Gynaecology Flashcards

Question

Endometrial hyperplasia - features ?

Answer 1

Features | - abnormal vaginal bleeding e.g. intermenstrual

Answer 2

- 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

Answer 3

cervical ectropion

Answer 4

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix The term cervical erosion is used less commonly now This may result in the following features - vaginal discharge - post-coital bleeding Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms

Answer 5

an ectopic pregnancy

Answer 6

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding 1. lower abdominal pain - -due to tubal spasm - -typically the first symptom - -pain is usually constant and may be unilateral. 2. vaginal bleeding - -usually less than a normal period - -may be dark brown in colour 3. history of recent amenorrhoea - -typically 6-8 weeks from the start of last period - -if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion - peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination - dizziness, fainting or syncope may be seen - symptoms of pregnancy such as breast tenderness may also be reported (Shoulder tip pain and cervical excitation may be seen)

Answer 7

- abdominal tenderness - cervical excitation (also known as cervical motion tenderness) - adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended

Answer 8

- Where there is an increase in serum bHCG >63%, the woman is likely to have a developing intrauterine pregnancy. - Where there is a DECREASE in serum bHCG >50%, the pregnancy is unlikely to continue. - In the case of unstable serial bHCG measurements, there may be an ectopic pregnancy.

Answer 9

a complete miscarriage would also present with an empty uterus on transvaginal ultrasound, it is typically associated with heavy blood loss and considerable pain.

Answer 10

a fetus with no cardiac activity will be visible on transvaginal ultrasound.

Answer 11

- urge incontinence: bladder retraining | - stress incontinence: pelvic floor muscle training

Answer 12

Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females. Risk factors - advancing age - previous pregnancy and childbirth - high body mass index - hysterectomy - family history Classification - 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

Answer 13

- 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

Answer 14

Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant: - bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) - bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women' - mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients If stress incontinence is predominant: - pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months - surgical procedures: e.g. retropubic mid-urethral tape procedures

Answer 15

Fibroids are benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years. Associations - more common in Afro-Caribbean women - rare before puberty, develop in response to oestrogen, don't tend to progress following menopause Features - may be asymptomatic - menorrhagia - lower abdominal pain: cramping pains, often during menstruation bloating - urinary symptoms, e.g. frequency, may occur with larger fibroids - subfertility Diagnosis - transvaginal ultrasound

Answer 16

Management - symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line - other options include tranexamic acid, combined oral contraceptive pill etc - GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment - surgery is sometimes needed: myomectomy, hysteroscopic endometrial ablation, hysterectomy - uterine artery embolization Complications - red degeneration - haemorrhage into tumour - commonly occurs during pregnancy

Answer 17

marsupialisation

Answer 18

Bartholin's glands are a pair of glands located next to the entrance to the vagina. These are normally about the size of a pea, but can become infected and enlarge - forming a Bartholin's abscess. - This can be treated by antibiotics, - by the insertion of a word catheter or - by a surgical procedure known as marsupialization

Answer 19

giving vaginal misoprostol alone | however, oral misoprostol can alternatively be given if preferred by the patient.

Answer 20

3 types of management for miscarriage 1. Expectant management - 'Waiting for a spontaneous miscarriage' - First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously - If expectant management is unsuccessful then medical or surgical management may be offered

Answer 21

- increased risk of haemorrhage - -she is in the late first trimester - -if she has coagulopathies or is unable to have a blood transfusion - previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) - evidence of infection

Answer 22

'Using tablets to expedite the miscarriage' - Vaginal misoprostol - -Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue - The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines - Advise them to contact the doctor if the bleeding hasn't started in 24 hours. - Should be given with antiemetics and pain relief

Answer 23

- 'Undergoing a surgical procedure under local or general anaesthetic' - The two main options are vacuum aspiration (suction curettage) or surgical management in theatre - Vacuum aspiration is done under local anaesthetic as an outpatient - Surgical management is done in theatre under general anaesthetic. This was previously referred to as 'Evacuation of retained products of conception'

Answer 24

Methotrexate (It interferes with DNA synthesis and disrupts cell multiplication thus preventing the pregnancy from developing. ) anti- metabolite therefore is an anti- folic acid

Answer 25

If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)

Answer 26

It is diagnosed when a patient has at least two of the following: 1. polycystic ovary on ultrasound - or increased ovarian volume 2. irregular periods (>35 days apart) - wither infrequent or no ovulation (oligomenorrhoea) 3. and hirsutism (Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone) Patients with PCOS have disordered luteinising hormone (LH) production and peripheral insulin resistance, and thus raised levels of LH and insulin. This results in increased androgen production which disrupts folliculogenesis, leading to excess small ovarian follicles, irregular or absent ovulation and hirsutism.

Answer 27

Complications include obesity, type 2 diabetes, subfertility, miscarriage and endometrial cancer.

Answer 28

Clomifene As an antioestrogen, it works by blocking oestrogen receptors in the hypothalamus and pituitary and increasing the release of LH and follicle stimulating hormone (FSH), which are inhibited by oestrogen. It is only given on days 2 to 6 of each cycle to initiate follicular maturation. If no follicles develop then the dose can be increased from 50mg/day to 100mg/day and finally 150mg/day in subsequent cycles. It is limited to 6 months use and increases the risk of multiple pregnancy to 11%.

Answer 29

Polycystic ovarian syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. Management is complicated and problem based partly because the aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome. 1. General - 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) 2. 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 3. Infertility - weight reduction if appropriate - the management of infertility in patients with PCOS should be supervised by a specialist. - research shows clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene. - metformin is used, either combined with clomifene or alone, particularly in patients who are obese (Metformin can be used as an alternative to clomifene, or in addition to it if it fails to induce ovulation.) It also treats hirsutism and may reduce the risk of gestational diabetes and early miscarriage. - 2nd line treatments: ovarian diathermy and gonadotrophin induction - 3rd line: IVF is reserved for cases where neither first nor second-line treatment options have worked. (*work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion)

Answer 30

Used in PCOS - 2nd line infertility treatment -Gonadotropin induction involves a daily subcutaneous injection of recombinant or purified urinary FSH and/or LH. This stimulates follicular growth and is monitored by ultrasound. Once a follicle has reached approximately 17mm in size, the process of ovulation is artificially stimulated by injection of hCG or LH.

