ICSM Year 5 Gynaecology Flashcards
1
Q
What is Asherman’s syndrome?
A
Presence of intrauterine adhesions that may partially/ completely occlude the uterine cavity
2
Q
Recall what investigations should be done in suspected Asherman’s
A
Saline hysterosonography (HSG), TVUSS
3
Q
What would be seen on TVUSS in Asherman’s syndrome?
A
Sub-endothelial linear striations + ‘boggy’ uterus
4
Q
How is Asherman’s syndrome managed?
A
Initially: Hysteroscopic adhesionolysis + post-op copper IUD
Next: PO oestrogens and reasses cavity
5
Q
Recall some complications of Asherman’s
A
Infertility, miscarriage, oligomenorrhoea
6
Q
What is atrophic vaginitis?
A
Vaginal irritation caused by thinning of the vaginal epithelium
7
Q
What is the cause of atrophic vaginitis?
A
Reduction in circulating oestrogen ie. Post-menopause
8
Q
Give 3 signs of atrophic vaginitis
A
Irritation, dyspareunia, discharge (may be bloody)
9
Q
How does atrophic vaginitis appear O/E?
A
Pale, thin vaginal walls with loss of rugal folds, cracks or fissures
10
Q
What investigations would you order in suspected atrophic vaginitis?
A
- Clinical examination
- Swabs for potential infection
- Biopsy for potential malignancy/ ulcers
11
Q
How is atrophic vaginitis managed?
A
- Systemic HRT
2. If bleeding on intercourse –> water based moisturisers and lubricants
12
Q
What 8 things should be checked for when doing a history for gynaecological infections?
A
Discharge (smell, consistency, colour, volume), Blood Pain Urinary symptoms Itch FLAWS Pregnancy status Sexual history
13
Q
What investigations should be done in a suspected gynaecological infection?
A
pH, swabs (double or triple) and blood tests (for HIV/ syphilis)
14
Q
What is the normal pH for the lateral wall of the vagina?
A
3.5-4.5 (due to lactobacilii in vagina)
15
Q
What is a low vaginal pH indicative of?
A
Candida
16
Q
What is a raised vaginal pH indicative of?
A
Contamination, BV or TV
17
Q
Describe the method of ‘double swab’?
A
- Endocervical swab - tests for gonorrhoea and chlamydia
2. High vaginal swab, “charcoal swab” - fungal and bacterial (BV, TV, candida, GBS)
18
Q
Describe the method of ‘triple swab’?
A
- Endocervical (for chlamydia)
- Endocervical charcoal swab (for gonorrhoea)
- High vaginal charcoal swab (for fungal/ bacterial infection)
19
Q
What type of testing is done on the endocervical swab?
A
NAAT (nucleic acid amplification testing) for chlamydia/ gonorrhoea
20
Q
What type of testing is done on the high vaginal swab?
A
MCandS
21
Q
How does gonorrhoea appear under the microscope?
A
Gram neg diplococci
22
Q
What is the most common cause of abnormal discharge?
A
BV
23
Q
How does discharge appear in BV?
A
Thin and watery, grey/ white - FISHY SMELLING ODOUR
24
Q
What are the symptoms of BV?
A
Just the discharge
25
What is the cause of BV?
Overgrowth of anaerobic bacteria
26
What is the most commonly implicated microbe in BV?
Gardinella vaginalis
27
What is required for BV diagnosis?
Clinical diagnosis + microscopy, can show high pH
28
What would be shown on microscopy in BV?
Clue cells - vaginal epithelium cells coated with lots of bacilli
29
What are the criteria for BV diagnosis confirmation?
Amsel's criteria: need 3 out of 4 out of:
1. Thin, white, homogeneous discharge
2. Clue cells on microscopy
3. Vaginal pH > 4.5
4. Fishy odour on adding 10% KOH
30
How is BV managed?
1. If asymptomatic, no treatment
2. Metronidazole, PO, 400mg, BD, 7 days
Second line: Intravaginal clindamycin PV cream, 5g 2% 7 days
31
Recall some complications of BV
Late miscarriage, preterm birth, PROM and postpartum endometritis
32
Recall the symptoms of trichomonas vaginalis
Asymptomatic in 50%
Discharge: green/ yellow, "frothy", offensive odour
Dyspareunia
Vulval itch/ soreness
33
What is seen OE in trichomonas vaginalis?
Strawberry cervix
34
Recall some key investigations and results in trichomonas vaginalis?
High vaginal swab + direct microscopy shows flagellated organism
pH > 4.5 - it is only high in BV and TV
35
What is the treatment of trichomonas vaginalis?
First line: Metronidazole 400mg BD PO, 7 days
| Second line: Metronidazole, 2g, PO stat
36
What are the causative organisms that can cause thrush?
```
Candida albicans (in 90%)
Candida glabrata (in 5%)
```
37
What are the causes of candidiasis?
Can be spontaneous
| Can be secondary to a disruption of normal vaginal flora
38
Recall some risk factors for vaginal candidiasis
Oestrogen exposure (eg pregnancy, intercourse, poorly-controlled diabetes, HIV, recent Abx (eg for a UTI))
39
What is the most tell-tale examination finding in vaginal candidiasis?
'Cottage-cheese' type discharge
40
What is the expected pH in thrush?
Low/ normal
41
What investigations would you do in suspected thrush?
Wouldn't usually do any, but diagnostic is HVS MCandS showing speckled gram pos spores and pseudohyphae
42
What are pseudohyphae indicative of?
C. albicans infection specifically
43
How should thrush be managed?
1st line: clotrimazole pessary + 1% clotrimazole cream (BD)
2nd line/ severe: fluconazole PO STAT
If pregnant, use topical treatment only
44
What is the latin name for cutaneous warts?
Condylomata acuminate
45
What is the causative organism in cutaneous warts?
HPV 6 and 11
46
What is the name of the HPV vaccine?
Gardasil
47
Which seroforms of HPV cause cervical cancer vs cutaneous warts?
6 + 11 = cutaneous warts; 16 + 18 = cervical cancer
48
Recall the symptoms of cutaneous warts?
Generally painless warts but may itch/ bleed/ become inflamed
49
How do you investigate for cutaneous warts?
Usually a clinical diagnosis, but should also do an STI screen (triple swab: HIV, syphillis, HBV)
50
What sort of organism is chlamydia trachomatis?
Gram neg parasite - cannot be seen under microscope
51
What are the symptoms of chlamydia?
Asymptomatic in 75% of women - when sympatomatic --> purulent PV discharge, dyspareunia, IMB, PCB, abdo pain + dysuria
52
What investigations should be done in suspected chlamydia?
Unlike gonorrhoea, if there are signs and symptoms of chlamydia you can treat on suspicion alone
If not sure:
1. NAAT - vulvovaginal swab or first catch urine
2. Culture and sensitivities
Direct microscopy will show neutrophils but no organisms
53
How should chlamydia be managed?
1st line: doxycyline - but contraindicated in pregnancy and breastfeeding
2nd line/ pregnant/ breast-feeding: azithromycin (STAT)
54
Recall the signs and symptoms of gonorrhoea
Asymptomatic in 50%
| If symptomatic, symptoms similar to chlamydia: PV discharge, IMB, PCB, dysuria, dyspareunia, lower abdo pain
55
Recall the findings on speculum examination in gonorrhoea
Mucopurulent endocervical discharge
| Easily induced endocervical bleeding
56
Recall the findings on bimanual examination in gonorrhoea
Cervical motion/ adnexal tenderness
| Uterine tenderness
57
When can empirical treatment be given in suspected gonorrhoea?
ONLY if recent sexual contact with confirmed gonorrhoeal infection
58
What would be seen on direct microscopy in gonorrhoea?
