Gynaecology Flashcards
What is the treatment for a Bartholins gland cyst?
Incision and drainage
Broad spectrum antibiotics until cultures
Marsupialisation to prevent recurrence
What is Nabothian cyst?
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.
What is an Ectropion and what causes it?
Eversion of columnar endocervix
Driven by oestrogen - normal in young women
What the investigation is the gold standard for diagnosing endometriosis?
Laparoscopy
What are the main symptoms of endometriosis?
Premenstrual pain
Dysmenorrhea
Deep dyspareunia
Subfertility
Management of endometriosis:
Expectant
Medical: NSAIDs
- Hormonal
Surgical: Diathermy
How long is contraception not required for post partum and when is the earliest first ovulation?
not required till 21 days
Earliest ovulation in non breast feeding women is 28 days
Options for post partum contraception:
Barrier methods - Condoms
POP - start any time
COC - from 21 days if not breast feeding
LARC
Explain LARCs for post partum contraception:
IUD - from 28 days
IUS - from 28 days
Progestogen inplant - at any time
Injectable - at any time if not breast feeding
What are the Rotterdam criteria for PCOS?
SHOP
String of pearls
Hyperandrogenism
Oligomenorrhae
Prolactin normal
What defines oligomenorrhae?
periods occurring at intervals greater than 35 days
What are important differentials to rule out when diagnosing PCOS?
Prolactinoma - Prolactin levels
Hypothyroidism - T4 and TSH
Congenital adrenal hyperplasia - 17-hydroxyprogesterone
Investigations for suspected PCOS:
Bedside:
Bloods: Serum total and free testosterone
- prolactin, T4, TSH and 17-hydroxyprogesterone
- Fasting glucose, HbA1c and lipids
Imagining: US of ovaries
What are the main 4 causes of secondary amenorrhoea ?
Pregnancy
Prolactinoma
PCOS
Premature ovarian insufficiency
What is the pathophysiology behind PCOS?
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
Management of PCOS:
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
What are the main presenting complaints of PCOS?
Irregular, heavy periods
Subfertility
Acne
Hirsutism
What defines primary amenorrhoea?
Failure to menstruate by 16 years in the presence of otherwise normal secondary sexual characteristics
What defines secondary amenorrhoea?
absent periods for 6 months in a normally regular woman
absent periods for 12 months in a irregular woman
Investigations for amenorrhoea:
Pregnancy test! T4 and TSH LH and FSH Testosterone - androgen secreting tumour US scan - if abnormal genital tract suspected
What might LH and FSH levels tell you when investigating amenorrhoea?
If raised = Ovarian insufficiency?
If reduced = Hypothalamic pituitary problem?
If increased LH/FSH ratio = PCOS?
What defines sub fertility?
Failure to conceive after 12 months of regular unprotected sexual intercourse
Primary if female has never conceived
Secondary if female has conceived previously
What are the main 3 causes of sub fertility:
Anovulation
Tubal disease
Male factors
Causes of anovulation:
Hypothalamic - Stress, anorexia
Pituitary - prolactinoma
Ovarian - Insufficiency, PCOS
Causes of tubal disease:
Pelvic Inflammatory disease (PID)
Endometriosis
Surgical adhesions
Investigations for suspected tubal disease to assess patency:
Hysterosalpingogram “fill and spill”
Laparoscopy and dye test - if you suspect surgery may be needed
Investigations for a subfertile couple:
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
Council on lifestyle advice for subfertile couple:
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
What is as an early pregnancy loss and what is miscarriage?
Loss within the first 12 weeks
Miscarriage up to 24 weeks
What are the types of miscarriage and the status of the cervical Os in each:
Threatened - Closed Inevitable - Open Incomplete - Open Delayed - Closed but no foetal heart beat Complete - Closed
Investigations for bleeding in early pregnancy:
Bloods: FBC, Group and rhesus status
Imaging: Trans Vaginal Ultrasound
Management of retained products of conception:
Give Anti-D if rhesus negative
Expectant management
Medical: Misoprostol
Surgical evacuation
What are the risks of surgical evacuation of retained products of contraception:
Cervical damage
Uterine perforation
Infection
Failure - re evacuation required
Counsel post miscarriage:
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
Investigation for pregnancy of unknown location on transvaginal ultrasound:
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
What triad of symptoms do ectopics usually present with?
Amenorrhea
Pain
PV Bleeding
Above what serum level of hCG would you expect to see an intrauterine pregnancy on a TVUS?
1500iu
Management of ectopic:
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
Risk factors for ectopic:
PIPPA
Previous ectopic Intrauterine contraceptive Pelvic inflammatory disease Pelvic or tubal surgery Assisted reproduction
