Gynaecology Flashcards
1
Q
Urinary incontinence: Treatment
A
Stress: pelvic floor muscle training, 8 contractions performed 3 times per day for a minimum of 3 months, surgical
Urge: bladder retraining (lasts for a minimum of 6 weeks, antimuscarinics are first-line. oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Avoid immediate release oxybutynin in ‘frail older women’
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
2
Q
Urinary incontinence: Classification
A
Overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
Stress incontinence: leaking small amounts when coughing or laughing
Mixed incontinence: both urge and stress
Overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
3
Q
Urinary incontinence: Risk factors
A
advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
4
Q
Premenstrual syndrome: Treatment
A
NSAIDs, COC, CBT, SSRIs
5
Q
Cervical cancer screening: Age
A
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self refer once past screening age)
6
Q
Cervical cancer screening: Special situations
A
cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears.
women who have never been sexually active have very low risk of developing cervical cancer, therefore, they may wish to opt-out of screening
7
Q
Cervical cancer screening: Aim
A
to detect pre-malignant changes rather than to detect cancer
8
Q
Cervical cancer screening: Weakness
A
cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening
9
Q
Cervical cancer screening: Methods
A
Usually done at mid-cycle
Liquid-based cytology advantages:
reduced rate of inadequate smears
increased sensitivity and specificity
10
Q
Endometrial hyperplasia: Risk factors
A
Taking oestrogen unopposed by progesterone Obesity Late menopause Early menarche Aged over 35-years-old Being a current smoker Nulliparity Tamoxifen
Tamoxifen is a risk factor due to its pro-oestrogen effect on the uterus and bones. It does also have an anti-oestrogen effect on the breast.
11
Q
Endometrial hyperplasia: Types
A
simple
complex
simple atypical
complex atypical
12
Q
Endometrial hyperplasia: S/S
A
abnormal vaginal bleeding e.g. intermenstrual
13
Q
Endometrial hyperplasia: Treatment
A
- simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
- atypia: hysterectomy is usually advised
14
Q
Hyperemesis gravidarum: Association
A
multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity
Smoking is associated with a decreased incidence of hyperemesis.
15
Q
Hyperemesis gravidarum: Traid
A
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
16
Q
Hyperemesis gravidarum: Treatment
A
- 1st line - antihistamines (promethazine, cyclizine)
- ondansetron and metoclopramide
- metoclopramide may cause extrapyramidal side effects
- ginger and P6 (wrist) acupressure
- admission may be needed for IV hydration
17
Q
Hyperemesis gravidarum: Complications
A
Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis fetal: small for gestational age, pre-term birth
18
Q
Cervical smear (Mild dyskaryosis): Management
A
Test for HPV
if HPV negative the patient goes back to routine recall
if HPV positive the patient is referred for colposcopy
19
Q
Cervical smear (Moderate CIN IIor severe CIN IIIdyskaryosis): Management
A
urgent colposcopy within 2 weeks
Repeat 6 months after treatment for ‘test of cure’ repeat cytology in the community.
20
Q
Cervical smear: High-risk subtypes of HPV
A
16, 18, 33
21
Q
Cervical smear: Opting out
A
who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt out of screening
22
Q
Most common type of ovarian pathology associated with Meigs’ syndrome
A
Fibroma
23
Q
Most common benign ovarian tumour in women under the age of 25 years
A
Dermoid cyst (teratoma)
24
Q
Most common cause of ovarian enlargement in women of a reproductive age
A
Follicular cyst
25
Corpus luteum cyst: What is
during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
26
Female genital mutilation: Types
Female Genital Mutation in under 18s - mandatory reporting duty to POLICE applies
Four types
27
Ovarian cyst: Types
Simple: unilocular, more likely to be physiological or benign
Complex: multilocular, more likely to be malignant
28
Ovarian cyst (Premenopausal): Management
-a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as 'simple' then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists
29
Ovarian cyst (Postmenopausal): Management
- by definition physiological cysts are unlikely
- any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
30
Cervical smear: "Inadequate"
Repeat in 3 months
| 3 consecutive "inadequate" needs colposcopy
31
Body temperature and ovulation
Body temperature rises following ovulation
32
Menstrual cycle phase
Menstruation 1-4
Follicular phase (proliferative phase) 5-13
Ovulation 14
Luteal phase (secretory phase) 15-28
33
Earlier referral for infertility in women:
Age 36 years and older (refer after 6 months).
Amenorrhoea or oligomenorrhoea.
Previous abdominal or pelvic surgery.
Previous pelvic inflammatory disease.
Previous sexually transmitted infection (STI).
Abnormal pelvic examination.
Known reason for infertility (for example prior treatment for cancer)
34
Earlier referral for infertility in men:
```
Previous genital pathology.
Previous urogenital surgery.
Previous STI.
Varicocele.
Significant systemic illness.
Abnormal genital examination.
Known reason for infertility (for example prior treatment for cancer).
```
35
Interpretation of day 21 serum progestogen
< 16 nmol/l Repeat, if consistently low, refer to specialist
16 - 30 nmol/l Repeat
> 30 nmol/l Indicates ovulation
36
Infertility: Basic investigations
semen analysis
| serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21
37
Investigation for vaginal thrust not responding to initial treatment
High vaginal swab (lateral fornix)
38
Ovarian cancer: S/S
```
Clinical features are notoriously vague
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea
```
39
Ovarian cancer: Investigations
CA125
| US
40
Ovarian cancer: Risk factors
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
*(basically unsupressed ovulation has increased risk)
41
Ovarian torsion: Risk factors
ovarian mass: present in around 90% of cases of torsion
being of a reproductive age
pregnancy
ovarian hyperstimulation syndrome
42
Ovarian torsion: S/S
Usually the sudden onset of deep-seated colicky abdominal pain.
