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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
Define Polymenorrhoea
An abnormally short interval between regular menses | <21 days
26
Define Oligomenorrhoea | What is most likely to cause this?
An abnormally long interval between regular menses >35 days ?PCOS
27
What should post-menopausal bleeding be treated as until proven otherwise
Endometrial cancer (Number one cause is atrophic vaginitis)
28
Primary Amenorrhoea
Failure to start menstruating by 14 | or 16 yrs with no breast development
29
What is secondary amenorrhoea
Periods stop for 6 months without pregnancy
30
What investigations should be done for secondary amenorrhoea?
TSH, Gonadotrophins, Prolactin, Beta-HCG, Androgen levels
31
Causes of secondary amenorrhoea
44% Hypothalamic-Pituitary-Ovarian axis disorders- COMPETITIVE ATHLETES Hyperprolactinaemia Ovarian insufficiency because Chemo/RT? Ashermanns or Sheehans
32
Key causes of post-coital bleeding
Cervical ectropion | or... Cervicitis, Cancer, Polyps, Trauma
33
Key investigations if a women presents with abnormal bleeding
``` Rule out pregnancy related problems with PT Review Meds LFTs, Urinalysis, FBC + Haematinics Examination Clotting ?Uss ?biopsy?Scopy ```
34
What is Post-menstrual syndrome
Common and typically mild appearance of a myriad of cyclical symptoms that interfere with the day's normal events
35
How do you manage post-menstrual syndrome
1) Supportive measures +/- COCP +/- Fluoxetine 2) Estradiol patches or Mirena 3) GNRH antagonists or HRT 4) Total Hysterectomy and BSO
36
How does PCOS impact the levels of different hormones
LH Chronically elevated FSH suppressed Increased circulating testosterone
37
What part of the menstrual cycle is fixed at 14 days
Luteal phase
38
What is the Rotterdam criteria for PCOS?
2/3 needed 1) Polycystic ovaries on USS 2) Hyperandrogenism- Body hair, Acne 3) Oligo/Anovulation
39
Key features of PCOS starting with the most common
``` Menstrual irregularities Subfertility Hirsutism Obesity Acne, Acanthosis Nigricans ```
40
What does PCOS look like on USS
String of pearls appearance
41
Management of PCOS if wanting to promote fertility
Weight loss Ovulation induction- CLOMIFENE Metformin to improve insulin sensitivity and improve fertility ?Anti-androgen
42
PCOS management if not wanting to promote fertility
COCP- Dianette and Yasmin both good at ameliorating androgenic symptoms Regular 3/12 withdrawal bleeds Wx loss
43
Complications of PCOS
``` Endometrial cancer Insulin resistance/T2DM HTN/CVD/Dyslipidaemia/Strokes Weight Gain Ovarian hyperstimulation risk if IVF etc ```
44
Average age of the menopause
52 years (51-54)
45
What increases the risk of an early menopause
Smoking | Hysterectomy
46
How do you diagnose the menopause
Retrospective >50= 12 months later <50= 24 months later
47
What is the physiology of the menopause
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
48
What are the menstrual irregularities associated with the menopause
Mostly 4-5 years of varying cyle length | 10% cease abruptly
49
What are the early changes associated with the menopause
Vasomotor symptoms- Sweats, Tiredness, mood, Cognitive, Concentration Loss of collagen- Joints, skin Fat redistribution
50
What are the medium term changes associated with the menopause
Vaginal atrophy, dyspareunia, soreness Bladder frequencey, dysuria, UTis Bleeding
51
What are the long term changes associated with the menopause
Osteoporosis | CVD
52
What are the hypoestrogenic changes associated with the menopause?
Vasomotor instability 5-7years decreases with age Osteoporosis Genital atrophy Mood disturbance
53
What are the benefits of HRT
Improves vasomotor symptoms Improves urogenital/Sexual function Decreases OP related fractures Decreases CRC risk
54
What are the disadvantages of HRT
Endometrial hyperplasia and adenocarcinoma Breast cancer VTE risk
55
CI to HRT
Liver disease, Thromboembolic disorders, Oestrogen dependent cancer, Pregnancy/Breast feeding
56
Apart from HRT, How can the menopause be managed
``` 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 ```
57
Indication of oestrogen only HRT in the menopause
Absent uterus
58
Indication for continuous combined HRT in the menopause | Benefits?
