Gynaecology Flashcards
1
Q
Migraine with aura excludes what contraceptive?
A
COCP
2
Q
What is the Mx for stress incontinence?
A
Pelvic floor exercises for 3mths
3
Q
What is the Mx for urge incontinence?
A
Bladder retraining for
4
Q
What are the risk factors for ectopic pregnancy?
A
- Previous ectopics
- STI
- Delayed conception
5
Q
What are the contraindications to oestrogen based contraception?
A
- Smoking
- Obesity
- Migraine with aura
- Thromboembolism
- Age
6
Q
What are some features of PCOS?
A
Oligomenorrhoea
Hirsutism
Excess weight
Acne
7
Q
How long is the normal uterus?
A
9cm in length
8
Q
In who is a endometrial biopsy indicated?
A
Indicated for women > 45 with menstrual symptoms (HMB and PCB) after confirming that the women is NOT pregnant
9
Q
Up until what week do the gonads remain sexually indifferent?
A
7th week
10
Q
What reaction helps virilise the external genitalia in males?
A
Conversion of testosterone to DHT
by alpha-reductase
11
Q
What are the two types of cells in testes? What hormones do they make and why?
A
Sertoli cells - make AMH - suppress development of mullerian ducts
Leydig cells - make testosterone - promote development of wolffian ducts to make epididymis, vas deferens, seminal vesicles
12
Q
What is the structure of a primordial follice?
A
Ooycyte surrounded by single layer of granulosa cells
13
Q
By how many weeks are the max no. of primordial follices reached?
A
20 weeks
14
Q
Roughly how many follicles remain by birth?
A
1-2 million
15
Q
In what stage are the oocytes arrested and until when?
A
Prophase of first meiotic division until atresia or preceding ovulation
16
Q
What allows the development of mullerian structures in females?
A
Absence of AMH
17
Q
The proximal 2/3 of the vagina develop from the
A
paired mullerian ducts
18
Q
What produces the uterus, cervix and upper vagina
A
fusion of paired mullerian ducts
- unfused caudal segments form the fallopian tubes
19
Q
The paramesonephric duct later forms what?
A
Mullerian system = precursor of female genital development
20
Q
What are bartholin’s glands?
A
Two pea sized compound alveolar glands located slightly posterior and to the left and right of the opening of the vagina - contribute to lubrication during intercourse - can get cysts on them causing their enlargement
21
Q
Carunculae myrtiformes
A
remaining tags of the hymen after rupture
22
Q
What is the vagina lined by?
A
Stratified squamous epithelium
23
Q
Before puberty and after menopause, the vagina has no …. and why?
A
Glycogen, due to lack of stimulation by oestrogen
24
Q
What breaks down glycogen in the vagina?
A
Doderlein’s bacillus - breaks down glycogen to form lactic acid, to make low pH
25
The cardinal ligaments and uterosacral ligaments form
the parametrium
26
The cornu of the uterus is the
site of insertion of the fallopian tube
27
In 20% of women, the uterus is tilted
backwards - retroversion and retroflexion
28
What are the three layers of the uterus?
Peritoneum, myometrium, endometrium
29
The endometrial layer of the uterus is covered by what
Single layer of columnar epithelium
30
Describe the epithelium of the cervix
Endocervix is columnar and ciliated in upper two thirds
Transitions to squamous epithelium at squamocolumnar junction
31
At birth what is the size of the cervix compared to the uterus
Twice length
32
What are the four parts of fallopian tubes and how long are they?
```
10cm long
Four parts
- Fimbriae
- Infundibulum
- Ampulla
- Isthmus
```
33
What are the two types of cells in the fallopian tubes?
Ciliated cells - produce a constant current of fluid in direction of the uterus
Secretory cells - contribute to the volume of the tubal fluid
34
When the corpus luteum undergoes atresia what does it become?
Corpora albicans
35
How is the muscle of the bladder arranged?
Involuntary muscle
Inner layer -> longitundinal
Middle layer -> circular
Outer -> longitudinal
36
What is the bladder lined by? What is its average capacity?
Transitional epithelium
| 400mL
37
What is the trigone?
The internal meatus of the urethra
38
What muscles form the pelvic diaphragm?
Levator ani, comprised of:
- Pubococcygeus
- Iliococcygeus
39
What lung manifestation is common for malignancies?
PE
40
What is often removed in ovarian cancer?
The omentum
41
What are the relapse rates for ovarian cancer? What is the 5 year survival rate? What is a big problem of treatment?
70% within 3 years
- Chemo resistance is a big problem
5 year survival rate = 46%
42
In what 3 settings can chemo be given?
Adjuvant - often given to treat micrometastatic disease we can't see and reduce chance of cancer coming back
Neo-adjuvant
Palliative
43
What does bevacizumab target?
VEGF, targets angiogenesis as a treatment for cancer
44
What role do BRCA1 and BRCA2 play in the cell?
Repair damaged DNA via homogolous recombination
45
What could cause a rising creatinine in gynae malignancy?
Ureteric obstruction
46
What are you worried about if a patient develops a fever after chemotherapy?
Neutropenic sepsis
47
What is the treatment for neutropenic sepsis?
```
Admit
IV Antibiotics (if not allergic) - don't wait until bloods come back, start immediately
```
48
What is the most common gynaecological cancer?
Endometrial
49
What is high grade serous epithelial ovarian carcinoma characterised by?
Psammoma bodies -> concentric rings of calcification
50
Pseudomyxoma peritoneii characterises what ovarian tumour?
= mucin in the peritoneal cavity
| characterises mucinous carcinomas
51
30% of high-grade pelvic serous cancers have
BRCA mutations
52
Endometriod ovarian cancer is often found alongside what other cancer?
Endometriod endometrial Ca
53
Endometriosis-associated ovarian cancers are usually what types of epithelial ovarian cancers?
Endometriod
| Clear cell
54
What may be a precursor to high grade pelvic serous carcinoma (ovarian Ca)?
STIC = serous tubal intraepithelial carcinoma (fallopian tube precursor)
55
What is Lynch syndrome and what is it associated with?
Hereditary non-polyposis colorectal cancer, MLH-1, MLH-2 mutations
Associated with:
- endometrial ca
- ovarian ca
- stomach, small intestine, biliary tract etc
56
What % of hereditary cancers does BRCA account for?
