Gynaecology Flashcards
Sx fibroids
Often asymptomatic
Can present as suprapubic mass and menorrhagia
Ix fibroids
Transvaginal US and bimanual exam
Treatment for fibroids <3cm
Mirena coil and NSAIDs
Tx fibroids >3cm
surgery
Sx endometriosis
Cyclical abdo pain
Ix endometriosis
Laparoscopy
Tx endometriosis
Analgesics and COCP
Sx ectopic pregnancy
Sholder tip pain
Unilateral pelvic pain
Vaginal bleeding
Ix ectopic pregnancy
Transvaginal US
Stress incontinence
Leaking of urine when intra-abdominal pressure increases
Tx stress incontinence
Pelvic floor exercises
Fluoxetine
Urge incontinence
Sudden loss of urine
Tx urge incontinence
Bladder training
Anticholinergics - oxybutynin
What is primary amenorrhoea?
Absence of periods in >15 girls with secondary sexual features or >13 without secondary sexual features
Causes of primary amenorrhoea
Turner’s, anorexia, malformed genital tract etc
Tx primary amenorrhoea
HRT
What is secondary amenorrhoea
No menstruation for 3-6 months if previously normal menses or 6-12 months if previous oligomenorrhoea
Causes of secondary amenorrhoea
Exercise, PCOS, hyperprolactinaemia, Sheehan’s/Asherman’s
When do you do artificial insemination?
Poor sperm or difficulty having sex
When do you do IVF?
If woman is <43 y/o, can screen genetics
What is a bartholin’s abscess?
Infected bartholin’s glands
treatment bartholin’s abscess
ABx and marsupialization
what is a bartholin’s cyst?
The duct becomes blocked, which leads to a build up of mucus
Sx bartholin’s cyst
- Normally painless
- Large cysts cause pain sitting etc
- Unilateral
- Soft, painless lump
treatment bartholin’s cyst
asymptomatic = no intervention
Cause of 1st trimester bleeding
- Miscarriage
- Ectopic pregnancy (+ve test with abdo pain, pelvic/cervical tenderness)
- Implantation bleeding
Management bleeding >6 weeks pregnant
early pregnancy assessment
Management bleeding <6 weeks + no ectopic sx
manage expectantly and safety net
Symptoms ectopic pregnancy
- bHCG>1500
- Lower abdo pain - constant and unilateral
- Vaginal bleeding - dark brown and little amount
- Amenorrhoea for 6-8 weeks
- Dizziness/syncope
What is dyspareunia?
Pain during/after sexual intercourse
Causes of superficial dyspareunia
Lack of arousal. vaginal atrophy
vaginitis/vaginismus
Causes of deep dyspareunia
PID
endometriosis/adenomyosis
What is dysmenorrhoea
painful periods
Primary dysmenorrhoea
Usually in younger pts as periods start, no underlying pathology, due to excess prostaglandins
Mx primary dysmenorrhoea
NSAIDs to reduce prostaglandin production
what is secondary dysmenorrhoea
Usually in older patients due to pathology
Management secondary dysmenorrhoea
gynae referral
What does a blue cervix indicate?
Chadwick’s sign for early pregnancy
Cervical ectropion
Columnar epithelialium extends into ectocervix and causes post-coital bleeding
How to differentiate ruptured ovarian cyst vs ovarian torsion
Ovarian cyst has symptoms in the past
Signet-ring cell on biopsy
Ovarian cancer metastases from stomach
Treatment Bartholin’s abscess/cyst
Word catheter, normally e.coli
How to differentiate between adenomyosis and endometriosis
adenomyosis uterus feels enlarged
most treatable cancer
choriocarcinoma
Management bleeding >6 weeks of pregnancy
Refer to early pregnancy unit
Management of bleeding <6 weeks of pregnancy
manage expectantly and safety net
sx ectopic pregnancy
bHCG >1500
Lower abdo pain
Dark brown vaginal bleeding
Amenorrhoea
Management primary dysmenorrhoea
NSAIDs to reduce prostaglandins
Management secondary dysmenorrhoea
Gynae referral
Risk factors for endometrial cancer
Obesity, nulliparity, increased oestrogen exposure
Sx endometrial cancer
post-menopausal bleeding
Ix endometrial cancer
> 55 with bleeding needs 2ww and trans-vaginal US
management endometrial cancer
hysterectomy with bilateral salpino-oophorectomy
what is fibroid degeneration?
