Joe Vincent Passmedicine O&G Flashcards
You review a 34-year-old woman who is 13 weeks pregnant. During her previous pregnancy she developed pre-eclampsia and had to have a caesarean section at 36 weeks gestation. Her blood pressure both following the last pregnancy and today is normal. Which one of the following interventions should be offered to reduce the risk of developing pre-eclampsia again?
A. Prophylactic nifedipine therapy B. Prophylactic labatelol therapy C. Vitamin B6 supplementation D. Extended folic acid supplementation E. Low-dose aspirin
E. Low-dose aspirin
Hypertension in pregnancy
NICE published guidance in 2010 on the management of hypertension in pregnancy. They also made recommendations on reducing the risk of hypertensive disorders developing in the first place. Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
The classification of hypertension in pregnancy is complicated and varies. Remember, in normal pregnancy:
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks. After this time the blood pressure usually increases to pre-pregnancy levels by term
Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
After establishing that the patient is hypertensive they should be categorised into one of the following groups:
Pre-existing hypertension
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
Occurs in 3-5% of pregnancies and is more common in older women
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
Occurs in around 5-7% of pregnancies
Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
Pre-eclampsia
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
Oedema may occur but is now less commonly used as a criteria
Occurs in around 5% of pregnancies
A 62-year-old female presents as she feels she is becoming incontinent. She describes no dysuria or frequency, but commonly leaks urine when she coughs or laughs. What is the most appropriate initial management?
A. Bladder retraining B. Topical oestrogen cream C. Regular toileting D. Trial of oxybutynin E. Pelvic floor muscle training
E. Pelvic floor muscle training
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Causes
overactive bladder (OAB)/urge incontinence: due to detrusor over activity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigation
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude cystocele
urine dipstick and culture
Management depends on whether urge or stress UI is the predominant picture. If 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
surgical management: e.g. sacral nerve stimulation
If stress incontinence is predominant:
pelvic floor muscle training (for a minimum of 3 months)
surgical procedures: e.g. retropubic mid-urethral tape procedures
A 31-year-old woman presents as she has noted an offensive, fishy vaginal discharge. She describes a grey, watery discharge. What is the most likely diagnosis?
A. Trichomonas vaginalis B. Candida C. Chlamydia D. Bacterial vaginosis E. Physiological discharge
D. Bacterial Vaginosis
Vaginal discharge
Vaginal discharge is a common presenting symptom and is not always pathological
Common causes: physiological Candida Trichomonas vaginalis bacterial vaginosis
Less common causes: whilst cervical infections such as Chlamydia and Gonorrhoea can cause a vaginal discharge this is rarely the presenting symptoms ectropion foreign body cervical cancer
Key features of the common causes are listed below
Candida = ‘Cottage cheese’ discharge, Vulvitis, Itch
Trichomonas vaginalis = Offensive, yellow/green, frothy discharge, Vulvovaginitis, Strawberry cervix
Bacterial vaginosis = Offensive, thin, white/grey, ‘fishy’ discharge
Which one of the following is less common in women who take the combined oral contraceptive pill?
A. Stroke B. Endometrial cancer C. Pulmonary embolism D. Cervical cancer E. Ischaemic heart disease
B. Endometrial cancer
Combined oral contraceptive pill
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
Combined oral contraceptive pill: advantages/disadvantages
Advantages of combined oral contraceptive pill highly effective (failure rate
Theme: Pelvic pain
A. Appendicitis B. Ovarian torsion C. Urogenital prolapse D. Endometriosis E. Urinary tract infection F. Ovarian cyst G. Threatened miscarriage H. Irritable bowel syndrome I. Pelvic inflammatory disease J. Ectopic pregnancy
For each one of the following scenarios please select the most likely diagnosis:
A 24-year-old woman presents with mild, crampy suprapubic pain and light vaginal bleeding. Her last period was 10 weeks ago. Vaginal examination shows a small amount of blood around the cervix but is otherwise unremarkable.
G. Threatened miscarriage - The question asks what is the most likely diagnosis. The mild suprapubic pain at 10 weeks gestation is more characteristic of a miscarriage than an ectopic pregnancy. In clinical practice this patient would be referred the same day for an ultrasound scan.
Pelvic pain
In women the most common cause of pelvic pain is primary dysmenorrhoea. Some women also experience transient pain in the middle of their cycle secondary to ovulation (mittelschmerz). The table below gives characteristic features for other conditions causing pelvic pain:
Usually acute
Ectopic pregnancy - 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
Urinary tract infection - Dysuria and frequency are common but women may experience suprapubic burning secondary to cystitis
Appendicitis - Pain initially in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF
Pelvic inflammatory disease - Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
Ovarian torsion - Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Miscarriage - Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
Usually chronic
Endometriosis - Chronic pelvic pain
Dysmenorrhoea, pain often starts days before bleeding
Deep dyspareunia
Subfertility
Irritable bowel syndrome - 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
Ovarian cyst -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
Urogenital prolapse - Seen in older women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency
Theme: Pelvic pain
A. Appendicitis B. Ovarian torsion C. Urogenital prolapse D. Endometriosis E. Urinary tract infection F. Ovarian cyst G. Threatened miscarriage H. Irritable bowel syndrome I. Pelvic inflammatory disease J. Ectopic pregnancy
For each one of the following scenarios please select the most likely diagnosis:
A 67-year-old woman presents with a heavy, dragging sensation in the suprapubic region. She also has frequency and urgency.
C. Urogenital prolapse
Women who have a urogenital prolapse typically describe a ‘bearing down’, ‘heaviness’ or ‘dragging’ sensation.Women who have a urogenital prolapse typically describe a ‘bearing down’, ‘heaviness’ or ‘dragging’ sensation.
Pelvic pain
In women the most common cause of pelvic pain is primary dysmenorrhoea. Some women also experience transient pain in the middle of their cycle secondary to ovulation (mittelschmerz). The table below gives characteristic features for other conditions causing pelvic pain:
Usually acute
Ectopic pregnancy - 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
Urinary tract infection - Dysuria and frequency are common but women may experience suprapubic burning secondary to cystitis
Appendicitis - Pain initially in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF
Pelvic inflammatory disease - Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
Ovarian torsion - Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Miscarriage - Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
Usually chronic
Endometriosis - Chronic pelvic pain
Dysmenorrhoea, pain often starts days before bleeding
Deep dyspareunia
Subfertility
Irritable bowel syndrome - 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
Ovarian cyst -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
Urogenital prolapse - Seen in older women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency
Theme: Pelvic pain
A. Appendicitis B. Ovarian torsion C. Urogenital prolapse D. Endometriosis E. Urinary tract infection F. Ovarian cyst G. Threatened miscarriage H. Irritable bowel syndrome I. Pelvic inflammatory disease J. Ectopic pregnancy
For each one of the following scenarios please select the most likely diagnosis:
A 29-year-old woman presents with suprapubic pain, irregular periods, dysuria and pain during intercourse. There is cervical excitation on examination.
