Gynaecology Flashcards
Define post-menopausal bleeding.
Bleeding more than 1 year after cessation of periods.
Define heavy menstrual bleeding.
Blood loss of > 80mL per period. As this is difficult to quantify, it is usually taken as whatever the patient regards as abnormally heavy.
What proportion of women of reproductive age suffer from heavy menstrual bleeding?
20-30%.
What are the common causes of heavy menstrual bleeding?
Fibroids Adenomyosis Endometrial polyps Coagulation disorders Pelvic inflammatory disease Thyroid disease Drug therapy (e.g. warfarin) Intrauterine devices Endometrial/cervical carcinoma
Name a diagnosis of exclusion associated with heavy menstrual bleeding.
Bleeding of endometrial origin (BEO).
What are the indications to perform endometrial biopsy in a patient reporting heavy menstrual bleeding? (5)
PMB and endometrial thickness on TVUSS > 4mm HMB > 45 years HMB associated with IMB Treatment failure Prior to ablative techniques
What are the medical management options for heavy menstrual bleeding? (4)
Levonorgestrel intrauterine system (LNG-IUS, Mirena) - requires long-term use, not suitable for women wishing to conceive.
Tranexamic acid - taken during menstruation.
Norethisterone - 15mg/day from day 6-26 of menstrual cycle.
GnRH agonists - stop production of oestrogen, causing amennorhoea. Only used short-term due to osteoporosis risk.
What are the surgical management options for heavy menstrual bleeding? (5)
Endometrial ablation
Uterine artery embolisation (useful for HMB associated with fibroids)
Myomectomy (useful for large fibroids causing pressure symptoms in women who wish to conceive)
Transcervical resection of fibroid (appropriate for women wishing to conceive)
Hysterectomy (useful for large fibroids causing pressure symptoms)
What is the medical management for acute heavy menstrual bleeding?
Tranexamic acid (oral or IV) High-dose progestogens to arrest bleeding Consider suppression with GnRH or ulipristal acetate
What are the causes of secondary dysmenorrhoea?
Endometriosis or adenomyosis
Pelvic inflammatory disease
Cervical stenosis and haematometra (rare)
When should diagnostic laparoscopy be performed to investigate dysmenorrhoea? (3)
When the history suggests endometriosis
When swabs and ultrasound scans are normal but symptoms persist
When the patient wants a definitive diagnosis or wants reassurance
The gonads originate from…
…the genital ridge overlying the embryonic kidney in the intermediate mesoderm during the 4th week of life.
Gonads remain sexually indifferent until when?
The 7th week.
Which gene causes the undifferentiated gonads to develop into testes?
the SRY gene.
As gonads become testes, which 2 types of cell do they differentiate into? What do these cells do?
Sertoli cells - produce anti-Mullerian hormone (AMH)
Leydig cells - produce testosterone
Which hormone surpassed development of the Mullerian ducts in males?
Anti-Mullerian hormone.
Which hormone stimulates the Wolffian ducts to develop into the vas deferens, epididymis and seminal vesicles?
Testosterone.
Which hormone causes the conversion of testosterone to DHT in the external genital skin to virile the external genitalia?
5-alpha reductase.
Development of the male genitalia: The ____ ____ becomes the penis and the _____ _____ fuse to form the scrotum. The _____ _____ fuse along the ventral surface of the penis and enclose the urethra.
Development of the male genitalia: The genital tubercle becomes the penis and the labioscrotal folds fuse to form the scrotum. The urogenital folds fuse along the ventral surface of the penis and enclose the urethra.
In the primitive ovary, which cells surround the germ cells and form primordial follicles?
Granulosa cells.
NOTE: Each follicle consists of an oocyte within a single layer of granulosa cells.
Development of the female sexual organs: Thecal cells develop from the proliferating ____ ____ and are separated from granulosa cells by the ____ ____.
Development of the female sexual organs: Thecal cells develop from the proliferating coelomic epithelium and are separated from granulosa cells by the basal lamina.
What is the maximum number of primordial follicles and when is this number reached?
6-7 million, reached at 20 weeks.
NOTE: By birth this is just 1-2 million (due to atresia), and by menarche 300,000-400,000 remain.
Development of the female sexual organs: The proximal 2/3 of the vagina develop from what?
The paired Mullerian ducts.
What forms the Fallopian tubes?
