Passmedicine - Gynaecology Flashcards
After giving birth on what day to women require contraception?
Day 21
When can the POP be used in the post-partum?
Anytime
If you start the POP on day 21 post-partum, do you require additional contraception for any amount of time?
Yes - 2 days
Is POP okay to use whilst breastfeeding?
Yes (small amount enters milk but this does not harm infant)
When can the COCP be used after giving birth?
UKMEC 4 (completely contraindicated) <6w post-partum UKMEC2 if breast feeding 6w-6m post-partum
What affect can the COCP have on lactating mothers?
May reduce breast milk production
When can the IUS/IUD be inserted after birth?
Within 48h of birth or after 4 weeks
How effective is the lactational amenorrhoea method at preventing pregnancy?
98% if woman is fully breast feeding + amenorrhoeic + <6m post-partum
What is an inter-pregnancy interval of <12m between childbirth and conceiving again associated with?
Increased risk of preterm birth, low birth weight and small for gestational age babies
When can the progesterone only implant be inserted after birth?
Any time
How common is infertility?
Affects 1 in 7 coples
What are the causes of infertility?
Male factor 30% Unexplained 20% Ovulation failure 20% Tubal damage 15% Others 15%
What are the two basic initial tests you should do for infertility?
Semen analysis
Serum progesterone 7 days prior to next expected period
What is the average length of a cycle?
28 days
On the average cycle, when should you do a serum progesterone?
21st day
How should you interpret a serum progesterone?
<16nmol/l - repeat, if consistently low refer to specialist
16-30nmol/l - repeat
>30nmol/l - ovulation has occured
What advice can you give couples trying to conceive?
Take folic acid
Maintain BMI 20-25
Have regular unprotected vaginal intercourse every 2-3 days
Smoking/drinking advice
Follow ovulation does basal temperature increase or decrease?
Increase
If a cervical smear comes back as borderline/mild dyskaryosis what happens?
Original sample tested for HPV:
-ve: returns to routine recall
+ve: referred for colposcopy
If a cervical smear comes back as moderate dyskaryosis what happens?
Consistent with CIN II - refer for urgent colposcopy within 2w
If a cervical smear comes back as severe dyskaryosis what happens?
Consistent with CIN III
Refer for urgent colposcopy within 2w
If a cervical smear comes back as suspected invasive cancer what happens?
Refer for urgent colposcopy within 2w
If cervical smear comes back as inadequate what action is taken?
Repeat smear - if persistent (3 inadequate samples), assess via colposcopy
How are women treated for CIN 1-3 reassessed?
Invited 6m after treatment for test of cure with repeat cytology in the community
What are the oncogenic subtypes of HPV associated with cervical cancer?
HPV 16, 18, 33
What are the different types of miscarriage?
Threatened Missed Inevitable Incomplete Complete
How does threatened miscarriage present?
Painless vaginal bleeding before 24w
Usually lighter than a period
Cervical os is closed
When do threatened miscarriages typically occur?
6-9 weeks
What is a missed miscarriage?
Gestational sac contains dead foetus before 20w without the symptoms of expulsion
How does a missed miscarriage present?
Light vaginal bleeding/discharge + symptoms of pregnancy may disappear
Not usually painful
Cervical os is closed
What is the description ‘blighted ovum’ or ‘anembyronic pregnancy’ used to describe?
Gestational sac >25mm + no embyronic/fetal part can be seen
How does inevitable miscarriage present?
Heavy bleeding with clots + pain
Cervical os is open
What occurs in an incomplete miscarriage?
Not all products of conception have been expelled
How does incomplete miscarriage tend to present?
Pain + vaginal bleeding
Cervical os is open
In routine diagnostic workup for abdominal pain, what examinations and tests should be done in all females?
Bimanual vaginal examination
Urine pregnancy test
Consider abdominal + pelvic USS
If after investigation of abdominal pain in a female, diagnostic doubt remains what investigation may be good for assessing suspected tubulo-ovarian pathology?
Laparoscopy
What are gynae causes of abdominal pain?
Mittelschmerz Endometriosis Ovarian torsion Ectopic gestation PID
When do you get pain in Mittelschmzer?
Midcycle
Describe the pain experienced in Mittelschmzer?
Sharp onset
Little systemic disturbance
Usually settles over 24-48h but may be recurrent
How do you investigate suspected Mittelschmzer?
FBC - usually normal
US - may show small quantity of free fluid
How do you manage Mittelschmzer?
Conservatively
How does endometriosis typically present?
Dysmenorrhoea (pain often days before period starts)
Subfertility
Chronic pelvic pain
Deep dyspareuina
What may occur in complex endometriosis?
Pelvic adhesions –> episodes of intermittent small bowel obstruction
What can intra-abdominal bleeding in endometriosis lead to?
Localised peritoneal inflammation
What can you see on investigation of endometriosis?
US - free fluid
Laparoscopy - lesions
How does ovarian torsion tend to present?
Sudden onset of deep unilateral colicky abdominal pain
Nausea, vomiting and distress
Onset my coincide with exercise
VE - unilateral tender adnexal mass
What might you see on investigation of ovarian torsion?
US - free fluid, whirlpool sign
Laparoscopy is diagnostic + therapeutic
How do you manage ovarian torsion?
Laparoscopy
How can ectopic pregnancy present?
- symptoms of pregnancy without intrauterine gestation
2. emergency with rupture/impending rupture
How does ectopic pregnancy rupture present?
Sudden onset abdominal pain, circulatory collapse
Adnexial tenderness
Shoulder tip pain
What investigations should you do for suspected ectopic pregnancy + what will they show?
US - no intrauterine pregnancy, may show free fluid in abdomen
b-HCG elevated
How does PID tend to present?
Bilateral lower abdominal pain, vaginal/cervical discharge, deep dyspareunia
Dysuria + menstrual irregularities may be present
Fever
Cervical excitation on ex
What is Fitz Hugh Curtis syndrome?
Peri-hepatic inflammation secondary to chlamydia leading to RUQ discomfort
What investigations should you do for suspected PID and what will they show?
FBC - leucocytosis
Pregnancy test
Amylase - normal/slightly raised
High vaginal + urethral swabs
What causes Mittleschmerz?
Very small amounts of fluid released during ovulation
What is the medical term for heavy menstrual bleeding?
Menorrhagia
How did menorrhagia used to be defined?
Blood loss >80ml per menses
How is menorrhagia defined now?
A volume of blood the women considers to be excessive
What investigations should be done for menorrhagia?
FBC in all women
Consider TVU in those with symptoms (e.g. IMB/PCB, pelvic pain…) suggestive of a structural /histological abnormality or abnormal pelvic Ex
What is the first line treatment for a women with menorrhagia who does not require contraception?
