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Phase 3a > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is amenorrhoea?

A

Absence of menses

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2
Q

Define primary amenorrhoea

A

Failure to start menstruation by 16 (14 if no other secondary sexual characteristics)

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3
Q

Define secondary amenorrhoea

A

Previous menses, no menstruation for >6mo.
If previous oligomenorrhoea - for 12 mo
Not pregnant

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4
Q

Name of staging for pubertal development?

A

Tanner stages

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5
Q

Causes of primary amenorrhoea?

A

Constitutional delay (familial)
GU abnormalities - imperforated hymen/transverse vaginal septum - blood accumulates in vagina/uterus
Hypothalamic hypogonadism - often from low weight (Kallman’s syndrome - GnRH deficiency –> high FSH/LH (also anosmia, cranio-facial abnormalities)
Gonadal failure - Turners syndrome (45X) -neck webbing, short stature, obesity
Hyperprolactinaemia from pituitary hyperplasia/benign tumour/hypothyroidism
PCOS
Congenital adrenal hyperplasia

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6
Q

Causes of secondary amenorrhoea?

A

Premature ovarian failure - (low oestrogen, high FSH/LH and -ve feedback)
HPO axis - stress, exercise, weight
Hyperprolacinaemia (Sheehans syndrome - pituitary necrosis after severe PPH)
Ovarian: PCOS, tumour, menopause)
Iatrogenic - depot, implant, post COCP
Obstruction - cervical stenosis, Asherman’s syndrome (uterine adhesions from excessive curettage of ERPC)
Virilising adrenal/ovarian tumour
Hyper/hypothyroidism

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7
Q

Ix for Amenorrhoea?

A 
hCG - r/o pregnancy
FSH/LH - high in premature ovarian failure, low in hypothalamic
Testosterone/sex hormone binding protein - PCOS
Prolactin
TFT
Pelvic USS - PCOS, haematometra, POF
Karyotype - Turners
CT/MRI - visualise pituitary fossa
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8
Q

Management of amenorrhoea?

A

Treat cause
Hyperprolactinaemia - bromocriptine (D2 agonist)
PCOS - COCP
Tract - cervical dilation, incision of hymen
HPO - HRT.OCP

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9
Q

What is dysmenorrhoea?

A

Painful cramping in lower abdomen before/at the start of menstruation

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10
Q

What is primary dysmenorrhoea?Aetiology and pathology?

A

Absence of of identifiable pelvic pathology
Fall in progesterone
Increased prostaglandins in endometrium
Uterine contraction and ischaemia

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11
Q

What is secondary dysmenorrohoea and what causes it?

A

Secondary to underlying pelvic pathology - usually starts many years after menarche.
Endometriosis, fibroids, adenomyoisis, PID, endometrial polyps, malignancy, adhesions from previous sx

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12
Q

Features of dysmenorrhoea?

A

Deep dyspareunia, menorrhagia, irregular menses

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13
Q

Ix of dysmenorrhoea?

Mx of primary?

A

Pelvic USS, laparoscopy
Mx: NSAIDs - mefanamic acid + ibuprufen (prostaglandin inhibitors)
2nd line: COCP

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14
Q

What is endometriosis?

A

The presence and growth of ectopic endometrial tissue outside the uterine cavity

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15
Q

Common sites of endometriosis and why?

A

Pelvis: common due to retrograde menstruation (Samsons) - bowel, pouh of douglas, bladder, fallopian tube, ovaries (get chocolate cysts - dark blood accumulated)
Extra-pelvic - spread through haematogenous (Halbans theory), metaplasia (Meyers’ theory) –> URT eg lungs, orophraynx

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16
Q

Presentation of endometriosis?

A

Chronic pelvic pain, affects fertility
Dysmenorrhoea before, during and after menses
Acute pain on rupture of chocolate cyst
deep dysspareunia
Non gynae: Dyschezia (painful bowel movements), dysuria, urgency, haematuria
Exam: reduced organ mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions seen

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17
Q

Ix of for ?endometriosis?

A

Laparoscopy - gold standard
Abdo/pelvic USS, examination, swabs
r/o ovarian carcinoma - CA125

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18
Q

Management of endometriosis?

A

Medical: NSAIDs, paracetamol Triphasing (3 mo, break) OCP (combined or progesteorne - eg medroxyprogesterone) - uninterrupted causes glandular hypertrophy
GnRH analogue - initial gonadotrophin secretion then pituitary down growth –> inhibit secretion -> ‘pseudomenapuase’
HRT to avoid osteoporosis
Progesterone - depot/IUD
Surgical: Ablation/excision - laser treatment
Oophorohysterectomy if completed family

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19
Q

40 year old woman presents with cyclical pain that is quite constant. Laparascopy shows no endometriosis. Obstetric hx of 3 children. Likely dx? and cause? Ix? Management?