90%
BRCA 1 = 80%
BRCA 2 = 15%
57
Differential diagnoses for pelvic mass
- Ovarian tumour (epithelial or non-epithelial)
- Tubo-ovarian abscess
- Endometrioma
- Fibroids
58
What is the presentation of ovarian Ca?
Often vague and non-specific, can be abdominal fullness/bloating, early satiety, abdo or pelvic pain
59
In what conditions is CA125 raised?
80% of epithelial ovarian cancers
- pregnancy
- endometriosis
- alcoholic liver disease
60
In ovarian cancer what is the RMI (risk of malignant index) calculated from and what are the rough ranges for high/low risk?
- Menopausal status
- USS features
- Ca125 level
>250 high risk
<25 low risk
61
What staging is used for ovarian cancer?
```
FIGO
1 - within ovary
2- outside ovary but within pelvis
3- outside ovary but within abdomen
4- mets
```
62
What is the main management of ovarian cancer?
Surgery + platinum based chemo eg carboplatin + paclitaxel
63
What is the most common type of malignant germ cell ovarian tumour?
Dysgerminoma
64
Mature teratoma is also often called a
dermoid cyst
65
What is the most common type of benign germ cell ovarian tumour?
Mature teratoma
66
What ovarian tumour secretes alpha-fetoprotein?
Germ cell tumour: endodermal sinus yolk sac tumour
67
What is the most common chemo regimen for germ cell tumours?
BEP
- Bleomysin
- Etoposide
- CisPlatin
68
What is the Mx of germ cell ovarian tumours?
Surgery + Chemo
- fertility sparing treatments may be preferred as patients likely to be younger
- post-op chemo depends on staging: often includes BEP: bleomycin, etoposide, cisplatin
69
How may sertoli-leydig cells present?
They may produce androgens so can present with
- Virilisation
- Amenorrhoea
- Deep voice
They can also produce renin leading to HTN
70
What can granulosa cell tumours produce which can be helpful in follow-up surveillance?
Inhibin
71
Which type of sex cord stromal tumour requires long-term follow up?
Granulosa cell as they often recurr
72
What is the mainstay of treatment for sex cord stromal tumours?
SURGERY
| - chemo is not effective
73
What ovarian tumours usually present with endocrine effects?
Sex cord stromal due to hormone production eg
- Granulosa -> oestrogen
- Sertoli-Leydig -> androgens
74
What are the two types of ascites?
Transudate: <30g/L protein
Exudate: >30g/L
75
What are some causes of exudative ascites?
1) Malignant infiltration of peritoneum
2) Pancreatitis
3) Abdominal TB
76
What are some causes of transudative ascites?
1) Cardiac failure
2) Hypoalbuminaemia
3) Hepatic cirrhosis
4) Myxoedema
5) Renal failure
77
What is a Krukenberg tumour?
Ovarian metastases (bilateral) from breast/gastric/colonic carcinoma
78
Meig’s syndrome
TRIAD: Ovarian fibroma causing ascites + pleural effusions
| - most are benign + resolve with tumour resection
79
What cell type are most cervical cancers?
Squamous
80
What is the most common histological subtype of ovarian carcinoma?
Cystadenocarcinoma
81
On transvaginal USS when should endometrial biopsy be attempted?
If >4mm thick
82
Risk factors for endometrial cancer
- Anovulatory cycles that cause unopposed oestrogen exposure
- High BMI/Obese
- Nulliparity
- T2DM
83
Why may breast cancer patients be at increased risk of endometrial cancer?
If treated with tamoxifen -> anti-oestrogenic in breast, but stimulatory effect in endometrium
84
What are some causes of post-menopausal bleeding?
1. Assume ENDOMETRIAL CANCER unless otherwise ruled out
2. Other cancer eg vaginal, vulvulal, cervical or ovarian
3. Atrophic vaginitis
4. Unscheduled bleeding on HRT
85
At what site do malignancy and premalignancies develop in the cervix?
Transformation zone - ie the area between the original SCJ and the new SCJ
86
If CIN 2 or higher is seen on cervical smear, what do you do?
Urgent colposcopy
87
If a low grade neoplasia is seen on colposcopy what do you do?
Repeat colposcopy + cytology in 6 months
88
If a high grade neoplasia is seen on colposcopy what do you do?
See and treat
89
What stains are used in colposcopy and what do they show?
Acetic acid - cells of increased turnover stain white
| Iodine - stains brown for intracytoplasmic glycogen stores - neoplastic cells LACK these so they do NOT stain brown
90
What are the risks of loop diathermy eg LLETZ?
Midtrimester miscarriage
| Preterm delivery
91
What are the risks of cone biopsy?
Cervical stenosis
| Cervical incompetence
92
What is given prophylactically to chemo patients at risk of neutropenic sepsis?
GCSF
93
If hypercalcaemia is noted in a cancer patient, what medication review should you do?
Stop thiazides and Ca supplements
| - Consider starting bisphosphonates
94
What are the side effects of bisphosphonates?
- Bone and joint pain
- Electrolyte imbalances
- Nausea
- Transient flu like symptoms
Rarely
- osteonecrosis of jaw
- acute renal failure
95
What is the standard operation for stage 1B tumours in cervical cancer?
Wertheim's hysterectomy = radical hysterectomy + pelvic node disssection
96
What is Wertheim's hysterectomy?
Radical hysterectomy + pelvic node dissection (obturator, external, internal iliac nodes)
97
If a patient has early stage cervical cancer and wants to have children in the future, what treatment can be given?
```
Fertility sparing treatment
Radical trachelectomy (removal of cervix and upper vagina) and pelvic node dissection
```
98
What are the risks/SEs of wertheim's hysterectomy / radical trachelectomy procedure?
1. Bladder incontinence (common in post-op period)
2. Sexual dysfunction (due to vaginal shortening)
3. Lymphoedema (due to pelvic node removal)
99
What procedure should be done regarding the lymph nodes in vulvulal cancer?
Spread via inguinofemoral lymph nodes so
| full inguinofemoral lymphadenectomy for all tumours >1mm depth
100
What cells synthesise and release FSH and LH in the anterior pituitary gland?
Basophil cells
101
What causes the periovulatory LH surge?
