Gynaecology Flashcards
What drug is used before myomectomy?
Use of a gonadotrophin-releasing hormone analogue could be considered prior to surgery which helps to reduce the size of the fibroids.
Who are the common target groups for uterine fibroids?
- Nulliparity
- Early menarche (< 10 years old)
- Age: 25–45 years
Fibroids are largely found in women of reproductive age
influenced by hormones (i.e., estrogen, growth hormone, and progesterone)
During menopause, hormone levels begin to decrease and leiomyomas begin to shrink - Increase incidence in African Americans - V.V. imp
- Obesity
- Family history
What are the typical symptoms of fibroids?
- may be asymptomatic - depending on the size, number and location
- Abnormal menstruation - menorrhagia and dysmenorrhea- increased total surface area as a result of the bulging uterine wall, impaired uterine wall contractility, or micro/macrovascular abnormalities.
- Features of mass effect:
i. Back or pelvic pain: cramping pains, often during menstruation
ii. urinary symptoms, e.g. frequency, may occur with larger fibroids and bowel symptoms (bloating, constipation) - Reproductive abnormality - Infertility and Dyspareunia (obstructed uterine cavity and/or impaired contractility of the uterus)
How are fibroids diagnosed?
Transvaginal US
What is the crude pathophysiology of fibroids?
Oestrogen-dependent benign tumours
What are the complications of fibroids during pregnancy?
Pain (red degeneration) -haemorrhage into tumour - commonly occurs during pregnancy
Premature labour
Malpresentation
Obstructed labour (cervical uterine fibroid)
Difficulty for CS (C-section)
What is primary Amenorrhoea? and what are the possible causes?
failure to start menses by the age of 16 years
- Turner’s syndrome
- testicular feminisation
- congenital adrenal hyperplasia
- congenital malformations of the genital tract
What is secondary Amenorrhoea? and what are the possible causes?
cessation of established, regular menstruation for 6 months or longer
- hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis*
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions)
What is oligomenorrhoea?
Menstruation occurs every 35days -6mths
What is hypothalamic hypogonadism? What are the hormone findings expected to be?
It is a cause of secondary amenorrhoea. It is caused due to psychological factors, low weight, anorexia nervosa and excessive exercise (atheletes).
GnRH, FSH , LH and oestradiol are all reduced.
(Bone density is reduced to low oestrogen)
What other gynaecological tests are required to rule out abdo pain in women?
In addition to routine diagnostic work up of abdominal pain, all female patients should also undergo a bimanual vaginal examination, urine pregnancy test and consideration given to abdominal and pelvic ultrasound scanning.
What are the features of mittelschmerz?
Usually mid cycle pain. (recurrent unilateral pain) Often sharp onset. Little systemic disturbance. May have recurrent episodes. Usually settles over 24-48 hours.
What type of ovarian cysts immediately require biopsy?
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy
What is the commonest type of ovarian cyst seen in young women?
Follicular cysts - commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
Commonly regress after several menstrual cycles
Functional cysts associated with hyperestrogenism and endometrial hyperplasia
Which ovarian cyst is more likely to be associated with intraperioteneal bleeding?
Corpus leuteal cyst - Unreleased corpus luteum may fill with blood or fluid and form a corpus luteal cyst
Functional cysts - Produces progesterone, which may delay menses
Associated with progesterone-only contraceptive pills and ovulation-inducing medication
What the broad types of ovarian cysts and give examples
Functional - Follicular cysts, Corpus leuteal cysts, Theca Leutin cyst
Non-functional - Benign germ cell tumours (Dermoid cysts), Benign epithelial tumours ( Serous cystadenoma, Mucinous cystadenoma)
What is the most common benign germ-cell ovarian tumour in woman under the age of 30 years
Dermoid cyst
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
What is the most common benign epithelial ovarian tumour?
Serous cystadenoma- the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
What are 6 gynaecological Differentials for abdo pain in females?
- Ovarian Torsion
- Ruptured ovarian cyst
- Endometriosis
- Ectopic pregnancy
- Mittelschmerz
- PID
How to differentiate ovarian torsion from ruptured ovarian cyst?
Ruptured ovarian cyst presents as sharp unilateral pain immediately following intercourse or strenuous exercise. Bimanual examination in non-severe cases is generally unremarkable but the lower abdomen is tender. Ultrasound shows free fluid in the pelvic cavity.
Ovarian or adnexal torsion can present similarly with sharp unilateral pain often associated with nausea and vomiting. There is a tender palpable adnexal mass on bimanual exam. Ultrasound shows an enlarged, oedematous ovary with impaired blood flow.
How is the risk stratification performed for ovarian cycts and tumours
RMI - Risk of malignancy index
U x M x CA125
o U = Ultrasound score (0/1/3)
o M = Menopausal status (1/3)
o CA125 = Serum cancer antigen 125 level (U/L)
RMI <25 - Low risk
RMI 25-250 - Moderate risk
RMI >250 - High risk
What is the management of ovarian cysts in premenopausal women?
In a premenopausal woman, cyst of <5cm should NOT cause concern unless:
o Other suspicious features
o /Patient is symptomatic (eg: pain)
If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Consider laparoscopic cystectomy:
o Avoid spillage of contents (in all >5cm cysts & dermoid cysts)
o Can be done by removing cyst in an ‘endobag’
What is the follow up of ovarian cysts in premenopausal women if cyst is persistent after conservative theraphy and waiting
• Rescan in 6wks to see if the cyst has resolved:
o If cyst is persistent then monitor with:
USS
/CA125
What is the management of ovarian cysts in postmenopausal women?
By definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst
**Regardless of nature or size should be referred to gynaecology for assessment
Treatment include Bilateral laprosocopic oophorectomy or in high RMI cases - full staging laprotomy
What is the most sinister diagnosis to suspect when fairly young patient presents with amenorrhoea and pain?
Ectopic pregnancy
What is the commonest site of ectopic preganancy and which is the most dangerous?
- Most common in ampulla
* Most dangerous (highest risk to rupture) = isthmus
What causes rupture of the ovarian cysts?
increase in intracystic pressure or intra-abdominal pressure
Vigorous physical activity
Vaginal intercourse
Large cysts
Reproductive age
What are the most common gynae causes of sudden onset lower abdo pain?
ovarian torsion
ovarian cyst rupture
What are the risk factors of ectopic pregnancy?
Anything slowing the ovum’s passage to the uterus
Anatomic alteration of the fallopian tubes is the main cause of ectopic pregnancy
- A history of PID
- Previous ectopic pregnancy
- Past surgeries involving the fallopian tubes (damage to tubes (pelvic inflammatory disease, surgery)
- Endometriosis
- Bicornate uterus
Non‑anatomical risk factors
1. Intrauterine device (IUD) - Pregnancies that occur despite IUD contraception tend to attach more frequently outside of the uterus
- History of infertility -Infertility is often caused by tubal abnormalities, which also increase the risk of ectopic pregnancy.
- Hormone therapy - Hormone therapy may cause hormonal dysregulations, which are thought to slow down the transport of fertilized eggs
- IVF
- Progestrone only pill
What is the typical history seen with ectopic preganancy?
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
What are the typical clinical features in ectopic pregancy?
!Often asymptomatic (Unsure dates)!
