Gynaecology 3a

Question 1

Gonorrhoea

Neisseria gonorrhoea which is a gram-negative diplococcus bacteria.

Acute infection can occur on any mucous membrane surface, typically genitourinary but also rectum and pharynx
- acute incubation period is 2-5 days
males: urethral discharge, dysuria, testicular swelling
females: cervicitis e.g. leading to vaginal discharge (green or yellow)
urethral strictures
rectal and pharyngeal infection is usually asymptomatic
- More likely to be symptomatic as compared to Chlamydia infection.

Answer 1

• Nucleic acid amplification testing used to detect RNA or DNA of gonorrhoea. swabs or urine
• Single dose IM Cefitraxone or 500mg Oral Ciprofloxacin
• Re test at 72h, 1wk and 2wk
• reinfection is common due to antigen variation of type IV pili

lead to PID, infertility, adult conjunctivitis

Key complication is gonococcal conjunctivitis in a neonate due to spread from mother during birth. Medical emergency that is associated with sepsis, perforation of the eye and blindness. treated with saline drops & Ceftriaxone in a single dose (25-50 mg/kg IM or IV, up to a maximum of 125 mg).

Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults
- tenosynovitis
- migratory polyarthritis
- dermatitis (lesions can be maculopapular or vesicular)

Question 2

Chlamydia

Chlamydia trachomatis – gram-negative, intracellular bacteria.

Infection occurs due to elementary bodies which enter cells and then form inclusion bodies which rapidly divide.
- The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic
- Females: cervicitis (discharge, bleeding), dysuria
- Males: urethral discharge, dysuria

Answer 2

-NAATs: Men=Urine Women=Vaginal swab
- Chlamydiatesting should be carried out two weeks after a possible exposure
- Doxcycline for 1wk
- if pregnant or breast feeding then azithromycin, erythromycin or amoxicillin

Potential complications
* epididymitis
* pelvic inflammatory disease
* endometritis
* increased incidence of ectopic pregnancies
* infertility
* reactive arthritis
* perihepatitis (Fitz-Hugh-Curtis syndrome)
* Neonatal conjunctivitis and pneumonia

Question 3

Trichomonas vaginalis

Trichomonas vaginalis protozoa; single celled organism with flagella.

• ## Parasitic

Answer 3

Features
* vaginal discharge: offensive, yellow/green, frothy
* vulvovaginitis
* strawberry cervix
* pH > 4.5
* in men is usually asymptomatic but may cause urethritis

microscopy of a wet mount shows motile trophozoites

Management
* oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole
* - Pregnancy-related complications such as preterm delivery

Question 4

common in elderly women

Urinary Incontinence

RF, Age, Chilbirth, BMI, Hyterectomy, FH

Investigations
- Bladder diary for 3 days
- Vag examination to exclude pelvic organ prolaps
- Dipstick and cultures

Answer 4

• Overactive bladder/Urge incontinence, detrusor overactivity - urge to urinate quickly followed by unccontrollable leakage.
• Stress incontinence: Leaking small amount when coughing or laughing
• Mixed: Signs of Urge and Stress
• Overflow incontinence: Bladder outlet obstruction (more common in men)
• Functional incontinence: Other conditions prevent pt from getting to toilet in time. (dementia, medications, injury)

Management
Urge
- Bladder retraining (6wks)
- Oxybutnin (antimuscarinic) risk of falls then give mirabegron.

Stress
- Pelvic floor excercises
- surgery
- Duloxetine.

Question 5

Pelvic Organ Prolapse

RF; Vag elivert, ehlers danlos, menopause, pelvic surgery, obesity

• descent of one of the pelvic organs resulting in protrusion on the vaginal walls. It probably affects around 40% of postmenopausal women

Types
- Cystocele - bladder into vagina
- Rectocele - rectum into vagina (constipation, urinary retention)
- Uterine Prolapse - uterus itself descends into the vagina.
- Enterocoele: prolapse of upper posterior wall of the vagina, with pouch containing loops of small bowel.

