Gynaecology Flashcards
What are the Rotterdam criteria for diagnosing PCOS?
You need 2 of the 3 to diagnose PCOS:
1) Signs of infrequent or absent ovulation -> Oligomenorrhoea (menstrual cycles > 35 days) or Amenorrhea
2) Clinical (acne, hirsutism, male-pattern baldness)
or Biochemical indicators (raised Free Androgen Index [ total testosterone level / sex hormone binding globulin x 100]
of hyperandrogenism
3) USS showing polycystic ovary (>12 follicles in one or both ovaries) or increased ovarian volume (>10mls)
What are the recommended baseline investigations if PCOS suspected as per NICE CKS?
LH
FSH
Testosterone
Sex Hormone Binding Globulin
Prolactin
Thyroid Stimulating Hormone
HbA1C / FBG to assess for impaired glucose tolerance
What are the classical biochemical changes seen in bloods in PCOS?
The only blood marker that is involved in official diagnosis as per the Rotterdam criteria is the Free Androgen Index (total testosterone / SHBG x 100) - this is raised in PCOS as testosterone is usually normal or high and SHBG is usually normal or low)
Other blood markers that may support the diagnosis though are:
Total testosterone - normal to slightly raised (if markedly elevated consider other diagnosis)
Sex Hormone Binding Globulin (SHBG) - normal to low
Prolactin - normal to slightly raised
LH: FSH ratio - may be elevated - in PCOS LH is elevated more continuously and so you don’t get the same LH surge effect to prompt ovulation
What is the normal postmenopausal endometrial thickness?
<4mm
Under what circumstances is Anti-D required / not required in ectopic pregnancy in rhesus negative woman?
If medical management - anti- D not required
if surgical management of ectopic - anti-D immunoglobulin required (250 IU)
Do not offer anti-D rhesus prophylaxis to women who:
receive solely medical management for an ectopic pregnancy or miscarriage or
have a threatened miscarriage or
have a complete miscarriage or
have a pregnancy of unknown location.
What are the reporting / recording obligations in cases of suspected or confirmed FGM?
ALL cases of known FGM must be recorded with the FGM Enhanced Dataset - details are NOT annonymous but the women should be assured it is secure.
Confirmed/reported FGM in girl <18 - must report to the police within 1 month of disclosure
Suspected or at-risk of FGM in girl < 18 - refer to social services or police depending on severity of risk
Non-pregnant women > 18 - no obligation to report to police / social services UNLESS a child is thought to be at risk
Pregnant women - FGM safeguarding risk assessment tool, if risk to unborn child or other child then refer to social services or police
Classic presentation of ovarian torsion?
Severe localised pain in RIF or LIF
Associated N+V
Onset may coincide with exercise
May have low-grade fever if ovarian necrosis set in
May have unilateral tender addnexal mass on examination
What are contraindications to expectant management of miscarriage as per NICE guidelines?
1st line miscarriage mx is expectant (Await 7-14 days before then offering medical or surgical)
Exceptions to this are if:
1) Evidence of infection
2) Increased risk of haemorrhage (in late first trimester, coagulopathy or pt unable to have a blood transfusion)
3) prev adverse / traumatic experience in pregnancy (stillbirth etc)
What is the most common cause of postcoital bleeding?
Cervical ectropion
Which medications are contraindicated in combination with Tamoxifen due to interactions?
The SSRIs fluoxetine and paroxetine
(they inhibit CYP450 which reduces the effectiveness of tamoxifen)
What is the general management approach for a lady presenting with menorrhagia?
FBC and Hx/exam in all.
If symptoms/signs suggestive of underlying pathology do further Ix including Pelvic USS
If not:
-> if does NOT require contraception, 1st line = Tranexamic Acid 1g TDS OR Mefanamic Acid 500mg TDS (or other NSAID) both started on first day of period
-> if DOES require contraception, 1st line = Mirena coil (if acceptable to the woman) 2nd line = COCP 3rd line = Depot provera
What is the upper limit of termination of pregnancy in the UK?
23+6 weeks (ie <24 weeks
(legal beyond 24 weeks only if mother’s life is at risk or child at risk of severe disability)
Beyond which gestation do rhesus negative women require anti D?
Rhesus neg women need anti D during TOP from 10+0 weeks onwards
What criteria are stipulated for expectant management of an ectopic pregnancy?
Size < 35mm
Beta HCG < 1,000 and declining
Asymptomatic
Nil heartbeat
Unruptured
How should cervical bleeding during cervical smear procedure be managed?
Contact bleeding in otherwise healthy-looking cervix - reassure, explain sample may be insufficient -> if repeated problem of contact bleeding, refer to gynae
Contact bleeding + suspicion of malignancy - DO NOT send off the smear -> refer with 2WW to gynae
Under what circumstances should the cervical smear be delayed?
