Gynaecology - done Flashcards

Question

What is congenital adrenal hyperplasia?

Answer 1

**Congenital deficiency** of the **21-hydroxylase enzyme** Causing **underproduction** of **cortisol** and **aldosterone** and an **overprodution** of **androgens** from birth.

Answer 2

**Autosomal recessive** pattern

Answer 3

**21-hydroxylase enzyme** 11-beta-hydroxylase

Answer 4

- Usually neonate is severely unwell after birth with **electrolyte disturbances** and **hypoglycaemia**

Answer 5

- Tall for age - Facial hair - Absent periods (primary amenorrhoea) - Deep voice - Early puberty

Answer 6

Tissues are **unable to respond to androgen hormones** (e.g. testosterone) Causes a **female phenotype** (female external gentalia and breast tissue) Internally = testes in abdomen / inguinal canel and absent uterus, upper vagina, fallopian tube and ovaries

Answer 7

- **Imperforate hymen** - Transverse **vaginal septae** - **Vaginal agenesis** - **Absent uterus** - **FGM**

Answer 8

**No evidence** of **pubertal changes** in a girl **aged 13**

Answer 9

FBC and ferritin for **anaemia** U&E for **chronic kidney disease** Anti-TTG or anti-EMA for **coeliacs disease** FSH and LH Thyroid function tests Insulin-like growth factor I for **GH deficiency** Prolactin for **hyperprolactinoma** Testosterone - raised in **PCOS**, **Androgen insensitivity syndrome** and **congenital adrenal hyperplasia** Genetic testing with a **microassay** for **Turner's syndrome**

Answer 10

**Imaging** (X-ray of the wrist - assess for constitutional delay) **Pelvic ultrasound** (assess the ovaries and other pelvic organs) **MRI** of the **brain** (for pituitary pathology and olfactory bulbs in Kallman syndrome)

Answer 11

- Establish and treat the underlying cause - **Replacement hormones** where necessary - Patients with **constitutional delay in growth and development** may only require reassurance and observation - Patients with **low body weight / stress** causes require reduction in stress, CBT and healthy weight gain - Patients with **hypogonadotropism** treated with pulsatile GnRH to induce ovulation / mensturation (can induce fertility) / if pregnancy is not wanted then COOP can induce regular mensturation and prevent symptoms of oestrogen deficiency - Patients with **ovarian causes** e.g. PCOS, damage to the ovaries or absence of can have the COCP to induce regular mensturation and prevent the symptoms of oestrogen deficiency

Answer 12

No mensturation for **more than three months** after previous regular menstural periods

Answer 13

After 3-6 months after **regular periods** After 6-12 months after **irregular periods**

Answer 14

**- Pregnancy** - **Menopause** and **premature ovarian failure** - **Hormonal contraception** (IUS or POP) - Hypothalamic or pituitary pathology - Ovarian causes e.g. **polycystic ovarian syndrome** - Uterine pathology such as **Asherman's syndrome** - **Thyroid pathology** - **Hyperprolactinaemia**

Answer 15

Prevent pregnancy in situations where the body may not be fit for it e.g.: - **Excessive exercise** (e.g. athletes) - **Low body weight** - **Chronic disease** - **Psychological stress**

Answer 16

**Pituitary tumours** e.g. prolactin-secreting **prolactinoma** **Pituitary failure** due to trauma, radiotherapy, surgery or Sheehan syndrome

Answer 17

High prolactin levels, this acts on the **hypothalamus** to prevent the release of **GnRH**, without GnRH there is no release of LH and FSH = **hypogonadotrophic hypogonadism**

Answer 18

**Pituitary adenoma** secreting prolactin

Answer 19

CT or MRI scan of the brain

Answer 20

**Microadenoma**

Answer 21

**Dopamine agonists** such as **bromocriptine** or **cabergoline** can be used to reduce prolactin production.

Answer 22

**Hyperprolactinaemia** **Parkinson's** **Acromegaly**

Answer 23

- Detailed history and examination to assess for causes - Hormonal blood tests - Ultrasound of the pelvis to diagnose **polycystic ovarian syndrome**

Answer 24

**Beta human chorionic gonadotrophin** (HCG) urine or blood tests for pregnancy **Luteinising hormone** and **follicle-stimulating hormone** High **FSH** suggests primary ovarian failure High LH or LH:FSH ratio suggests **polycystic ovarian syndrome** **Prolactin** can be measured to assess for **hyperprolactinaemia** followed by an **MRI** to identify a **pituitary tumour** **Thyroid stimulating hormone** (TSH) to screen for thyroid pathology, followed by **T3** and **T4** when the TSH is abnormal **Raised** TSH and **low** T3 and T4 indicates **hypothyroidism** **Low** TSH and **raised** T3 and T4 indicates **hyperthyroidism** **Raised testosterone** indicates **polycystic ovarian syndrome**, **androgen insensitivity syndrome** or **congenital adrenal hyperplasia**

Answer 25

Establishing and treating underlying cause **Replacement hormones** can induce mensturation and improve symptoms

Answer 26

Require a withdrawal bleed every 3-4 months to reduce the risk of **endometrial hyperplasia** and endometrial cancer **Medroxyprogesterone** for 14 days, or regular use of the combined oral contraceptive pill - to stimulate a withdrawal bleed

Answer 27

When the amnorrhoea lasts more than 12 months treat with: - Adequate **vitamin D** and **calcium** intake - **Hormone replacement therapy** or the **combined oral contraceptive pill**

Answer 28

Psychological, emotional and physical symptoms that occur during the **luteal phase** of the **menstural cycle** particularly in the days prior to onset of mensturation

Answer 29

Once mensturation begins

Answer 30

**Before menarche** **During pregnancy** **After menopause**

Answer 31

Fluctuation in **oestrogen** and **progesterone** during the **menstural cycle** (exact cause unknown) May be due to increased **sensitivity** to **progesterone** or an interation between the sex hormones and the neutotransmitters **serotonin** and **GABA**

Answer 32

* Low mood * Anxiety * Mood swings * Irritability * Bloating * Fatigue * Headaches * Breast pain * Reduced confidence * Cognitive impairment * Clumsiness * Reduced libido

Answer 33

After a hysterectomy, endometrial ablation or on the mirena coil as the ovaries continue to function and the hormonal cycle continues

Answer 34

In response to the **combined contraceptive pill** or **cyclical hormone replacement therapy**

Answer 35

**Premenstrual dysmorphic disorder**

Answer 36

**Symptom diary** spanning two menstrual cycles - demonstrating **cyclical symptoms** which occur just before and resolve after the onset of menstruation Adminstering **GnRH** to temporarily halt the menstrual cycle and temporarily induce the menopause, to see if symptoms improve

Answer 37

- Improve diet, exercise, alcohol, smoking, stress and sleep - COCP - SSRI antidepressants - CBT

Answer 38

**Drospirenone** containing COCP (i.e. **Yasmin** )

Answer 39

**Continuous use** of the pill as opposed to cyclical (has some antimineralocorticoid effects - similar to spironolactone)

Answer 40

**Continuous transdermal oestrogen** (progesterone are required for **endometrial protection** against **endometrial hyperplasia** when using oestrogen - this can be in the form of low dose **cyclical progestogens** e.g. norethisterone to trigger a withdrawal bleed or the **minera coil**)

Answer 41

**GnRH analogues** they are very effective however they have adverse effects (e.g. osteoporosis) HRT can be used to add back the hormones to mitigate these effects

