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Gynaecology Flashcards

1
Q

What is the average blood loss per menstrual cycle?

A

30-40ml

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2
Q

What are some systemic causes of menorrhagia?

A

Hypothyroidism
Chronic liver disease
Blood thinning drugs
Bleeding disorders (e.g. Von Willebrands)

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3
Q

What are some local causes of menorrhagia?

A 
Vulval/vaginal/cervical cancer or malignancy
IUCD
DUB
Fibroids
Endometriosis
Adenomyosis
Endometrial polyp/malignancy
PID
Granulosa ovarian tumours
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4
Q

What is the commonest cause of menorrhagia?

A

Dysfunctional Uterine Bleeding (DUB)

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5
Q

What is DUB?

A

Heavy and/or irregular bleeding with no underlying pelvic pathology

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6
Q

What are the two commonest underlying causes of DUB?

A

Anovulatory cycles - often post-menarche or peri-menopause

Poor quality eggs leading to poor quality corpus luteums and luteal phase defects

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7
Q

What are the different medical management option for DUB?

A

Mirena IUS
Tranexamic acid
Mefenamic acid (not as effective as tranexamic)
COCP
Progestogens (depo-provera or oral norethisterone)

If anovulatory cycles, try COCP to regulate. If not, try tranxeamic acid. PATIENT CHOICE is important.

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8
Q

What are the surgical options for DUB?

A

Endometrial ablation

Hysterectomy

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9
Q

How many and for how long should medical management of DUB be done before considering surgical options?

A

Trial of 2 different options both for at least 3 months

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10
Q

What are some long term complications of endometrial ablation?

A

Decreases fertility

May lead to placenta percreta if do concieve

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11
Q

Woman presents with intensely itchy white vaginal discharge. Vulva sore and red.

A

Thrush

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12
Q

What is the organism causing thrush?

A

Candida Albicans (yeast)

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13
Q

How is thrush treated?

A

Topical clotrimazole 500mg pessary + cream
OR
Oral fluconazole 150mg stat

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14
Q

Woman presents with watery, grey, fishy discharge. Vaginal pH >4,5. Clue cells seen on HVS.

A

Bacterial Vaginosis

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15
Q

What causes bacterial vaginosis?

A

Overgrowth of normal vagina flora - Gardnerella vaginalis, mobiluncus, anaerobes

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16
Q

How is bacterial vaginosis treated?

A

Metronidazole 400 mg BD (7 days)

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17
Q

What chlamydia serovars cause genital infection?

A

Serovars D-K

A-C cause trachoma. L-lymphogranuloma

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18
Q

How does chlamydia present in females?

A

Asymptomatic. Post coital/intermenstrual bleeding. Lower abdominal pain. Dyspareunia. Mucopurluent cervicitis.

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19
Q

How does chlamydia present in males?

A

Urethral discharge, dysuria, urethritis, epididimo-orchitis

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20
Q

How is chlamydia/gonorrhoea diagnosed?

A

Combined test for both organisms
Females - HVS for PCR/NAATs
Males - first void urine for PCR/NAATs

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21
Q

How is chlamydia treated?

A

Azithromycin 1g stat

If allergic, doxycycline 100mg BD (7 days)

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22
Q

What are some complications of untreated chlamydia?

A

PID, pelvic pain, sexually acquired reactive arthritis, Fitz-Hugh-Curtis syndrome.

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23
Q

How is pelvic inflammatory disease treated?

A

Metronidazole 400mg BD and Ofloxacin 400mg BD (14 days)

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24
Q

How does gonorrhoea present in men and women?

A

Asymptomatic, altered/urethral discharge, dysuria

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25
Q

How is gonorrhoea treated?

A

IM ceftriaxone 500mg and oral azithromycin 1g stat

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26
Q

What is the causative organism of syphilis?

A

Treponema Pallidum

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27
Q

How does primary syphilis present?

A

Chancre - indurated, firm papule, with raised edge. Usually heals itself without treatment.