High levels of oestrogen in late follicular phase
102
What does the COCP do to oestrogen levels and what impact does this have on LH?
Maintains oestrogen levels within the negative feedback range - prevents LH surge
103
What effect does progesterone have on LH and FSH levels?
Low progesterone stimulates LH and FSH release from basophil cells in anterior pituitary
High progesterone prevents LH and FSH release
104
What are the four "general" phases of menstrual cycle?
Menstruation
Follicular phase
Ovulation
Luteal phase
105
What are the three phases the ovary goes through in the menstrual cycle?
Follicular
Ovulation
Luteal
106
If LH and FSH are absent, what happens to follicular development?
Will fail at the preantral phase and follicular atresia occurs
107
Why should women wanting to get pregnant avoid taking aspirin or ibuprofen?
These are prostaglandin synthetase inhibitors. Prostaglandins help influence the breakdown of the follicular wall and subsequent ovulation.
108
Why is haemostasis different to usual in the endometrium?
It does NOT involve clot formation and fibrosis
109
How does the process of aromatisation work within the follicles and what does it require?
Thecal cells convert cholesterol to androgens under the influence of LH
Granulosa cells under the influence of FSH convert these androgens (from thecal cells) into oestrogens via the process of aromatisation
110
What does rasburicase do and why is it given with chemotherapy?
Decrease production and urinary excretion of uric acid, by converting it to allantoin. Helps prevent tumour lysis syndrome
111
What two hormones are secreted by granulosa cells and what impact do they have on FSH release?
Inhibin - downregulates FSH release and enhances androgen synthesis
Activin (nb: also released by pituitary cells)- upregulates FSH binding on follicles
112
By the end of the follicular phase, the dominant follicle will be of what diameter?
20mm
113
What causes progesterone levels to rise in the ovulation phase of the menstrual cycle?
LH-induced luteinisation of granulosa cells in the dominant follicle
114
What causes the resumption of meiosis in the ovum?
LH surge
115
What cellular mediators influence the physical ovulation?
Prostaglandins
Proteolytic enzymes
LH
FSH
116
What makes up the corpus luteum?
Remaining granulosa and thecal cells after release of the oocyte
117
How long does the luteal phase last?
14 days
118
What cellular change occurs at the beginning of the proliferative phase of the menstrual cycle?
Single layer of columnar cells become pseudostratified epithelium
119
What are the three layers of the uterus immediately before menstruation occurs?
Stratum compactum
Stratum spongiosum
Basalis
120
What are some cellular mediators involved in menstruation?
Prostaglandins, endothelins, platelet activating factor, prostacyclin, nitric oxide
121
What is amenorrhoea?
Absence of menstruation for more than 6 months in the absence of pregnancy in a woman of fertile age
122
What is oligomenorrhoea?
Irregular periods at intervals of more than 35 days, with only 4-9 periods per year
123
What is Premature ovarian failure?
Cessation of periods <40yrs of age
124
Define Primary Amenorrhoea
when a girl fails to menstruate by 16 years of age
125
Define secondary amenorrhoea
Absence of menstruation for > 6 months in a normal female of reproductive age that is not due to pregnancy, lactation or menopause
126
What is PCOS associated with?
T2DM
| Cardiovascular events
127
What drug can be given to women with PCOS who are having fertility issues?
Clomiphene -> SERM
128
What criteria is used for PCOS?
Rotterdam consensus criteria
1. Oligomenorrhoea/amenorrhoea
2. Polycystic ovaries
3. Clinical or biochemical androgenism
129
Management of PCOS
1. COCP
2. Cyclic progesterone
3. Clomiphene
4. Lifestyle advice + weight loss advice
5. Ovarian drilling
6. Tx of androgenism: COCP, co-cyprindiol
130
What does a "pearl necklace" sign indicate on TVUSS?
PCOS
131
What endocrine condition should be potentially checked for in PCOS?
```
Diabetes
OGTT @ diagnosis for
– BMI >25
– Non-Caucasian ethnicity
– Any BMI + >40yo, FHx, DM, GDM (gestational diabetes) hx
Annual OGTT for
– IFG (fasting 6.1-6.9mmol/L)
– IGT (OGTT 7.8-11.1mmol/L)
```
NB: also check for CVD health ie cholesterol, BP etc
132
What endocrine condition can be associated with premature ovarian failure?
Addison's disease
| - steroid cell autoAbs can cross react with thecal and granulosa cells
133
What hormone marks premature ovarian failure?
High FSH, 2 results >30 taken 4-6wks apart
134
What three things are needed to diagnose premature ovarian failure?
1. Raised FSH >30 on two occasions 4-6wks apart
2. Menopausal symptoms
3. <40YO
135
What are the signs and symptoms of asherman's syndrome?
Amenorrhoea
Cyclical abdo pain
Subfertility
136
Mutations in p53 are associated with which type of endometrial cancer?
Type 2 (SC ie uterine papillary Serous carcinoma or Clear cell carcinoma)
137
Mutations in PTEN or PI3KCA are associated with which type of endometrial cancer?
Type 1 (SEM ie secretory, endometroid or mucinous)
138
What is intermenstrual bleeding associated with?
Cervical and endometrial polyps
| Endometriosis
139
What is post-menopausal bleeding?
Bleeding more than 1 yr after cessation of periods
140
How do we define HMB?
previously >80ml blood lost per period
| - now: based on patient perception about what is unusually heavy for them
141
What are the indications for GnRH agonists?
Act on pituitary to stop production of oestrogen and cause amenorrhoea
- ->used only in SHORT term eg
- shrinking fibroids preoperatively
- suppressing endometrium to enhance visualisation on hysteroscopy
142
How can recent pregnancy or miscarriage result in PV bleeding?
Retained placental tissue
143
What are benign leiomyomata?
Fibroids = benign tumours of smooth muscle tissue
144
What can happen with respect to fibroids in pregnancy?
They grow rapidly during pregnancy due to the increased hormone exposure. They can outgrow blood supply and infarct or they can also cause obstruction during delivery.
145
How do dermoid cysts tend to present?
15% present acutely with torsion
146
"clue cells" on microscopy suggest what condition?
Bacterial vaginosis
| - usually presents with a watery, grey, fish smelling discharge
147
Strawberry cervix suggests what condition?
