Gynaecology

Question 1

what is a normal endometrial thickness in a post menopausal woman

Answer 1

4-5mm

> 8 mm in a premenopausal weomn is abnormal

Question 2

What is Sheehan syndrome

Answer 2

post-partum pituitary necrosis

significant post-partum bleeding, hypovolemia, and shock

Presents (weeks- years post partum with)
- difficulty with breastfeeding or cannot produce milk at all (agalactorrhea)
- Irregular menses or amennhorrea
- fatigue, weakness, hair loss, constipation, weight gain
- hyponatremia, hypoglycemia, anaemia
- Low cortisol/TSH/GH/LH/FSH/ACTH/prolactin

Question 3

Which ethnic group is ovarian cancer highest in?

most commmon type of ovarian cancers

Answer 3

Pacific islanders

Epithelial cell cancers make up 90% of cases

other types are malignant germ cell and stromal

Question 4

Risk fators for ovarian cancer

Answer 4

Ovulation (therefore early menses, late menopause, COCP protective)
Genetics: BRCA1/BRCA2, lynch
Pasifica ethnicity

obesity
Etoh
smoking
prolonged MHT
PCOS
PID
endometriosis

Question 5

how does CA-125 guide management

Answer 5

<35 - consider ddx
35-200:
- if pre-menopausal repeat in 6 weeks
- if post menopausal for USS
>200: USS +/- gynae referral

Menstruation can raise CA 125 levels; avoid testing during this time

In pre-menopausal females, also measure hcg and AFP (can be elevated in germ cell tumours)

Question 6

First line hormonal treatment for endometriosis (along with analgesia)

Answer 6

POP is first line- provera, noriday, jadelle, mirena

COCP

Other options include
-gonadotropin-releasing hormone (GnRH) analogues (e.g. goserelin, leuprorelin, buserelin)
- androgenic medicines (e.g. danazol)

Question 7

Fertility and endometriosis

Answer 7

Extent of disease burden does not perfectly correlate to fertility

however, surgery to ablate or excise endometriomas, adhesions and scar tissue is the most common treatment for women with endometriosis who wish to conceive.
Flushing with lipiodol (an oil soluble contrast medium) has been shown to increase the rate of pregnancy, and may be considered in the setting of a specialist fertility clinic.

Question 8

What % of women re-develop symptoms post endometrial surgical resection

Answer 8

20–40% of women re-develop symptoms within five years of surgery, although rates vary by subtype.

Hormonal treatment, e.g.mirea following surgery can reduce the risk of recurrence

Question 9

Risk factors for endometrial cancer

Answer 9

Largely linked to excessive exposure to endogenous or exogenous oestrogen unopposed by progesterone

-age (≥ 55 years)
-obesity
- familial cancer syndromes
- tamoxifen
- oestrogen only HRT

Question 10

HPV vaccine - who is eligible, when do we give it, what strains does it protect against

Answer 10

Anyone aged 9-26yrs

ideally give at 9yrs
2x dose: 0 and 5 months

Protects against 6, 11 (warts), 16, 18 (cancerous) and 5 additional cancerous strains

Question 11

Common pathogens associated with an uncomplicated infection

Answer 11

E.coli 70+ %
Staphylococcus saprophyticus
Proteus spp
Klebsiella spp
Enterococcus spp.

Complicated UTIs are also more commonly caused by E. coli, however, the range of possible causative species is much broader than for uncomplicated infections

Question 12

Implication of nitrites and leus on urine dipstick

Answer 12

Nitrite status – sterile urine generally should not contain detectable traces of nitrite. Enterobacteriaceae bacteria (most UTIs) metabolise nitrates to nitrites.

Leukocyte esterase is an enzyme produced by white blood cells. If the test is positive, it may indicate that white blood cells have been generated by the body in response to infection, and that they are present in the urine (pyuria).

A positive result for either + LUTS is sufficient for diagnosis, however negative urine dipstick results may not reliably exclude the possibility of a UTI e.g. some UTIs caused by bacterial species that are unable to produce nitrites

Haematuria is commonly associated with a UTI but not urethritis

Question 13

should you request an MSU for an uncomplicated UTI

Answer 13

No

only request if complicated (recurrent, known abnormalities, suspected pyleo, immunosuppressed, diabetes, renal calculi etc)

Question 14

should we prescribe ural

Answer 14

Ural is no longer routinely recommended during the acute treatment of UTIs as it raises the urinary pH, which in turn reduces the effectiveness of some antibiotics, e.g. nitrofurantoin.

Use NSAIDs instead

Question 15

Common pathogens causing urethritis

(most cases are associated with a sexually transmitted infection (STI) but not all)

Answer 15

Gonococcal: Neisseria gonorrhoeae

Non-Gonococcal (NGU)
- Chlamydia trachomatis (2nd most common)
- Mycoplasma genitalium (often recurrent)
- Trichomonas vaginalis, herpes simplex virus (HSV), adenovirus, enteric bacteria (insertive anal sex) and pharyngeal organisms (oral sex)

Question 16

complications of urethritis

Answer 16

Epididymo-orchitis
Reactive arthritis (reiters)

Question 17

Symptoms and signs of urethritis

Answer 17

Symptoms:
Dysuria
Urethral discharge
Urethral irritation.

Signs:
Discharge
Urethral inflammation
Testicular or epididymal tenderness
Genital skin changes or ulceration
Local lymphadenopathy

Question 18

Causes of post coital bleeding

Answer 18

STIs, e.g. chlamydia or gonorrhoea infection
Cervical ectropion or polyps
Atrophic vaginitis
Cervical cancer
Vaginal cancer
Trauma

Question 19

causes of galactorrhea

Answer 19

Hyperprolactinaemia: Often due to pituitary adenomas (prolactinomas) or hypothyroidism

Medications: Antipsychotics, antidepressants, antihypertensives, opiates, oral contraceptives.

Physiological: Recent pregnancy, breastfeeding, or excessive nipple stimulation.

Chest wall trauma/irritation

Idiopathic:

Investigations:
Serum prolactin, thyroid function tests, pregnancy test, and imaging (e.g., MRI of pituitary, breast ultrasound/mammography for unilateral or suspicious discharge).