Gynaecology & Breast Flashcards
Features and management of a breast fibroadenoma?
Highly mobile (“breast mouse”)
Firm, smooth, non tender
< 3cm = watch and monitor
> 3cm = surgical excision
Mammogram feature of breast cysts and radial scar?
Breast cyst = halo appearance
Radial scar = stellate pattern
Breast conditions associated with thick green discharge, bloody discharge, lumpy breasts, eczematous nipple, trauma and obesity?
Thick green discharge = duct ectasia
Bloody discharge = duct papilloma, carcinoma
Lumpy breasts = fibrocystic disease
Eczematous nipple = Paget’s disease of the breast
Trauma/obesity = fat necrosis
Features and management of lactational mastitis?
Red, hot and tender breast
1st line = continue breastfeeding/expressing
2nd line = continue breastfeeding/expressing + oral flucloxacillin
Risk factor for breast abscess, common pathogen and management?
Untreated mastitis
Staphylococcus aureus
Management = antibiotics + aspiration
Tender breast lump in women who recently stopped breastfeeding?
Galactocele
Most common type of breast cancer?
Invasive ductal carcinoma
Outline the NHS Breast Screening Programme.
Mammogram every 3 years for women 50-70
N.B. over 70s are still eligible but must self-refer
Risk factors for breast cancer?
BRCA1/BRCA2
p53 gene mutation
1st degree pre-menopausal relative
Nulliparity or first child when > 30 years
Early menarche
Late menopause
Obesity
CHRT and COCP
Not breastfeeding
Criteria for urgent breast cancer referral (2 week pathway)?
Skin changes suggestive of cancer
≥ 30 with unexplained breast or axillary lump
≥ 50 with unilateral nipple symptoms
Management of patients < 30 years with an unexplained breast lump?
Non-urgent referral to breast assessment clinic
Triple assessment provided by breast assessment clinic?
Physical exam
Imaging (US/mammogram)
Biopsy (core/FNAC)
Receptors tested for in breast cancer and targeted treatment?
Progesterone (PR)
Oestrogen (ER) = tamoxifen (pre- and peri-menopausal), anastrozole (post-menopausal)
HER2 = traztuzumab (herceptin)
Drug class and side effects of tamoxifen, anastrozole and herceptin?
Tamoxifen (oestrogen receptor antagonist) = increased risk of endometrial cancer, VTE, menopausal symptoms
Anastrozole (aromatase inhibitor) = osteoporosis
Herceptin (monoclonal antibody) = cardiac disease
Axillary lymphadenopathy guidance for breast cancer surgery?
None = axillary US +/- biopsy
Lymphadenopathy = axillary node clearance during primary surgery
Complications of axillary node clearance?
Lymphoedema
Brachial plexus injury
Types of contraception?
Barrier method
→ condom
Daily method
→ COCP, POP
Long-acting methods (LARCs)
→ implantable, injectable or intrauterine
Mechanism of action, benefits and risks of the COCP?
Inhibits ovulation
Benefits = highly effective, makes periods lighter/less frequent, reduces risk of ovarian/endometrial cancer
Risks = increased risk of VTE and breast/cervical cancer
Guidance on taking the COCP?
- If started within first 5 days of cycle, no need for additional contraception
- If not started within first 5 days of cycle, additional contraception for 7 days
- If 1 pill missed, take it alongside regular daily pill
- If 2 or more pills missed, take the last one alongside daily regular pill and use condoms or abstain for sex for 7 days
- Emergency contraception may be required if 2 or more pills are missed during the first week of the cycle
How is the COCP taken?
21 days on, 7 days off
3 packets consecutively, 7 days off
Continuously with no break
List some contraindications to the COCP?
Age > 35 smoking > 15/day
Breastfeeding < 6 weeks post-partum
CVD e.g. hypertension
Immobility
BRCA +ve
Migraine with aura
Antiphospholipid antibody +ve
Mechanism of action of the POP?
Thickens cervical mucus
Guidance on taking the POP?