The unpaired caudal sections of the Mullerian ducts.
Development of the female sexual organs: Cells from the upper part of the urogenital sinus proliferate to produce what?
The sinovaginal bulbs.
Development of the female sexual organs: Cloacal folds fuse anteriorly to become what? What does this later develop into?
They become the genital tubercle, which later becomes the clitoris.
Development of the female sexual organs: The cloacal folds anteriorly are called what? What do these form?
The urethral folds - these form the labia minora.
NOTE: Another pair of folds within the cloacal membrane forms the labioscrotal folds which form the labia majora.
Which part of the vulva contains sebaceous and sweat glands?
The labia majora.
NOTE: The labia majora also contain fatty tissue at the deepest parts. The labia minora contain sebaceous glands but no adipose tissue.
The labia minora divide anteriorly to form which 2 structures of the vulva?
The prepuce
The clitoral hood (frenulum of the clitoris)
The labia minora divide posteriorly to form which structure of the vulva?
The fourchette.
The clitoris is made up of paired columns of erectile and vascular tissue called what?
The corpora cavernosa.
What is the function of the Bartholin’s glands?
They contribute to lubrication during intercourse.
What is the medical name for any tags remaining after perforation of the hymen?
Carunculae myrtiformes.
What type of epithelium lines the vagina?
Stratified squamous epithelium.
The vagina has no glands - how it is kept moist?
By secretions form the uterine and cervical glands and by transudation from the epithelial lining.
Why does the vagina have no glycogen before puberty or after menopause?
Lack of stimulation by oestrogen.
Name the normal vaginal commensal that breaks down glycogen to form lasting acid, producing a low pH (which protects against growth of bacteria).
Doderlein’s bacillus.
The parametrium is formed by which 2 sets of ligaments?
The cardinal and uterosacral ligaments.
How much does the adult uterus weigh?
70g
What is meant by the term cornu?
The site of insertion of a Fallopian tube into the uterus.
What are the 3 layers of the uterus?
Peritoneum - the outer serous layer
Myometrium - the middle muscular layer
Endometrium - the inner mucous later
The endometrial layer of the uterus is lined by a single layer of what form of epithelium?
Columnar epithelium.
Roughly how long is the adult cervix?
2.5cm
What is the name of the layer of connective tissue lateral to the cervix?
The parametrium.
What is the name if the anterior and posterior columns of the endocervix from which folds radiate out?
Arbour vitae.
What does the endocervix secrete?
Clear, alkaline mucus - this is the main component of physiological vaginal discharge.
What types of epithelia are found on the endocervix?
The epithelium of the endocervix is columnar and ciliated in the upper 2/3, and transitions to squamous at the squamocolumnar junction.
Where do the Fallopian tubes open up into the peritoneal cavity?
At the abdominal ostium.
What is the function of the Fallopian tubes?
They take the ovum from the ovary to the uterus and promote oxygenation and nutrition for sperm, ovum and zygote.
The Fallopian tubes run in the upper margin of the broad ligament, otherwise known as the what?
Mesosalpinx.
How long are the Fallopian tubes?
Roughly 10cm.
What are the four parts of the Fallopian tubes?
Interstitial portion - lies within the wall of the uterus
Isthmus - narrow portion adjoining the uterus
Ampulla - widest and longest part
Infundibulum or fimbrial portion - opening of the tube into the peritoneal cavity
What is the name of the longitudinal folds in the epithelia of the Fallopian tubes?
Plicae.
What are the 2 cell types in the epithelia of the Fallopian tubes?
Ciliated cells (produce constant current of fluid in the direction of the uterus) Secretory cells (contribute to volume of tubal fluid)
What attaches the ovary to the cornu of the uterus?
The ovarian ligament.
Describe the structure of an ovary.
It has a central vascular medulla consisting of loose connective tissue containing elastin fibres and non-striated muscle cells
It has an outer thicker cortex which is denser than the medulla
It contains networks of reticular fibres and fusiform cells
The surface of the ovaries has a single layer of cuboidal cells (germinal epithelium)
Underneath this layer is another layer called the tunica albuginea (increases in density with age)
After puberty, some primordial follicles become Graafian follicles and ovulate to become the corpus luteum. This will then undergo atresia to become what?
Corpora albicans.
What is the arrangement of muscle in the bladder?
An inner longitudinal layer, a middle circular layer and an outer longitudinal layer.