fibroids are sensitive to oestrogen so grow in pregnancy. if they out-grow supply then they can degenerate
sx fibroid degeneration
pain, fever, vomiting
management fibroid degeneration
analgesia, self resolves <1 week
Investigations for heavy periods
FBC and trans-vaginal US
treatment for heavy bleeding if contraception needed
Mirena coil IUS
COCP
treatment for heavy bleeding if no contraception needed
tranexamic/mefenamic acid if pain
HRT side effects
nausea, tender breasts, weight gain, increased risk of breast/endometrial cancer and VTE
When do you normally see hyperemesis gravidarum?
8-12 weeks
Protective factor for morning sickness
Smoking
Diagnosis morning sickness
Dehydration, electrolyte imbalance and 5% weight loss
Management hyperemesis gravidarum
antihistamine (cyclising) or ondansetron/metocloprmaide
side effect ondansetron
increased risk of cleft palate
side effect metoclopramide
EPSEs
main cause of infertility
male factor
investigations for infertility
semen analysis and progesterone 7 days before period expected
progesterone results infertility
> 30 means ovulating
16-30 needs repeat
<16 needs repeat and referral
management of post-menopausal woman with cyst
urgent gynaecology referral
RF endometrial cancer
increased oestrogen
treatment for localised endometrial cancer
hysterectomy + bilateral salpino-oophorectomy
Types of HRT
oestrogen alone or oestrogen + progesterone
When should you prescribe combined HRT?
If woman has a uterus (just oestrogen increases endometrial cancer risk) give combined
What is the point of HRT?
A drop in oestrogen (menopause) is associated with vasomotor symptoms (flushing, insomnia, headaches) so this counteracts that
Indications for HRT
Indications include vasomotor symptoms (headaches, flushing, insomnia) and premature menopause (continue until ≥50 to reduce osteoporosis risk
When do you favour transdermal over oral HRT
if at high risk of VTE (smoker, obese, past stroke etc)
what does oestrogen increase your chances of getting?
endometrial and breast cancer and VTE
A 50-year-old woman attends requesting hormone replacement therapy (HRT). She has been experiencing hot flushes, night sweats, mood swings, vaginal dryness and reduced libido.
Her last period was 10 months ago and her uterus is intact. She is obese but has no other risk factors and has been counselled on the risks and benefits.
What HRT regimen would be most appropriate?
transdermal cyclical regimen - continuous should not be used within 12m of LMP
What is VIN?
pre-squamous cell vulval carcinoma
RF for vulval cancer
HPV 16 and 18, HSV 2
lesions vulval cancer
itchy/burning, raised, inguinal lymphadenopathy
tx vulval cancer
surgery, chemo and radio
diagnosing fibroids
TVUS
Urge incontinence
Overactive detrusor - sudden urge and then urine passes
mx urge incontinence
oxybutynin and bladder re-training >6w
stress incontinence
Increased abdo pressure causes urine to leak
mx stress incontinence
duloxetine, pelvic floor retraining (8 exercises TDS for >3m)
Up to how many weeks can you abort a baby?
24
TOP <9 weeks
mifepristone followed by misoprostol (a prostaglandin to induce contractions) 48h later
TOP <13 weeks
surgical dilation and evacuation
TOP >15 weeks
surgical dilation and evacuation to induce mini labour
define recurrent miscarriage
> 3 consecutive and spontaneous miscarriages, often due to anti phospholipid syndrome, endocrine disorders, uterine abnormality etc
cause of pruritus vulvae
irritation - commonly condoms
mx pruritus vulvae
take showers not baths, wash once a day
pruritus vulvae vs ani
ani is perianal area, vulvae is vulval area
sx pruritus vulvae
itching
How long is follicular phase?