Answer 31

Treatment options are obviously different for patients not wishing to conceive. - The combined oral contraceptive pill (COCP) can be used to regulate menstruation, with three to four bleeds necessary every year to protect the endometrium. It also helps to treat hirsutism. - Likewise, co-cyprindiol treats menstrual irregularity and hirsutism, with the addition of acne. ( Antiandrogens e.g. cyproterone acetate, spironolactone are effective treatments for hirsutism but conception must be avoided. )

Answer 32

``` Premenstrual syndrome (PMS) - PMS is defined as a condition which manifests with distressing physical, psychological and behavioural symptoms in the absence of an organic disease. These symptoms regularly occur during the luteal phase of the menstrual cycle and improve at the end of menstruation. ```

Answer 33

Premenstrual syndrome describes the emotional and physical symptoms that women may experience prior to menstruation. Common symptoms include: - anxiety - stress - fatigue - mood swings - irritability - bloating - mastalgia The precise aetiology is unknown, however it is associated with the hormonal changes that occur following ovulation. The absence of PMS before puberty, in pregnancy and after the menopause further support this theory.

Answer 34

Management of PMS includes: - lifestyle advice - healthy diet, exercise, reduction in stress levels and regular sleep. - The combined oral contraceptive pill and selective serotonin re-uptake inhibitors are recommended for moderate to severe symptoms.

Answer 35

- Increased maternal age - Smoking in pregnancy - Consuming alcohol - Recreational drug use - High caffeine intake - Obesity - Infections and food poisoning - Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes - Medicines, such as ibuprofen, methotrexate and retinoids - Unusual shape or structure of womb - Cervical incompetence

Answer 36

``` Heavy lifting Bumping your tummy Having sex Air travel Being stressed ```

Answer 37

benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion

Answer 38

Dermoid cyst (teratoma)

Answer 39

Follicular cyst

Answer 40

1. Follicular cysts - commonest type of ovarian cyst - due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle - commonly regress after several menstrual cycles 2. Corpus luteum cyst - 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

