Gynaecology Flashcards
1
Q
Management of Urge incontinence
A
1) 6/52 Bladder retraining
2) Pv Oestrogens/Desmopressin
3) Antimuscarinics
2
Q
Stress Incontinence-management
A
1) Pelvic Floor exercises (supervised)
2) Duloxetine
3) Surgery
3
Q
IOTA rules- benign
A
unilocular
multilocular <10cm
solid and smooth <70mm
acoustic shadowing
no doppler
4
Q
IOTA rules- malignant
A
irregular, solid
multilocular >10cm
>4 papillary structures
ascites
high doppler
5
Q
What % of HMB is idiopathic
A
50%
6
Q
A
7
Q
Relugolix
A
GnRH analogue
Ryeqo- relugolix + NET + estradiol
contraceptive after 1/12
8
Q
What is the first line antimuscarinic for urge incontinence?
A
lowest acquisition cost eg oxybutynin/tolterodine/solifenacin 5mg (up to 10mg OD)
-varies by locality
Do not offer oxybutynin first line if over 65
only use mirabegron if not suitable/effective
9
Q
Bladder capacity/flow
A
300-550ml
(afferent signal to void at 400ml)
M- 10-25
F- 25-30
10
Q
Maintenance of continence
A
Detrusor relaxes (noradenaline)
IUS contracts (alpha 1)
EUS contracts (beta 3)
cerebral cortex >pons >sympathetic nuclei >T10-L2
Hypogastric nerve
11
Q
Voiding
A
Bladder > Sympathetic cortex > pontine micturition centre > cerebrum
Pelvic Nerve S2-4, acetylcholine
Detrusor contracts- M3
EUS relaxes -nicotinic
Inhibition of Onuf’ nucleus= reduced SNS input to IUS
12
Q
Normal voiding
A
4-7 x day
1 x night (If <70 yo)
13
Q
Assessment of incontinence
A
Dip (infection/diabetes)
residual volume
MSU
pad test
cystoscopy
14
Q
Anticholinergics
A
Work at muscarinic receptors to reduce action of acetylcholine (relaxation)
Increase capacity and reduced desire to void
May take 4 weeks to work
15
Q
Oxybutynin
A
PG 1, 2 and 3
M3>2 antagonist
2.5mg TDS then titrate up
Max 20mg/day
16
Q
Tolterodine
A
2mg BD/4mg OD SR
competitive agonist at M receptors
better tolerated than oxybutynin
non selective acetylcholine
17
Q
Antimuscarinic side effects
A
dry mouth
constipation
increased risk of falls in elderly (especially oxybutynin)
18
Q
Dorifenacin/Solifenacin
A
M3 antimuscarinics
19
Q
Mirabegron
A
NOT an antimuscarinic
use if antimuscarinics are contraindicated
bind to B3 Receptor= relaxation
increase capacity to stoe, good for urge incontienence
50mg OD
s/e UTI, tachycardia, headache, dizziness
20
Q
Non pharmacological treatments of incontinence
A
Botox
Sacral Nerve Stimulation
21
Q
Neurological bladder
A
spinal cord lesions above T12
EUS relaxed
IUS relaxed
detrusor contracted
autonomic- bladder empties as it fills
22
Q
Desmopressin- pharmacology
A
V2 receptor agonist
adenylyl cyclase> increase water uptake via aquaporins
23
Q
Baden Walker- Prolapse
A
1- 1/2 down vagina
2- at hymenal remnant on straining
3- outside hymenal remnant
4- procidentia
24
Q
POP-Q
A
A methodical way to classify prolapse
25
Investigation of Prolapse
USS to r/o masses
urodynamics
ECG, CXR, FBC, U+E (fitness for surgery)
26
Lifestyle measures for prolapse
weight management
constipation
chronic cough
27
vaginal atrophy + overactive bladder
topical oestrogens
28
Bladder/fluid diary
3 days
two different settings ie work/home
29
Bladder pain syndrome- treatment
1) change medications/irritants
2) amitryptilline/cimetidine
3)intravesical (lidocaine, botox, heparin)
30
Types of pessary
Ring- 1st/2nd degree, can have SI
Gellhorn- no SI, 3rd degree
Shelf
Shaatz- like gellhorn with no stem so can have SI
31
Surgery for prolapse
Uterine:
hysterectomy, sacrospinous fixation of vault
sacrospinous hysteropexy
Manchester repair (shortens cervix, preserves uterus)
Sacrohysteropexy/colpocleisis
Vault
fixation
sacrocolpopexy