Associated with vomiting and distress
fever may be seen in a minority (possibly secondary to adnexal necrosis)
Vaginal examination may reveal adnexial tenderness
43
Urinary incontinence: Initial investigations
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises)
urine dipstick and culture
urodynamic studies
44
Secondary amenorrhoea: Definition
Secondary amenorrhoea is defined as when menstruation has previously occurred but has now stopped for at least 6 months
45
Secondary amenorrhoea: Causes
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis (hypothyroidism may also cause amenorrhea)
Sheehan's syndrome
Asherman's syndrome (intrauterine adhesions)
46
Primary amenorrhoea: Causes
Turner's syndrome
testicular feminisation
congenital adrenal hyperplasia
congenital malformations of the genital tract
47
Amenorrhoea: Initial investigations
exclude pregnancy with urinary or serum bHCG
gonadotrophins: low levels indicate a hypothalamic cause whereas raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
prolactin
androgen levels: raised levels may be seen in PCOS
oestradiol
thyroid function tests
48
Sheehan's syndrome
Sheehan's syndrome is postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive haemorrhage during or after delivery.
49
Asherman's syndrome
Cervical stenosis and intrauterine adhesions
50
Pruritus vulvae: Underlying causes
irritant contact dermatitis (e.g. latex condoms, lubricants): most common cause
atopic dermatitis
seborrhoeic dermatitis
lichen planus
lichen sclerosus
psoriasis: seen in around a third of patients with psoriasis
51
Pruritus vulvae: Management
women who suffer from this should be advised to take showers rather than taking baths
they should also be advised to clean the vulval area with an emollient such as Epaderm or Diprobase
clean only once a day as repeated cleaning can aggravate the symptoms
most of the underlying conditions will respond to topical steroids
combined steroid-antifungal may be tried if seborrhoeic dermatitis is suspected
52
Which method of contraception may be made less effective with intravaginal and topical clotrimazole?
Barrier method
53
HRT: Potential complications
- Increased risk of breast cancer: increased by the addition of a progestogen
- Increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely. The BNF states that the additional risk is eliminated if a progestogen is given continuously
- Increased risk of venous thromboembolism: increased by the addition of a progestogen
- Increased risk of stroke
- Increased risk of ischaemic heart disease if taken more than 10 years after menopause
54
Infertility: Causes
```
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%
```
55
HRT: Contraindications
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
56
HRT: Management
Lifestyle modifications
Hormone replacement therapy (HRT)
Non-hormone replacement therapy
57
HRT: Non-hormone replacement therapy
Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants
Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required
58
HRT: Treament duration
Usually 2-5 years
59
Recurrent vaginal candidiasis: Definition
BASHH define recurrent vaginal candidiasis as four or more episodes per year
60
Vaginal candidiasis: Management
options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
61
Vaginal candidiasis: S/S
'cottage cheese', non-offensive discharge
vulvitis: dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
62
Recurrent vaginal candidiasis: Management
-compliance with previous treatment should be checked
-confirm initial diagnosis i.e. high vaginal swab, exclude differential diagnoses such as lichen sclerosus
exclude predisposing factors (see above)
-consider the use of an induction-maintenance regime, with daily treatment for a week followed by maintenance treatment weekly for 6 months
63
PCOS Hirsutism and acne: Management
Hirsutism and acne
a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
if doesn't respond to COC then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision
64
PCOS Infertility: Management
weight reduction if appropriate
the management of infertility in patients with PCOS should be supervised by a specialist. There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
a 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS
metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins
65
PCOS: General management
weight reduction if appropriate
if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below)
66
Which HRT treatment causes dry mouth and dizziness
Clonidine
67
HRT: Which HRT treatment is unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
Tibolone
68
Dysmenorrhoea pain onset (Primary and secondary)
Primary: pain typically starts just before or within a few hours of the period starting
Secondary: pain usually starts 3-4 days before the onset of the period
69
Post menopausal woman with simple ovarian cyst; refer or not?
Any ovarian mass in a post-menopausal woman needs to be investigated.
70
Cervical cancer: Risk factors
Human papillomavirus (HPV), particularly serotypes 16,18 & 33
smoking
human immunodeficiency virus
early first intercourse, many sexual partners
high parity
lower socioeconomic status
combined oral contraceptive pil
71
What should you consider when a women >50 years of age presents with IBS symptom?
Check CA 125 to exclude ovarian cancer
72
Endometrial cancer: Risk factors
```
obesity
nulliparity
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
diabetes mellitus
tamoxifen
polycystic ovarian syndrome
hereditary non-polyposis colorectal carcinoma
```
73
Menorrhagia: Definition
total blood loss > 80 ml per menses
74
Menorrhagia: Investigations
a full blood count should be performed in all women
NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings
75
Menorrhagia, contraception not required: management
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
76
Menorrhagia, contraception required: management
```
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens
```
77
Normal semen analysis result
```
volume > 1.5 ml
pH > 7.2
sperm concentration > 15 million / ml
morphology > 4% normal forms
motility > 32% progressive motility
vitality > 58% live spermatozoa
```
78
Ovarian cyst: Sometimes referred to as chocolate cysts due to the external appearance
Endometriotic cyst
79
The most common ovarian cancer
Serous carcinoma
80
The commonest type of ovarian cyst
Follicular cysts