Answer 41

``` Benign ovarian cysts are extremely common. They may be divided into - physiological cysts - benign germ cell tumours - benign epithelial tumours - benign sex cord stromal tumours. ``` Complex ovarian cysts - e.g, multi-loculated

Answer 42

Dermoid cyst - also called mature cystic teratomas. - benign neoplasms derived from multiple germ cell layers - Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth - most common benign ovarian tumour in woman under the age of 30 years - median age of diagnosis is 30 years old - bilateral in 10-20% - usually asymptomatic. Torsion is more likely than with other ovarian tumours The inner lining of every mature cystic teratoma contains single or multiple white shiny masses projecting from the wall toward the centre of the cysts. When hair, other dermal appendages, bone and teeth are present, they usually arise from this protuberance. This protuberance is referred to as the Rokitansky protuberance.

Answer 43

Arise from the ovarian surface epithelium 1. Serous cystadenoma - the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma) - bilateral in around 20% 2. Mucinous cystadenoma - second most common benign epithelial tumour - they are typically large and may become massive - if ruptures may cause pseudomyxoma peritonei

Answer 44

dryness of the vaginal mucosa

Answer 45

Atrophic vaginitis often occurs in women who are post-menopausal women. - It presents with vaginal dryness, dyspareunia and occasional spotting. - On examination, the vagina may appear pale and dry. - Atrophic vaginitis is a diagnosis of exclusion. - Endometrial cancer must be ruled out, and the first line investigation for this is always TVUS. - Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used. (Oestrogen secreting pessaries are an alternative to topical oestrogen cream)

Answer 46

Lubricants and moisturisers

Answer 47

Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.

Answer 48

In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible. Features - pain typically starts just before or within a few hours of the period starting - suprapubic cramping pains which may radiate to the back or down the thigh Management - NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production - combined oral contraceptive pills are used second line

Answer 49

NSAIDs e.g. mefenamic acid are offered first-line as they will inhibit prostaglandin synthesis, one of the main causes of dysmenorrhoea pains.

Answer 50

Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. ``` Causes include: - endometriosis - adenomyosis - pelvic inflammatory disease intrauterine devices* - fibroids ``` Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. *this refers to normal copper coils. Note that the intrauterine system (Mirena) may help dysmenorrhoea

Answer 51

Vaginal candidiasis ('thrush') is an extremely common condition which many women diagnose and treat themselves. The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop: - diabetes mellitus - drugs: antibiotics, steroids - pregnancy - immunosuppression: HIV, iatrogenic Features - 'cottage cheese', non-offensive DISCHARGE - vulvitis: dyspareunia, dysuria - itch - vulval erythema, fissuring, satellite lesions may be seen Investigations - a high vaginal swab is not routinely indicated if the clinical features are consistent with 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 Recurrent vaginal candidiasis - BASHH define recurrent vaginal candidiasis as 4 or more episodes per year - 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

Answer 52

precipitated or exacerbated by recent antibiotic exposure

Answer 53

Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year. Other than age, risk factors include: - Human papilloma virus (HPV) infection - Vulval intraepithelial neoplasia (VIN) - Immunosuppression - Lichen sclerosus Features - lump or ulcer on the labia majora - may be associated with itching, irritation

Answer 54

- commonly ulcerated | - can present on the labium majora

Answer 55

oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or 'carneous' degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.

Answer 56

Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years Causes - male factor 30% - unexplained 20% - ovulation failure 20% - tubal damage 15% - other causes 15% 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. Interpretation of serum progestogen: < 16 nmol/l - Repeat, if consistently low refer to specialist 16 - 30 nmol/l - Repeat > 30 nmol/l - Indicates ovulation Key counselling points - folic acid - aim for BMI 20-25 - advise regular sexual intercourse every 2 to 3 days - smoking/drinking advice

Answer 57

are having regular unprotected sexual intercourse: - do not routinely offer intrauterine insemination, either with or without ovarian stimulation (exceptional circumstances include, for example, when people have social, cultural or religious objections to IVF) advise them to try to conceive for a total of 2 years (this can include up to 1 year before their fertility investigations) before IVF will be considered'.

Answer 58

COCP | Ectropions are more common when taking the pill, in pregnancy and during puberty.

Answer 59

oxybutynin solifenacin tolterodine

Answer 60

Chlamydia trachomatis

Answer 61

- sudden sharp onset unilateral pelvic pain | - precipitated by intercourse or strenuous activity

Answer 62

Mid cycle pain is very common and is due to the small amount of fluid released during ovulation Features: - Usually mid cycle abdominal pain. - Often sharp onset. - Little systemic disturbance. - May have recurrent episodes. - Usually settles over 24-48 hours. Ix: - Full blood count- usually normal. Inflammatory markers are usually normal - Ultrasound- may show small quantity of free fluid Tx: Conservative

Answer 63

Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of a reproductive age have a degree of endometriosis. Features: - 25% asymptomatic, in a further - 25% associated with other pelvic organ pathology. - Remaining 50% may have menstrual irregularity, infertility, pain and deep dyspareurina. - Chronic pelvic pain - dysmenorrhoea - pain often starts days before bleeding - deep dyspareunia - subfertility - non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements) - on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen - Complex disease may result in pelvic adhesional formation with episodes of intermittent small bowel obstruction. - Intra-abdominal bleeding may produce localised peritoneal inflammation. - Recurrent episodes are common.

Answer 64

Features: - Usually SUDDEN onset of unilateral deep seated colicky lower abdominal pain. - Onset may coincide with exercise - Associated with vomiting and distress. Ix: - Vaginal examination may reveal unilateral adnexial tenderness. Ultrasound may show free fluid - Laparoscopy is usually both diagnostic and therapeutic Mx: Laparoscopy

Answer 65

Features: - Symptoms of pregnancy without evidence of intra uterine gestation. - Present as an emergency with evidence of rupture or impending rupture. - Open tubular ruptures may have sudden onset of abdominal pain and circulatory collapse, in other the symptoms may be more prolonged and less marked. - Small amount of vaginal discharge is common. - There is usually adnexial tenderness. Ix: - Ultrasound showing no intra uterine pregnancy and beta HCG that is elevated - May show intra abdominal free fluid Mx: - Laparoscopy or laparotomy is haemodynamically unstable. A salphingectomy is usually performed.

Answer 66

Features : - Bilateral lower abdominal pain associated with vaginal discharge. - Dysuria may also be present - menstrual irregularities may occur - deep dyspareunia - Peri-hepatic inflammation secondary to Chlamydia (Fitz Hugh Curtis Syndrome) may produce right upper quadrant discomfort. - Fever >38C Ix: - Full blood count- Leucocytosis - Pregnancy test negative (Although infection and pregnancy may co-exist) - Amylase - usually normal or slightly raised - High vaginal and urethral swabs Cervical excitation may be found on examination Mx: Usually medical management

Answer 67

A total hysterectomy with bilateral salpingo-oophorectomy - due to the risk of malignant progression

Answer 68

It may be divided into: - squamous cell cancer (80%) - adenocarcinoma (20%) Features - may be detected during routine cervical cancer screening - abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding - vaginal discharge Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Other risk factors include: - smoking - human immunodeficiency virus - early first intercourse, many sexual partners - high parity - lower socioeconomic status - combined oral contraceptive pill Mechanism of HPV causing cervical cancer - HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively - E6 inhibits the p53 tumour suppressor gene - E7 inhibits RB suppressor gene

Answer 69

Hormone replacement therapy (HRT) may be used to replace decreasing oestrogen levels around the perimenopausal period

Answer 70

Cyclical HRT is recommended in perimenopausal women because it produces predictable withdrawal bleeding, whereas continuous regimens often cause unpredictable bleeding.

Answer 71

- Gold standard of treatment is hysterectomy +/- lymph node clearance - Nodal clearance for A2 tumours - For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed - Close follow-up of these patients is advised - For A2 tumours, node evaluation must be performed - Radical trachelectomy is also an option for A2