Mefenamic acid 500mg tds (if painful) or tranezamic acid 1g tds (if painless) started on the first day of period
If mefenamic/tranexamic acid don’t work to manage a pts menorrhagia what is the next step?
Try other drug whilst awaiting referral
What is the first line treatment for a women with menorrhagia who does require contraception?
IUS (mirena)
What is the second and third line treatment for a women with menorrhagia who does require contraception?
2nd: COCP
3rd: long acting progesterone
What drug can be used as a short term option to rapidly stop heavy menstrual bleeding?
Norethisterone 5mg
At what age is ovarian torsion most common?
Reproductive age
What is a typical history of someone presenting with an ectopic pregnancy?
6-8w history of amenorrhoea with lower abdominal pain, + vaginal bleeding
What two features are sometimes seen in ectopic pregnancy?
Shoulder tip pain
Cervical excitation
In women what is the most common cause of pelvic pain?
Primary dysmenorrhoea
What things may cause pelvic pain?
Primary dysmenorrhoea Ectopic pregnancy UTI Appendicitis PID Ovarian torsion Miscarriage Endometriosis IBS Ovarian cyst Urogenital prolapse
How does appendicitis tend to present?
Pain in central abdomen --> RIF Anorexia, low grade fever Tenderness in RIF Tachycardia Rovsing's sign
What is Rovsing’s sign?
More pain in RIF than LIF when palpating LIF
How does IBS tend to present?
Abdominal pain
Bloating
Change in bowel habit
Lethargy, nausea, backache, bladder symptoms may be present
How does ovarian cyst tend to present?
Unilateral dull ache which may be intermittent/only occur during intercourse
What happening to an ovarian cyst may lead to severe abdominal pain?
Torsion or rupture
What symptoms may large ovarian cysts cause?
Abdominal swelling or pressure effects on the bladder
Who is urogenital prolapse seen in?
Older women
What are the features of urogenital prolapse?
Sensation of pressure, heaviness, bearing down
Incontinence, frequency, urgency
How does tranexamic acid work?
Plasminogen activator inhibit that acts as an anti-fibrinolytic
In what age group do most cases of endometrial cancer occur?
Post-menopausal women
What is the prognosis of endometrial cancer?
Usually good as it is usually detected early
What are RFs for endometrial cancer?
Obesity Nulliparity Early menarche Late menopause Unopposed oestrogen DM Tamoxifen PCOS HNPCC
How can you avoid giving unopposed oestrogen to a women with a womb?
Add in progesterone when giving HRT
What is the classic symptom associated with endometrial cancer?
PMB
How might a women who is premenopausal present with endometrial cancer?
Change in intermenstrual bleeding
How is PMB investigated?
Women => 55 with PMB should be referred using the suspected cancer pathway
1st line Ix: TVU - normal endometrial thickness (<4mm) has high -ve predictive value
Hysteroscopy with endometrial biopsy if >4mm
How is localised endometrial cancer treated?
Total abdominal hysterectomy + bilateral salphino-oophorectomy
How is localised HIGH RISK endometrial cancer treated?
TAH + BSO + post-op radio
What treatment may be used for endometrial cancer in frail elderly women not suitable for surgery?
Progesterone therapy
PMB = ? until proven otherwise
Endometrial cancer
What are causes of menorrhagia?
Dysfunctional uterine bleeding Anovulatory cycles Uterine fibroids Hypothyroidism IUD (Cu coil) PID Bleeding disorders,e.g. vWB
What is dysfunctional uterine bleeding?
Menorrhagia in the absence of underlying pathology
When are anovulatory cycles most common?
Extremes of a women’s reproductive life
What is endometriosis?
Growth of ectopic endometrial tissue outside the uterine cavity
How common is endometriosis?
Affects 10% of women of a reproductive age
What non-gynae symptoms can those with endometriosis get?
Urinary symptoms, e.g. dysuria, urgency, haematuria
Dyzchezia (painful bowel movements)
What do you see in pelvic examination in those with endometriosis?
Reduced organ mobility
Tender nodularity in posterior vaginal fornix
Visible vaginal endometriotic lesions may be seen
What is the gold standard investigation for endometriosis?
Laparoscopy
What can be done for endometriosis in primary care?
Not much, if pt has significant symptoms she should be referred for definitive diagnosis
How is endometriosis managed?
1st line: NSAIDs/Paracetamol
2nd line: hormonal treatments, e.g. COCP, progesterones
3rd line/if trying for children: refer to secondary care for GnRH analogues, surgery
How do GnRH analogues work in treating endometriosis?
Induce a pseudomenopause due to low oestrogen lvels
What surgery may be offered for severe endometriosis?
Laparoscopic excision
Laser treatment of endometriotic ovarian cysts
Is endometriosis oestrogen dependent or independent?
Dependent - starts after menarche and regresses after menopause
How should the COCP be used in those with endometriosis?
Back to back with no pill free interval
What contraceptive is not suitable for those with endometriosis?
Cu coil as it makes periods painful and longer
What causes the lower abdominal pain in ectopic pregnancy?
Tubal spasm
Describe the pain in ectopic pregnancy?
Lower abdominal
Unilateral
Constant
What symptoms can peritoneal bleeding in ectopic pregnancy cause?
Shoulder tip pain and pain on defaecation or urination
Apart from vaginal bleeding and lower abdominal pain what other symptoms may you see in ectopic pregnancy?
Symptoms of pregnancy, e.g. breast tenderness
Circulatory collapse in ruptured ectopic, e.g. syncope, dizziness
What findings may you see on examination in ectopic pregnancy?
Abdominal tenderness
Cervical excitation
Adnexal mass - do not examine for adnexal mass as this may increase chance of rupture (do check for cervical excitation)
In case of pregnancy of unknown location what can point towards a diagnosis of ectopic pregnancy?
Serum bHCG >1, 500
What is the medical treatment for an ectopic pregnancy?
Methotrexate
What is the surgical treatment for ectopic pregnancy?
Salpingectomy unless they have other RFs for inferility, e.g. contralateral tube damage - then offer salpinotomy
What is the average age to go through menopause?
51
When should women nearing the menopause use contraception up until?
12m after last period if >50
24m after last period if <50
What is PID?
Infection and inflammation of the female pelvic organs (uterus, fallopian tubes, ovaries, surrounding peritoneum)
What tends to cause PID?
Ascending infection from the endocervix
What is the most common cause of PID?
Chlamydia trachomatis
What are other causes of PID?
