PassMed Flashcards
Ectopic pregnancy: epidemiology and risk factors
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
Epidemiology
- incidence = c. 0.5% of all pregnancies
Risk factors (anything slowing the ovum’s passage to the uterus)
- damage to tubes (pelvic inflammatory disease/STIs, surgery)
- previous ectopic
- endometriosis
- IUCD
- smoking
- progesterone only pill
- IVF (3% of pregnancies are ectopic)
Ectopic pregnancy: pathophysiology
Basics
- 97% are tubal, with most in ampulla
- more dangerous if in isthmus Ectopic pregnancy localised to the isthmus increases the risk of rupture
- 3% in ovary, cervix or peritoneum
- trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo
Natural history - most common are absorption and tubal abortion
- tubal abortion
- tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
- tubal rupture
Ectopic pregnancy: symptoms and examination findings
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
-
lower abdominal pain
- due to tubal spasm
- typically the first symptom
- pain is usually constant and may be unilateral.
-
vaginal bleeding
- usually less than a normal period
- may be dark brown in colour
-
history of recent amenorrhoea
- typically 6-8 weeks from the start of last period
- if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
- peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
- dizziness, fainting or syncope may be seen
- symptoms of pregnancy such as breast tenderness may also be reported
Examination findings
- abdominal tenderness
- cervical excitation (also known as cervical motion tenderness)
- adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
Ectopic pregnancy: investigation and management
Cervical ectropion
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
The term cervical erosion is used less commonly now
This may result in the following features
- vaginal discharge
- POST-COITAL BLEEDING
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
Placenta praevia
Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment
Epidemiology
- 5% will have low-lying placenta when scanned at 16-20 weeks gestation
- incidence at delivery is only 0.5%, therefore most placentas rise away from cervix
Associated factors
- multiparity
- multiple pregnancy
- embryos are more likely to implant on a lower segment scar from previous caesarean section
Clinical features
- shock in proportion to visible loss
- no pain
- uterus not tender
- lie and presentation may be abnormal
- fetal heart usually normal
- coagulation problems rare
- small bleeds before large
Investigations
- placenta praevia is often picked up on the routine 20 week abdominal ultrasound
- the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
Classical grading
- I - placenta reaches lower segment but not the internal os
- II - placenta reaches internal os but doesn’t cover it
- III - placenta covers the internal os before dilation but not when dilated
- IV (‘major’) - placenta completely covers the internal os
Genital herpes
A 22-year-old female attends your practice complaining of feeling ‘sore’ in the genital area. She has had multiple sexual partners recently and has not always used barrier contraception. You find small red blisters on the vulva and vagina.
There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap
Features
- painful genital ulceration
- may be associated with dysuria and pruritus
- the primary infection is often more severe than recurrent episodes
- systemic features such as headache, fever and malaise are more common in primary episodes
- tender inguinal lymphadenopathy
- urinary retention may occur
Investigations
- nucleic acid amplification tests (NAAT) is the investigation of choice in genital herpes and are now considered superior to viral culture
- HSV serology may be useful in certain situations such as recurrent genital ulceration of unknown cause
Management
- general measures include:
- saline bathing
- analgesia
- topical anaesthetic agents e.g. lidocaine
-
oral aciclovir
- some patients with frequent exacerbations may benefit from longer-term aciclovir
Pregnancy
- elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
- women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
Cervical cancer screening: interpretation of results
The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Negative hrHPV
- return to normal recall, unless
- the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
- the untreated CIN1 pathway
- follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
- follow-up for borderline changes in endocervical cells
Positive hrHPV
- samples are examined cytologically
- if the cytology is abnormal → colposcopy
- this includes the following results:
- borderline changes in squamous or endocervical cells.
- low-grade dyskaryosis.
- high-grade dyskaryosis (moderate).
- high-grade dyskaryosis (severe).
- invasive squamous cell carcinoma.
- glandular neoplasia
-
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
- if the repeat test is now hrHPV -ve → return to normal recall
- if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
- If hrHPV -ve at 24 months → return to normal recall
- if hrHPV +ve at 24 months → colposcopy
If the sample is ‘inadequate’
- repeat the sample within 3 months
- if two consecutive inadequate samples then → colposcopy
If HIV:
- annual cervical screening
If pregnant:
- normal cytology = 3 months post party
- abnormal cytology (low-grade) = wait until post-delivery
- abnormal cytology (high-grade) = colposcopy (later first or early second trimester)
The follow-up of patients who’ve previously had CIN is complicated but as a first step, individuals who’ve been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.