Trichomonas vaginalis
148
What does a high vaginal swab for nucleic acid amplification test (NAAT) for?
Chlamydia and Gonorrhoea
149
How common is organism identification in pelvic inflammatory disease? What are the most common organisms identified?
50% of cases organisms are identified, most commonly Chlamydia trachomatis and Neisseria gonorrhoeae.
150
What is the first line treatment for gonorrhoea?
Ceftriaxone 1g i.m. STAT. Ciprofloxacin can be used as an alternative, only if all sites of exposure are cultured and found to be sensitive.
151
What is the drug of choice to treat Chlamydia in a pregnant woman?
Azithromycin 1g STAT followed by 500mg OD for 2days
Erythromycin 500mg QDS for 7 days is an acceptable second line therapy as per BASHH Guidelines 2017 for Chlamydia management
152
What advice should be given to patients who have CIN?
Stop smoking -> it lowers local immune responses + allows HPV infection to persist and cause cellular changes
153
How often should a woman be followed up after a diagnosis of CIN?
Yearly
154
What is the commonest cause of lost threads of a coil?
Movement of the IUD into cervical canal or a uterine cavity. If they cannot be located on speculum examination then do TVUSS if still not then AXR.
155
If a IUD translocates into the abdominal cavity what should you do?
Laparoscopy and removal.
| Small risk of adhesions and therefore bowel obstruction if left in
156
What is the appropriate management of a symptomatic Bartholin's cyst? What is a complicated presentation of Bartholin's cyst and how should it be managed?
Marsupialisation = drainage of cyst and suturing of inner wall of affected gland to the skin to reduce risk of recurrence
Can present as acute Bartholin's abscess ->need to expedite the marsupialisation and provide broad spec Abx if pt is unwell
157
When would you elect to remove a Bartholin's cyst and what are the complications of this procedure?
Heavy blood loss => consider only in rare cases of Bartholin gland cancer
158
Gold standard for diagnosing endometriosis?
Laparoscopy + focused biopsies
159
How can endometriosis affect fertility?
Can cause subfertility due to pelvic adhesions and distortion which interferes with tubal function and egg capture
160
Powder burn spots under the peritoneum or ovaries seen on laparoscopy are diagnostic of what?
Endometriosis
161
What are possible options after endometrial surgery to manage pain and prolong benefits of surgery?
```
COCP
Progesterone only pill
GnRH analogue injections
NSAIDs
TENS
```
162
Describe what happens to the following hormones in the perimenopausal, early postmenopausal and late postmenopausal/elderly period
- Inhibin B
- GnRH
- LH & FSH
- Oestrogen
- Progesterone
- Testosterone
- Inhibin B: declines in perimenopausal period (as less follicles) to rapid decrease in early postmenopause and undetectable in late menopause
- GnRH: increase in pulsatility in perimenopause to progressive decline across early post-menopause.
- LH & FSH: increased in perimenopause and early post, to progressive decline in late menopause
- Oestrogen: slightly declines, then rapid decline in early postmenopause, to sustained very low levels in late postmenopause
- Progesterone: moderate fall to variable levels in early postmenopause. Undetectable in late postmenopause.
- Testosterone: progressive decline throughout, to circulating low levels in late menopause onwards
163
What are some causes of premature ovarian insufficiency?
PRIMARY:
- Chromosomal abnormalities eg turners or fragile X
- Autoimmune disease eg hypothyroidism, addison's, myasthenia gravis
- Enzyme deficiencies eg 17-alpha-hydroxylase deficiency
SECONDARY:
- Chemo or radiotherapy
- Infections eg TB, mumps, varicella, malaria
164
What are some examples of GnRH agonists? What is problematic about their long term use?
Buserelin or goserelin
- Cause hypooestrogenic state eventually
- Problematic as desensitisation occurs so LH and FSH release will eventually dwindle -> can induce a temporary menopause
165
When can you diagnose ovulatory/endometrial dysfunction?
Diagnosis of exclusion
166
What are some examples of antifibrinolytic agents?
Tranexamic acid
| Mefanemic acid
167
A 16-year-old patient was admitted as an emergency with retention of urine. She never had any period. She experienced lower abdominal pain, which got worse from time to time. She was not taking any medication and her past history as well as family histories were unremarkable. General examination showed average normal weight and height with developed secondary sexual characters. Abdominal examination showed tenderness and distension below the umbilicus. Vaginal examination showed violet bulging membrane.
Imperforate hymen
168
What does anterior vaginal wall prolapse result in and how does this manifest?
Cystocele ie prolapse bladder. Causes acute retention spells due to urethral kinking.
169
What is an operation for stress incontinence of urine?
Mid-urethral tape sling insertion
170
What is a biochemical pregnancy?
+ve pregnancy test before the woman's period, then a -ve pregnancy test after. Means the fertilised embryo failed to implant.
171
What type of contraception increases weight?
Depo-provera injection
172
What state will the cervical os be in a complete miscarriage?
Closed
173
What should NOT be offered for miscarriage?
Mifepristone
174
What drug should be offered for medical management of miscarriage?
Vaginal misoprostol (can also give orally depending on patient preference)
175
What should be offered to all Rhesus-negative women undergoing surgical management of miscarriage?
Anti-D prophylaxis
176
How do you screen for antiphospholipid syndrome?
Lupus anticoagulant and anti-cardolipin Abs
| +ve = 2 + results at least 12 weeks apart
177
What is recurrent miscarriage?
Loss of 3 or more pregnancies
178
What are the causes of recurrent miscarriage?
* Antiphospholipid syndrome
* Cervical abnormalities
* Foetal chromosomal abnormalities
* Uterine malformations
* Thrombophilia
179
What are the investigations for recurrent miscarriage?
• Screen for antiphospholipid syndrome
o Lupus anticoagulant
o Anti-cardiolipin antibodies
o DIAGNOSTIC: 2 positive results at least 12 weeks apart
• Cytogenetic analysis
o Of products of conception in the last miscarriage
o Of both partners peripheral blood
• TVUSS to assess for uterine anomalies
• Screen for inherited thrombophilia (e.g. factor V leiden)
180
How can we reduce miscarriage risk in anti-phospholipid syndrome?
o Low-dose aspirin + LMWH in future pregnancy reduces risk of miscarriage by 54%
181
What is a Heterotopic pregnancy?