I. Pelvic inflammatory disease
Cervical excitation is found in both pelvic inflammatory disease and ectopic pregnancy.
Pelvic pain
In women the most common cause of pelvic pain is primary dysmenorrhoea. Some women also experience transient pain in the middle of their cycle secondary to ovulation (mittelschmerz). The table below gives characteristic features for other conditions causing pelvic pain:
Usually acute
Ectopic pregnancy - 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
Urinary tract infection - Dysuria and frequency are common but women may experience suprapubic burning secondary to cystitis
Appendicitis - Pain initially in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF
Pelvic inflammatory disease - Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
Ovarian torsion - Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Miscarriage - Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea
Usually chronic
Endometriosis - Chronic pelvic pain
Dysmenorrhoea, pain often starts days before bleeding
Deep dyspareunia
Subfertility
Irritable bowel syndrome - 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
Ovarian cyst -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
Urogenital prolapse - Seen in older women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency
You review a 28-year-old woman who is 26 weeks pregnant. She has just had a routine glucose tolerance test as her BMI is 34 kg/m^2. The following results were obtained:
Time (hours) Blood glucose (mmol/l)
0 7.1
2 11.2
There have been no other antenatal problems and her anomaly scan was normal. What is the most appropriate action?
A. Start metformin + advice about diet / exercise
B. Start metformin + advice about diet / exercise + self-monitor glucose levels
C. Advice about diet / exercise + self-monitor glucose levels
D. Start insulin + advice about diet / exercise + self-monitor glucose levels
E. Advise weight loss + start metformin
C. Advice about diet/exercise + self-monitorins glcose levels
Most women with gestational diabetes can be managed with a combination of diet and self-monitoring.
Pregnancy: diabetes mellitus
Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. It complicates around 1 in 40 pregnancies
Risk factors for gestational diabetes
BMI of > 30 kg/m^2
previous macrosomic baby weighing 4.5 kg or above.
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening for gestational diabetes
if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
currently the same WHO diagnostic criteria are used as for non-pregnant patients. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes
NICE issued guidelines on the management of diabetes mellitus in pregnancy which were updated in 2008
Management of pre-existing diabetes:
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 18-20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Management of gestational diabetes
responds to changes in diet and exercise in around 80% of women
oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.g. macrosomia)
there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin
hypoglycaemic medication should be stopped following delivery
a fasting glucose should be checked at the 6 week postnatal check
A 22-year-old woman who is an immigrant from Malawi presents for review as she thinks she is pregnant. This is confirmed with a positive pregnancy test. She is known to be HIV positive. Which one of the following should NOT be part of the management plan to ensure an optimal outcome?
A. Oral zidovudine for the newborn until 6 weeks of age B. Maternal antiretroviral therapy C. Encourage breast feeding D. Intrapartum zidovudine infusion E. Elective caesarean section
C. Encourage breast feeding
The 2008 BHIVA guidelines suggest vaginal delivery may be an option for women on HAART who have an undetectable viral load but whether this will translate into clinical practice remains to be seen
HIV and pregnancy
With the increased incidence of HIV infection amongst the heterosexual population there are an increasing number of HIV positive women giving birth in the UK. In London the incidence may be as high as 0.4% of pregnant women. The aim of treating HIV positive women during pregnancy is to minimise harm to both the mother and fetus, and to reduce the chance of vertical transmission.
Guidelines regularly change on this subject and most recent guidelines can be found using the links provided.
Factors which reduce vertical transmission (from 25-30% to 2%) maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding)
Screening
NICE guidelines recommend offering HIV screening to all pregnant women
Antiretroviral therapy
all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
if women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situation
Mode of delivery
vaginal delivery is recommenced if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
Neonatal antiretroviral therapy
zidovudine is usually administered orally to the neonate if maternal viral load is
A 24-year-old woman who is 18 weeks pregnant presents for review Earlier on in the morning she came into contact with a child who has chickenpox. She is unsure if she had the condition herself as a child. What is the most appropriate action?
A. Advise her to present within 24 hours of the rash developing for consideration of IV aciclovir
B. Reassure her that there is no risk of fetal complications at this point in pregnancy
C. Give varicella immunoglobulin
D. Check varicella antibodies
E. Prescribe oral aciclovir
D. Check varicella antibodies - Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies
Chickenpox exposure in pregnancy
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
Fetal varicella syndrome (FVS)
risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Management of chickenpox exposure
if there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies
if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash
A 36-year-old woman presents for a routine antenatal review. She is now 15 weeks pregnant. Her blood pressure in clinic is 154/94 mmHg. This is confirmed with ambulatory blood pressure monitoring. On reviewing the notes it appears her blood pressure four weeks ago was 146/88 mmHg. A urine dipstick is normal. There is no significant past medical history of note. What is the most likely diagnosis?
A. Pre-eclampsia B. Pregnancy-induced hypertension C. White-coat hypertension D. Normal physiological change E. Pre-existing hypertension
E. Pre-existing hypertension
This lady has pre-existing hypertension. Pregnancy related blood pressure problems (such as pregnancy-induced hypertension or pre-eclampsia) do not occur before 20 weeks. The raised ambulatory blood pressure readings exclude a diagnosis of white-coat hypertension.
Note the use of the term ‘pre-existing hypertension’ rather than essential hypertension. Raised blood pressure in a 36-year-old female is not that common and raises the possibility of secondary hypertension.