- If started within first 5 days of cycle, no need for additional contraception
- If not started within first 5 days of cycle, additional contraception for 2 days
- If pill missed < 3 hours ago, continue as normal
- If pill missed > 3 hours ago, take the last one alongside regular daily pill and use condoms or abstain from sex for 2 days
How is the POP taken?
Continuously with no pill break
Options for emergency contraception?
“Morning after” pill
→ levonorgestrel (Levonelle) or ulipristal (EllaOne)
Intrauterine device (IUD)
N.B. both pills are ineffective if ovulation has occured
Timescales of emergency contraception?
Levonorgestrel = within 3 days of UPSI
Ulipristal = within 5 days of UPSI
IUD = within 5 days of UPSI or within 5 days after ovulation
Side effects of emergency contraception?
Pills = nausea and vomiting, delayed or early menses
IUD = infection, expulsion, heavy bleeding, perforation
Commencing contraception after levonorgestrel vs ulipristal?
Levonorgestrel = can be started immediately
Ulipristal = can be started after 5 days
Most effective type of contraception?
Implantable e.g. Nexplanon
Nexplanon mechanism of action?
Inhibits ovulation and thickens cervical mucus
Guidance on using Nexplanon and duration of effectiveness?
- If inserted more than 5 days into menstrual cycle, additional contraception needed for 7 days
- Lasts for 3 years
Depo Provera mechanism of action and main side effects?
Inhibits ovulation and thickens cervical mucus
Main side effects = irregular bleeding, weight gain, takes up to a year for fertility to return
How is Depo Provera given?
IM every 12 weeks (up to 14 without need for additional contraception)
Most effective method of emergency contraception?
Intrauterine device (IUD)
a.k.a copper coil
Mechanism of action of IUD vs IUS?
IUD = decreases sperm motility and survival
IUS = inhibits endometrial proliferation
Guidance on the IUD (copper coil) start and duration of effectiveness?
- Immediately effective
- Lasts for 5-10 years
Guidance on the IUS (Mirena coil) start and duration of effectiveness?
- Effective after 7 days
- Lasts 4 years (if on oestrogen only HRT) or 5 years
Complications of IUD/IUS insertion?
- Dysmenorrhoea, amenorrhoea
- Increased risk of PID within first 20 days
- 1 in 20 risk of expulsion
Only contraception options for PMH or FH of breast cancer or BRCA mutation?
Barrier e.g. condom
Copper coil
Options for starting postpartum contraception?
POP = immediately
COCP = after 21 days
IUD/IUS = within 48 hours or after 4 weeks
N.B. if commenced after 21 days postpartum, additional contraception required for 7 days (COCP/IUS) or 2 days (POP)
Amenorrhoea vs dysmenorrhoea vs oligomenorrhoea?
Amenorrhoea = absent periods
Dysmenorrhoea = painful periods
Oligomenorrhoea = irregular periods
Primary vs secondary amenorrhoea and most common causes?
Primary = no period by age 15
→ gonadal dysgenesis e.g. Turner’s
Secondary = absence of periods in women who have previously menstruated
→ pregnancy
Investigations for amenorrhoea?
bHCG
Gonadotrophins (LH/FSH)
Prolactin
Androgens
Oestradiol
Primary vs secondary dysmenorrhoea?
Primary = no underlying pathology
Secondary = pathological e.g. endometriosis
Management of primary dysmenorrhoea?
1st line = NSAID e.g. mefenamic acid
2nd line = COCP
Most common cause of menorrhagia?
Dysfunctional uterine bleeding (DUB)
Management of menorrhagia?
1st line = IUS (Mirena)
2nd line = NSAID, COCP
Features, investigation and management of endometriosis?
Chronic pelvic pain
Dysmenorrhoea
Deep dyspareunia
Painful bowel movements
Investigation = laparoscopy
Management = NSAID/paracetamol (1st line), contraception (2nd line), GnRH analogue or surgery (3rd line)
Features, investigations and management of PCOS?
