OBGYN Flashcards
What is involved in female hormone testing for infertility? What do they indicate?
- Serum LH and FSH on day 2 to 5 of the cycle
- Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
- Anti-Mullerian hormone
- Thyroid function tests when symptoms are suggestive
- Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
High FSH = poor ovarian reserve
High LH = ?PCOS
Anti-Mullerian hormone indicates ovarian reserve
What imaging investigations can be done in female infertility?
- Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
- Hysterosalpingogram to look at the patency of the fallopian tubes
- Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
What is the management of anovulation?
- weight loss in PCOS
- clomifene (stimulates ovulation)
- letrozole 2nd
- gonadotrophins if resistant to clomifene
- ovarian drilling in PCOS
- metformin if insulin sensitivity and obesity
How does clomifene work?
anti-oestrogen (selective oestrogen receptor modulator)
given on days 2-6 of cycle
stops negative feedback of oestrogen on hypothalamus => inc in GnRH => inc in FSH and LH
What is the management of tubal factors?
- Tubal cannulation during a hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- In vitro fertilisation (IVF)
What is a suitable contraception in someone with breast cancer?
Avoid hormonal contraception, use copper coil or barrier method
What is a suitable contraception in someone with cervical or endometrial cancer?
Avoid intrauterine system e.g. Mirena coil
What is a suitable contraception in someone with Wilson’s disease?
Avoid copper coil
What are some contraindications for COCP?
- Uncontrolled hypertension (particularly ≥160 / ≥100)
- Migraine with aura
- History of VTE
- Aged over 35 smoking more than 15 cigarettes per day
- Major surgery with prolonged immobility
- Vascular disease or stroke
- Ischaemic heart disease, cardiomyopathy or atrial fibrillation
- Liver cirrhosis and liver tumours
- Systemic lupus erythematosus and antiphospholipid syndrome
- Breastfeeding before 6 weeks postpartum
How long after menopause is contraception still required?
2 years in women under 50 and 1 year in women over 50
What contraception should not be used in women over 50 and why?
progesterone injection (Depo-Provera) due to risk of osteoporosis
How long should amenorrhoeic women keep taking POP?
- until FSH > 30 IU/L on 2 tests 6 wks apart then cont contraception for 1 more year OR
- 55 years of age
How long before fertility returns after childbirth?
21 days
lactational amenorrhoea is 98% effective for up to 6 months (if fully breastfeeding)
What contraception can be used after childbirth?
POP and implant are safe at any time
Copper coil or Mirena coil can be inserted either within 48hrs of birth or 4 weeks after but not in between
COCP should be avoided in breastfeeding before 6 weeks post partum
How does COCP prevent pregnancy?
- Preventing ovulation (this is the primary mechanism of action)
- Progesterone thickens the cervical mucus
- Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
How do oestrogen and progesterone affect the hypothalamus and anterior pituitary?
They suppress the release of GnRH, LH, and FSH through negative feedback.
Why are pills containing drospirenone (e.g., Yasmin) used for premenstrual syndrome?
Drospirenone has anti-mineralocorticoid and anti-androgen effects that help with bloating, water retention, and mood changes.
What COCP is used for treating acne and hirsutism, and why is its use limited?
Dianette (containing cyproterone acetate); it has a higher risk of venous thromboembolism (VTE) and is usually stopped after acne control.
What are the three common regimes for taking the COCP?
21 days on, 7 days off; 63 days on, 7 days off (tricycling); continuous use without a pill-free period.
How should the COCP be started to provide immediate contraceptive protection?
On the first day of the menstrual cycle.
What is the protocol when switching from a traditional progesterone-only pill to the COCP?
Extra contraception (e.g., condoms) is required for 7 days.
What are common side effects in the first three months of COCP use?
Unscheduled bleeding, breast pain, mood changes, headaches, and hypertension.
What are the long-term risks associated with COCP use?
Small increased risk of venous thromboembolism, breast and cervical cancer, myocardial infarction, and stroke.
What are some benefits of the COCP?
Effective contraception, rapid return of fertility, and reduced risks of endometrial, ovarian, and colon cancer.
What BMI level is a relative contraindication (UKMEC 3) for the COCP?
A BMI above 35.
What should be done if a woman misses one pill?
Take the missed pill as soon as possible, and no extra contraception is required if the other pills are taken correctly.
What should be done if more than one pill is missed (72 hours since the last pill)?
Take the most recent missed pill and use additional contraception (e.g., condoms) for 7 days.
When is emergency contraception required after missing more than one pill?