colpocleisis
Anterior/posterior
repair
32
Overflow incontinence- drug causes
Detrusor underactivity/outlet obstructed
ACEI
Antidepressants
antihistamines
Calcium channel blockers
Opioids
Sedatives
33
Pelvic Floor strength classification
Modified Oxford Grading
0- nil
1- flicker
2- weak contraction
3- moderate
4- good
5- strong
34
UTI
urine dip <65
nitrites + leucocytes+ Hb = UTI
no nitrites + leucocytes/Hb= culture ?UTI
no nitrites/leucocytes= not a UTI
35
Who to culture when ?UTI
pregnant
not better with antibiotics
>65 yo
2 in 6/12 or 3 in 12/12
catheterised
36
UTI treatment
1. analgesia and fluids
2. nitrofurantoin 100mg SR BD or trimethoprim 200mg BD (3 days)
3. piv/nitro
37
Drugs associated with UTI
Opioids
nifedipine
cyclophosphamide
38
Treatment of recurrent UTI
vaginal oestrogens
200mg trimethoprim or 100mg nitrofurantoin after trigger or at night if no trigger
39
UTI in pregnancy
7 day course
1) Nitrofurantoin
2) Amoxicillin
3) Cefalexin
40
Interstitial Cystitis-management
1) Reduce stress, smoking, alcohol
2) Analgesia, OTC antihistamine, neuropathics, antimuscarinics, cimetidine (H2)
3) Physiotherapy, Psychotherapy, TENS
41
Definition of chronic pelvic pain
1 in 6 women
more than six months, not related to sex or menses
not urological/infection/GI
Recommend USS as first line
42
Management of pelvic pain
3-6 months of hormonal treatment/laparoscopy to diagnosis (1/3 negative)
ovarian suppression:
LNGIUD, COCP/POP
GnRH, danazol (reduce pituitary Gns), Letrozole (reduce T to E)
43
When to do MRI for pelvic pain
assess nodules
rectovaginal disease
adenomyosis
44
When to do Ca125
bloating, early satiety, pain, urinary changes
>12 times per month
age over 50
45
Endometrioma USS appearances
Ground glass appearance (dark degenerated blood)
no papillary structures/blood flow
46
Pathophysiology of endometriosis
?retrograde menstruation
=local inflammation
=neuroangiogenesis
=increased pain sensitivity
=increase adhesions
=scarring and reduce function of oocytes= subfertility
47
48
GnRH and addback HRT
If use >3/12 as 6% reduction in BMD at 6/12
49
Danazol
inhibits Gn release at pituitary
=reduced E
=anovulation/amenorrhoea
s/e= androgenic
50
FIbroid
benign neoplasm of smooth muscle
0= submucosal pedunculated
1= submucosal
2=
3= entirely intramural
4=
5=
6=
7= subserosal
51
Fibroid epidemiology
70% F age 50
80% Black F
high risk:
FHx, black/asian, early menarche, obesity
low risk:
hormonal contraception
pregnancy
52
Pathophysiology of fibroid
oestrogen induces progesterone receptors= growth
53
Uterine Artery Embolisation
>3cm, HMB, reduce QOL
similar satisfaction to hysterectomy but reduced recovery time/shorter inpatient stay
unknown impact on fertility, unable to do histology
31% reintervention (4% reintervention if surgery)
54
Dermoid cyst USS appearances
hypoechoic area and hyperechoic areas
heterogenous with fatty layer
55
Meig's Syndrome
ascites, pleural effusion and fibroma (benign)
-resect tumor to resolve symptoms
-exclude Ca
56
Sertoli-Leydig Tumor
Androgenic
secrete Testosterone
rare, <30yo
10-20% malignant
Reinke crystals
Sertoli/Leydig- Testosterone
57
Thecoma
80% postmenopausal
secrete oestrogen
>20% have a concurrent carcinoma
otherwise benign
ThEcoma
58
Granulosa cell tumor
Malignant but slow growing
~age 50
increase E (hyperplasia/polyp/Ca)
Increase inhibin B
large complex masses on USS
treat by resection
59
Epithelial cell tumor
>40 yo
unilocular with projections
eg cystadenoma, bremer, clear cell (malignant)
60
M rule
irregular
solid
ascites
>4 papillary structures
>10cm
increased blood flow
=gynae onc r/v