Human papilloma viruses 6 and 11 are non-carcinogenic and associated with genital warts so if HPV+ve → return to normal 3-yearly screening, and discuss safe-sex practices
Mechanism of HPV causing cervical cancer
- HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
- E6 inhibits the p53 tumour suppressor gene
- E7 inhibits RB suppressor gene
Cervical cancer: FIGO cervical staging and mx
Management of stage IA tumours
- Gold standard of treatment is hysterectomy +/- lymph node clearance
- Nodal clearance for A2 tumours
- For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
- Close follow-up of these patients is advised
- For A2 tumours, node evaluation must be performed
- Radical trachelectomy is also an option for A2
Management of stage IB tumours
- For B1 tumours: radiotherapy with concurrent chemotherapy is advised
- Radiotherapy may either be bachytherapy or external beam radiotherapy
- Cisplatin is the commonly used chemotherapeutic agent
- For B2 tumours: radical hysterectomy with pelvic lymph node dissection
Management of stage II and III tumours
- Radiation with concurrent chemotherapy
- See above for choice of chemotherapy and radiotherapy
- If hydronephrosis, nephrostomy should be considered
Management of stage IV tumours
- Radiation and/or chemotherapy is the treatment of choice
- Palliative chemotherapy may be best option for stage IVB
Management of recurrent disease
- Primary surgical treatment: offer chemoradiation or radiotherapy
- Primary radiation treatment: offer surgical therapy
Cervical cancer prognosis
HNPCC and associated GYN cancers
Patients with HNPCC are also at a higher risk of other cancers, with endometrial cancer being the next most common association, after colon cancer.
Hormone replacement therapy: adverse effects
Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
Side-effects
- nausea
- breast tenderness
- fluid retention and weight gain
Potential complications
- increased risk of breast cancer
- increased by the addition of a progestogen
- in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
- the increased risk relates to the duration of use
- the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
- increased risk of endometrial cancer
- oestrogen by itself should not be given as HRT to women with a womb
- reduced by the addition of a progestogen but not eliminated completely
- the BNF states that the additional risk is eliminated if a progestogen is given continuously
- increased risk of venous thromboembolism
- increased by the addition of a progestogen
- transdermal HRT does not appear to increase the risk of VTE
- NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
- increased risk of stroke
- increased risk of ischaemic heart disease if taken more than 10 years after menopause
Ovarian cancer
Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis.
Pathophysiology
- around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
- interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers
Risk factors
- family history: mutations of the BRCA1 or the BRCA2 gene
- many ovulations*: early menarche, late menopause, nulliparity
- Age, FHx, obesity, HRT, endometriosis, smoking, diabetes
Protective factors = COCP, pregnancy and breastfeeding, hysterectomy
Clinical features are notoriously vague
- abdominal distension and bloating
- abdominal and pelvic pain
- urinary symptoms e.g. Urgency
- early satiety
- diarrhoea
Investigations
- CA125
- NICE recommends a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
- if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
- a CA125 should not be used for screening for ovarian cancer in asymptomatic women
- ultrasound
Diagnosis is difficult and usually involves diagnostic laparotomy
Management
- usually a combination of surgery and platinum-based chemotherapy
Prognosis
- 80% of women have advanced disease at presentation
- the all stage 5-year survival is 46%
*It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.
Combined oral contraceptive pill: contraindications
The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below:
- UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method
- UKMEC 2: advantages generally outweigh the disadvantages
- UKMEC 3: disadvantages generally outweigh the advantages
- UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
Examples of UKMEC 4 conditions include
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Changes in 2016
- breast feeding 6 weeks - 6 months postpartum was changed from UKMEC 3 → 2
Tumour markers
Raised beta-human chorionic gonadotropin with a raised alpha-feto protein level
- a raised AFP level excludes a seminoma → non-seminomatous testicular cancer
Premature ovarian failure
Premature ovarian failure is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.
In premature ovarian failure, the pituitary responds to low levels of oestrogen by increasing the production of gonadotropins in an attempt to stimulate the production of oestradiol in the ovary but fails to do so.
