Gynaecology Flashcards
What are the two subtypes of primary amenorrhoea?
Hypogonadotropic hypogonadism (low FSH and LH)
Hypergonadotropic hypogonadism (high FSH and LH)
What are causes of hypogonadotropic hypogonadism?
Stress
Excessive exercise/dieting
Hypopituitarism (damage/surgery/Sheehan’s syndrome)
Kallmann syndrome = failure to start puberty and reduced sense of smell
Growth hormone deficiency
Hypothyroidism
Cushing’s disease
Constitutional delay
What are causes of hypergonadotropic hypogonadism?
Turner syndrome
Damaged ovaries
In men = Klinefelter’s, damaged testes
How is primary amenorrhoea investigated?
Check FSH and LH TFTs Insulin like growth factor Testosterone Prolactin
What is the definition of primary amenorrhoea?
No period by 13 and no other signs of puberty
No period by 15 with other signs of puberty
What is secondary amenorrhoea?
No menstruation for 3 months after previous regular menstrual periods
What are causes of secondary amenorrhoea?
Pregnancy Hyperprolactinaemia PCOS Menopause /premature ovarian failure Pituitary failure Sheehan syndrome Asherman syndrome Hypothyroidism Physiological/psychological stress
What is Sheehan syndrome?
Damage to pituitary gland caused by bleeding during childbirth
(Lack of oxygen causes damage to the pituitary)
What is Asherman’s syndrome
Adhesions within the uterus - usually due to D&C
What lab results are seen in hyperprolactinaemia?
Raised prolactin
Low GnRH
Low FSH and LH
How is Hyperprolactinaemia managed?
Dopamine agonist - bromocriptine or cabergoline
What does raised FSH + secondary amenorrhoea suggest?
Menopause / premature ovarian failure
What does raised LH + secondary amenorrhoea suggest?
Polycystic ovarian syndrome
What is premature ovarian failure?
Menopause before 40 years
Hypergonadotropic hypogonadism
What lab results are seen in premature ovarian failure?
Raised FSH and LH
Low oestrogen
How is premature ovarian failure managed?
HRT
Is contraception required in premature ovarian failure?
Yes - 2 years after last period
How does polycystic ovary syndrome present?
Hirsutism Acne Weight gain Oligomenorrhoea Male pattern hair loss
What is needed for diagnosis for PCOS?
Rotterdam criteria
Polycystic ovaries on ultrasound - at least 12 follicles seen on ultrasound or ovarian volume of more than 10cm^3
Anovulation
Raised testosterone
What lab results are seen in PCOS?
Raised testosterone Raised LH Raised LH:FSH ratio Normal FSH Raised insulin Raised testosterone Low sex-hormone binding globulin Raised anti mullerian hormone
How is PCOS managed?
Main issue with anovulation = risk of endometrial hyperplasia
Need to start COCP / POP / Mirena
2nd line after COCP for symptoms = spironolactone
How is PCOS managed in those looking to conceive?
- Clomifene
2. Ovarian drilling OR Metformin OR Gonadtrophins
How is heavy menstrual bleeding/menorrhagia defined?
Any bleeding that interferes with the woman’s quality of life
What are causes of menorrhagia?
Fibroids Polyps Endometriosis Adenomyosis Clotting disorder
Idiopathic
How is menorrhagia investigated?
FBC - look for anaemia
Transvaginal ultrasound
Bimanual examination - if boggy suggests fibroids
How is idiopathic menorrhagia managed?
If idiopathic and no identified pathology, or fibroids less than 3cm:
- Mirena
- NSAIDs/Tranexamic acid/COCP/POP
What are the two types of dysmenorrhea ?
Primary and secondary
What is the management of dysmenorrhea ?
First line is NSAIDs
Also mefenamic acid
Then COCP
How is secondary dysmenorrhea managed?
Refer to gynae
What is a fibroid?
Benign tumour of the myometrium
How do fibroids present?