Hypertension in pregnancy
NICE published guidance in 2010 on the management of hypertension in pregnancy. They also made recommendations on reducing the risk of hypertensive disorders developing in the first place. Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
The classification of hypertension in pregnancy is complicated and varies. Remember, in normal pregnancy:
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term
Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
After establishing that the patient is hypertensive they should be categorised into one of the following groups:
Pre-existing hypertension
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
Occurs in 3-5% of pregnancies and is more common in older women
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
Occurs in around 5-7% of pregnancies
Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
Pre-eclampsia
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
Oedema may occur but is now less commonly used as a criteria
Occurs in around 5% of pregnancies
Theme: Ovarian cysts
A. Dermoid cyst (teratoma) B. Endometriotic cyst C. Granulosa cell tumour D. Clear cell tumour E. Corpus luteum cyst F. Mucinous cystadenoma G. Follicular cyst H. Serous cystadenoma I. Dysgerminoma J. Fibroma
For each one of the following please select the answer from the list above:
Most common type of ovarian pathology associated with Meigs’ syndrome
J. Fibroma
Ovarian cysts: types
Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours
Physiological cysts (functional cysts)
Follicular cysts
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
Corpus luteum cyst
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
Benign germ cell tumours
Dermoid cyst
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
Benign epithelial tumours
Arise from the ovarian surface epithelium
Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
Theme: Ovarian cysts
A. Dermoid cyst (teratoma) B. Endometriotic cyst C. Granulosa cell tumour D. Clear cell tumour E. Corpus luteum cyst F. Mucinous cystadenoma G. Follicular cyst H. Serous cystadenoma I. Dysgerminoma J. Fibroma
For each one of the following please select the answer from the list above:
Most common benign ovarian tumour in women under the age of 25 years
Theme: Ovarian cysts
A. Dermoid cyst (teratoma) B. Endometriotic cyst C. Granulosa cell tumour D. Clear cell tumour E. Corpus luteum cyst F. Mucinous cystadenoma G. Follicular cyst H. Serous cystadenoma I. Dysgerminoma J. Fibroma
For each one of the following please select the answer from the list above:
Most common type of ovarian pathology associated with Meigs’ syndromeOvarian cysts: types
Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours
Physiological cysts (functional cysts)
Follicular cysts
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
Corpus luteum cyst
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
Benign germ cell tumours
Dermoid cyst
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
Benign epithelial tumours
Arise from the ovarian surface epithelium
Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
Theme: Ovarian cysts
A. Dermoid cyst (teratoma) B. Endometriotic cyst C. Granulosa cell tumour D. Clear cell tumour E. Corpus luteum cyst F. Mucinous cystadenoma G. Follicular cyst H. Serous cystadenoma I. Dysgerminoma J. Fibroma
For each one of the following please select the answer from the list above:
The most common cause of ovarian enlargement in women of a reproductive age
Ovarian cysts: types
Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours
Physiological cysts (functional cysts)
Follicular cysts
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
Corpus luteum cyst
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
Benign germ cell tumours
Dermoid cyst
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
Benign epithelial tumours
Arise from the ovarian surface epithelium
Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
A 31-year-old woman presents for review. For the past few months she has been feeling generally tired and has not had a normal period for around 4 months. Prior to this she had a regular 30 day cycle. A pregnancy test is negative, pelvic examination is normal and routine bloods are ordered:
FBC Normal
U&E Normal
TFT Normal
Follicle-stimulating hormone 41 iu/l ( 100 pmol/l)
What is the most likely diagnosis?
Ovarian cancer Gonadotropin-producing pituitary adenoma Turner syndrome Premature ovarian failure Aromatase enzyme deficiency
Premature ovarian failure
Premature ovarian failure is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
Causes idiopathic - the most common cause chemotherapy autoimmune radiation
Features are similar to those of the normal climacteric but the actual presenting problem may differ
climacteric symptoms: hot flushes, night sweats
infertility
secondary amenorrhoea
raised FSH, LH levels
A 33-year-old female presents with a vaginal discharge. Which one of the following features is not consistent with bacterial vaginosis?
Vaginal pH > 4.5 Thin, white homogenous discharge Strawberry cervix Clue cells on microscopy Positive whiff test
A strawberry cervix is associated with Trichomonas vaginalis, a condition which may present in a similar fashion to bacterial vaginosis
Bacterial vaginosis
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.
Features
vaginal discharge: ‘fishy’, offensive
asymptomatic in 50%
Amsel’s criteria for diagnosis of BV - 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)
Management oral metronidazole for 5-7 days 70-80% initial cure rate relapse rate > 50% within 3 months the BNF suggests topical metronidazole or topical clindamycin as alternatives
© Image used on license from PathoPic
Clue cells - epithelial cells develop a stippled appearance due to being covered with bacteria
Bacterial vaginosis in pregnancy
results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy. The BNF still advises against the use of high dose metronidazole regimes
Which one of the following statements regarding endometrial cancer is incorrect?
Trans-vaginal ultrasound is the first-line investigation Has a poor prognosis Progestogen treatment may be used in frail elderly patients not fit for surgery Treatment of early disease is with total abdominal hysterectomy with bilateral salpingo-oophorectomy Pelvic pain is rarely a presenting feature
Endometrial cancer
Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection
The risk factors for endometrial cancer are as follows*: obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome
Features
post-menopausal bleeding is the classic symptom
pre-menopausal women may have a change intermenstrual bleeding
pain and discharge are unusual features
Investigation
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (
A 29-year-old female presents to her GP as she missed her Micronor pill (progestogen only) this morning and is unsure what to do. She normally takes the pill at around 0830 and it is now 1100. What advice should be given?
Take missed pill now and no further action needed Emergency contraception should be offered Take missed pill now and advise condom use until pill taking re-established for 48 hours Take missed pill now and omit pill break at end of pack Perform a pregnancy test
Progestogen only pill: missed pill
The missed pill rules for the progestogen only pill (POP) are simpler than those used for the combined oral contraceptive pill, but it is important not to confuse the two.
‘Traditional’ POPs (Micronor, Noriday, Nogeston, Femulen)
If less than 3 hours late
no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed - see below
Cerazette (desogestrel)
If less than 12 hours late
no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed - see below
Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
A woman who is 34 weeks pregnant is found to have an amniotic fluid volume of 440 ml. Which one of the following conditions is not part of the differential diagnosis?
Premature rupture of membranes Pre-eclampsia Tracheo-oesophageal fistula Renal agenesis Intrauterine growth restriction
An amniotic fluid volume of 440ml indicates oligohydramnios. Tracheo-oesophageal fistula is associated with polyhydramnios.
Oligohydramnios
In oligohydramnios there is reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI)
A 25-year-old woman presents for her first cervical smear. What is the most important aetiological factor causing cervical cancer?
Human papilloma virus 6 & 11 Early first intercourse Smoking Combined oral contraceptive pill use Human papilloma virus 16 & 18
Whilst all of the above are known to contribute to the development of cervical cancer infection with human papilloma virus 16 & 18 is by far the most important factor.
Cervical cancer
The incidence of cervical cancer peaks around the 6th decade. It may be divided into
squamous cell cancer (80%)
adenocarcinoma (20%)
Features
may be detected during routine cervical cancer screening
abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
vaginal discharge
Risk factors human papilloma virus 16,18 & 33 smoking human immunodeficiency virus early first intercourse, many sexual partners high parity lower socioeconomic status combined oral contraceptive pill*
Which one of the following clinical features would be least consistent with a diagnosis of severe pre-eclampsia?
