Gynaecology Flashcards
Define atrophic vaginitis
Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen.
Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause.
It occurs in women entering the menopause.
Describe the presentation of atrophic vaginitis
Atrophic vaginitis presents in postmenopausal women with symptoms of:
- Itching
- Dryness
- Dyspareunia (discomfort or pain during sex)
- Bleeding due to localised inflammation
Consider atrophic vaginitis in older women presenting with recurrent UTI, stress incontinence or pelvic organ prolapse.
Describe what can be seen in the examination of atrophic vaginitis
Examination of the labia and vagina will demonstrate:
Pale mucosa Thin skin Reduced skin folds Erythema and inflammation Dryness Sparse pubic hair
Describe the management of atrophic vaginitis
Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES.
Topical oestrogen can make a big difference in symptoms. Options include:
- Estriol cream, applied using an applicator (syringe) at bedtime
- Estriol pessaries, inserted at bedtime
- Estradiol tablets (Vagifem), once daily
- Estradiol ring (Estring), replaced every three months
Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. Women should be reviewed annnually.
Define bacterial vaginosis
BV refers to overgrowth of anaerobic bacteria in the vagina. It is caused by a loss of the lactobacilli bacteria in the vagina. BV can increase the risk of women developing STIs.
Describe the aetiology of bacterial vaginosis
Lactobacilli are part of healthy vaginal bacterial flora. These produce lactic acid which keeps the vaginal pH under 4.5.
The acidic environment keeps other bacteria from overgrowing but in BV, since there is less lactobacilli, the pH rises. Te more alkaline environment enables anaerobic bacteria to multiple.
Give examples of anaerobic bacteria associated with bacterial vaginosis
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
Describe the risk factors of bacterial vaginosis
- Multiple sexual partners (although it is not sexually transmitted)
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
Describe the presentation of bacterial vaginosis
- FISHY-SMELLING
- watery grey or white vaginal discharge
half of the women with BV are asymptomatic
itching, irritation and pain are not typically associated with BV so think other causes
Describe the investigations of bacterial vaginosis
- speculum examination to confirm typical discharge and swab
- vaginal pH testing using swab and pH paper (normal = 3.5-4.5)
- charcoal swab for microscopy which shows CLUE CELLS!
What are clue cells?
epithelial cells from the cervix that have bacteria stuck inside them, usually gardnerella vaginalis.
Describe the management of bacterial vaginosis
Metronidazole orally or by vaginal gel. Clindamycin is an alternative but less optimal.
Assess the risk of additional pelvic infections with swabs for chlamydia and gonorrhoea
What should you advice to someone when prescribing metronidazole?
Avoid alcohol as it can have disulfiram-like-reaction with nausea and vomitting, flushing and sometimes severe symptoms of shock and angioedema
What are the complications of bacterial vaginosis?
Can increase the risk of catching STIs
In pregnant women:
- miscarriage
- preterm delivery
- premature rupture of membranes
- chorioamnionitis
- low birth weight
- postpartum endometritis
Define vaginal candidiasis
commonly referred to as “thrush” is a vaginal infection with a yeast from the candida family, most commonly candida albicans.
What are the risk factors for vaginal candidiasis?
Diabetes Mellitus
Drugs: antibiotics, steroids
High oestrogen: Pregnancy
Immunosuppression: HIV
Describe the presentation of vaginal candidiasis
- COTTAGE CHEESE , non offensive discharge
- thick white discharge
- vulval and vaginal itching, irritation and discomfort
- dyspareunia
- dysuria
Describe the investigations of vaginal candidasis
often treatment is started based on presentation.
Vaginal pH using swab and pH paper to differnetiate between BV and trichomonas (pH >4.5) and candidiasis (pH <4.5)
Charcoal swab with microscopy can confirm diagnosis
Describe the management based on NICE guidelines of vaginal candidiasis
Initial uncomplicated cases, any of the following:
- single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
- A single dose f clotrimazole pessary (500mg) at night
- 3 doses of clotrimazole pessaries (200mg) over 3 nights
- single dose of fluconazole (150mg)
What is the OTC medication for vaginal candidiasis?
Canesten Duo: it contains a single fluconazole tablet and clotrimazole cream to use externally.