Answer 72

- For B1 tumours: radiotherapy with concurrent chemotherapy is advised - Radiotherapy may either be bachytherapy or external beam radiotherapy - Cisplatin is the commonly used chemotherapeutic agent - For B2 tumours: radical hysterectomy with pelvic lymph node dissection

Answer 73

- Radiation with concurrent chemotherapy - See above for choice of chemotherapy and radiotherapy - If hydronephrosis, nephrostomy should be considered

Answer 74

- Radiation and/or chemotherapy is the treatment of choice | - Palliative chemotherapy may be best option for stage IVB

Answer 75

- Primary surgical treatment: offer chemoradiation or radiotherapy - Primary radiation treatment: offer surgical therapy

Answer 76

Complications of surgery - Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk) - Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies - Radical hysterectomy may result in a ureteral fistula Complications of radiotherapy - Short-term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness - Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema

Answer 77

- painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks - the bleeding is often less than menstruation - cervical os is closed - complicates up to 25% of all pregnancies

Answer 78

- a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion - mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature - cervical os is closed - when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'

Answer 79

- heavy bleeding with clots and pain | - cervical os is open

Answer 80

- not all products of conception have been expelled - pain and vaginal bleeding - cervical os is open

Answer 81

- 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 *the combined oral contraceptive pill and smoking are protective

Answer 82

Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection Features: - postmenopausal bleeding is the classic symptom - premenopausal women may have a change intermenstrual bleeding - pain and discharge are unusual features Investigation: - women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway - first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value - hysteroscopy with endometrial biopsy Management: - localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy - progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

Answer 83

removing the lining of the womb and is not recommended for those who wish to have children in the future as there is a high chance of miscarriage, it would also be an inappropriate first line option

Answer 84

Monitor expectantly and advise to repeat pregnancy test in 7 days. If negative, this confirms miscarriage. If positive, or continued or worsening symptoms, refer to the early pregnancy assessment unit

Answer 85

Bleeding in the first trimester is a common reason women in early pregnancy seek medical attention. The main differential diagnosis is as follows: - miscarriage - ectopic pregnancy - -the most 'important' cause as missed ectopics can be potentially life-threatening - implantation bleeding - -a diagnosis of exclusion - miscellaneous conditions - -cervical ectropion - -vaginitis - -trauma - -polyps

Answer 86

If a woman has a positive pregnancy test and any of the following she should be referred immediately to an early pregnancy assessment service: - pain and abdominal tenderness - pelvic tenderness - cervical motion tenderness

Answer 87

If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to an early pregnancy assessment service

Answer 88

If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised: - to return if bleeding continues or pain develops - to repeat a urine pregnancy test after 7–10 days and to return if it is positive - a negative pregnancy test means that the pregnancy has miscarried

Answer 89

The definition of menorrhagia has changed to reflect the woman's subjective experience rather than trying to quantify blood loss

Answer 90

Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The assessment and management of heavy periods has therefore shifted towards what the woman considers to be excessive and aims to improve quality of life measures. Causes: - dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients - anovulatory cycles: these are more common at the extremes of a women's reproductive life - uterine fibroids - hypothyroidism - intrauterine devices* - pelvic inflammatory disease - bleeding disorders, e.g. von Willebrand disease *this refers to normal copper coils. Note that the intrauterine system (Mirena) is used to treat menorrhagia

Answer 91

Menopause is defined as the permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months. Menopausal symptoms are very common and affect roughly 75% of postmenopausal women. Symptoms typically last for 7 years but may resolve quicker and in some cases take much longer. The duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause. The management of menopause can be split into three categories: 1. Lifestyle modifications 2. Hormone replacement therapy (HRT) 3. Non-hormone replacement therapy

Answer 92

Hot flushes - regular exercise, weight loss and reduce stress Sleep disturbance - avoiding late evening exercise and maintaining good sleep hygiene Mood - sleep, regular exercise and relaxation Cognitive symptoms - regular exercise and good sleep hygiene

Answer 93

Contraindications: - Current or past breast cancer - Any oestrogen-sensitive cancer - Undiagnosed vaginal bleeding - Untreated endometrial hyperplasia Roughly 10% of women will have some form of HRT to treat their menopausal symptoms. If the woman has a uterus then it is important not to give unopposed oestrogens as this will increase her risk of endometrial cancer. Therefore oral or transdermal combined HRT is given. If the woman does not have a uterus then oestrogen alone can be given either orally or in a transdermal patch. Women should be advised that the symptoms of menopause typically last for 2-5 years and that treatment with HRT brings certain risks: - Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT. - Stroke: slightly increased risk with oral oestrogen HRT. - Coronary heart disease: combined HRT may be associated with a slight increase in risk. - Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised. - Ovarian cancer: increased risk with all HRT.

Answer 94

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

Answer 95

For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment. Vaginal oestrogen may be required long term. When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control. Although menopausal symptoms can be managed mainly in primary care, there are some instances when a woman should be referred to secondary care. She should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.

Answer 96

Expectant management (watchful waiting) is very rarely a suitable management option for ectopic pregnancies. 1) An unruptured embryo 2) <35mm in size 3) Have no heartbeat 4) Be asymptomatic 5) Have a B-hCG level of <1000IU/L and declining

Answer 97

Women who are stable are typically investigated and managed in an early pregnancy assessment unit. If a woman is unstable then she should be referred to the emergency department. - A pregnancy test will be positive. - The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.

Answer 98

1. Expectant management 2. Medical management 3. Surgical management

Answer 99

- Size <35mm - Unruptured - No pain - No fetal heartbeat - serum B-hCG <1500IU/L - Not suitable if intrauterine pregnancy

Answer 100

Medical management involves giving the patient METHOTREXATE and can only be done if the patient is willing to attend follow up.

Answer 101

- Size >35mm - Can be ruptured - Severe pain - Visible fetal heartbeat - serum B-hCG >1500IU/L - Compatible with another intrauterine pregnancy

Answer 102

Surgical management can involve salpingectomy or salpingotomy

Answer 103

- Amenorrhoea/ irregular - fluid leaking from her nipples =milky - menopausal symptoms (hot flashes and vaginal dryness)

Answer 104

Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock. Features may include: - agalactorrhoea (problems with milk production) - amenorrhoea (secondary) - symptoms of hypothyroidism - symptoms of hypoadrenalism

Answer 105

Asherman's syndrome, or intrauterine adhesions, may occur following dilation and curettage - This may prevent the endometrium responding to oestrogen as it normally would. - Cause of Secondary amenorrhoea

Answer 106

Vaginal discharge is a common presenting symptom and is not always pathological Common causes: - physiological - Candida - Trichomonas vaginalis - bacterial vaginosis Less common causes: - Gonorrhoea - Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms - ectropion - foreign body - cervical cancer

Answer 107

'Cottage cheese' discharge Vulvitis Itch

Answer 108

Offensive, yellow/green, frothy discharge Vulvovaginitis Strawberry cervix

Answer 109

Offensive, thin, white/grey, 'fishy' discharge

Answer 110

Amsel's criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present: - thin, white homogenous discharge - clue cells on microscopy: stippled vaginal epithelial cells - vaginal pH > 4.5 - positive whiff test (addition of potassium hydroxide results in fishy odour)

Answer 111

Oral metronidazole

Answer 112