Headache Epigastric pain Reflexes difficult to elicit Low platelet count Papilloedema
Severe pre-eclampsia is associated with hyperreflexia and clonus. A low platelet count may indicate the patient is developing HELLP syndrome
Pre-eclampsia
Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific
Pre-eclampsia is important as it predisposes to the following problems
fetal: prematurity, intrauterine growth retardation
eclampsia
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
multi-organ failure
Risk factors > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease
Features of severe pre-eclampsia
hypertension: typically > 170/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count 160/110 mmHg although many clinicians have a lower threshold
oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
Which one of the following is an absolute contraindication to combined oral contraceptive pill use?
Controlled hypertension History of cholestasis 36-year-old woman smoking 20 cigarettes/day BMI of 38 kg/m^2 Migraine without aura
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below:
UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
UKMEC 2: advantages generally outweigh the disadvantages
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
migraine without aura and more than 35 years old
family history of thromboembolic disease in first degree relatives 20 years ago is classified as UKMEC 3 or 4 depending on severity
*The UKMEC 4 rating for a BMI > 40 kg/m^2 was removed in 2009.
You are reviewing test results. The midstream specimen of urine (MSU) from a 24-year-old woman who is 11 weeks pregnant shows a urinary tract infection. On discussing the result with the patient she does describe some dysuria and ‘smelly urine’. What is the most appropriate management?
Ciprofloxacin for 7 days Amoxicillin for 7 days Repeat MSU Trimethoprim for 3 days No treatment
As this woman is symptomatic she should be treated with an antibiotic that is safe to use in pregnancy.
Urinary tract infection in adults: management
Lower urinary tract infections in non-pregnant women
local antibiotic guidelines should be followed if available
2012 SIGN guidelines recommend trimethoprim or nitrofurantoin for 3 days
Pregnant women with symptomatic bacteriuria should be treated with an antibiotic for 7 days. A urine culture should be sent. For asymptomatic pregnant women:
a urine culture should be performed routinely at the first antenatal visit
if positive, a second urine culture should be sent to confirm the presence of bacteriuria
SIGN recommend to treat asymptomatic bacteriuria detected during pregnancy with an antibiotic
a 7 day course of antibiotics should be given
a further urine culture should be sent following completion of treatment as a test of cure
For patients with sign of acute pyelonephritis hospital admission should be considered
local antibiotic guidelines should be followed if available
the BNF currently recommends a broad-spectrum cephalosporin or a quinolone for 10-14 days
A 12-year-old girl comes with her mother to surgery. She is requesting the combined oral contraceptive (COC) pill as she has recently started a relationship with an 18-year-old man who she met at the local games arcade, although she has not yet had sex with him. You discuss the age difference but her mother states that she has met the boyfriend and says he treats her daughter well. Both the girl and her mother insist that they do not want anyone else involved. What is the most appropriate course of action?
Assess using Fraser guidelines + prescribe a Long Acting Reversible Contraceptive method such as Implanon Assess using Fraser guidelines + prescribe the COC Advise her to abstain and refer to a 'Safer Sex for Young Adults' program Obtain consent from mother + prescribe the COC Immediately phone local child protection lead and refer to social services
Children under the age of 13 years are not able to consent to sexual intercourse and hence any sexual activity would be regarded as rape under the law. This is one situation under the GMC guidelines where you are compelled to break confidentiality
Consent: children
The General Medical Council have produced guidelines on obtaining consent in children:
at 16 years or older a young person can be treated as an adult and can be presumed to have capacity to decide
under the age of 16 years children may have capacity to decide, depending on their ability to understand what is involved
where a competent child refuses treatment, a person with parental responsibility or the court may authorise investigation or treatment which is in the child’s best interests*
With regards to the provision of contraceptives to patients under 16 years of age the Fraser Guidelines state that all the following requirements should be fulfilled:
the young person understands the professional’s advice
the young person cannot be persuaded to inform their parents
the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Gillick or Fraser?
Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children. The (widespread) rumours that Victoria Gillick removed her permission to use her name or applied copyright have recently been debunked.
More information can be found in the following article:
Wheeler R. Gillick or Fraser? A plea for consistency over competence in children BMJ 2006;332:807
*in Scotland those with parental responsibility cannot authorise procedures a competent child has refused
A woman presents to have a Nexplanon (etonogestrel) inserted. Where is the most appropriate place to insert the implant?
Subcutaneous, buttock Subdermal, non-dominant arm Subcutaneous, non-dominant arm Intradermal, non-dominant arm Subdermal, buttock
Implantable contraceptives
Implanon was a non-biodegradable subdermal contraceptive implant which has been replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as Implanon. The two main differences are:
the applicator has been redesigned to try and prevent ‘deep’ insertions (i.e. subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.
Key points
highly effective: failure rate 0.07/100 women/year
long-acting: lasts 3 years
doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
can be inserted immediately following a termination of pregnancy
Disadvantages include
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle
Adverse effects
irregular/heavy bleeding is the main problem
‘progestogen effects’: headache, nausea, breast pain
Interactions
enzyme-inducing drugs such as certain antiepileptic and rimampicin may reduce the efficacy of Nexplanon
the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
Contraindications
UKMEC 3*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer, positive antiphospholipid antibodies**
UKMEC 4**: current breast cancer
- proven risks generally outweigh the advantages
- *there is some contradiction in the guidance issued by the FSRH but their most recent document (revised 2010) lists positive antiphospholipid antibodies as UKMEC 3
- **a condition which represents an unacceptable risk if the contraceptive method is used
What is the failure rate of female sterilisation?
1 in 100 1 in 200 1 in 300 1 in 400 1 in 500
Sterilisation
Male sterilisation - vasectomy
failure rate: 1 per 2,000*
simple operation, can be done under LA (some GA), go home after a couple of hours
doesn’t work immediately
semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men)
the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years
Female sterilisation
failure rate: 1 per 200*
usually done by laparoscopy under general anaesthetic
generally done as a day case
many different techniques involving clips (e.g. Filshie clips) , blockage, rings (Falope rings) and salpingectomy
complications: increased risk of ectopic if sterilisation fails, general complications of GA/laparoscopy
the current success rate of female sterilisation reversal is between 50-60%
*source = Royal College of Obstetricians and Gynaecologists
How often is the Depo Provera (medroxyprogesterone acetate) injectable contraceptive given?
Every 2 weeks Every 4 weeks Every 8 weeks Every 12 weeks Every 24 weeks
Injectable contraceptives
Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions**
The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.
Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
Adverse effects
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time
*Noristerat, the other injectable contraceptive licensed in the UK, is rarely used in clinical practice. It is given every 8 weeks
**the BNF gives different advice, stating a pregnancy test should be done if the interval is greater than 12 weeks and 5 days - this is however not commonly adhered to in the family planning community
Which one of the following statements regarding cervical ectropion is incorrect?