Simultaneous development of two pregnancies, one WITHIN and one OUTSIDE of uterine cavity
182
What is the acute presentation of ectopic pregnancy?
Rupture + massive intraperitoneal bleeding
- signs of acute abdomen (abdo rebound tenderness + guarding)
- signs of hypovolaemic shock
+ a POSITIVE pregnancy test
183
Presence of moderate to significant free fluid in pouch of douglas on TVUSS is suggestive of...
ruptured ectopic pregnancy
184
What happens to serum hCG in a normal pregnancy? How does this differ to an ectopic?
Normally it DOUBLES every 48HRs
| - in ectopic the rise is often suboptimal
185
What are the investigations of ectopic pregnancy?
1. ABCDE
2. Abdopelvic examination
3. TVUSS
4. hCG (serial measurements if possible)
5. Hb + Group + Save
186
Why would you do a Hb/group and save in ectopic pregnancy?
Degree of intra-abdo bleeding and RHESUS STATUS
187
How do you manage a ectopic pregnancy?
1. Expectant (take serial hCG until undetectable), suitable if asymptomatic and no haemodynamic compromise
2. Medical (if no FH, no IU pregnancy confirmed by USS, hCG<1500 and adnexal mass of <3.5mm, no sig pain)
IM Methotrexate +
- 2 serum hCG measurements day 4 and 7, then one a week until neg
- no sex, minimise alcohol + vit D exposure during, no conception for at least 3mths
3. Surgical (if adnexal mass >3.5mm, hCG>5000, sig pain, visible FH)
- ideally laparoscopic: salpingotomy or saplingectomy (ideally) depending on fertility + previous gynae/obs Hx
- may need anti-D prophylaxis if rhesus neg
FOLLOW-UP for Salpingotomy: 1 serum hCG at 1 weeks, then 1 serum hCG per week until negative result is obtained
FOLLOW-UP for Salpingectomy: urine pregnancy test at 3 weeks
188
Diaphragmatic + shoulder tip pain in a woman with PV bleeding suggests?
Ruptured ectopic pregnancy
189
What is the cut off level above which a gestational sac should be seen in the uterus on transvaginal ultrasound?
bHG >1000IU
190
In a non-urgent ectopic pregnancy presentation, what should be measured and over what time?
Serial hCG measurements over 48 hrs
- if doubles every 48hrs then healthy progressing pregnancy
- if does not substantially rise and uterus is empty + positive preg test -> ectopic
191
What is protamine sulphate used for?
To reverse the effects of unfractioned heparin
192
What are the "best" forms of contraception?
LARCs - long acting reversible forms of contraception
193
How often does Nexplanon need to be replaced?
(=implant) 3 years
194
How should MEC be used for contraception prescribing?
```
The WHO medical eligibility criteria:
4 levels:
1 - no restriction for use
2 - benefits outweight risks
3 - risks outweigh benefits
4 - absolute contraindication
```
195
What should be advised to women taking liver-enzyme inducing drugs and needing contraception?
```
If on hormonal contraception -> also use condoms
OR
Switch to non-affected method eg
- cu-IUD
- LNG-IUS
- progesterone implant (nexplanon)
```
196
What are some side effects of hormonal contraceptives?
```
o Unexpected bleeding
o Weight gain (IMPORTANT)
o Headaches
o Mood swings
o Loss of libido
```
197
What should a lady do if she misses a pill or more in the last week of her 21 day on-pill?
Finish remaining pack of pills and then immediately take another pack back to back (ie don't have withdrawal bleed)
198
In what circumstances with the patch and the ring should a woman take extra-contraceptive precaution eg condoms or abstinence?
* Patch is not applied for 48 hours
| * Ring is not applied for more than 3 hours
199
What are the cancer risks among COCP users?
12% reduced risk of any cancer
• Reduced risk of colorectal, endometrial and ovarian cancer
• Increased risk of breast cancer during use
• Increased risk of cervical cancer
200
KEY contraindications for combined contraceptives?
- Previous/current VTE or strong FHx
- Migraine with aura -> increased risk of cerebral vasospasm + stroke
- 35yo or older + smoker -> risk of arterial disease
- any Hx of MI or stroke or VTE
201
What are the SEs of progesterone only contraceptives?
* Irregular bleeding
* Persistent ovarian follicles (simple cysts)
* Acne
202
What should a woman do if she misses a progesterone only pill?
Take extra precaution for next 48hrs
203
How is nexplanon inserted?
Subdermally 8 cm above the medial epicondyle usually in the non-dominant arm under local anaesthesia
204
MOST COMMONLY used injectable worldwide is a depot injection of
Medroxyprogesterone acetate (ie progesterone implant)
205
What investigation do women with strawberry cervix and frothy yellow discharge need? What is the likely cause?
Vulvovaginal swab + mcs. Trichomoniasis.
206
What contraception is associated with increased risk of actinomycosis and PID?
Copper coil. It also has an increased risk of perforation.
207
What contraceptive is associated with a decreased risk of PID and may cause irregular bleeding in the first 3mths?
Mirena
208
What contraceptive has side effects inducing weight gain, irregular bleeding and an increased risk of osteoporosis?
Medroxyprogesterone IM
209
What contraceptive is known to be effective against PID and endometrial cancer?
Implant. Also can be used in breastfeeding mothers.
210
What is a oestrogen-secreting tumour associated with abdominal bleeding seen commonly in women 40+?
Endometrial
211
What is the diagnostic test for gonorrhoea? How do we treat it?
Endocervical swab. Tx: ciprofloxacin or ampicillin.
212
What is the lx of choice in a afro-carribean woman with painful periods and urinary retention?
USS. Likely to be PCOS.
213
What is the mainstay of treatment in patients with ovarian cancer except those with stage 1a?
Surgery + chemo
214
What is the most common form of female sterilisation?
Filshie clips to occlude the fallopian tubes
215
How long should contraception be used after female sterilisation?
If laparoscopic then until next menstruation
| If hysteroscopic then 3 mths after
216
What does hysteroscopic sterilisation involve?