What type of epithelium is found in the bladder?
Transitional epithelium.
What is the average bladder capacity?
400mL
The internal meatus of the urethra is known as what?
The trigone.
What separates the bladder from the anterior vaginal wall?
The pubocervical fascia.
What type of epithelium is found in the urethra?
Transitional epithelium.
How is the smooth muscle of the wall of the urethra arranged?
Into outer longitudinal and inner circular layers.
The ureter lies in front of the bifurcation of which artery?
The common iliac artery.
The blood supply of the ureter is mainly from small branches of which artery?
The ovarian artery.
The rectum begins at which vertebral level?
S3.
The rectum is separated from the posterior vaginal wall by what?
The rectovaginal fascial septum.
Which ligaments are found lateral to the rectum?
The uterosacral ligaments.
The pelvic diaphragm is formed by the levator ani muscles, and is described in 2 parts - name these parts.
Pubococcygeus - arises from the pubic bone and the anterior part of the tendinous arch of the pelvic fascia.
Iliococcygeus - arises from the posterior part of the tendinous arch and the ischial spine.
What is the urogenital diaphragm (aka the triangular ligament) and which 2 structures pierce it?
Two layers of pelvic fascia that fill the gap between the descending pubic rami and lie beneath the levator ani muscles.
It is pierced by the urethra and the vagina.
When taking a cervical smear, you put the brush into the cervical os and rotate how many times? Then, you put it into the pot and rotate how many times?
5x in the os
10x in the pot
What are the 2 types of speculum?
Bivalve (aka Cusco’s) - holds back the anterior and posterior walls of the vagina to allow visualisation of the cervix, and has a screw so that it can be tightened to keep it in place.
Sim’s - allows inspection of the vaginal walls, and is used in left lateral position.
Microbiology swabs are taken from which part of the vagina?
The vaginal fornices.
Endocervical swabs for chlamydia are taken from where?
The endocervical canal.
How is the size of the uterus described upon bimanual examination?
In terms of week of gestation (e.g. a 6 weeks size uterus).
When performing a transvaginal USS, what can be done to distend the uterine cavity and allow easier detection of abnormalities?
Saline instillation sonography (instilling saline through the cervix).
What must you always do before performing an endometrial biopsy on a woman.
Confirm that she is not pregnant.
Which hypothalamic hormone stimulates pituitary secretion of LH and FSH?
GnRH
Which cells in the hypothalamus synthesise and release LH and FSH?
Basophil cells.
How does the COCP stop the periovulatory LH surge?
It maintains constant oestrogen levels within the negative feedback range, preventing high levels of oestrogen in the late follicular phase which would lead to increased LH production due to increased concentrations of GnRH receptors.
Which 3 phases does the ovary go through during a cycle?
Follicular
Ovulatory
Luteal
What affects to LH and FSH have on the theca and granulosa cells of follicles?
Theca cells - LH stimulates production of androgens from cholesterol.
Granulosa cells - Convert androgens from theca cells into oestrogen via the process of aromatisation under the influence of FSH.
NOTE: Therefore, as follicles grow, oestrogen secretion increases.
Which 2 substances are released by granulosa cells to downregulate and upregulate FSH?
Inhibin - down regulates FSH release and enhances androgen synthesis.
Activin - produced by granulosa cells and the pituitary and acts to increase FSH binding on follicles.
How big will the dominant follicle be by the end of the follicular phase?
20mm diameter
What causes the LH surge at ovulation? (2)
- Oestrogen production increases until it reaches a positive feedback threshold
- LH-induced luteinisation of granulosa cells in the dominant follicle causes progesterone to be produced, which exerts more positive feedback for LH secretion
Ovulation occurs after breakdown of the follicular wall under the influence of what? (4)
LH
FSH
Proteolytic enzymes
Prostaglandins
Why should women wanting to become pregnant avoid taking PG synthetase inhibitors such as aspirin or ibuprofen?
Because prostaglandins are important in ovulation, so inhibiting their production can lead to anovulation.
Why does the corpus luteum undergo extensive vascularisation?
To supply granulosa cells with a rich blood supply for continued steroid production (aided by local VEGF production).
How long does the luteal phase last?
14 days.
Luteolysis of the corpus luteum occurs in the absence of what?
Beta-hCG produced by the implanting embryo.
What are the phases of the endometrium throughout the menstrual cycle?