Others patients usually present with signs and symptoms 4–6 weeks after their last menstrual period.:
1. Typcially Amenorrhoea of 6-8 weeks. if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
- Lower abdominal pain and guarding (often mild, constant and unilateral) - mostly if ruptured or due to tubal spasm;
typically the first symptom - Vaginal bleeding - often confused as delayed menstruation, usually small amount and often brown
- Signs of pregnancy- amenorrhea, nausea, breast tenderness, frequent urination
- Peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination (haemoperitoneium)
What are the signs observed in ectopic preganancy?
Often have no specific signs
o Uterus usually normal size
o Cervical excitation, cervical motion tenderness
o Adnexal tenderness
o Adnexal masses – Very rarely
o Peritonism: Due to intra-abdominal blood if ectopic ruptured
What are the DDx to consider if cervical excitation is positive?
Ectopic pregnancy
Pelvic inflammatory disease
Positive sign can also exclude appendicitis
What are the features than can be used to differentiate ectopic pregnancy from PID
Ectopic - Lower unilateral abdominal pain and guarding with findings of amenorrhoea, positive pregnancy test and echogenic mass on US
PID - bilateral lower abdominal pain and fever, menorrhagia and metrorrhagia (IMB), dyspareunia, purulent cervical discharge§
Differentiating features between ectopic pregnancy and ruptured ovarian cyst
Ectopic - Lower unilateral abdominal pain and guarding with findings of amenorrhoea, positive pregnancy test and echogenic mass on US
Ruptured cyst - Sudden onset of unilateral abdominal pain, Onset usually during physical activity (exercise, sexual intercourse)
What is the best test to diagnose ectopic pregnancy?
TVS - to locate the pregnancy
Supportive Findings:
- Adnexal mass - most common finding
- Free fluid - strongly indicating the presence of haemoperitoneum - however non-specific
- Empty uterine cavity in combination with a thickened endometrial lining
What is the test used to check for failing pregnancy and what are the threshold values?
Serum progesterone
If <20nmol/L = Highly suggestive of failing pregnancy in both:
Ectopic pregnancy
Intrauterine pregnancy (IUP)
What is the blood test used to check for pregnancy
Serum β-hCG level
What is the discriminatory level for a single Serum β-hCG level to observe IUP with TVS
Cutoff is typically β-hCG > 1,500–2,000 IU/L
Inability to visualize pregnancy on ultrasound at the discriminatory level strongly suggests ectopic pregnancy.
Multiple pregnancies may have higher β-hCG levels (In multiple pregnancies, the β-hCG discriminatory level may be reached before the pregnancy can be visualized.)
How do you suspect ectopic from one serum β-hCG?
Inability to visualize pregnancy on ultrasound at the discriminatory level (> 1,500–2,000 IU/L) strongly suggests ectopic pregnancy.
How often do you perform a serial serum β-hCG?
48hrs after the admission
What do you expect to see in the serial serum β-hCG for a normal IUP?
Intrauterine pregnancies: β-hCG increases by ≥ 66%
Suboptimal rise is suspicious
What do you expect to see in the serial serum β-hCG for an ectopic pregancy?
An insufficient increase or decrease of β-hCG. (<66%)
What do you expect to see in the serial serum β-hCG for a spontaneous abortion?
patients have a decrease of β-hCG ≥ 35%
A decrease < 35% should raise concern for either ectopic pregnancy or spontaneous abortion.
What is the gold standard diagnostic test for ectopic but should only be done if clinically necessary?
Exploratory laproscopy - Unstable patients suspected of having an ectopic pregnancy
In pregnancy of unknown location if the location is still uncertain after 7–10 days
What is the criteria for patients applicable for expectant management in ectopic pregnancy?
- Unruptured
- Size <35mm / 3cm
- Asymptomatic
- No foetal heartbeat
- serum B-hCG <1000IU/L and declining
- Compatible if another intrauterine pregnancy
What does expectant management involve in ectopic pregnancy?
Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.
To monitor serum hCG:
- Initial serum hCG
- Repeat every 48h until repeated fall in level
- Then weekly until <15IU
***No level of hCG at which rupture can’t occur!!! (Even when it’s falling) – So monitor the S&S rather than just blood tests and scans!!!
What is the criteria for patients applicable for medical management in ectopic pregnancy?
- Unruptured
- Size <35mm / 3.5cm
- No pain
- No foetal heartbeat
- serum B-hCG <1500IU/L
- Not Compatible if another intrauterine pregnancy
What does medical management involve in ectopic pregnancy?
Methotrexate IM
o 1 dose of 50mg/m2
hCG level:
Measured at 4 & 7d
If the ↓ of hCG btwn 4 & 7d <15%: (up to 25% of cases)- Give 2nd dose of methotrexate
What are the SEs of methotrexate?
o Conjunctivitis
o Stomatitis
o GI upset
o Abdominal pain (difficult to differentiate from a rupturing ectopic)
After treatment, use reliable contraception for 3mths (because methotrexate is teratogenic)
What are the contraindication for using methotrexate
Breastfeeding Methotrexate sensitivity Immunodeficiency Peptic ulcer disease Ruptured ectopic pregnancy Pulmonary diseases - severe asthma Low creatinine clearance Alchohol use disorder, chronic liver disease
How does methotrexate function
inhibits folate-dependent steps in DNA synthesis to terminate the rapidly dividing ectopic pregnancy.
What is the criteria for patients applicable for surgical management in ectopic pregnancy?
- Can be ruptured
- Size > 35mm / 3.5cm
- Severe pain
- Visible foetal heartbeat
- serum B-hCG >1500IU/L
- Compatible if another intrauterine pregnancy
What does surgical management involve in ectopic?
- Salpingostomy/ Salpingotomy (tube‑conserving operation) - Create an opening into the tube to remove EP BUT do not remove the tube
- Salpingectomy - removal of the tube
How do you chose salpingotomy vs salpingectomy
If the contralateral tube is healthy, salpingectomy over salpingotomy.
Salpingotomy is the primary treatment if the other tube is not healthy to preserve chance of future ectopic pregnancy.
Women with salpingotomy should be followed up with serum hCG to detect and treat persistent trophoblast early.
What is the definition of recurrent miscarriage?
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women
What are the some causes of recurrent miscarriages?
- antiphospholipid syndrome
- endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. 3. Polycystic ovarian syndrome
- uterine abnormality: e.g. uterine septum
- parental chromosomal abnormalities
- smoking
What is the histological change in cervical ectropion?
the squamous cell epithelium of the ectocervix is replaced by columnar cell epithelium of the endocervix
What causes the cervical ectropion?
physiological influence of estrogen (e.g., puberty, pregnancy, certain oral contraceptives)
What are the features of cervical ectropion?
- vaginal discharge
- post-coital bleeding
- red ring around the os
What is the treatment for cervical ectropion?
stop hormonal contraception
cautery with diathermy as an outpatient if the women wishes
What are the causes of primary amenorrhoea?
- Constitutional delay i.e. a late bloomer, has secondary sexual characteristics
- Anatomical i.e. mullerian agenesis (patient develops secondary sexual characteristics and has variable absence of female sexual organs)
- Imperforate hymen (characterised by cyclical pain and the classic bluish bulging membrane on physical examination)
- Transverse vaginal septae (characterised by cyclical pain and retrograde menstruation)
- Turner syndrome (XO chromosome)
- Testicular feminisation syndrome (XY genotype, no internal female organs)
- Kallmann syndrome (failure to secrete GNRH)
- congenital adrenal hyperplasia
what are the causes of secondary amenorrhoea?