Describes an increased area of columnar epithelium May result in post-coital bleeding Is less common in women who use the combined oral contraceptive pill May result in excessive vaginal discharge Is more common during pregnancy
Cervical ectropion
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
The term cervical erosion is used less commonly now
This may result in the following features
vaginal discharge
post-coital bleeding
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
Which one of the following is not a recognised adverse effect of the combined oral contraceptive pill?
Increased risk of ovarian cancer Increased risk of deep vein thrombosis Increased risk of breast cancer Increased risk of ischaemic heart disease Increased risk of cervical cancer
Combined oral contraceptive pill
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
The combined oral contraceptive pill has actually been shown to reduce the risk of ovarian cancer
Combined oral contraceptive pill: advantages/disadvantages
Advantages of combined oral contraceptive pill highly effective (failure rate
Which one of the following statements regarding the management of rhesus negative pregnancy is true?
A. It mainly causes problems for the mother’s first-born child
B. Anti-D is still required following delivery even if the mother received routine antenatal anti-D prophylaxis
C. Anti-D should be given within 72 hours of a spontaneous miscarriage at 9 weeks
D. Anti-D should be given as soon as the mother is found to be rhesus negative (usually around 10 weeks)
E. Coombs test is used to determine the rhesus status of the mother
B. Anti-D is still required following delivery even if the mother received routine antenatal ant-D prophylaxis
Subsequent pregnancies are most at risk following the sensitising event of the first childbirth.
Rhesus negative pregnancy
A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies
along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system
around 15% of mothers are rhesus negative (Rh -ve)
if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur
this causes anti-D IgG antibodies to form in mother
in later pregnancies these can cross placenta and cause haemolysis in fetus
this can also occur in the first pregnancy due to leaks
Prevention
test for D antibodies in all Rh -ve mothers at booking
NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks
the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used ‘depending on local factors’
anti-D is prophylaxis - once sensitization has occurred it is irreversible
if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
Tests
all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant
Affected fetus oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls) jaundice, anaemia, hepatosplenomegaly heart failure kernicterus treatment: transfusions, UV phototherapy
A 34-year-old woman presents requesting emergency contraception. She had unprotected sexual intercourse with her ex-partner four days ago and is very keen to avoid a pregnancy. Today she is 14 days into a 28 day cycle. Her past medical history includes an ectopic pregnancy around four years which resulted in a salpingectomy. Of the availalbe options, what is the most appropriate action?
Do a pregnancy test Prescribe a stat dose of levonorgestrel 1.5mg but explain it may not be effective Insert an intrauterine device Explain she is outside the emergency contraception window and advise her take a pregnancy test if her period is late Insert a intrauterine system (Mirena)
IUD - Previous ectopic pregnancy is not a contraindication to intrauterine device insertion. Intrauterine systems (Mirena) cannot be used for emergency contraception.
Emergency contraception
There are two methods currently available in the UK:
Emergency hormonal contraception
There are now two methods of emergency hormonal contraception (‘emergency pill’, ‘morning-after pill’); levonorgestrel and ulipristal, a progesterone receptor modulator.
Levonorgestrel
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
Ulipristal
a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills
caution should be exercised in patients with severe asthma
repeated dosing within the same menstrual cycle is not recommended
breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel
Intrauterine device (IUD)
must be inserted within 5 days of UPSI, or
if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
may inhibit fertilisation or implantation
prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication
Which one of the following correctly describes the frequency of the cervical cancer screening program in England?
25-64 years - 5-yearly screening 20-49 years - 3-yearly screening; 50-69 years - 5-yearly screening 25-49 years - 5-yearly screening; 50-64 years - 3-yearly screening 25-64 years - 3-yearly screening 25-49 years - 3-yearly screening; 50-64 years - 5-yearly screening
Cervical cancer screening
25-49 years: 3-yearly
50-64 years: 5-yearly
The question is specific to England as there are some variations in practice across the UK
Cervical cancer screening
The UK has a well established cervical cancer screening program which is estimated to prevent 1,000-4,000 deaths per year. It should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening
Who is screened and how often?
A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
How is performed?
There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid.
Advantages of LBC includes
reduced rate of inadequate smears
increased sensitivity and specificity
It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS.
In Scotland women from the ages of 20-60 years are screened every 3 years.
A 26-year-old woman presents due to heavy, painful periods. She typically has heavy bleeding for around 6 days with severe crampy pains for the first 3 days. She does not want to be on contraception as she is getting married shortly and plans to start a family. A full blood count is performed and is normal. What is the most appropriate first-line treatment?
Tranexamic acid Paracetamol Mefenamic acid Norethisterone Intrauterine system (Mirena)
Mefenamic acid - Tranexamic acid would not treat the dysmenorrhoea.
Menorrhagia: management
Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The management has therefore shifted towards what the woman considers to be excessive. Prior to the 1990’s many women underwent a hysterectomy to treat heavy periods but since that time the approach has altered radically. The management of menorrhagia now depends on whether a women needs contraception.
Investigations
a full blood count should be performed in all women
further investigations are based upon the history and examination findings
Does not require contraception
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
Requires contraception, options include
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
A woman who is 36 weeks pregnant is reviewed. This is her first pregnancy. Her baby is known to currently lie in a breech presentation. What is the most appropriate management?
Reassure mother baby will most likely turn to a cephalic presentation prior to delivery Refer for external cephalic version Admit for induction of labour and trial of vaginal delivery Refer for radiological pelvimetry Admit for caesarean section
Refer for external cephalic version
Breech presentation
In a breech presentation the caudal end of the fetus occupies the lower segment. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term. A frank breech is the most common presentation with the hips flexed and knees fully extended. A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity
Risk factors for breech presentation
uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality (e.g. CNS malformation, chromosomal disorders)
prematurity (due to increased incidence earlier in gestation)
Cord prolapse is more common in breech presentations
Management
if
Which one of the following statements is not correct regarding hypertension in pregnancy?
A. An increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic suggests hypertension
B. Pre-eclampsia occurs in around 5% of pregnancies
C. Urine dipstick showing protein + is consistent with gestational hypertension
D. A rise in blood pressure before 20 weeks suggests pre-existing hypertension
E. With gestational hypertension the blood pressure rises in the second half of pregnancy
C. Proteinuria suggests pre-eclampsia
Hypertension in pregnancy
NICE published guidance in 2010 on the management of hypertension in pregnancy. They also made recommendations on reducing the risk of hypertensive disorders developing in the first place. Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
The classification of hypertension in pregnancy is complicated and varies. Remember, in normal pregnancy:
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term
Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
Which one of the following statements regarding polycystic ovarian syndrome (PCOS) is incorrect?
