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Gynaecology Flashcards

1
Q

What is used in the medical management of miscarriage?

A

Vaginal misoprostol
Bleeding should start within 24 hours
NOTE: also give antiemetics and analgesia for the symptoms

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2
Q

What is the surgical management option for miscarriage?

A

Manual vacuum aspiration

NOTE: surgical management of miscarriage requires anti-D in RhD-negative patients

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3
Q

Which tests should be requested in a patient with recurrent miscarriage?

A

Antiphospholipid antibodies (anticardiolipin and lupus anticoagulant)
Cytogenetics (products of conceptions or both partners)
Ultrasound scan for structural anomalies
Screen for thrombophilia (e.g. factor V Leiden)

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4
Q

How is antiphospholipid syndrome in pregnancy treated to reduce risk of miscarriage?

A

Low-dose aspirin + LMWH

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5
Q

What conditions need to be fulfilled for expectant management of ectopic pregnancy?

A 
Size < 30 mm
Asymptomatic 
No foetal heartbeat 
Serum hCG < 200 IU/L and declining 
Expectant management involves taking serial serum hCG measurements until the levels are undetectable
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6
Q

What is the medical management of ectopic pregnancy and what conditions need to be fulfilled for this option?

A

IM Methotrexate
• No significant pain
• Unruptured ectopic pregnancy with adnexal mass < 35 mm with no visible heartbeat
• Serum -hCG < 1500 iU/L
• No intrauterine pregnancy (confirmed by USS)

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7
Q

How should a patient be followed-up after medical management of ectopic pregnancy?

A

2 serum hCG measurements on days 4 and 7
1 serum hCG measurement every week until negative
Don’t have sex during treatment
Don’t conceive for 3 months after treatment
Avoid alcohol and prolonged sun exposure

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8
Q

What conditions need to be fulfilled to consider surgical management of ectopic pregnancy?

A
  • Significant pain
  • Adnexal mass > 35 mm
  • Ectopic pregnancy with a foetal heartbeat visible on ultrasound scan
  • Serum b-HCG > 5000 iU/L
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9
Q

Describe the follow-up after salpingectomy and salpingotomy.

A

Salpingectomy - urine pregnancy test at 3 weeks

Salpingotomy - 1 serum hCG per week until negative

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10
Q

Is anti-D required after ectopic pregnancy or miscarriage?

A

Only if they were managed surgically

NOTE: also required for all cases of molar pregnancy

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11
Q

What is the first line management option for molar pregnancy?

A

Suction curettage

NOTE: methotrexate may be used as chemotherapy

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12
Q

What advice should be given to women who have had a molar pregnancy?

A

If receiving chemotherapy, do not get pregnant for 1 year
Do not conceive until follow-up is complete
COCP and IUD can be used once hCG has normalised

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13
Q

Which investigations should be used in secondary amenorrhoea?

A

o Urinary or serum hCG (exclude pregnancy)
o Gonadotrophins (low indicates hypothalamic cause, high indicates ovarian cause)
o Prolactin
o Androgen (high in PCOS)
o Oestradiol
o TFTs

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14
Q

What are the Rotterdam criteria for PCOS?

A

Oligo/anovulation
Clinical or biochemical hyperandrogenism
Polycystic ovaries on ultrasound

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15
Q

How should PMS be investigated?

A

Symptom diary for 2 cycles

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16
Q

What are some medical management options for PMS?

A

COCP
Transdermal oestrogen
GnRH analogues (if severe)
SSRI (if severe)

Conservative: stress reduction, alcohol and caffeine reduction, exercise

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17
Q

Which investigation should be performed in all women with heavy menstrual bleeding?

A

FBC

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18
Q

What are the management options for menorrhagia of no known cause or menorrhagia caused by < 3 cm fibroids or adenomyosis?

A 
	1st line: LNG-IUS 
	2nd line non-hormonal:
•	Tranexamic acid 
•	NSAIDs (e.g. mefenamic acid) 
	2nd line hormonal:
•	COCP
•	Cyclical oral progestogens 
	Surgical:
•	Endometrial ablation 
•	Hysterectomy
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19
Q

What are some medical management options for menorrhagia caused by fibroids > 3 cm?

A

Non-Hormonal: tranexamic acid, NSAIDs
Hormonal: Ulipristal acetate, LNG-IUS, COCP and cyclical oral progestogens

NOTE: ulipristal acetate carries a risk of liver injury

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20
Q

What are some surgical management options for fibroids > 3 cm?