Answer 42

**Hysterectomy and bilateral oophorectomy** HRT will be required particularily in women under 45 years

Answer 43

**Danazole** and **tamoxifen** (initiated and monitored by a breast specialist)

Answer 44

**Spironolactone** to treaat breast swelling, water retention and bloating

Answer 45

Menorrhagia

Answer 46

80ml or more

Answer 47

Symptoms: - Changing pads every 1-2 hours - Bleeding lasting more that 7 days - Passing large clots

Answer 48

**Dysfunctional uterine bleeding** (no identifiable cause) **Extremes** of reproductive **age** **Fibroids** **Endometriosis** and adenomyosis Pelvic inflammatory disease (**infection**) Contraceptives, particularly the **copper coil** **Anticoagulant** medications Bleeding disorders (e.g. **Von Willebrand disease**) **Endocrine disorders** (diabetes and hypothyroidism) **Connective tissue disorders** **Endometrial hyperplasia** or cancer **Polycystic ovarian syndrome**

Answer 49

**Age** at **menarche** **Cycle length**, days **menstruating** and **variation** **Intermenstrual bleeding** and post coital bleeding **Contraceptive history** **Sexual** history Possibility of **pregnancy** Plans for **future pregnancies** **Cervical screening** history **Migraines** with or without aura (for the pill) **Past medical history** and past drug history **Smoking** and alcohol history **Family** history

Answer 50

- **Pelvic examination** with a **speculum** and **bimanual** (to assess for fibroids, ascites and cancers) - **FBC** for iron deficiency anaemia

Answer 51

- Suspected **submucosal fibroids** - Suspected **endometrial pathology** such as endometrial hyperplasia or cancer - Persistent **intermenstrual bleeding**

Answer 52

- Possible large fibroids (palpable pelvic mass) - Possible adenomyosis (associated pelvic pain or tenderness on examination - Examination is difficult to interpret (e.g. obesity) - Hysteroscopy is declined

Answer 53

**Swabs** if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history) **Coagulation screen** if there is a family history of clotting disorders (e.g. **Von Willebrand disease**) or periods that have been heavy since menarche **Ferritin** if they are clinically anaemic **Thyroid function tests** if there are additional features of hypothyroidism

Answer 54

- Exclude underlying pathology such as anaemia, fibroids, bleeding disorders and cancer - Identifiable causes should be managed initially (e.g. menorrhagia caused by a copper coil should stop when the coil is removed) - Next step is to determine if **contraception is required or acceptable**

Answer 55

**Tranexamic acid** when no associated pain (antifibrinolytic - reduces bleeding) **Mefenamic acid** when there is associated pain (NSAID - reduces bleeding and pain)

Answer 56

- **Mirena coil** (first line) - **COCP** - **Cyclical oral progestogens** such as norethisterone 5mg three times daily from day 5-26 (although this is associated with progestogenic side effects and an increase risk of venous thromboembolism Progesterone only contraception may also be tried, as it can suppress menstruation (e.g. progesterone-only pill or a long-acting progesterone (e.g. depo injection or implant)

Answer 57

If treatment is unsuccessful, symptoms are severe or there are large fibroids (\>3cm)

Answer 58

**Endometrial ablation** and **hysterectomy**

Answer 59

First generation technique = **hysteroscopy** and direct destruction of the endometrium Second generation technique = (not using hysteroscopy) e.g. passing a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining (**ballon thermal ablation**)

Answer 60

**Benign tumours** of the **smooth muscle** of the uterus

Answer 61

**Uterine leiomyomas**

Answer 62

**40-60%** of women

Answer 63

Black women

Answer 64

**Oestrogen** (oestrogen sensitive)

Answer 65

**Intramural** means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. **Subserosal** means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity. **Submucosal** means just below the lining of the uterus (the endometrium). **Pedunculated** means on a stalk.

Answer 66

Often **symptomatic**, however they can present: **Heavy menstrual bleeding (menorrhagia)** is the most frequent presenting symptom **Prolonged menstruation,** lasting more than 7 days **Abdominal pain**, worse during menstruation **Bloating or feeling full** in the abdomen **Urinary or bowel symptoms** due to pelvic pressure or fullness **Deep dyspareunia** (pain during intercourse) **Reduced fertility**

Answer 67

**Abdominal examination** may reveal a **palpable pelvic mass** or an **enlarged firm non-tender uterus**

Answer 68

**Hysteroscopy** **Pelvic ultrasound** is the investigation of choice for larger fibroids. **MRI scanning** before surgical options, where **more information is needed about the size,** shape and blood supply of the fibroids.

Answer 69

**Less than 3cm** (same as with heavy menstrual bleeding): **Mirena coil** (1st line) – fibroids must be less than 3cm with no distortion of the uterus **Symptomatic management with NSAIDs and tranexamic acid** **Combined oral contraceptive** **Cyclical oral progestogens**

Answer 70

**Endometrial ablation** **Resection** of submucosal fibroids during hysteroscopy **Hysterectomy**

Answer 71

**Referral to gynaecology** for investigation and management, options: **Symptomatic management with NSAIDs and tranexamic acid** **Mirena coil** – depending on the size and shape of the fibroids and uterus **Combined oral contraceptive** **Cyclical oral progestogens**

Answer 72

**Uterine artery embolisation** **Myomectomy** **Hysterectomy**

Answer 73

**GnRH agonists** e.g. **goserelin** (Zoladex) or **leuprorelin** (Prostap) - induce a menopause-like state and reduce the amount of oestrogen maintaining the fibroid - only used short term

Answer 74

Performed by **interventional radiologists** - using a catheter into an artery (usually femoral) - passed through to the **uterine artery** under x-ray guidance Once in place, particles are injected creating a blockage in the supply to the fibroid - causing it to shrink

Answer 75

Surgically removing the fibroids via **laparoscopic** (keyhole) surgery or **laparotomy** (open surgery) - only treatment to potentially improve fertility in patients with fibroids

Answer 76

Used to destroy the endometrium **Second generation,** non-hysteroscopic techniques are used e.g. **balloon thermal ablation** Inserting a balloon in the uterus and filling with high temp fluid to burn the endometrial lining of the uterus

Answer 77

**Removing the uterus and fibroids** - may be done laparoscopically or laparotomy or vaginally - ovaries may be left

Answer 78

**Heavy menstrual bleeding**, often with iron deficiency anaemia **Reduced fertility** **Pregnancy complications**, such as miscarriages, premature labour and obstructive delivery **Constipation** **Urinary outflow obstruction** and urinary tract infections **Red degeneration of the fibroid** **Torsion of the fibroid,** usually affecting pedunculated fibroids **Malignant change to a leiomyosarcoma** is very rare (\<1%)

Answer 79

**Ischaemia, infarction** and **necrosis** of the fibroid due to disrupted blood supply More likely in **larger fibroids** (above 5cm) during the second and third trimester of pregnancy May occur to growing of fibroid during pregnancy or kinking in the blood vessel as the uterus changes shape and expands

Answer 80

**Severe abdo pain** **Fever** **Tachycardia** **Vomiting**

Answer 81

Supportive, rest, fluids and analgesia

Answer 82

**Ecotopic endometerial tissue** outside of the uterus (lump of tissue = endometrioma)

Answer 83

**Chocolate cysts**

Answer 84

Endometrial tissue within the **myometrium** (muscle layer) of the uterus

Answer 85

**Not clear**, but there is a **genetic component** * **Retrograde menstruation:** during menstration flow is backwards through fallopian tubes and into the pelvis and peritoneum * **Embryonic cells** destined to become endometrial tissue may remain in **areas outside the uterus during the delelopment of the fetus** and become ectopic tissue * **Lymphatic system** may spread the tissue * **Metaplasia** may change cells outside the uterus