What do you need to warn women about in regards to antifungal creams and pessaries?
They can damage latex condoms and prevent spermicides from working so alternative contraception is required for at least 5 days after use.
What is the management for recurrent vaginal candidiasis?
Recurrent = 4 or more in 1 year.
Induction: oral fluconazole every 3 days for 3 doses
Maintenance: oral fluconazole weekly for 6 months.
What is tested first in the cervical smear?
hrHPV first and if that is positive then cytology is performed
Management of negative hrHPV test
return to normal recall, unless:
- the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
Management of positive hrHPV test
samples are examined cytologically:
if the cytology is abnormal → colposcopy this includes the following results: borderline changes in squamous or endocervical cells. low-grade dyskaryosis. high-grade dyskaryosis (moderate). high-grade dyskaryosis (severe). invasive squamous cell carcinoma. glandular neoplasia
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
Cervical screening timeframe
Between ages of 24.5 to 49, offered every 3 years
Between ages of 50 and 64, offered every 5 years
What is chlamydia?
A gram negative bacteria. It is an intracellular organism.
Most common STI in the UK.
50% men and 75% women are asymptomatic
Describe the national chlamydia screening programme
National chamydia screening programme (NCSP) aims to screen every sexually active person under 25 years of age annually or when they change partners.
If they test positive, they have to re-test in 3 months.
What tests should be done when a patient attends a GUM clinic for STI screening?
Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)
What are the types of swabs used in sexual health and what do they look for?
Charcoal swab: allow for microscopy, culture and sensitivities. Can confirm: BV, Candidiasis, Gonorrhoea, Trichomonas vaginalis and other bacteria such as Group B strep.
Nucleic acid amplification test (NAAT) swabs: checck directly for DNA or RNA of the organism. Can confirm chlamydia and gonorrhoea.
Describe the presentation of chlamydia
Women: discharge, pelvic pain, abnormal vaginal bleeding, dyspareunia and dysuria.
Men: discharge, dysuria, epididymo-orchitis and reactive arthritis.
What are the examination finds in chlamydia?
Pelvic or abdominal tenderness Cervical motion tenderness Inflamed cervix (cervicitis) Purulent discharge
Describe the diagnosis of chlamydia including time frame
NAAT used:
Women first line: vulvovaginal swab
Men first line: first catch urine
testing should be carried out 2 weeks after possible exposure
Describe the management for chlamydia
first-line: doxycycline 100mg twice a day for 7 days
If contraindicated e.g. pregnancy then:
azithromycin 1g stat then 500mg once a day for 2 days
Contacts of confirmed chlamydia cases should be treated before investigation results
What are the complications of chlamydia?
pelvic inflammatory disease increased incidence of ectopic pregnancies infertility reactive arthritis conjunctivitis lymphogranuloma venerum
Describe lymphogranuloma venerum
LGV is a complication of chlamydia. Most commonly occurs in MSM.
Stage 1 is a painless ulcer
Stage 2 is lymphadenitis
Stage 3 is proctitis and anal inflammation.
Treatment is doxycyline 100mg twice daily for 21 days
What are the different methods of contraception?
Natural family planning Barrier methods Combined contraceptive pills Progesterone only pills Coils Progesterone injection Progesterone implant Surgery (
Describe the UKMEC
UKMEC 1: No restriction in use (minimal risk)
UKMEC 2: Benefits generally outweigh the risks
UKMEC 3: Risks generally outweigh the benefits
UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)
What are some key risk factors and contraindications in contraception?
Breast cancer: avoid any hormonal contraception and go for the copper coil or barrier methods
Cervical or endometrial cancer: avoid the intrauterine system (i.e. Mirena coil)
Wilson’s disease: avoid the copper coil
What are the UKMEC absolute contraindications for the combined contraceptive pill?
Uncontrolled hypertension (particularly ≥160 / ≥100)
Migraine with aura
History of VTE
Aged over 35 smoking more than 15 cigarettes per day
Major surgery with prolonged immobility
Vascular disease or stroke
Ischaemic heart disease, cardiomyopathy or atrial fibrillation
Liver cirrhosis and liver tumours
Systemic lupus erythematosus and antiphospholipid syndrome
Which form of contraception is safe and which is not while breast feeding?