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28
Q

How does secondary syphilis present?

A

Maculopapular rash and flu like symptoms. Occurs when the organism is in the blood stream.

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29
Q

How does tertiary syphilis present?

A

Neuological/cardiovacular complications

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30
Q

How is syphilis diagnosed?

A

If lesion present - swab lesion for PCR

If none present - bloods

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31
Q

What blood tests are done to diagnose syphilis?

A

Combined IgG and IgM ELISA test (IgM positive in active infection)
TPPA (stays positive for life even if syphilis treated)
VDRL and RPR (non-specific tests of inflammation. Useful for assessing response to treatment)

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32
Q

How is syphilis treated?

A

Long acting injectable penicillins

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33
Q

What organism causes genital warts?

A

HPV 6 & 11

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34
Q

How are genital warts treated?

A

Cryotherapy or Podophyllin toxin

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35
Q

What causes genital herpes?

A

Herpes Simplex Virus I and II

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36
Q

How does genital herpes present?

A

Painful, multiple small vesicles that are easily deroofed. May be dysuria, discharge, lymphadenopathy

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37
Q

How is genital herpes diagnosed?

A

Swab for PCR

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38
Q

How is genital herpes treated?

A

Aciclovir 200mg 5 times a day for 5 days

Subsequent attack - aciclovir cream

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39
Q

Woman presents with frothy green, offensive discharge. Strawberry cervix. HVS shows flagellae motion of organism.

A

Trichomonas vaginalis - single celled protozoal parasite

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40
Q

How is trichomonas vaginalis treated?

A

Metronidazole 400mg BD (7days)

Treat partners even if asymptomatic as can be carriers

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41
Q

Woman has itching, inflammation in pubic area. Black ‘powder’ seen in underwear.

A

Pubic lice

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42
Q

How are pubic lice treated?

A

Malathion lotion

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43
Q

Where is the target of HIV virus?

A

CD4+ receptors

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44
Q

How does HIV affect the immune system?

A

Reduces circulation and proliferation of CD4+ cells
Reduces activity of CD8+ cells
Reduces anitbody class switching

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45
Q

What are the implications of HIV affecting the immune system?

A

Increased susceptibility to viral, fungal and bacterial infections as well as infection induced cancers

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46
Q

What is a normal CD4+ count?

A

500-1600 cells/mm2

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47
Q

At what CD4+ count is there a risk of opportunistic infection?

A

200 cells/mm2 and less

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48
Q

When does primary HIV infection occur?

A

Around 2-4 weeks after contracting HIV

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49
Q

What are the symptoms of primary HIV infection?

A

fever, maculopapular rash, myalgia, pharyngitis

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50
Q

What are the 3 broad areas of AIDS?

A

Opportunistic infections, constitutional symptoms and AIDS related cancers

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51
Q

Name 3 AIDS related cancers

A

Kaposi’s sarcoma, Burkitts lymphoma, Cervical cancer (all virally driven)

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52
Q

How is HIV treated?

A

Highly active anti-retroviral treatments (HAART)

Combination of 3 drugs from 2 classes

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53
Q

When is post-exposure prophylaxis given?

A

Taken within 72 hours of exposure for 28 days

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54
Q

What measures should be taken for a HIV +ve male to conceive?

A

Sperm washing + IUI/IVF

Timed UPSI with HAART +/- PrEP

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55
Q

What measures should be taken for a HIV +ve female to conceive?

A

Self-insemination

Timed UPSI with HAART

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56
Q

Should HIV+ve women take HAART during pregnancy?

A

Yes as risk of HIV greater to the baby than the medications

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57
Q

What factors affect whether a HIV+ve women has a vaginal delivery or a c-section?

A

Viral load (<50 vaginal birth is safe)
CD4+ count (>350 vaginal birth is safe)
Previous obstetric history

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58
Q

Should newborns be given antiretrovirals?

A

YES - babies should receive PEP within 4 hours of delivery and continue for 28 days

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59
Q

What is the histology of the ectocervix?

