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Gynaecology Flashcards

1
Q

causes of primary amenorrhoea

A

Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
Imperforate hymen or other structural pathology

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2
Q

causes of secondary amenorrhoea

A

Pregnancy (the most common cause)
Menopause
Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
Polycystic ovarian syndrome
Medications, such as hormonal contraceptives
Premature ovarian insufficiency (menopause before 40 years)
Thyroid hormone abnormalities (hyper or hypothyroid)
Excessive prolactin, from a prolactinoma
Cushing’s syndrome

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3
Q

irregular menstruation causes

A

Extremes of reproductive age (early periods or perimenopause)
Polycystic ovarian syndrome
Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
Medications, particularly progesterone only contraception, antidepressants and antipsychotics
Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin

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4
Q

causes of intermenstrual bleeding

A

Hormonal contraception
Cervical ectropion, polyps or cancer
Sexually transmitted infection
Endometrial polyps or cancer
Vaginal pathology, including cancers
Pregnancy
Ovulation can cause spotting in some women
Medications, such as SSRIs and anticoagulants

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5
Q

causes of dysmenorrhoea

A

Primary dysmenorrhoea (no underlying pathology)
Endometriosis or adenomyosis
Fibroids
Pelvic inflammatory disease
Copper coil
Cervical or ovarian cancer

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6
Q

causes of menorrhagia

A

Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cance
Polycystic ovarian syndrome

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7
Q

causes of postcoital bleeding

A

Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer

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8
Q

causes of pelvic pain

A

Urinary tract infection
Dysmenorrhoea (painful periods)
Irritable bowel syndrome (IBS)
Ovarian cysts
Endometriosis
Pelvic inflammatory disease (infection)
Ectopic pregnancy
Appendicitis
Mittelschmerz (cyclical pain during ovulation)
Pelvic adhesions
Ovarian torsion
Inflammatory bowel disease (IBD)

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9
Q

causes of vaginal discharge

A

Bacterial vaginosis
Candidiasis (thrush)
Chlamydia
Gonorrhoea
Trichomonas vaginalis
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception

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10
Q

pruritis vulvae definition

A

itching of vulva and vagina

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11
Q

pruritus vulvae causes

A

Irritants such as soaps, detergents and barrier contraception
Atrophic vaginitis
Infections such as candidiasis (thrush) and pubic lice
Skin conditions such as eczema
Vulval malignancy
Pregnancy-related vaginal discharge
Urinary or faecal incontinence
Stress

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12
Q

primary amenorrhoea definition

A

defined as not starting menstruation:

By 13 years when there is no other evidence of pubertal development
By 15 years of age where there are other signs of puberty, such as breast bud development

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13
Q

puberty girls

A

8-14
breast bud, pubic hair, menstrual periods
pubertal growth spurt earlier than boys

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14
Q

hypogonadotropic hypogonadism

A

lack of LH and FSH

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15
Q

hypergonadotropic hypogonadism

A

lack of response to LH and FSH by gonads (testes and ovaries)

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16
Q

causes of hypogonadotropic hypogonadism

A

Hypopituitarism (under production of pituitary hormones)
Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer
Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease)
Excessive exercise or dieting can delay the onset of menstruation in girls
Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology
Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia
Kallman syndrome

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17
Q

causes of hypergonadotropic hypogonadism

A

Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps)
Congenital absence of the ovaries
Turner’s syndrome (XO)

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18
Q

kallman syndrome clinical fx

A

delayed puberty
anosmia

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19
Q

CAH hormones

A

lack of cortisol and aldosterone
overproduction of androgens

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20
Q

CAH inheritance

A

aut rec
congenital deficiency of the 21-hydroxylase enzyme

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21
Q

clinical fx of CAH

A

neonates - hypoglycaemia, electrolyte disturbances
childhood - Tall for their age
Facial hair
Absent periods (primary amenorrhoea)
Deep voice
Early puberty

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22
Q

AIS in males patho

A

the tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop

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23
Q

AIS clinical fx

A

female phenotype - normal female external genitalia and breast
internally - undescended testis and absent uterus etc

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24
Q

if ovaries unaffected by pathology…

A

typical secondary sexual characteristics develop but no periods

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25
Q

structural pathology causes of absent periods

A

Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absent uterus
Female genital mutilation

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26
Q

ix for primary amenorrhoea

A

FBC and ferritin - anaemia
U+E - CKD
anti-TTG and anti-EMA - coeliac
FSH and LH
TFT
IGF-1 - GH def
prolactin - hyperprolactinaemia
testosterone - high in PCOS, AIS, CAH
genetic testing - turners
x ray of wrist - constituional delay
pelvis USS
MRI of brain

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27
Q

tx of hypogonadotropic hypogonadism

A

pulsatile GnRH - esp if want to induce fertility
or COCP to replace sex hormones

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28
Q

tx of ovarian causes of primary amenorrhoea

A

can give COCP ot induce regular menstruation and prevent sx of oestrogen def

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29
Q

causes of secondary amenorrhoea

A

Pregnancy is the most common cause
Menopause and premature ovarian failure
Hormonal contraception (e.g. IUS or POP)
Hypothalamic or pituitary pathology
Ovarian causes such as polycystic ovarian syndrome
Uterine pathology such as Asherman’s syndrome
Thyroid pathology
Hyperprolactinaemia

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30
Q

when can hypogonadotropic hypogonadism be induced to cause secondary amenorrhoea

A

Excessive exercise (e.g. athletes)
Low body weight and eating disorders
Chronic disease
Psychological stress