TO MAKE DIAGNOSIS = hormones (FSH, LH) need to be elevated when tested TWICE, FOUR weeks aka A MONTH apart
Causes of premature menopause include:
- idiopathic
- the most common cause
- there may be a family history
- bilateral oophorectomy
- having a hysterectomy with preservation of the ovaries has also been shown to advance the age of menopause
- radiotherapy
- chemotherapy
- infection: e.g. mumps
- autoimmune disorders
- resistant ovary syndrome: due to FSH receptor abnormalities
Features are similar to those of the normal climacteric but the actual presenting problem may differ
- climacteric symptoms: hot flushes, night sweats
- infertility
- secondary amenorrhoea
- raised FSH, LH levels
- e.g. FSH > 40 iu/l, FSH í >20 in a woman <40
- low oestradiol
- e.g. < 100 pmol/l
Mx:
The patient should be treated with hormone replacement therapy (HRT) until at least the age of normal menopause (51), unless the risks of HRT treatment outweigh the benefits.
ovarian tumours
There are 4 main types of ovarian tumours
- surface derived tumours
- germ cell tumours
- sex cord-stromal tumours
- metastasis
Germ cell tumours mainly affects YOUNGER WOMEN
Associated with benign fibroma The three features of Meig’s syndrome are:
- a benign ovarian tumour
- ascites
- pleural effusion
It is a rare condition usually occurring in woman over the age of 40 years and the ovarian tumour is generally a fibroma. It is managed by the surgical removal of the tumour, however the ascites and pleural effusion may need to be drained first to allow symptomatic relief and improve pulmonary function before the anaesthetic. It has excellent prognosis due to the benign nature of the tumour.
Most common benign ovarian tumour in women under the age of 25 years = dermoid cyst (teratoma)
The most common cause of ovarian enlargement in women of a reproductive age = follicular cyst
Germ cell tumours (table below)
Endometriosis
A 17-year-old obese girl presents with worsening dysmenorrhea. She began menarche aged 9, and her periods were initially fine. In the last 2 months, they have been more painful, and she has had to take days off school due to the pain. She has not tried any medications for the pain and has never been sexually active.
Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of a reproductive age have a degree of endometriosis.
Ddx:
- Adenomyosis
- Chronic PID
- Chronic pelvic pain
- other causes of pelvic masses
- IBS
Clinical features
- chronic pelvic pain
- dysmenorrhoea - pain often starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
- on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Investigation
- laparoscopy is the gold-standard investigation
- there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis
Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE published guidelines in 2017:
- NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
- AVOID OPIATES/CODEINE as could worsen co-existing IBS
- if analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried → more effective tricycled (3 packs back to back)
If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include:
- GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
- drug therapy unfortunately does not seem to have a significant impact on fertility rates
- surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility
IUI and IVF for sub fertility if complication of endometriosis
Endometrial Cancer (endometrial hyperplasia is in picture)
Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection
The risk factors for endometrial cancer are as follows*:
- obesity and HTN
- diabetes mellitus
- nulliparity
- early menarche
- late menopause
- unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
- tamoxifen
- polycystic ovarian syndrome
- hereditary non-polyposis colorectal carcinoma
Features
- postmenopausal bleeding is the classic symptom
- premenopausal women may have a change intermenstrual bleeding
- pain and discharge are unusual features
Investigation
- women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
- first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
- 2nd line = hysteroscopy with endometrial biopsy
- also speculum and bimanual to exclude other differentials of PMB
Management
- localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
- progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
- Wertheim’s radical hysterectomy includes removal of lymph nodes and is used to treat stage IIB endometrial carcinoma.
Prognosis
- 75% 5-year survival = good prognosis
*the combined oral contraceptive pill and smoking are protective
PMS
Premenstrual syndrome (PMS) describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle.
PMS only occurs in the presence of ovulatory menstrual cycles - it doesn’t occur prior to puberty, during pregnancy or after the menopause.
Emotional symptoms include:
- anxiety
- stress
- fatigue
- mood swings
Physical symptoms
- bloating
- breast pain
Management
Options depend on the severity of symptoms
- mild symptoms can be managed with lifestyle advice
- apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
- moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP) CONTRAINDICATED IN AURA W/ MIGRAINE
- examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
- severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
- this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
vulval carcinoma
Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year.
Sx:
- Lump with or without lymphadenopathy
- Itching
- Non-healing ulcer
- Vulval pain
Other than age, risk factors include:
- Human papilloma virus (HPV) infection
- Vulval intraepithelial neoplasia (VIN)
- Immunosuppression
- Lichen sclerosus
Features
- lump or ulcer on the labia majora
- inguinal lymphadenopathy
- may be associated with itching, irritation
mx
Lichen sclerosus
A 72 year-old woman presents to the GP with an itchy, sore white plaque on her vulva. The patient has a past medical history of type 1 diabetes and no personal or family history of cancer. Which of the following is the most likely diagnosis?