Neisseria gonorrhoea
Mycoplasma genitalium
Mycoplasma hominis
What investigations should be done for suspected PID?
Pregnancy test to exclude ectopic
High vaginal swabs
Screen for chlamydia/gonorrheoa
Why is there a low threshold for treating PID?
Difficulty in making diagnosis
Potential complications of untreated PID are severe
How is PID managed?
Oral olofaxin + oral metronidazole
OR
IM ceftriazone + oral doxycyline + oral metronidazole
Should IUDs be removed in PID?
If mild might be okay to leave, but evidence suggests removal may be better
What are complications of PID?
Fitz Hugh Curtis syndrome
Infertility
Chronic pelvic pain
Ectopic pregnancy
What is the risk of infertility after a single episode of PID?
10-20%
Give e.g.s of minor symptoms of pregnancy?
N/V
Tiredness
MSK pains
What is UTI in pregnancy associated with?
Premature birth (inflammatory mediators trigger pre-term labour by irritating neck of uterus + cervix)
Why do pregnant ladies get lower back pain?
Due to increased laxity in SI joints due to release of hormone relaxin
Increased mechanical load
How common is PCOS in women of reproductive age?
5-20%
High levels of what two hormones are seen in PCOS?
Insulin
LH
What is the general management of PCOS?
Wt loss
COCP may regulate cycle+ induce a monthly bleed
What drugs may be used to treat hirsutism/acne in PCOS?
COCP
Topical eflornithine
Spirnolactone, flutamide, finasteride under specialist supervision
What is the management of infertility in PCOS?
Wt loss
Under specialist supervision - clomifene/metformin or combo of both
Gonadotrophins
How does clomifene work?
Occupies hypothalamic oestrogen receptors without activating them, this interferes with binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion
How is PCOS diagnosed?
When 2/3 of the following are present:
- Polycystic ovary on USS/increased ovarian volume
- Infrequent periods (>35d apart) or no ovulation
- Clinical/biochemical signs of hyperandrogenism/elevated levels of total/free testosterone
What is the pathophysiology of PCOS?
Increased LH and insulin –> increased androgen production which disrupts folliculogenesis –> excess small ovarian follicles + irregular/absent ovulation + hirsutism
What are complications of PCOS?
T2DM Obesity Subfertility Miscarriage Endometrial cancer
When is clomifene given?
Days 2-6 of cycle to initiate follicular maturation
How many uses of clomifene are you allowed?
6
What does clomifene increase the risk of?
Multiple pregnancy
What are the pros and cons of using metformin for PCOS?
Pros - increases effectiveness of clomifene in clomifene-resistant women, treats hirsutism, reduces risk of gestational diabetes + early miscarriages
Con - less effective than clomifene
What are second line treatments for infertility in PCOS?
Ovarian diathermy
Gonadotrophin induction
How does gonadotrophin induction work?
Daily s/c injection of recombinant/purified FSH + or LH
This stimulates follicular growth which is monitored by USS
Once follicle is big enough, ovulation is stimulated by injection of hCG or LH
What is the 3rd line treatment option for infertility in those with PCOS?
IVF
How should women taking COCP for control of PCOS symptoms take the pill?
Back to back with 3/4 bleeds a year to protect the endometrium
Who does atrophic vaginitis tend to affect?
Post menopausal women
How does atrophic vaginitis tend to pesent?
Vaginal dryness, pain, itching, dyspareunia, occasional spotting
What might atrophic vaginitis look like o/e?
Pale, dry
How is atrophic vaginitis treated?
Vaginal lubricants and moisturisers
2nd line: topical oestrogen cream
Define endometrial hyperplasia
Abnormal proliferation of the endometrium in excess of normal proliferation that occurs during the menstrual cycle
What are the types of endometrial hyperplasia
Simple
Complex
Simple atypical
Complex atypical
What do a minority of pts with endometrial hyperplasia go on to develop?
Endometrial cancer
What are the features of endometrial hyperplasia
Abnormal vaginal bleeding, e.g. IMB
How do you manage simple endometrial hyperplasia without atypica?
High dose progestogens with repeat sampling in 3-4 months (IUS may be used)
How do you manage atypical endometrial hyperplasia?
Hysterectomy
What are the types of benign ovarian cysts?
Physiological cysts
Benign germ cell tumours
Benign epithelial tumours
Benign sex cord stromal tumours
What kind of ovarian cysts should be biopsied to exclude malignancy?
Complex (i.e. multi-loculated) ovarian cysts
What are the commonest types of ovarian cysts?
Follicular cysts
What are the two functional/physiological cysts?
Follicular cysts
Corpus luteum cysts
What causes a follicular cyst?
Non-rupture of a dominant follicle or failure of atresia in a non-dominant follicle
Do follicular cysts go away?
Commonly regress after several menstrual cycles
What is a corpeus luteum cyst?
If pregnancy doesn’t occur the corpus luteum usually breaks down + disappears
If it doesn’t it may fill with blood/fluid to form a corpus luteum cyst
What are corpus luteum cysts more likely to present with when compared to follicular cysts?
Intraperitoneal bleeding
Give an example of a benign germ cell tumour that may affect the ovary
Dermoid cyst
What is the other name for dermoid cysts?
Mature cystic teratomas
What is the appearance of dermoid cysts?
Epithelial lined, may contain skin appendages, hair + teeth
What is the most common benign ovarian tumour in women under 30?
Dermoid cyst
How do dermoid cysts in the ovary tend to present?
Usually asymptomatic but increase risk of torsion
What tissue do benign epithelial tumours of the ovary develop from?
Ovarian surface epithelium
Give e.g.s of two benign epithelial tumours of the ovary
Serous cystadenoma
Mucinous cystadenoma
What is the most common benign epithelial tumour?
Serous cystadenoma
What cancer does serous cystadenoma of the ovary bear resemblance to?
Serous carcinoma of ovary
If mucinous cystadenoma of the ovary ruptures what can it cause?
Pseudomyxoma peritoni
What are the 3 features of Meig’s syndrome?
Benign ovarian tumour (usually fibroma)
Ascites
Pleural effusion
What test should you order for a women who has had heavy bleeding since her period started?
Coagulation screen
What is a Rokitansky protuberance?
The inner lining of a mature cystic teratoma has single/multiple white shiny masses projecting from the wall to the centre of the cyst and this is where the hair, bone, teeth etc. grows from
What occurs in urogenital prolapse?
Descent of one of the pelvic organs –> protrusion on the vaginal walls
How common is urogenital prolapse?
Affects 40% of post-menopausal women
What are the types of urogenital prolapse?
Cystocele, cystourethrocele
Rectocele
Uterine prolapse
Urethrocele, enterocele
What is an enterocele?
