Gynaecology Flashcards
Cervical cancer screening
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
Breast cancer: Risk factors
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
Breast cancer: Screening Low risk
Low risk: Family member diagnosed at 50 years or over.
Screening: mammograms
every two years for women aged 50–74 years
Breast cancer: Screening Moderate risk
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
Breast cancer: Screening High risk
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.
List of all enzyme inducers
- Phenobarbital
- Primidone
- Phenytoin
- Carbamazepine
- Oxcarbazepine
- Topiramate
-ST John’s Wort
Non-enzyme inducing anti epileptics
- lamotrigine
- Levetiracetam
NOTE: Increase dose in case of OCP as they increase metabolism
When does ovulation occur?
14th day (midcycle)
- LH surge
- next 24 h (12-36)
Ovulation occurring investigation
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
Investigation of choice to predict ovulation has occurred
Serum progesterone surge at day 21 (luteal phase)
- level > 20nmol/L
Ovulation pain is also known as
Mittelschmerz syndrome
Ovulation inducing drugs
Clomiphene
Primary Dysmenorrhoea
- Pain occurs before menses
- Initial treatments NSAID’s
- Trial of OCP’s for 2 months upon px request
Secondary dysmenorrhoea
- Treat underlying problem
DRAFT
Difference between biphasic and triphasic contraceptive pills
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.
COCP doses
- low dose: 20mcg of oestrogen.
- regular dose: 30-35mcg oestrogen.
- high dose: 50mcg of oestrogen.
High dose COCP indications
- Break through bleeding on low dose pills.
- When low dose pill fails.
- Concomitant use of enzyme inducing drugs
- Control of menorrhagia.
Approach to PMS
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
OCP absolute contraindications
- 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.
OCP relative contraindications
- 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
Monthly COCP contents
28 pill pack:
* 21 hormonal pills and
*7 sugar pills.
COCP administration
- 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.
COCP advantages
- 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
OCP’s increase the risk of which cancer/s
if used more than 5 years:
- cervical
- breast
NOTE: conflicting data, use with caution
OCP decreased risk of which cancer/s
- Ovarian cancer 30-50%
- Colorectal cancer 15-20%
- Endometrial cancer >30%
OCP’s and ovarian cancer
OCP’s have no relation to developing ovarian cancer. Some sources have even labelled it as a protective factor
COCPs mild side effects
- Break through bleeding
- Nausea
- Vomiting
- Bloating
COCPs breakthrough bleeding management
- 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
COCPs major side effects
Irregular bleeding while on OCP risks
– 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
OCP’s and diarrhoea
Severe diarrhoea & vomiting decrease the effectiveness of OCP’s
- take an extra pill add barrier method in addition
Missed pills on OCP > 48 h
-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)
Px with hypertension on OCP
Change to POP
OCP and Otosclerosis
O bad for O
- Systemic hormones from OCP can exacerbate otosclerosis
- Prescribe IUD instead
Px with DVT on OCP
- If px has family history but DOESN’T have DVT herself: POP
- if px has history of DVT: POP
- prescribe barrier methods
DRAFT
Contraindications to POP
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
Absolute contraindication for progesterone implant (Implanon)
Breast cancer
Contraception of choice in breastfeeding women
POP for around 6 months, changing to OCP
POP’s in surgery
can be given but be on lookout for VTE
Progesterone increases the risk of
DVT
Px on epileptics wanting contraception
- 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%
Postinor-2
Progesterone only emergency contraceptive
- 2 tablets at the same time associated with less adverse effects (Virilisation)
DRAFT
Best emergency contraception until 5 days
1st Ulipristal
2nd Copper IUD
IUD best time for insertion
During the first 7 days of your menstrual cycle, which starts with the first day of bleeding
1st line treatment for Dysfunctional uterine bleeding
Mild: NSAID’s & Tranexamic acid
Moderate: COCP or POP
Severe: IV fluids, tranexamic acid, high dose norethisterone
HPV vaccination
administered in high school
Uterine prolapse
weakening of the uterosacral ligament
risk factors for the development of urinary incontinence
- 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)
Post menopause is defined as
permanent end of menstruation and fertility, defined as occurring 12 months after the last
menstrual period
Most likely cause of post-menopausal bleeding
vaginitis due to oestrogen deficiency
Age of onset for ovarian cancer
50
HPV can cause what type of cancers
– Cancer of cervix.
– Cancer of oro-pharyngeal cavity.
– Squamous cell carcinoma of anus, penis and vagina.
– Cancer of the uterus
Cervical cancer risk factors
-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
genital warts HPV
6-11
Conservative methods to manage urinary incontinence
-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
Investigation of choice for the diagnosis of endometriosis
Diagnostic laparoscopy with histopathology
What criteria of women that do not need cervical screening?