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31
Q

pituitary causes of secondary amenorrhoea

A

Pituitary tumours, such as a prolactin-secreting prolactinoma
Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome

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32
Q

hyperprolactinaemia causing secondary amenorrhoea patho

A

High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH. This causes hypogonadotropic hypogonadism

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33
Q

true or false, galactorrhoea a common sign of hyperprolactinaemia

A

false -, only 30% of women

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34
Q

most common causes of hyperprolactinaemia

A

pituitary adenoma secreting prolactin

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35
Q

ix for hyperprolactinaemia

A

CT/MRI of brain

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36
Q

tx for hyperprolactinaemia

A

dopamine agonist - bromocriptine, cabergoline

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37
Q

ix for secondary amenorrhoea

A

USS of pelvis (PCOS)
beta hCG
LH and FSH
prolactin
TSH
testosterone

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38
Q

LH:FSH ratio interpretation

A

High FSH suggests primary ovarian failure
High LH, or LH:FSH ratio, suggests polycystic ovarian syndrome

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39
Q

tx of PCOS

A

require a withdrawal bleed every 3 – 4 months to reduce the risk of endometrial hyperplasia and endometrial cancer. Medroxyprogesterone for 14 days, or regular use of the combined oral contraceptive pill, can be used to stimulate a withdrawal bleed

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40
Q

when vit D required in secondary amenorrhoea

A

low oestrogen levels so amenorrhoea lasts for more than 12 months…risk of osteoporosis

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41
Q

PMS occurs at which part of menstrual cycle

A

luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation

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42
Q

cause of PMS

A

caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle. The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA

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43
Q

clinical fx of PMS

A

Low mood
Anxiety
Mood swings
Irritability
Bloating
Fatigue
Headaches
Breast pain
Reduced confidence
Cognitive impairment
Clumsiness
Reduced libido

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44
Q

causes of PMS without menstruation

A

after a hysterectomy, endometrial ablation or on the Mirena coil
combined contraceptive pill or cyclical hormone replacement therapy containing progesterone, and this is described as progesterone-induced premenstrual disorder.

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45
Q

severe form of PMS

A

premenstrual dysphoric disorder

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46
Q

diagnosis of PMS

A

symptom diary for two menstrual cycles
cyclical sx
definitive - administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve

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47
Q

mx of PMS

A

General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep
Combined contraceptive pill (COCP) - containing drospirenone, continuous use
SSRI antidepressants
Cognitive behavioural therapy
continuous transdermal oestrogen patches + low dose cyclical progestogens or mirena to prevent endometrial hyperplasia
GnRH + HRT = menopause
hysterectomy and b/l oophorectomy - induce menopause
danazole and tamoxigen - cyclical breast pain
spironlactone - breast swell, water retention and bloating

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48
Q

menorrhagia definition

A

> 80 ml
based on sx - changing pads every 1-2 hrs, bleeding lasts more than 7 days, clots

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49
Q

causes of menorrhagia

A

Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome

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50
Q

hx of menorrhagia

A

Age at menarche
Cycle length, days menstruating and variation
Intermenstrual bleeding and post coital bleeding
Contraceptive history
Sexual history
Possibility of pregnancy
Plans for future pregnancies
Cervical screening history
Migraines with or without aura (for the pill)
Past medical history and past drug history
Smoking and alcohol history
Family history

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51
Q

ix of menorrhagic

A

pelvic exam with speculum and bimanual -> fibroids, ascites and cancers
FBC - iron def anaemia
outpatient hysteroscopy - fibroids, endometrial hyperplasia or cancer, peristent intermenstrual bleeding
pelvic and transvaginal USS - large fibroids, adenomyosis, hard to examine
swabs - infection
coag screen
ferritin
TFT

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52
Q

mx of menorrhagia

A

mx causes
Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding)
Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

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53
Q

first line contraception with menorrhagia

A

Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens

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54
Q

when refer menorrhagia to secondary acree

A

further ix or mx
tx unsuccessful
sx severe
large fibroids >3cm

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55
Q

last choice options in menorrhagia

A

endometrial ablation and hysterectomy

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56
Q

fibroids definition

A

benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas

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57
Q

fibroids risk fx

A

later reproductive years
black women

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58
Q

why fibroids grow

A

in response to oestrogent

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59
Q

types of fibroids

A

Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus.
Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity.
Submucosal means just below the lining of the uterus (the endometrium).
Pedunculated means on a stalk.

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60
Q

clinical fx of fibroids

A

asx
Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom
Prolonged menstruation, lasting more than 7 days
Abdominal pain, worse during menstruation
Bloating or feeling full in the abdomen
Urinary or bowel symptoms due to pelvic pressure or fullness
Deep dyspareunia (pain during intercourse)
Reduced fertility

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61
Q

ix for fibroids

A

abdo and bimanual exam - palpable pelvic mass or enlarged firm non tender uterus
hysteroscopy - submucosal
pelvic USS - larger
MRI - surgical decision

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62
Q

medical mx of smaller fibroids

A

< 3 cm

Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus
Symptomatic management with NSAIDs and tranexamic acid
Combined oral contraceptive
Cyclical oral progestogens

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63
Q

surgical mx of smaller fibroids

A

Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy

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64
Q

medical mx of larger fibroids

A

referral to gynaecology!
Symptomatic management with NSAIDs and tranexamic acid
Mirena coil – depending on the size and shape of the fibroids and uterus
Combined oral contraceptive
Cyclical oral progestogens

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65
Q

surgical mx for larger fibroids

A

Uterine artery embolisation
Myomectomy
Hysterectomy
before surgery - GnRH agonists to reduce size of fibroids

