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AMC MCQ - You Can Do It!!!!!❤️❤️ > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Cervical cancer screening

A

2 years after first sexual intercourse or 25–75 years.

HPV test + cell cytology

Negative Result: Every five years.

Unsatisfactory: repeat 6-12 weeks

Positive NON 16-18: Repeat in 12 month. Again positive: Colposcopy.

Positive 16-18: Colposcopy.

Low grade: Repeat in 12 month. Again positive: Colposcopy.

High grade: Colposcopy

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2
Q

Breast cancer: Risk factors

A

Risk factors:
- Individuals with age of onset of cancer less than 50 years
- Individuals with ovarian cancer
*Increasing age is a major risk factor.
*Personal history of atypical hyperplasia or lobular carcinoma in situ.
*Strong family history of the disease or mutation in a breast cancer predisposition gene.
*Previous radiotherapy.
*High bone mass or obesity.
-Jewish ancestry
- Breast cancer in a male relative

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3
Q

Breast cancer: Screening Low risk

A

Low risk: Family member diagnosed at 50 years or over.

Screening: mammograms
every two years for women aged 50–74 years

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4
Q

Breast cancer: Screening Moderate risk

A

Moderate risk:

One 1st degree diagnosed before 50 years
or
Two 1st degree in the same family side at any age
or
Two 2nd degree in the same family side diagnosed before 50 years.

Screening: Annual mammogram for women age 40 years

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5
Q

Breast cancer: Screening High risk

A

High risk:

Member of the family in prescence of BRCA 1-2.

or

Two 1st or 2nd degree on the same family side diagnosed with BC or ovarian Ca PLUS:

*Additional relatives with BC or OC.
*BC diagnosed before 40 years.
*Bilateral BC.
*Breast & Ovarian Ca in the same woman.
*BC in a male relative.
*Ashkenazi jewish ancestry.

or

One 1st or 2nd degree with BC < 45 PLUS One 1st or 2nd degree with sarcoma < 45

Screening:

Annual mammogram for women age 40 years

Referral to a cancer clinic for risk assessment, possible genetic testing and management plan.

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6
Q

List of all enzyme inducers

A
  • Phenobarbital
  • Primidone
  • Phenytoin
  • Carbamazepine
  • Oxcarbazepine
  • Topiramate
    -ST John’s Wort
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7
Q

Non-enzyme inducing anti epileptics

A
  • lamotrigine
  • Levetiracetam
    NOTE: Increase dose in case of OCP as they increase metabolism
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8
Q

When does ovulation occur?

A

14th day (midcycle)
- LH surge
- next 24 h (12-36)

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9
Q

Ovulation occurring investigation

A

plasma oestradiol peaks
- ovulation to occur in 36-48 hrs

Cervical mucus alteration immediately before ovulation
-more abundant/maximal
- clear and slippery

NOTE: These are less accurate ways to predict ovulation

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10
Q

Investigation of choice to predict ovulation has occurred

A

Serum progesterone surge at day 21 (luteal phase)
- level > 20nmol/L

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11
Q

Ovulation pain is also known as

A

Mittelschmerz syndrome

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12
Q

Ovulation inducing drugs

A

Clomiphene

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13
Q

Primary Dysmenorrhoea

A
  • Pain occurs before menses
  • Initial treatments NSAID’s
  • Trial of OCP’s for 2 months upon px request
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14
Q

Secondary dysmenorrhoea

A
  • Treat underlying problem

DRAFT

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15
Q

Difference between biphasic and triphasic contraceptive pills

A

biphasic: same amount of oestrogen but level of progestin is increased halfway through
triphasic: 3 different doses of oestrogen and progesterone every week for 3 weeks along with sugar pills

Biphasic and triphasic contraceptive pills are both types of combined oral contraceptives, meaning they contain two hormones: estrogen and progestin. The difference between them lies in how the hormone levels change throughout the pill cycle.

Biphasic Pills:

•	What They Are: In biphasic pills, the hormone levels change once during the cycle.
•	How They Work:
•	For the first part of the cycle (typically the first 10 days), the pills contain one level of hormones.
•	For the second part of the cycle (typically the next 11 days), the pills contain a different level of hormones (usually an increase in progestin).
•	Why It’s Used: Biphasic pills are designed to more closely mimic the natural hormonal changes in a woman’s menstrual cycle while still preventing ovulation.

Triphasic Pills:

•	What They Are: In triphasic pills, the hormone levels change twice during the cycle, creating three different phases.
•	How They Work:
•	The cycle is divided into three phases, each with different hormone levels (estrogen and/or progestin).
•	The amount of hormones changes every 7 days across the three weeks.
•	Why It’s Used: Triphasic pills are also designed to mimic the natural menstrual cycle, but with more gradual changes in hormone levels, which some women find reduces side effects.

Summary:

•	Biphasic Pills: Have two phases with different hormone levels during the cycle.
•	Triphasic Pills: Have three phases with different hormone levels during the cycle.

Both types aim to closely mimic the body’s natural hormone fluctuations to reduce side effects while effectively preventing pregnancy. The choice between biphasic and triphasic pills depends on how a woman’s body responds to the different hormone levels and her specific health needs.