>54 or >1 year amenorrhoea NO BLEEDING
59
What is sequential combined cyclical HRT
Daily oestrogen and then progesterone for last 10-14 days of the cycle There is a withdrawal bleed
60
What is sequential long cyclical HRT
Oes for 3 months Prog for the 2nd half of the 1st month has 3 monthly withdrawal bleeds
61
Which HRT is associated with the highest risk of breast cancer?
E+P> Tibolone>E only
62
What is premature ovarian failure
Menopausal symptoms (1 yr meses cessation) and inc Gondotrophin levels before 40 yrs
63
How is premature ovarian failure confirmed
FSH test where levels are v.High
64
Risk factors for premature ovarian failure
Chemo, RT | Although can be idiopathic
65
What 3 key factors must be considered when deciding the best HRT?
1) Uterus present? 2) Perimenopausal or menopausal? 3) Systemic or local effect required?
66
What HRT is best if someone is Perimenopausal and amenorrhoea <1 yr
Cyclical combined | Can track periods as there will be withdrawal bleeds
67
When is continuous combined HRT most appropriate
>1 yr since LMP or taken cyclical for >1 yr | There will likely be No bleeds
68
What type of HRT has a strictly local effect?
Creams and pessaries
69
Key side effects of HRT to tell patients
Nausea, erratic PV bleed, headaches, leg cramps, Dyspepsia, Bloating, Breast tenderness
70
What is the difference between endometriosis and adenomyosis?
Endometriosis is ectopic endometrial tissue outside the uterine cavity Adenomyosis is endometrium within the myometrium
71
How does adenomyosis look on an MRI
Enlarged and boggy
72
Where is the most common site of endometrial tissue
Ovary | then- Peritoneum, pouch of douglas
73
What age range is endometriosis likely to present? When does it regress?
Post menarche likely ~20s | Regression post-menopause (oestrogen dependent)
74
Key hallmark feature of endometriosis
CYCLICAL PAIN
75
Aside from cyclical pain, what other features does endometriosis present with?
``` Abnormal bleeding- PCB, IMB Deep dyspareunia Dyschezia Enlarged tender adnexa Sub-fertility ```
76
What position is the position of the uterus likely to be in endometriosis? Why?
FIXED RETROVERTED | The scar tissue reduces mobility
77
Gold standard diagnosis of endometriosis
Laparoscopy for direct visualisation
78
How can endometriosis cause free fluid in the abdomen?
Rupture of an endometrioma | + Intense pain
79
What is the goal of treatment for endometriosis?
Suppression of ovulation and induction of amenorrhoea
80
Medical management of endometriosis
1) NSAIDS 2) COCP Back to back or Mirena Coil 3) GnRH Antagonists (Chemical menopause)
81
When is surgical management for endometriosis good?
Young women desiring fertility
82
Surgical management of endometriosis
Laparoscopic excision or laser Definitive is Hysterectomy with BSO + HRT after
83
Presentation of PID
``` Bilateral lower abdominal pain, adnexal tenderness, perihepatitis Fever Purulent discharge Deep dyspareunia IMB, PCB, Menorrhagia ```
84
What core history points must you cover in ?PID
O+G Hx, Sexual Hx
85
Key Core investigations for ?PID
Pregnancy test to exclude ectopic Bimanual- Cervical motion tenderness, mass Speculum- VVS, HVS, EC Urine dip, Obs, MSU?
86
Core criteria for diagnosis of PID
One of: T>38, Leucocytosis, ESR>15 | One of: Adnexal pain, Cervical motion tenderness, Adnexal mass
87
Complications of PID
Ectopic, Infetility, Chronic dyspareunia/pain, Fitz Hugh Curtis, Abscess
88
In a PID what would a palpable adnexal mass suggest?
Abscess | Especially if systemically unwell
89
How do you manage PID?
Treat as if it is an STI Rest Analgesia Consider IUD removal
90
Advice on sexual intercourse for a PID patient
No sex until both you and your partner are treated
91
Top 2 causes of PID
1) chlamydia | 2) Gonorrhoea
92
What are the RF for PID
<25yrs, Multiple partners, vaginal douching, unprotected sex, IUD, ToP
93
In a patient with chronic pelvic pain and abnormal VE findings what must be done?
