Obstetrics & Gynaecology/Contraception/Sexual Health Flashcards
(264 cards)
1
Q
What criteria can be used when choosing appropriate contraception?
A
WHO Eligibility criteria- graded 1-4 from no restriction to unacceptable risk
2
Q
How does the COCP work?
A
Acts on hypothalamic-pituitary-ovarian axis, suppresses synthesis and secretion of FSH + LH - inhibits development of ovarian follicles + ovulation
- -> Increased cervical mucus
- -> Reduces endometrial receptivity to prevent implantation
3
Q
Pros of COCP
A
Very effective and reversible
Can relieve menstrual problems, endometriosis
Reduces risk of ovarian, endometrial and colorectal cancer
Can take up to 24hrs after missed pill- take 2
4
Q
Cons of COCP
A
Breakthrough bleeding, mood swings, breast tenderness
Increased risk VTE, MI, Stroke
Increased risk breast cancer
5
Q
Contraindications to the COCP
A
Migraine with aura, <6wks postpartum, smoker age > 35, Hypertension, Hx VTE, ischaemic heart disease, Hx CVA, active breast ca, diabetes with complications
6
Q
How does the progesterone-only pill work?
A
Inhibits ovulation, delayed transport of ovum, thickens cervical mucus, endometrium unsuitable for implantation
7
Q
Pros of progesterone-only pill
A
Reliable + reversible Avoids CNS risk of oestrogen Can be used when CIs for oestrogen Can be used during breast-feeding Can be used up to age 55
8
Q
Cons of progresterone-only pill
A
Menstrual problems eg amenorrhoea + breakthrough bleeding
Only 3hr window
Increased risk functional ovarian cysts
Risk of ectopic
9
Q
Contraindications to the progesterone-only pill
A
Hx breast ca, stroke, coronary heart disease, SLE
10
Q
How does the DEPO injection work?
A
Suppresses ovulation, makes endometrium unsuitable for implantation, increases thickness of cervical mucus
11
Q
Pros of DEPO
A
Effective and convenient
Can be used during breastfeeding
Amenorrhoea common
12
Q
How often is DEPO given?
A
Every 12 weeks
13
Q
Cons of DEPO
A
Not quickly reversible- delayed return to fertility up to 1yr
Associated with breast and cervical cancer
Reduced bone density
Proven weight gain
14
Q
Contraindications to DEPO
A
<18s, breast cancer, liver impairment, risk of VTE
15
Q
How does the contraceptive implant work?
A
Contains etonogestrel
Inhibits ovulation, thickens cervical mucus, thins endometrium
16
Q
Pros of contraceptive implant
A
Very effective
Long duration of action
Reversible
Reduction in menstrual problems eg dysmenorrhoea
17
Q
Cons of contraceptive implant
A
Irregular bleeding, changes in weight, mood and libido
18
Q
Contraindications to contraceptive implant
A
Active breast cancer
19
Q
How does the copper IUD work?
A
Fertilisation prevented
Effect of copper on cervical mucus –> reduced penetration by sperm
Endometrial inflammatory reaction –> anti-implantation effect
20
Q
Pros of copper IUD
A
Very effective, reversible Effective directly after fitting- emergency contraception No hormones Effective up to 10yrs Reduced risk of endometrial cancer Immediate return to fertility on removal
21
Q
Cons of copper IUD
A
Insertion unpleasant Spotting, IMB, increased blood loss Pelvic pain Longer periods 1 in 20 expulsion/displacement Increased risk of PID Uterine perforation Ectopic pregnancy
22
Q
Contraindications to copper IUD
A
History of PID, recent STI exposure, up to 4wks post-partum, uterine abnormality eg fibroids, gynae cancer, copper allergy, immunosuppression
23
Q
How does IUS work?
A
Reduces endometrial growth and prevents implantation
Effects on cervical mucus prevent penetration by sperm
24
Q
Pros of IUS
A
Very effective and reversible
Reduces blood loss and dysmenorrhoea
Can be used for menorrhagia & endometrial protection with HRT
25
Cons of IUS
```
Insertion unpleasant
Menstrual irregularities in 1st 6 months
Progestogenic SEs: acne, breast tenderness, headache, mood changes
Dysfunctional ovarian cysts
Expulsion/perforation risk
```
26
Contraindications to IUS
Hx PID, recent STI exposure, up to 4 weeks postpartum, uterine abnormality eg fibroids, gynae cancer, VTE, IHD, immunosuppression
27
What methods can be used for emergency contraception?
