Gynaecology Flashcards
1
Q
Amenorrhoea classification?
A
- Primary = by 15 y/o with normal secondary sexual characteristics, or by 13 y/o with no secondary sexual characteristics
- Secondary = cessation for 3-6m in women with previously normal menses, or 6-12 months with previous oligomenorrhoea
2
Q
Primary amenorrhoea causes?
A
- Gonadal dysgenesis = Turner’s
- Testicular feminisation
- Congenital malformation of the genital tract
- Functional hypothalamic amenorrhoea e.g. occurs due to disruption of the hypothalamic-pituitary-ovarian (HPO) axis, often in the absence of structural abnormalities.
- CAH
- Imperforate hymen
3
Q
Most common cause of primary amenorrhoea?
A
Gonadal dysgenesis = Turner’s
4
Q
Secondary amenorrhoea causes?
A
- Hypothalamic = stress, exercise
- PCOS
- POF
- Hyperprolactinaemia
- Thyrotoxicosis
- Sheehan’s
- Asherman’s syndrome
5
Q
Asherman’s syndrome?
A
Intrauterine adhesions
6
Q
Amenorrhoea Ix?
A
- Exclude pregnancy with urinary or serum bHCG
- FBC, U&E, TFT, Coeliac
- Gonadotrophins = low levels indicate hypothalamic cause, raised levels suggest ovarian problem/gonadal dysgenesis e.g. POF or Turner’s
- Prolactin
- Androgens = raised levels may be seen in PCOS
- Oestradiol
7
Q
Primary amenorrhoea Rx?
A
- Underlying cause
- POF due to gonadal dysgenesis are likely to benefit from HRT to prevent osteoporosis etc.
8
Q
Secondary amenorrhoea Rx?
A
- Exclude pregnancy, lactation and menopause (in > 40 y/o)
- Underlying cause
9
Q
Urinary incontinence affects what % of the population?
A
4-5%
10
Q
Urinary incontinence RFs?
A
- Age
- Pregnancy and childbirth
- High BMI
- Hysterectomy
- FHx
11
Q
Urinary incontinence classification?
A
- Overactive bladder (OAB)/Urge
- Stress
- Mixed
- Overflow
- Functional
12
Q
Stress incontinence?
A
Leaking small amounts when coughing or laughing
13
Q
Mixed incontinence?
A
Both urge and stress
14
Q
Functional incontinence?
A
- Comorbid conditions impair pt’s ability to get to bathroom in time
- Dementia, sedating medication, injury/illness resulting in decreased ambulation
15
Q
Urinary incontinence Ix?
A
- Bladder diaries for minimum 3 days
- Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- Urine dipstick and culture
- Urodynamic studies
16
Q
Urge incontinence predominant Rx?
A
- Bladder retraining 6w minimum
- Bladder stabilising drugs = antimuscarinics e.g. oxybutynin, tolterodine, darifenacin
- Mirabegron (B3 agonist) if concern about anticholinergic s/e in frail elderly pts
17
Q
When should immediate release oxybutynin be avoided?
A
Frail older women
18
Q
Stress incontinence predominant Rx?
A
- PFMT (8 contractions 3 x day for 3m)
- Surgery = Retropubic mid-urethral tape procedures
- Duloxetine if decline surgical procedures (combines NSRI)
19
Q
Simple ovarian cyst?
A
Unilocular, more likely to be physiological or benign
20
Q
Complex ovarian cyst?
A
Multilocular, more likely to be malignant
21
Q
Premenopausal women cyst management?
A
A conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
22
Q
Postmenopausal ovarian cyst management?
A
By definition physiological cysts are unlikely –> any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
23
Q
Ovarian hyperstimulation syndrome?
A
Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment
24
Q
When is OHSS more likely to be seen?
A
With gonadotrophin or hCG treatment. Rarely seen with clomifene therapy?
25
What % of women having IVF may experience a mild form of OHSS?
Up to 1/3rd
26
OHSS Classification?
1. Mild = abdominal pain and bloating
2. Moderate = nausea + vomiting, ascites on US
3. Severe = clinical ascites, oliguria, haematocrit > 45%, hypoproteinaemia
4. Critical = VTE, ARDS, anuria, tense ascites
27
Premature ovarian insuffiency (POI) definition?