Often asymptomatic
Most common symptom = dysmenorrhoea (painful periods
Other symptoms Prolonged menstruation Abdominal pain Deep dyspareunia Urinary/bowel symptoms due to pressure Reduced fertility
How are fibroids diagnosed?
Bimanual examination will reveal a boggy uterus (firm, non-tender)
Pelvic ultrasound will be initial investigation
Hysteroscopy for better view
How are fibroids managed ?
If less than 3cm can just manage menorrhagia with mirena or tranexamic acid . If symptoms persist then can refer to gynae for endometrial ablation
If more than 3cm then refer to gynae for a myomectomy, or can still trial medical management e.g. Mirena
How do you reduce the size of the fibroid prior to myomectomy?
A GnRH agonist e.g. goserelin/leuprolelin/triptorelin
When do fibroids regress?
In menopause - because they are oestrogen dependent
What is red degeneration ?
A complication of fibroids in pregnancy
Presents as abdominal pain, fever and vomiting
What is a polyp?
Benign growth of the endometrium in the uterus / cervix
What is the most common cause of post menopausal bleeding?
A polyp
How does a polyp present?
Intermenstrual bleeding
Post menopausal bleeding
Menorrhagia
How is a polyp managed ?
Diathermy
How does endometriosis present?
Cyclical pelvic pain
Deep dyspareunia
Dysmenorrhea
Reduced fertility
Cyclical urinary/bowel symptoms
How is endometriosis diagnosed?
Definitive diagnosis is laparoscopic surgery
Pelvic ultrasound may show an endometrioma (lump of endometrial tissue) or chocolate cysts (an endometrioma in the ovary)
How is endometriosis managed?
1st line = Analgesia (NSAID)
COCP / POP / Mirena can be trialled prior to surgery
GnRH agonist
What is Adenomyosis and how does it present?
Endometrial tissue that lies within the myometrium
Chronic pelvic pain
Dysmenorrhea
Menorrhagia
Enlarged, boggy uterus (but not firm as seen with fibroids)
Dyspareunia
How is adenomyosis diagnosed?
Gold standard diagnosis is MRI Pelvis
How is adenomyosis managed?
Same as menorrhagia
First line = Mirena
Also - COCP, tranexamic acid
How long must a woman have amenorrhoea to be classed as menopausal?
12 months
What is classed as premature menopause
Before 40 years
What are features of menopause?
Hot flushes
Low mood
Irregular periods (in perimenopausal period) - may be heavier or lighter
Joint pains
Vaginal dryness
Reduced libido
What does menopause increase the risk of?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
How does hormonal analysis look in menopause?
High FSH and LH (due to lack of negative feedback from oestrogen)
Low oestrogen and progesterone
How long does contraception need to be used after the last period?
Under 50 - continue contraception for 2 years
Over 50 - continue contraction for 1 year
What are the different types of hormone replacement therapy and when are they used?
Combined / oestrogen only - oestrogen only is only used if there is no uterus or if there is another form of progesterone (eg. Mirena)
Cyclical - if LMP less than 1 year ago
Continuous - If no periods cor at least 1 year
What are contraindications to hormone replacement therapy?
Current/past breast cancer
Any oestrogen sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Previous or current idiopathic VTE (unless woman is on anticoagulant)
Active or recent angina/MI
Active liver disease
Thrombophilic disorder
What does HRT increase the risk of?
Breast cancer
Endometrial cancer
VTE
What else can be used to manage symptoms in menopause other than HRT?
Fluoxetine can be used for vasomotor symptoms
Vaginal lubricants
What are causes of post-coital bleeding?
The most common cause is cervical ectropion
Cervicitis
Cervical polyp
Cervical cancer
Trauma
Often no cause
What is cervical ectropion and what is the most important risk factor?
The columnar epithelium of the endodermis extends to the ectocervix
This columnar epithelium is more fragile than normal squamous epithelium and bleeds easily
Causes post-coital bleeding
Most important risk factor is COCP. Also pregnancy.
