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Year 5 > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

Define heavy menstrual bleeding

A

Excessive menstrual blood loss which has an adverse impact on a woman’s quality of life

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2
Q

Give 3 causes of heavy menstrual bleeding

A 
Fibroids 
Endometrial polyps
Adenomyosis
Pelvic infection 
Endometrial malignancy 
Anovulatory 
Ovulatory 
Clotting disorders
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3
Q

How should heavy menstrual bleeding be assessed and investigated?

A

History
Examination - abdominal, bimanual
Blood tests - FBC, coagulation (if long history/FH), thyroid (if other signs/symptoms)
Biopsy (persistent intermenstrual, >45 treatment failure)
Imaging (palpable uterus, pelvic mass, treatment failure) - US

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4
Q

How is heavy menstrual bleeding managed?

A

Pharmacological - non-hormonal (mefenamic acid, tranexamic acid), hormonal (pseudo-pregnancy, pseudo-menopause)
Surgical - endometrial ablation, hysterectomy

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5
Q

What are mefenamic acid and tranexamic acid?

A

Mefenamic - prostaglandin synthase inhibitor, take during menses
Tranexamic - antifibrinolytic, take during menses
Reduce bleeding by 50% when taken in combination

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6
Q

What are the pseudo-pregnancy medical hormonal management options for heavy menstrual bleeding?

A

COCP

Progestogens - systemic (POP, depo-provera, nexplanon), local (LNG-IUS/Mirena)

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7
Q

What is the pseudo-menopause medical hormonal management option for heavy menstrual bleeding?

A

GnRH analogues (inhibit FH and LH release)

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8
Q

What are the effects of progesterone receptor modulators?

A 
Bind to progesterone receptor 
Act directly on endometrial blood vessels 
Induce amenorrhoea 
Shrink fibroids by 20-40%
E.g. ulipristal acetate
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9
Q

What 2 things must be noted when sending a sample from a hormone sensitive tissue to pathology?

A

Time in cycle

Hormonal preparations being taken by patient

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10
Q

What does a Mirena coil do?

A

Thickens cervical mucus
Inhibits sperm from reaching egg
Thins uterine lining

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11
Q

What can the Mirena coil be used for?

A 
Small fibroids 
Adenomyosis
Endometriosis
Contraceptive
Progesterone component of HRT
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12
Q

What is contraindicated after endometrial ablation?

A

Pregnancy

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13
Q

Define amenorrhoea. What are the 2 types?

A

Absent menses
Primary - failure to menstruate by 15 years of age
Secondary - established menses stop for ≥6 months in absence of pregnancy

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14
Q

Define oligomenorrhoea

A

A cycle which is persistently greater than 35 days in length

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15
Q

What are the common causes of primary amenorrhoea?

A

Physiological delay
Weight loss/anorexia/heavy exercise
PCOS
Imperforate hymen

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16
Q

How is primary amenorrhoea assessed?

A

History - FH, weight, exercise, stress, sexual history

Examination - secondary sexual characteristics, Tanner staging

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17
Q

How is amenorrhoea investigated?

A 
Bloods - FSH, LH, oestradiol, prolactin, TFTs
US
Karyotype
XR for bone age 
Cranial imaging
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18
Q

What are the common causes of secondary amenorrhoea?

A 
Pregnancy 
Lactation 
Menopause
Weight loss/anorexia
Heavy exercise 
Stress
PCOS
Hysterectomy 
Endometrial ablation 
Progestogen IUD
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19
Q

What are the Rotterdam criteria for PCOS diagnosis?

A

Clinical or biochemical evidence of hyperandrogenism
Oligomenorrhoea/amenorrhoea
US features of PCOS

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20
Q

What are the complications of PCOS?

A 
Reduced fertility 
Insulin resistance and diabetes
Hypertension
Endometrial cancer 
Depression and mood swings 
Snoring and daytime drowsiness
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21
Q

How is PCOS managed?

A 
Education 
Weight loss and exercise 
Endometrial protection (progesterone) 
Fertility assistance 
Awareness and screening
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22
Q

Define dysmenorrhoea

A

Excessive menstrual pain

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23
Q

How is the pain of dysmenorrhoea described?

A

Cramping lower abdominal pain
Radiates to lower back and legs
Associated with GI symptoms and malaise

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24
Q

Give 2 features of primary dysmenorrhoea

A

Begins with onset of ovulatory cycle
Typically occurs within first 2 years of menarche
Pain most severe on the day of/day prior to start of menstruation

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25
Q

What substance is implicated in primary dysmenorrhoea and how?

A

Prostaglandins

Increases contractility of myometrium

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26
Q

How is primary dysmenorrhoea managed?

A

Discussion and reassurance
Transabdominal US
Medical therapy - prostaglandin synthesis inhibitors (NSAIDs), COCP, depot progestogens, LNG-IUS

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27
Q

When does secondary dysmenorrhoea occur and what are its causes?

A

Many years after menarche

Pelvic pathology - endometriosis, adenomyosis, infection, fibroids

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28
Q

How is secondary dysmenorrhoea investigated and managed?

A

Genital tract swab (chlamydia)
Pelvic US (fibroids)
Laparoscopy (endometriosis)
Management depends on pathology

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29
Q

Define intermenstrual bleeding (IMB), post-coital bleeding (PCB) and post-menopausal bleeding (PMB)

A

IMB - bleeding between periods
PCB - bleeding after intercourse
PMB - bleeding >12 months after LMP

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30
Q

What are the causes of IMB and PCB?

A 
Infection
Trauma 
Polyp
Cervical ectropion
Malignancy 
Contraception
Pregnancy
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31
Q

How are IMB/PCB investigated?

A

Cervical smear history
Speculum and bimanual examination - urgent colposcopy if cancer suspicion
STD screen
Urine pregnancy test

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32
Q

When is urgent gynaecology referral suitable for IMB/PCB?

A

Women >35 with >4 weeks of symptoms

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33
Q

When is routine gynaecology referral suitable for IMB/PCB?

A

Women <35 with >12 weeks of symptoms

Single heavy episode of bleeding at any age

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34
Q

When is simple reassurance suitable for IMB/PCB?

A

Women <35 with normal examination and results

Most will resolve within 6 months, consider changing hormonal contraception

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35
Q

What is the risk of cancer in post-menopausal bleeding?

A

5%

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36
Q

How is PMB investigated?

A

Transvaginal US
Biopsy if endometrial lining >3mm (non-HRT/CC-HRT users) or if EL >5mm (sequential HRT users)
Hysteroscopy/biopsy in tamoxifen users

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37
Q

What is the incidence of infertility and when should investigation start?

A

1 in 6

After 1 year

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38
Q

Name 5 benign gynaecological conditions

A 
Vulva - Bartholin cyst/abscess, lichen sclerosus, genital herpes
Cervix - ectopy, polyps
Uterus - fibroids, polyps
Fallopian tubes - PID, hydrosalpinx
Ovary - cysts 
Endometriosis
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39
Q

How can a Bartholin gland abscess and cyst be differentiated?

A

Abscess - acute infection of the gland by bacteria, very painful
Cyst - chronic swelling after previous infection, painless

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40
Q

How are Bartholin gland abscesses/cysts managed?

A

Broad spectrum antibiotics

Marsupialisation (GA) or word catheter (LA)

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41
Q

What is lichen sclerosus?

A

Autoimmune condition causing patchy thinned white skin which is especially common in postmenopausal women

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42
Q

Give 3 signs/symptoms of lichen sclerosus

A 
Itching 
Excoriation (can cause pain and painful sex)
Whitened vulval skin 
Loss of labial and clitoral contours 
Narrowed entry to vagina
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43
Q

How can a diagnosis of lichen sclerosus be confirmed and how is it managed?

A

Clinical diagnosis, biopsy can confirm

Treatment - potent topical steroids (e.g. dermovate)

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44
Q

What are the signs/symptoms of genital herpes?

A

Painful vesicular rash
Dysuria
Dyspareunia

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45
Q

How is genital herpes managed?