Onset of menopausal symptoms and elevated gonadotrophin levels before 40 y/o
28
POI prevalence?
1 in 100 women
29
Causes of premature menopause?
1. Idiopathic = most common, may be FHx
2. Bilateral oophorectomy
3. Radiotherapy
4. Chemotherapy
5. Infection e.g. mumps
6. Autoimmune disorders
7. Resistant ovary syndrome: due to FSH receptor abnormalities
30
Resistant ovary syndrome?
Due to FSH receptor abnormalities
31
POI bloods?
1. FSH > 40 , on 2 blood samples taken 4-6 weeks apart
2. Raised LH
3. Low oestradiol e.g. < 100
32
POI Rx?
HRT or COCP to women until average age of menopause 51 y/o
33
Does HRT provide contraception?
No
34
Oestrogen protective for?
Bone health and cardiovascular disease
35
Why may doxazosin worsen stress incontinence?
Alpha blocker --> relaxes bladder outlet and urethra
36
Menorrhagia quantity?
>80mls per menses but obviously hard to quantify
37
Menorrhagia causes?
1. Dysfunctional uterine bleeding
2. Anovulatory cycles
3. Fibroids
4. Hypothyroidism
5. IUD
6. PID
7. Bleeding diatheses
38
Dysfunctional uterine bleeding?
Half of all patients. Menorrhagia in the absence of underlying pathology.
39
When are anovulatory cycles more common?
At the extremes of a woman's reproductive life
40
vWD typical inheritance?
AD
41
Most common inherited bleeding disorder?
vWD
42
vWD Bloods?
1. Prolonged bleeding time
2. APTT may be prolonged
3. Factor VIII levels may be moderately reduced
4. Defective platelet aggregation with ristocetin
43
Oxybutynin MOA?
Anti-muscarinic
44
Cervical adenocarcinomas account for what % of cases?
15%, frequently undetected by screening
45
Smear test offering?
1. 25-49 y/o = 3 yearly
2. 50-64 y/o = 5 yearly
3. Cannot be offered to > 64 y/o, in Scotland is offered every 5 years 25-64 y/o
46
Cervical screening special situations?
1. Pregnancy = delayed until 3m post-partum unless missed screening or previous abnormal smears
2. Never sexually active can opt out of screening as very low risk
47
Best time to take cervical smear?
Around mid-cycle
48
4 types of miscarriage?
1. Threatened
2. Missed (delayed)
3. Inevitable
4. Incomplete
49
Threatened miscarriage?
1. Painless vaginal bleeding before 24 weeks but typically occurs at 6-9 weeks
2. Bleeding often less than menstruation
3. Cervical os closed
4. Complicates up to 25% of all pregnancies
50
Missed (delayed) miscarriage?
1. A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
2. Light vaginal bleeding/discharge and symptoms of pregnancy which disappear, pain is not usually a feature
3. Cervical os is closed
4. When the gestational sac is >25mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'
51
Inevitable miscarriage?
1. Heavy bleeding with clots and pain
2. Cervical os is open
52
Incomplete miscarriage?
1. Not all products of conception have been expelled
2. Pain and vaginal bleeding
3. Cervical os is open
53
Vulval carcinoma mushkies?
1. 80% SCCs
2. Mostly > 65 y/o
3. Rare, 1200 in UK each year
54
Vulval carcinoma RFs?
1. HPV infection
2. VIN
3. Lichen sclerosus
4. Immunosuppression
55
Vulval carcinoma features?
1. Lump or ulcer on labia majora
2. Inguinal lymphadenopathy
3. May be associated with itching, irritation
56
Mittelschmerz mushkies?
Mittelschmerz literally translates to 'middle pain' and refers to abdominal pain associated with ovulation. This mid-cyclical pain is experienced by 20% of women and there are several theories as to why it occurs. One explanation is that is occurs due to a leakage of follicular fluid containing prostaglandins at the time of ovulation, which causes the pain. Another explanation is that the growth of the follicle stretches the surface of the ovary, causing pain
57
Mittelschmertz presentation?
1. Sudden onset of pain in iliac fossa which then manifests as generalised pelvic pain
2. Typically pain is not severe and varies in duration, lasting from mins to hours
3. Self-limiting and resolves within 24 hours of onset
4. Pain may switch side from month to month, depending on site of ovulation
58
Mittelschmertz Ix?