Women who have never engaged in sexual intercourse
Mastalgia causes
- cyclical mastalgia (most common)
- pregnancy
- caffeine
- breast cancer
< 10%
mastitis carcinomatosa (red and hot breast during lactation)
Oral contraceptive pills increase the incidence of which cancer
cervical cancer
most common type of cervical cancer
Sq of Ad
- Squamous cell carcinoma 80%
- adenocarcinoma
Stein- Leventhal syndrome is also known as
PCOS
Ovarian cyst: premenopausal cyst less than 5cm and asymptomatic
reassure
Ovarian cyst: premenopausal cyst 5-7cm and asymptomatic
Repeat US in 3-4months and monitor to see if the cyst grows
Ovarian cyst: premenopausal cyst >7cm and symptomatic
high risk of torsion
Refer to gynaecologist
Ovarian cyst: Post menopausal Simple unilateral, unilocular ovarian cysts of <5 cm and low risk of malignancy (normal Ca125)
managed conservatively conservatively as the RMI would be zero and 50% of these will resolve spontaneously in 3 months.
Ovarian cyst: Post menopausal
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.
Menopause hot flushes due to oestrogen
SSRI
Menopause hot flushes
Cyclical oestrogen and progesterone HRT (oestrogen only in hysterectomy)
progestogen-only conditions
1-Hypertension
2-Superficial thrombophlebitis
3-History of thromboembolism
4-Biliary tract disease
5-Thyroid disease
6-Epilepsy
7-Diabetes without vascular disease
Premature menopause
- < 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
Ovarian cancer risk factors
– 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
sexually active malodorous gray vaginal
Gardenerella vaginalis
Endometrial cancer risk factor
– 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
Lynch syndrome
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)
Tumour with hair and teeth upon presentation
mature cystic teratoma (dermoid tumor)
Presentation of PID
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
Risk factors of familial breast-ovarian syndrome
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
Breast cancer age cut off
50
Colon cancer age cut off
55
Prostatic cancer age cut off
65
hyperprolactinemia anovulation and should be treated with
bromocriptine
Minimum time for a couple for infertility before starting treatment
1 year
gynaecology referral cases
– 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
Painless mass
- rule out malignancy
- biopsy
Indications to use progestogen-only pills
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)
Contraindications to use progestogen-only pills
- pregnancy
- undiagnosed genital tract bleeding
- concomitant use of enzyme-inducing drugs
Features of dysfunctional uterine bleeding
Post menopausal treatment for endometriosis
Danazol
Medical treatment for endometriosis
- OCP
- continuous progestins
- danazol
- GnRH analogues
Premenstrual dysmorphic disorder
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)
Contraindication to oral administration of oestrogen
DVT (liver metabolism is a contraindication)
Features of trichomoniasis
- increased frothy, yellowish, fouls smelling vaginal discharge
- dyspareunia and dysuria.
- genital area is usually red and sore
Treatment of trichomoniasis
Metronidazole 2 g
severe symptoms of premenstrual dysmorphic
disorder treatment
Clomipramine and danazol
significant intrauterine adhesions symptoms
-Infertility.
-Menstrual irregularities (amenorrhea).
-Cyclic pelvic pain.
-Recurrent pregnancy loss.
The gold standard is diagnostic
hysteroscopy.
Pituitary necrosis + hx of postpartum haemorrhage + lactation failure+ signs of early menopause
Sheehan’s Syndrome
Diagnostic method for Sheehan’s syndrome
MRI
diagnosis of bacterial vaginosis
– 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
Treatment of bacterial vaginosis
Metronidazole
Clindamycin (if pregnant)
premature ovarian failure investigation of choice
FSH & LH levels are high and oestradiol levels are low
LOW (<1) LH/FSH ratio
Tanner stages
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
Menorrhagia features
- 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)
Menorrhagia Investigation
- 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)
Atrophic vaginitis features
- 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
Atrophic vaginitis management
- Topical Oestrogen
Atrophic vaginitis contraindication
- 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.
-
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.
-
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.
-
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.