- Pregnancy
- Patient is using contraception
- Menopause
- Lactational amenorrhoea
- Hypothalamic amenorrhoea (suppression of GnRH due to stress, excessive exercise, eating disorder)
- Endocrinological (hyperthyroidism, polycystic ovary disease, Cushing’s syndrome, hyperprolactinaemia, hypopituitarism)
- Premature ovarian failure (autoimmune, chemotherapy, radiation therapy)
- Asherman’s syndrome (iatrogenic intrauterine adhesions/cervical stenosis)
- Sheehan syndrome
What are the investigations required for amenorrhoea?
- Exclude pregnancy with urinary or serum bHCG
- Gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
- Prolactin
- Androgen levels: raised levels may be seen in PCOS
- Oestradiol
- Thyroid function tests
What are the causes of delayed puberty with short stature?
Turner’s syndrome
Prader-Willi syndrome
Noonan’s syndrome
What are the causes of delayed puberty with normal stature?
Polycystic ovarian syndrome
Androgen insensitivity
Kallman’s syndrome
Klinefelter’s syndrome
What is the triad of features in hyperemesis gravidarum?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
When does hyperemesis gravidarum mostly present?
Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks
What are the common associations of hyperemesis gravidarum?
- Multiple pregnancies
- Trophoblastic disease - Molar pregancy
(Both cause increased hCG) - Hyperthyroidism (Thyroid resembles hCG)
- Nulliparity
- Obesity
True or false: smoking exacerbates hyperemesis gravidarum
Smoking is associated with a decreased incidence of hyperemesis.
What is the referral criteria for nausea and vomiting?
- Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
- A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
A lower threshold for admitting to hospital if the woman has a co-existing condition (for example diabetes) which may be adversely affected by nausea and vomiting.
What investigations do you perform for suspected hyperemesis gravidarum?
- Urinalysis: Ketones (As body switches to ketogenesis as lack of glucose from N&V)
- MSU – To exclude UTI
- FBC - increased haematocrit
- U&E -
↓K+ ↑Na+ (body try to reabsorb water thru Na+ reabsorption)
Metabolic hypochloraemic alkalosis (Losing H+ thru vomiting) - LFT - Increased transaminases, reduced albumin
- USS - to exclude multiple and molar pregnancies
What are the complications of hyperemesis gravidarum?
- Thiamine deficiency - Wernicke’s encephalopathy
- Mallory-Weiss tear
- Hyponatraemia - rapid reversal may lead to central pontine myelinolysis
- acute tubular necrosis
- fetal: small for gestational age, pre-term birth
How do you grade the severity of Nausea and vomiting in pregnancy?
Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.
What is the 1st line management in hyperemesis gravidarum?
Fluids - NaCL or Hartmann’s
• Avoid glucose-containing fluids as they can precipitate Wernicke’s encephalopathy
For the conversion of pyruvate to enter Krebs cycle (requires Thiamine!!!):
So if giving glucose-containing fluids without Thiamine first = Produce more lactate!!!
What is 2nd line in hyperemesis gravidarum management after fluids
If no response to IV fluid & electrolyte replacement; then consider:
- antihistamines such as Promethazine OR Cyclizine
- Procholarpezine +/- Metaclopramide
- Ondensetron/Granisetron
What are some S&S of hyperemesis gravidarum?
o Muscle wasting o Ptyalism (inability to swallow saliva) o Inability to keep food/fluid down o Hypovolaemia o Behaviour disorder o Haematemesis (Mallory-Weiss tears)
What type of ovarian cyst ruptures and may cause pseudomyxoma peritonei
Mucinous cystadenoma
A 32-year-old female presents with lower abdominal pain. She is 8 weeks pregnant. A simple ovarian cyst is evident on transvaginal ultrasound. An 8-week intrauterine pregnancy is also confirmed. What is the most appropriate management of the cyst?
Reassure the patient that it is normal and leave the cyst alone
In early pregnancy, ovarian cysts are usually physiological - known as a corpus luteum. They will usually resolve from the second trimester on wards. Reassurance is important in the above situation as maternal anxiety is likely to be high. Anxiety in pregnancy should be avoided wherever possible in order to avoid adverse outcomes to both mother and foetus.
What are the types of cervical cancer?
squamous cell cancer (80%)
adenocarcinoma (20%)
What is the peak incidence in cervical cancer?
Dual peak in incidence:
o 30-39yo
o Over 70s
What is the most common causative factor for cervical cancer?
Most due to persistent infection with high risk HPV subtypes; mainly:
o HPV 16
o HPV 18
HPV 33
Untreated high grade CIN leads to cervical cancer in 20-30% of women over 10yrs
What are the risk factors for cervical cancer?
- Early onset of sexual activity; multiple sexual partners (strongest risk factors)
- High parity
- Immunosuppression (e.g., HIV infection, transplant patients)
- History of sexually transmitted infections (e.g., herpes simplex, chlamydia)
- Cigarette smoking and/or exposure to second-hand smoke (for squamous cell cancer types only)
- Oral contraceptives
- Low socioeconomic status
What is the mechanism by which HPV causes cervical cancer?
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
What are the features of cervical cancer?
PCB Cervical smear showing invasion? Incidental finding on treatment of CIN Post-menopausal bleeding: <1% of PMB women have cervical cancer Watery vaginal discharge
What are the signs of advanced disease in cervical cancer
o Heavy bleeding PV o Ureteric obstruction o Weight loss o Bowel disturbance o Fistula (Vesicovaginal = Most common)
What type of ovarian cyst is most likely to cause pseudomyxoma peritonei
Mucinous cystadenoma
What is the diagnosis in post menopausal bleeding until and proven otherwise?
endometrial cancer
What is the diagnosis of exclusion in post-menopausal bleeding?
Atrophic vaginitis is a diagnosis of exclusion. Endometrial cancer must be ruled out, and the first line investigation for this is always TVUS. While this is most likely atrophic vaginitis, it still must be investigated to rule this out. Once a TVUS is done, if it comes back normal then either discharge with cream or referral to HRT clinic would be the most appropriate, but TVUS must be done first. If it is abnormal (>4mm), then endometrial biopsy would be done. Laparoscopy would not help.
What are the features of atrophic vaginitis?
Vaginal soreness, dryness
Dyspareunia, burning sensation after sex
Discharge, occasional spottin
Decreasing labial fat pad
On examination, the vagina may appear pale and dry.
What is the management of atrophic vaginitis?
vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
What is the first line treatment for stress incontinence? What is the medical mx?
Pelvic floor muscle training (8 contractions 3 times per day for 3mths)
• Duloxetine = ONLY drug to treat moderate to severe SUI (BUT NOT RECOMMENDED BY NICE)
What is the first line treatment for urge incontinence?
Bladder retraining for >6 weeks (To gradually increase intervals between voiding)
What are the risk factors of urinary incontinence in women?
advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
What are the types of urinary incontinence in women?
- overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
- stress incontinence: leaking small amounts when coughing or laughing
- mixed incontinence: both urge and stress
- overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
What are the investigations done for urinary incontinence/
- Bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
What is the pathophysiology fo PCOS
- Reduced insulin sensitivity (peripheral insulin resistance) is present in PCOS, as in metabolic syndrome → hyperinsulinemia
- Hyperinsulinaemia increases GnRH pulse frequency
- Raised LH:FSH
- Leading to: (Insulin acts on ovary & adrenal) Increased ovarian androgen production and Reduced follicular maturation
Increased androgen production in ovarian theca cells → not getting converted to oestrogen because of the low stimualtion of the granulosa cell by FSH
- As patient becomes obese (due to insulin resistance)
- More adipose tissue available:
Adipose tissue has aromatase; convert:
Androstenedione –> oestrone
Testosterone –>oestradiol - Inhibits the production of SHBG (sex hormone-binding globulin) in the liver → ↑ free androgens and estrogens
!!!!!Thus PCOS = ↑ Androgen + ↑ Oestrogen!!! (&normal FSH, high LH)
What are the characteristic features of PCOS?
- Menstrual irregularities (primary or secondary amenorrhea, oligomenorrhea)
- Subfertility or infertility
- Obesity and signs of metabolic syndrome (DM2, HTN, CVD, Dyslipidaemia)
- Hirsuitism
- Androgenic alopecia
- Acne vulgaris and oily skin
- Acanthosis nigrican - hyperpigmented, velvety plaques - axilla and neck (Elevated levels of insulin stimulate keratinocyte and dermal fibroblast proliferation via interaction with insulin-like growth factor 1.)
How is PCOS diagnosed?
Rotterdam criteria for diagnosing PCOS
Presence of 2 out of the 3 following variable:
1. Oligo/Anovulation - cycle >42 days
2. Clinical/ biochemical signs of hyperandrogenism - acne, hirsutism or alopecia
3. Polycystic ovaries on pelvic USS > 12 antral follicles on 1 ovary and ovarian volume> 10ml
need to exclude other causes of irregular cycles before the diagnosis is made
What are the investigations required for PCOS?
- pelvic ultrasound: multiple cysts on the ovaries - strong of pearls appearance
- FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis.
- Prolactin may be normal or mildly elevated.
- Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes (Both free and total)
- check for impaired glucose tolerance
What are the differentials for virlization and menstrual changes?
Congenital adrenal hyperplasia
Cushings disease (ACTH can stimulate the
PCOS
Thyroid disorders
hyperprolactinaemia
androgen secreting tumour
What are the long term consequences of PCOS?
- PCOS increase risk factors for ischaemic heart disease
- Pregnant women with PCOS: Increased risk of gestational diabetes
- Long periods of 2o amenorrhoea leads to unopposed oestrogen (raised due to more adipose tissue); risk factor of: endometerial hyperplasia and endometrial carcinoma
What is the management of PCOS patient
Weight loss - in order to increase insulin sensitivity .
Smoking cessation
If treatment for infertility is not sought: therapy aimed at controlling menstrual, metabolic, and hormonal irregularities
If the patient is overweight (BMI ≥ 25 kg/m2)
First-line: weight loss via lifestyle changes (e.g., dietary modifications, exercise)
Second-line (as an adjunct): combined oral contraceptive therapy - co-cyprindiol
If the patient is not overweight: combined oral contraceptive therapy
If seeking treatment for infertility:
First-line: Ovulation induction with clomiphene citrate. Risk of ovarian cancer and multiple pregnancy ! (Only use in BMI<35 and only for limited period of time)
Clomiphene inhibits hypothalamic estrogen receptors, thereby blocking the normal negative feedback effect of estrogen → increased pulsatile secretion of GnRH → increased FSH and LH, which stimulates ovulation.
Metformin - improves insulin sensitivity in the short term and may improve menstrual disturbance and ovulatory function but does not have a significant impact on hirsutism and acne. metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
Second line : Ovarian drilling -
What is the treatement for hirsuitism in PCOS
- a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
- if doesn’t respond to COC then topical eflornithine (anti androgen) may be tried
- spironolactone, flutamide and finasteride may be used under specialist supervision
What is the definition of premature ovarian failure?
Onset of menopausal symptoms (Cessations of menses for 1 yr) + ↑ Gonadotrophin lvl before 40 yo
In patients with primary ovarian insufficiency, the ovaries do not function normally in response to gonadotropin stimulation provided by the hypothalamus and pituitary. They fail to produce normal amounts of estrogen and ovulate each month. This could be due to follicular depletion or dysfunction
What is the risk factor for premature ovarian failure?
idiopathic - the most common cause chemotherapy autoimmune - hashimoto's thyroditis radiation Prolonged GnRH therapy
What are the features of premature ovarian failure?
Climacteric symptoms:
o Hot flushes
o Night sweats
• Irregular menstrual cycles:
o May precede the cessation of menses
- Vaginal dryness (Hence dyspareunia)
- Sleep disturbance
- Irritability
- Infertility
- Secondary amenorrhoea
What are is blood test findings of premature ovarian failure or ovarian insufficiency ?
High FSH and High LH
What is the medical management of urge incontinece?
Bladder stabiliting drugs
1st line - Anti muscuranics
- Oxybutynin (Immediate release)
- Tolterodine (Immediate release)
- Darifenacin (Once daily preparation)
AVOID immediate release oxybutynin in ‘frail older women’
Mirabegron (Beta-3 agonist):
May be useful if concern about anticholinergic SEs in frail elderly patients
What are the causes of stress incontinence?
- Childbirth - most common causative factor
- Menopasue - deficiency in oestrogen - weakening of pelvic support
- Surgery - weakness of baldder neck
When is surgery considered in women with stress incontinence?
o Conservative measures have failed
o & Women’s QoL compromised
What is the surgical management of stress incontinence?
Peri- urethral injection -
1. Injectable peri-urethral bulking agents (good immediate success, but long term decline in continence) - good for old, frail women and young women who have yet to complete their family
- Burch colposuspension / laproscopic colposuspension
Other management - Tension free vaginal tape and trans-obturartor tape
What are the SE of the anti-muscarinic medications?
Dry mouth (up to 30%)
Constipation, nausea, dyspepsia, flatulence
Blurred vision, dizziness, insomnia
Palpitation & arrhythmia
What are the CI of the anti-muscarinic medications?
Acute (narrow angle) glaucoma Myasthenia gravis Urinary retention / outflow obstruction Severe ulcerative colitis GI obstruction
What are the causes of OAB?
• Idiopathic (most cases)
• Neurogenic DO:
MS
Spina bifida
UMN lesions
• 2o to pelvic / incontinence surgeryWho is the most common affected group for pelvic organ prolapse?
Most older parous women
Many women DO NOT seek help. It probably affects around 40% of postmenopausal women
What are the risk factors of pelvic organ prolapse?
Vaginal delivery
Higher risk in: large babies, prolonged 2nd stage, Instrumental delivery (Forceps)
Ehler-Danlos syndorme
Menopause - oestrogen withdrawal
Chronic increase in abdominal pressure - obesity, chronic cough, constipation, heavy lifting, pelvic mass
Iatrogenic- Hysterectomy
Types of pelvic organ prolapse?
cystocele, cystourethrocele
rectocele
uterine prolapse
less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)
What are the causes of anterior vaginal wall prolapse?
- Cystocele (bladder bulge into vagina)
- Urethrocele (urethra bulge into vagina)
- Cystourethrocele (bladder + urethra bulge into vagina)
What are the causes of posterior vaginal wall prolapse?
- . Enterocele (small intestine bulge into vagina)
* Rectocele (rectum bulge into vagina)
What are the causes of apical vaginal wall prolapse?
- Uterine prolapse (uterus prolapse into vagina)
* Vaginal vault prolapse (roof of vagina prolapse) – after hysterecetomy
What are the S&S of pelvic organ prolapse?
