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Passmedicine - Gynaecology Flashcards

1
Q

After giving birth on what day to women require contraception?

A

Day 21

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2
Q

When can the POP be used in the post-partum?

A

Anytime

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3
Q

If you start the POP on day 21 post-partum, do you require additional contraception for any amount of time?

A

Yes - 2 days

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4
Q

Is POP okay to use whilst breastfeeding?

A

Yes (small amount enters milk but this does not harm infant)

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5
Q

When can the COCP be used after giving birth?

A 
UKMEC 4 (completely contraindicated) <6w post-partum
UKMEC2 if breast feeding 6w-6m post-partum
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6
Q

What affect can the COCP have on lactating mothers?

A

May reduce breast milk production

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7
Q

When can the IUS/IUD be inserted after birth?

A

Within 48h of birth or after 4 weeks

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8
Q

How effective is the lactational amenorrhoea method at preventing pregnancy?

A

98% if woman is fully breast feeding + amenorrhoeic + <6m post-partum

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9
Q

What is an inter-pregnancy interval of <12m between childbirth and conceiving again associated with?

A

Increased risk of preterm birth, low birth weight and small for gestational age babies

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10
Q

When can the progesterone only implant be inserted after birth?

A

Any time

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11
Q

How common is infertility?

A

Affects 1 in 7 coples

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12
Q

What are the causes of infertility?

A 
Male factor 30%
Unexplained 20%
Ovulation failure 20%
Tubal damage 15%
Others 15%
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13
Q

What are the two basic initial tests you should do for infertility?

A

Semen analysis

Serum progesterone 7 days prior to next expected period

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14
Q

What is the average length of a cycle?

A

28 days

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15
Q

On the average cycle, when should you do a serum progesterone?

A

21st day

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16
Q

How should you interpret a serum progesterone?

A

<16nmol/l - repeat, if consistently low refer to specialist
16-30nmol/l - repeat
>30nmol/l - ovulation has occured

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17
Q

What advice can you give couples trying to conceive?

A

Take folic acid
Maintain BMI 20-25
Have regular unprotected vaginal intercourse every 2-3 days
Smoking/drinking advice

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18
Q

Follow ovulation does basal temperature increase or decrease?

A

Increase

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19
Q

If a cervical smear comes back as borderline/mild dyskaryosis what happens?

A

Original sample tested for HPV:
-ve: returns to routine recall
+ve: referred for colposcopy

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20
Q

If a cervical smear comes back as moderate dyskaryosis what happens?

A

Consistent with CIN II - refer for urgent colposcopy within 2w

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21
Q

If a cervical smear comes back as severe dyskaryosis what happens?

A

Consistent with CIN III

Refer for urgent colposcopy within 2w

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22
Q

If a cervical smear comes back as suspected invasive cancer what happens?

A

Refer for urgent colposcopy within 2w

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23
Q

If cervical smear comes back as inadequate what action is taken?

A

Repeat smear - if persistent (3 inadequate samples), assess via colposcopy

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24
Q

How are women treated for CIN 1-3 reassessed?

A

Invited 6m after treatment for test of cure with repeat cytology in the community

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25
Q

What are the oncogenic subtypes of HPV associated with cervical cancer?

A

HPV 16, 18, 33

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26
Q

What are the different types of miscarriage?

A 
Threatened
Missed
Inevitable 
Incomplete
Complete
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27
Q

How does threatened miscarriage present?

A

Painless vaginal bleeding before 24w
Usually lighter than a period
Cervical os is closed

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28
Q

When do threatened miscarriages typically occur?

A

6-9 weeks

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29
Q

What is a missed miscarriage?

A

Gestational sac contains dead foetus before 20w without the symptoms of expulsion

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30
Q

How does a missed miscarriage present?

A

Light vaginal bleeding/discharge + symptoms of pregnancy may disappear
Not usually painful
Cervical os is closed

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31
Q

What is the description ‘blighted ovum’ or ‘anembyronic pregnancy’ used to describe?

A

Gestational sac >25mm + no embyronic/fetal part can be seen

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32
Q

How does inevitable miscarriage present?

A

Heavy bleeding with clots + pain

Cervical os is open

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33
Q

What occurs in an incomplete miscarriage?

A

Not all products of conception have been expelled

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34
Q

How does incomplete miscarriage tend to present?

A

Pain + vaginal bleeding

Cervical os is open

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35
Q

In routine diagnostic workup for abdominal pain, what examinations and tests should be done in all females?

A

Bimanual vaginal examination
Urine pregnancy test
Consider abdominal + pelvic USS

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36
Q

If after investigation of abdominal pain in a female, diagnostic doubt remains what investigation may be good for assessing suspected tubulo-ovarian pathology?

A

Laparoscopy

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37
Q

What are gynae causes of abdominal pain?

A 
Mittelschmerz
Endometriosis
Ovarian torsion 
Ectopic gestation 
PID
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38
Q

When do you get pain in Mittelschmzer?

A

Midcycle

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39
Q

Describe the pain experienced in Mittelschmzer?

A

Sharp onset
Little systemic disturbance
Usually settles over 24-48h but may be recurrent

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40
Q

How do you investigate suspected Mittelschmzer?

A

FBC - usually normal

US - may show small quantity of free fluid

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41
Q

How do you manage Mittelschmzer?

A

Conservatively

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42
Q

How does endometriosis typically present?

A

Dysmenorrhoea (pain often days before period starts)
Subfertility
Chronic pelvic pain
Deep dyspareuina

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43
Q

What may occur in complex endometriosis?

A

Pelvic adhesions –> episodes of intermittent small bowel obstruction

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44
Q

What can intra-abdominal bleeding in endometriosis lead to?

A

Localised peritoneal inflammation

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45
Q

What can you see on investigation of endometriosis?

A

US - free fluid

Laparoscopy - lesions

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46
Q

How does ovarian torsion tend to present?

A

Sudden onset of deep unilateral colicky abdominal pain
Nausea, vomiting and distress
Onset my coincide with exercise
VE - unilateral tender adnexal mass

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47
Q

What might you see on investigation of ovarian torsion?

A

US - free fluid, whirlpool sign

Laparoscopy is diagnostic + therapeutic

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48
Q

How do you manage ovarian torsion?

A

Laparoscopy

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49
Q

How can ectopic pregnancy present?

A
  1. symptoms of pregnancy without intrauterine gestation

2. emergency with rupture/impending rupture

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50
Q

How does ectopic pregnancy rupture present?

