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AKT revision > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Describe the physiology of the monophasic COCP?

A

Releases high amounts of progesterone and oestrogen throughout the monthly cycle. These act as negative feedback on the pituitary gland, to reduce levels of FSH and LH, thus preventing stimulation of a follicle to mature. This overall prevents an egg from being released, thus causing contraceptive effects.

The low level of oestrogen also has local effects on the endometrial lining in order to maintain a constant thin endometrial lining. Progesterone works synergistically with oestrogen to do this.

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2
Q

what are the benefits of a monophasic COCP?

A

Highly effective contraceptive rates (> 99%)
Regular bleeding - predictable
Constant hormone levels - simple and easy to use, rather than remembering different doses and levels
Improvement in acne
Improvement in menorrhagia
reduced rates of ovarian and uterine cancer

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3
Q

what are the negatives of monophasic COCP?

A

Can have higher level of side effects than the multiphasic COCP
Does not follow natural fluctuations in hormones

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4
Q

what are some examples of the monophasic COCP?

A

Microgynan 30
Microgynan 20

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5
Q

what are some examples of multiphasic COCP?

A

Qlaira
Yaz

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6
Q

How do multiphasic COCP work?

A

Release varying levels of oestrogen and progesterone throughout the cycle, to mimic natural fluctuations more closely.
These can be biphasic or triphasic depending on the type. They typically have 2 pills which are placebo, to again mimic the natural fall in hormone levels towards the end of the cycle.

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7
Q

what are the benefits of multiphasic COCP?

A

reduced side effects
tolerated better
reduced uterine and ovarian cancer rates

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8
Q

what is the benefit of the Yaz pill specifically?

A

It is taken over 24 days, with 4 pill free days.
This reduces the amount of pre-menstrual symptoms, by reducing the amount of time without progestin/oestrogen. This stability reduces the risk of premenstrual symptoms.

Additionally, the Yaz pill contains drospirenone, a progestin that has anti-androgenic and mild diuretic properties similar to spironolactone. This can help reduce water retention, bloating, and symptoms related to excess androgens, such as oily skin and hair growth.

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9
Q

which is better for PMDD - the COCP continuous dosing or the Yaz pill?

A

Continuous Regimen: Ideal for those who want to completely avoid periods and associated symptoms, or those with severe PMS/PMDD.

Yaz 24/4 Regimen: Better suited for those who prefer to have some regularity in their cycle while still managing premenstrual symptoms.

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10
Q

what are the negatives of continuous dosing of the COCP?

A

Breakthrough bleeding
psychological discomfort due to the absence of periods
potential delays in detecting pregnancy
concerns about long-term effects

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11
Q

how long can you use the COCP continuously for?

A

3 months (12 weeks) followed by a 4- or 7-day break to allow for withdrawal bleeding
although many healthcare providers suggest 6, 9 or even 12 months. There is no specific rule.

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12
Q

what are the rules if you miss one COCP?

A

take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day

no additional contraceptive protection needed

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13
Q

what are the rules if you miss 2 or more pills in week 1 of COCP?

A

take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day

emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1.

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14
Q

what are the rules if you miss 2 or more pills in week 2 of COCP?

A

After seven consecutive days of taking the COC there is no need for emergency contraception.

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15
Q

what are the rules if you miss 2 or more pills in week 3 of COCP?

A

she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

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16
Q

what are the contraindications to the COCP?

A

< 6 wks postpartum
smoker over the age of 35 (>15 cigarettes per day)
hypertension (systolic > 160mmHg or diastolic > 100mmHg)
current of past histroy of venous thromboembolism (VTE)
ischemic heart disease
history of cerebrovascular accident
complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, histroy of subacute bacterial endocarditis)
migraine headache with focal neurological symptoms
breast cancer (current)
diabetes with retinopathy/nephropathy/neuropathy
severe cirrhosis
liver tumour (adenoma or hepatoma)

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17
Q

how do you start the COCP in a woman that is amenorrheic?

A

Start the combined oral contraceptive (COC) at any time, if it is reasonably certain that the woman is not pregnant.

if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days.

Additional contraception is required for 7 days (9 days for Qlaira®).

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18
Q

how do you start the COCP in a woman that is postpartum and not breastfeeding?

A

Start the COC on day 21 postpartum if there are no additional risk factors for venous thromboembolism.
Additional contraception is required for 7 days.

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19
Q

how do you start the COCP in a woman that is postpartum and is breastfeeding?

A

Do not start a COC if the woman is less than 6 weeks postpartum.

After 6 weeks and before 6 months postpartum, start the COC as for postpartum women who are not breastfeeding.

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20
Q

what are the negatives of the COCP?

A

people may forget to take it
offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects such as headache, nausea, breast tenderness may be seen

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21
Q

what form do combined contraceptives come in?

A

transdermal patch
oral contraceptives
vaginal ring

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22
Q

how does the transdermal combined patch work?