Diagnostic laparoscopy or uss
94
Presentation of a threatened miscarriage
Bleeding +/- Pain OS= Closed Uterine size= Correct for gestational age
95
What % of threatened miscarriages actually miscarry
25%
96
Presentation of inevitable miscarriage
Heavy clotted vaginal bleeding | OS= Open
97
Presentation of a complete miscarriage
Presents with bleeding that has no lessened OS= Closed Uterine size= Returned to Normal size
98
Presentation of an incomplete miscarriage
OS= Open | Uterine scan shows mixed debris
99
Presentation of a missed or delayed miscarriage
``` Entire gestational sac in uterus No growth No fetal heart beat OS= Closed Light discharge Uterus is small for GA ```
100
When is a miscarriage defined as recurrent
3+ times
101
When do most miscarriages present
<12 weeks | MOST FIRST 12-14 DAYS
102
Best way to investigate a miscarriage
TV USS
103
USS Dx criteria for miscarriage
No FHB + CRL> 7mm or Ges.Sac size>25mm
104
What is a miscarriage
Loss of pregnancy before 24 weeks
105
General presenting features of a miscarriage
Vaginal bleeding, Abdominal pain, Regression of pregnancy related symptoms
106
1st line management for miscarriage? When is a PT done?
Expectant 7-14 days PT 3/52 after
107
During expectant management why would you repeat the scan?
Pain and bleeding not started or are persisting/increasing
108
When is expectant management for miscarriage not appropriate?
``` Late 1st TM as increased haemorrhage risk Hx of miscarriage, stillbirth, APH Coagulopathies Transfusions CI ?Infection ```
109
What types of miscarriage is medical management good for?
Missed and Incomplete
110
Medical management of miscarriage
Vaginal misprostol (~800mcg) +/- Analgesia +/- Antiemetics
111
When do the majority of miscarriages complete after medical management?
Within 7 days May bleed for 3/52 after Do PT 3/52 after also
112
Two options for surgical management of miscarriage
Manual Vacuum Aspiration- Outpatient and Local | Evacuation of the Uterus- Inpatient and general
113
Key risks of Evacuation procedure for treating miscarriage
Infection damage, bleeding, adhesions, perforation, retention of products
114
When is Anti-D given in miscarriage management? When is it not?
Surgical + Rh-ve mum | NOT IF Medical management/Threatened/Complete/PuL
115
What are the risk factors for an ectopic pregnancy
PID, Damage to the fallopian tubes, Sterilisation, Intra-uterine device (if P+ve), Endometriosis, IVF, Hx Ectopic
116
Most common site of an ectopic? Which location ruptures earliest?
Ampulla | Isthmus
117
Which type of ectopic can only be managed medically?
Cornual
118
Signs of an ectopic pregnancy
Tenderness +/- Rebound Cervical motion tenderness Unilateral adnexal tenderness (N.B dont look for a mass)
119
Symptoms of an ectopic
Often asymptomatic Shoudler tip pain, Dark brown vaginal bleeding, Amenorrhoea, Pain on defacation/urination Collapse...
120
What investigation confidently excludes an ectopic
-ve PT
121
What can a TV USS show us in ?Ectopic
Confirms an intrauterine pregnancy Adnexal mass/Free fluid Location of ectopic? Is there a FHB?
122
How does bHCG change in normal pregnancy and pathological pregnancy?
<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
If there is diagnostic doubt over ?Ectopic what is indicated
Laparoscopy
124
How do ectopics and miscarriages present differently
Pain typically precedes bleeding in ectopics, other way round in miscarriage
125
What percentage of people with an ectopic have a subsequent IU pregnancy
~70%
126
Indications for expectant management of an ectopic pregnancy?
``` Unruptured Pain free, Stable, <35mm (Tubal) No FHB on TVS HCG<1000 IU/L (?If <1500) ```
127
When should you repeat bHCG levels when using expectant management for an ectopic
D2, D4, D7
128
What should happen to bHCG if you use expectant management
Should fall by >15%
129
Indications for medical management of an ectopic
No significant pain, <35mm, No FHB HCG<1500IU/L, (?<5000) No IU pregnancy
130
When should bHCG be repeated in medical management of an ectopic?
D4, D7 | Then weekly until <20
131
When is anti-D indicated in ectopic management?
Surgical management only | 250Iu (50mcg) if Rh-ve
132
How do you manage an ectopic medically? How effective is this?
IM Methotrexate Can take~4-6 weeks ~5% need surgery despite the above...