>7cm- MRI +/- gynae review
61
Ovarian cysts- premenopausal
<5cm- NAD
5-7cm- annual USS
>7cm or persist/increase (unlikely to be functional) need MRI/surgery
Complex: septation, solid nodules, papillary projections
check: LDH, afp, hCG
62
Ovarian Cysts epidemiology
1 in 10 F will have surgery for this
1 in 1000 are malignant
(3 in 1000 at age 50)
63
RMI
Risk of Malignancy Index
Ca125 x USS x menopausal status
>200= concern
64
Ovarian cyst- postmenopausal
asymptomatic, simple, <5cm and normal Ca 125
= rescan 4-6 months
discharge at 12 months if static or decreasing in size
RMI <200 = laparoscopy and BSO
RMI >200= laparotomy
65
Management of torsion
surgical detorsion
resect if not viable
oophoropexy if recurrent and wants to conceive
66
PID- causes
1 in 4 are GC/CT
Other causes:
Mycoplasma, gardnerella, other anaerobes
most common within 4-6 weeks of coil fit
rx any F <25 with new bilateral pelvic pain
67
Fitz Hugh Curtis Syndrome
RUQ+ perihepatitis
associated with chlamydia
68
Pus cells on cervix as an indicator for PID
NPV 95%
PPV 17%
69
PID in pregnancy
really uncommon, consider alternative diagnosis
70
PID treatment- 2nd line
ofloxacin 400mg BD 14/7 + metronidazole
moxifloxacin 14/7
71
PID inpatient treatment
IV ceftriaxone 2g OD and doxycycline BD
switch 24 hours after improving
72
PID- TB/actinomyosis
high suspicion of TOA
73
Bartholin's cyst
non infectious occlusion or duct leading to retention of secretions
3% women (nullip/low parity)
74
Bartholin's abscess
Strep/Staph/ gram -ve anaerobes
MC+S and histology if >45
co-amox/fluclox/I+D
up to 38% recurrence
marsupialisation- epithelializes 7-14 days, lowest risk of recurrence
Word Catheter- 4 weeks, 1 in 5 recur
75
VIN types by cause
1) Usual type- HPV 16
2) non HPV- eg Lichen Planus/Sclerosus
-differentiated is highest risk of progression
76
VIN risk
Smoker/immunocompromised
9-18.5% transform to SCC
recurrences common
| VIN- 10-20%
77
VIN histology
loss of organisation of squamous epithelium, cytological atypia
78
VIN management
Ensure smears up to date
colposcopy/anoscopy
excision, imiquimod, laser, 5 fluorouracil
79
HSIL
High grade squamous intraepithelial lesion
most common, HPV related
35-49yo
VIN 2/3
needs rx
80
LSIL
Low grade squamous intraepithelial lesion
VIN 1, mild changes
can observe
low risk HPV 6 and 11
81
dVIN
uncommon, 50-60yo
no HPV, ?lichen sclerosus
highest risk of Ca, likely need surgery
82
Vulval Cancer
90% SCC
Also: meningioma, Paget's, verrucous, Sarcoma, Bartholin's, BCC
any skin change in postmenopausal woman- biopsy
83
Treatment of vulva Ca
spread to **inguinofemoral** nodes
offer excision, may need radio/chemotherapy
up to 1/3 recur- need follow up
84
Lichen Sclerosus- pathophysiology
autoantibodies to **extracellular matrix protein 1**
may have other AI disease
85
Lichen Sclerosus- presentation
pale, atrophic, white areas
purpura and echymosis
loss of architecture in figure of 8 pattern
SCC <5%
86
Lichen Sclerosus- histology
thinned epidermis, subepidermal hyalinisation and deep inflammatory infiltrate
87
Lichen Sclerosus- treatment
ultrapotent steroids and review at three months (eg clobetasol)
Refer to vulval clinic if unsure
88
Lichen simplex- causes
1) Infectious/dermatitis
2) systemic eg renal failure/lymphoma
3) environmental- heat/skincare
4) psychiatric- itch scratch
89
Management of Lichen Simplex
Clinical diagnosis
check for infection
ferriting/biopsy
emollients, patch test, potent steroids
sedating antihistamine
reduce dose at 3-4 months
90
Lichen Planus- pathophysiology
inflammatory disorder of skin/genital/oral mucosa