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks).
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3).
Describe the efficacy and mechanism of action of the combined contraceptive pill
Combination of oestrogen and progesterone. 99% effective (91% with typical use). Licensed for use upto 50 years of age.
MOA:
PREVENTS OVULATION
oestrogen and progesterone have a negtative feedback effect on the hypothalamus and anterior pituitary, suppressing the release of GnRH, LH and FSH. PREVENTS OVULATION.
What is the protocol for a missed pill in relation to the COC?
Less than 72 hours: Take the pill as soon as you remember even if it means taking 2 on the same day.
After 72 hours: additional contraception is needed until they take the pill 7 days in a row.
Describe the efficacy and contraindications of the progesterone only pill
99% effective (91% with typical use).
Only UKMEC 4 absolute contraindication is active breast cancer.
What are the different types of POP?
- Traditional progesterone only (cannot be taken more than 3 hours late)
- Desogestrel-only pill (cannot be taken more than 12 hours late)
Describe the mechanism of action of the traditional POP
Thickening the cervical mucus
Altering the endometrium and making it less accepting of implantation
Reducing ciliary action in the fallopian tubes
Describe the MOA of the desogestrel only pill
Inhibiting ovulation
Thickening the cervical mucus
Altering the endometrium
Reducing ciliary action in the fallopian tubes
Describe the efficacy and use of the progesterone only injection
99% effective (94% with typical use)
Every 12 to 13 weeks injection.
Can take upto 12 months for fertility to return.
What are the contraindications for progesterone only injection?
UKMEC 4: active breast cancer UKMEC 3: ischaemic heart disease and stroke unexplained vaginal bleeding severe liver cirrhosis liver cancer
Can cause osteoporosis in older women.
Describe the MOA of the progesterone only injection
inhibits ovulation by inhibiting FSH secretion by the pituitary gland, preventing the development of the follicles in the ovaries.
What are the side effects fo the progesterone only injection?
changes to the bleeding schedule (1/3s)
Other SE:
- WEIGHT GAIN
- OSTEOPOROSIS
- acne
- reduced libido
- mood changes
- headaches
- flushes
- hair loss
How does the progesterone only injection cause osteoporosis?
Oestrogen helps maintain bone mineral density in women and is mainly produced by the follicles in the ovaries. Suppressing the development of follicles reduces the amount of oestrogen produced leading to decreased bone mineral density.
Describe the efficacy, contraindication and use of the progesterone implant
99% effective. Needs to be replaced every 3 years.
only UKMEC 4: active breast cancer
MOA of the progesterone implant
inhibits ovulation
thicken cervical mucus
altering the endometrium and making it less accepting of implantation
Benefits of the progesterone implant
Effective and reliable contraception
It can improve dysmenorrhoea (painful menstruation)
It can make periods lighter or stop all together
No need to remember to take pills (just remember to change the device every three years)
It does not cause weight gain (unlike the depo injection)
No effect on bone mineral density (unlike the depo injection)
No increase in thrombosis risk (unlike the COCP)
No restrictions for use in obese patients (unlike the COCP)
What are the different types of intrauterine devices and their MOA?
- Copper coil contains copper and creates a hostile environment for pregnancy
- Levonorgestrel IUS: contains progestogen that is slowly released into the uterus
What are the contraindications for IUS/IUD?
Pelvic inflammatory disease or infection Immunosuppression Pregnancy Unexplained bleeding Pelvic cancer Uterine cavity distortion (e.g. by fibroids)
What needs to be excluded and then done when threads of an intrauterine device cannot be located?
Expulsion
Pregnancy
Uterine perforation
- US
- abdominal and pelvic x-ray if elsewhere
- hysteroscopy or laparoscopic surgery may be required depending on the location of the coil
What is the mirena coil licensed for?
Effective for 5 years of contraception and menorrhagia and 4 years of HRT
What are the different types of emergency contraception?
Levonorgestrel should be taken within 72 hours of UPSI
Ulipristal (ellaOne) should be taken within 120 hours of UPSI
Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
Describe tubal occlusion
female sterilisation process where laparoscopically the tubes are tied and cut or removed all together.
prevents ovum travelling from the ovary to the uterus.