What is seen on speculum examination in patients with cervical ectropion?
A well demarcated border between the red columnar epithelium and pink squamous epithelium
How is cervical ectropion treated?
Treatment is not necessary but cryotherapy can be conducted
How does an ovarian cyst present?
Usually asymptomatic
Can be a palpable mass in the pelvis
Can cause symptoms - pelvic pain, bloating, fullness (early satiety)
What is the most common type of ovarian cyst?
Follicular cyst
Developing follicle that fails to rupture and release an egg
Harmless
Usually regresses after several menstrual cycles
How are symptoms of ovarian cyst/ovarian cancer investigated?
Transvaginal ultrasound = first line
If 5cm or more/ complex cyst (solid material) or in post-menopausal women -> CA125 + Alpha fetoprotein + bHCG
How are simple ovarian cysts treated?
<5cm: no further management
5-7cm: yearly monitoring
> 7cm: consider MRI or surgical evaluation
What is Meig’s syndrome?
Triad of:
Ovarian fibroma
Pleural effusion
Ascites
Management = removal of ovarian tumour
How does ovarian cyst rupture present?
Severe one sided abdominal pain
Shock
Nausea+vomiting
Often precipitated by intercourse/exercise
What is ovarian torsion and how does it present?
When the ovary twists
Usually due to an ovarian mass larger than 5cm (cyst or tumour)
Twisting leads to ischaemia and can cause necrosis
Presents with sudden onset severe unilateral pain
Nausea and vomiting
Examination will reveal localised tenderness and maybe a palpable mass
How is ovarian torsion diagnosed?
TVUSS
whirlpool sign
free fluid in pelvis
oedema of ovary
How is ovarian torsion managed?
Emergency laparoscopic surgery
Either detorsion or oophorectomy
What is the main type of ovarian cancer?
Epithelial
What are risk factors for ovarian cancer?
Early menarche
Late menopause
Nulliparity
(More periods = more risk)
How does ovarian cancer present?
Vague symptoms
Bloating
Early satiety
Diarrhoea
Urinary symptoms
May be abdominal/pelvic pain
What is the criteria for checking CA125?
In any post-menopausal female presenting with IBS-like symptoms (IBS rarely presents for the first time in this age)
Any woman with early satiety/pelvic or abdominal pain/urinary symptoms
How do you manage a woman with symptoms of ovarian cancer and raised CA125?
Calculate RMI
How is RMI (Risk of malignancy index) for ovarian cancer calculated?
Menopause score x ultrasound score x CA125
Pre-menopausal = 1 Post-menopausal = 2
Ultrasound signs = multi lobar cyst, solid areas, bilateral lesions, Ascites, intra-abdominal metastases (1 = 1, 2-5 = 3)
If RMI >250 = 2WW REFERRAL
How is ovarian cancer staged?
Stage 1 = tumour confined to ovary
Stage 2 = outside ovary but within pelvis
Stage 3 = outside pelvis but within abdomen
Stage 4 = outside abdomen (distant metastases)
Which women get direct referral to 2WW for possible ovarian cancer without further investigation?
Post menopausal women with…
Ascites
Pelvic mass
Abdominal mass
Which tumour markers can suggest a possible germ cell tumour in ovarian cancer?
Alpha feto-protein
HCG
What are causes of a raised CA125 other than ovarian cancer?
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Endometrial hyperplasia seen on TVUSS - how is this managed? What is endometrial hyperplasia?
Endometrial hyperplasia = >4mm
Hysteroscopy + Sample for histology
If typical/simple (without atypia) -> observation alone, peat sampling. Consider high dose progesterone (oral or Mirena)
If atypia is present -> hysterectomy + bilateral salpingo-oophorectomy
What is the main type of endometrial cancer?
Adenocarcinoma
What is the 2WW criteria for endometrial cancer?
Post-menopausal woman with bleeding
What are risk factors for endometrial cancer?