A

Transcervical resection of fibroid (for submucosal)
Myomectomy
Uterine artery embolisation
Hysterectomy

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21
Q

What are the 1st and 2nd line management options for dysmenorrhoea?

A

1st line: NSAIDs

2nd line: COCP

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22
Q

What are the three forms of emergency contraception and what is the window for taking them after UPSI?

A

Levonorgestral (Levonelle) - 72 hours
Ulipristal Acetate (EllaOne) - 120 hours
Copper IUD - 120 hours

NOTE: levonorgestrel and ulipristal should NOT be taken together, but both can be used more than once in a single cycle

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23
Q

How long after taking emergency contraception must it be repeated if the patient vomits?

A

2 hours

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24
Q

What are the main side-effects and risks of the COCP?

A

Side-Effects: headache, nausea, breast tenderness

Risks: VTE, breast and cervical cancer, stroke, ischaemic heart disease

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25
Q

How do periods tend to change with the COCP?

A

Usually makes periods regular, lighter and less painful

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26
Q

How long before an elective operation should the COCP be stopped?

A

4 weeks

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27
Q

How should a patient on the COCP who has missed 1 pill be counselled?

A

Take last pill

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28
Q

How should a patient on the COCP who has missed 2 pills be managed?

A
  • Use condoms until pill has been taken correctly for 7 days in a row
  • 2 Missed in Week 1: consider emergency contraception
  • 2 Missed in Week 2: no need for emergency contraception
  • 2 Missed in Week 3: finish pills in current pack and start the new pack immediately with no pill-free break
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29
Q

Aside from emergency contraception, what else should be offered to women coming in asking for emergency contraception?

A

STI screen
Long-acting contraception

NOTE: this should be discussed with all TOP patients as well

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30
Q

Describe how progesterone-only pills should be taken.

A

1 pill at the same time every day with no pill-free week

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31
Q

Which POP has longer leeway with regards to taking the next dose?

A

Cerazette (desorgestrel) - 12 hours

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32
Q

How should you advice a patient who is >12 hours late to take her cerazette?

A

Take the missed pill ASAP and continue with the rest of the pack
Use extra precautions (condoms) until pill taking has been re-established for 48 hours

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33
Q

What is the main side-effect associated with POPs?

A

Irregular menstrual bleeding

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34
Q

Describe how the combined hormonal transdermal patch should be used?

A

Apply patch for 3 weeks (replacing at the end of every week)
Take 1 week off (withdrawal bleed)

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35
Q

What benefit does the transdermal patch have over the COCP?

A

No increased risk of clots

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36
Q

Describe how the combined hormonal ring is used.

A

Worn vaginally for 21 days followed by a 7-day hormone-free period

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37
Q

How long does the mirena last?

A

3 or 5 years

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38
Q

How do periods tend to change with mirena?

A

They become lighter and less painful

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39
Q

List some side-effects of mirena.

A

Acne
Breast tenderness
Mood disturbance
Headache

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40
Q

What is Jaydess?

A

Smaller form of LNG-IUS that is effective for contraception but not for treating heavy periods
Lasts 2 years
Easier to put in

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41
Q

How long does nexplanon last?

A

3 years

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42
Q

How long does depo-provera last?

A

12 weeks

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43
Q

What are some important side-effects of depo-provera?

A 
Weight gain (only form of contraception with proven link)
May take up to 6-12 months for fertility to return
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44
Q

How long does the copper coil last?

A

5 or 10 years

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45
Q

What are some side-effects of the copper coil?

A

Heavy, painful periods
Expulsion
Infection

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46
Q

How long do all LARCs take to be effective?

A

1 week

Except copper coil

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47
Q

How is female sterilisation performed at laparoscopy?

A

Occlude Fallopian tubes with Filshie clips

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48
Q

What advice should be given to women who have had a laparoscopic sterilisation?

A

Additional contraception should be used until the first period after the procedure

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49
Q

What is hysteroscopic sterilisation?

A

Insert expanding springs into the tubal ostia via a hysteroscope
This induces fibrosis over 3 months
Additional contraception should be used during this time

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50
Q

Which drugs are used in the medical termination of pregnancy?

A

Mifepristone
Misoprostol (after 48 hours)

NOTE: pain relief should also be provided

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51
Q

Where should medical TOP take place?