A

Inhibition of Ovulation: The primary way the patch prevents pregnancy is by inhibiting ovulation. The hormones suppress the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland, preventing the ovary from releasing an egg each month.
Thickening of Cervical Mucus: The progestin in the patch also thickens the cervical mucus, making it difficult for sperm to travel through the cervix and reach an egg.
Thinning of the Endometrial Lining: The patch causes changes to the endometrium (the lining of the uterus), making it less suitable for implantation if an egg were to be fertilized.

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23
Q

how long do you wear the transdermal combined patch?

A

Each patch is worn for one week, and it is replaced with a new patch on the same day of the week for three consecutive weeks. After three weeks (21 days), no patch is worn during the fourth week, allowing for a withdrawal bleed similar to a menstrual period.

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24
Q

what is oestrogens role in maintaining bone density?

A

Estrogen plays a crucial role in maintaining bone density by inhibiting bone resorption (the process where bone is broken down) and promoting bone formation. A reduction in estrogen levels can lead to increased bone loss and a higher risk of osteoporosis.

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25
Q

what are some common side effects in general of the COCP?

A

Nausea
breast tenderness
bloating and fluid retention
headache
dysmenorrhoea
decreased libido
breakthrough bleeding

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26
Q

If on a COCP and experiencing nausea, how should the COCP be adjusted?

A

reduce oestrogen dose
exclude pregnancy
take pills at night

consider switching to progesterone only

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27
Q

if on COCP and experiencing breast tenderness, how should the COCP be adjusted?

A

reduce ostrogen and/or progesterone dose
change to different type of progesterone
consider using pill containing drospirenone

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28
Q

if on COCP and experiencing bloating and fluid retention, how should COCP be adjusted?

A

reduce oestrogen dose
change to progesterone with mild diuretic effect such as drospirenone

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29
Q

if on COCP and experiencing headaches, how should COCP be adjusted

A

reduce oestrogen and/or change progesteron

30
Q

if on COCP and experiencing dysmenorrhea, how should COCP be adjusted?

A

extended pill regimen to reduce frequency of bleeding

31
Q

if on COCP and having breakthrough bleeding, how should COCP be adjusted?

A

if taking an ethinyloestradiol 20 microgram pill, increase oestrogen dose to a maximum of 35 micrograms

change progesterone already

try another form of contraception

32
Q

what is the hormone content of microgynan 30?

A

ethinylestradiol 30
levonorgestrel 150

33
Q

what are some specific side effects of COCP’s such as microgynan and rigevidon?

A

oily hair or skin
loss of libido
bloating

34
Q

what are some gynaecological red flags?

A

post menopausal bleeding
abnormal discharge
feeling of bloating/fullness
pelvic masses
ascites
post-coital bleeding
dyspaerunia
lump/skin changes of vulva
vulval itching
vulval pain/soreness

35
Q

what are some red flags of endometrial cancer?

A

post-menopausal bleeding
heavier periods
vaginal discharge
weight loss

36
Q

what are the risk factors for endometrial cancer?

A

Prolonged periods of unopposed oestrogen are the main risk factor. When oestrogen is not modified by the effects of progesterone, this is termed ‘unopposed oestrogen’.

PCOS - persistently high oestrogen causes proliferation of the endometrium
family history of endometrial cancer
Nulliparity
Obesity - raises levels of oestrogen
Tamoxifen use
hereditary nonpolyposis colon cancer (HNPCC) - 30-60% lifetime risk of endometrial cancer
Menopause past the age of 52

37
Q

what are the types of endometrial cancer?

A

80% adenocarincoma
20% squamous cell carcinoma

Endometrial cancers can also be subclassified into: oestrogen-dependent endometrioid (type 1) and oestrogen-independent non-endometrioid carcinomas (type 2).

38
Q

what is the management of a woman who presents to the practice with first episode of post-menopausal bleeding?

A

referral via 2ww

39
Q

what investigations are done to investigate a possible endometrial cancer? (these are typically done by the gynaecology team via 2ww)

A

TVUSS - measure the endometrial thickness
Hysteroscopy + endometrial biopsy

most women will also have bloods as routine + CXR.
test for lynch syndrome.

40
Q

what are the stages of endometrial cancer?

A

stage 1- confined to the corpus uteri
stage 2- This involves the corpus and there is invasion into the cervical stroma but it has not extended outside the uterus
stage 3- This has local or regional spread outside the uterus but still confined to the reproductive organs.
stage 4 - This is involvement of the bladder or bowel mucosa, or distant metastasis

41
Q

Management of stage 1 endometrial cancer?

A

Stage I requires total abdominal hysterectomy with bilateral salpingo-oophorectomy. The role of lymphadenectomy is debated.

The use of progestogen in the treatment of stage IA endometrioid endometrial cancer without myometrial invasion is an option for those women who want to preserve their fertility.

42
Q

Management of stage 2 endometrial cancer?

A

In stage II there should be radical hysterectomy with systematic pelvic node clearance.

43
Q

Management of stage 3 and stage 4 endometrial cancer?

A

Stage III and IV are best treated with maximal de-bulking surgery in those women with good performance status and resectable tumour

44
Q

what is the prognosis of endometrial cancer?