Answer 86

**Pelvic pain** is the main symptom - cells of endometrial tissue respond to hormones in same way as endometrial tissue - causing the ectopic tissue to shed lining and bleed causing irritation and inflammation in the tissues around the sites of endometriosis. **Cyclical**, **dull**, **heavy** or burning pain is the result **Deposits of endometriosis in the bladder or bowel** can lead to blood in the urine or stools

Answer 87

**Adhesions** from localised bleeding and inflammation (e.g. ovaries to the peritoneum, uterus to bowel) Causes **chronic, non-cyclical pain** which can be sharp, stabbing or pulling and associated with nausea

Answer 88

Can lead to **reduced fertility** (maybe due to adhesions around the ovaries and fallopian tubes)

Answer 89

**Cyclical abdominal or pelvic pain** **Deep dyspareunia** (pain on deep sexual intercourse) **Dysmenorrhoea (**painful periods) **Infertility** **Cyclical bleeding from other sites**, such as haematuria

Answer 90

**Urinary** symptoms **Bowel** symptoms

Answer 91

**Endometrial tissue visible in the vagina** on speculum examination, particularly in the posterior fornix **A fixed cervix** on bimanual examination **Tenderness in the vagina**, cervix and adnexa

Answer 92

**Pelvic ultrasound** - for large endometriomas and chocolate cysts **Laparoscopic surgery** - gold standard - definitiev diagnosis with **biopsy** of the lesion during laparoscopy (surgeon can remove deposits of endometriosis

Answer 93

**Stage 1:** Small superficial lesions **Stage 2:** Mild, but deeper lesions than stage 1 **Stage 3:** Deeper lesions, with lesions on the ovaries and mild adhesions **Stage 4:** Deep and large lesions affecting the ovaries with extensive adhesions

Answer 94

Establishing a **diagnosis** Providing a **clear explanation** **Listening to the patient**, establishing their ideas, concerns and expectations and building a partnership **Analgesia as required** for pain (NSAIDs and paracetamol first line)

Answer 95

**Combined oral contractive pill,** which can be used back to back without a pill-free period if helpful **Progesterone only pill** **Medroxyprogesterone acetate injection** (e.g. Depo-Provera) **Nexplanon implant** **Mirena coil** **GnRH agonists**

Answer 96

**Laparoscopic surgery** to **excise** or **ablate** the endometrial tissue and remove adhesions (adhesiolysis) ## Footnote **Hysterectomy**

Answer 97

**Laparoscopic treament** (hormonal therapies do not improve fertility)

Answer 98

**Cyclical pain** - COCP, oral progesterone-only pill, progestin depot injection, progestin implant (nexplanon) **stop ovulation** and **reduce endometrial thickening** **GnRH agonists** - induce **menopause-like state** using GnRH agonists e.g. **goserelin** (zoladex) or **leuprorelin** (prostap) (risk of **osteoporosis**) **Laparoscopic surgery** - excise or ablate the ectopic endometrial tissue, where there is chronic pelvic pain due to **adhesions** surgery can dissect these **Hysterectomy and bilateral salpingo-opherectomy** - final surgical option, removing ovaries induces menopause, stopping ectopic endometrial tissue responding to menstrual cycle **Infertility** - treated by removing as much of the endometriosis as possible

Answer 99

**Endometrial tissue** inside the **myometrium** (muscle layer of uterus)

Answer 100

- Later reproductive years - Several pregnancies (multiparous) - 10% of women overall - Cause is not fully understood (hormone dependent)

Answer 101

Painful periods (**dysmenorrhoea**) Heavy periods (**menorrhagia**) Pain during intercourse (**dyspareunia**)

Answer 102

**Enlarged and tender uterus** **Feels more soft** than a uterus containing fibroids

Answer 103

**Transvaginal ultrasound** of the pelvis (first-line) **MRI** and **transabdominal ultrasound** alternatives where TV is nor suitable **Gold standard** is to perform a **histological examination** of the uterus after a hysterectomy (not always suitable for obvious reasons)

Answer 104

Depends on **symptoms**, **age** and **plans for pregnancy**: - Non-contraceptive: **tranexamic acid** (antifibrinolytic - used when no pain), **mefenamic acid** (NSAID - reduces bleeding and pain - Contraceptive: **Mirena coil** (first line), **COCP**, **cyclical oral progestogens** (progesterone only medication e.g. the pill, implant or depot injection may also be helpful)

Answer 105

GnRH analogues (menopause-like state) Endometrial ablation Uterine atery embolisation Hysterectomy

Answer 106

**Infertility** **Miscarriage** **Preterm** birth **Small for gestational age** **Preterm premature rupture of membranes** **Malpresentation** **Need for caesarean section** **Postpartum haemorrhage**

Answer 107

Retrospectively - after woman has **no periods for 12 months**

Answer 108

**51 years old**

Answer 109

Period from 12 months after the final period

Answer 110

Time around menopause, **vasomotor symptoms** and **irregular periods** Including time leading up and 12 months after menopause Women **older that 45**

Answer 111

Menopause **before the age of 40** - result of **premature ovarian insufficiency**

Answer 112

Lack of **ovarian follicular function**: - **Oestrogen** and **progesterone** levels are low - **LH** and **FSH** levels are **high** in response to an **absence** of negative feedback from oestrogen

Answer 113

In ovaries **primordial follicles** mature into **primary and secondary follicles** (independent of the menstrual cycle) at start of menstrual cycle **FSH** stimulates the development of **secondary follicles** - as these grow **granulosa cells** which surround them secrete increasing amounts of **oestrogen** **Menopause begins** in the decline of the development of follicles - reducing oestrogen levels - increasing LH and FSH **Anovulation results** and without oestrogen the endometrium doesnt develop = **amenorrhoea** **Low levels of oestrogen** cause **perimenopausal symptoms**

Answer 114

**Hot flushes** **Emotional lability or low mood** **Premenstrual syndrome** **Irregular periods** **Joint pains** **Heavier or lighter periods** **Vaginal dryness and atrophy** **Reduced libido**

Answer 115

**Cardiovascular disease** and stroke ## Footnote **Osteoporosis** **Pelvic organ prolapse** **Urinary incontinence**

Answer 116

**Perimenopause / menopause** diagnosis can be made in women **over 45 years old** with typical symptoms **FSH** blood test is recommended in women under 40 with premature menopause / women aged 40-45 with menopausal symptoms/ change in menstrual cycle

Answer 117

- Two years after LMP in women \< 50 - One year after LMP in women \> 50

Answer 118

**No**, they may suppress and mask the symptoms

Answer 119

**Barrier methods** Mirena or copper **coil** **Progesterone only pill** **Progesterone implant** **Progesterone depot injection** (under 45 years) **Sterilisation**

Answer 120

Those containing **norethisterone or levonorgestrel** due to the relatively lower risk of VTE

Answer 121

**Weight gain** **Osteoporosis** (so, unsuitable for women over 45)

Answer 122

**No treatment** Hormone replacement therapy (**HRT**) **Tibolone**, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) **Clonidine**, which act as agonists of alpha-adrenergic and imidazoline receptors Cognitive behavioural therapy (**CBT**) **SSRI** antidepressants, such as fluoxetine or citalopram **Testosterone** can be used to treat **reduced libido** (usually as a gel or cream) **Vaginal oestrogen cream** or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) **Vaginal moisturisers**, such as Sylk, Replens and YES

Answer 123

**Premature ovarian insufficiency**

Answer 124

**Hypergonadotrophic hypogonadism** - lack of negative feedback on the pituitary gland resulting in an excess or gonadotrophins: ## Footnote **Raised LH and FSH** **Low oestradiol levels**

