O+G 3 Flashcards
What treatment is used for high stage cervical cancer?
platinum-based chemotherapy
What is endometrial hyperplasia associated with?
- Taking oestrogen unopposed by progesterone
- Obesity
- Late menopause
- Early menarche
- Being a current smoker
- Nulliparity
- Aged over 35-years-old
- Tamoxifen
At what point in the menstrual cycle can the IUD be inserted?
Any time
It can also be fitted immediately after first or second-trimester abortion, and from 4 weeks postpartum.
What’s the difference between an IUD and an IUS?
conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena)
both the IUD and IUS are more than 99% effective
Uses of IUS
- contraception
- menorrhagia
Mode of action of intrauterine contraceptive devices
- 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
From when are intrauterine devices effective?
IUD is effective immediately following insertion
IUS can be relied upon after 7 days
Risks of intrauterine devices
- 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
What advice do you give for couples wishing to become pregnant?
- folic acid
- aim for BMI 20-25
- advise regular sexual intercourse every 2 to 3 days
- smoking/drinking advice
12 months before referral
When is fertility testing done and what does it involve?
12 months of trying to conceive
- semen analysis in the man
- mid-luteal progesterone level in the female to confirm ovulation (7 days prior to beginning next period)
When would you consider early referral to a fertility clinic?
Female
- Age above 35
- Amenorrhoea
- Previous pelvic surgery
- Previous STI
- Abnormal genital examination
Male
- Previous surgery on genitalia
- Previous STI
- Varicocele
- Significant systemic illness
- Abnormal genital examination
What’s the incidence of infertility?
1 in 7 couples
Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years
Causes of infertility
- male factor 30%
- unexplained 20%
- ovulation failure 20%
- tubal damage 15%
- other causes 15%
What are the possible results and management for progesterone test?
< 16 nmol/l
Repeat, if consistently low refer to specialist
16 - 30 nmol/l
Repeat
> 30 nmol/l
Indicates ovulation
When would you check for gonadotrophins?
to check for ovarian function in patients with irregular menstrual cycles
A 38-year-old woman complains that she is experiencing hot flushes and has not had a period for the past five months. She is worried that she going through an ‘early menopause’.
What is the most appropriate investigation to diagnose premature ovarian failure?
Follicle stimulating hormone (FSH) level is raised significantly in menopausal patients. Test FSH to confirm menopause. At menopause (and in premature ovarian failure), ovarian function ceases, leading to high levels of FSH due to the removal of the negative feedback mechanisms.
Define premature ovarian failure. How common is it?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.
What are the causes of premature ovarian failure?
- idiopathic - the most common cause
- chemotherapy
- autoimmune
- radiation
Features of premature ovarian failure or menopause
- climacteric symptoms: hot flushes, night sweats
infertility - secondary amenorrhoea
- raised FSH, LH levels
What’s the condition?
post-menopausal patient with pain during sex and dryness, they may also have some postcoital bleeding
Vaginal atrophy
What is the criteria for a confirmed miscarriage?
A confirmed miscarriage can be diagnosed on ultrasound if there is no cardiac activity and:
- The crown-rump length is greater than 7mm OR
- The gestational sack is greater than 25mm
What is a cervical ectropion and what causes it? What features can it cause?
- 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
Features:
- vaginal discharge
- post-coital bleeding
What’s the most common cause of PPH?
Uterine atony
The uterus to contract fully following the delivery of the placenta, which hinders the achievement of haemostasis
Management of PPH due to uterine atony
- bimanual uterine compression to manually stimulate contraction
- intravenous oxytocin and/or ergometrine
- intramuscular carboprost
- intramyometrial carboprost
- rectal misoprostol
- surgical intervention such as balloon tamponade