The proliferative phase
The secretory phase
Menstruation
During the proliferative phase, glandular and stromal growth of the endometrium begins. The epithelium changes from a single layer of columnar cells to what type of epithelium?
Pseudofenestrated epithelium.
The endometrium enters the proliferative phase at 0.5mm thickness - how thick does it become during this phase?
3.5-5mm
During the secretory endothelial phase, what does progesterone do?
Induces the formation of a temporary layer (decidua) in the endometrial stroma.
During the secretory endothelial phase, apical membrane projection of epithelial cells appear (after day 21-22), making the endometrium more receptive for implantation. What are these projections called?
Pinopodes.
What are the 3 layers of the endometrium seen immediately before menstruation?
Basalis - lower 25% which remains throughout the menstrual cycle.
Stratum spongiosum - oedematous stroma and exhausted glands.
Stratum compactum - upper 25% with prominent decidualised stromal cells.
What causes the breakdown and loss of the upper endometrial layers during menstruation?
Fall in oestrogen and progesterone at the end of the luteal phase leads to loss of tissue fluid, vasoconstriction of spiral arterioles and distal ischaemia.
Why may people who are underweight not go through puberty?
Because leptin plays a permissive role in puberty, and is produced by white adipose tissue.
In terms of puberty, what is meant by the terms:
Thelarche
Adrenarche
Menarche
Thelarche - breast development
Adrenarche - pubic and axillary hair growth
Menarche - onset of menstruation
Which staging can be used to describe pubertal development?
Tanner staging.
Precocious puberty:
Definition
Classification
Definition - onset of puberty by the age of 8 in a girl, or 9 in a boy.
Classification:
Central - gonadotrophin development
Peripheral - gonadotrophin independent (this may be caused by exogenous ingestion of oestrogen or a hormone producing tumour)
Delayed puberty:
Definition
Causes associated with a central defect (4)
What is gonadal failure (hypergonadotrophic hypogonadism) associated with? (2)
Definition - when there are no signs of secondary sexual characteristics by the age of 14 years.
Causes associated with a central defect: Anorexia nervosa Excessive exercise Chronic illness Kallmann's syndrome
What is gonadal failure (hypergonadotrophic hypogonadism) associated with?
Turner syndrome
XX gonadal dysgenesis
List the non-structural causes of disorders of sexual development. (5)
Turner syndrome (45 X) 46 XY Gonadal Dysgenesis 46 XY DSD 5-Alpha Reductase Deficiency 46 XX DSD
Turner syndrome (45 X):
Main clinical features (3)
Associated medical conditions (5)
NOTE: In Turner syndrome, the gonads are called streak gonads and do not function to produce oestrogen or oocytes.
Main clinical features:
Short stature
Webbing of the neck
Wide carrying angle
Associated medical conditions: Coarctation of the aorta Inflammatory bowel disease Sensorineural and conductive deafness Renal anomalies Endocrine dysfunction
What is it Swyer syndrome?
Complete 46 XY gonadal dysgenesis - the gonad remains as a streak and does not produce any hormones.
In 46 XY gonadal dysgenesis, why must the dysgenetic gonad be removed following diagnosis?
High malignancy risk
What is mixed gonadal dysgenesis also known as?
Ovotesticular disorder of sexual development - both functioning ovarian and testicular tissue can be present.
How can puberty be induced in a patient with 46 XY gonadal dysgenesis?
Using oestrogen.
46 XY DSD:
Most common cause
Why does virilisation not occur, despite normal functioning of the testes and production of AMH?
When/how does presentation usually occur?
Management (3)
Most common cause - complete androgen insensitivity.
Why does virilisation not occur, despite normal functioning of the testes and production of AMH?
Partial or complete inability of the androgen receptor to respond to androgen stimulation.
When/how does presentation usually occur?
At puberty with primary amenorrhoea.
Management:
Gonadectomy (due to risk of testicular malignancy)
Long-term HRT
Vaginal dilatation (to allow penetrative intercourse)
5-alpha reductase deficiency - how does it present and why?
Usually with ambiguous genitalia - this is because the foetus is XY and has functioning testes which produce both testosterone and AMH, but testosterone cannot be converted to DHT causing normal virilisation.