Often absent
- sensation of pressure, heaviness, ‘bearing-down’
- cysto-urethrocele - urinary symptoms: incontinence, frequency, urgency
- Rectocele - constipation, difficulty with defecation
What is the management of pelvic organ prolapse?
If asymptomatic and mild prolapse then no treatment needed
- conservative: weight loss, pelvic floor muscle exercises
- intravaginal devices - ring pessary (Decline surgery, unfit for surgery or surgery CI) / Shelf pessary (If ring pessary doesnt fit - cannot be used if sexually active)
- surgery
What are the various surgical options for the different types of pelvic organ prolapse?
Cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
Uterine prolapse: hysterectomy, sacrohysteropexy
Rectocele: posterior colporrhaphy
What is the definition of ovarian torsion?
Ovarian torsion may be defined as the partial or complete torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply. If the fallopian tube is also involved then it is referred to as adnexal torsion.
What are the risk factors for ovarian torsion?
- ovarian mass: present in around 90% of cases of torsion
- being of a reproductive age
- pregnancy
- ovarian hyperstimulation syndrome
What are the features of ovarian torsion
- Usually the sudden onset of deep-seated colicky abdominal pain.
- Associated with vomiting and distress
fever may be seen in a minority (possibly secondary to adnexal necrosis) - Vaginal examination may reveal adnexial tenderness
What are the US features of ovarian torsion?
Ultrasound may show free fluid or a whirlpool sign.
However, Laproscopy is both diagnostic and therapeutic !!!!!!!
Who are mostly affected by ovarian hyperstimulation syndrome?
A complication in some forms of infertility treatment
What is the pathogenesis of ovarian hyperstimualtion syndrome?
Presence of multiple luteinized cysts within ovaries results in high lvl of:
Oestrogen & Progesterone
Vasoactive substances (Eg: Vascular endothelial growth factor (VEGF))
Leads to ↑ membrane permeability
Then loss of fluid fro intravascular component
Which group of pts receiving infertility tx are more likely to have ovarian hyperstimulation syndrome?
PCOS pts undergoing treatment for infertility
What are the drugs or treatment that are likely to trigger ovarian hyperstimulation syndrome?
- Gonadotrophin treatment (> Likely)
- hCG treatment (> Likely)
- IVF (Up to 1/3 of women having IVG have mild form of OHSS)
• Clomifene (< Likely)
What are the features of ovarian hyperstimulation syndrome? How are they treated
Lower abdominal discomfort, nausea, vomiting and abdominal distension .
Patients may also develop ascites, hypotension and in serious cases acute respiratory distress syndrome and venous thromboembolism.
Patients are treated with fluid replacement and thromboprophylaxis.
What hormone does endometriosis depend on?
Oestrogen
What are the RFs of endometriosis?
o Early menarche
o Obesity
o > Common in nulliparous
What are the features of endometriosis?
Cyclical dysmenorrhoea + Deep Dyspareunia + Menorrhagia + infertility
What is the 1st line mx for endometriosis?
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief +
COCP - administered continuously - ovarian suppression - stop ovulation and the cycle!!
What is the 2nd line mx for endometriosis after COCP?
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
Use - add-back HRT
Which group is mostly affected by endometrial Ca?
Post menopausal women (because no protective effect of progestrone)
What are some of the risk factors of endometrial Ca?
Presence of unopposed oestrogen !
- Nulliparity (Pregnancy associated with high progesterone lvl)
- Early menarche and late menopause (anovulatory cycles)
- PCOS (polycystic ovary syndrome)
- Unopposed oestrogen replacement therapy - menopausal symptoms
- Breast cancer - history of breast Ca and tamoxifen treatment
- Metabolic syndorme - obesity and DM2
- Lynch syndrome - herediatry nonpolyposis colorectal cancer (Autosomal dominant - endometrial, colorectal and ovarian)
What are the protective factors of endometrial Ca?
Low estrogen and high progestin or progesterone levels have a protective effect.
- Multiparity
- Combination oral contraceptive pills
- Smoking is protective
- Regular physical exercise
- Lifelong soy-rich diet
What is the common presentation of endometrial Ca?
Postmenopausal bleeding
Premenopausal women may have a change intermenstrual bleeding
Instead of bleeding, may have PV discharge & pyometra (infection of uterus)
Pain is unusual
How is endometrial Ca diagnosed?
- Women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway (2 week cancer pathway)
- First-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
- Pipelle biopsy . If not then Hysteroscopy with endometrial biopsy
What is the criteria for endometrial biopsy?
Performed if:
- ET ≥ 4mm
- Persistent bleeding in women with ET <4mm (also consider hysteroscopy)
- Women >45yo with abnormal menstrual symptoms
What is the management of endometrial Ca?
• Surgery:
1. TAH + BSO + Pelvic washings:
- TAH = Total abdominal hysterectomy
- BSO = Bilateral salpingo-oophorecetmy
Localised disease is treated with TAH + BSO Patients with high-risk disease may have post-operative radiotherapy
- progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
What is pseudomyxoma pertonei?
Bursting of a mucinous cystadenoma/carcinoma may spread tumor cells throughout the peritoneum.
Mucinous cells cause gelatinous ascites and intra-abdominal adhesions.
May require several surgical treatments and, in the long term, usually leads to cachexia and death.
What is the cervical cancer screening intervals?
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
What are the special situations for cervical cancer screening?
- cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears.
- women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening
What is the interval for cervical cancer screening for women with HIV+ve?
Annual check ups
What do you do when someone has Borderline or mild dyskaryosis on their cervical smear?
The original sample is tested for HPV*
- if negative the patient goes back to routine recall
- if positive the patient is referred for colposcopy
What do you do when someone has moderate dyskaryosis on their cervical smear?
Consistent with CIN II. Refer for urgent colposcopy (within 2 weeks)
What do you do when someone has severe dyskaryosis on their cervical smear?
Consistent with CIN III. Refer for urgent colposcopy (within 2 weeks)
What do you do when someone has invasive cancer on their cervical smear?
Refer for urgent colposcopy (within 2 weeks)
What do you do when someone has an inadequate cervical smear?
Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy
What is the treatment for CIN-1 ?
Will spontaneously regress in ≥50-60% of cases within 2yrs
Conservative monitoring for mth: colposcopy
LLETZ if persistent
Women who have been treated for CIN1 / CIN2 / CIN3 should be invited 6 mths after Rx for ‘test of cure’ repeat cytolology (cervical smear) in community!!!
What is the treatment for CIN-2 ?
LLETZ is recommended
Women who have been treated for CIN1 / CIN2 / CIN3 should be invited 6 mths after Rx for ‘test of cure’ repeat cytolology (cervical smear) in community!!!
What do you do when someone’s cervix cannot be visualised during cervical smear?
• Referred for colposcopy
What are the types of endometrial hyperplasia?
- Simple
- Complex
- Simple atypical
- Complex atypical
What is the management of simple endometrial hyperplasia without atypia?
- IUS - 1 st line / High dose continuous progestogens + repeat sampling in 3-4mths
What is the management of simple endometrial hyperplasia with atypia?
Hysterectomy
what are the risk factors of ovarian cancer?