A slightly elevated prolactin is consistent with a diagnosis of PCOS Luteinizing hormone levels are usually raised Hyperinsulinaemia is seen Acanthosis nigricans may be seen Affects around 1% of women of reproductive age
Polycystic ovarian syndrome is extremely common, affecting between 5-20% of women of reproductive age
Polycystic ovarian syndrome: features and investigation
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
Features
subfertility and infertility
menstrual disturbances: oligomenorrhea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)
Investigations
pelvic ultrasound: multiple cysts on the ovaries
FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
check for impaired glucose tolerance
Theme: Menopause: management
A. Clonidine B. Hormone replacement therapy C. Tibolone D. Topical oestrogens E. Topical steroids F. Selective serotonin reuptake inhibitor G. Black cohosh H. Raloxifene
For each one of the following select the most appropriate answer from the options above:
Useful for vaginal atrophy
Topical oestrogens
Menopause: management
Many women have little or no symptoms around the menopause do not require any specific treatment other than advice and reassurance. Hormone replacement therapy (HRT) should be used primarily for the treatment of menopausal symptoms. It should no longer be given in an attempt to modify cardiovascular risk (following the Women’s Health Initiative Study) but may be beneficial in the prevention and treatment of osteoporosis.
Management options for hot flushes or night sweats
lifestyle advice: exercise, avoiding caffeine/spicy foods, lighter clothing
hormone replacement therapy: most effective
tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea
selective serotonin reuptake inhibitors: only small trials have been completed to date
Vaginal atrophy
topical oestrogens
Theme: Menopause: management
A. Clonidine B. Hormone replacement therapy C. Tibolone D. Topical oestrogens E. Topical steroids F. Selective serotonin reuptake inhibitor G. Black cohosh H. Raloxifene
For each one of the following select the most appropriate answer from the options above:
Unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
Tibolone
Menopause: management
Many women have little or no symptoms around the menopause do not require any specific treatment other than advice and reassurance. Hormone replacement therapy (HRT) should be used primarily for the treatment of menopausal symptoms. It should no longer be given in an attempt to modify cardiovascular risk (following the Women’s Health Initiative Study) but may be beneficial in the prevention and treatment of osteoporosis.
Management options for hot flushes or night sweats
lifestyle advice: exercise, avoiding caffeine/spicy foods, lighter clothing
hormone replacement therapy: most effective
tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea
selective serotonin reuptake inhibitors: only small trials have been completed to date
Vaginal atrophy
topical oestrogens
Theme: Menopause: management
A. Clonidine B. Hormone replacement therapy C. Tibolone D. Topical oestrogens E. Topical steroids F. Selective serotonin reuptake inhibitor G. Black cohosh H. Raloxifene
For each one of the following select the most appropriate answer from the options above:
Often causes dry mouth and dizziness
Clonidine
Menopause: management
Many women have little or no symptoms around the menopause do not require any specific treatment other than advice and reassurance. Hormone replacement therapy (HRT) should be used primarily for the treatment of menopausal symptoms. It should no longer be given in an attempt to modify cardiovascular risk (following the Women’s Health Initiative Study) but may be beneficial in the prevention and treatment of osteoporosis.
Management options for hot flushes or night sweats
lifestyle advice: exercise, avoiding caffeine/spicy foods, lighter clothing
hormone replacement therapy: most effective
tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea
selective serotonin reuptake inhibitors: only small trials have been completed to date
Vaginal atrophy
topical oestrogens
A 31-year-old female presents to the genitourinary medicine clinic due to four fleshy, protuberant lesions on her vulva which are slightly pigmented. She has recently started a relationship with a new partner. What is the most appropriate initial management?
Oral aciclovir Topical podophyllum Topical salicylic acid Topical aciclovir Electrocautery
Genital wart treatment
multiple, non-keratinised warts: topical podophyllum
solitary, keratinised warts: cryotherapy
Cryotherapy is also acceptable as an initial treatment for genital warts (see below)
Genital warts
Genital warts (also known as condylomata accuminata) are a common cause of attendance at genitourinary clinics. They are caused by the many varieties of the human papilloma virus HPV, especially types 6 & 11. It is now well established that HPV (primarily types 16,18 & 33) predisposes to cervical cancer.
Features
small (2 - 5 mm) fleshy protuberances which are slightly pigmented
may bleed or itch
Management
topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy
imiquimod is a topical cream which is generally used second line
genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years
A woman who is 14 weeks pregnant presents as she came into contact with a child who has chickenpox around 4 days ago. She is unsure if she had the condition herself as a child. Blood tests show the following:
Varicella IgM Negative
Varicella IgG Negative
What is the most appropriate management?
Varicella zoster immunoglobulin No action required IV aciclovir Varicella zoster vaccination Varicella zoster vaccination + varicella zoster immunoglobulin
Chickenpox exposure in pregnancy - if not immune give VZIG
The negative IgG indicates no previous exposure to chickenpox
Chickenpox exposure in pregnancy
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
Fetal varicella syndrome (FVS)
risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Management of chickenpox exposure
if there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies
if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash
A 44-year-old female has a Mirena (intrauterine system) fitted for contraception on day 12 of her cycle. How long will it take before it can be relied upon as a method of contraception?
Immediately 2 days 5 days 7 days Until first day of next period
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
Which one of the following statements regarding the management of diabetes mellitus during pregnancy is incorrect?
A previous macrosomic baby is a risk factor for gestational diabetes Diabetes complicates around 1 in 40 pregnancies A higher dose of folic acid (5 mg/day) should be used Metformin is contraindicated Tight glycaemic control reduces complication rates
There is increasing evidence that metformin is safe during pregnancy
Pregnancy: diabetes mellitus
Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. It complicates around 1 in 40 pregnancies
Risk factors for gestational diabetes
BMI of > 30 kg/m^2
previous macrosomic baby weighing 4.5 kg or above.
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening for gestational diabetes
if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
currently the same WHO diagnostic criteria are used as for non-pregnant patients. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes
NICE issued guidelines on the management of diabetes mellitus in pregnancy which were updated in 2008
Management of pre-existing diabetes
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 18-20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Management of gestational diabetes
responds to changes in diet and exercise in around 80% of women
oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.g. macrosomia)
there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin
hypoglycaemic medication should be stopped following delivery
a fasting glucose should be checked at the 6 week postnatal check
A 27-year-old female asks for advice regarding the Mirena (intrauterine system). What is the most likely affect on her periods?
