Gynaecology Flashcards
what are the different types of benign ovarian cyst?
physiological cysts
benign germ cell tumours
benign epithelial tumours
benign sex cord stromal tumours
what type of cyst should be biopsied to exclude malignancy?
multi-loculated ovarian cysts
what is the most common type of ovarian cyst?
follicular cyst
what is a follicular cyst?
due to rupture of a non-dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
what are the symptoms of a corpus luteum cyst?
during menstrual cycle, if a pregnancy does not occur then the corpeus luteum usually breaks down and disappears. If this does not happen - the corpeus luteum may fill with blood or fluid and form a cyst.
what condition is associated with the production of multiple follicular cysts in the ovaries?
PCOS
what are the symptoms of a follicular cyst?
unilateral aching pelvic pain
dyspareunia
abnormal uterine bleeding can occur due to the hormonal imbalances produced by the cyst
what are some complications of follicular cysts?
rupture
torision
haemorrhage
what size cysts require follow up imaging?
usually simple cysts size 5cm - 7cm require follow up imaging to monitor resolution
which type of ovarian cyst has higher risk of torision>?
dermoid - heavier, will weigh on the ovary and can cause torsion
what is a dermoid cyst?
mature cystic teratoma - sac like growth which is formed from abnormal germ cell layer - can contain hair, teeth, connective tissue
what is the most common benign ovarian tumour in under 30 years?
dermoid cyst
what are the two types of benign epithelial tumour?
serous cystadenoma - most common
mucinous cystadenoma
what must be organised by GP if dermoid cyst found>?
ca-125, if > 34 -> urgent 2ww ref to gynae
if < 34 and > 5cm - refer routine to gynae
management of a small simple cyst (<5cm) in premenopausal woman?
conservative approach - repeat USS in 8-12 weeks, referral considered if persistant
management of small simple cyst (<5cm) in post menopausal woman?
by definition a simple cyst is less likely as they are no longer ovulating
referrral to gynae in any ovarian cyst in women of this age
clinical features of ovarian Ca?
notoriously vague
abdominal and pelvic pain
bloating
early satiety
diarrhoea
urinary symptoms - urgency
postmenopausal bleeding
weight loss/night sweats
ascites on examination
SOB due to pleural effusion
if a woman over 50 years presents with symptoms suggestive of IBS - screen for ovarian Ca
what is the most common type of ovarian cancer?
epithelial in origin (90%)
what is the lifetime risk for a woman for developing ovarian cancer?
1 in 50
age of peak incidence of ovarian cancer?
60 years
what is the 5th most common cancer in women?
ovarian
what are the risk factors for ovarian Ca?
increasing age
family history of ovarian or breast cancer
gene mutation - BRCA 1 and 2
endometriosis
early menarche + late menopause
what are the protective factors for ovarian Ca?
COCP
breast feeding
pregnancy
management of woman with symptoms suggestive of ovarian ca?
abdo + pelvic USS - any ascites / masses -> 2ww ref
if examination is normal -> Ca -125 measurement
if Ca-125 raised -> urgent abdo and TVUSS -> if features of ovarian Ca -> refer via 2ww, if normal consider watch and wait / alternative diagnosis
symptoms of ovarian torsion?
sudden onset deep seated colicky abdominal pain
associated with vomiting
distress
fever - due to adnexal necrosis
PV exam - adnexal tendrness
what causes PCOS?
endocrine disorder - cause multifactorial and not entirely clear thought to be due to combination of genetic and environmental factors. Thought to be due to hyperinsulinaemia, and high levels of LH.
what criteria is used to diagnose PCOS?
Rotterdam criteria
what is the rotterdam criteria for PCOS diagnosis?
2 of the following 3 must be present - - infrequent or no ovultation
- clinical signs of hyperandrogenism 0 i.e hirstuism, acne, high levels of testosterone
- polycystic ovaries on ultrasound - i.e. presence of > 12 follicles in one or both ovaries
what are the clinical features of PCOS?
subfertility
infertility
menstrual disturbance - oligomenorrhea and amenorrhoea
hirstuism
acne
obesity
acanthosis nigricans - due to insulin resistance
what investigations to organise in patient who is suspected of having PCOS?