A

Oral aciclovir 400mg 3x/day for 5-10 days
Self care - oral analgesia, salt water application, vaseline/lidocaine (painful micturition), increase fluid intake to dilute urine, urinate in bath to reduce stinging

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46
Q

What is cervical ectropion?

A

Columnar cells from the cervical canal are everted to the cervix

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47
Q

What are the symptoms of cervical ectropion and how is it managed?

A

Symptoms - none, chronic discharge, PCB

Treatment - cautery/cryotherapy/silver nitrate if symptomatic

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48
Q

What are the symptoms of cervical polyps and how are they managed?

A

Symptoms - none, PCB/PMB

Treatment - avulsion if symptomatic

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49
Q

What are the correct medical terms for fibroids?

A

Leiomyomas

Fibromyomas

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50
Q

What are fibroids?

A

Benign tumours of the myometrium

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51
Q

In what population are fibroids most common and faster growing?

A

Afro-Caribbean women

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52
Q

Why do fibroids grow during pregnancy and shrink after menopause?

A

Oestrogen dependent

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53
Q

Give 3 signs/symptoms of fibroids

A

Heavy menstrual bleeding
Abdominal swelling
Pressure symptoms - ureteric obstruction
Subfertility
Difficulties in pregnancy - miscarriage, red degeneration
Pain (torsion, degeneration)
Abdominal/pelvic mass

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54
Q

How are fibroids diagnosed?

A

Clinical suspicion confirmed by USS

MRI may be needed to plan management

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55
Q

How are fibroids managed?

A

Conservative
Medical - control symptoms (heavy bleeding), before surgery (GnRH analogues, ulipristal acetate)
Surgical - hysterectomy, myomectomy (preservation of fertility)
Uterine artery embolisation - minimally invasive

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56
Q

What are the symptoms of endometrial polyps, how are they diagnosed and how are they managed?

A

Symptoms - PMB, IMB, HMB
Diagnosis - TVUS, hysteroscopy and biopsy
Treatment - polypectomy

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57
Q

What is PID?

A

Pelvic inflammatory disease - salpingitis, tubo-ovarian abscess
Ascending infection from cervix e.g. chlamydia

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58
Q

What are the complications of PID?

A

Infertility
Ectopic pregnancy
Chronic pelvic pain

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59
Q

What are the symptoms of PID?

A 
Asymptomatic 
Anorexia and general malaise 
Lower abdominal pain 
Deep dyspareunia 
Variable discharge (often purulent)
PCB or IMB
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60
Q

What are the signs of PID?

A 
Pyrexia 
Tachycardia
Abdominal distension and tenderness, rebound and guarding
Very tender on vaginal examination 
Discharge seen on speculum
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61
Q

What is Fitz-Hugh-Curtis syndrome?

A

Peri-hepatic inflammation causing RUQ tenderness in PID

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62
Q

What investigations should be carried out for suspected PID?

A 
Urine pregnancy test 
FBC and CRP (raised WCC and CRP)
MSU (exclude UTI)
Swabs (chlamydia) 
Transvaginal USS (tubo-ovarian abscess)
Laparoscopy (uncertain, no improvement)
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63
Q

How is PID managed?

A

Empirical antibiotics when suspected - ceftriaxone 500mg IM stat, followed by oral doxycycline 100mg BD and metronidazole 400mg BD for 14 days
Pain refief - paracetamol, ibuprofen
Refer to GU medicine - further infection screening, contact tracing

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64
Q

What is hydrosalpinx?

A

A condition that occurs when the distal fallopian tube is blocked and fills with serous fluid

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65
Q

What are the symptoms of hydrosalpinx?

A

None
Pelvic pain
Subfertility

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66
Q

How is hydrosalpinx diagnosed and managed?

A

Diagnosis - suspected on TVU, laparoscopy, hysterosalpingogram (HSG)
Treatment - conservative (no symptoms), bilateral salpingectomy (pelvic pain), IVF for infertility

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67
Q

What are the 4 types of ovarian cyst?

A

Functional
Dermoid
Epithelial
Endometriotic

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68
Q

What are the symptoms of ovarian cysts?

A

None
Pelvic pain
Abdominal/pelvic swelling

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69
Q

How are ovarian cysts diagnosed and managed?

A

Diagnosis - US/CT/MRI, CA125/CEA/aFP/hCG

Treatment - conservative (symptom free, <6cm), remove otherwise (cystectomy/oophorectomy)

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70
Q

What are the 2 types of functional cysts and how are they managed?

A

Follicular and luteal

Avoid unnecessary intervention, will normally resolve in 6-12 weeks

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71
Q

What is endometriosis?

A

Oestrogen-dependent benign inflammatory disease characterised by ectopic endometrium, often accompanied by cysts and fibrosis

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72
Q

What are the 3 types of endometriosis

A

Superficial peritoneal lesion (minimal and mild)
Deep infiltrating lesion (moderate and severe)
Ovarian cysts (endometriomas)

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73
Q

What are the signs/symptoms of endometriosis?

A 
None
Dysmenorrhoea 
Dyspareunia
Pelvic pain
Subfertility 
Fixed tender retroverted uterus
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74
Q

How is endometriosis investigated?

A

Suspected from history and exam
TVU, raised CA125
Laparoscopy and biopsy - gold standard

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75
Q

How is endometriosis managed?

A 
Conservative (symptom free)
Medical - NSAIDs, progestogens, COCP, Mirena (symptom relief)
Prior to surgery - GnRH analogues
Surgical - cautery, cystectomy
IVF for infertility
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76
Q

What should be considered when assessing pelvic pain?

A

Lower abdominal pain
Acute - cyst torsion, PID, ectopic
Chronic - endometriosis, CPP
Is the pain cyclical and related to menstruation?

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77
Q

What are the symptoms of dysmenorrhoea?

A

Cramping lower abdominal pain

Radiation to lower back and legs

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78
Q

What are the 2 types of dysmenorrhoea?

A

Primary - idiopathic, onset soon after start of ovulatory cycle due to increased prostaglandin
Secondary - years after menarche, due to pelvic pathology

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79
Q

What is vulvodynia?

A

Sensation of vulval burning/pain with no obvious skin problem due to hypersensitivity of vulval nerve fibres (e.g. post-herpetic neuralgia)

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80
Q

How is vulvodynia managed?

A

Low dose TCA (e.g. amitriptylline)
Lubricant
Vulval care advice

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81
Q

What is chronic pelvic pain syndrome?

A

Intermittent/constant lower abdominal pain for >6 months not occurring exclusively with menstruation or intercourse and not associated with pregnancy

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82
Q

How is CPP investigated?

A

Allow time to listen to patient
Rule out any gynaecological pathology
Consider - IBS, interstitial cystitis, MSK, psychological/social issues, past/ongoing sexual abuse

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83
Q

How is CPP managed?

A

Medication - antispasmodics (IBS), NSAIDs (MSK)
Referral - urology, gastroenterology, surgery
MDT - chronic pain, psychology, PT, psychosexual therapy, self-help groups

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84
Q

What is the incidence of cervical cancer?

A

Two peaks - 25-29 years, >80 years

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85
Q

What are the risk factors for cervical cancer?

A 
HPV (high risk 16 and 18)
Smoking
Early onset of sexual activity 
COCP use 
Multiple sexual partners
Immunosuppression
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86
Q

How does HPV cause cervical cancer?

A

HPV releases proteins which bind to tumour suppressors, rendering cervical cells vulnerable to unchecked genetic changes

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87
Q

Outline the HPV vaccination programme

A

All girls aged 11-13
2 injections given at least 6 months apart
HPV 6, 11, 16 and 18 - protection against cervical, vulval, vaginal and anal cancer and genital warts
10 year protection

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88
Q

Outline the cervical screening programme

A

Aims to detect and treat abnormal changes in a woman’s cervix which may develop into cervical cancer
25-65 year olds - 3 yearly until 50, 5 yearly from then on

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89
Q

What is the transformation zone of the cervix?