A

Adenomyosis - endometrial tissue in myometrium
Laparotomy/USS
Rx: GnRH agonists, hysterectomy

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20
Q

Name 2 differetials for bleeding and infertility?

A

Fibroids

Uterine polyps

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21
Q

27 old Afro-caribbean woman has hx of pelvic cramping pain esp around menstruation, constipation, bloating, urinary frequency and urgency, menorrhagia, subfertility. O/E she has a bulky non-tender uterus. Possible diagnosis? How might you investigate

A

Fibroids - benign uterine tumours (Leiomyoma) of smooth muscle (myometrium)
Transvaginal USS

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22
Q

On Pelvic USS, fibroids are found. What possible locations might there be? Management?

A 
Pedunculated
Subserosal
Intra-mural
Submucosal
Intracavitary
Rx: <3 cm - levonorgestrel IUS 1st line
COCP/Tranexamic acid
GnRH agonists can be used short term to reduce fibroid size
>3cm - myomectomy, hysterectomy, transcervical resection of fibroids, hysteroscopic endometrial ablation, uterine artery embolisation
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23
Q

Define menorrhagia

A

Excessive menstrual blood loss that interferes with a womans physical, emotional, social or material quality of life OR >80mL in otherwise normal cycle

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24
Q

Causes of menorrhagia?

A

50% - no cause = Dysfunctional uterine bleeding
Fibroids
Polyps
Anovulatory cycles - common in extremes of woman’s reproductive life
Chronic infection
Ovarian, cervical, endometrial malignancy
IUD - copper coils
Bleeding disorders - eg von Willebrands disease
PID
Hypothyroidism

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25
Q

17 yr old female with 6 month hx of excess menstrual bleeding, fatigue and pallor. Inestaigations?

A

Hx, bimanual exam
Speculum exam
FBC - Hb - iron deficiency
Coagulation/thyroid (rare haemostatic/VW)
Routine TVUS - endometrial thickness/polyps
If >10mm - do biopsy and hysteroscopy

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26
Q

What other features on the examination are you looking for in menorrhagia presentation?

A

Irregular enlargement of uterus = fibroids
Tenderness/enlargement = adenomyosis
Ovarian mass

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27
Q

Medical management of menorrhagia?

A

1st: IUS (coil) - contranceptive, secretes progesterone

2nd: COCP
Anti-fibrinolytics (tranexamic acid) with NSAID mefenamic acid (reduce prostaglandins)

3rd: High hose progesterone/GnRH agonist

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28
Q

Surgical management of menorrhagia?

A 
Hyseroscopic polyp removal
Transcervical resection of endometrium (fibroids)
Radical: Endometrial ablation
Myomectomy (fibroidectomy)
Hysterectomy
Uterine artery embolization
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29
Q

What symptoms might indicate underlying pelvic pathology?

A 
Persistent postcoital bleeding
Persistent intermenstrual bleeding
Dyspareunia
Dysmenorrhoea
Pelvic pain
Vaginal discharge
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30
Q

15 year old girl presents with intermenstrual bleeding and irregular periods. What might cause this and how might you investigate?

A

Anovulatory cycles
Pathology: fibroids, polyps, adenomyosis, ovariam cyst, malignancy
Ix: Hb, cervical smear
If 35+ - USS, endometrial biopsy w/ pipelle at hysteroscopy

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31
Q

Management of irregular bleeding?

A

Medical: If no pathology - anovulatory cycles - give IUS/COCP
HRT for menopausal eratic bleeding
Sx - for menorrhagia, avulse cervical polyp and histology

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32
Q

A 24 year old lady presents with post coital bleeding? What might cause this?

A

When cervix not covered in healthy squamous epithelium: carcinoma (most r/o), polyp, ectropion
cervicitis, vaginitis

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33
Q

How should post coital bleeding be managed?

A

Inspect cervix and smear
Polyp - avulse and histology
Ectropion - cryotherapy
Colposcopy smear - r/o malignancy

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34
Q

What is a functional cycts and how should it be managed?

A

Enlarged persistent follicle (follicular cyst)
or corpus luteum cyst (if pregnancy doesn’t occur, CL may fill w/ blood - may present w/ intraperitoneal bleeding
Usually resolves after 2/3 cycles
Causes pain, possibly peritonitis
Sx if bleed, COCP inhibits

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35
Q

35 yr old presents with large solid mass in her lower left abdomen. likely Dx? How likely to be malignant?