TVUSS - multiple cysts on ovaries
bloods - FSH, LH, TSH, testosterone, SHBG, prolactin
check for impaired glucose tolerance
calculate free andorgen index
look at LH:FSH ratio - should be high
what would you expect the testosterone level to be in women with PCOS?
raised
what would you expect the SHBG to be in women with PCOS?
reduced - used as a surrogate measure of hyperinsulinaemia
what would the free androgen index be in PCOS and how do you calculate this?
100 multiplied by the total testosterone value divided by the SHBG value
normal or elevated in PCOS
what are the possible complications of PCOS?
infertility due to anovulation
complications during pregnancy
CVD increase
risk of T2DM increased
obesity
NAFLD
endometrial Ca
OSA
anxiety/depression
management of PCOS?
lifestyle - weight loss will significantly improve menstrual regulatiry, insulin resistance and all symptoms
hirstuism and ance -
- trial of COCP
- if no improvement can try spironolactone, flutamide, finasteride under supervision
infertility -
- weight management
- clomifene -> under gynae
- metformin
- gonadotropins
which combined oral contraceptives are usually contraindiacted in PCOS?
COCs with 35 micrograms of ethinyloestradiol plus cyproterone acetate preparations should not be considered first line in polycystic ovary syndrome (PCOS) due to adverse effects, including venous thromboembolic risks
what investigations should be done for a woman with known PCOS who is presenting with less than one bleed every 3 months or irregular bleeding?
Prescribe a cyclical progestogen (such as medroxyprogesterone 10 mg daily for 14 days) to induce a withdrawal bleed, then refer for a transvaginal ultrasound to assess endometrial thickness.
If endometrial thickening is present (greater than 10 mm) or the endometrium has an unusual appearance, refer for endometrial sampling to exclude endometrial hyperplasia or cancer.
If the endometrium is of normal thickness and appearance, advise treatment to prevent endometrial hyperplasia.
what treatment options are available to women with PCOS who have amenorrhoea/irregular bleeding, who have had a TVUSS with normal endometrium?
A cyclical progestogen, such as medroxyprogesterone 10 mg daily for 14 days every 1–3 months.
A low-dose COC
The levonorgestrel-releasing intrauterine device (LNG-IUD).
how is metformin used in management of PCOS?
used off label in PCOS
can be initiated in GP but usually with specialist input if there is no T2DM present
can help with reducing metabolic syndrome, management of obesity and other PCOS symptoms but evidence is not clear
what monitoring should be offered to women with PCOS to monitor their CVD risk?
regular BMI monitoring / weight - 6-12 months
BP measurement
HbA1c 1-3 years
lipids 1-3 years
Smoking status
which virus causes cervical cancer?
HPV 16 & 18
what are the two types of cervical cancer?
squamous cell
adenocarcinoma
what are risk factors for cervical cancer?
HPV - most important
otherwise -
smoking
HIV
early intercourse, many sexual partners
high parity
how does a vulval cancer most commonly present?
vulval carcinoma presents with labial lump
inguinal lymphadenopathy
pruritis of labia
ulceration of skin
at what age is vulval carcinoma most common?
over the age of 65 years
risk factors for vulval carcinoma?
HPV
age
immunosuppression
lichen sclerosis
vulval intraepithelial neoplasia
what is the first line treatment of urge incontinence?
Bladder retraining - This involves teaching patients to gradually increase the interval between voids using distraction techniques and suppressing the urge to void. Lasts for minimum of 6 weeks.
what is the first line treatment of stress incontinence?
pelvic floor muscle training
what are the intial investigations of incontinence?
Advise patients to keep a bladder diary for minimum of 3 days
vaginal examination - to exclude pelvic organ prolapse
urine dip + culture
what are second line investigations of incontinence?
Urodynamic studies
what is the medical management of urge incontinence?
1) oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
Immediate release oxybutynin should, however, be avoided in ‘frail older women.