Answer 5

Presentation
- Sensation of pressure/heaviness in vagina - bearing down.
- Incontince, frequency, urgenct

Management
* if asymptomatic and mild prolapse then no treatment needed
* conservative: weight loss, pelvic floor muscle exercises
* ring pessary
* surgery (Colposuspension, hysterectomy…)

POP-Q system used for grading Grade 0-4
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina

Question 6

Renal Stones Management

RF Dehydration, cystinuria, PCKD, gout

Types:
Calcium Oxalate - Hypecalciuria RF - Most common
Cystine
Uric Acid
Calcium Phosphate

Answer 6

• Im diclofenac for severe pain
• non-contrast CT KUB should be done
• Stones <5mm pass spontaneously
• Lithotripsy and nephrolithotomy may be for severe cases.
• Ureteroscopy

Question 7

What is Cervical ectropion and its symptoms.

transformation

Answer 7

• 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

Symptoms
- Vaginal Discharge
- Post-Coital Bleeding

Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms

Question 8

Androgen Insensitivity Syndrome

X linked recessive

MALE CHILDREN HAVE FEMALE PHENOTYPE 46XY
caused by a mutation in the androgen receptor gene

Answer 8

Features
* ‘primary amenorrhoea’
* undescended testes causing groin swellings
* breast development may occur as a result of conversion of testosterone to oestradiol
* Raised LH, Normal FH, Raised oestrogen and testosterone
* Body insensitive to testosterone.

Management
* counselling - raise child as female
* bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
* oestrogen therapy

Patients have testes in the abdomen or inguinal canal, and absence of a uterus, upper vagina, cervix, fallopian tubes and ovaries. The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.

Question 9

Menstrual Cycle

The menstrual cycle may be divided into the following phases:

• Menstruation 1-4d
• Follicular phase (proliferative phase) 5-13d
• Ovulation 14d
• Luteal phase (secretory phase) 15-28d

Answer 9

The end result is the production of an ovum and thickening of the endometrium to allow for implantation, should fertilisation should occur.

Question 10

menarche

In childhood, girls have relatively little GnRH, LH, FSH, oestrogen and progesterone in their system. During puberty, these hormones start to increase sequentially, causing the development of female secondary sexual characteristics, the onset of the menstrual cycle and the ability to conceive children.

• In girls, puberty starts with the development of breast buds, followed by pubic hair and finally the onset of menstrual periods. The first episode of menstruation is called menarche. Menstrual periods usually begin about two years from the start of puberty.

Answer 10

• Growth hormone (GH) increases initially, causing a spurt in growth during the initial phases of puberty.
• The hypothalamus starts to secrete GnRH, initially during sleep, then throughout the day in the later stages of puberty. GnRH stimulates the release of FSH and LH from the pituitary gland. FSH and LH stimulate the ovaries to produce oestrogen and progesterone. FSH levels plateau about a year before menarche. LH levels continue to rise, and spike just before they induce menarche.

Taner scale usedstahe 1 to 5

Question 11

Menopause

average women in the UK goes through the menopause when she is 51 years

• The climacteric (reduced fertility/sexy time) is the period prior to the menopause where women may experience symptoms, as ovarian function starts to fail

It is recommended to use effective contraception until the following time:
* 12 months after the last period in women > 50 years
* 24 months after the last period in women < 50 years

Answer 11

• Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.
• Symptoms typically last for 7 years

Symptoms Specific Management
Hot flushes
* regular exercise, weight loss and reduce stress

Sleep disturbance
* * avoiding late evening exercise and maintaining good sleep hygiene

Mood
* sleep, regular exercise and relaxation

Cognitive symptoms
* regular exercise and good sleep hygiene

Vasomotor symptoms
* fluoxetine, citalopram or venlafaxine

Vaginal dryness
* vaginal lubricant or moisturiser

Psychological symptoms
* self-help groups, cognitive behaviour therapy or antidepressants

Urogenital symptoms
* if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
* vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

contraindications of HRT

• Current or past breast cancer
• Any oestrogen-sensitive cancer
• Undiagnosed vaginal bleeding
• Untreated endometrial hyperplasia
• Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
• Stroke: slightly increased risk with oral oestrogen HRT.
• Coronary heart disease: combined HRT may be associated with a slight increase in risk.
• Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
• Ovarian cancer: increased risk with all HRT.