A

< 9 weeks = can be done at home if easy access to follow-up, perform urine pregnancy test after 3 weeks
> 9 weeks = done in clinical setting (higher risk of bleeding/discomfort), repeated misoprostol may be needed every 3 hours

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52
Q

What extra treatment may be required in TOP over 21 weeks?

A

Intracardiac KCl injection (feticide)

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53
Q

What are the surgical management options for TOP?

A 
Vacuum aspiration (< 15 weeks)
Dilatation and Evacuation (D&amp;E) > 15 weeks
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54
Q

What additional management should you discuss with all TOP patients?

A

Long-acting reversible contraception (copper IUD, mirena, nexplanon)

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55
Q

How many doctors need to sign a form to agree to TOP?

A

2

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56
Q

Which investigations should you request for subfertility?

A 
Blood hormone profile (FSH, LH, oestrogen, AMH, mid-luteal progesterone)
TFTs
Prolactin
Testosterone
STI screen
TVUSS (antral follicle count)
Semen analysis (2 tests 3 months apart)
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57
Q

Which tests are used to assess ovarian reserve?

A

Anti-Mullerian hormone (AMH)

Antral follicle count (AFC)

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58
Q

How can tubal patency be assessed?

A

Hysterosalpingography (HSG) either by X-ray or ultrasound (HyCoSy)
Laparoscopy and dye (lap and dye)

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59
Q

List some medical management options for subfertility.

A

Ovarian induction (clomiphene)
Intrauterine insemination
Donor insemination
IVF

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60
Q

List some surgical management options for subfertility.

A

Treat anatomical disease (e.g. adhesions, endometriosis, cyst)
Myomectomy (if fibroids)
Tubal surgery
Laparoscopic ovarian drilling (PCOS)

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61
Q

What is cyclical HRT?

A

Either 1 monthly or 3 monthly
Take oestrogen every day
Take progesterone for last 14 days of time period (during which withdrawal bleed will happen)

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62
Q

What is continuous HRT?

A

Take oestrogen and progesterone every day

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63
Q

Which patient groups are cyclical and continuous HRT recommended for?

A

Cyclical - perimenopausal

Continuous - postmenopausal

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64
Q

What are the possible routes of administration of HRT?

A

Oral
Transdermal
Vaginal (if predominantly vaginal symptoms)

NOTE: transdermal HRT will avoid hepatic metabolism so isn’t associated with VTE/cardiovascular risks

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65
Q

What are the main benefits of HRT?

A

Improved vasomotor symptoms
Reduced risk of osteoporosis
Improved genital tract symptoms

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66
Q

What are the main side-effects and risks of HRT?

A

Side-Effects: breast tenderness, headaches, mood swings, fluid retention
Risks: breast cancer, cardiovascular disease, VTE

NOTE: cardiovascular risk is decreased in younger women and increased in older women

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67
Q

List some absolute contraindications for HRT.

A 
Pregnancy
Breast cancer 
Endometrial cancer 
Uncontrolled HTN 
Current VTE 
Thrombophilia
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68
Q

List some non-hormonal treatments for menopause.

A

Alpha agonists (clonidine)
Beta-blockers (propanolol)
SSRIs (fluoxetine)
Symptomatic: lubricants, osteoporosis treatments

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69
Q

What investigation is used to diagnose premature ovarian insufficiency?

A

2 x FSH results > 30 IU/L

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70
Q

How should the osteoporosis be managed in patients with premature ovarian insufficiency?

A

Regular DEXA scans every few years

All patients should be recommended HRT

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71
Q

Which lifestyle measures could help lessen the symptoms of menopause?

A

Regular exercise
Weight loss
Reduce stress
Sleep hygiene

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72
Q

How is bacterial vaginosis treated?

A

Metronidazole

Alternative: clindamycin

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73
Q

How is vulvovaginal candidiasis treated?

A

Intravaginal/pessary clotrimazole (canestan duo)
Alternative: oral antifungal (fluconazole)
Pregnancy: topical treatments ONLY

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74
Q

How is trichomonas vaginalis treated?

A

Metronidazole

IMPORTANT: male contacts will also need treatment as this is an STI

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75
Q

How is chlamydia managed?

A

Doxycycline or azithromycin

Contact tracing and treatment

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76
Q

How is gonorrhoea managed?

A

IM ceftriaxone 1 g

With single dose oral azithromycin and doxycycline

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77
Q

Which tests should be done in a patient with PID?

A

Test for chlamydia and gonorrhoea (swabs)

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78
Q

Which antibiotic regimen is recommended for PID?