Clinical
59
Mittelschmerz Rx?
Simple analgesia
60
Ovarian cancer pathophysiology?
1. 90% epithelial in origin, with 70-80% being due to serous carcinomas
2. Distal end of fallopian tube is often the site of origin
61
Ovarian cancer RFs?
1. FHx = BRCA1/BRCA2
2. Many ovulations = early menarche, late menopause, nulliparity
62
Ovarian cancer clinical features?
Notoriously vague = abdominal distension, bloating, abdo+pelvic pain, urinary symptoms, early satiety, diarrhoea
63
Ovarian cancer Ix?
1. Ca-125 --> if raised >35 then urgent:
2. US
64
Ca-125 mushkies?
Endometriosis, menstruation, and benign ovarian cysts may raise Ca 125. Should not be used for screening in asymptomatic women.
65
Ovarian Cancer diagnosis?
Is difficult and usually involves diagnostic laparotomy
66
Ovarian cancer Rx?
Usually combination of surgery and platinum-based chemotherapy
67
Ovarian cancer prognosis?
1. 80% of women have advanced disease at presentation
2. All stage 5 year survival is 46%
68
COCP risk on ovarian cancer?
Decreases risk
69
PCOS mushkies?
Polycystic ovarian syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. Management is complicated and problem based partly because the aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
70
PCOS management domains?
1. General
2. Hirsutism and acne
3. Infertility
71
PCOS general management?
1. Weight reduction if appropriate
2. If requires contraception then COCP may help regulate her cycle and induce a monthly bleed
72
PCOS hirsutism and acne Rx?
1. COCP or co-cyprindiol
2. Topical eflornithine
3. Spironolactone, flutamide and finasteride under specialist supervision
73
PCOS infertility management?
1. Clomifene first line
2. Metformin if obese (can be used in combination)
3. Gonadotrophins
74
Clomifene MOA?
Work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion
75
Dysmenorrhoea definition?
Excessive pain during menstrual period
76
Dysmenorrhoea classification?
Primary and secondary
77
Primary Dysmenorrhoea mushkies?
No underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.
78
Primary Dysmenorrhoea features?
1. Pain typically starts just before or within a few hours of period starting
2. Suprapubic cramping pains which may radiate to the back or down the thigh
79
Primary dysmenorrheoa Rx?
1. NSAIDs e.g. mefenamic acid and ibuprofen effective in up to 80% women, inhibit PG production
2. COCP 2nd line
80
Secondary dysmenorrhoea mushkies?
Typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period
81
Secondary dysmenorrhoea causes?
1. Endometriosis
2. Adenomyosis
3. PID
4. IUD
5. Fibroids
82
Secondary menorrhoea Rx?
Refer all pts to gynaecology for Ix
83
Vaginal candidiasis predisposing factors?
1. DM
2. Drugs = Abx, steroids
3. Pregnancy
4. Immunosuppression
84
Vaginal candidiasis features?
1. 'Cottage cheese', non-offensive discharge
2. Vulvitis: superficial dyspareunia, dysuria
3. Itch
4. Vulval erythema, fissuring, satellite lesions may be seen
85
Vaginal candidiasis Ix?
Clinical
86
Vaginal candidiasis Rx?
1. Oral fluconazole 150mg single dose 1st line
2. Clotrimazole 500mg IV pessary as single dose if oral therapy C/I
3. If vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
4. If pregnant then orals C/I
87
Recurrent vaginal candidiasis Rx?
1. Defined as 4 or more episodes per year
2. Confirm diagnosis = high vaginal swab for MCS, consider blood glucose to exclude DM
3. Exclude DDx e.g. lichen sclerosus
4. Consider induction-maintenance regime = Induction oral fluconazole OD 3 days. Maintenance oral fluconazole weekly 6m.
88
PID definition?
Infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix.
89
PID causative organisms?
1. Chlamydia trachomatis +
2. Neisseria gonorrhoeae/mycoplasma genitalium/mycoplasma hominis
90
PID features?
1. Lower abdominal pain
2. Fever
3. Deep dyspareunia
4. Dysuria and menstrual irregularities
5. Vaginal or cervical discharge
6. Cervical excitation
91
PID Ix?
1. Pregnancy test to exclude ectopic
2. High vaginal swab = often -ve
3. Chlamydia and gonorrhoea screen
92
PID Rx?