Longer term complications
osteoporosis
increased risk of ischaemic heart disease

Question 12

Adenomyosis Features and Management

Presence of endometrial tissue within myometrium
- more common in multipparous women before perimenopause

Answer 12

Features
* dysmenorrhoea
* menorrhagia
* enlarged, boggy uterus

Management
* GnRH agonists
* hysterectomy

GnRH agonists; Leuprolide, goserelin, triptorelin and histrelin

Question 13

Asherman’s Syndrome presentation

adhesions form within uterus following damage

usually occurs after pregnancy related ed dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth). or occur in endometriosis

Answer 13

• secondary amenorrhoea
• Significantly lighter periods
• Dysmenorrhoea

Hysterocopy is gold stanndard.

Management
- Dissect adhesions during hysterocoppy
- reoccurence is common

Question 14

Lichen Sclerosus presentation & Management

Genitalia of elderly women

Increased risk of vulval cancer

Answer 14

• White patches that scar (cigarette)
• Itchyness
• Painful intercourse
• Clinical Diagnosis
• Topical Steroids and Emollients

Do not perform biopsy unless if the woman fails to respond to treatment or there is clinical suspicion of VIN or cancer.

Question 15

Post Menopausal

Atrophic Vaginitis Presentation and Management

Answer 15

• Vagina; dryness
• Dyspareunia
• Ocassional spotting
• Dry and pale vagina
• no atypia present on biopsy

Managemet
- 1st line: vaginal lubricants & moisturisers
- 2nd line: topical oestrogen creanm

Question 16

Vulval Carcinoma

Majority are squamous cell carcinomas

RF: HPV (16&18), Vulval inraepthelial neoplasia, immunosupression, Lichen sclerosus

Answer 16

• Lump on Labia Majora
• Inguianal Lymphadenopathy
• Associated with itching/irritation

Question 17

extremely rare

vaginal cancer

squamous cell carcinoma

Same RF as cervical cancer

Answer 17

• Vaginal mass - biopsy
• no mass then cytology performed

Question 18

50% cases in U45 highest 25-29

Cervical Cancer

HPV 16+18. Not familial Squamous cell majority

RF: Early sex, lots of sex buddys, no contraception ,smoking, COC pill, HIV, multiparity, poor background
* HPV 11 &6 are genital warts not cancer

Answer 18

• often asymptoatic - seen on smear
• Abnormal uterine bleeding (intramenstual, post coital or post menopausal)
• Vag discharge with pelvic pain and pain during sex
• cervical mass bleeding on speculum exam
• Colposcopy allows examination of cervical lining.
• Stage 4A disease may involve a combination of surgery, radiotherapy, chemotherapy and palliative care.
  Bevacizumab

Management
- LLETZ or Cone biopsy for early stage
- Radical hysterectomy and removal of lymph nodes is option.

Question 19

Cervical Cancer Screening

start at 24.5Y then recall interval: every 3Y until 50+ then every 5Y

• cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)
• cervical screening in pregnancy is usually delayed until 3 months post-partum unless previous abnormalities

Answer 19

• HPV first - Cervical smear tested for hrHPV
• if +ve then cytological exam performed
• If -ve then recall interval resumes

Inadequate sample x1= repeat 3m x2= colposcopy

Positive hrHPV
- Cytology abnormal then colposcopy
- cytology normal then repeat at 12m. If repeat is normal then back to normal recall (3or5Y)
- if repear is +ve and cytology normal then repet after 12m
- at 24m hrHPV -ve then normal recall
- if hrHPV still +ve then Colposcopy

Question 20

Mean age 64 - Poor Prognosis

Ovarian Cancer

distal end of fallopian tubes seen as origin of cancer

RF: early mearche, late menopause, nulliparity

Answer 20

• Abdo distension/bloating and pelvic pain
• Urinary symptoms
• Early Satiety
• Diarrhoea
• Raised CA125 (not specific)- urgent USS of abdo & pelvis
• Diagnostic Laparotomy
• Platinum based Chemo & surgery

Epithelial carcinoma

-Important to ask about breast and GI symptoms as there is potential for metastasis.
In woman under 40, alpha fetoprotein and hCG are measured – raised in germ cell tumours.
- Krukenburg tumour refers to metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly in the stomach.