Oligomenorrhea
Ameonorrhoea
Fertility issues
Hirsutism
Obesity
Investigations = TVUS, LH/FSH, androgens, prolactin
Management = weight loss, COCP
Biochemical features of PCOS?
Raised LH:FSH
Raised androgens
Raised prolactin
Raised insulin
Drug options for ovulation induction?
1st line = letrozole
2nd line = clomiphene citrate
3rd line = pulsatile GnRH therapy
Rotterdam criteria for PCOS?
Need 2 out of these 3:
→ irregular or no menstruation
→ hyperandrogenism e.g. hirsutism, acne
→ ≥ 12 follicles in one or both ovaries
Management of uterine fibroids?
Asymptomatic = monitor
Symptomatic = contraception, GnRH analogue before surgery e.g. myomectomy
Antenatal complication of uterine fibroids, features and management?
Red degeneration
Features = low-grade fever, pain, N&V
Management = self-resolving
Features, investigation and management of ovarian cancer?
Abdominal distension
Early satiety
Urinary symptoms
Diarrhoea
Investigation = CA125, USS, CT
Management = surgery + chemotherapy
Feature, investigations and management of endometrial cancer?
Postmenopausal bleeding
Investigation = TVUS +/- hysteroscopy with biopsy
Management = hysterectomy with bilateral salpingo-oophorectomy +/- chemotherapy, radiotherapy
Normal endometrial thickness?
< 5mm
Management of endometrial hyperplasia?
No atypical cells = mirena coil
Atypical cells = hysterectomy
List causes of PMB?
Vaginal atrophy
HRT
Endometrial hyperplasia
Endometrial cancer
Other gynae cancers
Features, investigations and management of menopause?
Changes in periods
Hot flushes, night sweats
Vaginal dryness, atrophy
Urinary frequency
Anxiety, depression
Memory problems
Investigations = FSH (raised)
Management = lifestyle changes, HRT, SSRIs, topical oestrogen
Which hormone “protects” the endometrium and clinical implication?
Progestogen
Women with a uterus must have progestogen in their HRT treatment
Which type of HRT to give?
Oestrogen = oral, transdermal or topical
Progestogen = oral, transdermal or IUS
Combined (both of above) = cyclical (perimenopausal) or continuous (postmenopasual)
Risks associated with HRT?
VTE (not transdermal)
Stroke
Breast cancer
Ovarian cancer
Features, investigation and management of ovarian torsion?
Sudden colicky abdo pain
Low-grade fever, N&V
Adnexal tenderness
Investigation = abdominal USS
Management = laparoscopy
USS feature of ovarian torsion?
“Whirlpool” sign
Most common identifiable cause of postcoital bleeding?
Cervical ectropion
What is cervical ectropion and management?
Increased area of columnar epithelium present on the endocervix
Management = ablation (only if symptomatic)
Features and management of adenomyosis?
Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus
Management = symptomatic e.g. TXA
HPV serotypes associated with cervical cancer?
16, 18 and 33
Features, investigation and management of cervical cancer?
Vaginal bleeding
Suprapubic pain
Urinary symptoms
Investigation = colposcopy
Management = hysterectomy +/- lymph node clearance, radiotherapy, chemotherapy
Cervical screening in Scotland?
- Offered every 5 years for women aged 25-64
- Smear taken and tested for HPV
- Cytology only if HPV +ve
- Colposcopy if abnormal cytology
Screening of HPV -ve vs HPV +ve but cytology -ve vs cytology +ve?
HPV -ve = routine recall in 5 years
HPV +ve and cytology -ve = repeat cytology in 12 months
Cytology +ve = colposcopy
Screening of inadequate cervical sample?
Repeat within 3 months
If inadequate again = colposcopy
Management of cervical intra-epithelial neoplasia (CIN)?
Large loop excision of transformation zone (LLETZ) or cone biopsy
Screening of woman with PMH of CIN1, CIN2 or CIN3?
Cervical sample 6 months post-treatment
Investigations for infertility?