If more than one pill is missed between day 1 – 7 of the packet and unprotected sex has occurred.
What is the only UKMEC 4 contraindication for using the POP?
Active breast cancer.
What are the two types of progestogen-only pills?
Traditional POP (e.g., Norgeston, Noriday) and desogestrel-only POP (e.g., Cerazette).
What is the time limit for taking the traditional POP and still being protected?
It must be taken within 3 hours of the scheduled time.
What is the time limit for taking the desogestrel-only POP and still being protected?
It can be taken up to 12 hours late and still be effective.
How do traditional progestogen-only pills work?
By thickening the cervical mucus, altering the endometrium, and reducing ciliary action in the fallopian tubes.
What is the primary mechanism of action of the desogestrel-only pill?
Inhibiting ovulation
(+thickening the cervical mucus, altering the endometrium, and reducing ciliary action in the fallopian tubes)
When does the POP provide immediate protection from pregnancy?
When started between day 1 to 5 of the menstrual cycle.
How long does it take for the POP to thicken cervical mucus enough to prevent sperm entry?
48 hours.
When switching from a COCP to a POP, when can the POP be started without extra contraception?
If the woman has taken the COCP consistently for more than 7 days or is on days 1-2 of the hormone-free period.
What is the most common side effect of the POP?
What other side effects can occur with the POP?
Changes in the bleeding schedule (unscheduled bleeding).
Breast tenderness, headaches, and acne.
What are the risks associated with the traditional POP?
Increased risk of ovarian cysts, small risk of ectopic pregnancy, and minimal increased risk of breast cancer.
What should be done if a POP is missed?
Take the missed pill as soon as possible, continue with the next pill at the usual time, and use extra contraception for 48 hours.
How often is the DMPA/progesterone-only injection given?
Every 12 to 13 weeks.
How long can it take for fertility to return after stopping the DMPA?
Up to 12 months.
What are the two versions of DMPA used in the UK?
Depo-Provera (intramuscular) and Sayana Press (subcutaneous, self-injectable).
What is the UK MEC 4 contraindication for DMPA?
Active breast cancer.
Name a few UK MEC 3 conditions where DMPA use is cautioned.
Ischaemic heart disease, stroke, unexplained vaginal bleeding, severe liver cirrhosis, liver cancer.
Why is osteoporosis a concern with DMPA?
It decreases bone mineral density due to suppressed estrogen production.
At what age is DMPA UK MEC 2, and when should women consider switching to an alternative?
MEC 2 for women over 45 years, and switching should occur by age 50.
What is the main action of the DMPA injection? What other mechanisms contribute to DMPA’s contraceptive effects?
Inhibition of ovulation by suppressing FSH secretion from the pituitary gland.
Thickening cervical mucus and altering the endometrium.
What is the lifetime risk of developing breast cancer for women?
Approximately 1 in 8 women will develop breast cancer in their lifetime.
Name risk factors for developing breast cancer.
- Increased estrogen exposure,
- more dense breast tissue,
- obesity,
- smoking, and
- family history (first-degree relatives).
How does the combined contraceptive pill affect breast cancer risk?
It gives a small increase in risk, but this risk returns to normal ten years after stopping the pill.
What type of hormone replacement therapy (HRT) increases breast cancer risk?
Combined HRT (containing both estrogen and progesterone).
What are the BRCA genes?
Tumor suppressor genes that, when mutated, increase the risk of breast cancer, as well as ovarian and other cancers.
What is the risk of breast cancer by age 80 for women with a faulty BRCA1 gene?
Around 70% will develop breast cancer by age 80.
What is the risk of ovarian cancer by age 80 for women with a faulty BRCA2 gene?
Around 20%
What does Ductal Carcinoma In Situ (DCIS) signify?
Pre-cancerous or cancerous epithelial cells in the breast ducts, localized to a single area.
What is Lobular Carcinoma In Situ (LCIS)?
A pre-cancerous condition usually found in pre-menopausal women, often asymptomatic and diagnosed incidentally.
How common is Invasive Ductal Carcinoma (NST)?
It makes up about 80% of invasive breast cancers.
Describe Inflammatory Breast Cancer.
It accounts for 1-3% of breast cancers and presents with swollen, warm, tender breast tissue, often mimicking an abscess.
What is Paget’s Disease of the Nipple?
It appears as an erythematous, scaly rash on the nipple, indicating potential underlying breast cancer.
What is the NHS breast cancer screening program?
It offers a mammogram every 3 years for women aged 50-70
What criteria may warrant referral for patients at higher risk due to family history?
