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Medicine Finals > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What are the two subtypes of primary amenorrhoea?

A

Hypogonadotropic hypogonadism (low FSH and LH)

Hypergonadotropic hypogonadism (high FSH and LH)

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2
Q

What are causes of hypogonadotropic hypogonadism?

A

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

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3
Q

What are causes of hypergonadotropic hypogonadism?

A

Turner syndrome
Damaged ovaries

In men = Klinefelter’s, damaged testes

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4
Q

How is primary amenorrhoea investigated?

A 
Check FSH and LH
TFTs
Insulin like growth factor
Testosterone 
Prolactin
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5
Q

What is the definition of primary amenorrhoea?

A

No period by 13 and no other signs of puberty

No period by 15 with other signs of puberty

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6
Q

What is secondary amenorrhoea?

A

No menstruation for 3 months after previous regular menstrual periods

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7
Q

What are causes of secondary amenorrhoea?

A 
Pregnancy
Hyperprolactinaemia
PCOS
Menopause /premature ovarian failure
Pituitary failure 
Sheehan syndrome
Asherman syndrome
Hypothyroidism
Physiological/psychological stress
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8
Q

What is Sheehan syndrome?

A

Damage to pituitary gland caused by bleeding during childbirth

(Lack of oxygen causes damage to the pituitary)

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9
Q

What is Asherman’s syndrome

A

Adhesions within the uterus - usually due to D&C

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10
Q

What lab results are seen in hyperprolactinaemia?

A

Raised prolactin
Low GnRH
Low FSH and LH

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11
Q

How is Hyperprolactinaemia managed?

A

Dopamine agonist - bromocriptine or cabergoline

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12
Q

What does raised FSH + secondary amenorrhoea suggest?

A

Menopause / premature ovarian failure

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13
Q

What does raised LH + secondary amenorrhoea suggest?

A

Polycystic ovarian syndrome

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14
Q

What is premature ovarian failure?

A

Menopause before 40 years

Hypergonadotropic hypogonadism

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15
Q

What lab results are seen in premature ovarian failure?

A

Raised FSH and LH

Low oestrogen

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16
Q

How is premature ovarian failure managed?

A

HRT

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17
Q

Is contraception required in premature ovarian failure?

A

Yes - 2 years after last period

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18
Q

How does polycystic ovary syndrome present?

A 
Hirsutism
Acne
Weight gain
Oligomenorrhoea 
Male pattern hair loss
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19
Q

What is needed for diagnosis for PCOS?

A

Rotterdam criteria

Polycystic ovaries on ultrasound - at least 12 follicles seen on ultrasound or ovarian volume of more than 10cm^3

Anovulation

Raised testosterone

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20
Q

What lab results are seen in PCOS?

A 
Raised testosterone 
Raised LH
Raised LH:FSH ratio
Normal FSH
Raised insulin
Raised testosterone
Low sex-hormone binding globulin 
Raised anti mullerian hormone
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21
Q

How is PCOS managed?

A

Main issue with anovulation = risk of endometrial hyperplasia

Need to start COCP / POP / Mirena

2nd line after COCP for symptoms = spironolactone

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22
Q

How is PCOS managed in those looking to conceive?

A
  1. Clomifene

2. Ovarian drilling OR Metformin OR Gonadtrophins

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23
Q

How is heavy menstrual bleeding/menorrhagia defined?

A

Any bleeding that interferes with the woman’s quality of life

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24
Q

What are causes of menorrhagia?

A 
Fibroids
Polyps
Endometriosis
Adenomyosis
Clotting disorder

Idiopathic

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25
Q

How is menorrhagia investigated?

A

FBC - look for anaemia
Transvaginal ultrasound
Bimanual examination - if boggy suggests fibroids

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26
Q

How is idiopathic menorrhagia managed?

A

If idiopathic and no identified pathology, or fibroids less than 3cm:

  1. Mirena
  2. NSAIDs/Tranexamic acid/COCP/POP
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27
Q

What are the two types of dysmenorrhea ?

A

Primary and secondary

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28
Q

What is the management of dysmenorrhea ?

A

First line is NSAIDs
Also mefenamic acid

Then COCP

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29
Q

How is secondary dysmenorrhea managed?

A

Refer to gynae

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30
Q

What is a fibroid?

A

Benign tumour of the myometrium

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31
Q

How do fibroids present?