A

Junction between columnar epithelium of cervical canal and squamous epithelium of the outer cervix - location of dysplasia and carcinoma

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90
Q

If the cervix is visibly abnormal on speculum examination during a smear, what should be done?

A

Smear should not be taken as it is a screening test

Diagnostic test required - biopsy (punch or LETZ)

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91
Q

What is colposcopy and what is it for?

A

Referral for - abnormal screening smear or suspicious symptoms/cerix appearance
Colposcope (microscope) used to visualise cervix on application of acetic acid which highlights abnormal cells for biopsy

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92
Q

What is CIN? What is the significance of staging?

A

Cervical intraepithelial neoplasia - abnormal, pre-cancerous cells
CIN 1 - low grade changes, given time to resolve
CIN 2 and 3 - high grade changes, treatment offered

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93
Q

How is CIN 2/3 managed?

A

Destructive - cold coagulation, cryotherapy
Excisional - LETZ, cold knife cone, laser excision
Follow up - 6 months smear

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94
Q

What subtypes of cervical cancer are there and which is the most common?

A 
Squamous cell carcinoma (most common)
Adenocarcinoma 
Adenosquamous carcinoma 
Endometroid 
Clear cell
Serous
Neuroendocrine (e.g. small cell)
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95
Q

How does cervical cancer present?

A 
Vaginal bleeding 
Sero-sanguineous offensive vaginal discharge 
Obstructive renal failure 
Supraclavicular lymphadenopathy 
Asymptomatic
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96
Q

How should a woman with suspected cervical cancer be examined?

A 
Supraclavicular palpation 
Abdominal exam 
Speculum 
Bimanual 
PR (assess parametrium) 
Colposcopy
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97
Q

What is the parametrium?

A

Fibrous and fatty connective tissue that surrounds the uterus Separates the supravaginal portion of the cervix from the bladder

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98
Q

How should a woman with suspected cervical cancer be investigated?

A

Bloods - FBC, U&Es, LFTs
Biopsy - punch or LETZ
Imaging - MRI, CT, PET

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99
Q

What staging is used in cervical cancer?

A

FIGO staging

Based on clinical examination - examination under anaesthetic/MRI, bloods and prognostic factors

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100
Q

What prognostic factors apply to cervical cancer?

A

Lymph node involvement
Lymphovascular space involvement
Parametrial extension

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101
Q

Outline FIGO staging for cervical cancer

A

Stage 1 - contained
Stage 2 - involves upper vagina/parametrium
Stage 3 - involves lower vagina/pelvic side wall/kidneys
Stage 4 - involves adjacent pelvic organs/distant organs

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102
Q

How is cervical cancer managed?

A

MDT discussion
Surgery - LETZ, trachelectomy, pelvic lymphadenectomy, hysterectomy
Chemotherapy and radiotherapy - cisplatin, external beam radiotherapy, vaginal vault brachytherapy

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103
Q

What is a trachelectomy?

A

Surgery for early stage cervical cancer that removes the cervix
Fertility sparing surgery as it does not remove the uterus meaning it may be possible to become pregnant in the future

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104
Q

How is advanced cervical cancer managed?

A

MDT - chemotherapy, radiotherapy, biologics
Guided by patient co-morbidity and wishes
Palliative medicine input
Nephrostomy/ureteric stent may be needed

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105
Q

What type of vulval cancers are there and which is the most common?

A 
Squamous cell carcinoma (most common, 90%)
Adenocarcinoma 
Melanoma
BCC
Sarcoma
Metastatic
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106
Q

What are the risk factors for vulval cancer?

A 
VIN 
HPV
Squamous metaplasia
Chronic skin conditions (e.g. lichen sclerosus)
Smoking 
Immunosuppression
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107
Q

What are the 4 VIN types?

A

Usual - thickened, high nuclear:cytoplasmic ratio, nuclear atypia, abnormal mitotic figures
Warty - papillary configuration, multinucleate cells, koilocytes, dyskeratotic cells
Basaloid - flat surface, less differentiated, high nuclear:cytoplasmic ratio
Differentiated - thickened epidermis, enlarged keratinoctyes, surface parakeratosis

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108
Q

What pattern may disease follow in vulval cancer?

A

Multifocal

Multicentric - vulva, vagina, cervix, perianal, anal, natal cleft

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109
Q

How does VIN present?

A 
Pruritus
Pain 
Ulceration 
Leukoplakia 
Lumps/warts 
Asymptomatic - may be noticed on smear
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110
Q

What are the commonest sites affected by VIN?

A

Labia majora
Labia minora
Posterior fourchette

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111
Q

How can the appearance of VIN be described?

A

Variable
Red/white plaques
Papular, polypoid, verruciform

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112
Q

How is VIN diagnosed?

A

Biopsy - incisional or excision

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113
Q

How is high grade VIN managed?

A

Exclude invasive disease, relieve symptoms, eradicate HPV, reduce progression to invasive disease, preserve anatomy and function, sustain remission
Observe or excise (surgery, ablation)

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114
Q

What methods of ablation can be used in high grade VIN?

A

Chemical - imiquimod (immune response modifier, 2-3x/week for 16 weeks, side effects limit complicance)
Laser
Photodynamic therapy

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115
Q

What are the signs/symptoms of vulval cancer?

A 
Lump 
Pain 
Bleeding 
Discharge 
Swollen leg 
Groin lump 
Mass
Ulceration 
Colour changes 
Elevation and irregularity of surface 
Lower limb lymphoedema
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116
Q

What staging is used for vulval cancer?

A

FIGO staging
Depth of invasion measured from deepest point of tumour to epithelial-stromal junction
Nodal status critical in predicting survival

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117
Q

Outline FIGO staging for vulval cancer

A

Stage 1 - confined
Stage 2 - involves lower vagina/urethra/anus
Stage 3 - involves nodes
Stage 4 - involves upper vagina/urethra/bladder/anus/pelvic bone/higher pelvis

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118
Q

What is the 5 year survival of cervical and vulval cancer?

A

Cervical - 67%

Vulval - 64%

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119
Q

How is vulval cancer managed?

A

Surgery - WLE, vulvectomy, inguinal lymphadenectomy
Reconstruction - grafts (split skin, full thickness), flaps (myocutaneous, fasciocutaneous, lotus petal)
Chemotherapy
Radiotherapy

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120
Q

What prognostic factors are applicable to vulval cancer?

A 
Depth of involvement 
Involvement of other structures 
Histological sub type
Lymphovascular space invasion
Excision margins
Nodes
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121
Q

What are the complications of lymphadenectomy in vulval cancer?

A 
Delayed wound healing 
Infection 
Wound breakdown 
Lymphoedema
Recurrent infection (erysipelas)
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122
Q

What is erysipelas?

A

Relatively common bacterial infection of the superficial layer of the skin (upper dermis), extending to the superficial lymphatic vessels within the skin, characterized by a raised, well-defined, tender, bright red rash, typically on the face or legs, but which can occur anywhere on the skin

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123
Q

What are the types of ovarian cancer and what is the most common?

A

Epithelial (most common, 90%)
Germ cell (oocytes)
Stromal
Metastasis (Krukenburg - mucin-filled signet-ring cells)

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124
Q

What are the 2 types of epithelial ovarian cancer?

A

High grade serous - resembles fallopian tube mucosa, P53 mutations
Ovarian surface/Mullerian inclusion cysts - endometrioid, clear cell, mucinous, low grade serous

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125
Q

What are the 3 routes of ovarian cancer spread?

A 
Direct extension (transcoelomic) 
Exfoliation into peritoneal cavity 
Lymphatic invasion
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126
Q

What are the risk factors for ovarian cancer?

A 
Smoking 
Low parity 
Oral contraceptives 
Infertility 
Tubal ligation 
Early menarche
Late menopause
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127
Q

What are the main genetic/familial causes of ovarian cancer?