A

Sudden onset abdominal pain, circulatory collapse
Adnexial tenderness
Shoulder tip pain

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51
Q

What investigations should you do for suspected ectopic pregnancy + what will they show?

A

US - no intrauterine pregnancy, may show free fluid in abdomen
b-HCG elevated

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52
Q

How does PID tend to present?

A

Bilateral lower abdominal pain, vaginal/cervical discharge, deep dyspareunia
Dysuria + menstrual irregularities may be present
Fever
Cervical excitation on ex

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53
Q

What is Fitz Hugh Curtis syndrome?

A

Peri-hepatic inflammation secondary to chlamydia leading to RUQ discomfort

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54
Q

What investigations should you do for suspected PID and what will they show?

A

FBC - leucocytosis
Pregnancy test
Amylase - normal/slightly raised
High vaginal + urethral swabs

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55
Q

What causes Mittleschmerz?

A

Very small amounts of fluid released during ovulation

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56
Q

What is the medical term for heavy menstrual bleeding?

A

Menorrhagia

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57
Q

How did menorrhagia used to be defined?

A

Blood loss >80ml per menses

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58
Q

How is menorrhagia defined now?

A

A volume of blood the women considers to be excessive

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59
Q

What investigations should be done for menorrhagia?

A

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

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60
Q

What is the first line treatment for a women with menorrhagia who does not require contraception?

A

Mefenamic acid 500mg tds (if painful) or tranezamic acid 1g tds (if painless) started on the first day of period

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61
Q

If mefenamic/tranexamic acid don’t work to manage a pts menorrhagia what is the next step?

A

Try other drug whilst awaiting referral

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62
Q

What is the first line treatment for a women with menorrhagia who does require contraception?

A

IUS (mirena)

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63
Q

What is the second and third line treatment for a women with menorrhagia who does require contraception?

A

2nd: COCP
3rd: long acting progesterone

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64
Q

What drug can be used as a short term option to rapidly stop heavy menstrual bleeding?

A

Norethisterone 5mg

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65
Q

At what age is ovarian torsion most common?

A

Reproductive age

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66
Q

What is a typical history of someone presenting with an ectopic pregnancy?

A

6-8w history of amenorrhoea with lower abdominal pain, + vaginal bleeding

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67
Q

What two features are sometimes seen in ectopic pregnancy?

A

Shoulder tip pain

Cervical excitation

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68
Q

In women what is the most common cause of pelvic pain?

A

Primary dysmenorrhoea

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69
Q

What things may cause pelvic pain?

A 
Primary dysmenorrhoea
Ectopic pregnancy 
UTI 
Appendicitis
PID
Ovarian torsion 
Miscarriage
Endometriosis
IBS
Ovarian cyst
Urogenital prolapse
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70
Q

How does appendicitis tend to present?

A 
Pain in central abdomen --> RIF
Anorexia, low grade fever
Tenderness in RIF
Tachycardia
Rovsing's sign
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71
Q

What is Rovsing’s sign?

A

More pain in RIF than LIF when palpating LIF

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72
Q

How does IBS tend to present?

A

Abdominal pain
Bloating
Change in bowel habit
Lethargy, nausea, backache, bladder symptoms may be present

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73
Q

How does ovarian cyst tend to present?

A

Unilateral dull ache which may be intermittent/only occur during intercourse

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74
Q

What happening to an ovarian cyst may lead to severe abdominal pain?

A

Torsion or rupture

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75
Q

What symptoms may large ovarian cysts cause?

A

Abdominal swelling or pressure effects on the bladder

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76
Q

Who is urogenital prolapse seen in?

A

Older women

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77
Q

What are the features of urogenital prolapse?

A

Sensation of pressure, heaviness, bearing down

Incontinence, frequency, urgency

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78
Q

How does tranexamic acid work?

A

Plasminogen activator inhibit that acts as an anti-fibrinolytic

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79
Q

In what age group do most cases of endometrial cancer occur?

A

Post-menopausal women

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80
Q

What is the prognosis of endometrial cancer?

A

Usually good as it is usually detected early

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81
Q

What are RFs for endometrial cancer?

A 
Obesity
Nulliparity
Early menarche
Late menopause
Unopposed oestrogen 
DM
Tamoxifen 
PCOS
HNPCC
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82
Q

How can you avoid giving unopposed oestrogen to a women with a womb?

A

Add in progesterone when giving HRT

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83
Q

What is the classic symptom associated with endometrial cancer?

A

PMB

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84
Q

How might a women who is premenopausal present with endometrial cancer?

A

Change in intermenstrual bleeding

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85
Q

How is PMB investigated?

A

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

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86
Q

How is localised endometrial cancer treated?

A

Total abdominal hysterectomy + bilateral salphino-oophorectomy

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87
Q

How is localised HIGH RISK endometrial cancer treated?

A

TAH + BSO + post-op radio

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88
Q

What treatment may be used for endometrial cancer in frail elderly women not suitable for surgery?

A

Progesterone therapy

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89
Q

PMB = ? until proven otherwise

A

Endometrial cancer

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90
Q

What are causes of menorrhagia?

A 
Dysfunctional uterine bleeding
Anovulatory cycles
Uterine fibroids
Hypothyroidism
IUD (Cu coil)
PID
Bleeding disorders,e.g. vWB
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91
Q

What is dysfunctional uterine bleeding?

A

Menorrhagia in the absence of underlying pathology

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92
Q

When are anovulatory cycles most common?

A

Extremes of a women’s reproductive life

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93
Q

What is endometriosis?

A

Growth of ectopic endometrial tissue outside the uterine cavity

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94
Q

How common is endometriosis?

A

Affects 10% of women of a reproductive age

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95
Q

What non-gynae symptoms can those with endometriosis get?

A

Urinary symptoms, e.g. dysuria, urgency, haematuria

Dyzchezia (painful bowel movements)

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96
Q

What do you see in pelvic examination in those with endometriosis?

A

Reduced organ mobility
Tender nodularity in posterior vaginal fornix
Visible vaginal endometriotic lesions may be seen

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97
Q

What is the gold standard investigation for endometriosis?

A

Laparoscopy

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98
Q

What can be done for endometriosis in primary care?

A

Not much, if pt has significant symptoms she should be referred for definitive diagnosis

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99
Q

How is endometriosis managed?

A

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

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100
Q

How do GnRH analogues work in treating endometriosis?

A

Induce a pseudomenopause due to low oestrogen lvels

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101
Q

What surgery may be offered for severe endometriosis?

A

Laparoscopic excision

Laser treatment of endometriotic ovarian cysts

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102
Q

Is endometriosis oestrogen dependent or independent?