A

Ceftriaxone 500 mg IM
Doxycycline 100 mg BD for 14 days
Metronidazole 400 mg BD for 14 days

Alternative: ofloxacin + metronidazole

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79
Q

How should sexual contacts of someone with PID be treated?

A

Single dose azithromycin 1 g

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80
Q

List some investigations that may be used in syphilis.

A

Dark field microscopy or PCR
Non-treponemal: rapid plasma reagin (RPR) or VDRL
Treponemal: EIA, treponema pallidum particle or haemagglutination assay (TPPA/TPHA)

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81
Q

How is syphilis treated?

A

Penicillin (depot)

82
Q

What are some indication for elective C-section in women with HIV in pregnancy?

A

Detectable HIV viral load
HCV coinfection
PROM

83
Q

How should urinary incontinence be investigated?

A

Bladder diaries for at least 3 days
Vaginal examination (check for pelvic organ prolapse and control of pelvic floor muscles)
Urine dipstick and culture

84
Q

List the steps in the management of urge incontinence.

A

1 - bladder retraining for 6 weeks
2 - bladder stabilising drugs (e.g. oxybutynin, tolteridone)
3 - mirabegron
4 - surgical (botox injection, percutaneous tibial nerve stimulation, sacral nerve stimulation)

85
Q

List the steps in the management of stress incontinence.

A

1 - pelvic floor muscle training for 3 months
Medical - duloxetine
Surgical - retropubic midurethral tape, bulking, autologous fascial slings, Burch colposuspension, periurethral injection

86
Q

List some conservative approaches to managing vaginal prolapse.

A

Lifestyle - healthy weight, stop smoking, avoid heavy lifting
Pelvic floor exercises
Oestrogens (pill, patch, cream)
Vaginal ring pessary (replaced every 6 months)

87
Q

Which investigation would help confirm a diagnosis of ovarian torsion?

A

Pelvic USS (may show free fluid, whirlpool sign, oedematous ovary)

88
Q

How should a functional ovarian cyst be managed?

A

Asymptomatic - reassure and perform repeat USS in 3-4 months to check for resolution
Symptomatic - laparoscopic cystectomy

89
Q

What long-term side-effect is associated with GnRH analogue use?

A

Osteoporosis

90
Q

What is the gold-standard investigation for endometriosis?

A

Diagnostic laparoscopy

Look out for ‘powder burn spots’ on the pelvic peritoneum

91
Q

Outline the management options for endometriosis.

A

1st line symptomatic relief: NSAIDs and/or paracetamol
COCP and progestogens (e.g. LNG-IUS)
GnRH analogues
Surgery (laparoscopic excision or ablation) - may improve fertility

92
Q

Which investigations would be considered in a patient with chronic pelvic pain?

A

Genital tract swab
Pelvic USS
MRI
Laparoscopy (gold standard)

93
Q

How should a woman with cyclical pelvic pain and no abnormalities on USS or pelvic examination be treated?

A

Therapeutic trial of hormonal treatment to suppress ovarian function for 3-6 months (COCP, LNG-IUS, progestogens, GnRH analogues)

94
Q

Which investigations should be performed in a patient with post-coital bleeding/intermenstrual bleeding?

A

Speculum
Smear
Swabs for STIs

95
Q

How might cervical ectropion be treated?

A 
Change from oestrogen-based contraceptives 
Cervical ablation (cryocautery)
96
Q

Which investigations are useful for suspected endometrial polyps?

A

TVUSS

Hysteroscopy (and saline infusion sonography)

97
Q

How are endometrial polyp managed?

A

Some small polyps resolve spontaneously

Polypectomy may be recommended to relieve AUB symptoms and optimise fertility

98
Q

How is Asherman’s syndrome managed?

A

Surgical breakdown of intrauterine adhesions

99
Q

List some examples of GnRH analogues.

A

Triptorelin, goserelin, buserelin

100
Q

What are the main treatment options for heavy menstrual bleeding?

A

LNG-IUS
Tranexamic acid
Mefenamic acid
COCP

101
Q

Name two medical treatments that can reduce the size of fibroids.

A

Injectable GnRH agonist

Ulipristal acetate

102
Q

Why can’t GnRH analogues be used for longer than 6 months?

A

Causes osteoporosis

103
Q

List some surgical and radiological options for the treatment of fibroids.

A 
Myomectomy 
Hysterectomy 
Transcervical resection of fibroid 
Uterine artery embolisation 
MRgFUS 
Endometrial ablation
104
Q

Which types of fibroids may be removed via a hysteroscopic approach?