A

Often asymptomatic
Most common symptom = dysmenorrhoea (painful periods

Other symptoms
Prolonged menstruation
Abdominal pain
Deep dyspareunia
Urinary/bowel symptoms due to pressure
Reduced fertility
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32
Q

How are fibroids diagnosed?

A

Bimanual examination will reveal a boggy uterus (firm, non-tender)

Pelvic ultrasound will be initial investigation

Hysteroscopy for better view

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33
Q

How are fibroids managed ?

A

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

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34
Q

How do you reduce the size of the fibroid prior to myomectomy?

A

A GnRH agonist e.g. goserelin/leuprolelin/triptorelin

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35
Q

When do fibroids regress?

A

In menopause - because they are oestrogen dependent

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36
Q

What is red degeneration ?

A

A complication of fibroids in pregnancy

Presents as abdominal pain, fever and vomiting

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37
Q

What is a polyp?

A

Benign growth of the endometrium in the uterus / cervix

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38
Q

What is the most common cause of post menopausal bleeding?

A

A polyp

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39
Q

How does a polyp present?

A

Intermenstrual bleeding
Post menopausal bleeding
Menorrhagia

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40
Q

How is a polyp managed ?

A

Diathermy

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41
Q

How does endometriosis present?

A

Cyclical pelvic pain

Deep dyspareunia

Dysmenorrhea

Reduced fertility

Cyclical urinary/bowel symptoms

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42
Q

How is endometriosis diagnosed?

A

Definitive diagnosis is laparoscopic surgery

Pelvic ultrasound may show an endometrioma (lump of endometrial tissue) or chocolate cysts (an endometrioma in the ovary)

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43
Q

How is endometriosis managed?

A

1st line = Analgesia (NSAID)

COCP / POP / Mirena can be trialled prior to surgery

GnRH agonist

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44
Q

What is Adenomyosis and how does it present?

A

Endometrial tissue that lies within the myometrium

Chronic pelvic pain

Dysmenorrhea

Menorrhagia

Enlarged, boggy uterus (but not firm as seen with fibroids)

Dyspareunia

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45
Q

How is adenomyosis diagnosed?

A

Gold standard diagnosis is MRI Pelvis

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46
Q

How is adenomyosis managed?

A

Same as menorrhagia

First line = Mirena

Also - COCP, tranexamic acid

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47
Q

How long must a woman have amenorrhoea to be classed as menopausal?

A

12 months

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48
Q

What is classed as premature menopause

A

Before 40 years

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49
Q

What are features of menopause?

A

Hot flushes

Low mood

Irregular periods (in perimenopausal period) - may be heavier or lighter

Joint pains

Vaginal dryness

Reduced libido

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50
Q

What does menopause increase the risk of?

A

CVD and stroke

Osteoporosis

Pelvic organ prolapse

Urinary incontinence

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51
Q

How does hormonal analysis look in menopause?

A

High FSH and LH (due to lack of negative feedback from oestrogen)

Low oestrogen and progesterone

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52
Q

How long does contraception need to be used after the last period?

A

Under 50 - continue contraception for 2 years

Over 50 - continue contraction for 1 year

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53
Q

What are the different types of hormone replacement therapy and when are they used?

A

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

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54
Q

What are contraindications to hormone replacement therapy?

A

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

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55
Q

What does HRT increase the risk of?

A

Breast cancer

Endometrial cancer

VTE

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56
Q

What else can be used to manage symptoms in menopause other than HRT?

A

Fluoxetine can be used for vasomotor symptoms

Vaginal lubricants

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57
Q

What are causes of post-coital bleeding?

A

The most common cause is cervical ectropion

Cervicitis

Cervical polyp

Cervical cancer

Trauma

Often no cause

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58
Q

What is cervical ectropion and what is the most important risk factor?

A

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.

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59
Q

What is seen on speculum examination in patients with cervical ectropion?

A

A well demarcated border between the red columnar epithelium and pink squamous epithelium

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60
Q

How is cervical ectropion treated?

A

Treatment is not necessary but cryotherapy can be conducted

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61
Q

How does an ovarian cyst present?

A

Usually asymptomatic

Can be a palpable mass in the pelvis

Can cause symptoms - pelvic pain, bloating, fullness (early satiety)

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62
Q

What is the most common type of ovarian cyst?

