Obstetrics and Gynaecology Flashcards
Management of ovarian enlargement in post menopausal women
Urgent referral to gynaecology
Management of ovarian enlargement in premenopausal women
Conservative
Repeat ultrasound in 8-12 weeks and refer if persists
How many couples are affected by infertility?
1 in 7
Causes of infertility
Male factor - 30%
Unexplained - 20%
Ovulation failure - 20%
Tubal damage - 15%
Basic investigations for infertility
Semen analysis
Serum progesterone 7 days prior to expected next period (day 21 ish)
Interpretation of progesterone for infertility
<16 = repeat, if consistently low refer
16-30 = repeat
> 30 = ovulation
Key counselling points for couples with infertility
92% conceive within 2 years
Folic acid
Aim BMI 20-25
Sex every 2-3 days
Smoking/drinking advice
Treatment for Bartholin’s abscess
Antibiotics
Ward catheter
Marsupialization
Presentation of Bartholin’s cyst
Asymptomatic
Soft painless lump in labium
What is a cervical ectropion?
Larger area of columnar epithelium present on ectocervix
due to elevated oestrogen levels
Causes of superficial dyspareunia
Lack of sexual arousal
Vaginal atrophy (e.g. post menopause)
Vaginitis secondary to infection
Painful episiotomy scar
Vaginismus
Causes of deep dysparenunia
PID
Endometriosis
Cervicitis secondary to infection
Prolapsed ovaries in the pouch of douglas
Adenomyosis
Fixed retroverted uterus
Management of endometrial hyperplasia
Simple without atypia = high dose progesterones with repeat sampling in 3-4 months
Atypia = hysterectomy
Type 1 female genital mutilation
Partial or total removal of clitoris and/or prepuce
Type 2 female genital mutilation
Partial or total removal of the clitoris and labia minor, with or without excision of labia majora
Type 3 female genital mutilation
Narrowing of vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora, without or without excision of the clitoris
What is fibroid degeneration?
Growth of uterine fibroid outstrips blood supply
Presentation of fibroid degeneration
Low grade fever
Pain
Vomiting
Management of fibroid degeneration
Rest, analgesia
Should resolve in 4-7 days
What is vulval intraepithelial neoplasia?
Pre-cancerous skin lesion of the vulva, risk of squamous skin cancer
Presentation of vulval intraepithelial neoplasia
Itching, burning
Raised, well defined skin lesions
Risk factors for vulval intraepithelial neoplasia
HPV 16 and 18
Smoking
HSV 2
Lichen planus
Features of vulval carcinoma
Lump or ulcer on labia majora
Inguinal lymphadenopathy
Itching, irritation
Vaginal discharge in trichomonas vaginalis
offensive, yellow/green, frothy
Vaginal discharge in bacterial vaginosis
offensive, thin, white/grey, fishy odour
When should semen analysis be performed?
After a minimum of 3 days and maximum of 5 days abstience
Needs to arrive at the lab within 1 hour
Normal semen volume
> 1.5ml
Normal semen pH
> 7.2
Normal sperm concentration
> 15 million/ml
Normal sperm morphology
> 4% normal forms
Normal sperm motility
> 32% progressive motility
Normal sperm vitality
> 58% live spermatozoa
Define recurrent miscarriage
3 or more consecutive spontaneous miscarriage
Causes of recurrent miscarriage
Antiphospholipid syndrome
Endocrine disorders e.g. diabetes/thyroid, PCOS
Uterine abnormality e.g. uterine septum
Parental chromosomal abnormalities
Smoking
Causes of pruritis vulvae
Irritant contact dermatitis e.g. latex condoms, lubricants
Atopic dermatitis
Seborrhoeic dermatitis
Lichen planus
Lichen sclerosus
Psoriasis
Management of pruritis vulvae
Take showers not baths
Clean with emollient e.g. diprobase
Clean only once a day
Topical steroids
Steroid-antifungal if seborrhoeic dermatitis suspected
Medical options for management of premenstrual syndrome
Combined oral contraceptive pill e.g. Yasmin
SSRI either continuously or during luteal phase
Indication for letrozole
Ovulation induction in PCOS
Side effects of letrozole
Fatigue
Dizziness
Side effects of clomifene
Hot flushes
N+V
Abdo distension and pain
What is ovarian hyperstimulation syndrome?
Ovarian enlargement with multiple cyst spaces, fluid shifts from intravascular to extra vascular space
Complications of ovarian hyperstimulation syndrome
Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism
Management of ovarian hyperstimulation syndrome
Fluid and electrolyte replacement
Anticoagulation therapy
Abdominal ascitic paracentesis
Pregnancy termination if critically unwell
What type of ovarian cyst is called ‘chocolate cyst’?
