Joe Vincent Passmedicine Gynae

Question 1

A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
Shoulder tip pain and cervical excitation may be seen

Answer 1

Ectopic

Question 2

Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination

Answer 2

PID

Question 3

Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination

Answer 3

Ovarian torsion

Question 4

Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit
Features such as lethargy, nausea, backache and bladder symptoms may also be present

Answer 4

IBS

Question 5

Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder

Answer 5

Ovarian cyst

Question 6

When do women get cyclical combined HRT? Continuous?

Answer 6

Women should be prescribed cyclical combined HRT if their LMP was less than 1 year ago

continuous combined HRT if they have:
taken cyclical combined for at least 1 year or
it has been at least 1 year since their LMP or
it has been at least 2 years since their LMP, if they had premature menopause (menopause below the age of 40)

Question 7

Who gets oestrogen only HRT?

Answer 7

Women who have had a hysterectomy

Question 8

What can be offered to women who do not want HRT ? What is not useful for treating hot flushes?

Answer 8

elective serotonin and noradrenaline reuptake inhibitors, clonidine and gabapentin.
Sertraline is not helpful in treating hot flushes.

Question 9

Lichen sclerosis associations? Ix? Mx? Risk?

Answer 9

Autoimmune Eg type 1 diabetes
Clinical diagnosis but a biopsy can be performed if atypical features

Mx
Topical steroids and emollients

Risk of vulval cancer - follow up

Question 10

What do low levels of gonadotrophins in amenorrhea indicate?

Answer 10

Hypothalamic cause

Question 11

Initial management of urge incontinence ?

Options further down line?

Answer 11

Bladder retraining

Oxybutynin OR botulin injections

Question 12

Initial investigations in incontinence?

Answer 12

bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture

Question 13

Mx of urge incontinence? Stress?

Answer 13

urge incontinence is predominant:
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinic is first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women'

If stress incontinence is predominant:
pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures