Gynaecology Flashcards
1
Q
Differentials for primary amenorrhoea?
A
Abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
Abnormal functioning of the gonads (hypergonadotropic hypogonadism)
Imperforate hymen or other structural pathology
2
Q
Differentials for pruritis vulvae?
A
Irritants such as soaps, detergents and barrier contraception
Atrophic vaginitis
Infections such as candidiasis (thrush) and pubic lice
Skin conditions such as eczema
Vulval malignancy
Pregnancy-related vaginal discharge
Urinary or faecal incontinence
Stress
3
Q
Differentials for secondary amenorrhoea?
A
Pregnancy (the most common cause)
Menopause
Physiological stress due to excessive exercise, low body weight, chronic disease or psychosocial factors
Polycystic ovarian syndrome
Medications, such as hormonal contraceptives
Premature ovarian insufficiency (menopause before 40 years)
Thyroid hormone abnormalities (hyper or hypothyroid)
Excessive prolactin, from a prolactinoma
Cushing’s syndrome
4
Q
Differentials for intermenstrual bleeding?
A
Hormonal contraception
Cervical ectropion, polyps or cancer
Sexually transmitted infection
Endometrial polyps or cancer
Vaginal pathology, including cancers
Pregnancy
Ovulation can cause spotting in some women
Medications, such as SSRIs and anticoagulants
5
Q
Differentials for abnormal uterine bleeding?
A
Extremes of reproductive age (early periods or perimenopause)
Polycystic ovarian syndrome
Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors)
Medications, particularly progesterone only contraception, antidepressants and antipsychotics
Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin
6
Q
Differentials for dysmenorrhoea?
A
Primary dysmenorrhoea (no underlying pathology)
Endometriosis or adenomyosis
Fibroids
Pelvic inflammatory disease
Copper coil
Cervical or ovarian cancer
7
Q
Differentials for mennorhagia?
A
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome
8
Q
Differentials for post coital bleeding?
A
Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
9
Q
Differentials for pelvic pain?
A
Urinary tract infection
Dysmenorrhoea (painful periods)
Irritable bowel syndrome (IBS)
Ovarian cysts
Endometriosis
Pelvic inflammatory disease (infection)
Ectopic pregnancy
Appendicitis
Mittelschmerz (cyclical pain during ovulation)
Pelvic adhesions
Ovarian torsion
Inflammatory bowel disease (IBD)
10
Q
Differentials for vaginal discharge?
A
Bacterial vaginosis
Candidiasis (thrush)
Chlamydia
Gonorrhoea
Trichomonas vaginalis
Foreign body
Cervical ectropion
Polyps
Malignancy
Pregnancy
Ovulation (cyclical)
Hormonal contraception
11
Q
What is primary amenorrhoea?
A
Not starting menstruation
12
Q
What are the types of hypogonadism?
A
Hypogonadotropic; lack of LH and FSH released from pituitary gland
Hypergonadotropic; lack of response to LH and FSH by the gonads
13
Q
Causes of hypogonadotropic hypogonadism amenorrhoea?
A
Hypopituitarism
Damage to pituitary/ hypothalamus from radiotherapy, surgery
Cystic fibrosis
Excessive exercise/ dieting
Constitutional delay in development
Endocrine disorders; growth hormone deficiency, hypothyroidism, cushings, hyperprolactinaemia
Kallman syndrome
14
Q
Causes of hypergonadotropic hypogonadism?
A
Previous damage to gonad; torsion, cancer, infection, mumps
Congenital absence
Turner syndrome
Androgen insensitivity
Congenital adrenal hyperplasia
15
Q
What structural pathologies can present with amenorrhoea?
A
Imperforate hymen
Transverse vaginal septae
Vaginal agenesis
Absent uterus
FGM
16
Q
Investigations to assess cause of amenorrhoea?
A
FBC; anaemia
U+E; CKD
Coeliac screen
Hormone panel; FSH, LH, TFT, IGF-1, Prolactin, Testosterone
Genetic testing
X-ray wrist
Pelvic USS
MRI of brain
17
Q
Management of primary amenorrhoea?
A
Replacement hormones
Reduce stress
Gain/ lose weight
Pulsatile GnRH
COCP
18
Q
What is secondary amenorrhoea?
A
Pregnancy
Menopause
Premature ovarian failure
Hormonal contraception
Hypothalamic pituitary pathology
Ovarain; PCOS
Uterine; ashermas syndrome
Thyoid pathology
Hyperprolactinaemia
Pituitary failure; trauma, radiotherapy, sheehan syndrome
19
Q
What is premenstrual syndrome?
A
Psychological, physical and emotional symptoms that occur during the luteal phase of the menstrual cycle
20
Q
Pathophysiology of premenstrual syndrome?
A
Fluctuation of oestrogen and progesterone during menstrual cycle
21
Q
Presentation of premenstrual syndrome?
A
Low mood
Anxiety
Mood swings
Irritability
Bloating
Headache
Fatigue
Breast pain
Reduced confidence
Clumsiness
Reduced libido
22
Q
How is premenstrual syndrome diagnosed?
A
Clinical diagnosis
Administration of GnRH analogues to see if symptoms resolve
23
Q
Management of premenstrual syndrome?
A
General healthy lifestyle
COCP- containing drospirenone
SSRI antidepressant
CBT
GnRH analogues
Hysterectomy and bilateral oophorectomy
Danazole and tamoxifen for breast pain
Spironolactone
24
Q
What defines menorrhagia?
A
> 80 mls blood loss
what the woman says is a lot
25
Causes of menorrhagia?
Idiopathic
Extreme of reproductive age
Endometriosis/ adenomyosis
Fibroids
Pelvic inflammatory disease
Contraceptives; especially copper coil
Anticoagulant medication
Bleeding disorder
Endocrine disorder
Connective tissue disorder
Endometrial hyperplasia/ cancer
PCOS
26
What to ask when taking a menstrual history?
Age at menarche
Cycle length, days menstruation and variation
Intermenstrual bleeding and post coital bleeding
Contraceptive history
Sexual history
Possibility of pregnancy
Plans for future pregnancy
Cervical.screening history
Migraines with/without aura
Past medical history and drug history
Smoking and alcohol history
Family history
27
Investigations to diagnose menorrhagia?
Speculum and bimanual pelvic examination; fibroids, ascites, cancer
FBC; IDA
Hysteroscopy; fibroids, endometrial pathology
Pelvic and transvaginal USS; large fibroids, adenomyosis, obesity, declined hysteroscopy
Coagulation screen
TFT
28
Management of menorrhagia?
Symptomatic relief; tranexamic acid, mefenamic acid
When contraception is allowed;
Mirena coil- first line
COCP
Cyclical oral progesterone
Endometrial ablation, Hysterectomy
29
What is a uterine fibroid?
Benign tumours of the smooth muscle of the uterus which are oestrogen sensitive
AKA Uterine leiomyoma
30
Types of uterine fibroids?
Intramural; within the myometrium
Subserosal; just below the outer layer and grow outward into the abdominal cavity
Submucosal; found below the endometrium
Pedunculated; on a stalk
31
Presentation of uterine fibroids?
Menorrhagia
Prolonged menstruation
Abdominal pain worse on menstruation
Bleeding/ feeling full in abdomen
Urinary/ bowel symptoms due to pelvic pressure
Deep dyspareunia
Reduced fertility
32
Investigations to assess uterine fibroids?
Abdominal/ bimanual examination; palpable pelvic mass
Hysteroscopy
Pelvic ultrasound
MRI Scan; before surgery to assess size, shape, blood supply
33
Management of fibroids?
Less than 3cm;
First line; mirena coil
NSAID, and tranexamic acid - symptom relief
Combined oral contraceptive
Cyclic oral progesterones
Surgery; endometrial ablation, resection, hysterectomy
More than 3cm;
Referal to gynaecology
Medical management same as above
Surgery; uterine artery embolisation, myomectomy, Hysterectomy
GnRH agonists maybe used preoperatively to reduce size of fibroids
34
Complications of uterine fibroids?
Iron deficiency anaemia
Reduced fertility
Pregnancy complications; miscarriages, premature labour, obstructive delivery
Constipation
Urinary outflow obstruction/ UTI
Red degeneration Of fibroid
Torsion of fibroid
Malignant change
35
What is red degeneration of fibroid?
Ischaemia, infarction and necrosis of the fibroid due to disrupted flow of blood supply and more likely to affect those larger than 5cm
36
Presentation of red degeneration of fibroid?
Severe abdominal pain
Low grade fever
Tachycardia
Vomiting
37
Risk factor for red degeneration of fibroid?
Pregnancy
38
Management of red degenration?
Fluids
Analgesia
Supportive
39
What is endometriosis?
Growth of ectopic endometrial tissue outside the uterine cavity
40
Aetiology of endometriosis?
Retrograde menstruation resulting in blood flow backwards into fallopian tube into peritoneum and pelvis
Endometrial cells destined to be uterine cells failed to migrate during embryonic development
Endometrial cells travel through lymphatics
Metaplasia of non endometrial cells
41
Presentation of endometriosis?
Cyclical abdominal/ pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility
Cyclical bleeding from other sites
42
Investigations to diagnose endometriosis?
Pelvic ultrasound
Laparoscopy and biopsy - gold standard
43
Staging of endometriosis?
American society of reproductive medicine staging system;
Stage 1; small superficial lesions
Stage 2; mild, but deeper lesions compared to stage 1
Stage 3; deeper lesions, with lesions on ovaries and mild adhesions
Stage 4; deep and large lesions affecting ovaries with extensive adhesions
44
Management of endometriosis?
Initial management;
Establish diagnosis, educate patient and establish relationship
Analgesia
Hormonal management;
Combined pill
Progesterone only pill
Mirena coil
GnRH agonist
Surgical management;
Laparoscopic removal and ablation
Hysterectomy
45
What is adenomyosis?
Endometrial tissue within the myometrium
46
Risk factors for adenomyosis?
Later reproductive years
Multiparity
Hormone dependant
47
Presentation of adenomyosis?
Dysmenorrhoea
Menorrhagia
Dyspareunia
48
Investigations to diagnose adenomyosis?
First line- transvaginal USS
MRI or transabdominal ultrasound
Gold standard- histological
49
Management of adenomyosis?
Tranexamic acid, mefenamic acid
Mirena coil
COCP
Cyclical oral progestogens
GnRH analogues
Ablation
Uterine artery embolisation
Hysterectomy
50
Complications during pregnancy with adenomyosis?
Infertility
Miscarriage
Preterm birth
SGA
Preterm premature rupture of membrane
Malpresentation
Need for C-section
PPH
51
What is menopause?
Lack of menstruation for 12 months
52
What is the average age of menopause in UK?
51
53
What age is premature menopause diagnosed?
Before the age of 40 years
54
Hormonal changes that take place in menopause?
Oestrogen and progesterone are low
LH and FSH are high
55
Perimenopausal symptoms?
Hot flushes
Emotional lability
Premenstrual syndrome
Irregular menstruation
Joint pain
Heavier/ lighter periods
Vaginal dryness/ atrophy
Reduced libido
56
Risk associated with depleting oestrogen?
CVD and stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
57
When should FSH blood test be considered in women presenting with perimenopausal symptoms?
Under 40 years with suspected premature menopause
40-45 years with symptoms and change in menstrual cycle
58
How long is contraception needed after last menstrual period?
2 years in women under 50 years
1 year in over 50 women
Since last menstrual period
59
UKMEC1 contraceptive options for women approaching menopause?
Barrier
Mirena/ copper coil
POP
Progesterone implant
Progesterone depot in under 45
Sterilisation
60
Why is progesterone depot not suitable for women over 45 years?
Reduced bone mineral density meaning higher risk of osteoporosis
61
Management of perimenopausal symptoms?
Nothing
HTR
Tibolone
Clonidine
CBT
SSRI antidepressant
Testosterone
Vaginal oestrogen/ moisturiser
62
What is premature ovarian insufficiency?
Menopause before the age of 40 years
63
Causes of premature ovarian insufficiency?
Idiopathic
Iatrogenic; chemotherapy, radiotherapy, surgery
Autoimmune
Genetics; turner's syndrome
Infections; mumps, CMV, TB
64
When is premature insufficiency diagnosed?
Persistently raised FSH (>25) on two consecutive occassions 4 weeks apart in women under 40 years
65
Risks of premature ovarian insufficiency?
CVD
Stroke
Osteoporosis
Cognitive impairment
Dementia
Parkinsonism
66
Management of premature ovarian insufficiency?
HRT atleast until age of menopause either with traditional HRT or COCP
Manage VTE risk
67
What is HRT?
Treatment used in perimenopausal or postmenopausal women yo alleviate symptoms of menopause caused by the relative lack of oestrogen
68
Non hormonal treatment options for menopause?
Lifestyle changes; diet, exercise, weightloss, smoking cessation, reduce alcohol/ caffeine/ stress
CBT
Clonidine
SSRI antidepressants
Venlafaxine
Gabapentin
69
What is clonidine?
Alpha-2 adrenergic receptor agonist and imidazoline receptors in the the which lowers BP and reduced heart rate
Helps with vasomotor symptoms and hot flushes
70
Side effects of clonidine?
Dry mouth
Headache
Dizziness
Fatigue
Sudden withdrawal can result in rapid rise in BP and agitation
71
Alternative therapies for HRT?
Black cohosh- may cause liver damage
Dong quai; may cause bleeding disorder
Red clover; may have oestrogenic effects
Evening primrose; lots of interactions, seizures, clotting disorders
72
Indications for HRT?
Replacement of hormones in premature ovarian failure
Reduce vasomotor symptoms
Improve symptoms; low mood, low libido, poor sleep, joint pain
Reduce risk of osteoporosis in women under 60
73
Benefits of HRT?
Improved vasomotor symptoms; mood, urogenital, joint symptoms
Improved quality of life
Reduce risk of osteoporosis and fractures
74
Risk of HRT?
Increased risk of breast cancer, endometrial cancer
Increased VTE risk
Increased stroke and CVD
75
How can risks associated with HRT be reduced?
Endometrial cancer; progesterone
VTE; use patch rather than pill
Breast cancer, CVD; local progesterone rather than systemic
76
Contraindications to HRT?
Undiagnosed abnormal bleeding
Endometrial hyperplasia/ cancer
Breast cancer
Uncontrolled HTN
VTE
Liver disease
Active angina/ MI
Pregnancy
77
Assessment before commencing HRT?
Take history
Assess risk for oestrogen dependent cancer
Check BMI and blood pressure
Ensure cervical and breast cancer screening is upto date
Encourage lifestyle changes to minimise risks
78
How to chose formulation of HRT?
Local symptoms; topical oestrogen
Has uterus; combined HRT
No uterus; oestrogen only HRT
Perimenopausal; cyclical combined HRT
Post menopausal; continuous HRT
79
How long is a mirena coil licensed for endometrial protection?
4 yeas
80
Types of progestogens?
C19; testosterone derived- help to improve libido e.g norethisterone, levonorgestrel, desogestrel
C21; progesterone derived- help improve mood, acne e.g dydrogesterone, medroxyprogesterone
81
What is tibolone?
Synthetic steroid that stimulates oestrogen and progesterone receptors, weak androgen receptor stimulator
82
Cautions with tibolone?
Can cause irregular bleeding requiring further investigations to rule out other cause
83
Monitoring required for women on HRT?
Follow up in 3 months to monitor side effects when initiating
Problematic irregular bleeding should be refered to specialist
Stop oestrogen containing contraceptives 4 weeks before major surgery
84
Oestrogenic side effects of HRT?
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
85
Progestogenic side effects of HRT?
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
86
What is PCOS?
Metabolic and reproductive deranged characterised by androgen excess
87
What is the diagnostic criteria for PCOS?
Rotterdam criteria
88
Diagnostic criteria for PCOS?
2 of the following
Oligoovulation/ anovulation
Hyperandrogenism
Polycystic ovaries
89
Presentation of PCOS?
Oligomenorrhoea
Infertility
Obesity
Hirsutism
Acne
Hair loss in a male pattern
Ancanthosis nigricans
90
Complications of PCOS?
Insulin resistance and diabetes
Ancanthosis nigricans
CVD
Hypercholestrolaemia
91
Pathophysiology of insulin resistance in PCOS?
Insulin resistance results in increased pancreatic secretion of insulin
Insulin stimulates adrenal glands and ovaries to release androgens
Insulin suppresses sex hormone binding globulin production in liver which normally act to modulate androgen function
92
Investigations to diagnose PCOS?
LH, FSH; LH is raised more than FSH, increased LH to FSH ratio
Raised testosterone
Raised insulin
Pelvic ultrasound; string of pearls appearance
93
Diagnostic criteria for ultrasound scan appearance in PCOS?
12 or more developing follicles on one ovary
Ovarian volume >10 cm3
94
Gold standard investigation for PCOS?
Transvaginal ultrasound scan
95
Management of PCOS?
General lifestyle improvement to optimise risks associated with obesity, T2DM, CVD, hypercholesterolemia
Manage risk of endometrial cancer
Endometrial cancer risk reduction; mirena, cyclical progesterone, COCP
Fertility treatment; clomifene, laparoscopic ovarian drilling, IVF, metformin, letrozole
Manage hirsutism; Weightloss, Co-cyprindiol, topical eflornithine, electrolysis, laser, Spironolactone, Finasteride, flutamide,
Manage acne
96
Complications of PCOS?
Endometrial hyperplasia, cancer
Infertility
Hirsutism
Arne
Obstructive sleep apnoea
Depression/anxiety
97
Why are women with PCOS at higher risk of endometrial cancer?
Under normal circumstances corpus luteum produces progesterone, with infrequent ovulation there is unopposed oestrogen
98
Presentation of ovarian cysts?
Largely asymptomatic
Pelvic pain
Bloating
Fullness in abdomen
Palpable pelvic mass
99
Types of ovarian cysts?
Follicular cyst; developing follicle, most common type of cyst with thin walls and tend to disappear after a few cycles
Corpus luteum cysts; develops when corpus luteum fails to break down causing pelvic discomfort and delayed menstruation
Serous cystadenoma; tumours of the epithelial cells in the ovary
Mucinous cystadeoma; tumours of epithelial cells in patients with endometriosis causing pain and disrupt ovulation
Dermoid/ Germ cell tumours; benign ovarian teratoma arising from germ cells
Sex chord tumours; arise from stroma or sex chords and encompass several types of tumours
100
Investigations to assess ovarian cysts?
Premenopausal women with simple ovarian cysts less than 5cm on USS require no further tests
CA125 tumour marker
Women under 40 with complex ovarian mass require germ cell tumour markers;
Lactate dehydrogenase
Alpha fetoprotein
hCG
101
Causes of raised CA125?
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
102
What is risk of malignancy index and what does it take into account?
Estimates risk of ovarian mass being malignant
Menopausal status
Ultrasound finding
CA125
103
Management of ovarian cysts?
Possible ovarian cancer (Complex cyst or raised CA125) requires 2 week wait referral
Possible dermoid cyst requires referral for surgical removal
Simple ovarian cysts in pre-menopausal women management depends on size;
<5cm; does not require follow up scan and typically resolves in 3 cycles
5-7cm; routine referral to gynae and annual USS monitoring
>7cm; consider MRI for surgical removal
Simple cysts in postmenopaual women;
<5cm; review in 4-6 months
>5cm with raised CA125 requires 2 week wait referral to gynae
104
Complications of ovarian cyst?
Torsion
Haemorrhage
Rupture
105
Triad of Meig's syndrome?
Ovarian fibroma
Pleural effusion
Ascites
Older women
106
Management of Meig's syndrome?
Removal of tumour results in resolution of symptoms
107
What is ovarian torsion?
Twisting of the ovary in relation to surrounding connective tissue, fallopian tube and blood supply
108
Causes of ovarian torsion?
Large cysts
Long indofundibular ligament
109
Presentation of ovarian torsion?
Sudden onset severe unilateral pelvic pain
Localised tenderness
Palpable mass
110
Management of ovarian torsion?
Laparoscopic surgery;
Detorsion
Oophorectomy
Decision is made during surgery
111
How is ovarian torsion diagnosed?
Pelvic USS; whirlpool sign, free fluid and oedematous ovary
112
Complications of ovarian torsion?
Delay in treatment can result in loss of ovary
Infection
Abscess, sepsis
Rupture
Intra-abdominal adhesions
Peritonitis
113
What is asherman's syndrome?
Intrauterine adhesions as a result of uterine damage
114
Causes of ashermans syndrome?
D+C procedure
Following uterine surgery
Pelvic infection
115
Presentation of ashermans syndrome?
Secondary amenorrhoea
Lighter periods
Dysmenorrhoea
Infertility
116
Investigations to diagnose ashermans syndrome?
Hysteroscopy
Hysterosalpingogram
MRI scan
Usually found incidently
117
Gold standard investigation for ashermans syndrome?
Hysteroscopy due to option of treating
118
What is cervical ectropion?
Columnar epithelium of endocervix extends out to the ectocervix, these columnar epithelial cells are more fragile and prone to bleeding and is associated with elevated oestrogen
119
What is the transformation zone?
Border between columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix
120
Presentation of cervical ectropian?