133
Safety netting advice when using expectant/medical management of an ectopic
Watch for: | Heavy bleeding, shoulder tip pain, Abdo pain, Dizziness, syncope, Do not travel, do not stay alone
134
When is surgery indicated for management of an ectopic
FHB present HCG>5000IU/L >35mm Significant pain
135
How is an ectopic managed surgically? When is a PT done after this?
Laparoscopy +/- Salpingectomy +/- Salpingotomy (20% need further treatment) PT 3/52 after
136
What is a molar pregnancy?
Gestational trophoblastic disease E.G. Hydatidiform mole, Choriocarcinoma, Placental site trophoblastic tumour Proliferating chorionic villi that have swollen and degenerated
137
What is the difference in formation between a partial and complete hydatidiform mole
``` Partial= Dispermy and normal egg Complete= Sperm and empty egg ```
138
How does molar pregnancy present and why?
Lots of HCG produced= Exaggerated pregnancy symptoms e.g hyperemesis gravidum Heavy bleeding Large uterus
139
What can the HCG produced by a molar pregnancy do to the thyroid gland?
Stimulates it inducing thyrotoxicosis | TSH decreased T3/4 increased
140
What does a molar pregnancy look like on an USS?
Snowstorm effect + No foetus if complete | Focal cystic spaces if partial
141
How is Molar pregnancy managed?
Electric Vacuum Aspiration +/- Hysterectomy Samples sent for histology for Dx Or... 6 cycles of methotrexate or till 6/12 after cleared
142
What must be done after treating a molar pregnancy?
Monitor bHCG until its undetectable | No decrease sugegsts invasive mole or choriocarcinoma
143
After a molar pregnancy when can you try again for a baby?
After bHCG has been normal for 6/12
144
When can a choriocarcinoma present?
Many years after a pregnancy
145
What are the different types of fibroids?
Submucosal Intramural Subserosal
146
What can induce an increase in fibroid size? What does this lead to?
Progestins, Clomifene, Pregnancy | Haemorrhage, Degeneration, Pain, vomiting, fever
147
When not asymptomatic, What are the core symptoms of fibroids?
Menorrhagia/Abnormal bleeding Pain with torsion or during menstruation Subfertility
148
How are fibroids diagnosed
TV USS
149
Which type of fibroid commonly give rise to pressure symptoms like bloating?
Subserosal
150
Risk factors for fibroids?
Black ethnicity, Oestrogen (Pre-menopausal women)
151
What are fibroids?
Bening uterine smooth muscle tumours
152
1st line medical management for fibroids? Why?
Mirena coil- Decreases bleeding | Progesterone based oral contraceptive can also be used
153
When are GnRH antagonists used in the treatment of fibroids? What is the side effect of this?
Short term induction of amenorrhoea In preparation for surgery Transient infertility 'Chemical Menopause'
154
Surgical option for fibroid treatment that improves fertility? Other surgical options?
Hysteroscopic myomectomy if up to 4cm Endometrial ablation, Laparoscopy/otomy Uterine embolisation is a non-invasive technique
155
Indications for surgical intervention in fibroids?
Bulky symptoms, Excessive bleeding, Rapid growth, Hydronephrosis, Contemplating pregnancy, recurrent miscarriage, Uterine distortion
156
When is a hysterectomy indicated for fibroids?
>45yrs | Completed their family
157
What is a follicular cyst? When do they regress
Functional/Physiological ovarian cyst Most common Regression after a few menstrual cycles
158
What is a corpus luteum cyst? When do they regress?
Physiological cyst caused by the CL not breakign down, instead it fills with blood and fluid Spontaneous resolution in 4-6 weeks
159
What is the most common beign ovarian epithelial tumour?
Serous cystadenomas
160
Name 2 benign ovarian epithelial tumours
Serous and mucinous cystadenomas
161
What is Pseudomyxoma peritonei
Cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelatinous ascites.
162
What is a dermoid cyst?
Mature cystic teratoma of the ovary lined with epithelial tissue and skin/teeth Median age 30yrs
163
What does torsion of an ovarian cyst look like on USS? | How will the patient present?
Whirlpool sign | Pain and vomiting
164
What does ovarian endometriosis present as?
'Chocolate cyst' | Tender immobile adnexa
165
What is Meig's syndrome?
