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Osha 3a > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is polycystic ovarian syndrome?

A
  • condition causing metabolic and reproductive problems in women
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2
Q

What are the Rotterdam criteria?

A
  • requires at least 2 of 3 key features to make a diagnosis of PCOS
  • Oligoovulation/anovulation
  • hyperandrogenism
  • polycystic ovaries on ultrasound
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3
Q

What is anovulation?

A
  • absence of ovulation
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4
Q

What is oligoovulation?

A
  • irregular, infrequent ovulation
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5
Q

What is amenorrhoea?

A
  • absence of menstrual periods
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6
Q

What are androgens?

A
  • male sex hormones, e.g. testosterone
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7
Q

What is hyperandrogenism?

A
  • effects of high levels of androgens
  • characterised by hirsutism and acne
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8
Q

What is hirsutism?

A
  • thick dark hair growth in a male pattern
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9
Q

How does PCOS present?

A
  • oligomenorrhoea/amenorrhoea
  • infertility
  • obesity
  • hirsutism
  • acne
  • male pattern hair loss
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10
Q

What are other common features of PCOS?

A
  • insulin resistance and diabetes
  • acanthosis nigricans
  • CVD + high cholesterol
  • obstructive sleep apnoea
  • endometrial hyperplasia and cancer
  • depression and anxiety
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11
Q

What is Acanthosis nigricans?

A
  • thickened, rough, velvety skin
  • typically found in axilla and on elbows
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12
Q

Why is insulin resistance related to PCOS?

A
  • insulin promotes the release of androgens from ovaries and adrenal glands
  • higher insulin > higher androgens
  • also suppresses sex hormone-binding globulin production by liver
  • SHBG normally suppresses androgens so there is hyperandrogenism
  • high insulin > halts development of follicles in ovary
  • leads to anovulation and partially developed follicles
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13
Q

What blood tests are done for PCOS?

A
  • testosterone
  • SHBG
  • LH
  • FSH
  • Prolactin
  • TSH
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14
Q

What do hormonal blood tests show in PCOS?

A
  • raised LH
  • raised LH to FSH ratio
  • raised testosterone
  • raised insulin
  • normal/raised oestrogen
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15
Q

What scans are done in PCOS investigations?

A
  • Pelvic ultrasound
  • GOLD: transvaginal ultrasound
  • follicles arranged around periphery of ovary giving a string of pearls appearance
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16
Q

What are the diagnostic criteria in ultrasound for PCOS?

A
  • 12 or more developing follicles in one ovary
  • ovarian volume of 10cm3+
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17
Q

How is diabetes screened for in PCOS?

A
  • 2hr 75g oral glucose tolerance test
  • take a baseline fasting plasma glucose and give glucose drink
  • measure plasma glucose 2hrs later
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18
Q

What are the results of an OGTT?

A
  • impaired fasting glucose: 6.1-6.9 mmol/l
  • impaired glucose tolerance: 7.8-11.1mmol/l
  • plasma glucose above 11.1mmol/l
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19
Q

What is the general management for PCOS?

A
  • weight loss
  • low glycaemic index
  • exercise
  • smoking cessation
  • antihypertensives + statins where indicated
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20
Q

What medication can be used for weight loss/insulin resistance in PCOS?

A
  • orlistat
  • if BMI above 30
  • lipase inhibitor stopping fat absorption in intestines
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21
Q

How is infertility managed in women with PCOS?

A
  • weight loss
  • clomifene
  • laparoscopic ovarian drilling
  • IVF
  • metformin and letrozole to restore ovulation
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22
Q

What should women with PCOS who become pregnant be screened for?

A
  • gestational diabetes
  • oral glucose tolerance test
  • before pregnancy and at 24-28 weeks gestation
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23
Q

What risk factors for endometrial cancer do women with PCOS have?

A
  • obesity
  • diabetes
  • insulin resistance
  • amenorrhoea
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24
Q

What is the physiology behind the increased risk of endometrial cancer in women with PCOS?

A
  • normally: corpus luteum releases progesterone after ovulation
  • infrequent ovulation > low progesterone and unopposed oestrogen
  • endometrial hyperplasia and risk of cancer
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25
Q

How is endometrial cancer risk reduced in PCOS?

A
  • mirena coil
  • inducing withdrawal bleed every 3-4 months: cyclical progestogens or cocp
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26
Q

How and when is amenorrhoea investigated?

A
  • for inc endometrial cancer risk
  • periods with gaps of 3+ months
  • pelvic USS for endometrial thickness
  • cyclical progestogen to induce bleed before scan
  • if >10mm then refer for biopsy
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27
Q

How is acne managed in PCOS?

A
  • 1st line: cocp
  • co-cyprindiol (VTE risk)
  • topical Abx (clindamycin w/ benzyl peroxide)
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28
Q

How is hirsutism managed?

A
  • weight loss
  • co-cyprindiol (cocp - anti-androgenic effect)
  • topical eflornithine
  • electrolysis/laser
  • spironolactone
  • finasteride
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29
Q

What is menopause?