Continual, light bleeding is seen in 70% Initially irregular bleeding later followed by periods that are generally heavier and longer Heavy period approximately every 3 months Amenorrhoea in > 90% after 2 months Initially irregular bleeding later followed by light menses or amenorrhoea
Initially irregular bleeding later followed by light menses or amenorrhoea
Intrauterine contraceptive devices
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia
Effectiveness
both the IUD and IUS are more than 99% effective
Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
Counselling
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
uterine perforation: up to 2 per 1000 insertions
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
A 22-year-old female has a Nexplanon inserted. For how long will this provide effective contraception?
12 weeks 12 months 3 years 5 years 7 years
3 Years
Implantable contraceptives
Implanon was a non-biodegradable subdermal contraceptive implant which has been replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as Implanon. The two main differences are:
the applicator has been redesigned to try and prevent ‘deep’ insertions (i.e. subcutaneous/intramuscular)
it is radiopaque and therefore easier to locate if impalpable
Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.
Key points
highly effective: failure rate 0.07/100 women/year
long-acting: lasts 3 years
doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
can be inserted immediately following a termination of pregnancy
Disadvantages include
the need for a trained professional to insert and remove device
additional contraceptive methods are needed for the first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle
Adverse effects
irregular/heavy bleeding is the main problem
‘progestogen effects’: headache, nausea, breast pain
Interactions
enzyme-inducing drugs such as certain antiepileptic and rimampicin may reduce the efficacy of Nexplanon
the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
Contraindications
UKMEC 3*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer, positive antiphospholipid antibodies**
UKMEC 4**: current breast cancer
- proven risks generally outweigh the advantages
- *there is some contradiction in the guidance issued by the FSRH but their most recent document (revised 2010) lists positive antiphospholipid antibodies as UKMEC 3
- **a condition which represents an unacceptable risk if the contraceptive method is used
A baby is born to a mother who is known to have chronic hepatitis B. The mothers latest results are as follows:
HBsAg Positive
HBeAg Positive
What is the most appropriate strategy for reducing the vertical transmission rate?
Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin Give the newborn hepatitis B vaccine Give the newborn hepatitis B immunoglobulin Give the mother intravenous zidovudine during labour Give the mother hepatitis B immunoglobulin shortly before birth + the newborn hepatitis B vaccine
Hepatitis B and pregnancy
Basics
all pregnant women are offered screening for hepatitis B
babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the latter part of pregnancy
there is little evidence to suggest caesarean section reduces vertical transmission rates
hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
A 41-year-old female is diagnosed as having Trichomonas vaginalis. What is the most appropriate management?
Clotrimazole pessary Oral doxycycline Advice regarding hygiene and cotton underwear Oral itraconazole Oral metronidazole
Trichomonas vaginalis
Trichomonas vaginalis is a highly motile, flagellated protozoan parasite
Features
vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis
Investigation
microscopy of a wet mount shows motile trophozoites
Management
oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole
A 25-year-old female presents to her GP as she has missed two consecutive Microgynon 30 pills. She has taken the Microgynon for the past 5 years and is currently 11 days into a packet of pills. Last night she had sexual intercourse with a new partner but unfortunately the condom split. What is the correct management?
Perform a pregnancy test in two days time Advise the women she may be at risk from pregnancy and refer give a patient information leaflet explaining her options Advise condom use for the next 7 days Give a Depo-Provera (depot medroxyprogesterone acetate) injection to prevent implantation Omit pill break at end of pack
Updated guidance from the FSRH states the following after a woman has missed two pills:
‘If you have missed two or more pills (i.e. more than 48 hours late), anywhere in the pack continue taking the rest of the pack as usual and use an extra method of contraception for the next 7 days’
For further information please consult the link to the FSRH guidelines. As this was a new partner consideration should be given to STI screening after an appropriate interval.
According to the FSRH emergency contraception does not need to be given in this scenario.
Depo-Provera is a long-acting contraceptive. It should not be used for emergency contraception and not given unless there is no chance of pregnancy.
Combined oral contraceptive pill: missed pill
The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
A couple present to the surgery as they are having trouble conceiving. They have been having regular unprotected sex for the past 12 months. The woman is 27-years-old and has a regular 28 day cycle. The man has no past history of note. What is the most appropriate initial management?
Check day 21 progesterone + semen analysis Reassurance Check day 14 progesterone + semen analysis Referral to infertility services Check day 14 progesterone + semen analysis + testosterone level in male
It should be noted that whilst NICE define infertility as ‘failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology’ they advise that investigations are offered after 1 year
Infertility
Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years
Causes male factor 30% unexplained 20% ovulation failure 20% tubal damage 15% other causes 15%
Basic investigations
semen analysis
serum progesterone 7 days prior to expected next period
Key counselling points folic acid aim for BMI 20-25 advise regular sexual intercourse every 2 to 3 days smoking/drinking advice
A pregnant woman in her 35th week of gestation goes in to spontaneous labour. Which one of the following is least associated with preterm birth?
Antepartum haemorrhage Uterine abnormalities Cervical incompetence Endometriosis Twin pregnancy
Endometriosis
Preterm birth
Preterm birth is defined as delivery of an infant before 37 weeks gestation. It occurs in around 5-10% of pregnancies (6% of singletons, 45% of twins)
Causes unexplained (30-40%) multiple pregnancies (20-30%) congenital abnormalities antepartum haemorrhage pre-eclampsia cervical incompetence diabetes mellitus polyhydramnios uterine abnormalities infections e.g. Pyelonephritis
Which one of the following statements regarding uterine fibroids is incorrect?
Are benign smooth muscle tumours of the uterus May cause urinary symptoms Undergo malignant change in 1 in 200 cases Occur in around 20% of white women Are more common in black women
The majority of pathologists believe that uterine leiomyosarcomas which may initially present as ‘fibroids’ are probably de novo lesions rather than a transformation of existing fibroids
Uterine fibroids
Fibroids are benign smooth muscle tumours of the uterus. They are through to occur in around 20% of white and around 50% of black women in the later reproductive years
Associations
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen, don’t tend to progress following menopause
Features may be asymptomatic menorrhagia bloating urinary symptoms, e.g. frequency, may occur with larger fibroids subfertility
Management
medical: symptomatic management e.g. with combined oral contraceptive pill. GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
surgery is sometimes needed
uterine artery embolization
Complications
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
A 25-year-old woman comes to surgery as she has not had a normal period for the past 12 months. She has done a pregnancy test recently which was negative. You arrange baseline investigations. Which one of the following is not part of your differential diagnosis?
Microprolactinoma Polycystic ovarian syndrome Turner's syndrome Premature ovarian failure Thyrotoxicosis
Turner’s syndrome causes primary rather than secondary amenorrhoea.
Amenorrhoea
Amenorrhoea may be divided into primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer).