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16
Q
A
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17
Q

COCP doses

A
  • low dose: 20mcg of oestrogen.
  • regular dose: 30-35mcg oestrogen.
  • high dose: 50mcg of oestrogen.
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18
Q

High dose COCP indications

A
  • Break through bleeding on low dose pills.
  • When low dose pill fails.
  • Concomitant use of enzyme inducing drugs
  • Control of menorrhagia.
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19
Q

Approach to PMS

A

1st line: Conservative treatment for 3 menstrual cycles (yoga)
2nd line: COCP, SSRI
3rd: GNRH antagonists due tenderness (danazol) careful because this drug can induce menopause, main complaint of fluid retention spironolactone, main complaint of dysmenorrhoea (mefenamic acid)

BEST method: endometrial ablation, hysterectomy?

DRAFT

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20
Q

OCP absolute contraindications

A
  • Pregnancy.
  • < 6 weeks post-partum.
  • Thromboembolic disease.
  • CVA.
  • CAD like known IHD
  • Migraine with aura.
  • Age >35 years and smoking > 15 cigarettes per day.
  • Oestrogen dependent tumours.
  • Active liver disease.
  • Polycythaemia.
  • Undiagnosed vaginal bleeding.
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21
Q

OCP relative contraindications

A
  • Age > 35-45
  • BMI > 35
  • Smoker >15 cigarettes per day
  • Breast feeding
  • HT ( >160/ 100)
  • DM
  • Hyperlipidaemia.
  • Depression
  • SLE
  • 4 weeks before and 2weeks after surgery
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22
Q

Monthly COCP contents

A

28 pill pack:
* 21 hormonal pills and
*7 sugar pills.

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23
Q

COCP administration

A
  • Start on 1st day of menstrual period, continue till 21 days and then 7 sugar pills.
  • Take pill on the same time every day, 1pill /day.
  • On starting sugar pills, the lady gets periods.
  • Protection starts from 1st day of using pills if taken from the 1st day of periods.
  • Or if at any other time of the cycle, alternate methods of contraception should be used
    for 7 days and pregnancy needs to be ruled out.

NOTE: a 24/4 pill pack is also available.

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24
Q

COCP advantages

A
  • Decreased menorrhagia, dysmenorrhea and pre-menstrual syndrome. (Periods become
    shorter, lighter and regular).
  • Decreased iron deficiency anaemia.
  • Decreased incidence of functional ovarian cysts, PID, acne, thyroid disorders
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25
Q

OCP’s increase the risk of which cancer/s

A

if used more than 5 years:
- cervical
- breast

NOTE: conflicting data, use with caution

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26
Q

OCP decreased risk of which cancer/s

A
  • Ovarian cancer 30-50%
  • Colorectal cancer 15-20%
  • Endometrial cancer >30%
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27
Q

OCP’s and ovarian cancer

A

OCP’s have no relation to developing ovarian cancer. Some sources have even labelled it as a protective factor

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28
Q

COCPs mild side effects

A
  • Break through bleeding
  • Nausea
  • Vomiting
  • Bloating
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29
Q

COCPs breakthrough bleeding management

A
  • Usually settles in 3-4 months. If not, check compliance
  • Change from low dose to regular dose
  • Change progesterone to 2nd or 3rd generation if already on regular dose
    OR
  • Another contraceptive or vaginal ring
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30
Q

COCPs major side effects

A
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31
Q

Irregular bleeding while on OCP risks

A

– Smoking
– Chronic malabsorption syndrome
– Severe nausea, vomiting and diarrhoea.
– Hepatic enzyme-inducing drugs
(anti-epileptics, anti-tuberculosis and drugs used to treat HIV.)

NOTE: Modafinil is a drug used in patients with a history of narcolepsy can also interfere with contraceptive pills efficacy due to enhanced liver metabolism

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32
Q

OCP’s and diarrhoea

A

Severe diarrhoea & vomiting decrease the effectiveness of OCP’s
- take an extra pill add barrier method in addition

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33
Q

Missed pills on OCP > 48 h

A

-1st week (1-7) emergency contraception, finish the pack as regular after
- 2nd week (8-14): No need for emergency contraception, finish the pack
- 3rd week (15-21): Next pack of pills should be started without a break (pill-free period omitted)

NOTE: > 7 pills missed, start new fresh pack (exclude pregnancy)

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34
Q

Px with hypertension on OCP

A

Change to POP

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35
Q

OCP and Otosclerosis
O bad for O

A
  • Systemic hormones from OCP can exacerbate otosclerosis
  • Prescribe IUD instead
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36
Q

Px with DVT on OCP

A
  • If px has family history but DOESN’T have DVT herself: POP
  • if px has history of DVT: POP
  • prescribe barrier methods

DRAFT

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37
Q

Contraindications to POP

A

Current VTE
Rifampicin (absolute contraindication)
CYP3A4 inducers
malabsorption syndromes
ovarian cysts
previous sex steroid-dependent cancers (breast cancer)
undiagnosed vaginal bleeding
previous ectopic pregnancy
severe active liver disease
successfully treated Breast Cancer > 5 years

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38
Q

Absolute contraindication for progesterone implant (Implanon)

A

Breast cancer

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39
Q

Contraception of choice in breastfeeding women

A

POP for around 6 months, changing to OCP

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40
Q

POP’s in surgery

A

can be given but be on lookout for VTE

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41
Q

Progesterone increases the risk of

A

DVT

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42
Q

Px on epileptics wanting contraception

A
  • Give IUD (Mirena)
  • IF patient is seizure free for 2 years we can reduce the dose of anti-epileptics and give high dose OCP
  • If patient not seizure free then only high dose OCP

NOTE: anti-epileptics are enzyme inducers and reduce OCP efficacy by 40-50%

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43
Q

Postinor-2

A

Progesterone only emergency contraceptive
- 2 tablets at the same time associated with less adverse effects (Virilisation)