A

Mucinous cystadenomas
15%
If it ruptures - may cause pseudomyxoma peritonei

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36
Q

46 yr old lady presents bilateral mass in ovaries. Dx? How likely to be malignant?

A

Serous cystadenoma

25%

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37
Q

What is a dermoid cyst? Concern?

A

A mature cystic teratoma - contains skin/hair/teeth

Most likely to have torsion

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38
Q

A 26 year old lady pesents with with acute abdo pain whilst running, PV bleed, N&V, weakness and syncope. Likely Dx? Ix? Management?

A 
Ruptured ovarian cyst (mid cycle follicular likely)
Ix: R/o ectopic - hCG dip
FBC, swabs
USS
Laparoscopy is diagnostic
Rx: if stable - analgesia
Unstable/bleeding - Sx
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39
Q

23 year old lady presents with acute abdo pain whilst cycling. Pain radiates to back, thigh and pelvis, N&V and fever. Likely Dx? What might fever indicate? Ix and Rx?

A

Ovarian torsion - usually enlarged ovary
Ix: r/o ectopic - hCG and dip, FBC, swabs
USS w/ colour Doppler analysis - may show free fluid
Rx: Laparscopy + analgesia - NSAIDs, opiates

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40
Q

Suspected ovarian torsion or cyst rupture. Now appears in hypovolaemic shock. Likely dx?

A

Ovarian cyst hameorrhage

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41
Q

25 year old presents with vague abdo symptoms such as bloating, early satiety, anorexia, urinary urgency/frequency, PV bleed, lower back, abdo & pelvic pain, dyspareunia, change in bowel habbit (diarrhoea). O/E you suspect some ascites. ikely Dx? Risk factors/cause?

A

Ovarian cancer - most (85%) epithelial serous carcinoma, others sex cord (granulosa) or germ cell (dysgerminosa/teratoma)
RF: Increased ovualtions (early menarche, late menopause, null parity
BRCA1/2, HNPCC gene mutations

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42
Q

Protective factors of ovarian Ca?

A 
COCP
Parity
Anovualtion
Pregnancy
Lactation
POP/Mirena
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43
Q

Management of suspected Ovarian Ca?

A 
CA125 (under, suspect IBS if under 35
Under 35 - AFP, HCG - germ cell tumour
Referral based on Risk of Malignancy Index (RMI) - USS score (U) (1 or 3 if more than 1 cytic feature), pre or post menopause (M) (1 or 3): If U x M x CA125 > 250 --> Gyn Onco MDT
CT and laparoscopy for staging
Surgery + chemotherapy
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44
Q

How is Ovarian Ca staged?

A

1) Limited to ovaries
2) Limited to pelvis
3) Limited to abdomen
4) Distant mets outside abdo

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45
Q

57 year old lady presents with post menopausal bleeding, pain, watery discharge and weight loss. Likely Dx and case? Risk factors?

A

Endometrial cancer
90% adenocarcinoma, 10% adenosquamous
Rf: obesity, DM, nulliparity, early menarche, late menopause, ovarian tuours, HRT (unopposed oestrogen), pelvic irradiation, Tamoxifen, PCOS

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46
Q

Management of suspected endometrial ca?

A

Ix: TV USS - endometrial thickening (<4mm - r/o), hysteroscopy w/ endometrial biopsy
CXR and MRI for spread
Rx: If limited to uterus/cervix = total hysterectomy and bilateral salpingo-oophorectomy
Pelvic lymph node clearance
Radiotherapy and progestogens eg medroxyprogesterone (if spread)

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47
Q

Poor prognostic indicators of endometrial Ca?

A

Older age
Advanced stage
Deep myometrial invasion
Adenosquamous histology

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48
Q

29 year old lady presents with post-coital bleeding, and other PV bleed such as when micturating, dyspareunia, offensive vaginal discharge, painless haematuria, leg oedema. likely Dx, cause and RF?

A

Dx: Cervical cancer - 80% squamous cell carcinoma, 200% adenocarcinoma from columnar epithelium
RF: HPV - human papillomavirus 16/18/33 (E6/E7 oncoproteins - inhibits tumour suppressor genes), early age intercourse, multiple partners, STIs, multiparity, COCP, other neoplasia

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49
Q

Ix of suspected cervical Ca?