Neutrophils and gram neg diplococci
59
What other investigations can confirm gonorrhoea infection?
NAAT / culture and sensitivities
60
How should gonorrhoea be managed?
AFTER confirmation by NAAT/ MCandS/ direct microscopy (any will do)
Ceftriaxone 1g IM (NEW for 2019)
Then:
Screening for other STIs, abstain for 1 week, contact tracing - cure rate = 95% with treatment
61
Recall some of the complications of gonorrhoea
PID, or a version of PID with liver-abdo wall adhesions called Fitz-Hugh-Curtis syndrome
Disseminated disease in 1%
62
What is the causative organism in syhillis?
Treponema pallidum (gram neg spirochete)
63
What are the symptoms of primary syphillis?
Painless chancre and local lymphadenopathy
64
How long does primary syphillis last?
3-4 weeks
65
What are the symptoms of secondary syphillis?
ONLY 25% GET SYMPTOMS
| Rough papulonodular rash, "snail track oral ulcer", condylomata lata (really gross)
66
How long does secondary syphillis last, and after how long will it resolve?
It appears 4-10 weeks after the chancre, and resolves in 2 - 12 weeks before the infection becomes latent
67
How is latent syphilis categorised?
Early and late - which guides management
| Early = exposure/ symtoms <2 years after infection, late = >2 years
68
How long does tertiary syphillis last?
1-20 years
69
What % of untreated syphillis progresses to tertiary?
30%
70
Recall the subtypes of tertiary syphillis
1. Gummatous: erosive skin and bone lesions
2. Cardiovascular: early diastolic decrescendo from aortic regurgitation
3. Neurosyphillis - might be meningovascular, general paresis or tabes dorsalis (lightening pains)
71
How can suspected syphillis be investigated for?
1. Microbiology = if chancre/ chondylomata are present, the most sensitive one is the 'dark ground' method, if not, PCR
2. Serology
- Routine screening in pregnant women to detect treponemal antibodies
- Can use a 'treponomal test' - eg. EIA, TPHA
72
Recall how syphillis is managed in adults
In primary/ secondary/ early latent:
Benzathine-Pen IM STAT OR doxycycline BD 14/7
If late latent/ non-neuro tertiary;
Benzathine-Pen IM OW 3/52, or doxycycline BD 28/7
If neurosyphillis, penicillin IV, 4-hourly, 14/7 or doxycycline BD 28/7
Prednisolone
73
What is the Jarish-Herxheimer reaction?
Release of proinflammatory cytokines in response to dying organisms
Signs and symptoms = 24 hours of febrile myalgia
May follow syphillis treatment
74
How does congenital syphillis appear?
Rash on soles of feet and hands +/- bone lesions
75
What is the cause of PID?
Ascending infection from the genital tract
76
What is the most common organism implicated in PID?
Chlamydia trachomatis
77
What are the symptoms of PID?
Often asymptomatic - but causes infertility and chronic pelvic pain
Acutely: BL lower abdo pain, PV discharge, fever, irregular PCB, dyspareunia
78
How should PID be investigated for?
Must start Abx before swabs
- Triple swabs
- Speculum (to look for signs of inflammation + discharge)
- Bimanual (cervical excitation, adnexal masses (eg tuboovarian abscess)
- If febrile do blood cultures
79
How should PID be managed?
First assess patient for admission - admit if pyrexial or septic
Otherwise
- Outpatient Abx, all 3 of ceftriaxone, doxycycline + metronidazole
- If inpatient, do IV cefoxitin + doxycycline
Remove any IUD, + other obvious stuff like STI screen, contact
80
What is the mechanism by which PID can cause ectopic pregnancy?
Paralysed cilia in fallopian tubes
81
What is Bartholin's cyst?
A cyst/ abscess of bartholin's gland (greater vestibular gland)
Likely to have overlying streptococcal/ GBS infection
= blockage of a duct to a gland in vagina which has become infected
82
What is the difference between Bartholin's cyst and labial cysts?
Bartholin's cysts may extend into the vaginal canal, but labial cysts will remain in labia
83
Recall the appropriate investigations in suspected Bartholin's cyst
If person is >40, consider a vulval biopsy
| If infected, MCandS from abscess - most are sterile but may help organism differentiation
84
How should Bartholin's cysts be managed?
Conservatively if draining and the patient is well
If not, Incision and drainage + 'word' catheter + flucloxacillin OD
If not - marsupialisation (forming an open pouch to stop the cyst from reforming)
85
What is CIN?
Premalignant atypia in squamous lining of cervix (FIGO stage 0)
86
What serotypes of HPV are usually implicated in cervical cancer?
HPV 16 and 18
87
What is the peak age range of onset of CIN?
25-29 y/o
88
What are the dysplastic epithelial changes that occur in CIN?
Increased nuclear to cytoplasmic ratio
| Abnormal nuclear shape: poikilocytosis
89
Recall the grading system for CIN
Grade 1 = mild dysplasia confined to lower 1/3 of epithelium
Grade 2 = Moderate dysplasia affecting 2/3 of epithelial thickness
Grade 3 = Severe dysplasia extending to the upper 1/3 of epithelium
90
What are the symptoms of CIN?
Same as cervical cancer symptoms: PV bleeding. IMB, PCB, PMB
91
If a smear test revealed CIN grade I, what should be done next?
An HPV test: If it's positive, do a colposcopy, if it's negative, do a routine recall
92
What does dyskaryosis mean?
Abnormal nucleus appearance
93
If a smear test revealed moderate to severe dyskaryosis (CIN grades II and III),
what should be done next?
Urgent colposcopy (within 2 weeks) followed by treatment if necessary
94
If a smear test revealed suspected invasive cancer, what should be done next?
Urgent colposcopy (<2 weeks)
95
How should CIN grade 1 be managed?
Smear in 12 months (conservative)
96
How can CIN be treated?
1st line: Large loop excision of the transformational zone (LLETZ - loop diathermy) - involves a wire loop with current running through that removes cells - however it is heavy on the side effects
Biggest risk = increases risk of miscarriage
2nd line - core biopsy - only performed if a large area needs to be removed, done under GA
Always do a follow-up test of cure 6 months later - smear and HPV test
97
What are the subtypes of cervical cancer and their relative prevalences?
Squamous (80%)
| Adenocarcinoma (20%)
98
What is the staging sysytem used in cervical cancer?
FIGO
99
Recall the signs and symptoms of cervical cancer
PV discharge
PCB, IMB, PMB
Dyspareunia (deep)
Symptoms of late metastasis (ie SOB, DIC) + FLAWS
100
To which lymph nodes does cervical cancer metastasise?
Iliac (NOT para-aortic)
101
Other than the screening pathway, how can cervical cancer be investigated?
MRI is better than CT-CAP (whereas CT-CAP is better for ovarian cancer)
Bloods to show anaemia, UandEs showing obstructive picture, LFTs may show metastasis, clotting and group and save
102
Recall all the stages of cervical cancer and their management!
Stage Ia1 (microinvasive) - mx = LLETZ/ cone biopsy
Stage Ia2 to IIa - mx =
- Fertility sparing: radical trachelectomy (removal of cervix) + BL pelvic node dissection
- If tumour is <4cm: radical hysterectomy + BL pelvic node dissection (Wertheim's)
- If tumour is >4cm: chemoradiation
Stage IIb to IVa (locally advanced disease) - mx = chemoradiation
103
What types of radiotherapy can be useful in cervical cancer?
1. External beam radiotherapy
| 2. Internal radiotherapy
104
What are the main complications of Wertheim's hysterectomy to be aware of?