Question 21

Most common gynae cancer

Endometrial Cancer

usually post menopause

RF: obesity, nuliparity, early mearche, late menopause. Oestrogen, DM, Tamoxifen, PCOS

Answer 21

• Post Menopausal Bleeding (heavy)
• Premenopausal: intermenstrual bleeding change
• if Bleeding in PMB women then 2week check
• Transvaginal USS - endometial lining >4mm then further investigation
• hysterescopy with endometrial biopsy

- COCP is protective factor ffor endometrial cancer

Management
* localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have postoperative radiotherapy
* progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery

Question 22

Endometrial hyperplasia features and management

defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer

Answer 22

• Abnormal vaginal bleeding (intermenstrual)

Management
- w/out atypia: High dose progesterone, Levo IUS may also be used
- atypia: hysterectomy is usally advised

Question 23

endometrial polyps

benign growth of endometrial glands and stroma and protrude into uterine cavity

Answer 23

• Increased rik with tamoxifen
• Hx of breast cancer treatment
• asymptomatic or uterine bleeding

Transvaginal USS

Teated using hysterescopy and polyp removal

Question 24

Endometriosis

growth of ectopic endometrial tissue outside uterine cavity

Oestrogen dependent cells.
Ectopic endometrial-like tissue can induce fibrosis.
Accumulated altered blood is dark brown and can form a ‘chocolate cyst’ or endometrioma in the ovaries.

Answer 24

• Chronic Pelvic pain
• 2ndry dysmenorrhoea - pain starts days before bleeding
• deep dypareunia
• subfetility
• Dysuria, urgency, haemtouria, Dyschezia
• Tender nodularity in posterior vaginal fornix

Laprascopy is gold standard

1st line: NSAID, paracetamol
2nd line: COC pill or progestogens, medroxyprogesterone acetate should be tried
- GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
- surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Question 25

Fibroids

Fibroids are benign smooth muscle tumours of the uterus

20% of white and around 50% of black women in the later reproductive years.
- Rare in puberty, develop in response to oestrogen

Answer 25

• Mennorhagia - leading to IDA
• Dysmenorrhoea
• bloating
• Urinary symptoms (w/ larger fibroids)
• Subfertility
• Polycythaemia 2ndry to autnomour production of erythropoietin

Transvaginal USS

Management

• Asymptomatic: regular monitoring
• Mennorhagia: levonorgestrel intrauterine system, NSAID (mfenamic acid), Tranxamic acid, COCP, Oral progestogen
• Fibroid removal/shrinkage: GnRH agonists (gives menopausal symptoms - used short-term)
• Surgical: myomectomy performed - preferred option in subfertility

Question 26

Fibroids in Pregnancy

Answer 26

• In early pregnancy, growth of fibroids in response to oestrogen and can cause pelvic pain and pressure symptoms

Fibroid Degeneration
* When growth of fibroids outstrip blood supply, degeneration can occur.
* low-grade fever, pain and vomiting.
* Managed with analgesia and rest

presence of pelvic pain, the history of menorrhagia, usually indicates pre-existing fibroids

Question 27

Prolactinoma symptoms and management

type of adenoma, a benign tumour of the pituitary gland.

Prolactinomas are the most common type and they produce an excess of prolactin.