1. Copper IUD
2. Ulipristal acetate
3. Levonorgestrel
28
How long after unprotected sex can Copper IUD be used for emergency contraception?
Up to 5 days
29
How does Ulipristal acetate work?
Delays or inhibits ovulation- selective progesterone modulator
30
How long after unprotected sex can Ulipristal acetate be used for emergency contraception?
Up to 120hrs
31
Contraindications to Ulipristal acetate?
Need to exclude pregnancy, severe liver disease, uncontrolled asthma, repeated use in same menstrual cycle
32
Side effects of Ulipristal acetate
N&V- repeat dose if vomit within 2hrs
| Dizziness, menstrual irregularities, abdominal/back/pelvic pain, headache, mood disorders
33
How does Levonorgestrel work?
Delays ovulation- needs to be used early in cycle
34
How long after unprotected sex can Ulipristal acetate be used for emergency contraception?
Up to 72hrs
35
Contraindications to Levonorgestrel
Severe liver disease, severe malabsorption
36
Side effects of Levonorgestrel
N&V- repeat dose if vomit within 2hrs
| Menstrual irregularities, dizziness, diarrhoea, breast tenderness
37
How can sexual dysfunction be grouped?
1. Desire- HSDD, Sexual aversion
2. Arousal- ED, FSAD, paraphilias
3. Orgasm- ejaculatory disorders
4. Resolution- pain disorders, dyspareunia, vaginismus
38
Define dyspareunia
Pain during intercourse
39
Causes of dyspareunia
Physiological: infection, injury, circumcision, interstitial cystitis, poor lubrication, menopause, vaginal atrophy, endometriosis, adhesions, IBS
Psychological: previous sexual abuse, insufficient relaxation
Relationship- poor partner technique, fear of intimacy
40
Management of dyspareunia
Steroid creams eg dermovate
Treat the cause
Couples therapy
41
What is Sexual Aversion Disorder?
Persistent or recurrent extreme aversion to and avoidance of all or almost all genital sexual contact with a sexual partner which causes distress or interpersonal difficulty
42
Management of Sexual Aversion Disorder?
Psychosexual therapy
43
What is Hypoactive Sexual Desire Disorder (HSDD)?
Deficient sexual fantasies and desire for sexual activity in the context of age and a person's life, not better accounted for by another condition
44
Causes of Hypoactive Sexual Desire Disorder (HSDD)
Cardiovascular disease, Diabetes, depression, androgen deficiency, hypothyroidism, Addison's disease, anti-depressants, COCP, previous trauma/abuse etc
45
Management of Hypoactive Sexual Desire Disorder (HSDD)
Androgen deficient- Androgen therapy
Testosterone replacement
Psychosexual therapy
46
What is Female Orgasmic Disorder?
Orgasm does not occur or is markedly delayed
47
Management of Female Orgasmic Disorder
Psychotherapy/behavioural interventions
48
What is Vaginismus?
Involuntary contraction of muscles around the entry point to the vagina
49
Causes of vaginismus
Thrush, FGM, fear, relationship dissatisfaction, previous sexual abuse/trauma
50
What is Erectile Dysfunction?
Difficulty attaining or maintaining an erection
51
Causes of Erectile Dysfunction
Cardiovascular disease, diabetes, psychological, neurogenic, endocrine, drugs (SSRIs, TCAs)
52
Management of Erectile Dysfunction
Manage risk factors
1st line drug- Oral phosphodiesterase-5-inhibitors- Sildenafil
Vaccuum device, psychological therapy
2nd line drug- Intraurethral/intercavernosal eg Alprostadil
53
What is rapid/premature ejaculation?
Inability to control ejaculations sufficiently for both partners to enjoy sexual interaction
54
Causes of rapid/premature ejaculation
Hyperthyroidism, Prostatitis, Penile hypersensitivity, Anxiety, Lack of sexual experience
55
Management of rapid/premature ejaculation
Therapy
Sertraline/Paroxetine
Local anaesthetic Lidocaine spray
56
What is Peyronie's disease?
Curvature and bend of penis due to plaques
57
Presentation of Peyronie's disease
Erectile dysfunction, pain and shortening of shaft of penis
58
What are Petok's 4 principles?
Relate to religion in sexual health problems
1. Ask about religious beliefs in initial visit
2. Ask about religious teachings regarding sexual behaviour
3. When in doubt, consult with a religious expert
4. Help couples to set reasonable expectations consistent with their beliefs
59
What are the 4 couples therapy approaches?