A

Dependent - starts after menarche and regresses after menopause

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103
Q

How should the COCP be used in those with endometriosis?

A

Back to back with no pill free interval

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104
Q

What contraceptive is not suitable for those with endometriosis?

A

Cu coil as it makes periods painful and longer

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105
Q

What causes the lower abdominal pain in ectopic pregnancy?

A

Tubal spasm

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106
Q

Describe the pain in ectopic pregnancy?

A

Lower abdominal
Unilateral
Constant

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107
Q

What symptoms can peritoneal bleeding in ectopic pregnancy cause?

A

Shoulder tip pain and pain on defaecation or urination

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108
Q

Apart from vaginal bleeding and lower abdominal pain what other symptoms may you see in ectopic pregnancy?

A

Symptoms of pregnancy, e.g. breast tenderness

Circulatory collapse in ruptured ectopic, e.g. syncope, dizziness

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109
Q

What findings may you see on examination in ectopic pregnancy?

A

Abdominal tenderness
Cervical excitation
Adnexal mass - do not examine for adnexal mass as this may increase chance of rupture (do check for cervical excitation)

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110
Q

In case of pregnancy of unknown location what can point towards a diagnosis of ectopic pregnancy?

A

Serum bHCG >1, 500

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111
Q

What is the medical treatment for an ectopic pregnancy?

A

Methotrexate

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112
Q

What is the surgical treatment for ectopic pregnancy?

A

Salpingectomy unless they have other RFs for inferility, e.g. contralateral tube damage - then offer salpinotomy

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113
Q

What is the average age to go through menopause?

A

51

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114
Q

When should women nearing the menopause use contraception up until?

A

12m after last period if >50

24m after last period if <50

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115
Q

What is PID?

A

Infection and inflammation of the female pelvic organs (uterus, fallopian tubes, ovaries, surrounding peritoneum)

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116
Q

What tends to cause PID?

A

Ascending infection from the endocervix

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117
Q

What is the most common cause of PID?

A

Chlamydia trachomatis

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118
Q

What are other causes of PID?

A

Neisseria gonorrhoea
Mycoplasma genitalium
Mycoplasma hominis

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119
Q

What investigations should be done for suspected PID?

A

Pregnancy test to exclude ectopic
High vaginal swabs
Screen for chlamydia/gonorrheoa

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120
Q

Why is there a low threshold for treating PID?

A

Difficulty in making diagnosis

Potential complications of untreated PID are severe

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121
Q

How is PID managed?

A

Oral olofaxin + oral metronidazole
OR
IM ceftriazone + oral doxycyline + oral metronidazole

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122
Q

Should IUDs be removed in PID?

A

If mild might be okay to leave, but evidence suggests removal may be better

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123
Q

What are complications of PID?

A

Fitz Hugh Curtis syndrome
Infertility
Chronic pelvic pain
Ectopic pregnancy

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124
Q

What is the risk of infertility after a single episode of PID?

A

10-20%

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125
Q

Give e.g.s of minor symptoms of pregnancy?

A

N/V
Tiredness
MSK pains

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126
Q

What is UTI in pregnancy associated with?

A

Premature birth (inflammatory mediators trigger pre-term labour by irritating neck of uterus + cervix)

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127
Q

Why do pregnant ladies get lower back pain?

A

Due to increased laxity in SI joints due to release of hormone relaxin
Increased mechanical load

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128
Q

How common is PCOS in women of reproductive age?

A

5-20%

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129
Q

High levels of what two hormones are seen in PCOS?

A

Insulin

LH

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130
Q

What is the general management of PCOS?

A

Wt loss

COCP may regulate cycle+ induce a monthly bleed

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131
Q

What drugs may be used to treat hirsutism/acne in PCOS?

A

COCP
Topical eflornithine
Spirnolactone, flutamide, finasteride under specialist supervision

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132
Q

What is the management of infertility in PCOS?

A

Wt loss
Under specialist supervision - clomifene/metformin or combo of both
Gonadotrophins

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133
Q

How does clomifene work?

A

Occupies hypothalamic oestrogen receptors without activating them, this interferes with binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion

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134
Q

How is PCOS diagnosed?

A

When 2/3 of the following are present:

  1. Polycystic ovary on USS/increased ovarian volume
  2. Infrequent periods (>35d apart) or no ovulation
  3. Clinical/biochemical signs of hyperandrogenism/elevated levels of total/free testosterone
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135
Q

What is the pathophysiology of PCOS?

A

Increased LH and insulin –> increased androgen production which disrupts folliculogenesis –> excess small ovarian follicles + irregular/absent ovulation + hirsutism

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136
Q

What are complications of PCOS?

A 
T2DM
Obesity
Subfertility
Miscarriage
Endometrial cancer
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137
Q

When is clomifene given?

A

Days 2-6 of cycle to initiate follicular maturation

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138
Q

How many uses of clomifene are you allowed?

A

6

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139
Q

What does clomifene increase the risk of?

A

Multiple pregnancy

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140
Q

What are the pros and cons of using metformin for PCOS?

A

Pros - increases effectiveness of clomifene in clomifene-resistant women, treats hirsutism, reduces risk of gestational diabetes + early miscarriages

Con - less effective than clomifene

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141
Q

What are second line treatments for infertility in PCOS?

A

Ovarian diathermy

Gonadotrophin induction

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142
Q

How does gonadotrophin induction work?

A

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

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143
Q

What is the 3rd line treatment option for infertility in those with PCOS?

A

IVF

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144
Q

How should women taking COCP for control of PCOS symptoms take the pill?

A

Back to back with 3/4 bleeds a year to protect the endometrium

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145
Q

Who does atrophic vaginitis tend to affect?

A

Post menopausal women

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146
Q

How does atrophic vaginitis tend to pesent?

A

Vaginal dryness, pain, itching, dyspareunia, occasional spotting

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147
Q

What might atrophic vaginitis look like o/e?

A

Pale, dry

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148
Q

How is atrophic vaginitis treated?

A

Vaginal lubricants and moisturisers

2nd line: topical oestrogen cream

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149
Q

Define endometrial hyperplasia

A

Abnormal proliferation of the endometrium in excess of normal proliferation that occurs during the menstrual cycle

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150
Q

What are the types of endometrial hyperplasia

A

Simple
Complex
Simple atypical
Complex atypical

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151
Q

What do a minority of pts with endometrial hyperplasia go on to develop?

A

Endometrial cancer

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152
Q

What are the features of endometrial hyperplasia

A

Abnormal vaginal bleeding, e.g. IMB

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153
Q

How do you manage simple endometrial hyperplasia without atypica?