Answer 27

Women
- Amenorrhoea
- Infertility
- Galactorrhoea
- osteoporosis

Men
- Impotence
- loss of libido
- Galactorrhoea

Both
- headaches
- visual disturbances
- hypopituitarism

MRI diagnosis

Managment
- dopamine agonists (e.g. cabergoline, bromocriptine) which inhibit the release of prolactin from the pituitary gland
- surgery is performed for patients who cannot tolerate or fail to respond to medical therapy. A trans-sphenoidal approach is generally preferred unless there is a significant extra-pituitary extension

Question 28

linked to FH

Polycystic Ovarian Snydrome

ovarian dysfunction

Other Ovarian Cysts
- Follicular - most common - regress after menstrual cycles
- Corpus Luteum - CL fails to break down and fills with pus or blood - intraperitoneal bleeding
- Dermoid cyct - most common u30, asymptomatic

Answer 28

• Oligomenorrhoea (+)
• Hisutism + acne and male-like pattern baldness (+)
• PCOS on USS (+)
• subfertility
• Obesity
• Recurrent miscarriage.

Complications
insulin resistance and diabetes; leads to pancreas releasing more insulin that promotes release of androgens from ovaries and adrenal glands, and suppresses sex hormone-binding globulin production from the liver – promotes

pelvic ultrasound: multiple cysts on the ovaries + Raised LH:FSH ratio

(+) = Rotterdam Criteria

Management
- lifestyle changes, lose weight
- : COC pill or cyclical oral progesterone can help regulate menstruation. LNG-IUS gives continuous endometrial protection.

Question 29

Ovarian Torsion

RF: Ovarian mass, pregannacy, young, ovarian hyperstimulation syndrome

partial or complete torsion of the ovaryon itssupporting ligaments that compromise its blood supply
+ + fallopian tubes = adnexal torsion

Answer 29

Features
* Usually the sudden onset of deep-seated colicky abdominal pain.
* Associated with vomiting and distress
* fever may be seen in a minority (possibly secondary to adnexal necrosis)
* Vaginal examination may reveal adnexial tenderness

Ultasound: Whirlpool sign

Laparoscopy is usually both diagnostic and therapeutic.

Question 30

Pelvic Inflammatory Disease

Ascending from cervix affecting uterus fallop tubes, ovaries, peritoneum

Causative organisms: chlamydia tachomatis, Neisseria gonnorrohoa, mycoplasma genitalum, Mycoplasm hominis

Answer 30

• Lower abdo pain
• Fever
• Deep dyspareunia
• Dysuria
• Vaginal discharge
• rule out Ectopic Pregnancy
• Vaginal swab and screen for chlamydia and gonorrhoea

Complications
* perihepatitis (Fitz-Hugh Curtis Syndrome)
* occurs in around 10% of cases
* it is characterised by right upper quadrant pain and may be confused with cholecystitis
* infertility - the risk may be as high as 10-20% after a single episode
* chronic pelvic pain
* ectopic pregnancy

Management
* oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
* RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in.

Question 31

Dysmenorrhoea

Excessive pain during menstrual period. 1imary and 2ndry

Primary: ususally from menarche
Secondary: - Endometriosis and adenomyosis , Pelvic inflammatory disease, Cervical stenosis and haematometra, IUD (copper coil)

Answer 31

• very painful period
• Associated with flushing and nausea.
• Red flags: abnormal cervix, persistent PCB, IMB or pelvic mass

Swabs and USS perfomed

Management
* NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
* combined oral contraceptive pills are used second line
* Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
* IUS mirena coil may help

Question 32

heavy periods

Menorrhagia

what the woman considers to be excessive

dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
Other causes
* anovoluntary cycles
* uterine fibroids
* hypothyroidsm
* IUD (copper coils)
* PID
* vWD

Answer 32

• Objective definition is blood loss of greater than 80ml per period, in an otherwise normal menstrual cycle
• NICE recommend full blood count, coagulation screen (if since menarche/family history), pelvic USS (if history suggests structural/histological abnormality), high vaginal and endocervical swabs, thyroid tests with suggestive history

Management
* Mirena (LNG IUS) - provided long-term use (12 months) is expected. Very effective – mean blood loss reduction of 95% after 1 year.
* Transxaemic Acid - antifibrinolytic reduces blood loss by 50%
* Norethisterone taken 15mg daily in cyclical pattern from day 6 to 26.
* Gonadotrophin-releasing hormone (GnRH) agonists – act on pituitary to stop oestrogen production leading to amenorrhoea. Only used short term however due to osteoporosis risk.
* Endometrial ablation – destroy endometrial lining to a depth that prevents regeneration

Question 33

Pre Menstrual Syndrome

Women should be asked to complete a menstrual diary, recording their moods and other symptoms for at least two cycles.

