Other Important Topics Flashcards
What is Asherman syndrome?
Formation of fibrous bands and adhesions within the endometrial cavity resulting in subfertility.
RFs for asherman syndrome
Pelvic Surgery (e.g. C-section, myomectomy, dilation and curettage)
Pelvic Irradiation
Pelvic Inflammatory Disease
Presentation of asherman syndrome
Reduced or absent menstrual bleeding
Subfertility
Pelvic pain
Investigations for asherman syndrome
Imaging & Other
Hysteroscopy
Management of asherman syndrome
Adhesiolysis (surgical breakdown of adhesions)
Pain management
What is bartholin’s cyst?
Cyst formation within Bartholin’s gland.
PACES: what are bartholin’s glands?
pea-sized glands that are located around the vaginal introitus and produce vaginal lubricant.
RFs for Bartholin’s cysts?
Nulliparous
Child-bearing age
Previous Bartholin’s cyst
Sexually active (though STIs do not, themselves, cause cysts)
Presentation of bartholin’s cyst
Discomfort or pain
Dyspareunia
Discharge from cyst
Presentation of bartholin’s abscess
Significant pain and tenderness
Erythema
Fever
Investigations for bartholin’s cyst
Clinical diagnosis
Bedside
Swab (for MC&S)
Management of bartholin’s cyst
Conservative
Soak cyst for 10-15 mins in warm water several times per day for 3-4 days
Apply a warm compress to the area
Advise taking simple analgesia like paracetamol and ibuprofen
Medical
Abscesses are likely to require intervention of some form
If the abscess is discharging and the patient is well, it can be treated with oral antibiotics (e.g. flucloxacillin or co-amoxiclav)
May require incision and drainage
May be accompanied by insertion of a balloon catheter or marsupialisation of the cyst
PACES: Conservative management for bartholin’s cyst
Soak cyst for 10-15 mins in warm water several times per day for 3-4 days
Apply a warm compress to the area
Advise taking simple analgesia like paracetamol and ibuprofen
Medical management for bartholin’s abscess
Abscesses are likely to require intervention of some form
If the abscess is discharging and the patient is well, it can be treated with oral antibiotics (e.g. flucloxacillin or co-amoxiclav)
May require incision and drainage
May be accompanied by insertion of a balloon catheter or marsupialisation of the cyst
ABx options for bartholin’s asbscess
flucloxacillin or co-amoxiclav
Options for incision and drainage of bartholin’s abscess
May be accompanied by insertion of a balloon catheter or marsupialisation of the cyst
What is cervical ectropion?
Condition in which the columnar epithelium of the endocervix becomes visible on the ectocervix. This may appear macroscopically as a red area around the external cervical os. It is NOT pathological.
What causes cervical ectropion?
Cervical ectropion normally develops under the influence of high circulating oestrogen levels
This, in turn, may be related to puberty, the combined oral contraceptive pill or pregnancy
Presentation of cervical ectropion
Often asymptomatic and incidentally noted upon speculum examination (e.g. when attending for a cervical smear)
Postcoital bleeding
Intermenstrual bleeding
Abnormal vaginal discharge
post-coital bleeding on COCP
cervical ectropion
When is cervical ectropion usually noted?
speculum examination
Management of cervical ectropion
Does NOT require treatment if it is asymptomatic
If symptoms are problematic, the following should be conisdered:
Changing from oestrogen-based hormonal contraceptives
Cervical ablation (cryocautery)
Take cervical and genital tract swabs to exclude STI
Take smear to exclude cervical malignancy/premalignancy
What should be excluded in cervical ectropion if symptoms are problematic?
Take smear to exclude cervical malignancy/premalignancy
Classification of FGM
Type 1: Clitoridectomy (partial or total removal of the clitoris)
Type 2: Excision (partial or total removal of the clitoris and the labia minora with or without excision of the labia majora)
Type 3: Infibulation (narrowing of the vaginal orifice with creation of a covering seal)
Type 4: Unclassified (all other harmful procedures to the female genitalia for non-medical purposes)
Type 1 FGM
Type 1: Clitoridectomy (partial or total removal of the clitoris)
Type 2 FGM
Type 2: Excision (partial or total removal of the clitoris and the labia minora with or without excision of the labia majora)
Type 3 FGM
Type 3: Infibulation (narrowing of the vaginal orifice with creation of a covering seal)
Type 4 FGM
Type 4: Unclassified (all other harmful procedures to the female genitalia for non-medical purposes)
Complications of FGM
Infection and abscess formation
Urethral injury
Recurrent UTI
Dysmenorrhoea
Sexual dysfunction
Psychological trauma
Obstetric complications
Management of FGM
Any case of FGM must be reported in the notes
Any case of FGM in children < 18 years must be referred to the police and social services
The mandatory duty to tell the appropriate agency will NOT apply to at risk of suspected cases over 18 years
Check to see whether other young girls in the family are at risk of FGM
De-Infibulation (reversal of infibulation)
Should be performed with adequate analgesia and sedation to reduce the risk of psychological distress
Provide access to specialist services and support groups
What is the surgical procedure that can be performed for FGM?