A

Smear at squamous-columnar junction and HPV screen
Smear done every 3 yrs 25-49, every 5 yrs 50-64 - liquid based cytology (LBC)
Refer to colposcopy if:
1) Borderline dyskaryosis AND HPV +ve
2) Moderate/severe dyskaryosis

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50
Q

Treatment of cervical ca?

A

Dysplasia - laser therapy/cryotherapy w/ cone biopsy
Stage 1B+ - Trachelectomy (removal of uterine cervix) and chemotherapy
Stage 2B+ - Chemoradiotherpay, pelvic lymph node clearance

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51
Q

55 year old presents with vulval itching and soreness, a persistent lump on labia majora, bleeding, dysuria, past hx of Lichen sclerosis. RF? Dx? Cause? Management?

A

Vulval cancer - 90% squamous
RFs: HPV, vulval intraepithelial neoplasia, immunosuppression, lichen sclerosis
Rx: Surgical resection/radical
Radiotherapy

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52
Q

21 year old presents with acute pelvic pain, lower abdo pain, deep dyspareunia, fever, dysuria, abnormal vaginal bleeding and discharge, RUQ pain. PMH of multiple sexual partners and endometriosis.
O/E she is tachycardic, bitleral adnexal tenderness, cervical excitation (pain on moving cervix). A small pelvic abscess may be palpable. Likely Dx? Cause?

A

Acute pelvic inflammatory disease
Note - 10% cases get RUQ pain - called Fitz-Hugh Curtis syndrome
Ascending infection from vagina/cervix
Sexual - multiple partners, STIs - Chlamydia trochomatis, Neisseria gonorrhoea,
Uterine instrumentation - abortion, laparoscopy, ERCP
Can be endometritis, salpingitis, parametritis (parametium = connective tissue around uterus)

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53
Q

Management of PID including Ix?

A

Endocervical swabs - for chlamydia/gonococcus, cultures, FBC - raised WCC/CRP
USS - exclude cyst/abscess
hCG
Urine dipstick - if nitrites/leucocytes - MSU
gold standard = laparoscopy/fimbrial biopsy/culture
Rx: analgesia
Abx - IM ceftriaxone + PO ofloxacin + PO doxycycline + PO metronidazole
IV if febrile
If no improvement- laparoscopy and abscess drain

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54
Q

Complications of PID?

A

Abscess
Tubal obstruction and subfertility
Ectoptic pregnancy more likely
Chronic pelvic pain

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55
Q

35 yr old w/ 2 month hx of pelvic pain, dysmenorrhoea, deep dyspareunia, irregular menses, chronic vaginal discharge
O/E there appear to b dense pelvic adhesions, abdo and adnexal tenderness and a fixed retroverted uterus.. Dx, Ix, Rx?

A

Chronic PID
Ix: USS show fluid collection in fallopian tube, laparoscopy
Rx: analgesia, abx if infection, removal of affected tube (salpingectomy)

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56
Q

What is uterovaginal prolapse?

RFs?

A

Descend of uterus/vagina or its walls beyond normal anatomical confines.
Occur due to weakness of supporting structures eg pelvic floor (muscular/fascial structures)
Increasing age, multiparity = vaginal deliveries, obesity, spina bifida

57
Q

What is a urethrocoele?

A

Prolapse of lwer anterior vaginal wall - urethra only

58
Q

What is a cyctocoele?

A

Prolpase of upper anterior vaginal wall - bladder (also urethra = cystourethrocoele

59
Q

What is an apical prolapse?

A

Prolapse of upper vagina, cervix, uterus

60
Q

What is an enterocoele?

A

Prolapse of posterior wall of vagina - pouch of small loop of bowel

61
Q

What is a rectocoele?

A

Prolapse of posterior wall of vagina - anterior wall of rectum

62
Q

How is prolapse graded?

A

ICS Pelvic Organ Prolapse (POP) scoring system

0-4

63
Q

67 year old lady presenst with a dragging/pressure sensation of lump which is worse at the end of the day, increased urinary frequency, occasional difficulty defacating. What is likely dx? What predisposes?

A

Uterovaginal prolapse
Child birth - esp if prolonged 2nd stage of labour, instrumental delivary
Congenital - abnormal collagen metabolism - EDS
Menopause - deterioration of collagenous connective tissue
Predisposing - intra abdo P increase - obesity, cough, constipation, heavy lifting, high parity (vaginal deliveries)
Iatrogenic - pelvic surgery eg hysterectomy

64
Q

Ix for prolapse?

A

Pelvic USS for cause/mass
Urodynamic testing if incontinence complaint
Fitness for surgery - ECG, CXR, FBC, renal fucntion

65
Q

Prevention for prolapse?