1. Cognitive-behavioural
2. Psychodynamic
3. Systemic
4. Integrative
60
What are the 5 key principles of couples therapy?
1. Improve communication
2. Modify dysfunctional behaviour
3. Decrease emotional avoidance
4. Change view of relationships
5. Promote strengths
61
Define paraphilia
Abnormal sexual desire, typically extreme or dangerous activities, desires are specific and unchanging
62
Define fetishism
Sexual fixation on a non-living object or non-genital body part
63
Define gender dysphoria
The distress experienced by an individual about their assigned gender which is in comflict with their internal gender identity
64
Management Trans-male
```
Testosterone injections
Psychotherapy
Store eggs?
Androgens/GnRH analogue
SALT
Male chest reconstruction
Hysterectomy + Bilateral oophorectomy
Phalloplasty
```
65
Management Trans-female
```
Oestrogens/anti-androgens
SALT
Facial hair removal
Vaginoplasty
Augmentation mammoplasty
Facial feminisation surgery
```
66
At what age can hormonal treatment start to be prescribed for transgender management?
Age 7
67
Define sex addiction
Compulsive participation or engagement in sexual activity
68
What is the causative organism in Syphilis?
Treponema pallidum
69
Presentation of Syphilis
Primary: days to weeks, chancre (painless genital sore)
Secondary: mths, gum lesions, rash, lymphadenopathy
Tertiary: years, gummatous, neuro, cardiac
70
Management of Syphilis
IM Penicillin
71
What type of infection is Trichomonas Vaginalis?
Protozoal
72
Presentation of Trichomonas Vaginalis
Green, frothy, smelly discharge
| Strawberry cervix
73
Green, frothy, smelly discharge
Strawberry cervix
What is the diagnosis?
Trichomonas Vaginalis
74
Diagnosis of Trichomonas Vaginalis
High vaginal swab
75
Management of Trichomonas Vaginalis
Metronidazole
76
What is the aetiology of Bacterial Vaginosis?
Anaerobes overgrowing normal vaginal flora
77
Presentation of Bacterial Vaginosis
Grey-white discharge with fishy odour
78
Grey-white discharge with fishy odour, what is the diagnosis?
Bacterial Vaginosis
79
Management of Bacterial Vaginosis
Metronidazole
80
What is the aetiology of thrush?
Candida albicans infection
81
Risk factors for thrush
Diabetes, pregnancy, tight clothing, over-washing
82
Presentation of thrush
Itching, local inflammation, superficial dyspareunia
| Odourless cottage cheese discharge
83
Itching, local inflammation, superficial dyspareunia
Odourless cottage cheese discharge
What is the diagnosis?
Thrush- candida albicans
84
Diagnosis of thrush
High vaginal/urethral swabs (low pH)
85
Management of thrush
Antifungals- Clotrimazole pessary or Fluclonazole tablets
86
Asymptomatic sexual health screening- Female
Swab for chlamydia/gonorrhoea NAAT
| Bloods for Syphilis/HIV
87
Asymptomatic sexual health screening- Male
1st void urine for chlamydia/gonorrhoea NAAT
| Bloods for Syphilis/HIV
88
Asymptomatic sexual health screening- MSM
1st void urine for chlamydia/gonorrhoea NAAT
Pharyngeal + rectal swabs for chl/gon NAAT
Bloods for Syphilis, Hep B and HIV
89
What is primary, secondary and tertiary prevention in sexual health?
Primary- reduce risk of acquiring STIs eg condoms, advice, hep B vaccine
Secondary- earlier identification of asymptomatic disease eg targeted screening, contact tracing
Tertiary- reduce morbidity/mortality eg treat the disease
90
What is the causative organism in Chlamydia?
Chlamydia trachomatis
91
Presentation of Chlamydia
Discharge, dysuria/pelvic pain, bleeding
92
Diagnosis of Chlamydia
1st void urine NAAT/endocervical swabs
93
Management of Chlamydia
1 week Azithromycin
94
What is the causative organism in Gonorrhoea?
Neisseria Gonorrhoea
| Gram -ve diplococci
95
Diagnosis of Gonorrhoea
1st void urine NAAT/endocervical swabs
96
Presentation of Gonorrhoea
Discharge, dysuria/pelvic pain, bleeding
97
Management of Gonorrhoea
Single-dose Ceftriaxone
98
What is classed as a prolonged 2nd stage of labour?
