Gynaecology 2 Flashcards
List some absolute contraindications to the combined oral contraception pill:
Migraine with aura
BMI >35 + Smoker >15
Breast feeding until 6 weeks postpartum
What are the treatment options for endometrial fibroids and which is an absolute contraindication for pregnancy?
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
What is the management for an ectopic pregnancy where the patient is unstable?
Laparoscopic salinpingectomy
or
Laproscopic Salinpingotomy
- where only the ectopic is removed
Which type of HRT has a better impact on lipid levels?
Oral
What are some absolute contraindications to HRT?
Liver disease
Thromboembolic disease
Recurrent DVTs
Previous breast cancer
Which ligament provides the greatest degree of support to the uterus?
Cardinal ligament
What is part of the malignancy risk index for ovarian cancers?
Menopause status
Ca125
Ultrasound findings
What are the symptoms of lichen sclerosus?
Vulva itch
White discoloration
thinning
What is the management of endometriosis?
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)
What are the main causes of vaginal discharge?
Vaginal infection:
- Candida infection
- Bacterial vaginosis
- Trichomonas Vaginalis
Cervical infection:
- chlamydia
- gonorrhoea
Other::
- cervical ectropion
- retained products of conception
- retained tampon
What treatment can be given to patients with endometriosis to improve chances of successful fertilisation?
clomiphene
On a biopsy of endometriosis - what might histology show?
Endometrial stroma
Endometrial glands
Hemosiderin laden macrophages
List 3 things which may block the fallopian tubes preventing pregnancy:
Endometriosis
PID
- adhesions
Hydrosalpinx
What factors need to be discussed for IVF?
Success rate
limited amount of times on NHS
- 3 times
Alternatives
- such as adoption
Where are the most common places for endometriosis to develop endometrial tissue on?
Ovaries
Uterosacral ligament
Pouch of Douglas
What are some differentials for endometriosis?
PID
IBD
Primary dysmenorrhoea
Fibroids
What are some surgical options for endometriosis?
Surgical ablation
Surgical resection
Adhesiolysis
- can be used surgically to improve outcomes for pregnancy
Bilateral salpingo-oophorectomy
What are the three groups of of hypothalamus, pituitary and ovarian dysfunction causing infertility in women?
- Hypothamic- pituitary failure (low FSH, LH)
- anorexia
- Kalmann’s syndrome
- Pituitary adenoma - Hypothamic pituitary ovarian dysfunction
- PCOS - Ovarian failure
- Premature ovarian failure
- Turner’s syndrome
- chemotherapy
What tests are done to asses tubal patency?
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
What are some medical and surgical options for infertility in PCOS?
Medical:
- clomiphene
- risk of multiple pregnancy
- risk of ovarian hyperstimulation
- Metformin
- GnRH pulsatile
Surgical:
- laparoscopic ovarian drilling
- increases FSH and reduces androgens
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?
Retrograde ejaculation
Investigations:
- Post ejaculation urine analysis
List some causes of menorrhagia:
Idiopathic
Endocrine:
- Hypothyroidism
- Unopposed oestrogen (obesity, Liver disease)
Structural:
- fibroids
- polyps
Others:
- clotting disorders
- PID
- Endometrial cancer (rare pre menopause)
What are some red flags for menorrhagia which warrant further investigation?
Post coital bleeding
Intermenstrual bleeding
Dyspareunia
Pain discomfort/ compressional pain
What important topic needs to be discussed when deciding on particular surgeries for heavy menstruation?
If they have completed their family
- endometrial ablation
- hysterectomy
What are some risk factors for fibroids?
African Early menarche / late menarche Advancing age Nulliparity Obesity (oestrogen driven)
*oestrogen driven so very similar risk factors for breast cancer
What are the typical symptoms of fibroids and list two complications of fibroids:
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)
What surgical options are available for fibroids to when wanting to preserve fertility?
Myomectomy
Uterine artery embolism
What is the risk factors for an ectopic pregnancy?
Previous ectopic
PID
Previous Tubal surgery
- scarring
IUD
Smoking
> 35 years old
Where is an ectopic most likely to implant?
Ampulla of the tubes
*97% are tubal pregnancy
Why do you get shoulder tip pain in an ectopic?
Blood/ fluid can move up through the intra-abdominal cavity and irritate the diaphragm
What is the diagnostic test of choice for a suspected ectopic and if it is negative what are the next investigations?
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
How is the methotrexate for a medical management of an ectopic given, what are the indications and how is it followed up?
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
When is premature menopause and what are some causes?
<40 years old is premature.
**Average age in UK is 52
Primary ovarian failure
Turner’s syndrome
Iatrogenic
Hypothyroidism
Addison’s disease
What are some differentials for the symptoms of menopause?
Night sweats:
- leukaemia
- lymphoma
- TB
Libido:
- depression
Joint aches:
- OA
What are some of the complications of menopause?
Psychological effect
Osteoporosis
Recurrent UTIs
Accidental pregnancy
What are the forms HRT can be given, which is usually advised and why?
Oral Transdermal patches Gels Implants Nasal spray
Parental is usually preferred as has lower risk of DVT
*any non-oral type
Which women should receive the continuous and sequential HRT?
Periods stopped (menopause) = continuous
Period stopped but symptomatic (climatic)
= sequential
What are the alternatives to HRT:
Flushes:
- SSRIs
- Clonidine
- Gabapentin
Topical lubricants
CBT
What are the main types of urinary incontinence in females and list some risk factors:
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
What are some differentials for urinary incontinence and list some initial investigations that should be done along with some specialist ones:
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
What are the treatments of urinary incontinence?
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
What are some risk factors for prolapse?
Parity - especially instrumental delivery Smoking Age -reduced oestrogen Pelvic surgery Connective tissue disease
What is the management of ovarian cysts and what does the RMI score consist of?
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