A

BRCA1 (chromosone 17q)
BRCA2 (chromosome 13q)
Lynch syndrome/HNPCC (mismatch repair genes)
Other undiscovered genes

128
Q

Give 2 features suggestive of a familial ovarian cancer

A 
Early onset breast cancer <50 years 
Male breast cancer 
Ashkenazi Jewish ancestry 
Bilateral breast cancer 
Multiple family members with breast/colon/ovarian/stomach/renal tract/endometrial/small bowel cancer
129
Q

What is the risk of ovarian cancer in patient with BRCA mutation?

130
Q

What does risk reducing surgery for ovarian cancer involve and what is the risk reduction?

A

Prophylactic bilateral salpingo-oophorectomy (BSO)
Ovary RR - 96%
Breast RR - 53%

131
Q

What are the signs/symptoms of ovarian cancer?

A 
Vague and non-specific 
Altered bowel habit 
Abdominal pain/bloating 
Feeling full quickly 
Difficulty eating 
Urinary/pelvic symptoms 
Bowel obstruction
SOB
Abdominal distension 
Upper abdominal mass 
Pleural effusion 
Nodules on vaginal exam 
Paraneoplastic syndromes
132
Q

How should suspected ovarian cancer be investigated?

A

USS
Bloods - CA125
Calculate risk of malignancy index (RMI)
CT - determines treatment and allows monitoring of response

133
Q

What is CA125?

A

Glycoprotein antigen
Elevated in malignancy (ovarian, pancreas, breast, lung, colon) and benign conditions (menstruation, endometriosis, PID, pleural/pericardial effusion, recent laparotomy)

134
Q

How is the risk of malignancy index (RMI) calculated?

A

USS (1/2/3) x menopausal status (pre/post) x CA125

135
Q

What USS features are used in RMI calculation?

A

Multilocular
Solid areas
Ascites
Intra-abdominal metastasis

136
Q

How is an ovarian cancer diagnosis confirmed?

A

Cytology - pleural/ascitic fluid

Histology - biopsy

137
Q

Outline FIGO staging for ovarian cancer

A

Stage 1 - ovaries/ascites/rupture
Stage 2 - involves uterus/fallopian tubes/other pelvic tissue
Stage 3 - involves retroperitoneal lymph nodes/microscopic beyond pelvis/peritoneal metastasis
Stage 4 - pleural effusion/abdominal involvement

138
Q

What is the 5 year survival for ovarian and endometrial cancer?

A

Ovarian - 46%

Endometrial - 79%

139
Q

How is ovarian cancer managed?

A

Surgery - primary debulking, midline laparotomy, total abdominal hysterectomy (TAH), BSO, washings, omentectomy, appendicectomy, resection of peritoneum
Chemotherapy - neoadjuvant/adjuvant carboplatin and paclitaxel, biologics (anti-VEGF), hormonal (tamoxifen)
Fertility conservation - 9% recurrence risk in contralateral ovary

140
Q

How does endometrial cancer present?

A 
PMB
PCB
IMB
Altered menstrual pattern 
Persistent vaginal discharge
141
Q

What are the types of endometrial cancer and which is most common?

A

Adenocarcinoma (most common)
Sarcoma (e.g. leiomyosarcoma)
Uterine carcinosarcoma

142
Q

What are the 2 types of adenocarcinoma of the endometrium?

A

Type 1 - oestrogen excess, endometroid, grade I-III

Type 2 - no oestrogen excess, papillary serous or clear cell

143
Q

What is the malignant potential of simple hyperplasia, complex hyperplasia and atypical hyperplasia of the endometrium?

A

Simple - 1-3%
Complex - 3-4%
Atypical - 23%

144
Q

What are the risk factors for endometrial cancer?

A 
Obesity 
Physical inactivity 
HRT
Diabetes
Metabolic syndrome 
Unopposed oestrogen 
Tamoxifen 
Nulliparity 
Longer menstrual lifespan 
Genetics (HNPCC)
145
Q

What is the difference between Lynch I and II syndromes?

A

I - site-specific colorectal cancer

II - colorectal, endometrial, ovarian, stomach, hepatobiliary, brain, skin, upper urinary tract and small bowel cancers

146
Q

What is the risk of endometrial cancer in a patient with Lynch II syndrome?

147
Q

How can risk of endometrial cancer be reduced in those genetically susceptible?

A 
Reduce BMI 
Avoid diabetes
Parity and COCP use 
TVS and biopsy
Prophylactic hysterectomy (and BSO) when family is complete to eliminate risk
148
Q

Outline the FIGO staging for endometrial cancer

A

Stage 1 - confined to uterus
Stage 2 - cervical stromal invasion, but not beyond uterus
Stage 3 - tumour outwith uterus
Stage 4 - invasion of bladder/bowel mucosa, distant metastasis

149
Q

What investigations should be done in suspected endometrial cancer?

A

Basic bloods
Imaging - TVU (measure thickness of endometrium), MRI (assess for extra-uterine disease), CT/PET
Biopsy - pipelle, hysteroscopy

150
Q

When should a biopsy be taken based on endometrial thickness in patients with PMB?

A

Thickness >3mm and not on HRT
Thickness >5mm and on sequential HRT
All tamoxifen users

151
Q

How is endometrial cancer managed?

A

Early stage disease - total hysterectomy, BSO and washings; examine all peritoneal surfaces
Adjuvant - based on histopathology
Advanced disease - MDT discussion regarding surgery, chemotherapy, radiotherapy and hormonal treatment
Inoperable disease - histopathology important (ER/PR), palliative input

152
Q

What are the uses and side-effects of radiotherapy in endometrial cancer?

A

Post-operative radiotherapy in high risk disease
Types - external beam or brachytherapy (vault insertions)
Side effects - proctitis, cystitis, lethargy, skin changes

153
Q

Define subfertility

A

The inability of the couple to achieve pregnancy after 12 months of regular unprotected sexual intercourse
Primary or secondary (previous pregnancy)

154
Q

Give 2 factors affecting fertility

A

Age (female)
Duration of sub-fertility
Timing of intercourse (needs to occur before ovulation, 2-3 times/week)
Weight (less likely if BMI <20 or >30)

155
Q

Give 2 causes of infertility

A 
Male factor (30%)
Ovulatory (25%)
Unexplained (25%)
Tubal (15%)
Endometriosis (5%)
156
Q

What pre-conception health promotion advise can be given to couples?

A 
Smoking cessation
Limit alcohol intake 
Stop recreational drugs (e.g. anabolic steroids)
Weight loss/gain 
Folic acid supplementation
157
Q

How is male semen investigated?

A

Semen analysis - sample after 2-5 days abstinence; concentration (>15m/ml), motility (>40%), normal form (>4%), volume, vitality

158
Q

Define azoospermia, oligospermia, asthenospermia and teratospermia

A

Azoospermia - absent sperm
Oligospermia - very few sperm
Asthenospermia - very immotile sperm
Teratospermia – abnormal morphology

159
Q

What are the 3 ways in which male subfertility may occur?

A

Sperm transportation
Sperm production
Hypogonadotrophism

160
Q

How should a subfertile male be assessed?

A 
Semen analysis
History 
Testicular examination 
FSH levels 
Karyotype (if no/few sperm)
161
Q

What are the 3 types of azoospermia?

A

Obstructive - normal production/FSH and volume but no sperm in ejaculate due to blocked epididymis/vas or absent vas (test for CF)
Non-obstructive - testicular failure/increased FSH, small volume, biopsy and karyotype
Failure to stimulate spermatogenesis - hypogonadotrophic hypogonadism/low FSH

162
Q

How is male subfertility managed?

A

IVF with ICSI (intra-cytoplasmic sperm injection) - better for obstructive azoospermia
Donor insemination - no quality sperm

163
Q

What is the first thing which should be checked in a woman with suspected ovulatory subfertility and how?

A

Is she releasing an egg?
Regular cycle - check mid-luteal phase progesterone (day 21 of 28 day cycle)
Irregular/no cycle - unlikely to be releasing eggs

164
Q

What is the WHO classification of anovulation?