Answer 125

**Idiopathic** (the cause is unknown in more than 50% of cases) **Iatrogenic**, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy) **Autoimmune,** possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease **Genetic,** with a positive family history or conditions such as Turner’s syndrome **Infections** such as mumps, tuberculosis or cytomegalovirus

Answer 126

**Irregular menstrul periods**, lack of menstrual periods (secondary amenorrhea), symptoms of **low oestrogen levels** such as **hot flushes**, **night sweats** and **vaginal dryness**

Answer 127

**Women younger than 40** years old with **typical menopausal symptoms** plus **elevated FSH** **FSH elevation** needs to be on two consecutive samples separated by more than 4 weeks (results are difficult to interpret in women taking hormonal contraception)

Answer 128

- CVD - Stroke - Osteoporosis - Cognitive impairment - Dementia - Parkinsonism

Answer 129

**Hormone replacement therapy** - reducing risk of CVD, osteoporosis, cognitive and psychological risks * **Traditional HRT** (associated with a lower BP compared to COCP) * **COCP** (less stigma for younger women) **Contraception** - as pregnancy is still possible

Answer 130

Not before the age of 50 as women would produce these hormones BUT increased risk of **VTE** (decreased using transdermal methods - patches)

Answer 131

**Without a uterus:** exogenous **oestrogen** **With a uterus:** Oestrogen and **progesterone** (prevents **endometrial hyperplasia** and **endometrial cancer** due to "unopposed" oestrogen) **Still having periods**: cyclical HRT, with cyclical progesterone and regular breakthrough bleeds

Answer 132

**Lifestyle changes such as improving the diet**, **exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress** Cognitive behavioural therapy (**CBT**) **Clonidine**, which is an agonist of alpha-adrenergic and imidazoline receptors **SSRI antidepressants (e.g. fluoxetine)** **Venlafaxine,** which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) **Gabapentin**

Answer 133

**Agonist** of **alpha-2 adrenic receptors** and **imidazoline receptors** in the brain **Lower BP** and **reduced HR** Useful for **vasomotor symptoms** and **hot flushes** particularly when there are contraindications to HRT

Answer 134

**Dry mouth** **Headaches** **Dizziness** **Fatigue** (sudden withdrawal can cause rapid increase in BP and agitation)

Answer 135

**Black cohosh,** which may be a cause of liver damage **Dong quai,** which may cause bleeding disorders **Red clover,** which may have oestrogenic effects that would be concerning with oestrogen sensitive cancers **Evening primrose oil,** which has significant drug interactions and is linked with clotting disorders and seizures **Ginseng** may be used for mood and sleep benefits

Answer 136

**Replacing hormones in premature ovarian insufficiency,** even without symptoms **Reducing vasomotor symptoms** such as hot flushes and night sweats **Improving symptoms such as low mood**, decreased libido, poor sleep and joint pain **Reducing the risk of osteoporosis in women under 60 years**

Answer 137

**More significant in older women** and increase with longer duration of treatment: - Increased risk of **breast/endometrial cancer** - Increased risk of **VTE** (2-3 times background risk) - Increased risk of **stroke** and **coronary artery disease** - Inconclusive evidence about **ovarian cancer**

Answer 138

- Not increased in **women under 50 years** compared with other women their age - No risk of endometrial cancer in women **without a uterus** - No increased risk of **breast cancer** with **oestrogen-only HRT** (risk may even be reduced) - No increased risk of **CVD** with **oestrogen-only HRT** (risk may be reduced)

Answer 139

- Adding **progesterone** in women with a uterus to **reduce risk of endometrial cancer** - Using **patches** instead of **pills** to reduce the risk of VTE - Using **local progestogens** (e.g. mirena coil) to reduce the risk of **breast cancer** and **CVD**

Answer 140

**Undiagnosed abnormal bleeding** **Endometrial hyperplasia or cancer** **Breast cancer** Uncontrolled **hypertension** **Venous thromboembolism** **Liver disease** **Active angina** or myocardial infarction **Pregnancy**

Answer 141

- **Full history** to ensure no contraindications - **Family history** (for **oestrogen dependent cancers** (e.g. breast cancer and **VTE**) **- BMI** and **BP** - Ensure **cervical** and **breast screening** is up to date - Encourage **lifestyle changes** which are likely to **improve symptoms**

Answer 142

**_Local / systemic symptoms:_** **Local symptoms:** use topical treatments such as topical oestrogen cream or tablets **Systemic symptoms:** use systemic treatment – go to step 2 **_Step 2: Does the woman have a uterus?:_** **No uterus:** use continuous oestrogen-only HRT **Has uterus**: add progesterone (combined HRT) – go to step 3 **Step 3:** Have they had a period in the past 12 months? **Perimenopausal:** give cyclical combined HRT **Postmenopausal** (more than 12 months since last period): give continuous combined HRT

Answer 143

- Oral (tablets) - Transdermal (patches / gels)

Answer 144

Women with poor control on oral treatment Women with higher risk of VTE, CVD, headaches

Answer 145

Reduces the risk of **endometrial hyperplasia** and **endometrial cancer** Only required in women that have a uterus

Answer 146

**Cyclical = 10 - 14 days per month** - women that **have had a period within 12 months** allowing to have monthly breakthrough bleeds **Continuous** = woman has **no period** in the past: * 24 months if under 50 * 12 months if over 50

Answer 147

**Irregular breakthrough bleeding**

Answer 148

**At least 12 months** of treatment in women over 50 **At least 24 months** in women under 50

Answer 149

**Oral** (tablets) **Transdermal** (patches) **Intrauterine system** (e.g. mirena coil)

Answer 150

4 years after which it needs replacing Added benefit of **contraception** and treating **heavy menstrual periods**

Answer 151

**Progestogens:** any chemical which targets and stimulates progesterone receptors **Progesterone:** hormone produced naturally in the body **Progestins**: synthetic progestogens

Answer 152

**C19** and **C21 progestogens** (referring to chemical structure and number of carbon atoms in molecule)

Answer 153

**Testosterone** **Norethisterone, levonorgestrel** and **desogestrel** Helpful with **reduced libido**

Answer 154

Derived from **progesterone** **Progesterone**, **dydrogesterone** **medroxyprogesterone** Helpful with depressed mood / acne

Answer 155

**Oestrogen-only pills**, for example, Elleste Solo or Premarin **Oestrogen-only patches,** for example, Evorel or Estradot

Answer 156

Cyclical combined tablets Cyclical combined patches Mirena coil plus oestrogen-only pills Mirena coil plus oestrogen-only patches

Answer 157

Continuous combined tablets Continuous combined patches Mirena coil plus oestrogen-only pills Mirena coil plus oestrogen-only patches

Answer 158

**Oestrogen** = with patches (reduced risk of VTE) **Progesterone** = with intrauterine device (e.g. mirena - treats heavy periods and provides contraception)

Answer 159

**Synthetic steroid** which stimulates **oestrogen** and **progesterone receptors** (also weakly stimulates **androgen receptors** - helpful in patients with reduced libido)

Answer 160

**Form of** continuous combined HRT **(**need to be more than 12 months without period / more than 24 if below 50) Expected to not have breakthrough bleeding Tibolone can cause **irregular bleeding**, resulting in **futher investigations** to exclude other causes

Answer 161

Yes, **helps with low energy and reduced libido** (sex drive Given as **transdermal** application, applied as a gel/cream to the skin

Answer 162

- Follow-up in 3 months - Takes 3-6 months to experience full effects - Problematic / irregular bleeding is an indication for referral - Ensure woman has contraception - Stop oestrogen-containing contraceptives **4 weeks before major surgery** - Consider other diagnoses where symptoms persist (e.g. thyroid, liver disease, diabetes)