Describe vasectomy
male sterilisation where the vas deferens is cut so preventing sperm travelling from the testes to join the ejaculated fluid.
Semen testing done after 12 weeks.
What does the law state with regards to minors requesting contraception
Children under 16 can make treatment decisions but only if they are deemed to have gillick competence.
Children under 13 cannot give consent for sexual activity - should be escalated as safeguarding concern
Define endometriosis
A condition where there is ectopic endometrial tissue outside the uterus.
A lump of endometrial tissue outside the uterus is described as an endometrioma. Endometriomas in the ovaries are called ‘chocolate cysts’.
Adenomyosis refers to endometrial tissue within the myometrium of the uterus.
Describe the pathophysiology of pelvic pain in endometriosis
The cells of the endometrial tissue outside the uterus responds to hormones the same way the ones inside the uterus does. So, during menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, the same thing happens in the endometrial tissue elsewhere in the body. This causes irritation and inflammation of the tissues around the sites of endometriosis.
Describe the pathophysiology of blood in stools or urine in endometriosis
Deposits of endometriosis in the bladder or bowel can lead to blood in stools or urine.
describe the presentation of endometriosis
Can be asymptomatic or:
- cyclical abdominal or pelvic pain
- deep dyspareunia
- dysmenorrhoea
- infertility
- cyclical bleeding from other sites
- urinary or bowel symptoms
What are the examinations for endometriosis?
endometrial tissue visible in the vagina on speculum examination, particularly int he posterior fornix
a fixed cervix on bimanual exam
tenderness in the vagina, cervix and adnexa
Describe the diagnosis of endometriosis
Pelvic US: may reveal large endometriomas and chocolate cysts but are often unremarkable.
Laparoscopic surgery: GOLD STANDARD. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy.
Describe the staging of endometriosis
According to the americal society of reproductive medicine:
Stage 1: Small superficial lesions
Stage 2: Mild, but deeper lesions than stage 1
Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions
Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions
Describe the management of endometriosis
Initial management:
- establishing a diagnosis
- explaining to pt
- establish ICE
- analgesia as required for pain
Hormonal management:
- COCP straddle method
- progesterone only pill
- progesterone injection
- implant
- mirena coil
- GnRH agonists (induce menopause)
Surgical mangement:
- Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions
- hysterectomy
Laparoscopic treatment may improve fertility. hormonal therapies may improve symptoms but not fertility.
Define fibroids
Benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas.
They are oestrogen sensitive
What are the types of fibroids?
- Intramural means within the myometrium. As they grow they change the shape and distort the uterus
- Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large filling the abdominal cavity.
- Submucosal means just below the lining of the uterus
- Pedunculated means on the stalk.
Describe the presentation of fibroids and what examinations would reveal
Often asymptomatic. Can present with:
- MENORRHAGIA
- prolonged menstruation lasting more than 7 days
- abdominal pain worse during menstruation
- bloating or feeling full
- urinary or bowel symptoms
- deep dyspareunia
- reduced fertility.
abdominal and bimanual exam may reveal palpable pelvic mass or an enlarged firm non-tender uterus.
What are the investigations for fibroids?
Hysteroscopy is the initial investigation for submucosal fibroids presenting ith menorrhagia.
pelvic US for larger fibroids
MRI scanning before surgical options where more info is needed about firboid
Describe the management of fibroids less than 3cm
for fibroids less than 3cm, the medical management is the same as with menorrhagia:
- mirena coil first line
- symptomatic management with NSAIDs and TXA
- COCP
- Cyclical oral progestogens
Surgical options for managing smaller fibroids with mennorrhagia are:
- endometrial ablation
- resection of submucosal fibroids during hysteroscopy
- hysterectomy
Describe the management for fibroids more than 3cm
refer to gynaecology for investigation and management. Medical management options are:
- symptomatic with NSAIDs and TXA
- Mirena coil
- COCP
- cyclical oral progestogens
Surgical options are:
- uterine artery embolisation
- myomectomy
- hysterectomy
GnRH can be used to shrink the fibroid short term before surgery.