Can be performed as outpatient without GA
- Microinserts (expanding springs) inserted into tubal ostia via a hysteroscope -> they induce fibrosis in cornual section of fallopian tube (takes 3mths)
217
What is the most effective form of emergency contraception?
Cu-IUD
| - can be put in place up to 5 days after unprotected sex or 5 days after predicted ovulation
218
What are the two forms of oral emergency contraception?
1. Levonorgestrel: effective 72hr after unprotected sex
| 2. Ulipristal acetate: effective up to 5 days after
219
What does medical abortion involve?
Combination of
- mifepristone (progesterone receptor modulator) - brings about increase in uterine contractility and sensitises the uterus to exogenous prostaglandins, max effect at 48hr
- misoprostol (prostaglandin analogue) - brings about expulsion through dilated cervix with cramping, pain + bleeding
<9wks: done at home
9-21wks: done in clinical setting as more blood/bigger fetus. give woman 3hrly doses of misoprostol until expulsion occurs
21-24wks: clinical setting + feticide (as fetus might display signs of life) eg intracardiac injection of KCl or intrafoetal /intramniotic digoxin
220
What are the surgical methods of abortion?
Up to 14 wks: manual vacuum aspiration or electrical vacuum aspiration (give cervical dilator to assist eg 400mcg misoprostol sublingually 1hr before procedure)
After 14wks: dilation and evacuation +USS after to confirm
- need to really dilate cervix eg 20mm (can use osmotic dilators, misoprostol (vaginal or sublingual), mifepristone)
221
What is subfertility?
Failure to conceive after 12mths of regular unprotected intercourse
222
What are the SEs of surgical management of miscarriage?
- Cervical Trauma
- Bleeding
- Infection
- Retained products of conception
- Repeat ERPC
- Uterine perforation
223
What is a potential SE of ovulation induction?
Ovarian hyperstimulation syndrome (esp caused with gonadotrophin therapy)
- ascites
- vomiting
- diarrhoea
- high haemocrit
NB: ovulation may also be induced with clomiphene citrate, raloxifene, letrozole or anastrozole
224
MOST IMPORTANT FACTOR affecting fertility is
female age
225
What is antral follicle count?
Parameter of ovarian reserve
<4 = poor response
16+ = good response
226
What investigations can be done to explore subfertility in a female?
- Blood hormone levels: FSH, LH, Oestradiol, AMH, Testosterone, TFTs, Prolactin
- Chlamydia screening
- HIV, HBV, HCV screening
- TVUSS (pathology? antral follicle count)
227
What is the most successful biomarker of ovarian reserve?
Anti-mullerian hormone
228
What two markers may be used by clinics to establish ovarian reserve?
- AMH
| - Antral follicle count
229
How is a tubal assessment done in women?
Hysterosalpingography using an X-ray or USS
230
What is the main male investigation for subfertility?
Semen fluid analysis
• Looks at: volume, sperm concentration, total sperm number, motility, morphology, vitality and pH
Refrain from ejaculation 2-4days before
231
What options are there for managing subfertility?
```
MEDICAL
1 Ovulation induction
2 Intrauterine insemination
3 Artificial insemination
4 IVF
5 Donor egg + IVF
```
```
SURGERY
1 Operative laparoscopy to treat disease and restore anatomy
2 Myomectomy
3 Tubal surgery
4 Laparoscopic ovarian drilling
```
232
What may insemination procedures be accompanied with?
SC injections of FSH for stimulation
233
What is the most common cause of post-partum haemorrhage?
The 4 'T's
- Tone eg uterine atony
- Tissue eg retained placenta
- Trauma eg vaginal, cervical or uterine
- Thrombin eg deranged clotting as a result of bleeding
234
What management should be undertaken for fibroids?
If <3cm in size and not distorting the uterine cavity - Medical treatment
1st line: IUS
2nd Line: Tranxemic acid, COCP
3rd Line: GnRH agonists
Surgical treatment
1. Myomectomy
2. Hysteroscopic endometrial ablation
3. Hysterectomy
4. Uterine artery embolisation
235
VERY RARELY, infants born to mothers with HPV may develop what condition?
Respiratory papillomatosis (papillomas grow in the resp tract)
236
Treponema pallidum causes what condition? How is it spread?
Syphilis. Direct contact with secretions from infected lesions or via transplacental passage during pregnancy.
237
What is the first manifestation of syphilis?
Chancre at the site of exposure: single, painless, indurated, exudative lesion leaking T pallidum
238
Causes of secondary amenorrhoea
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan's syndrome
Asherman's syndrome (intrauterine adhesions)
239
How does secondary syphilis present?
Widespread erythematous rash including palms and soles. Condylomata lata.
240
How may haematagenous spread of Gonorrhoea present?
Disseminated gonococcal infection causing a purpuric non-blanching rash and/or arthralgia (usually monoarticular in a weight bearing joint)
241
How is trichomoniasis managed?
Metronidazole
| Simultaneous treatment to current and historic sexual partners
242
What spread of infections can be associated with gonorrhoea?
Rectal (receptive anal sex), pharyngeal (oral sex), haematogneous, ophthalmic (genital secretions), neonatal infection (if endocervical infection at time of delivery)
243
What is the management of gonorrhoea?
IM Ceftriaxone
244
How is a dual infection with gonorrhoea and chlamydia managed?
3rd gen cephalosporin eg ceftriaxone AND azithromycin
245
Neonates born to mothers with cervical chlamydia infection may develop what infection?
Conjunctivitis
246
What STIs require simultaneous treatment?
Gonorrhoea. Chlamydia. Trichomoniasis.
247
Management of chlamydia
Azithromycin or doxycycline
248
In what condition should you test for ALL stis?
Pelvic inflammatory disease
249
What are the most common causes of PID?
Chlamydia
Mycoplasma genitalium
Vaginal flora
[less common with gonorrhoea]
250
How should you manage women with first-acquisition genital herpes in the 3rd trimester?
C-section
251
What are the most common causes of genital warts?
Types 6 and 11 HPV
252
In what type of incontinence do you have an incompetent urethral sphincter?
Stress - bladder neck falls through urogenital hiatus during increases in intraabdominal pressure
253
Treponema pallidum causes what condition?
Syphilis
254
What is the first manifestation of syphilis?