A

Recognise obstructed labour, avoid long 2nd stage

Pelvic floor exercises after child birth

66
Q

Non surgical management of prolapse?

A 
Ring pessary - act as artificial pelvic floor - change 6-9 mo
Post menopausal women - HRT
Weight reduction
Physiotherapy (pelvic floor exercises)
Discourage smoking
67
Q

Surgical management of prolapse?

A

Uterine prolapse - vaginal hysterectomy/sacrohysteropexy - lift to normal position
fix vault to sacrum using mesh
Vaginal wall - wall repair w/ mesh (cystocele -> anterior colporrhaphy, rectocele -> posterior colporrhaphy)
Urodynamic stress incontinence - tenson free vaginal tape, trans obturator tape

68
Q

40r old woman has constant dull ache that’s worse at the end of the day, after long periods of standing, after intercourse, before periods, dysmenorrhoea, pain. O/E the uterus appears large. She has 2 children. What is ikely dx and what causes it?

A

Pelvic pain syndrome
Varicose veins in lower abdomen
Pregnancy worsens
Venous congestion in pelvis

69
Q

Management of pelvic pain syndrome?

A

Ix: USS, laparsopy, CT venogram
Rx: NSAIDs, embolization to stop flow of varicose veins

70
Q

What is chronic pelvic pain?

A

Intermittent/constant pain in lower abdomen/pelvis for over 6 months. not excessive on mensturation or sexual intercourse
Often associated w/ migraine, lower back pain, economic burden

71
Q

Causes of chronic pelvic pain?

A

Endometriosis/adenomyosis
Pelvic adhesions
Psychological: depression/childhood sexual abuse
Pelvic congestion syndrome

72
Q

How would you manage a lady with chronic pelvic pain

A

Hx, exam, TVUS, laparoscopy, MSU, MRI, swabs
Analgesia
IBS - antispasmodics/refer to dietician
Cyclic pain: COCP/GnRH/progesterone IUS
Counselling/therapy
amitriptyline/gabapentin
If fail: laparoscopy: cut adhesions, treat cause

73
Q

History points for chronic pelvic pain?

A 
Timing
Nature/site of pain
Menstruation
Dyspareunia
Sexual/contraceptive hx
GI sypmtoms
Any recent pelvic infections
74
Q

Examination points for chronic pelvic pain?

A

General appearance, pulse
Abdomen - tenderness, bowel sounds
Pelvic: inspect, vulva, speculum, bimanual, adnexal tenderness

75
Q

Define a spontaneous miscarriage

A

A foetus dies/delivers dead before a 24 wk pregnancy

76
Q

Describe 2 possible appearances on EPAU TVUS

A

7 wk gestational sac seen but no fetal pole

Fetus seen but no cardiac activity

77
Q

What is a threatened miscarriage?

A

Vaginal bleeding before 24 weeks (usually 6-9)
but foetus still alive
Uterus is size expected for dates
Os closed

78
Q

What is an inevitable miscarriage?

A

Heavy bleeding, clots & pain
Os open
Miscarriage about to occur

79
Q

What is an incomplete miscarriage?

A

Some fetal parts passed
Pain & vaginal bleeding
os open

80
Q

What is a complete miscarriage?

A

All fetus tissue passed
Uterus not enlarged
Os closed

81
Q

What is a septic miscarriage?

A

Contents of uterus infected –> endometritis
Offensive vaginal discharge
Fever
Tender uterus/abdo/peritonitis

82
Q

What is a missed miscarriage?

A

Gestational sac contains dead fetus before 20 weeks w/o symptoms of expulsion
Light bleeding/discharge
Not recognised until USS
Os closed
‘Blighted ovum’/’anembryonic pregnancy’ = gestational sac >25mm & no fetal parts seen - The crown-rump length is greater than 7mm OR
The gestational sack is greater than 25mm

83
Q

Recently pregnant woman now has vaginal bleeding and has lower abdominal pain. Likely dx? Investiagtions?

A

Miscarriage
EPAU
TVUS - check viability of foetus
hCG - if viable foetus - increase by >66%

84
Q

Management of miscarriage?

A

Admission if ectopic, septic, rescusitation
IV access and colloid
Cross match blood
IM ergometrine
Anti-D if Rh -ve
Prostaglandins - If >12 weeks - anti-progesterone (mifepristone) then (36-48hr) - prostaglandin vaginal misoprostol
If <12 weeks - vaginal misoprostol
Give antiemetics & pain relief
Surgical - manual vacuum aspiration under LA or GA - previously ERPC

85
Q

Complications of miscarriage?