2) Mirabegron - useful if there is concern about the anticholinergic side effects of elderly patients
what is the medical management of stress incontinence?
duloxetine - may be useful if surgical intervention is declined
what is the MOA of antimuscarinics for urge incontinence?
depress voluntary and involuntary bladder contractions by blocking the muscarinic receptions
side effects of antimuscarinic medications?
dry mouth
dry eyes
urinary retention
constipation
blurred vision
hot and flushed skin
what is the MOA of duloxetine in stress incontinence?
increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve leading to increased stimulation of urethral muscles within the sphincter leading to enhanced closure of the urethra.
what is the definition of primary amenorrhea?
failure to establish menstruation by 15 years of age in girls with normal secondary characteristics , or by 13 years of age in girls with no secondary sexual characteristics
what is the definition of secondary amenrrohea?
cessation of menstruation for 3-6 months in women with previous normal and regular menses, or 6-12 months in women with previous oligomenorrhoea
what are the initial investigations to be organised in amenorrhoea?
exclude pregnancy with urinary or serum bHCG
full blood count, urea & electrolytes, coeliac screen, thyroid function tests
gonadotrophins- low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
raised if gonadal dysgenesis (e.g. Turner’s syndrome)
prolactin
androgen levels-raised levels may be seen in PCOS
oestradiol
causes of primary amenorrhoea?
gonadal dysgenesis e.g. turners syndrome - most common
testicular feminisation
congenital malformations of genital tract
functional hypothalamic amenorrhoea i.e.e secondary to anorexia
congenital adrenal hyperplasia
imperforate hymen
causes of secondary amenorrhoea (after excluding pregnancy) ?
hypothalamic amenorrhoea e.g. stress, excessive exercise
PCOS
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis
sheehans syndrome
ashermans syndrome (intrauterine adhesions)
what is the definition of premature ovarian insufficiency?
onset of menopausal symptoms and elevated gonadotropin levels before the age of 40 years
how common is premature ovarian insufficiency?
1 in 100
what are the causes of premature ovarian insufficiency>?
idiopathic- most common, can have FH
bilateral oophrectomy
radiotherapy
chemotherapy
infection e.g mumps
autoimmune disorder
resistant ovary syndrome
what are the features of premature ovarian insufficiency?
similar to those of normal climacteric state i.e.
hot flushes
night sweats
infertility
secondary amenorrhoea
what would you see on lab results in primary ovarian insufficiency?
FSH >30
LH raised
low oestradiol
should be demonstrated on 2 blood samples taken 4-6 weeks apart
management of primary ovarian insufficiency?
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)
it should be noted that HRT does not provide contraception, in case spontaneous ovarian activity resumes
how long should smears be delayed during pregnancy?
delay screening until 3 months post partum
when is the best time to perform a smear in a womans cycle?
mid cycle
what is the minimum number of episodes per year needed to diagnose recurrent thrush?
4 episodes per year
what are the first line options for management of thrush?
oral fluconazole 150mg singe dose
clotrimazole 500mg PV pessary
when is fluconazole contraindicated?
if pregnant !!!! have to use topical treatments ONLY
Treatment of recurrent thrush?
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
how long is contraception indicated for women going through the menopause?
if < 50 years- for 24 months after last period
if > 50 years - for 12 months after last period
which examination should be avoided in a patient who has presented with potential ectopic pregnancy?
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
what are the causative organisms of PID?
Chlamydia trachomatis: the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
what are the symptoms of PID?
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
what investigations should be done for PID?
a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab
these are often negative
screen for Chlamydia and Gonorrhoea
what is the first line treatment for PID?
stat IM ceftriaxone + followed by 14 days of oral doxycycline + oral metronidazole - this now considered first-line due to the desire to avoid systemic fluoroquinolones where possible
what is second line treatment for PID?
oral ofloxacin + oral metronidazole
what are the possible complications of PID?
endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess, and/or pelvic peritonitis
what are some risk factors for developing PID?
multiple recent partners
no barrier contraception
recent instrumental intervention i.e. coil/hysteroscopy
under 25 years
management of PID if suspected in a pregnant woman?>
same day hospital admission
how quickly should you review a woman with confirmed PID?
initial review and then within 72 hours to ensure response to abx
what advice should you give a woman with PID regarding sexual intercourse?
avoid sexual intercourse until swabs back, abx completed (14 day course) and test of cure done if needed
ensure sexual partners also screened and treated
what should be done regarding an IUD in a woman who has PID with IUD in situ?