1. Oral ofloxacin + oral metronidazole OR
2. IM Ceftriaxone + oral metronidazole + oral doxycycline
2. Consider removing IUD/IUS
93
PID complications?
1. Perihepatitis = Fitz-Hugh Curtis syndrome (10% cases, characterised by RUQ pain and may be confused with cholecystitis)
2. Infertility = risk 10-20% after a single episode
3. Chronic pelvic pain
4. Ectopic pregnancy
94
Infertility prevalence?
1/7 couples. 84% who have regular sex will conceive within 1 year and 92% within 2 years
95
Infertility causes?
1. Male = 30%
2. Unexplained = 20%
3. Ovulation failure = 20%
4. Tubal damage = 15%
5. Other = 15%
96
Basic infertility Ix?
1. Semen analysis
2. Serum progesterone 7 days prior to expected next period. Usually, day 21.
97
Infertility Ix interpretation of serum progestogen?
1. < 16 = repeat, if consistently low refer to specialist
2. 16 - 30 = repeat
3. >30 = indicates ovulation
98
Key infertility counselling points?
1. Folic acid
2. Aim BMI 20-25
3. Regular sexual intercourse every 2-3 days
4. Smoking/drinking advice
99
Referral after 6m for infertility criteria?
1. Female = > 35 y/o, amenorrhoea, previous pelvic surgery, previous STI, abnormal genital examination
2. Male = previous surgery on genitalia, previous STI, varicocoele, significant systemic illness, abnormal genital examination
100
< 35 y/o woman when should referral for infertility be made?
After 12m of regular sexual intercourse
101
Pregnant thrush infection Rx?
Clotrimazole pessary
102
Secondary amenorrhoea with low gonadotrophin levels?
Hypothalamic cause
103
Cervical cancer types?
1. SCC = 80%
2. Adenocarcinoma = 20%
104
Cervical cancer incidence?
Around 50% of cases of cervical cancer occur in women under the age of 45 years, with incidence rates for cervical cancer in the UK are highest in people aged 25-29 years
105
Cervical cancer features?
1. Detected during screening
2. Abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
3. Vaginal discharge
106
HPV cervical cancer serotypes?
16, 18 and 33
107
Cervical cancer risk factors?
1. Smoking
2. HIV
3. Early intercourse, many sexual partners
4. High parity
5. Low SEC
6. COCP
108
Mechanism of HPV causing cervical cancer?
1. HPV 16 and 18 produces oncogenes E6 and E7 respectively
2. E6 inhibits p53 TS gene
3. E7 inhibits RB suppressor gene
109
When can expectant management of ectopic pregnancy be performed?
1. Unruptured embryo
2. <35mm in size
3. Have no heartbeat
4. Be asymptomatic
5. bHCG < 1000 and declining
110
Ectopic pregnancy Ix?
TVUS
111
Ectopic pregnancy 3 management strategies?
1. Expectant
2. Medical
3. Surgical
112
Expectant pregnancy management?
1. Size <35mm, unruptured, asymptomatic
2. No fetal heartbeat, hCG < 1000
3. Compatible if another intrauterine pregnancy
4. Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed
113
Ectopic pregnancy medical management?
1. Size <35mm, unruptured, no significant pain
2. No fetal heartbeat, hCG <1500
3. Not suitable if intrauterine pregnancy
4. Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow-up
114
Ectopic pregnancy surgical management?
1. Size > 35mm, can be ruptured, pain
2. Visible fetal heartbeat, hCG > 5000
3. Compatible with another intrauterine pregnancy
4. Salpingectomy 1st line for women with no other risk factors for infertility. Saplingotomy considered for women with RFs for infertility e.g. contralateral tube damage (1/5 who undergo salpingotomy may require further treatment with methotrexate and/or a salpingectomy)
115
Body temperature rises when in menstrual cycle?
Following ovulation
116
Menstrual cycle phases?
1. Days 1-4 = Menstruation
2. Days 5-13 = Follicular (proliferative) phase
3. Day 14 = Ovulation
4. Days 15-28 = Luteal (secretory) phase
117
Follicular (proliferative) phase mushkies?