A

Infection

Ashermans syndrome if manual vacuum aspiration

86
Q

Define recurrent miscarriage

A

When 3 or more miscarriages (result in spontaneous abortions) occur in succession

87
Q

Management of reuccrent miscarriage?

A

Support and counselling

High risk monitoring w/ USS in future pregancies

88
Q

Causes of recurrent miscarriage and rx?

A

Antiphospholipid antibodies –> LMWH
Chromosomal abnormalities –> refer to geneticist, chorionic villus sampling/amniocentesis
Endocrine - DM, thyroid, PCOS
Uterine abnormalities
Infection - treat bacterial vaginosis, or uterine septum - surgery
Smoking - cessation

89
Q

23 year old woman presents to EPAU with lower abdo unilateral colicky pain which is constant. Amenorrhoea for 6-8 weeks. She has now collapsed. Was complaing of shoulder tip pain & pain on defacation.
O/E she is tachycardic, hypotensive, pain on abdo palpattion. cervical excitation, cervical os is closed, Likely dx and cause?

A

Ectopic pregnancy
Fertilized ovum implants outside uterus (fallopian tube wall) and thinned wall unable to cope w/ trophoblastic invasion –> rupture, intraperitoneal bleeding, peritonis

Shoulder tip/defecation pain due to intraperitoneal bleeding

RF: damage to tubes (salpingitis, surgery)
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF (3% of pregnancies are ectopic)
90
Q

Ix of ectopic pregnancy?

A

hCG - v high (>1500)
TVUS to detect foetal location
Quantitative serum hCG - Shows declining/slow rising levels in ectopic
Laparoscopy- most sensitive but invasive

91
Q

Management of ectopic?

A

NBM
IV access and Cross match blood
Laparoscopy
Anti-D if Rh -ve
If haemodynamically unstable - resuscitation and surgery - esp if B-hCG >1500, salpingectomy
If stable: salpingostomy (remove ectopic from fallopian tube)
If unruptured and no cardiac activity & B-hCG <1500 - methotrexate. If small and low hCG, asymptomatic - watch and wait - closely monitor B-hCG

92
Q

A 29 year old woman presents with vaginal bleeding, a large uterus, severe N&V, an uncomfortable pelvis, vaginal discharge. A pregnancy test is performed and very high hCG levels are found. What mimght be the cause? What could be done about it?

A

Molar pregnancy: Non viable fertilized egg implants into uterus. No fetus, all genetic material is paternal.
If beta hCG fail to come down –> methotrexate

93
Q

A 27 year old lady presents to EPAU (8-12) weeks pregnant with excessive vomiting, v high B-hCG. She is now dehydrated and has abnormal U&Es. TVUS shows twins. Likely dx and rx?

A

Hyperemesis gravidarum

RF: multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity

Mx: 1st line: antihistamines (promethazine/cyclizine)
2nd line: Antiemetics - metroclopramide, ondansetron
Admission if IV fluids for dehydtration required
Thiamine - prevent neuro complications
Psychological support

Complications: Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinosis, acute tubular necrosis

94
Q

What is the characteristic TVUS of PCOS?

A

Multiple (>12) small (2-8mm) cystsin an enlarged ovary (>10mL)

95
Q

A 17 year old girl presents with acne, excessive body hair, oligomenorrhoea, acanthosis nigrans and is overweight. What is the liely dx? What would confirm this?

A

Polycystic ovary syndrome - Rotterdam Criteria:
PCO on TVUS
Irregular periods (>35 days apart) - Check FSH (high in ovarian failure, low in hypothalamic disease), prolactin - may be raised
Evidence of hirsutism - serum testosterone - can be high but if v high - consider cause to be androgen secreting tumour/congenital adrenal hyperplasia)
LH high in PCOS
Hyperinsulinaemia & impaired glucose tolerance

96
Q

Management of PCOS?

A

Treat weight - diet and exercise
Treat hirsutism: COC pill, eflornithine topically, metformin (lower insulin and thus androgens)
Under specialist supervision: spironolactone, flutamide, finasteride
COCP to regulate menstruation

Infertility: weight reduction, clomifene (risk of multiple pregnancies w/ anti-oestrogens).

97
Q

A 67 year old lady presenst with involuntaqry leaking of urine, urgency, frequency, nocturia, high BMI, high parity. PMH - hysterectomy What is the cause and pathology?