Define red degeneration of fibroids and give the aetiology, presentation and management
Exam possibility
Refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.
May occur as fibroid rapidly enlarges during pregnancy out-gowing its blood supply and becoming ischaemic.
presents with severe abdo pain, low grade fever, tachycardia and often vomiting. Management is supportive with rest, fluids and analgesia
Define gonorrhoea and describe its aetiology
Gram-negative diplococcus bacteria that infects mucous membranes with a columnar epithelium. Spreads via contact with mucous sections from infected areas
It is an STI. There is a high level of abs resistance.
Describe the presentation of gonorrhoea
males: odourless purulent discahrge, possibly green or yellow, dysuria and epididymo-orchitis.
females: odourless purulent discharge, possible green or yellow, dysuria, pelvic pain.
rectal and pharyngeal infection is usually asymptomatic
Describe the diagnosis for gonorrhoea
NAAT is used to check if the infection is present or not and a standard charcoal swab is also taken to check for abs sensitivity and culture.
Describe the management of gonorrhoea
A single dose of IM ceftriaxone 1g if the sensitivities are not known.
single dose of oral ciprofloxacin 500mg if the sensitivities are known.
When do you do the test of cure for gonorrhoea?
72 hours after treatment for culture
7 days after treatment for RNA NATT
14 days after treatment for DNA NATT
What is a key complication of gonorrhoea?
Gonococcal conjunctivitis in a neonate. Contracted from the mother during birth. this is a medical emergency and associated with sepsis, perforation of the eye and blindness.
What is disseminated gonococcal infection?
Complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:
- skin lesions
- polyarthralgia
- migratory polyarthritis
- tenosynovitis
- systemic symptoms
Describe the presentation of Herpes Simplex Virus
Primary infection: may present with a severe gingivostomatitis
cold sores
painful genital ulceration
What are the different HSV strains?
HSV-1 and HSV-2. Most HSV-1 account for oral lesions and HSV-2 account for genital herpes but there is overlap
What is the management of HSV?
gingivostomatitis: oral aciclovir, chlorhexidine mouthwash
Cold sores: topical aciclovir,
Genital herpes: oral aciclovir
Describe the relationship between HSV and pregnancy
elective c-section at term is advised if a primary attack of heres occurs during pregnancy at greater than 28 weeks gestation
women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low.
Define menopause and give the different stages
It is retrospective diagnosis made after a woman has had no periods for 12 months.
Menopause: point at which menstruation stops
Postmenopause: the period from 12 months after the final menstrual period onwards
Perimenopause: time around the menopause where the woman may experience vasomotor symptoms and irregular periods.
Premature menopause: menopause before the age of 40 as a result of premature ovarian insufficiency.
What is the summary of the cause of menopause?
Lack of ovarian follicular function resulting in changes to the sex hormones associated with the menstrual cycle.
oestrogen and progesterone levels are low.
LH and FSH levels are high in response to the absence of negative feedback from oestrogen.
What are the perimenopausal symptoms?
Hot flushes Emotional lability or low mood Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness and atrophy Reduced libido
What are the risks when going into menopause?
Lack of oestrogen increases the risk of: Cardiovascular disease and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence
How do you diagnose menopause?
Perimenopause and menopause can be diagnosed in women over the age of 45 with typical symptoms without performing any tests.
But, an FSH blood test is recommended to diagnose:
- women under 40 with suspected premature menopause
- women aged 40-45 with menopausal symptoms or change in the menstrual cycle
How long do women undergoing menopause have to use contraception?
2 years after the LMP in women under 50
1 year after LMP in women over 50
Which contraceptives can be used for menopausal women
UKMEC 1: Barrier methods Mirena or copper coil Progesterone only pill Progesterone implant Progesterone depot injection (under 45 years) Sterilisation
UKMEC 2: COCP
Depo injection is a no because it can decrease bone mineral density.
Describe the management of perimenopausal symptoms
Vasomotor symptoms are likely to resolve after 2-5years without any treatment.
No treatment
Hormone replacement therapy (HRT)
Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
Cognitive behavioural therapy (CBT)
SSRI antidepressants, such as fluoxetine or citalopram
Testosterone can be used to treat reduced libido (usually as a gel or cream)
Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy
Vaginal moisturisers
What are the causes of menorrhagia?