If she has mild-to-moderate symptoms, advise that the IUD can remain in situ, provided she is clinically improving within 48–72 hours of starting antibiotic treatment. If symptoms are not improving, the IUD should be removed
what antibiotics should be prescribed to a woman with PID who tests positive for mycoplasma genitalium?
moxifloxacin 400mg once daily for 14 days
what is the criteria for referral to 2ww for breast Ca?
unexplained axillary lump > 30yrs
unexplained breast lump with or without pain > 30 yrs
Nipple changes of concern (in one nipple only) including discharge and retraction, age 50 years and over
skin changes suggestive of breast ca - skin eczema that has not responded to 2 weeks of steroid cream
DVT
what are some differential diagnoses for breast lump?
fibroadenoma
breast cyst
sclerosing adenosis
epithelial hyperplasia
fat necrosis
duct papilloma
what is the most common benign breast lump?
fibroadenoma - accounts for 12% of all breast masses
features of a fibroadenoma?
firm, mobile breast lump
can become painful particularly just before period
what is the pathophysiology of a fibroadenoma?
unclear, thought to be the development of a collection of fibrous tissue within the lobule of the breast in response to oestrogen
what is the management of fibroadenoma?
20% will usually get smaller on their own - can either watcha dn wait or organise excision if < 3cm
is there an increased risk of malignancy with a fibroadenoma?
no - no increase in risk of malignancy
how does a breast cyst present?
smooth discrete lump which may be fluctuant, usually sits above the lobule
can have pain around period or become infected
management of cyst?
will usually need drainage if large enough - will be done by breast team
can treat with abx if infected and review
what is sclerosing adenosis?
a benign condition where scar like fibrous tissue forms within the breast lobules (glands that produce milk)
how does sclerosing adenosis present?
usually either a breast lump or generalised pain
lesions should be biopsied, but excision is not mandatory
is there an increased risk of breast ca with breast cysts?
slight increased risk of breast Ca, especially when younger
is there are an increased risk of breast ca with sclerosing adenosis?
no
what is epithelial hyperplasia?
hyperplasia of the epithelium wtihin the breast - causing increased cellularity of the terminal lobular unit
is there an increased risk of breast ca with epithelial hyperplasia?
possibly - if there are also risk factors present for breast Ca or atypical features
what is a duct papilloma?
Abnormal proliferation of ductal epithelial cells causes tumor growth.
A solitary intraductal papilloma is usually found centrally posterior to the nipple, affecting the central duct.
is there an increased risk of malignancy with duct papilloma?
no
how is duct papilloma managed?
microdochectomy
what is mammary duct ectasia?
dilation of the large breast ducts - usually occurs around menopause
what are the symptoms of mammary duct ectasia?
tender lump around the areola +/- a green nipple discharge
what are the different types of breast cancer?
ductal - arises from the milk ducts
lobular - arises from the lobules (where the milk is produced)
in situ - not spread
invasive - spread
i.e. - ductal carcinoma in situ, invasive ductal carcinoma, lobular carcinoma in situ, invasie lobular carcinoma
give some examples of some of the rare forms of breast cancer?
medullary breast cancer
mucinous breast cancer
tubular breast cancer
lymphoma of breast
what are the risk factors for breast cancer?
brca 1 + 2 gene - lifetime risk of over 40%
1st degree relative premenopausal with breast Ca
nulliparity
1st pregnancy > 30 yrs
early menarche, late menopause
COCP
not breast feeding
radiation
p53 gene mutations
obestiy
previous surgery for benign disease
what is the NHS breast screening programme?
breast screening offered to women between 50-70 yrs with 3 yearly mammogram
what are some of the treatment options for breast cancer?
