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GOSH > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Where is FSH and LH released from?

A

Anterior pituitary gland

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2
Q

Role of FSH

A

Stimulates follicular activity promoting estradiol production from granulosa cells

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3
Q

Role of LH

A

Egg release Corpus luteum progesterone production

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4
Q

What are the different phases of the menstrual cycle?

A

FOLLICULAR PHASE 0-7 Menses 7-14 Proliferative phase

LUTEAL PHASE 14-28 Secretory phase

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5
Q

How long does an unfertilised egg live for?

How long does sperm survive for?

A

72 hours

5 days

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6
Q

What day of the menstrual cycle is there an egg released?

A

Day 14

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7
Q

What hormone test is best for measuring whether ovulation has occured?

A

Day 21 Progesterone (MID-LUTEAL)

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8
Q

What happens during the follicular phase?

A

Shedding- FSH surge- Follicle maturation- follicle release oestrogen- Thickening of endometrium

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9
Q

What happens during the luteal/secretory phase?

A

High oestrogen stimulates an LH surge
LH surge causes ovulation
Corpus luteum- Progesterone release

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10
Q

For how many days does the corpus luteum survive?

A

14

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11
Q

What happens after death of the corpus luteum

A

Progesterone decreases
Endometrial arteries constrict
Menstruation

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12
Q

How is progesterone production maintained after implantation?

A

Blastocyst implants in decidua causing HCG production which maintains CL progesterone production early on, placenta takes over prog production after 10-12 weeks

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13
Q

When is HCG production from the blastocyst detectable

A

9-10 days post-conception

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14
Q

What happens to HCG levels in the first few weeks of pregnancy?

A

Doubles every 48 hours

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15
Q

After ovulation when does implantation occur?

A

8-10 days (~D23 of cycle) estimated from LMP

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16
Q

What is dysmenorrhoea?

A

Excessive pain during the menstrual period

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17
Q

Causes of primary and secondary dysmenorrhoea?

A 
Primary= No underlying pathology likely 1-2 years following menarche 50% of women!
Secondary= Many years after menarche, underlying pathology, may have dyspareunia (Endometriosis, IUD, Adenomyosis, Fibroids, PID)
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18
Q

Management of primary dysmenorrhoea

A

NSAIDS- Mefenamic acid

Then COCP to suppress ovulation

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19
Q

What do you do if someone presents with secondary dysmenorrhoea

A

Refer to Gynae for investigation

Causes usually treated with contraception

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20
Q

What is Mettelschmerz

A

Mild pain

14 days before ovulation

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21
Q

How do you define menorrhagia?

A

Prolonged >7D and Heavy >80ml bleeding

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22
Q

Causes of menorrhagia

A

IUCD, Fibroids, Endometriosis, Adenomyosis, PID, Polpys, Hypothyroidsim, Coag disorders

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23
Q

Essential investigations for Menorrhagia

A

FBC!

+/- TVUS, Endometrial biopsy, Outpatient hysteroscopy

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24
Q

Management of menorrhagia

A

1) Mirena coil
2) Tranexamic acid, Mefenamic acid, NSAIDS,COCP
3) Ablation, Hysterectomy

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25
Q

Define Polymenorrhoea

A

An abnormally short interval between regular menses

<21 days

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26
Q

Define Oligomenorrhoea

What is most likely to cause this?

A

An abnormally long interval between regular menses
>35 days
?PCOS

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27
Q

What should post-menopausal bleeding be treated as until proven otherwise

A

Endometrial cancer (Number one cause is atrophic vaginitis)

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28
Q

Primary Amenorrhoea

A

Failure to start menstruating by 14

or 16 yrs with no breast development

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29
Q

What is secondary amenorrhoea

A

Periods stop for 6 months without pregnancy

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30
Q

What investigations should be done for secondary amenorrhoea?

A

TSH, Gonadotrophins, Prolactin, Beta-HCG, Androgen levels

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31
Q

Causes of secondary amenorrhoea

A

44% Hypothalamic-Pituitary-Ovarian axis disorders- COMPETITIVE ATHLETES
Hyperprolactinaemia
Ovarian insufficiency because Chemo/RT?
Ashermanns or Sheehans

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32
Q

Key causes of post-coital bleeding

A

Cervical ectropion

or… Cervicitis, Cancer, Polyps, Trauma

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33
Q

Key investigations if a women presents with abnormal bleeding

A 
Rule out pregnancy related problems with PT
Review Meds
LFTs, Urinalysis, FBC + Haematinics 
Examination 
Clotting 
?Uss ?biopsy?Scopy
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34
Q

What is Post-menstrual syndrome

A

Common and typically mild appearance of a myriad of cyclical symptoms that interfere with the day’s normal events

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35
Q

How do you manage post-menstrual syndrome

A

1) Supportive measures +/- COCP +/- Fluoxetine
2) Estradiol patches or Mirena
3) GNRH antagonists or HRT
4) Total Hysterectomy and BSO

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36
Q

How does PCOS impact the levels of different hormones

A

LH Chronically elevated
FSH suppressed
Increased circulating testosterone

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37
Q

What part of the menstrual cycle is fixed at 14 days

A

Luteal phase

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38
Q

What is the Rotterdam criteria for PCOS?