Bladder dysfunction (common, may require self-catheterisation), sexual dysfunction (due to vaginal shortening), lymphoedema - manage with leg elevation, good skin care + massage
105
Recall some side effects of radiotherapy for gynaecological cancer
Fatigue, skin erythema, infertility, dysuria, urgency, dyspareunia (due to vaginal stenosis), diarrhoea, incontinence
106
What is DUB (dusfunctional uterine bleeding)?
Abnormal uterine bleeding in the absence of organic pathology
107
What are the subtypes of DUB?
Anovulatory (90%) and ovulatory (10%)
108
What is the broad pathophysiology in anovulatory vs ovulatory DUB
Anovulatory: failure of follicular development --> no increase in progesterone --> cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelium due to unopposed oestrogen stimulation --> heavy bleeds
Ovulatory: prolonged progesterone secretion --> irregular shedding
109
How is menorrhagia defined?
Whatever the woman defines as menorrhagia individually!
110
Recall some possible differentials that may cause DUB
Polyps, adenomyosis, leiomyoma, malignancy, iatrogenic, coagulopathy, endometriosis, PCOS, hypothyroid
111
What investigations should be done in DUB?
Speculum and bimanual first: bimanual will be bulky, may reveal fibroids
Next: bloods --> FBC (anaemia?), TFTs (hypothyroid?), clotting screen (VWD?)
2nd line (if cause not found): TVUSS (PCOS, fibroids, Ca?)
If still can't find diagnosis: OPD hysterectomy, laparoscopy +/- biopsy (endometriosis?)
112
In what cases is DUB treated as a symptom, rather than just treating the cause?
No identified pathology/ fibroids are present <3cm, or patholgy is adenomysosis
113
How should DUB be managed?
1st line, if contraception is required: LNG IUS
2nd line, if fertility is required - tranexamic acid to treat bleed, mefenamic acid for pain
2nd line, if contraception is required but LNG IUS didn't work: COCP/ cyclical oral progestogens
If it needs to be surgical: endometrial ablation/ hysterectomy
114
On what tissues is tamoxifen oestrogenic, and on which tissues is it anti-oestrogenic?
Oestrogenic on uterus and bone, anti-oestrogenic on breast
115
What are the risk factors for endometrial hyperplasia?
Oestrogen: so early menarche, late menopause, nulliparity, tamoxifen, HRT, COCP
PLUS
Increasing age, high insulin levels, obesity, smoking, FHx for ovarian Ca
116
What are the symptoms of endometrial hyperplasia?
PV bleeding, usually PMB
117
How should potential endometrial hyperplasia be investigated?
```
1st line = TVUSS - if more than 4mm, --> hysteroscopy + biopsy
2nd line (and gold standard) = hysteroscopy + pipelle biopsy
```
118
How does presence/ absence of atypia in endometrial hyperplasia guide management?
If there is no atypia, <5% will become malignant in 20 years so it's pretty chill, if there is atypia, that's more suboptimal
Without atypia: 1st line = progestogens (either LNG-IUS (mirena) or oral non-cyclical), 2nd line = possible hysterectomy - review in 3-6 months
If there is atypia: 1st line is a hysterectomy, but if fertility needs to be spared then use progestogens - endometrial surveillance with biopsy every 3 months
119
Which symptom signals endometrial cancer until proven otherwise?
PMB
120
What are the subtypes of endometrial cancer?
```
Type 1 (85%) - secretory, endometrioid, mucinous (SEM) carcinoma
Type 2 (15%) - uterine papillary Serous carcinoma, Clear cell carcinoma (SC)
```
121
What are the main differences between the different types of endometrial cancer?
Type 1 = younger patients, oestrogen-dependent, superficially invade, lower grade
Type 2 = older patients, less oestrogen-dependent, deeper invasion, higher grade
122
Describe the genetic components of each type of endometrial Ca
Type 1 - need to acquire >= 4 mutations, most importantly PTEN and PI3KCA
Type 2 - P53 is very associated with SCC, Her-2 amplification is associated with both
123
To which lymph nodes does endometrial cancer metastasise?
Para-aortic LNs
124
Recall the general FIGO staging of Endometrial Ca
I - limited to uterus
II - spread to cervix
III - spread to adjacent
IV - distant spread
125
Which investigations are appropriate in endometrial Ca?
Similar to EH
1st line = TVUSS - >4mm --> hysteroscopy + biopsy
2nd line - hysteroscopy
126
What is the most useful investigation for deciding FIGO stage of ovarian cancer?
CT CAP (better than MRI in this case)
127
Recall the management of endometrial Ca depending on stage
Stage 1 - total abdominal hysterectomy, BL salpingoophrectomy + peritoneal washings
Stage 2+ - radical hysterectomy + radiotherapy adjunct
128
What are the symptoms of endometriosis?
Cyclical/ chronic pelvic pain before/ during menstruation, dyspareunia, dyschezia, dysmenorrhoea
129
What is the simplest way to differentiate endometriosis and fibroids clinically?
There is no menorrhagia in endometriosis
130
Which investigations are appropriate in suspected endometriosis?
```
Bimanual and speculum
TVUSS
HSG (hysterosalpingography)
HyCoSy (Hysterosalpingo Contrast Sonography)
DIAGNOSTIC LAPAROSCOPY = GOLD STANDARD
```
131
What are the typical bimanual and speculum findings in endometriosis?
Reduced motility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions, fixed retroverted uterus
132
What would a diagnostic laparoscopy show in endometriosis?
Red vesicles or punctate marks on peritoneum
133
Recall the management protocol for endometriosis
1st line is a 3m trial of paracetamol + NSAIDs - avoid opiates to prevent constipation
OR 3m trial of COCP or progesterone (which induces amenorrhoea)
2nd line = surgical - laparoscopic ablation/ hysterectomy with BSO
134
What are the 4 main types of FGM?
Type 1: clitoridectomy
Type 2: Excision = removal of clitoris + labia minora +/- labia majora
Type 3: Infibulation - narrowing vaginal opening by creating a seal by cutting and repositioning the labia
Type 4: Any other mutilation
135
Recall some symptoms caused by FGM?
Constant pain, incontinence, dyspareunia, depression, bleeding, abscesses
136
Recall some options for management for FGM
Deinfibulation: offered to those unable to have sex/ pass urine
If <18, record in notes, report to police and social services
If >18, record in notes but no obligation to report - may offer deinfibulation
137
What are fibroids?
Benign tumours arising from the myometrium
138
What are the subtypes of fibroids?
Submucosal (within cavity), intramural, subserosal (can undergo secondary changes)
139
Recall the changes that fibroids go through
1. Hyaline degeneration
2. Calcification (post menopausal)
3. Red degeneration (coagulative necrosis in pregnancy)
140
What is the aetiology of fibroids?
They are hormone dependent - they enlarge in pregnancy (due to oestrogen) but shrink in menopause
141
What are the signs and symptoms of fibroids?
May be asymptomatic and found OE (uterine enlargement, palpable pelvic masses)
Symptoms of DUB, miscarriage, sub-fertility
Signs --> abdominal swelling, pressure symptoms on bowel or bladder
142
Which investigations are appropriate in fibroids?
1st line is TVUSS
| Otherwise, DUB investigations
143
What are some recognised risk and protective factors for fibroids?
```
RISK = BONE:
B - black women
O - obesity
N - nulliparity
E - expecting (pregnancy)
```
```
Protecting = SMC:
S = smoking
M = multiparity
C = COCP
```
144
How should fibroids >3cm be managed?