A

High dose progestogens with repeat sampling in 3-4 months (IUS may be used)

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154
Q

How do you manage atypical endometrial hyperplasia?

A

Hysterectomy

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155
Q

What are the types of benign ovarian cysts?

A

Physiological cysts
Benign germ cell tumours
Benign epithelial tumours
Benign sex cord stromal tumours

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156
Q

What kind of ovarian cysts should be biopsied to exclude malignancy?

A

Complex (i.e. multi-loculated) ovarian cysts

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157
Q

What are the commonest types of ovarian cysts?

A

Follicular cysts

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158
Q

What are the two functional/physiological cysts?

A

Follicular cysts

Corpus luteum cysts

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159
Q

What causes a follicular cyst?

A

Non-rupture of a dominant follicle or failure of atresia in a non-dominant follicle

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160
Q

Do follicular cysts go away?

A

Commonly regress after several menstrual cycles

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161
Q

What is a corpeus luteum cyst?

A

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

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162
Q

What are corpus luteum cysts more likely to present with when compared to follicular cysts?

A

Intraperitoneal bleeding

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163
Q

Give an example of a benign germ cell tumour that may affect the ovary

A

Dermoid cyst

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164
Q

What is the other name for dermoid cysts?

A

Mature cystic teratomas

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165
Q

What is the appearance of dermoid cysts?

A

Epithelial lined, may contain skin appendages, hair + teeth

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166
Q

What is the most common benign ovarian tumour in women under 30?

A

Dermoid cyst

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167
Q

How do dermoid cysts in the ovary tend to present?

A

Usually asymptomatic but increase risk of torsion

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168
Q

What tissue do benign epithelial tumours of the ovary develop from?

A

Ovarian surface epithelium

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169
Q

Give e.g.s of two benign epithelial tumours of the ovary

A

Serous cystadenoma

Mucinous cystadenoma

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170
Q

What is the most common benign epithelial tumour?

A

Serous cystadenoma

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171
Q

What cancer does serous cystadenoma of the ovary bear resemblance to?

A

Serous carcinoma of ovary

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172
Q

If mucinous cystadenoma of the ovary ruptures what can it cause?

A

Pseudomyxoma peritoni

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173
Q

What are the 3 features of Meig’s syndrome?

A

Benign ovarian tumour (usually fibroma)
Ascites
Pleural effusion

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174
Q

What test should you order for a women who has had heavy bleeding since her period started?

A

Coagulation screen

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175
Q

What is a Rokitansky protuberance?

A

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

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176
Q

What occurs in urogenital prolapse?

A

Descent of one of the pelvic organs –> protrusion on the vaginal walls

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177
Q

How common is urogenital prolapse?

A

Affects 40% of post-menopausal women

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178
Q

What are the types of urogenital prolapse?

A

Cystocele, cystourethrocele
Rectocele
Uterine prolapse
Urethrocele, enterocele

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179
Q

What is an enterocele?

A

Herniation of the pouch of Douglas, incl. the small intestine into the vagina

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180
Q

What are RFs for urogenital prolapse?

A 
Increasing age
Multiparity
Vaginal deliveries
Obesity
Spina bifida
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181
Q

How is asymptomatic mild urogenital prolapse managed?

A

No treatment req.

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182
Q

What are conservative managements for urogenital prolapse?

A

Wt loss

PFMT

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183
Q

What other treatments are available for urogenital prolapse?

A

Ring pessary

Surgery

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184
Q

What surgeries are available for cystocele/cystourethrocele?

A

Anterior colporrhaphy/colposuspension

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185
Q

What surgeries are available for uterine prolapse?

A

Hysterectomy, sacrophysteropexy

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186
Q

What surgeries are available for rectocele?

A

Posterior colporrhaphy

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187
Q

What is sacrocolpoplexy?

A

Suspending the vaginal apex to the sacral promontory

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188
Q

What are the two kinds of amenorrhoea?

A

Primary

Secondary

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189
Q

What is primary amenorrhoea?

A

Failure to start menses by 16y

190
Q

What is secondary amenorrhoea?

A

Cessation of established, regular menstruation for 6m or longer (12m in those with previous oligomenorrhoea)

191
Q

What are causes of primary amenorrhoea?

A 
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)
192
Q

What are causes of secondary amenorrhoea?

A 
Hypothalamic amenorrhoea (e.g. stress/excessive exercise) 
PCOS
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis
Sheehan's syndrome 
Asherman's syndrome
Contraception
Lactational amenorrhoea
193
Q

What is Asherman’s syndrome?

A

Intrauterine adhesions

194
Q

How do you investigate amenorrhoea?

A 
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
195
Q

What thyroid problem can cause amenorrhoea?

A

Thyrotoxicosis or hypothyroidism

196
Q

What % of the population does urinary incontinence affect?

A

4-5%

197
Q

Who is urinary incontinence most common in?

A

Elderly females

198
Q

What are RFs for urinary incontinence?

A 
Advancing age
Prev pregnancy + childbirth 
High BMI
Hysterectomy
FH
199
Q

What are the types of urinary incontinence?

A

Overactive bladder/urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence

200
Q

What causes overactive bladder/urge incontinence?

A

Detrusor overactivity

201
Q

How does stress incontinence present?

A

Leaking small amounts of urine when laughing/coughing

202
Q

What is mixed incontinence?

A

Urge and stress incontinence

203
Q

What causes overflow incontinence?

A

Bladder outlet obstruction, e.g. prostate enlargement

204
Q

How should urinary incontinence be investigated?

A

Bladder diaries for at least 3d
Vaginal ex to rule out POP + ability to contact PFMs
Urine dipstick + culture
Urodynamic studies

205
Q

What is the initial management for urge incontinence?

A

Bladder retraining (min 6w)

206
Q

What are other treatments for urge incontiennce?

A

First line: anti-muscarinics (e.g. oxybutinin, tolterodine, darifenacin)

207
Q

What drug can be used in frail pts for urge incontiennce?

A

Mirabegron

Avoid oxybutinin in frail older women

208
Q

What is the initial management for stress incontinence?

A

PFMT (8 contractions 3x day for 3m)

209
Q

What surgical procedures can be done for stress incontinence?

A

Retropubic mid-urethral tape procedures

210
Q

What are fibroids?

A

Benign smooth muscle tumours of the uterus

211
Q

What race tend to get fibroids more often?

A

Afro-caribbean women

212
Q

What are the features of fibroids?