46 XX DSD:
Most common cause
Physical changes seen as a result of female virilisation (3)
Management (2)
Most common cause - congenital adrenal hyperplasia (CAH)
Physical changes seen as a result of female virilisation: Enlarged clitoris Fused labia (scrotal in appearance) Upper vagina joins the urethra and opens as one common channel into the perineum
Management:
Lifelong steroid replacement
Surgical treatment of genitalia may be considered
Define: Amenorrhoea Primary amenorrhoea Secondary amenorrhoea Oligomenorrhoea Premature ovarian failure
Amenorrhoea - absence of menstruation for more than 6 months in the absence of pregnancy in a woman of fertile age.
Primary amenorrhoea - when a girl fails to menstruate by 16 years of age.
Secondary amenorrhoea - absence of menstruation for > 6 months in a normal female of reproductive age that is not due to pregnancy, lactation or menopause.
Oligomenorrhoea - irregular periods at intervals of more than 35 days, with only 4-9 periods per year.
Premature ovarian failure - cessation of periods < 40 years of age.
What is haematocolpos?
Filling of the vagina with blood - this can be seen in primary amenorrhoea where Mullerian defects are present in the genital tract.
What is Asherman syndrome?
Secondary amenorrhoea caused by scarring of the endometrium.
When investigating amenorrhoea or oligomenorrhoea, bloods should be taken to measure hormone levels - what will be seen in a patient with:
PCOS
Premature ovarian failure
PCOS = raised LH and testosterone
Premature ovarian failure = raised FSH
Management of Asherman syndrome.
Adhesiolysis and IUD insertion at time of diagnostic hysteroscopy.
What are the diagnostic criteria for PCOS?
Rotterdam Consensus Criteria - must have 2 of:
Amenorrhoea/Oligomenorrhoea
Clinical or biochemical hyperandrogenism
Polycystic ovaries on USS - 12+ sub capsular follicular cysts < 10mm in diameter and increased ovarian stroma
Management of PCOS.
COCP to regulate menstruation (increases sex hormone-binding globulin which helps relieve androgenic symptoms)
Cyclical oral progesterone (regulate withdrawal bleed)
Clomiphene (SERM which can induce ovulation if subfertility is an issue)
Lifestyle advice/Weight reduction
Ovarian drilling (destroys ovarian stroma and may prompt ovulatory cycles)
Treatment of androgenic symptoms
Which drugs can be used to treat moderate to severe premenstrual syndrome? (4)
SSRIs
Transdermal oestradiol (cycle suppression)
Some COCPs (cycle suppression)
GnRH analogues
NOTE: Hysterectomy with bilateral salpingo-oophorectomy can be used as a last resort.
How does the implanted blastocyst maintain the thickness of the endometrium?
It secretes hCG which acts on the corpus luteum to rescue it from luteolysis. The corpus luteum produces progesterone which maintains the endometrium, prevents menstruation and supports the early conceptus.
At what stage of pregnancy does the placental tissue take over from the corpus luteum as the main supply of progesterone?
8 weeks.
What is a biochemical pregnancy?
A pregnancy that fails during the early stages of implantation - it will present with a transiently positive hCG (positive before expected period, but negative after).
The foetal heartbeat is visible as early as…
…6 weeks gestation.
Define miscarriage.
Pregnancy that ends spontaneously before 24 weeks gestation.
What are the types of miscarriage? (5)
Threatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage Missed miscarriage
Threatened miscarriage management.
Return for further assessment if the bleeding gets worse or persists beyond 14 days.
Continue routine antenatal care if bleeding stops.
Medical management of miscarriage.
Offer vaginal misoprostol
If bleeding has not started within 24 hours of treatment, contact a healthcare professional
Pain relief/anti-emetics
Surgical management of miscarriage.
Manual vacuum aspiration under local anaesthetic
Surgical management in theatre under GA
Vaginal/sublingual misoprostol may be used to ripen the cervix to facilitate cervical dilatation for suction insertion
Offer anti-D prophylaxis to all Rhesus negative women
Recurrent miscarriage:
Definition
Risk factors (5)
Causes (5)
Definition - loss of three or more consecutive pregnancies.