Benign Ovarian tumour + Pleural effusion + ascites secondary to Removal of said tumour usually induces resolution
166
How do you diagnose an ovarian cyst?
USS
167
Malignancy red flags when investigating a ?ovarian cyst
``` Irregular borders Ascites Populations Separations within cyst POST-MENOPAUSAL ```
168
How do you manage a post-menopausal women presenting with a ?new onset ovarian cyst
Gynae referral because it is unlikely to be physiological
169
When is 4-6 week observation appropriate for the management of an ovarian cyst
<5cm, Simple, Mobile, Unilateral, No ascites
170
What is likely to happen to simple cysts during pregnancy
Regress after 2nd TM
171
When is laparoscopic cystectomy indicated for an ovarian cyst?
>10cm, Solid, Complex, Fixed, Bilateral, Ascites
172
How can an ovarian cyst cause frequency?
Presses on the bladder
173
When would you follow up an ovarian cyst with yearly USSs?
5-7cm | Still manage conservatively
174
What size ovarian cysts are unlikely to resolve spontaneously and are at increased risk of torsion?
>5cm
175
Most common cause of infertility
Male factor | Then ovulatory disorders
176
The three groups of ovulatory disorders causing female infertility
1- Hypothalamic pituitary failure 2- Hypothalamic pituitary ovarian dysfunction 3- Ovarian failure
177
What is Hypothalamic pituitary failure in relation to infertility?
Hypothalamic amenorrhoea | Hypogonadotrophic hypogonadism
178
What is Hypothalamic pituitary ovarian dysfunction in relation to infertility?
PCOS! | Sheehan's, Turners, Klinefelters, Hyperprolactinaemia
179
When is ovarian failure classified as premature?
<40yrs
180
What are the AMH and Oes/FSH levels for the below? 1- Hypothalamic pituitary failure 2- Hypothalamic pituitary ovarian dysfunction 3- Ovarian failure
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
What structural problems can cause female infertility
Bicornuate uterus, Tubal damage, Ashermanns, Fibroids, Endometriosis, STIs/PID
182
Causes of male infertility?
Testis/Spermatogenesis disorders Disorders of the genital tract Idiopathic Ejaculatory disorders
183
Examples of Testis/Spermatogenesis disorders causing male infertility
Azoospermia, Klinefelters XXY, Cryptorchidism, Tumours (Testicular or pituitary), Hyperprolactinaemia, Cushings
184
When do you investigate infertility?
After 1 year of UPSI
185
How can you investigate female infertility?
``` Mid-Luteal progesterone FSH, LH Rubella status Tubal patency Ovarian reserve testing ```
186
When would you do a hysterosalpingogram and not laparoscopy/Dye test to assess tubal patency in female infertility?
HSG= No Comorbidities E.G PID | Always screen for CT before uterine intervention
187
How do you investigate male factor infertility?
``` Semen analysis after 3-5 days abstinence Hormone analysis Genetic testing Testicular biopsy Viral screen ```
188
What is asthenospermia?
Immotile sperm
189
What is teratozoospermia?
Excessive abnormal sperm
190
How can you induce secondary ovarian failure?
BMI<19, V high exercise levels, Hypopituitarism, PCOS, Hyperprolactinaemia
191
Syndromes Causing primary ovarian failure
Turners, FXS, Kallmanns
192
RF for infertility
``` BMI <19 or >30 (Dont forget Anorexia Nervosa) Smoking >2 units alc/wk Illicit drugs Dyspareunia, Inadequete penetration AI CKD Poor DM control ```
193
General advice for management of subfertility
``` 0.4mg folic acid pre-conception-12 wks UPSI 2-3X/Wk Decrease Alcohol Stop Smoking Optimise BMI ```
194
CI to IVF
Partner not living together | Has another child
195
What male factor is incompatible with fertility?
Persistent abnormal sperm counts
196
How do you improve fertility in hypogonadotrophic hypogonadism?
Gonadotrophins
197
Treatment of G1 ovulatory disorder related infertility?
Increase Wx, Decrease exercise levels | Pulsatile administration of gonadotrophin-releasing hormone optimised with LH activity
198
Treatment of G2 ovulatory disorder related infertility?
Lose Wx if BMI>30 Treat PCOS per guidelines (Clomifene etc) ?Laparoscopic ovarian drilling
199
How do you treat hyperprolactinaemia related infertility?
Dopamine agonists like Bromocriptine
200
Indications for Intrauterine insemination?