A

May be asymptomatic
Menorrhagia
Crampy lower abdominal pain often during period
Bloating
Urinary symptoms, e.g. frequency with larger fibroids
Subfertility

213
Q

How do you diagnose fibroids?

A

TVU

214
Q

How are fibroids managed?

A

Symptomatically - IUS first line
Other options: tranexamic acid, COC
GnRH agonists may reduce fibroid size in short term
Surgery sometimes needed

215
Q

What surgeries may be used for fibroids?

A

Myomectomy, hysteroscopic endometrial ablation, hysterectomy, uterine artery embolisation

216
Q

What are complications of fibroids?

A

Red degeneration (haemorrhage into tumour, commonly occurs during pregnancy)

217
Q

Define premature ovarian failure

A

Onset of menopausal symptoms + elevated gonadotrophins before age 40

218
Q

What are causes of premature ovarian failure?

A

Idiopathic (most common)
Chemotherapy
Autoimmune
Radiation

219
Q

What are features of premature ovarian failure?

A

Same as menopause (hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH, LH)

220
Q

Define dysmenorrhoea

A

Excessive pain during the menstrual period

221
Q

What are the two types of dysmenorrhoea

A

Primary

Secondary

222
Q

What is primary dysmenorrhoea?

A

There is no underlying pelvic pathology

223
Q

How common is primary dysmenorrhoea?

A

Affects 50% of women

224
Q

What is thought to be related to primary dysmenorrhoea?

A

Excessive endometrial prostaglandin production

225
Q

What are the features of primary dysmenorrhoea?

A

Pain just before/within a few hours of period starting

Suprapubic cramping which can radiate to back or down thigh

226
Q

How is dysmenorrhoea managed?

A

NSAIDs (e.g. mefenamic acid/ibuprofen)

COCP second line

227
Q

What is secondary dysmenorrhoea?

A

Is due to underlying pathology

228
Q

When does the pain for secondary dysmenorrhoea tend to start?

A

3-4 days before the onset of the period

229
Q

What are causes of secondary dysmenorrhoea?

A 
Endometriosis
Adenomyosis
PID
IUD
Fibroids
230
Q

What should be involved in the management of all women with secondary dysmenorrhoea?

A

Refer to gynae for investigation

231
Q

What is hyperemesis gravidarum thought to be related to?

A

Raised bHCG levels

232
Q

When is hyperemesis gravidarum most common?

A

Between 8 and 20 weeks

233
Q

What things are associated with hyperemesis gravidarum?

A 
Multiple pregnancies
Trophoblastic disease
Hyperthyroidism
Nulliparity
Obesity
234
Q

What thing is associated with decreased incidence of hyperemesis gravidarum?

A

Smoking

235
Q

When should you consider admission for nausea and vomiting in pregnancy?

A

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)

236
Q

For which individuals should you have a lower threshold for admitting with N+V during pregnancy?

A

Those with conditions that may be adversely affected by N+V, e.g. DM

237
Q

What triad is used for the diagnosis of hyperemesis gravidarum?

A

5% pre-pregnancy wt loss
Dehydration
Electrolyte imbalance

238
Q

What scoring system can be used to classify the severity of NVP?

A

Pregnancy-Unique Quantification of Emesis

239
Q

How is hyperemesis gravidarum managed?

A

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

240
Q

What is the issue with giving metoclompramide?

A

EPS

241
Q

What are complications of hyperemesis gravidarum?

A 
Wernicke's encepahlopathy
Mallory-Weiss tear
Central pontine myelinolysis
Acute tubular necrosis
Fetal - small for gestational age, pre-term birth
242
Q

What is the peak age to get ovarian cancer?

A

60 years old

243
Q

What are the most common ovarian tumours/

A

Epithelial ones, most are serous carcinomas

244
Q

Lately it has been recognise that what weird place is often the site of origin of many ovarian cancers?

A

The distal end of the fallopian tube

245
Q

What are RFs for ovarian cancer?

A

BRCA1/2 mutation

Many ovulations, e.g. early menarche, late menopause, nulliparity

246
Q

What are the clinical features of ovarian cancer?

A 
Abdominal distension + bloating
Abdominal + pelvic pain 
Urinary symptoms, e.g. urgency
Early satiety
Diarrhoea
247
Q

What is the initial test for ovarian cancer?

A

CA125

248
Q

What things can raise CA125 besides ovarian cancer?

A

Endometriosis
Menstruation
Benign ovarian cysts

249
Q

What level of CA125 would indicate a need for further investigation?

A

Raised (35IU/ml or greater)

250
Q

What should you do if CA125 is raised?

A

Urgent US of abdomen + pelvis

251
Q

How is ovarian cancer generally diagnosed?

A

Diagnostic laparotomy

252
Q

How is ovarian cancer usually managed?

A

Surgery + platinum based chemo

253
Q

What is a common complication of open myomectomy?

A

Adhesions most common

Bladder injury + uterine perforation can also occur but they are less common

254
Q

What are predisposing factors for candidiasis?

A

DM
Drugs - steroids, antibiotics
Pregnancy
Immunosupression - HIV, iatrogenic

255
Q

What are the features of vaginal candidiasis?

A

Cottage cheese, non-offensive discharge
Vulvitis - dyspareunia, dysuria
Itch
Vulval erythema, fissuring, satellite lesions may be seen

256
Q

How do you investigate suspected candidiasis?

A

Don’t usually need to if clinical features are consistent with candidiasis
Can do high vaginal swab if unsure

257
Q

How do you manage thrush?

A

Local Rx: clotrimazole pessary

Oral: itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat

258
Q

How do you treat thrush in pregnancy?

A

Local treatments only (creams/pessaries)

259
Q

Define recurrent vaginal candidiasis

A

4+ episodes per year

260
Q

How do you manage recurrent vaginal candidiasis?

A

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)

261
Q

What is the discharge of thrush like?

A

White, curdy with pH <4.5

262
Q

What causes thrush?

A

Candida albicans

263
Q

What test can you do to confirm menopause?

A

FSH - this is very raised in menopausal pts

264
Q

What causes menopause?

A

Loss of follicular activity

265
Q

How is menopause diagnosed?

A

Usually in primary care after the cessation of periods

266
Q

What % of women will get menopausal symptoms?

A

75%

267
Q

How long do menopausal symptoms generally last for?

A

7 years

268
Q

What lifestyle modifications may help with hot flushes associated with menopause?

A

Regular exercise, weight loss, stress reduction

269
Q

What lifestyle modifications may help with sleep disturbance associated with menopause?