A

Group 1 - hypothalamic pituitary failure
Group 2 - hypothalamic pituitary ovarian axis dysfunction
Group 3 - ovarian failure

165
Q

How common is group 1 anovulation, give an example and how does it present?

A

Uncommon (5-10%)
E.g. hypogonadotrophic hypogonadism
Amenorrhoea, low gonadotrophins and oestrogen

166
Q

What are the causes of group 1 anovulation?

A

Hypothalamic - idiopathic, weight, stress, exercise; craniopharyngioma, Kallman syndrome
Pituitary - tumour; Sheehan syndrome, cerebral radiotherapy

167
Q

How is group 1 anovulation managed?

A

Increase BMI and decrease exercise
GnRH agonist - pump, limited, mono-ovulation
FSH/LH - problems with ovarian hyperstimulation (multiple pregnancy)

168
Q

How common is group 2 anovulation, give an example and how does it present?

A

Commonest (80-85%)
E.g. PCOS
Hyperprolactinaemia, thyroid/adrenal dysfunction

169
Q

What are the Rotterdam criteria for anovulatory infertility in PCOS?

A
  1. Biochemical/clinical evidence of androgen excess
  2. Amenorrhoea/oligomenorrhoea
  3. TVUS features of PCOS
170
Q

How is anovulatory infertility in PCOS managed?

A

Weight loss
Drug therapy - clomifene (SERM, increases FSH, induces ovulation), letrozole (aromatase inhibitor, increases FSH), metformin, FSH injection
Ovarian drilling (miscarriage risk)
Assisted reproductive technology - IVF

171
Q

What are the complications of clomifene therapy for anovulatory infertility in PCOS?

A

Increased multiple pregnancy - not an issue for letrozole as one follicle is stimulated
Increased ovarian cancer risk (>12 months use)

172
Q

What is ovarian hyperstimulation?

A

Ovaries over-respond to gonadotrophin injections and release vasoactive products

173
Q

What are the complications of ovarian hyperstimulation?

A

Thrombosis
Renal dysfunction
Liver dysfunction
ARDS

174
Q

What causes group 3 anovulatory infertility?

A

Premature ovarian insufficiency - idiopathic (premature ovarian failure), autoimmune, ovarian chemotherapy/radiation/surgery, chromosomal (Turner syndrome)

175
Q

What do bloods show in group 3 anovulatory infertility?

A 
Increased FSH 
Decreased oestrogen (menopausal levels)
176
Q

How is group 3 anovulatory infertility managed?

A

May have functional Graafian follicles in ovary - can conceive without treatment
Assisted conception - IVF and oocyte donation

177
Q

What causes tubal subfertility?

A

Problems with ovum pick-up or transport

PID, endometriosis

178
Q

What 2 features of a history are suggestive of tubal subfertility?

A

Previous infection

Ectopic pregnancy

179
Q

How should suspected tubal infertility be investigated?

A 
Chlamydia 
TVUS
Hystero-salpingo-gram (HSG)
Hysterosalpingo-contrast-ultrasonography (Hy-Co-Sy)
Laparoscopy and dye test
180
Q

How is tubal subfertility managed?

A

IVF

Salpingesctomy/clipping if hydrosalpinx

181
Q

How is endometriosis related subfertility managed?

A

Medical - symptom relief only, all effective drugs are anti-fertility
Surgical - diathermy, ovarian cystectomy
IVF

182
Q

How is unexplained subfertility managed?

A

Full history and investigations

IVF

183
Q

What assisted reproductive technology options are there?

A

Ovulation induction - intrauterine insemination (IUI)
IVF - intra-cytoplasmic sperm injections (ICSI)
Donor sperm/eggs +/- IVF

184
Q

What are the eligibility criteria for IVF in Scotland?

A 
Co-habiting in a stable relationship >2 years
<42 years of age
BMI >18.5 and <30
Both partners non-smokers
At least one partner with no child
Not sterilised
185
Q

What is the average age of menopause?

186
Q

Outline the histology of an infant ovary

A

Filled with primordial follicles which contain oocytes (female germ cells)
Halted in prophase I of meiosis until puberty

187
Q

Outline the process of folliculogenesis

A

Recruitment of primordial follicles
FSH - proliferation of granulosa cells and arrangement of theca cells around follicle
Primordial follicles -> primary follicles -> antral follicles -> 1 dominant follicle which releases an oocyte in response to LH

188
Q

What are the causes of menopause?

A 
Normal process of ageing 
Surgical removal of ovaries 
Radio/chemotherapy 
Hysterectomy 
Smoking 
Deletions of X chromosome
189
Q

How should a patient <45 years old in whom menopause has began be investigated?

A

FSH levels

Genetic testing

190
Q

Give 3 symptoms of menopause

A 
Vasomotor - hot flushes, night sweats 
Vulvo-vaginal dryness 
Sleep disturbance 
Mood disturbance 
Sexual dysfunction
191
Q

What change occurs to the vaginal epithelium in menopause?

A

Change from thick layer of mature superficial cells in high oestrogen environment to thin layer in low oestrogen environment

192
Q

Give 3 changes to the urogenital tract in menopause and their consequences

A

Atrophic ovary and tubes
Fibroids shrink
Vagina lining becomes thin, low secretions and pH - vaginal dryness, dyspareunia, relationship breakdown, discomfort, bleeding
Atrophic urethral mucosa - frequency, dysuria, incontinence, recurrent UTI
Decreased tone and blood supply to pelvic floor - uterovaginal prolapse
Atrophic external genitalia

193
Q

How does menopause affect mood/sleep/cognition?

A 
Depression 
Irritability 
Anxiety 
Poor memory 
Sleep disturbance 
Alzheimer's
194
Q

What are the options for hormone replacement therapy in menopause?

A 
Tablets 
Implants 
IUS
Gel
Patches
Pessaries
Vaginal rings
Creams
195
Q

What hormones need to be replaced in menopause and why?

A

Oestrogen and progesterone (reduce risk of endometrial cancer)

196
Q

How are the urinary symptoms of menopause managed?

A

Weight reduction
Pelvic floor muscle training
Bladder training
Antimuscarinics

197
Q

How is osteoporosis risk assessed in menopause?

A

Assess fracture possibility - FRAX

Prevention - falls, mobility, nutrition

198
Q

What effect does HRT have on risk of CHD in menopause?

A

Reduces CHD by 50% if commenced within 10 years of menopause

199
Q

What treatment options are there for flushing in menopause other than HRT?

A

Prescribed - clonidine, gabapentin, SSRI
Alternative - acupuncture, lifestyle, stellate ganglion blockade
Non-prescribed - vitamin E, evening primrose oil, phytoestrogens, black cohosh
CBT

200
Q

Give 3 side effects of clonidine

A 
Headache 
Constipation 
Dry mouth 
Dry eyes 
Impotence 
Drowsiness 
Confusion 
Gynaecomastia
Hallucinations 
Paraesthesia)
Dizziness 
Nausea and vomiting 
postural hypotension 
Hair loss (alopecia) 
Peripheral vasoconstriction 
Decreased Libido 
Depressed mood
201
Q

Outline the micturition cycle which maintains continence

A

1 - bladder fills; detrusor muscle relaxes, urethral sphincter and pelvic floor contract
2 - first sensation to void; bladder half full, urination voluntarily inhibited until appropriate time
3 - normal desire to void
4 - micturition; detrusor muscle contracts, pelvic floor relaxes

202
Q

What are the 3 types of urinary incontinence?

A

Urgency/overactive bladder
Mixed
Stress - anatomical defect in urethral support or sphincter muscle weakness

203
Q

Which type of urinary incontinence is the most common? What causes it?