Nulliparous: >2hrs
Multiparous: >1hr
99
What is abnormal 1st stage of labour?
- Inefficient uterine contractions --> amniotomy + Syntocinon
- Cephalopelvic disproportion (malposition/malpresentation/inadequate pelvis) --> C section
100
Describe active management of the 3rd stage of labour
- IM Syntometrine/Syntocinon
- Deferred clamping + cutting of cord
- Controlled cord traction
101
What score is used to predict likelihood of successful vaginal delivery?
Bishops score
102
What is Bishops score?
```
Used to predict likelihood of successful vaginal delivery
BISHOP:
- I- (e)ffacement
- Station
- Hard or soft- consistency
- Open or closed- dilatation
- Position/presenting part
```
103
At what Bishop score is induction considered?
<=5
104
What is cord prolapse?
Cord is the presenting part --> vasospasm
105
Risk factors for cord prolapse
PROM, polyhydramnios, long cord, malpresentation, multiparity, multiple pregnancy
106
Management of cord prolapse
Trendelenburg with knees and hips up
| Push presenting part off cord with hand
107
What is shoulder dystocia?
Failure of the anterior shoulder to pass under symphysis pubis after delivery of the head
108
Risk factors for shoulder dystocia
Macrosomia, maternal diabetes, post-maturity, maternal obesity, prolonged labour
109
Management of shoulder dystocia
HELPERR:
- call for Help
- Episiotomy
- Legs in McRoberts
- supraPubic pressure
- Enter pelvis
- Rotational maneouvres
- Remove posterior arm
110
Complications of shoulder dystocia
Mum- tear, PPH, psychological
| Baby- hypoxia, fits, cerebral palsy
111
Risk factors for gestational diabetes
Maternal obesity, previous macrosomic baby, previous GDM
112
Complications of gestational diabetes
SMASH
- Shoulder dystocia
- Macrosomia
- Amniotic fluid excess- polyhydramnios
- Stillbirth
- Hypertension/Hypoglycaemia
113
Diagnosis of gestational diabetes
OGTT > 7.8, Fasting glucose > 5.6
114
Management of gestational diabetes
Drugs- stop ACEi, statins, hypoglycaemics except Metformin, Insulin and Glibenclamide
Give folic acid
Delivery < 40+6- offer induction at 37-38+6
Consider C-section if >4kg
Intrapartum- insulin sliding scale + IV dextrose
115
In gestational diabetes, how should glucose levels be controlled during labour?
Insulin sliding scale + IV dextrose
116
What is the aetiology of Rhesus disease in pregnancy?
Sensitisation in 1st pregnancy, initial IgM cannot cross placenta
Re-exposure in subsequent pregnancy, memory B cells - IgG immune response- crosses to foetal circulation
--> Haemolytic anaemia
117
What events can cause Rhesus sensitisation?
Previous pregnancy
| TOP, Ectopic, external cephalic version, blunt abdo trauma, CVS, delivery
118
Investigations for Rhesus disease
Rhesus status checked at booking, 28+34 weeks
MCA doppler to assess foetal anaemia
Kleihauer test to determine how much foetal blood been transferred to mother's bloodstream
119
Management of Rhesus disease
Prevention by anti-D immunoglobulin
120
How is hypertension in pregnancy classified?
1. Chronic hypertension- before pregnancy or <20wks
2. Pregnancy-induced hypertension- >20 weeks without pre-eclampsia
3. Pre-eclampsia- Hypertension + Proteinuria
121
What is classified at hypertension in pregnancy (cut-off)?
> 140/90
122
Risk factors for pre-eclampsia
NOPE2FAT:
- Nulliparity
- Obesity
- Previous history
- Extremes of age
- 2- twins
- FH
- Autoimmune
- Twins
123
What is the aetiology of pre-eclampsia?
Failure of trophoblastic endovascular remodelling --> placental ischaemia
124
Presentation of Pre-eclampsia
Headaches, visual disturbance, epigastric/RUQ pain, brisk hyperreflexia, ankle clonus
125
Maternal complications of pre-eclampsia
Eclampsia (seizures), HELLP syndrome, cerebral haemorrhage/stroke, renal failure, placental abruption
126
Foetal complications of pre-eclampsia
IUGR, Preterm, oligohydramnios, IUFD
127
What is HELLP syndrome?