DRAFT

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44
Q

Best emergency contraception until 5 days

A

1st Ulipristal

2nd Copper IUD

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45
Q

IUD best time for insertion

A

During the first 7 days of your menstrual cycle, which starts with the first day of bleeding

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46
Q

1st line treatment for Dysfunctional uterine bleeding

A

Mild: NSAID’s & Tranexamic acid
Moderate: COCP or POP
Severe: IV fluids, tranexamic acid, high dose norethisterone

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47
Q

HPV vaccination

A

administered in high school

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48
Q

Uterine prolapse

A

weakening of the uterosacral ligament

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49
Q

risk factors for the development of urinary incontinence

A
  • Obesity (stress)
    – Prenatal urinary incontinence (detrusor)
    – Constipation (stress)
    – Instrumental delivery
    -Third and fourth-degree tears
    -Baby with a birth weight of more than 4.0 kg (detrusor)
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50
Q

Post menopause is defined as

A

permanent end of menstruation and fertility, defined as occurring 12 months after the last
menstrual period

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51
Q

Most likely cause of post-menopausal bleeding

A

vaginitis due to oestrogen deficiency

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52
Q

Age of onset for ovarian cancer

A

50

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53
Q

HPV can cause what type of cancers

A

– Cancer of cervix.
– Cancer of oro-pharyngeal cavity.
– Squamous cell carcinoma of anus, penis and vagina.
– Cancer of the uterus

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54
Q

Cervical cancer risk factors

A

-All women who are or ever have been sexually active.
-Early age at first sexual intercourse.
- after 35
- prolonged use of OCP ( > 5 years)
- immunosuppression
- multiparity (>5)
- persistent HPV infection
-Multiple sexual partners.
-Genital warts virus infection.
-Cigarette smoking

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55
Q

genital warts HPV

A

6-11

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56
Q

Conservative methods to manage urinary incontinence

A

-Lose weight by 5% or more
-Reduce caffeine intake
-Modify fluid intake-according to hydration status.
-Pelvic floor muscle training
-Treat constipation to avoid straining.
-Treatment of respiratory conditions leading to a chronic cough

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57
Q

Investigation of choice for the diagnosis of endometriosis

A

Diagnostic laparoscopy with histopathology

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58
Q

What criteria of women that do not need cervical screening?

A

Women who have never engaged in sexual intercourse

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59
Q

Mastalgia causes

A
  • cyclical mastalgia (most common)
  • pregnancy
  • caffeine
  • breast cancer
    < 10%
    mastitis carcinomatosa (red and hot breast during lactation)
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60
Q

Oral contraceptive pills increase the incidence of which cancer

A

cervical cancer

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61
Q

most common type of cervical cancer
Sq of Ad

A
  • Squamous cell carcinoma 80%
  • adenocarcinoma
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62
Q

Stein- Leventhal syndrome is also known as

A

PCOS

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63
Q

Ovarian cyst: premenopausal cyst less than 5cm and asymptomatic

A

reassure

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64
Q

Ovarian cyst: premenopausal cyst 5-7cm and asymptomatic

A

Repeat US in 3-4months and monitor to see if the cyst grows

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65
Q

Ovarian cyst: premenopausal cyst >7cm and symptomatic

A

high risk of torsion
Refer to gynaecologist

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66
Q

Ovarian cyst: Post menopausal Simple unilateral, unilocular ovarian cysts of <5 cm and low risk of malignancy (normal Ca125)

A

managed conservatively conservatively as the RMI would be zero and 50% of these will resolve spontaneously in 3 months.

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67
Q

Ovarian cyst: Post menopausal

A

Cysts of 2–5 cm should be rescanned in 3–4
months.
Women with a moderate-to-high risk RMI should be referred to a referred to a gynaecologist or gynaecological oncologist for consideration of surgical management.

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68
Q

Menopause hot flushes due to oestrogen

A

SSRI

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69
Q

Menopause hot flushes

A

Cyclical oestrogen and progesterone HRT (oestrogen only in hysterectomy)

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70
Q

progestogen-only conditions

A

1-Hypertension
2-Superficial thrombophlebitis
3-History of thromboembolism
4-Biliary tract disease
5-Thyroid disease
6-Epilepsy
7-Diabetes without vascular disease

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71
Q

Premature menopause

A
  • < 40 years
  • oocytes produce less oestrogen and progesterone, both LH and FSH start to rise
  • Menstrual irregularity and vaginal atrophy
  • increased FSH level is diagnostic
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72
Q

Ovarian cancer risk factors

A

– A family history of either ovarian or breast cancer.
– Personal history of breast cancer due to BRACA genes.
– Early menarche.
– Late menopause.
– Nulliparity.
– Increasing age
- obesity

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73
Q

sexually active malodorous gray vaginal

A

Gardenerella vaginalis

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74
Q

Endometrial cancer risk factor

A

– History of chronic anovulation
– Exposure to unopposed oestrogen
– Polycystic ovary syndrome (PCOS) associated
with chronic anovulation
– Exposure to tamoxifen
– Strong family history of endometrial or colon cancer (Lynch syndrome)
– Nulliparity
– Obesity
– Endometrial thickness more than 8mm in premenopausal woman

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75
Q

Lynch syndrome

A

MLH1 + MSH2 mutation
- 40% endometrial cancer
- 10% ovarian cancer

Strong family history of endometrial or colon cancer (<50 years)
- 3 family members
- generational
- (<50 years)

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76
Q

Tumour with hair and teeth upon presentation

A

mature cystic teratoma (dermoid tumor)