1st line: (non-contraceptive)
- Tranexamic acid
- Mefenamic acid/ NSAIDs
1st line (contraceptive)
- Mirena (NICE/PassMed)
- COCP (WestMid tuition/Ludley's notes)
- Cyclical oral progestogens
Surgical/ radiological:
- Prior to surgery: injectable GnRH agonist - induced menopausal state
- Another short-term option = ulipristal acetate - as effective as GnRH agonists but does not induce a menopausal state
Surgical: hysteroscopic (if small submucosal or polypoid fibroid), myomectomy (best for improving fertility) or hysterectomy
Radiological: Uterine artery embolisation - it infarcts the fibroids, and may preserve fertility (but may also cause ovarian failure)
145
What are the symptoms of red degeneration of fibroids?
Low fever, pain and vomiting
146
What syndrome is associated with leiomyosarcoma?
Gardner's syndrome (subtype of FAP with exta-colonic polyps)
147
What are the types of gynaecological polyp?
Cervical, endometrial, ectropion
148
What is the appearance of normal cervical epithelium?
Endocervix is columnar, ectocervix is squamous
149
How should gynaecological polyps be investigated?
Speculum for cervical polyps, TVUSS/ outpatient hysteroscopy for endometrial polyps
150
What is cervical ectropion?
Ectocervical migration of columnar epithelium (so columnar epithelium on the side of the cervix seen with the speculum)
151
What are the signs and symptoms of cervical ectropion?
IMB, PCB, increased discharge
152
What is the main risk factor associated with cervical ectropion?
Oestrogen - so pregnancy and COCP
153
How should cervical ectropion be managed?
Reassurance, cryotherapy + move from oestrogen-based contraceptives
154
What is a cervical polyp?
Overgrowth of endocervical columnar epithelium - benign and solitary
155
What are the signs and symptoms of cervical polyps?
Asymptomatic or small bleeding and discharge
156
How should cervical polyps be managed?
Reassurance, generally advised to be removed (if small can just be twisted off!)
157
How should endometrial polyps be managed?
May resolve spontaneously if small
| If AUB symptoms, can have polypectomy
158
What are the subtypes of HPV, and which are high and low risk?
Low risk = 6 and 11 (benign genital warts)
| High risk = 16 and 18 (CIN, VIN, VAIN)
159
What is the prevalence of HPV?
50% of sexually active adults
160
What are the signs and symptoms of HPV?
May be asymptomatic
| May present with genital warts
161
What are the types of genital wart?
Small popular, cauliflower, keratotic, flat papules/ plaques
162
How is HPV diagnosed?
Clinical diagnosis using dermatoscope
Histology = biopsy
Cytology = smear
163
How should HPV warts be managed?
Medical mx = imiquimod cream or trichloroacetic acid
Surgical - cryotherapy/ laser
Prevention via vaccine
164
What is lichen sclerosus?
Chronic inflammation of skin: usually genital skin and/or perineum
165
Which age group is most likely to be affected by lichen sclerosus?
The very young and the elderly (0.1% of children, 3% of women >80)
166
What are the signs and symptoms of lichen sclerosus?
Hypopigmentation
Pruritis
White/ shiny vulva ('figure of 8')
Dyspareunia
167
How should lichen sclerosus be treated?
```
1st line (3 months) = clobetasol propionate (strong steroid ointment)
2nd line = tacrolimus (topical calcineurin inhibitor) + biopsy (if steroid-resistant)
```
168
What is the most commonly-implicated pathogen in breast abscess?
S. aureus
169
Who is mastitis most likely to affect?
Breastfeeding women due to backup of milk ducts
170
Recall 2 RFs for mastitis?
Nipple injury
| Smoking
171
How should mastitis be investigated?
It's a clinical diagnosis
172
How should mastitis/ breast abscess be managed?
If non-severe/ lactational: simple analgesia and supportive care (warm compresses) - continue breastfeeding
If non-lactational/ severe = infected nipple fissure
1st line = flucloxacillin
2nd line = co-amox (if failed to settle 48 hours later)
173
How is menopause defined?
Absence of menses for >12 months (retrospective diagnosis)
174
Recall the signs and symptoms of menopause
Amenorrhoea
Vasomotor (hot flushes, night sweats, palpitations)
Urogenital (vaginal dryness, dyspareunia, recurrent UTI)
Psychological (poor concentration, lethargy, mood diturbance)
175
What should the FSH/LH/ serum oestradiol be in menopause?
FSH/LH = high (as unopposed), oestradiol LOW
176
How should menopause be managed?
If they have a uterus - systemic oestrogen combined with progesterone to protect against endometrial carcinoma
If they don't have a uterus --> systemic oestrogen (note contraindications eg DVT)
177
How can HRT be given if there is a history of DVT/ stroke?
Topically/ transdermally
178
When should HRT be offered in menopause?
When lifestyle adaptations (eg exercise and alcohol reduction) have been insufficient
179
When is cyclical/ sequential HRT indicated?
In perimenopausal women
180
How should cyclical/ sequential HRT be administered?
If they are having regular periods: monthly - oesterogen every day + progesterone for last 14 days
If they are having irregular periods: oestrogen every day for 3 months + progesterone for last 14 days
181
When should continuous HRT be used?
If post menopausal
182
How should continuous HRT be administered?
Oestrogen and progesterone every day
183
What are some absolute contraindications for HRT?
```
Undiagnosed vaginal bleeding
Breast cancer
History of VTE
Pregnancy
Severe liver disease
Current thrombophilia (eg FV Leiden)
```
184
What are some non-hormonal alternatives to HRT?
For vasomotor symptoms:
1st line = SSRIs (eg fluoxetine), 2nd line = citalopram/ venlaxafine
For vaginal dryness: lubricants
Osteoporosis treatments eg bisphosphonates
185
Recall the subtypes of ovarian cyst
Follicular/ corpus luteal (physiological/functional)
Dermoid cyst/ mature cystic teratoma (benign germ cell)
Serous cystadenoma/ mucinous cystadenoma (benign epithelial)
186
What is follicular cyst?
Failed rupture of dominant Graafian follicle, lined by granulosa cells
187
Describe the composition/ appearance of dermoid cells
Lined by epithelial cells
| May have Rokitansky protuberances = white shiny mass protruding out
188
What is the consequence of rupture of a mucinous cystadenoma?
Pseudomyxoma peritonei (mucin in abdomen)
189
What are the signs and symptoms of ovarian cysts?
Lower abdo pain
Swelling with pressure symptoms
Deep dyspareunia
Acute abdomen
190
Which investigations are appropriate for suspected ovarian cyst?
Pregnancy test
| TVUSS (outcome is dependent on menopausal status)
191
How should ovarian cysts be managed premenopausally?
It's based on size:
If <5cm: no follow-up
If 5-7cm: repeat USS yearly
If >7cm: MRI +/- surgery
If recurrent/ unresolved: COCP
Surgery (lararoscopic cystectomy) usually curative is suspicious/ multiloculated/ recurrent)
192
What are the indications for watchful waiting in ovarian cysts?
Unilateral
Pre-MP
Normal Ca-125
No free fluid
193
How should ovarian cysts be managed postmenopausally?
Managed always based on calculated RMI
RMI < 200: either repeat USS and Ca125 in 4-6 months - in which case it will either have resolved/ been unchanged (in which case repeat) or changed (in which case do a lap cystectomy)
If symptomatic/ complex/ >5cm --> BSO (BL salpingo-oophrectomy)
RMI >200: CT-AP + MDT management
194
Which type of ovarian cyst is most likely to rupture?
Functional ones
195
How shold ruptured ovarian cyst be managed?
Pain relief + watchful waiting - if evidence of actve bleeding --> laparoscopy + cautery
196
Which type of ovarian cyst is most likely to cause a torsion?
Dermoid
197
What are some protective factors against ovarian tumours?
Pregnancy, COCP
198
What are some risk factors for ovarian tumour?