A

2/3 needed

1) Polycystic ovaries on USS
2) Hyperandrogenism- Body hair, Acne
3) Oligo/Anovulation

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39
Q

Key features of PCOS starting with the most common

A 
Menstrual irregularities 
Subfertility
Hirsutism 
Obesity 
Acne, Acanthosis Nigricans
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40
Q

What does PCOS look like on USS

A

String of pearls appearance

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41
Q

Management of PCOS if wanting to promote fertility

A

Weight loss
Ovulation induction- CLOMIFENE
Metformin to improve insulin sensitivity and improve fertility
?Anti-androgen

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42
Q

PCOS management if not wanting to promote fertility

A

COCP- Dianette and Yasmin both good at ameliorating androgenic symptoms
Regular 3/12 withdrawal bleeds
Wx loss

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43
Q

Complications of PCOS

A 
Endometrial cancer 
Insulin resistance/T2DM
HTN/CVD/Dyslipidaemia/Strokes
Weight Gain 
Ovarian hyperstimulation risk if IVF etc
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44
Q

Average age of the menopause

A

52 years (51-54)

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45
Q

What increases the risk of an early menopause

A

Smoking

Hysterectomy

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46
Q

How do you diagnose the menopause

A

Retrospective
>50= 12 months later
<50= 24 months later

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47
Q

What is the physiology of the menopause

A

Termination of ovarian follicular development despite high FSH and LH
Gonadotrophin/LH/FSH rise to try and stimulate, but this fluctuates therefore not useful as a reading

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48
Q

What are the menstrual irregularities associated with the menopause

A

Mostly 4-5 years of varying cyle length

10% cease abruptly

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49
Q

What are the early changes associated with the menopause

A

Vasomotor symptoms- Sweats, Tiredness, mood, Cognitive, Concentration
Loss of collagen- Joints, skin
Fat redistribution

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50
Q

What are the medium term changes associated with the menopause

A

Vaginal atrophy, dyspareunia, soreness
Bladder frequencey, dysuria, UTis
Bleeding

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51
Q

What are the long term changes associated with the menopause

A

Osteoporosis

CVD

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52
Q

What are the hypoestrogenic changes associated with the menopause?

A

Vasomotor instability 5-7years decreases with age
Osteoporosis
Genital atrophy
Mood disturbance

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53
Q

What are the benefits of HRT

A

Improves vasomotor symptoms
Improves urogenital/Sexual function
Decreases OP related fractures
Decreases CRC risk

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54
Q

What are the disadvantages of HRT

A

Endometrial hyperplasia and adenocarcinoma
Breast cancer
VTE risk

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55
Q

CI to HRT

A

Liver disease, Thromboembolic disorders, Oestrogen dependent cancer, Pregnancy/Breast feeding

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56
Q

Apart from HRT, How can the menopause be managed

A 
Diet and exercise good for symptom relief 
Mirena coil if menorrhagia 
SSRIs for vasomotor symptoms 
Calcium, Vit D, Bisphos for OP 
Contraception until >1 yr amenorrhoea
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57
Q

Indication of oestrogen only HRT in the menopause

A

Absent uterus

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58
Q

Indication for continuous combined HRT in the menopause

Benefits?

A

> 54 or >1 year amenorrhoea

NO BLEEDING

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59
Q

What is sequential combined cyclical HRT

A

Daily oestrogen and then progesterone for last 10-14 days of the cycle
There is a withdrawal bleed

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60
Q

What is sequential long cyclical HRT

A

Oes for 3 months
Prog for the 2nd half of the 1st month
has 3 monthly withdrawal bleeds

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61
Q

Which HRT is associated with the highest risk of breast cancer?

A

E+P> Tibolone>E only

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62
Q

What is premature ovarian failure

A

Menopausal symptoms (1 yr meses cessation) and inc Gondotrophin levels before 40 yrs

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63
Q

How is premature ovarian failure confirmed

A

FSH test where levels are v.High

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64
Q

Risk factors for premature ovarian failure

A

Chemo, RT

Although can be idiopathic

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65
Q

What 3 key factors must be considered when deciding the best HRT?

A

1) Uterus present?
2) Perimenopausal or menopausal?
3) Systemic or local effect required?