1. Number of follicles develop, one will become dominant around mid-follicular phase
2. Proliferation of endometrium
3. Rise in FSH results in development of follicles which in turn secrete oestradiol. When the egg has matured, it secretes enough oestradiol to trigger the acute release of LH. This in turn leads to ovulation
4. Following menstruation the cervical mucus is thick and forms a plug across the external os. Just prior to ovulation the mucus becomes clear, acellular, low viscosity. It also becomes 'stretchy' - a quality termed spinnbarkeit
5. Basal body temperature falls prior to ovulation due to the influence of oestradiol
118
Luteal (secretory) phase mushkies?
1. Corpus luteum present
2. Endometrium changes to secretory lining under influence of progesterone
3. Progesterone secreted by corpus luteum rises through the luteal phase. If fertilisation does not occur the corpus luteum will degenerate and progesterone levels fall. Oestradiol levels also rise again during the luteal phase.
4. Under influence of progesterone, cervical mucus becomes thick, scant and tacky
5. Temperature rises following ovulation in response to higher progesterone levels
119
Ovarian cyst classification?
1. Physiological
2. Benign germ cell tumours
3. Benign epithelial tumours
4. Benign sex cord stromal tumours
120
Physiological (functional) ovarian cysts types?
1. Follicular
2. Corpus luteum
121
Follicular cyst?
1. Commonest type of ovarian cyst
2. Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
3. Commonly regress after several menstrual cycles
122
Corpus luteum cyst?
1. If corpus luteum doesnt break down as normal, may fill with blood or fluid and form a corpus luteal cyst
2. More likely to present with intraperitoneal bleeding than follicular cysts
123
Benign germ cell tumour?
Dermoid cyst
124
Dermoid cyst mushkies?
1. AKA Mature cystic teratomas, usually lines with epithelial tissue and hence may contain skin appendages, hair and teeth
2. Most common benign ovarian tumour in women under the age of 30 years
3. Median age of diagnosis is 30 years old
4. Bilateral in 10-20%
5. Usually asymptomatic, torsion is more likely than with other ovarian tumours
125
Torsion most likley with which ovarian tumour?
Dermoid cyst
126
Benign epithelial tumours arise from?
Ovarian surface epithelium
127
Benign epithelium tumour types?
1. Serous cystadenoma
2. Mucinous cystadenoma
128
Serous cystadenoma types?
1. Most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
2. Bilateral in around 20%
129
Mucinous cystadenoma types?
1. Second most common benign epithelial tumour
2. Typically large and may become massive
3. If ruptures may cause psueomyxoma peritonei
130
Chocolate cyst?
Endometriotic cyst
131
Sheehan's syndrome?
Hypopituitarism caused by ischaemic necrosis due to blood loss and hypovolaemic shock
132
Sheehan's syndrome features?
1. Agalactorrhoea
2. Amenorrhoea
3. Symptoms of hypothyroidism
4. Symptoms of hypoadrenalism
133
Fibroid definition?
Benign smooth muscle tumours of the uterus
134
Uterine fibroid epidemiology?
20% of white an 50% black women in the later reproductive years
135
Fibroid associations?
1. Afro-Caribbean
2. Rare before puberty, develop in response to oestrogen
136
ibroid features?
1. Asymptomatic
2. Menorrhagia and IDA
3. Lower abdominal pain
4. Bloating, urinary symptoms
5. Subfertility
6. Rare = polycythaemia secondary to autonomous production of EPO
137
Fibroid Dx?
TVUS
138
Asymptomatic fibroid Rx?
None apart from periodic review to monitor size and growth
139
Fibroid menorrhagia Rx?
1. IUS = useful if requires contraception, cannot be used if distortion of uterine cavity
2. NSAIDs e.g. mefenamic acid
3. Tranexamic acid
4. COCP
5. Oral/injectable progestogen
140
Treatment to shrink/remove fibroids?
1. Medical = GnRH agonist
2. Surgical = myomectomy, hysteroscopic endometrial blation, hysterectomy
3. Uterine artery embolization
141
Fibroid prognosis and complications?
1. Generally regress after the menopause
2. Red degeneration = haemorrhage into tumour = commonly occurs during pregnancy
142
GnRH agonist s/e?
1. Menopausal symptoms = hot flushes, vaginal dryness
2. Loss of BMD
143
Menopause definition?
Permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.
144
Menopausal symptoms epidemiology?