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66
Q

potential complications of fibroids

A

Heavy menstrual bleeding, often with iron deficiency anaemia
Reduced fertility
Pregnancy complications, such as miscarriages, premature labour and obstructive delivery
Constipation
Urinary outflow obstruction and urinary tract infections
Red degeneration of the fibroid
Torsion of the fibroid, usually affecting pedunculated fibroids
Malignant change to a leiomyosarcoma is very rare (<1%)

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67
Q

define red degeneration of fibroids

A

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy

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68
Q

red degeneration of fibroids clinical fx

A

severe abdo pain, low grade fever, tachycardia and vomit

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69
Q

red degeneration of fibroids mx

A

rest
fluid
analgesia

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70
Q

endometriosis definition

A

a condition where there is ectopic endometrial tissue outside the uterus

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71
Q

define endometrioma

A

A lump of endometrial tissue outside the uterus
if in ovaries - ‘chocolate cysts’

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72
Q

define adenomyosis

A

endometrial tissue within the myometrium (muscle layer) of the uterus

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73
Q

one theory for aetiology of endometriosis

A

during menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum. This is called retrograde menstruation. The endometrial tissue then seeds itself around the pelvis and peritoneal cavity

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74
Q

pathophysiology of sx of endometriosis

A

pelvic pain….The cells of the endometrial tissue outside the uterus respond to hormones in the same way as endometrial tissue in the uterus. During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body. This causes irritation and inflammation of the tissues around the sites of endometriosis
blood in urine or stools - deposits of endometriosis in bladder or bowel
Adhesions lead to a chronic, non-cyclical pain
reduced fertility - adhesions, blocking release of eggs or kinking fallopian tubes

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75
Q

clinical fx of endometriosis

A

Cyclical abdominal or pelvic pain
Deep dyspareunia (pain on deep sexual intercourse)
Dysmenorrhoea (painful periods)
Infertility
Cyclical bleeding from other sites, such as haematuria
urinary or bowel sx

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76
Q

O/E endometriosis

A

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix
A fixed cervix on bimanual examination
Tenderness in the vagina, cervix and adnexa

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77
Q

diagnosis of endometriosis

A

pelvic USS - large endometriomas and chocolate cysts
laprascopic surgery - gold standard…biopsy of lesions

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78
Q

staging of endometriosis

A

ASRM
Stage 1: Small superficial lesions
Stage 2: Mild, but deeper lesions than stage 1
Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions

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79
Q

hormonal mx of endometriosis

A

Combined oral contractive pill, which can be used back to back without a pill-free period if helpful
Progesterone only pill
Medroxyprogesterone acetate injection (e.g. Depo-Provera)
Nexplanon implant
Mirena coil
GnRH agonists

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80
Q

surgical mx of endometriosis

A

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (improve fertility) (adhesiolysis)
Hysterectomy

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81
Q

how hormonal meds help endometriosis

A

Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening

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82
Q

GnRH agonists

A

induce menopause

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83
Q

adenomyosis risk fx

A

later reproductive years
multiparous

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84
Q

clinical fx of adenomyosis

A

Painful periods (dysmenorrhoea)
Heavy periods (menorrhagia)
Pain during intercourse (dyspareunia)
infertility
pregnancy related complications
O/E enlarger and tender uterus

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85
Q

fibroids v adenomyosis

A

O/E - adenomyosis softer than fibroids

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86
Q

diagnosis adenomyosis

A

transvag USS 1st line
MRI nad transabdo USS
Gold standard - histological exam of uterus after hysterectomy

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87
Q

mx adenomyosis without contracpetion

A

tranexamic acid
mefenamic acid

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88
Q

mx adenomyosis for contraception

A

Mirena coil (first line)
Combined oral contraceptive pill
Cyclical oral progestogens

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89
Q

specialist mx for adenomyosis

A

GnRH analogues to induce a menopause-like state
Endometrial ablation
Uterine artery embolisation
Hysterectomy

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90
Q

adenomyosis associations in pregnancy

A

Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage

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91
Q

menopause definition

A

point at which menstruation stops

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92
Q

postmenopause definition

A

describes the period from 12 months after the final menstrual period onwards.

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93
Q

perimenopause definition

A

refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.

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94
Q

premature menopause definition and cause

A

menopause before the age of 40 years. It is the result of premature ovarian insufficiency.

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95
Q

menopause caused by

A

lack of ovarian follicular function-
Oestrogen and progesterone levels are low
LH and FSH levels are high, in response to an absence of negative feedback from oestrogen

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96
Q

menopause patho

A

The process of the menopause begins with a decline in the development of the ovarian follicles. Without the growth of follicles, there is reduced production of oestrogen. Oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced. As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH.

The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles. Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea). Lower levels of oestrogen also cause the perimenopausal symptoms.

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97
Q

perimenopausal sx

A

Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido

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98
Q

risks from lack of oestrogen in menopause

A

Cardiovascular disease and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence

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99
Q

diagnosis menopause

A

> 45 - typical sx- clinical diagnosis
<40 or 40-45 - FSH blood test

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100
Q

how long contraception required for in regards to menopause

A

Two years after the last menstrual period in women under 50
One year after the last menstrual period in women over 50

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101
Q

contraceptive first lines for women approaching menopause

A

hormonal - suppress sx so…
Barrier methods
Mirena or copper coil
Progesterone only pill
Progesterone implant
Progesterone depot injection (under 45 years)
Sterilisation

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102
Q

cocp in over 40

A

up to 50 years old if no c/i
containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options

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103
Q

s/e of progesterone depot injection

A

weight gain osteoporosis

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104
Q

c/i of progesterone depot injection

A

> 45 as osteoporosis

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105
Q

mx of perimenopausal sx

A

No treatment
Hormone replacement therapy (HRT)
Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
Cognitive behavioural therapy (CBT)
SSRI antidepressants, such as fluoxetine or citalopram
Testosterone can be used to treat reduced libido (usually as a gel or cream)
Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
Vaginal moisturisers, such as Sylk, Replens and YES

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106
Q

primary ovarian insufficiency def

A

menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age.