Atrophic vaginitis ddx
- Candidiasis (topical antifungal)
- Lichen Sclerosis (very potent topical corticosteroids)
Postcoital bleeding in post-menopausal woman investigation
Co-test of HPV and LBC (Rule out cervical cancer)
Most common causes of intrauterine bleeding
- STI (chlamydia cervicitis)
- cervical ectropion
- cervical polyp (30-40 years)
Primary amenorrhoea
- Turner syndrome (ovarian dysgenesis) (pubes grow normally) 43%
- Mullerian agenesis 15%
Imperforated hymen (cyclic abdominal pain, abdominal mass)
Most common cause of non-menopausal hot flushes
Think endocrine
- Hyperthyroidism
- Hypertension
Primary ovarian insufficiency
- 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)
Primary ovarian insufficiency management
Desire to conceive: HRT until menopausal age (51 yo)
Contraception: COCP
- calcium and Vitamin D supplementation
Emergency contraception window
5 days post coitus
Cervical cancer during pregnancy
Same outline as regular screening
BUT if there’s evidence of invasive carcinoma, termination is recommended but dependant on px’s choice
CIN grading
I: low grade (lower 1/3)
II/III: high grade (entire thickness of the epithelium)
Cervical motion tenderness indicates
PID or Ectopic pregnancy
Pelvic inflammatory disease (PID) dx
- Risk of STD
- Lower abdominal pain
- **cervical motion **, uterine, adnexal tenderness
Pelvic inflammatory disease (PID) investigation
- Cervical swabs for culture
Pelvic inflammatory disease (PID) management
- empirical antibiotics
Ovarian teratoma features
- 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
Endometriosis common sites
- ovaries
- posterior cul-de-sac
- broad ligament
- uterosacral ligament
- rectosigmoid colon
- bladder
- distal ureter
Green vaginal discharge
Chlamydia trachomatous
-trachomonous vaginalis (frothy yellow- green)
Drospirenone and ethinylestradiol
- less fluid retention
- less weight gain
Dilation & curettage complications
intrauterine adhesions (90%)
- infertility
- amenorrhoea
- cyclic pelvic pain
- recurrent miscarriages
intrauterine adhesions investigation
transvaginal US (initial)
Hysteroscopy (gold standard)
Post menopausal HRT protocol (MHT)
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
MHT CONTRAINDICATIONS
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
MHT increase the Risk of:
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)
MHT Side Effects
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
MHT FOLLOW UP
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
Hormonal Alternative to continuous
combined MHT (>1y of menopause)
- 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
- Conjugated oestrogens + bazedoxifene
Less effective than MHT
Increases hip and spine bone density
Non hormonal Alternatives to MHT
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
PCOS features
- Clinical or biochemical hyperandrogenism
-hirsutism
- acne
- deep voice
- acanthosis nigricans - Menstrual dysfunction
- irregularity
- lack of ovulation - Polycystic ovaries on US
PCOS Rotterdam Criteria
PCOS hormonal changes
- increased serum free testosterone
- Serum FSH low/normal
- LH elevated
- FSH/LH ratio 2:1/3:1 perhaps
PCOS biochemical hyperandrogenism
Bartholin abscess features
- 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
Endometrial cancer/hyperplasia risk factors
-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%
Smoking protective factor
uterine leiomyomas
ulcerative colitis
Parkinson’s
Uterine fibroids/leiomyoma risk factors
Features of Turner syndrome
- 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
Bacterial vaginosis management
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
High grade squamous intraepithelial lesion (HSIL)
- Colposcopy & cervical cytology in 4-6 months
- cervical cytology and human papilloma virus typing at 12 months after treatment annually until tested negative BOTH tests for 2 consecutive occasions
- Returned to standard 5 yearly screening
Most common cause of chronic pelvic pain in developed countries
Endometriosis
Most common symptom of endometriosis
dysmenorrhoea
premenopausal management of ovarian cysts
- 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.
Lactation amenorrhoea
1st 6 months after delivery
- baby fully breastfed
- woman remains amenorrhoeic
Endometrial cancer types
- simple
- complex
- cystic glandular (most common in perimenopausal women)
-atypical simple - atypical complex
Endometrial cancer features
- bleeding between periods
- heavy and/or prolonged periods
- vaginal discharge
- abdominal pain
Treatment of infertility
- < 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
HRT and mammography
- continue HRT (no need to reduce dose or stop) and commence mammography screening as per guidelines
HRT and breast cancer
- 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
HRT & PE/DVT/ stroke
increased incidence
- oestrogen only not enough evidence
HRT reduced incidence
- Osteoporosis/fractures
- colon cancer
Osteoporosis treatment
- 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
Osteoporosis treatment not going to plan, what to do
- 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
Stress incontinence management
Pelvic floor exercises (Kiegel)
Urge incontinence management
Bladder training
Urinary incontinence with cystocele management
Anterior colporrhaphy
shoulder tip main mainly refers to
ectopic pregnancy
unilateral dull pain that can become diffuse smooth adnexal mass with or without peritoneal signs
ovarian cyst
ascites + pleural effusion + ovarian tumour
Meig’s syndrome
- Ovarian fibroma
- spindle shaped cells
Presence of Signet cells on histology
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:
- 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.
- Appearance: These tumors are usually made up of cells that look like “signet rings” under the microscope, which is a characteristic feature.