A
  • the point at which menstruation stops
  • a retrospective diagnosis
  • no periods for 12 months
  • permanent end to menstruation
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30
Q

What is postmenopause?

A
  • the period from 12 months after the final menstrual period
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31
Q

What is perimenopause?

A
  • includes time leading up to last period and 12 months afterwards
  • may experience vasomotor symptoms and irregular periods
  • typically in women over 45
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32
Q

What is premature menopause?

A
  • menopause before 40 y/o
  • result of premature ovarian insufficiency
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33
Q

What is the cause of menopause?

A
  • lack of ovarian follicular function
  • low oestrogen and progesterone levels
  • LH and FSH high in response to an absence of negative feedback
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34
Q

What are some perimenopausal symptoms and what causes these?

A
  • lack of oestrogen
  • hot flushes
  • low mood
  • irregular/lighter/heavier periods
  • joint pains
  • vaginal dryness + atrophy
  • reduced libido
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35
Q

Risk of which conditions are increased due to a lack of oestrogen?

A
  • CVD and stroke
  • osteoporosis
  • pelvic organ prolapse
  • urinary incontinence
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36
Q

How is menopause diagnosed in women over 45?

A
  • without typical symptoms and no investigations
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37
Q

When is an FSH blood test used?

A
  • women under 40 with suspected premature menopause
  • women 40-45 with menopausal symptoms/change in menstrual cycle
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38
Q

How long do women need to keep using contraception in menopause?

A
  • 2yrs after last period if <50
  • 1yr after last period if >50
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39
Q

What are good contraceptive options for women approaching menopause?

A
  • barrier methods
  • Mirena/copper coil
  • mini pill/implant
  • depo injection (<45)
  • sterilisation
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40
Q

Which is the best type of contraceptive pill in menopause?

A
  • cocp is UKMEC2 aged 40-50
  • consider pills containing norethisterone or levonorgestrel >40 due to lower risk of VTE
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41
Q

How does hormonal contraception affect women approaching menopause?

A
  • doesn’t affect when it occurs/how long it lasts
  • masks symptoms
  • makes diagnosis more difficult
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42
Q

Why shouldn’t depo injection be used in women over 45/50?

A
  • weight gain
  • reduced bone mineral density > osteoporosis
  • DEXA scan
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43
Q

How can perimenopausal symptoms be managed?

A
  • HRT
  • tibolone (cont comb HRT)
  • clonidine
  • CBT
  • SSRIs
  • testosterone (for dec libido)
  • vaginal oestrogen/moisturisers
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44
Q

What is endometriosis?

A
  • ectopic endometrial tissue outside the uterus
  • lump is called endometrioma
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45
Q

What are endometriomas?

A
  • lumps of endometrial tissue
  • in ovaries: chocolate cysts
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46
Q

What is retrograde menstruation as a theory for the aetiology of endometriosis?

A
  • endometrial lining flows backwards
  • through fallopian tubes and out into pelvis and perineum
  • seeds itself in the cavity
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47
Q

What is the pathophysiology of endometriosis?

A
  • ectopic endometrial tissue cells respond to hormones in same way
  • also sheds and bleeds during menstruation
  • causes irritation and inflammation
  • leads to cyclical, heavy pain
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48
Q

What are adhesions in endometriosis?

A
  • caused by localised bleeding and inflammation
  • scar tissue binds organs e.g. ovaries with peritoneum
  • causes chronic, non-cyclical pain
  • sharp, stabbing and associated with nausea
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49
Q

Why does endometriosis reduce fertility?

A
  • adhesions around ovaries and fallopian tubes obstruct route to uterus
  • endometriomas in ovaries damage eggs/prevent ovulation
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50
Q

What is the presentation of endometriosis?

A
  • abdominal or pelvic pain
  • dysmenorrhoea
  • dyspareunia
  • infertility
  • cyclical bleeding
  • urinary or bowel symptoms
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51
Q

What would be seen on examination in endometriosis?

A
  • endometrial tissue in vaginal exam, esp in posterior fornix
  • fixed cervix on bimanual exam
  • tenderness in vagina, cervix and adnexa
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52
Q

How is endometriosis diagnosed?

A
  • pelvic USS: can show large endometriomas and chocolate cysts
  • GOLD: laparoscopic surgery: biopsy of lesions and removal of deposits
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53
Q

How is endometriosis managed (hormonal)?

A
  • analgesia
  • cocp, mini pill, depo injection
  • implant
  • mirena
  • GnRH agonist
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54
Q

What are surgical management options for endometriosis?

A
  • laparoscopic surgery to excise or ablate tissue and remove adhesions
  • hysterectomy
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55
Q

What is urge incontinence?

A
  • overactivity of the detrusor muscle
  • causes sudden urge to pass urine
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56
Q

What is stress incontinence?

A
  • weakness of pelvic floor and sphincter muscles
  • allows leakage of urine at times of increased pressure on the bladder
  • typically occurs when laughing, coughing or surprised
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57
Q

What is mixed incontinence?