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77
Q

Presentation of PID

A

lower abdominal pain that is gradual in onset and bilateral

Fever, vaginal discharge, dysuria, and occasionally abnormal vaginal bleeding
PID can lead to tubal scarring

diagnostic criteria include
uterine, adnexal, or cervical motion tenderness

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78
Q

Risk factors of familial breast-ovarian syndrome

A

1.Two first-degree or second-degree relatives on one side of the family with ovarian or breast cancer.
2.Individuals with age of onset of cancer less than 50 years.
3.Individuals with bilateral or multifocal breast cancer.
4.Individuals with ovarian cancer.
5.Breast cancer in a male relative.
6.Jewish ancestry

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79
Q

Breast cancer age cut off

A

50

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80
Q

Colon cancer age cut off

A

55

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81
Q

Prostatic cancer age cut off

A

65

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82
Q

hyperprolactinemia anovulation and should be treated with

A

bromocriptine

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83
Q

Minimum time for a couple for infertility before starting treatment

A

1 year

84
Q

gynaecology referral cases

A

– Unexplained pelvic pain.
– Pelvic mass which is tender on bi-manual vaginal examination.
– Primary infertility of greater than a year.
– Patient with suspected diagnosis of endometriosis unresponsive to initial
treatment

85
Q

Painless mass

A
  • rule out malignancy
  • biopsy
86
Q

Indications to use progestogen-only pills

A

1-Age 45 years or more
2-Smokers aged 45 years or more
3-Contraindications to oestrogen
4-Diabetes Mellitus
5-A migraine (combined oral contraceptive pills have absolute contraindication)
6-Well-controlled hypertension
7-Lactation
8-Chloasma (large brown patches on skin)

87
Q

Contraindications to use progestogen-only pills

A
  • pregnancy
  • undiagnosed genital tract bleeding
  • concomitant use of enzyme-inducing drugs
88
Q

Features of dysfunctional uterine bleeding

A
89
Q

Post menopausal treatment for endometriosis

A

Danazol

90
Q

Medical treatment for endometriosis

A
  • OCP
  • continuous progestins
  • danazol
  • GnRH analogues
91
Q

Premenstrual dysmorphic disorder

A

Mimics PMS but displays more severe symptoms that get in the way of the patients ability to function and feeling overwhelmed/ out of control, frequent tearfulness
(abdominal bloating, headaches, reduced libido, reduced concentration and anger management issues)

92
Q

Contraindication to oral administration of oestrogen

A

DVT (liver metabolism is a contraindication)

93
Q

Features of trichomoniasis

A
  • increased frothy, yellowish, fouls smelling vaginal discharge
  • dyspareunia and dysuria.
  • genital area is usually red and sore
94
Q

Treatment of trichomoniasis

A

Metronidazole 2 g

95
Q

severe symptoms of premenstrual dysmorphic
disorder treatment

A

Clomipramine and danazol

96
Q

significant intrauterine adhesions symptoms

A

-Infertility.
-Menstrual irregularities (amenorrhea).
-Cyclic pelvic pain.
-Recurrent pregnancy loss.
The gold standard is diagnostic
hysteroscopy.

97
Q

Pituitary necrosis + hx of postpartum haemorrhage + lactation failure+ signs of early menopause

A

Sheehan’s Syndrome

98
Q

Diagnostic method for Sheehan’s syndrome

A

MRI

99
Q

diagnosis of bacterial vaginosis

A

– Thin, white, fishy, offensive and grey homogeneous discharge.
– Vaginal fluid pH more than 4.5.
– Clue cells visualised on a wet preparation of a vaginal swab or Gram-stained smear.
– Fishy odour when adding alkali (potassium hydroxide 10%) to discharge.
- Gardenerella vaginalis
- Relapse rate is more than 50% in 3 months time

100
Q

Treatment of bacterial vaginosis

A

Metronidazole
Clindamycin (if pregnant)

101
Q

premature ovarian failure investigation of choice

A

FSH & LH levels are high and oestradiol levels are low

LOW (<1) LH/FSH ratio

102
Q

Tanner stages

A

I:
- 0–15 years
- None
II:
- Commencement of puberty
-8–15
- Pubic hair first, along with breast budding (pubes flow, boobs grow)
III:
- Increase in hair and pigmentation

103
Q

Menorrhagia features

A
  • menstrual periods lasting over 7 days and/or involving blood loss greater than 80mL
    Ovulatory:
  • Abnormal blood loss at regular intervals
  • uterine issue (leiomyoma, endometriosis, adenomyosis, polyps)

Anovulatory:
- irregular and unpredictable
- Hormonal issue (PCOS, hypothyroidism, hyperprolactinemia, Cushing syndrome)

104
Q

Menorrhagia Investigation

A
  • Exclude pregnancy first
    Ovulatory:
  • Transvaginal US (abdominal if adolescent px)

Anovulatory:
- FBE if anaemia present
- Serum TSH, prolactin, LH (look for signs of hyperthyroidism to consider this)

105
Q

Atrophic vaginitis features

A
  • Atrophic changes 5 years after menopause
  • oestrogen deficiency
  • brown vaginal discharge
  • itching, burning, dryness and irritation
  • dyspareunia
  • can lead to bacterial vaginosis with vaginal discharge
  • increased risk of UTI
  • thinning of bladder and urethral linings leading to chronic dysuria
106
Q

Atrophic vaginitis management

A
  • Topical Oestrogen
107
Q

Atrophic vaginitis contraindication

A
  • Breast cancer (can give SSRI for mood changes)

Atrophic vaginitis is a condition where the lining of the vagina becomes thin, dry, and inflamed due to a decrease in estrogen, often occurring after menopause.