ALWAYS 14
What happens during follicular phase (hormones)
Egg (ovum) is developing inside follicle
Hypothalamus secretes GnRH which acts on ant.pituitary to secrete FSH and LH
FSH stimulates a few follicles
The granulosa cells surrounding these follicles secrete oestrogen
Oestrogen has -ve feedback on hypothalamus = less FSH and LH
Dip in ovulation as cells mature means FSH and LH spike = ovulation
What happens during luteal phase (hormones)
Successful follicle releases ovum and collapses to form CL
CL secretes progesterone
If pregnant, placenta takes over progesterone production from 12 weeks to maintain lining and thicken cervical mucus
Cells also make oestrogen
if not pregnant, CL degenerates = less oestrogen and progesterone (menstruation)
This means no negative feedback
FSH and LH rise again
Hormonal changes in menopause
low oestrogen (which means less -ve feedback), high LH and FSH
What is premature ovarian insufficiency?
Onset of menopausal sx and increased gonadotrophin levels before 40 yo
Causes of premature ovarian insufficiency
idiopathic, bilateral oophorectomy, radio/chemo
Sx menopause
night sweats/hot flushes, infertility, secondary amenorrhoea, hormonal changes
what is PMS
emotional (stress, fatigue, anxiety, mood swings) and physical (bloating and breast pain) changes that occur in the luteal phase of an ovulatory cycle
management for PMS (mild, mod and severe)
mild = lifestyle changes and frequent, small, carb-heavy meals
mod = COCP
severe = SSRI
cervical excitation is a sign of
PID
urogenital prolapse sx
pressure/heaviness, incontinence, ‘bearing down’
Sx ovarian torsion
Colicky deep abdo pain, sudden onset, N and V, whirlpool USS
Tx ovarian torsion
laparoscopy
threatened miscarriage
os closed, painless bleeding with viable foetus
missed miscarriage
os closed, no viable foetus, light bleeding/discharge with sx of pregnancy disappearing
inevitable miscarriage
os open, heavy bleeding
incomplete miscarriage
open os, products of conception partially expelled
Average age of menopause
51
For how long should women use contraception if menopausal sx >50?
12m
For how long should women use contraception if <50
24m
sx menopause
- Change in cycle length
- Hot flushes
- Night sweats
- Vaginal dryness
- Psychological SEs
mx menopause
- Lifestyle changes
- Vasomotor sx can be treated with fluoxetine/citalopram
- If woman has uterus, give her transdermal combined HRT (oestrogen alone increases risk of cancers)
- Vaginal oestrogen may be required for life for urogenital atrophy
rapid acting treatment for heavy vaginal bleeding
Norethisterone 5 mg tds
sx ectropion
vaginal discharge
post-coital bleeding
mx ectropion
ablation
what is cervical ectropion?
On the ectocervix, the transformation zone is where the stratified squamous epithelium meets the columnar epithelium of endocervix. High oestrogen levels result in a larger area of columnar epithelium being present on the ectocervix
How should you refer women >55 with post-menopausal bleeding
2ww
management endometriosis
NSAIDs/paracetamol
COCP
intermenstrual bleeding
endometrial hyperplasia
type 1 FGM
clitoridectomy
type 2 FGM
removal of clitoris and labia minor, +/- labia major
type 3 FGM
Narrowing of vaginal orifice with creation of covering seal using the labia minora/majora (infundibulation)
type 4
all other harmful procedures to female genitalia
how to postpone periods
norethisterone to be taken 3 days before the onset of her periods until when you want period to be, will not offer contraception
treatment of thrush if pregnant
topical
when do you do a HVS for thrush?
if symptoms are unclear - if clinical diagnosis is clear, treat straight away
tests if recurrent candidiasis
diabetes and HVS
most common cause of recurrent first trimester miscarriage
anti-phospholipid syndrome
what is antiphospholipid syndrome?
arterial/venous thromboses, recurrent foetal loss and thrombocytopenia
management anti-phospholipid syndrome
aspirin once pregnancy confirmed on urine dip
heparin once fetal heart seen -> 34 weeks
treatment for severe PMS
SSRI in luteal phase
how many episodes of candidiasis in a year for it to be classed as recurrent?
4
Low oestrogen, high FSH and LH
premature ovarian insufficiency
example muscarinic antagonist for urge incontinence
tolterodine
PROM happens before how many weeks?
37
Stillbirth is defined after how many weeks?
24
