Gynaecology Flashcards
What are the risk factors for endometrial cancer?
- 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 (Lynch syndrome)
What are the protective risk factors for endometrial cancer?
The combined oral contraceptive pill and smoking are protective.
What is the first line investigation performed in women suspected of endometrial cancer?
- 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
Symptoms of cervical ectropion?
- Vaginal discharge (excessive, non-purulent)
- Post-coital bleeding (fine blood vessels easily traumatised)
An offensive, yellow/green, frothy vaginal discharge is seen in what condition?
Trichomonas vaginalis.
- Erythematous cervix with pinpoint areas of exudation (strawberry cervix)
A ‘Cottage cheese’ vaginal discharge is seen in what condition?
Candida.
- ‘Cottage cheese’ discharge
- Vulvitis
- Itch
An offensive, thin, white/grey, ‘fishy’ vaginal discharge is seen in what condition?
Bacterial vaginosis
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)
What is the pharmacological management for primary dysmenorrhoea?
NSAIDs such as mefenamic acid and ibuprofen are first line.
Combined oral contraceptive pills are used second line.
What is the pharmacological management for a women presenting with menorrhagia who does not require contraception?
Either:
- Mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well)
OR
- Tranexamic acid 1 g tds
Both are started on the first day of the period
What is the management for a women presenting with menorrhagia who also requires ongoing contraception?
1st line: Intrauterine system IUS (Mirena)
2nd line: Combined oral contraceptive pill
3rd line: Long acting progestogen (Depo-Provera)
What is the pharmacological management for vaginal candidiasis (thrush)?
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!
Hyperemesis gravidarum is associated with which conditions?
- Multiple pregnancies
- trophoblastic disease/ molar pregnancies
- hyperthyroidism
- nulliparity
- obesity
Multiple and molar pregnancies have been associated with hyperemesis gravidarum, thought to be due to the increased placental mass, and therefore higher beta-hCG levels.
What are the 3 diagnostic criteria triad for hyperemesis gravidarum?
The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis of hyperemesis gravidarum:
- 5% pre-pregnancy weight loss AND
- Dehydration AND
- Electrolyte imbalance
What does PUQE score measure?
Pregnancy-Unique Quantification of Emesis (PUQE) score is a validated scoring system that can be used to classify the severity of nausea and vomitting of pregnancy (NVP).
When is hyperemesis most common?
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels.
Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks (and in very rare cases beyond 20 weeks).
What is the pharmacological management for hyperemesis?
1st line:
Antihistamines: Oral Cyclizine or Promethazine.
Phenothiazines: Oral Prochlorperazine or Chlorpromazine
2nd line:
- Oral Ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate.
- Oral Metoclopramide or Domperidone: Metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days
Admission may be needed for IV hydration.
What are the management options for fibroids?
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)
- Symptomatic management with a levonorgestrel-releasing intrauterine system IUS is recommended by CKS first-line
- Other options include tranexamic acid, combined oral contraceptive pill etc
- GnRH agonists (Leuprolide) may reduce the size of the fibroid but are typically useful for short-term treatment. Shrink the fibroid before surgery
- Surgery is sometimes needed: myomectomy, hysteroscopic endometrial ablation, hysterectomy
uterine artery embolization
What are the causes of secondary amenorrhoea?
Secondary amenorrhoea is defined as when menstruation has previously occurred but has now stopped for at least 6 months.
Causes of secondary amenorrhoea (after excluding pregnancy):
- hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
- polycystic ovarian syndrome (PCOS)
- hyperprolactinaemia
- premature ovarian failure
- thyrotoxicosis* (hypothyroidism may also cause amenorrhoea)
- Sheehan’s syndrome
- Asherman’s syndrome (intrauterine adhesions)
What are the symptoms of fibroids?
May be asymptomatic
- Menorrhagia
- Lower abdominal pain: cramping pains, often during menstruation
- Bloating
- Urinary symptoms, e.g. frequency, may occur with larger fibroids
- Subfertility
What is the most common causative organism of pelvic inflammatory disease?
Chlamydia trachomatis
other:
- Neisseria gonorrhoeae
- Mycoplasma genitalium
- Mycoplasma hominis
What are the symptoms suggestive of PID?
- lower abdominal pain
- fever
- deep dyspareunia
- dysuria and menstrual irregularities may occur
- vaginal or cervical discharge
- cervical excitation
What are the important investigations performed in suspicion of PID?
- Pregnancy test should be done to exclude an ectopic pregnancy
- High vaginal swab (these are often negative)
- Screen for Chlamydia and Gonorrhoea
What is the Abx management for Pelvic inflammatory disease?