A

Follicular cyst

Developing follicle that fails to rupture and release an egg

Harmless

Usually regresses after several menstrual cycles

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63
Q

How are symptoms of ovarian cyst/ovarian cancer investigated?

A

Transvaginal ultrasound = first line

If 5cm or more/ complex cyst (solid material) or in post-menopausal women -> CA125 + Alpha fetoprotein + bHCG

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64
Q

How are simple ovarian cysts treated?

A

<5cm: no further management

5-7cm: yearly monitoring

> 7cm: consider MRI or surgical evaluation

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65
Q

What is Meig’s syndrome?

A

Triad of:

Ovarian fibroma

Pleural effusion

Ascites

Management = removal of ovarian tumour

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66
Q

How does ovarian cyst rupture present?

A

Severe one sided abdominal pain

Shock

Nausea+vomiting

Often precipitated by intercourse/exercise

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67
Q

What is ovarian torsion and how does it present?

A

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

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68
Q

How is ovarian torsion diagnosed?

A

TVUSS

whirlpool sign

free fluid in pelvis

oedema of ovary

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69
Q

How is ovarian torsion managed?

A

Emergency laparoscopic surgery

Either detorsion or oophorectomy

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70
Q

What is the main type of ovarian cancer?

A

Epithelial

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71
Q

What are risk factors for ovarian cancer?

A

Early menarche

Late menopause

Nulliparity

(More periods = more risk)

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72
Q

How does ovarian cancer present?

A

Vague symptoms

Bloating

Early satiety

Diarrhoea

Urinary symptoms

May be abdominal/pelvic pain

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73
Q

What is the criteria for checking CA125?

A

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

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74
Q

How do you manage a woman with symptoms of ovarian cancer and raised CA125?

A

Calculate RMI

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75
Q

How is RMI (Risk of malignancy index) for ovarian cancer calculated?

A

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

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76
Q

How is ovarian cancer staged?

A

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)

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77
Q

Which women get direct referral to 2WW for possible ovarian cancer without further investigation?

A

Post menopausal women with…

Ascites

Pelvic mass

Abdominal mass

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78
Q

Which tumour markers can suggest a possible germ cell tumour in ovarian cancer?

A

Alpha feto-protein

HCG

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79
Q

What are causes of a raised CA125 other than ovarian cancer?

A

Endometriosis

Fibroids

Adenomyosis

Pelvic infection

Liver disease

Pregnancy

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80
Q

Endometrial hyperplasia seen on TVUSS - how is this managed? What is endometrial hyperplasia?

A

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

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81
Q

What is the main type of endometrial cancer?

A

Adenocarcinoma

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82
Q

What is the 2WW criteria for endometrial cancer?

A

Post-menopausal woman with bleeding

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83
Q

What are risk factors for endometrial cancer?

A

Unopposed oestrogen

PCOS (lack of ovulation)

Obesity (adipose is a source of oestrogen)

T2DM (insulin stimulates endometrial cell growth)

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84
Q

What factors are protective for endometrial cancer?

A

Smoking

COCP

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85
Q

What endometrial measurement is classed as hyperplasia?

A

More than 4mm

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86
Q

How is endometrial cancer staged?

A

Stage 1: confined to uterus

Stage 2: involves cervix

Stage 3: involves ovaries/fallopian tubes/vagina/lymph nodes

Stage 4: bladder/rectum/beyond pelvis

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87
Q

What is the main type of cervical cancer?

A

Squamous cell carcinoma

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88
Q

Which virus is cervical cancer strongly associated with?

A

HPV - 16 and 18

89
Q

What are risk factors for cervical cancer?

A

Smoking

HIV

COCP

Multiparity

Family history

90
Q

How does cervical cancer present?

A

Often asymptomatic

Can present with post-coital/intermenstrual bleeding and dyspareunia

91
Q

How are symptoms of cervical cancer investigated?

A

Speculum examination

If abnormal appearance of cervix (ulceration/bleeding/inflammation/visible tumour) -> urgent referral to gynae 2WW for colposcopy

92
Q

What is cervical intraepithelial neoplasia?

A

Pre-malignant change of cells in the cervix

Diagnosed on colposcopy

93
Q

How often are women invited for smear tests?

A

Every 3 years from 25 to 49

Every 5 years from 50 to 64

Every year in women with HIV

94
Q

How often are women with HIV invited for a smear test?