A

Overactive bladder - due to detrusor over activity

98
Q

What causes involuntary leakage of urine when coughing, lifting, laughing, exercise etc?

A

Stress incontinence - sphincter weakness

99
Q

How should incontinence be assessed?

A

Bladder diary for minimum 3 days
Vaginal exam - r/o pelvic organ prolapse
Urodynamics studies A frequency volume chart - voided vol, frequency of urination, quantity leaked, fluid intake, diurnal variation
Residual volume measurement using USS/catheter
Urinalysis & culture
Questionnaire on urinary/bowel/sexual symptoms

100
Q

Management of stress incontinence?

A

Conservative - physiotherapy - pelvic floor exercises to compress urethra (8 contractions TDS for 3/12
Surgery: retropubic mid-urethral tape procedures - to restore pressure transmission to urethra

101
Q

Management of overactive bladder?

A

Bladder retraining - for 6/52, increase intervals between voiding)
Drugs: Anticholingergics - M2/M3 antagonists eg oxybutynin, tolterodine - immediate release - (SE dry mouth, blurred vision, drowsiness, avoid oxybutynin in frail older women)
Mirabegron - beta3 agonist - relaxes detrusor (concerns over anti-cholinergic SE in elderly)
Bladder drill
Indwelling catheter
Botox
Lifestyle: weight loss, smoking cessation, reduce caffeine
Local vaginal oestrogen

102
Q

What is menopause? Average age?

A

Cessation of menstruation

51

103
Q

How is menopause diagnosed?

A

After 12 months of amenorrhoea

104
Q

4 perimenopausal symptoms?

A 
Irregular periods
Hot flushes &amp; night sweats
Mood swings
Urogenital atrophy &amp; urinary incontinence 
Anxiety &amp; depression
Memory problems
105
Q

Central and local symtoms? Why?

A

Due to low oestrogen?
Central: Vasomotor - hot flushes/swats - last 2-7 years, impacts sleep, mood
Joints/muscle aches, headavhe, loss of memory/concentration
Local: Vaginal dryness, atrophy, dyspareunia, recurrent UTIs, post menopausal bleeding

106
Q

Lon term effects of menopause?

A

Osteoporosis
CVD
Dementia

107
Q

Management of Menopuase?

A

Holistic - lifestyle advice, reduce risk factirs, exercise, good sleep hygiene
Inform about options - HRT (Oral or transdermal to reduce unopposed oestro n (risk of endometrialca), vaginal oestrogens
CBT
HRT - relief of menopause symptoms, bone mineral protection, prevent slong term morbidity
Psychological: fluoxetine/citalopram - helps vasomotor symptoms also
Vaginal dryness: lubricants
Vaginal atrophy - topical oestrogen (CI In HRT)

108
Q

Risks of HRT?

A

Breast ca (if have, discontinue, do not offe)
Ovarian ca
VTE - If have thromboohilia, refer to haematologist
Stroke increased risk
CVD - if started <60, risk not increased

109
Q

How is HRT prescribed?

A

Progesterone used for 12-14 days every 4 weeks - as proetects endometrium from unopposed oestrogen
Mirena
Tibolone - not suitable within 12 mo of LMP
PO estradiol if intact uterus
Transdermal patches if gastric upset/Crohns/increased VTE risk/older women

110
Q

What is premature ovarian insufficiency (POI) and what might cause it?

A

Menopuase in <40yrs & elevated Gonadotrophins
Natural: chromosome abnormalities eg FSH receptor gene polymorphisms, inhibin B mutations
Iatrogenic: surgery, chemo/radiotherapy
Autoimmune

111
Q

Dx of POI?

A

FSH <25 IU/L in 2 samples >4 weeks apart from each other

4 mo of amenorrhoea

112
Q

Rx of POI?

A

Oestrogen replacement: HRT/COCP - HRT alleviates symptoms and minimises risks (European Menopause and Andropause Society)
Androgen replacement - testosterone gel
Fertility: donor egg

113
Q

When might contraception be needed with menopausal women?

A

If <50: remain fertile for 2 years

If >50: remain fertile for 1 yr

114
Q

A married couple are trying to conceive for their first baby. They have been trying for 9 months and have not yet conceived. What advice would you give them?

A 
See partners together
Kep trying - get referral after a year. Early referral if woman >35
Intercourse 2-3 times a week
Folic acid
Smear for rubella
Smoking cessation
Stop alcohol consumption (women)
Keep BMI 20-25
115
Q

Factors contributing to female subfertility?