A

Stratified squamous epithelium

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60
Q

What is the histology of the endocervix?

A

Simple columnar epithelium

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61
Q

What is the transitional zone of the cervix?

A

The squamo-columnar junction between the endocervix and ectocervix

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62
Q

What is cervicitis?

A

Inflammation of the cervix

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63
Q

How does cervicitis present?

A

Asymptomatic/ discharge, dyspareunia, intermenstrual bleeding, post-coital bleeding

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64
Q

What are some causes of cervicitis?

A

STIs, allergies (e.g. latex), BV

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65
Q

What is a cervical ectropion?

A

When the endocervical columnar epithelium extends over the stratified sqaumous epithelium of the ectocervix

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66
Q

How does a cervical ectropion present?

A

Bleeding (intermenstrual, post coital), excess mucus, infections

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67
Q

How is a cervical ectropion treated?

A

Silver nitrate cautery

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68
Q

What are cervical polyps?

A

Pedunculated benign tumours of endocervix

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69
Q

What is cervical intraepithelial neoplasia?

A

Pre invasive stage of cancer, occurring at transitional zone

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70
Q

What is CIN I?

A

Basal 1/3rd of epithelium has abnormal cells

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71
Q

What is CIN II?

A

Basal 2/3rd of epithelium has abnormal cells

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72
Q

What is CIN III?

A

Full thickness of epithelium has abnormal cells

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73
Q

What is seen histologically in CIN?

A

Delay in differentiation, nuclear abnormalities, excess mitosis, koiliocytosis

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74
Q

How is CIN I managed?

A

Expectant management - repeat smear in 12 months

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75
Q

How is CIN II/III managed?

A

Cold coagulation

LLETZ (if suspicious of malignancy do this)

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76
Q

What is a complication of LLETZ?

A

Can lead to preterm labour (due to cervical insufficiency) - favour cold coagulation in women who have not completed their families

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77
Q

What type of cervical cancer is commonest?

A

Squamous cell (from ectocervix)

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78
Q

How does cervical cancer present?

A

Abnormal bleeding (PCB, IMB, brown stained discharge), pelvic pain, urinary infections

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79
Q

What is the main viral driver of cervical cancer?

A

HPV - mainly types `16, 18 and 33

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80
Q

What are some risk factor for cervical cancer?

A

HPV, smoking, HIV, early intercourse, many sexual partners, high parity, low socioeconomic status, COCP

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81
Q

How is early stage cervical cancer treated?

A

Surgery - dependent on extent and need to preserve fertility

82
Q

How are stages IB-IV of cervical cancer treated?

A

Platinum based chemotherapy, radical radiotherapy and vaginal brachytherapy

83
Q

How often do women aged 25-49 need a smear?

A

Every 3 years

84
Q

How often do women aged 50-64 need a smear?

A

Every 5 years

85
Q

If a smear comes back borderline, what should be done?

A

Repeat the smear test

86
Q

If a smear comes back unsatisfactory sample, what should be done?

A

Repeat the smear test

87
Q

If a smear comes back low grade dyskaryosis, what should be done?

A

Repeat the smear test

88
Q

After 3 unsatisfactory samples on smear test, what is the next step?

A

Routine colposcopy (<8 weeks)

89
Q

After 3 borderline samples on smear test, what is the next step?

A

Routine colposcopy (<8 weeks)

90
Q

After 2 low grade dyskaryosis samples on smear test, what is the next step?

A

Routine colposcopy (<8 weeks)

91
Q

If a smear comes back as high grade dyskaryosis, what should be done?

A

Urgent colposcopy (<4 weeks)

92
Q

If a smear comes back as invasive dyskaryosis what should be done?

A

Urgent colposcopy with suspicion of malignancy (<2 weeks)

93
Q

If CIN is treated, when should the next smear test be?

A

6 months time - do cytology and HPV for ‘test of cure’

94
Q

What is the commonest histological type of primary ovarian tumour?

95
Q

What are dermoid cysts?