- 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.
- Diagnosis: Diagnosis usually involves imaging studies like ultrasound or CT scans, and a biopsy to confirm the tumor type and its origin.
- 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.
Turner syndrome is also known as
- Gonadal dysgenesis
- Ovarian dysgenesis
Endometriosis diagnostic time period
Due to the variability in this condition, there is a diagnostic delay around 8-10 years
Post coital bleeding ddx
Rule out malignancy first
1-Cervical erosion
2-Cervical polyp
3-Presence of IUCD
4-Cervical cancer
5-Intra-uterine cancer
Ectopic pregnancy high risk factors
Previous ectopic pregnancy
Previous tubal surgery
Tubal pathology
Past & current use of IUD
IVF
Mirena contraindications
– 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
Endometrial ablation contraindications
– Pregnancy.
– Suspected genital tract infection.
– The desire to preserve fertility.
– Post-menopausal women.
Post-menopausal endometrial thickness
Suspect endometrial malignancy - endometrial thickness of 4mm or more with vaginal bleeding mandates endometrial biopsy
Ovarian cancer diagnostic approach
CA-125 test along with transvaginal ultrasound
Features of endometritis
- Lower abdominal pain and uterine tenderness (first 24 to 72 hours)
- Purulent lochia
- chills, headache
- malaise
- anorexia
endometritis management
- augmentin
- triple test
Preoperative staging for endometriosis
MRI
- visualising soft tissues as well as all pelvic compartments at one time as opposed to US
Asymptomatic bacteriuria treatment indication
- Pregnancy
- elective urological procedures (TURP)
Right lower quadrant (RLQ) pain ddx
Gynae
-ectopic pregnancy
- tubo-ovarian abscess
- ruptured corpus luteum ovarian cyst
- ovarian torsion
GI
-appendicitis
-inflammatory bowel disease
- diverticulitis
- hernia
Features of threatened abortion
- closed cervical os
- absent history of passing foetal tissue
Features of inevitable abortion
- open cervical os
- bulging of membranes of the os
Features of complete abortion
- closed cervical os
- passing of foetal tissue
Features of septic abortion
- uterine infection during any time
- vaginal bleeding
-cramping pain - fever
- purulent cervical discharge
Features of missed abortion
- Closed cervical os
- No spotting or bleeding (no foetal tissue passed)
- Ultrasound scans diagnosis of a non-viable IUP (empty sac)
HPV 6 & 11 indicate
benign condyloma (genital warts)
features of Sertoli-Leydig tumour
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:
-
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.
-
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).
-
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.
-
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)
Features of Kruckenberg tumour
- Bilateral solid mass on the ovary
-Metastasis from other organs (stomach, intestine)
evidence of glial tissue and
immature cerebellar and cortical tissue
Immature teratoma
Testosterone cream uses
- Lichen sclerosis
- vaginal dryness
- vulvar atrophy
- post menopause
Prader-Willi syndrome
deletion of chromosome 15 (70%) after the newborn period:
- hypotonia
- hypogonadism
- hyperphagia
- hypomentia
- obesity
Infertility Treatment for premature ovarian failure/ menopause
IVF only
Premature menopause dx
occurs spontaneously before 40 years.
- frequent follicular development
- infrequent ovulation
HPV can cause what type of cancers
– Cervical cancer.
– Cancer of oro-pharyngeal cavity.
– Squamous cell carcinoma of anus, penis and vagina.
– Cancer of the uterus.
common cause of gynaecological cancer deaths
Ovarian cancer
Most common type of ovarian cancer
Epithelial ovarian cancer (90%)
Treatment of Lichen- sclerosis
Potent topical steroids
Lichen- Sclerosis dx
- pre-pubertal and peri-menopausal women
TRIAD: genital itching, soreness and white wrinkled plaques
in the genital area
-Dx: biopsy
Specific Indications for cone biopsy
- Fail to visualize Transformation zone in pt with HSIL on her Cervical smear ref
- Suspecting early invasive Cx cancer on cytology, biopsy or colposcopic assessment
- Suspecting glandular abnormalities on cytology or biopsy
chlamydial urethritis treatment
Azithromycin 1 g oral
Post menopausal + endometrial thickness 4mm or above + vaginal bleeding
Suspect Endometrial cancer and refer to gynaec for endometrial biospy
GBS treatment
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
most important Endocrine test in assessing male infertility
FSH : more than 2time the normal indictaed irreversible testicular failure
Aromatase inhibitors cause
- increased osteoporosis
- cardiac abnormalities
Cushing syndrome symptoms in women
- 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
Contraceptives used in the treatment of acne
- Cyproterone acetate
- Desogestrel
- Drospirenone
- Gestodene