A first-degree relative with breast cancer under 40,
a first-degree male relative with breast cancer,
or two first-degree relatives with breast cancer.
What are some clinical features that may suggest breast cancer?
Hard, irregular, painless lumps; nipple retraction; skin dimpling; lymphadenopathy in the axilla.
What may be offered to high-risk women for breast cancer prevention?
Chemoprevention with Tamoxifen (if premenopausal) or Anastrozole (if postmenopausal).
What is the NICE guideline for urgent referral of suspected breast cancer?
A two-week wait referral for unexplained breast lumps in patients aged 30 or above, unilateral nipple changes in patients aged 50 or above, unexplained lump in the axilla in patients aged 30 or above, and skin changes suggestive of breast cancer.
What comprises the triple diagnostic assessment for suspected breast cancer?
Clinical assessment, imaging (ultrasound or mammography), and biopsy.
What are the surgical options for breast cancer treatment?
Breast-conserving surgery (e.g., wide local excision) and mastectomy (removal of the whole breast).
What are the two main types of hormone treatment for oestrogen-receptor positive breast cancer?
Tamoxifen for premenopausal women and aromatase inhibitors for postmenopausal women.
What is the follow-up recommendation for breast cancer survivors?
Yearly surveillance mammograms for 5 years.
What is a fibroadenoma, and who is it most commonly found in? Describe the characteristics of a fibroadenoma.
A fibroadenoma is a common benign tumor of breast duct tissue, typically found in women aged 20-40.
Fibroadenomas are painless, smooth, round, well-circumscribed, firm, and mobile lumps, usually up to 3 cm in diameter.
What are fibrocystic breast changes, and how are they classified?
Fibrocystic breast changes are a normal variation characterized by lumpiness and tenderness, fluctuating with the menstrual cycle. They are considered a benign condition.
What symptoms are associated with fibrocystic breast changes?
Lumpiness, breast pain (mastalgia), and fluctuation of breast size.
How are fibrocystic breast changes managed?
Management includes excluding cancer and addressing symptoms through supportive bras, NSAIDs, avoiding caffeine, heat application, and hormonal treatments.
What are breast cysts, and when do they commonly occur? What are the characteristics of breast cysts?
Breast cysts are benign, fluid-filled lumps most common between ages 30 and 50, particularly during the perimenopausal period.
Breast cysts are smooth, well-circumscribed, mobile, and possibly fluctuating lumps.
What is fat necrosis, and what causes it? Describe the appearance of fat necrosis on examination.
Fat necrosis is a benign lump formed by localized degeneration of fat tissue, commonly triggered by trauma, radiotherapy, or surgery.
Fat necrosis can be painless, firm, irregular, and may be fixed in local structures, sometimes causing skin dimpling or nipple inversion.
What is a lipoma, and how is it characterized?
A lipoma is a benign tumor of fat tissue, typically soft, painless, mobile, and without skin changes.
What is a galactocele, and in which population does it occur?
A galactocele is a milk-filled cyst that occurs in lactating women, often after stopping breastfeeding.
What are phyllodes tumors, and what is their potential behavior?
Phyllodes tumors are rare tumors of breast connective tissue, which can be benign, borderline, or malignant, with the potential to metastasize.
What is the primary treatment for phyllodes tumors?
Surgical removal of the tumor and surrounding tissue, with possible chemotherapy for malignant cases.
What is mammary duct ectasia?
Mammary duct ectasia is a benign condition characterized by dilation of the large ducts in the breasts, often associated with inflammation.
What type of nipple discharge is associated with mammary duct ectasia?
The discharge may be white, grey, or green.
In which population is mammary duct ectasia most frequently observed?
It most frequently occurs in perimenopausal women.
What is a significant risk factor for developing mammary duct ectasia?
Smoking is a significant risk factor.
What are common presentations of mammary duct ectasia?
Common presentations include nipple discharge, tenderness or pain, nipple retraction or inversion, and a breast lump that may discharge when pressure is applied.
What is a key finding on a mammogram associated with mammary duct ectasia? What other investigations may be performed for mammary duct ectasia?
Microcalcifications are a key finding, although they are not specific to this condition.
Other investigations include ductography, nipple discharge cytology, and ductoscopy.
How does mammary duct ectasia typically resolve? What management strategies may be used for mammary duct ectasia?
Mammary duct ectasia may resolve without treatment and is not associated with an increased risk of cancer.