Answer 163

**Mirena coil** **Progesterone only pill**, given in addition to HRT

Answer 164

**Nausea and bloating** **Breast swelling** **Breast tenderness** **Headaches** **Leg cramps**

Answer 165

**Mood swings** **Bloating** **Fluid retention** **Weight gain** **Acne and greasy skin**

Answer 166

Change **type of HRT** or **route of administration** (switch between patches and pills)

Answer 167

Switch to different form of progesterone e.g. **dyhydrogesterone for acne and mood swings** **Norethisterone** for reduced libido **Mirena coil** for endometrial protection (avoiding progesterone all together)

Answer 168

First 3-6 months of HRT (in women with a uterus) - if it continues the consider referral for investigations

Answer 169

No specific regime - can be abrupt or gradual

Answer 170

**Multiple ovarian cysts** **Infertilify** **Oligomenorrhoea** **Hyperandrogenism** **Insulin resistance**

Answer 171

Anovulation refers to the absence of ovulation Oligoovulation refers to irregular, infrequent ovulation Amenorrhoea refers to the absence of menstrual periods **Oligomenorrhoea** refers to irregular, infrequent menstrual periods **Androgens** are male sex hormones, such as testosterone **Hyperandrogenism** refers to the effects of high levels of androgens **Hirsutism** refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair **Insulin resistance** refers to a lack of response to the hormone insulin, resulting in high blood sugar levels

Answer 172

**Rotterdam criteria -** At least 2 of the 3 key features: * **Oligoovulation / anovulation** - presenting with irregular / absent periods * **Hyperandrogenism** - hirsutism and acne * **Polycystic ovaries** on ultrasound (or ovarian

Answer 173

Oligomenorrhoea or amenorrhoea **Infertility** **Obesity** (in about 70% of patients with PCOS) **Hirsutism** **Acne** **Hair loss in a male pattern**

Answer 174

**Insulin resistance and diabetes** **Acanthosis nigricans** **Cardiovascular disease** **Hypercholesterolaemia** **Endometrial hyperplasia and cancer** **Obstructive sleep apnoea** **Depression and anxiety** **Sexual problems**

Answer 175

Thickened, rough skin, typically found on the **axilla** and on the **elbows,** has a **velvety texture** occurs with **insulin resistance**

Answer 176

**Medications**, such as **phenytoin, ciclosporin, corticosteroids,** testosterone and anabolic steroids **Ovarian or adrenal tumours** that **secrete androgens** **Cushing’s syndrome** **Congenital adrenal hyperplasia**

Answer 177

Pancreas produces **more insulin** which **promotes** the release of **androgens** from the **ovaries** and **adrenal glands** - causing **higher levels of testosterone** **Insulin suppresses sex hormone-binding globulin** (SHBG) production by the **liver**. SHBG normally binds to androgens, supressing them - thus less SHBG promotes **hyperandrogenism** in women with PCOS **Diet, exercise and weight loss** help to reduce insulin resistance

Answer 178

**Testosterone** **Sex hormone-binding globulin** **Luteinizing hormone** **Follicle-stimulating hormone** **Prolactin** (may be mildly elevated in PCOS) **Thyroid-stimulating hormone**

Answer 179

**Raised luteinising hormone** **Raised LH to FSH ratio** (high LH compared with FSH) **Raised testosterone** **Raised insulin** **Normal or raised oestrogen levels**

Answer 180

**Transvaginal ultrasound** (gold standard) - follicles may be arranged around the periphery of the ovary, giving a "string of pearls" appearance. Diagnostic criteria: * 12/ more developing follicles * Ovarian volume of more than 10cm3

Answer 181

**2-hour 75g oral glucose tolerance test** (OGTT): Morning prior to having breakfast, take baseline **fasting plasma glucose,** then 75g glucose drink, then measure plasma glucose 2 hours later

Answer 182

**Impaired fasting glucose** – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink) **Impaired glucose tolerance** – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l **Diabetes** – plasma glucose at 2 hours above 11.1 mmol/l

Answer 183

**Weight loss** **Low glycaemic index**, calorie-controlled diet **Exercise** **Smoking cessation** **Antihypertensive medications** where required **Statins** where indicated (QRISK \>10%)

Answer 184

**Endometrial hyperplasia and cancer** **Infertility** **Hirsutism** **Acne** **Obstructive sleep apnoea** **Depression and anxiety**

Answer 185

**Weight loss** - result in ovulation, restoration of fertility, improve insulin resistance, reduce hirsutism, reduce the risks of associated conditions. **Orlistat** may be used to help in women with a BMI about 30 **Orlistat is a lipase inhibitor** (preventing absorption of fat in the intestines)

Answer 186

**Obesity** **Diabetes** **Insulin resistance** **Amenorrhoea**

Answer 187

Normally **corpus luteum** releases **progesterone** after ovulation - women with PCOS ovulate infrequently - less progesterone Oestrogen is "unopposed" and continues to **proliferate** the endometrial lining - causing **endometrial hyperplasia**

Answer 188

**Pelvic ultrasound** to assess **endometrial thickness** **Cyclical progestogens** should be used to induce a period **prior to the ultrasound** scan If **endometrial thickness** is more than 10mm, need to be referred for a biopsy to exclude endometrial hyperplasia / cancer

Answer 189

**Mirena coil** for continuous endometrial protection **Inducing a withdrawal bleed** (every 3-4 months) with: * Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) * COCP

Answer 190

**Weight loss**, can restore regular ovulation **Clomifene** **Laparoscopic ovarian drilling** **In vitro fertilisation** (IVF)

Answer 191

**Metformin** and **letrozole** may also help under guidance of a specialist, evidence to support their use is not clear **Ovarian drilling** involving **laparoscopic surgery** - surgeon punctures multiple holes in the ovaries using **diathermy** or **laser therapy** Screening for **gestational diabetes** using **OGTT** performed before pregnancy and at 24-28 weeks gestation

Answer 192

**Weight loss** or hair removal e.g. waxing, shaving and plucking **Co-cyprindiol** is a **COCP** liscensed for the treatment of **hirsutism** and **acne** (anti-androgenic effect) - BUT significant risk of VTE, co-cyprindiol is usually stopped after 3 months of use **Topical eflornithine** - used to treat facial hirsutism - takes 6-8 weeks to see improvement (hirsutism will return in 2 months of stopping eflornithine)

Answer 193

**Electrolysis** **Laser hair removal** **Spironolactone** (mineralocorticoid antagonist with anti-androgen effects) **Finasteride** (5α-reductase inhibitor that decreases testosterone production) **Flutamide** (non-steroidal anti-androgen) **Cyproterone acetate** (anti-androgen and progestin)

Answer 194

**COCP** (first line) - co-cyprindiol has anti-androgen effects (high risk of VTE) Other standard acne treatments: * **Topical adapalene** (a retinoid) * **Topical antibiotics** (e.g. clindamycin 1% with benzoyl peroxide 5%) * **Topical azelaic acid** 20% * **Oral tetracycline antibiotics** (e.g. lymecycline)

Answer 195

**Cyst** = fluid filled sac **Functional ovarian cysts** = related to fluctuating hormones of menstrual cycle, very common in **premenopausal women** (vast majority are benign) Cysts in post menopausal women are more concerning for malignancy

Answer 196

**Pelvic pain** **Bloating** **Fullness** in the abdomen **A palpable pelvic mass** (particularly with very large cysts such as **mucinous cystadenomas**)