Asymptomatic and found on speculum examination
Increased vaginal discharge, bleeding
Dyspareunia
Post coital bleeding
121
Management of cervical ectropion?
If asymptomatic do nothing
Cauterisation of the ectropion using silver nitrate or cold coagulation
122
What is a nabothian cyst?
Fluid filled cyst seen on the surface of the cervix upto 1cm in size and harmless
123
Presentation of nabothian cyst?
Often found incidentally on speculum examination
Smooth rounded bumps on the cervix near the os with a white/ yellow appearance
124
Management of nabothian cyst?
Nothing
If suspicious of cancer, biopsy
125
What is pelvic organ prolapse?
Descent of pelvic organs into vagina due to weakness of ligaments and muscles surrounding uterus, rectum and bladder
126
Types of pelvic organ prolapse?
Uterine prolapse; uterus descends into vagina
Vault prolapse; when women have had hysterectomy the vault of the uterus (the top) descends into the vagina
Rectocele; defects in posterior vaginal wall allow rectum to prolapse forward into vagina
Cystocele; defect in anterior vaginal wall allowing bladder to prolapse backward into vagina
127
Risk factors for pelvic organ prolapse?
Multiple vaginal deliveries
Instrumental, prolonged, traumatic delivery
Advanced age
Post menopause
Obesity
Chronic respiratory disease causing coughing
Chronic constipation and straining
128
Presentation of pelvic organ prolapse?
Feeling something coming down into vagina
Dragging or heavy sensation in pelvis
Urinary symptoms
Bowel symptoms
Sexual dysfunction
May feel lump or mass in vagina
129
Investigations to assess pelvic organ prolapse?
Sim's speculum
130
Grades of uterine prolapse?
Pelvic organ prolapse quantification (POP-Q);
Grade 0; Normal
Grade 1; lowest part is more than 1cm above introitus
Grade 2; lowest part is within 1cm of the introitus
Grade 3; lowest part is more than 1cm below the introitus but not fully descended
Grade 4; full descent with inversion of the uterus
131
What is uterine procidentia?
Prolapse extending beyond introitus
132
Management of pelvic organ prolapse?
Conservative;
Physiotherapy, weight loss, lifestyle change, treatment of related symptoms, vaginal oestrogen cream
Vaginal pessary;
Ring shape, Shelf and gellhorn, Cube, Donut, Hodge
Surgery;
Definitive treatment
133
Complications of pelvic organ prolapse surgery?
Pain, bleeding, infection, DVT, risk of anaesthetic
Damage to bladder/ bowel
Recurrence of prolapse
Altered sexual function
134
Complications of mesh repair of pelvic organ prolapse?
Chronic pain
Altered sensation
Dyspareunia
Abnormal bleeding
Urinary/ bowel symptoms
135
Types of incontinence?
Urge; detrusor muscle overactivity which means patient has sudden urge to urinate
Stress; pelvic floor weakness and sphincter weakness
Mixed; mixture of stress and urge incontinence
Overflow; chronic urinary retention
136
Risk factors for urinary incontinence?
Parity
Vaginal delivery
Increasing age
Post menopausal
High BMI
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions
Cognitive impairement
137
Lifestyle factors that contribute to urinary incontinence?
Caffeine consumption
Alcohol
Medications
BMI
138
Modified oxford grading system for pelvic muscle strength?
Grade 0; no contraction
Grade 1; faint contraction
Grade 2; weak contraction
Grade 3; moderate contraction with some contraction
Grade 4; good contraction with resistance
Grade 5; strong contraction, a firm squeeze and drawing inwards of examining fingers
139
Investigations performed to diagnose urinary incontinence?
Bladder diary
Urine dipstick
Post void residual bladder volume
Urodynamic testing
140
Management of stress incontinence?
Lifestyle management
Supervised pelvic floor exercises; for atleast 3 months
Surgery
Duloxetine
141
Management of urge incontinence?
Bladder retraining
Anticholinergic medication; oxybutynin, tolterodine, solifenacin
Mirabegron
Invasive procedure; botox injection, percutaneous sacral nerve stimulation, augmentation cystoplasty, urinary diversion
142
What is a contraindication to mirabegron?
Hypertension as it is a beta-3 agonist
143
What is atrophic vaginitis?
Dryness and atrophy of the vaginal mucosa due to a lack of oestrogen
144
Pathophysiology of atrophic vaginitis?
Lack of oestrogen results in thinner vaginal mucosa which is less elastic and dry and more prone to inflammation
145
Presentation of atrophic vaginitis?
Itching
Dryness
Dyspareunia
Bleeding due to localised inflammation
Recurrent UTI, stress incontinence, pelvic organ prolapse
146
Examination findings in atrophic vaginitis?
Pale mucosa
Thin skin
Reduced skin folds
Erythema/ inflammation
Dryness
Sparse pubic hair
147
Management of atrophic vaginitis?
Oestrogen cream, pessary, ring or tablets
148
Contraindications to topical oestrogen?
Breast cancer
Angina
VTE
149
What is bartholin's cyst?
Blockage in ducts for bartholin's gland becomes blocked resulting in swelling, erythema
150
Management of bartholins cyst?
Analgesia, cleanliness
Abscess requires antibiotics
Severe cases may require surgical removal
151
What is lichen sclerosus?
Chronic inflammatory skin condition presenting as patches of shiny, porcelain white skin commonly affecting labia, perineum, perianal skin
152
Presentation of lichen sclerosus ?
Itching
Soreness and pain, possibly worse at night
Skin tightness
Superficial pyspareunia
Erosions
Fissures
Koebners phenomenon
Skin changes; porcelain white, shiny, tight, thin, slightly raised, papules or plaques
153
Management of lichen sclerosus?
Follow-up every 3-6 months
Clobetasol propionate
Emollients
154
Complications of lichen sclerosus?
5% risk of squamous cell carcinoma of the vulva
Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of vaginal/ urethral openings
155
What is FGM?
Surgically changing female genitalia for non medical reasons and is illegal under the Female Genital Mutilation act of 2003
156
Epidemiology of FGM?
Common cultural practice in parts of africa
Somalia has the highest rate
Other countires, ethopia, sudan, yemen, indonesia
157
Types of FGM?
Type 1; removal of part or all of clitoris
Type 2; removal of part or all of the clitoris and labia minora
Type 3; narrowing and closure of the vaginal orifice
Type 4; all other unnecessary procedures
158
Complications of FGM?
Immediate;
Pain, bleeding, infection, swelling, urinary retention, urethral damage and incontinence
Long term complications;
Vaginal infections, pelvic infection, UTI, dysmenorrhoea, sexual dysfunction, infertility and pregnancy related complications, psychological issues, reduced engagement with screening and healthcare
159
Management of FGM?
Report all cases under 18 to the police
Social services, paediatrics, FGM services, counselling
160
What is a bicornate uterus?
Two horns to the uterus and is associated with poor obstetric outcomes such as miscarriage, PTB, malpresentation
161
What is an imperforate hymen?
Hymen at entrance of vaginal orifice is completely sealed presenting with cyclical abdominal pain with no vaginal bleeding and needs an incision to treat
Can lead to retrograde menstruation and hence endometriosis
162
What are transverse vaginal septae?