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66
Q

What HRT is best if someone is Perimenopausal and amenorrhoea <1 yr

A

Cyclical combined

Can track periods as there will be withdrawal bleeds

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67
Q

When is continuous combined HRT most appropriate

A

> 1 yr since LMP or taken cyclical for >1 yr

There will likely be No bleeds

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68
Q

What type of HRT has a strictly local effect?

A

Creams and pessaries

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69
Q

Key side effects of HRT to tell patients

A

Nausea, erratic PV bleed, headaches, leg cramps, Dyspepsia, Bloating, Breast tenderness

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70
Q

What is the difference between endometriosis and adenomyosis?

A

Endometriosis is ectopic endometrial tissue outside the uterine cavity
Adenomyosis is endometrium within the myometrium

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71
Q

How does adenomyosis look on an MRI

A

Enlarged and boggy

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72
Q

Where is the most common site of endometrial tissue

A

Ovary

then- Peritoneum, pouch of douglas

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73
Q

What age range is endometriosis likely to present? When does it regress?

A

Post menarche likely ~20s

Regression post-menopause (oestrogen dependent)

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74
Q

Key hallmark feature of endometriosis

A

CYCLICAL PAIN

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75
Q

Aside from cyclical pain, what other features does endometriosis present with?

A 
Abnormal bleeding- PCB, IMB 
Deep dyspareunia 
Dyschezia 
Enlarged tender adnexa
Sub-fertility
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76
Q

What position is the position of the uterus likely to be in endometriosis? Why?

A

FIXED RETROVERTED

The scar tissue reduces mobility

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77
Q

Gold standard diagnosis of endometriosis

A

Laparoscopy for direct visualisation

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78
Q

How can endometriosis cause free fluid in the abdomen?

A

Rupture of an endometrioma

+ Intense pain

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79
Q

What is the goal of treatment for endometriosis?

A

Suppression of ovulation and induction of amenorrhoea

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80
Q

Medical management of endometriosis

A

1) NSAIDS
2) COCP Back to back or Mirena Coil
3) GnRH Antagonists (Chemical menopause)

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81
Q

When is surgical management for endometriosis good?

A

Young women desiring fertility

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82
Q

Surgical management of endometriosis

A

Laparoscopic excision or laser

Definitive is Hysterectomy with BSO + HRT after

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83
Q

Presentation of PID

A 
Bilateral lower abdominal pain, adnexal tenderness, perihepatitis
Fever
Purulent discharge 
Deep dyspareunia 
IMB, PCB, Menorrhagia
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84
Q

What core history points must you cover in ?PID

A

O+G Hx, Sexual Hx

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85
Q

Key Core investigations for ?PID

A

Pregnancy test to exclude ectopic
Bimanual- Cervical motion tenderness, mass
Speculum- VVS, HVS, EC
Urine dip, Obs, MSU?

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86
Q

Core criteria for diagnosis of PID

A

One of: T>38, Leucocytosis, ESR>15

One of: Adnexal pain, Cervical motion tenderness, Adnexal mass

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87
Q

Complications of PID

A

Ectopic, Infetility, Chronic dyspareunia/pain, Fitz Hugh Curtis, Abscess

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88
Q

In a PID what would a palpable adnexal mass suggest?

A

Abscess

Especially if systemically unwell

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89
Q

How do you manage PID?

A

Treat as if it is an STI
Rest
Analgesia
Consider IUD removal

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90
Q

Advice on sexual intercourse for a PID patient

A

No sex until both you and your partner are treated

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91
Q

Top 2 causes of PID

A

1) chlamydia

2) Gonorrhoea

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92
Q

What are the RF for PID

A

<25yrs, Multiple partners, vaginal douching, unprotected sex, IUD, ToP

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93
Q

In a patient with chronic pelvic pain and abnormal VE findings what must be done?

A

Diagnostic laparoscopy or uss

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94
Q

Presentation of a threatened miscarriage

A

Bleeding +/- Pain
OS= Closed
Uterine size= Correct for gestational age

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95
Q

What % of threatened miscarriages actually miscarry

A

25%

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96
Q

Presentation of inevitable miscarriage

A

Heavy clotted vaginal bleeding

OS= Open

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97
Q

Presentation of a complete miscarriage

A

Presents with bleeding that has no lessened
OS= Closed
Uterine size= Returned to Normal size

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98
Q

Presentation of an incomplete miscarriage

A

OS= Open

Uterine scan shows mixed debris

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99
Q

Presentation of a missed or delayed miscarriage

A 
Entire gestational sac in uterus 
No growth 
No fetal heart beat 
OS= Closed
Light discharge 
Uterus is small for GA
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100
Q

When is a miscarriage defined as recurrent

A

3+ times

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101
Q

When do most miscarriages present

A

<12 weeks

MOST FIRST 12-14 DAYS

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102
Q

Best way to investigate a miscarriage

A

TV USS

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103
Q

USS Dx criteria for miscarriage

A

No FHB + CRL> 7mm or Ges.Sac size>25mm

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104
Q

What is a miscarriage

A

Loss of pregnancy before 24 weeks

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105
Q

General presenting features of a miscarriage

A

Vaginal bleeding, Abdominal pain, Regression of pregnancy related symptoms

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106
Q

1st line management for miscarriage? When is a PT done?

