Gynaecology Flashcards
1
Q
what is the treatment for thrush? what if pregnant?
A
options include local or oral treatment
NICE Clinical Knowledge Summaries recommends:
oral fluconazole 150 mg as a single dose first-line
clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
2
Q
What is the criteria for recurrent vaginal candidiasis? what is the management?
A
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
3
Q
What are the risk factors for ovarian torsion?
A
ovarian mass: present in around 90% of cases of torsion
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome
4
Q
Describe the clinical features and investigations/management of ovarian torsion?
A
Features
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
Ultrasound may show free fluid or a whirlpool sign.
Laparoscopy is usually both diagnostic and therapeutic
5
Q
What are the features of endometriosis (5)? what can be seen on pelvic exam?
A
-chronic pelvic pain
-secondary dysmenorrhoea
pain often starts days before bleeding
-deep dyspareunia
-subfertility
-non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
-on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
6
Q
What is the investigation for endometriosis?
A
laparoscopy is the gold-standard investigation
there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
7
Q
Describe the treatment in primary care for endometriosis?
A
Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE published guidelines in 2017:
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief if analgesia doesn't help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
8
Q
Describe the treatment in secondary care for endometriosis? What can be done for women trying to conceive?
A
If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority, the patient should be referred to secondary care. Secondary treatments include:
GnRH analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels
drug therapy unfortunately does not seem to have a significant impact on fertility rates
surgery
this may be an option for women who have not responded to conventional medical treatment
for women who are trying to conceive, NICE recommend laparoscopic excision or ablation of endometriosis plus adhesiolysis as this has been shown to improve the chances of conception. Ovarian cystectomy (for endometriomas) is also recommended
9
Q
Describe the VTE risk for patients on HRT
A
For women aged 50-59 the background incidence of VTE women not using HRT is 5 per 1,000. The use of oestrogen only HRT adds 2 per 1,000 cases. The use of combined HRT adds 7 per 1,000 cases.
transdermal HRT does not appear to increase the risk of VTE
NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
10
Q
What are three side effects of HRT?
A
nausea
breast tenderness
fluid retention and weight gain
11
Q
What are 5 risks of HRT?
A
- increased risk of breast cancer-increased risk of endometrial cancer-increased risk of venous thromboembolism
- increased risk of stroke
-increased risk of ischaemic heart disease if taken more than 10 years after menopause
12
Q
Describe the increased risk of breast cancer in women on HRT?
A
increased risk of breast cancer
increased by the addition of a progestogen
in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
the increased risk relates to the duration of use
the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
13
Q
Describe the increased risk of endometrial cancer in women on HRT?
A
increased risk of endometrial cancer
oestrogen by itself should not be given as HRT to women with a womb
reduced by the addition of a progestogen but not eliminated completely
the BNF states that the additional risk is eliminated if a progestogen is given continuously
14
Q
What are the 4 different types of ovarian cysts?
A
Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours.
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
15
Q
What are the 2 physiological ovarian cysts?
A
Follicular cysts
Corpus luteum cyst
16
Q
What is a follicular cyst? is this common? what is the natural history of these?
A
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
17
Q
what is a corpus luteum cyst? how does this present?
A
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
18
Q
What cyst is a benign cell tumour? is this common? what is a risk with this cyst?
A
Dermoid cyst
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
19
Q
What are the two benign epithelial tumours?
A
Serous cystadenoma
Mucinous cystadenoma
20
Q
What is the most common benign epithelial tumour? is this bilateral?
A
Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
21
Q
What is the second most common benign epithelial tumour? what can happen if this ruptures?
A
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
22
Q
What is meigs syndrome?
A
Meigs’ syndrome is a benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
23
Q
What is the menopause defined by?
A
Menopause is defined as the permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.
24
Q
What are the three categories of the management of the menopause?
A
Lifestyle modifications
Hormone replacement therapy (HRT)
Non-hormone replacement therapy
25
what is tibolone and when is this unsuitable for use?
synthetic compound with both oestrogenic, progestogenic, and androgenic activity
Unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
26
Describe the lifestyle changes that can be advised to reduce:
-Hot flushes
-Sleep disturbance
-Mood
-Cognitive symptoms
Hot flushes
regular exercise, weight loss and reduce stress
Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene
Mood
sleep, regular exercise and relaxation
Cognitive symptoms
regular exercise and good sleep hygiene
27
what are the 4 contra-indications to HRT?