T cell response to unidentified antigen
91
Lichen Planus- presentation
papules, hypertrophy, erosions
Wickham's striae
telangectasia- PCB
stenosis/scarring
SCC up to 3%
92
Lichen Planus- biopsy
Sawtooth acanthosis, thickened granular layer, basal cell liquefaction
lymphocytic dermal infiltrate
93
Lichen Planus- management
Rule out thyroid/autoimmune disease
clobetasol
may need systemic treatment if extensive
annual review (can be GP)
94
Eczema
erythema, lichenification, excoriation and fissuring
give emollient/steroids
95
Psoriasis- pathophysiology
chronic inflammation, epidermal skin disease
2% population
96
Psoriasis- presentation
well demarcated erythematous plaques
always check natal cleft
skin/nail disease
97
Psoriasis- treatment
emollients, steroids, vit d analogues
98
Dermatology treatment and pregnancy
Steroids are safe
topical calcineurin inhibitors (cyclosporin, tacrolimus) are contraindicated
avoid retinoids for 2 years before pregnancy
99
Vulvodynia definition
burning pain with no abnormal findings (except mild erythema)
may be primary or secondary to something else
100
Treatment of vulvodynia
psychosexual therapy
antidepressants
TCAs
LA/Analgesia
101
Secondary dysmenorrhoea
underlying pelvic pathology
102
Drop in Progesterone-menstruation
1) increase inflammatory cytokines, prostaglandins and vascular EGF/MMPs
2)degradation and reduced integrity of blood vessels and reduced endometrial interstitial matrix
3) Prostaglandin E from endometrium stimulated myometrial contraction and vasoconstriction (=ischaemic pain)
Women who report dysmenorrhoea have higher prostaglandin levels
103
Management of dysmenorrhoea
NSAIDs
COCP
POC
Uterosacral nerve stimulation
TENS/B1 and Magneisum/heat
104
Celomic metaplasia theory
celomic epithelium= mullerian duct= peritoneum, pleura, ovaries
- differentiation by an unknown stimulus leads to patches of endometriosis
105
Dysgerminoma
Germ cell tumor
secretes LDH
germ ceLL = LDH
106
Yolk Sac Tumor
AFP
Schiller duval bodies on histology
yolk sac= a FETAL protein
107
Pruritus Vulvae- investigations
FBC (lymphoma)
TFTs
U+E (CKD)
Ferritin
HbA1c/glucose
108
What is the infundibulopelvic ligament?
aka suspensory ligament
contains ovarian artery and vein
109
What is the ovarian ligament
ovary to uterus
110
What is the round ligament
remnant of gubernaculum
uterus to pelvis
contains vessels and nerves
111
Which artery within broad ligament
uterine artery/vein
112
What is cardinal ligament
cervix to pelvic side wall
| cervix = cardinal
113
Thickness of endometrium
menses- 1-4mm
proliferative 5-7mm
secretory 7-16mm
114
vaginal artery supplies which other arteries?
from internal iliac
to inferior vesical
clitoral branch of pudendal
115
vagina venous drainage
vaginal venous plexus>
vaginal vein (anastomosed with uterines)
internal iliac
116
ovarian venous drainage
right > IVC
L> renal vein
| L to R (not L to L :( )
117
lymphatic drainage of vagina
lower 1/3- superficial inguinal (same as vulva)
middle 1/3- internal iliac
upper 1/3- external iliac
118
lymphatic drainage of cervix/endometrium
iliac/ para aortic nodes
119
lymphatic drainage of ovaries
para aortic nodes
120
Innervation of the vulva
Mons- ilioinguinal nerve
Anterior- genital branch of genitofemoral nerve
lateral- post cutaneous nerve of thigh
posterior- pudendal/perineal branch of pudendal nerve
121
SNS to uterus
uterovaginal plexus
122
PNS to uterus
S2-4
pelvic splanchnic nerve
| PNS= peeing
123
GnRH pulses
90 mins follicular
120min luteal
(LH every hour follicular, every 2-4 hours luteal)
124
Where is testosterone produced?