More ovulations eg nulliparity, early menarche, late menoapuse
Increasing age (obviously)
Endometriosis
Talcum powder?!
199
Recall some genetic associations of ovarian Ca
```
Lynch syndrome (Autosomal dominant HNPCC), BRCA1/2
Type 1 epithelial ovarian tumours: PTEN/P13KCA
Type 2 epithelial tumours: p53 mutation present in 95%
```
200
What is the most common type of ovarian cancer?
Tumour of epithelial origin - most of which are benign
201
Recall the type 1 ovarian epithelial tumour types
```
These are low-grade
Mnemonic = Less Exciting, More Cancers
L: low-grade serous
E: endometrioid
M: mucinous
C: clear cell tumour (only one that's not solid or cystic)
```
202
Recall the subtypes of type 2 ovarian epithelial tumours
High grade serous (solid or cystic)
203
If an ovarian tumour is malignant, what type is it most likely to be?
Epithelial
204
Which type of germ cell ovarian tumour is most likely to be benign?
Teratoma
205
Which types of germ cell ovarian tumour are most likely to be malignant?
Dysgerminoma
Endodermal sinus tumour
Choriocarcinoma
206
What are the different types of sex-cord stromal tumour, and which of these are most likely to be benign?
Fibroma and thecoma (likely to be benign)
| Granulosa cell/ sertoli-Leydig cell tumour
207
Which type of ovarian tumour is associated with endometriosis?
Clear cell
208
How does the maturity of teratoma affect prognosis?
```
Mature = benign
Immature = malignant
```
209
What is Meig's syndrome?
Triad of benign ovarian fibroma, ascites and right-sided pleural effusion
210
What is the krukenberg tumour?
BL metastasis from breast/ gastric cancer - mucin producing signet ring cell
211
How are the symptoms and signs of ovarian and endometrial cancer different?
Ovarian: adnexal mass and no PV bleeding
Endometrial: uterine mass and PMB
212
Recall the FIGO staging for ovarian tumours
Stage 1 = confined to ovary
Stage 2 = tumour within pelvis but outside ovary
Stage 3 = Outside pelvis but within abdomen
Stage 4 = distant metastasis
213
Describe the appropriate investigations for Ovarian tumour
1st line = Ca125 tumour marker: >35IU/mL --> 2ww referral to O and G and TVUSS
TVUSS --> size, consistency, solid elements? UL/BL? Ascites?
Risk of malignant index (RMI) calculated from menopausal status, USS features and Ca125
Score >250 is considered hig
Do not biopsy - this can cause dissemination of maligant tissue
214
With what scan is ovarian Ca staged?
CT CAP
215
How should Ovarian Ca be managed?
1st line is surgery and chemo, 2nd line is just chemo
Chemo = platinum compound (usually carboplatin) with paclitaxel
Follow up with CT scan and Ca125 to assess response to treatment
216
How does platinum treat ca?
Cross linkage of DNA --> cell cycle arrest
217
What is the MOA of Paclitaxel?
Causes microtubular damage --> prevention of cell division
218
What should be given alongside paclitaxel and why?
Pre-emptive steroids given - this reduces hypersensitivity reactions
219
Recall some side effects of paclitaxel
Total loss of body hair, peripheral neuropathy, neutropaenia and myalgia
220
Which drug is available for the treatment of recurrent Ovarian Ca and what is its MOA?
Bevacizumab
| Monoclonal Ab directed against VEGF to inhibit angiogenesis
221
Describe the surgical intervention in ovarian Ca
Laparotomy
Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO)
Plus omentectomy
Plus extra debulking
222
In what ovarian tumours is chemotherapy not useful?
Sex cord stromal tumours - so surgery is the mainstay
223
What is the 5 year survival rate for ovarian Ca?
46% (stage 1 = 90%, stage 3 = 30%)
224
What is the cause of ovarian torsion?
It's a complication of something big being in the ovary that makes it twist round eg ovarian cyst/ tumour
225
What type of cyst is most likely to undergo torsion?
Dermoid cysts
226
What are the symptoms of ovarian torsion?
Severe RIF/LIF pain and vomiting
227
What are some appropriate investigations in suspected ovarian torsion?
```
Pregnancy test
FBC
Speculum (to exclude PID)
Bimanual examination to look for an adnexal mass
Urinalysis to exclude ureteric colic
```
USS with dopplers (although this may give false neg) - shows whirlpool sign
228
How should ovarian torsion be managed?
1st line = laparoscopic detorsion +/- cystectomy
| 2nd line = salpingo-oophorectomy
229
Recall and describe the 5 types of incontinence
Stress - increaed pressure on bladder causes small losses
Urge - string urge and not qiuck enough to loo --> large losses
Mixed - often stress and urge together
Overflow - difficulty emptying --> filling --> incontinence
Functional - due to difficulties in mobility
230
Recall some appropriate investigations for incontinence
1st = speculum - exclude pelvic organ prolapse
- Ask pt to cough during exam (Valsalva) to check for fluid leakage
1st = urine dip (rule out DM or UTI)
1st - bladder diaries (3 days)
If inconclusive:
2nd - urodynamic testing - 3 pressures measured from inside rectum and uretha
Bladder pressure = detrusor + IAP
231
How can stress incontinence be managed?
Check need for referral - trigone tumour needs to be checked
1st line = lifestyle advice and WL and pelvic floor exercises: 8 contractions, TDS, 3 months
2nd line - surgical treatment or SNRI duloxetine (if no surgery wanted)
Surgery = 1. Burch colpo
232
How can urge incontinence be managed?
Check need for referral to specialist as trigone tumour needs to be checked
1st line is conservative: lifestyle advice and bladder training (6 weeks) and avoid fizzy drinks
2nd line = medical: antimuscarinic eg oxybutynin, tolterodine or AD
233
Recall an important side effect of oxybutynin
Increased risk of falls
234
How can overflow incontinence be managed?
Refer to a specialist urogynaecologist - 1st line treatment is timed voiding
235
What should be suspected if there is dribbling incontinence after having a child?
Vesicovaginal fistula: do urinary dye studies
236
Recall the name of the criteria used to diagnose PCOS, and the criteria themselves
Rotterdam criteria
Need >2 of the following:
1. oligo/anovulation
2. Clinical/ biochemical features of hyperandrogenism
3. Polycystic ovaries on USS (>12 measuring 2-9mm)
237
Recall some signs and symptoms of PCOS
Hirsuitism, amenorrhoea, sub-fertility, WG, acne and insulin resistance
238
What sign is seen on TVUSS In PCOS?
Pearl necklace sign
239
Recall some appropriate investigations in PCOS
1. TVUSS
2. LH:FSH index of >1:1
3. Testosterone/ SHBG/ prolactin
240
What should be monitored for in PCOS?
DM and CVD
241
Recall in detail the management of PCOS
To treat oligomenorrhoea/ amoenorrhoea: COCP/ cyclical progesterone/ LNG-IUS
To treat symptoms of hyperandrogenism: COCP or Co-cyprindiol (COCP with extra anti-androgenic effects)
To treat infertility:
1st line: WL
2nd line: (up to 6 months) clomiphene, then clomiphene and metformin
Clomiphene = SERM
3rd line = gonatrophins, IVF
242
What is the main risk of IVF in PCOS?
Ovarian Hyperstimulation Syndrome (OHSS)
| OHSS --> multiple luteinized cysts --> lots of oestrogen, progesterone, VEGF --> pain + bloating
243
Define Premature Ovarian Insufficiency
Secondary amenorrhoea before the age of 40
244
What are the causes of Premature Ovarian Insufficiency?
1. Iatrogenic (eg oophrectomy)
| 2. Unknown! But Addisson's produces steroid-cell antibodies which cross-react with granulosa cells and theca interna
245
What is required for a diagnosis of premature ovarian insufficiency?