A
  • combination of urge and stress incontinence
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58
Q

What is overflow incontinence?

A
  • occurs with chronic urinary retention due to obstruction of outflow of urine
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59
Q

What are possible causes of overflow incontinence?

A
  • anticholinergic meds
  • fibroids
  • pelvic tumours
  • MS
  • diabetic nephropathy
  • spinal cord injury
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60
Q

What is the epidemiology of overflow incontinence?

A
  • more common in men
  • rare in women so they should be referred for urodynamic testing
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61
Q

What are some risk factors for urinary incontinence?

A
  • increased age
  • postmenopausal
  • high BMI
  • previous pregnancies/vaginal delivery
  • pelvic organ prolapse or surgery
  • dementia
  • MS
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62
Q

How is incontinence investigated?

A
  • bladder diary: fluid intake, urination and incontinence
  • urine dipstick
  • post-void residual bladder volume
  • urodynamic testing
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63
Q

What modifiable lifestyle factors can contribute to incontinence?

A
  • caffeine + alcohol consumption
  • medications
  • BMI
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64
Q

How is severity of incontinence assessed?

A
  • frequency of urination
  • frequency of incontinence
  • nighttime urination
  • use of pads and change of clothing
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65
Q

What should be assessed in pelvic examination for incontinence?

A
  • pelvic organ prolapse
  • atrophic vaginitis
  • urethral diverticulum
  • pelvic masses
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66
Q

How are strength of pelvic muscle contractions graded in bimanual examination?

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

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67
Q

What is cystometry?

A
  • measures detrusor contraction and pressure
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68
Q

What is uroflowmetry?

A

measures flow rate

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69
Q

What is leak point pressure?

A
  • point at which bladder pressure results in leakage of urine
  • patient is asked to cough, move, jump with bladder filled to various capacities
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70
Q

What does post-void residual bladder volume test?

A
  • test for incomplete emptying of the bladder
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71
Q

What is video urodynamic testing?

A
  • filling bladder with contrast and taking x-ray images as it is emptied
  • only performed where necessary
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72
Q

How is stress incontinence managed?

A
  • avoid caffeine
  • restrict fluid intake
  • pelvic floor exercises
  • surgery
  • duloxetine
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73
Q

What are surgical options for stress incontinence?

A
  • tension-free vaginal tape
  • retropubic mid urethral tape
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74
Q

How is urge incontinence managed?

A
  • bladder retraining (min 6 weeks)
  • anticholinergics
  • mirabegron
  • invasive procedures
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75
Q

What anticholinergics are used in urge incontinence?

A
  • oxybutinin
  • tolterodine
  • solefenacin
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76
Q

What are side effects of anticholinergics?

A
  • dry eyes and mouth
  • urinary retention
  • constipation
  • postural hypotension
  • can lead to cognitive decline, memory problems, worsening dementia
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77
Q

When is mirabegron contraindicated?

A
  • uncontrolled hypertension
  • β-3 agonist
  • stimulates sympathetic nervous system
  • can lead to inc risk of TIA and stroke
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78
Q

What are invasive procedures for urge incontinence?

A
  • botulinum toxin type A
  • sacral nerve stimulation
  • augmentation cystoplasty
  • urinary diversion
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79
Q

Describe the epidemiology of breast cancer

A
  • most common form of cancer in UK
  • around 1 in 8 women will develop breast cancer
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80
Q

What are risk factors for breast cancer?

A
  • female (99% cases)
  • increased oestrogen exposure (earlier menarche and later menopause)
  • obesity
  • smoking
  • family history (1º relative)
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81
Q

How do contraception/HRT affect breast cancer risk?

A
  • COCP: small increase in risk, returns to normal 10 years after stopping
  • HRT: inc risk of breast cancer, esp combined HRT
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82
Q

What is BRCA?

A
  • BReast CAncer gene
  • tumour suppressor genes
  • mutations lead to inc risk of breast and ovarian cancer among others
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83
Q

What is BRCA1?

A
  • on chromosome 17
  • 70% develop breast cancer by age 80
  • 50% develop ovarian cancer
  • inc risk of bowel and prostate cancer
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84
Q

What is BRCA2?

A
  • on chromosome 13
  • 60% develop breast cancer by age 80
  • 20% develop ovarian cancer
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85
Q

Describe ductal carcinoma in situ

A
  • pre-cancerous or cancerous ductal epithelial cells
  • localised to single area
  • often picked up by mammogram
  • potential to spread locally
  • potential to become invasive (30%)
  • good prognosis if excised and adjuvant therapy
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86
Q

Describe lobal carcinoma in situ

A
  • pre-cancerous
  • asymptomatic and undetectable on mammogram
  • usually incidental on biopsy
  • represents inc risk of invasive breast cancer in future
  • managed with close monitoring
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87
Q

What is a vault prolapse?

A
  • occurs in women with hysterectomy
  • vault of vagina descends into vagina
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88
Q

What is a cystocele?