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
28
What percentage of women use HRT to control their menopausal symptoms?
10%
29
How long should you advise women that the symptoms of menopause should last?
Women should be advised that the symptoms of menopause typically last for 2-5 years
30
What are the risks that treatment with HRT can bring?
and that treatment with HRT brings certain risks:
Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer: increased risk with all HRT.
31
Describe the non-hormonal treatments of
-Vasomotor symptoms
-Vaginal dryness
-Psychological symptoms
-urogenital symptoms
-Hot flushes
Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants
Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
Hot flushes
Offer lifestyle advice to control symptoms (regular exercise, lighter clothing, less stress and avoiding triggers e.g. spicy foods). If this is not effective, consider other treatments
A 2 week trial of paroxetine (20 mg daily), fluoxetine (20 mg daily), citalopram (20 mg daily), or venlafaxine (37.5 mg twice a day)
A 24 week trial of clonidine (50 to 75 micrograms twice a day, licensed use)
A progestogen such as norethisterone or megestrol (both off-label use) seek specialist advice if this option is being considered
32
what percentage of women of a reproductive age suffer from PCOS?
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age
33
What are 5 clinical features of PCOS?
subfertility and infertility
menstrual disturbances: oligomenorrhoea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)
34
What are the investigations for PCOS?
pelvic ultrasound: multiple cysts on the ovaries
NICE Clinical Knowledge Summaries recommend the following baseline investigatons: FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG) 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
SHBG is normal to low in women with PCOS (so no
check for impaired glucose tolerance
35
What is SHBG and how does this impact the features of PCOS?
SHBG is a plasma protein that binds the steroid hormones oestrogen, testosterone, and dihydrotestosterone. Low concentrations of SHBG increase the concentration of unbound, biologically active testosterone and dihydrotestosterone, leading to features of hyperandrogenism associated with PCOS.
36
Describe the diagnosis of PCOS?
a formal diagnosis should only be made after performing investigations to exclude other conditions
the Rotterdam criteria state that a diagnosis of PCOS can be made if 2 of the following 3 are present:
infrequent or no ovulation (usually manifested as infrequent or no menstruation)
clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
polycystic ovaries on ultrasound scan (defined as the presence of ≥ 12 follicles (measuring 2-9 mm in diameter) in one or both ovaries and/or increased ovarian volume > 10 cm³)
37
PCOS management - what lifestyle change can be advised? what contraception can be advised?
weight reduction if appropriate
if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below)
38
PCOS - describe the management of hirsutism and acne
Hirsutism and acne
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 may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision
39
PCOS - describe the management of infertility
weight reduction if appropriate
the management of infertility in patients with PCOS should be supervised by a specialist. There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
a 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS
metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins
40
How is a negative hrHPV smear result managed? (high risk HPV)
return to normal recall, unless
-the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
-the untreated CIN1 pathway
-follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
-follow-up for borderline changes in endocervical cells
41
What happens to smear samples that test positive for HPV?
samples are examined cytologically
42
What happens to patients with smear samples that test positive for HPV and abnormal cytology?
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
43
What happens to patients who have smear results with a +ve HPV but normal cytology?
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still 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
44
What happens to patients with inadequate smear sample?
If the sample is 'inadequate'
repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy
45
How many deaths is the cervical cancer screening programme estimated to prevent? what is the aim?
The UK has a well-established cervical cancer screening program which is estimated to prevent 1,000-4,000 deaths per year. The main aim of cervical screening is to detect pre-malignant changes rather than to detect cancer. It should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening
46
Who is offered a smear test and how regularly?
A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)
in Scotland, it is offered from 25-64 every 5 years
47
When would cervical screening tests be delayed? who may wish to opt out of 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 a very low risk of developing cervical cancer therefore they may wish to opt out of screening
48
Define menorrhagia
Heavy menstrual bleeding (also known as menorrhagia) was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The management has therefore shifted towards what the woman considers to be excessive.
49
What are the two investigations for menorrhagia?
Investigations
a full blood count should be performed in all women
NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.