Unopposed oestrogen
PCOS (lack of ovulation)
Obesity (adipose is a source of oestrogen)
T2DM (insulin stimulates endometrial cell growth)
What factors are protective for endometrial cancer?
Smoking
COCP
What endometrial measurement is classed as hyperplasia?
More than 4mm
How is endometrial cancer staged?
Stage 1: confined to uterus
Stage 2: involves cervix
Stage 3: involves ovaries/fallopian tubes/vagina/lymph nodes
Stage 4: bladder/rectum/beyond pelvis
What is the main type of cervical cancer?
Squamous cell carcinoma
Which virus is cervical cancer strongly associated with?
HPV - 16 and 18
What are risk factors for cervical cancer?
Smoking
HIV
COCP
Multiparity
Family history
How does cervical cancer present?
Often asymptomatic
Can present with post-coital/intermenstrual bleeding and dyspareunia
How are symptoms of cervical cancer investigated?
Speculum examination
If abnormal appearance of cervix (ulceration/bleeding/inflammation/visible tumour) -> urgent referral to gynae 2WW for colposcopy
What is cervical intraepithelial neoplasia?
Pre-malignant change of cells in the cervix
Diagnosed on colposcopy
How often are women invited for smear tests?
Every 3 years from 25 to 49
Every 5 years from 50 to 64
Every year in women with HIV
How often are women with HIV invited for a smear test?
Every year
When can a pregnant woman receive a smear test?
Not until at least 12 weeks post partum
Smear result: inadequate?
Repeat in 3 months
If still inadequate - colposcopy within 6 weeks
Smear result: HPV negative?
Return to normal pathway
Smear result: HPV positive and abnormal cytology?
Refer for colposcopy
Smear result: HPV positive and normal cytology?
Repeat smear in 12 months
If HPV negative -> return to normal recall
If still HPV positive -> cytology again
If cytology normal -> repeat in another 12 months
If still HPV positive at 24 months, refer for colposcopy
What is the most common type of vulval cancer?
Squamous cell carcinoma
What are risk factors for vulval cancer?
Advanced age (>75)
Immunosuppression
Lichen sclerosis
HPV infection
How does vulval cancer present?
Vulval limp or ulcer
Itching / pain / bleeding
Groin lymphadenopathy
How is suspected vulval cancer managed?
Urgent 2WW referral
Biopsy and sentinel node biopsy
What is lichen sclerosus and how does it present?
Autoimmune Inflammatory skin condition that commonly affects labia (associated with other autoimmune conditions)
Older woman with vulval itching, soreness, pain, superficial dyspareunia
NO LUMP
How does lichen sclerosus appear?
Porcelain-white appearance
Shiny, tight, thin
Slightly raised
How is lichen sclerosus managed?
Potent topical corticosteroids - Clobetasol 0.05% (Dermovate)
Emollients
What is atrophic vaginitis? How does it present?
Dryness and atrophy of the vaginal mucosa caused by lack of oestrogen in menopause
causes itching, dryness, dyspareunia, bleeding
How is atrophic vaginitis managed?
Vaginal lubricants
Topical oestrogen (CI in breast cancer, angina and VTE)
What is pelvic inflammatory disease and what is the most common organism?
Infection and inflammation of the pelvic organs (uterus, Fallopian tubes, ovaries)
Most common organism = Chlamydia, also Gonorrhoea (tends to produce more severe PID)
What are symptoms and signs pelvic inflammatory disease?
SYMPTOMS
Lower abdominal pain
Fever
Deep dyspareunia
Irregular bleeding
Dysuria
SIGNS
Purulent discharge
Cervicitis
Cervical motion tenderness
Pelvic tenderness
What are risk factors for pelvic inflammatory disease?
New or multiple sexual partners
Recent IUD insertion
Not using barrier contraception
Existing STIs
Previous PID
How do you investigate pelvic inflammatory disease?
Pregnancy test - rule out ectopic pregnancy
High vaginal swab
Microscope - pus cells
Inflammatory markers
How is pelvic inflammatory disease treated?
Antibiotics
E.g.