2 x FSH results >30 (4-6 weeks apart) and menopause symptoms
246
How can premature ovairan insufficiency be managed?
Fertility management: Donor oocyte IVF/ surrogacy
| Manage menopause as you normally would
247
What is the main difference in how menopause and POI are diagnosed?
POI is diagnosed biochemically whereas menopause is a retrospective diagnosis
248
What are some risk factors for PMS?
Obesity, lack of exercise, dietary, smoking FHX
249
What is required for diagnosis of PMS?
Symptom diary over 2 cycles
250
What should be included in the management of all cases of PMS regardless of severity?
Conservative lifestyle measures, painkillers
251
How is moderate PMS defined and managed?
Definition: some impact on personal, social and professional life
Management: COCP + CBT
252
How is severe PMS defined and managed?
Definition: withdrawal from social and professional activities, preventing normal functioning
Management: SSRI + CBT
253
What is the most common cause of pruritis vulvae?
Vulvovaginitis (eg vulvovaginal candidiasis, atrophic vaginitis, vulvar vestibulitis and contact dermatitis)
254
Describe the appearance of discharge in vulvovaginal candidiasis
Thick white curd-like
255
Describe the signs of chronic vulvovaginal candidiasis
Grey-sheen of epithelium, severe pruritis, irritation and pain, lichenification of vulva
256
In which type of pruritic vaginitis might you see burning leucorrhoea?
Atrophic vaginitis
257
What are the symptoms of primary and secondary vulvar vestibulitis?
Primary: introital dyspareunia
Secondary: introital dyspareunia that develops after a period of comfortable sexual intercourse
Pain, soreness, burning, rawness
258
What are the appropriate investigations for vulvovaginal candidiasis?
Wet-mount test or KOH preparation
259
What are the appropriate investigations to do in a case of pruritis vulvae to rule out atrophic vaginitis?
Vaginal pH and wet-mount test
Wet mount test often shows white blood cells and paucity of lactobacillus - this is a NEGATIVE result, showing the cause may be atrophic vaginitis rather than TV/BV
260
Recall the management of vulvovaginal candidiasis
Ketoconazole (400mg/ day) or fluconazole (100mg/ week) for 6 weeks
Cotrimazole 500mg suppositories once per week
nb: In Ludley's notes this is different to thrush treatment
261
Recall the management of atrophic vaginitis
Topical vaginal oestrogen or HRT
262
Recall the management of vulvar vestibulitis
Pain management with sex therapy, behaviour modification, topical steroid, anaesthetic, petroleum jelly, anti-inflammatories
Surgical excision as last resort - success rate of 60-80%
263
Recall the management of contact dermatitis
Remove itching agent
If mild: 1% hydrocortisone cream
If moderate: Betamethosone
Wet compresses of aluminium acetate for severe lesions
264
Recall a possible complication of atrophic vaginitis
Superimposed infection due to raised vaginal pH
265
How is sub-fertility defined?
A woman of reproductive age who has not conceived after 1 year of regular, unprotected sexual intercourse
266
Recall the groups of ovulatory disorders that may contribute to sub-fertility
Group 1: hypothalamic-pituitary failure (low weight, Kallman's, Sheehan's)
Group 2: Hypothalamic-pituitary-ovarian dysfunction (PCOS)
Group 3: Ovarian failure (POI)
Group 4: Prolactinaemia, thyroid disease
(prolactinoma, primary hypothyroidism, CRF, drugs)
267
Other than ovulatory disorders, what can cause sub-fertility in the female?
Tubal disorders
Cervical/ uterine (eg fibroids)
Genetic/ developmental (Turner's/ CF)
Lifestyle/ functional (smoking, method of sex)
268
Recall 3 structural causes of infertility in men
Cryptochordism, CF, varicocele
269
What should be included in the history when investigating sub-fertility?
Duration and type of infertility, coital frequency, menstrual history, PCOS symptoms, contraceptive history, previous STI, PSHx, DHx, SHx (EtOH and smoking)
270
What are the first-line basic tests to do in men and women to investigate sub-fertility?
Men: semen analysis (2 tests, 3m apart) and chlamydia screen
Women: Day 21 progesterone (>30 indicated ovulation has occurred), chlamydia screen, prolactin, TFTs, progesterone, LH/FSH
271
What are the Ovarian Reserve Tests?
FSH at Day 3 (to find basal level)
Anti-Mullerian hormone (AMH)
Antral follicle count (using TVUSS)
272
How can a tubal assesment be performed?
```
If no other comorbidities: hysterosalpingography (HSG) to assess patency
If comorbidities (eg history of PID/ ectopics/ endometriosis) --> laparoscopy and dye
```
273
What is the 1st line management for sub-fertility?
Wait for regular intercourse to be established for at least 12 months (every 2-3 days)
Key information: aim for BMI between 20-25, sufficient folic acid, sex 3 times per week, reduce EtOH, stop smoking
Perform investigations after 12 months
274
What is the second-line management for sub-fertility?
If sub-fertility is unexplained, due to mild endometriosis or due to a 'male factor' --> try for another 12 months, after this you can consider IVF
275
How can anovulation be managed in PCOS?
Ovulation induction:
1st line: clompihene (blocks oestrogen receptor to increase LH/FSH release)
2nd line: FSH/LH injections
3rd line: Pulsatille GnRH or DA agonists
276
Which causes of sub-fertility can be managed surgically?
Operative laparoscopy for adhesions, cysts and endometriosis
Myomectomy for fibroids
Tubal surgery for blocked tubes that are amenable to repair
Laparoscopic ovarian drilling for PCOS
277
Recall the 5 options for assisted conception
1. Intrauterine insemination +/- LH/FSH
2. IVF
3. Intracytoplasmic sperm injection
4. Donor insemination +/- LH/FSH
5. Donor egg with IVF
278
How is IVF performed?
Leave the egg and sperm in a petri dish and they fertilise each other
279
What is the NICE guidance for availability of IVF?
Women <40 offered 3 cycles of IVF if
1. Subfertile for 2 years
2. Not pregnant after 12 cycles of artificial/ intrauterine insemination
Women 40-42 offered 1 cycle of IVF if:
1. subfertile for 2 years and/ or after 12 cycles of AI
2. never had IVF
3. No evidence of low ovarian reserve
4. Informed about additional implications of IVF at this age
280
What are the indications for intracytoplasmic sperm injection?
Oligospermia, poor fertilisation (DM, erectile dysfunction)
281
How is ICSI carried out?
Sperm directly injected into the egg
282
What are some indications for donor egg with IVF treatment?
POI, BL oophrectomy, gonadal dysgenesis, high-risk genetic disorder
283
What is TSS?
Septicaemia from toxin (TSST1) produced by staphylococcus and streptococcus bacteria
Staphylococcus --> exotoxins (TSS toxin 1)
Streptococcis --> inflammatory cascade initiation
284
Recall some symptoms of TSS
Fever >39, DandV, desquamation of palms and soles, myalgia, sore throat, shock, diffuse red macular rash, headache
285
Recall the appropriate investigations in suspected TSS
Bloods: FBC (high WCC, low platelets), UandEs (impaired renal fx), LFTs, raised CK, raised CRP
Microbiology: HVS, blood culture, culture of tampon
286
How should TSS be managed?
ABCs and remove tampon
| Abx (broad spectrum, IV)
287
What is a uterine prolapse?
Prolapse of uterus into vagina
288
What is a cystocele?
Prolapse anterior vaginal wall involving the bladder
289
What is rectocele?
Prolapse of lower posterior vaginal wall involving the anterior wall of the rectum
290
What is enterocele?