``` Oral metronidazole (present with 'strawberry cervix' - 'musty', frothy, green vaginal discharge ) ```

Answer 113

a single dose of IM ceftriaxone 1g (If sensitivities are known (and the organism is sensitive to ciprofloxacin) then a single dose of oral ciprofloxacin 500mg should be given)

Answer 114

Gonorrhoea

Answer 115

GnRH agonists | - may reduce the size of the fibroid but are typically useful for short-term treatment

Answer 116

iliac fossa pain that can radiate to the loin, groin or back - Nausea and vomiting are commonly associated symptoms. - Patients also sometimes present with a low-grade fever, especially for longer durations of torsion where ovarian necrosis may be present.

Answer 117

Could cause right iliac fossa pain but this would be mild, and not associated with nausea and vomiting.

Answer 118

GnRH agonists may reduce the SIZE of the fibroid but are typically useful for short-term treatment - can be used prior to surgery - The risk of post-operative blood loss is directly related to the size of the uterus.

Answer 119

COCP should not be taken 4-6 weeks prior to major surgery due to increased risk of venous thromboembolism. Antiplatelet drugs such as Ibuprofen should be avoided before surgery.

Answer 120

Ectopic pregnancy

Answer 121

You BETTER GO PRO AND check EAST THYROID! - BETA-HCG - GOnadotrophins - PROlactin - ANDrogens - oESTradiol - THYROID function

Answer 122

If the cyst were simple (thin walled, non-loculated, <5cm in size).

Answer 123

A serum CA-125, αFP and βHCG are performed for all pre-menopausal women with complex ovarian cysts (And book for elective cystectomy) - Aspiration of cysts is associated with higher rate of recurrence and increased spillage into the peritoneal cavity, which may disseminate possible malignant cells, hence the guideline prefers cystectomy over aspiration.

Answer 124

bladder outlet obstruction (overflow incontinence) - happens when your bladder doesn't empty completely when you urinate - Voiding symptoms (e.g. straining, poor flow, and incomplete emptying of the bladder) are also suggestive of bladder outlet obstruction.

Answer 125

a voiding detrusor pressure rise of < 70 cm H20 with a peak flow rate of > 15 ml/second

Answer 126

sacrocolpoplexy - This procedure suspends the vaginal apex to the sacral promontory. This support is usually afforded by the uterosacral ligaments.

Answer 127

In urogenital prolapse there is descent of one of the pelvic organs resulting in protrusion on the vaginal walls. It probably affects around 40% of postmenopausal women Types - cystocele, cystourethrocele - rectocele - uterine prolapse - less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)

Answer 128

Risk factors - increasing age - multiparity, vaginal deliveries - obesity - spina bifida Presentation: - sensation of pressure, heaviness, 'bearing-down' - urinary symptoms: incontinence, frequency, urgency

Answer 129

Management - if asymptomatic and mild prolapse then no treatment needed - conservative: weight loss, pelvic floor muscle exercises - ring pessary - surgery Surgical options: - cystocele/cystourethrocele: anterior colporrhaphy, colposuspension - uterine prolapse: hysterectomy, sacrohysteropexy - rectocele: posterior colporrhaphy

Answer 130

- First line in the treatment of miscarriage - expectant management Unless one of the following factors is present: - there is an increased risk of bleeding - there are previous adverse experiences associated with pregnancy - there is increased risk from the effects of haemorrhage or there is evidence of infection.

Answer 131

- associated with a whirlpool sign (A whirlpool sign arises when a structure twists upon itself. ) - as well as free fluid

Answer 132

- Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment. - It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). - This results in increased membrane permeability and loss of fluid from the intravascular compartment Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS

Answer 133

Mild- Abdominal pain; Abdominal bloating Moderate - As for mild Nausea and vomiting; Ultrasound evidence of ascites Severe - As for moderate Clinical evidence of ascites, Oliguria; Haematocrit > 45%; Hypoproteinaemia Critical - As for severe thromboembolism, acute respiratory distress syndrome, anuria, tense ascites

Answer 134

- should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. - A dye stains (Urinary dye studies ) the urine and hence identifies the presence of a fistula.

Answer 135

Pelvic floor exercises 3 months | - (Non responders should have urodynamics performed to confirm the diagnosis.)

Answer 136

Urodynamic studies are indicated when there is diagnostic uncertainty (a bladder diary is inconclusive.) or plans for surgery.

Answer 137

evidence of infection (e.g. raised WCC and raised temperature), possibly due to septic miscarriage. ) or increased risk of haemorrhage

Answer 138

Ix: - Ultrasound- may show free fluid - there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis - LAPAROSCOPY will usually show lesions (gold standard investigation) Mx: Management depends on clinical features: - NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief - if analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include: - GnRH analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels - drug therapy unfortunately does not seem to have a significant impact on fertility rates - surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Answer 139

Reassure patient that this is normal and leave the cyst alone. In early pregnancy, ovarian cysts are usually physiological - known as a corpus luteum. They will usually resolve from the second trimester on wards. Reassurance is important in the above situation as maternal anxiety is likely to be high. Anxiety in pregnancy should be avoided wherever possible in order to avoid adverse outcomes to both mother and foetus.