Dysfunctional uterine bleeding (no identifiable cause)
Extremes of reproductive age
Fibroids
Endometriosis and adenomyosis
Pelvic inflammatory disease (infection)
Contraceptives, particularly the copper coil
Anticoagulant medications
Bleeding disorders (e.g. Von Willebrand disease)
Endocrine disorders (diabetes and hypothyroidism)
Connective tissue disorders
Endometrial hyperplasia or cancer
Polycystic ovarian syndrome
What investigations should be carried out in a menorrhagia case?
Pelvic examination with a speculum and bimanual unless there is a straightforward history with no risk factors and pt is not sexually active.
FBC to look for iron deficiency anaemia.
Outpatient hysteroscopy if:
- suspected submucosal fibroids
- suspected endometrial pathology such as hyperplasia or cancer
- persistant intermenstrual bleeding
Pelvic and transvaginal US if:
- possible large fibroids (palpable pelvic mass)
- possible adenomyosis (pelvic pain on exam)
- examination is difficult to interpret (obesity)
- hysteroscopy is declined
Additions tests to consider:
- swabs if there is evidence of infection
- coagulation screen if FHx of clotting disorders
- ferritin if they are clinically anaaemic
- TFTs with other syx
What is the management of menorrhagia?
No contraception:
- TXA (if no pain)
- Mefenamic acid (if pain)
Contraception:
- mirena coil
- COCP
- Cyclical oral progestogens
When should you refer to secondary care with menorrahgia?
If syx are severe, treatment unseccesfful or large fibroids (>3cm)
endometrial ablation and hysterectomy are final options.
Describe the diagnosis of menorrahgia
- changing pads every 1-2 hours
- bleeding lasting more than 7 days
- passing large clots
Define pelvic inflammatory disease and its technical terms
inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.
Endometritis is inflammation of the endometrium
Salpingitis is inflammation of the fallopian tubes
Oophoritis is inflammation of the ovaries
Parametritis is inflammation of the parametrium, which is the connective tissue around the uterus
Peritonitis is inflammation of the peritoneal membrane
What are the causes of PID?
Most are due to one of the STIs:
- Neisseria gonorrhoeae tends to produce more seevere PID
- Chlamydia trachomatis
- Mycoplasma genitalium
Can less commonly be caused by non STIs such as:
- Gardnerella vaginalis (associated with BV)
- Haemophilus influenzae
- E. coli
What are the risk factors for PID?
- Not using barrier contraception
- Multiple sexual partners
- Younger age
- Existing STI
- Previous PID
- Intrauterine device (e.g. copper coil)
Describe the presentation of PID
- Pelvic or lower abdo pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- dyspareunia
- Fever
- Dysuria
What are the examination findings in PID?
- pelvic tenderness
- cervical motion tenderness
- inflamed cervix
- purulent discharge
What are the investigations for PID?
- NAAT swabs for gonorrhoea and chlaamydia
- NAAT swabs for mycoplasma genitalium
- HIV test
- Syphilis test
High vaginal swab for BV, candidiasis and trichomoniasis
Microscopy for pus cells (absence = not PID)
pregnancy test
inflammatory markers
What is the management of PID?
refer to GUM and start abs before swab results
BASSH guidelines:
- single dose of IM ceftriaxone 1g
- doxycycline 100mg twice daily for 14 days
- metronidazole 400mg twice daily for 14 days
What are the complications of PID?
Sepsis Abscess Infertility Chronic pelvic pain Ectopic pregnancy Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis syndrome?
Complication of PID caused by inflammation and infection of the liver capsule leading to adhesions between the liver and the peritoneum.
results in right upper quadrant pain that can be referred to the R shoulder tip.
Laparoscopy can be used to visualise and treat adhesions
Define the cause of stress incontinence
stress incontinence is due to weakness of the pelvic floor and sphincter muscles. Thus urine leaks at times of increased pressure on the bladder.
Define the cause of urge incontinence
urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Typical presentation is having the urge to pass urine and having to rush and not arriving before the urine does.
What are the risk factors for urinary incontinence?