A

Expectant
7-14 days
PT 3/52 after

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107
Q

During expectant management why would you repeat the scan?

A

Pain and bleeding not started or are persisting/increasing

108
Q

When is expectant management for miscarriage not appropriate?

A 
Late 1st TM as increased haemorrhage risk 
Hx of miscarriage, stillbirth, APH
Coagulopathies
Transfusions CI
?Infection
109
Q

What types of miscarriage is medical management good for?

A

Missed and Incomplete

110
Q

Medical management of miscarriage

A

Vaginal misprostol (~800mcg) +/- Analgesia +/- Antiemetics

111
Q

When do the majority of miscarriages complete after medical management?

A

Within 7 days
May bleed for 3/52 after
Do PT 3/52 after also

112
Q

Two options for surgical management of miscarriage

A

Manual Vacuum Aspiration- Outpatient and Local

Evacuation of the Uterus- Inpatient and general

113
Q

Key risks of Evacuation procedure for treating miscarriage

A

Infection damage, bleeding, adhesions, perforation, retention of products

114
Q

When is Anti-D given in miscarriage management? When is it not?

A

Surgical + Rh-ve mum

NOT IF Medical management/Threatened/Complete/PuL

115
Q

What are the risk factors for an ectopic pregnancy

A

PID, Damage to the fallopian tubes, Sterilisation, Intra-uterine device (if P+ve), Endometriosis, IVF, Hx Ectopic

116
Q

Most common site of an ectopic? Which location ruptures earliest?

A

Ampulla

Isthmus

117
Q

Which type of ectopic can only be managed medically?

118
Q

Signs of an ectopic pregnancy

A

Tenderness +/- Rebound
Cervical motion tenderness
Unilateral adnexal tenderness (N.B dont look for a mass)

119
Q

Symptoms of an ectopic

A

Often asymptomatic
Shoudler tip pain, Dark brown vaginal bleeding, Amenorrhoea, Pain on defacation/urination
Collapse…

120
Q

What investigation confidently excludes an ectopic

121
Q

What can a TV USS show us in ?Ectopic

A

Confirms an intrauterine pregnancy
Adnexal mass/Free fluid
Location of ectopic?
Is there a FHB?

122
Q

How does bHCG change in normal pregnancy and pathological pregnancy?

A

<8 weeks + Normal= 2X every 48 hours
8-10 weeks= Doubles every 5 days
Ectopic- Slow rise or plateau… Rise <66%!
Miscarriage= Rapid fall

123
Q

If there is diagnostic doubt over ?Ectopic what is indicated

A

Laparoscopy

124
Q

How do ectopics and miscarriages present differently

A

Pain typically precedes bleeding in ectopics, other way round in miscarriage

125
Q

What percentage of people with an ectopic have a subsequent IU pregnancy

126
Q

Indications for expectant management of an ectopic pregnancy?

A 
Unruptured 
Pain free, Stable, 
<35mm (Tubal)
No FHB on TVS
HCG<1000 IU/L (?If <1500)
127
Q

When should you repeat bHCG levels when using expectant management for an ectopic

A

D2, D4, D7

128
Q

What should happen to bHCG if you use expectant management

A

Should fall by >15%

129
Q

Indications for medical management of an ectopic

A

No significant pain, <35mm, No FHB
HCG<1500IU/L, (?<5000)
No IU pregnancy

130
Q

When should bHCG be repeated in medical management of an ectopic?

A

D4, D7

Then weekly until <20

131
Q

When is anti-D indicated in ectopic management?

A

Surgical management only

250Iu (50mcg) if Rh-ve

132
Q

How do you manage an ectopic medically? How effective is this?

A

IM Methotrexate
Can take~4-6 weeks
~5% need surgery despite the above…

133
Q

Safety netting advice when using expectant/medical management of an ectopic

A

Watch for:

Heavy bleeding, shoulder tip pain, Abdo pain, Dizziness, syncope, Do not travel, do not stay alone

134
Q

When is surgery indicated for management of an ectopic

A

FHB present
HCG>5000IU/L
>35mm
Significant pain

135
Q

How is an ectopic managed surgically? When is a PT done after this?

A

Laparoscopy
+/- Salpingectomy
+/- Salpingotomy (20% need further treatment)
PT 3/52 after

136
Q

What is a molar pregnancy?