A

Submucosal fibroids

105
Q

Describe the examination and imaging findings seen in adenomyosis.

A

Bulky and boggy uterus
TVUSS: haemorrhage-filled, distended endometrial glands
MRI (BEST INVESTIGATION)

106
Q

How is adenomyosis treated?

A

Long-acting reversible contraceptives containing progestin (e.g. LNG-IUS)
Hysterectomy (only definitive management)

107
Q

How is lichen planus treated?

A

High dose topical steroids

108
Q

How is lichen sclerosus treated?

A

Strong steroid ointments

Biopsy may be considered if it fails to respond to treatment

109
Q

How are Bartholin’s cysts/abscesses managed?

A

Conservative - observation and consider antibiotics (flucloxacillin)
Marsupialisation (performed under GA)
Word catheter insertion (performed under LA and left in place for 4 weeks)

110
Q

How is vaginismus treated?

A

Vaginal dilators (little evidence to show efficacy)
Encourage self-exploration and stretching of the vagina
Explore patient anxieties and psychosocial factors

111
Q

What must you always do with cases of FGM?

A

Document in the hospital notes
If < 18 years, refer to police and social services
Explore whether other children are at risk

112
Q

Which procedure is performed to reverse FGM?

A

Deinfibulation

113
Q

Which investigations are used for suspected ovarian cancer?

A

TVUSS

CA125

114
Q

What are the components of the Risk Malignancy Index (RMI) for ovarian masses?

A

Menopausal status
Appearance on TVUSS
CA125

115
Q

What level of CA125 in a woman complaining of lower abdominal pain would warrant an urgent ultrasound scan?

A

> 35 IU/mL

116
Q

Which surgical treatment is usually recommended for ovarian cancer?

A

Total abdominal hysterectomy with BSO

NOTE: platinum-based chemotherapy may also be recommended after surgery

117
Q

List some drugs that are used in chemotherapy for ovarian cancer.

A

1st line: platinum-based chemotherapy (carboplatin)
Paclitaxel
Bevacizumab (anti-VEGF)

118
Q

Which forms of contraception are unaffected by EIDs?

A

Copper IUD
Mirena IUS
Depo-Provera

119
Q

Which forms of contraception work by inhibiting ovulation?

A

COCP
Desorgestrel (cerazette)
Depo-Provera
Nexplanon

120
Q

Which forms of contraception work by a different mechanism other than inhibition of ovulation?

A

POP - thickens cervical mucus
Copper IUD - spermicide + reduces implantation
Mirena IUS - prevents endometrial proliferation + thickens cervical mucus

121
Q

List some risk factors for endometrial cancer.

A 
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
122
Q

How is endometrial cancer usually managed?

A

Total abdominal hysterectomy with BSO

Frail elderly women may be given progestogen therapy

123
Q

How long should the use of contraception continue for in perimenopausal women?

A

< 50 = for 2 years after the last menstrual period

> 50 = for 1 year after the last menstrual period

124
Q

How long would you expect a urine pregnancy test to stay positive for after a termination of pregnancy?

125
Q

What are the risks associated with intrauterine contraceptive devices?

A

Uterine perforation (2 in 1000)
Ectopic pregnancy (relative not absolute)
Infection (in first 20 days)
Expulsion (risk is 1 in 20)
Abnormal bleeding (IUS: initial frequent bleeding and spotting followed by intermittent light menses; IUD: heavier, longer and more painful)

126
Q

Define secondary amenorrhoea.

A

Cessation of menstruation for 6 months in a woman who was previously menstruating

127
Q

What is shoulder tip pain in a gynaecology patient suggestive of?

A

Peritoneal bleeding (e.g. ruptured ectopic)

128
Q

What are the UKMEC4 contraindications for the COCP?

A

more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation

129
Q

Define primary amenorrhoea.

A

When a girl fails to menstruate by 16 years of age.

130
Q

Define oligomenorrhoea.

A

Irregular periods with intervals of > 35 days with only 4-9 periods per year

131
Q

List some causes of recurrent miscarriage.

A 
Antiphospholipid syndrome 
Cervical abnormalities 
Foetal chromosomal abnormalities 
Uterine malformations 
Thrombophilia
132
Q

What is the incidence of ectopic pregnancy?

A

1% of pregnancies

133
Q

List some risk factors for ectopic pregnancy.