A complication of pregnancy usually seen in eclampsia or pre-eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
128
Definition of pre-eclampsia
New persistent BP >140/90 after 20wks gestation + Proteinuria > 300mg in 24hrs or +2 on dipstick
129
What is the only cure for pre-eclampsia?
Delivery
130
Management of pre-eclampsia
Only cure- delivery
Low-dose aspirin 75mg from 12wks to birth
Steroids (Betamethasone) at 34wks
Labetalol
131
What is Eclampsia?
Pre-eclampsia (BP + Proteinuria) WITH seizures
132
Management of Eclampsia
IV Magnesium Sulphate then delivery
133
Define Antepartum haemorrhage
Vaginal bleeding from 24wks to onset of labour
134
How is antepartum haemorrhage classified?
Minor < 50ml
Major 50-1000ml
Massive > 1000ml + signs of shock
135
Causes of Antepartum haemorrhage
Uterine- placental abruption, placenta/vasa praevia
Cervical- show, cervical cancer, ectropion
Vaginal- trauma, infection
136
Risk factors for placenta accreta
Previous accreta, previous c-section, uterine surgery
137
What is placenta accreta?
When the placenta is morbidly attached to the uterine wall to an increasing degree
138
Name the different types of placenta accreta
1. Placenta accreta
2. Placenta increta
3. Placenta percreta
139
Management of placenta accreta
Deliver at 35-36wks
| C-section hysterectomy or uterine-preserving surgery
140
What is placenta praevia?
Where the placenta is lying in the lower portion of the uterus, at a lower point than the presenting part of the fetus
141
Risk factors for placenta praevia
Multiparity, smoking, multiple pregnancy, increased age, previous praevia or c-section
142
How is placenta praevia classified?
- Marginal- close to cervical os- 2cm away
| - Major- overlying os
143
Presentation of placenta praevia
Intermittent painless bleeds
| Foetal malpresentation- head not engaged and high
144
Investigations for placenta praevia
TVUSS at 2nd trimester- repeat at 32 weeks, repeat at 36 weeks
145
Management of placenta praevia
Avoid sex/intense exercise- vaginal examination contraindicated
Major: admit until delivery, elective CS at 37-39wks
If severe bleed- emergency CS
Single dose steroids 34-36wks
Tocolysis eg Nifedipine prevents contractions
146
What is placental abruption?
Premature separation of a normally sited placenta from uterine wall
147
Risk factors for placental abruption
Previous abruption, pre-eclampsia, IUGR, rapid uterine decompression
148
Presentation of placental abruption
Abdo pain +/- bleeding
| Woody hard uterus, maternal shock, foetal distress
149
Woody hard uterus, what is the diagnosis?
Placental abruption
150
Management of placental abruption
Emergency C-section and resuscitation
151
What is vasa praevia?
Foetal vessels run in the membrane below the presenting part
152
Presentation of vasa praevia
Triad of...
1. Rupture of membranes
2. Antepartum haemorrhage (painless bleed)
3. Foetal distress (bradycardia)
153
How is postpartum haemorrhage classified?
Minor 500-1000ml
Major > 1000ml
Primary- within 24hrs of giving birth
Secondary- 24hrs-6wks postpartum
154
What is secondary PPH?
24hrs-6wks postpartum
155
What is the main cause of secondary PPH?
Infection (endometritis) or retained products of conception
156
What is primary PPH?
Within 24hrs of giving birth
157
Causes of primary PPH
4Ts:
- Tissue- retained placenta
- Tone- uterine atony
- Trauma- lacerations
- Thrombin- coagulopathy- haemophilia A/B, DIC
158
Complications of PPH
Shock, DIC
159
Management of PPH
```
Minor- IV fluids, cross match, monitor
Major: ABCDE
- Lacerations- suture
- Retained placenta- manual evacuation
- Uterine Atony- Bimanual uterine compression --> Ergometrine IV/IM --> Oxytocin infusion --> Surgery eg uterine tamponade
```
160
What is a TORCH screen?
Tests for infections in pregnant women
- Toxoplasmosis
- Other- HIV, Syphilis, Measles, EBV, HepB)
- Rubella
- Cytomegalovirus
- Herpes simplex
161
Management of Group B Streptococcal infection in pregnancy
Intrapartum IV Benzylpenicillin if...
- previous baby with GpB strep
- GpB strep colonisation in current pregnancy
162
What are the routine antenatal US scans?
12 weeks- dating pregnancy and confirming viability
| 18-20+6 weeks- structural abnormalities
163
What is the combined test in pregnancy?