A

Every year

95
Q

When can a pregnant woman receive a smear test?

A

Not until at least 12 weeks post partum

96
Q

Smear result: inadequate?

A

Repeat in 3 months

If still inadequate - colposcopy within 6 weeks

97
Q

Smear result: HPV negative?

A

Return to normal pathway

98
Q

Smear result: HPV positive and abnormal cytology?

A

Refer for colposcopy

99
Q

Smear result: HPV positive and normal cytology?

A

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

100
Q

What is the most common type of vulval cancer?

A

Squamous cell carcinoma

101
Q

What are risk factors for vulval cancer?

A

Advanced age (>75)

Immunosuppression

Lichen sclerosis

HPV infection

102
Q

How does vulval cancer present?

A

Vulval limp or ulcer

Itching / pain / bleeding

Groin lymphadenopathy

103
Q

How is suspected vulval cancer managed?

A

Urgent 2WW referral

Biopsy and sentinel node biopsy

104
Q

What is lichen sclerosus and how does it present?

A

Autoimmune Inflammatory skin condition that commonly affects labia (associated with other autoimmune conditions)

Older woman with vulval itching, soreness, pain, superficial dyspareunia

NO LUMP

105
Q

How does lichen sclerosus appear?

A

Porcelain-white appearance

Shiny, tight, thin

Slightly raised

106
Q

How is lichen sclerosus managed?

A

Potent topical corticosteroids - Clobetasol 0.05% (Dermovate)

Emollients

107
Q

What is atrophic vaginitis? How does it present?

A

Dryness and atrophy of the vaginal mucosa caused by lack of oestrogen in menopause

causes itching, dryness, dyspareunia, bleeding

108
Q

How is atrophic vaginitis managed?

A

Vaginal lubricants

Topical oestrogen (CI in breast cancer, angina and VTE)

109
Q

What is pelvic inflammatory disease and what is the most common organism?

A

Infection and inflammation of the pelvic organs (uterus, Fallopian tubes, ovaries)

Most common organism = Chlamydia, also Gonorrhoea (tends to produce more severe PID)

110
Q

What are symptoms and signs pelvic inflammatory disease?

A

SYMPTOMS

Lower abdominal pain

Fever

Deep dyspareunia

Irregular bleeding

Dysuria

SIGNS

Purulent discharge

Cervicitis

Cervical motion tenderness

Pelvic tenderness

111
Q

What are risk factors for pelvic inflammatory disease?

A

New or multiple sexual partners

Recent IUD insertion

Not using barrier contraception

Existing STIs

Previous PID

112
Q

How do you investigate pelvic inflammatory disease?

A

Pregnancy test - rule out ectopic pregnancy

High vaginal swab

Microscope - pus cells

Inflammatory markers

113
Q

How is pelvic inflammatory disease treated?

A

Antibiotics

E.g.

IM Ceftriaxone (gonorrhoea) + PO Doxycycline (chlamydia and mycoplasma genitalium) + PO Metronidazole (anaerobes)

114
Q

What is Turner Syndrome and what are features?

A

Only one X chromosome or deletion of short arm

Short stature

Widely spaced nipples

Webbed neck

Bicuspid aortic valve

Primary amenorrhoea

115
Q

What conditions are associated with Turner syndrome?

A

Recurrent otitis media

Recurrent UTI

Coarctation of the aorta

Hypothyroidism

Obesity

Diabetes

Osteoporosis

116
Q

What are the different types of pelvic organ prolapse?

A

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)

117
Q

What are risk factors for pelvic organ prolapse?

A

Multiple vaginal deliveries

Prolonged / traumatic delivery

Advanced age / postmenopausal

Obesity

Chronic constipation

118
Q

How does pelvic organ prolapse present?

A

Feeling of something coming down / draggingl

Urinary symptoms - incontinence, urgency, frequency

Bowel symptoms - constipation, incontinence, urgency

Sexual dysfunction (pain, altered sensation)

119
Q

What is the stepwise management of pelvic organ prolapse?

A
  1. Conservative (physio, weight loss, vaginal oestrogen cream, treating associated stress incontinence)
  2. Vaginal pesssaries (ring, shelf, cube, donut, hodge)
  3. Surgery
120
Q

What is the difference between stress and urge incontinence?

A

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

121
Q

How is urinary incontinence investigated?