Very common and affect roughly 75% of postmenopausal women. Symptoms typically last for 7 years but may resolve quicker and in some cases take much longer. The duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.
145
Management of menopause classification?
1. Lifestyle modifications
2. HRT
3. Non-HRT
146
Lifestyle modification Rx?
1. Hot flushes = regular exercise, weight loss and reduce stress
2. Sleep disturbance = avoid late evening exercise and maintaining good sleep hygeine
3. Mood = sleep, regular execise and relaxation
4. Cognitive symptoms = regular exercise and good sleep hygeine
147
HRT contraindications?
1. Current or past breast cancer
2. Any oestrogen-sensitive cancer
3. Undiagnosed vaginal bleeding
4. Untreated endometrial hyperplasia
148
HRT treatment risks?
1. VTE
2. Stroke
3. Coronary heart disease
4. Breast cancer
5. Ovarian cancer
149
Non-HRT management?
1. Vasomotor symptoms = fluoxetine, italopram or venlafaxine
2. Vaginal dryness = vaginal lubricant or moisturiser
3. Psychological symptoms = self-help groups, CBT or antidepressants
4. Urogenital symptoms = urogenital atrophy --> vaginal oestrogen
150
HRT stopping treatment?
For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment. Vaginal oestrogen may be required long term. When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.
151
When should menopause be referred to secondary care?
1. If treatment ineffective
2. If ongoing side effects
3. Unexplained bleeding
152
Ovarian torsion presentation?
Sudden onset unilateral lower abdominal pain, onset may coincide with exercise. N&V are common. Unilateral, tender adnexal mass on examination.
153
Endometriosis features?
1. Chronic pelvic pain
2. Dysmenorrhoea - pain often starts days before bleeding
3. Deep dyspareunia
4. Subfertility
154
Ovarian cyst features?
Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder
155
Urogenital prolapse features?
1. Seen in older women
2. Sensation of pressure, heaviness, bearing down
3. Urinary symptoms: incontinence, frequency, urgency
156
Endometriosis definition?
Common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of a reproductive age have a degree of endometriosis.
157
Endometriosis clinical features?
1. Chronic pelvic pain
2. Secondary dysmenorrhoea, pain often starts days before bleeding
3. Deep dyspareunia
4. Subfertility
5. Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria, dyschezia (painful bowel movements)
7. O/e = reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
158
Endometriosis Ix?
1. Laparoscopy: gold standard
2. Little role for Ix in primary care e.g. US - if significant, pt should be referred for a definitive diagnosis
159
Correlation between laparoscopic findings and severity of symptoms in endometriosis?
Poor
160
Endometriosis Rx?
1. NSAIDs +/- paracetamol
2. COCP or progestogens e.g. medroxyprogesterone acetate
3. Refer to secondary care
161
Endometriosis secondary care Rx?
1. GnRH analogues = said to induce a 'pseudomenopause' due to the low oestrogen levels
2. Drug therapy does not seem to have a significant impact on fertility rates
3. Surgery = some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
162
HMB Ix?
1. FBC in all women
2. Routine TVUS if symptoms e.g. intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms suggest a structural or histological abnormality, other indications include abnormal pelvic exam findings
163
HMB Rx classification?
1. Requires contraception
2. Doesn't require contraception
164
HMB requires contraception Rx?
1. IUS (Mirena) 1st line
2. COCP
3. Long-acting progestogens
165
HMB doesnt require contraception Rx?
1. Mefenamic acid 500mg TDS (esp. if dysmenorrhoea as well) or tranexamic acid 1g TDS, both are started on the first day of the period
2. If not improvement then try other drug whilst awaiting referral
166
SHort term option to rapidly stop HMB?
Norethisterone 5mg TDS
167
Termination of pregnancy key points?
1. 2 registered medical practitioners must sign a legal document (in an emergency only one is needed)
2. Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
168
Method used to terminate pregnancy?
Depends on gestation:
1. < 9 weeks = mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
2. < 13 weeks = surgical dilation and suction of uterine contents
3. > 15 weeks = surgical dilation and evacuation of uterine contents or late medical abortion (induces 'mini-labour')
169
1967 abortion act?
1. That the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
2. That the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
3. That the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
4. That there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
170
Menopause contraception age mushkies?
1. 12 months after the last period in women > 50 years
2. 24 months after the last period in women < 50 years
171
Raised FSH/LH in primary amenorrhoea?