  1. Common Treatment for Atrophic Vaginitis:
    • The usual treatment for atrophic vaginitis involves estrogen therapy (like creams or pills) to replace the estrogen the body is lacking, which helps relieve symptoms.
  2. Why It’s a Problem with Breast Cancer:
    • Many breast cancers are hormone-sensitive, meaning they grow in response to hormones like estrogen. If a woman has or had hormone-sensitive breast cancer, adding extra estrogen (even through creams) could potentially stimulate cancer growth or increase the risk of cancer returning.
  3. Alternative Treatment:
    • Instead of estrogen, SSRI medications (a type of antidepressant) can be given to help manage mood changes that often accompany menopause or the side effects of breast cancer treatment, without the risk of adding estrogen.

Estrogen therapy, commonly used to treat atrophic vaginitis, is not safe for women with a history of hormone-sensitive breast cancer because it could increase the risk of cancer growth or recurrence. Instead, SSRIs may be used to help manage mood changes related to menopause or cancer treatment.

108
Q

Atrophic vaginitis ddx

A
  • Candidiasis (topical antifungal)
  • Lichen Sclerosis (very potent topical corticosteroids)
109
Q

Postcoital bleeding in post-menopausal woman investigation

A

Co-test of HPV and LBC (Rule out cervical cancer)

110
Q

Most common causes of intrauterine bleeding

A
  • STI (chlamydia cervicitis)
  • cervical ectropion
  • cervical polyp (30-40 years)
111
Q

Primary amenorrhoea

A
  • Turner syndrome (ovarian dysgenesis) (pubes grow normally) 43%
  • Mullerian agenesis 15%
    Imperforated hymen (cyclic abdominal pain, abdominal mass)
112
Q

Most common cause of non-menopausal hot flushes
Think endocrine

A
  • Hyperthyroidism
  • Hypertension
113
Q

Primary ovarian insufficiency

A
  • ovarian failure before 40 years of age
  • amenorrhoea = or > 4 months
  • High FSH > 40U/L and LOW oestradiol
  • oestrogen deficiency symptoms
  • increased gonadotropin levels
  • LOW LH/FSH ratio (<1)
114
Q

Primary ovarian insufficiency management

A

Desire to conceive: HRT until menopausal age (51 yo)
Contraception: COCP

  • calcium and Vitamin D supplementation
115
Q

Emergency contraception window

A

5 days post coitus

116
Q

Cervical cancer during pregnancy

A

Same outline as regular screening

BUT if there’s evidence of invasive carcinoma, termination is recommended but dependant on px’s choice

117
Q

CIN grading

A

I: low grade (lower 1/3)
II/III: high grade (entire thickness of the epithelium)

118
Q

Cervical motion tenderness indicates

A

PID or Ectopic pregnancy

119
Q

Pelvic inflammatory disease (PID) dx

A
  • Risk of STD
  • Lower abdominal pain
  • **cervical motion **, uterine, adnexal tenderness
120
Q

Pelvic inflammatory disease (PID) investigation

A
  • Cervical swabs for culture
121
Q

Pelvic inflammatory disease (PID) management

A
  • empirical antibiotics
122
Q

Ovarian teratoma features

A
  • occurs in ages 20-30 years
  • diameter <10cm usually, can exceed 15cm (super rare)
  • made of different cells (hair, teeth, sebum, eyes, bone etc)
  • adnexal location
123
Q

Endometriosis common sites

A
  • ovaries
  • posterior cul-de-sac
  • broad ligament
  • uterosacral ligament
  • rectosigmoid colon
  • bladder
  • distal ureter
124
Q

Green vaginal discharge

A

Chlamydia trachomatous
-trachomonous vaginalis (frothy yellow- green)

125
Q

Drospirenone and ethinylestradiol

A
  • less fluid retention
  • less weight gain
126
Q

Dilation & curettage complications

A

intrauterine adhesions (90%)
- infertility
- amenorrhoea
- cyclic pelvic pain
- recurrent miscarriages

127
Q

intrauterine adhesions investigation

A

transvaginal US (initial)
Hysteroscopy (gold standard)

128
Q

Post menopausal HRT protocol (MHT)

A

Cyclical or sequential therapy
Continuous estrogen + cyclic progestogen
Continuous estrogen for 28 days and then progesterone is added during the last 14 days.
Indication: Peri menopausal women and during 1st year of menopause. Will get cyclical bleeds.

Continuous combined therapy
Continuous estrogen+ continuous progestogen
Indication: after 1 year of menopause. Spotting and breakthrough bleeding is common in the first 3-4 months of therapy.

