Gynaecology - Management Flashcards
PCB - Examination
Abdominal exam
Speculum
- Ectropion
Bimanual exam
PCB - Investigations
HVS, VVS, Endocervical
- STI Screen
Smear/Colposcopy
PCB - Management
- Silver nitrate for ectropion
- Polyp removal
- Treat STI if present
- Treat CIN if present
IMB - Examination
Abdominal exam
Speculum
- Ectropion
Bimanual exam
IMB - Investigations
TV USS
- Endometrial thickness
Pipelle biopsy
Hysteroscopy
Amenorrhoea - Classification
Primary - no period by 16
Secondary - no period for 6 months
Oligmenorrhoea = cycle longer than 35 days
Amenorrhoea - Physiological
Pregnancy
Menopause
Lactation
Amenorrhoea - Pathological
Hypothalamus/hypogonadism
- Anorexia
- Athleticism
Pituitary
- adenoma
Hyperthyroid
Ovarian
- PCOS
- Premature ovarian failure (Turner’s syndome)
Pre-Menstrual Syndrome - Management
SSRIs
COCP (avoid progesterone only contraception)
PCOS - Investigations
USS Ovaries
Bloods
- Increased testosterone
- Increased LH
- Low 21 day progesterone (no corpus luteum)
PCOS - Management
- Weight loss
- For infertility - clomiphene, metformin
- Oligmenorrhoea - COCP to induce bleed
PCOS - Complications
Diabetes
CVD
Endometrial/ovarian/breast Ca
HRT - Contraindications
Absolute
- current breast/endometrial Ca
- vaginal bleeding
- breast mass
- VTE
- Liver disease
Relative
- Endometriosis
- Fibroids
- Fam hx breast/endometrial ca, VTE/liver disease
HRT - Pros and Cons
Pros
- Symptom relief
- Less oesteoporosis
Cons
- increase breast Ca
- progest/oestrogen SE
- VTE and CVD risk
PMB - Investigations
Fast track TV USS
If more than 5mm
Urgent hysteroscopy and biopsy
PMB - Management
Endometrial Ca - oncology
Endometrial hyperplasia
- Atypical cells = hysterectomy
- Typical cells = Mirena/COCP
Vaginal Atrophy
- Topical cream (local ok in breast Ca)
- Lubrication and reassurance
PMB - Risk Factors
Increased Oestrogen = increased proliferation
- Early menarche, late menopause
- Oestrogen HRT
- PCOS
Endometriosis - O/E
Bimanual
- Fixed, retroverted, tender uterus
- Bilateral cervical motion tenderness
- Adnexal tenderness
Endometriosis - Investigations
Laparotomy = diagnostic
Endometriosis - Medical Management
- NSAIDS
- COCP back to back
- Mirena
- GnRH analogues (6 months max due to bone demineralisation)
Endometriosis - Surgical Management
- Ablation
- Cystectomy
- Hysterectomy (last resort) - may need HRT
PID - Investigations
PT
Triple Swabs
Bloods
- HIV
- Syphilis
PID - Examination
Abdominal
Speculum
Bimanual
PID - When to treat?