For T13, T18 and T21
Done in 1st trimester
1. Nuchal translucency + serum testing (PAPP-A + BhCG)
2. CVS/Amniocentesis if +ve
164
What abnormalities are testing for in the combined test in pregnancy?
T13- Patau syndrome
T18- Edwards syndrome
T21- Down's syndrome
165
What is included in serum testing for trisomies in the combined test?
PAPP-A
| BhCG
166
When in pregnancy is blood tested for haemoglobinopathy and what is it tested for?
8-10wks
| Sickle cell and thalassaemia
167
Difference between CVS and Amniocentesis
CVS can be done earlier but less accurate and increased risk of miscarriage than amniocentesis
168
What are the 'baby blues'?
Brief period of feeling emotional and tearful about 3-10 days after giving birth
169
What is endometriosis?
Presence of endometrial tissue outside of the uterus
170
What is stress incontinence?
Involuntary leakage of urine on effort or exertion due to urethral sphincter weakness
171
Causes of stress incontinence
Pregnancy, vaginal delivery, instrumental delivery, oestrogen deficiency (menopause), pelvic trauma/irradiation, age
172
Investigation of stress incontinence
Exclude UTI
Frequency-volume chart
Urodynamics
173
Management of stress incontinence
1st line- pelvic floor training
2nd line- surgery
Drug- Duloxetine
174
What is urge incontinence?
Involuntary leakage of urine associated with urgency due to detrusor overactivity
175
Causes of urge incontinence
Idiopathic, secondary to pelvic/incontinence surgery, UTI, neurogenic
176
Investigation of urge incontinence
Exclude UTI
| Urodynamics
177
Management of urge incontinence
Conservative- avoid ++ fluid intake, avoid caffeine/fizzy drinks, weight loss, pelvic floor exercises
1st line- Bladder training
Drugs- Anticholinergic- Oxybutinin
178
Types of vaginal prolapse
Anterior wall- Cystocele, Urethrocele, Cystourethrocele
Posterior wall- Enterocele (small bowel), Rectocele
Apical- Uterovaginal, Vault prolapse
179
Risk factors for vaginal prolapse
Pelvic floor weakness
| Vaginal delivery, pregnancy, congenital, menopause, raised intra-abdominal pressure eg obesity, surgery
180
Presentation of vaginal prolapse
Dragging sensation, feeling of a lump, dyspareunia
181
Management of vaginal prolapse
Pessary
| Surgery if symptomatic or severe
182
Prevention of vaginal prolapse
Weight loss
Smoking cessation
Pelvic floor exercises
183
How does the menopause and pregnancy affect endometriosis?
Endometriosis is oestrogen-dependent, so it regresses after the menopause and pregnancy
184
Aetiology of endometriosis
Theory of retrograde menstruation
Free blood --> inflammation, progressive fibrosis + adhesions
--> frozen pelvis
--> chocolate cysts- accumulated dark brown blood on ovaries
185
Presentation of endometriosis
Chronic cyclical pelvis pain, deep dyspareunia and backache
| Infertility due to adhesions and inflammation
186
Diagnosis of endometriosis
Laparoscopy + biopsy gold standard
187
Management of endometriosis
NSAIDs
Continuous COCP/GnRH agonists
Laparoscopic surgery- laser ablation + adhesiolysis
Hysteretomy + BL salpingo-oophorectomy
188
What are fibroids?
Leiomyoma
| Benign neoplasm of smooth muscle in myometrium
189
Types of fibroids
```
Pedunculated
Subserosal
Submucosal
Intramural
Intracavity
```
190
How to fibroids change in pregnancy?
Oestrogen dependent
Increase in size with oestrogen/progesterone therapy/Clomifene/Pregnancy
Most regress after menopause
191
Presentation of fibroids
Menorrhagia, intermenstrual bleeding, dysmenorrhoea, subfertility
Pressure effects: bladder retention, constipation
192
What is a risk of fibroids in pregnancy?
Red degeneration- loss of blood supply causes acute pain and fever
193
Management of fibroids
Medical: tranexamic acid, NSAIDs, progestogens, IUS, COCP
Uterine artery embolisation
Surgery
194
What is ectopic pregnancy?
Implantation of conceptus outside of the uterine cavity
195
What is the most common location for ectopic pregnancy?
Ampulla of the fallopian tube
196
Risk factors for ectopic pregnancy
PIPA:
- Previous ectopic
- IUCD
- Pelvic surgery
- Assisted reproduction
197
Presentation of ectopic pregnancy
Triad of...