A 
PID 
Smoking 
Increased maternal age 
Abdominal surgery
IVF 
Endometriosis 
IUD
134
Q

What percentage of couples will conceive within a year?

135
Q

Which forms of contraception are not affected by enzyme-inducing drugs?

A

LNG-IUS
Copper IUD
Depo-Provera

136
Q

When should alternative contraception be started in a patient who is currently reliant on lactational amenorrhoea?

A

6 months

Or if menses occur or if breastfeeding is reduced

137
Q

What is section C of the UK abortion law?

A

Pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman

138
Q

For how long are eggs fertilisable after ovulation?

A

12-24 hours

139
Q

At what point do you start investigating subfertility?

A

After 1 year of failing to conceive naturally

140
Q

Outline the steps in IVF.

A 
Pituitary downregulation 
Controlled ovarian stimulation 
Inhibition of premature ovulation 
hCG trigger 
Egg collection 
Fertilisation 
Embryo culture 
Embryo transfer 
Luteal phase support
141
Q

What are some features of a high risk ovarian cyst (high risk of cancer)?

A

High CA125
Complex, bilateral, multinodular
> 5 cm

142
Q

Describe how bhCG changes in an ectopic pregnancy.

A

It will plateau

NOTE: a fall in bhCG suggests miscarriage

143
Q

How is an ectopic pregnancy managed surgically?

A 
Salpingectomy 
Salpingotomy (if the opposite Fallopian tube is damaged)
144
Q

Describe how GnRH, FSH and LH levels change around menopause.

A

GnRH pulsatility increases
FSH and LH increases
NOTE: inhibin A, which is produced by follicles, will decline leading to reduced negative feedback on the hypothalamus and pituitary

145
Q

Define premature ovarian insufficiency.

A

Menopause occurring before the age of 40 years

146
Q

List some causes of premature ovarian insufficiency.

A 
Chromosomal abnormalities (e.g. Turner's syndrome, fragile X)
Autoimmune disease (e.g. hypothyroidism, Addison's, myasthenia gravis) 
Enzyme deficiencies (e.g. galactosaemia, 17a-hydroxylase deficiency)
Chemotherapy or radiotherapy 
Infections (e.g. TB, mumps, malaria, varicella)
147
Q

List some immediate, intermediate and long-term effects of menopause.

A

Immediate: flushes, sweats, mood swings, loss of concentration, reduced libido
Intermediate: vaginal dryness, dyspareunia, urinary urgency, urogenital prolapse, recurrent UTI
Long-term: osteoporosis, cardiovascular disease, dementia

148
Q

Which STIs can be tested using NAAT of vulvovaginal swab?

A

Gonorrhoea
Chlamydia
TV

149
Q

What is the most common cause of abnormal vaginal discharge?

150
Q

Which criteria are used to diagnose BV?

A

Amsel’s criteria (based on discharge, pH, whiff test and presence of clue cells)

151
Q

Where else might you consider taking swabs from in a patient with a suspected STI?

A

Oral cavity

Rectum

152
Q

Which organisms are most commonly implicated in PID?

A

Chlamydia (MOST COMMON)
Gonorrhoea
Mycoplasma genitalium and vaginal microflora

153
Q

What might you do in a patient with PID and an IUD in situ?

A

Consider removing the IUD (if symptoms haven’t improved in a few days)

154
Q

What is the test of choice for HSV?

155
Q

List some treatment options for genital warts.

A

Cryotherapy (liquid nitrogen ablation)
Topical (podophyllotoxin, imiquimod)

NOTE: treatment is optional because the lesions are benign

156
Q

How often should HIV-positive women have cervical smears?

157
Q

What types of muscle make up the urethral sphincter?

A 
Internal = smooth muscle 
External = striated muscle

NOTE: these are under sympathetic and somatic control

158
Q

List some risk factors for stress incontinence.

A 
Multiparity 
Forceps delivery 
Long labour 
High birthweight 
Age 
Obesity 
Connective tissue disease 
Chronic cough
159
Q

How is a urogynamic test performed?

A

Urinary catheter - measures pressure in the bladder
Rectal catheter - measures pressure in the rectum
Bladder s filled with warm saline whilst pressure recordings are taken and the patient is sitting on a commode that records leakage

160
Q

What are the three levels of supporting structures for the uterus, vagina and other pelvic organs?

A 
Level 1 (apical) - uterosacral ligaments attaching the cervix to the sacrum (defect causes vaginal vault prolapse) 
Level 2 - fascia around the vagina (defect causes vaginal wall prolapse)
Level 3 - fascia of the posterior vagina attached to the perineal body (defect causes lower posterior vaginal wall prolapse)
161
Q

What are the two types of posterior vaginal wall prolapse?