IM Ceftriaxone (gonorrhoea) + PO Doxycycline (chlamydia and mycoplasma genitalium) + PO Metronidazole (anaerobes)
What is Turner Syndrome and what are features?
Only one X chromosome or deletion of short arm
Short stature
Widely spaced nipples
Webbed neck
Bicuspid aortic valve
Primary amenorrhoea
What conditions are associated with Turner syndrome?
Recurrent otitis media
Recurrent UTI
Coarctation of the aorta
Hypothyroidism
Obesity
Diabetes
Osteoporosis
What are the different types of pelvic organ prolapse?
Uterine prolapse - uterus descends into vaginal
Vault prolapse - top of vagina descends into vagina (when a woman has had a hysterectomy)
Rectocele - defect in posterior vaginal wall, rectum prolapse into vagina
Cystocele - defect in anterior vaginal wall, bladder prolapses into vaginal
Can also be urethrocele (prolapse of urethra)
What are risk factors for pelvic organ prolapse?
Multiple vaginal deliveries
Prolonged / traumatic delivery
Advanced age / postmenopausal
Obesity
Chronic constipation
How does pelvic organ prolapse present?
Feeling of something coming down / draggingl
Urinary symptoms - incontinence, urgency, frequency
Bowel symptoms - constipation, incontinence, urgency
Sexual dysfunction (pain, altered sensation)
What is the stepwise management of pelvic organ prolapse?
- Conservative (physio, weight loss, vaginal oestrogen cream, treating associated stress incontinence)
- Vaginal pesssaries (ring, shelf, cube, donut, hodge)
- Surgery
What is the difference between stress and urge incontinence?
Stress incontinence = weak pelvis floor muscles leading to leakage of urine on laughing/coughing
Urge incontinence = over activity of the detrusor muscle, sudden needing to go to the toilet
How is urinary incontinence investigated?
Urine dipstick - rule out infection and DM
Bladder diary
Post-void residual bladder volume
If unclear diagnosis/difficulty urinating/previous surgery -> urodynamic testing
What medication needs to be stopped prior to urodynamic testing? And how long before?
Anticholinergic medication needs to be stopped at least 5 days prior
How can stress incontinence be managed?
Lifestyle modifications - avoid caffeine/diuretics, avoid excessive fluid intake, weight loss
Pelvic floor exercises (must be trialled for at least 3 months before considering surgery)
Duloxetine (SNRI)
Surgery
Which medication can be offered for stress incontinence?
Duloxetine (SNRI)
How can urge incontinence be managed?
1st line = bladder training for at least 6 weeks
2nd line = Anticholinergic e.g. oxybutynin
Another medical option is Mirabegron
3rd = invasive procedures e.g. Botox, sacral nerve stimulation
What are side effects of oxybutynin?
Dry mouth
Dry eyes
Urinary retention
Constipation
What are contraindications for Micabegron?
Uncontrolled hypertension
Which contraception should be avoided in active breast cancer?
Avoid all hormonal contraception
Which contraceptions should be avoided in cervical/endometrial cancer?
Mirena
What is the first line COCP?
Microygnon/Leostrin (lower risk of VTE
Which is the first line COCP for premenstrual syndrome?
Yasmin (drosperinone)
What is the first line contraceptive for acne and hirsutism?
Dianette (but there is a higher risk of VTE)
What are adverse effects and risks of the COCP?
Adverse effects - unscheduled bleeding, breast tenderness, mood changes, headaches
Risks - increased risk of VTE, breast cancer, cervical cancer, MI, stroke
What are contraindications to the COCP?
Uncontrolled HTN
History of migraine with aura
History of VTE
Aged over 35 and smoking more than 15 a day
Vascular disease /stroke
Ischaemic heart disease/cardiomyopathy
SLE/antiphospholipid syndrome
BMI >35 (UKMEC 3)
How long after starting the COCP is a woman protected?
If started in cycle days 1-5 = immediately
Otherwise = after 7 days
What should a woman do if she has missed one COCP?