50
Describe the non-hormonal management of menorrhagia
Does not require contraception
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
51
describe the hormonal management of menorrhagia
Requires contraception, options include
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
52
what percentage of the population are affecte by urinary incontinence?
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
53
what are 5 risk factors for urinary incontinence?
advancing age
previous pregnancy and childbirth
high body mass index
hysterectomy
family history
54
what are the 5 different types of urinary incontinence?
-overactive bladder (OAB)/urge incontinence
due to detrusor overactivity
the urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
-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
-functional incontinence
comorbid physical conditions impair the patient’s ability to get to a bathroom in time
causes include dementia, sedating medication and injury/illness resulting in decreased ambulation
55
what are 4 investigations of 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
56
Describe the management of urge incontinence?
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinics are first-line
NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
Immediate release oxybutynin should, however, be avoided in 'frail older women'
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
57
Describe the management of stress incontinence?
If stress incontinence is predominant:
pelvic floor muscle training
NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
58
what is the diagnostic triad of hyperemesis gravidarum? how many pregnancies does this affect? When does this occur?
Hyperemesis gravidarum, diagnostic criteria triad:
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks.
59
what are the 4 risk factors for hyperemesis? what is protective?
increased levels of beta-hCG
multiple pregnancies
trophoblastic disease
nulliparity
obesity
family or personal history of NVP
Smoking is associated with a decreased incidence of hyperemesis.
60
what are three indications for referral for patients with hyperemesis?
-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)
61
what scoring system can be used for patient with nausea and vomiting in pregnancy? (NVP)
Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.
62
Describe simple measures for nausea and vomiting in pregnancy?
Management
simple measures
rest and avoid triggers e.g. odours
bland, plain food, particularly in the morning
ginger
P6 (wrist) acupressure
63
Describe the first line medications for nausea and vomiting in pregnancy?
irst-line medications CKS
antihistamines: oral cyclizine or promethazine
phenothiazines: oral prochlorperazine or chlorpromazine
combination drug doxylamine/pyridoxine: pyridoxine (vitamin B6) monotherapy is actually used commonly outside of the UK as a first-line treatment for NVP. However, pyridoxine monotherapy is specifically not recommended in the RCOG guidelines
64
Describe the second line medications for nausea and vomiting in pregnancy? what is used in hospital to treat these patients?
second-line medications
oral ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. The Medicines and Healthcare products Regulatory Agency (MHRA) advise that if ondansetron is used then these risks should be discussed with the pregnant woman
oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days
admission may be needed for IV hydration
see criteria above for referral/admission
normal saline with added potassium is used to rehydrate
65
Name some complications in addition to wieght loss, dehydration and electrolyte disturbance that can result from hyperemesis? (5)
acute kidney injury
Wernicke's encephalopathy
oesophagitis, Mallory-Weiss tear
venous thromboembolism
fetal outcome CKS
studies generally show little evidence of adverse outcomes for birth weight/other markers for mild-moderate symptoms
severe NVP resulting in multiple admissions and failure to 'catch-up' weight gain may be linked to a small increase in preterm birth and low birth weight
66
what is the treatment for bartholins abscess?
This can be treated by antibiotics, by the insertion of a word catheter or by a surgical procedure known as marsupialization.
67
what is dysmenonorrhoea?
Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.
68
What is primary dysmenorrhoea? how many people does this affect? when does this most likely occur?
In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.
69
what are the features of dysmenorrhoea?
Features
pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh
70
what is the management of dysmenorrhoea?
Management
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line
71
what is secondary dysmenorrhoea? when does the pain start?
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.
72
what are causes of secondary dysmenorrhoea? when to refer?
Causes include:
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*
fibroids
Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
73
Describe the phases of the menstrual cycle and when do they occur?
Menstruation 1-4
Follicular phase (proliferative phase) 5-13
Ovulation 14
Luteal phase (secretory phase) 15-28
74
what happens to the ovaries in the follicular phase? what happens to the ovaries in the luteal phase?
Follicular (proliferative)
A number of follicles develop.
One follicle will become dominant around the mid-follicular phase
Luteal (secretory)
Corpus luteum
75
what happens to the endometrium in the follicular phase?
what happens to the endometrium in the luteal phase?
Follicular
Proliferation of endometrium
Luteal
Endometrium changes to secretory lining under influence of progesterone
76
what happens to hormones during the follicular phase?