Answer 197

Ovarian torsion Haemorrhage Rupture of cyst

Answer 198

**Follicle fails to rupture** and release egg **Most common** ovarian cyst **Harmless** and disappear after a few menstrual cycles **Thin walled and no internal structure** (reassuring on ultrasound)

Answer 199

**Corpus luteum fails to break down** and instead fills with fluid Cause pelvic discomfort, pain or delayed menstruation Seen in **early pregnancy**

Answer 200

**Serous cystadenoma** = benign tumour of epithelial cells **Mucinous cystadenoma** = benign tumour of epithelial cells, can become huge **Endometrioma** = lumps of endometrial tissue within the ovary, occur in patients with endometriosis **Dermoid cyst / germ cell tumour** = benign ovarian tumours, **teratomas** meaning they come from the **germ cells** and may contain various tissue types e.g. skin, teeth, hair and bone - associated with **ovarian torsion** **Sex cord-stromal tumours**= rare tumours that can be **benign** or **malignant** - arise from stroma (connective tissue) or sex cords (embryonic structures associated with the follicles) e.g. **Sertoli-Leydig cell tumours** and **granulosa cell tumours**

Answer 201

Abdominal **bloating** ## Footnote **Reduce appetite** **Early satiety** **Weight loss** **Urinary symptoms** **Pain** **Ascites** **Lymphadenopathy**

Answer 202

**Age** **Postmenopause** **Increased number of ovulations** **Obesity** **Hormone replacement therapy** **Smoking** **Breastfeeding** (protective) **Family history and BRCA1 and BRCA2 genes**

Answer 203

**Later onset of periods** (menarche) **Early menopause** **Any pregnancies** Use of the **combined contraceptive pill**

Answer 204

**Premenopausal women** with a **simple ovarian cyst** less than 5cm on **ultrasound** do not need further investigations **CA125** is the tumour market for epithelial cell ovarian cancer (forms part of the risk malignancy index) **Women under 40 years** with a complex ovarian mass require tumour markers for a possible **germ cell tumour**: * **Lactate dehydrogenase** (LDH) * **Alpha-fetoprotein** (alpha-FP) * **Human chorionic gonadotrophin** (HCG)

Answer 205

**Endometriosis** **Fibroids** **Adenomyosis** **Pelvic infection** **Liver disease** **Pregnancy**

Answer 206

Estimates the risk of an **ovarian mass being malignant**: * Menopausal status * Ultrasound findings * CA125 level

Answer 207

**Possible ovarian cancer**: 2WW referral to a gynae oncology specialist **Possible dermoid cysts**: referral to a gynaecologist for further investigations **Simple ovarian cysts** in **premenopausal women**: * Less than 5cm cysts will almost always resolve in 5 cycles * 5cm-7cm: resuire routine referral to gynar and yearly ultrasound * \> 7cm consider an MRI scan or surgical evaluation (difficult to characterise with ultrasound)

Answer 208

Require correlation with the CA125 (2WW referral if raised) Simple cysts under 5cm with normal CA125 may be **monitored with ultrasound every 4-6 months**

Answer 209

**Surgical intervention** (usually with **laparoscopy**) **Ovarian cystectomy** (removing cyst) **Oophorectomy** (removing the affected ovary)

Answer 210

**Torsion** **Haemorrhage** into the cyst **Rupture**, with bleeding into the peritoneum

Answer 211

Triad: **- Ovarian fibroma** (benign ovarian tumour) **- Pleural effusion** **- Ascites** Typically occurs in older women - removal results in complete resolution of effusion and ascites

Answer 212

**Ovarian mass** larger than 5cm e.g. **cyst** or a **tumour** (usually benign) more likely in pregnancy

Answer 213

Younger girls, who have longer **infundibulopelvic ligaments** that can twist more easily

Answer 214

Twisting of blood supply leads to **ischaemia** and **necrosis**

Answer 215

**Sudden onset severe unilateral pain** - constant - gets worse - associated with N&V **Pain is not always severe** (can twist and untwist) **Localised tenderness** (may be a palpable mass)

Answer 216

**Pelvic ultrasound** - TV is ideal but transabdominal will do **"Whirlpool sign", free fluid** in pelvis and **oedema** of the ovary may be seen **Doppler studies** may show a lack of blood flow **Definitive diagnosis** = **laparoscopic surgery**

Answer 217

Admission under gynaecology Require **laparoscopic** **surgery** to either: - **Untwist** the ovary and fix it in place (detorsion) - **Remove** the affected ovary (oophorectomy) Decision is made during surgery **based on visual inspection**

Answer 218

If only ovary - can lead to infertility and menopause Necrotic ovary which isnt removed can become **infected**, develop an **abscess** and lead to **sepsis** May **rupture** resulting in **peritonitis** and **adhesions**

Answer 219

**Adhesion** (aka **synechiae**) form within the uterus following damage

Answer 220

Pregnancy related **dilatation** and **curettage** procedure e.g. in treatment of **RPOC** (e.g. removing placental tissue left after birth) Occurs after **uterine surgery** (e.g. myomectomy) or several **pelvic infections** (e.g. endometritis)

Answer 221

Damages **basal layer** of the **endometrium** - tissue may heal abnormally

Answer 222

Menstration abnormalities Infertility Recurrent miscarriages

Answer 223

Following recent dilatation and curettage: **Secondary amenorrhoea** (absent periods) Significantly **lighter periods** **Dysmenorrhoea** (painful periods)

Answer 224

**Hysteroscopy** - gold standard - can dissect and treat adhesions **Hysterosalpingography** - contrast is injected into the uterus and imaged with xrays **Sonohysterography** - uterus is filled with fluid and pelvic ultrasound **MRI**

Answer 225

Dissecting the adhesions during hysteroscopy (recurrence is common)

Answer 226

**Cervical ectopy** **Cervical erosion**

Answer 227

**Columnar epithelium** of the **endocervix** (the canal of the cervix) has extended out to the **ectocervix** (outer area od the cervix) Cells of the **endocervix** are more fragile and prone to trauma - more likely to bleed with **sexual intercourse** - often presents with **post-coital bleeding**

Answer 228

Higher **oestrogen levels** and therefore more common in **younger women**, the COCP and pregnancy

Answer 229

Border between the **columnar epithelium** of the **endocervix** (the canal) and the **stratified squamous epithelium** of the **ectocervix** (the outer area of the cervix)

Answer 230

Mainly **asymptomatic** - found incidentally suring speculum examination * Increased **vaginal discharge** * **Vaginal bleeding** * **Dyspareunia** (pain during sex) * Postcoital bleeding

Answer 231

Asymptomatic requires **no treatment** - typically resolves as patient gets older, stops the pill or is no longer pregnant (not a contraindication to the COCP) **Problematic bleeding** - treated with **cauterisation** of the ectropion using **silver nitrate** or **cold coagulation** during colposcopy

Answer 232

**Fluid filled cysts** seen on **surface of cervix** (also called nabothian follicles or mucinous retention cysts) **Up to 1cm in size** - harmless and unrelated to cancer

Answer 233

When the **squamous epithelium** of the **ectocervix** slightly covers the **mucus-secreting columnar epithelium** of the endocervix then the **mucus becomes trapped** and forms a cyst Happens: after childbirth, minor trauma to the cervix or **cervicitis** secondary to infection

Answer 234

Incidentally on speculum - smooth rounded bumps near the os Whitish or yellow appearance

Answer 235

If diagnosis is clear then only reassurance If diagnosis is uncertain then women can be reffered for **colposcopy** to examine in detail - **excised or biopsied** to exclude other pathology