Lichen sclerosus was previously termed lichen sclerosus et atrophicus. It is an inflammatory condition which usually affects the genitalia and is more common in elderly females. Lichen sclerosus leads to atrophy of the epidermis with white plaques forming
Features
- itch is prominent
The diagnosis is usually made on clinical grounds but a biopsy may be performed if atypical features are present*
Management
- topical steroids and emollients
Follow-up:
- increased risk of vulval cancer
*the RCOG advise the following → no biopsy needed
PCOS: features and investigation
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
Features
- subfertility and infertility
- menstrual disturbances: oligomenorrhea and amenorrhoea → HMB when they do happen
- hirsutism, acne (due to hyperandrogenism)
- obesity (weight gain)
- acanthosis nigricans (due to insulin resistance)
Investigations
- pelvic ultrasound: multiple cysts on the ovaries
- FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
- check for impaired glucose tolerance (hyperinsulinaemia, high HbA1c)
Ovarian cysts: types
Complex (i.e. multi-loculated) ovarian cysts should be biopsied (cystectomy) with high suspicion of ovarian malignancy
Complex cysts - defined as cysts containing a solid mass, or those which are multi-loculated - should be treated as malignant until proven otherwise.
serum CA-125, αFP and βHCG are performed for all pre-menopausal women with complex ovarian cysts.
ovarian cyst rupture and mx
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
HPV vaccination
t has been known for a long time that the human papillomavirus (HPV) which infects the keratinocytes of the skin and mucous membranes is carcinogenic.
There are dozens of strains of HPV. The most important to remember are:
- 6 & 11: causes genital warts
- 16 & 18: linked to a variety of cancers, most notably cervical cancer
HPV infection is linked to:
- over 99.7% of cervical cancers
- HPV testing is now integral to cervical cancer screening
- samples are first tested for HPV and only if they are positive is cytology then performed
- around 85% of anal cancers
- around 50% of vulval and vaginal cancers
- around 20-30% of mouth and throat cancers
It should of course be remembered that there are other risk factors important in developing cervical cancer such as smoking, combined oral contraceptive pill use and high parity.
Immunisation
A vaccination for HPV was introduced in the UK back in 2008. As you may remember the Department of Health initially chose Cervarix. This vaccine protected against HPV 16 & 18 but not 6 & 11. There was widespread criticism of this decision given the significant disease burden caused by genital warts. Eventually in 2012 Gardasil replaced Cervarix as the vaccine used. Gardasil protects against HPV 6, 11, 16 & 18. This was initially just given to girls but from September 2019 boys were given the vaccine as well.
All 12- and 13-year-olds (girls AND boys) in school Year 8 are offered the human papillomavirus (HPV) vaccine.
- the vaccine is normally given in school
- information given to parents and available on the NHS website make it clear that the daughter may receive the vaccine against parental wishes
- given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy
HPV vaccination should also be offered to men who have sex with men under the age of 45 to protect against anal, throat and penile cancers.
Injection site reactions are particularly common with HPV vaccines.
urogenital prolapse
In urogenital prolapse there is descent of one of the pelvic organs resulting in protrusion on the vaginal walls. It probably affects around 40% of postmenopausal women
Types
Anterior vaginal wall:
- Cystocele: bladder (may lead to stress incontinence)
Urethrocele: urethra
- Cystourethrocele: both bladder and urethra
Posterior vaginal wall:
- Enterocele: small intestine
- Rectocele: rectum
Apical vaginal wall
- Uterine prolapse: uterus
- Vaginal vault prolapse: roof of vagina (common after hysterectomy)
Risk factors
- increasing age
- multiparity, vaginal deliveries
- obesity
- spina bifida
Presentation
- sensation of pressure, heaviness, ‘bearing-down’
- urinary symptoms: incontinence, frequency, urgency
Management
- if asymptomatic and mild prolapse then no treatment needed
- conservative: weight loss, pelvic floor muscle exercises
- ring pessary
- surgery
Surgical options
- cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
- uterine prolapse: hysterectomy, sacrohysteropexy
- rectocele: posterior colporrhaphy
- vaginal vault: sacrocolpoplexy
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.
Risk factors
- advancing age
- previous pregnancy and childbirth
- high body mass index
- hysterectomy
- family history
Classification
- overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
- stress incontinence: leaking small amounts when coughing or laughing
- mixed incontinence: both urge and stress
- overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigation
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
- bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
- mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
If stress incontinence is predominant:
- pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
- surgical procedures: e.g. retropubic mid-urethral tape procedures
-
duloxetine may be offered to women if they decline surgical procedures
- a combined noradrenaline and serotonin reuptake inhibitor
- mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
contraction
Bacterial vaginosis mx
most common cause of vaginal discharge in women of reproductive age
loss of lactobacilli → increase of anaerobic and BV-associated bacteria → proteolytic enzymes (vaginal peptides into malodorous amines) → rise in pH → G. vaginalis and Atopobium vaginae → exfoliate epithelial cells and biofilm development
Diagnosis:
- grey-white discharge (fishy odour) = positive whiff test aka fishy odour when KOH added to secretions
- presence of clue cells on microscopy = epithelial cells studied with Gram-variable coccobacilli
Tx:
- symptomatic = intravaginal metronidazole/clindamycin cream
can cause 2o infection in PID
association with pre-term labour
Vaginal discharge
What is Mittelschmerz?
one-sided, lower abdominal pain associated with ovulation.
