Gynaecology Flashcards
How would you investigate somebody with heavy menstrual bleeding?
Full history: duration, frequency, volume, presence of clots
Associated symptoms, any IM bleeding, pain, signs of infection
Clotting abnormalities/bleeding disorders
TV, abdominal and speculum examinations
Bloods: FBC, clotting
TV/Abdominal USS
What is the treatment for menorrhagia?
Mirena coil= first line
COCP if opposed to a coil
TXA or mefanamic acid for non-hormonal/contraceptive option
Surgical: endometrial ablation, myomectomy of fibroids, hysterectomy
What are the differentials for dysfunctional uterine bleeding?
Polyps
Adenomyosis
Leiomyoma (fibroids)
Malignancy
Coagulopathy Ovarian dysfunction Endometrial processes Iatrogenic e.g. anticoagulants No clear cause STIs
What are the symptoms of uterine fibroids?
Dysfunctional/heavy bleeding
Dysmenorrhoea
Abdominal bloating/palpable mass
Subfertility
How should fibroids be investigated?
Full obstetric and gynaecological history
Abdominal, PV and speculum examination
TVUSS
How can fibroids be managed?
If not too troublesome, don’t need to be treated.
For bleeding: COCP / TXA + mefanamic acid
Surgical methods: uterine artery embolisation, myomectomy, hysterectomy
Recommended surgical treatment for those still wanting to conceive = myomectomy
What are the characteristic symptoms of BV?
White/grey discharge
Offensive smell- fishy
How is BV diagnosed?
Combination of: presence of homogenous white/grey discharge characteristic foul-smell vaginal pH >5.5 clue cells on microscopy
How is BV managed?
Oral metronidazole: 2g stat dose or 5 day course
alt- topical clindamycin
Avoid over-washing
What are the symptoms of chlamydia (if there are any)
Dysuria
Abnormal discharge
Abnormal PV bleeding
In men: penile discharge
May present with complications: epididymo-orchitis, Reiter synd: arthritis/conjunc/urethritis
How is chlamydia treated?
Azithromycin 1g STAT
Doxycycline 7 day course
Oral erythromycin in pregnancy
Contact tracing + no unprotected sex for 1 week
Which types of HPV cause warts?
6 & 11
Which types of HPV cause cervical cancer?
16 & 18
What are the symptoms of HPV?
May be asymptomatic
Painless lumps in genito-anal region
Genital itch/contact bleeding
How is HPV diagnosed?
Clinical diagnosis
Smear testing
How is HPV treated?
Cryotherapy 1st line
Topical podophyllotoxin or imiquimod - not in pregnancy
Surgical removal
What are the complications of chlamydia?
PID
Tubal infertility
Reiter syndrome: reactive arthritis, conjunctivitis, urethritis
Epididymo-orchitis
Fitz-Hugh-Curtis syndrome: perihepatitis syndrome
What would chlamydia look like on gram stain?
Gram negative
Can be rod or cocci
What would gonorrhoea look like on gram stain?
Gram negative diplococci
How is gonorrhoea managed?
IM ceftriaxone + stat 1g oral azithromycin
Which type of HSV causes genital herpes?
HSV 2
What are the symptoms of genital herpes?
Prodromal genital itch and pain
Painful genital blisters
Inguinal lymphadenopathy
May also have general flu-like illness
How is herpes diagnosed?
Clinical appearance
PCR of blister fluid
How is herpes treated?
No cure Contact tracing Topical anaesthetics + simple analgesia Oral acyclovir 5 days No unprotected sex while blisters still present
What are the symptoms of trichomonas vaginalis?
Yellow-green discharge, may be frothy and foul smelling
Strawberry cervix
Dysuria, vaginal soreness/itchiness
How is trichomonas diagnosed?
Wet smear from posterior fornix
How is trichomonas vaginalis treated?
Stat dose oral metronidazole 2g OR 5-7 day course
What are the signs of primary syphilis?
Painless genital ulcer: chancre
Inguinal lymphadenopathy
What are the symptoms of secondary syphilis?
Widespread lymphadenopathy
Generalised rash on palms and soles
Anterior uveitis
Genital wart-like lesions: condyloma lata
How is syphilis diagnosed?
Treponemal + non-treponemal enzyme immunoassay
If both positive: syphilis
If trep +ve and non-trep -ve: primary/latent
If trep -ve and non-trep +ve: false positive result
If both negative: no syphilis
How is syphilis managed?
IM Benzathine benzylpenicillin stat
How is vaginal candidiasis managed?
Topical Clotrimazole cream or pessary
Oral fluconazole- omit in pregnancy
What are the symptoms of PID?
Lower abdominal pain Discharge- classically foul smelling Abdominal tenderness Systemic symptoms- fever, vomiting Abnormal bleeding, painful/irregular periods Deep dyspareunia
Cervical excitation
Can present with sepsis/pelvic abscesses
What investigations are indicated in suspected PID?
Full gynaecological history Abdominal, PV, speculum examination Comprehensive PV swabs Bloods: FBC, CRP, cultures if septic, B-hcg TV USS Laparoscopy= gold standard but invasive
How is PID managed?
Contact tracing
Sepsis 6 if septic
IV antibiotics- ceftriaxone and doxycycline -> oral metronidazole and doxy 14/7
If milder- IM ceftriaxone STAT and oral doxy 14/7
What are the potential complications of PID?
Tube-Ovarian abscesses, tubal strictures -> reduced fertility Sepsis Fitz-Hugh-Curtis syndrome Recurrent PID Ectopic pregnancy
What are the symptoms of endometriosis?