1. Amenorrhoea
2. Lower abdominal pain- unilateral colicky then constant
3. PV Bleed
Intraperitoneal blood loss- collapse + shoulder-tip pain
Cervical excitation
198
Investigations for ectopic pregnancy
Pregnancy test- BhCG + serial serum hCG
| Laparoscopy gold standard
199
Management of ectopic pregnancy
1. Expectant- serial serum hCG
2. Medical- IM Methotrexate + monitor hCG
3. Surgical- Salpingectomy/Salpingotomy
200
How is infertility defined?
Failure to conceive after 1 year of trying- refer
201
When should somebody be referred for infertility?
After 1 year of trying
202
Investigations of infertility
Semen analysis
Mid-luteal (day 21) progesterone
FSH, antral follicle count, anti-Mullerian hormone
Tubal patency
203
Management of female infertility
Clomifene ovulation induction
Donor eggs
Refer for IVF after 2 years of trying
204
What is Polycystic Ovarian Syndrome (PCOS)?
Transvaginal ultrasound appearance of 12 or more small (2-8mm) follicles in an enlarged (>10cm) ovary
205
What criteria is used for diagnosis of Polycystic Ovarian Syndrome (PCOS)?
Rotterdam criteria- need 2/3 of...
1. PCO on USS
2. Oligoovulation/Anovulation
3. Clinical/Biochemical Hyperandrogenism: acne, hirsutism, raised serum testosterone
206
What are the clinical/biochemical criteria in the Rotterdam criteria for Polycystic Ovarian Syndrome (PCOS)?
Acne
Hirsutism
Raised serum testosterone
207
What is the Rotterdam criteria?
Criteria used for diagnosis of Polycystic Ovarian Syndrome (PCOS):
Need 2/3 of...
1. PCO on USS
2. Oligoovulation/Anovulation
3. Clinical/Biochemical Hyperandrogenism: acne, hirsutism, raised serum testosterone
208
What conditions does Polycystic Ovarian Syndrome (PCOS) increase a patient's risk of?
Type 2 Diabetes
| Gestational diabetes
209
Blood tests in Polycystic Ovarian Syndrome (PCOS)
LH:FSH ratio 3:1
| Raised serum testosterone day 21
210
Management of Polycystic Ovarian Syndrome (PCOS)
Conservative- lose weight, smoking cessation
Menstrual regularity- COCP, Metformin
Control Sx- Antiandrogens (Cyproterone acetate)
Ovulation induction- Anti-oestrogens (Clomifene citrate), Laparoscopic ovarian diathermy
211
Most common cause of Pelvic Inflammatory Disease (PID)?
Chlamydia
212
Risk factors for Pelvic Inflammatory Disease (PID)
Chlamydia infection
| Surgical TOP, ERCP, IUD, miscarriage
213
Presentation of Pelvic Inflammatory Disease (PID)
Pelvic pain, deep dyspareunia, vaginal discharge, fever, intermenstrual bleeding/post-menstrual bleeding
Cervical excitation
214
Complications of Pelvic Inflammatory Disease (PID)
Ectopic pregnancy, infertility, adhesions
215
Diagnosis of Pelvic Inflammatory Disease (PID)
Laparoscopy gold standard
| Swab for STIs
216
Management of Pelvic Inflammatory Disease (PID)
IM Ceftriaxone + PO Doxycycline + PO Metronidazole
217
Presentation of ovarian cyst accident
Sharp unilateral abdominal pain after sex or strenuous exercise, tenderness
218
Investigation of ovarian cyst accident
Free fluid in pelvic cavity
219
Presentation of adnexal torsion
Unilateral sharp waxing/waning pain, N&V, tender palpable mass on bimanual examination
220
Investigation of adnexal torsion
USS- enlarged oedematous ovary with Whirlpool sign
221
Define primary amenorrhoea
No menses by age 16 in the presence of secondary sexual characteristics
222
Causes of primary amenorrhoea
Hypothalamic, Turner's, PCOS, intense exercise, Mullerian agenesis, Kallman's syndrome
223
Define secondary amenorrhoea
Cessation after onset of menses
224
Causes of secondary amenorrhoea
Weight loss, exercise, PCOS, Sheehan's syndrome
225
What BMI is needed to start periods and to maintain regular?
Start- 17
| Regular- 19
226
What age is defined as precocious puberty?
