ≥ 25 kg/m2 ) and women with PCOS who are not overweight (BMI \< 25 kg/m2 ), but who have additional risk factors such as advanced age (\> 40 years), personal history of gestational diabetes or family history of type II diabetes, should have a 2-hour post 75 g oral glucose tolerance test performed. In women with impaired fasting glucose (fasting plasma glucose level from 6.1 mmol/l to 6.9 mmol/l) or impaired glucose tolerance (plasma glucose of 7.8 mmol/l or more but less than 11.1 mmol/l after a 2-hour oral glucose tolerance test), an oral glucose tolerance test should be performed annually

Answer 209

* Simple: unilocular, more likely to be physiological or benign * Complex: multilocular, more likely to be malignant

Answer 210

An enterocele is formed by a prolapse of the small bowel through the rectouterine pouch, i.e. the pouch of Douglas, through the upper part of the vaginal vault

Answer 211

AUB is any bleeding disturbance that occurs during or between menstrual periods, or that is excessive, frequent or prolonged. This is the overarching term to describe any significant disturbance of menstruation or the menstrual cycle. Structural lesions: PALM * Polyps- endometrial, endocervical * Adenomysois * Leiomyoma (uterine fibroids) * Malignancy and hyperplasia Non-structural causes: COEIN * Coagulopathies * Von Willebrand disease * Platelet dysfunctions * Rare clotting factor deficiencies * Thrombocytopenia * Ovulatory dysfunction * Anovulation * PCOS * Thyroid disease * Endometrial primary causes * Iatrogenic- eg IUDs * Not yet classified- rare or novel causes eg uterine arteriovenous malformations which can cause very HMB

Answer 212

Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea. Primary: no underlying pelvic pathology, usually appears within 1-2 hrs of menarche * Excessive endometrial prostaglandin production is thought to be partially responsible. * Mefenamic acid/ ibuprofen * COCP second line Secondary: evelops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes: endometriosis, adenomyosis, PID, IUD (copper- IUS mirena may help), fibroid * Refer all pts with secondary dysmenorrhoea to gynae for ix

Answer 213

* Speculum and bimanual examination whilst getting pt to cough to feel for prolapse * Assess pelvic tone and examine for pelvic organ prolapse, atrophic vaginitis, urethral diverticulum, pelvic masses

Answer 214

* Combined serotonin and noradrenaline reuptake inhibitor * Thought to increase serotonin and noradrenaline in the pudendal motor nucleus of the sacral spinal segments leading to increased urethral muscular tone and closure pressure, improving the functions of the urethral sphincter * S/E: Anxiety; appetite decreased; constipation; diarrhoea; dizziness; drowsiness; dry mouth; fall; fatigue; flushing; gastrointestinal discomfort; gastrointestinal disorders; headache; muscle complaints; nausea; pain; palpitations; paraesthesia; sexual dysfunction; skin reactions; sleep disorders; sweat changes; tinnitus; tremor; urinary disorders; vision disorders; vomiting; weight changes; yawning

Answer 215

* Pelvic organ prolapse: more common after colposuspension that after a retropubic mesh sling * Mesh-related complications after retropubic mesh sling including pain and vaginal problems * Bleeding: needing a transfusion occurs in \<1% * Damage to bladder: 1-10% - more likely with mesh surgery * Damage to bowel * Damage to nerves leading to loss of sensation or persistent pain * Problems emptying bladder fully- may require catheter for a few days or weeks or longer * Having to get to the toilet quickly to urinate or not getting to the toilet in time * Infections including wound infections, vaginal infections and UTIs * Persistent pain in abdomen, pelvis, or during sex