Septum which sit transversely across vagina which can be perforate or imperforate
Problems with tampon use and sexual intercourse
If imperforate can present similar to imperforate hymen
163
What is vaginal hypoplasia/ agenesis?
Abnormally small vagina/ absent vagina due to errors in mullarian duct development
Treated with vaginal dilator
164
Inheritance pattern of androgen insensitivity syndrome?
X-linked recessive
165
What is androgen insensitivity syndrome?
Cells are not able to respond to androgens due to lack of androgen receptors in genetically male patients with female secondary sexual characteristics
166
Presentation of androgen insensitivity syndrome?
Inguinal hernia in infancy or primary amenorrhoea in puberty
Biological male with female secondary charatceristics
No uterus, upper vagina, fallopian tubes and ovaries as testes produce AMH
Lack of androgen conversion to testosterone, high oestrogen
167
Most common type of cervical cancer?
Squamous cell carcinoma of the cervix accounts for upto 80% of cases
Adenocarcinoma is the next most common
168
What HPV strains are linked to cervical cancer?
16 and 18
169
How to HPV strains contribute to cancer?
Produces proteins E6 and E7 which are responsible for inhibiting tumour suppressor genes promoting development of cancer
E6 inhibits p53
E7 inhibits pRb
170
Risk factors for cervical cancer?
Increased risk of HPV
Non engagement with screening
Smoking
HIV
COCP
Increased number of full term pregnancies
Family history
Exposure to diethylstilbestrol
171
Presentation of cervical cancer?
Asymptomatic- picked up on screening
Intermenstrual/ post coital/ post menopausal bleeding
Pelvic pain
Dyspareunia
172
Appearance on colposcopy suggestive of cancer?
Ulceration
Inflammation
Bleeding
Visible tumour
173
What is the Cervical Intraepithelial Neoplasia grading system?
CIN 1; mild dysplasia, affecting 1/3 the thickness of the epithelial layer and is likely to return to normal without treatment
CIN 2; moderate dysplasia affecting 3/3 thickness, likely to progress to cancer if untreated
CIN 3; severe dysplasia, very likely to progress to cancer if untreated (AKA cervical carcinoma insitu)
174
What is the age for cervical screening and frequency?
Every 3 years aged 25-49
Every 5 years aged 50-64
HIV positive screened annually
Women with previous CIN require additional tests
Immunocompromised women may have additional tests
Pregnant women due routine smear should wait 12 weeks post partum
175
Actions to take after smear result?
Inadequate sample; repeat smear after 3 months
HPV negative; return to routine screening
HPV positive with normal cytology; repeat HPV test in 12 months
HPV positive and abnormal cytology; refer to colposcopy
176
What type of sample is taken during cervical screening?
Liquid based cytology
177
What tests are performed during colposcopy?
Acetic acid; abnormal cells appear white
Schiller's iodine test; healthy cells stain brown, unhealthy cells do not stain
Punch biopsy or large loop excision of transformational zone can be performed
178
Risk associated with loop biopsy?
Preterm birth
179
What is a cone biopsy
Treatment for CIN where a cone shaped piece of the cervix is removed
180
Risks of cone biopsy?
Pain
Bleeding
Infection
Scar formation and stenosis of the cervix
Increased risk of miscarriage and preterm labour
181
Staging of cervical cancer?
Stage 1; confined to cervix
Stage 2; invades uterus or upper 2/3 of vagina
Stage 3; Invades pelvic wall or lower 1/3 of vagina
Stage 4; Involves bladder, rectum or beyond pelvis
182
Management of cervical cancer?
CIN and early stage 1A; LLETZ, Cone biopsy
Stage 1B- 2A; radical hysterectomy and removal of local lymph nodes +/- chemotherapy, radiotherapy
Stage 2B- 4A; chemotherapy, radiotherapy
Stage 4B; combination therapy and palliative care
Pelvic exenteration; removal of most of the pelvic organs
183
What type of endometrial cancer is most common?
Adenocarcinoma
184
What is endometrial hyperplasia?
Pre-cancerous condition with thickened endometrium, only 5% go on to develop cancer
185
Treatment of endometrial hyperplasia?
Progesterone
186
Is endometrial cancer oestrogen dependant?
Yes
Risk factors include those that increase oestrogen exposure
187
Risk factors for endometrial cancer?
Increased age
Earlier onset menstruation
Late menopause
Oestrogen only HRT
No or few pregnancies
Obesity
PCOS
Tamoxifen- anti-oestrogen on breast tissue but pro-oestrogen on endometrium
T2DM
188
Protective factors for endometrial cancer?
COCP
Mirena coil
Increased pregnancies
Cigarette smoking
189
Presentation of endometrial cancer?
Postcoital bleeding
Intermenstrual bleeding
Menorrhagia
Abnormal vaginal discharge
post menopausal bleeding
Haematuria
Anaemia
Raised platelet count
190
Indications to transvaginal USS in suspected endometrial cancer?
Over 55 years with
Unexplained vaginal discharge
Visible haematuria
And one of; raised platelets, anaemia, elevated glucose
191
Investigations to diagnose endometrial cancer?
Transvaginal USS for endometrial thickness
Pipelle biopsy
Hysteroscopy with endometrial biopsy
192
What is normal endometrial thickness in post-menopausal women?
<4mm
193
Staging for endometrial cancer?
Stage 1; confined to uterus
Stage 2; invades into cervix
Stage 3; invades ovaries, fallopian tubes, vagina, lymph nodes
Stage 4; invades bladder, rectum, beyond pelvis
194
Management of endometrial cancer?
Stage 1 and 2; total abdominal hysterectomy with bilateral salpingo-oophorectomy
Other options;
Radical hysterectomy
Radiotherapy
Chemotherapy
Progesterone
195
When does ovarian cancer present?
late stages, 70% present when it has spread to other organs
196
Types of ovarian cancers?
Epithelial cell cancers;
Serous
Endometrioid carcinomas
Clear cell tumour
Mucinous tumour
Undifferentiated tumour
Dermoid cyst/ germ cell tumour
Sex chord/ stromal tumour
Metastasis
197
What is a krukenberg tumour?
Metastasis to the ovary
198
Risk factors for ovarian cancer?
Age; peak at 60
BRCA1 and BRCA2
Increased number of ovulations
Obesity
Smoking
Recurrent use of clomifene
199
Presentation of ovarian cancer?
Abdominal bloating
Early satiety
Loss of appetite
Pelvic
Urinary symptoms
Weight loss
Abdominal or pelvic mass
Ascites
Hip/ groin pain- obturator nerve
199
When is a CA125 blood test indicated for suspected ovarian cancer?
Woman over 50 years old with;
New symptoms of IBS
Abdominal bloating
Early satiety
Pelvic pain
Urinary frequency/ urgency
Weight loss
199
Investigations to diagnose ovarian cancer?
CA125 blood test (>35 is significant)
Pelvic ultrasound
CT scan
Histology
Paracentesis
199
Referral criteria under 2 week wait for suspected ovarian cancer?
Ascites
Pelvic mass
Abdominal mass
199
Staging system for ovarian cancer?