surgery - most commonly wide local excision
radiotherapy - usually post surgery
hormonal therapy
biological therapy
chemotherapy
what is the hormonal therapy offered for breast cancer?
used if tumours are positive for hormone receptors
tamoxifen for premenopausal and perimenopausal women
amoratase inhibitor such as anastrozole for post menopausal women
mechanism of action of tamoxifen?
used to treated oestrogen receptor positive breast cancers
selective estrogen receptor modulator - competitively binds to oestrogen receptors on the tumour, to prevent its proliferation with oestrogen
common side effects of tamoxifen?
hot flushes, nausea, vaginal bleeding, discharge, fluid retention, fatigue, and skin rash
what are some key drugs which may interact with tamoxifen?
anastrozole
warfarin
cytochrome p45 inhibitors (paroxetine, fluoxetine)
HRT
risks of taking tamoxifen?
increased risk of VTE
reduced bone density
acute porphyria
who usually initiates tamoxifen?
usually initiated in secondary care
but can be monitored in primary care if agreed
how do aromatase inhibitors work?
aromatose enzyme converts testosterone to oestrogen
aromatase inhibitors prevent this - reducing the overall amount of oestrogen available to bind to ER positive tumours
why are aromatase inhibitors preferred in postmenopausal women?
higher effectiveness rate
cannot be used in pre or perimenopausal women as the ovaries are still producing oestrogen, and will just respond to the low levels of oestrogen by producing more
what side effects are caused by aromatase inhibitors?
same as tamoxifen -
PV bleeding
hot flushes
joint and muscle pain
increases risk of VTE and loss of BMD
what are some examples of aromatase inhibitors?
anastrozole
letrozole
can aromatase inhibitors ever be used in pre menopausal women?
they can sometimes be used if the ovarian function is supressed with other medications such as goserelin
what is a bartholins cyst?
entrance to the bartholin dut becomes blocked, the gland produces mucus which builds up behind the entrance, eventually causing a mass to form
management of bartholins cyst?
usually no management needed
can use hot compress
OTC analgeisa
risk of bartholins cyst?
can form an abscess
how do you manage a bartholins abscess?
if systemically well or has started to drain spontaneously - can use oral flucloxacillin for 5-7 days / doxycycline if pen allergic
review on day 3
but usually requires hospital admission and assessment as likely to deed I+D
what are differentials for pruritis vulvae?
contact dermatitis- most common cause
atopic dermatitis
seborrhoeic dermatitis
lichen planus
lichen sclerosus
psoriasis
management of a woman with vulval contact dermatitis?
advise to take showers rather than baths
use emollient for washing
clean only once a day
combined antifungal and steroid can be used in seborrhoeic dermatitis suspected
what is lichen sclerosus?
autoimmune inflammatory condition that causes hypopigmentation around the vulva and itching ++
what are the risks of lichen scleorsus?
if left untreated can lead to scarring and atrophy
increased risk of vulval Ca
management of lichen sclerosis?
very potent steroid i.e. dermovate oitnment (clobetasol proprionate) use OD for 1 month, then alternative day for month 2, then twice weekly for month 3 and then review
maintenance is usually required therafter once or twice a week as likely to flare
should review annually if stable
should refer to secondary care if not responding to steroids, worsening or any doubt regarding the diagnosis
how does lichen simplex present?
usually hyper or hypopigmented lesions
scaly skin
thickened skin
excoriation
itching
broken hairs or alopecia in various area
which areas does lichen simplex usually affect?
neck
scalp
vulva , pubis , scrotum
wrists , extensor surfaces
ankles , shins and thighs
management of lichen simplex?
usually can use antihistamines to help with the itch
topical corticosteroids - clobetasone proprionate 1-2x daily for 4 weeks then review
what is bacterial vaginosis ?
Bacterial vaginosis (BV) is characterized by an overgrowth of predominantly anaerobic organisms and a loss of lactobacilli.
risk factors for BV?
Being sexually active — BV is not a sexually transmitted infection (STI), but being sexually active or having concurrent STIs increases the risk of developing BV.
The use of douches, deodorant, and vaginal washes.
Factors linked to an alkaline vaginal pH (menstruation, semen.)