A
  • defect in anterior vaginal wall
  • bladder prolapses into vagina
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89
Q

What is a urethrocele and what is a cystourethrocele?

A
  • prolapse of urethra
  • prolapse of bladder and urethra
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90
Q

What are risk factors for pelvic organ prolapse?

A
  • multiple vaginal deliveries
  • instrumental/prolonged delivery
  • age and post menopause
  • obesity
  • coughing and straining
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91
Q

What is a rectocele and what are the symptoms?

A
  • defect in posterior vaginal wall
  • rectum prolapses into vagina
  • women can develop facial loading > constipation, urinary retention and palpable lump
  • press lump back to open bowel
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92
Q

What is the presentation of prolapse?

A
  • feeling of something coming down
  • heavy or dragging pelvic sensation
  • urinary symptoms
  • bowel symptoms
  • sexual dysfunciton
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93
Q

How are prolapses examined?

A
  • empty bladder and bowel before exam
  • dorsal and left lateral position
  • Sim’s speculum (U-shaped single-blade)
  • held on anterior wall for rectocele and posterior for cystocele
  • asked to cough
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94
Q

How are prolapses graded?

A
  • 0: normal
  • 1: lowest part >1cm above introitus
  • 2: lowest part within 1cm of introitus
  • 3: lowest part >1cm below introitus
  • 4: full descent and eversion of vagina
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95
Q

What is conservative management of prolapse?

A
  • weight loss
  • pelvic floor exercises
  • lifestyle changes: dec caffeine intake
  • vaginal oestrogen cream
  • treat related symptoms e.g. anticholinergics for stress incontinence
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96
Q

Describe the types of vaginal pessaries:

A
  • ring: sit around cervix and hold up uterus
  • Shelf/Gellhorn: flat disc with stem
  • cube
  • donut
  • hodge: rectangular hooking around posterior cervix and extending into vagina
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97
Q

How and why should pessaries be changed?

A
  • comfort and symptom relief
  • cleaned
  • cause vaginal irritation and erosion
  • oestrogen cream protects from irritation
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98
Q

What are fibroids?

A
  • benign smooth muscle tumours
  • also called uterine leiomyomas
  • oestrogen sensitive
99
Q

What is an intramural fibroid?

A
  • within the myometrium
  • changes shape and distorts uterus as it grows
100
Q

What is a subserosal fibroid?

A
  • just below outer layer of uterus
  • grows outwards and becomes large
  • fills abdominal cavity
101
Q

What is a submucosal fibroid?

A
  • grows below lining of uterus in endometrium
  • projects into uterus
102
Q

What is a pedunculated fibroid?

A
  • grows on a stalk
103
Q

How do fibroids present?

A
  • often asymptomatic
  • menorrhagia
  • prolonged menstruation
  • abdo pain and bloating
  • urinary/bowel symptoms
  • deep dyspareunia
  • reduced fertility
104
Q

What is felt on examination with fibroids?

A
  • abdominal and bimanual
  • palpable pelvic mass
  • enlarged, firm, non-tender uterus
  • bulky
105
Q

How are fibroids investigated?

A
  • hysteroscopy (submucosal)
  • pelvic USS (larger fibroids)
  • MRI before surgery
106
Q

What is the management of fibroids?

A
  • mirena (1st line if <3cm)
  • NSAIDs and tranexamic acid (1st line if >3cm)
  • cocp
  • cyclical oral progestogens
107
Q

What are surgical options for fibroids <3cm?

A
  • endometrial ablation
  • resection if submucosal during hysteroscopy
  • hysterectomy
108
Q

What are surgical options for fibroids >3cm?

A
  • uterine artery embolisation
  • myomectomy
  • hysterectomy
109
Q

How can fibroid size be reduced pre-surgery?

A
  • GnRH agonists: Zoladex, Prostate
  • induce a menopause like state
  • reduce oestrogen maintaining fibroid
110
Q

How does uterine artery embolisation work?

A
  • catheter into femoral artery
  • particles injected causing blockage
  • starves fibroid of oxygen
  • causes shrinkage
111
Q

What is myomectomy?

A
  • surgical removal of fibroids - laparoscopic or laparotomy
  • improves fertility
112
Q

What is endometrial ablation?

A
  • destroys endometrium
  • balloon thermal ablation
  • insert balloon and fill with high-temp fluid
  • burns endometrial lining
113
Q

What are complications of fibroids?

A
  • menorrhagia w/ iron deficiency anaemia
  • reduced fertility
  • constipation
  • pregnancy complications
  • torsion
114
Q

What is red degeneration of fibroids?

A
  • ischaemia, infarction and necrosis of fibroids
  • occurs in >5cm during 2nd and 3rd trimester
  • fibroid enlarges and outgrows its blood supply
115
Q

How does red degeneration present?

A
  • severe abdo pain
  • low-grade fever
  • tachycardia
  • vomiting
116
Q

How is red degeneration managed?

A
  • rest
  • fluids
  • analgesia
117
Q

What is an ovarian cyst?