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107
Q

hormone analysis of POI

A

hypergonadotropic hypogonadism
Raised LH and FSH levels (gonadotropins)
Low oestradiol levels

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108
Q

causes of POI

A

Idiopathic (the cause is unknown in more than 50% of cases)
Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy)
Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease
Genetic, with a positive family history or conditions such as Turner’s syndrome
Infections such as mumps, tuberculosis or cytomegalovirus

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109
Q

clinical fx of POI

A

irregular menstrual periods, lack of menstrual periods (secondary amenorrhea) and symptoms of low oestrogen levels, such has hot flushes, night sweats and vaginal dryness

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110
Q

diagnosis of POI

A

younger than 40 years with typical menopausal symptoms plus elevated FSH
FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis
—can be hard to diagnose if taking hormonal contraceptives

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111
Q

associations POI

A

Cardiovascular disease
Stroke
Osteoporosis
Cognitive impairment
Dementia
Parkinsonism

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112
Q

mx of POI

A

HRT until age at which go rhough menopause - can give traditional HRT or COCP

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113
Q

HRT s/e

A

an increased risk of venous thromboembolism with HRT in women under 50 years. The risk of VTE can be reduced by using transdermal methods (i.e. patches)

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114
Q

HRT given with which drug

A

progesterone to women that have a uterus…prevent endometrial hyperplasia

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115
Q

when be on cyclical HRT

A

Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.

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116
Q

when go on continuous combined HRT

A

Postmenopausal women with a uterus and more than 12 months without periods

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117
Q

non hormonal x for menopausal sx

A

Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress
Cognitive behavioural therapy (CBT)
Clonidine, which is an agonist of alpha-adrenergic and imidazoline receptors
SSRI antidepressants (e.g. fluoxetine)
Venlafaxine, which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI)
Gabapentin

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118
Q

clonidine moa

A

an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication

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119
Q

indications clonidine

A

vasomotor sx and hot flushes
used when c/i to HRT

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120
Q

s/e of clonidine

A

dry mouth
headaches
dizziness
fatigue
sudden withdrawal - rapid increases in BP and agitation

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121
Q

alternative remedies for sx control of menopause and s/e

A

Black cohosh, which may be a cause of liver damage
Dong quai, which may cause bleeding disorders
Red clover, which may have oestrogenic effects that would be concerning with oestrogen sensitive cancers
Evening primrose oil, which has significant drug interactions and is linked with clotting disorders and seizures
Ginseng may be used for mood and sleep benefits

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122
Q

indications for HRT

A

Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing risk of osteoporosis in women under 60 years

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123
Q

benefits of HRT

A

Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
Improved quality of life
Reduced the risk of osteoporosis and fractures

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124
Q

risks of HRT

A

Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
Increased risk of endometrial cancer
Increased risk of venous thromboembolism (2 – 3 times the background risk)
Increased risk of stroke and coronary artery disease with long term use in older women
The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal

125
Q

oestrogen only HRT adv

A

no risk of coronary artery disease

126
Q

reduce risks of VTE

A

using patches not pills of HRT

127
Q

c/i to HRT

A

Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or myocardial infarction
Pregnancy

128
Q

assessment before HRT

A

Take a full history to ensure there are no contraindications
Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE
Check the body mass index (BMI) and blood pressure
Ensure cervical and breast screening is up to date
Encourage lifestyle changes that are likely to improve symptoms and reduce risks

129
Q

choosing HRT formulation

A

Step 1: Do they have local or systemic symptoms?

Local symptoms: use topical treatments such as topical oestrogen cream or tablets
Systemic symptoms: use systemic treatment – go to step 2

Step 2: Does the woman have a uterus?

No uterus: use continuous oestrogen-only HRT
Has uterus: add progesterone (combined HRT) – go to step 3

Step 3: Have they had a period in the past 12 months?

Perimenopausal: give cyclical combined HRT
Postmenopausal (more than 12 months since last period): give continuous combined HRT

130
Q

switching from cyclical to continuous HRT

A

You can switch from cyclical to continuous HRT after at least 12 months of treatment in women over 50, and 24 months in women under 50. Switch from cyclical to continuous HRT during the withdrawal bleed. Continuous HRT has better endometrial protection than cyclical HRT.