Prolapse of the upper posterior vaginal wall containing loops of small bowel
291
What is a vault prolapse?
Prolapse of vaginal vault after hysterectomy
292
Recall some signs and symptoms of urogenital prolapse
Feelings of heaviness of descent PV
Back pain + dyspareunia
Recurrent UTI
Urinary symptoms is cystocele/ constipation or incontinence if rectocele
293
What is the NICE recommended grading system for urogenital prolapse? Describe it.
POP-Q
| Position given as a coordinate relative to the pelvic organs
294
What is the most frequently-used grading system for urogenital prolapse? Describe it.
Shaw's
1st degree: descent to the introitus
2nd degree: extends to the introitus but descent past the introitus on straining
3rd degree: prolapse descends through the introitus
295
Recall the step-wise managemet of urogenital prolapse
1st line is conservative: WL, minimise weightlifting, stop smoking
2nd line:
- Pelvic floor exercies
- Topical oestrogen in older patients
- Pessary: Ring (doesn't prevent sex), shelf (common, hard, prevents sex), gellhorn (like shelf but soft, also prevents sex). If more severe - Gehrung or cube (which uses suction to keep things in place)
3rd line - surgical options:
Uterine prolapse: depends on whether there is desire to preserve uterus
To preserve uterus:
- Vaginal sacrospinous hysteropexy with sutures
- Manchester repair, unless the woman may wish to have children in the future
- Sacro-hysteropexy with mesh (abdominal or laparoscopic)
Doesn't preserve uterus:
- Vaginal hysterectomy, Manchester repair, VSH with sutures
Vault prolapse: Sacrolpopexy with mesh
Anterior/ posterior colporrhaphy without mesh for anterior/ posterior prolapses
296
What staging system is used for vulval Ca?
FIGO
297
What type of cancer is the majority of vulval cancers?
SSC (95%)
298
Recall some risk factors for usual and differentiated types of vulval Ca
Usual type (warty/ basaloid) - VIN (HPV 16), immunosuppression, smoking
Differentiated (keratinised SCC) - lichen sclerosus
299
What is the usual aetiology of vulval Ca?
Progression of certain vulval dermatoses or progresssion of VIN
300
How is VIN classified?
Low grade squamous, high-grade squamous and differentiated VIN
301
Recall some symptoms of vulval Ca
Vulvar swelling, pruritis, pain, bleeding, discharge
May be a nodule or ulcer visible on vulva (usually labia majora)
Inguinal lymphadenopathy
302
What is the management for vulval ca?
Vulvectomy and BL inguinal lymphadenectomy
For stage 1a: wide local excision (10mm clear margin)
For >1a: radical vulvectomy + BL inguinal lymphadenectomy
Sentinel node can be identified using dye and radioactive nucleotide
If unsuitable for surgery, ra
303
What are some general complications of all gynae procedures?
Infections, bleeding, failure, damage to local structures
304
What is a colposcopy?
A diagnostic procedure obtaining a magnified view of the cervix, the lower part of the uterus and the vagina in order to examine the transformation zone and detect malignant or premalignant changes
305
What is a cervical punch biopsy?
Small amount of tisue removed from the cervix
306
What are some indications for colposcopy and cervical punch biopsy?
Moderate/severe dyskaryosis or mild dyskaryosis with positive HPV test
3 x inadequate smears
Glandular neoplasia on smear
Suspicious looking cervix
307
Recall some possible complicatons of colposcopy
Few complications from colposcopy alone
| Excisional treatments may cause bleeding and infection, cervical incompetence in future pregnancies
308
What are the general indications for endometrial ablation?
Menorrhagia - removal of layers of endometrium make periods lighter
Post-menopausal bleeding of unknown origin
Bleeding with anovulation/ fibroids
309
Recall some possible complications of endometrial ablation
General: infection, bleeding, failure, damage to local structures (all guessable!)
Minor side effects: cramping, nausea, frequent urination, watery discharge mixed with blood
Rarely - pulmonary oedema due to fluid used to expand uterus being absorbed into bloodstream
310
What device is usually used for endometrial biopsy
Pipelle
311
Recall the indications for endometrial biopsy
Under 55 and unexplained bleeding 12+ months after LMP
Over 55 and:
- PMB
- Unexplained discharge that is either new, has thrombocytosis or haematuria
- Visible haematuria and low Hb, thrombocytosis and raised blood glucose
312
What is the main trouble with the pipelle?
Has a poor negative predictive value
313
How does epidural differ from a spinal?
Anaesthesia injected into epidural space
314
Recall some possible complications of epidural
Urinary retention, shivering, pruritis, headache (from anaesthesia going to head)
Hypotension, epidural haematoma, epidural meningitis, respiratory depression (!)
315
Recall 2 diagnostic indications for gynaecological laparoscopy
Pelvic pain, endometriosis diagnosis, infertility (dye test for tubal patency)
316
Recall 5 therapeutic uses of gynaecological laparoscopy
Sterilisation, endometrial ablation, salpingectomy, ovarian cystectomy, adhesiolysis
317
Recall 3 possible approaches for hysterectomy
Vaginal (removed through vagina)
Laparoscopic-assisted vaginal
Laparoscopic hysterectomy
318
What is removed in a total hysterecotomy?
Uterus and cervix
319
What is removed in a radical hysterectomy?
Removal of structures +/- BSO
| Eg. Wertheim's hysterectomy
320
What is removed in a sub-total hysterectomy?
Upper part of uterus but cervix not removed so smears are needed
321
In what situation would smears still be done in total/ radical hysterectomy (even though there's no cervix to smear!)?
If the hysterectomy was due to cancer or CIN - do smears at 6 and 18 months
322
Which type of hysterectomy has the quickest recovery?
Vaginal
323
Recall 3 indications and 2 contraindications for vaginal hysterectomy
Indications: Menstrual disorders with uterus <12w size, microinvasive cervical carcinoma, uterovaginal prolapse
Contraindications: malignancy, uterus 12w+ pregnancy
324
What is the name of the incision used in abdominal hysterectomy?
Pfannenstiel incision (although a midline incision is used if larger masses/ malignancy)
325
Recall some indications for abdominal hysterectomy
Uterine/ ovarian/ fallopian tube carcinoma
Pelvic pain from chronic endometriosis or chronic PID where pelvis is froxen, so vaginal is impossible
Symptomatic fibroid uterus 12w+ in size
326
What should always be given intra-operatively in a hysterectomy?
Augmentin (co-amoxiclav)
327
How does a flexible and rigid hysteroscopy differ?
Flexible: can be done in OP setting with CO2 as filling medium
Rigid: use circulating fluids to visualise uterine cavity even if the woman is bleeding
328
Recall 6 indications for hysteroscopy
PMB, PCB, IMB, menorrhagia and/or abnormal discharge, suspected uterine malformations or suspected Asherman's
329
What is a LLETZ?
Use of a small small wire diathermy to cut away affected cervical tissue and seal a wound
330
Recall 2 indications for LLETZ
1. High-grade squamous intraepithelial lesion of the cervix (CIN2/3)
2. Persistent low-grade squamous intraepithelial lesion of the cervix (CIN1)
331
What are the non-general complications of LLETZ?
Discharge for 3-4 weeks and bleeding
| Avoid tampons, sex and swimming until discharge has stopped to prevent infection
332
What is a myomectomy?
Surgical removal of fibroids from the uterus - prior to surgery GnRH analogues are used to shrink size to reduce bleeding
333
What are the 3 methods of myomectomy?
Hysteroscopic, laparoscopic and open
334
What are the indications for each of the different types of myomectomy?