A

Gestational trophoblastic disease
E.G. Hydatidiform mole, Choriocarcinoma, Placental site trophoblastic tumour
Proliferating chorionic villi that have swollen and degenerated

137
Q

What is the difference in formation between a partial and complete hydatidiform mole

A 
Partial= Dispermy and normal egg
Complete= Sperm and empty egg
138
Q

How does molar pregnancy present and why?

A

Lots of HCG produced= Exaggerated pregnancy symptoms e.g hyperemesis gravidum
Heavy bleeding
Large uterus

139
Q

What can the HCG produced by a molar pregnancy do to the thyroid gland?

A

Stimulates it inducing thyrotoxicosis

TSH decreased T3/4 increased

140
Q

What does a molar pregnancy look like on an USS?

A

Snowstorm effect + No foetus if complete

Focal cystic spaces if partial

141
Q

How is Molar pregnancy managed?

A

Electric Vacuum Aspiration +/- Hysterectomy
Samples sent for histology for Dx

Or… 6 cycles of methotrexate or till 6/12 after cleared

142
Q

What must be done after treating a molar pregnancy?

A

Monitor bHCG until its undetectable

No decrease sugegsts invasive mole or choriocarcinoma

143
Q

After a molar pregnancy when can you try again for a baby?

A

After bHCG has been normal for 6/12

144
Q

When can a choriocarcinoma present?

A

Many years after a pregnancy

145
Q

What are the different types of fibroids?

A

Submucosal
Intramural
Subserosal

146
Q

What can induce an increase in fibroid size? What does this lead to?

A

Progestins, Clomifene, Pregnancy

Haemorrhage, Degeneration, Pain, vomiting, fever

147
Q

When not asymptomatic, What are the core symptoms of fibroids?

A

Menorrhagia/Abnormal bleeding
Pain with torsion or during menstruation
Subfertility

148
Q

How are fibroids diagnosed

149
Q

Which type of fibroid commonly give rise to pressure symptoms like bloating?

A

Subserosal

150
Q

Risk factors for fibroids?

A

Black ethnicity, Oestrogen (Pre-menopausal women)

151
Q

What are fibroids?

A

Bening uterine smooth muscle tumours

152
Q

1st line medical management for fibroids? Why?

A

Mirena coil- Decreases bleeding

Progesterone based oral contraceptive can also be used

153
Q

When are GnRH antagonists used in the treatment of fibroids? What is the side effect of this?

A

Short term induction of amenorrhoea
In preparation for surgery
Transient infertility ‘Chemical Menopause’

154
Q

Surgical option for fibroid treatment that improves fertility?
Other surgical options?

A

Hysteroscopic myomectomy if up to 4cm

Endometrial ablation, Laparoscopy/otomy
Uterine embolisation is a non-invasive technique

155
Q

Indications for surgical intervention in fibroids?

A

Bulky symptoms, Excessive bleeding, Rapid growth, Hydronephrosis, Contemplating pregnancy, recurrent miscarriage, Uterine distortion

156
Q

When is a hysterectomy indicated for fibroids?

A

> 45yrs

Completed their family

157
Q

What is a follicular cyst? When do they regress

A

Functional/Physiological ovarian cyst
Most common
Regression after a few menstrual cycles

158
Q

What is a corpus luteum cyst? When do they regress?

A

Physiological cyst caused by the CL not breakign down, instead it fills with blood and fluid
Spontaneous resolution in 4-6 weeks

159
Q

What is the most common beign ovarian epithelial tumour?

A

Serous cystadenomas

160
Q

Name 2 benign ovarian epithelial tumours

A

Serous and mucinous cystadenomas

161
Q

What is Pseudomyxoma peritonei

A

Cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelatinous ascites.

162
Q

What is a dermoid cyst?

A

Mature cystic teratoma of the ovary lined with epithelial tissue and skin/teeth
Median age 30yrs

163
Q

What does torsion of an ovarian cyst look like on USS?

How will the patient present?

A

Whirlpool sign

Pain and vomiting

164
Q

What does ovarian endometriosis present as?

A

‘Chocolate cyst’

Tender immobile adnexa

165
Q

What is Meig’s syndrome?

A

Benign Ovarian tumour + Pleural effusion + ascites secondary to
Removal of said tumour usually induces resolution

166
Q

How do you diagnose an ovarian cyst?

167
Q

Malignancy red flags when investigating a ?ovarian cyst

A 
Irregular borders
Ascites
Populations 
Separations within cyst
POST-MENOPAUSAL
168
Q

How do you manage a post-menopausal women presenting with a ?new onset ovarian cyst

A

Gynae referral because it is unlikely to be physiological

169
Q

When is 4-6 week observation appropriate for the management of an ovarian cyst

A

<5cm, Simple, Mobile, Unilateral, No ascites

170
Q

What is likely to happen to simple cysts during pregnancy

A

Regress after 2nd TM

171
Q

When is laparoscopic cystectomy indicated for an ovarian cyst?