Herniation of the pouch of Douglas, incl. the small intestine into the vagina
What are RFs for urogenital prolapse?
Increasing age Multiparity Vaginal deliveries Obesity Spina bifida
How is asymptomatic mild urogenital prolapse managed?
No treatment req.
What are conservative managements for urogenital prolapse?
Wt loss
PFMT
What other treatments are available for urogenital prolapse?
Ring pessary
Surgery
What surgeries are available for cystocele/cystourethrocele?
Anterior colporrhaphy/colposuspension
What surgeries are available for uterine prolapse?
Hysterectomy, sacrophysteropexy
What surgeries are available for rectocele?
Posterior colporrhaphy
What is sacrocolpoplexy?
Suspending the vaginal apex to the sacral promontory
What are the two kinds of amenorrhoea?
Primary
Secondary
What is primary amenorrhoea?
Failure to start menses by 16y
What is secondary amenorrhoea?
Cessation of established, regular menstruation for 6m or longer (12m in those with previous oligomenorrhoea)
What are causes of primary amenorrhoea?
Constitutional delay Turner's syndrome Testicular feminisation syndrome Kallmann syndrome Congenital adrenal hyperplasia Congenital malformations of the genital tract (e.g. imperforate hymen, mullerian agenesis, transverse vaginal septae)
What are causes of secondary amenorrhoea?
Hypothalamic amenorrhoea (e.g. stress/excessive exercise) PCOS Hyperprolactinaemia Premature ovarian failure Thyrotoxicosis Sheehan's syndrome Asherman's syndrome Contraception Lactational amenorrhoea
What is Asherman’s syndrome?
Intrauterine adhesions
How do you investigate amenorrhoea?
Urinary/serum bHCG to exclude pregnancy Gonadotrophins: low levels indicate hypothalamic cause, raised levels indicate ovarian problem Prolactin Androgen levels: raised in PCOS Oestradiol TFTs
What thyroid problem can cause amenorrhoea?
Thyrotoxicosis or hypothyroidism
What % of the population does urinary incontinence affect?
4-5%
Who is urinary incontinence most common in?
Elderly females
What are RFs for urinary incontinence?
Advancing age Prev pregnancy + childbirth High BMI Hysterectomy FH
What are the types of urinary incontinence?
Overactive bladder/urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
What causes overactive bladder/urge incontinence?
Detrusor overactivity
How does stress incontinence present?
Leaking small amounts of urine when laughing/coughing
What is mixed incontinence?
Urge and stress incontinence
What causes overflow incontinence?
Bladder outlet obstruction, e.g. prostate enlargement
How should urinary incontinence be investigated?
Bladder diaries for at least 3d
Vaginal ex to rule out POP + ability to contact PFMs
Urine dipstick + culture
Urodynamic studies
What is the initial management for urge incontinence?
Bladder retraining (min 6w)
What are other treatments for urge incontiennce?
First line: anti-muscarinics (e.g. oxybutinin, tolterodine, darifenacin)
What drug can be used in frail pts for urge incontiennce?
Mirabegron
Avoid oxybutinin in frail older women
What is the initial management for stress incontinence?
PFMT (8 contractions 3x day for 3m)
What surgical procedures can be done for stress incontinence?
Retropubic mid-urethral tape procedures
What are fibroids?
Benign smooth muscle tumours of the uterus
What race tend to get fibroids more often?
Afro-caribbean women
What are the features of fibroids?
May be asymptomatic
Menorrhagia
Crampy lower abdominal pain often during period
Bloating
Urinary symptoms, e.g. frequency with larger fibroids
Subfertility
How do you diagnose fibroids?
TVU
How are fibroids managed?
Symptomatically - IUS first line
Other options: tranexamic acid, COC
GnRH agonists may reduce fibroid size in short term
Surgery sometimes needed
What surgeries may be used for fibroids?
Myomectomy, hysteroscopic endometrial ablation, hysterectomy, uterine artery embolisation
What are complications of fibroids?
Red degeneration (haemorrhage into tumour, commonly occurs during pregnancy)
Define premature ovarian failure
Onset of menopausal symptoms + elevated gonadotrophins before age 40
What are causes of premature ovarian failure?
Idiopathic (most common)
Chemotherapy
Autoimmune
Radiation
What are features of premature ovarian failure?
Same as menopause (hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH, LH)
Define dysmenorrhoea
Excessive pain during the menstrual period
What are the two types of dysmenorrhoea
Primary
Secondary
What is primary dysmenorrhoea?
There is no underlying pelvic pathology
How common is primary dysmenorrhoea?
Affects 50% of women
What is thought to be related to primary dysmenorrhoea?
Excessive endometrial prostaglandin production
What are the features of primary dysmenorrhoea?
Pain just before/within a few hours of period starting
Suprapubic cramping which can radiate to back or down thigh
How is dysmenorrhoea managed?
NSAIDs (e.g. mefenamic acid/ibuprofen)
COCP second line
What is secondary dysmenorrhoea?
Is due to underlying pathology
When does the pain for secondary dysmenorrhoea tend to start?
3-4 days before the onset of the period
What are causes of secondary dysmenorrhoea?
Endometriosis Adenomyosis PID IUD Fibroids
What should be involved in the management of all women with secondary dysmenorrhoea?
Refer to gynae for investigation
What is hyperemesis gravidarum thought to be related to?
Raised bHCG levels
When is hyperemesis gravidarum most common?
Between 8 and 20 weeks
What things are associated with hyperemesis gravidarum?
Multiple pregnancies Trophoblastic disease Hyperthyroidism Nulliparity Obesity
What thing is associated with decreased incidence of hyperemesis gravidarum?
Smoking
When should you consider admission for nausea and vomiting in pregnancy?
Continued N+V + unable to keep liquids or oral antiemetics down
Continued N+ V with ketonuria +/or wt loss (>5% body wt), despite oral antiemetics
Confirmed/suspected co-morb (e.g. unable to tolerate antibiotics for a UTI)
For which individuals should you have a lower threshold for admitting with N+V during pregnancy?
Those with conditions that may be adversely affected by N+V, e.g. DM
What triad is used for the diagnosis of hyperemesis gravidarum?
5% pre-pregnancy wt loss
Dehydration
Electrolyte imbalance
What scoring system can be used to classify the severity of NVP?
Pregnancy-Unique Quantification of Emesis
How is hyperemesis gravidarum managed?
1st line: antihistamines, e.g. promethazine, cyclizine
2nd line: onansetron, metoclompramide
Ginger and P6 (wrist) acupressure can be used (little evidence for these)
Admission for IV hydration
What is the issue with giving metoclompramide?