A

Stress

Increased intra-abdominal pressure

204
Q

Give 3 causes of urge incontinence/overactive bladder

A 
Neurological - Parkinsons, stroke, MS, cognitive function 
Mobility 
Constipation 
Previous surgery 
Acute UTI
Caffeine
Alcohol
Bladder abnormalities - tumours, stones
High urine output - medication, excess fluid, diabetes, poor kidney function
205
Q

Give 5 risk factors for urinary incontinence

A 
Pregnancy
Parity 
Pelvic surgery/radiation 
Pelvic prolapse and repair 
Race 
Family history 
Anatomical/neurological abnormalities
Drugs 
Menopause 
Cognitive impairment 
UTI 
Increased intra-abdominal pressure 
Obesity 
Co-morbidities
Age
206
Q

How might urinary incontinence affect a patient’s quality of life?

A 
Exercise
Sleep
Employment 
Emotions 
Relationships 
Socialising 
Self with 
Travel 
Holidays
207
Q

Give 3 symptoms to ask about when urinary incontinence is suspected

A 
Stress incontinence
Frequency
Urgency
Urge incontinence
Nocturia
Enuresis
Haematuria
Dysuria
Voiding problems
Pain
Prolapse symptoms
208
Q

How should a patient with suspected urinary incontinence be examined?

A

Abdominal/bimanual examination - masses, palpable bladder, pelvic floor tone
Vaginal examination - speculum, cervix/vaginal vault, check walls (prolapse, atrophy, fistula, ulceration), urine leakage on coughing

209
Q

What investigations can be done for suspected urinary incontinence?

A

Urinalysis +/- culture - UTI, haematuria, diabetes
Bladder diary - 3 days minimum, in/out/time of leak
Cystoscopy and renal tract imaging
Urodynamic testing

210
Q

What is urodynamics, why might it be carried out and which patients are suitable?

A

Dynamic study of bladder function - uroflowmetry measures flow and filling/voiding cystometry measures pressures
Why - obtain diagnosis, choose operation, predict complications
Who - failed conservative management/prior surgery, prior to surgery, treatment complications, suspected voiding problem

211
Q

How is urinary incontinence managed?

A

Conservative - education, lifestyle changes (avoid caffeine/alcohol/carbonated drinks, weight loss, smoking cessation, treat cough/constipation), PT (pelvic floor exercises), bladder retraining (relearning higher cortical control of detrusor, empty bladder to strict hourly schedule and increase gradually)
Medical - antibiotics, anticholinergics (e.g. oxybutynin, inhibits contraction), B3 agonists (increase relaxation), duloxetine
Surgical

212
Q

What is the success rate of conservative urinary continence management and what patients would not be suitable for this?

A

Cure in 75-85%
Not suitable if - haematuria, infection, pain, difficulty voiding, tried and failed, patient unable/unwilling to engage, no facilities

213
Q

What are the side effects of anticholinergics for overactive bladder urinary incontinence and how is treatment managed?

A

Side effects - dry mouth, dry eyes, constipation

4-6 weeks needed to assess response, trial withdrawal every 3-4 months if successful

214
Q

How does duloxetine work for treating stress urinary incontinence and what are its side effects?

A

Stimulated pudendal nerve which increases sphincter contraction
Side effects - GI disturbance, dry mouth, headache, suicidal ideation

215
Q

How can an overactive bladder be managed surgically?

A

Detrusor botox injections
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion

216
Q

How can an stress urinary incontinence be managed surgically?

A

Synthetic tapes/mid-urethral sling
Colposuspension
Biological slings
Intramural bulking agents

217
Q

Define uterovaginal prolapse

A

Protrusion of the uterus and/or vagina beyond normal anatomical confines
Often involves bladder, urethra, rectum and bowel

218
Q

What is the pelvic floor?

A

Muscular and fascial structures which provide support to the pelvic viscera and external openings of the vagina, urethra and rectum

219
Q

What structures support the uterus and cervix/upper vagina?

A

Uterus - vaginal walls, transverse cervical ligaments, round and broad ligaments
Cervix and upper vagina - transverse cervical ligaments, uterosacral ligaments

220
Q

Give 3 risk factors for uterovaginal prolapse

A

Increasing age
Menopause
Vaginal delivery - direct trauma (avulsion of levator ani/ligaments via forceps), pudendal nerve damage (against bony pelvis)
Increased parity
Raised intra-abdominal pressure - obesity, chronic cough/constipation
Abnormal collagen metabolism

221
Q

What are the symptoms of uterovaginal prolapse?

A 
Asymptomatic 
Sensation of pressure/fullness/heaviness 
Sensation of bulge/something coming down which is worse at the end of the day and better on lying down
Bleeding/discharge 
Backache 
Dyspareunia 
Urinary incontinence/frequency/urgency
Need to manually reduce before voiding 
Constipation/straining 
Faecal incontinence/urgency 
Incomplete faecal evacuation
222
Q

How should a patient with suspected uterovaginal prolapse be examined?

A

Vaginal examination - speculum, cervix/vaginal vault, check walls for descent/atrophy/ulceration, ask patient to cough
Abdominal/bimanual examination - masses

223
Q

How are uterovaginal prolapses graded?

A

Pelvic organ prolapse quantification (POPQ) - based on position of most distal portion during straining

224
Q

Outline the pelvic organ prolapse quantification used for grading uterovaginal prolapses

A

Stage 0 - no prolapse
Stage 1 - >1cm above hymenal ring
Stage 2 - extends from 1cm above to 1cm below hymenal ring
Stage 3 - extends >1cm below hymenal ring
Stage 4 - vagina completely everted (complete procidentia)

225
Q

How are prolapses classified anatomically according to site of the defect and pelvic viscera that are involved?

A

Cystocele - bladder protrudes (anterior)
Urethrocele - descent of the lower anterior vaginal wall where the urethra sits
Rectocele - rectum protrudes (posterior)
Enterocele - upper posterior vaginal wall (fornix) and pouch of Douglas, contains small bowel
Uterine prolapse - uterus into vagina
Vaginal vault prolapse - following hysterectomy

226
Q

What is the commonest type of prolapse?

A

Prolapse of upper anterior vaginal wall and bladder (cystocele)

227
Q

What are the 3 degrees of uterine prolapse?

A

1st - cervix does not pass outside introitus
2nd - cervix protrudes beyond introitus
3rd - total prolapse

228
Q

How are prolapses managed?

A

Conservative - none, lifestyle (weight, smoking), PT (pelvic floor exercises), pessaries, vaginal oestrogen
Surgical - vaginal, abdominal

229
Q

What factors will influence management of a patient with prolapse?

A 
Severity of symptoms 
Impact on quality of life 
Age/parity/future plans 
Sexual activity 
Presence of smoking or obesity 
Urinary symptoms 
Other gynaecological issues (e.g. menorrhagia)
230
Q

Where is a ring pessary placed?

A

Between posterior aspect of symphysis pubis and posterior fornix of vagina

231
Q

Name 3 types of pessary

A 
Ring 
Shelf 
Gelhorn 
Hodge (correction of uterine retroversion)
Cube (if difficulty retaining others)
Donut (if difficulty retaining others)
232
Q

Give 3 complications of pessaries

A 
Interfere with sexual intercourse 
Ulceration 
Infection 
Difficulty and discomfort on insertion/removal 
Fistula can occur if neglected
233
Q

What are the surgical management options for prolapse?

A

Anterior compartment defect (cyctocele) - anterior colporrhaphy
Posterior (rectocele) - posterior colporrhaphy
Uterovaginal prolapse - hysterectomy, Manchester repair, sacrohysteropexy
Vaginal vault prolapse - sacrospinous ligament fixation, sarcocolpopexy
Vaginal closure - colpocleisis

234
Q

What are the indications for prolapse sugery?

A

Pessaries failed
Patient request for definitive treatment
Prolapse combined with urinary/faecal incontinence

235
Q

What are the complications of prolapse surgery?

A

Anterior - dyspareunia, incontinence, failure, recurrence

Posterior - dyspareunia

236
Q

How can prolapse be prevented?

A 
Weight reduction 
Treatment of constipation/cough
Smoking cessation 
Avoidance of heavy lifting 
Pelvic floor exercises 
Good intrapartum care - avoid unnecessary instrumentation/prolonged labour
237
Q

What are the 3 gynaecological emergencies?