Answer 140

Uterus is large for dates | Snow storm

Answer 141

``` hyperemesis gravidarum ( This is a rare complication of pregnancy where women have raised B-hCG and an exaggerated physiological response and so generally present with dehydration and in severe cases, weight loss.) ```

Answer 142

Minor symptoms of pregnancy may include: - nausea/vomiting - tiredness - musculoskeletal pains

Answer 143

Pregnancy-Unique Quantification of Emesis (PUQE)

Answer 144

- Abdominal pain - Bloating - Change in bowel habit. Features such as lethargy, nausea, backache and bladder symptoms may also be present

Answer 145

- Common long term complications of vaginal hysterectomy with antero-posterior repair include enterocoele and vaginal vault prolapse. - Urinary retention may occur acutely following hysterectomy, but it is not usually a chronic complication.

Answer 146

Cervical ectropion

Answer 147

Postcoital bleeding describes vaginal bleeding after sexual intercourse. Causes - no identifiable pathology is found in around 50% of cases - cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill - cervicitis e.g. secondary to Chlamydia - cervical cancer - polyps - trauma

Answer 148

abdominal swelling and pressure effects on the bladder

Answer 149

- Ectopic pregnancy - Urinary tract infection - Appendicitis - Pelvic inflammatory disease - Ovarian torsion - Miscarriage

Answer 150

- Endometriosis - Irritable bowel syndrome - Ovarian cyst - Urogenital prolapse

Answer 151

Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea

Answer 152

- Endometriosis - Irritable bowel syndrome - Ovarian cyst - Urogenital prolapse

Answer 153

- Unilateral dull ache which may be intermittent or only occur during intercourse. - Torsion or rupture may lead to severe abdominal pain - Large cysts may cause abdominal swelling or pressure effects on the bladder

Answer 154

``` 1. Non-gynaecological causes appendicitis UTI constipation irritable bowel syndrome gallstones ``` 2. Menstrual related problems dysmenorrhoea endometriosis Mittelschmerz 3. Other causes pelvic inflammatory disease ovarian torsion uterine rupture (e.g. with IUD/IUS in-situ) ``` 4. Pregnancy related ectopic pregnancy spontaneous abortion placental abruption premature labour pre-eclampsia ```

Answer 155

The average women in the UK goes through the menopause when she is 51 years old. The climacteric is the period prior to the menopause where women may experience symptoms, as ovarian function starts to fail It is recommended to use effective contraception until the following time: - 12 months after the last period in women > 50 years - 24 months after the last period in women < 50 years (LESS THAN)

Answer 156

ectopic pregnancy - (shoulder tip pain suggesting peritoneal bleeding)

Answer 157

a complication seen in some forms of infertility treatment (e.g. IVF)

Answer 158

If the fibroids are large the uterus can feel bulky on examination. (An abdominal ultrasound confirming an enlarged uterus with multiple masses is virtually diagnostic. )

Answer 159

Fibroids (Leiomyoma) are a common cause of menorrhagia and abdominal pain in a menstruating female.

Answer 160

7 days before the end of the lady's regular cycle when progesterone levels should be tested. (An individual who has a normal 28-day cycle would be tested on Day 21. ) Regardless of the length of the individual's menstrual cycle - the progesterone levels should be carried out 7 days before the end of the cycle, so will, therefore, vary from individual to individual. (Women who are having regular monthly cycles should be informed that they are likely to be ovulating, but this will be checked with a mid-luteal serum progesterone level.)

Answer 161

Atyplical hyperplasia of the endometrium is classified as a premalignant condition - which develops due to overstimulation of the endometrium by oestrogen.

Answer 162

Thecomas Fibromas Sertoli cell Granulosa cell tumours - associated with an increased production of hormones

Answer 163

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy Epidemiology incidence = c. 0.5% of all pregnancies Risk factors (anything slowing the ovum's passage to the uterus) - damage to tubes (pelvic inflammatory disease, surgery) - previous ectopic - endometriosis - IUCD - progesterone only pill - IVF (3% of pregnancies are ectopic)

Answer 164

Oxybutynin | - Safer alternatives include solifenacin and tolterodine.