EPS
What are complications of hyperemesis gravidarum?
Wernicke's encepahlopathy Mallory-Weiss tear Central pontine myelinolysis Acute tubular necrosis Fetal - small for gestational age, pre-term birth
What is the peak age to get ovarian cancer?
60 years old
What are the most common ovarian tumours/
Epithelial ones, most are serous carcinomas
Lately it has been recognise that what weird place is often the site of origin of many ovarian cancers?
The distal end of the fallopian tube
What are RFs for ovarian cancer?
BRCA1/2 mutation
Many ovulations, e.g. early menarche, late menopause, nulliparity
What are the clinical features of ovarian cancer?
Abdominal distension + bloating Abdominal + pelvic pain Urinary symptoms, e.g. urgency Early satiety Diarrhoea
What is the initial test for ovarian cancer?
CA125
What things can raise CA125 besides ovarian cancer?
Endometriosis
Menstruation
Benign ovarian cysts
What level of CA125 would indicate a need for further investigation?
Raised (35IU/ml or greater)
What should you do if CA125 is raised?
Urgent US of abdomen + pelvis
How is ovarian cancer generally diagnosed?
Diagnostic laparotomy
How is ovarian cancer usually managed?
Surgery + platinum based chemo
What is a common complication of open myomectomy?
Adhesions most common
Bladder injury + uterine perforation can also occur but they are less common
What are predisposing factors for candidiasis?
DM
Drugs - steroids, antibiotics
Pregnancy
Immunosupression - HIV, iatrogenic
What are the features of vaginal candidiasis?
Cottage cheese, non-offensive discharge
Vulvitis - dyspareunia, dysuria
Itch
Vulval erythema, fissuring, satellite lesions may be seen
How do you investigate suspected candidiasis?
Don’t usually need to if clinical features are consistent with candidiasis
Can do high vaginal swab if unsure
How do you manage thrush?
Local Rx: clotrimazole pessary
Oral: itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
How do you treat thrush in pregnancy?
Local treatments only (creams/pessaries)
Define recurrent vaginal candidiasis
4+ episodes per year
How do you manage recurrent vaginal candidiasis?
Check compliance with Rx
Confirm initial diagnosis - high vaginal swab, exclude ddx, e.g. lichen sclerosus
Exclude predisposing factors
consider use of induction-maintenance regimen (daily treatment for a week followed by maintenance treatment weekly for 6m)
What is the discharge of thrush like?
White, curdy with pH <4.5
What causes thrush?
Candida albicans
What test can you do to confirm menopause?
FSH - this is very raised in menopausal pts
What causes menopause?
Loss of follicular activity
How is menopause diagnosed?
Usually in primary care after the cessation of periods
What % of women will get menopausal symptoms?
75%
How long do menopausal symptoms generally last for?
7 years
What lifestyle modifications may help with hot flushes associated with menopause?
Regular exercise, weight loss, stress reduction
What lifestyle modifications may help with sleep disturbance associated with menopause?
Avoiding late evening exercise, maintaining good sleep hygiene
What lifestyle modifications may help with mood problems associated with menopause?
Sleep, regular exercise, relaxation
What lifestyle modifications may help with cognitive symptoms associated with menopause?
Regular exercise, good sleep hygiene
What are contraindications for HRT?
Current/past breast cancer
Any oestrogen sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
What are is the big difference in giving HRT for a women with and without a womb?
Womb - must give progesterone with oestrogen
No womb - can give unopposed oestrogen
What are the risks of HRT?
VTE for oral HRT Stroke for oral HRT Coronary heart disease Breast cancer Ovarian cancer
What are the ways women with no womb can be given HRT?
Oestrogen either orally or in a transdermal patch
What are the ways women with a womb can be given HRT?
Oral or transdermal combined HRT
What are non-HRT treatments to help with vasomotor symptoms?
Fluoxetine, citalopram, venlafaxine
What are non-HRT treatments to help with vaginal dryness?
Vaginal lubricant or moisturiser
What are non-HRT treatments to help with psychological symptoms?
Self help groups
CBT
Antidepressants
What are non-HRT treatments to help with urogenital symptoms?
Vaginal oestrogen if suffering from urogenital atrophy
How long may HRT need to be used for vasomotor symptoms?
2-5y (should make regular attempts to come off it)
Does stopping HRT gradually help with recurrence?
Limits recurrence in the short term only
When should a women be referred to secondary care for management of her menopausal symptoms?
If treatment in primary care has been ineffective or if there are ongoing side effects or unexplained bleeding
What is the initial imaging used for ovarian cysts/tumours?
USS
What will an USS report about an ovarian cyst/tumour?
Simple - unilocular (more likely to be benign/physiological)
Complex - multilocular (more likely to be malignant)
What is your approach to the management of an ovarian mass in someone who is premenopausal?
Conservative approach in women <35y
Cyst is small + simple on USS likely to be benign
Repeat USS in 8-12w + referral if it persists
What is your approach to the management of an ovarian mass in someone who is postmenopausal?
Physiological cysts unlikely
Regardless of size/nature of cyst refer to gynae for assessment
How does rupture ovarian cyst tend to present?
Sudden onset unilateral pelvic pain precipitated by intercourse/strenuous activity
What may you see on USS in an ovarian cyst rupture?
Free fluid in the abdomen
What are side effects of HRT?
Nausea
Breast tenderness
Fluid retention + wt gain
What are potential complications of HRT?
Increased risk of:
- Breast cancer (only during use + for 5y after use)
- Endometrial cancer (reduced by addition of progesterone)
- VTE
- Stroke
- IHD
What may indicate a need for a biopsy to exclude endometrial cancer in a women who is premenopausal?
Persistent IMB in someone =<45 + treatment failure/ineffective treatment
How does rupture endometrioma present?
Sudden intense pain
Pelvis will be filled with fluid
What are potential common long term complications of hysterectomy?
Enterocele
Vaginal vault prolapse
Urinary retention
Give an example of what can be used as the progesterone component of HRT
Mirena (IUS)
Licensed up to 4y use
What is the classic exam history of ectopic pregnancy rupture?
Amenorrhoea
Abdominal pain
Vaginal bleeding
Shoulder tip pain
What is adenomyosis?
Endometrial tissue in the myometrium
Who is adenomyosis most common in?
Multiparous women towards end of their reproductive years
What are the features of adenomyosis?
Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus
What is the management of adenomyosis?
GnRH agonists
Hysterectomy - definitive
What are the commonest causes of vaginal discharge?
Physiological
Candida
Trichomonas vaginalis
Bacterial vaginosis
What are less common causes of vaginal discharge?