Zona reticularis of adrenals
125
Oligomenorrhea definition
>35 days or <9 per year
126
Rotterdam Criteria
2 of:
1) Oligo/amenorrhea
2) Clinical/biochemical hyperandrogenism
-LH:FSH >2.5
-low/normal SHBG
-normal/high FAI
3)
PCO
>12 peripheral follicles or >10cm in volume
127
PCOS- associated risks
Metabolic disorders
CVD
PET/GDM
Endometrial Ca
subfertility
Anxiety/Depression
OSA
128
PCOS + BMI >25
Annual OGTT
3 fold increase risk of DM
129
PCOS treatment
If bleeding less than 3 monthly:
TVUSS (>10mm ET= pipelle)
MPA 14/7 10mg at least 3x year
COCP/LNGIUD
130
When to be concerned about HMB
>40 and RF (BMI, PCOS, T2DM)
>45
>4mm ET= pipelle
131
Treatment of HMB
Normal USS:
Medical:
1) LNGIUD
2) TXA/NSAIDs/CHC/POC
Surgical:
Ablation
Hysterectomy
Fibroids>3cm
resection
UPA
Myomectomy
UAE
132
Ibuprofen and HMB
Inhibits COX 1 + 2
arachidonic acid not converted to thrombanes/ prostaglandins/ prostacyclines
133
TXA and HMB
1g TDS D1-4
40% reduction
s/e:
Caution if hx CVD
GI changes
cramping
134
MFA and HMB
500mg TDS D1-5
20-30% reduction
s/e
GI/renal/peptic ulcer
135
LNGIUD and HMB
90% reduction of bleeding
30% amenorrheic at 12 months
136
COCP and HMB
20-20% reduction
137
NET and PMB
P receptor agonist
5-10mg BD/TDS
10 days to stop bleeding
3-4/12 for dysmenorrhoea
138
MPA and HMB
P derivative, stops gonadotrophin production
regulates cycle but little effect on amount of bleeding
2.5mg-10mg daily, 5-10 days
from d16 of cycle
139
UPA and HMB
Progesterone receptor modulator (reduces progesterone levels)
reduces bleeding and size of fibroids
liver metabolism so check LFTs
5mg OD up to 4 courses of 3 months
140
GnRH analogue- pharmacology
20x more potent than GnRH and resistant to proteolysis
binds to anterior pituitary= increased FSH and LH, then desensitisation
s/e- initial flare then menopausal symptoms
6-12 months only (reduction in BMD)
141
Endometrial Hyperplasia without atypia- management
LNGIUD
MPA 10-20mg OD/NET 10-15mg/day
Treat for at least 6 months, need 2 biopsies that are negative 6 months apart
Not resolved at 12 months, relapse after treatment= hysterectomy
142
Endometrial Hyperplasia without atypia- sequelae
5% cancer at 20 years
75% regress at 6 months
Will need annual surveillance if declined LNGIUD or obese
143
Endometrial Hyperplasia with atypia-management
Give progesterone whilst awaiting hysterectomy
28% Cancer by 20 years
| hyperplAsia= 28%
144
Endometrial Cancer- symptoms
age 75-79
PMB, >55yo, haematuria, anaemia, change in discharge, thrombocytosis
145
Endometrial Cancer- risks
4 fold higher if on tamoxifen
3% Lynch Syndrome- annual USS and hysteroscopy and biopsy from age 35
BMI, PCOS, HTN, T2DM
146
Endometrial Cancer- protective factors
35% less if COCP
78% less if LNGIUD
147
Endometrial Cancer- types
most commonly adenocarcinoma
1= excess Estrogen, slow and unlikely to spread
2= serous/clear cell, not due to estrogen levels
148
Endometrial Ablation- mechanism
0.7% pregnancy rate
c/i if hyperplasia
aim to destroy and remove endometrium and 5mm of myometrium (basal endometrial glands)
149
Endometrial Hyperplasia- outcomes
80% satisfaction
50% amenorrhoea
pain tends to improve but may worsen
PMS improves (unclear mechanism)
TCRE= best method
150
Endometrial Ablation- complications
infection
pregnancy
post ablation syndrome (increased pain at menstruation)
10-30% will have hysterectomy at 5 years
151
Cowden Syndrome
Autosomal dominant
change to PTEN (tumor suppressor gene on chromosome 10)
Increased hamartomas (benign growths), skin and cognitive changes
High risk uterine, thyroid, breast cancer
152
Lynch Syndrome
Autosomal dominant
Hereditary non-polyposis colorectal cancer