Pregnant
<12 weeks postpartum or post-miscarriage or TOP
Currently menstruating
Active infection / abnormal discharge
Which other QTc prolonging medications should be avoided being given in combination wih fluconazole?
Erythromycin
Quinodine
Pimozide
Cisapride
Which route of taking Misoprostol (2nd step) in medical TOP is better tolerated?
Vaginal misoprostol carries a lower risk of side-effects (N+V) than buccal or sublingual
What is the typical presentation of partial v complete molar pregnancy?
Partial molar pregnancy -> may mimic a miscarriage [may have intrauterine sac +/- fetal pole] but with a disproportionally high beta HCG
Complete mole - snowstorm appearance on USS, large-for-dates uterus, symptoms of thyrotoxicosis (hcg has common alpha unit as TSH so in large amounts can stimulate thyroid gland), hyperemesis
What is Nageles Rule to predict EDD?
LMP + 9 months + 7 days
What is the only intervention which is shown to reduce the rate of further miscarriage in couples with recurrent unexplained miscarriage?
Psychological support & regular scans
What is the recurrence risk of a further ectopic pregnancy after a previous ectopic?
Recurrence = ~ 10%
How long after management of a hydatiform mole should the woman wait until TTC again?
If had chemo (with MTX) -> wait 1 year
If surgical evacuation, wait for 6 months post-evacuation or post-HCG levels normalising whichever is later
Which investigation is now considered the most accurate / gold-standard investigation for diagnosing ectopic pregnancy?
Transvaginal USS
- laparoscopy is no longer considered gold standard as false negative rate may be upto 5% if undertaken too early in the pregnancy*
What is the classical USS finding in ovarian torsion?
Enlarged ovary in the midline with free pelvic fluid
& WHIRLPOOL SIGN = as a result of the ovary twisting on itself
Risk factors for ovarian torsion?
Ovarian Mass
Reproductive Age
Pregnancy (^ ligament laxity & corpus luteum cyst)
Ovarian stimulation for fertility tx
High-intensity exercise
R cyst more likely to tort than left cyst as ligament longer and L cyst held in place more by sigmoid colon
Potential causes of paralytic ileus post-operatively?
HYPOkalaemia - important to check U&Es as replacing the potassium helps resolve the ileus
Urine in the abdomen 2ndary to ureteric or bladder injury can also cause ileus.
What is the rate of progression to endometrial cancer in women found to have endometrial hyperplasia WITHOUT atypia?
< 5% over 20 years
Most cases of endometrial hyperplasia without atypia resolve spontaneously
Differentials for post-hysterectomy PV bleeding?
Early - vault dehiscence (rare) presents w/ haematoma running down vagina
Days - weeks - infection - 2ndary haemorrhage
Late (several weeks+) granulation tissue - can cause sudden onset bleeding, apply silver nitrate topically locally.
Which tumour markers should be performed in women <40 with an ovarian mass?
CA-125 & hCG & alpha fetoprotein (due to risk of germ cell tumours in younger women) & LDH
What is the baseline risk of endometrial cancer in a woman presenting with postmenopausal bleeding?
5-10%
What is the typical presentation of lichen sclerosus et atrophicus and which complication should you be wary of?
Painful white skin on the vuva with cracks
^ risk of SCC developing in the area so ensure any ulceration / new lesions are biopsied
Typical presentation of imperforate hymen?
Primary amenorrhoea
Cyclical lower suprapubic pain
Palpable mass due to extended vagina filled with bloods (haematocolpos)
Surgical intervention pre-pubertal only if symptomatic as pubertal oestrogen normally causes the hymen to open
NICE recommendations for endometriosis management?
1st line symptomatic relief: paracetamol + NSAID (ibuprofen or mefenamic acid) for cyclical pain
2nd line; COCP or Depot provera injection
3rd line or if fertility a priority: refer to gynae for consideration of GnRH analogues or laparoscopic excision or ablation + adhesionolysis +/- endometrioma removal
Surgical Mx improves fertility outcomes, not drug Tx
Cervical screening programme for HIV positive women?
ANNUAL cervical HPV testing AND liquid-based cytology
Typical presentation of and risk factors for vulval squamous carcinoma?
Presents as non-healing lump / ulcer on the vulva, may have associated itch or irritation.
Risk factors:
Age > 65
Lichen sclerosus
Immunocompromise
HPV infection
VIN (vulval intraepithelial neoplasm)
What are the main long-term sequelae of PCOS?
^ risk endometrial hyperplasia & cancer (due to amenorrhoea or oligmenorrheoa while being exposed to pre-menopausal oestrogen levels) - highest risk in people not getting periods for > 3 months - can reduce this risk by inducing a bleed every 1-3 months with COCP or Lg-IUS
Subfertility
diabetes
obstructive sleep apnoea
Coronary artery disease
Stroke / TIA
How to diagnose premature ovarian insufficiency
Suspect in women < 40 with menopausal symptoms.