131
Q

progesterone how given alongside HRT for women WITH uterus

A

as require endometrial protection-
Oral (tablets)
Transdermal (patches)
Intrauterine system (e.g. Mirena coil)

132
Q

types of progesterone

A

Progestogens refer to any chemicals that target and stimulate progesterone receptors
Progesterone is the hormone produced naturally in the body
Progestins are synthetic progestogens

133
Q

s/e of progesterone

A

C19 progesterones s(norethisterone) - useful for reduced libido
C21 progestogens - useful if women have depressed mood or acne

134
Q

example regimes in women with no uterus

A

Oestrogen-only pills, for example, Elleste Solo or Premarin
Oestrogen-only patches, for example, Evorel or Estradot

135
Q

examples regimes in a perimenopaursal woman with periods

A

Cyclical combined tablets, for example, Elleste-Duet, Clinorette or Femoston
Cyclical combined patches, for example, Evorel Sequi or FemSeven Sequi
Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin
Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot

136
Q

examples regimes in postmenopaursal woman with uterus

A

Continuous combined tablets, for example, Elleste-Duet Conti, Kliofem or Femoston Conti
Continuous combined patches, for example, Evorel-Conti or FemSeven Conti
Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin
Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot

137
Q

tibolone what

A

a synthetic steroid that stimulates oestrogen and progesterone receptors. It also weakly stimulates androgen receptors. The effects on androgen receptors mean tibolone can be helpful for patients with reduced libido.

Tibolone is used as a form of continuous combined HRT.

138
Q

testosterone uses menopause

A

Menopause can be associated with reduced testosterone, resulting in low energy and reduced libido (sex drive). Treatment with testosterone is usually initiated
transdermal

139
Q

how long for meds to work in menopause

A

3-6 months
f/u in 3 months

140
Q

how long before surgery stop HRT

A

4 weeks

141
Q

other causes of sx of menopause

A

thyroid
liver disease
DM

142
Q

1st line contraception with HRT

A

Mirena coil
Progesterone only pill, given in addition to HRT

143
Q

oestrogenic s/e

A

Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps

144
Q

progestogenic s/e

A

Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin

145
Q

unscheduled bleeding with HRT

A

Unscheduled bleeding can occur in the first 3 – 6 months of HRT (in women with a uterus). If unscheduled bleeding continues, consider referral for investigations, particularly regarding endometrial cancer.

146
Q

STOPPING hrt

A

NO SPECIFIC REGIME
can just stop
gradually reduce so reduce risks of sx occuring

147
Q

criteria used to diagnose PCOS

A

2/3 of…
Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

148
Q

presentation of PCOS

A

oligomenorrhoea or amenorrhoea
Infertility
Obesity (in about 70% of patients with PCOS)
Hirsutism
Acne
Hair loss in a male pattern

149
Q

other fx and complications PCOS

A

Insulin resistance and diabetes
Acanthosis nigricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia and cancer
Obstructive sleep apnoea
Depression and anxiety
Sexual problems

150
Q

ddx of hirsutism

A

medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids
Ovarian or adrenal tumours that secrete androgens
Cushing’s syndrome
Congenital adrenal hyperplasia

151
Q

insulin resistance in PCOS

A

When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.

The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles

152
Q

ways to reduce insulin resistance

A

diet
exercsise
weight loss

153
Q

ix when suspecting PCOS

A

Testosterone
Sex hormone-binding globulin
Luteinizing hormone
Follicle-stimulating hormone
Prolactin (may be mildly elevated in PCOS)
Thyroid-stimulating hormone
Pelvic USS
transvaginal USS - gold standard ‘string of pearls’

154
Q

hormonal blood test PCOS +ve

A

Raised luteinising hormone
Raised LH to FSH ratio (high LH compared with FSH)
Raised testosterone
Raised insulin
Normal or raised oestrogen levels

155
Q

pelvic USS diagnosis PCOS

A

12 or more developing follicles in one ovary
Ovarian volume of more than 10cm3

156
Q

screening test of choice for DM with PCOS

A

a 2-hour 75g oral glucose tolerance test (OGTT)
Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink)
Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l
Diabetes – plasma glucose at 2 hours above 11.1 mmol/l

157
Q

general mx of PCOS

A

Weight loss
Low glycaemic index, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensive medications where required
Statins where indicated (QRISK >10%)

158
Q

complications of PCOS

A

Endometrial hyperplasia and cancer
Infertility
Hirsutism
Acne
Obstructive sleep apnoea
Depression and anxiety

159
Q

ways for weight loss PCOS

A

orlistat - lipase inhibitor - stops absorption of fat in the intestines

160
Q

risk fx for endometrial cancer for people with PCOS

A

Obesity
Diabetes
Insulin resistance
Amenorrhoea

161
Q

PCOS ovulation

A

Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation…endometrial cancer

162
Q

indications for pelvis USS PCOS

A

Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness

162
Q

manage fertility PCOS

A

weight loss - restores regular ovulation
specialist involvement - Clomifene, Laparoscopic ovarian drilling, In vitro fertilisation (IVF)
metformin and letrozole - restore ovulation
ovarian drilling using diathermy or laser therapy - regular ovulation

162
Q

options for reducing the risk of endometrial cancer

A

Mirena coil for continuous endometrial protection
Inducing a withdrawal bleed at least every 3 – 4 months with either:
Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)
Combined oral contraceptive pill

163
Q

manage hirsutism PCOS

A

weight loss
co-cyprindiol (COCP) - anti-androgenic
topical eflornithine
electrolysis
Laser hair removal
Spironolactone (mineralocorticoid antagonist with anti-androgen effects)
Finasteride (5α-reductase inhibitor that decreases testosterone production)
Flutamide (non-steroidal anti-androgen)
Cyproterone acetate (anti-androgen and progestin)

164
Q

1st line mx for acne in PCOS

A

co-cypyrindiol - anti-androgen
Topical adapalene (a retinoid)
Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%)
Topical azelaic acid 20%
Oral tetracycline antibiotics (e.g. lymecycline)

165
Q

ovarian cyst when

A

premenopausal women - benign
postmenopausal women - malignancy

166
Q

presentation of ovarian cyst

A

asx - found incidentally
vague sx->
Pelvic pain
Bloating
Fullness in the abdomen
A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)

167
Q

complications of ovarian cyst

A

ovarian torsion, haemorrhage or rupture of the cyst.