Treat if lower abdo pain + one of:
- Adnexal pain
- Cervical motion tenderness
- Adnexal mass
With negative PT
PID - Abx
Ceftrioxone 500mg IM stat
Doxyclycline 100mg PO BD 14 days
Metronidazole 400mg BD 14 days
PID - Complications
TF infertility
Increased risk ectopic
Fitz-Hugh-Curtis (peri-hepatitis)
Chronic pain
Miscarriage
- Refer to EPU
- PT
- TVUSS if positive
Miscarriage - TV USS Empty
- Complete miscarriage
- PUL (safety net)
- Too early (bHCG blood test)
Miscarriage - Intrauterine Pregnancy
- Heartbeat = viable
- Too early = return 7-10 days
- No heartbeat = incomplete/missed/inevitable miscarriage (requires management)
Miscarriage - Options
Conservative
- <12 weeks
Surgical
- Infection, bleeding, damage
- 5% failure
Medical
- Misoprostol <13 weeks
- Preg test after 3 weeks to check success
- 5% failure
- increased risk of RPOC
Ectopic Pregnancy - O/E
- Shocked, collapse
- Tenderness
- Cervical motion tenderness
Ectopic Investigations
PT
TV USS - empty or adnexal pregnancy
B-HCG over 48 hours - plateau (<66% rise)
Ectopic - TV USS Findings
- Free peritoneal fluid
- Thickened endometrium
- Adnexal mass
Ectopic - Management
Medical <35mm/no heartbeat/bHCG <1500
- Methotrexate
- Need 6m contraception following as teratogenic
Surgical >35mm/heartbeat/pain/rupture
- Salpingectomy
Molar Pregnancy - Causes
Complete
- 1 sperm, empty ovum 46XX
Partial
- 2 sperm, 1 egg
Molar Pregnancy - Investigations
USS - Snowstorm appearance
Confirmed on histology
Molar Pregnancy - Management
ERPC Suction and cutterage removal
Rising bHCG levels suggest malignancy (100% survival)
Fibroids - Investigations
TV USS
Fibroids - Medical Management
Wanting children
- Tranexamic Acid, Mefanamic Acid
Not wanting children
- Mirena
- COCP
- GNRH
Fibroids - Surgical Management
- Resection
- Myomectomy (keeps fertility)
- UAE
- Hysterectomy
Stress Incontinence - Investigations
Urodynamics
- urine leaks with no change in bladder pressure
- Response to increase abdo pressure
Stress Incontinence - Management
- 3 months Pelvic floor exercises
- Lose weight
Medical
- Duloxetine
Surgical
- TV tape
- Collagen/injectable
Urge Incontinence - Investigations
Urodynamics
- Involuntary increase in detrusor activity
- Increased bladder pressure and leakage of urine
Urge Incontinence - Management
- Avoid caffeine
- Stop smoking
- Bladder retraining
Medical
- Anticholinergics - tolteradine, oxybutinin, TCAs
Surgical
- Botox
Prolapse - Classification
I - Cervix within vagina
II - Cervix at introitus
III - Entire uterus outside vagina
Prolapse - Management
- Lose weight
- Pelvic floor exercises
- Pessary (ring, shelf, gelhorn)
Surgical
- Ant/post repair
- Hysterectomy (risk vault prolapse)
- Vaginal Mesh
Cervical Ca - Investigations
Colposcopy +/- biopsy
MRI Pelvis
CT abdomen and chest for staging
Cervical Ca - Spread
Direct
- Vagina, bladder, peritoneum, bowel
Indirect
- Parametrial, internal, external and common iliac nodes
Cervical Screening
Mild Dyskaryosis, Test for HPV
\+ve = colposcopy -ve = return to normal screening
Moderate dyskaryosis or worse
= colposcopy
CIN
CIN 1
- mild, lower 1/3
- Repeat 6/12/24 months then back to normal screening
CIN II
- Moderate, lower 2/3
- LETTZ
- 6M, 12M, yearly for 9 years
CIN III
- Severe, throughout
- LETTZ
- 6M, 12M, yearly for 9 years
PMB ?Endometrial Ca - Investigations
TV USS - thickness >4mm
Biopsy/pipelle in clinic
Hysteroscopy
Endometrial Ca - Risk Factors
Increased oestrogen
- obesity, diabetes, sedentary
- early menarche, late menopause
- PCOS, HRT, Tamoxifen
Ovarian Ca - Investigations
Pelvic USS
Ca-125
CT abdomen/pelvis for staging
Ovarian Ca - Staging
I - ovaries
II - pelvis
III - small bowel or omentum
IV - Distant mets
Subfertility - Lifestyle
- Stop smoking
- Folic acid 5mg
- Lose weight (BMI <30)
- Decrease alcohol intake
Subfertility - Investigations
STI Screen
Mid-luteal progesterone (day 21 in 28 day cycle)
Sperm analysis
- USS
- Hysterosalpingogram
- Lap and Dye
Subfertility - Mx
PCOS
- lose weight
- Metformin, clomifene
Premature ovarian insufficiency
- Stop smoking
- Specialist referral
- Egg donation
Tubal Factor
- Intrauterine insemination
- IVF
- ICSI
Fertility Treatment - Risks
Multiple pregnancy (10 x higher chance)
Ovarian hyperstimulation syndrome
- fluid accumulation and dehydration due to increase capillary permeability
- Young, PCOS, pregnant