Confirm with 2x FSH levels > 30 IU taken 4-6 weeks apart & oligo/amenorrhoea for > 3 months
Clinical features of adenomyosis?
= endometrial tissue growing in myometrium
Tends to present towards END of reproductive years
Dysmenorrhoea, menorrhagia & enlarged boggy uterus of TV USS.
Mx:
TXA and mefanamic acid
COCP or IUS
Uterine artery embolisation
Why is ullipristal acetate no longer recommended for fibroid drug treatment?
Concerns re risk of it causing severe liver deficiency
What endometrial thickness is considered abnormal on TV USS in post-menopausal woman and would merit a referral for hysteroscopy and biopsy?
> 4mm in post menopausal woman = need to refer for hysteroscopy & biopsy
If < 4mm endometrial Ca excluded
What are the 4x types of FGM?
Type I - clitoridectomy
Type 2 - excision of the clitoris & labia minora +/- excision of the labia majora
Type 3 - narrowing of the vaginal orifice by apposition of the labia minora/majora
Type 4 - other non-medical procedures to the female genitalia eg piercing, cauterisation
Stress versus urge incontinence and their recommended management?
Stress Incontinence:
coughing/sneezing/laughing
1st line = pelvic floor exercises (8 exercises TDS for min 3 months)
-> then consider surgical referal for retropubic mid-urethral taping
If declines surgical referral = Duloxetine = increases contractility of urethral sphincter
Urge incontinence / Detrusor overactivity:
sudden urge to urinate followed by uncontrolled leakage
1st line = bladder retraining for min 6 weeks (^ time between voids)
-> Antimuscarinic agent
- Oxybutynin IR (caution in elderly), Tolteridone, Darifenacin
In elderly consider Mirabegron (beta 3 agonist) instead to avoid anticholinergic side effects
What is the single greatest risk factor for ovarian torsion?
Having an ovarian mass
Is there an association between presence of cervical ectropion and cervical cancer risk?
NO
COCP slightly increases the risk of cervical cancer but the presence of a cervical ectropion even if symptomatic does not increase the risk of cervical Ca.
What category of drug is clonidine for the menopause?
Alpha 2 agonist
What medication can be prescribed to help delay a period in the short term eg when going on holiday?
Norethisterone 5mg TDS taken 3 days prior next expected period
Menses will resume 2-3 days after stopping the tablets
Caution in using norethisterone in those with lots of CVD risk factors or VTE risk factors
Definition of primary amenorrhoea?
Failure to develop menses by 15 in someone WITH secondary sexual characteristics or by 13 in someone WITH NO secondary sexual characteristics.
Definition of secondary amenorrhoea?
Absence of menses for 3-6 months in someone with previous normal regular cycles or 6-12 months in someone with prev irregular cycles
Definition of oligmenorrhoea?
Menses occurring less frequently than every 35 days
How long after a breast exam must you wait to take a prolactin level?
48 hrs
(prolactin may be falsely elevated for 48 hrs post breast exam)
What are indications for referral to urologist in context of woman presenting with urinary continence issues?
- Associated faecal incontinence
- Palpable bladder on bimanual or abdo exam post-voiding
- Suspected neurological disease
- Suspected fistula
- Prev continence or pelvic cancer surgery
- Prev pelvic radiotherapy
- Persisting bladder or urethral pain
- Symptoms of voiding difficulty
What is the only surgical management option for uterine prolapse that protects future fertility?
Vaginal sacro-hysteroplexy with sutures
Where is the most common location for an ectopic pregnancy?
AMPULLA (~ 97%)
More dangerous if in the isthmus
Indications for surgical Mx in ectopic pregnancy?
HCG > 5,000
Visible fetal heartbeat
Significant pain
Ruptured
Size > 35 mm
Indications for methotrexate Mx in ectopic pregnancy?
HCG < 1,500
Unruptured
No fetal heartbeat
Size < 35mm
Nil significant pain
Indications for expectant Mx in ectopic pregnancy?
HCG < 1,000
Pain-free, unruptured and nil heartbeat
Size < 35 mm
Management of ovarian mass / cyst in pre-menopausal women?