A
  • fluid filled sac
  • related to hormones of menstrual cycle
118
Q

What is the epidemiology of ovarian cysts?

A
  • v common in premenopausal women
  • postmenopausal: concerning for malignancy
119
Q

How do ovarian cysts present?

A
  • pelvic pain
  • bloating
  • fullness in abdomen
  • palpable pelvic mass
120
Q

When can cysts present with acute pelvic pain?

A
  • ovarian torsion
  • haemorrhage
  • rupture
121
Q

What are the two types of functional cysts?

A
  • follicular
  • corpus luteum
122
Q

What is a follicular cyst?

A
  • form from developing follicle
  • failure to rupture and release egg > persistence of cyst
  • most common type
  • thin walls and no internal structure
123
Q

What is a corpus luteum cyst?

A
  • corpus luteum fails to break down
  • fills with fluid
  • cause pelvic discomfort, pain and delayed menstruation
  • seen in early pregnancy
124
Q

What is a serous cystadenoma?

A

benign tumour of epithelial cells

125
Q

What is a dermoid cyst?

A
  • germ cell tumour (teratoma)
  • benign
  • can contain various tissue types: skin, hair, bone, teeth
  • associated with ovarian torsion
126
Q

What are risk factors for ovarian malignancy?

A
  • age
  • post menopause
  • increased no of ovulations
  • obesity
  • HRT
  • smoking
  • FHx of BRCA
127
Q

How does ovulation correlate with ovarian cancer?

A
  • more ovulations = inc risk
  • reduced by later menarche, early menopause, pregnancies, use of cocp
128
Q

Which factors can cause a raised CA125?

A
  • endometriosis
  • fibroids
  • adenomyosis
  • pelvic infection
  • liver disease
  • pregnancy
129
Q

What bloods are done for women <40 with a complex ovarian mass?

A
  • LDH
  • AFP
  • hCG
130
Q

What factors are taken into account in the risk of malignancy index?

A
  • menopausal status
  • USS findings
  • CA125 level
131
Q

How are dermoid cysts managed?

A
  • referral to gynae
  • for further investigation and consideration of surgery
132
Q

How are cysts in post menopausal women managed?

A
  • correlation with CA125
  • referral to gynae
  • if raised then 2ww pathway
  • <5cm then monitor with USS every 4-6mo
133
Q

How are ovarian cysts managed surgically?

A
  • laparoscopy
  • ovarian cystectomy
  • oophorectomy if necessary
134
Q

How are simple ovarian cysts in premenopausal women managed?

A
  • <5cm = resolves within 3 cycle
  • 5-7cm = referral to gynae and yearly USS monitoring
  • > 7cm = consider MRI or surgical eval
135
Q

What are complications of an ovarian cyst?

A
  • torsion
  • haemorrhage
  • rupture
136
Q

What is Meig’s syndrome?

A
  • ovarian fibroma
  • pleural effusion
  • ascites
137
Q

How is ovarian cancer staged?

A
  1. confined to ovary
  2. past ovary but in pelvis
  3. past pelvis but inside abdomen
  4. outside abdomen
138
Q

What is lichen sclerosus?

A
  • chronic inflammatory skin
  • autoimmune
139
Q

Where does lichen sclerosus present in women?

A
  • labia
  • perineum
  • perianal skin
  • potentially axilla and thighs
140
Q

Where does lichen sclerosus present in men?

A
  • foreskin
  • glans of penis
141
Q

Which other autoimmune diseases is lichen sclerosus associated with?

A
  • T1DM
  • alopecia
  • hypothyroid
  • vitiligo
142
Q

How does lichen sclerosus present?

A
  • itching
  • soreness
  • pain worse at night
  • skin tightness
  • superficial dyspareunia
  • erosions
  • fissures
143
Q

What is the Koebner phenomenon?

A
  • signs and symptoms made worse by friction to skin
  • made worse by tight underwear, urinary incontinence and scratching
144
Q

Describe the appearance of lichen sclerosus

A
  • ‘porcelain white’
  • shiny
  • tight
  • thin
  • slightly raised
  • papules or plaques
145
Q

How is lichen sclerosus managed?

A
  • cannot be cured; symptoms controlled
  • FU every 3-6 months
  • clobetasol propionate 0.05% (dermovate)
  • is a potent topical steroid
  • used OD for 4 weeks
  • also use emollients
146
Q

What is a critical complication of lichen sclerosus?

A
  • 5% risk of squamous cell carcinoma of vulva
147
Q

What are other complications of lichen sclerosus?

A
  • pain and discomfort
  • sexual dysfunction
  • bleeding
  • narrowing of urethral or vaginal openings
148
Q

What is pelvic inflammatory disease (PID)?

A
  • inflammation and infection of pelvic organs
  • caused by infection spreading up through cervix
149
Q

What is a key complication of PID?

A
  • tubular infertility
  • chronic pelvic pain
150
Q

Which infections cause PID?

A
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
  • Mycoplasma genitalium
151
Q

Which non-sexually transmitted infections can cause PID?