Men = semen analysis
Women = serum progestogen (day 21)
Serum progestogen level which indicates ovulation?
> 30nmol/l
Types of anovulatory disorders and main causes?
Class I (hypogonadotropic hypogonadal anovulation) = hypothalmic dysfunction
Class II (normogonadotropic normoestrogenic anovulation) = PCOS
Class III (hypergonadotropic hypoestrogenic anovulation) = premature ovarian failure
Features of OHSS?
Hypovolaemia
Tense ascites
Thromboembolism
Renal failure
Investigations for everyone attending a sexual health clinic, regardless of presentation?
Chlamydia (NAAT)
Gonorrhoea (NAAT, microscopy)
HIV (blood sample)
Syphilis (blood sample)
Types of GUM swabs and what they are used for?
Charcoal swabs (high-vaginal or endocervical)
→ microscopy, culture and sensitivities
NAAT swabs (endocervical or vulvovaginal)
→ detecting gonorrohoea and chlamydia
Where is a vulvovaginal vs endocervical vs high-vaginal swab taken from?
Vulvovaginal = 5cm inside vaginal canal
Endocervical = cervical os
High-vaginal = posterior fornix
Features and management of chlamydia?
Women = discharge, bleeding, dysuria
Men = discharge, dysuria
Management = oral doxycycline (1st line), oral azithromycin (2nd line)
Investigation for chlamydia?
NAAT:
→ vulvovaginal swab for women
→ first void urine sample for men
Features and management of gonorrhoea?
Women = discharge, dysuria
Men = discharge, dysuria
Management = IM ceftriaxone
Investigation for gonorrhoea?
NAAT:
→ vulvovaginal swab for women
→ first void urine sample for men
Charcoal swab for microscopy
Features and management of trichomonas?
Yellow/green, frothy discharge
Inflamed vulva
Strawberry cervix
Vaginal pH > 4.5
Management = oral metronidazole
Main organism associated with BV?
Gardnerella vaginalis
Features and management of BV?
Fishy, white discharge
Clue cells
Vaginal pH > 4.5
Management = none (asymptomatic), oral metronidazole (symptomatic)
Features of primary vs secondary vs tertiary syphilis and management?
Primary = painless chancre, local non-tender lymphadenopathy
Secondary = fevers, rash, buccal ulcers
Tertiary = aortic aneurysms, granulomatous lesions, neurosyphilis
Management = IM benzathine penacillin
Cause, investigation and management of genital warts?
HPV 6 and HPV 11
Investigation = clinical diagnosis
Management = none, podophyllum, imiquimod, cryotherapy
Cause, investigation and management of genital herpes?
HSV-1 and HSV-2
Investigation = clinical diagnosis or swab base of ulcer
Management = oral aciclovir
Features and management of thrush?
Cottage cheese discharge
Dyspareunia
Vaginal itch
Inflamed vulva
Management = oral fluconazole (1st line), clotrimazole pessary (2nd line)
Features and management of PID?
Lower abdo pain
Deep dyspareunia
Fever, N&V
Discharge
Period changes
Management = IM ceftriaxone + oral ofloxacin or metronidazole + oral doxycycline
Fitz-Hugh-Curtis syndrome?
Inflammation of the liver capsule (perihepatitis) typically secondary to an STI or PID
Features, investigation and management of HIV seroconversion?
3-12 weeks post-exposure
Sore throat
Lymphadenopathy
Malaise, myalgia
Maculopapular rash
Investigation = HIV p24 antigen + HIV antibody
Management = ART (combination of at least 3 drugs)
When should an asymptomatic patient be screened for HIV?
4 weeks post-exposure
Offer 12 week re-test if -ve
Additional care offered to HIV patients?
PCP (co-trimoxazole)
Annual cervical smear
Monitoring of HIV and target values?
CD4 count = > 500
Viral load = undetectable
HIV prevention during birth?
Maternal viral load < 50 = normal delivery
Maternal viral load > 50 = C-section
Prophylactic zidovudine for babies after birth