De-Infibulation (reversal of infibulation)
Should be performed with adequate analgesia and sedation to reduce the risk of psychological distress
Provide access to specialist services and support groups
ETHICAL RULES FOR FGM
Any case of FGM must be reported in the notes
Any case of FGM in children < 18 years must be referred to the police and social services
The mandatory duty to tell the appropriate agency will NOT apply to at risk of suspected cases over 18 years
Check to see whether other young girls in the family are at risk of FGM
When is it mandatory to tell the appropriate agency aboutFGM?
Any case of FGM in children < 18 years must be referred to the police and social services
The mandatory duty to tell the appropriate agency will NOT apply to at risk of suspected cases over 18 years
Should FGM be reported in the notes?
Any case of FGM MUST be reported in the notes
What is lichen sclerosis?
Chronic skin condition characterised by the formation of itchy, pale patches on the genitals, perineal and perianal skin. It can, more rarely, affect other parts of the body like the axilla.
Where does lichen sclerosis usually affect?
genitals, perineal and perianal skin
Presentation of lichen sclerosis
itchy, pale patches that are usually asymptomatic
If symptomatic:
Itching
Skin tightness (e.g. phimosis)
Pain
Dyspareunia
Investigations for lichen sclerosis
Primarily a clinical diagnosis
Imaging & Other
Biopsy
Usually only considered if it fails to respond to a trial of treatment
When is biopsy considered in lichen sclerosis?
Usually only considered if it fails to respond to a trial of treatment
Management of lichen sclerosis
Encourage good skin care
1st Line: Strong Steroid Ointments (e.g. clobetasol propionate)
2nd Line: Topical Calcineurin Inhibitor
1st line management for lichen sclerosis
1st Line: Strong Steroid Ointments (e.g. clobetasol propionate)
Followed by
2nd Line: Topical Calcineurin Inhibitor
Strong steroid ointment used 1st line in lichen sclerosis
cobetasol propionate
What is menopause?
The state that is reached once a woman has not had a period for 12 months and is not on any contraception.
Presentation of menopause
Hot flushes
Mood swings
Night sweats
Sleep disturbance
Weight gain
Conservative management of menopause
Stop smoking
Reduce alcohol consumption
Aim for a healthy BMI
Types of HRT
Oestrogen only
Oestrogen with progesterone
Who can use oestrogen only HRT?
Only suitable for women who have had a hysterectomy
Why is progesterone added in combined HRT?
Progestogen is added to protect the endometrium from the action of oestrogen
What types of combined HRT is most appropriate for women who still have periods but are approaching menopause?
Cyclical. Types:
Monthly: oestrogen every day of the month + progestogen for the last 14 days
3-Monthly: oestrogen every day for 3 months + progestogen for the last 14 days
Withdrawal bleed is likely to occur when receiving the progestogen
Perimenopausal
women who still have periods but are approaching menopause
What type of combined HRT is most appropriate for women who have reached the menopause?
Continuous, progesterone can be administered as a levonorgestrel IUS
Benefits of HRT
Improved vasomotor symptoms
Prevention of osteoporosis
Improved genital tract symptoms (e.g. dryness)
Risks of HRT
Breast cancer
Cardiovascular disease
Venous thromboembolism
Contraindications for HRT
Pregnancy
Breast Cancer
Endometrial Cancer
Uncontrolled Hypertension
Current VTE
Current Thrombophilia
ABSOLUTE CONTRAINDICATIONS FOR HRT
PREGNANCY, BREAST CANCER, ENDOMETRIAL CANCERN
Non-hormonal treatments for HRT
Alpha Agonists (e.g. clonidine)
Beta-Blocker (e.g. propranolol)
SSRIs (e.g. fluoxetine)
Symptomatic Treatments (e.g. vaginal lubricants)
What is a nabothian cyst?