A

Avoiding late evening exercise, maintaining good sleep hygiene

270
Q

What lifestyle modifications may help with mood problems associated with menopause?

A

Sleep, regular exercise, relaxation

271
Q

What lifestyle modifications may help with cognitive symptoms associated with menopause?

A

Regular exercise, good sleep hygiene

272
Q

What are contraindications for HRT?

A

Current/past breast cancer
Any oestrogen sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

273
Q

What are is the big difference in giving HRT for a women with and without a womb?

A

Womb - must give progesterone with oestrogen

No womb - can give unopposed oestrogen

274
Q

What are the risks of HRT?

A 
VTE for oral HRT
Stroke for oral HRT
Coronary heart disease
Breast cancer
Ovarian cancer
275
Q

What are the ways women with no womb can be given HRT?

A

Oestrogen either orally or in a transdermal patch

276
Q

What are the ways women with a womb can be given HRT?

A

Oral or transdermal combined HRT

277
Q

What are non-HRT treatments to help with vasomotor symptoms?

A

Fluoxetine, citalopram, venlafaxine

278
Q

What are non-HRT treatments to help with vaginal dryness?

A

Vaginal lubricant or moisturiser

279
Q

What are non-HRT treatments to help with psychological symptoms?

A

Self help groups
CBT
Antidepressants

280
Q

What are non-HRT treatments to help with urogenital symptoms?

A

Vaginal oestrogen if suffering from urogenital atrophy

281
Q

How long may HRT need to be used for vasomotor symptoms?

A

2-5y (should make regular attempts to come off it)

282
Q

Does stopping HRT gradually help with recurrence?

A

Limits recurrence in the short term only

283
Q

When should a women be referred to secondary care for management of her menopausal symptoms?

A

If treatment in primary care has been ineffective or if there are ongoing side effects or unexplained bleeding

284
Q

What is the initial imaging used for ovarian cysts/tumours?

A

USS

285
Q

What will an USS report about an ovarian cyst/tumour?

A

Simple - unilocular (more likely to be benign/physiological)

Complex - multilocular (more likely to be malignant)

286
Q

What is your approach to the management of an ovarian mass in someone who is premenopausal?

A

Conservative approach in women <35y
Cyst is small + simple on USS likely to be benign
Repeat USS in 8-12w + referral if it persists

287
Q

What is your approach to the management of an ovarian mass in someone who is postmenopausal?

A

Physiological cysts unlikely

Regardless of size/nature of cyst refer to gynae for assessment

288
Q

How does rupture ovarian cyst tend to present?

A

Sudden onset unilateral pelvic pain precipitated by intercourse/strenuous activity

289
Q

What may you see on USS in an ovarian cyst rupture?

A

Free fluid in the abdomen

290
Q

What are side effects of HRT?

A

Nausea
Breast tenderness
Fluid retention + wt gain

291
Q

What are potential complications of HRT?

A

Increased risk of:

  • Breast cancer (only during use + for 5y after use)
  • Endometrial cancer (reduced by addition of progesterone)
  • VTE
  • Stroke
  • IHD
292
Q

What may indicate a need for a biopsy to exclude endometrial cancer in a women who is premenopausal?

A

Persistent IMB in someone =<45 + treatment failure/ineffective treatment

293
Q

How does rupture endometrioma present?

A

Sudden intense pain

Pelvis will be filled with fluid

294
Q

What are potential common long term complications of hysterectomy?

A

Enterocele
Vaginal vault prolapse
Urinary retention

295
Q

Give an example of what can be used as the progesterone component of HRT

A

Mirena (IUS)

Licensed up to 4y use

296
Q

What is the classic exam history of ectopic pregnancy rupture?

A

Amenorrhoea
Abdominal pain
Vaginal bleeding
Shoulder tip pain

297
Q

What is adenomyosis?

A

Endometrial tissue in the myometrium

298
Q

Who is adenomyosis most common in?

A

Multiparous women towards end of their reproductive years

299
Q

What are the features of adenomyosis?

A

Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus

300
Q

What is the management of adenomyosis?

A

GnRH agonists

Hysterectomy - definitive

301
Q

What are the commonest causes of vaginal discharge?

A

Physiological
Candida
Trichomonas vaginalis
Bacterial vaginosis

302
Q

What are less common causes of vaginal discharge?

A 
Gonorrhoea
Chlamydia 
Ectropion 
Foreign body 
Cervical cancer
303
Q

What are the key features of trichomas vaginalis infection?

A

Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
pH >4.5

304
Q

What is the discharge of BV like?

A

Offensive, thin, white/grey, fishy discharge

305
Q

Define recurrent miscarriage

A

3+ consecutive spontaneous abortions

306
Q

What are causes of recurrent miscarriages?

A 
Antiphospholipid syndrome
Endocrine disorders (poorly controlled DM/thyroid dx/PCOS)
Uterine abnormality, e.g. uterine septum
Parental chromosomal abnormalities
Smoking
307
Q

What is the most reliable test to confirm ovulation?

A

Day 21 progesterone

308
Q

When does serum progesterone peak?

A

7 days after ovulation (nb luteal phase is always 14 days, so peaks always 7 days before period)

309
Q

What are the stages of ovarian cancer?

A

Stage 1 - confined to ovaries
Stage 2 - local spread within pelvis
Stage 3 - spread beyond pelvis into abdomen
Stage 4 - distant mets

310
Q

What kind of spread is most common in ovarian cancer?

A

Local spread

311
Q

What is Sheehan’s syndrome?

A

Reduction in function of pituitary gland following ischaemic necrosis due to hypovolaemic shock following birth

312
Q

What are features of Sheehan’s syndrome?

A

Amenorrhoea, problems with milk production, hypothyroidism

Symptoms can be varied + take sometimes take years to develop

313
Q

Define FGM

A

All procedures involving partial/total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons

314
Q

What is type 1 FGM

A

Clitoridectomy

315
Q

What is type 2 FGM

A

Partial/total clitoridectomy + removal of labia minora +/- excision of labia majora

316
Q

What is type 3 FGM

A

Narrowing of vaginal orifice with creation of a covering seal by cutting + appositioning the labia minor +/- labia majora +/- clitoridectomy
INFIBULATION

317
Q

What is type 4 FGM

A

All other harmful procedures to the female genitalia, e.g. pricking, piercing, incising, scraping, cauterization

318
Q

Is reinfibulation legal?

A

NO

319
Q

What are non-gynae causes of lower abdominal pain in women?

A 
Appendicitis
UTI
Constipation
IBS
Gallstones
320
Q

What are menstrual related causes of lower abdominal pain in women?