Stage 1; confined to ovary
Stage 2; spread past ovary but confined to pelvis
Stage 3; spread past pelvis but in abdomen
Stage 4; spread outside abdomen
200
What is risk of malignancy index?
Estimates risk of ovarian mass being malignant accounting for menopausal status, USS findings, CA125 level
200
Management of ovarian cancer?
Combination of surgery and chemotherapy
200
Most common type of vulval cancer?
Squamous cell carcinoma
200
Types of vulval intraepithelial neoplasia?
High grade squamous intraepithelial neoplasia; HPV infection typically occurs in 35-50 years
Differentiated VIN; associated with lichen sclerosis in women 50-60
200
Risk factors for vulval cancer?
Advanced age
Immunosuppression
HPV infection
Lichen sclerosus - 5% of patients develop vulval cancer
200
Management of VIN?
Watch and wait
Wide local excision
Imiquimod cream
Laser ablation
201
Presentation of vulval cancer?
Vulval lump
ulceration
Bleeding
Pain
Itching
Lymphadenopathy
202
What is bacterial vaginosis?
Overgrowth of anaerobic bacteria in the vagina due to depletion of lactobacili in the vagina
203
What are lactobacili?
Main component of vaginal flora that produce lactic acid to maintain vaginal pH
204
Bacteria associated with bacterial vaginosis?
Gardnerella vaginalis
Mycoplasma hominis
Prevotella species
205
Risk factors for bacterial vaginosis?
Multiple sexual partners
Excessive vaginal cleaning
Recent antibiotics
Smoking
Copper coil
206
Presentation of bacterial vaginosis?
Fishy smelling vaginal discharge
207
Investigations to diagnose bacterial vaginosis?
Clinical diagnosis with speculum examination
High vaginal swab to rule out STD and speculum examination
Vaginal pH
Microscopy reveals clue cells
208
What are clue cells?
Cervical epithelial cells that contain gardnerella vaginalis
209
Management of bacterial vaginosis?
Nothing resolves on its own
Can give Metronidazole, second line is clindamycin
210
Complications of bacterial vaginosis?
Increased risk of developing STI
Pregnancy associated;
Miscarriage, preterm delivery, premature rupture of membranes, chorioamnionitis, low birth weight, post partum endometritis
211
What is candidasis?
Vaginal infection with yeast of the Candida family
Most commonly candida albicans
212
Risk factors for candidasis?
Pregnancy
Poorly controlled diabetes
Immunosuppression
Broad spectrum antibiotics
213
Investigations to diagnose candidasis?
Vaginal pH
Charcoal swab for microscopy
214
Management of candidasis?
Antifungal cream (clotrimazole)
Antifungal pessary (clotrimazole)
Antifungal tablets (fluconazole)
Treatment regime options
Single dose of intravaginal clotrimazole cream at night
Single dose of 500mg clotrimazole pessary at night
Three doses of clotrimazole 200mg pessary over 3 nights
Single dose of oral fluconazole 150mg
215
Advice to women taking Antifungal creams and pessarys?
Damage condoms and reduce effectiveness of spermicide so consider other forms of contraception
216
Most common STI in UK?
Chlamydia
217
What type of organism is chlamydia?
Gram negative intracellular organism
218
What STIs are screened for when attending GUM clinic?
Chlamydia
Gonorrhoea
Syphilis
HIV
219
What is a charcoal swab?
Used in GUM clinics for microscopy, culture and sensitivities
Can identify; bacterial vaginosis, gonorrhoea, candidiasis, trichomonas vaginalis, other bacteria
220
What is a NAAT test?
Checks DNA/ RNA of microorganism specifically chlamydia and gonorrhoea
vulvovaginal, endocervical swab
First catch urine
Urethral swab
Rectal, pharyngeal swab
221
Presentation of chlamydia?
Asymptomatic
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding
Dyspareunia
Dysuria
Men;
Urethral discharge
Dysuria
Epididymo-orchitis
Reactive arthritis
222
How is chlamydia diagnosed?
NAAT test
223
Management of chlamydia?
First line for uncomplicated infection; doxycycline 100mg BD for 7 days
Alternative for pregnant or breastfeeding women;
Azithromycin 500mg QDS for 2 days
Erythromycin 500mg QDS for 7 days or BD for 14 days
Amoxicillin 500mg TDS
224
When is doxycycline contraindicated?
Pregnant or breastfeeding women
225
Other advice given to patients diagnosed with chlamydia?
Abstain from sex for 7 days
Refer all close contacts for contact tracing
Test for treat any other STIs
Advice to prevent future infection
Consider safeguarding
226
Complications of chlamydia infection?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
Pregnancy related complications;
Preterm delivery
Premature rupture of membranes
Low birth weight
Post partum endometritis
Neonatal infection
227
What is lymphogranuloma venereum?
Condition affecting lymphoid tissue around site of infection more commonly in men who have sex with men
228
Stages of lymphogranuloma venereum?
Primary stage; painless ulcer usually on penis, vaginal wall, rectum
Secondary stage; lymphadenitis, swelling, inflammation and pain in lymph nodes
Tertiary stage; inflammation of the rectum
229
Management of lymphogranuloma venereum?
Doxycycline 100mg BD for 21 days
Alternatives erythromycin, azithromycin, ofloxacin
230
What does gonorrhoea infect?
Mucous membranes with columnar epithelium such as endocervix, urethra, rectum, conjunctiva and pharynx
231
Type of microorganism is gonorrhoea?
Gram negative diplococcus
232
Presentation of gonorrhoea?
Odourless purulent discharge, maybe green or yellow in colour
Dysuria
Pelvic pain
Testicular pain or swelling
Pharyngeal infection
Rectal pain
Conjunctivitis
233
How is gonorrhoea diagnosed?
NAAT
Charcoal swab
234
Management of gonorrhoea?
Single dose of IM ceftriaxone 1g if sensitivities are not known
Single dose of oral ciprofloxacin 500mg if sensitivities are known
235
What is a test of cure?
Follow up test after receiving treatment for gonorrhoea with NAAT testing
72 hours after treatment for culture
7 days after for RNA NAAT
14 days after for DNA NAAT
236
Complications of gonorrhoea?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo- orchitis
Prostatitis
Conjunctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz- Hugh- Curtis syndrome
Endocarditis
236
What is ophthalmia neonatorum?
Gonococcal conjunctivitis of neonate due to maternal infection during pregnancy
237
Complications of ophthalmia neonatorum?
Sepsis
Perforation of eye
Blindness
238
What is disseminated gonococcal infection?
Complication of untreated gonorrhoea where bacteria spreads to skin and joints causing;
Various non specific skin lesions
Polyarthralgia
Migratory polyarthritis
Tenosynovitis
Systemic symptoms
239
What is mycoplasma genitalium?
Bacteria causing non gonococcal urethritis
240
What is the purpose of test of cure?
High level of antibiotic resistance
241
Complications of mycoplasma genitlium?
Epididymitis
Cervicitis
Endometritis
Pelvic inflammatory disease
Reactive arthritis
Preterm delivery in pregnancy
Tubal infertility
242
Key feature of mycoplasma genitalium?
Urethritis
243
Investigations to diagnose mycoplasma genitalium?