Consider gonadal dysgenesis e.g. Turner's syndrome
172
What medication can be used to reduce size of a fibroid?
GnRH agonist, can be used prior to surgery
173
Only effective Rx for large fibroids causing problems with fertility?
Myomectomy
174
Why cant Tibolone be used within 12m of last LMP?
May cause irregular bleeding
175
Most common ovarian cyst?
Follicular cyst
176
Secondary dysmenorrhoea Rx?
Refer all to gynaecology for Ix
177
Cervical screening system?
Sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
178
Cervical smear negative hrHPV Rx?
Return to normal recall, unless:
1. The test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
2. Untreated CIN1 pathway
3. F/up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
4. Follow-up for borderline changes in endocervical cells
179
Cervical smear positive hrHPV Rx?
All samples are examined cytologically
1. If abnormal --> colposcopy
2. If normal --> repeat test 12m later
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Abnormal cytology of HPV sample?
1. Borderline changes in squamous or endocervical cells
2. Low grade dyskaryosis and worse
3. Invasive squamous cell carcinoma
4. Glandular neoplasia
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hrHPV +ve and cytology normal repeat test 12m interpretation?
1. If the repeat test is now hrHPV -ve → return to normal recall
2. If the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later
3. If hrHPV -ve at 24 months → return to normal recall
4. If hrHPV +ve at 24 months → colposcopy
182
Cervical smear 'inadequate' sample Rx?
1. Repeat sample within 3m
2. If two consecutive inadequate samples then --> colposcopy
183
Individuals treats for CIN1/2/3 Rx?
Should be invited 6m after treatment for a test of cure repeat cervical sample in the community
184
CIN Rx?
Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic. Alternative techniques include cryotherapy.
185
Oxybutynin for urge incontinence alternatives in the elderly?
Solifenacin, tolterodine, mirabegron
186
Morning sickness AKA?
Nausea and Vomiting of pregnancy (NVP)
187
Hyperemesis gravidarum prevalence?
1% pregnancies, thought to be related to raised beta hCG levels
188
When is hyperemesis gravidarum most common?
Between 8 and 12 weeks, but may persist up to 20 weeks
189
Hyperemesis gravidarum associations?
1. Multiple pregnancies
2. Trophoblastic disease
3. Hyperthyroidism
4. Nulliparity
5. Obesity
190
Smoking and hyperermesis gravidarum?
Smoking associated with decreased incidence
191
Referral criteria for NVP?
1. Unable to keep down liquids or oral antiemetics
2. Ketonuria and/or weight loss >5% body weight
3. Confirmed or suspected comorbidity (e.g. can't tolerate oral abx for a UTI)
4. Lower threshold if co-existing condition that may be adversely affected e.g. DM
192
Hyperemesis gravidarum diagnosis triad?
1. 5% pre-pregnancy weight loss
2. Dehydration
3. Electrolyte imbalance
193
NVP scoring system?
PUQE score
194
Hyperemesis gravidarum Rx?
1. Antihistamine 1st line = Oral cyclizine, promethazine, prochlorperazine
2. Ondansetron and metoclopramide 2nd line
3. Ginger and P6 (wrist) acupuncture
4. Admission may be needed for IV hydration
195
Why shouldnt metoclopramide be used for more than 5d?
EPSEs
196
Ondansetron in 1st trimester?
Small increased risk of the baby having a cleft lip/palate. Risks should be discussed with the pregnant woman.
197
Hyperemesis gravidarum complications?
1. Wernicke's encephalopathy
2. Mallory-Weiss tear
3. Central Pontine myelinolysis
4. Acute Tubular Necrosis
5. Fetal: SGA, pre-term birth
198
What hormone surge causes ovulation?
LH
199
Trichomonas features?
1. Offensive, yellow/green, frothy discharge
2. Vulvovaginitis
3. Strawberry cervix
200
BV features?
Offensive, thin, white/grey, 'fishy' discharge
201
Older woman with labial lump and inguinal lymphadenopathy?
Likely vulval carcinoma
202
Vulval carcinoma RFs?
1. HPV
2. VIN
3. Immunosuppression
4. Lichen sclerosus
203
Vulval carcinoma features?
1. Lump or ulcer on the labia majora
2. Inguinal lymphadenopathy
3. May be associated with itching, irritation
204
Recurrent miscarriage definition?