A

Benign cystic teratomas - totipotent. May contain hair, teeth, bone etc. Can be asymptomatic.

96
Q

What may rupture of a dermoid cyst cause?

A

Acute chemical peritonitis

97
Q

What is struma ovarii?

A

Type of teratoma containing thyroid tissue which may result in hyperthyroidism

98
Q

What is the triad of Meig’s Syndrome?

A

Ovarian tumour, ascites and pleural effusion

99
Q

What cancers metastasise to the ovary?

A

Breast, pancreas and GI

100
Q

What are some risk factors for ovarian cancer?

A

Increased age, nulliparity, early menarche, late menopause, family history

101
Q

How does the COCP affect ovarian cancer risk?

A

COCP is protective against ovarian cancer

102
Q

How does ovarian cancer present?

A

May be asymptomatic

Bloating, abdominal mass, early satiety, urinary frequency, change of bowel habit, weight loss, fatigue.

103
Q

What should be checked if history and examination raises suspicion of ovarian cancer?

104
Q

What level of CA-125 warrants an ultrasound?

105
Q

How is risk of malignancy index (RMI) calculated?

A

RMI = menopausal status X ca-125 X USS score

106
Q

What RMI should patients be referred to a specialist?

A

RMI ≥250

107
Q

How is early ovarian cancer treated?

A

Surgery - TH, BSO, omental/lymph node biopsy for staging.

Adjuvant chemotherapy if high grade tumour

108
Q

How is advanced ovarian cancer treated?

A

Primary debulking surgery
Neo/adjuvant chemotherapy with platinum based agent
RELAPSES - if platinum sensitive, use chemo again. If resistant, use tamoxifen/letrozole

109
Q

What are the muscles of the pelvic floor?

A 
Levator ani (pubococcygeus, puborectalis, iliococcygeus)
Coccygeus
110
Q

What nerves supply the muscles of the pelvic floor?

A 
Pudendal nerve (S2,3,4)
Nerve to levator ani (S4)
111
Q

What are the symptoms of pelvic organ prolapse?

A 
'Something coming down'
Urinary symptoms (hesitancy, poor flow, frequency, urge)
Bowel symptoms (constipation, dyschezia)
Sexual symptoms
112
Q

What are risk factors for pelvic organ prolapse?

A

Child birth - big babies, multiple pregnancy, prolonged labour
Increased age, obesity, smoking, heavy lifting

113
Q

What is a urethrocele?

A

Anterior inferior prolapse of the urethra

114
Q

What is a cystocele?

A

Anterior superior prolapse of the bladder

115
Q

What is an enterocele?

A

Posterior superior prolapse of the bowel via pouch of douglas

116
Q

What is a rectocele?

A

Posterior inferior prolapse of the rectum

117
Q

What is a procidentia?

A

Grade III uterine prolpase where the majority of the uterus is in the vagina

118
Q

What are some conservative management options for pelvic organ prolapse?

A

Lose weight, stop smoking, reduce constipation, bladder/defecation techniques. Pelvic floor physiotherapy.
Pessaries (ring, cube, shelf, gelhorn)

119
Q

What is the medical management of pelvic organ prolapse?

A

Vaginal oestrogens (used if symptomatic atrophic vaginitis)

120
Q

What are the surgical management options for pelvic organ prolapse?

A

Anterior/posterior repair
Sacrospinous fixation (vaginal vault prolapse)
Laparoscopic hysteropexxy (uterine prolapse)
Colpocleisis

121
Q

Which gynaecological cancers is the COCP protective in?

A

Endometrial and Ovarian

122
Q

Which gynaecological cancers is the COCP a risk factor for?

A

Breast and Cervical

123
Q

How long is the time frame to take Levonelle for emergency contraception?

A

Within 72 hours

124
Q

How long is the time frame to take Ullipristal (EllaOne)?

A

Within 120 hours

125
Q

How long is the time frame to have an IUCD inserted for emergency contraception?

