Gynaecology Flashcards
what are the risk factors for endometrial cancer?
1) nulliparity
2) more exposure to oestrogen (nulliparity, early menarche, late menopause, oestrogen only HRT)
3) metabolic syndrome- obesity, diabetes, PCOS
4) tamoxifen (used to treat breast ca. Blocks oestrogen receptor activity in breast, but acts like oestrogen in uterus. also increases risk of dvt)
5) HNPCC
what is the most common type of vulval cancer?
SCC
what are the risk factors for vulval cancer?
1) older age
2) smoking
3) HPV
4) VIN (vulval intraepithelial neoplasia)
5) immunosuppression
6) lichen sclerosus
does smoking increase the risk of endometrial cancer?
no, it decreases the risk because it can reduce oestrogen levels and induce endometrial apoptosis, and lead to earlier menopause
what is the investigation of choice for ectopic pregnancy?
1) Pregnancy test
2) Transvaginal USS
what are the criteria for being able to manage an ectopic pregnancy expectantly?
<35mm
asymptomatic
unruptured
no foetal heartbeat
b-hCG <1000 IU/L
what are the criteria for being able to manage an ectopic pregnancy medically?
<35mm
unruptured
no significant pain
no foetal heartbeat
b-hCG <1500 IU/L
what are the criteria for managing an ectopic pregnancy surgically?
> 35mm
pain/rupture
foetal heartbeat
b-hCG >5000IU/L
for ectopic pregnancy, when would you do salpingectomy vs salpingotomy if surgical intervention indicated?
1) salpingectomy is first line
2) salpingotomy if risk factors for infertility e.g. contralateral tube is damaged
how is menopause diagnosed?
usually a clinical diagnosis when a lady had not had a period for 12 months if >50 and no period for 24 montsh if <50
what are contraindications for HRT?
1) current or past breast cancer
2) any oestrogen-sensitive cancer (endometrial, ovarian)
3) undiagnosed vaginal bleeding
4) untreated endometrial hyperplasia
how long do menopause symptoms typically last?
2-5 years
what risks are associated with HRT?
VTE
stroke
coronary heart disease
breast cancer
ovarian cancer
does transdermal HRT increase risk of VTE?
no because the oestrogen is absorbed through the skin therefore bypasses the liver = no increase in production of clotting factors in the liver
what are the potential complications of HRT?
1) side effects
- nausea, breast tenderness, weight gain
2) risks
- breast cancer (increases with duration of use, risk declines after stopping and returns to baseline 5 years after stopping)
- endometrial cancer (always give progesterone in addition to oestrogen in women with a womb to reduce risk- note doesn’t eradicate risk entirely)
- VTE (although transdermal doesn’t increase risk of VTE, should refer to haem if woman has high risk of clotting)
- stroke
- IHD if taken more than 10 years after menopause
what are risk factors for ovarian cancer?
1) more ovulations (early menarche, late menopause, nulliparity
2) family history
3) mutations in BRCA1/BRCA2
what is the tumour marker for ovarian cancer?
CA-125
what are BRCA 1 and 2?
1) tumour suppressor genes
2) mutation can cause increased risk of cancers, particularly breast and ovarian
what is the most common type of cervical cancer?
SCC
what are risk factors for cervical cancer?
1) HPV (16, 18, 33 in particular)
2) smoking
3) HIV
4) smoking
5) early first intercourse, many sexual partners
6) high parity
7) lower socioeconomic status
8) COCP
how does HPV cause cervical cancer?
HPV 16 & 18 produce oncogenes E5, E6, and E7
what is the difference between primary and secondary amenorrhoea?
primary = periods haven’t started
secondary = periods stop
1) primary
- no periods by age 15 but has secondary sexual characteristics
- or no periods by age 13 and no secondary sexual characteristics
2) secondary
- periods stop for 3-6 months in someone with previously normal periods, or 6-12 months in women with previous oligomenorrhoea
what type of drug is duloxetine?
SNRI (serotonin noradrenaline reuptake inhibitor)
how does duloxetine help manage stress incontinence
enhances activation of the pudendal nerve, which innervates the external urethral sphincter, allowing for stronger contraction
what is a threatened miscarriage?
1) painless vaginal bleeding <24 weeks (typically 6-9 weeks)
2) closed cervical os
what is a missed miscarriage?
1) gestational sac containing dead foetus <20 weeks
2) closed cervical os
3) mother may have light vaginal bleeding, usually no pain, symptoms of pregnancy disappear
what is an inevitable miscarriage?
1) heavy bleeding with clots and pain
2) cervical os open
what is an incomplete miscarriage?
1) not all products of conception expelled
2) pain and vaginal bleeding
3) cervical os open
what is a miscarriage?
loss of pregnancy <24 weeks
most commonly occurs in first 12 weeks of pregnancy
what is the age range for cervical cancer screening?
25-64 (invites sent at age 24.5)
every 3 years, then from age 50 every 5 years
how does the cervical screening test work?