Hysteroscopic: fibroids on inner wall
Laparoscopic: removing 1 or 2 fibroids of less than 2 inches that are growing outside the uterus
Open: large fibroids, many fibroids, fibroids that are deep into the uterine wall
335
Recall the minimum size/ age of a cyst for indication of removal
Size: 7.6cm
Age: 2-3 months unresolved
336
Other than larger/ older cysts, what else is an indication for cystectomy?
Diagnostic (to exclude ovarian Ca)
BL lesions
Symptomatic cysts
337
Whata are the 3 main types of emergency contraception and the time-frame in
which they need to be used? Which is most effective?
Levonogesterol (Levonelle) - 72 hours
Ulipristal (ellaOne) - 120 hours
Copper IUD - 120 hours (works immediately) - most effective
338
What is the MOA of levonorgesterol as an emergency contraception?
Stops ovulation and inhibits implantation
339
What is the stat dose of levonorgesterol?
1.5mg (double dose if >70kg or BMI >26 BMI)
340
When should the dose of levongorgesterol be repeated?
If vomiting within 2 hours of dose
341
What is the MOA of ullipristal acetate?
elective progesterone receptor inhibitor
342
What is the stat dose of ellaOne?
30mg
343
Recall an important contraindication of ellaOne
Severe asthma
344
What advice about hormonal contraception would you give to someone taking ellaOne?
If already on pill, restart 5 days after the morning-after pill (use barrier for 5 days)
345
When should the dose of ullipristal acetate be repeated?
If vomiting within 3 hours
346
What are the indications for the copper coil?
<5 days of last UPSI, or up to 5 days after the likely ovulation date
347
What is the pearl index?
Describes the chance of becoming pregnant on contraception - number of pregnancies occuring per 100 woman-years
ie. Pearl of 2 = 2 pregnancies per year in 100 women
348
How often does a transdermal patch need to be used to make it effective contraception?
Every week
349
How often does a vaginal ring need to be used to make it effective as contraception?
3-weekly
350
What is the MOA of the COCP?
Prevention of ovulation
351
How quickly does the COCP connvey contraceptive protection?
If started on first 5 days of the cycle = immediate
| If started at any other time, us additional measures for first 7 days
352
What precaution should be taken if on the COCP and undergoing surgery?
Stop taking 4w before, restart 2w after
353
Recall some absolute contraindications to any long term contraception that contains oestrogen
```
CV: Ischaemic/ valvular HD, VTE history, HTN severe, TIA/ stroke history
Diabetes with complications
Migraine with aura
Liver tumour/ severe cirrhois
Current brease Ca
```
354
Recall the missed dose procedure for the COCP
1 pill missed: take last pill and current pill (even if 2 in one day)
2 pills missed: same as above, PLUS:
If in week one: consider emergency contraception
If in week two: no need for emergency contraception
If in week 3: finish current pack, start new pack without pill free break
355
Recall the MOA of the POP
Thickens cervical mucus and primarily stops ovulation
356
How should the POP be taken?
OD at the same time every day - no pill-free break
357
What is the most common complaint with the POP?
Initial irregular bleeding
358
What disorders does the POP increase the risk of?
Osteoporosis/ ovarian cyst
359
Recall the missed dose protocol for the POP
```
If <3 hours late, continue as normal
If 3+ hours late, take missed pill asap and take extra precautions until the pill has been re-established for 48 hours
With Cerazette (desogesterel) - can continue as normal if <12 hours late
```
360
What is the MOA of the transdermal patch?
Thickens cervical mucus and prevents ovulation
361
What is contained within Mirena?
Progesterone (levonorgesterol)
362
For how long can mirena be left in?
3-5 years
363
For how long after insertion is extra contraception needed for mirena?
7 days
364
What are some risks of mirena?
Expulsion, infection, perforation
365
How long does the copper coil last?
5-10 years
366
Recall one important contraindication of the copper coil
Menorrhagia
367
What is contained within the implant?
Progesterone (etonogestrel)
368
How long does the implant last?
3 years
369
Recall a contraindication of the implant
IHD
370
What is in the contraceptive injection?
Progesterone
371
How long does the contraceptive injection work for?
12-14 weeks
372
How long does it take for fertility to return after last contraceptive injection?
6-12 months
373
Recall two significant risk associations with the contraceptive injection
Weight gain and ectopic pregnancy
374
What are some important elements of the history to ascertain when counselling
about contraception?
Previous FHx of VTE, migraine, Ca, stroke and HTN
375
When around childbirth is the COCP contraindicated?
<6 weeks post-partum + breastfeeding
376
When around childbirth is the POP contraindicated?
You can start any time, but if >21 days post-partum, use barrier for 2 days
377
Which forms of contraception can be continued past 50 years old?
Implant, POP, IUS
378
What are the Fraser guidelines?
Guidelines under which an under-age person is given contraception
379
What is adenomyosis?
Similar to endometriosis - but endometriosis is endometrial cells existing outside the uterus whereas adenoyosis is endometrial cells existing inside the uterine muscular wall
380
What are the signs/ symptoms of adenomyosis?
Menorrhagia/ dysmenorrhoea
| Chonic pelvic pain
381
What would be seen on USS in adenomyosis?
Haemorrhage-filled, distended endometrial glands
382
What is the gold-standard investigation for adenomyosis?
MRI pelvis
383
What is the only definitive treatment for adenomysosis?
Hysterectomy
384
Recall the FIGO stages for endometrial cancer
Stage I: uterus
Stage II: uterus + cervix
Stage III: adnexa
Stage IV: distant metastasis
385
Recall the FIGO stages for ovarian cancer
Stage I: limited to ovaries
Stage II: Pelvic extension (ie uterus)
Stage III: abdo extension (extra-pelvic)
Stage IV: distant metastasis
386
Recall the FIGO stages of cervical cancer
Stage I: cervix
Stage II: beyond cervix, not into pelvic wall or lower 1/3 of vagina
Stage III: extends into pelvic wall or lower 1/3 of vagina +/- hydronephrosis
Stage IV: extend beyond pelvis + involves musosa of bladder/ rectum
387
What are the 3 types of functional ovarian cyst - and which is most common?
Follicular (most common), corpus luteal and theca lutein
388
How do follicular cysts appear on USS?
Thin walled, unilocular, anechoic
389
What is the main risk with corpus luteal cysts?
Rupture at end of menstrual cycle
390
How do corpus luteal cysts appear on USS?
Diffusely thick wall, <3cm, lacey pattern
391
What are theca lutein cysts associated with?
Pregnancy
392
How do theca lutein cysts appear on USS?
BL enlargement, multicystic ovaries, thin-walled and anechoic
393
What are the types of inflammatory ovarian cyst?
Tubo-ovarian abscess, endometrioma
394
Describe the USS appearance of the different types of inflammatory ovarian cyst
Tubo-ovarian abscess: ovary and tube cannot be distinguished from mass
Endometrioma: unilocular with ground-glass echoes
395
What are germ cell ovarian cysts, and what are the subtypes?
Dermoid cysts
| May be immature (embryonic elements may be seen) or mature (may contain teeth)
396
What are the types of epithelial ovarian cysts, and which is most common?
Serous cystadenoma (most common), mucinous cystadenoma, Brenner's tumour
397
Which type of epithlial ovarian cyst is likely to be large?
Mucinous cystadenoma
398
What is a Brenner's tumour?
Type of epithelial ovarian tumour which contains uroepithlial-ike epithelium
399
What are the subtypes of sex cord stromal ovarian tumour?
Fibroma, thecoma and granulosa cell
400
Recall the elements of a vaginal examination
Outer vulval examination
Part labia and insert 2 fingers into the vagina to under the cervix
Left hand on top if tummy - all fingers pointing in same direction
Ballot uterus
Examine adnexa - stroke on each side of the cervix