Answer 33

• Behavioural changes include ‘tension’, irritability, aggression, depression, and loss of control. Mood swings
  In addition, a sensation of bloating, minor gastrointestinal upset and breast pain can occur
• Minor Symptoms: advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
• Moderate: new gen COCP (yasmin - drospirenone 3mg)
• severe: SSRI during luteal phase (days 15-28)

Question 34

Amenorrhoea

primary vs secondary

primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

Answer 34

Primary amenorrhoea
* gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
* testicular feminisation
* congenital malformations of the genital tract
* functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
* congenital adrenal hyperplasia
* imperforate hymen (most common in the ones who have regular cycle - corrected via surgery)

Secondary
* hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
* polycystic ovarian syndrome (PCOS)
* hyperprolactinaemia
* premature ovarian failure
* thyrotoxicosis
* Sheehan’s syndrome
* Asherman’s syndrome (intrauterine adhesions)

Excl pregnancy. Low level gonadotroph= hypothalmic cause. raised=turners

Management
* primary amenorrhoea:
investigate and treat any underlying cause
with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)#

• secondary amenorrhoea
  exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
  treat the underlying cause

Question 35

Ovarian Hyperstimulation Syndrome

complication seen in some IVF infertility treatment.

Primary mechanism is an increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles, which increases vascular permeability and causes fluid to leak from capillaries. Fluid moves from intravascular to extravascular space – leads to oedema and hypovolaemia.

Answer 35

Mild
• Abdominal pain
• Abdominal bloating
Moderate
• As for mild
• Nausea and vomiting
• Ultrasound evidence of ascites
Severe
• As for moderate
• Clinical evidence of ascites
• Oliguria
• Haematocrit > 45%
• Hypoproteinaemia
Critical
• As for severe
• Thromboembolism
• Acute respiratory distress syndrome
• Anuria
• Tense ascites

Early: within 7d of the hCG injection Late: OHSS presents from 10d+

management
- Oral fluids
- Monitoring urine output
- LMWH
- Ascitic fluid removal
- IV colloids (human albumin solution)

Question 36

Herpes Simplex

Caused by infection with herpes simplex virus. HSV-2 typically causes genital herpes and is mostly an STI; can also cause lesions in the mouth. HSV-1 is most associated with cold sores – genital herpes caused by HSV-1 usually contracted though oral sex.

Answer 36

• Ulcers or blistering lesions in genital area
• Neuropathic pain (tingling, burning, shooting)
• Flu-like symptoms
• Dysuria
• Inguinal lymphadenopathy

Aciclovir is used to treat (+lidocaine)

Post-herpetic neuropathy can lead to long term neuropathic pain after the infection.
Recurrence one of the main complications.
Neonatal herpes is a serious infection with mortality of around 30%. Most often acquired at delivery of the mother has an active infection in the third trimester, especially in the last 6 weeks. Caesarean often indicated in these mothers.

Question 37

Post menopausal Bleeding Causes

defined as vaginal bleeding occurring after 12m of ammenorrhoea

Answer 37

vaginal atrophy
the most common cause of postmenopausal bleeding
the thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding
HRT (hormone replacement therapy)
periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding
endometrial hyperplasia
an abnormal thickening of the endometrium and a precursor for endometrial carcinoma
risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes
endometrial cancer
although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently
cervical cancer
it is important to obtain a full record of prior cervical screening programme attendance
ovarian cancer
can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours
vaginal cancer
uncommon but can present with postmenopausal bleeding
other uncommon causes include
trauma
vulval cancer
bleeding disorders

vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
if a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this
in the case of endometrial hyperplasia, usually dilatation and curettage is performed to remove the excess endometrial tissue