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Gynaecology 2 Flashcards

1
Q

List some absolute contraindications to the combined oral contraception pill:

A

Migraine with aura

BMI >35 + Smoker >15

Breast feeding until 6 weeks postpartum

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2
Q

What are the treatment options for endometrial fibroids and which is an absolute contraindication for pregnancy?

A

Medical:

  • Tranexamic acid
  • Ulipristal acetate (progesterone receptor modulator)
  • GnRH analogies
Surgical: 
- Myomectomy 
- Hysteroscopic resection 
- Uterine artery embolization 
- Endometrial ablation 
`
***endometrial ablation is an absolute contraindication
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3
Q

What is the management for an ectopic pregnancy where the patient is unstable?

A

Laparoscopic salinpingectomy

or

Laproscopic Salinpingotomy
- where only the ectopic is removed

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4
Q

Which type of HRT has a better impact on lipid levels?

A

Oral

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5
Q

What are some absolute contraindications to HRT?

A

Liver disease

Thromboembolic disease

Recurrent DVTs

Previous breast cancer

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6
Q

Which ligament provides the greatest degree of support to the uterus?

A

Cardinal ligament

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7
Q

What is part of the malignancy risk index for ovarian cancers?

A

Menopause status
Ca125
Ultrasound findings

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8
Q

What are the symptoms of lichen sclerosus?

A

Vulva itch

White discoloration

thinning

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9
Q

What is the management of endometriosis?

A

1st line:

  • NSAIDs
  • Contraceptive pill (COCP and Progesterone only)

If not working or fertility is of concern then referral to secondary centre:
- GnRH analogies

Surgical:

  • Ablation of ectopic tissue
  • resection of endometriosis tissue
  • Adhesiolysis

Definitive:

  • hysterectomy
  • Bilateral salpingectomy (stop oestrogen production)
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10
Q

What are the main causes of vaginal discharge?

A

Vaginal infection:

  • Candida infection
  • Bacterial vaginosis
  • Trichomonas Vaginalis

Cervical infection:

  • chlamydia
  • gonorrhoea

Other::

  • cervical ectropion
  • retained products of conception
  • retained tampon
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11
Q

What treatment can be given to patients with endometriosis to improve chances of successful fertilisation?

A

clomiphene

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12
Q

On a biopsy of endometriosis - what might histology show?

A

Endometrial stroma

Endometrial glands

Hemosiderin laden macrophages

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13
Q

List 3 things which may block the fallopian tubes preventing pregnancy:

A

Endometriosis

PID
- adhesions

Hydrosalpinx

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14
Q

What factors need to be discussed for IVF?

A

Success rate

limited amount of times on NHS
- 3 times

Alternatives
- such as adoption

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15
Q

Where are the most common places for endometriosis to develop endometrial tissue on?

A

Ovaries

Uterosacral ligament

Pouch of Douglas

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16
Q

What are some differentials for endometriosis?

A

PID

IBD

Primary dysmenorrhoea

Fibroids

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17
Q

What are some surgical options for endometriosis?

A

Surgical ablation

Surgical resection

Adhesiolysis
- can be used surgically to improve outcomes for pregnancy

Bilateral salpingo-oophorectomy

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18
Q

What are the three groups of of hypothalamus, pituitary and ovarian dysfunction causing infertility in women?

A
  1. Hypothamic- pituitary failure (low FSH, LH)
    - anorexia
    - Kalmann’s syndrome
    - Pituitary adenoma
  2. Hypothamic pituitary ovarian dysfunction
    - PCOS
  3. Ovarian failure
    - Premature ovarian failure
    - Turner’s syndrome
    - chemotherapy
19
Q

What tests are done to asses tubal patency?

A

Hysterosalpingogram
- this is done as a day case where the radioactive dye is injected into the uterus and should be seen to take the shape of the uterus and the across the fallopian tubes.

If it doesn’t then the female is referred on for:
- laparoscopic blue dye test

20
Q

What are some medical and surgical options for infertility in PCOS?

A

Medical:

  • clomiphene
  • risk of multiple pregnancy
  • risk of ovarian hyperstimulation
  • Metformin
  • GnRH pulsatile

Surgical:

  • laparoscopic ovarian drilling
  • increases FSH and reduces androgens
21
Q

If on a sperm analysis there is seen to be aspermia (no sperm or semen) then what has most likely occurred and how is this investigated for?

A

Retrograde ejaculation

Investigations:
- Post ejaculation urine analysis

22
Q

List some causes of menorrhagia:

A

Idiopathic

Endocrine:

  • Hypothyroidism
  • Unopposed oestrogen (obesity, Liver disease)

Structural:

  • fibroids
  • polyps

Others:

  • clotting disorders
  • PID
  • Endometrial cancer (rare pre menopause)
23
Q

What are some red flags for menorrhagia which warrant further investigation?

A

Post coital bleeding

Intermenstrual bleeding

Dyspareunia

Pain discomfort/ compressional pain

24
Q

What important topic needs to be discussed when deciding on particular surgeries for heavy menstruation?