Answer 165

surgical management

Answer 166

``` postpartum hypopituitarism (is a reduction in the function of the pituitary gland following ischaemic necrosis due to hypovolaemic shock following birth.The symptoms can be varied due to the damage in the pituitary and can sometimes take years to develop. ) ```

Answer 167

Sheehan's syndrome.

Answer 168

Urinary overflow incontinence | - (think retention with urinary overflow)

Answer 169

Endometriosis

Answer 170

hypogonadotrophic hypogonadism, where the anterior pituitary gland stops producing FSH and LH, thus meaning follicles do not develop sufficiently. Gaining weight should reverse the subfertility.

Answer 171

pelvic inflammatory disease and ectopic pregnancy.

Answer 172

Vaginal candidiasis

Answer 173

Premature ovarian failure is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women. Causes: - idiopathic - the most common cause - chemotherapy - autoimmune - radiation Features are similar to those of the normal climacteric but the actual presenting problem may differ - climacteric symptoms: hot flushes, night sweats - infertility - secondary amenorrhoea - raised FSH, LH levels (and low oestradiol ?)

Answer 174

Fitz-Hugh-Curtis syndrome | It is a complication of PID causing inflammation of the liver capsule forming 'Glisson's Capsule'.

Answer 175

- hyperemesis gravidarum - molar pregnancies (thought to be due to the increased placental mass (and therefore higher beta-hCG levels))

Answer 176

It is not uncommon for women to feel nauseated in pregnancy, and for most this settles by around 16 weeks pregnancy. If the vomiting is prolonged (over a longer period during the pregnancy) or extensive (in frequency each day) then it can become problematic.

Answer 177

Serous carcinoma | - Around 90% of ovarian cancers are epithelial in origin.

Answer 178

Immediately referred for assessment

Answer 179

- Subfertility - Diabetes mellitus - Stroke & transient ischaemic attack - Coronary artery disease - Obstructive sleep apnoea - Endometrial cancer

Answer 180

Hyperemesis gravidarum | - refer a woman to gynaecology for urgent assessment and intravenous fluids.

Answer 181

the cessation of menses for 1 year before the age of 40 (It can, however, be preceded by irregular menstrual cycles. Common symptoms include hot flushes, vaginal dryness, vaginal atrophy, sleep disturbance, and irritability. )

Answer 182

Management of stage IA tumours- cervical cancer | - When a woman wants to preserve her fertility - in order to have children in the future.

Answer 183

Vesicovaginal fistulae | CONTINUOUS dribbling

Answer 184

Smoking is associated with a decreased incidence of hyperemesis gravidarum

Answer 185

A confirmed miscarriage can be diagnosed on ultrasound if there is no cardiac activity and: - The crown-rump length is greater than 7mm OR - The gestational sack is greater than 25mm

Answer 186

Progesterone level | - Day 21 progesterone test is the most reliable test to confirm ovulation

Answer 187

Hydatidiform mole

Answer 188

'snow storm' appearance on ultrasound scan

Answer 189

- vaginal bleeding - uterus size greater than expected for gestational age - abnormally high serum hCG - ultrasound: 'snow storm' appearance of mixed echogenicity

Answer 190

A complete hydatidiform mole occurs when all of the genetic material comes from the father. There will be no foetal parts present and snowstorm appearance is seen on ultrasound. Vaginal bleeding early in pregnancy is often the presenting feature.

Answer 191

Incomplete hydatidiform mole occurs due to two sets of paternal chromosomes and one set of maternal chromosomes. (There are often foetal parts present and snowstorm appearance is NOT seen on ultrasound)

Answer 192

Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis. Pathophysiology: around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many 'ovarian' cancers Risk factors - family history: mutations of the BRCA1 or the BRCA2 gene - many ovulations*: early menarche, late menopause, nulliparity *It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

Answer 193

Clinical features are notoriously vague. - abdominal distension and bloating - abdominal and pelvic pain - urinary symptoms e.g. Urgency (increased urgency/frequency) - early satiety (Feeling full (early satiety) or loss of appetite) - diarrhoea Investigations - CA125 --NICE recommends a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level --if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered --a CA125 should not be used for screening for ovarian cancer in asymptomatic women ultrasound Diagnosis is difficult and usually involves diagnostic laparotomy Management - usually a combination of surgery and platinum-based chemotherapy Prognosis 80% of women have advanced disease at presentation the all stage 5-year survival is 46%

Answer 194

Adenomyosis is characterized by the presence of endometrial tissue within the myometrium. It is more common in multiparous women towards the end of their reproductive years. Features dysmenorrhoea menorrhagia enlarged, boggy uterus Management - GnRH agonists - hysterectomy (is the only definitive tx)

Answer 195

Uterine myomectomy is a used in the removal of uterine fibroids which are well circumscribed

Answer 196

breast cancer | Progestogens carry the increased risk of breast cancer, venous thromboembolism and cardiovascular disease.

Answer 197

Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms. Side-effects - nausea - breast tenderness - fluid retention and weight gain

Answer 198

1. - increased risk of breast cancer - - increased by the addition of a progestogen - - the increased risk relates to the duration of use - - the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT 2. increased risk of endometrial cancer - -oestrogen by itself should not be given as HRT to women with a womb - -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 3. increased risk of venous thromboembolism - -increased by the addition of a progestogen - -transdermal HRT does not appear to increase the risk of VTE - -NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal) 4. increased risk of stroke 5. increased risk of ischaemic heart disease if taken more than 10 years after menopause

Answer 199

If the patient appears well but is suffering cyclical pain with no evidence of menstruation - this rules out mullerian agenesis and constitutional delay which are both classically painless - likely to be imperforate hymnen

Answer 200

mild symptoms of bleeding but a closed cervical os | usually little or no pain

Answer 201

- threatened - inevitable - incomplete - complete - missed

Answer 202

a rupture endometrioma

Answer 203

Use of the combined oral contraceptive pill can mask an underlying polycystic ovarian syndrome in women who would otherwise experience symptoms

Answer 204

- Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. - If growth outstrips their blood supply, they can undergo red or 'carneous' degeneration. - This usually presents with low-grade fever, pain and vomiting. - The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.

Answer 205

May develop during pregnancy, presenting with low-grade fever, pain and vomiting.

Answer 206

Metronidazole is used in the treatment of bacterial vaginosis and Trichomonas vaginalis.

Answer 207

Vaginal candidiasis - This patient has thrush which is treated with antifungal medication. This patient is pregnant, therefore cannot be given oral fluconazole as this is contraindicated in pregnancy due to its association with congenital abnormalities. - therefore give - clotrimazole pessary

Answer 208

``` Age above 35 Amenorrhoea Previous pelvic surgery Previous STI Abnormal genital examination ```