If it has been between 24 to 72 hours - take the missed pill and usual pill
What should a woman who has missed more than 2 pills of COCP do?
Take the last missed pill (no more than 2 pills in one day)
Barrier contraception for 7 days
If in week 1 - consider emergency contraception
Week 2 - no emergency contraception needed
Week 3 - continue with next pack and omit break, no emergency contraception needed
How long prior to major surgery should COCP be stopped?
4 weeks
What to do if someone on COCP/POP has had diarrhoea or vomiting?
Assume missed pill
What is the only major contraindication for the progesterone only pill?
Active breast cancer
What are the two types of POP and what is the difference?
Traditional progesterone - missed pill is after 3 hours
Desogestrel pill - pill can be taken up to 12 hours late. Pill inhibits ovulation
How long after starting the POP is a woman protected?
Day 1-5 of cycle = immediately
Otherwise = after 48 hours
What is the main side effect of the POP?
Unscheduled bleeding
A third have amenorrhoea
A third have regular bleeding
A third have irregular or prolonged bleeding
What are increased risks of the POP?
Ovarian cysts
Ectopic pregnancy
Breast cancer
What should a woman who has missed a POP do?
Take pill as soon as possible then take next pill as normal
Extra contraception for 48 hours
If they have had sex since missing pill - emergency contraception needed
What are contraindications to the progesterone only injection?
UKMEC4 = active breast cancer
UKMEC3: ischaemic heart disease, stroke, severe liver cirrhosis, liver cancer, unexplained vaginal bleeding
What are adverse effects of the progesterone only injection?
Irregular bleeding (can use COCP to manage bleeding)
Weight gain
Osteoporosis - switch to alternative by age 50
Reduced libido
What to do if there is a delay in changing contraceptive patch?
If delay at end of week 1 or week 2 - If been less than 48hrs, put on now, If been more than 48hrs, put on now and barrier for 7 days
If delay at end of week 3 - remove asap and start new one as normal
If delay at end of patch free week - barrier needed for 7 days
When does contraception need to be started after delivering?
After day 21
If breast-feeding and amenorrhoea - no contraception needed for 6 months
What contraception is first line in breastfeeding?
POP
COCP is contraindicated
What are the options of emergency contraception available in the UK?
Levonorgestrel = must be taken within 72 hours. Dose = 1.5mg. Double dose if BMI>26 or weight >70kg. 3mg
Ulipristal (ellaOne) = taken up to 120 hours after sex. Dose = 30mg. Caution in severe asthma. Delay breastfeeding for week.
Copper coil = taken within 5 days.
What is subfertility and how is it investigated?
When a couple has been unsuccessful in conceiving for at least 12 months
Blood tests - LH, FSH, anti-mullerian hormone, mid-luteal progesterone
Semen analysis
Refer for hysterosalpingogram
Scenario: sub fertility, irregular periods and raised LH
Polycystic ovarian syndrome
Scenario: subfertility, raised FSH and LH
Premature ovarian failure
Scenario: subfertility and low anti-mullerian hormone
Poor ovarian reserve
How is subfertility managed?
Anovulation (irregular periods) - Clomifene, ovarian drilling
Tubal problems - removal of adhesions, endometriosis etc
Uterine problems - removal of fibroids/polyps/adhesions etc
How long must men abstain from ejaculation prior to providing a semen sample?
3 days
Also avoid hot bags, saunas, tight underwear, caffeine
What to do if semen analysis comes back abnormal?
Repeat again in 3 months
If still abnormal - check LH, FSH, testosterone, genetic testing
What are causes of male factor infertility?
Pre-testicular causes = Low LH and FSH (leading to low testosterone) = pituitary or hypothalamus pathology, suppression due to stress, Kallmann’s syndrome
Testicular causes = Testicular damage
Genetic disorder e.g. Klinefelter’s
Post-testicular e.g. obstruction/retrograde ejaculation/absence of vas deferens in CF
What is the most common site for ectopic pregnancy and what is the most common site for ruptured ectopic pregnancy?