A

If they have completed their family

  • endometrial ablation
  • hysterectomy
25
Q

What are some risk factors for fibroids?

A 
African 
Early menarche / late menarche 
Advancing age 
Nulliparity
Obesity (oestrogen driven)

*oestrogen driven so very similar risk factors for breast cancer

26
Q

What are the typical symptoms of fibroids and list two complications of fibroids:

A 
Usually asymptomatic 
Menorrhagia 
Intermenstrual bleeding
Abdominal fullness 
Abdominal pain

Complications:
- fibroid torsion (pedunculated twists on itself causing necrosis)

  • Red degeneration (usually seen in pregnancy)

-infertility and pregnancy complications
(pre-term, malrotation, placenta previa, spontaneous miscarriage)

27
Q

What surgical options are available for fibroids to when wanting to preserve fertility?

A

Myomectomy

Uterine artery embolism

28
Q

What is the risk factors for an ectopic pregnancy?

A

Previous ectopic

PID

Previous Tubal surgery
- scarring

IUD

Smoking

> 35 years old

29
Q

Where is an ectopic most likely to implant?

A

Ampulla of the tubes

*97% are tubal pregnancy

30
Q

Why do you get shoulder tip pain in an ectopic?

A

Blood/ fluid can move up through the intra-abdominal cavity and irritate the diaphragm

31
Q

What is the diagnostic test of choice for a suspected ectopic and if it is negative what are the next investigations?

A

TVS is diagnostic test of choice.

If it is negative then a Beta- hCG level should be conducted over 48 hours.

  • increased >63% = intrauterine pregnancy
  • halved = miscarriage
  • stayed the same = ectopic

Laparoscopy can be done if there is still uncertainty

32
Q

How is the methotrexate for a medical management of an ectopic given, what are the indications and how is it followed up?

A

IM injection
- followed up 4 and 7 days later looking for <15% drop in bhCG, if not dropped 2nd dose can be given.

Indications:

  • stable patient
  • b- hCG <1500iU
  • no heart beat
  • <35mm
33
Q

When is premature menopause and what are some causes?

A

<40 years old is premature.

**Average age in UK is 52

Primary ovarian failure

Turner’s syndrome

Iatrogenic

Hypothyroidism

Addison’s disease

34
Q

What are some differentials for the symptoms of menopause?

A

Night sweats:

  • leukaemia
  • lymphoma
  • TB

Libido:
- depression

Joint aches:
- OA

35
Q

What are some of the complications of menopause?

A

Psychological effect
Osteoporosis
Recurrent UTIs
Accidental pregnancy

36
Q

What are the forms HRT can be given, which is usually advised and why?

A 
Oral 
Transdermal patches 
Gels 
Implants 
Nasal spray

Parental is usually preferred as has lower risk of DVT
*any non-oral type

37
Q

Which women should receive the continuous and sequential HRT?

A 
Periods stopped (menopause) 
= continuous

Period stopped but symptomatic (climatic)
= sequential

38
Q

What are the alternatives to HRT:

A

Flushes:

  • SSRIs
  • Clonidine
  • Gabapentin

Topical lubricants

CBT

39
Q

What are the main types of urinary incontinence in females and list some risk factors:

A

Stress incontinence

  • Obesity
  • Pregnancies/ births
  • Chronic cough
  • Smoking
  • increasing age
  • note these are same risk factors for prolapses

Urge incontinence:

  • caffeine/ alcohol use
  • Excessive fluid intake
  • Neurological conditions (MS, Parkinson’s)
  • Bladder tumour
40
Q

What are some differentials for urinary incontinence and list some initial investigations that should be done along with some specialist ones:

A

Differentials:

  • diabetes
  • diabetes insipidus
  • Excessive fluid intake
  • repetitive UTIs
  • Functional/ passive incontinence
  • Prolapse

Investigations:

  • urinalysis (glucose? UTI?)
  • bladder diary
  • post void residual volume (too much left tells you the bladder isn’t emptying correctly)

Specialist test:

  • cytometry (measurement of pressures - bladder should be relaxing)
  • Uroflowmetry
41
Q

What are the treatments of urinary incontinence?

A

Stress:

  • weight loss
  • reduced fluid/ caffeine intake
  • Pelvic floor exercises (Kegel exercises)
  • Urethral sling operation
  • Duloxetine (increases sphincter tone)

Urge incontinence:

  • lifestyle
  • bladder retraining
  • Anti-muscarines (oxybutynin)
  • Beta - 3 agonists (increased sphincter tone)
  • botulism injection
  • sacral nerve stimulation
42
Q

What are some risk factors for prolapse?

A 
Parity - especially instrumental delivery 
Smoking 
Age -reduced oestrogen 
Pelvic surgery 
Connective tissue disease
43
Q

What is the management of ovarian cysts and what does the RMI score consist of?

A

Pre-menopausse:
<5cm: discharge

> 5cm
Dermoid
Endometrial cyst
- cystectomy

Post- menopausal:
Low RMI: Follow up

Intermediate/ high RMI:
- Bilateral oopherectomy + salpingectomy
+/- Hysterectomy depending on histological analysis of the cyst

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