A rise in FSH results in the development of follicles which in turn secrete oestradiol
When the egg has matured, it secretes enough oestradiol to trigger the acute release of LH. This in turn leads to ovulation
77
what happens to hormones during the luteal phase?
Progesterone secreted by corpus luteum rises through the luteal phase.
If fertilisation does not occur the corpus luteum will degenerate and progesterone levels fall
Oestradiol levels also rise again during the luteal phase
78
what happens to the cervical mucus following menstruation? and what happens just prior to ovulation?
Following menstruation the mucus is thick and forms a plug across the external os
Just prior to ovulation the mucus becomes clear, acellular, low viscosity. It also becomes 'stretchy' - a quality termed spinnbarkeit
79
what happens to the cervical mucus under the influence of progesterone?
Under the influence of progesterone it becomes thick, scant, and tacky
80
what happens to basal body temperature during the follicular phase? what happens in the luteal phase?
Falls prior to ovulation due to the influence of oestradiol
Rises following ovulation in response to higher progesterone levels
81
in surrogacy who is the childs legal mother?
the party giving birth to the child is its legal mother.
82
what is PMS and when does this occur?
Premenstrual syndrome (PMS) describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
PMS only occurs in the presence of ovulatory menstrual cycles - it doesn't occur prior to puberty, during pregnancy or after the menopause.
83
what are the emotional symptoms and physical symptoms of PMS?
Emotional symptoms include:
anxiety
stress
fatigue
mood swings
Physical symptoms
bloating
breast pain
84
describe the management of PMS mild/moderate and severe symptoms?
mild symptoms can be managed with lifestyle advice
apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
85
When should abnormal semen samples be rechecked?
for abnormal semen samples this should be rechecked 3 months after the initial analysis to allow time for the cycle of spermatozoa formation to be completed.
Guidelines recommend that an immediate recheck should only be performed if there is gross spermatozoa deficiency (azoospermia or severe oligozoospermia - defined as a sperm concentration of <5 million per ml) has been detected.
86
when should semen analysis be taken?
Semen analysis should be performed after a minimum of 3 days and a maximum of 5 days abstinence. The sample needs to be delivered to the lab within 1 hour
87
how common is infertility?
Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years
88
what are the 5 causes of infertility?
Causes
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%
89
When are couples usually referred to fertility services?
We should consider referral for a couple (for further assessment and management), who's history, examination, and investigations are normal and they have not conceived after 1 year (depending on local guidelines).
90
Which women would you consider an earlier referral to fertility services?
Age 36 years and older (refer after 6 months).
Amenorrhoea or oligomenorrhoea.
Previous abdominal or pelvic surgery.
Previous pelvic inflammatory disease.
Previous sexually transmitted infection (STI).
Abnormal pelvic examination.
Known reason for infertility (for example prior treatment for cancer).
91
Which men warrant an earlier referral to fertility services?
Previous genital pathology.
Previous urogenital surgery.
Previous STI.
Varicocele.
Significant systemic illness.
Abnormal genital examination.
Known reason for infertility (for example prior treatment for cancer).
92
what are the three classes of ovulatory disorder?
Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women)
Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases)
Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
93
Letrozole
-when is this used?
-What is the mechanism of action?
-what are the side effects of letrozole?
According to UptoDate, this is now considered the first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate
Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction
Side effects: fatigue (20%), dizziness (10%)
94
Clomiphene citrate
-When is this used?
-what is the mechanism of action?
-What are the side effects?
While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead
Mechanism of action: 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%)
95
When are GnRH analogues used for fertility services? what is the mechanism of action?
This tends to be the treatment used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism
For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial
This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome
Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development
96
what is ovarian hyperstimulation syndrome?
Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction, and unfortunately can be life-threatening if not identified and managed promptly
In OHSS, ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications.
97
what are the complications of ovarian hyperstimulation syndrome?
Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
This is a rare side effect which varies in severity, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction
98
what is the management of ovarian hyperstimulation syndrome?
Depending on the severity, the management includes:
Fluid and electrolyte replacement
Anti-coagulation therapy
Abdominal ascitic paracentesis
Pregnancy termination to prevent further hormonal imbalances
99
what are the two basic investigations for semen analysis?