Answer 236

**Weakness** and **lengthening** of the **ligaments** anf **muscles** surrounding the **uterus**, **rectum** and **bladder**

Answer 237

Uterus descends into the vagina

Answer 238

Women who have had a **hysterectomy** Top of **vagina** descends into the **vagina**

Answer 239

Rectum prolapses into the vagina due to a defect in the **posterior vaginal wall** - associated with constipation

Answer 240

**Faecal loading** into the part of the rectum which has prolapsed causing **constipation**, **urinary retention** (due to compression on the urethra) and a **palpable lump** in the vagina

Answer 241

Dur to a defect in the **anterior vaginal wall** allowing the bladder to **prolapse backwards** into the vagina (prolapse of the urethra is called a **urethrocele**, or both **cystourethrocele**)

Answer 242

**Multiple vaginal deliveries** **Instrumental, prolonged or traumatic delivery** **Advanced age and postmenopause status** **Obesity** **Chronic respiratory disease causing coughing** **Chronic constipation causing straining**

Answer 243

**Feeling of "something coming down"** in the vagina **Dragging or heavy sensation** in pelvis **Urinary symptoms** e.g. incontinence, urgency, frequency, weak stream, retention **Bowel symptoms** e.g. constipation, incontinence and urgency **Sexual dysfunction** e.g. pain, altered sensation and reduced enjoyment

Answer 244

Patient should **empty bladder and bowel** before examination of prolapse A **Sim's speculum** is a U-shaped, single bladed speculum used to support the anterior wall to examine for a rectocoele and the posterior wall for a cystocele Woman **asked to cough**

Answer 245

**Grade 0**: Normal **Grade 1:** The lowest part is more than 1cm above the introitus **Grade 2:** The lowest part is within 1cm of the introitus (above or below) **Grade 3**: The lowest part is more than 1cm below the introitus, but not fully descended **Grade 4:** Full descent with eversion of the vagina

Answer 246

**Uterine procidentia**

Answer 247

**Conservative** = physio (pelvic floor exercises), weight loss, reduced coffee intake, incontinence pads, treat related symptoms e.g. stress incontinence with anticholinergic medications, vaginal oestrogen cream **Vaginal pessary** = placed into vagina for support, many types (**ring** sit around cervix, **shelf** and **gellhorn** pessaries are a flat disc with a stem, **cube** are cube shaped, **donut** are a thick ring, **hodge**), oestrogen cream can help protect against irritation **Surgey** = **mesh repairs** (now avoided entirely - over a lot of controversy)

Answer 248

**Pain, bleeding, infection, DVT and risk of anaesthetic** **Damage** to **bladder** **Recurrence** of the prolapse **Altered** experience of **sex**

Answer 249

Chronic pain Altered sensation Dyspareunia (painful sex) for the woman / partner Abnormal bleeding Urinary / bowel problems

Answer 250

**Overactive bladder** caused by overactivity of the detrusor muscle of the bladder

Answer 251

Weakness of the **pelvic floor** and **sphincter muscles** causing leakage when **laughing, coughing** or **surprised**

Answer 252

Combination of **urge** and **stress** incontinence

Answer 253

**Obstruction** to the **outflow** of the urine **causing chronic urinary retention** (incontinence occurs without the urge to pass urine) Occurs without the urge to pass urine

Answer 254

**Anticholinergic medications** **Fibroids** **Pelvic tumours** **Neurological conditions** e.g. MS, diabetic neuropathy, spinal cord injuries

Answer 255

**More common in men** than women

Answer 256

Increased age Post menopausal High BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neuro conditions e.g. MS Cognitive impairment / dementia

Answer 257

Caffeine consumption Alcohol consumption Medications BMI

Answer 258

**Frequency** of Urination/ Incontinence **Nighttime** urination **Use of pads and changes of clothing**

Answer 259

**Pelvic organ prolapse** **Atrophic vaginitis** **Urethral diverticulum** **Pelvic masses** Ask for patient to cough and watch for leakage from urethra

Answer 260

**0:** No contraction **1:** Faint contraction **2:** Weak contraction **3:** Moderate contraction with some resistance **4:** Good contraction with resistance **5:** Strong contraction, a firm squeeze and drawing inwards

Answer 261

**Bladder diary** tracking fluid intake and episodes of urination and incontinence over 3 days (mix of work and leisure days) **Urine dipstick** for infection, microscopic haematuria and other pathology **Post-void residual bladder volume** measured using a bladder scan to assess for incomplete emptying **Urodynamic testing** for urge incontinence patients not responding to first line medical treatments, difficulties urinating, urinary retention, previous surgery, unclear diagnosis

Answer 262

Patients **stop any anticholinergic** medication (and other bladder meds) **5 days before** Thin catheter (that **measures pressure**) is inserted into the bladder and rectum, **bladder is filled with liquid** and various outcome measures are taken: **Cystometry** measures the **detrusor muscle contraction** **Uroflowmetry** measures the **flow rate** **Leak point pressure** is the **point at which the bladder pressure results in leakage** (after coughing - for stress incontinence) **Post void residual bladder volume** for incomplete emptying of bladder **Video urodynamic testing** - filling the bladder with contrast and taking x-rays images as the bladder is emptied (this is not routine)

Answer 263

Distinguish between **urge and stress incontinence** as this dictates management

Answer 264

**Avoid caffeine, diuretics and overfilling** of the bladder **Avoid excessive / restrictive** fluid intake **Weight loss** (if appropriate) **Supervised pelvic floor exercise** for at least 3 months before considering surgery (8 contractions 3 times daily) **Surgery** **Duloxetine** is a SNRI antidepressant used second line where surgery is less preferred

Answer 265

**Tension-free vaginal tape** (TVT) - procedure involving a mesh sling looped under the urethra and up behind the pubic symphysis to abdo wall (supporting urethra) **Autologous** **sling procedure** (similar to TVT procedure but strip of fascia from abdo wall is used rather than tape) **Colposuspension** involves using stitches connecting the anterior vaginal wall and the pubic symphysis around the urethra - for support **Intramural urethral bulking** - injections around the urethra to reduce diameter and add support

Answer 266

Operation to create an **artificial urinary sphincter** - using a pump inserted into the labia which inflates and deflates a cuff around the urethra

Answer 267

**Bladder retraining** - gradually increasing time between voiding (for at least 6 weeks) **Anticholinergic medication**: oxybutynin, tolterodine, solifenacin **Mirabegron**: alternative to anticholinergic medication **Invasive procedures** where medical treatment fails

Answer 268

Dry mouth Dry eyes Urinary retention Constipation Postural hypotension **Coginitive decline** **Memory problems** Worsening of dementia

Answer 269

**Beta-3-agonist** (contraindicated in uncontrolled hypertension, bp needs to be monitored) Less of anticholinergic burden

Answer 270

**Botulinum toxin type A** injection into the bladder wall **Percutaneous sacral nerve stimulation** involves implanting a device in the back that stimulates the sacral nerves **Augmentation cystoplasty** involves using bowel tissue to enlarge the bladder **Urinary diversion** involves redirecting urinary flow to a urostomy on the abdomen

Answer 271

**Dryness** and **atrophy** of the vaginal mucosa due to a lack of oestorgen occuring in women entering the menopause

Answer 272

**Thickens** **More elastic** **Produces secretions**

Answer 273

Pelvic organ prolapse Stress incontinence

Answer 274

**Itching** **Dryness** **Dyspareunia** (discomfort or pain during sex) **Bleeding due to localised inflammation**

Answer 275

Pale mucosa Thin skin Reduced skin folds Erythma and inflammation Dryness Sparse pubic hair

