Gynaecology

Question 1

What is the treatment for a Bartholins gland cyst?

Answer 1

Incision and drainage
Broad spectrum antibiotics until cultures
Marsupialisation to prevent recurrence

Question 2

What is Nabothian cyst?

Answer 2

A small mucus filled cyst on the cervix

Squamous epithelium of the ectocervix grows over the columnar epithelium of the endocervix, blocking the cervical crypts.

Question 3

What is an Ectropion and what causes it?

Answer 3

Eversion of columnar endocervix

Driven by oestrogen - normal in young women

Question 4

What the investigation is the gold standard for diagnosing endometriosis?

Answer 4

Laparoscopy

Question 5

What are the main symptoms of endometriosis?

Answer 5

Premenstrual pain
Dysmenorrhea
Deep dyspareunia
Subfertility

Question 6

Management of endometriosis:

Answer 6

Expectant
Medical: NSAIDs
- Hormonal
Surgical: Diathermy

Question 7

How long is contraception not required for post partum and when is the earliest first ovulation?

Answer 7

not required till 21 days

Earliest ovulation in non breast feeding women is 28 days

Question 8

Options for post partum contraception:

Answer 8

Barrier methods - Condoms
POP - start any time
COC - from 21 days if not breast feeding
LARC

Question 9

Explain LARCs for post partum contraception:

Answer 9

IUD - from 28 days
IUS - from 28 days
Progestogen inplant - at any time
Injectable - at any time if not breast feeding

Question 10

What are the Rotterdam criteria for PCOS?

Answer 10

SHOP

String of pearls
Hyperandrogenism
Oligomenorrhae
Prolactin normal

Question 11

What defines oligomenorrhae?

Answer 11

periods occurring at intervals greater than 35 days

Question 12

What are important differentials to rule out when diagnosing PCOS?

Answer 12

Prolactinoma - Prolactin levels
Hypothyroidism - T4 and TSH
Congenital adrenal hyperplasia - 17-hydroxyprogesterone

Question 13

Investigations for suspected PCOS:

Answer 13

Bedside:
Bloods: Serum total and free testosterone
- prolactin, T4, TSH and 17-hydroxyprogesterone
- Fasting glucose, HbA1c and lipids
Imagining: US of ovaries

Question 14

What are the main 4 causes of secondary amenorrhoea ?

Answer 14

Pregnancy
Prolactinoma
PCOS
Premature ovarian insufficiency

Question 15

What is the pathophysiology behind PCOS?

Answer 15

Hypothalamic disturbances lead to basal increases in LH and relative reduction in FSH.
Causes raised androgens and less aromatisation to oestrogens.
Loss of positive feedback - no LH surge - anovulation
Lack of corpus luteum = proliferative endothelium causing heavy, irregular periods

Question 16

Management of PCOS:

Answer 16

All women: Adise on weight loss
Screen for CV risk factors
Annual check of glucose tolerance

Oligomenhorrea - check endometrial thickness
- Induce regular withdrawal bleed with COC

Acne - Topical Benzylperoxide, retinol, antibiotics

Infertility - weightloss and Metformin
- Ovulation induction with clomifene and IVF

Question 17

What are the main presenting complaints of PCOS?

Answer 17

Irregular, heavy periods
Subfertility
Acne
Hirsutism

Question 18

What defines primary amenorrhoea?

Answer 18

Failure to menstruate by 16 years in the presence of otherwise normal secondary sexual characteristics

Question 19

What defines secondary amenorrhoea?

Answer 19

absent periods for 6 months in a normally regular woman

absent periods for 12 months in a irregular woman

Question 20

Investigations for amenorrhoea:

Answer 20

Pregnancy test!
T4 and TSH 
LH and FSH 
Testosterone - androgen secreting tumour
US scan - if abnormal genital tract suspected

Question 21

What might LH and FSH levels tell you when investigating amenorrhoea?

Answer 21

If raised = Ovarian insufficiency?
If reduced = Hypothalamic pituitary problem?
If increased LH/FSH ratio = PCOS?

Question 22

What defines sub fertility?

Answer 22

Failure to conceive after 12 months of regular unprotected sexual intercourse

Primary if female has never conceived
Secondary if female has conceived previously

Question 23

What are the main 3 causes of sub fertility:

Answer 23

Anovulation
Tubal disease
Male factors

Question 24

Causes of anovulation:

Answer 24

Hypothalamic - Stress, anorexia
Pituitary - prolactinoma
Ovarian - Insufficiency, PCOS

Question 25

Causes of tubal disease:

Answer 25

Pelvic Inflammatory disease (PID) Endometriosis Surgical adhesions

Question 26

Investigations for suspected tubal disease to assess patency:

Answer 26

Hysterosalpingogram "fill and spill" Laparoscopy and dye test - if you suspect surgery may be needed

Question 27

Investigations for a subfertile couple:

Answer 27

Bedside: Semen analysis Bloods: Prolactin - LH and FSH - T4 and TSH - Oestrogen and Testosterone - Progesterone - 7 days after ovulation Imaging: Hysterosalpingogram Special: Laparocopy and dye

Question 28

Council on lifestyle advice for subfertile couple:

Answer 28

``` Weight loss if overweight Smoking cessation Reduce caffeine intake Reduce alcohol intake Have intercourse 2 -3 times a week Timing during cycle is not recommended ```

Question 29

What is as an early pregnancy loss and what is miscarriage?

Answer 29

Loss within the first 12 weeks Miscarriage up to 24 weeks

Question 30

What are the types of miscarriage and the status of the cervical Os in each:

Answer 30

``` Threatened - Closed Inevitable - Open Incomplete - Open Delayed - Closed but no foetal heart beat Complete - Closed ```

Question 31

Investigations for bleeding in early pregnancy:

Answer 31

Bloods: FBC, Group and rhesus status Imaging: Trans Vaginal Ultrasound

Question 32

Management of retained products of conception:

Answer 32

Give Anti-D if rhesus negative Expectant management Medical: Misoprostol Surgical evacuation

Question 33

What are the risks of surgical evacuation of retained products of contraception:

Answer 33

Cervical damage Uterine perforation Infection Failure - re evacuation required

Question 34

Counsel post miscarriage:

Answer 34

Reassure - 1 in 5 pregnancies end in miscarriage Nothing you have done wrong Miscarriage association for support Wait for one period before trying again when feel ready Emphasise most likely successful next time Folic acid, Healthy diet, Smoking cessation

Question 35

Investigation for pregnancy of unknown location on transvaginal ultrasound:

Answer 35

Serum hCG at 0 and 48hours Increase > 63% = early intrauterine pregnancy - repeat transvaginal US in 7-14 days Suboptimal rise/fall = Ectopic - Clinical review within 24 hours hCG decrease >50% = Failing pregnancy - Urine pregnancy test in 2 weeks

Question 36

What triad of symptoms do ectopics usually present with?

Answer 36

Amenorrhea Pain PV Bleeding

Question 37

Above what serum level of hCG would you expect to see an intrauterine pregnancy on a TVUS?

Answer 37

1500iu

Question 38

Management of ectopic:

Answer 38

Expectant - if failing Medical - Methotrexate - if stable and hCG <5000iu Surgical - Laparoscopic salpingectomy Need to be followed up next pregnancy See in EPAU at 6 weeks for assessment and US

Question 39

Risk factors for ectopic:

Answer 39

PIPPA ``` Previous ectopic Intrauterine contraceptive Pelvic inflammatory disease Pelvic or tubal surgery Assisted reproduction ```