Answer 209

``` Previous surgery on genitalia Previous STI Varicocele Significant systemic illness Abnormal genital examination ```

Answer 210

Myomectomy if the woman wishes to conceive in the future (Myomectomy, which involves surgically removing the fibroid from the uterus is currently the only form of treatment for fibroids which has sufficient evidence of improving fertility. This is most likely to be successful for submucosal fibroids which reduce fertility through preventing implantatio)

Answer 211

Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women Causes - antiphospholipid syndrome - endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome - uterine abnormality: e.g. uterine septum - parental chromosomal abnormalities - smoking

Answer 212

Mucinous cystadenoma

Answer 213

day 21 progesterone. This is a non-invasive test and can tell you whether the patient is actually ovulating.

Answer 214

Women should be prescribed cyclical combined HRT if their LMP was less than 1 year ago and continuous combined HRT if they have: - taken cyclical combined for at least 1 year or - it has been at least 1 year since their LMP or - it has been at least 2 years since their LMP, if they had premature menopause (menopause below the age of 40)

Answer 215

MRI (The best imaging technique that is able to confirm this diagnosis is MRI, however ultrasound can also aide diagnosis, but it is not the most effective imaging. ) (Laparoscopy is used to diagnose endometriosis, but as adenomyosis occurs within the wall of the uterus, it will not be seen on laparoscopy.)

Answer 216

Adenomyosis is the presence of endometrial tissue in the myometrium.

Answer 217

Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome. Features: - subfertility and infertility - menstrual disturbances: oligomenorrhea and amenorrhoea - hirsutism, acne (due to hyperandrogenism) - obesity - acanthosis nigricans (due to insulin resistance) Investigations: - pelvic ultrasound: multiple cysts on the ovaries - FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes - check for impaired glucose tolerance

Answer 218

Anti -muscarinic - The contraction of the detrusor muscle is controlled by muscarinic cholinergic receptors, with oxybutynin being a direct antimuscarinic agent.

Answer 219

The Mirena intrauterine system

Answer 220

clomifene | clomifene is superior to metformin

Answer 221

- Complete miscarriage is a spontaneous abortion with expulsion of the entire fetus through the cervix. - Pain and uterine contractions stop after fetus has been expelled. - Diagnosis: U/S shows an empty uterus

Answer 222

pelvic pain, dysmenorrhoea, dyspareunia and subfertility

Answer 223

- a benign ovarian tumour - ascites - pleural effusion It is a rare condition usually occurring in woman over the age of 40 years and the ovarian tumour is generally a fibroma. It is managed by the surgical removal of the tumour, however the ascites and pleural effusion may need to be drained first to allow symptomatic relief and improve pulmonary function before the anaesthetic. It has excellent prognosis due to the benign nature of the tumour.

Answer 224

- surface derived tumours - germ cell tumours - sex cord-stromal tumours

Answer 225

Trans vaginal USS

Answer 226

1. The most common cause of postmenopausal bleeding is vaginal atrophy: The thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding 2. HRT (hormone replacement therapy) is also a common cause of postmenopausal bleeding: Periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding 3. Endometrial hyperplasia, an abnormal thickening of the endometrium and a precursor for endometrial carcinoma: Risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes 4. Endometrial cancer: Although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently 5. Cervical cancer: It is important to obtain a full record of prior cervical screening programme attendance 6. Ovarian cancer: Can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours 7. Vaginal cancer: Uncommon but can present with postmenopausal bleeding 8. Other uncommon causes include trauma, vulval cancer and bleeding disorders

Answer 227

- NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer - A thorough history is necessary: Enquire about timing, consistency and quantity of the bleeding, as well as a full gynaecological and obstetric history. It is especially important to ask about risk factors for endometrial cancer and to establish a menstrual timeline from menarche to menopause. A full drug history including HRT use should be sought. Red flag symptoms for gynaecological cancer should be enquired about - A vaginal and a full abdominal examination should be performed: Looking for any masses or abnormalities within the abdomen or felt from within the vagina, as well as a speculum visualisation of the walls of the vagina and cervix. Blood or discharge may be seen - Immediate testing could include a urine dipstick to look for haematuria or infection, a full blood count to look for anaemia or a bleeding disorder, as well as CA-125 levels - For those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice: The endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm. However, it may miss some pathology and if clinical suspicion is high, further testing is required - A definitive diagnosis of endometrial cancer can be achieved by an endometrial biopsy: This can either be taken during hysteroscopy or by an aspiration (pipelle) biopsy, where a thin flexible tube is inserted into the uterus via a speculum to remove cells for testing - Imaging in secondary care could include a CT or MRI of the uterus, pelvis and abdomen - Women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer

Answer 228

- Once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding - Vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used - If a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this - endometrial hyperplasia, usually dilatation and curettage is performed

Answer 229

UTI and diabetes mellitus

Answer 230

A post-void residual volume is used in cases of voiding dysfunction or in patients in whom overflow incontinence is suggested. Features that would indicate this are a full bladder on examination after voiding. These symptoms are more likely in elderly males as they are associated with prostate problems.

Answer 231

Metformin | metformin is also used, either combined with clomifene or alone, particularly in patients who are obese

Answer 232

Increases peripheral insulin insensitivity - The majority of patients with polycystic ovarian syndrome have a degree of insulin resistence which in turn can lead to complicated changes in the hypothalamic-pituitary-ovarian axis.

Answer 233

Tranexamic acid is used for heavy menstrual bleeding, rather than dysmenorrhoea.

Answer 234

Large cervical cone biopsy is a risk factor for 2nd-trimester miscarriage

Answer 235

1- Age - Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35, you have about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it's about 80 percent. 2- Previous miscarriages- Women who have had two or more consecutive miscarriages are at higher risk of miscarriage. 3- Chronic conditions - Women who have a chronic condition, such as uncontrolled diabetes, have a higher risk of miscarriage. 4- Uterine or cervical problems - Certain uterine abnormalities (Mullerian duct anomalies, large cervical cone biopsies) 5- Smoking, alcohol and illicit drugs- Women who smoke during pregnancy have a greater risk of miscarriage than do nonsmokers. Heavy alcohol use and illicit drug use also increase the risk of miscarriage. 6- Weight- Being underweight or being overweight has been linked with an increased risk of miscarriage. 7- Invasive prenatal tests- Some invasive prenatal genetic tests, such as chorionic villus sampling and amniocentesis, carry a slight risk of miscarriage.

Answer 236

breast cancer | - combined HRT increases the risk of breast cancer

Answer 237

fetal heart beat, the size of the uterus and examination to determine whether the cervical os is opened or closed.

Answer 238

FSH level Follicle stimulating hormone (FSH) level is raised significantly in menopausal patients. Test FSH to confirm menopause

Answer 239

admission should be considered in cases of ketonuria and/or weight loss despite use of oral anitemetics - admit for IV fluid and electrolyte replacement, anti-emetics and trial of bland diet