Causes of primary amenorrhoea Turner's syndrome testicular feminisation congenital adrenal hyperplasia congenital malformations of the genital tract
Causes of secondary amenorrhoea (after excluding pregnancy)
hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Initial investigations
exclude pregnancy with urinary or serum bHCG
gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
prolactin
androgen levels: raised levels may be seen in PCOS
oestradiol
thyroid function tests
*hypothyroidism may also cause amenorrhoea
What is the most common adverse effect experienced by women taking the progestogen only pill?
Irregular vaginal bleeding Acne Mood swings Reduced libido Weight gain
Irregular vaginal bleeding
Progestogen only pill: advantages/disadvantages
Advantages
highly effective (failure rate = 1 per 100 woman years)
doesn’t interfere with sex
contraceptive effects reversible upon stopping
can be used whilst breast-feeding
can be used in situations where the combined oral contraceptive pill is contraindicated e.g. in smokers > 35 years of age and women with a history of venous thromboembolic disease
Disadvantages
irregular periods: some users may not have periods whilst others may have irregular or light periods. This is the most common adverse effect
doesn’t protect against sexually transmitted infections
increased incidence of functional ovarian cysts
common side-effects include breast tenderness, weight gain, acne and headaches. These symptoms generally subside after the first few months
A 12-year-old girl comes to surgery with her mother who requests more information about human papilloma virus (HPV) vaccination. Which one of the following statements regarding HPV vaccination is incorrect?
Gardasil is given in 2 doses HPV is the main aetiological factor in the development of cervical cancer Gardasil protects against HPV 6, 11, 16 & 18 A vaccination program has been introduced for girls aged 12-13 years Cervarix has the advantage over Gardasil of offering protection against genital warts
Gardasil, rather than Cervarix, has the advantage of offering protection against genital warts.
Human papilloma virus vaccination
It has been known for a longtime that the human papilloma virus (HPV) which infects the keratinocytes of the skin and mucous membranes is carcinogenic.
There are dozens of strains of HPV. The most important to remember are:
6 & 11: causes genital warts
16 & 18: linked to a variety of cancers, most notably cervical cancer
HPV infection is linked to: over 99.7% of cervical cancers around 85% of anal cancers around 50% of vulval and vaginal cancers around 20-30% of mouth and throat cancers
It should of course be remembered that there are other risk factors important in developing cervical cancer such as smoking, combined oral contraceptive pill use and high parity.
Testing for HPV has now been integrated into the cervical cancer screening programme. If a smear is reported as borderline or mild dyskaryosis the original sample is tested for HPV
if HPV negative the patient goes back to routine recall
if HPV positive the patient is referred for colposcopy
Immunisation
A vaccination for HPV was introduced in the UK back in 2008. As you may remember the Department of Health initially chose Cervarix. This vaccine protected against HPV 16 & 18 but not 6 & 11. There was widespread criticism of this decision given the significant disease burden caused by genital warts. Eventually in 2012 Gardasil replaced Cervarix as the vaccine used. Gardasil protects against HPV 6, 11, 16 & 18.
Girls aged 12-13 years are offered the vaccine in the UK
the vaccine is normally given in school
information given to parents and available on the NHS website make it clear that the daughter may receive the vaccine against parental wishes
given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy
Injection site reactions are particularly common with HPV vaccines.
A 36-year-old female starts Cerazette (desogestrel) on day 7 of her cycle. How long will it take before it can be relied upon as a method of contraception?
Immediately 2 days 5 days 7 days Until first day of next period
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Progestogen only pill: counselling
Women who are considering taking the progestogen only pill (POP) should be counselled in a number of areas:
Potential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2 days
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
Taking the POP
should be taken at same time everyday, without a pill free break (unlike the COC)
Missed pills
if 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours
Other potential problems
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce effectiveness
Other information
discussion on STIs
*for Cerazette (desogestrel) a 12 hour period is allowed
**unless the antibiotic alters the P450 enzyme system, for example rifampicin
A 29-year-old woman presents to the genitourinary medicine clinic for treatment of recurrent genital warts. Which one the following viruses are most likely to be responsible?
Human papilloma virus 16 & 18 Human papilloma virus 13 & 17 Human papilloma virus 6 & 11 Human papilloma virus 12 & 14 Human papilloma virus 15 & 21
Genital warts - 90% are caused by HPV 6 & 11
Types 6 and 11 are responsible for 90% of genital warts cases
Genital warts
Genital warts (also known as condylomata accuminata) are a common cause of attendance at genitourinary clinics. They are caused by the many varieties of the human papilloma virus HPV, especially types 6 & 11. It is now well established that HPV (primarily types 16,18 & 33) predisposes to cervical cancer.
Features
small (2 - 5 mm) fleshy protuberances which are slightly pigmented
may bleed or itch
Management
topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy
imiquimod is a topical cream which is generally used second line
genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years
A 38-year-old female develops hypertension in the third trimester of her first pregnancy. A 24 hour urine collection shows 0.5g protein. Which one of the following complications is least associated with this condition?
Intracerebral haemorrhage Pulmonary oedema Fetal prematurity Transverse myelitis Fetal intrauterine growth retardation
Transverse myelitis is not associated with pre-eclampsia
Pre-eclampsia
Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific
Pre-eclampsia is important as it predisposes to the following problems
fetal: prematurity, intrauterine growth retardation
eclampsia
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
multi-organ failure
Risk factors > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease
Features of severe pre-eclampsia
hypertension: typically > 170/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count 160/110 mmHg although many clinicians have a lower threshold
oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
A 62-year-old woman presents with abdominal bloating. Examination reveals shifting dullness. Which one of the following is a risk factor for ovarian cancer?
Combined oral contraceptive pill use Late menarche Having many children Early menopause BRCA2 gene
BRCA2 gene
Ovarian cancer: risk factors relate to increased number of ovulations
Ovarian cancer
Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin.
Risk factors
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations: early menarche, late menopause, nulliparity
It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.
Clinical features are notoriously vague abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea
Diagnosis is difficult and usually involves diagnostic laparotomy
A 57-year-old female presents due to problems with urine leakage over the past six months. She describes frequent voiding and not always being able to get to the toilet in time. She denies losing urine when coughing or sneezing. What is the most appropriate initial treatment?
Trial of oxybutynin Bladder retraining Regular toileting Pelvic floor muscle training Topical oestrogen cream
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Causes
overactive bladder (OAB)/urge incontinence: due to detrusor over activity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigation
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude cystocele
urine dipstick and culture
Management depends on whether urge or stress UI is the predominant picture. If 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
surgical management: e.g. sacral nerve stimulation
If stress incontinence is predominant:
pelvic floor muscle training (for a minimum of 3 months)
surgical procedures: e.g. retropubic mid-urethral tape procedures