Risk factors: Advancing maternal and paternal age Obesity Balanced chromosomal translocations Uterine structural anomalies Antiphospholipid syndrome
Causes: Antiphospholipid syndrome Cervical abnormalities Foetal chromosomal abnormalities Uterine malformations Thrombophilia
Recurrent miscarriage:
Investigations
Management
Investigations:
- Screen for antiphospholipid syndrome - lupus anticoagulant and anti-cardiolipin antibodies
- Cytogenetic analysis of products of conception in last miscarriage, and of both partners’ peripheral blood
- TVUSS - assess for uterine anomalies
- Screen for haemophilia
Management:
Anti-phospholipid syndrome - low-dose aspirin and LMWH in future pegnancies
Consider cervical cerclage if applicable
Define ectopic pregnancy.
Implantation of a pregnancy outside the normal uterine cavity (98% occur in the Fallopian tubes).
Define heterotypic pregnancy. When does this occur more commonly?
Simultaneous development of two pregnancies, one within and one outside the uterine cavity. Incidence is higher in patients receiving IVF.
How does ectopic pregnancy present?
Abdominal pain and/or vaginal bleeding in early pregnancy.
NOTE: Rarely presents with very acute rupture of the ectopic pregnancy and massive intraperitoneal bleeding.
How might an ectopic pregnancy present with shoulder tip pain?
If patients present with rupture of the ectopic pregnancy and massive intraperitoneal bleeding, the free blood in the peritoneal cavity can cause diaphragmatic irritation and shoulder tip pain.
How can serum hCG help to identify ectopic pregnancy?
In normal pregnancies, it doubles every 48 hours, but in ectopic pregnancy, this rise in hCG is suboptimal.
What are the medical and surgical management options for ectopic pregnancy?
NOTE: Expectant management is used when possible, on the assumption that a significant proportion of ectopic pregnancies resolve without treatment. Only use this if the patient is haemodynamically stable and asymptomatic.
IM Methotrexate (if the presentation is not particularly concerning i.e. no significant pain, serum bhCG < 1500).
Anti-D prophylaxis in RhD negative women undergoing surgical management.
Surgery (if presentation is concerning i.e. significant pain, bhCG > 5000):
Laparoscopic where possible
Salpingectomy or salpingotomy
Define gestational trophoblastic disease.
A spectrum of conditions that includes complete and partial hyatidiform mole, invasive mole and choriocarcinoma.
Vulval vestibule:
Definition
Type of epithelium
What does it contain? (3)
Definition - the area between the lower end of the vaginal canal at the hymenal ring and the labia minora.
Type of epithelium - non-keratinised, non-pigmented squamous epithelium.
What does it contain?
Ducts of the minor vestibular glands
Ducts of the periurethral Skene’s glands
Ducts of the Bartholin’s glands
What type of epithelium lines the labia minora/majora?
Keratinised, pigmented, squamous epithelium.
Define vulvodynia.
Chronic vulval pain with no identifiable cause.
NOTE: It is considered neuropathic and may be treated with amitriptyline.
How might vulval pruritus cause dysuria?
If the patient itches then urine may burn the excoriated vulval skin.
What diagnosis should be considered in patients presenting with recurrent thrush?
Diabetes mellitus.
How should vulval candidal infection be treated?
1st line = 150mg clotrimazole nightly over 3 consecutive nights
2nd line = fluconazole
What proportion of women with vulval pruritus have low ferritin?
5% - correction of this will help to improve symptoms.
What type of biopsy is used to test for malignancy of the vulva?
Keyes punch biopsy.
Lichen Planus:
Definition
Symptoms (5)
Management (2)
Definition - autoimmune disorder affecting 1-2% of the population. It affects the skin, genitalia and oral and GI mucosa.
Symptoms: Pruritus Superficial dyspareunia Oral lesions Longitudinal ridging of the nailbeds Genital lesions
Management:
High-dose topical steroids
If vaginal stenosis, dilatation with manual measures should be attempted in the first instance
Lichen Sclerosus: Definition Symptoms (4) Management (1) Association (1)
Definition - destructive inflammatory skin condition that mainly affects the anogenital area of women.
Symptoms: Pruritus Hypopigmentation Loss of anatomy Vaginal stenosis and cracking
Management:
Strong steroid ointments
Association:
Vulval cancer
What are the 3 types of vulval cysts?
Bartholin’s cysts (may become infected causing Bartholin’s abscess)
Skene gland cysts
Mucous inclusion cysts
What is meant by marsupialisation of a cyst?
Suturing the internal aspect of the cyst to the outside to prevent it from reforming.
What is the difference between superficial and deep dyspareunia?