colorectal/endometrial cancer likely before age 50
MLH1/2/6 or PMS 2
153
Pain management at hysteroscopy
NSAIDs 1 hour prior
penthrox reduces pain of treatment only
dysmenorrhoea= more painful
No benefit of conscious sedation
-no reduction in pain but increased side effects
154
Hysteroscopy-technique
saline at lowest pressure
smallest diameter (<3.5mm)
flexible scope may reduce pain but increased risk of failure/prolonging procedure
vaginoscopy as standard unless speculum needed ie for block/dilation
-may consider vaginoscopy after block to reduce pain and increase manoeuvrability
155
Prevalence of CIN
1= 4%
2/3= 5%
70-90% asymptomatic
156
HPV sequelae
HPV is 99% Ca (16 and 18 2/3)
90% self resolves
dsDNA 8 genes
157
Risk factors for Cervical Ca
many partners
smoking
OCP
reduced immunity
many pregnancies
co-infections (HSV/HIV)
Previous Ca
158
CIN sequelae
CIN1:
90% regress 2 year, 11% CIN3
1% Cancer
CIN2:
50% regress 2 years, 22% CIN3
5% Cancer
CIN3
32% regress
~12% Cancer
| 90, 50, 30
1,5,12
159
Cervical histology
ectocervix:
non-keratinised stratified squamous epithelium
resistant to low pH
endocervix:
mucin-secreting columnar epithelium
change to pH= squamous metaplasia
highest risk at transformation zone
T1= entire transformation zone visible
T2= some
T3= nil
160
VIN epidemiology
1 in 4 have CIN
1in 100000
2-14% to vulval cancer
161
VIN types
usual= HPV 16
smoking, low immunity, premenopausal, low risk SCC
differentiated= high risk SCC, LS/LP, post menopausal
162
VIN treatment
wide local excision
imiquimod
vulvectomy
laser
163
VaIN
Vaginal intraepithelial dysplasia
50-60yo
85% previous VIN/CIN
upper 1/3 vagina
low risk SCC
same rx as VIN
164
PIN
Uncommon
uncircumcised, over 50yo
HPV16, Smoker, LP/LS, chronic irritation
rx= imiquimod, 5-FU, cryo, laser, excision
10-30% SCC
165
AIN
90% HPV 16
HIV, RAI, VIN, CIN, low immunity
laser, imiquimod, 5FU
1-2% progress
| PIN/AIN HPV 16
166
What is screening?
Asymptomatic
determines chances of having disease
167
Cervical screening- when called?
24.5
25-49= 3 yearly
50-64= 5 yearly
If over 65 and one of last 3 abnormal, or not had one since 50/ever
168
Breast screening- when called?
50-71 yo, every 3 years by mammography XR
MRI if <40 as breast tissue very dense
169
Cervical Screening- evidence
>99% Ca is HPV
saves 4500 lives/year
PLWH= annual recall
170
HPV and cervix- pathophysiology
causes dyskaryosis:
-increased nuclear to cytoplasmic ratio, mitotic figures, nuclear pleomorphism
-koilocytosis halo cells, keratosis, multinucleation
low grade= nucleus:cytoplasm <50%
moderate= 50-75%
high= >75%
171
CIN types
1= basal 3rd epithelium
2= 2/3
3= 3/3
1= observe
2/3- treat (LLETZ/cone/ablation)
6 month TOC smear after any rx
172
Cervical screening process- normal cytology
1) HPV +ve:
cytology -ve:
rescreen in 12/12
-if normal for routine recall
-if abnormal x3 at 12/12= colposcopy
if colposcopy normal= routine
173
Cervical screening process- abnormal cytology
CIN 1= recall 12/12
CIN2/3= treat and recall 6/12
174
Cervical screening process- HPV negative
At any point, after any testing/treatment=
recall at 3 years
175
CIN treatment
CIN2/3- LLETZ
176
Breast screening- process
prevents 1300 deaths/year
RR 0.8 (reduces by 20%)
BRCA= MRI yearly 25-39
MRI and mammogram 40-50
mammogram >50
every 1 death prevented= 3 treated unnecessarily
177
Bowel screening
FIT every 2 years from 56 to 74
178
HPV vaccination
1 dose (if under 25) age 12/13
MSM= 2 doses up to age 45
HIV = 3 doses, 1 month and 4 months
Gardasil = HPV, 31, 33, 45, 52, 58
as well as 6, 11, 16 and 18
179
BRCA
Breast Ca
1= 55-72%
2= 45-69%
Ovarian Cancer
1= 39-44%
2= 11-17%