NAAT; first urine sample in men, vaginal swabs in women
244
Management of mycoplasma genitalium?
Doxycycline 100mg BD for 7 days then azithromycin 1g stat then 500mg OD for 2 days
Azithromycin alone in pregnancy and breastfeeding
245
What is pelvic inflammatory disease?
Inflammation and infection of pelvic organs caused by infection spreading up through cervix
246
Causes of PID?
STI; neisseria gonorrhoea, chlamydia, mycoplasma genitalium
Haemophilus influnezae, e.coli
247
Risk factors for PID?
Not using barrier contraception
Multiple sexual partners
Younger age
Existing STI
Previous PID
IUD
248
Presentation of PID?
Pelvic/ lower abdominal pain
Abnormal vaginal discharge
Abnormal vaginal bleeding
Dyspareunia
Fever
Dysuria
249
Pelvic examination findings in PID?
Pelvic tenderness
Cervical motion tenderness
Inflammed cervix
Purulent discharge
250
Investigations to diagnose PID?
NAAT swabs
HIV test
Syphilis test
High vaginal swab for bacterial vaginosis, candidiasis, trichomoniasis
Inflammatory markers
251
Management of PID?
Referral to GUM
Single dose of 1g IM ceftriaxone to cover gonorrhoea
Doxycycline 100mg BD for 14 days covers chlamydia and mycoplasma genitalium
Metronidazole 400mg BD for 14 days
252
Complications of PID?
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
253
What is Fitz-Hugh-Curtis syndrome?
Complication of PID caused by inflammation and infection of the liver capsule leading to adhesions between liver and peritoneum presenting as RUQ pain and reffered right shoulder tip pain
254
What is trichomoniasis?
Infection of protozoan parasite called trichomonas vaginalis, a single celled organism
255
Complications of trichomoniasis infection?
Increased risk of contracting HIV
Bacterial vaginosis
Cervical cancer
PID
Pregnancy related complications
256
Presentation of trichomoniasis infection?
Vaginal discharge; frothy, yellow green fishy smell
Itching
Dysuria
Dyspareunia
Balanitis
Strawberry cervix on examination
Raised vaginal pH
257
Diagnosis of trichomoniasis infection??
Charcoal swab for microscopy
Swab from posterior fornix of vagina
Urethral swab
First catch urine
258
Management of trichomoniasis infection?
GUM contact tracing
Metronidazole
259
Features of chlamydial conjunctivitis?
Chronic erythema
Irritation
Discharge for more than 2 weeks
260
What is gonorrhoea?
Infection with gram negative diplococcus affecting mucous membranes with columnar epithelium such as endocervix, urethra, rectum, conjunctiva and pharynx
261
Is test of cure indicated for chlamydia?
No
262
Is routine test of cure indicated for gonorrhoea?
Yes
263
Investigations to diagnose mycoplasma genitalium?
First urine sample, vaginal swab NAAT
264
Risk factors for PID and STIs?
Not using barrier contraception
Multiple sexual partners
Younger age
Existing STI
Previous PID
IUD
265
Investigations to diagnose trichomonas vaginalis?
Charcoal swab
265
Where does HSV lie in the latent phase?
Associated sensory nerve ganglia
Trigeminal nerve ganglion for cold sores (HSV1)
Sacral nerve ganglion for genital herpes (HSV2)
266
Presentation of genital herpes?
Ulcers/ blistering ulcers
Neuropathic pain; tingling, shooting, burning
Flu like symptoms
Dysuria
Inguinal lymphadenopathy
267
Investigations to diagnose genital herpes?
Viral PCR
268
Management of genital herpes?
GUM referral
Lidocaine
Aciclovir
269
Complications of herpes in pregnancy?
Not known to cause any complications but can be passed to foetus during birth
270
How is genital herpes treated in pregnancy?
Before 28 weeks treated with aciclovir during infection and prophylactic treatment from 36 weeks until delivery, vaginal birth if asymptomatic
After 28 weeks; aciclovir for infection followed by regular prophylaxis and C-section delivery
271
Complication of neonatal herpes simplex infection?
High rate of mortality and morbidity
272
Type of virus is HIV?
RNA retrovirus
273
Examples of AIDS defining illness?
Kaposi's sarcoma
Pneumocystis jirovecii pneumonia
CMV infection
Candidasis
Lymphoma
Tuberculosis
274
Testing for HIV?
Antibody test
p24 antigen
PCR; number of viral copies and hence viral load
275
How is HIV monitored?
CD4 count;
500-1200 cells/ mm3 is normal
Below 200 is end stage HIV
Viral load;
Undetectable is 50-100 copies/ ml
276
Management of HIV?
HAART;
Protease inhibitors, integrase inhibitor, nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, entry inhibitors
Prophylactic co-trimoxazole to protect against PCP
Monitor CVD risk
Vaccines upto date, avoid live vaccine
277
Prophylactic treatment in neonate born to HIV mothers?
Zidovudine <50/ ml for 4 weeks
Zidovudine, lamivudine, nevirapine >50/ ml for 4 weeks
278
Should HIV mothers breastfeed?
No, even if undetectable
279
Causative agent for syphilis?
Treponema pallidum , spirochete
280
Stages of syphilis?
Primary syphilis; painless ulcer (chancre)
Secondary syphilis; systemic symptoms which resolve in 3 to 12 weeks
Latent; asymptomatic but still infected
Tertiary; involes multiple organs, CVS and neurological complications
Neurosyphilis; infection involving CNS
281
What is PEP?
Reduce risk of HIV transmission commenced within 72 hours of possible contact
282
PEP regime?
Combination ART; Truvada (emttricitabine and tenofovir) and raltegravir for 28 days
Immediate HIV test and follow up in 3 months
283
Presentation of syphilis?
Primary; chancre, local lymphadenopathy
Secondary; maculopapular rash, condylomata lata, low grade fever, lymphadenopathy, alopecia, oral lesion
Tertiary; gummas, aortic aneurysm, neurosyphilis
284
Features of neurosyphilis?
Headache
Altered behaviour
Dementia
Tabes dorsalis
Ocular syphilis
Paralysis
Sensory impairment
Argyll Robertson pupil
285
Investigations to diagnose syphilis?
T.pallidum antibody test
Dark field microscopy
PCR
286
Concepts for contraception in older women?
After LMP contraception for 2 years under 50 and 1 year in over 50 years
Stop progesterone injection before 50
287
Why does progesterone injection need to be stopped before 50?
Risk of osteoporosis
288
When should progesterone only contraception be stopped?
FSH above 30 on two separate occasions 6 weeks apart
Age over 55
289
Guidance around contraception under 20?
COCP, POP pill
IDU, coil have higher risk of expulsion
290
Effectiveness of COCP?
99% with perfect use, typical use 91%
291
COCP mechanism of action?
Prevents ovulation
Progesterone thickens cervical mucus and inhibits proliferation of endometrium
292
Types of COCP?
Monophasic
Multiphasic
293
First line COCP?
Pill containing levonoregestrel or norethisterone
Pills containing drospirenone is first line for PMS
294
Side effects of COCP?
Breast pain and tenderness
Unscheduled bleeding
Mood changes and depression
Headache
Hypertension
VTE
Increased risk of breast and cervical cancer
Increased risk of MI and stroke
295
Benefits of COCP?