A

> 10cm, Solid, Complex, Fixed, Bilateral, Ascites

172
Q

How can an ovarian cyst cause frequency?

A

Presses on the bladder

173
Q

When would you follow up an ovarian cyst with yearly USSs?

A

5-7cm

Still manage conservatively

174
Q

What size ovarian cysts are unlikely to resolve spontaneously and are at increased risk of torsion?

175
Q

Most common cause of infertility

A

Male factor

Then ovulatory disorders

176
Q

The three groups of ovulatory disorders causing female infertility

A

1- Hypothalamic pituitary failure
2- Hypothalamic pituitary ovarian dysfunction
3- Ovarian failure

177
Q

What is Hypothalamic pituitary failure in relation to infertility?

A

Hypothalamic amenorrhoea

Hypogonadotrophic hypogonadism

178
Q

What is Hypothalamic pituitary ovarian dysfunction in relation to infertility?

A

PCOS!

Sheehan’s, Turners, Klinefelters, Hyperprolactinaemia

179
Q

When is ovarian failure classified as premature?

180
Q

What are the AMH and Oes/FSH levels for the below?
1- Hypothalamic pituitary failure
2- Hypothalamic pituitary ovarian dysfunction
3- Ovarian failure

A

1- Hypothalamic pituitary failure- AMH Normal Oes low, FSH low/Norm
2- Hypothalamic pituitary ovarian dysfunction- AMH increased, Oes/FSH norm
3- Ovarian failure- AMH and Oes low, FSH inc

181
Q

What structural problems can cause female infertility

A

Bicornuate uterus, Tubal damage, Ashermanns, Fibroids, Endometriosis, STIs/PID

182
Q

Causes of male infertility?

A

Testis/Spermatogenesis disorders
Disorders of the genital tract
Idiopathic
Ejaculatory disorders

183
Q

Examples of Testis/Spermatogenesis disorders causing male infertility

A

Azoospermia, Klinefelters XXY, Cryptorchidism, Tumours (Testicular or pituitary), Hyperprolactinaemia, Cushings

184
Q

When do you investigate infertility?

A

After 1 year of UPSI

185
Q

How can you investigate female infertility?

A 
Mid-Luteal progesterone 
FSH, LH
Rubella status 
Tubal patency 
Ovarian reserve testing
186
Q

When would you do a hysterosalpingogram and not laparoscopy/Dye test to assess tubal patency in female infertility?

A

HSG= No Comorbidities E.G PID

Always screen for CT before uterine intervention

187
Q

How do you investigate male factor infertility?

A 
Semen analysis after 3-5 days abstinence 
Hormone analysis
Genetic testing
Testicular biopsy
Viral screen
188
Q

What is asthenospermia?

A

Immotile sperm

189
Q

What is teratozoospermia?

A

Excessive abnormal sperm

190
Q

How can you induce secondary ovarian failure?

A

BMI<19, V high exercise levels, Hypopituitarism, PCOS, Hyperprolactinaemia

191
Q

Syndromes Causing primary ovarian failure

A

Turners, FXS, Kallmanns

192
Q

RF for infertility

A 
BMI <19 or >30 (Dont forget Anorexia Nervosa)
Smoking 
>2 units alc/wk
Illicit drugs
Dyspareunia, Inadequete penetration  
AI
CKD
Poor DM control
193
Q

General advice for management of subfertility

A 
0.4mg folic acid pre-conception-12 wks
UPSI 2-3X/Wk
Decrease Alcohol 
Stop Smoking 
Optimise BMI
194
Q

CI to IVF

A

Partner not living together

Has another child

195
Q

What male factor is incompatible with fertility?

A

Persistent abnormal sperm counts

196
Q

How do you improve fertility in hypogonadotrophic hypogonadism?

A

Gonadotrophins

197
Q

Treatment of G1 ovulatory disorder related infertility?

A

Increase Wx, Decrease exercise levels

Pulsatile administration of gonadotrophin-releasing hormone optimised with LH activity

198
Q

Treatment of G2 ovulatory disorder related infertility?

A

Lose Wx if BMI>30
Treat PCOS per guidelines (Clomifene etc)
?Laparoscopic ovarian drilling

199
Q

How do you treat hyperprolactinaemia related infertility?

A

Dopamine agonists like Bromocriptine

200
Q

Indications for Intrauterine insemination?

A

Physical limitations
Man is HIV +ve
Donor sperm (Same-sex couple)

201
Q

What must be done before IVF?

A

Ovarian stimulation

202
Q

When is IUI not effective?

A

Structural problem in the uterus

203
Q

How mant cycles of IVF are offered to an <40yr old?

204
Q

What are the indications for trying 2 years of UPSI before Recommending IVF?