Endometriotic cyst
Most common cause of first trimester miscarriage?
Antiphospholipid syndrome
How does combined oral contraception work?
Inhibits ovulation
How does progesterone only pill work?
Thickens cervical mucus
How does injectable contraceptive work?
Inhibits ovulation
also: thickens cervical mucus
How does implantable contraceptive work?
Inhibits ovulation
also: thickens cervical mucus
How does intrauterine contraceptive device work?
Decreases sperm motility and survival
How does the intrauterine system work?
Prevents endometrial proliferation
also: thickens cervical mucus
How to stop implant, POP, or IUS in women age 50
Check FSH
Stop if FSH >30
or stop at 55 years
How to stop depo-provera in women age 50
Switch to non-hormonal method and stop after 2 years amenorrhoea
or switch to progesterone
When to stop non-hormonal contraception in women over 40
Stop after 2 years amenorrhoea if <50
Stop after 1 year amenorrhoea if >50
What are the methods of emergency contraception?
Levonorgestrel
Ulipristal
Intrauterine contraceptive device
How does levonorgestrel work?
Inhibits ovulation
How does ulipristal work?
Inhibits ovulation
How does intrauterine contraceptive device work?
Toxic to sperm and ovum
Inhibits implantation
Contraception in obese patients
Transdermal patch less effective over 90kg
COCP is class 2 for BMI 30-34, class 3 for BMI >35
People with bariatric surgery cannot have oral contraception including emergency contraception
What is dianette licensed for?
Severe acne in women
Moderately severe hirsuitism
Female sterilisation failure rate
1 per 200
Complications for female sterilisation
Increased risk of ectopic if sterilisation fails
Complications of GA/laparoscopy
Success rate of female sterilisation reversal
50-60%
How soon after childbirth can an intrauterine device or system be inserted?
Within 48 hours or after 4 weeks
When after childbirth can you start combined oral contraception?
6 weeks if breastfeeding
Sooner if not
Additional contraception first 7 days
How long after abortion can you start combined oral contraceptive?
Immediately
Protected from pregnancy straight away
How long until the IUD gives effective contraception?
instant
How long until the POP gives effective contraception?
2 days
How long until the COCP gives effective contraception?
7 days
How long until depro vera gives effective contraception?
7 days
How long until the implant gives effective contraception?
7 days
How long until the IUS gives effective contraception?
7 days
Which cancers does the COCP increase your risk of?
Breast and cervical
Which cancers does COCP decrease your risk of?
Ovarian, endometrial and colorectal
What is the best method of contraception for patients who are taking enzyme inducers?
Depro Vera
How long after giving birth do you need to start contraception?
21 days
How does IUD work?
Prevents fertilisation by causing reduced sperm motility and survival
How long does it take IUD to work?
immediate
How long does IUD last?
5 to 10 years depending on type
How does IUS work?
Prevents endometrial proliferation
Causes cervical mucous thickening
How long does it take IUS to work?
7 days
How long does IUS last?
5 years if for contraception
4 years if for HRT reasons
How long does Jaydess work?
3 years
How long does Kyleena work?
5 years
Rate of uterine perforation with coil insertion
2 in 1000
Higher if breastfeeding
Risks with coil insertion
Perforation
Ectopic pregnancy proportion higher
Higher risk of PID for 20 days
Expulsion
Rate of expulsion in coil insertion
1 in 20
How long after delivery can you have a coil?
in the first 48 hours or after 4 weeks
Absolute contraindications to progesterone only pill
Breast cancer in the last 5 years
POP - missed a pill >12 hours late
Take pill and continue pack
Extra precautions for 2 days
How does POP work?
Inhibits ovulation
How long does POP take to give protection?
Immediate if started up to day 5 of cycle
Otherwise 2 days
How long does POP take to give protection if switching from COCP?
Immediate if continued from end of pill packet
Adverse effects of injectable progesterone (depo provera)
irregular bleeding
weight gain
increased risk of osteoporosis (not good for adolescents)
How does depo provera work?
inhibits ovulation
secondary effects - cervical mucous thickening, endometrial thickening
How long does it take for fertility to return after stopping depo provera?
up to 12 months
How long does nexplanon take to give protection?
7 days
How does nexplanon work?
Prevents ovulation
How long after termination of pregnancy can nexplanon be inserted?