Ectopic pregnancy = Ampulla of Fallopian tube
Ruptured ectopic pregnancy = Isthmus of Fallopian tube
How does an ectopic pregnancy present?
Missed period
Lower abdominal pain/tenderness
Vaginal bleeding (may be dark brown)
Cervical motion tenderness
How might a ruptured ectopic pregnancy present?
Shoulder tip pain
How is ectopic pregnancy seen on TVUSS?
Gestational sac containing a yolk sac or fetal pole
May be a non specific mass (it will move separately to the ovary - this is how you differentiate it from the corpus Luteum)
Empty uterus
Free fluid in the pouch of Douglas (more so in ruptured but can still be in ectopc pregnancy)
How does the HCG level change over 48 hours in ectopic pregnancy?
Will rise but less than 63% rise
What are the three types of management for an ectopic pregnancy?
Expectant - monitor over 48 hours
Medical - Methotrexate. Follow up needed. Contraception for 3 months.
Surgical - salpingectomy or salpingotomy
What are the requirements for expectant management of ectopic pregnancy?
Adnexal mass no more than 35mm
Unruptured
Asymptomatic
No heart beat
bHCG <1000
What are the requirements for medical management of ectopic pregnancy?
Adnexal mass no more than 35mm
Unruptured
No significant pain
No heartbeat
bHCG <1500
What are indications for surgical management of ectopic pregnancy?
Adnexal mass more than 35mm
Ruptured
Significant pain
Visible heartbeat
bHCG >5000
What is a molar pregnancy and what are the two types?
A tumour that grows like a pregnancy inside the uterus
Complete mole - two sperm cells fertilise empty ovum
Partial mole - two sperm cells fertilise a normal ovum
What are features of a molar pregnancy?
Stopped periods
More severe morning sickness
Increased enlargement of uterus
Abnormally high bHCG
Thyrotoxicosis - low TSH, high thyroxin
What is seen on ultrasound in molar pregnancy?
Complete mole - snowstorm appearance
Partial mole - fetal tissue may be seen
How is a molar pregnancy managed?
Evacuation of the uterus - send products to histology
Scenario: woman who has had an evacuation for molar pregnancy, bHCG levels have not dropped
Choriocarcinoma
Specialist referral for chemotherapy
What is a threatened miscarriage?
Painless bleeding before 24 weeks
Cervical os = closed
What is a missed miscarriage?
Fetus died
No symptoms of miscarriage
Cervical os is closed
What is an inevitable miscarriage?
Bleeding before 24 weeks
Cervical os = open
What is an incomplete miscarriage?
Not all products have been expelled
Pain and bleeding
Cervical os = open
How is a miscarriage managed?
Less than 6 weeks - send home
More than 6 weeks:
If no heavy bleeding/infection - repeat bHCG in 48 hours
If persistent bleeding - vaginal misoprostol
If Rh -ve = Anti-D is needed
What are causes of recurrent miscarriage?
3 or more consecutive miscarriages
Idiopathic
Antiphospholipid syndrome
Hereditary Thrombophilia
Uterine abnormalities
Diabetes
Thyroid disease
What are the three things that you look for on ultrasound in early pregnancy?
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat
What is the criteria for hyperemesis gravidarum?
Long lasting nausea and vomiting
More than 5% weight loss
Dehydration
What are first line anti-emetics for nausea and vomiting in pregnancy?
Anti-histamines -> Cyclizine or promethazine
Prochlorperazine
Chlorpromazine
When should you consider admission for nausea and vomiting in pregnancy?
Unable to keep down fluids
More than 5% weight loss
Ketones in urine
What is the medical method of termination of pregnancy?
Oral mifepristone
Oral or vaginal misoprostol 1-2 days later
If Rh -ve = anti-D needed if woman is at least 10 weeks pregnant
How long can a pregnancy test remain positive after termination?