Genetic predisposition : BRCA1/BRCA2 mutation , Lynch/ HNPCC syndrome , Peutz-Jeghers syndrome
Due to irritation of ovarian surface epithelium by damage during ovulation
Hormonal imbalance and menstrual cycle
↑ Risk if multiple ovulations:
- Nulliparity
- Early menarche and Late menopause
- PCOS
What are the protective factors of ovarian cancer
↓ Risk if ovulation suppressed:
- COCP (RR = 0.5)
- Pregnancy
What is the prophylaxis required in pts with Lynch syndrome?
Consider prophylactic surgery:
o Hysterectomy
o + BSO
What are the features of ovarian cancer?
abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea
What are the investigations required for diagnosing ovarian cancer
- CA125 - non specific marker - Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
- If the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
- A CA125 should not be used for screening for ovarian cancer in asymptomatic women
What is the management of ovarian cancdr?
Current standard Rx for ↑ RMI = Staging laparotomy (performed thru a midline incision)
Advanced ovarian cancer - neoadjuvant chemotherapy
How are patients with ovarian tumour monitored post op?
Clinical examination ± CA125
o Monitor:
1st year = 3-monthly
2nd year = 4-monthly
If no recurrence = every 6mths for up to 5yrs
What are the different tumour markers for the different types of ovarian tumours?
Serous cystadenocarcinoma - CA125
Choriocarcinoma - hCG
Embryonal carcinoma - hCG and AFP
Granulosa cell tumour - Inhibin and Oestradiol
What is the management of stage 1A cercical cancer? (Confined to cervix, only visible by microscopy and less than 7 mm wide)
Gold standard of treatment is hysterectomy +/- lymph node clearance
For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
Radical trachelectomy is also an option for A2
What is the management of stage 1B cercical cancer? (Confined to cervix, clinically visible or larger than 7 mm wide)
Radiotherapy with concurrent chemotherapy is advised
What is the management of stage II, III,IV cercical cancer?
Radiation with concurrent chemotherapy
What is meigs syndrome?
Ascites and pleural effusion in association with an ovarian tumor (e.g., ovarian fibroma)
In 90% of cases, the ovarian tumor is unilateral.
Surgical removal of the tumor leads to a complete resolution of symptoms.
What are the common features of bacterial vaginosis?
- vaginal discharge: milky or ‘fishy’, offensive
- asymptomatic in 50%
- Pruritus and pain are uncommon
What causes bacterial vaginosis?
Gardnerella vaginalis - anaerobic organism - causes fall in lactic acid producing aerobic lactobacilli - resulting in raised vaginal pH
What is the diagnostic criteria for bacterial vaginosis?
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
what is the management of bacterial vaginosis?
Oral metronidazole for 5-7 days
Other options - topical metronidazole and topical clindamycin
70-80% initial cure rate
relapse rate > 50% within 3 months
What is the risk of BV during pregnancy and how is it managed?
Results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
It was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy. The BNF still advises against the use of high dose metronidazole regimes
What are the common features of trichomonas vaginalis infections?
- vaginal discharge: offensive, yellow/green, frothy
- vulvovaginitis
- strawberry cervix
- pH > 4.5
- in men is usually asymptomatic but may cause urethritis
How is trichomonas infection diagnosed and managed?
Investigation - microscopy of a wet mount shows motile trophozoites
Management- Oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole
What causes genital warts?
HPV 6 and 11
What are the features of genital warts?
- small (2 - 5 mm) fleshy protuberances which are slightly pigmented
- may bleed or itch
What is the management of genital warts?
1st line - Topical podophyllum or cryotherapy (Multiple non-keratinsed warts are best treated with topical agents whereas solitary, keratinised warts respond better to cryotehrapy.
2nd line - Topical Imiquimod
Vaccination in all girls 12-13yo old (against HPV 6,11, 16 and 18)
Which are the 2 non-sexually transmitted genital tract infections?
- Bacterial vaginosis
2. Candida albicans
What are the common features of gonorrhoea in men and women?
Males:
1. urethritis - purulent urethral discharge (yellow-green, possibly blood-tinged), dysuria and urinary infection
- potentially epididymitis: one-sided scrotal pain and swelling
Females:
1. cervicitis - Purulent, yellow, malodorous cervical discharge, cervical pain and bleeding on manipulatioon
- PID- Fever, abdominal/pelvic pain, dyspareunia, Abnormal, intermenstrual bleeding, Fitz-Hugh-Curtis syndrome (liver capsule inflammation - perihepatitis with RUQ pain)
Can also affect pharynx and rectum
What is disseminated gonococcal infection (DGI)?
Haematogenous spread from mucosal infection
Triad:
- Polyarthralgias: migratory, asymmetric arthritis that may become purulent
- Tenosynovitis: simultaneous inflammation of several tendons (e.g., fingers, toes, wrist, ankle)
- Dermatitis: vesicular, pustular, or maculopapular lesions, possibly with a necrotic or hemorrhagic center
Later - septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)
Can present just as Purulent gonococcal arthritis with Abrupt inflammation in up to 4 joints (commonly knees, ankles, and wrists). No tenosynovitis
How is gonorrhoea diagnosed and managed?
Vulvaginal/Endocervical NAAT If +ve on NAAT - Endocervical Swab for MC&S
Management -
IM cetriazone 1g
Old guidlines - IM ceftriaxone + oral azithromycin
If ceftrizone is refused - need-phobic - then oral cefixime + oral azithromycin should be used
What are the implications of gonorrhoea infection during pregnancy?
Gonorrhoea associated with:
o Preterm rupture of membranes
o Premature delivery
o Chorioamnionitis
Risk to baby - ophthalmia neonatarum - neonatal conjunctivitis - can cause blindness if left untreated
What are the RFs of vaginal candidiasis?
- Immunosuppression
- Antibiotics and steroids
- Pregnancy - high oestrogen levels
- Diabetes mellitus
What are the features of vaginal candidiasis?
- ‘cottage cheese’, non-offensive discharge
- vulvitis: dyspareunia, dysuria
itch - vulval erythema, fissuring, satellite lesions may be seen
How is candidiasis diagnosed and managed?
Mostly clinical diagnosis
Microscopic detection of spores + pseudohyphae on wet slides; Culture from high vaginal swab (not routinely recommended)
Management -
Local tx - clotrimazole pessary
Oral tx - itraconazole PO or Flucanazole PO
If preganant - only use local treatment - oral treatment CI
What is the criteria for recurrent vaginal candidiasis and how is it managed?
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
- Check compliance to previous treatment
- Confirm initial diagnosis - high vaginal swab, exclude ddx such as lichen sclerosus
- Exclude predisposing factors
- Consider induction-maintenance regime - daily treatment for a week followed by maintenance tx weekly for 6mths.
What are the features of primary syphilis?
Primary lesions - chancre - painless, firm ulcer with indurated borders and smooth base - at the site of sexual contact
local non-tender lymphadenopathy
What are the features of secondary syphilis?
Constitutional symptoms:
Fever, fatigue, myalgia, headache, non-tender lymphadenopathy
rash on trunk, palms and soles - nonpruritic macular or papular rash - reddish or copper coloured
buccal ‘snail track’ ulcers (in 30%)
Condylomata lata - mioist, Broad-based, wart like erosions located on the anogenital region and oral mucosa
What are the features of latent syphilis?
Having serologic proof of infection
• But WITHOUT symptoms of disease
What are the features of tertiary syphilis?
Presents up to 40% of people infected for at least 2yrs
Gummatous - (Inflammatory plaques / nodules) Neurosyphilis (Tabes dorsalis, dementia) Cardiovascular syphilis (Aortic root affected)
What are the implications of syphilis during pregnancy?