Cysts that form when the columnar glands within the transformation zone of the cervix become sealed over.
Presentation of nabothian cyst
Asymptomatic and usually noted incidentally on speculum examination
Management of nabothian cyst
Reassurance
What is urinary incontinence defined as?
involuntary loss of urine
Types of urinary incontinence
Urge Incontinence (also known as Overactive Bladder)
Due to overactivity of the detrusor muscle
Stress Incontinence
Leaking during times of increased intra-abdominal pressure (e.g. coughing or laughing) due to weakness of the urethral sphincter
Mixed Incontinence
Combination of both urge and stress incontinence
Overflow Incontinence
Leakage of urine in the context of chronic bladder outflow obstruction
Urge incontinence AKA
overactive bladder
Urge incontinence
Overactivity of the detrusor muscle
Stress incontinence
Leaking during times of increased intra-abdominal pressure (e.g. coughing or laughing) due to weakness of the urethral sphincter
Mixed incontinence
Combination of both urge and stress incontinence
Overflow incontinence
Leakage of urine in the context of chronic bladder outflow obstruction
RFs for urge incontinence
Diabetes mellitus
Medications (e.g. diuretics)
Neurological disorders (e.g. Parkinson’s disease, multiple sclerosis)
Obesity
Smoking
Parity
RFs for stress incontinece
Age
Instrumental delivery
Obesity
Previous pelvic surgery
Presentation of urge incontinence
Sudden need to go to the toilet
Presentation of stress incontinence
Leakage of urine when sneezing, coughing, laughing or lifting heavy objects
Investigations for urinary incontinence
Bedside
Ask the patient to maintain bladder diaries
Vaginal examination (exclude structural cause such as vaginal prolapse)
Urine Dipstick and MSU
Imaging & Other
Urodynamic Testing
Why may vaginal examination be done for urinary incontinence?
exclude structural cause such as vaginal prolapseM
Management of urge incontinence
Conservative: Avoid caffeinated drinks, aim for 1.5-2.5 L fluid intake per day, lose weight
1st Line: Bladder Retraining for 6 weeks
Aims to gradually increase the intervals between voiding
2nd Line: Bladder Stabilising Drugs
Antimuscarinics: Oxybutynin, Tolterodine, Darifenacin
WARNING: Caution should be exercised with antimuscarinics in frail elderly patients as it can worsen cognitive impairment
3rd Line: Mirabegron (beta-3 agonist)
4th Line: Surgical Procedures
Botox Injection
Percutaneous Tibial Nerve Stimulation (PTNS) or Sacral Nerve Stimulation (SNS)
PACES: conservative management advice for urge incontinence
Avoid caffeinated drinks, aim for 1.5-2.5 L fluid intake per day, lose weight
1st line management for urge incontinence
1st Line: Bladder Retraining for 6 weeks
Aims to gradually increase the intervals between voiding
Followed by:
2nd Line: Bladder Stabilising Drugs
Antimuscarinics: Oxybutynin, Tolterodine, Darifenacin
3rd Line: Mirabegron (beta-3 agonist)
4th Line: Surgical Procedures
Botox Injection
Percutaneous Tibial Nerve Stimulation (PTNS) or Sacral Nerve Stimulation (SNS)
Why should caution be exercised with antimuscarinics in frail elderly patients?
can worsen cognitive impairment and cause falls
usually 2nd line treatment after bladder retraining
Alternative to antimuscarinics if patient is old and frail with urge incontinence
Mirabegron (beta-3-agonist)
Beta 3 agonist
Mirabegron
Antimuscarinic
Oxybutynin, Tolterodine
Surgical procedures for urge incontinence
Botox Injection
Percutaneous Tibial Nerve Stimulation (PTNS) or Sacral Nerve Stimulation (SNS)
Management of Stress incontinence
1st Line: Pelvic Floor Muscle Training
Recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
Adjunct: Duloxetine
Alternative: Pseudoephedrine
2nd Line: Surgical Procedures
Retropubic Mid-Urethral Tape Procedures
Bulking (injection into the urethral sphincter)
Autologous Fascial Slings
Burch Colposuspension
1st like management for stress incontinence
1st Line: Pelvic Floor Muscle Training
Recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
Adjunct: Duloxetine
Alternative: Pseudoephedrine
What is recommended for pelvic floor muscle training in stress incontinence?
8 contractions performed 3 times per day for a minimum of 3 months
Duloxetine is given adjunct as 1st line treatment