< 8 in girls
| < 9 in boys
227
Causes of menorrhagia
Coagulopathy, uterine fibroids, uterine polyps, adenomyosis, endometriosis
228
What are the 2 week wait criteria in menorrhagia?
Endometrial biopsy for women aged >45 with IMB which is unresponsive to treatment
229
Management of menorrhagia
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Antifibrinolytics: Tranexamic acid
NSAIDs: Mefenamic acid
Progestogens
COCP/IUS
ENdometrial ablations
Hysterectomy
```
230
What is adenomyosis?
Presence of endometrium and underlying stroma in the myometrium
231
How does the menopause affect adenomyosis?
It subsides after menopause
232
Presentation of adenomyosis
Painful heavy menstruation, cyclical pain, dysmenorrhoea, dyspareunia
233
Investigation of adenomyosis
MRI: black halo line around uterus
234
Management of adenomyosis
IUS, COCP, NSAIDs
| Hysterectomy
235
Risk factors for endometrial cancer
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Increased oestrogen (COCP reduces risk)- PCOS, diabetes, obesity, early menarche, late menopause, HRT
Inherited syndromes- Lynch, BRCA1, Cowden
Precancerous conditions- Endometrial hyerplasia/neoplasia
```
236
What inherited syndromes are associated with endometrial cancer?
Lynch, BRCA1, Cowden
237
What precancerous conditions are associated with endometrial cancer?
Endometrial hyperplasia/neoplasia
238
What types of endometrial cancer are there?
Sarcoma/Carcinoma/Mixed
239
Presentation of endometrial cancer
Uterine bleeding
240
Investigation of endometrial cancer
TVUSS: endometrial thickness, biopsy
241
Staging of endometrial cancer
Stage 1: within endometriun
Stage 2: into cervix
Stage 3A: ovary 3B: vagina 3C: lymph nodes
Stage 4: spread to other organs
242
Management of endometrial cancer risk in Lynch syndrome
Prophylactic hysterectomy
243
Risk factors for ovarian cancer
Prolonged ovulation, COCP, multiparity
244
Staging of ovarian cancer
Stage 1A: in one ovary
1B: Both ovaries
1C: ovary and surface of other obary
Stage 4: spread to other organs
245
Investigations of ovarian cancer
Ca125, USS
246
What score can be used to calculate risk of ovarian cancer?
RIsk of malignancy index =
| Ca125 x USS score x pre/postmenopausal
247
Types of cervical cancer
Squamous cell carcinoma or Adenocarcinoma
248
Risk factors for cervical cancer
HPV16/18, intraepithelial neoplasia, smoking, COCP
249
Presentation of cervical cancer
Post-coital bleeding, irregular bleeding, mucopurulent discharge
250
What staging score is used for cervical cancer?
FIGO score 1-4
251
Prevention of cervical cancer
Smear, HPV vaccine
252
Risk factors for breast cancer
Age, FH (BRCA1+2, TP53), duration of oestrogen exposure, late 1st pregnancy, HRT > 5yrs, obesity, alcohol
253
What factor is protective of breast cancer?
Breast feeding
254
What is the name of the risk assessment tool for breast cancer
Manchester risk assessment tool
255
What is the screening programme for BRCA1+2 carriers?
Annual MRI up to age 50
Annual mammogram over age 40
Triannual mammogram over age 60
256
What is the NHS screening programme for breast cancer?
Age 50-71 every 3 years
257
Presentation of breast cancer
Painless lump, nipple discharge/inversion, skin tethering, surface ulceration/erythema
258
What is the triple assessment for breast cancer?
1. Clinical score- Hx and Ex
2. Imaging score- mammogram/USS
3. Biopsy- fine needle aspiration/core needle biopsy/excision biopsy/incisional
259
Types of breast cancer
Mostly ductal or lobular
| Also Paget's disease of nipple
260
Management of breast cancer
```
Radiotherapy
Hormonal- Tamoxifen if premenopausal; Letrozole if postmenopausal
HER2+ve- Trastuzumab (Herceptin)
ER+ve- Docetaxel
Chemotherapy
Surgery
```
261
Average age of menopause
51
262
Presentation of the menopause
- Vasomotor- hot flushes + sweats
- MSK- muscle and joint pain
- Low mood + sexual dysfunction
- Local effects- vaginal atrophy --> dryness
- Loss of memory/concentration
- Osteoporosis
- Cardiovascular disease
263
When can menopause be diagnosed?
12 months after last period
264
What is premature ovarian insufficiency?
Menopause < 40yrs