A

Enterocele - upper 1/3 of the vagina

Rectocele - lower 2/3 of the vagina

162
Q

Describe the stages of uterine prolapse.

A

Stage I – the uterus is in the upper half of the vagina
Stage II – the uterus has descended nearly to the opening of the vagina
Stage III – the uterus protrudes out of the vagina
Stage IV – the uterus is completely out of the vagina.

163
Q

Name and describe a few different types of procedures for pelvic organ prolapse.

A

Colporrhaphy - used for anterior and posterior vaginal wall prolapse (stitches are placed to strengthen the vagina)
Sacrocolpopexy - used for vaginal vault prolapse and enterocele (mesh is attached from the prolapsed wall to the sacrum)
Sacrohysteropexy - used in women who want to avoid hysterectomy (mesh is attached to the cervix and the sacrum)

164
Q

List some examples of functional ovarian cysts.

A

Follicular cyst
Corpus luteal cyst
Theca luteal cyst (associated with pregnancy)

More common in younger women

165
Q

List some examples of epithelial ovarian cysts.

A

Serous cystadenoma
Mucinous cystadenoma
Brenner tumour

More common in older women

166
Q

List some examples of sex cord stromal cysts.

A

Fibroma

Thecoma

167
Q

In which subset of women would a transabdominal USS be preferred over a transvaginal USS?

A

Women who have never been sexually active

168
Q

List some tumour markers used for ovarian cysts.

A

CA125: epithelial ovarian cancer (CA19-9 is likely to also be raised)
Inhibin: granulosa cell tumours
bhCG: dysgerminoma, choriocarcinoma
AFP: endodermal yolk sac, immature teratoma

169
Q

What size of functional ovarial cyst is considered pathological?

A

> 3 cm

NOTE: normal ovulatory follicles can reach 2.5 cm

170
Q

When do corpus luteal cysts tend to form?

A

After ovulation

May cause pain due to rupture or haemorrhage late in the cycle

171
Q

What are some examples of inflammatory ovarian cysts?

A

Tubo-Ovarian Abscess

Endometrioma

172
Q

What is Meig syndrome?

A

Triad of fibroma, pleural effusion and ascites

173
Q

How can thecomas manifest?

A

They secrete oestrogen
Usually present after menopause
May have features of excess oestrogen (e.g. PMB)
Associated with endometrial carcinoma

174
Q

What is the prevalence of endometriosis?

A

10% of women of reproductive age

NOTE: it resolves after menopause

175
Q

Define chronic pelvic pain.

A

Intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months duration, NOT occurring exclusively with menstruation (dysmenorrhoea) or intercourse (dyspareunia) and not associated with pregnancy

176
Q

What is a nabothian follicle?

A

Benign lesion of the cervix formed when columnar glands of the transformation zone become sealed over, forming small, mucous-filled cysts on the ectocervix

177
Q

List some causes of cervical stenosis.

A

Usually iatrogenic

E.g. due to cone biopsy, LLETZ or endometrial ablation

178
Q

Define Asherman syndrome.

A

Fibrosis and adhesion formation within the endometrial cavity following irreversible damage of the single layer thick basal endometrium (does not allow normal regeneration or the endometrium)

179
Q

Name and briefly describe the three types of fibroid degeneration.

A

Red - haemorrhage and central necrosis usually occurring in pregnancy and presenting acutely
Hyaline - asymptomatic softening and liquefaction of the fibroid
Cystic - asymptomatic central necrosis leaving cystic spaces at the centre. Becomes calcified.

180
Q

What is the difference between the epithelium of the vulval vestibule and the labia majora/minora?

A

Vestibule: non-keratinised, non-pigmented squamous epithelium
Labia: keratinised, pigmented squamous epithelium

181
Q

Which ducts are present in the vulval vestibule?

A

Minor vestibular glands
Skene’s glands
Bartholin’s glands (major)

NOTE: major and minor vestibular glands contain mucus-secreting acini with ducts lined by transitional epithelium

182
Q

What are some key differences between the labia majora and the labia minora?

A

Majora: adipose tissue, covered by skin containing follicles, sebaceous glands and sweat glands
Minora: no adipose tissue, no hair follicles, contains sebaceous follicles

183
Q

In which patient groups is vulvovaginal candidiasis uncommon?