168
Q

2 types of functional cysts

A

follicular cyst
corpus luteum cyst

169
Q

follicular cyst definition

A

represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist.
harmless
thin walls and no internal structures

170
Q

corpus luteum cysts definition

A

occur when the corpus luteum fails to break down and instead fills with fluid

171
Q

clinical fx corpus luteum cysts

A

pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy

172
Q

other types of ovarian cysts

A

serous cystadenoma
mucinous cystadenoma
endometrioma
dermoid cyst/germ cell tumour
sex cord-stromal tumour

173
Q

serous cystadenoma

A

benign tumours of the epithelial cells.

174
Q

mucinous cystadenoma

A

benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen

175
Q

endometrioma definition

A

lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.

176
Q

dermoid cyst definition

A

benign ovarian tumours…teratomas

177
Q

dermoid cyst clinical fx and associations

A

contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion.

178
Q

sex cord stromal tumours definition

A

can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.

179
Q

red flag sx of ovarian cyst

A

Abdominal bloating
Reduce appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy

180
Q

risk fx for ovarian malignancy

A

Age
Postmenopause
Increased number of ovulations - early periods, late menopause, nullparity
Obesity
Hormone replacement therapy
Smoking
Breastfeeding (protective)
Family history and BRCA1 and BRCA2 genes

181
Q

ix for ovarian cyst

A

Premenopausal women with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations.
CA-125
under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:

Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)

182
Q

causes of raised CA 125

A

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

183
Q

risk of malignancy index define

A

estimates the risk of an ovarian mass being malignant, taking account of three things:

Menopausal status
Ultrasound findings
CA125 level

184
Q

mx of ovarian cyst

A

complex cysts or raised CA125 - 2WW
dermoid cyst - referral for further ix or surgery
simple ovarian cyst in pre - <5cm will resolve, 5-7cm - USS monitor, >7cm - MRI/surgical evaluation
if <5cm with normal Ca125 in postmenopausal woman - monitor 4-6mths
if persistent or enlarging - surgery - ovarian cystectomy or oophorectomy

185
Q

complications of ovarian cyst

A

Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum

186
Q

meig’s syndrome triad

A

Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites

187
Q

ovarian torsion definition

A

a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).

188
Q

causes of ovarian torsion

A

ovarian mass >5cm
most likely due to benign tumours
normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.

189
Q

main risk of ovarian torsion

A

Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency,

190
Q

clinical fx of ovarian torsion

A

sudden onset severe unilateral pelvic pain
N+V
can untwist causing intermittent pain
localised tenderness
palpable mass in pelvis (not always)

191
Q

diagnosis of ovarian torsion

A

pelvis USS- whirpool sign - free fluid in pelvis and oedema of ovary
doppler - lack of blood flow
transvaginal USS
definitive - laparascopic surgery

192
Q

mx of ovarian torsion

A

EMERGENCY ADMISSION
laparascopic surgery -> detorsion or oophorectomy

193
Q

complications of ovarian torsion

A

loss of function…infertility and menopause
Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions.

194
Q

asherman’s syndrome definition

A

adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.

195
Q

causes of asherman’s syndrome

A

after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth). It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).

196
Q

asx adhesions…

A

NOT classified as asherman’s syndrome

197
Q

clinical fx of asherman’s syndrome

A

Secondary amenorrhoea (absent periods)
Significantly lighter periods
Dysmenorrhoea (painful periods)
infertility

198
Q

diagnosis of asherman’s syndrome

A

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions
Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays
Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed
MRI scan

199
Q

mx of asherman’s syndrome

A

dissecting the adhesions during hysteroscopy

200
Q

cervical ectropion definition

A

also be called cervical ectopy or cervical erosion. Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). The lining of the endocervix becomes visible on examination of the cervix using a speculum.

201
Q

risks of cervical entropion

A

more likely to bleed with sexual intercourse…postcoital bleeding

202
Q

cervical ectropion associations

A

higher oestrogen levels, and therefore, is more common in younger women, the combined contraceptive pill and pregnancy.

203
Q

transformation zone defintion

A

the border between the columnar epithelium of the endocervix (the canal), and the stratified squamous epithelium of the ectocervix (the outer area of the cervix visible on speculum examination).

204
Q

presentation of cervical ectropion

A

asx
increased vaginal discharge, vaginal bleeding or dyspareunia (pain during sex)

205
Q

O/E cervical ectropion

A

well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix.

206
Q

mx of cervical ectropion

A

typically resolve
can be tx if problematic bleeding with cauterisation of ectropion using silver nitrate or cold coagulation

207
Q

nabothian cysts definition

A

fluid-filled cysts often seen on the surface of the cervix. They are also called nabothian follicles or mucinous retention cysts

208
Q

nabothian cysts risk of cancer

A

harmless

209
Q

patho nabothian cysts

A

The columnar epithelium of the endocervix (the canal) produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.

210
Q

presentation of nabothian cysts

A

found incidentally
if large can feel fullness in pelvis
O/E - smooth rounded bumps on cervix, near os usually, range from 2mm to 30mm, whitish/yellow appearance

211
Q

mx of nabothian cysts

A

reassured
no tx
can be referred for colposcopy to examine in detail. Occasionally they may be excised or biopsied

212
Q

pelvic organ prolapse definition

A

refers to the descent of pelvic organs into the vagina. Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.