Estrogen alone therapy
In women who had hysterectomy

129
Q

MHT CONTRAINDICATIONS

A

 Age 60 years or older
 Previous DVT
 Previous MI, Uncontrolled HT
 Stroke, Previous TIA
 Breast cancer
 Endometrial cancer
 Undiagnosed vaginal bleeding
 Significant liver disease
 Porphyria/ SLE

130
Q

MHT increase the Risk of:

A

Not to be given after 60 years due to the risk of
VTE and stroke

 Invasive breast cancer (increased with longer duration of combined MHT and persists up to 10 years after MHT is stopped. Risks greater for continuous combined than with cyclical MHT)
 Stroke (usually above 60 years)
 DVT
 Gallbladder disease
 Coronary heart disease (usually above 60 years)

131
Q

MHT Side Effects

A

 Breakthrough bleed- settles in 8 to 12 weeks
 In cyclical if not settled within 2 to 3 months, increase duration of progestogen
 In continuous combined, increase progestogen dose, change type or route or change to tibolone
 Review in 2 to 3 months. If still present investigate
 Nausea- change to transdermal therapy
 Breast tenderness- reduce oestrogen or progestogen
 Initiating therapy with low dose will minimise these side effects

132
Q

MHT FOLLOW UP

A

 Review in 6 to 8 weeks and then at 6 months
and then every 6 – 12 months with general
health check, breast check
 Mammogram every 2 years
 DEXA where indicated
 Vaginal bleed after 6 months of therapy
needs further investigations
 Most guidelines recommend using MHT for 4
to 5 years

133
Q

Hormonal Alternative to continuous
combined MHT (>1y of menopause)

A
  1. Tibolone

 Synthetic steroid with oestrogenic and progestogenic
activity and weak androgenic activity
Less effective than MHT
 Improves bone mineral density and decreases risk of vertebral and non vertebral fractures
 Does not increase breast density but increases risk of breast cancer recurrence
 Increases risk of stroke after 60 years of age
No increased risk of DVT

  1. Conjugated oestrogens + bazedoxifene

 Less effective than MHT
 Increases hip and spine bone density

134
Q

Non hormonal Alternatives to MHT

A

 SSRI like citalopram, escitalopram, paroxetine
 SNRI- venlafaxine, desvenlafaxine
Both of above alleviates vasomotor symptoms
but to a lesser degree than MHT

 Gabapentin-equally effective as low dose
estrogen for vasomotor symptoms.

 Pregabalin

 Clonidine- mildly effective

135
Q

PCOS features

A
  1. Clinical or biochemical hyperandrogenism
    -hirsutism
    - acne
    - deep voice
    - acanthosis nigricans
  2. Menstrual dysfunction
    - irregularity
    - lack of ovulation
  3. Polycystic ovaries on US
136
Q

PCOS Rotterdam Criteria

A
137
Q

PCOS hormonal changes

A
  • increased serum free testosterone
  • Serum FSH low/normal
  • LH elevated
  • FSH/LH ratio 2:1/3:1 perhaps
138
Q

PCOS biochemical hyperandrogenism

A
139
Q

Bartholin abscess features

A
  • base of labia minora
  • Neisseria gonorrhoea/ Chlamydia trachomatis
    asymptomatic <3cm: no treatment/warm compress
    symptomatic:
  • < 3cm Incision & drainage
  • > 3cm word catheter
  • marsupialisation if after 1-2 failed then word catheter
  • gland excision if marsupialisation fails
140
Q

Endometrial cancer/hyperplasia risk factors

A

-unopposed oestrogen therapy 2-10%
- increasing age 50-70 years 1-4%
- obesity 2-4%
- chronic anovulation (PCOS) 3%
- late menopause >55 25
- Nulliparity 2%
- Diabetes 2%

141
Q

Smoking protective factor

A

uterine leiomyomas
ulcerative colitis
Parkinson’s

142
Q

Uterine fibroids/leiomyoma risk factors

A
143
Q

Features of Turner syndrome

A
  • Short stature
  • Webbed neck
  • Puffy hands and feet
  • Coartaction of the aorta
  • cardiac abnormalities
  • high- arched palate
  • absent secondary sexual characteristics during puberty
  • B/L streak ovaries
  • horse shoe kidney
  • obstructed Uteropelvic junction
144
Q

Bacterial vaginosis management

A

1st line: oral metronidazole 7 days (400mg twice daily)
2nd line: vaginal clindamycin (1g at night)

NOTE: for pregnancy: Clindamycin 300mg orally for 7 days initially
or metronidazole 400mg orally 7 days

145
Q

High grade squamous intraepithelial lesion (HSIL)

A
  1. Colposcopy & cervical cytology in 4-6 months
  2. cervical cytology and human papilloma virus typing at 12 months after treatment annually until tested negative BOTH tests for 2 consecutive occasions
  3. Returned to standard 5 yearly screening
146
Q

Most common cause of chronic pelvic pain in developed countries

A

Endometriosis

147
Q

Most common symptom of endometriosis

A

dysmenorrhoea

148
Q

premenopausal management of ovarian cysts

A
  • Asymptomatic women with simple ovarian cyst <5 cm on ultrasound = no follow-up, cysts will resolve within 3 menstrual cycles
  • Simple cysts of 5–7 cm, a repeat ultrasound should be obtained
  • cysts of >7 cm surgical intervention should be considered.
    If surgery is required, a laparoscopic cystectomy is the operation of choice, as aspiration can cause recurrence.
149
Q

Lactation amenorrhoea

A

1st 6 months after delivery
- baby fully breastfed
- woman remains amenorrhoeic

150
Q

Endometrial cancer types

A
  • simple
  • complex
  • cystic glandular (most common in perimenopausal women)
    -atypical simple
  • atypical complex
151
Q

Endometrial cancer features

A
  • bleeding between periods
  • heavy and/or prolonged periods
  • vaginal discharge
  • abdominal pain
152
Q

Treatment of infertility

A
  • < 35 years but BMI > 25, lifestyle modifications for 1st 6 months
  • > 35 years BMI 30-32 metformin (with or without clomiphene citrate)
  • > 32 BMI combined metformin with clomiphene citrate
  • Metformin & clomiphene citrate unsuccessful, then gonadotropins
  • if PCOS present, laparoscopy with ovarian surgery
  • IVF
153
Q