A

Unexplained
Mild endometriosis
Mild male factor

205
Q

Risks of IVF

A

Multiple pregnancy
Ovarian Hyperstimulation syndrome
Increased placenta praevia risk
Failure= Psych distress

206
Q

Presentation of ovarian hyperstimulation syndrome?

A

Lower abdo pain, N&V, Distension

Ascites, Wx gain, Tachycardia, Hypotension, Oliguria, U&E abnormalities

207
Q

When is intracytoplasmic sperm injection indicated?

A

Severe deficits in sperm quality, Azoospermia
Failed IVF
Generally only useful if there is a problem with the Male’s sperm

208
Q

After what age is there a low chance of success with IVF?

209
Q

When can an earlier than 1 yr referral for fertility treatment be considered?

A

> 36yrs, Known cause, Hx predisposition, No chance with expectant management

210
Q

Apart from HPC what important points must you cover in a UroGynae Hx?

A 
Hysterectomy? Gynae surgery?
How many children and VD?
Intercourse problems?
Diuretics, Laxatives?
Smear up to date?
Caffeine, smoking, alcohol
211
Q

Management of stress incontinence

A

1- Pelvic floor exercises + Lifestyle changes
2- Duloxetine
3- Surgical, Tension free vaginal tape

212
Q

Key investigation if ?Stress incontinence; when is this done

A

Urodynamics

After 1st line management before duloxetine

213
Q

Key investigation of urge incontinence

A

Bladder diary minimum 3 days

Fluid input, micturation/volume, Pads, incontinence

214
Q

Recommended programme of pelvic floor exercises for Stress incontinence

A

8 squeezes, 3X day, 3 months

215
Q

Management of urge incontinence

A

1- Lifestyle changes, Bladder training to increase time between voiding
2- +/- Antimuscarinic (Oxybutynin)

216
Q

Antimuscarinic side effects

A

Dry mouth, Blurring, Dry eyes, Drowsy, Constipation, Skin reaction, Headahces, Diarrhoea

217
Q

When is urodynamics done in the management of urge incontinence?

A

After 2nd anticholinergic has been tried

218
Q

When do urodynamics indicate stress UI?

A

Incontinence + Strain - Detrusor activity

219
Q

When is urodynamics appropriate prior to surgery?

A

? Detrusor OA
?Hx surgery for SUI
? Incomplete emptying

220
Q

When is urodynamics not appropriate?

A

Prior to conservative therapy in ?Stress incontinence

221
Q

Prolapse risk factors

A

Post-menopausal, Obesity, COCOP, Constipation, Multiparity

222
Q

When is a Sim’s Speculum most useful?

A

Assess vaginal wall in ?Prolapse

223
Q

What are the 3 grades of a utero-vaginal prolapse?

A

1- Half way down to introitus
2-As far as introitus
3- Beyond introitus

224
Q

Management of Utero-vaginal prolapse?

A

1- Conservative- Wx reduction, Pelvic floor exercises, Avoid heavy lifting.. IF ASYMPTOMATIC CAN JUST LEAVE
2- Pessary- change 4-6/6
3- Surgical

225
Q

What is an ectropion?

A

Endocervical epithelium extends over paler ectocervical epithelium

226
Q

What would an ectropion present as?

A

Isolated PCB +/- Increased discharge

227
Q

Risk factors for ectropion?

A

ELEVATED OESTROGEN: Ovulation, Pregnancy, COCP

228
Q

At what ages is cervical smearing done?

A

Smear tests every 3 years if 25-49 Then every 5 years from 50-64

229
Q

Different grades of Cervical Intraepithelial Neoplasia

A

CIN1/Mild dyskaryosis- Lower 1/3rd affected
CIN2/Moderate dyskaryosis- <2/3rds
CIN3/Severe- >2/3rds

230
Q

Which types of HPV are most associated with cervical cancer?

A

16,18,31,33

231
Q

When should cervical screening be done if CIN1/2 is found?

A

Annually until 2 normal results then move back to 3 yearly

232
Q

If CIN1 is found on a smear what should be done?

A

1- Test for HPV 16, 18. 33

2- +ve= Colposcopy -ve= Routine recall

233
Q

What should be done if CIN2/3 is found?

A

Urgent Colposcopy

234
Q

To whom is the HPV vaccine given? What types of HPV does the Gardasil quadrivalent vaccine work against?

A

All 12-13 male and females

HPV- 6,11,16,18

235
Q

Treatment options for CIN? When is a core cytology test needed after this?

A

Large Loop excision of transformation zone LLETZ
Colposcopy to excise and destruct
Cold coag, Cryotherapy, Lashes vaporisation

6 months

236
Q

Risk factors for Cervical cancer?