A
  • gardnerella vaginalis
  • H. influenzae
  • E. coli
152
Q

What are the risk factors for PID?

A
  • not using barrier contraception
  • multiple partners
  • younger age
  • existing STIs
  • previous PID
  • IUD
153
Q

How does PID present?

A
  • pelvic or lower abdo pain
  • abnormal discharge or bleeding
  • dyspareunia
  • dysuria
  • fever
154
Q

What is found on examination in PID?

A
  • pelvic tenderness
  • cervical motion tenderness
  • inflamed cervix
  • purulent discharge
155
Q

How should patients with PID be tested?

A
  • NAAT swabs for chlamydia and gonorrhoea
  • HIV test
  • syphilis test
  • HVS
  • inflammatory markers (CRP/ESR)
156
Q

What does a high vaginal swab test for?

A
  • bacterial vaginosis
  • candidiasis
  • trichomoniasis
157
Q

How is PID managed?

A
  • GUM specialist
  • contact tracing
  • Abx empirically
  • admit if septic or pregnant
158
Q

What are the guidelines for Abx for PID?

A
  • single dose IM ceftriaxone
  • doxycycline 100mg BD for 14 days (chlamydia and Mycoplasma)
  • metronidazole 400mg BD for 14 days (anaerobes)
159
Q

What are possible complications of PID?

A
  • sepsis
  • abscess
  • infertility
  • chronic pelvic pain
  • ectopic pregnancy
  • Fitz-Hugh-Curtis syndrome
160
Q

What is Fitz-Hugh-Curtis syndrome?

A
  • inflammation and infection of liver capsule
  • leads to adhesions between liver and peritoneum
  • bacteria may spread via peritoneal cavity, lymphatics or blood
161
Q

What is the presentation of Fitz-Hugh-Curtis syndrome?

A
  • RUQ pain
  • R shoulder tip pain
162
Q

What is the management of Fitz-Hugh-Curtis syndrome?

A
  • laparoscopy
  • adhesiolysis
163
Q

What is adenomyosis?

A
  • endometrial tissue in the myometrium
  • more common in older age and multiparous
  • hormone dependent
164
Q

How does adenomyosis present?

A
  • dysmenorrhoea
  • menorrhagia
  • dyspareunia
  • may present with infertility or pregnancy complications
165
Q

What is seen on examination in adenomyosis?

A
  • enlarged and tender uterus
  • more soft than fibroid uterus
166
Q

How is adenomyosis diagnosed?

A
  • transvaginal ultrasound
  • MRI/transabdo USS are alternatives
  • GOLD: histological after hysterectomy
167
Q

How is adenomyosis managed when contraception is unwanted?

A
  • tranexamic acid if no pain
  • mefenamic acid with pain
168
Q

How is adenomyosis managed when contraception is an option?

A
  • mirena
  • cocp
  • cyclical oral progestogens
169
Q

What are specialist options for adenomyosis?

A
  • GnRH analogues
  • endometrial ablation
  • uterine artery embolisation
  • hysterectomy
170
Q

What complications are associated with adenomyosis in pregnancy?

A
  • infertility
  • miscarriage
  • preterm
  • SGA
  • preterm PROM
  • malpresentation
  • PPH
  • C-section
171
Q

What is ovarian torsion?

A
  • ovary twists in relation to surrounding connective tissue, fallopian tube and blood supply
172
Q

What causes ovarian torsion?

A
  • ovarian mass >5cm e.g. cyst or tumour
  • more likely to occur with benign tumour
  • long infundibulopelvic ligaments in pre-menarchal girls
173
Q

How does ovarian torsion present?

A
  • sudden onset, severe unilateral pelvic pain
  • constant pain getting progressively worse
  • nausea and vomiting
174
Q

What is found on examination for ovarian torsion?

A
  • localised tenderness
  • possible palpable mass in pelvis
175
Q

How is ovarian torsion diagnosed?

A
  • transvaginal USS
  • whirlpool sign
  • free fluid in pelvis
  • ovarian oedema
  • GOLD: laparoscopic surgery
176
Q

How is ovarian torsion managed?

A
  • emergency admission
  • detorsion and possible oophorectomy
  • laparotomy if large ovarian mass suspected
177
Q

What are possible complications of ovarian torsion?

A
  • loss of function due to ischaemia
  • dependent on if there’s another functioning ovary
  • infection, abscess, sepsis
  • rupture, peritonitis, adhesions
178
Q

What is atrophic vaginitis?

A
  • dryness and atrophy
  • due to lack of oestrogen
179
Q

How does lack of oestrogen affect the vagina?

A
  • epithelial lining becomes thinner, less elastic and more dry
  • tissue more prone to inflammation
  • changes in vaginal pH and microbial flora
180
Q

How does atrophic vaginitis present?

A
  • itching
  • dryness
  • dyspareunia
  • bleeding
  • recurrent UTIs/stress incontinence
181
Q

What does examination show in atrophic vaginitis?

A
  • pale mucosa
  • thin skin and reduced folds
  • erythema
  • dryness
  • sparse pubic hair
182
Q

How is atrophic vaginitis managed?