Answer 276

**Vaginal lubricants** e.g. sylk, replens and YES ## Footnote **Topical oestrogen**

Answer 277

**Estriol cream,** applied using an applicator (syringe) at bedtime **Estriol pessaries,** inserted at bedtime **Estradiol tablets (Vagifem)**, once daily **Estradiol ring (Estring)**, replaced every three months

Answer 278

Breast cancer Angina VTE

Answer 279

**Pair of glands** located either side of the posterior part of the **vaginal introitus** (vaginal opening) - usually pea sized and not palpable - produce mucus for lubrication

Answer 280

When the ducts become blocked - glands swell and become tender causing a **cyst** (unilateral and fluid filled up to 4cm) this can then become **infected** forming an **abscess** which will be **hot, red,** and potentially **draining pus**

Answer 281

Clinically

Answer 282

Good hygiene Analgesia Warm compresses **Biopsy** (if vulval malignancy needs to be excluded)

Answer 283

**Antibiotics** Swab of pus for organism and sensitivities (E. Coli most common, send swabs for chlamydia and gonorrhoea too) **Surgical intervention** = Word catheter / Marsupilisation

Answer 284

**Small rubber tube** with a **balloon** on the end **Local anaesthetic** is used to numb the area - incision is made - pus is drained from abscess **Catheter** in inserted in the space and inflated with saline (keeping catheter in place) - fluid can drain around catheter preventing a cyst of abscess reoccuring - **tissue heals around catheter** which can then be deflated and removed at a later date

Answer 285

Using a **GA** in **theatre** - incision is made and the abscess is drained - sides of abscess are sutured open (allowing **continuous drainage** and preventing recurrence)

Answer 286

**Chronic inflammation** of the skin which causes patches of white shiny areas on **labia, perineum** and **perianal** skin in women (can affect men on **foreskin** and **glans** of the penis)

Answer 287

**Autoimmune condition** associated with other sutoimmune diseases e.g. **type 1 diabetes**, **alopecia**, **hypothyroid** and **vitiligo**

Answer 288

Clinically Vulval biopsy can be used to **confirm the diagnosis**

Answer 289

Flat eruption which spreads

Answer 290

Chronic inflammation and irritation caused by repeated scratching of an area of skin **Excoriations**, **plaques**, **scaling** and **thickened skin**

Answer 291

Autoimmune condition which causes **chronic inflammation** with shiny, purplish, flat-topped raised aread with white lines across the surface called **Wicham's striae**

Answer 292

45-50 year old woman with **vulval itching** and **skin changes** Itching Soreness and pain (worse at night) Skin tightness Painful sex (superficial dyspareunia) Erosions Fissures

Answer 293

Where symptoms of lichen sclerosus is **made worse with friction to the skin** e.g. wearing tight underwear, scratching

Answer 294

"porcelain-white" in colour Shiny Tight Thin Slightly raised Papules / plaques

Answer 295

Chronic disease, symptomatic treatment: * **potent topical steroids** clobebasol propionate **(dermovate) 0.05%** * Steroids once a day for 4 weeks until condition controlled * **Emollients** used regularly

Answer 296

**Squamous cell carcinoma of the vulva** Other complications: * Pain and discomfort * Sexual dysfuction * Bleeding * Narrowing of the vaginal / urethral openings

Answer 297

Surgically changing the genitals of a female for non medical reasons - form of **child abuse** and **safeguarding issue**

Answer 298

**Type 1:** Removal of part or all of the clitoris. **Type 2:** Removal of part or all of the clitoris and labia minora. The labia majora may also be removed. **Type 3:** Narrowing or closing the vaginal orifice (infibulation). **Type 4:** All other unnecessary procedures to the female genitalia.

Answer 299

**Somalia**, **Ethiopia**, **Sudan** and **Eritrea** (data from UNICEF)

Answer 300

Coming from a **community which practises FGM** Having **relatives** with FGM

Answer 301

**Pain** **Bleeding** **Infection** **Swelling** Urinary retention Urethral damage and incontinence

Answer 302

Vaginal infections (e.g. BV) UTIs **Dysmenorrhoea** **Dyspareunia** Infertility Psychological issues (e.g. depression) Reduced engagement with screening

Answer 303

- Educate that **its illegal** - Report all **FGM** under 18 to police (and social services, paediatrics, specialist gynae services, counselling) - **Consider reporting** in over 18s using risk assessment tool, consider relatives at risk, unborn child at risk? - **De-infibulation** - to correct narrowing or closure (re-infibulation is illegal)

Answer 304

**Paramesonephric ducts** (Mullerian ducts)

Answer 305

**Anti-Mullerian hormone**

Answer 306

Where there are **"two horns" to the uterus**, giving it a heart shaped appearance (diagnosed on pelvic ultrasound)

Answer 307

Adverse pregnancy outcomes: ## Footnote **- Miscarriage** **- Premature death** **- Malpresentation**

Answer 308

Hymen is **fully formed** without an opening (discovered when menstration starts - menses trapped = cyclical pain and cramping, no bleeding) Diagnosed on examination, treated with surgical incision

Answer 309

**Retrograde menstruation** causing endometriosis

Answer 310

Error in development where a **septum** (wall) forms **across the vagina** - can either be **perforate** (with a hole) or **imperforate** (completely sealed) **Perforate** = still menstruate but difficulty with intercourse/tampon **Imperforate** = present similarly to an imperforate hymen with cyclical pelvic symptoms Can cause **infertility**

Answer 311

**Examination** **Ultrasound** **MRI** **Treat** with **surgical correction** (complication = vaginal stenosis / recurrence of septae)

Answer 312

Abnormally **small vagina**

Answer 313

Absent vagina

Answer 314

Failure of the **Mullerian ducts** to properly develop (may have absent uterus and cervix)

Answer 315

When there is **androgen insensitivity syndrome** creating testes rather than ovaries

Answer 316

**Vaginal dilator** over a **prolonged period of time** or vaginal surgery

Answer 317

Condition where cells are unable to respond to **androgen hormones** due to a **lack of androgen receptors**

Answer 318

**X-linked recessive** (caused by mutation in the **androgen receptor gene** on the **X chromosome**)

Answer 319

Extra androgens are converted into oestrogen resulting in **female secondary sexual characteristics** - previously known as **testicular feminisation syndrome**

Answer 320

**Genetically male** with **XY sex chromosome** Absent response to testosterone and conversion of androgens to oestrogen results in **female phonetype externally** - male sexual characteristics don't develop, patients have normal female external genitalia and breast tissue

Answer 321

**Testes** in the abdomen or inguinal canal with **absence** of a **uterus**, **upper vagina**, **cervix**, **fallopian tube** and **ovaries** (these organs don't develop as the **testes** produce **anti-Mullerian hormone**)

Answer 322

Lack of pubic hair / facial hair and male type muscle development Slightly **taller than the average female, infertile, increased risk of testicular cancer** unless testes are removed

Answer 323

**Ambiguous signs** cells have a partial response to androgens, micropenis, clitoromegaly, bifid scrotum, hypospadias, diminished male characteristics

Answer 324

**Infancy** with **inguinal hernias** containing **testes** Alternatively, in **puberty** with **primary amenorrhoea**

Answer 325

Raised LH Normal / raised FSH Normal / raised testosterone levels (for a male) Raised oestrogen levels (for a male)

Answer 326

**Bilateral orchidectomy** (removal of the testes) to avoid testicular tumours **Oestrogen therapy** **Vaginal dilators** / **vaginal surgery** to create length (management involves paediatrics, gynae, urology, endocrinology, clinical psychology) Generally patients are **raised as female** but this is sensitive and tailored to the individual, offered support and counselling