Usually mid cycle pain.
Often sharp onset.
Little systemic disturbance.
May have recurrent episodes.
Usually settles over 24-48 hours.
Full blood count- usually normal
Ultrasound- may show small quantity of free fluid
Conservative
pelvic discomfort, soft abdomen with mild suprapubic discomfort
Differentiating genital tract infections SUMMARY
Endometritis
Infection of uterus cavity alone
spread of infection to pelvis
cause = instrumentation of uterus or complication of pregnancy, chlamydia/gonorrhoea (BV, E. coli, staph may be implicated), common after C. section, also after miscarriage and ToP
sx = persistent heavy vaginal bleeding, pain
signs = tender uterus, cervical os open
ix = cervical swabs, FBC
tx = broad-spectrum abx, ERPC
Atrophic vaginitis
Atrophic vaginitis often occurs in women who are post-menopausal women. It presents with vaginal dryness, dyspareunia and occasional spotting. On examination, the vagina may appear pale and dry. Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
lack of oestrogen is cause
MUST EXCLUDE MALIGNANCY (ENDOMETRIAL CANCER)
vulvovaginal candidiasis and recurrent vulvovaginal candidiasis
Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species.
The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop:
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV
Features
- ‘cottage cheese’, non-offensive discharge
- vulvitis: superficial dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions may be seen
Investigations
- a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
MANAGEMENT
Prescribe antifungal treatment
Most women:
- Local: clotrimazole pessary or cream (e.g. clotrimazole 500mg PV stat)
- Oral: itraconazole 200 mg PO BD for 1 day or fluconazole 150mg PO stat (FLUCONAZOLE FIRST LINE)
- Girls aged 12-15 years: consider prescribing topical clotrimazole 1% or 2% applied 2-3 times per day (do not prescribe intravaginal or oral antifungal)
- Pregnant women: intravaginal clotrimazole (Do not use oral antifungals)
- If vulval symptoms: topical imidazole (clotrimazole, ketoconazole) in addition to an oral or intravaginal antifungal
- NOTE: intravaginal clotrimazole (Canesten), oral fluconazole, topical clotrimazole → OTC
Advice
- Return if symptoms have not resolved in 7-14 days
Avoid predisposing factors:
- Wash the vulval area with a soap substitute - used externally and not more than once per day
- Use simple emollient to moisturise vulval area
- Consider probiotics (e.g. live yoghurts) orally or topically to relieve symptoms
- Do not routinely treat asymptomatic sexual partner → Male partner could get candida balanitis
Summary
Either local or oral treatment
o Local: clotrimazole pessary or cream (e.g. clotrimazole 500 mg PV stat)
o Oral: itraconazole 200mg PO BD for 1 day or fluconazole 150 mg PO stat
Recurrent vaginal candidiasis
- BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
- compliance with previous treatment should be checked
- confirm the diagnosis of candidiasis
- high vaginal swab for microscopy and culture
- consider a blood glucose test to exclude diabetes
- exclude differential diagnoses such as lichen sclerosus
- consider the use of an induction-maintenance regime
- induction: oral fluconazole every 3 days for 3 doses
- maintenance: oral fluconazole weekly for 6 months
Endometrioma (ruptured)
A 30-year-old woman is brought into the emergency department in intense pain. She has a past medical history of endometriosis, and it is one week since her last period. On ultrasound scan there is free fluid in the pelvis. What is the cause of her acute abdomen?
The history of endometriosis, acute abdomen, and the pelvis filled with fluid all point towards a rupture endometrioma.
Infertility: initial investigations
When should you consider early referral to fertility clinic?
Menopause: contraception
It is recommended to use effective contraception until the following time:
- 12 months after the last period in women > 50 years
- 24 months after the last period in women < 50 years
Which HRT?
A.Oral oestrogen only
B.Oestrogen patch
C.Vaginal oestrogen
D.Oral cyclical combined HRT
E.Topical cyclical combined HRT
F.Oral continuous combined HRT
G.Topical continuous combined HRT
H.Testosterone
I.HRT contraindicated
J.Sertraline
A 48-year-old woman presents with perimenopausal symptoms. Apart from suffering from migraines with aura, she does not have any relevant medical history. She has a family history of deep vein thrombosis (DVT). The patient’s last menstrual periods are irregular, the last one being 3 months ago. She is not currently on any contraception.