A
  • estriol cream/pessaries
  • estradiol tablets/ring
183
Q

What contraindications are there for topical oestrogen?

A
  • breast cancer
  • angina
  • VTE
184
Q

What are the most common types of cervical cancer?

A
  • squamous cell carcinoma (80%)
  • adenocarcinoma
185
Q

What is the most common cause of cervical cancer?

A
  • HPV (STI)
  • type 16 and 18
  • produces proteins E6 and E7 which inhibit p53 and pRb (tumour suppressor genes)
186
Q

What increases risk of catching HPV (therefore inc cervical cancer risk)?

A
  • early sexual activity
  • inc no of partners
  • sexual partners who have had more partners
  • not using condoms
187
Q

What are other risk factors for cervical cancer?

A
  • non-engagement with screening
  • smoking
  • HIV
  • cocp
  • inc. no of full term pregnancies
  • family history
188
Q

With which presenting symptoms should you consider cervical cancer?

A
  • abnormal vaginal bleeding (IM, PC, PMB)
  • vaginal discharge
  • pelvic pain
  • dyspareunia
189
Q

What abnormal appearances of the cervix suggest cervical cancer?

A
  • ulceration
  • inflammation
  • bleeding
  • visible tumour
190
Q

How is cervical intraepithelial neoplasia (CIN) graded?

A
  • CIN I: mild dysplasia, affecting 1/3 thickness - likely to return to normal w/out treatment
  • CIN II: moderate, affects 2/3, likely to progress to cancer
  • CIN III: severe, very likely to progress
191
Q

How is cervical cancer staged?

A

1: confined to cervix
2: invades uterus or upper 2/3 of vagina
3: pelvic wall or lower 1/3 of vagina
4: bladder, rectum or beyond pelvis

192
Q

What are the differences between stages 1a and 1b in cervical cancer?

A

1a: only visible by microscopy or<7mm wide
1b: clinically visible or >7mm

193
Q

How does a smear test work?

A
  • collection of cells from cervix using brush
  • deposited into preservation fluid
  • liquid based cytology
194
Q

What is being looked for in a smear test?

A
  • precancerous changes: dyskaryosis
  • high risk HPV
195
Q

How often is smear testing done?

A
  • every 3yrs for 25-49
  • every 5yrs for 50-64
196
Q

What are possible cytology results from smear testing?

A
  • Inadequate
  • Normal
  • Borderline changes
  • Low-grade dyskaryosis
  • High-grade dyskaryosis (moderate)
  • High-grade dyskaryosis (severe)
  • Poss invasive squamous cell carcinoma
  • Poss glandular neoplasia
197
Q

What are the possible management options based on smear results?

A
  • inadequate sample – repeat the smear after at least 3mo
  • HPV -ve – continue routine screening
  • HPV +ve w/ normal cytology – repeat the HPV test after 12 months
  • HPV +ve w/ abnormal cytology – refer for colposcopy
198
Q

How does colposcopy work?

A
  • inserting speculum and using colposcope
  • epithelial lining examined in detail
  • stains to differentiate abnormal areas
199
Q

Which stains are used in colposcopy and what colours do they appear?

A
  • acetic acid: white
  • iodine: brown
200
Q

What is large loop excision of the transformation zone (LLETZ)?

A
  • loop biopsy
  • diathermy to remove abnormal epithelial tissue
  • current cauterises tissue and stops bleeding
201
Q

What is cone biopsy?

A
  • treatment for CIN + v early stage cancer
  • removes cone-shaped piece of cervix
  • sent for histology to assess for malignancy
202
Q

What are the main risks of cone biopsy?

A
  • pain
  • bleeding
  • infection
  • scar formation with stenosis
  • inc risk of miscarriage and prem labour
203
Q

Which strains of HPV does the vaccine prevent against?

A
  • given to girls and boys
  • strains 6 and 11 (genital warts)
  • strains 16 and 18 (cervical cancer)
204
Q

What is pelvic exenteration?

A
  • removing most or all pelvic organs
  • vagina, cervix, uterus, tubes, ovaries, bladder, rectum
205
Q

What is the management for CIN or early stage 1a cervical cancer?

A
  • LLETZ
  • cone biopsy
206
Q

What is the management for stage 1b-2a cervical cancer?

A
  • radical hysterectomy
  • removal of local lymph nodes
  • chemotherapy and radiotherapy
207
Q

What is the management for stage 2b-4a cervical cancer?

A
  • chemotherapy and radiotherapy
208
Q

What is the management of stage 4b cervical cancer?

A
  • surgery
  • radiotherapy
  • chemotherapy
  • palliative care
209
Q

Which monoclonal antibody can be used in cervical cancer?

A
  • bevacizumab
  • metastatic or recurrent cancer
  • targets vascular endothelial growth factor A
  • stops development of new blood vessels
210
Q

What are risk factors for vulval cancer?

A
  • age (>75)
  • immunosuppression
  • HPV
  • lichen sclerosus
211
Q

How does vulval cancer present?