213
Q

uterine prolapse

A

uterus descends into vagina

214
Q

vault prolapse definition

A

occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina

215
Q

rectocele caused

A

a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina
particularly associated with constipation

216
Q

rectocele clinical fx

A

can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina.

217
Q

rectocoele mx

A

use finger to press lump back

218
Q

cystocele cause

A

caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina

219
Q

prolapse of urethra

A

urethrocele

220
Q

prolapse of both bladder and urethra

A

cystourethrocele

221
Q

risk fx for pelvic organ prolapse

A

Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

222
Q

presentation pelvic organ prolapse

A

A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

223
Q

how examine pelvic organ prolapse

A

empty their bladder and bowel before examination of a prolapse. When examining for pelvic organ prolapse, various positions may be attempted, including the dorsal and left lateral position.
sim’s speculum - supports anterior or posterior vaginal walls while other vaginal walls are examined

224
Q

grades of uterine prolapse

A

pelvic organ prolapse quantification (POP-Q) system:

Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina

225
Q

uterine procidentia definition

A

A prolapse extending beyond the introitus

226
Q

mx of uterine prolapse

A

conservative -
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream
surgery - definitive option - hysterectomy

227
Q

types of pessaries

A

Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
Cube pessaries are a cube shape
Donut pessaries consist of a thick ring, similar to a doughnut
Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina

228
Q

complications of pelvic organ prolapse surgery

A

Pain, bleeding, infection, DVT and risk of anaesthetic
Damage to the bladder or bowel
Recurrence of the prolapse
Altered experience of sex

229
Q

potential complications of mesh repairs

A

Chronic pain
Altered sensation
Dyspareunia (painful sex) for the women or her partner
Abnormal bleeding
Urinary or bowel problems

230
Q

stress incontinence due to

A

weakness of the pelvic floor and sphincter muscles

231
Q

overflow incontinence causes

A

anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries

232
Q

risk fx for urinary incontinence

A

Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia

233
Q

how assess severity of urinary incontinence

A

Frequency of urination
Frequency of incontinence
Nighttime urination
Use of pads and changes of clothing

234
Q

O/E urinary incontinence

A

Pelvic organ prolapse
Atrophic vaginitis
Urethral diverticulum
Pelvic masses

235
Q

how assess urinary incontinence

A

sk the patient to cough and watch for leakage from the urethra.

The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers.

236
Q

modified oxygen grading system urinary incontinence

A

0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards

237
Q

ix for urinary incontinence

A

bladder diary
urine dipstick
post voidal residual bladder volume
urodynamic testing

238
Q

urodynamic testing how done

A

Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests.
catheter inserted into bladder and another into rectum…pressures in the bladder and rectum

239
Q

terms of urodynamic tests

A

Cystometry measures the detrusor muscle contraction and pressure
Uroflowmetry measures the flow rate
Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
Post-void residual bladder volume tests for incomplete emptying of the bladder
Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.

240
Q

mx of stress incontinence

A

Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

241
Q

surgical options to tx stress incontinence

A

tension-free vaginal type
autologous sling procedure
colosuspension
IM urethral bulking
artificial urinary sphincter

242
Q

mx of urge incontinence

A

Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications
Invasive procedures where medical treatment fails

243
Q

mirabegron c/i

A

uncontrolled HTN

244
Q

mirabegron moa

A

beta-3-agonist

245
Q

mirabegron increased risk

A

TIA and stroke
hypertensive crisis

246
Q

invasive options for overactive bladder

A

Botulinum toxin type A injection into the bladder wall
Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen

247
Q

atrophic vaginitis

A

refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen

248
Q

atrophic vaginitis patho

A

The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry

249
Q

presentation atrophic vaginitis

A

Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation

250
Q

atrophic vaginitis when consider

A

recurrent urinary tract infections, stress incontinence or pelvic organ prolapse

251
Q

O/E atrophic vaginitis

A

Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair

252
Q

mx of atrophic vaginitis

A

vaginal lubricants
topical oestrogen ->
Estriol cream, applied using an applicator (syringe) at bedtime
Estriol pessaries, inserted at bedtime
Estradiol tablets (Vagifem), once daily
Estradiol ring (Estring), replaced every three months

253
Q

topical oestrogens c/i

A

breast cancer
angina
VTE

254
Q

bartholin’s gland definition

A

a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.

255
Q

bartholin’s cyst patho

A

When the ducts become blocked, the Bartholin’s glands can swell and become tender, causing a Bartholin’s cyst.
if become infected - abscess

256
Q

bartholin’s cyst clinical fx

A

swelling is typically unilateral and forms a fluid-filled cyst between 1 – 4 cm

257
Q

mx of bartholin’s cyst

A

resolve with simple tx -good hygiene, analgesia and warm compresses. Incision is generally avoided
biopsy if vulval malignancy
if abscess - abx, swab and culture…e.coli is the most common cause, specific swabs for chlamydia and gonorrhoea
surgical - word catheter (local anaesthetic), marsupialisation (GA)

258
Q

lichen sclerosus definition

A

a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin

259
Q

lichen sclerosus associations

A

autoimmune -> type 1 diabetes, alopecia, hypothyroid and vitiligo

260
Q

diagnosis of lichen sclerosus

A

clinical diagnosis
vulval biopsy

261
Q

lichen simplex definition

A

chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.

262
Q

lichen planus definition

A

an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

263
Q

presentation lichen sclerosus

A

asx
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures

264
Q

koebner phenomenon

A

refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.