Chancre at the site of exposure: single, painless exudative lesion leaking T pallidum
255
In what condition are condylomata lata seen?
Late stage syphilis. They are raised papules/plaques usually seen on anogenital area.
256
How does secondary syphilis present?
Widespread erythematous rash including palms and soles. Condylomata lata.
257
How may haematagenous spread of Gonorrhoea present?
Disseminated gonococcal infection causing a purpuric non-blanching rash and/or arthralgia
258
Complications of syphilis?
- Meningitis
- 8th nerve palsy leading to deafness or tinnitus
- Ophthalmic involvement (uveitis)
```
Late Complications
- Gummatous lesions (granulomatous, locally destructive lesions typically affecting the skin and bone)
- Cardiovascular involvement (usually affecting ascending aorta, resulting in aortic valve incompetence)
- Neurological involvement
Meningo-vascular disease
Tabes dorsalis
Progressive dementing illness
General paresis
```
259
What are some of the complications in pregnancy of syphilis?
- FGR
- Stillbirth
- Foetal hydrops
- Preterm birth
- Congenital syphilis (rash on soles and feet, bone lesions)
- Neonatal death
260
In women, the urethral sphincter mechanism consists of
Internal sphincter: smooth muscle
| External: striated muscle
261
In what type of incontinence do you have an incompetent urethral sphincter?
Stress
262
What is the NICE recommended staging system for prolapse?
POP-Q
263
What are the common urodynamic diagnoses?
1. Detrusor overactivity
2. Detrusor overactivity incontinence
3. Urodynamic stress incontinence
4. Mixed incontinence
264
What are the types of functional cyst and what size do they have to be diagnosed? What one is associated with ovulation and what one with pregnancy?
>3cm.
Follicular cysts
Corpus luteal cysts - ovulation associated
Theca luteal - pregnancy associated
265
What do “chocolate cysts” refer to?
Presence of altered blood within the ovary with endometriomas
266
What has a characteristic “ground glass” appearance on USS?
Inflammatory ovarian cysts
267
What is Meig syndrome and what causes it?
Pleural effusion, ascites and ovarian fibroma. Cause by ovarian fibroma and the pleural effusion usually resolves once it is removed.
268
What are the SEs of antimuscarnics? What is a contraindication to their use?
- Blurred vision
- Dry mouth
- Constipation
Don't use in
- open angle glaucoma
- frail pts who are prone to falling
269
LOSS of levator ani support allows what type of prolapse?
Anterior vagina
270
Loss of perineal body support allows what type of prolapse?
Posterior
271
What is the best investigation for adenomyosis?
MRI (but actually technically it can only definitively be diagnosed following histopathological examination of a hysterectomy specimen)
272
What is procidentia?
When the uterus prolapses wholly outside of the hymen
273
What are the different stages of prolapse?
1: Prolapse does not reach hymen
2: reaches hymen
3: prolapses wholly outside of hymen
274
What type of prolapse can occur post-hysterectomy and why?
If the uterosacral ligaments are not restored properly anatomically then vaginal vault prolapse can occur
275
What is the best staging system for prolapse?
POP-Q
276
What are the risk factors for dyspareunia?
- FGM
- Suspected PID
- Endometriosis
- Peri/postmenopausal
- Depression and anxiety
- History of sexual assault
277
A 57yo lady presents in clinic with soreness and itching "down below". She said the area has become increasingly fragile and feels like it has changed in shape. She has a Hx of hypothyroidism and pernicious anaemia. What is the likely diagnosis?
Lichen Sclerosus - thought to be autoimmune hence link in Hx
| NB: vulva appears white like PARCHMENT PAPER and loss of anatomy can occur
278
What is the difficulty with using GnRH agonists to treat fibroids?
- Induce menopausal like state - can get associated symptoms eg hot flushes
- If used long term then induce osteoporosis so shouldn't use for more than 6mths
279
What is infibulation? What treatment should be offered?
Stitching/narrowing of vagina. De-infundibulation to reverse procedure.
280
What is the best investigation for adenomyosis?
MRI
281
What is the definitive treatment for adenomyosis?
Hysterectomy
282
Rapid fibroid growth and AUB in postmenopausal women is associated with what?
Leiomyosarcoma
283
Where is the most common site of ectopic pregnancy?
Ampulla of fallopian tube
| second most common is isthmus
284
What is the difference between the labia minora and majora?
Majora contains hair follicles, sweat glands, sebaceous glands
Minora contains no adipose tissue, no hair follicles
285
- Lower genital tract =
| - Upper genital tract =
Lower = vulva + vagina
Upper = cervix, uterus, tubes and ovaries
286
What should always be considered in a women presenting with recurrent thrush?
Diabetes
287
When is a biopsy indicated for vulval conditions and what type of biopsy is done?
```
Keyes punch biopsy
If
- pigmented change
- indurated or raised
- ulcerated lesions
```
288
What is infibulation?
Stitching/narrowing of vagina
289
What is the management of large, complex eg multi-loculated ovarian cysts?
Biopsy to exclude malignancy
290
What aminoglycoside Abx should be avoided in pregnancy and why?
Gentamicin - can cause cochlear damage in fetus
291
Where is the most common site of ectopic pregnancy?
Ampulla of fallopian tube
292
What hormone helps predict a patients response to IVF therapy?
AMH
293
What happens to the LH and FSH levels in
- Pregnancy
- Premature ovarian failure
- PCOS
Pregnancy: low FSH/LH, high oestrodiol
Premature ovarian failure: raised FSH
PCOS: high LH, normal FSH
294
What function should be checked every year in women who has premature ovarian failure?
Thyroid = women are at increased risk of autoimmune disorders
295
What are the common routes of oestrogen therapy in UK?
Transvaginal
Transdermal
Oral
296
What are the side effects of progesterone therapy?
Bloating, constipation, irritability
also: alopecia, breast abnormalities, depression, dizziness, fluid retention, insomnia, menstrual cycle irregularities, nausea, sexual dysfunction, skin reactions, weight changes
297
What are the side effects of Bromocriptine therapy?
Postural hypotension
also: constipation; drowsiness; headache; nasal congestion; nausea
298
What are some of the complications of VBAC?
72-75% chance of successful delivery - the rest involve emergency C section
If labour is induced it can result in increased risk of uterus rupture
299
What is an absolute contraindication to trial of VBAC due to the greater risk of uterine rupture?
