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MRCOG Gynaecology Part 2 Revision - Hay > NICE Endometriosis, Heavy mental bleeding, menopause > Flashcards

NICE Endometriosis, Heavy mental bleeding, menopause Flashcards

1
Q

What first investigation should be performed for all HMB?

A

FBC

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2
Q

For whom should a coagulation should be performed?

A

If HMB started since menus or Fhx coagulation disorder.

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3
Q

Should you start treatment for HMB without imaging?

A

If from history and examination low risk fibroids/uterine cavity abnormality/histological abnormality/adenomyosis

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4
Q

What are the 1st line investigations other than bloods?

A

USS or hysteroscopy

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5
Q

Which women should have hysterscopy as 1st line Ix?

A

Recurrent IMB
Risk factors for endometrial pathology

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6
Q

What is standard technique of OP hysteroscopy?

A

OP: Analgesia, miniature hysteroscope 3.5mm or smaller
Vaginoscopy

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7
Q

Which women should have endometrial Bx at hysterscopy?

A

Endometrial Bx if high risk: IMB, persistent irregular bleeding, infrequent heavy bleeding, obese, PCOS, tamoxifen, unsuccessful medical Tx HMB

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8
Q

For which women should have USS as first line?

A

USS – uterus palpable abdominally, hx or exam of pelvic mass, examination inconclusive/difficult (obese)

TVUS if Sx of ?adenomyosis -dysmenorrhoea, bulky/tender uterus – If decline TAUS or MRI

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9
Q

Main Qs when deciding which Tx?

A

?Trying to conceive
?Wants to retain fertility/uterus

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10
Q

1st line treatment for women with no identified pathology, fibroids< 3 cm, or suspected or diagnosed adenomyosis

A

LNG-IUS – irregular PVB 6 months

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11
Q

2nd line treatment for women with no identified pathology, fibroids< 3 cm, or suspected or diagnosed adenomyosis

A
  • Non hormonal: TXA, NSAIDS
  • Hormonal: COCP, cyclical POP
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12
Q

For submucosal fibroids, what treatment should be consider

A

TCRF

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13
Q

Treatment options for fibroids >3cm

A

o Non hormonal TXA/NSAIDS
o Hormonal: LNG-IUS, COCP, POP, uliprostal acetate
o UAE
o Surgical: Myomectomy, hysterectomy – pretreatment GnRH analogue if fibroids enlarged/distort the uterus
 Discuss route and total/subtotal, keep ovaries V not

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14
Q

What major complication needs to monitored for ulipristal acetate?

A

Serious liver injury

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15
Q

When should LFTs be checked when using ulipristal acetate?

A

Before starting, monthly for first 2 courses, once new treatment started

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16
Q

How should ulipristal acatete be given/prescribed?

A

5 mg OD for 3 months, start 1st week of menstruation.

Can give up to 4 courses.

Start no sooner than 1st week of 2nd menstruation.

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17
Q

Which patients should be considered for ulipristal acatate?

A
  • No underlying liver damage
  • Surgery and UAE no suitable
  • premenopausal
  • fibroids >3cm
  • Hb <102
18
Q

If considering hysterectomy, what 4 factors of the pre-surgery and surgical treatment should be considered and discussed with the patient?

A

Pretreatment GnRH analogue
Route
Total/subtotal
+/- oopherectomy/salpingectomy

19
Q

If >45 how to diagnose peri menopause/menopause

A

o Perimenopause: Vasomotor + irregular peroids
o Menopause: No peroids for 12 months, no contraception
o Based on symptoms if no uterus

20
Q

Consider FSH testing for the menopause for which patients?

A
  • Consider FSH age 40-45, perform if <40
  • Not taking COCP/progesterone
21
Q

5 main group of symptoms of the menopause (other than menstrual irregularity/termination)

A
  • Vasomotor
  • MSK – joint/muscle pain
  • Effect on mood
  • Urogenital – vaginal dryness
  • Sexual difficulties
22
Q

Treatments for vasomotor symptoms

A
  • Offer HRT
    o Oestrogen + progesterone with uterus
    o Oestrogen alone no utuerus
  • 2nd line – SSRI/SNRI or clonidine
  • Isoflavens or black cohosh
    o Multiple preperations, safety uncertain
23
Q

Treatment for psychological symptoms

A
  • HRT
  • CBT – no evidence SSRI/SNRI improve mood
24
Q

Treatment for altered sexual function?

A
  • Consider testosterone supplement if HRT not effective
25
Q

Treatment for urogenital atrophy

A
  • Offer vaginal oestrogen
  • If does not relieve consider increasing dose
  • Symptoms may come back when stop, adverse effects V rare, report PVB
  • Can use moisturisers & lubricants alone
26
Q

For women with a uterus commencing HRT, for how long is unscheduled bleeding considered normal?

A

3 months, after 3 months must be reported

27
Q

What medications should not be given to women with breast cancer who are taking tamoxifen

A
  • Do not give SSRIs paroxetine/fluoxetine
28
Q

Which route of HRT has lower risk of VTE?

A

o Increased risk, higher if PO vs transdermal – transdermal same as baseline
o If RF VTE e.g. BMI >30 consider transdermal – if very high risk (FHx VTE/hereditary thrombophilia) – refer to haemotologist

29
Q

Does HRT commenced <60 years increase risk of CVD?

A

No
CVD risk not CI for HRT
Small increase risk of stroke with PO HRT

30
Q

Does HRT increase risk of T2DM

A

No

31
Q

Does HRT increase risk of breast cancer?

A
  • Oestrogen alone no increased risk BC
  • Progesterone + oestrogen small increased risk, realated to duration of Tx and reduces after stopping
  • E.g. 10 yrs combine continuous – increased cases 40/1000
32
Q

Does HRT affect the risk of osteoporosis?

A
  • Risk of fragility frscture is lower when taking HRT, decreases on TX stopped
33
Q

How to diagnose premature ovarian failure?

A
  • <40 yrs +
  • Menopausal Sx, no/infrequent peroids +
  • FSH x 2 4-6 weeks
34
Q

Management of POF

A
  • Offer HRT or COCP – continue until age of natural menopause
  • HRT has beneficial effect on BP vs COCP
  • Both offer bone protection
  • HRT not contraceptive
  • Give advice on bone and CV health & symptoms Mgmt
35
Q

Suspect endometriosis if 1 or more of:

A

Chronic pelvic pain
Dysmenorrhoea effecting daily activities/QoL
Deep pain during/after intercourse
Period related/cyclical GI symptoms, painful bowel movements
Period related/cyclical urinary symptoms,
Infertility with any 1 above

36
Q

Initial Ix

A

Pain/symptoms diary
Offer pelvic examination abdo and BM
Consider USS

37
Q

Initial Tx if fertility not priority

A

Analgesia
Hormonwal - COCP/POP
Neuromodulators

If no improvement refer - Gynaecology/paediatric and adolescent gynaecology (<17) or specialist Endometriosis service (deep Endo, involving bladder/bowe/ureter)

38
Q

If USS +/- MRI can laparoscopy be offered?

A

Yes

39
Q

What needs to be explained to patient consider laparoscopy?

A

What involves + potential surgical Tx
How could effect Endo Sx
benefits and risk
Possible need for further Sx
Alternatives

40
Q

Surgical considerations for fertility is priority vs not priority?

A

MRCOG Gynaecology Part 2 Revision - Hay (44 decks)

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