Physical limitations Man is HIV +ve Donor sperm (Same-sex couple)
201
What must be done before IVF?
Ovarian stimulation
202
When is IUI not effective?
Structural problem in the uterus
203
How mant cycles of IVF are offered to an <40yr old?
3
204
What are the indications for trying 2 years of UPSI before Recommending IVF?
Unexplained Mild endometriosis Mild male factor
205
Risks of IVF
Multiple pregnancy Ovarian Hyperstimulation syndrome Increased placenta praevia risk Failure= Psych distress
206
Presentation of ovarian hyperstimulation syndrome?
Lower abdo pain, N&V, Distension | Ascites, Wx gain, Tachycardia, Hypotension, Oliguria, U&E abnormalities
207
When is intracytoplasmic sperm injection indicated?
Severe deficits in sperm quality, Azoospermia Failed IVF Generally only useful if there is a problem with the Male's sperm
208
After what age is there a low chance of success with IVF?
>35yrs
209
When can an earlier than 1 yr referral for fertility treatment be considered?
>36yrs, Known cause, Hx predisposition, No chance with expectant management
210
Apart from HPC what important points must you cover in a UroGynae Hx?
``` Hysterectomy? Gynae surgery? How many children and VD? Intercourse problems? Diuretics, Laxatives? Smear up to date? Caffeine, smoking, alcohol ```
211
Management of stress incontinence
1- Pelvic floor exercises + Lifestyle changes 2- Duloxetine 3- Surgical, Tension free vaginal tape
212
Key investigation if ?Stress incontinence; when is this done
Urodynamics | After 1st line management before duloxetine
213
Key investigation of urge incontinence
Bladder diary minimum 3 days | Fluid input, micturation/volume, Pads, incontinence
214
Recommended programme of pelvic floor exercises for Stress incontinence
8 squeezes, 3X day, 3 months
215
Management of urge incontinence
1- Lifestyle changes, Bladder training to increase time between voiding 2- +/- Antimuscarinic (Oxybutynin)
216
Antimuscarinic side effects
Dry mouth, Blurring, Dry eyes, Drowsy, Constipation, Skin reaction, Headahces, Diarrhoea
217
When is urodynamics done in the management of urge incontinence?
After 2nd anticholinergic has been tried
218
When do urodynamics indicate stress UI?
Incontinence + Strain - Detrusor activity
219
When is urodynamics appropriate prior to surgery?
? Detrusor OA ?Hx surgery for SUI ? Incomplete emptying
220
When is urodynamics not appropriate?
Prior to conservative therapy in ?Stress incontinence
221
Prolapse risk factors
Post-menopausal, Obesity, COCOP, Constipation, Multiparity
222
When is a Sim's Speculum most useful?
Assess vaginal wall in ?Prolapse
223
What are the 3 grades of a utero-vaginal prolapse?
1- Half way down to introitus 2-As far as introitus 3- Beyond introitus
224
Management of Utero-vaginal prolapse?
1- Conservative- Wx reduction, Pelvic floor exercises, Avoid heavy lifting.. IF ASYMPTOMATIC CAN JUST LEAVE 2- Pessary- change 4-6/6 3- Surgical
225
What is an ectropion?
Endocervical epithelium extends over paler ectocervical epithelium
226
What would an ectropion present as?
Isolated PCB +/- Increased discharge
227
Risk factors for ectropion?
ELEVATED OESTROGEN: Ovulation, Pregnancy, COCP
228
At what ages is cervical smearing done?
Smear tests every 3 years if 25-49 Then every 5 years from 50-64
229
Different grades of Cervical Intraepithelial Neoplasia
CIN1/Mild dyskaryosis- Lower 1/3rd affected CIN2/Moderate dyskaryosis- <2/3rds CIN3/Severe- >2/3rds
230
Which types of HPV are most associated with cervical cancer?
16,18,31,33
231
When should cervical screening be done if CIN1/2 is found?
Annually until 2 normal results then move back to 3 yearly
232
If CIN1 is found on a smear what should be done?
1- Test for HPV 16, 18. 33 | 2- +ve= Colposcopy -ve= Routine recall
233
What should be done if CIN2/3 is found?
Urgent Colposcopy
234
To whom is the HPV vaccine given? What types of HPV does the Gardasil quadrivalent vaccine work against?