A 55-year-old woman presents with mood swings and night sweats for the last few years which she has managed herself. She reports her last period was over 1 year ago but reports some vaginal bleeding a few days ago. She is not on any contraception.
A 49-year-old patient presents with hot flushes and mood swings. She has no previous medical history or family history. She has been amenorrheic since her Mirena (levonorgestrel) coil was placed 2 years ago. She would like to consider HRT with the least side effects.
Topical cyclical combined HRT
HRT contraindicated
Oestrogen patch
Topical > oral if migraine with aura
If has a uterus → COMBINED
Not combined if no uterus, or one of P+O already provided (e.g. mirena coil in situ giving P)
Undiagnosed vaginal bleeding is a contraindication to HRT
Patch has least side effects = do not have an increased risk of DVT compared oral oestrogen preparations
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix (can be descending from local organs such as the appendix).
RFs = young, poor, sexually active
partially PFs = COCP, IUS
Causative organisms
- Chlamydia trachomatis (MOST COMMON CAUSE)
- Neisseria gonorrhoeae
- Mycoplasma genitalium
- Mycoplasma hominis
Other causes = TOP, ERPC, laparoscopy and dye test and IUD (and/or complications of childbirth and miscarriage)
Features
- lower abdominal pain/pelvic pain (constant, or intermittent)
- fever (unusual in chronic infection)
- deep dyspareunia
- dysuria and menstrual irregularities may occur (intermenstrual/postcoital bleeding)
- vaginal or cervical discharge
- cervical excitation
- adnexal discomfort
Investigation
- a pregnancy test should be done to exclude an ectopic pregnancy
-
high vaginal swab
- these are often negative
- screen for Chlamydia (NAAT on urine) and Gonorrhoea (NAATs of endocervcical/vulvovaginal swabs)
Complications
-
perihepatitis (Fitz-Hugh Curtis Syndrome)
- occurs in around 10% of cases
- it is characterised by right upper quadrant pain and may be confused with cholecystitis
- adhesions visible at laparoscopy between liver and anterior abdominal wall
- infertility - the risk may be as high as 10-20% after a single episode
- chronic pelvic pain
- ectopic pregnancy
Cylical vs continuous HRT?
Cyclical (oestrogen daily, progesterone used for a few weeks in the cycle) = menopause not achieved (amenorrhoea less than a year)
Continuous (P+O daily) = reached menopause (amenorrhoea >1 year)
How does metformin lead to ovulation in PCOS?
Insulin resistance -> hyperinsulinaemia -> androgen excess -> arrest in antral follicular development -> anovulation
Metformin treats insulin resistance and hyperinsulinaemia, therefore allowing follicular development and subsequent ovulation
When to give clomifene vs metformin in PCOS?
Clomifine FIRST LINE
Metformin SECOND LINE
Turner’s syndrome (a cause of primary amenorrhoea)
no secondary sexual characteristics
RAISED GONADOTROPINS (FSH, LH)
Adenomyosis
gold standard Ix
Tx
Adenomyosis is characterized by the presence of endometrial tissue within the myometrium. It is more common in multiparous women towards the end of their reproductive years.
Features (mainly asymptomatic)
- DYSmenorrhoea (fibroids cause HMB)
- menorrhagia
- enlarged, boggy uterus
Ix: MRI (US to aid)
Management
Medical treatment with the progesterone IUS or the combined oral contraceptive pill with or without NSAIDs may control the menorrhagia and dysmenorrhoea, but hysterectomy is often required.
For some women, a trial of GnRH analogue therapy may determine if symptoms attributed to adenomyosis are likely to improve with hysterectomy. The condition is oestrogen dependent, but why it occurs is unknown. The effects on fertility are unclear.
- GnRH agonists
- hysterectomy
Placental abruption: epidemiology, cause, and clinical features
Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
Epidemiology
- occurs in approximately 1/200 pregnancies
Cause - not known but associated factors:
- proteinuric hypertension
- cocaine use
- multiparity
- maternal trauma
- increasing maternal age
- current smoker
- pre-eclampsia
- transverse lie
- *A** for Abruption previously;
- *B** for Blood pressure (i.e. hypertension or pre-eclampsia);
- *R** for Ruptured membranes, either premature or prolonged;
- *U** for Uterine injury (i.e. trauma to the abdomen);
- *P** for Polyhydramnios;
- *T** for Twins or multiple gestation;
- *I** for Infection in the uterus, especially chorioamnionitis;
- *O** for Older age (i.e. aged over 35 years old);
- *N** for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
Clinical features
- shock out of keeping with visible loss
- pain constant
- tender, tense uterus
- normal lie and presentation
- fetal heart: absent/distressed
- coagulation problems
- beware pre-eclampsia, DIC, anuria
Placenta praevia: management and diagnosis
Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment.