4 weeks
If still positive beyond 4 weeks - further investigation needed
What is the Rotterdam criteria for diagnosing PCOS?
- Oligovulation/Anovulation
- Hyperandrogenism
- Polycystic ovaries on ultrasound (at least 12 follicles) OR ovarian volume of more than 10cm^3
How is diabetes screened for in patients with PCOS?
2 hour oral glucose tolerance test
What are complications of PCOS?
Insulin resistance and diabetes
Acanthosis nigricans
Cardiovascular disease
Endometrial hyperplasia/endometrial cancer
Depression and anxiety
Sexual problems
What is the differential diagnosis for hirsutism?
Medications – phenytoin, ciclosporin, corticosteroids, testosterone, anabolic steroids
Ovarian/adrenal tumours secreting androgens
PCOS
Cushing’s syndrome
Congenital adrenal hyperplasia
What medication can be used to help women with PCOS lose weight?
Orlistat
How can hirsutism be managed in patients with PCOS?
COCP – specifically Dianette
Topical eflornithine
Electrolysis/laser hair removal
Spironolactone
Finasteride
How can acne be managed in women with PCOS?
First line = COCP
Other options = topical adapalene, oral antibiotics
How long does it take for all contraception to start working (if not started on first day of cycle)?
POP - 2 days
All others - 7 days
Which type of ovarian cyst is most likely to rupture?
Corpus luteum cyst
What is the characteristic finding on ultrasound in a ruptured ovarian cyst?
Free fluid in the pouch of Douglas
What are medication causes of hirsutism?
Phenytoin Ciclosporin Corticosteroids Testosterone Anabolic steroids
What might be seen on pelvic ultrasound in endometriosis?
Endometrioma (lump of endometrial tissue) Chocolate cysts (endometrioma in the ovary)
How is subfertility related to anovulation managed?
Clomifene
Ovarian drilling
How is subfertility related to tubal problems managed?
Removal of adhesions
Removal of endometriosis
How is subfertility related to uterine problems managed?
Removal of fibroids/polyps/adhesions etc
What is the 2WW criteria for ovarian cancer?
Ascites + pelvic or abdominal mass which is not obviously utrine fibroids
What does CA125 need to be to arrange an ultrasound?
> 35
If ultrasound suggests ovarian cancer – urgent referral 2WW gynae
What other tumour markers alongside Ca125 needs to be done in women under 40 when suspecting ovarian cancer?
Alpha fetoprotein + beta HCG
What does free fluid in the pouch of douglas indicate on TVUSS?
Ectopic pregnancy or ruptured ovarian cyst
When is the Copper IUD more effective than Levonogestel/EllaOne for emergency contraception?
When ovulation has occurred
When does ovulation typically occur?
Day 14
Does a pregnancy test need to be taken after taking emergency contraception?
Only if period is late or going straight back onto hormonal contraception
What is the most effective emergency contraceptive?
Copper IUD
How long after taking ulipristal (EllaOne) do patients need to wait before restarting contraception?
Wait 5 days before starting any hormonal contraception
How long after taking levonogestrel emergency contraception can a woman restart her normal hormonal contraception?
Immediately
Can ulipristal and levonogestrel be used more than once in the same cycle?
Yes
In which patients should ulipristal be avoided/used with caution?
Patients with asthma
Can copper IUD be used more than 5 days after unprotected sex for emergency contraception?
Yes - if up to 5 days post-ovulation
In which patient should the copper coil be avoided for emergency contraception?
If there is any risk of STI
Which HRT increases risk of breast cancer?
Combined HRT
How long after delivery do you need to wait before restarting COCP?
3 weeks (due to increased risk of VTE)
When can an IUD/IUS be fitted after delivery?
Either within 48 hours of delivery or 4 weeks after delivery
Which is the most common type of ovarian cancer in pre-menopausal women? What tumour markers are associated?
Germ cell ovarian tumour
bHCG and alpha fetoprotein
What is the most common type of ovarian cancer?
Epithelial ovarian tumour