Increased age Postmenopausal status Increase BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions, such as multiple sclerosis Cognitive impairment and dementia
What are the examinations for urinary incontinence?
Should assess the pelvic tone and examine for:
- pelvic organ prolapse
- atrophic vaginitis
- urethral diverticulum
- pelvic masses
What are the investigations for urinary incontinence?
A bladder diary
Urine dipstick test
Post-void residual bladder volume
Urodynamic testing
Describe the management of stress incontinence
- avoiding caffeine, diuretics and overfilling of the bladder
- avoid excessive or restricted fluid intake
- weight losss
- supervised pelvic floor exercises
- surgery
- duloxetine
Surgical option:
- tension-free vaginal tape
- autologous sling procedure
- colposuspension
- intramural urethral bulking
Describe the management of urge incontinence
- bladder retraining
- anticholinergic medication
- mirabegron (contraindicated in HTN)
- invasive procedures
Invasive options:
- botulinum toxin type A
- percutaneous sacral nerve stimulation
- augmentation cystoplasty
- urinary diversion
Define trichomonas vaginlais and what can it increase the risk of?
A type of parasite spread through sex. Classed as a protozoan and is single celled.
Lives in the urethra of men and women and the vagina of women
Can increase risk of:
- contracting HIV
- BV
- Cervical ca
- PID
- pregnancy complications
Describe the presentation of trichomonas vaginalis
50% are asymptomatic, others:
- vaginal discharge (frothy and yellow-green)
- itching
- dysuria
- dysparaunia
- balanitis
What does examinations reveal for trichomonas vaginalis?
Examination of the cervix can reveal a characteristic “strawberry cervix”
Testing vaginal pH will reveal >4.5 similar to BV
Describe the diagnosis of trichomonas vaginalis
can be confirmed by standard charcoal swab with microscopy.
swabs should be taken from the posterior fornix of the vagina.
urethral swab or first-catch urine is used in men
ovoid mobile parasites
Describe the management of trichomonas vaginalis
refer to GUM for diagnosis, treatment and contact tracing.
Treatment is with metronidazole.
What is polycystic ovarian syndrome?
Common condition causing metabolic and reproductive problems in women.
Characteristic features of multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism and insulin resistance
What is the diagnostic characteristics of polycystic ovarian syndrome?
At least two of the three key features:
1. Anovulation presenting with irregular or absent periods
- Hyperandrogenism - hirtuism and acne
- Polycystic ovaries on US
What is the presentation of polycystic ovarian syndrome?
Oligomenorrhoea Infertility Obesity Hirtuism Acne Hair loss in male pattern Insulin resistance
What are the investigation findings in polycystic ovarian syndrome?
Raised LH Raised LH:FSH ratio Raised testosterone Raised insulin Normal or raised oestrogen
What is the diagnostic investigation for polycystic ovarian syndrome?
Transvaginal US showing 12 or more developing follicles in one ovary and ovarian volume of more than 10cm3
STRING OF PEARLS
What is the management of polycystic ovarian syndrome?
Weight loss Calorie-controlled diet Exercise Smoking cessation Antihypertensive meds Statins
What are the stages of syphilis?
Primary syphilis: painless ulcer (chancre) on the genitals.
Secondary syphilis: systemic symptoms (skin and mucous membranes). Happens after 2-8wks
Latent syphilis: symptoms disappear and becomes asymptomatic. within two years of initial infection
Tertiary syphilis: can occur many years after the initial infection and affect many organs of the body (gummas, CVS and neurological complications).
Neurosyphilis occurs if the infection involves the central nervous system, presenting with neurological symptoms.
When do you get PMS symptoms?
Luteal phase
Abortion treatments and time frame
<14 weeks Medical (mifepristone and misoprostol)
>14 weeks surgical evacutation
What is the investigation for recurrent candidiasis?
Glycated haemoglobin to check for DM
What is the management of miscarriage?
Expectant management if there are no complications and pregnancy is smol
If expectant management doesn’t work after 14 days or if clinically not good then = MISOPROSTOL
If products are retained then do surgical vaccuum.
Which day do you confirm ovulation by checking progesterone?
7 days before start of next cycle
What is the management of ectopic pregnancy?
Methotrexate