A

Urine dipstick - rule out infection and DM

Bladder diary

Post-void residual bladder volume

If unclear diagnosis/difficulty urinating/previous surgery -> urodynamic testing

122
Q

What medication needs to be stopped prior to urodynamic testing? And how long before?

A

Anticholinergic medication needs to be stopped at least 5 days prior

123
Q

How can stress incontinence be managed?

A

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

124
Q

Which medication can be offered for stress incontinence?

A

Duloxetine (SNRI)

125
Q

How can urge incontinence be managed?

A

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

126
Q

What are side effects of oxybutynin?

A

Dry mouth

Dry eyes

Urinary retention

Constipation

127
Q

What are contraindications for Micabegron?

A

Uncontrolled hypertension

128
Q

Which contraception should be avoided in active breast cancer?

A

Avoid all hormonal contraception

129
Q

Which contraceptions should be avoided in cervical/endometrial cancer?

A

Mirena

130
Q

What is the first line COCP?

A

Microygnon/Leostrin (lower risk of VTE

131
Q

Which is the first line COCP for premenstrual syndrome?

A

Yasmin (drosperinone)

132
Q

What is the first line contraceptive for acne and hirsutism?

A

Dianette (but there is a higher risk of VTE)

133
Q

What are adverse effects and risks of the COCP?

A

Adverse effects - unscheduled bleeding, breast tenderness, mood changes, headaches

Risks - increased risk of VTE, breast cancer, cervical cancer, MI, stroke

134
Q

What are contraindications to the COCP?

A

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)

135
Q

How long after starting the COCP is a woman protected?

A

If started in cycle days 1-5 = immediately

Otherwise = after 7 days

136
Q

What should a woman do if she has missed one COCP?

A

If it has been between 24 to 72 hours - take the missed pill and usual pill

137
Q

What should a woman who has missed more than 2 pills of COCP do?

A

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

138
Q

How long prior to major surgery should COCP be stopped?

A

4 weeks

139
Q

What to do if someone on COCP/POP has had diarrhoea or vomiting?

A

Assume missed pill

140
Q

What is the only major contraindication for the progesterone only pill?

A

Active breast cancer

141
Q

What are the two types of POP and what is the difference?

A

Traditional progesterone - missed pill is after 3 hours

Desogestrel pill - pill can be taken up to 12 hours late. Pill inhibits ovulation

142
Q

How long after starting the POP is a woman protected?

A

Day 1-5 of cycle = immediately

Otherwise = after 48 hours

143
Q

What is the main side effect of the POP?

A

Unscheduled bleeding

A third have amenorrhoea

A third have regular bleeding

A third have irregular or prolonged bleeding

144
Q

What are increased risks of the POP?

A

Ovarian cysts

Ectopic pregnancy

Breast cancer

145
Q

What should a woman who has missed a POP do?

A

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

146
Q

What are contraindications to the progesterone only injection?

A

UKMEC4 = active breast cancer

UKMEC3: ischaemic heart disease, stroke, severe liver cirrhosis, liver cancer, unexplained vaginal bleeding

147
Q

What are adverse effects of the progesterone only injection?

A

Irregular bleeding (can use COCP to manage bleeding)

Weight gain

Osteoporosis - switch to alternative by age 50

Reduced libido

148
Q

What to do if there is a delay in changing contraceptive patch?

A

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

149
Q

When does contraception need to be started after delivering?

A

After day 21

If breast-feeding and amenorrhoea - no contraception needed for 6 months

150
Q

What contraception is first line in breastfeeding?

A

POP

COCP is contraindicated

151
Q

What are the options of emergency contraception available in the UK?

A

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.

152
Q

What is subfertility and how is it investigated?

A

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

153
Q

Scenario: sub fertility, irregular periods and raised LH

A

Polycystic ovarian syndrome

154
Q

Scenario: subfertility, raised FSH and LH

A

Premature ovarian failure

155
Q

Scenario: subfertility and low anti-mullerian hormone

A

Poor ovarian reserve

156
Q

How is subfertility managed?

A

Anovulation (irregular periods) - Clomifene, ovarian drilling

Tubal problems - removal of adhesions, endometriosis etc

Uterine problems - removal of fibroids/polyps/adhesions etc

157
Q

How long must men abstain from ejaculation prior to providing a semen sample?

A

3 days

Also avoid hot bags, saunas, tight underwear, caffeine

158
Q

What to do if semen analysis comes back abnormal?