A

<35 YEARS

Smoking, unprotected sex, Previous STI/HPV, HIV, Immunosuppression

237
Q

Key presenting symptoms of cervical cancer?

A

Abnormal bleeding + <35yrs
-PCB, IMB, Menorrhagia, Blood stained discharge
Could still be PMB

238
Q

What are the 4 FIGO stages of cervical cancer?

A

1- Confined to cervix
2- Local spread (Upper vagine, parametrium)
3- Extends to pelvic wall + Lower 1/3rd vagina
4- Distant spread

239
Q

What is a trachelectomy?

A

Possible treatment for cervical cancer
Removal of the cervix and pelvic lymph nodes
Preserves the body of the uterus for FERTILITY

240
Q

Risk factors for endometrial cancer

A

> 45yrs

Increased oestrogen exposure: Early menarche <12, Late menopause >52, Obesity, HRT, Chronic anovulation (PCOS/Infertility)

TAMOXIFEN if post-menopausal (Oes R agonist)

DM, HNPCC, Lynch syndrome

241
Q

Protective factors against endometrial cancer?

A

Smoking, Pregnancy, Diet, Exercise, IUS, Early menopause, COCP

242
Q

Number 1 type of endometrial cancer?

A

ADENOCARCINOMA

243
Q

How would you investigate a >55yr woman presenting with PMB?

A

FAST TRACK

Needs urgent Speculum and pelvic exam +/- USS+/-hysteroscopy +/- Biopsy

244
Q

What degree of endometrial thickening on USS suggests ?Endometrial cancer

245
Q

How is PMB defined?

A

Unexplained Vaginal Bleeding 12+ months after Menstruation has stopped

246
Q

FIGO staging of endometrial cancer?

A

1- Confined to uterus
2- Local spread to cervix
3- Spread to pelvis/Adnexa/Vagina/Nodes
4- Distant spread

247
Q

At what stage do the majority of endometrial cancers present at? Why is this?

A

1 (Confined to uterus)

The myometrium is a barrier to spread therefore early presentation correlates with a high cure rate

248
Q

Main surgical procedure to treat endometrial cancer?

A

TAH +/- BSO +/- RT

249
Q

Risk factors for Ovarian cancer?

A

ANYTHING THAT INCREASES THE NUMBER OF OVULATIONS

Nulliparity, Early menarche, Late menopause, FHx, HNPCC, BRCA (1>2), Endometriosis, Smoking, HRT

250
Q

What is protective against Ovarian cancer

A

COCP

Pregnancy

251
Q

How does ovarian cancer present?

A

Asymptomatic as pelvis easily accommodates a large tumour

Abdominal Pain/Bloating +/- Ascites +/- Swelling/Distension +/- Wx loss +/- Urgency

252
Q

indications for CA125?

A

Regular: Bloating, Appetite loss, Pain in abd/pelvis, Urgency/Frequency
ESPECIALLY IF >50yrs
IBS like symptoms

253
Q

If CA125 is raised what must you do?

A

USS Pelvis/Abdomen then if that is +ve urgent referral

IF there is ascites/Mass then skip USS and go straight to urgent referral

254
Q

What is a normal CA125 level?

255
Q

FIGO staging of ovarian cancer

A

1- Confined to ovary
2- Pelvic spread
3- Peritoneal mets or para-aortic lympthadenopathy
4- Distant mets

256
Q

Prognosis of ovarian cancer?

A

Poor- Presents late

25% 5 yr survival

257
Q

What is the RMI criteria?

A

Pre-surgical prognostic criteria for ovarian cancer

->CA125/Menopauasal status/USS score

258
Q

General treatment principles of ovarian cancer?

A

TAH +/- BSO +/- Omentectomy

+/- Platinum based chemotherapy like Cisplatin/Taxane

259
Q

Risk factors for Vulval cancer?

A 
Older post-menopasual 
High risk HPV
Lichen Sclerosis 
VIN
Smoking
Immunodeficiency
Personal or FHx of melanoma
260
Q

Presenting features of Vulval cancer?

A

Lump, Ulcer, Itchy patch, Ulceration,

Thicke or darker skin

261
Q

What colour is VIN?

A

White and not typically ulcerated

262
Q

If Vulval cancer is confined to vulva what is done?

A

Radical vulvectomy

263
Q

What gestation is the cut off for ToP?

264
Q

Drugs used in medical management of ToP?

A

Mifepristone and Misoprostol

265
Q

How do you surgically manage a ToP?

A

Vacuum aspiration if <14 weeks

Dilatation and evacuation if 14-24 weeks

266
Q

Key Complications of surgical management of ToP?

A

Infection
Cervical trauma
failed in 1%
Haemorrhage/Perforation/Retention of products rarely

267
Q

When should HCG return to normal after a ToP?

A

By 4 weeks

GOSH (5 decks)

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