3 or more consecutive spontaneous abortions. Occurs in 1% women.
205
Recurrent miscarriage causes?
1. Antiphospholipid syndrome
2. Endocrine = Poorly controlled DM/thyroid, PCOS
3. Uterine abnormality e.g. uterine septum
4. Parental chromosomal abnormalities
5. Smoking
206
Atrophic vaginitis?
In post-menopausal women. Presents with vaginal dryness, dyspareunia and occasional spotting. On examination, the vagina may appear pale and dry. Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
207
Endometrial cancer epidemiology?
Classically seen in post-menopausal women but around 25% occur before menopause
208
Endometrial cancer prognosis?
Usually caries a good prognosis due to early detection
209
Endometrial cancer RFs?
1. Obesity
2. Nulliarity
3. Early menarch, late menopause, unopposed oestrogen
4. DM
5. Tamoxifen
6. PCOS
7. HNPCC
210
Endometrial cancer features?
1. Classically postmenopausal bleeding
2. Premenopausal women may have a change e.g. intermenstrual bleeding
3. Pain is not common and typically signifies extensive disease
4. Vaginal discharge is unusual
211
Endometrial cancer Ix?
1. Women >=55 years with postmenopausal bleeding --> 2ww
2. 1st line Ix = TVUSS, normal endometrial thickness <4mm has a high negative predictive valye
3. Hysterosocopy with endometrial biopsy
212
Endometrial cancer Rx?
1. Localised disease --> TAH BSO. High risk --> post-op radiotherapy
2. Progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery
213
Protective for endometrial cancer?
COCP and smoking
214
Ectopic pregnancy definition?
Implantation of a fertilised ovum outside the uterus
215
Ectopic pregnancy Hx?
1. Lower abdominal pain
2. Vaginal bleeding
3. Hx of recent amenorrhoea
4. Dizziness, fainting or syncope
5. Peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination
216
Ectopic pregnancy examination findings?
1. Abdominal tenderness
2. Cervical tenderness
2. Adnexal mass = dont examine for adnexal mass due to increased risk of rupturing pregnancy, only check for cervical excitation
217
Pregnancy of unknown location and serum bHCG > 1500?
Points towards a diagnosis of ectopic pregnancy
218
PMS definition?
Emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle. Only occurs in the presence of ovulatory menstrual cycles (doesnt occur prior to puberty, during pregnancy or after the menopause)
219
PMS physical symptoms?
1. Bloating
2. Breast pain
220
PMS emotional symptoms?
1. Anxiety
2. Stress
3. Fatigue
4. Mood swings
221
PMS Rx?
Depends on severity of symptoms
1. Mild = usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
2. Moderate = COCP e.g. Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
3. Severe = SSRI = this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
222
If ruptures may cause pseudomyxoma peritonei?
Mucinous cystadenoma
223
Most common identifiable cause of postcoital bleeding?
Cervical ectropion
224
Postcoital bleeding causes?
1. NAD in 50%
2. Cervical ectropion in 33%
3. Cervicitis e.g. secondary to chlamydia
4. Cervical cancer
5. Polyps
6. Trauma
225
Cervical ectropion more common in women on what medication?
COCP
226
Meigs' syndrome?
1. Benign ovarian tumour (usually fibroma)
2. Ascites
3. Pleural effusion
227
Commonest type of ovarian cyst?
Follicular cyst
228
Most common benign ovarian tumour in women < 30 y/o?
Dermoid cyst
229
Cervical excitation causes?
PID or ectopic pregnancy
230
HRT s/e?
1. Nausea
2. Breast tenderness
3. Fluid retention and weight gain
231
HRT potential complications?
1. Increased risk of breast cancer = the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
2. Increased risk of endometrial cancer
3. Increased risk of VTE = not increased by transdermal HRT, if at high risk of VTE should be referred to haematology before starting any treatment, even transdermal
4. Increased risk of stroke
5. Increased risk of IHD = if taken more than 10 years after menopause
232
Ectopic pregnancy epidemiology?
0.5% of all pregnancies
233
Ectopic pregnancy risk factors?
1. Damage to tubes (PID/surgery)
2. Previous ectopic
3. Endometriosis
4. IUD/IUS
5. POP
6. IVF (3% all pregnancies are ectopic)