A

Repeat again in 3 months

If still abnormal - check LH, FSH, testosterone, genetic testing

159
Q

What are causes of male factor infertility?

A

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

160
Q

What is the most common site for ectopic pregnancy and what is the most common site for ruptured ectopic pregnancy?

A

Ectopic pregnancy = Ampulla of Fallopian tube

Ruptured ectopic pregnancy = Isthmus of Fallopian tube

161
Q

How does an ectopic pregnancy present?

A

Missed period

Lower abdominal pain/tenderness

Vaginal bleeding (may be dark brown)

Cervical motion tenderness

162
Q

How might a ruptured ectopic pregnancy present?

A

Shoulder tip pain

163
Q

How is ectopic pregnancy seen on TVUSS?

A

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)

164
Q

How does the HCG level change over 48 hours in ectopic pregnancy?

A

Will rise but less than 63% rise

165
Q

What are the three types of management for an ectopic pregnancy?

A

Expectant - monitor over 48 hours

Medical - Methotrexate. Follow up needed. Contraception for 3 months.

Surgical - salpingectomy or salpingotomy

166
Q

What are the requirements for expectant management of ectopic pregnancy?

A

Adnexal mass no more than 35mm

Unruptured

Asymptomatic

No heart beat

bHCG <1000

167
Q

What are the requirements for medical management of ectopic pregnancy?

A

Adnexal mass no more than 35mm

Unruptured

No significant pain

No heartbeat

bHCG <1500

168
Q

What are indications for surgical management of ectopic pregnancy?

A

Adnexal mass more than 35mm

Ruptured

Significant pain

Visible heartbeat

bHCG >5000

169
Q

What is a molar pregnancy and what are the two types?

A

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

170
Q

What are features of a molar pregnancy?

A

Stopped periods

More severe morning sickness

Increased enlargement of uterus

Abnormally high bHCG

Thyrotoxicosis - low TSH, high thyroxin

171
Q

What is seen on ultrasound in molar pregnancy?

A

Complete mole - snowstorm appearance

Partial mole - fetal tissue may be seen

172
Q

How is a molar pregnancy managed?

A

Evacuation of the uterus - send products to histology

173
Q

Scenario: woman who has had an evacuation for molar pregnancy, bHCG levels have not dropped

A

Choriocarcinoma

Specialist referral for chemotherapy

174
Q

What is a threatened miscarriage?

A

Painless bleeding before 24 weeks

Cervical os = closed

175
Q

What is a missed miscarriage?

A

Fetus died

No symptoms of miscarriage

Cervical os is closed

176
Q

What is an inevitable miscarriage?

A

Bleeding before 24 weeks

Cervical os = open

177
Q

What is an incomplete miscarriage?

A

Not all products have been expelled

Pain and bleeding

Cervical os = open

178
Q

How is a miscarriage managed?

A

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

179
Q

What are causes of recurrent miscarriage?

A

3 or more consecutive miscarriages

Idiopathic

Antiphospholipid syndrome

Hereditary Thrombophilia

Uterine abnormalities

Diabetes

Thyroid disease

180
Q

What are the three things that you look for on ultrasound in early pregnancy?

A

Mean gestational sac diameter

Fetal pole and crown-rump length

Fetal heartbeat

181
Q

What is the criteria for hyperemesis gravidarum?

A

Long lasting nausea and vomiting

More than 5% weight loss

Dehydration

182
Q

What are first line anti-emetics for nausea and vomiting in pregnancy?

A

Anti-histamines -> Cyclizine or promethazine

Prochlorperazine

Chlorpromazine

183
Q

When should you consider admission for nausea and vomiting in pregnancy?

A

Unable to keep down fluids

More than 5% weight loss

Ketones in urine

184
Q

What is the medical method of termination of pregnancy?

A

Oral mifepristone

Oral or vaginal misoprostol 1-2 days later

If Rh -ve = anti-D needed if woman is at least 10 weeks pregnant

185
Q

How long can a pregnancy test remain positive after termination?

A

4 weeks

If still positive beyond 4 weeks - further investigation needed

186
Q

What is the Rotterdam criteria for diagnosing PCOS?

A
  1. Oligovulation/Anovulation
  2. Hyperandrogenism
  3. Polycystic ovaries on ultrasound (at least 12 follicles) OR ovarian volume of more than 10cm^3
187
Q

How is diabetes screened for in patients with PCOS?