HRT and mammography

A
  • continue HRT (no need to reduce dose or stop) and commence mammography screening as per guidelines
154
Q

HRT and breast cancer

A
  • after 5 years risk of breast cancer increases
  • No breast cancer risk up to 7 years if HRT oestrogen alone (hysterectomy)
  • review medications annually
  • breast cancer screening per normal as other women
155
Q

HRT & PE/DVT/ stroke

A

increased incidence
- oestrogen only not enough evidence

156
Q

HRT reduced incidence

A
  • Osteoporosis/fractures
  • colon cancer
157
Q

Osteoporosis treatment

A
  • Alendronate, risedronate and zoledronic acid: first-line therapy in **postmenopausal osteoporosis **
    and prevent vertebral, Non-vertebral and hip fractures.
  • bisphosphonates: primary prevention of fractures in px who never had minimal trauma fracture, secondary prevention of fractures
  • Strontium ranelate: primary prevention of osteoporosis in women
  • bisphosphonates and raloxifene: secondary prevention of fractures in women who have had minimal trauma fractures
158
Q

Osteoporosis treatment not going to plan, what to do

A
  • BMD T-score of =<-3
  • > 1 symptomatic new
    fracture after at least 12-months of
    continuous therapy
  • > 2 minimal trauma fractures despite being on sufficient doses of bisphosphonates.

switch to teriparatide for 18 months

159
Q

Stress incontinence management

A

Pelvic floor exercises (Kiegel)

160
Q

Urge incontinence management

A

Bladder training

161
Q

Urinary incontinence with cystocele management

A

Anterior colporrhaphy

162
Q

shoulder tip main mainly refers to

A

ectopic pregnancy

163
Q

unilateral dull pain that can become diffuse smooth adnexal mass with or without peritoneal signs

A

ovarian cyst

164
Q

ascites + pleural effusion + ovarian tumour

A

Meig’s syndrome
- Ovarian fibroma
- spindle shaped cells

165
Q

Presence of Signet cells on histology

A

Krukenberg tumour

A Krukenberg tumor is a specific type of cancer that spreads to the ovaries from another part of the body, most often the stomach. Here’s a simple breakdown:

  1. Type of Tumor: Krukenberg tumors are secondary ovarian tumors, meaning they didn’t start in the ovaries but spread (metastasized) there from another location, typically the stomach. Sometimes, they can also come from the colon, appendix, or breast.
  2. Appearance: These tumors are usually made up of cells that look like “signet rings” under the microscope, which is a characteristic feature.
  3. Symptoms: Symptoms might include abdominal pain, bloating, and sometimes changes in menstrual cycles. However, because the primary cancer is often in the stomach or another organ, symptoms related to those areas (like digestive problems) might appear first.
  4. Diagnosis: Diagnosis usually involves imaging studies like ultrasound or CT scans, and a biopsy to confirm the tumor type and its origin.
  5. Treatment: Treatment typically focuses on the primary cancer and may include surgery, chemotherapy, or other therapies depending on where the cancer started and how far it has spread.

A Krukenberg tumor is a cancer that has spread to the ovaries from another part of the body, most commonly the stomach. It’s identified by a specific cell type and usually indicates that the cancer is advanced. Treatment depends on where the cancer originated and aims to manage both the primary cancer and the spread to the ovaries.

166
Q

Turner syndrome is also known as

A
  • Gonadal dysgenesis
  • Ovarian dysgenesis
167
Q

Endometriosis diagnostic time period

A

Due to the variability in this condition, there is a diagnostic delay around 8-10 years

168
Q

Post coital bleeding ddx

A

Rule out malignancy first
1-Cervical erosion
2-Cervical polyp
3-Presence of IUCD
4-Cervical cancer
5-Intra-uterine cancer

169
Q

Ectopic pregnancy high risk factors

A

Previous ectopic pregnancy
Previous tubal surgery
Tubal pathology
Past & current use of IUD
IVF

170
Q

Mirena contraindications

A

– History of breast, cervical or uterine cancer.
– History of liver disease.
- Septic abortion
– Uterine abnormalities, such as fibroids, that interfere with the placement or retention of Mirena.
– Current pelvic infection or have a history of a pelvic inflammatory disease (PID).
– Unexplained vaginal bleeding.
-Being at high risk of a sexually transmitted disease

171
Q

Endometrial ablation contraindications

A

– Pregnancy.
– Suspected genital tract infection.
– The desire to preserve fertility.
– Post-menopausal women.

172
Q

Post-menopausal endometrial thickness

A

Suspect endometrial malignancy - endometrial thickness of 4mm or more with vaginal bleeding mandates endometrial biopsy

173
Q

Ovarian cancer diagnostic approach

A

CA-125 test along with transvaginal ultrasound

174
Q

Features of endometritis

A
  • Lower abdominal pain and uterine tenderness (first 24 to 72 hours)
  • Purulent lochia
  • chills, headache
  • malaise
  • anorexia
175
Q

endometritis management

A
  • augmentin
  • triple test
176
Q

Preoperative staging for endometriosis

A

MRI
- visualising soft tissues as well as all pelvic compartments at one time as opposed to US

177
Q

Asymptomatic bacteriuria treatment indication

A
  • Pregnancy
  • elective urological procedures (TURP)
178
Q

Right lower quadrant (RLQ) pain ddx

A

Gynae
-ectopic pregnancy
- tubo-ovarian abscess
- ruptured corpus luteum ovarian cyst
- ovarian torsion
GI
-appendicitis
-inflammatory bowel disease
- diverticulitis
- hernia