Gonorrhoea Chlamydia Ectropion Foreign body Cervical cancer
What are the key features of trichomas vaginalis infection?
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
pH >4.5
What is the discharge of BV like?
Offensive, thin, white/grey, fishy discharge
Define recurrent miscarriage
3+ consecutive spontaneous abortions
What are causes of recurrent miscarriages?
Antiphospholipid syndrome Endocrine disorders (poorly controlled DM/thyroid dx/PCOS) Uterine abnormality, e.g. uterine septum Parental chromosomal abnormalities Smoking
What is the most reliable test to confirm ovulation?
Day 21 progesterone
When does serum progesterone peak?
7 days after ovulation (nb luteal phase is always 14 days, so peaks always 7 days before period)
What are the stages of ovarian cancer?
Stage 1 - confined to ovaries
Stage 2 - local spread within pelvis
Stage 3 - spread beyond pelvis into abdomen
Stage 4 - distant mets
What kind of spread is most common in ovarian cancer?
Local spread
What is Sheehan’s syndrome?
Reduction in function of pituitary gland following ischaemic necrosis due to hypovolaemic shock following birth
What are features of Sheehan’s syndrome?
Amenorrhoea, problems with milk production, hypothyroidism
Symptoms can be varied + take sometimes take years to develop
Define FGM
All procedures involving partial/total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons
What is type 1 FGM
Clitoridectomy
What is type 2 FGM
Partial/total clitoridectomy + removal of labia minora +/- excision of labia majora
What is type 3 FGM
Narrowing of vaginal orifice with creation of a covering seal by cutting + appositioning the labia minor +/- labia majora +/- clitoridectomy
INFIBULATION
What is type 4 FGM
All other harmful procedures to the female genitalia, e.g. pricking, piercing, incising, scraping, cauterization
Is reinfibulation legal?
NO
What are non-gynae causes of lower abdominal pain in women?
Appendicitis UTI Constipation IBS Gallstones
What are menstrual related causes of lower abdominal pain in women?
Dysmenorrhoea
Endometriosis
Mittelschmerz
What are gynae causes of lower abdominal pain in women?
PID Ovarian torsion Uterine rupture (e.g. with IUS/IUD in situ)
What are pregnancy related causes of lower abdominal pain?
Ectopic pregnancy Spontaneous abortion Placental abruption Premature labour Pre-eclampsia
How does metformin work in treating some of the symptoms of PCOS?
Increases peripheral insulin resistance
What is a risk factor for endometrial hyperplasia?
Tamoxifen use (unopposed oestrogen stimulates endometrial growth)
Progesterone usually stimulates shedding of this tissue
Obesity
PCOS
DM
How does tamoxifen work?
Used in oestrogen receptor +ve breast cancer (in breast has anti-oestrogen effects, in endometrium has pro-oestrogen effects)
What is the only effective treatment for someone with large fibroids causing problems who is wanting to conceive?
Myomectomy
Who is offered cervical screening?
Women aged 25 to 64
How often are women screened for cervical cancer?
25-49y: 3yrly
50-64y: 5yrly
Which women may opt out of cervical cancer screening?
Those who have never been sexually active as they have a very low risk
Can you do a cervical screen on a pregnant women?
You can if missed screening or previously abnormal smears but usually delayed until 3m post-partum
What is the method of cervical screening?
Liquid based cytology
When is theoretically the best time to take a cervical smear?
Mid cycle
What women may require cervical screening more often?
Those who are immunosupressed
What is the mechanism of action of oxytbutinin?
Anti-muscarinic
How many small (<3cm) uterine fibroids not distorting the uterine cavity be managed?
Medically, e.g. IUS, tranexamic acid, COCP
What are the majority of vulval cancers?
SCC
Over what age do most cases of vulval cancers occur?
65y
What are risk factors for vulval cancer?
HPV infection
VIN
Immunosupression
Lichen sclerosus
What are features of vulval cancer?
Lump/ulcer on labia majora
Often ulcerated
Itching/irritation may occur
What is the appearance of a VIN?
White/plaque like
Don’t tend to ulcerate
In which cases when someone has an ectopic pregnancy but is haemodyamically stable should they be treated wth surgery as opposed to just methotrexate?
If a foetal heartbeat is present
Do lesbians require cervical screening?
Yes - HPV can be transmitted during lesbian sex
What is the screening programme for ovarian cancer?
There is NO screening for ovarian cancer currently
Why does a urine dipstick need to be done in all women presenting with urinary incontinence?
Rule out UTI/DM
How often should women with HIV be screened for cervical cancer and how should this be done?
Yearly cervical cytology
Why do women with HIV require more frequent cervical cancer screening?
They are at increased risk of CIN due to decrease immune response + clearance of HPV
(Even if effectively treated with antiretrovirals)
What is ovarian hyperstimulation syndrome a complication of?
Some infertility treatments
What is the pathophysiology of ovarian hyperstimulation syndrome?
Presence of multiple lutenized cysts –> high levels of oestrogen, progesterone + also vasoactive substances, e.g. VEGF –> increased membrane permeability + loss of fluid from the intravascular compartment
What therapies cause the most ovarian hyperstimulation syndrome?
Gonadotrophin
hCG treatment
IVF (1/3rd get it)
What is the criteria for mild OHS?
Abdominal pain
Abdominal bloating
What is the criteria for moderate OHS?
Mild criteria +
NV
US evidence of ascites
What is the criteria for severe OHS?
Moderate criteria + Clinical evidence of ascites Oliguria Haematocrit >45% Hypoproteinaemia
What is the criteria for critical OHS?
Severe criteria + TE ARDS Anuria Tense ascites
Name 2 protective factors for endometrial cancer
COCP use
Smoking
What is post-coital bleeding?
Vaginal bleeding after sexual intercourse
What are causes of PCB?
Idiopathic 50% Cervical ectropion in 33% Cervicitis e.g. secondary to chlamydia Cervical cancer Polyps Trauma
What is the most common identifiable cause of PCB?
Cervical ectropion
What women are more at risk of developing a cervical ectropion?
Those on the COC
What are features of PCOS?
Subfertility/infertility
Menstrual disturbances, e.g. amenorrhoea/oligomenorrhoea
Hirsutism/acne (hyperandrogenism)
Obesity
Acanthosis nigricans (insulin resistance)
What investigations should be done for suspected PCOS?
Pelvic USS: multiple cysts on ovaries
FSH, LH (LH:FSH ratio), prolactin (raised/normal), TSH, testosterone (normal/raised)
Check for impaired glucose tolerance
What drug can mask the symptoms of PCOS?