A 
>35 yrs
Menstrual disorder
PID/STD
Previsu pelvic/abdo Sx - tubal problem b
Abnormal pelvic examination
116
Q

Factors contributing to male subfertility

A

Previous genital pathology, urogenital surgery, STI

Systemic illness

117
Q

Investigations for females with subfertility?

A 
Check ovulation (mid luteal progesterone taken 7 days prior to expected period) - (day 21) - if >30nmol/L - ovulation, <16 - anovulation. Between - further ix
Test for PCOS (Rotterdam criteria)
Test ovarian reserve - test FSH, antral follicle count, antimullerian hormone
118
Q

Ix for males w/ subfertility?

A 
Semen analysis
Clinical exam - secondary sexual characteristics/testicular size
Endocrine: FSH, prolactin
Testicular biopsy (azoospermia)
Imaging - vasogram, USS, urology
119
Q

Treatment for male subfertility?

A

Mild: intrauterine insemination
Moderate: IVF
Severe: Intracytoplasmic sperm injection
Azoospermia - surgical sperm recovery, donor insemination
Epididymal block - surgery
Hormonal - hypogonadotrophic hypogonadism - bromocriptine

120
Q

Treatment for female subfertility?

A

Treat PCOS
Treat tubal disease: tubal laparoscopy - salpingostomy, proximal anastomosis, tubal catheterisation
Assisted conception: ovulation induction, stimulated intrauterine insemination
IVF (risk of multiple pregnancy, miscarriage/ectopic)
Donar egg/embryo/surrogacy

121
Q

What might affect the success of conception?

A 
Age
Cause of infertility
Previous pregnancys
Duration of infertility
Specific medical conditions
122
Q

Define FGM

A

All procedures involving partial or total removal of female external genetalia or other injury to female organs for non medial reasons

123
Q

Why is FGM performed in some cultures?

A 
Bring status
Preserve chastity/virginity
Rite of passage
Communty
Family honour
Cleanses woman
124
Q

Law surrounding FGM?

A

Illegal to perform or help carry out FGM under the Childrens Act 1989

125
Q

Gynae complications of FGM?

A 
Dyspareunia, sexual dysfunction
Chronic pain
Keloid scar formation
Dysmenorrhoea
Urinary outflow obstruction/UTI
PTSD
126
Q

Obstetric complications of FGM?

A

Fear of childbirth
Increased likelihood of C section/PPH
Difficulty monitoring fetus

127
Q

Treatment of FGM?

A 
Reversal of infibulation procedure
Specialist FGM clinics
Report cases
Ensure families know illegality status
Psychotherapy
128
Q

What is the COCP and advanatges?

A

Oestrogen and progesterone
Reversible and reliable, regular cycles, decrease dysmenorrhoea/menorrhagia, protective against ovarian, endometrial and colorectal ca, doesn’t interfere with sex

129
Q

Disadvantages of COCP?

A 
Risk of VTE
Drug interractions
Decreased efficacy after D&amp;V
No STI protection
Small breast/cervical ca risk
130
Q

Describe how contraceptive patches (Evra) work

A

Oestrogen and progesterone
Worn 3 weeks then break for 1 week
Expensive

131
Q

What is the POP and advantages?

A

Progesterone only pill
Thickens cervical mucous and thins endometrium
Prevent oestrogenic SE eg breast tenderness, headache
Though can have heavy affect on periods

132
Q

Advantages of condoms?

A

Prevent pregnancy and STI

But failure if poor technique

133
Q

How does the injectable contraception work?

A

Depo-Provera
IM progesterone - inhibits LSH/LH - given every 12 weeks
Reversible
May help PMS
BUT may increase appetite - weight gain, irregular bleeding

134
Q

How do implants work?

A

Nexplanon - slow release progesterone
Easy to remove and insert
Affects periods - irregular

135
Q

How does the intrauterine device work?

A

copper contained causing foreign body reaction with uterus - toxic to sperm and egg fertilizing chances
May cause menstrual irregularities, spotting, menorrhagia, PID risk, risk of ectopic

136
Q

How does the intrauterine system work

A

Mirena - contains progesterone
For menorrhagia
Though causes endometrial atrophy

137
Q

How does the emergency contraception work?

A

Progesterone only - Levonelle = levonorgestrel
Decrease viability of ova
Take asap - must be taken within 72hrs

IUD can be inserted within 5 days

138
Q

How is female sterilization undertaken?

A

Hysterectomy/hysteroscopic sterilisation
Irreversible
GA

139
Q

How is male sterilization undertaken

A

Vasectomy
Permanent
Cut and cauterise vas deferens

Phase 3a (8 decks)

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