by age 70-80
Autosomal dominant
0.2-0.3%, 2% ashkenazi jews
180
PMS- epidemiology
changes in luteal phases that leave after menstruation
40%F, 4-8% severe
181
PMS- diagnosis
Prospective symptom diary over at least 2 cycles
or 3/12 of GnRH
mainly physical changes, affect functioning
182
PMDD- diagnosis
severe, emotional changes
5 of 11 symptoms, 1 must be affective
final week of luteal phase
resolve with menses
must not be an exacerbation of mental health
183
PMS epidemiology
highest in white women
often family history
known to be worse at perimenopause
184
Pathophysiology of PMS
altered receptors in the limbic system
allopregnanolone attaches to GABAa, reducing its response (less calming, increased stress/anxiety)
185
PMS- investigations
TFTs
Screen for depression
FSH (perimenopausal)
FBC (anaemia)
186
PMS- 1st line treatment
CBT
Vitamin B6
COCP (continuous>cyclical), DRSP first line
SSRI (d15-18/continuous)
citalopram/escitalopram (low dose)
recommend a micronised progesterone at lowest possible dose
187
PMS- second line treatment
Estradiol patch 100mcg + 100-200mg micronised P (d17-28, oral/pv) or LNGIUD
citalopram/escitalopram 20-40mg
188
PMS- third line
GnRH + addback HRT (patch + P/tibolone) if over 6/12
189
PMS- fourth line
Surgery +/- HRT
If failed medical treatment and need longterm GnRH
190
SSRIs for PMS + pregnancy
Advise to stop as symptoms will get better (risk benefit ratio changes)
discontinue gradually to reduce withdrawal symptoms (if continuous)
191
PMS, when to refer?
COCP, B6 and SSRI have been explored and failed
severity justifies intervention
192
PMS and danazol
effective in luteal phase for breast symptoms
virilising
need effective contraception
reduces LH and FSH= reduced oestrogen
200mg PO BD
| synthetic andorgen- suppressive Gn release at pituiatry
193
DRSP and PMS
binds to aldosterone receptors
reduced estrogen stimulation of RAAS
reduced salt and water retention
Can consider spironolactone
194
Cervical cancer- types
80% SCC of ectocervix
20% adenocarcinoma
HPV 16 and 18 >70% cases, inhibits tumour suppressors p53 and pRb
195
Cervical Ca- management
1a1- TAH
<2A- TAH and lymphadenectomy/Chemoradiation
<4a- chemoradiation
4b- combined chemotherapy
Prognosis
>80% >1 year
>60% 5 years
>50% ten years
196
Smear for HPV
Compared to cytology:
better sensitivity >95%
lower specificity (85%)
197
Inadequate smear
repeat in no less than 3 months
if two inadequate->colposcopy
198
What happens at colposcopy?
Microscopic examination of the cervix
acetic acid 3%
-turns areas of dysplasia white
Iodine (schiller's test)
health cells- brown, unhealthy cells- yellow/orange
biopsy abnormal areas
LLETZ
excision 4-5mm deeper than affected area
199
Exposure to DES
Diethylstilbestrol (anti miscarriage drug)
daughters of individuals exposed to this increased risk of clear cell cancer of cervix (1 case/yr in UK
if stigmata of DES exposure= annual colposcopy
200
Smears in PLWH
Annual smear
delay if pelvic infection
201
Smears in pregnancy
wait until 3/12 after
can do TOC if previous abnormal results- risk/benefit discussion
202
Smears <25 or >65
cervical Ca rare but HPV common
would lead to over treatment (increased risk of premature delivery)
continue >65 if previous problems/never had before
203
Smear no GP
Can request at sexual health clinic
won't get invite
204
Endometrial polyp- risk
0.8% atypia
3% malignancy
205
PMB risk of endo Ca
10%
206
Clobetasol dose
Clobetasol propionate (Dermovate ointment - tapering regime)
1)A finger tip unit (0.5gm) once a night for 4 weeks
2)Alternate night for 4 weeks
3)Twice/week for 4 weeks
207
choriocarcinoma- hormone secretion
HCG