Basic investigations
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
100
describe the interpretation of day 21 progesterone results
< 16 nmol/l - Repeat, if consistently low refer to specialist
16 - 30 nmol/l -Repeat
> 30 nmol/l - Indicates ovulation
101
what are 4 counselling points for couples who are finding it difficult to conceive
Key counselling points
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
102
How common is ovarian cancer? what is the peak age?
Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis.
103
which are the most common ovarian cancers?
around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many 'ovarian' cancers
104
what are risk factors for ovarian cancer?
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
105
what are the clinical features of ovarian cancer? 5
Clinical features are notoriously vague
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea
106
what are the investigations for ovarian cancer? 2
CA125
NICE recommends a CA125 test is done initially. 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
ultrasound
107
what is the management and the prognosis of ovarian cancer?
Management
usually a combination of surgery and platinum-based chemotherapy
Prognosis
80% of women have advanced disease at presentation
the all stage 5-year survival is 46%
108
what are the 4 risk factors for endometrial cancer?
- excess oestrogen
nulliparity
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
-metabolic syndrome
obesity
diabetes mellitus
polycystic ovarian syndrome
-tamoxifen
-hereditary non-polyposis colorectal carcinoma
109
what are 3 protective factors for endometrial cancer?
Protective factors
multiparity
combined oral contraceptive pill
smoking (the reasons for this are unclear)
110
what are four features of endometrial cancer?
The classic symptom is postmenopausal bleeding
usually slight and intermittent initially before becoming heavier
Other features
premenopausal women may develop menorrhagia or intermenstrual bleeding
pain is not common and typically signifies extensive disease
vaginal discharge is unusual
111
what is the investigation for endometrial cancer?
All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
112
what is the management of endometrial cancer?
The mainstay of management for endometrial cancer is surgery.
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
patients with high-risk disease may have postoperative radiotherapy
Progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery.
113
Describe the typical history of
-ectopic pregnancy
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
Shoulder tip pain and cervical excitation may be seen
114
What are the examination findings of ectopic pregnancy?
Examination findings
abdominal tenderness
cervical excitation (also known as cervical motion tenderness)
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
115
Describe the typical history of
-appendicitis
Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing's sign: more pain in RIF than LIF when palpating LIF
116
Describe the typical history of
-PID
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
117
Describe the typical history of
-ovarian torsion
Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
118
Describe the typical history of
-miscarriage
Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
119
Describe the typical history of
-endometrisosi
Chronic pelvic pain
Dysmenorrhoea - pain often starts days before bleeding
Deep dyspareunia
Subfertility
120
describe the typical history of
-IBS
Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit
Features such as lethargy, nausea, backache and bladder symptoms may also be present
121
describe the typical history of
-ovarian cyst
Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder
122
describe the typical history of
-urogenital prolapse
Seen in older women
Sensation of pressure, heaviness, 'bearing-down'
Urinary symptoms: incontinence, frequency, urgency
123
what is primary amenorrhoea?
primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
124
What is secondary amenorrhoea?
secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
125
What are 6 causes of primary amenorrhoea?
gonadal dysgenesis (e.g. Turner's syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
126
What are 7 causes of secondary amenorrhoea?
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan's syndrome
Asherman's syndrome (intrauterine adhesions)
127
what is it important to exclude when investigating secondary amenorrhoea?
exclude pregnancy with urinary or serum bHCG
128
what baseline blood tests to get when investigating amenorrhoea?
-full blood count, urea & electrolytes, coeliac screen, thyroid function tests
-gonadotrophins
low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
raised if gonadal dysgenesis (e.g. Turner's syndrome)
-prolactin
-androgen levels
raised levels may be seen in PCOS
-oestradiol
129
what is the general management of primary amenorrhoea?
Investigate and treat any underlying cause
with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner's syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)
130
what is the general management of secondary amenorrhoea?
exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
treat the underlying cause
131
what is the treatment for PID?
oral ofloxacin + oral metronidazole or
intramuscular ceftriaxone + oral doxycycline + oral metronidazole
due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ' Removal of the IUD should be considered and may be associated with better short term clinical outcomes'
132
what are the causative organisms in PID?
Chlamydia trachomatis
+ the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
133
what are the features of PID? what is seen on examination?