A

Dysmenorrhoea
Endometriosis
Mittelschmerz

321
Q

What are gynae causes of lower abdominal pain in women?

A 
PID
Ovarian torsion 
Uterine rupture (e.g. with IUS/IUD in situ)
322
Q

What are pregnancy related causes of lower abdominal pain?

A 
Ectopic pregnancy 
Spontaneous abortion 
Placental abruption 
Premature labour
Pre-eclampsia
323
Q

How does metformin work in treating some of the symptoms of PCOS?

A

Increases peripheral insulin resistance

324
Q

What is a risk factor for endometrial hyperplasia?

A

Tamoxifen use (unopposed oestrogen stimulates endometrial growth)

Progesterone usually stimulates shedding of this tissue

Obesity
PCOS
DM

325
Q

How does tamoxifen work?

A

Used in oestrogen receptor +ve breast cancer (in breast has anti-oestrogen effects, in endometrium has pro-oestrogen effects)

326
Q

What is the only effective treatment for someone with large fibroids causing problems who is wanting to conceive?

A

Myomectomy

327
Q

Who is offered cervical screening?

A

Women aged 25 to 64

328
Q

How often are women screened for cervical cancer?

A

25-49y: 3yrly

50-64y: 5yrly

329
Q

Which women may opt out of cervical cancer screening?

A

Those who have never been sexually active as they have a very low risk

330
Q

Can you do a cervical screen on a pregnant women?

A

You can if missed screening or previously abnormal smears but usually delayed until 3m post-partum

331
Q

What is the method of cervical screening?

A

Liquid based cytology

332
Q

When is theoretically the best time to take a cervical smear?

A

Mid cycle

333
Q

What women may require cervical screening more often?

A

Those who are immunosupressed

334
Q

What is the mechanism of action of oxytbutinin?

A

Anti-muscarinic

335
Q

How many small (<3cm) uterine fibroids not distorting the uterine cavity be managed?

A

Medically, e.g. IUS, tranexamic acid, COCP

336
Q

What are the majority of vulval cancers?

A

SCC

337
Q

Over what age do most cases of vulval cancers occur?

A

65y

338
Q

What are risk factors for vulval cancer?

A

HPV infection
VIN
Immunosupression
Lichen sclerosus

339
Q

What are features of vulval cancer?

A

Lump/ulcer on labia majora
Often ulcerated
Itching/irritation may occur

340
Q

What is the appearance of a VIN?

A

White/plaque like

Don’t tend to ulcerate

341
Q

In which cases when someone has an ectopic pregnancy but is haemodyamically stable should they be treated wth surgery as opposed to just methotrexate?

A

If a foetal heartbeat is present

342
Q

Do lesbians require cervical screening?

A

Yes - HPV can be transmitted during lesbian sex

343
Q

What is the screening programme for ovarian cancer?

A

There is NO screening for ovarian cancer currently

344
Q

Why does a urine dipstick need to be done in all women presenting with urinary incontinence?

A

Rule out UTI/DM

345
Q

How often should women with HIV be screened for cervical cancer and how should this be done?

A

Yearly cervical cytology

346
Q

Why do women with HIV require more frequent cervical cancer screening?

A

They are at increased risk of CIN due to decrease immune response + clearance of HPV
(Even if effectively treated with antiretrovirals)

347
Q

What is ovarian hyperstimulation syndrome a complication of?

A

Some infertility treatments

348
Q

What is the pathophysiology of ovarian hyperstimulation syndrome?

A

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

349
Q

What therapies cause the most ovarian hyperstimulation syndrome?

A

Gonadotrophin
hCG treatment
IVF (1/3rd get it)

350
Q

What is the criteria for mild OHS?

A

Abdominal pain

Abdominal bloating

351
Q

What is the criteria for moderate OHS?

A

Mild criteria +
NV
US evidence of ascites

352
Q

What is the criteria for severe OHS?

A 
Moderate criteria + 
Clinical evidence of ascites
Oliguria
Haematocrit >45%
Hypoproteinaemia
353
Q

What is the criteria for critical OHS?

A 
Severe criteria +
TE
ARDS
Anuria
Tense ascites
354
Q

Name 2 protective factors for endometrial cancer

A

COCP use

Smoking

355
Q

What is post-coital bleeding?

A

Vaginal bleeding after sexual intercourse

356
Q

What are causes of PCB?

A 
Idiopathic 50%
Cervical ectropion in 33% 
Cervicitis e.g. secondary to chlamydia
Cervical cancer
Polyps
Trauma
357
Q

What is the most common identifiable cause of PCB?

A

Cervical ectropion

358
Q

What women are more at risk of developing a cervical ectropion?

A

Those on the COC

359
Q

What are features of PCOS?

A

Subfertility/infertility
Menstrual disturbances, e.g. amenorrhoea/oligomenorrhoea
Hirsutism/acne (hyperandrogenism)
Obesity
Acanthosis nigricans (insulin resistance)

360
Q

What investigations should be done for suspected PCOS?

A

Pelvic USS: multiple cysts on ovaries
FSH, LH (LH:FSH ratio), prolactin (raised/normal), TSH, testosterone (normal/raised)
Check for impaired glucose tolerance

361
Q

What drug can mask the symptoms of PCOS?

A

COCP

362
Q

Define PMB

A

Vaginal bleeding after 12m of amenorrhoea

363
Q

What is the most common cause of PMB?

A

Vaginal atrophy

364
Q

What is vaginal atrophy?

A

Thinning, drying and inflammation of the walls of the vagina due to a reduction in oestrogen after menopause

365
Q

What drug can cause PMB?

A

HRT (with no pathological cause or due to long-term oestrogen causing endometrial hyperplasia)

366
Q

What things can present with PMB?

A 
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
367
Q

What are the guidelines for investigating PMB?

A

If >55 + PMB –> investigate within 2w by TVU to rule out endometrial cancer

368
Q

What examinations should be done in PMB?

A

Vaginal
Abdominal
Speculum

Check for masses, abnormalities in abdomen/pelvis

369
Q

What other investigations might you do for PMB?

A

Urine dipstick (haematuria/infection)
FBC (anaemia/bleeding disorders)
CA125

370
Q

What is an acceptable depth of endometrial in someone who is post-menopausal?

A

<5mm

371
Q

How is a definitive diagnosis of endometrial cancer made?

A

Endometrial biopsy

372
Q

How is endometrial biopsy carried out?