DO NOT need to do a CA-125 in all premenopausal women if USS shows a simple cyst. Simple cysts < 50mm nil follow-up needed, almost always resolve within 3 cycles, simple cysts 50-70 mm consider annual USS, simple cysts > 70 mm should be referred for further Ix
LDH, AFP, HCG should be done in all women < 40 with a COMPLEX ovarian mass:
Elevated in the following malignant germ cell tumours
- Dysgerminoma (associated w/ Turner’s syndrome) - release HCG & LDH
- Yolk sac tumour - releases AFP
- Choriocarcinoma - release high levels of HCG
Ca-125 less reliable in pre-menopausal women (^ fibroids, endometriosis, adenomyosis and pelvic infection) - if < 200 investigate for one of these other differentials and consider serial levels (Static levels unlikely in malignancy), if > 200 then discuss w/ gynae oncology
If USS shows any of these red flags (‘M rules’) refer to gynae oncology:
- Strong blood flow
- 4+ papillary structures
- Irregular multiloculated solic tumour > 100mm
- Ascites
Calculate RMI I if suspect ovarian malignancy (although will be less reliable in pre-menopausal women):
- USS (1x score for bilateral, solid areas, multi-loculated, ascites, metastases U = 0 if 0 points, U = 1 if 1 point U = 3 if 2-5 points)
x
Pre-menopausal (1 point) Post-menopausal (3 points)
x
Ca-125
RMI 200+ = high malignancy risk
How should ovarian cysts / masses be managed in postmenopausal women?
Any post-menopausal woman with an ovarian cyst > 10mm should get CA-125 and TV USS & calculate RMI.
If RMI < 200:
If asymptomatic, unilateral, unilocular, simple AND < 50mm with normal Ca-125 consider conservative Mx - repeat USS & Ca-125 in 4-6 months if unchanged repeat again in 4-6 months. Consider discharging if resolved by 1 year.
If any of the following: symptomatic, multi-locular, non-simple, > 50mm, bilateral -> bilateral laparoscopic salpingo-oopherectomy (using laparoscopic retrieval bag)
if RMI > 200:
Need CT Abdo & Pelvis
&
Refer to Gynae Oncology MDT review
If gynae onc MDT thinks high risk of malignancy = full staging procedure
If thinks low risk of malignancy = laparotomy & pelvic clearance (TAH & BSO & omenectomy & peritoneal cytology)
NICE Guidelines on ectopic and miscarriage care?
If woman < 6 wks, nil risk factors for ectopic & PAINLESS PV bleeding
= conservative mx - advise to return if bleeding continues / worsens, advise UPT 7-10 days and that if negative = miscarriage
Refer to early pregnancy assessment unit or out-of-hours gynae if PV bleeding with;
- Pain
- Gestation > 6 weeks
- Pregnancy of uncertain gestation
for pregnancy viability scan
- If CRL < 7mm & no heartbeat - repeat in 7 days
- if CRL > 7mm & no heartbeat - either ask for 2nd opinion to confirm non-viability or repeat in 7 days
If no fetal pole, can measure gestational sac;
- if gestational sac < 25mm & no HB - repeat in 7 days
- if gestational sca > 25 mm & no HB either ask for 2nd opinion to confirm non-viability or repeat in 7 days
DO NOT DIAGNOSE COMPLETE MISCARRIAGE BASED ON USS IF NIL PREV USS TO CONFIRM INTRAUTERINE PREGNANCY - TREAT AS PUL AND HAVE F/U HCG OR USS
PUL: if stable
Measure HCG 48 hrs apart
- If ^ > 63% at 48 hrs - inform likely intrauterine pregnancy - offer USS at 7-14 days
- If > 50% drop in HCG at 48 hrs, inform likely non-viable pregnancy - urine PT at 14 days
- If between 50% drop to 63% increase refer for EPAU assessment within 24 hrs
Threatened miscarriage:
(Bleeding in woman with confirmed intrauterine pregnancy with fetal HB)
- If prev miscarriage - then give 400mg vaginal progesterone BD until 16 wks
- if nil prev miscarriage then don’t
- advise to re-contact if bleeding continues > 14 days
Confirmed miscarriage:
Expectant management for 7-14 days unless
* at risk of haemorrhage eg late first trimester or coagulopathy * signs of infection * prev traumatic experience
Medical management:
Missed miscarriage - 200mg oral mifepristone then 800 mcg misoprostol oral/sublingual/vaginal 48 hrs later
Incomplete miscarriage - 600mcg misoprostol oral/sublingual/vaginal
Expectant management ectopic:
repeat HCG day 2, 4, 7 then weekly until negative - should get at least 15% drop each time, if not refer for review
Fertility and safety outcomes similar between expectant and medical ectopic management
Post-MTX
HCG day 4 and 7 (should be > 15% drop)
then weekly until negative
Surgical ectopic mx:
Only offer salpingotomy if concern re the contralateral tube health
If offer salpingotomy advise 1 in 5 women will need either mTX or further surgical Mx
Repeat HCG 7 days post surgery then weekly until negative
If have salpingectomy then just need UPT at 3 weeks
Only need anti D if SURGICAL mx of ectopic or miscarriage (250IU, nil KH needed)