If low-lying placenta at the 20-week scan:
- rescan at 34 weeks
- no need to limit activity or intercourse unless they bleed
- if still present at 34 weeks and grade I/II then scan every 2 weeks
- final ultrasound at 36-37 weeks to determine the method of delivery
- elective caesarean section for grades III/IV between 37-38 weeks
- if grade I then a trial of vaginal delivery may be offered
- if a woman with known placenta praevia goes into labour prior to the elective caesarean section an emergency caesarean section should be performed due to the risk of post-partum haemorrhage
Placenta praevia with bleeding
- admit
- ABC approach to stabilise the woman
- if not able to stabilise → emergency caesarean section
- if in labour or term reached → emergency caesarean section
Prognosis
- death is now extremely rare
- major cause of death in women with placenta praevia is now PPH
Placental abruption: management and complications
Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
Management
Fetus alive and < 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: ADMIT, observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: deliver vaginally
Fetus dead
- induce vaginal delivery
Complications
Maternal
- shock
- DIC
- renal failure
- PPH
Fetal
- IUGR
- hypoxia
- death
Prognosis
- associated with high perinatal mortality rate
- responsible for 15% of perinatal deaths
Placenta accreta and others
Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage.
Risk factors
- previous caesarean section
- placenta praevia
Strictly speaking, there are 3 different types of placenta accreta, depending on the degree of invasion although this is quite small print:
- accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
- increta: chorionic villi invade into the myometrium
- percreta: chorionic villi invade through the perimetrium
Eclampsia management
Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following:
- should be given once a decision to deliver has been made
- in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
-
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
- respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
- treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload
What to do if suspicion of ovarian cancer but there is an abdominal or pelvic mass?
If suspicion of ovarian cancer but there is an abdominal or pelvic mass, CA125 and US test can be bypassed and the patient directly referred to gynaecology
2 types of cervical cancer
- squamous cell cancer (80%)
- adenocarcinoma (20%)
Features of cervical cancer?
- may be detected during routine cervical cancer screening
- abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
- vaginal discharge
Risk factors for cervical cancer?
- smoking
- human immunodeficiency virus
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- combined oral contraceptive pill*
Endometrial hyperplasia
Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
RFs = unopposed oestrogen (e.g. tamoxifen)
Types
- simple
- complex
- simple atypical
- complex atypical
Features
- abnormal vaginal bleeding e.g. intermenstrual
Management
- simple endometrial hyperplasia without atypia: lose weight + high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used (oral progestogens are second line)
- atypia: hysterectomy +/- bilateral salpingo-oophorectomy is usually advised
What do you do with a patient with secondary dysmenorrhoea
referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
What is primary dysmenorrhoea, features and mx
In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.
Features
- pain typically starts just before or within a few hours of the period starting
- suprapubic cramping pains which may radiate to the back or down the thigh
Management
- NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
- combined oral contraceptive pills are used second line
What is secondary dysmenorrhoea and its causes?
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes include:
- endometriosis
- adenomyosis
- pelvic inflammatory disease
- intrauterine devices*
- fibroids
When surgical > medical tx in fibroids? myomectomy > tranexamic acid/LNG-IUS
The only effective treatment for large fibroids causing problems with fertility is myomectomy if the woman wishes to conceive in the future
Myomectomy, which involves surgically removing the fibroid from the uterus is currently the only form of treatment for fibroids which has sufficient evidence of improving fertility. This is most likely to be successful for submucosal fibroids which reduce fertility
evonorgestrel-releasing IUS and tranexamic acid provide symptomatic relief but will not impact on fertility making them inappropriate. Additionally, this fibroid is rather large making medical treatment likely ineffective.
What is an abortion vs miscarriage + miscarriage epidemiology
An abortion is the expulsion of the products of conception before 24 weeks. The term miscarriage is used often to avoid any misunderstandings
Epidemiology
- 15-20% of diagnosed pregnancies will miscarry in early pregnancies
- non-development of the blastocyst within 14 days occurs in up to 50% of conceptions
- recurrent spontaneous miscarriage affects 1% of women
Miscarriage: when, presentation and four types
In miscarriages the I’s are open - inevitable and incomplete.