Oral Ofloxacin + Oral Metronidazole
OR
Intramuscular Ceftriaxone + oral Doxycycline + oral Metronidazole
- Removal of the IUD should be considered and may be associated with better short term clinical outcomes.
- mild cases of PID - can be left in
What are the complications associated with PID?
- Perihepatitis (Fitz-Hugh Curtis Syndrome)
occurs in around 10% of cases
inflammation of the liver capsule with adhesion formation accompanied by right upper quadrant pain
may be confused with cholecystitis - Infertility, the risk may be as high as 10-20% after a single episode
- Chronic pelvic pain
- Ectopic pregnancy
Who is screened in the UK cervical cancer screening program and how often?
A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self refer once past screening age)
- cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears.
- women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening
What are the features of endometriosis?
Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity.
- 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
Which investigation is performed for suspected endometriosis?
Laparoscopy is the gold-standard investigation
What are the risk factors for ovarian cancer?
- Family history: mutations of the BRCA1 or the BRCA2 gene
- Many Ovulations: Early menarche, Late menopause, Nulliparity
The COCP reduces the risk (fewer ovulations) as does having many pregnancies.
What are the symptoms of ovarian cancer?
Clinical features are notoriously vague:
- Abdominal distension and bloating
- Abdominal and pelvic pain
- Urinary symptoms e.g. Urgency
- Early satiety
- Diarrhoea
What are the causes of secondary amenorrhoea?
Causes of secondary amenorrhoea:
- Pregnancy
- Patient is using contraception
- Menopause
- Lactational amenorrhoea
- Hypothalamic amenorrhoea (suppression of GnRH due to stress, excessive exercise, eating disorder)
- Endocrinological (hyperthyroidism, polycystic ovary disease, Cushing’s syndrome, hyperprolactinaemia, hypopituitarism)
- Premature ovarian failure (autoimmune, chemotherapy, radiation therapy)
- Asherman’s syndrome (iatrogenic intrauterine adhesions/cervical stenosis)
What are the risk factors for ectopic pregnancy?
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)
What are the risk factors for ectopic pregnancy?
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)
What are the symptoms and clinical examination findings of 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
- Lower abdominal pain, due to tubal spasm, typically the first symptom, pain is usually constant and may be unilateral.
- Vaginal bleeding, usually less than a normal period, may be dark brown in colour
- 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
Examination findings:
- 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
What is premature ovarian failure and what are the causes?
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.
- secondary amenorrhoea
- raised FSH, LH levels!
Causes:
- idiopathic - the most common cause
- chemotherapy
- autoimmune
- radiation
Cervical ectropions are a more common finding in which women?
- ovulatory phase
- pregnancy
- combined oral contraceptive pill use
What are the risk factor for urinary incontinence?
- advancing age
- previous pregnancy and childbirth
- high body mass index
- hysterectomy
- family history
What is the treatment for stress incontinence?
First line: 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
What is the treatment for urge incontinence?
First line: 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
What are the symptoms of cervical cancer?
- Abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
- Vaginal discharge
What are the risk factors in the development of cervical cancer?
- 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
- HIV
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- combined oral contraceptive pill
What is the management for endometriosis?
- 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
What is the tumour marker for ovarian cancer?
CA-125
- 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.
- CA125 should not be used for screening for ovarian cancer in asymptomatic women
When is a cervical screen performed in the case of a pregnant woman?
Cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears.
note: women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening
What are the complications of hyperemesis gravidarum?
- Wernicke’s encephalopathy (Vitamin B + C = Pabrinex)
- Mallory-Weiss tear
- Central pontine myelinolysis
- Acute tubular necrosis
- Fetal: small for gestational age, pre-term birth
What are the 5 potential risks/complications of hormone replacement therapy HRT?
Increased risk of breast cancer
- increased by the addition of a progestogen
- the increased risk relates to the duration of use
- 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
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
Increased risk of venous thromboembolism
- increased by the addition of a progestogen
- transdermal HRT does not appear to increase the risk of VTE
- women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
Increased risk of stroke
Increased risk of ischaemic heart disease if taken more than 10 years after menopause
Features of complete miscarriage?
- 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: USS shows an empty uterus
Features of inevitable miscarriage?
Inevitable miscarriage
- heavy bleeding with clots and pain
- cervical os is open
Features of incomplete miscarriage?
Incomplete miscarriage
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os is open
Features of threatened miscarriage?
Threatened miscarriage
- 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
Features of missed miscarriage?
Missed (delayed) miscarriage
- 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’
What are the three features of Meig syndrome?
- A benign ovarian tumour
- Ascites
- Pleural effusion
What is the most reliable test to confirm ovulation in infertility investigation?
