Gynaecology Flashcards
what is the treatment for thrush? what if pregnant?
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
What is the criteria for recurrent vaginal candidiasis? what is the management?
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
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
Describe the clinical features and investigations/management of ovarian torsion?
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
What are the features of endometriosis (5)? what can be seen on pelvic exam?
-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
What is the investigation for endometriosis?
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
Describe the treatment in primary care for endometriosis?
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
Describe the treatment in secondary care for endometriosis? What can be done for women trying to conceive?
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
Describe the VTE risk for patients on HRT
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)
What are three side effects of HRT?
nausea
breast tenderness
fluid retention and weight gain
What are 5 risks of HRT?
- 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
Describe the increased risk of breast cancer in women on HRT?
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
Describe the increased risk of endometrial cancer in women on HRT?
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
What are the 4 different types of ovarian cysts?
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.
What are the 2 physiological ovarian cysts?
Follicular cysts
Corpus luteum cyst
What is a follicular cyst? is this common? what is the natural history of these?
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
what is a corpus luteum cyst? how does this present?
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
What cyst is a benign cell tumour? is this common? what is a risk with this cyst?
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
What are the two benign epithelial tumours?
Serous cystadenoma
Mucinous cystadenoma
What is the most common benign epithelial tumour? is this bilateral?
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%
What is the second most common benign epithelial tumour? what can happen if this ruptures?
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
What is meigs syndrome?
Meigs’ syndrome is a benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
What is the menopause defined by?
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.
What are the three categories of the management of the menopause?
Lifestyle modifications
Hormone replacement therapy (HRT)
Non-hormone replacement therapy
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
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
what are the 4 contra-indications to HRT?
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
What percentage of women use HRT to control their menopausal symptoms?
10%
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
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.
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
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
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)
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
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.
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)
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)
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
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
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
What happens to smear samples that test positive for HPV?
samples are examined cytologically
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
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
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
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
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
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
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.
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.
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
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.
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.
what are 5 risk factors for urinary incontinence?
advancing age
previous pregnancy and childbirth
high body mass index
hysterectomy
family history
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
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
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
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
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.
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.
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)
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.
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
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
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
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
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.
what is dysmenonorrhoea?
Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.
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.
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
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
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.
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.