Copper intrauterine devices.
Smoking.
symptoms of BV?
usually fishy smelling discharge
thin and homogenous discharge
not associated with soreness, itching or irritation.
pH of discharge/vagina in BV?
pH > 4.5 - more alkaline
test for BV?
send slide sample for gram staining and microscopy - usually dont need to do a test if symptoms are fitting, can be diagnosed clinically
management of woman who is not pregnant who has BV and is symptomatic?
oral metronidazole 400mg BD for 5-7 days
can also have intravaginal metronidazole gel 0.75% once daily for 5 days
management of woman is pregnant and has BV?
if asymptomatic - no tx needed usually, discuss with O+G
if symptomatic - metronidazole 400mg BD for 5-7 days (low dose is fine)
what causes genital warts?
anogenital warts - caused HPV 6 and 11 most commonly
has long latency period in men - around 11 months before sx appear and 2 months for women
who should be referred to sexual health clinic if they have genital warts?
women who are pregnant
children
immunocompromised i.e HIV
conisder for all
management of genital warts?
No treatment — one-third of visible warts disappear spontaneously within 6 months.
Self-applied treatments (podophyllotoxin 0.5% solution, or 0.15% cream, imiquimod 5% cream, sinecatechins 10% ointment).
Ablative methods (such as cryotherapy, excision, and electrocautery) — these should be considered only if the practitioner is appropriately trained
advise to give to patients who are treating genital warts?
active treatments usually take 1-6 months to work
have significant failure rates
have significant relapse rates
often involve discomfort and skin reactions
condom use advised - However, explain that latex condoms may be weakened if in contact with imiquimodsmoking cessation with improve response to treatment
what are non-hormonal management options for hot flushes due to menopause?
Offer lifestyle advice to control symptoms (regular exercise, lighter clothing, less stress and avoiding triggers e.g. spicy foods). If this is not effective, consider other treatments
A 2 week trial of paroxetine (20 mg daily), fluoxetine (20 mg daily), citalopram (20 mg daily), or venlafaxine (37.5 mg twice a day)
A 24 week trial of clonidine (50 to 75 micrograms twice a day, licensed use)
A progestogen such as norethisterone or megestrol (both off-label use) seek specialist advice if this option is being considered
how does vulval intraepithelial neoplasia usually present?
itching
burning
raised, well defined lesions
what is vulval intraepithelail neoplasia ?
Vulval intraepithelial neoplasia (VIN) is a pre-cancerous skin lesion of the vulva, and may result in squamous skin cancer if untreated.
risk factors for the development of VIN?
human papilloma virus 16 & 18
smoking
herpes simplex virus 2
lichen sclerosus
management of VIN?
referral to confirm diagnosis
topical therapies
imiquimod: Immune response modifier
5-Fluorouracil: Topical chemotherapeutic agent
surgical Interventions
aimed at complete removal of dysplastic areas while preserving normal anatomy and function as much as possible.
techniques include wide local excision, laser ablation, or more radical approaches like partial vulvectomy in cases of extensive disease.
follow-up and surveillance
regular monitoring with repeat colposcopy and biopsy if recurrence or progression is suspected.
what is premenstrual syndrome?
Premenstrual syndrome (PMS) describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
what are the symptoms of premenstrual syndrome?
Emotional symptoms include:
anxiety
stress
fatigue
mood swings - marked lability in mood , low mood, depressed, irritability, anger
difficulty concetration
lethargy
sleep changes
changes to appetite
Physical symptoms
bloating
breast pain
lifestyle advice for PMDD?
apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates
pharmacological management of PMDD?
moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasminµ (drospirenone 3 mg and ethinylestradiol 0.030 mg)
severe symptoms may benefit from a selective serotonin reuptake inhibitor (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)
when should women with PMDD be reviewed?
2 months after starting treatment
management if failure to manage PMDD in primary care?
referral to clinic with special interest in PMS or general gynae clinic for consideration of specialised treatment options such as
- transdermal oestrogen
- other antidepressants
- diuretics
- donazol
- GnRH agonists
- surgery
what are the causes of dysfunctional uterine bleeding?
fibroids
polyps
adenomyosis
endometriosis
causes of post coital bleeding?
ectropion
cerivcal Ca
cervical polyp
PID
STI
vaginal atrophy/dryness
what is a cervical ectropion?