Day 21 progesterone test
Day 21 progesterone will only be useful in women with a regular menstrual cycle length of 28 days
What are the causes of menorrhagia?
- 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 device (copper coil)
- Pelvic inflammatory disease
- Bleeding disorders, e.g. von Willebrand disease
What are the contrindications for using the COCP?
- More than 35 years old and smoking more than 15 cigarettes/day
- Migraine with aura (due to an increased risk of ischaemic stroke)
- 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
What are the emergency contraception options available?
Levonelle (levonorgestrel 1.5mg)
- must be taken within 72 hours of UPSI
EllaOne (ulipristal acetate)
- 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
Intrauterine device (IUD)
- must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
What is the age of consent in the UK?
The age of consent for sexual activity in the UK is 16 years. Practitioners may however provide advice and contraception if they feel that the young person is ‘competent’. Usually assessed using the Fraser guidelines.
Children UNDER THE AGE OF 13 years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures.
The Fraser Guidelines state that all the following requirements should be fulfilled:
- the young person understands the professional’s advice
- the young person cannot be persuaded to inform their parents
- the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
- unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
- the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Which cancer risks are increased and reduced by the COCP?
Combined oral contraceptive pill:
- Increased risk of breast and cervical cancer (less likely to use barrier contraception = HPV)
- Protective against ovarian and endometrial cancer, and bowel cancer
Disadvantages of COCP?
Disadvantages of combined oral contraceptive pill:
- people may forget to take it
- offers no protection against sexually transmitted infections
- increased risk of venous thromboembolic disease
- increased risk of breast and cervical cancer
- increased risk of stroke and ischaemic heart disease (especially in smokers)
- temporary side-effects such as headache, nausea, breast tenderness may be seen
The most common cause of ovarian enlargement in women of a reproductive age?
Follicular cyst.
commonest type of ovarian cyst.
How long do women need contraception if uncertain of menopause?
Need for contraception after the menopause:
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Which HPV strain is associated with genital warts?
HPV 6 and 11 are linked to the development of genital warts.
What is protective factor of endometrial cancer?
Past history of combined oral contraceptive pill use. COCP has been shown to reduce the risk of endometrial cancer. It provides a protective effect that persists for many years after discontinuing its use. This is due to the progestogen component of the COCP which counteracts the proliferative effect of oestrogen on the endometrium, thus reducing the risk of endometrial hyperplasia and subsequent malignancy.
COCP protective for Endometrial and Ovarian cancer.
COCP increase risk for breast and cervical cancer.
Management in Ectopic pregnancy? Criteria for expectant, medical and surgical management?
Expectant:
- size <35mm
- Unruptured
- Asymptomatic
- No fetal heartbeat
- HCG <1000
Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.
Medical:
- Size <35mm
- Unruptured
- No significant pain
- No fetal heartbeat
- HCG <1500
- Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow-up.
Surgical:
- Size >35mm
- Can be ruptured
- Visible heart beat
- Surgical management can involve salpingectomy or salpingotomy.
Salpingectomy is first-line for women with no other risk factors for infertility.
Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage.
How to differentiate ovarian cause (premature ovarian failure) and hypothalamus cause (hypothalmic amenorrhea)?
Gonadotrophins (FSH,LH)
Low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure).
Think about the negative feedback loops to differentiate hypothalamic vs ovarian cause.
When is progesterone checked when investigating for infertility?
Serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
The peak of progesterone in the blood will be around 7 days post-ovulation, which is why this blood test is often called (sort of misnamed) the ‘Day 21 Progesterone’.
Mx of PMS?
Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP).
Severe symptoms may benefit from a SSRI.
This may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length).
Pharmacological management for infertility in PCOS?
Infertility in PCOS - Clomifene is typically used first-line.
Most common cause of post coital bleeding?
Cervical ectropion is the most common identifiable causes, causing around 33% of cases.
It involves the eversion of the endocervical columnar epithelium onto the ectocervix, which can lead to an increased susceptibility to trauma and hence bleeding after intercourse.
This is more common in women on the combined oral contraceptive pill
Pharmacological Mx in stress incontinence?
Duloxetine may be offered to women if they decline surgical procedures.
A combined noradrenaline and serotonin reuptake inhibitor.
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction.
Which hormone causes ovulation?
LH
it is a surge of luteinising hormone (LH), not follicle-stimulating hormone (FSH), that triggers ovulation. The LH surge occurs in response to rising levels of oestrogens produced by the maturing follicle, leading to the release of an egg from the dominant follicle around day 14 of a typical 28-day menstrual cycle.