A

Those women who are diagnosed early have a far better prognosis. Most recurrences will occur within the first three years after treatment.

The majority of women (80% in stage I) will be diagnosed with early-stage disease and are cured with surgery.

For this group of women five-year survival rates are over 95%; however, five-year survival rates are much lower if there is regional spread or distant disease (68% and 17%, respectively)

45
Q

what are some causes of endometrial thickening?

A

PCOS
obesity
adhesions
fibroid with degeneration
ovarian tumours
endometrial hyperplasia

46
Q

how should suspected endometrial thickening be investigated?

A

TVUSS on day 5-12 of the cycle

47
Q

Management of endometrial thickening on USS?

A

refer via 2ww

48
Q

Management of confirmed endometrial hyperplasia?

A

Usually using contraceptive methods containing progesterone to regulate the endometrial lining growth - i.e. IUS

If pre-menopausal:
Hormonal contraceptives - can have POP, COCP, implant, injections and IUS

If menopausal:
Progestin-only birth control pills
Progestin injections
Vaginal cream containing progestin
An IUD that gradually releases progestin

49
Q

what are the indications for considering HRT?

A

perimenopausal women with vasomotor symptoms
perimenopausal women with low CVD risk
women who have a high FRAX score (who have a high risk of osteoporosis fractures)

50
Q

what type of HRT would you recommend to a perimenopausal woman who has vasomotor symptoms, who is 49 years old?

A

cyclical HRT - in order to avoid breakthrough bleeding

51
Q

what type of HRT would you recommend for a woman who has vasomotor symptoms who has been postmenopausal for 2 years?

A

continuous HRT - less risk if unscheduled bleeding

52
Q

what are the benefits of HRT?

A

improves hot flushing (77%); improves headaches (30%) and insomnia (55%)

reverses genital tract atrophy

improves psychological symptoms e.g. confidence improved in about 30%

reduces osteoporosis and thus, fracture rate

53
Q

how does HRT impact risk of stroke?

A

Explain to women that taking oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke

54
Q

in which forms can you prescribe sequential HRT?

A

oral
transdermal

55
Q

when does the perimenopause state usually happen?

A

Perimenopause usually occurs between the ages of 40 and 50. The average age of onset is 47 and can last between 4-8 years

56
Q

what are the risks with oral HRT?

A

increased risk of VTE - highest risk during the first 12 months
increased risk of CHD - using combined oral HRT started past the age of 60 years
slight increase in breast Ca incidence - particularly when using HRT for more than 5 years

57
Q

what are common SE of oestrogen component of HRT and COCP?

A

fluid retention
breast tenderness
bloating
nausea
headaches

58
Q

what are common SE of progesterone in HRT or POP?

A
  • Fluid retention
  • Breast tenderness
  • Headaches
  • Mood swings
  • PMT-like symptoms
59
Q

in which patients with menorrhagia should a LNG-IUS be considered first line?

A

no identified pathology
fibroids < 3cm in diameter
suspected adenomyosis

60
Q

what are some non-hormonal options for management of heavy menstrual bleeding?

A

tranexamic acid
NSAID’s

61
Q

what are some hormonal options for heavy menstrual bleeding?

A

COCP
cyclical POP

62
Q

symptoms of fibroids?

A

bowel/urinary symptoms - if pressing on the abdomen
bulky uterus
heavy and painful periods

63
Q

what are absolute contraindications to the COCP?

A

current breast Ca
breastfeeding and < 6 weeks postpartum
age > 35 years and > 15 cigarettes/day
elevated BP
history of DVT/PE
IHD or stroke
migraines with aura (at any age)
diabetes for > 20 years

64
Q

what are some relative contraindications to COCP?

A

history of breast ca > 5 years
breastfeeding and 6 weeks to <6 months post partum
age 35 years and smokes < 15 per day
elevated BP (systolic 140-159, or diastolic 90)
known hyperlipidaemia

65
Q

management of bartholins abscess?

A

flucloxacillin 500mg QDS or erythromycin 500mg QDS
Review - if persistent , not responding to abx, worsening - referral for I+D

66
Q

what are some conservative management fir bartholin cyst?

A

warm baths
hot compress
analgesia

67
Q

symptoms of BV?

A

fishy smelling discharge
thin discharge
can be grey in colour
can cause local irritation , no pruritis
may be asymptomatic

68
Q

what is the cause of BV?

A

gardnerella vaginallis

69
Q

what are the investigations for BV?

A

microscopy - “clue cells” seen epithelial cells densely covered with bacilli
positive amine test - a fishy ammoniacal smell when the discharge is mixed with 10% potassium hydroxide

70
Q

what is the 1st line treatment for BV?

A

metronidazole 400mg BD for 7 days

71
Q

management of pelvic organ prolapse?

A

pelvic floor muscle training
pessary
lifestyle advise - re weight loss, minimising straining or constipation, avoidance of heavy lifting / coughing or high impact exercise
surgical management

72
Q
A

AKT revision (10 decks)

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