A

Ectopic pregnancy
Miscarriage
Post-operative/intra-abdominal bleeding

238
Q

How common are abortions?

A

25% of all pregnancies end in abortion

1 in 3 people will have had an abortion by 45 years of age

239
Q

What is the national set up for abortion in Scotland?

A

Medical abortion up to 18 weeks
Surgical procedures up to 13 weeks
>18 weeks - access funded abortion care in England

240
Q

What are the 2 types of abortion?

A

Medical - at home or inpatient
Surgical - local or general anaesthetic
Same as miscarriage management

241
Q

How is medical abortion achieved?

A

Mifepristone 200mg - anti-progesterone taken orally in clinic
Misoprostol 800mcg - taken 24-48 hours later, vaginal/buccal/sublingual, prostaglandin analogue, can be taken at home

242
Q

What are the inclusion criteria for taking misoprostol at home for a medical abortion?

A

Clinic for the first drug (mifepristone)
Fulfils the criteria set out in the Abortion Act 1967
16 years +
No significant medical conditions or contraindications to medical abortion

243
Q

What should a woman undergoing medical abortion expect?

A

Will experience vaginal bleeding (heavy with clots, up to 2 weeks) and lower abdominal pain (cramping) 2-3 hours after misoprotsol usually completing within 4 hours
Simple analgesia and hot water bottle may be used during this time

244
Q

What should a woman undergoing surgical abortion expect?

A

Day case
Will need to be fasted and have an adult escort for GA
Symptoms - minimal abdominal pain, 1 week of vaginal bleeding

245
Q

What additional things should be considered in a patient undergoing abortion?

A

Contraception - needed 5 days after, most can start on day of
Antibiotic prophylaxis may be required
Anti D IgG may be required if medical >10 weeks or surgical
Cervical screening status
Sexual health screen
Female genital mutilation

246
Q

What are the complications of abortion?

A 
Failure to end pregnancy 
Retained tissue 
Infection 
Haemorrhage 
Cervical tear (late medical)
Uterine perforation (late medical)
247
Q

What are the risk factors for long term psychological issues following abortion?

A

Possible long term psychological risk factors:
Previous / current mental health problems
Pressure to have abortion
Unsure of decision / ambivalent about abortion
Unsupportive partner / limited social support
Belonging to a religious, social or cultural groups

248
Q

What are crisis pregnany centres?

A

Some CPCs do not provide impartial pregnancy decision-making support
Many have a specific anti-abortion agenda

249
Q

Give 3 contraindications to medical abortion

A 
Long term corticosteroids
Severe asthma
Adrenal insufficiency
Clotting disorders
Porphyria
Sickle cell
High cholesterol
Hypertension
250
Q

Give 2 contraindications to surgical abortion

A 
BMI 40
BMI 35 with comorbidities
Anaesthetic complications
Difficulty accessing cervix e.g. tumor
Gestational trophoblastic disease IP rather DS
251
Q

When should medical attention be sought following an abortion?

A

Very heavy bleeding - soaking >2 pads/hour for 2 consecutive hours, symptoms of anaemia (dizziness, SOB, palpitations, fatigue)
Persistent bleeding/pain
Offensive vaginal discharge
High fever/systemically unwell

252
Q

What should be covered in the history of a patient who has recently had an abortion and is bleeding?

A 
Assess bleeding 
Type of abortion and process
Associated symptoms 
Contraception 
STI screen 
Prophylactic antibiotics
253
Q

What is the differential diagnosis for bleeding after abortion?

A

Incomplete abortion
Endometritis
Uterine perforation
Contraception side-effect

254
Q

What is RPOC?

A

Retained products of conception

Placental/fetal tissue left inside uterus

255
Q

How is RPOC diagnosed?

A

History - persistent pain/bleeding, may have infection

USS - endometrial cavity filled with irregular vascular material

256
Q

How is RPOC managed?

A

Expectant - watch and wait
Medical - further misoprostol dose
Surgical - evacuation

257
Q

What is endometritis?

A

Infection of the lining of the uterus occurring within the first few days of abortion

258
Q

Give 3 signs/symptoms of endometritis

A 
Persistent lower abdominal pain / tenderness
Pain with intercourse (deep dyspareunia)
Persistent bleeding
Offensive vaginal discharge
Fever
Cervical motion tenderness
259
Q

How is endometritis managed?

A

Broad spectrum antibiotics (local PID guideline)
Analgesia
If septic - admit, IV antibiotics, IV fluids
If retained tissue - empty uterus ASAP

260
Q

When does uterine perforation after abortion usually present and how?

A

Usually recognised and managed at time of procedure

If not, may present up to 48 hours later with abdominal pain and bleeding

261
Q

How is uterine perforation after abortion managed?

A

Laparoscopy/lamarotomy and repair

262
Q

What affect does abortion have on future fertility and risk of breast cancer?

263
Q

What should be asked in a consultation where a woman has requested a pregnancy test?

A

LMP
Unprotected sexual intercourse
Contraception
How would they feel if it were positive

264
Q

What should be asked in a consultation where a woman has a positive pregnancy test and does not want to be pregnant?

A

LMP/ gestation calculation
Medical & sexual history
Past and current mental health illness
Assess STI risk and screen
Explore feelings about pregnancy/reasons for abortion
Ask if sure about decision/check for ambivalence
Assess risk of coercion (gender based violence)
Check support (partner/friends/relatives)
Ask about beliefs about abortion in general
Outline options (parenting, abortion, adoption)
Outline different abortion methods
Discuss/prescribe contraception
Explain how to access abortion service
Refer and sign Certificate A (optional)
Offer post abortion review

265
Q

What are the legal implications of having a conscientious objection to abortion as a doctor?

A

Abortion Act 1967
Doctors have a legal & professional right to opt out of participating in abortion care
As long as the woman can still access an abortion
Unless one is needed to save life/prevent serious harm

GMC: Personal beliefs and medical practice (2013)
Doctors may practise medicine in accordance with their beliefs, provided that they do not:
treat patients unfairly
deny patients access to appropriate medical treatment or services
cause patients distress

GMC: Good Medical Practice (2013)
You must explain to patients if you have a conscientious objection to a particular procedure
Tell them about their right to see another doctor
Make sure they have enough information to exercise their right

266
Q

What is the potential impact of conscientious objection of abortion?

A

Patients seeking abortion - feel judged and/or stigmatised, decision may be influenced by doctor, trust in doctor may be eroded
Medical colleagues - increased workload
Colleagues with objections - feel judged/stigmatised
Abortion service provision - care limited/compromised if too many opt out
Medical profession - trust undermined, reputation damaged

267
Q

What routine asymptomatic STI testing is available for men and woman?

A

Men - urine (chlamydia, gonorrhoea), blood (HIV, syphilis)

Women - self-take vaginal swab (chlamydia, gonorrhoea), blood (HIV, syphilis)

268
Q

What type of test is used for chlamydia and gonorrhoea and how is the sample taken?

A

Nucleic acid amplification testing (NAAT) - dual PCR, orange tube with swab which snaps
Women - low vaginal swab
Men - first pass urine
Extra-genital - pharynx, rectal

269
Q

How is HSV tested for?

A

Viral PCR vial with fluid
Plain swab used to obtain fluid from ulcer and then transferred to fluid in vial which is shaken
Also tests for syphilis

270
Q

How are BBV tested for?

A 
9ml EDTA (large/2 small purple top) tube to virology 
Tests for - HIV and syphilis, hepatitis B and C in high risk groups
271
Q

What is a window period?

A

The period of time when a person may be infected but the test is not yet positive depending on type of infection and test
Important that patients are not falsely reassured by a negative result when they may still have an infection and therefore pass it on unknowingly

272
Q

What is the window period for HIV?

A

4 weeks (8 weeks if high risk)

273
Q

How might partner notification occur?