Immediately
Differences of nexplanon to implanon
Applicator prevents deep insertion
Radioopaque
How do you use the combined patch?
Wear for three weeks, changing each week
One week off
What to do if patch change delayed at the end of week 1 or week 2
If <48 hours then change immediately, no further action
If >48 hours then change immediately and extra measures for 7 days
What to do if patch change is delayed at the end of week 3
Remove patch
New patch applied on usual start date
No extra measures
What to do if patch is delayed at the end of patch free week
Barrier contraception for 7 days
Options for emergency contraception
Levonorgestrel (levonelle)
Ulipristal (ella one)
Intrauterine device
How does levonorgestrel emergency contraception work?
Stops ovulation
Inhibits implantation
Within what time frame do you have to use levonorgestrel?
72 hours
Dose of levonorgestrel
1.5mg stat
DOUBLE DOSE if BMI >26 or weight lover 70kg
How does ulipristal emergency contraception work?
inhibits ovulation
Within what time frame do you have to use ulipristal?
120 hours
How long after ulipristal can you start hormonal contracpetion?
5 days
Which patient group should you avoid giving ulipristal to?
Asthmatics
In what time frame can you use the intrauterine device for emergency contraception?
Within 5 days or up to 5 days after the likley ovulation date
How does intrauterine device work for emergency contraception?
Inhibits fertilisation or implantation
Which UKMEC for COCP?
Migraine with aura
UKMEC 4
Which UKMEC for COCP?
>35 years and smoke >15 cigarettes
UKMEC 4
Which UKMEC for COCP?
History of VTE, stroke or IDH
UKMEC 4
Which UKMEC for COCP?
Breastfeeding less than 6 weeks post partum
UKMEC 4
Which UKMEC for COCP?
>35 years smoking <15 cigarettes
UKMEC 3
Which UKMEC for COCP?
BMI >35
UKMEC 3
Which UKMEC for COCP?
FHx of thromboembolism in a first degree relative under 45
UKMEC 3
Which UKMEC for COCP?
Uncontrolled HTN
UKMEC 4
Which UKMEC for COCP?
Current gallbladder disease
UKMEC 3
COCP - missed 1 pill
Take the last pill, no extra measures
COCP - missed 2 pills in week 1 of cycle
Emergency contraception
Take pill
Condoms for 7 days
COCP - missed 2 pills in week 2 of cycle
As long as taken for 7 days before then don’t need extra measures
COCP - missed 2 pills in week 3
Finish pill in current pack then start new pack, missing the free pill week
Condoms for 7 days
Patterns of bleeding with nexplanon
2 in 10 amenorrhoeic
3 in 10 infrequent bleeding
2 in 10 prolonged bleeding
Fewer than 1 in 10 have frequent bleeding
How long does it take COCP to be effective?
Immediately if in first 5 days
Otherwise 7 days
Management of urge incontience
Bladder retraining
Oxybutynin
Tolerodine
Micabegron
Drug management of urge incontinence in elderly/frail
Micabegron
Management of stress incontience
Pelvic floor muscle training
Surgery
Duloxetine
How often do you have to do pelvic floor muscle training exercises in stress incontience management?
8 contractions three times a day for three months
Management of pelvic inflammatory disease
Oral ofloxacin + oral metronidazole
OR
IM ceftriaxone + oral metronidazole
Risk of infertility with pelvic inflammatory disease
10-20%
Complications from pelvic inflammatory disease
Perihepatitis
Infertility
Chronic pelvic pain
Ectopic pregnancy
Management of hersutism in PCOS
Oral contraceptive pill
Topical eflornithine
Management of infertility in PCOS
Weight reduction
Clomifene
Metformin
Investigations in PCOS
Pelvic US - multiple cysts
Low FSH, high LH
Normal or slightly high testosterone
Normal or high prolactin
What is premature ovarian failure?
Onset of menopausal symptoms and elevated gonadotrophin levels before age 40
Investigations for premature ovarian failure
Raised FSH and LH (fsh >40)
Low oestradiol (<100)
Causes of premature ovarian failure
Idiopathic
Bilateral oophorectomy
Radio/chemo
Infection e.g. mumps
Autoimmune disorders
Resistant ovary syndrome due to FSH receptor abnormalities
What percentage of women get uterine fibroids?
20% white women
50% black women
Medical management to shrink uterine fibroids
GnRH agonists
Management of vaginal candidiasis
Clotrimazole pessary
Fluconazole 150mg
Only local treatments if pregnant
What counts as recurrent vaginal candidiasis?
≥ 4 episodes per year