A

Prepubescent
Postmenopausal
Consider diabetes mellitus or other underlying predisposing factor

184
Q

What is lichen planus?

A

Autoimmune disorder affecting 1-2% of the population (particularly > 40 years) affecting the skin, genitalia and oral and GI mucosa

Presents with itching, superficial dyspareunia, cobweb lesions in mouth and genital lesions

185
Q

Outline the expectant management of a miscarriage.

A

Expectant management for 7-14 days is first-line

If bleeding and pain resolves in this time period, advise taking a pregnancy test after 3 weeks

186
Q

What does the finding of free fluid in a patient with an ectopic pregnancy suggest?

A

It has ruptured

They will need surgical management

187
Q

How should patients who have been treated for gestational trophoblastic disease be followed up?

A

Refer to trophoblastic screening centre
Follow-up is individualised
Depends on the bhCG at 56 days from the pregnancy event

188
Q

When do products of conception need to be sent for histological assessment?

A

Material obtained from medical or surgical management of ALL failed pregnancies should be sent for histological analysis to exclude trophoblastic disease
NOTE: this does NOT include terminations

189
Q

Which measures can help improve fertility in patients with PCOS?

A

Weight loss
Clomiphene
Metformin

190
Q

What measure is recommended to reduce the risk of endometrial hyperplasia in PCOS?

A

Hormonal therapy (e.g. norethistrone) to induce a period at least 4 times per year

191
Q

List some absolute contraindications for the COCP.

A

< 6 wks postpartum
Smoker over the age of 35 (>15 cigarettes per day)
Hypertension (systolic > 160mmHg or diastolic > 100mmHg)
Current of past histroy of venous thromboembolism (VTE)
Ischemic heart disease
History of cerebrovascular accident
Complicated valvular heart disease (pulmonary Hypertension, atrial fibrillation, histroy of subacute bacterial endocarditis)
Migraine with aura
Breast cancer (current)
Diabetes with retinopathy/nephropathy/neuropathy
Severe cirrhosis
Liver tumour (adenoma or hepatoma)

192
Q

What prophylactic medication should be given to any patient having surgical management of miscarriage or TOP?

A

Prophylactic antibiotics

193
Q

Describe the impact of surgical management of miscarriage and TOP on future reproductive potential.

A

No impact on fertility and risk of ectopic pregnancy

194
Q

Outline the FIGO stages of endometrial cancer.

A

1 - confined to uterus
2 - confined to uterus + cervix
3 - invades through cervix/uterus
4 - bowel/bladder involvement or distant metastases

195
Q

Outline the FIGO stages of ovarian cancer.

A

1 - confined to the ovaries
2 - beyond the ovaries but confined to pelvis
3 - beyond the pelvis but confined to the abdomen
4 - beyond the abdomen

196
Q

Outline the FIGO stages of cervical cancer.

A

1 - cervix only
2 - extends into upper vagina but not pelvic wall
3 - extends to lower vagina/pelvic wall or causing ureteric obstruction
4 - invasion of bladder or rectal mucosa

197
Q

What advice would you give to a patient who has had a salpingectomy for an ectopic pregnancy about future contraception and pregnancy?

A 
Avoid intrauterine devices 
Avoid POP (associated with increased risk of ectopic) 
Get an early TVUSS whenever you next get pregnant to rule out ectopic
198
Q

What are the 7 sections of the UK Abortion Act?

A

A - continuance RISKS THE LIFE of the pregnant woman more than if the pregnancy was terminated
B - termination is necessary to prevent GRAVE PERMANENT INJURY to mental/physical health of woman
C - not exceeded 24 weeks and continuation involves GREATER RISK to physical/mental health of woman than termination
D - not exceeded 24 weeks and continuation involves RISK TO EXISTING CHILD(ren)’s mental/physical health
E - substantial risk that if the child were born it would be SERIOUSLY HANDICAPPED
F - to SAVE THE LIFE of the pregnant woman
G - prevent GRAVE PERMANENT INJURY to the woman

199
Q

Where can pregnancies be terminated?

A

Marie Stopes centre

British Pregnancy Advisory Service

200
Q

Describe some symptoms of Asherman’s syndrome.

A

Reduction or absence of bleeding

Deep dyspareunia

201
Q

What is a radical hysterectomy?

A

It is a total hysterectomy + BSO + removal of upper half of the vagina
This is done for cervical cancer

202
Q

What mid-luteal progesterone level is suggestive of ovulation?

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