COCP
Define PMB
Vaginal bleeding after 12m of amenorrhoea
What is the most common cause of PMB?
Vaginal atrophy
What is vaginal atrophy?
Thinning, drying and inflammation of the walls of the vagina due to a reduction in oestrogen after menopause
What drug can cause PMB?
HRT (with no pathological cause or due to long-term oestrogen causing endometrial hyperplasia)
What things can present with PMB?
Vaginal atrophy HRT use Endometrial hyperplasia Endometrial cancer Cervical cancer Ovarian cancer (esp. oestrogen secreting (theca cell) tumours Vaginal cancer Rarer: trauma, vulval cancer, bleeding disorders
What are the guidelines for investigating PMB?
If >55 + PMB –> investigate within 2w by TVU to rule out endometrial cancer
What examinations should be done in PMB?
Vaginal
Abdominal
Speculum
Check for masses, abnormalities in abdomen/pelvis
What other investigations might you do for PMB?
Urine dipstick (haematuria/infection)
FBC (anaemia/bleeding disorders)
CA125
What is an acceptable depth of endometrial in someone who is post-menopausal?
<5mm
How is a definitive diagnosis of endometrial cancer made?
Endometrial biopsy
How is endometrial biopsy carried out?
Hysteroscopy with biopsy
or
Aspiration (pipelle) biopsy - thin flexible tube inserted into uterus via speculum to remove cells for testing
What additional imaging may be done in suspected endometrial cancer in secondary care?
CT/MRI uterus, pelvis, abdomen
How might PMB due to endometrial hyperplasia be managed?
Dilation + curettage to remove excess endometrial tissue
What is Amsel’s criteria used for?
Diagnosis of BV
What is Amsel’s criteria?
3/4 points should be present:
- Thin, white homogenous discharge
- Clue cells on microscopy - stippled vaginal epithelial cells
- Vaginal pH >4.5
- Positive whiff test
What is a whiff test?
Addition of K hydroxide –> fishy odour in BV
How is BV treated?
Oral metronidazole
How is trichomonas vaginalis treated?
Oral metronidazole 5-7 days or one off 2g dose
How is gonorrhoea treated?
IM ceftriaxone 1g
Define miscarriage
Expulsion of products of conception before 24w
What factors are associated with an increased risk of miscarriage?
Increased maternal age Smoking in pregnancy Consuming alcohol Recreational drug use High caffeine intake Obesity Infections/food poisoning Health conditions, e.g. thyroid problems, severe HTN, uncontrolled DM Medicines, e.g. ibuprofen, methotrexate, retinoids Unusual shape/structure of womb Cervical incompetence
Define complex ovarian cyst
One that is multiloculated or contains a solid mass
These are malignant until proven otherwise
What investigations should be done when you find a complex ovarian cyst on USS?
CA125, aFP, bHCG
Book for elective cystectomy
What kind of HRT regimens should be used in perimenopausal women and why?
Cyclical as it provides a predictable withdraw bleed (continuous regimens cause unpredictable bleeding)
Can give continuous if LMP >1y ago or if has been on cyclical HRT >1y
How can you confirm a miscarriage?
Diagnosed on US if there is no cardiac activity +
- Crown rump length is greater than 7mm OR gestational sack is greater than 25mm
What is a cervical ectropion?
Elevated oestrogen levels –> larger area of columnar epithelium on the ectocervix
What is the transformation zone on the cervix?
Area on cervical canal where the stratified squamous epithelium meets the columnar epithelium
How might cervical ectropion present?
Vaginal discharge
PCB
Are cervical ectropions treated?
Only if they cause troublesome symptoms
How might a cervical ectropion be treated?
Ablative treatment, e.g. cold coagulation
What things predispose to cervical ectropion?
Ovulatory phase
Pregnancy
COC
What are risk factors for miscarriage?
Age (>35) Prev. miscarriages (2+) Chronic conditions, e.g. uncontrolled DM Uterine/cervical problems Smoking, alcohol, illicit drug use Over/under wt Invasive prenatal testing, e.g. CVS, amniocentesis
What is the risk of miscarriage in:
a. a 35 year old
b. a 40 year old
c. a 45 year old?
a. 20%
b. 40%
c. 80%
What kind of uterine/cervical problems can predispose to miscarriage?
Mullerian duct anomalies
Large cone cervical biopsies
How do NSAIDs work to help with pain?
Inhibit prostoglandin synthesis
What is the main clinical indication for starting HRT?
Vasomotor symptoms
What are the reasons someone should take continuous and NOT cyclical HRT?
- They have taken cyclical for at least 1 year
- It has been 1 year since their LMP
- If has been 2 years since their LMP + they are <40 years old
What are long term complications of PCOS?
Subfertility DM Stroke and TIA CAD Obstructive sleep apnoea Endometrial cancer
What is the tumour marker for pancreatic cancer?
CA 19-9
What is the tumour marker for bowel cancer?
CEA
What is the tumour marker for liver cancer and germ cell tumours (e.g. testicular)?
AFP
What is a tumour marker for breast cancer?
HER2
What are causes of delayed puberty with short stature?
Turner’s syndrome
Prader-Willi syndrome
Noonan syndrome
What are causes of delayed puberty wtih normal stature?
PCOS
Androgen insensitivity
Kallman’s syndrme
Klinefelter’s syndrome
What are the two ways primary amenorrhoea can be diagnosed?
No period by age 14 + no secondary sexual characteristics
No period by 16 + secondary sexual characteristics
What is constitutional delay?
Late bloomer - has secondary sexual characteristics
How would imperforate hymen present?
Cyclical pain + blueish bulging membrane oe
What are the features of transverse vaginal septae?
Cyclical pain + retrograde menstruation
What occurs in kallmann syndrome?
Failure to secrete GnRH
Where is the most common place for an ectopic pregnancy?
Ampulla of fallopian tube
Where is the most dangerous place to get an ectopic pregnancy?
Isthmus (increased risk of rupture)
When should you refer a couple to an infertility clinic?
After 1 year of trying (regular (every 2-3d) unprotected vaginal sex)
When should you consider earlier refer to the infertility clinic?
Female - age >35, amenorrhoea, prev. pelvic surgery, prev. STI, abnormal genital ex
Male - prev. surgery on genitalia, prev. STI, varicocele, significant systemic illness, abnormal genital ex
How is Meig’s syndrome managed?
Drainage of pleural effusion + ascites
Surgery to remove tumour
What is the GMC guidance on FGM?
Report all known cases of FGM under 18 to the police
In which age group is the highest incidence of cervical cancer?
25-29yos
What are the two types of cervical cancer?