Classical incision
300
What is the most reliable test for ovulation?
Day 21 progesterone
301
What phase of the menstrual cycle can be variable and what is fixed (and for how long)?
Follicular phase can be variable
| Luteal is fixed at 14 days
302
The serum progesterone level will peak how many days after ovulation has occured?
7 days. In simple terms, measure serum progesterone 7 days prior to expected next period (for 28-day cycle: 28 - 7 = 21. For 35-day cycle: 35 - 7= 28).
303
Risk factors for candidiasis
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV
304
How should candidiasis be treated in pregnancy?
Oral treatments are contraindicated
| Pessaries eg clotrimazole or vaginal creams of itraconazole or fluconazole
305
How should recurrent candidiasis be managed?
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
CHECK compliance with previous treatment
CONFIRM the diagnosis of candidiasis
high vaginal SWAB for MC&S
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an INDUCTION-MAINTENANCE regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
306
Who should oxybutynin not be used in and what could be prescribed instead?
Frail - can increase predisposition to falls
| Can use solferacin or tolterodine instead or consider using mirabegron instead
307
When is duloxetine prescribed for incontinence and what is its mechanism of action?
Medical management of stress incontinence if surgical is declined
= serotonin and NA reuptake inhibitor
increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
308
What is the most common type of cervical cancer?
80% squamous cell carcinoma
| 20% adenocarcinoma
309
The most common ovarian cancer is
Serous carcinoma
310
What should always be checked in a woman with thrush?
Diabetes Hx/FHx/diagnosis
311
The most common site for lymphatic spread of ovarian cancer is the
Para aortic lymph nodes
312
List some types of endometrial cancer
```
Endometriod
Mucinous
Secretory
Serous
Clear cell
```
313
List some risk factors for endometrial cancer
```
Obesity
Nulliparity
Early menarche and late menopause
Unopposed oestrogen therapy
Diabetes mellitus
Tamoxifen
PCOS
HNPCC
```
314
How is endometrial cancer treated?
Localised disease: total abdominal hysterectomy with bilateral salpingo-oophorectomy
High risk patients may receive post-operative radiotherapy
Progesterone therapy is sometimes used in frail elderly patients who are unfit for surgery
315
What is protective in endometrial cancer?
Smoking and COCP
316
What are the three types of fibroid? Which type causes the heavy bleeding?
Submucosal - cause of heavy bleeding
Intramural
Subserosal
317
What are some causes of subfertility?
Premature ovarian failure
Fibroids
Endometriosis
Polycystic ovarian syndrome
318
Risk factors for fibroids
```
Afrocarribean
FHx
Obesity
Nulliparity
Pregnancy
```
319
What is female genital mutilation?
Any procedure involving partial or total removal of the external genitalia and/or injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons
320
What are the different types of FGM?
1: Clitorectomy
2: Clitorectomy +/- partial or total labia minora, +/- labia majora
3: infibulation (stitching to narrow the vagina)
4: any other non-medical procedures to the external genitalia (e.g. piercings, cauterisation)
321
Side effects of FGM
Short-Term: severe pain, bleeding, infections, wound healing problems
Long-Term: urinary problems, menstrual problems, sexual problems (painful intercourse), psychological (PTSD)
Obstetric: difficult delivery, excessive bleeding, C-section, newborn death
322
What is the diagnostic criteria for PCOS?
Must have at least 2 of these 3 features: amenorrhoea/oligomenorrhoea, clinical or biochemical hyperandrogenism, polycystic ovaries on ultrasound (8 or more subcapsular follicular cysts < 10 mm in diameter)
323
What is the definition of secondary amenorrhoea?
Absence of menstruation for > 6 months in the absence of pregnancy in a woman who has previously menstruated
324
What can you warn pts of in PCOS in terms of future risks?
Subfertility
Diabetes mellitus
CVS disease risk
325
What are some risks of HRT?
VTE
Stroke
CHD
Breast and ovarian cancer
326
What are some contraindications for HRT?
```
Pregnancy
Undiagnosed abnormal vaginal bleeding
Active thromboembolic disease
Active breast or endometrial cancer
Acute liver disease
```
327
What is the most common gynae cancer in women and how does it present?
Endometrial with painless post menopausal or inter-menstrual bleeding
328
Which cancers have screening programmes in the UK and at what ages are they given etc?
```
Cervical:
25-50 smears every 3 years
50-65 smears every 5 years
65+ only if one of last 3 tests was abnormal
If high risk eg HIV then every year
```
Breast:
Aged 50-73
329
What are some risk factors for candidiasis?
Antibiotic use
Pregnancy
Uncontrolled diabetes
Impaired immunity
330
What is the difference between a high vaginal swab and an endocervical swab?
Endocervical – chlamydia and gonorrhoea
| High vaginal – anaerobes (e.g. BV)
331
What is the most common cause of abnormal vaginal discharge in women?
Bacterial vaginosis
332
What are some side-effects of the copper IUD?
Expulsion
Infection
Uterine perforation
Heavy, painful bleeding (especially when first inserted)
333
What are some complications of pelvic inflammatory disease?
```
Infertility
Ectopic pregnancy
Chronic pelvic pain
Sepsis
Fitz-Hugh-Curtis syndrome
```
334
What is cervical excitation a sign of?
PID or ectopic pregnancy (can help in excluding appendicitis)
335
What are the key risks of PID?
```
Infertility
Ectopic pregnancy
Adhesions
Fitz Hugh Curtis syndrome
Bacteraemia secondary to GI obstruction
Abscess (Tubo-ovarian)
Chronic pelvic pain
Peritonitis
```
336
What types of bleeding/pain do you need to ask about in a endometriosis history?
- Pelvic pain, dyspareunia (deep), abdominal pain
| - Dysmenorrhoea, cyclical PR bleeding/haematuria, possible bleeding from umbilicus
337
What type of cancer is endometriosis strongly associated to?
Clear cell ovarian cancer
338
Two complications of leiomyomas in pregnancy?
Red degeneration of fibroids
| Post-partum torsion
339
How may cervical cancer pts present?
Abnormal bleeding: PCB, IMB, PMB
Discharge
Pain