A

Within 120 hours of UPSI or ovulation

126
Q

If a traditional POP is missed by up to 3 hours, what advice should you give?

A

Take pill. No action required.

127
Q

If a traditional POP is missed by more than 3 hours, what advice should you give?

A

Take pill as soon as possible. If more than one has been missed just take one pill.
Continue rest of pack as normal.
Use condoms until 48 hours after pilltaking

128
Q

The same advice applies for cerazette as it does for traditional POPs, but what is the time frame?

129
Q

What advice would you recommend for a patient using the contraceptive patch who has forgotten to change her patch for less than 48 hours?

A

Change patch immediately

No extra precautions needed

130
Q

What advice would you recommend for a patient using the contraceptive patch who has forgotten to change her patch for more than 48 hours?

A

Change patch immediately
Extra precautions for 7 days
Emergency contraception if had unprotected sex in last 5 days

131
Q

Which contraception may cause a delay in return to fertility?

132
Q

How long after insertion is a copper IUD effective?

A

Immediately

133
Q

How long after starting a POP is it effective (not day 1 of period)?

134
Q

How long after starting COC, injection, implant, IUS (not on day 1 of period) are they effective?

135
Q

What hormone do you check for ovulation?

A

Mid-luteal progesterone (cycle length-7days)

136
Q

What is the primary mode of action of the COCP?

A

Inhibits ovulation

137
Q

What is the primary mode of action of the POP?

A

Thickens cervical mucus

138
Q

What is the primary mode of action of the injection?

A

Inhibits ovulation

139
Q

What is the primary mode of action of the implant?

A

Inhibits ovulation

140
Q

What is the primary mode of action of the IUCD?

A

Decreases sperm motility and survival

141
Q

What is the primary mode of action of the IUS?

A

Prevents endometrial proliferation

142
Q

If one pill of the COCP is missed at any time in the cycle, what should you do?

A

Take the last pill then continue taking the rest of the pack as normal
No additional protection required

143
Q

If 2 or more pills of the COCP are missed, what should the woman take?

A

Take the last pill, leave any earlier missed pills and continue taking pills one each day

144
Q

If two or more pills are missed in the first week of the cycle and the woman has had sex, what should you consider?

A

Emergency contraception

145
Q

If two or more pills are missed in the second week of the cycle, what extra precautions do you need to take?

A

No extra precautions

146
Q

If two or more pills are missed in the 3rd week of the cycle, what should you recommend?

A

Omit the pill free interval

147
Q

How long after giving birth do you not need contraception?

A

Up to 21 days

148
Q

Where is an implant inserted?

A

Sub-dermally, non-dominant arm

149
Q

When should the COCP be stopped before surgery?

A

4 weeks before surgery

150
Q

When can the COCP be restarted after surgery?

151
Q

What is the most effective emergency contraception?

A

Copper IUD

152
Q

What is the first line management of fibroids?

A

Mirena IUS

153
Q

Painless vaginal bleeding before 24 weeks, cervical os closed, fetal heart detected

A

Threatened miscarriage

154
Q

USS shows intrauterine sac with no fetal pole. cervical Os closed

A

Missed miscarriage

155
Q

8 weeks pregnant, heavy bleeding with clots, fetal heartbeat present, os is open

A

Inevitable miscarriage

156
Q

Bleeding, fetal heart absent, cervical os open

A

Incomplete miscarriage

157
Q

Bleeding, fetal hear absent, cervical os closed

A

Complete miscarriage

158
Q

What is Sheehans syndrome?

A

Post partum hypopituitarism following PPH

159
Q

What is Meigs syndrome?

A

Fibroma, ascites, pleural effusion

160
Q

What are the management options for PMS?

A

Lifestyle - healthy diet, exercise, good sleep

Medical - COCP, SSRIs

161
Q

What is the gold standard investigation for endometriosis?

A

Laparoscopy

162
Q

What are medical management options for symptomatic relief of endometriosis?

A

NSAIDs, paractamol

COCP, progestogens

163
Q

What are secondary treatments for endometriosis?