- Preterm delivery
- Stillbirth
- Congenital syphilis
- Miscarriage
What are the diagnostic tests for syphilis?
Serological tests can be divided into:
1. cardiolipin tests (not treponeme specific)
Syphilis infection leads to the production of non-specific antibodies that react to cardiolipin: examples include VDRL (Venereal Disease Research Laboratory) & RPR (rapid plasma reagin)
However, it is insensitive in late syphilis
becomes negative after treatment
- Treponemal-specific antibody tests
example: TPHA (Treponema pallidum HaemAgglutination test)
remains positive after treatment
What are the causes of false positive cardiolipin tests in syphlis?
Many false-positive results due to cross-reacting antibodies:
pregnancy SLE, anti-phospholipid syndrome TB leprosy malaria HIV
What is the treatment of syphlis?
IM Benzathine penicillin (benzylpenicillin) is the first-line management - can be used in pregancy
Alternative - Doxycyclin PO - CI In pregnancy
Alternative - Erythromcin PO - used in pregnancy
What is the complication of treatment in syphilis patients? What are the features of it and how is it treated?
Jarisch-Herxheimer reaction - 24hrs after commencement of antibiotics
Acute, transient, systemic reaction to bacterial endotoxins and pyrogens that are released after initiation of antibiotic therapy
- Flu like symptoms - fever, chills, headache myalgia, tachycardia and rash
- in contrast to anaphylaxis, there is no wheeze or hypotension
- Syphilitic exanthema may flare up
Usually self-limiting within 12–24 hours
No treatment required - only antipyretics
What do you suspect is a women presenting with Offensive, yellow/green, frothy discharge, Vulvovaginitis and punctate marks on cervix
Strawberry cervix - feature
Trichomonas vaginalis
What is the incubation period for chlamydia infections and what are the common features present?
Incubation period is around 7-21 days
Asymptomatic in around 70% of women and 50% of men
Women:
- cervicitis (discharge, bleeding- IMB, PCB)
- dysuria
men: urethral discharge, dysuria
What are the potential complications of chlamydia infection?
- Pelvic inflammatory disease
- endometritis
- increased incidence of ectopic pregnancies - tubal infertility
- infertility
- reactive arthritis
- perihepatitis (Fitz-Hugh-Curtis syndrome)
- Perinatal transmission of infection to new born - risk of conjunctivitis, otitis media and pneumonia
What are the features of Fitz-hugh curtis syndrome?
Acute onset of RUQ abdominal pain: Worsened by breathing / coughing / laughing, May be referred to right shoulder
How is chlamydia infection diagnosed?
Nuclear acid amplification tests (NAATs) are now the investigation of choice
for women: the vulvovaginal swab is first-line (can be self-taken) / Endocervical swab
for men: first pass urine - first line
Chlamydia testing should be carried out two weeks after a possible exposure
How is chlamydia screened and what is the target age group?
National Chlamydia Screening Programme is open to all men and women aged 15-24 years
relies heavily on opportunistic testing
How is a chlamydia infection treated?
o Azithromycin – 1g single dose (better compliance) - first line
OR
o Doxycycline – 100mg bd for 7d
How is a chlamydia infection treated in preganant women?
Pregnant woman = Erythromycin 500mg bd for 10-14d (73-95% effective)
What is the contact tracing period for men and women diagnosed with or suspected to have chlamydia infection?
- For men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms
- For women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
Contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)
What are the three types of swabs in triple swab?
High vaginal swab - posterior fornix
Endocervical swab - endocervix
Chlamydia swab - endocervix cells
What are the triple swabs looking for?
High vaginal swab - posterior fornix - TV, BV and Candida
Endocervical swab - endocervix - GC
Chlamydia swab - endocervix cells - Chlamydia
What is the management of PID?
Low threshold for treatment as clinical diagnosis
Oral ofloxacin + oral metronidazole
OR
IM ceftriaxone + oral doxycycline + oral metronidazole
What are the different types of herpes viruses and what are they associated with?
Genital herpes is mainly caused by HSV-2, but presumably due to unprotected oral sex becoming more commonplace, the number of HSV-1-related genital herpes infections is rising.
HSV-1 accounted for oral lesions (cold sores)
What is Herpetic Gingivostomatitis?
Severe manifestation of an (often primary) HSV-1 infection - mainly in children (1-6yrs old) and immunocompromised pts
Gingivitis; erythema and painful ulcerations on perioral skin and oral mucosa, especially on the inner cheek, soft palate, and tongue
Pharyngitis, cervical lymphadenopathy
What are the features of a herpes infection?
- Primary infection: may present with a severe gingivostomatitis
- cold sores
- painful genital ulceration
Primary HSV Infection - (Most severe)
Symptoms
- Prodrome (Tingling / Itching of the skin in affected area)
- Flu-like illness ± Inguinal lymphadenopathy
- Vulvitus + Pain
- Vesicles (Characteristics)
Recurrent (2o) - (Reactivation of latent virus in sacral ganglia)
Shorter & Less severe • Triggered by: o Stress o Sexual intercourse o Menstruation
How is a HSV infection diagnosed?
Dx = Clinical (Rash)
Gold Standard = PCR testing of vesicular fluid
What is the management of HSV1 and 2 infections?
Cold sores: topical aciclovir although the evidence base for this is modest
Genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir
Gingivostomatitis: oral aciclovir, chlorhexidine mouthwash
What are some of the complications of HSV infections?
- Meningitis
- Sacral radiculopathy (Urinary retention, Constipation)
- Transverse myelitis
- Disseminated infection
What is the management of a pregnant patient diagnosed with HSV infection?
- Elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
- Women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
When is a diagnosis of Non-specific urethritis or non-gonococcal urethritis made?
Non-gonococcal urethritis (NGU, sometimes referred to as non-specific urethritis) is a term used to describe the presence of urethritis when a gonococcal bacteria are not identifiable or the initial swab. A typical case would be a male who presented to a GUM clinic with a purulent urethral discharge and dysuria. A swab would be taken in clinic, microscopy performed which showed neutrophils but no Gram negative diplococci (i.e. no evidence of gonorrhoea). Clearly this patient requires immediate treatment prior to waiting for the Chlamydia test to come back and hence an initial diagnosis of NGU is made.
What are the causes of NGU?
Chlamydia trachomatis - most common cause
Mycoplasma genitalium - thought to cause more symptoms than Chlamydia
What is the management of 1st episode of mycoplasma NGU?
Responsible for 25% of NGU
Many men with. M.gen do not develop NGU
1st episode - Doxycycline 100mg BD
OR
Azithromycin 1g stat then 500mg OD for next 2d
Or
Ofloxacin (200mg BD for 7d)
What is the management of recurrent episodes after doxycycline of mycoplasma NGU?
Azithromycin
(1g stat then 500mg OD for next 2d
+
Metronidazole
(400mg BD for 5d)
What is the management of recurrent episodes after azithromycin of mycoplasma NGU?
1st line: Moxifloxacin (400mg OD for 10d) \+ Metronidazole (400mg BD for 5d)
Alternative: Doxycycline (100mg OD for 7d) \+ Metronidazole (400mg BD for 5d)
How do you do smear tests for pregnant women who have had abnormal smears previously? And what do you do if they had normal smears previously?