Effective contraception
Rapid return of fertility
Improvement in PMS, menorrhagia, dysmenorrhoea
Reduced risk of ovarian, endometrial and colon cancer
Reduced risk of benign ovarian cysts
296
Contraindications for starting COCP?
Uncontrolled HTN
Migraine with aura
History of VTE
Age over 35 and smoking more than 15 per day
Major surgery with prolonged immobility
Vascular disease/ stroke
Ischaemic heart disease, cardiomyopathy, atrial fibrillation
Liver cirrhosis/ tumours
SLE/ antiphospholipid tumour
297
When should COCP be commenced?
Day 1 of cycle
If after day 5 requires additional contraception for 7 days
If switching from POP requires additional contraception for 7 days
298
Things to check before commencing COCP?
Age
Height, BMI
Blood pressure
Smoking status
PMH (Migraine, VTE, cancer, CVD, SLE)
299
What is a missed pill?
When pill is more than 24 hours late, so 48 hours since last pill
300
Advice around missed pills when taking COCP?
Missing one pill within 72 hours;
Take missed pill ASAP
No extra protection if other pills taken correctly
Missing more than 1 pill and more than 72 hours since last pill;
Take missed pill ASAP
Additional contraception for 7 days
Consider emergency contraception
301
When should pill be stopped for medical reason?
4 weeks before planned surgery
302
What reduces efficacy of COCP?
Vomiting
Diarrhoea
Medications like rifampicin
303
Efficacy of POP?
99% with perfect use, 91% with typical use
304
UKMEC4 contraindication for POP?
Active breast cancer
305
Difference between traditional POP and cerazette?
Missed pill window is 3 hours in traditional pill compared to 12 hours in cerazette
306
Mechanism of action of traditional POP?
Thickens cervical mucus
Makes endometrium less favourable for implantation
307
Mechanism of action of desogestrel?
Inhibits ovulation
Thickens cervical mucus
Alters endometrium
Reduced ciliary action in fallopian tubes
308
When should POP be commenced?
Day 1-5; immediate protection
Any other time requires 48 hours
309
Best time to switch from COCP to POP?
Day 1-7 of hormone free period
310
Side effects of POP?
Amenorrhoea
Irregular prolonged bleeding
Breast tenderness
Headache
Acne
Risk of ovarian cysts, Breast cancer
311
Management of missed pills when taking POP?
Extra contraception for 48 hours
Emergency contraception is UPSI within 48 hours
Vomiting and diarrhoea accounts for missed pill
312
What is in the Progesterone only injection?
Medroxyprogesterone acetate
313
Efficacy of DMPA?
99% with perfect use and 94% with typical use
314
How long does it take for fertility to return following DMPA?
12 months
315
Preparations of Progesterone only injection?
Depo provera; IM injection
Sayana press; SC self injection
Noristerat; norethisterone containing preparation that works for 8 weeks
316
Contraindications to progesterone only injection?
UKMEC4; Active breast cancer
UKMEC3;
Ischaemic heart disease
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
UKMEC2;
Over 45 years and should switch to another form by 50
DMPA causes osteopororsis so caution in women on corticosteroids for asthma, inflammatory condition
317
Timing of progesterone only injection and insertion of implant?
Day 1-5 of cycle provides immediate protection
After day 5 requires 7 days of extra contraception
Injection every 12-13 weeks
318
Side effects of progesterone only injection?
Irregular bleeding
Weight gain
Acne
Reduced libido
Mood changes
Headaches
Flushes
Flushes
Hair loss
Skin reaction to injection site
Reduced bone mineral density
319
Benefits of progesterone only injection?
Improves dysmenorrhoea
Improves endometriosis symptoms
Reduces risk of ovarian and endometrial cancer
Reduces severity of sickle cell crisis
320
How long does progesterone only implant last?
3 years
321
Efficacy of progesterone implant?
99%
322
Which progesterone implant is licensed in the UK and what dosage?
Nexplanon containing 68mg of etonogestrel
Licensed for use in 18 to 40 year olds
323
Mechanism of progesterone only injection and implant?
Inhibits ovulation
Thickens cervical mucus
Alters endometrium
324
Where is progesterone implant inserted?
1/3 way up upper arm on the medial side
325
Benefits of progesterone implant?
Effective and reliable contraception
Improve dysmenorrhoea
Makes periods lighter or stop completely
Does not cause weight gain
Does not affect bone mineral density
No increase in risk of thrombosis
326
Drawbacks from using progesterone implant?
Minor operation to insert and remove
Worsen acne
No protection against STI
Can cause problematic bleeding
Implants can be bent or fractured or impalpable
327
How is prolonged bleeding managed when taking progesterone only contraception?
COCP
328
Contraindication to coils?
PID
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion
329
Risks related to coil insertion?
Bleeding
Pain on insertion
Vasovagal reactions
Uterine perforation
PID in first 20 days
Expulsion
330
Advice prior to removing coil?
Abstain from sex 7 days prior to removal
331
Causes of non visible coil thread?
Expulsion
Pregnancy
Uterine perforation
332
Management of non visible coil thread?
USS, pelvic Xray
Hysteroscopy or laparoscopy
333
Mechanism of copper coil?
Toxic to sperm
Makes endometrium less acceptable to implantation
334
Benefits of copper coil?
Reliable
Inserted at any time and effective immediately
No hormones
Reduces risk of endometrial and cervical cancer
335
Drawbacks of copper coils?
Procedure to insert coil carries risks
Heavy intermenstrual bleeding
Pelvic pain
Does not protect against pelvic pain
Increased risk of ectopic pregnancy
Expulsion1
336
Types of levonorgestrel systems?
Mirena; 5 years, licensed for mennorhagia, HRT
Levosert; 5 years, mennorhagia
Kyleena; 5 years
Jaydess; 3 years
337
What is ALO?
Actinomyces like organisms observed on smear tests in women using coils require no treatment unless symptomatic where consider taking coil out
338
Benefits of IUS?
Makes periods lighter or stop altogether
Improve dysmenorrhoea
No effect on bone mineral density
No risk of VTE
No restrictions in obese patients
Mirena has additional uses
339
Drawbacks of IUS?
Procedure to insert
Pelvic pain
Does not protect against STI
Increased risk of ectopic pregnancy, ovarian cyst,
Systemic absorption can lead to acne, headache, breast tenderness
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Options for emergency contraception?
Levonorgestrel- 72 hours of UPSI
Ulipristal- within 120 hours of UPSI
Copper coil- within 5 days of UPSI or within 5 days of estimated
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Gold standard emergency contraception?
Copper coil as it is not affected by BMI, enzyme inducing drugs, malabsorption
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What is ulipristal?
Selective progesterone receptor modulator which works by delayed ovulation
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Side effects of ulipristal?
Nausea, vomiting
Spotting and changes to next menstrual period
Abdominal/ pelvic pain
Back pain
Mood changes
Headache
Dizziness
Breast tenderness
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Restriction when taking ulipristal?
Avoid breast feeding for 1 week
Avoid in severe asthma
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Types of sterilisation procedures?
Tubal occlusion using filshie clips or tubal ties
Vasectomy