A 
GnRh analogues (induce pseudomenopause)
Laparoscopic excision/laser of cysts
164
Q

What is the commonest complication of TOP?

165
Q

Where is the commonest site of ectopic pregnancy?

A

Ampulla of uterine tube

166
Q

What ovarian tumour is associated with endometrial hyperplasia?

A

Granulosa cell tumours

167
Q

What is the commonest benign ovarian tumour in under 35s?

168
Q

How should post-menopausal women with atypical endometrial hyperplasia be managed?

A

Total hysterectomy +BSO

169
Q

‘Free pelvic fluid and whirlpool sign’

A

Ovarian torsion

170
Q

What is Ashermans syndrome?

A

Adhesions following D&C

171
Q

When is contraception required in the menopause in women over 50?

A

For at least 12 months after the last period

172
Q

When is contraception required in the menopause in women under 50?

A

For at least 24 months after the last period

173
Q

What is the imaging of choice for adenomyosis?

A

MRI pelvis

174
Q

What is the average age of menopause?

175
Q

What is early menopause defined as?

176
Q

What is premature menopause defined as?

177
Q

What is late menopause defined as?

178
Q

What are symptoms of menopause?

A

Hot flushes, night sweats, palpitations, insomnia, joint aches, headaches, mood swings, vaginal dryness, decreased libido, DUB

179
Q

What are conservative management options for menopause?

A

Diet, weight loss, exercise, caffeine reduction, sleeo hygiene

180
Q

How can menorrhagia be managed in menopause?

A

Tranexamic acid, progestogens, IUS, endometrial abltation, hysterectomy

181
Q

What HRT is given to women with a uterus?

A

Combined HRT (oestrogen and progestogen)

182
Q

What HRT is given to women without a uterus?

A

Oestrogen only HRT

183
Q

What regime of HRT do peri-menopausal women get?

184
Q

What regime of HRT do post-menopausal get?

A

Either cyclical or continuous but continuous preferred as no withdrawal bleeds

185
Q

What is an alternative to HRT?

186
Q

Who can take tibolone?

A

Post menopausal women who have not had periods for at least 12 months

187
Q

How can HRT be given?

A

Patches, tablets, IUS

Vaginal oestrogens can be given as creams, pessarys, rings

188
Q

What are side effects of HRT?

A

Bloating, breast tenderness, headache, acne, weight gain, bleeding

189
Q

What are the risks of HRT?

A

Increased risk of breast and endometrial cancer, VTE, stroke and IHD. Risk goes away once HRT stopped

190
Q

What can be used for the vasomotor symptoms of menopause?

A

SSRIs, venlafaxine, clonidine

191
Q

What are the legal gestation limits of termination of pregnancy?

A

Socially - 23+6 weeks

Fetal anomaly - any gestation

192
Q

What is the limit of TOP in Nhs Tayside?

A

18 weeks and 6 days

193
Q

What is considered an early medical termination?

A

Up to 9 weeks

194
Q

What is considered a late medical termination?

A

9-12 weeks

195
Q

What is considered a mid-trimester medical termination?

A

12-24 weeks

196
Q

What are the two main stages of a medical termination?

A

Anti-progesterone (oral mifepristone)

24-48hrs later PV/oral prostaglandin (misoprostol)

197
Q

Which patients have the option to complete the second part of a medical termination at home?

A

Early terminations (<9 weeks)

198
Q

What surgical termination procedure is done in Scotland?

A

Vacuum aspiration

199
Q

How is vacuum aspiration carried out?

A

Cervical priming with PV prostaglandin

GA, electrical vacuum aspiration

200
Q

What are complications of TOP?

A

Pain, infection, haemorrhage, cervical trauma, failure

201
Q

What are important aftercare considerations in TOP?

A

Follow up urinary pregnancy test in 2-3 weeks
Anti-D
Seeking help & support counselling
Contraception

202
Q

Which specialist carries out uterine artery embolization?

A

Radiologist

Finals Revision (22 decks)

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