A

Patient initiated

Provider initiated - anonymous text message service

274
Q

What is the window period for chlamydia and gonorrhoea?

275
Q

What is the window period for hepatitis B and C?

A

B - 3 months

C - 4 weeks to 3 months

276
Q

What is the window period for syphilis?

277
Q

What contraceptive options are available?

A

Long acting and reversible - implant, injection, intrauterine (hormonal, non-hormonal)
Long acting and permanent - vasectomy, sterilisation
Short acting - hormonal pills/patches/rings, condoms (male, female), diaphragm

278
Q

What is the contraceptive implant, how does it work and what are its side-effects?

A

Small flexible rod lying under the skin of the upper arm
Contains progestogen - stops ovulation, thickens mucus, thins lining
3 year duration
0.05% failure
Side-effects - unpredictable bleeding

279
Q

What is the contraceptive injection, how does it work and what are its side-effects?

A 
Injection into buttock or abdomen 
Contains progestogen 
Given every 13 weeks 
6% failure
Side-effects - irregular bleeding, weight gain, reduced BMD, 1 year after stopping for ovulation to be normal
280
Q

What is the hormonal intrauterine device, how does it work and what are its side-effects?

A

Progestogen
3-5 years duration
0.2% failure
Side-effects - lighter/stopped periods, irregular bleeding in first 6 months

281
Q

What is the non-hormonal intrauterine device, how does it work and what are its side-effects?

A

Copper - kills sperm, stops implantation, thickens mucus
5-10 year duration
0.8% failure
Side-effects - heavier more painful periods

282
Q

What are the combined hormonal contraceptive options, how do they work and what are their side-effects?

A

Oestrogen and progestogen - pill, patch, ring; inhibits ovulation, thickens mucus, thins lining
21 days on, 7 days off
Reduced effectiveness if missing, vomiting or diarrhoea
9% failure
Reduced bleeding and period pain
Risks - VTE/PE, contraindicated in migraine, increased risk of breast cancer

283
Q

What is the progestogen only pill, how does it work and what are its side-effects?

A

Progestogen (e.g. cerelle)
Take daily without breaks
9% failure
Can be used in smokers, >35 year olds, breastfeeding or CI to oestrogen
Side-effects - break through bleeding, amenorrhoea

284
Q

Outline sterilisation as a contraceptive option

A

Tubes cut/sealed/blocked - fallopian tube in women (GA), vas deferens in men (LA)
Women 0.5% failure, men 0.1% failure
Permanent
Will not improve periods

285
Q

What is the failure rate of condoms (typical use)?

286
Q

What are the most and least effective contraceptive options?

A 
Implant 
Male sterilisation 
LND-IUS
Female sterilisation 
Cu-IUD
Injection 
CHC/POP
Condoms 
None
287
Q

Outline the use of emergency contraception

A

If method has failed/been forgotten
Free from GP/chemist/Sandyford
Gold standard is copper intrauterine device within 5 days of unprotected sex/predicted ovulation
Oral hormonal - ullipristal acetate (ellaOne) up to 120 hours after sex, levonorgestrel (levonelle) up to 72 hours after sex

288
Q

What is FGM

A

Procedure that involves partial or total removal of the external female genitalia, or other injury to the female genitals
For non medical reasons

289
Q

Give 3 risk factors for STIs

A

Young age (less than 25, but especially less than 20) – especially cisgender women
Not in a monogamous relationship
Multiple sexual partners or recent change of sexual partner
Non use of barrier methods of contraception
Ethnicity for some STIs eg. hepatitis B in Asians, gonorrhoea and trichomonas in black Carribeans, HIV in Black Africans
Sexual orientation – men who have sex with men (MSM)
Residence in metropolitan areas

290
Q

What is the most common bacterial STI in the UK?

291
Q

What are the signs/symptoms of chlamydia in women?

A 
80% asymptomatic 
PCB/IMB
Purulent discharge 
Lower abdominal pain 
Proctitis 
Cervicitis
Cervical contact bleeding 
Pelvic infection
292
Q

What are the signs/symptoms of chlamydia in men?

A 
50% asymptomatic 
Urethral discharge 
Dysuria 
Testicular/epididymal pain 
Proctitis
293
Q

How is chlamydia managed?

A

Doxycycline 100mg for 7 days

Erythromycin 500mg for 14 days if pregnant/breastfeeding

294
Q

What are the complications of chlamydia?

A

Pelvic inflammatory disease - increasing risk of infertility, ectopic pregnancy and chronic pelvic pain with repeated infections.
Epididymitis.
Reactive arthritis
Fitz-Hugh Curtis syndrome

295
Q

What are the risks of chlamydia in pregnancy?

A

Neonatal conjunctivitis in 30-50%, less commonly pneumonitis
Low birth weight
Post-partum endometritis

296
Q

What are the signs/symptoms of gonorrhoea in women?

A

Cervical infection asymptomatic in 70%
Vaginal discharge
Low abdominal pain

297
Q

What are the signs/symptoms of gonorrhoea in men?

A

Urethral discharge
Dysuria
Rectal infection

298
Q

How is gonorrhoea managed?

A

Ceftriaxone 1g

299
Q

What are the complications of gonorrhoea for men and women?

A

Women - PID, bartholinitis, endometritis

Men - epididymitis, infection of penile glands (Tyson’s glands)

300
Q

How does HSV present?

A

70-80% asymptomatic
Primary infection - febrile illness of 5-7 days, dysuria, painful lymphadenopathy, neuropathic pain, genital blisters, ulcers, fissures

301
Q

What are the complications of HSV?

A

Urinary retention, constipation, rarely aseptic meningitis
Recurrent infections tend to be milder and resolve within 3-4 days
Risk of symptomatic recurrences greater in patients who have type 2 HSV, who have a severe first episode and who are immunocompromised

302
Q

How is HSV managed?

A

Primary - acyclovir 400mg TID for 5 days, simple analgesia, salt bath
Recurrence - acyclovir 800mg TID for 2 days

303
Q

What organism causes syphilis?

A

Treponema pallidum

304
Q

What are the symptoms of syphilis?

A

Indurated anogenital/oral ulcer - may be painless or painful

305
Q

How is syphilis diagnosed?

A

Syphilis serology
Swab of lesion for PCR testing
Dark ground microscopy (of fluid from lesion) in specialist sexual health services

306
Q

How is syphilis managed?

A

Benzathine penicillin 2.4 mu IM (early)

307
Q

What are the complications of syphilis?

A

Neurosyphilis (usually a late complication but may occur earlier if immune suppressed)
Cardiovascular syphilis (late complication)
Gummata

308
Q

What is a gumma?

A

A small soft swelling which is characteristic of the late stages of syphilis and occurs in the connective tissue of the liver, brain, testes, and heart

309
Q

What causes anogenital warts?

A

HPV (types 6 and 11)

310
Q

What are the symptoms of anogenital warts?

A

Warts around sites of trauma (e.g. introitus in women, penis in men)
Genital lumps which can itch and bleed

311
Q

How are anogenital warts diagnosed?

A

Clinical appearance

Biopsy should be done if atypical appearance

312
Q

How are anogenital warts managed?

A

Podophyllotoxin cream/solution
Imiquimod
Cryotherapy

313
Q

How can anogenital warts be prevented?

A

HPV vaccination (6, 11, 16, 18) to all women at school and all MSM <45 years old

314
Q

Give 3 causes of discharge

A 
Physiological 
STI - gonorrhoea, chlamydia 
Candida
Bacterial vaginosis
Trichomonas vaginalis (STI)
Allergic reaction/dermatosis
315
Q

How do candida, BV and TV differ in type of discharge and treatment?

A

Candida - thick, white, itchy, sore; anti-fungal (e.g. clotrimazole)
BV - thin, grey, watery, fishy, burning; metronidazole
TV - thin, frothy, yellow, fishy, itchy, sore, dysuria, vaginitis; metronidazole

316
Q

What is the normal vaginal pH?

Year 5 (10 decks)

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