NICE guidelines suggest that a woman who has been called for routine screening wait until 12 weeks post-partum for her cervical smear.
If a smear has been abnormal in the past and a woman becomes pregnant then specialist advice should be sought. If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.
What type of drug is clomiphene citrate and how does it function? What are the side effects?
Clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development
Side effects: hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%)
What are the types of miscarriage management availble?
expectant
medical
surgical
What does expectant management of miscarriage involve?
‘Waiting for a spontaneous miscarriage’
First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
If expectant management is unsuccessful then medical or surgical management may be offered
What does medical management of miscarriage involve?
Vaginal misoprostol - Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
Should be given with antiemetics and pain relief
What are the situations were expectant management of miscarriage is not recommended?
- Increased risk of haemorrhage -
i. she is in the late first trimester
ii. if she has coagulopathies or is unable to have a blood transfusion - Previous adverse and/or traumatic experience
- Associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
- Evidence of infection
What does surgical management of miscarriage involve?
The two main options are:
- Vacuum aspiration (suction curettage)
- surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
A 24-year-old female presents with a one day history of dysuria and urinary frequency. She was diagnosed with a simple urinary tract infection and prescribed a three day course of trimethoprim. She returns two weeks later with new onset vaginal discharge. A whiff test is negative and no clue cells are observed on microscopy.
What is the most likely explanation?
Vaginal candidiasis - caused due to the RF of taking antibiotics
How does red degeneration present?
Presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
Worse during pregnancy due to the rise in the level of oestrogen
How are patients with endometriosis who want to conceive managed?
In patients with endometriosis who wish to conceive, then a referral to fertility services is recommended if the couple have not conceived after 6 months of regular unprotected vaginal sexual intercourse.
Surgical options such as laparoscopic adhesiolysis may improve fertility rates in patients with mild-moderate disease.
What are the risks and benefits of cancer associated with HRT treatment?
Combined HRT - increases the risk of breast cancer (due to the addition of progesterone)
Unopposed oestrogen HRT - higher risk of endometrial cancer
VTE risk - increases with the use of HRT (addition of progesterone)
What are the counselling points for couple struggling to conceive?
- Folic acid
- Aim for BMI 20-25
- Advise regular sexual intercourse every 2 to 3 days
- Smoking/drinking advice
Which HRT regimen is preferred for perimenopausal women?
Systemic combined cyclical HRT
combined oestrogen and progestogen cyclical HRT.
Cyclical HRT is recommended in perimenopausal women because it produces predictable withdrawal bleeding, whereas continuous regimens often cause unpredictable bleeding.
A 63-year-old nulliparous lady presents to her general practitioner with symptoms of abdominal bloating and diarrhoea. She has a family history of irritable bowel syndrome. On examination, the abdomen is soft and non-tender with a palpable pelvic mass. Which one of the following is the most suitable next step ?
Measure CA-125 and refer to gynaecology
If suspicion of ovarian cancer but there is an abdominal or pelvic mass, CA125 and US test can be bypassed and the patient directly referred to gynaecology
What are the biochemical findings of premature ovarian failure?
Raised FSH and LH
Impaired follicular development → ↓ estrogen levels → loss of feedback inhibition of estrogen on FSH and LH → ↑ FSH and LH (usually FSH > LH)
What is the treatment for vaginal vault prolapse?
The most suitable surgical option is sacrocolpopexy
What are the features of threatened miscarriage?
Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
The bleeding is often less than menstruation
Cervical os is closed
Complicates up to 25% of all pregnancies
What are the features of missed miscarriage?
A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
Cervical os is closed
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
What are the features of inevitable miscarriage?
Heavy bleeding with clots and pain
cervical os is open
What are the features of incomplete miscarriage?
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
Which of the miscarriages have open os?
Open your I’s
Incomplete
Inevitable
What is the first line drug mx for premenstrual symptoms?
COCP
What time period of pregnancy do you suspect ectopic pregnancy?
6-8 weeks
What are the side effects of HRT in terms of symptoms?
nausea
breast tenderness
fluid retention and weight gain
What are the features of shehan syndrome and what is the pathophysiology?
- During pregnancy, hypertrophy of prolactin-producing regions increases the size of the pituitary gland, making it very sensitive to ischemia.
- Blood loss during delivery/postpartum hemorrhage → hypovolemia → vasospasm of hypophyseal vessels → ischemia of the pituitary gland
Sheehan syndrome: postpartum necrosis of the pituitary gland. Usually occurs following postpartum hemorrhage, but can also occur even without clinical evidence of hemorrhage.
Features: Low prolactin (breastfeed problems), Hypothyroid (Low TSH), Cushingoid (Low ACTH), DI, FSH,LH deficiency, GH deficiency
A 23-year-old woman who is 10 weeks pregnant presents with severe vomiting. She is now having difficulty keeping down fluids and a dipstick of her urine shows ketones ++. What is this condition?
Hyperemesis gravidarum
How do you treat a 24y old woman who is 36 weeks preganant and complains of white curd like vaginal discharge down below?
Vaginal pessary or cream
Only local treatment in pregnant women
If not pregnant - itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
What is the typical age range for vulval cancer?
65y
What are the risk factors for vulval cancer?
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
What are the causes of vulval carcinoma?
lump or ulcer on the labia majora
may be associated with itching, irritation
A 26-year-old woman attends the GP surgery reporting abdominal pains. She missed her last period and had unprotected sexual intercourse 7 weeks ago. She reports no vaginal discharge or per vaginal bleeding. She reports no urinary symptoms.
On examination, her abdomen is soft but there is mild suprapubic tenderness. Her heart rate is 70 beats per minute, blood pressure is 120/80 mmHg and she is apyrexial. You perform a pregnancy test which is positive.
What is the next step?
Admit her to Early pregnancy assessment unit under these conditions:
- Pain and abdominal tenderness
- Pelvic tenderness
- Cervical motion tenderness
When do you admit a patient to EPAU after she tests positive for preganancy?
Admit her to Early pregnancy assessment unit under these conditions:
- Pain and abdominal tenderness
- Pelvic tenderness
- Cervical motion tenderness
> = 6 weeks gestation
If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to an early pregnancy assessment service
< 6 weeks gestation
If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:
1. to return if bleeding continues or pain develops
to repeat a urine pregnancy test after 7–10 days and to return if it is positive
2. a negative pregnancy test means that the pregnancy has miscarried
What is the definitive treatment for adenomyosis?
hysterectomy
How do you differentiate fibroids from adenomyosis?
Both present with menorrhagia and abdominal pain
On palpation : FIbroids are non-tender, adenomyosis - tender
According to new guidelines for cervical cancer screening what is the first step
High risk HPV
What is the next step after high risk- HPV positive? and what if that is positive?
Samples are examined cytologically
If the cytology is abnormal → colposcopy this includes the following results: - borderline changes in squamous or endocervical cells. - low-grade dyskaryosis. - high-grade dyskaryosis (moderate). - high-grade dyskaryosis (severe). - invasive squamous cell carcinoma. - glandular neoplasia
What is the next step after high risk- HPV positive after negative cytology? And how are the results interpreted?
Repeat test in 12mths:
If the repeat test is now hrHPV -ve → return to normal recall
If the repeat test is now HrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
If hrHPV +ve at 24 months → colposcopy
According to the new cervical cancer screening guidelines what is done when an inadequate sample is obtained?
Repeat the sample within 3 months
If two consecutive inadequate samples then → colposcopy