265
Q

appearance lichen sclerosus

A

fissures
cracks
erosions
haemorrhages
“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques

266
Q

mx of lichen sclerosus

A

cannot be cured
mx and f/u in 3-6 mths
potent topical steroids are mainstay - clobetasol propionate …reduce risk of malignancy
emollient used regularly

267
Q

complications lichen sclerosus

A

s.c.c of vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings

268
Q

FGM law

A

female Genital Mutilation Act 2003

269
Q

epidemiology of FGM

A

somalia
ethiopia
sudan
eritea
yemen
indonesia

270
Q

4 types of FGM

A

Type 1: Removal of part or all of the clitoris.
Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed.
Type 3: Narrowing or closing the vaginal orifice (infibulation).
Type 4: All other unnecessary procedures to the female genitalia.

271
Q

risk of FGM

A

Pregnant women with FGM with a possible female child
Siblings or daughters of women or girls affected by FGM
Extended trips with infants or children to areas where FGM is practised
Women that decline examination or cervical screening
New patients from communities that practise FGM

272
Q

immediate complications FGM

A

Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence

273
Q

long term complications FGM

A

Vaginal infections, such as bacterial vaginosis
Pelvic infections
Urinary tract infections
Dysmenorrhea (painful menstruation)
Sexual dysfunction and dyspareunia (painful sex)
Infertility and pregnancy-related complications
Significant psychological issues and depression
Reduced engagement with healthcare and screening

274
Q

mx of FGM

A

mandatory to repot in pts under 18 to police
Social services and safeguarding
Paediatrics
Specialist gynaecology or FGM services
Counselling
>18 - risk assessment whether to report
de-infibulation
re-infibulation

275
Q

basic embryological development of female system

A

The upper vagina, cervix, uterus and fallopian tubes develop from the paramesonephric ducts (Mullerian ducts). These are a pair of passageways along the outside of the urogenital region that fuse and mature to become the uterus, fallopian tubes, cervix and upper third of the vagina. Errors in their development lead to congenital structural abnormalities in the female pelvic organs

276
Q

basic embyronic development of male

A

In a male fetus, anti-Mullerian hormone is produced, which suppresses the growth of the paramesonephric ducts, causing them to disappear.

277
Q

bicornuate uterus definition

A

where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance
- USS

278
Q

typical complications of bicornuate uteus

A

Miscarriage
Premature birth
Malpresentation

279
Q

imperforate hymen definition

A

where the hymen at the entrance of the vagina is fully formed, without an opening.

280
Q

imperforate hymen clinical fx

A

menses are sealed in the vagina. This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.

281
Q

imperforate hymen tx

A

incision

282
Q

complications of imperforate hymen

A

retrograde menstruation…endometriosis

283
Q

transverse vaginal septae definition

A

caused by an error in development, where a septum (wall) forms transversely across the vagina. This septum can either be perforate (with a hole) or imperforate (completely sealed).

284
Q

TVS sx

A

Where it is perforate, girls will still menstruate, but can have difficulty with intercourse or tampon use. Where it is imperforate, it will present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation.

285
Q

TVS complications

A

infertility and pregnancy related complications

286
Q

TVS tx and complications

A

surgery but can result in vaginal stenosis or recurrence of septae

287
Q

vaginal hypoplasia and agenesis definition

A

Vaginal hypoplasia refers to an abnormally small vagina. Vaginal agenesis refers to an absent vagina.

288
Q

vaginal hypoplasia patho

A

occur due to failure of the Mullerian ducts to properly develop, and may be associated with an absent uterus and cervix.

289
Q

vaginal hypoplasia ovaries

A

unaffected
if AIS then testis rather than ovaries

290
Q

mx of vaginal hypoplasia

A

vaginal dilator or surgery

291
Q

Androgen insensitivity syndrome definition

A

a condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors.

292
Q

AIS inheritance

A

x linked rec
caused by a mutation in the androgen receptor gene on the X chromosome

293
Q

AIS patho

A

Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics. It was previously known as testicular feminisation syndrome.

294
Q

clinical fx of AIS

A

genetically male, with XY sex chromosome. However, the absent response to testosterone and the conversion of additional androgens to oestrogen result in a female phenotype externally. Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue.
Patients have testes in the abdomen or inguinal canal, and absence of a uterus, upper vagina, cervix, fallopian tubes and ovaries. The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.
The insensitivity to androgens also results in a lack of pubic hair, facial hair and male type muscle development. Patients tend to be slightly taller than the female average. Patients are infertile, and there is an increased risk of testicular cancer unless the testes are removed.

295
Q

partial androgen insensitivity syndrome definition

A

where there the cells have a partial response to androgens. This presents with more ambiguous signs and symptoms, such as a micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics

296
Q

ways AIS can present

A

hernia
primary amenorrhoea

297
Q

hormonal levels AIS

A

Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)

298
Q

mx of AIS

A

Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
Oestrogen therapy
Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length
generally raised as female
psychological input

299
Q

gonorrhoea gram stain

A

gram negative diplococci
Neiserria gonorrhoeae

300
Q

complications of LLETZ

A

increased risk of late miscarriage
premature nirth
cervical stenosis

301
Q

what lab based test is done on HPV postitive smear

A

liquid based cytology

302
Q

where smear taken

A

transformation zone

303
Q

c/i to COCP

A

prev VTE
BP >160/110
AF
35 yrs and more than 15 a day

304
Q

herpes pain mx

A

topical lidocaine
vaseline

305
Q

herpes tx

A

aciclovir for 5 days

306
Q
A

obs and gynae (7 decks)

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