SSC
Adenocarcinoma
How might cervical cancer present?
- Screening
2. Abnormal vaginal bleeding (PCB, IMB PMB) or vaginal discharge
What are the risk factors for cervical cancer?
Infection with HPV 16, 18, 33 Smoking HIV Early first intercourse, many sexual partners High parity Lower socioeconomic status COCP
Why are HPV 16 and 18 oncogenic?
They produce the oncogenes E6 and E7
E6 inhibits p53 tumour supressor gene
E7 inhibits RB supressor gene
For which people would you advise to try having regular unprotected sex for 2 years prior to IVF?
Those with unexplained infertility, mild endometriosis, mild male factor infertility
Define ovarian torsion
Complete/partial torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply
What is an adnexal torsion?
Ovarian torsion where the fallopian tube is also involved
What are risk factors for ovarian torsion?
Ovarian mass (present in 90% cases of ovarian torsion)
Being of reproductive age
Pregnancy
Ovarian hyperstimulation syndrome
Why do fibroids grow during pregnancy?
Because they are oestrogen sensitive
What causes red degeneration of a fibroid?
If their growth outstrips their blood supply they degenerate
How does red degeneration tend to present?
Low grade fever
Pain
Vomiting
Where are the bartholin’s glands situated?
Next to the entrance of hte vagina
What size are the bartholin’s glands normally?
The size of a pea
What is a bartholin’s abscess?
Infection + enlargement of the bartholin’s glands
How can a bartholin’s abscess be treated?
Antibiotics
Insertion of a word catheter
Surgery - marsupialization
What are the three types of management of a miscarriage?
Expectant
Medical
Surgical
What does expectant management of a miscarriage involve?
Waiting for a spontaneous miscarriage
Waiting 7-14d for miscarriage to complete spontaneously
What is involved in medical management of a miscarriage?
Vaginal misoprostol
Anti-emetics, analgesia
Contact dr if bleeding
hasn’t started in 24h
How does misoprostol work?
Prostaglandin analogue
Binds to myometrial cells –> strong myometrial contractions –> expulsion of tissue
When is medical management of miscarriage prefered?
High risk of haemorrhaging (e.g. late first trimester)
Evidence of infection or prev. adverse experiences
What are the main two ways to surgically manage a miscarriage?
Vacuum aspiration (suction curettage) under LA or surgical management in theatre
When might you opt for a surgical management of miscarriage?
If evidence of infection, e.g. going into shock
Increased risk of haemorrhage
How are most miscarriages managed first line?
Expectant management
For patients opting for medical management of an ectopic pregnancy what must they agree to?
Attending follow up
When does fibroid degeneration commonly occur?
During pregnancy
By how much does smoking increase your risk of getting cervical cancer?
2x
What is premenstrual syndrome?
The emotional and physical symptoms women may experience prior to menstruation
What are common premenstrual syndrome symptoms?
Anxiety Stress Fatigue Mood swings Bloating Irritability Depression Mastalgia
What is involved in the management of PMS?
Lifestyle advice - healthy diet, exercise, reduction in stress levels, regular sleep
More severe symptoms - COC, SSRI
What are risk factors for ectopic pregnancy?
Damage to tubes (e.g. salphinitis, surgery) Prev. ectopic Endometriosis IUD POP IVF
What staging system is used for cervical cancer?
FIGO
What is FIGO IA?
Confined to cervix only visible by microscopy + less than 7mm wide:
A1: <3mm deep
A2: 3-5mm deep
What is FIGO IB?
Confined to cervix, clinically visible or larger than 7mm wide:
B1 <4cm
B2 >4cm
What is FIGO II?
Extension of tumour beyond cervix but not to pelvic wall
A = upper two thirds of vagina
B = parametrial involvement
What is FIGO III?
Extension of tumour beyond cervix + to the pelvic wall
A = lower third of vagina
B = pelvic side
OR any tumour causing hydronephrosis/non-functioning kidney
What is FIGO IV?
Extension of tumour beyond the pelvis/involvement of the bladder/rectum
A = bladder or rectum involvement
B = distant mets outside pelvis
How is stage IA cervical cancer managed?
Gold standard: hysterectomy +/- lymph node clearance
For those wanting to maintain fertility: cone biopsy with negative margins and follow up can be done
What are other treatment options for IA2 cervical cancer?
Node evaluation must be performed
Radial trachelectomy
How is stage IB cervical cancer managed?
B1: radio (brachy/EBR) + chemo (cisplatin)
B2: radical hysterectomy + pelvic node dissection
How is stage II and III cervical cancer managed?
Radio + chemo
If hydronephrosis consider nephrostomy
How is stage IV ovarian cancer managed?
Radiation +/or chemo
Palliative chemo best for IVB
How is recurrent ovarian cancer managed?
Primary surgical treatment - offer chemo/radio
Primary radio treatment - offer surgery
What are complications of surgery for ovarian cancer?
Bleeding, damage to local structures, infection, anaesthetic risk etc.
Cone biopsies + radical trachelectomy may increase risk of preterm birth
Radical hysterectomy may lead to ureteral fistula
What are complications of radiotherapy for ovarian cancer?
Short-term: diarrhoea, vaginal bleeding, radiation burns, pains on micturition, tiredness/weakness
long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
What ovarian tumour is associated with endometrial hyperplasia?
Granulosa cell tumour
When should methotrexate be the first line for management of an ectopic pregnancy?
Small (<35mm) Unruptured No visible heart beat Serum bHCG <1500 IU/L No interuterine pregnancy No pain
How does methorexate work in treating ectopic pregnancies?
It is an antimetabolite chemotherapeutic drug, it interferes with DNA synthesis + disrupts cell multiplication
When can you use expectant management for an ectopic pregnancy (watchful waiting)?
1) An unruptured embryo
2) <30mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <200IU/L and declining
What are the investigations of choice for suspected ectopic pregnancy?
Pregnancy test
TVU
What does expectant management of an ectopic pregnancy invoolve?
Closely monitoring the pt over 48h and if bHCG levels rise again or symptoms manifest intervention is performed
What is the criteria for using surgical management for ectopic pregnancies?
Size >35mm Can be ruptured Severe pain Visible fetal heart beat Serum bHCG >1500IU/L
What types of management of ectopic pregnancies are compatible with another intrauterine pregnancy?
Surgical + expectant
What is a typical history of vesicovaginal fistula?
Continuous dribbling incontinence after prolonged labour from an area of limited obstetric services
What is the risk malignancy index for ovarian cancer based off of?
US findings
Menopausal status
CA125 levels
What is the best imaging technique for diagnosing adenymosis?
MRI