A

2 hour oral glucose tolerance test

188
Q

What are complications of PCOS?

A

Insulin resistance and diabetes

Acanthosis nigricans

Cardiovascular disease

Endometrial hyperplasia/endometrial cancer

Depression and anxiety

Sexual problems

189
Q

What is the differential diagnosis for hirsutism?

A

Medications – phenytoin, ciclosporin, corticosteroids, testosterone, anabolic steroids

Ovarian/adrenal tumours secreting androgens

PCOS

Cushing’s syndrome

Congenital adrenal hyperplasia

190
Q

What medication can be used to help women with PCOS lose weight?

A

Orlistat

191
Q

How can hirsutism be managed in patients with PCOS?

A

COCP – specifically Dianette

Topical eflornithine

Electrolysis/laser hair removal

Spironolactone

Finasteride

192
Q

How can acne be managed in women with PCOS?

A

First line = COCP

Other options = topical adapalene, oral antibiotics

193
Q

How long does it take for all contraception to start working (if not started on first day of cycle)?

A

POP - 2 days

All others - 7 days

194
Q

Which type of ovarian cyst is most likely to rupture?

A

Corpus luteum cyst

195
Q

What is the characteristic finding on ultrasound in a ruptured ovarian cyst?

A

Free fluid in the pouch of Douglas

196
Q

What are medication causes of hirsutism?

A 
Phenytoin
Ciclosporin
Corticosteroids
Testosterone
Anabolic steroids
197
Q

What might be seen on pelvic ultrasound in endometriosis?

A 
Endometrioma (lump of endometrial tissue)
Chocolate cysts (endometrioma in the ovary)
198
Q

How is subfertility related to anovulation managed?

A

Clomifene

Ovarian drilling

199
Q

How is subfertility related to tubal problems managed?

A

Removal of adhesions

Removal of endometriosis

200
Q

How is subfertility related to uterine problems managed?

A

Removal of fibroids/polyps/adhesions etc

201
Q

What is the 2WW criteria for ovarian cancer?

A

Ascites + pelvic or abdominal mass which is not obviously utrine fibroids

202
Q

What does CA125 need to be to arrange an ultrasound?

A

> 35

If ultrasound suggests ovarian cancer – urgent referral 2WW gynae

203
Q

What other tumour markers alongside Ca125 needs to be done in women under 40 when suspecting ovarian cancer?

A

Alpha fetoprotein + beta HCG

204
Q

What does free fluid in the pouch of douglas indicate on TVUSS?

A

Ectopic pregnancy or ruptured ovarian cyst

205
Q

When is the Copper IUD more effective than Levonogestel/EllaOne for emergency contraception?

A

When ovulation has occurred

206
Q

When does ovulation typically occur?

A

Day 14

207
Q

Does a pregnancy test need to be taken after taking emergency contraception?

A

Only if period is late or going straight back onto hormonal contraception

208
Q

What is the most effective emergency contraceptive?

A

Copper IUD

209
Q

How long after taking ulipristal (EllaOne) do patients need to wait before restarting contraception?

A

Wait 5 days before starting any hormonal contraception

210
Q

How long after taking levonogestrel emergency contraception can a woman restart her normal hormonal contraception?

A

Immediately

211
Q

Can ulipristal and levonogestrel be used more than once in the same cycle?

A

Yes

212
Q

In which patients should ulipristal be avoided/used with caution?

A

Patients with asthma

213
Q

Can copper IUD be used more than 5 days after unprotected sex for emergency contraception?

A

Yes - if up to 5 days post-ovulation

214
Q

In which patient should the copper coil be avoided for emergency contraception?

A

If there is any risk of STI

215
Q

Which HRT increases risk of breast cancer?

A

Combined HRT

216
Q

How long after delivery do you need to wait before restarting COCP?

A

3 weeks (due to increased risk of VTE)

217
Q

When can an IUD/IUS be fitted after delivery?

A

Either within 48 hours of delivery or 4 weeks after delivery

218
Q

Which is the most common type of ovarian cancer in pre-menopausal women? What tumour markers are associated?

A

Germ cell ovarian tumour

bHCG and alpha fetoprotein

219
Q

What is the most common type of ovarian cancer?

A

Epithelial ovarian tumour

Medicine Finals (32 decks)

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