179
Q

Features of threatened abortion

A
  • closed cervical os
  • absent history of passing foetal tissue
180
Q

Features of inevitable abortion

A
  • open cervical os
  • bulging of membranes of the os
181
Q

Features of complete abortion

A
  • closed cervical os
  • passing of foetal tissue
182
Q

Features of septic abortion

A
  • uterine infection during any time
  • vaginal bleeding
    -cramping pain
  • fever
  • purulent cervical discharge
183
Q

Features of missed abortion

A
  • Closed cervical os
  • No spotting or bleeding (no foetal tissue passed)
  • Ultrasound scans diagnosis of a non-viable IUP (empty sac)
184
Q

HPV 6 & 11 indicate

A

benign condyloma (genital warts)

185
Q

features of Sertoli-Leydig tumour

A

A Sertoli-Leydig tumor is a rare type of ovarian tumor that produces male hormones (androgens), leading to certain distinct features. Here’s a simple breakdown:

  1. Hormonal Effects:
    • Increased Male Hormones: These tumors produce androgens, which can cause symptoms related to excess male hormones in females.
    • Virilization: This refers to the development of male characteristics in women, such as:
      • Deepening of the Voice: The voice may become lower and more masculine.
      • Facial and Body Hair: Increased hair growth, especially on the face (like a beard or mustache) and body.
      • Male-Pattern Baldness: Hair thinning or loss, particularly on the scalp.
  2. Menstrual Changes:
    • Irregular or Absent Periods: The tumor’s hormone production can disrupt normal menstrual cycles, causing irregular periods or even stopping them altogether (amenorrhea).
  3. Ovarian Mass:
    • Pelvic Pain or Fullness: The tumor itself might cause pain or a feeling of fullness in the lower abdomen due to its presence in the ovary.
  4. Rare in Nature:
    • Age of Onset: Sertoli-Leydig tumors can occur at any age but are most commonly found in young women and those of reproductive age.

Sertoli-Leydig tumors are rare ovarian tumors that produce male hormones, leading to symptoms like deepening of the voice, increased body and facial hair, and irregular periods. They might also cause pelvic pain due to the presence of a mass in the ovary.

  • high androgen production
    (seborrhoea, acne, menstrual irregularity, hirsutism, breast atrophy, alopecia, deepening of the voice, and clitoromegaly)
186
Q

Features of Kruckenberg tumour

A
  • Bilateral solid mass on the ovary
    -Metastasis from other organs (stomach, intestine)
187
Q

evidence of glial tissue and
immature cerebellar and cortical tissue

A

Immature teratoma

188
Q

Testosterone cream uses

A
  • Lichen sclerosis
  • vaginal dryness
  • vulvar atrophy
  • post menopause
189
Q

Prader-Willi syndrome

A

deletion of chromosome 15 (70%) after the newborn period:
- hypotonia
- hypogonadism
- hyperphagia
- hypomentia
- obesity

190
Q

Infertility Treatment for premature ovarian failure/ menopause

A

IVF only

191
Q

Premature menopause dx

A

occurs spontaneously before 40 years.
- frequent follicular development
- infrequent ovulation

192
Q

HPV can cause what type of cancers

A

– Cervical cancer.
– Cancer of oro-pharyngeal cavity.
– Squamous cell carcinoma of anus, penis and vagina.
– Cancer of the uterus.

193
Q

common cause of gynaecological cancer deaths

A

Ovarian cancer

194
Q

Most common type of ovarian cancer

A

Epithelial ovarian cancer (90%)

195
Q

Treatment of Lichen- sclerosis

A

Potent topical steroids

196
Q

Lichen- Sclerosis dx

A
  • pre-pubertal and peri-menopausal women
    TRIAD: genital itching, soreness and white wrinkled plaques
    in the genital area
    -Dx: biopsy
197
Q

Specific Indications for cone biopsy

A
  1. Fail to visualize Transformation zone in pt with HSIL on her Cervical smear ref
  2. Suspecting early invasive Cx cancer on cytology, biopsy or colposcopic assessment
  3. Suspecting glandular abnormalities on cytology or biopsy
198
Q

chlamydial urethritis treatment

A

Azithromycin 1 g oral

199
Q

Post menopausal + endometrial thickness 4mm or above + vaginal bleeding

A

Suspect Endometrial cancer and refer to gynaec for endometrial biospy

200
Q

GBS treatment

A

The following women should be treated for GBS during labour:
All women with a history of a GBS-related disease – these women should be given intrapartum antibiotics in all their subsequent pregnancies regardless of the swab culture results
All women with a GBS positive swab or urine culture result in the current pregnancy
Premature rupture of membranes for more than 18 hours, or when the time is unknown
Maternal pre- or intra-partum fever of 38°C
Women with unknown status of GBS colonization

201
Q

most important Endocrine test in assessing male infertility

A

FSH : more than 2time the normal indictaed irreversible testicular failure

202
Q

Aromatase inhibitors cause

A
  • increased osteoporosis
  • cardiac abnormalities
203
Q

Cushing syndrome symptoms in women

A
  • anxiety
  • tremulousness
  • weight gain
  • severe fatigue
  • menstrual irregularities
    -hypertension
  • hyperglycaemia
  • Pinkish stria on buttocks, thighs, breast
  • Skin becomes thin and bruises easily
  • check serum cortisol level
204
Q
A
205
Q

Contraceptives used in the treatment of acne

A
  • Cyproterone acetate
  • Desogestrel
  • Drospirenone
  • Gestodene

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