Threatened miscarriage
- painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
- the bleeding is often less than menstruation
- cervical os is closed
- complicates up to 25% of all pregnancies
- Foetal HR present
Missed (delayed) miscarriage
- a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
- mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
- cervical os is closed
- when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
Inevitable miscarriage
- heavy bleeding with clots and pain
- cervical os is open
Incomplete miscarriage
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os is open
Miscarriage mx
The latest edition (11th) of the Oxford Handbook of Clinical Specialties says that the medical management of a 2nd (mid)-trimester miscarriage uses mifepristone (an antiprogestogen) to prime, and then 24-48h start misoprostol and admit
mifepristone now, misprostol at home
vaginal bleeding, nausea, vomiting → anti-emetics and analgesics
Recurrent miscarriage: definition and causes
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women
Causes
- antiphospholipid syndrome (MOST COMMON CAUSE)
- endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
- uterine abnormality: e.g. uterine septum
- parental chromosomal abnormalities
- smoking
Risk factors for miscarriage
What is PCOS?
Common disorder, ovarian dysfunction associated with hyperandrogenism and polycystic ovarian morphology
Path – LH + hyperinsulinaemia leads to increased ovarian androgen production
Genetics are implicated
RF – FHx, obesity, insulin resistance, HTN, AI, thyroid disease
Most common endocrinopathy of women of reproductive age, affecting up to 10%
Ix for PCOS and Rotterdam Criteria
- pelvic ultrasound: multiple cysts on the ovaries
- FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
- check for impaired glucose tolerance
PCOS Mx
Therefore inducing a withdrawal bleed every 3-4 months or preventing proliferation of the endometrium is recommended. This can be achieved with a cyclical oral progestogen (e.g. medroxyprogesterone) for at least 12 days a month, a combined oral contraceptive (COC), or levonorgestrel-releasing intrauterine system (LNG-IUS).
Fertility → REFER TO FERTILITY SERVICES
- As this woman has a known cause of infertility in the form of PCOS, she should be referred immediately to fertility services for consideration of further treatment. NICE recommends that these women be offered clomifene citrate or metformin, or a combination of the two, as first-line treatment. If this proves unsuccessful, laparoscopic ovarian drilling or gonadotrophins may be considered.
What is co-pyrindol (Dianette)? when is it used?
Cyproterone acetate + ethinylestradiol, used in PCOS complicated by hirsutism and acne (also acts as contraception)
How can you treat subfertility in PCOS? How long for? What can you add to this and when would you add to this?
Clomiphene - 1st line in women with a normal BMI (selective oestrogen receptor modulator)
Can induce ovulation if subfertility is an issue; used for up to 6 months
Increased risk of multiple pregnancy
Given with/without metformin (usually added after 3 failed cycles with clomiphene)
How does PCOS lead to an ovulation? How does metformin work in PCOS?
Increased peripheral insulin sensitivity
The majority of patients with polycystic ovarian syndrome have a degree of insulin resistence which in turn can lead to complicated changes in the hypothalamic-pituitary-ovarian axis.
PCOS –> insulin resistance –> androgen excess –> arrest in antral follicular development –> anovulation.
Causes of amenorrhoea
Investigations and management of amenorrhoea
Management of early bleeding in pregnancy
Management of fibroids
GnRH agonists not for large fibroids
PID mx
- oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
- RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ’ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
FGM Type 1 to 4
Female genital mutilation (FGM) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
FGM mx
- if FGM is confirmed in a girl under 18 years of age (either o/e or because the patients or parents says it has been done within 1 month of confirmation) reporting to the police is mandatory and this must be within 1 month of confirmation
- Contact child protection services
- Refer to secondary care for further investigation
Triad to diagnose Hyperemesis Gravidarum and Scoring system
The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis hyperemesis gravidarum:
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.
Ix: hypochloraemic, hyponatraemia with elevated urea and raised ketones
metabolic alkalosis but acidosis if very severe (increased ketones aka ketosis)
Abortion Act 1990 key points
reducing the upper limit from 28 weeks gestation to 24 weeks*
Key points
- two registered medical practitioners must sign a legal document (in an emergency only one is needed)
- only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
The method used to terminate pregnancy depend upon gestation
- less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
- less than 13 weeks: surgical dilation and suction of uterine contents
- _more than 15 week_s: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
What is the classification for OHSS
Gynaecological causes of abdominal pain
Acute and chronic causes of pelvic pain in women
ToP management
Acute causes of pelvic pain?
Chronic causes of pelvic pain?
What is FGM and what types are there?
Ix for fertility
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
Ix for fertility
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
Types of endometrial cancer
Urogynaecology incontinence mx
POPQ staging for pelvic organ prolapse