Features
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
134
what are the three investigations for PID?
a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab
these are often negative
screen for Chlamydia and Gonorrhoea
135
what are the 4 complications of PID?
perihepatitis (Fitz-Hugh Curtis Syndrome)
occurs in around 10% of cases
it is characterised by right upper quadrant pain and may be confused with cholecystitis
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy
136
what is VIN?
Vulval intraepithelial neoplasia (VIN) is a pre-cancerous skin lesion of the vulva, and may result in squamous skin cancer if untreated. The average of an affected women is around 50 years
137
what are 4 risk factors of VIN?
Risk factors
human papilloma virus 16 & 18
smoking
herpes simplex virus 2
lichen planus
138
what are the features of VIN?
Features
itching, burning
raised, well defined skin lesions
139
What is the upper limit of termination of pregnancy? How many medical practitioners need to sign a legal document? who can perform an abortion?
The current law surrounding abortion is based on the 1967 Abortion Act. In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks*
Key points
two registered medical practitioners must sign a legal document (in an emergency only one is needed)
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
140
Is anti-D given to women undergoing termination of pregnancy?
anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks' gestation
141
How is a medical termination of pregnancy done? how long does this take? what is the follow up?
mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions
patient decision aids often refer to this as mimicking a miscarriage
this may be done at home depending on the gestation
takes time (hours to days) to complete and the timing may not be predictable
a pregnancy test is required in 2 weeks to confirm that the pregnancy has ended. This should detect the level of hCG (rather than just be positive or negative) and is termed a multi-level pregnancy test
142
What are the surgical options for termination of pregnancy? how long after this can you insert an intrauterine contraceptive?
Surgical options
use of transcervical procedures to end a pregnancy, including manual vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)
cervical priming with misoprostol +/- mifepristone is used before procedures
women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia
following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
143
Are patients offered a choice between medical and surgical abortion and up to what gestation? what is most common before 9 weeks?
NICE recommend that women are offered a choice between medical or surgical abortion up to and including 23+6 weeks' gestation
patient decision aids are usually given to allow women to make an informed decision
after 9 weeks medical abortions become less common. Factors include increased likelihood of women seeing products of conception pass and decreased success rate
before 10 weeks medical abortions are usually done at home
144
What has to happen if FGM is reported in an under 18 year old?
Female Genital Mutation in under 18s - mandatory reporting duty applies
145
What are the 4 different types of FGM?
Type 1 Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2 Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3 Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type 4 All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
146
How common is vaginal itch?
Vaginal itching is common. It is estimated that 1 in 10 women will seek help at some point.
147
what are 6 causes of vaginal itch?
n contrast to pruritus ani, pruritus vulvae usually has an underlying cause:
irritant contact dermatitis (e.g. latex condoms, lubricants): most common cause
atopic dermatitis
seborrhoeic dermatitis
lichen planus
lichen sclerosus
psoriasis: seen in around a third of patients with psoriasis
148
describe the management of vaginal itch (5 points)
Management
women who suffer from this should be advised to take showers rather than taking baths
they should also be advised to clean the vulval area with an emollient such as Epaderm or Diprobase
clean only once a day as repeated cleaning can aggravate the symptoms
most of the underlying conditions will respond to topical steroids
combined steroid-antifungal may be tried if seborrhoeic dermatitis is suspected
149
What is premature ovarian insufficiency?
Premature ovarian insufficiency is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.
150
What are 7 causes of premature ovarian insufficiency?
idiopathic
the most common cause
there may be a family history
bilateral oophorectomy
having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
radiotherapy
chemotherapy
infection: e.g. mumps
autoimmune disorders
resistant ovary syndrome: due to FSH receptor abnormalities
151
What are the features of premature ovarian insufficiency? 5
Features are similar to those of the normal climacteric but the actual presenting problem may differ
climacteric symptoms: hot flushes, night sweats
infertility
secondary amenorrhoea
raised FSH, LH levels
e.g. FSH > 40 iu/l
elevated FSH levels should be demonstrated on 2 blood samples taken 4–6 weeks apart
low oestradiol
e.g. < 100 pmol/l
152
What is the management of premature ovarian insufficiency?
Management
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)
it should be noted that HRT does not provide contraception, in case spontaneous ovarian activity resumes
153
What are 4 differentials for bleeding in the first trimester?