All 12-13 male and females | HPV- 6,11,16,18
235
Treatment options for CIN? When is a core cytology test needed after this?
Large Loop excision of transformation zone LLETZ Colposcopy to excise and destruct Cold coag, Cryotherapy, Lashes vaporisation 6 months
236
Risk factors for Cervical cancer?
<35 YEARS | Smoking, unprotected sex, Previous STI/HPV, HIV, Immunosuppression
237
Key presenting symptoms of cervical cancer?
Abnormal bleeding + <35yrs -PCB, IMB, Menorrhagia, Blood stained discharge Could still be PMB
238
What are the 4 FIGO stages of cervical cancer?
1- Confined to cervix 2- Local spread (Upper vagine, parametrium) 3- Extends to pelvic wall + Lower 1/3rd vagina 4- Distant spread
239
What is a trachelectomy?
Possible treatment for cervical cancer Removal of the cervix and pelvic lymph nodes Preserves the body of the uterus for FERTILITY
240
Risk factors for endometrial cancer
>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
Protective factors against endometrial cancer?
Smoking, Pregnancy, Diet, Exercise, IUS, Early menopause, COCP
242
Number 1 type of endometrial cancer?
ADENOCARCINOMA
243
How would you investigate a >55yr woman presenting with PMB?
FAST TRACK | Needs urgent Speculum and pelvic exam +/- USS+/-hysteroscopy +/- Biopsy
244
What degree of endometrial thickening on USS suggests ?Endometrial cancer
>4mm
245
How is PMB defined?
Unexplained Vaginal Bleeding 12+ months after Menstruation has stopped
246
FIGO staging of endometrial cancer?
1- Confined to uterus 2- Local spread to cervix 3- Spread to pelvis/Adnexa/Vagina/Nodes 4- Distant spread
247
At what stage do the majority of endometrial cancers present at? Why is this?
1 (Confined to uterus) | The myometrium is a barrier to spread therefore early presentation correlates with a high cure rate
248
Main surgical procedure to treat endometrial cancer?
TAH +/- BSO +/- RT
249
Risk factors for Ovarian cancer?
ANYTHING THAT INCREASES THE NUMBER OF OVULATIONS | Nulliparity, Early menarche, Late menopause, FHx, HNPCC, BRCA (1>2), Endometriosis, Smoking, HRT
250
What is protective against Ovarian cancer
COCP | Pregnancy
251
How does ovarian cancer present?
Asymptomatic as pelvis easily accommodates a large tumour | Abdominal Pain/Bloating +/- Ascites +/- Swelling/Distension +/- Wx loss +/- Urgency
252
indications for CA125?
Regular: Bloating, Appetite loss, Pain in abd/pelvis, Urgency/Frequency ESPECIALLY IF >50yrs IBS like symptoms
253
If CA125 is raised what must you do?
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
What is a normal CA125 level?
<35
255
FIGO staging of ovarian cancer
1- Confined to ovary 2- Pelvic spread 3- Peritoneal mets or para-aortic lympthadenopathy 4- Distant mets
256
Prognosis of ovarian cancer?
Poor- Presents late | 25% 5 yr survival
257
What is the RMI criteria?
Pre-surgical prognostic criteria for ovarian cancer | ->CA125/Menopauasal status/USS score
258
General treatment principles of ovarian cancer?
TAH +/- BSO +/- Omentectomy | +/- Platinum based chemotherapy like Cisplatin/Taxane
259
Risk factors for Vulval cancer?
``` Older post-menopasual High risk HPV Lichen Sclerosis VIN Smoking Immunodeficiency Personal or FHx of melanoma ```
260
Presenting features of Vulval cancer?
Lump, Ulcer, Itchy patch, Ulceration, | Thicke or darker skin
261
What colour is VIN?
White and not typically ulcerated
262
If Vulval cancer is confined to vulva what is done?
Radical vulvectomy
263
What gestation is the cut off for ToP?
24 weeks
264
Drugs used in medical management of ToP?
Mifepristone and Misoprostol
265
How do you surgically manage a ToP?
Vacuum aspiration if <14 weeks | Dilatation and evacuation if 14-24 weeks
266
Key Complications of surgical management of ToP?
Infection Cervical trauma failed in 1% Haemorrhage/Perforation/Retention of products rarely
267
When should HCG return to normal after a ToP?
By 4 weeks

GOSH (5 decks)

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