A
  • lump
  • ulceration
  • bleeding
  • pain
  • itching
  • lymphadenopathy
212
Q

What is seen on the labia majora in vulval cancer?

A
  • irregular mass
  • fungating lesion
  • ulceration
  • bleeding
213
Q

How is vulval cancer diagnosed?

A
  • 2ww pathway
  • (sentinel node) biopsy
  • imaging for staging
214
Q

How is vulval cancer managed?

A
  • wide local excision
  • groin lymph node dissection
  • chemo and radiotherapy
215
Q

What is the most common type of vulval cancer?

A
  • 90% squamous cell carcinoma
216
Q

What is vulval intraepithelial neoplasia?

A
  • premalignant condition
  • affects squamous epithelium
217
Q

What are the types of VIN?

A
  • high grade squamous intraepithelial lesion: associated with HPV in women aged 35-50
  • differentiated VIN: associated with lichen sclerosus in women aged 50-60
218
Q

How is VIN treated?

A
  • watch and wait
  • wide local excision
  • imiquimod cream
  • laser ablation
219
Q

Describe the most common types of endometrial cancer

A
  • 80% adenocarcinoma
  • oestrogen dependent
220
Q

What is endometrial hyperplasia?

A
  • precancerous thickening of endometrium
  • with or without atypia
221
Q

How is endometrial hyperplasia treated?

A
  • IUS e.g. mirena
  • continuous oral progestogens
222
Q

What are risk factors for endometrial cancer?

A
  • increased age
  • earlier onset of menstruation
  • late menopause
  • oestrogen only HRT
  • obesity
  • no pregnancy
  • PCOS
  • tamoxifen
223
Q

Why is obesity a risk factor for endometrial cancer?

A
  • adipose tissue is an oestrogen source
  • contains aromatase which converts androgens to oestrogen
  • more unopposed oestrogen
224
Q

What are protective factors against endometrial cancer?

A
  • COCP
  • mirena
  • inc pregnancies
  • smoking
225
Q

How does endometrial cancer present?

A
  • post coital bleeding
  • intermenstrual bleeding
  • heavy menstrual bleeding
  • abnormal discharge
  • haematuria
  • anaemia
226
Q

What is the 2ww referral criteria for endometrial cancer?

A
  • post menopausal bleeding
  • > 12 mo after last menstrual period
227
Q

Under what circumstances should women over 55 be referred for a transvaginal ultrasound?

A
  • unexplained vaginal discharge
  • visible haematuria + inc platelets, anaemia or inc glucose levels
228
Q

What are the investigations for endometrial cancer?

A
  • transvaginal ultrasound: endometrial thickness <4mm
  • pipelle biopsy
  • hysteroscopy w/ biopsy
229
Q

What are the stages of endometrial cancer?

A
  1. confined to uterus
  2. invades cervix
  3. invades ovaries fallopian tubes, vagina or lymph nodes
  4. invades bladder, rectum or beyond pelvis
230
Q

What is the management of endometrial cancer?

A
  • TAH w/ BSO
  • radio/chemotherapy
  • progesterone to slow progression
231
Q

What is cervical ectropion?

A
  • eversion of endocervix
  • due to high oestrogen
232
Q

What are the symptoms of ectropion?

A
  • PCB, IMB, discharge
  • reddish appearance around os
233
Q

What is the pathophysiology of ectropion?

A
  • mucus secreting glands > inc discharge
  • fine blood vessels > PCB
234
Q

What is the treatment for ectropion?

A
  • ablation
  • stop COCP
  • silver nitrate
235
Q

After how long can a couple be referred for infertility?

A
  • TTC for >12 months
  • 6 months if over 35
236
Q

Give lifestyle advice for a couple TTC

A
  • 400mcg folic acid daily
  • healthy BMI
  • avoid smoking, alcohol, stress
  • intercourse every 2-3 days
237
Q

What is involved in female hormone infertility testing?

A
  • serum LH and FSH on day 2-5
  • AMH
  • TFT
  • prolactin
  • serum progesterone 7d before period
238
Q

What is AMH?

A
  • anti-mullerian hormone
  • ovarian reserve marker
  • released by granulosa cells
239
Q

What does high FSH indicate?

A
  • poor ovarian reserve
  • pituitary producing extra FSH to attempt to stimulate follicular development
240
Q

What investigations are performed in secondary care infertility?

A
  • USS pelvis
  • hysterosalpingogram
  • laparoscopy and dye test
241
Q

How is anovulation managed?

A
  • weight loss
  • clomifene: stimulates ovulation
  • letrozole
  • gonadotropins
242
Q

What methods can be used to manage sperm problems in infertility?

A
  • surgical retrieval
  • IUI: collecting and separating high quality sperm
  • ICSI: injecting sperm into cytoplasm of egg
  • donor sperm
243
Q

What methods can be used to manage tubal problems in infertility?

A
  • tubal cannulation
  • laparoscopy
  • IVF

Osha 3a (15 decks)

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