Management may include reassurance after excluding cancer, symptomatic management of mastalgia, antibiotics for suspected infection, or surgical excision (microdochectomy) in problematic cases.
What is an intraductal papilloma?
An intraductal papilloma is a benign warty lesion that grows within one of the ducts in the breast, resulting from the proliferation of epithelial cells.
What is the typical presentation of an intraductal papilloma?
The typical presentation includes clear or blood-stained nipple discharge, tenderness or pain, and a palpable lump.
They are often asymptomatic and may be detected incidentally on mammograms or ultrasounds.
At what age do intraductal papillomas most commonly occur?
They most often occur between the ages of 35 and 55 years.
How can ductography be used in the diagnosis of intraductal papillomas?
Ductography involves injecting contrast into the abnormal duct and performing mammograms to visualize that duct; the papilloma appears as an area that does not fill with contrast (a “filling defect”).
What is the management for intraductal papillomas?
Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been detected on biopsy.
What is the management of lactational mastitis?
management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.
If fever/suspected infection: Flucloxacillin is the first line, or erythromycin.
A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.
Women should be encouraged to continue breastfeeding
What is the treatment in candida of the nipple in a breastfeeding person?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% to the nipple, after each breastfeed
- Treatment for the baby (e.g., oral miconazole gel or nystatin)
What are the typical presentations of mastitis or breast abscesses?
Symptoms include nipple changes, purulent nipple discharge, localized pain, tenderness, warmth, erythema, hardening of the skin, and swelling.
What feature suggests the presence of a breast abscess?
A swollen, fluctuant, tender lump within the breast suggests a breast abscess.
What antibiotics are recommended for non-lactational mastitis?
Co-amoxiclav or erythromycin/clarithromycin plus metronidazole are recommended for non-lactational mastitis.
What is required for the management of a breast abscess?
Management requires referral to the surgical team, antibiotics, ultrasound for diagnosis, drainage, and microscopy, culture, and sensitivities of the drained fluid.
What causes urge incontinence?
Urge incontinence is caused by overactivity of the detrusor muscle of the bladder.
What is stress incontinence?
Stress incontinence occurs due to weakness of the pelvic floor and sphincter muscles, allowing urine to leak during increased pressure (e.g., laughing, coughing).
What is overflow (urinary) incontinence?
Overflow incontinence occurs when there is chronic urinary retention, leading to leakage without the urge to urinate.
What are common causes of overflow incontinence?
Causes include obstruction, anticholinergic medications, fibroids, pelvic tumors, and neurological conditions.
What are some risk factors for urinary incontinence?
Risk factors include increased age, postmenopausal status, high BMI, previous pregnancies, pelvic organ prolapse, and neurological conditions.
What tests can help investigate urinary incontinence?
Urine dipstick testing, post-void residual volume measurement, and urodynamic testing may be performed.
How is stress incontinence managed?
Management involves pelvic floor exercises, lifestyle modifications, medications (like Duloxetine), and possibly surgery.
What surgical options exist for stress incontinence?
Surgical options include tension-free vaginal tape procedures, autologous sling procedures, colposuspension, and intramural urethral bulking.
What is the first-line treatment for urge incontinence?
Bladder retraining is the first-line treatment for urge incontinence.
What medications are commonly used for urge incontinence?
Anticholinergic medications (e.g., oxybutynin, tolterodine) and mirabegron are commonly used.
What are some potential side effects of anticholinergic medications?
Side effects can include dry mouth, urinary retention, constipation, cognitive decline, and worsening of dementia.
What are invasive options for managing overactive bladder?
Invasive options include botulinum toxin injections, percutaneous sacral nerve stimulation, augmentation cystoplasty, and urinary diversion.
What precautions should be taken when using mirabegron?
Blood pressure should be monitored regularly, as mirabegron is contraindicated in uncontrolled hypertension.
What is an endometrioma, and what is it commonly called?
An endometrioma is a lump of endometrial tissue outside the uterus, often referred to as a “chocolate cyst” when located in the ovaries.
What does adenomyosis refer to?
Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.
What is the exact cause of endometriosis?
The exact cause is unclear, but theories include retrograde menstruation, embryonic cell development, lymphatic spread, and metaplasia of cells.
What are the main symptoms of endometriosis?
The main symptom is pelvic pain, but it can also include cyclical abdominal or pelvic pain, dyspareunia, dysmenorrhea, infertility, and cyclical bleeding from other sites.
What complications can arise from endometriosis?
Complications include chronic non-cyclical pain due to adhesions, reduced fertility, and potential bleeding in urine or stools.
