Gynaecology + Obstetrics Flashcards
HPV cercial cancer types (1)
other RF (5)
Human papillomavirus infection (particularly 16,18 & 33) is by far the most important risk factor
Mechanism of HPV causing cervical cancer
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
E6 inhibits the p53 tumour suppressor gene
E7 inhibits RB suppressor gene
Other RF:
smoking, HIV, parity, low SES, COCP
widely spaced nipples and primary amenorrhoea
Turner’s syndrome
(X)
hormonal changes characteristic with turners
raised gonadotrophin levels (FSH/LH)
decreased levels of oestrogen and progesterone due to gonadal dysgenesis resulting in a compensatory increase in serum FSH and LH.
Gonadal dysgenesis causes an increase in FSH/LH by the negative feedback cycle to try to compensate for the lack of oestrogen and progesterone produced by the ovaries.
Increased serum androgen levels
polycystic ovarian syndrome. This will present a history of oligomenorrhoea, obesity, acne and hirsutism.
most common cause of primary amenorrhoea
gonadal dysgenesis (e.g. turners)
other causes:
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
secondary amenorrheoa
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
amenorrheoa- what do the gonatorohins show us
FSH/LH tell us:
low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
raised if gonadal dysgenesis (e.g. Turner’s syndrome)
secondary amenorrhoea + raised FSH/LH + lw oestradiol
POremature ovarian insufficiency (<40 years)
Gonadotropin-producing pituitary adenoma: hormones
elevated FSH and LH levels alongside normal or high oestradiol levels
- mass effect on surrounding structures, such as headaches or visual disturbances.
diagnostic test for POI
FSH level
Ectopic:
when can you do expectant:
hCG (1)
size (1)
<35mm
unruptured
asymptomatic
no fetal heartbead
hCG <1000
(involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.)
Ectopic:
when can you do medical management:
hCG (1)
size (1)
<35mm
no significant pain
no heart beat
hCG < 1,500
medical management ectopic
methotrexate
pt has to be willing to attend follow up
Ectopic:
when can you do surgical management:
hCG (1)
size (1)
> 35mm
hCG >5000
heart beat
pain
Salpingectomy is first-line for women with no other risk factors for infertility
Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage (around 1/5 require further methotrexate/ salpingostomy)
Infertility in PCOS - first line treatment
2nd line?
1st= clomifene
2nd line= metformin
(weight reduction)
uterine fibroids short term treatment to reduce size
GnRH agonists
typically used more for short-term treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
uterine fibroid surgical management
myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
uterine artery embolization
Benign ovarian cyst management:
premenopausal
postmenopausal
PREMENOPAUSAL
a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
POSTMENOPAUSAL
by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
gestational sac containing a dead fetus before 20 weeks without the symptoms of expulsion
missed misscarriage
threatened vs inevitable miscarroage
Inevitable miscarriage would have symptoms of imminent expulsion such as abdominal pain and vaginal bleeding with an open cervical os.
Threatened miscarriage would have vaginal bleeding with or without abdominal pain, with a closed cervical os.
HIV and cervical cancer screening
Women with HIV should be offered cervical cytology at diagnosis.. Cervical cytology should then be offered annually for screening.
Even those women who are effectively treated with antiretrovirals have a high risk of abnormal cytology and an increased risk of false-negative cytology.
bacterial vaginosis and Trichomonas vaginalis treatment
metronidazole
thrust treatment options (2)
if pregnant (1)
oral fluconazole 150 mg as a single dose first-line
clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
hormonal changes in menopause
The menopause can either be a natural or iatrogenic process that results in the cessation of oestradiol and progesterone production in the ovaries. Due to this decrease, FSH and LH levels will often increase.
temperature during period
Rises following ovulation in response to higher progesterone levels
Progesterone also highest in luteal (secretory) 15-28 days, as it is secreted by the egg
Urge incontinence management (2)
examples of the meds (3)
- bladder retraining
- anti muscarinic antagonist
NICE recommend oxybutynin (immediate release),
tolterodine (immediate release) or
darifenacin (once daily preparation)
who to not give oxybutynin to
Immediate release oxybutynin should, however, be avoided in ‘frail older women’
duloxetine MOA
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
duloxetine may be offered to women if they decline surgical procedures
STRESS INCONTINENCE
Amels’s criteria;
what cells? (1)
what pH (1)
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
Treatment for BV and trichomonads vaginalis
Oral metronidazole
recurrent candida - how to treat
if 4+ / year
–> check compliance
–> check for other causes e.g. diabetes
–> consider lichen sclerosis
TREAT with induction-maintenance regimen
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
Most common benign ovarian tumour in women under the age of 25 years
Dermoid cyst (teratoma)
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
Follicular cysts
sample “inadequate” in cervical smear
repeat in 3 months
if 2x samples inadequate in cervical smear
colposcopy
HPV +ve by cytology normal (i.e NO borderline changes) –> repeat in 12 months.
if repeat:
normal? (1)
+ve? (1)
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
(Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy)
progesterone surge in cycle
day 21
fertility: what hormone to test for
progesterone
management endometrial cancer
localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
patients with high-risk disease may have postoperative radiotherapy
Progestogen therapy is sometimes used in frail elderly women not considered suitable for surgery.
when to investigate infertility
> 35 = 6 months
<35= 12 months