Chronic pelvic pain
Extremely painful periods which may also be heavy
Dysparaeunia, dysuria, pain on defaecation
Blood in urine and stool
Chronic fatigue, change in bowel habit
Subfertility
How is endometriosis diagnosed?
Gold standard= laparoscopy, but this is invasive
TVUSS usually done first to look for endometriomas
How is endometriosis managed?
COCP first line
Mirena coil
GNRH analogues
aromatase inhibitors
- > surgical coagulation/ablation/excision of lesions
- > hysterectomy as last resort
Which nerve roots control the pelvic floor?
S2, 3 and 4
What investigations should be done in somebody presenting with incontinence?
Urine dip- rule out UTI
Medication review + frequency/volume chart
Abdominal and vaginal examination- rule out prolapse, assess pelvic floor
Bladder scan- rule out incomplete bladder emptying
Urodynamics
Cystourethroscopy
Contrast enhanced CT
What are the managements for stress incontinence?
- Weight loss, smoking cessation, manage triggers, reduce caffeine and alcohol
- Pelvic floor retraining
- Duloxetine- SNRI which helps enhance sphincter activity
- Colposuspension and urethral sling procedures
How is urge incontinence managed?
- Bladder retraining e.g. double voiding, prophylactic voiding
- Pelvic floor strengthening
- Anti-muscarinic medication: oxybutynin
- To reduce anti-cholinergic burden in the elderly, use mirabegron
How is overactive bladder syndrome managed?
Behavioural techniques: fluid restriction, caffeine and alcohol cessation,
Medication review
Bladder retraining
Anticholinergic medication: oxybutynin, mirabegron
Detrusor muscle botox
Sacral nerve stimulation
Detrusor myomectomy
What is a procidentia?
3rd degree uterine prolapse
-> lowest part of the prolapse lies outside the vagina
What are the symptoms of pelvic organ prolapse?
Uterine:
Dragging sensation down below / heaviness
Feeling of a mass, difficult inserting tampons
Dyspareunia
Leakage of urine
Perineal pain
Cysto-urethrocele:
Urgency, frequency, nocturia, recurrent UTI, incontinence
Rectocele:
Constipation, difficulty defecating
How would you investigate suspected uterine organ prolapse?
Bimanual and speculum examination - cough test
Assessment of pelvic floor muscle strength
USS to exclude any masses
Urodynamics if suffering incontinence
How can pelvic organ prolapse be managed?
- Pelvic floor exercises
- Vaginal cones
- Intra-vaginal pessary: need changing every 6 months, topical oestrogen to prevent atrophy
- Surgical repair: hysterectomy, ligament suspension, anterior/posterior/paravaginal repair
What is the gold standard test for ovarian torsion?
Pelvic ultrasound with doppler colour flow to assess blood supply
What are the symptoms of PCOS?
Oligo/amenorrhoea Hirsutism Acne Weight gain/inability to lose weight Alopecia Subfertility
What are the diagnostic criteria for PCOS?
ROTTERDAM CRITERIA
Symptomatic + Clinical + Investigative
Symptoms of oligo/amenorrhoea/subfertility
Clinical signs of hyperandrogegism: hirsutism, acne
USS evidence of polycystic ovaries/ovary volume >10ml
How would you investigate suspected PCOS?
Full history and menstrual history
Bloods: FSH, LH and oestrogen, androgens + prolactin
High LH, FSH + oestrogen normal/slightly low
Raised androgens, prolactin normal (excludes other cause of amenorrhoea)
Pelvic USS
How is PCOS managed?
Weight loss
COCP and metformin to try and regulate periods
Antiandrogens e.g. finasteride, spironolactone to try and reduce symptoms
Hair removal/laser
Acne treatment
If trying to conceive: clomiphene, ovarian diathermy
How often is the depot-provera given?
Every 12-13 weeks
What are the disadvantages associated with the contraceptive injection?
Weight gain
Irregular periods
Can take <12m for fertility to return
Which methods of contraception are associated with drug interactions?
Implant
Contraceptive patch
Combined oral contraceptive
anticonvulsants, St John’s wort, macrolides, rifampicin, HIV medication
What are the starting rules for the COCP/injection/implant/IUD?
If started in first 5 days of cycle: immediate protection
Otherwise, 7 day window in which barrier contraception should be used
What are the starting rules for the POP?
If in first 5 days of cycle, immediate protection
If later, need barrier protection for 48 hours
What are the missed pill rules for the COCP?
1 missed: take missed one ASAP and continue as normal (ie take 2 on first day)
2+ missed: if in week 2-3, take last missed one, condoms 7 days
if in week 1, consider EC, take last missed one, condoms 7 days
If you ever vomit within 2 hours of taking the pill, take another
If suffering from severe diarrhoea, use condoms until at least 2 days after symptoms resolve
When can each type of contraception be started again after pregnancy?
COCP: if breastfeeding then after 6 weeks
if started on day 21 PP, immediate protection- any later then need condoms 7 days
POP: can be started immediately, but if later than 21 days PP then need condoms 48 hours
Implant/injection: can be started immediately, but if later than 21 days PP then need condoms 7 days
IUD/IUS: can be inserted either immediately after birth or after 4 weeks
Which type of emergency contraception is contraindicated in asthmatics?
Ella-one
Which type of emergency contraception requires barrier protection until the next period?
Ella-one
Binds to progesterone receptors so can interfere with hormonal contraceptives
Which is the most effective and reliable emergency contraception?
Copper coil