Superficial = affecting the vagina, clitoris or labia Deep = pain within the pelvis
What is the difference between primary and secondary psychosexual dysfunction?
Primary = sexual difficulties where there may be psychosomatic pain.
Secondary = sexual difficulties resulting from pain or emotional issues.
Define vaginismus.
Involuntary contraction of the vaginal muscles during vaginal examination (or intercourse).
What are the 4 degrees of female genital mutilation?
NOTE: Treatment may involve cosmetic surgery and de-infibulation.
Type 1 - clitoroidectomy - excision of the clitoral hood with or without removal of the clitoris.
Type 2 - excision of the clitoris and partial or total removal of the labia minora.
Type 3 - excision of part of all of the external genitalia (clitoris, labia minora and majora) and stitching/narrowinf of the vagina (infibulation).
Type 4 - piercing the clitoris, cauterisation, cutting the vagina, inserting corrosive substances. Also includes any plastic surgery procedures done as an adult.
Which contraceptives prevent ovulation?
Combined hormonal methods (pill, patch and vaginal ring)
Progesterone-only injectables
Progesterone-only implant (Nexplanon)
Oral emergency contraception
Which contraceptives prevent sperm reaching the oocyte?
Female sterilisation Male sterilisation (vasectomy)
Which contraceptives prevent an embryo implanting in the uterus?
Cu-IUD
LNG-IUS
Which contraceptives block the passage of sperm beyond the vagina?
Diaphragm
Cap
Progestogens
How often does the Nexplanon implant need to be replaced?
Every 3 years.
How often are IUDs replaced?
Every 5-10 years.
What advise should you give to a woman who is using enzyme-inducing medication (e.g. anticonvulsants, antifungals, antibiotics, antiretrovirals) and wants to use hormonal methods of contraception?
Use condoms as well, or consider using methods that are unaffected by enzyme induction (Cu-IUD, LNG-IUS, progesterone-only injectable).
What is the only hormonal method of contraception that is evidenced to cause weight gain?
Progesterone-only injectable.
What does a woman need to know before starting a method of contraception? (6)
How to use the method and what to do when missed Typical failure rates Common side-effects Health benefits Fertility returning on stopping When she requires review
What are the 3 formulations of combined hormonal contraception (oestrogen and progestogen)?
Oral pill
Transdermal patch
Vaginal ring
How do combined hormonal contraceptives work?
They inhibit ovulation via negative feedback of oestrogen and progestogen on the pituitary with suppression of LH and FSH.
Most commonly, COCPs contain _____ _____ (15-35mcg), and preparations contain ___ pills followed by a 7-day pill-free interval.
Most commonly, COCPs contain ethinyl oestradiol (15-35mcg), and preparations contain 21 pills followed by a 7-day pill-free interval.
NOTE: Pill-free interval causes a withdrawal bleed and there is no reason a patient cannot take the pill continuously.
What should women taking the COCP do if experiencing dysmenorrhoea or headaches during the pill-free interval?
Tricycling - take 3 packets without a break.
How are progestogens (found in COCPs) categorised?
2nd generation - levonorgestrel, norethisterone
3rd generation - gestodene, desogestrel
4th generation - drospirenone, dienogest
Which generations of progestogens are associated with increased risk of venous thrombosis?
3rd generation (gestodene, desogestrel) and 4th generation (drospirenone, dienogest).
How much ethinyl oestradiol and how much norelgestromin does a combined hormonal transdermal patch release per day (it is left on for 7 days, and after 21 days patients undertake a 7-day hormone-free interval)?
Ethinyl oestradiol - 33.9mcg
Norelgestromin - 203mcg
How much ethinyl oestradiol and how much etonorgestrel does the combined hormonal ring release per day (it is inserted and left for 21 days, after which patients undertake a 7-day hormone-free interval)?
NOTE: It is the lowest dose combined hormonal method of contraception.
Ethinyl oestradiol - 15mcg
Etonorgestrel - 120mcg
What is the protocol for patients who have missed one or more COCPs?
If one pill has been missed, take the missed pill as soon as you remember, and continue to take remaining pills at the usual time.
If > 1 piss is missed, take the missed pill as soon as you remember, and continue to take remaining pills at the usual time. Use condoms or avoid sex for the next 7 days.
In the next 3 weeks if pills are missed, consider emergency contraception and consider omitting the pill-free interval.
