Gynaecology OSCE Flashcards
PID
- We need to investigate whether you are systemically unwell, in which case you would need admitting. This involves full set of observations.
- i need to perform a VE to assess cervical excitation. At the same time, I can perform 2 sets of swabs to look for any STIs
- I will also ask you for a urine sample in order to perform a culture. This needs to be the first bit of urine.
- I need to give you 3 types of antibiotics. One is an injection in the leg (IM Cef) and two are tablets that you need to take twice a day for 2 weeks (doxy/met)
- i will see you again in 3 days to see how you are doing, because there is a risk of an abscess, which won’t respond to treatment and needs draining
- there are two more things we need to discuss:
1. contact tracing
2. what this means for your future. increased risk of ectopic, subferitlity and chronic pain
pruritus vulvae
- reassurance
- emollients
- vulval care advice (loose clothing, soap not gels, clean once daily)
Ectropion
- speculum
- consider swapping out COCP to non hormonal contraception
- outpatient cryotherapy if desired
fibroids
- VE/speculum
- TV-USS
- MRI/hysteroscopy/FBC may be required
- medical management of menorrhagia can be tried first (IUS, COCP +/- tranexamic, mefanamic) but coil rarely stays in
- surgical
- goserelin + myomectomy
- hysterectomy, but can always wait for the menopause.
- uterine artery embolisation
adenomyosis
- MRI is gold standard
- FBC/USS/VE also used
- can try medical management of menorrhagia
- hysterectomy often needed, but can always wait for the menopause.
endometriosis
- laparoscopy + biopsy gold standard investigation
- VE/USS/MRI can be helpful
- VE often shows find retroverted uterus
- can try medical management of menorrhagia
- excision at laparoscopy tried first
- hysterectomy used as last line, but can always wait for the menopause.
amenorrhoea from ?PCOS
- USS for ovaries
- LH:FSH ratio
- other blood tests to exclude other causes (e.g. testosterone, TSH, prolactin)
- screen for diabetes with GTT
- weight loss and smoking cessation
- ask if fertility needed
- NO: COCP to regulate periods
- YES, steps are:
1. clomifene, which induces ovulation
2. metformin can be used
3. both
4. ovarian diathermy
5. IVF
premature ovarian failure
- check blood test hormone to see if it is premature ovarian failure (FSH)
- check another blood hormone (AMH) to check ovulatory reserve
- you can help yourself by modifying your lifestyle (weight loss, exercise, avoid late exercise, sleep hygiene)
- HRT
- symptomatic treatment (topical oestrogen, lubricants, CBT, fluoxetine can help vasomotor symptoms)
HRT
contraindications? breast cancer (past or present) undiagnosed vaginal bleeding/endometrial hyperplasia
do you have a uterus?
YES - combined HRT is where you have a pill as well as a progesterone which protects the endometrium
NO - oestrogen only HRT can be used
How long have you been amenorrhoeic?
<12m = cyclical HRT
>12m = continuous HRT
Benefits?
it helps vasomotor symptoms, reduces the chance of osteoporosis and improves urogenital symptoms
Risks?
VTE, stroke, CHD, breast, ovarian and endometrial cancer
Menorrhagia
- FBC
- TVUS if history suggests stuctural problem
Some treatments double up as contraception. Do you want contraception?
NO - tranexamic acid/mefanamic acid
YES - IUS, COCP, depo
ovarian cancer
- we need to do a blood test now called the CA125. If it is raised above 35 then we need to do an ultrasound.
- are you menopausal? Because this + CA125 + USS gives us a number which estimates the risk of this being cancer
- if we are suspicious, we will send you for a CT
- surgery with biopsy is the only way to definitively diagnose
- I will send you to 2ww clinic
- surgery is TLH-BSO +/- lymph nodes
- chemo-radiotherapy sometimes as adjunct
endometrial cancer/IMB
- TV-USS (<4mm is clear) + pipelle
- hysteroscopy/biopsy sometimes needed if pipelle inconclusive
- I will send you to 2ww clinic
- surgery is TLH-BSO +/- lymph nodes
- chemo-radiotherapy sometimes as adjunct
cervical cancer
You will have a smear test which determines whether you need to have colposcopy +/- HPV testing done. Colposcopy is used to see if you have CIN/cancer
If you have the lowest grade of intraepithelial neoplasia, CIN1, you will return to normal screening. If you have stage 2 or 3, you will have a LLETZ procedure
If you have a grade 1 cancer, you will have surgery (cone biopsy, trachelectomy or hysterectomy)
If you have a grade 2+ (beyond cervix) you will have chemoradiotherapy alone
Vulval cancer
I will need to take a biopsy of the lesion to see whether it is cancerous.
Treatment will involve a wide local excision +/- lymph node dissection
subfertility
We will need to investigate both the man and the woman. Semen analysis will be done on your partner and we will look at your hormone levels at a specific point in your cycle (7 days before period) to see whether you are ovulating.
We will also look to see if there are any structural abnormalities in your uterus by performing an USS. We will also investigate for PCOS (the most common cause)
We can advise the following:
- regular sex every 2-3 days
- stop smoking/drinking and get BMI 20-25
- take folic acid
If it is ongoing for 24 months, then we can consider IUI or IVF