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix. Columnar cells are thicker and so appear darker in colour.
management of ectropion?
no treatment needed
if decide to have treatment due to symptoms - can be referred to colposcopy for diathermy, cryocautery, silver nitrate treatment
what investigations should be done if you suspect an ectropion?
pregnancy test
triple swabs - ensure no STI infection
cervical smear - to r/o CIN
what are the different types of uterine fibroids?
Subserosal (occupying the muscle of the uterus but protruding to the outside of the uterus)
Intramural (which means solely within the muscle layer of the uterus)
Submucosal (partially or wholly within the cavity of the uterus)
Cervical (arising from part of the cervix or lower part of the uterus)
Broad ligament (occupying the lateral tissues of the uterus)
Pedunculated (on the outside of the uterus but attached to the uterus by a stalk)
what is the difference between a polyp and fibroid?
fibroid - smooth muscle tissue arrisng form various layers of the womb
polyp - thinner, made of the endometrial lining
management of endometrial polyps?
referral to gynae - needs eploration with hysteroscopy due to associated with endometrial Ca
management of endometrial hyperplasia without atypical features?
reassurance - rate of progression to endometrial Ca is 5% in 20 years
treatment with high dose progesterone - first line is IUS, second line is continuous oral progestogen treatment, in the form of medroxyprogesterone (10-20 mg per day) or norethisterone (10-15 mg per day). T
resampling every 6 months until 2 consecutive readings are negative
what is the management of atypical endometrial hyperplasia?
total hysterectomy usually advised as high risk for development of endometrial ca
progesterone can be used if want to preserve fertility and then advise hysterectomy after this
risk factors for endometrial Ca?
Risk factors
excess oestrogen
nulliparity
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
metabolic syndrome
obesity
diabetes mellitus
polycystic ovarian syndrome
tamoxifen
hereditary non-polyposis colorectal carcinoma
protective factors for endometrial ca?
multiparity
combined oral contraceptive pill
smoking (the reasons for this are unclear)
symptoms of endometrial Ca?
postmenopausal bleeding
pre menopausal women usually develop menorrhagia and IMB
investigations for PMB?
any woman > 55 yrs with postmenopausal bleeding - referral for TWR
what is the cervical cancer screening in the UK?
smear every 3 years from 25-49yrs
smear every 5 yrs from 50-65yrs
what is vaginismus?
Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina.
what is endometriosis?
Endometriosis is characterized by the growth of endometrium-like tissue outside the uterus.
Endometriotic deposits are most commonly distributed in the pelvis; on the ovaries, peritoneum, uterosacral ligaments, and pouch of Douglas. Extra-pelvic deposits, such as in the bowel and pleural cavity, are rare.
how common is endometriosis
About 1 in 10 women of reproductive age in the UK have endometriosis.
what is OHSS?
In OHSS, ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including:
Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
which medication is first line in infertility in PCOS?
clomifene -selective oestrogen-modulating medication to help induce ovulation in those with anovulatory conditions such as PCOS and is prescribed under supervision from a fertility specialist.
symptom of anovulatory cycles
menorrhagia - without ovulation there is no corpus luteum to release progesterone to modualte the thickening of the lining and so there is over thickening of the lining which can be heavy and painful to shed
what are the instructions for semen sample testing?
Semen analysis should be performed after a minimum of 3 days and a maximum of 5 days abstinence. The sample needs to be delivered to the lab within 1 hour
what causes the symptoms of hyperadrogenism in PCOS?
SHBG is a plasma protein that binds the steroid hormones oestrogen, testosterone, and dihydrotestosterone. Low concentrations of SHBG increase the concentration of unbound, biologically active testosterone and dihydrotestosterone, leading to features of hyperandrogenism associated with PCOS.
what is the most common cause of spontaenous recurrent first trimester miscarriage?
antiphospholipid syndrome