-miscarriage
-ectopic pregnancy
the most 'important' cause as missed ectopics can be potentially life-threatening
-implantation bleeding
a diagnosis of exclusion
-miscellaneous conditions
cervical ectropion
vaginitis
trauma
polyps
154
What should you do for patient who have bleeding in the first trimester and they are => 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.
A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.
155
What should you do for women who have PV bleeding and they are <6wks 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:
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
a negative pregnancy test means that the pregnancy has miscarried
156
what is an ectropion?
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
157
what are 6 causes of superficial dysparaunia
Lack of sexual arousal
Vaginal atrophy (e.g. post-menopausal)
Vaginitis secondary to infection e.g. Candida, Trichomonas
Painful episiotomy scar
Vaginismus
158
What are 6 causes of deep dysparaunia?
Pelvic inflammatory disease
Endometriosis
Cervicitis secondary to infection e.g. Chlamydia
Prolapsed ovaries in the pouch of Douglas
Adenomyosis
Fixed retroverted uterus
159
what is endometrial hyperplasia?
Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
160
What are the 4 different types of endometrial hyperplasia?
Types
simple
complex
simple atypical
complex atypical
161
what are the features and management of endometrial hyperplasia?
Features
abnormal vaginal bleeding e.g. intermenstrual
Management
simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
atypia: hysterectomy is usually advised
162
What is fibroid degeneration?
-how does this present?\
-how is this managed?
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or 'carneous' degeneration. This usually 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.
163
What is threatened miscarriage?
-when does this occur?
what is found on speculum?
how common is this?
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
164
What is a 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'
165
what is an inevitable miscarriage? what is an incomplete miscarriage?
nevitable miscarriage
heavy bleeding with clots and pain
cervical os is open
Incomplete miscarriage
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
166
What is the initial imaging modality for ovarian cysts? how is this reported?
The initial imaging modality for suspected ovarian cysts/tumours is ultrasound. The report will usually report that the cyst is either:
simple: unilocular, more likely to be physiological or benign
complex: multilocular, more likely to be malignant
167
What is the management of ovarian cyst in premenopausal wmen?
anagement depends on the age of the patient and whether the patient is symptomatic. It should be remembered that the diagnosis of ovarian cancer is often delayed due to a vague presentation.
Premenopausal women
a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. 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.
168
what is the management of ovarian cyst in postmenopausal women?
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
169
what is the definition of recurrent miscarriage and what are the 5 causes?
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women
Causes
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
170
What are uterine fibroids? What are the associations?
Fibroids are benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
Associations
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
171
what are 7 features of fibroids?
may be asymptomatic
menorrhagia
may result in iron-deficiency anaemia
bulk-related symptoms
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
rare features:
polycythaemia secondary to autonomous production of erythropoietin
172
what is the diagnosis of uterine fibroids?
transvaginal ultrasound
173
what is the management of asymptomatic fibroids?
Asymptomatic fibroids
no treatment is needed other than periodic review to monitor size and growth
174
What is the management of menorrhagia due to fibroids?
-6
Management of menorrhagia secondary to fibroids
levonorgestrel intrauterine system (LNG-IUS)
useful if the woman also requires contraception
cannot be used if there is distortion of the uterine cavity
NSAIDs e.g. mefenamic acid
tranexamic acid
combined oral contraceptive pill
oral progestogen
injectable progestogen
175
What treatments are available to shrink/remove fibroids?
Treatment to shrink/remove fibroids
medical
GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxicity
surgical
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization
176
What happens to fibroids after menopause?
Fibroids usually regress after menopause
177
What is the condition
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
trichomonas vaginalise
178
What are vulval cancers most commonly pathology?
Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.
179
What are four risk factors for vulval cancer?
Other than age, risk factors include:
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
180
What are three features of vulval cancer?
Features
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
181
When can you omit examination of women with vaginal discharge?
Examination of women with vaginal discharge should only be omitted, if they have a characteristic history of bacterial vaginosis (first time or if recurrent, that was previously examined) or vulvovaginal candidiasis (isolated or infrequent) and have a low likelihood of STI and don't have symptoms of severe illness and who are not pregnant (or post-natal, post-miscarriage, post-termination) and didn't have a recent gynaecological procedure.
182
Describe the need for contraception in the menopause? if above 50? if below 50?
Need for contraception after the menopause
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