Now moved to a HPV first system
1) test for presence of HPV
2) HPV positive –> cytology
HPV negative –> return to normal recall
3) Cytology abnormal –> colposcopy
Cytology normal repeat HPV test in 12 months
4) sample inadequate, repeat at 3 months
2 x inadequate samples, colposcopy
5) If CIN, LLETZ
what is Sheehan’s syndrome?
1) post-partum hypopituitarism
2) caused by hypovolaemic shock causing ischaemic necrosis of pituitary gland
define premature menopause
onset of menopausal symptoms and elevated gonadotropin levels before the age of 40
what causes premature ovarian insufficiency (premature menopause)?
1) idiopathic
- may have family history
2) bilateral oophorectomy
3) radiotherapy and chemotherapy
4) infection e.g. mumps
5) autoimmune
how is premature ovarian failure treated?
HRT or COCP until age 51
what is Asherman’s syndrome?
uterine/cervical adhesions leading to menstrual abnormalities, pelvic pain, infertility, recurrent miscarriage
prior to surgery to remove a fibroid, what medication may be given?
GnRH agonist = less oestrogen = reduce growth of fibroid (however only used short term as mimics other symptoms of menopause too)
what are the missed pill rules for the POP?
1) desogestrel (cerazette)
- if <12 hours late no action required
- if >12 hours late take missed pill asap and take next pill as usual, use condoms until pill taking has been established for 48 hours
2) traditional (non-desogestrel) e.g. micronor, noriday, femulen
- <3 hours late no action required
- >3 hours late take missed pill asap and take next pill as usual, use condoms until pill taking established for 48 hours
how does the depo provera work?
- progesterone IM injection given every 12 weeks
- primarily inhibits ovulation
- also thickens cervical mucus and thins endometrium
what are adverse effects associated with depo provera?
- irregular bleeding
- weight gain
- increased risk of osteoporosis (avoid in adolescents)
- not quickly reversible, may have delayed return of fertility
what is UKMEC? what are the different categories?
UK medical eligibility criteria (guidelines to assess which contraception is safe for a patient)
UKMEC 1 = no restrictions on use
UKMEC 2 = advantages generally outweigh risks
UKMEC 3= risks generally outweigh benefits
UKMEC 4 = unacceptable risk to health
what is a contraindication for depo provera?
breast cancer (as it increases risk of breast cancer)
current breast cancer is UKMEC4, past breast cancer is UKMEC 3
what is a contraindication to all forms of hormonal contraception?
breast cancer
What are three options for emergency contraception
1) levonorgestrel
2) ulipristal
3) IUD
how does levonorgestrel work as emergency contraception?
- inhibits ovulation and implantation
- must be taken within 72 hours of UPSI
how does ulipristal (EllaOne) work as emergency contraception?
- inhibits ovulation
- must be taken within 120 hours (5 days) of UPSI
- caution in severe asthma
how does the IUD work as emergency contraception?
- toxic to sperm
- insert within 5 days of UPSI
what are the missed pill rules for the COCP?
- 1 missed pill = take missed pill then continue taking pills as usual
- 2 missed pills = take missed pill then continue taking pills as usual and use condoms/abstain from sex until taken pills for 7 days in a row
- if 2 pills missed in week 1 (day 1-7), emergency contraception
- week 3 (day 15-21) omit pill free interval
COCP gives increased risk of (1) and (2), but is protective against (3) and (4)
increased risk breast and cervical cancer
protective against ovarian and endometrial cancer (as fewer ovulations)
does the COCP cause weight gain?
some users report this however a Cochrane review didn’t show any causal relationship
what are adverse effects of the COCP?
1) headache, nausea, breast tenderness
2) increased risk of cervical and breast cancer
3) increased risk of VTE, stroke, IHD
how soon will a pregnancy test read positive?
take on the first day of a missed period or at least 21 days after UPSI
b-hCG starts being produced 6-10 days after conception however can be unreliable to test this early, therefore advised to take on the first day of a missed period
what are some absolute contraindications for the COCP?
- migraine with aura
- breastfeeding <6 weeks post-partum
- age ≥35 smoking ≥15 cigarettes/day
- systolic 160mmHg or diastolic 95mmHg
- vascular disease
- current or previous hx VTE
- major surgery with prolonged immobilisation
- known thrombogenic mutations
- current/previous hx of IHD
- stroke (including TIA)
- complicated valvular and congenital heart disease
- current breast cancer
- nephropathy/retinopathy/neuropathy
- severe (decompensated) cirrhosis
- hepatocellular adenoma
- raynaud’s disease with lupus anticoagulant
Positive antiphospholipid antibodies
how doe GnRH agonists help reduce fibroid size?
usually GnRH increases oestrogne (more GnRH increases FSH and LH increases oestrogen), however this is when GnRH is released as intermittent pulses
when released continuously (i.e. GnRH agonist), this actually decreases FHS and LH and oestrogen
reduced oestrogen means the fibroid shrinks
A 27-year-old woman complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation. how would you treat?
sounds like trichomonas (strawberry cervix typical) which is treated with oral metronidazole
what stain and shape is gonorrhoea?
gram negative diplococci
what stain and shape is chlamydia?
gram negative cocci
how is chlamydia treated?
oral doxycycline
how is gonorrhoea treated?
IM ceftriaxone