A

Hysteroscopy with biopsy
or
Aspiration (pipelle) biopsy - thin flexible tube inserted into uterus via speculum to remove cells for testing

373
Q

What additional imaging may be done in suspected endometrial cancer in secondary care?

A

CT/MRI uterus, pelvis, abdomen

374
Q

How might PMB due to endometrial hyperplasia be managed?

A

Dilation + curettage to remove excess endometrial tissue

375
Q

What is Amsel’s criteria used for?

A

Diagnosis of BV

376
Q

What is Amsel’s criteria?

A

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
377
Q

What is a whiff test?

A

Addition of K hydroxide –> fishy odour in BV

378
Q

How is BV treated?

A

Oral metronidazole

379
Q

How is trichomonas vaginalis treated?

A

Oral metronidazole 5-7 days or one off 2g dose

380
Q

How is gonorrhoea treated?

A

IM ceftriaxone 1g

381
Q

Define miscarriage

A

Expulsion of products of conception before 24w

382
Q

What factors are associated with an increased risk of miscarriage?

A 
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
383
Q

Define complex ovarian cyst

A

One that is multiloculated or contains a solid mass

These are malignant until proven otherwise

384
Q

What investigations should be done when you find a complex ovarian cyst on USS?

A

CA125, aFP, bHCG

Book for elective cystectomy

385
Q

What kind of HRT regimens should be used in perimenopausal women and why?

A

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

386
Q

How can you confirm a miscarriage?

A

Diagnosed on US if there is no cardiac activity +

- Crown rump length is greater than 7mm OR gestational sack is greater than 25mm

387
Q

What is a cervical ectropion?

A

Elevated oestrogen levels –> larger area of columnar epithelium on the ectocervix

388
Q

What is the transformation zone on the cervix?

A

Area on cervical canal where the stratified squamous epithelium meets the columnar epithelium

389
Q

How might cervical ectropion present?

A

Vaginal discharge

PCB

390
Q

Are cervical ectropions treated?

A

Only if they cause troublesome symptoms

391
Q

How might a cervical ectropion be treated?

A

Ablative treatment, e.g. cold coagulation

392
Q

What things predispose to cervical ectropion?

A

Ovulatory phase
Pregnancy
COC

393
Q

What are risk factors for miscarriage?

A 
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
394
Q

What is the risk of miscarriage in:

a. a 35 year old
b. a 40 year old
c. a 45 year old?

A

a. 20%
b. 40%
c. 80%

395
Q

What kind of uterine/cervical problems can predispose to miscarriage?

A

Mullerian duct anomalies

Large cone cervical biopsies

396
Q

How do NSAIDs work to help with pain?

A

Inhibit prostoglandin synthesis

397
Q

What is the main clinical indication for starting HRT?

A

Vasomotor symptoms

398
Q

What are the reasons someone should take continuous and NOT cyclical HRT?

A
  1. They have taken cyclical for at least 1 year
  2. It has been 1 year since their LMP
  3. If has been 2 years since their LMP + they are <40 years old
399
Q

What are long term complications of PCOS?

A 
Subfertility
DM
Stroke and TIA
CAD
Obstructive sleep apnoea
Endometrial cancer
400
Q

What is the tumour marker for pancreatic cancer?

A

CA 19-9

401
Q

What is the tumour marker for bowel cancer?

A

CEA

402
Q

What is the tumour marker for liver cancer and germ cell tumours (e.g. testicular)?

A

AFP

403
Q

What is a tumour marker for breast cancer?

A

HER2

404
Q

What are causes of delayed puberty with short stature?

A

Turner’s syndrome
Prader-Willi syndrome
Noonan syndrome

405
Q

What are causes of delayed puberty wtih normal stature?

A

PCOS
Androgen insensitivity
Kallman’s syndrme
Klinefelter’s syndrome

406
Q

What are the two ways primary amenorrhoea can be diagnosed?

A

No period by age 14 + no secondary sexual characteristics

No period by 16 + secondary sexual characteristics

407
Q

What is constitutional delay?

A

Late bloomer - has secondary sexual characteristics

408
Q

How would imperforate hymen present?

A

Cyclical pain + blueish bulging membrane oe

409
Q

What are the features of transverse vaginal septae?

A

Cyclical pain + retrograde menstruation

410
Q

What occurs in kallmann syndrome?

A

Failure to secrete GnRH

411
Q

Where is the most common place for an ectopic pregnancy?

A

Ampulla of fallopian tube

412
Q

Where is the most dangerous place to get an ectopic pregnancy?

A

Isthmus (increased risk of rupture)

413
Q

When should you refer a couple to an infertility clinic?

A

After 1 year of trying (regular (every 2-3d) unprotected vaginal sex)

414
Q

When should you consider earlier refer to the infertility clinic?

A

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

415
Q

How is Meig’s syndrome managed?

A

Drainage of pleural effusion + ascites

Surgery to remove tumour

416
Q

What is the GMC guidance on FGM?

A

Report all known cases of FGM under 18 to the police

417
Q

In which age group is the highest incidence of cervical cancer?

A

25-29yos

418
Q

What are the two types of cervical cancer?

A

SSC

Adenocarcinoma

419
Q

How might cervical cancer present?

A
  1. Screening

2. Abnormal vaginal bleeding (PCB, IMB PMB) or vaginal discharge

420
Q

What are the risk factors for cervical cancer?

A 
Infection with HPV 16, 18, 33
Smoking
HIV
Early first intercourse, many sexual partners
High parity
Lower socioeconomic status
COCP
421
Q

Why are HPV 16 and 18 oncogenic?

A

They produce the oncogenes E6 and E7
E6 inhibits p53 tumour supressor gene
E7 inhibits RB supressor gene

422
Q

For which people would you advise to try having regular unprotected sex for 2 years prior to IVF?

A

Those with unexplained infertility, mild endometriosis, mild male factor infertility

423
Q

Define ovarian torsion

A

Complete/partial torsion of the ovary on it’s supporting ligaments that may in turn compromise the blood supply

424
Q

What is an adnexal torsion?

A

Ovarian torsion where the fallopian tube is also involved

425
Q

What are risk factors for ovarian torsion?

A

Ovarian mass (present in 90% cases of ovarian torsion)
Being of reproductive age
Pregnancy
Ovarian hyperstimulation syndrome

426
Q

Why do fibroids grow during pregnancy?

A

Because they are oestrogen sensitive

427
Q

What causes red degeneration of a fibroid?

A

If their growth outstrips their blood supply they degenerate

428
Q

How does red degeneration tend to present?

A

Low grade fever
Pain
Vomiting

429
Q

Where are the bartholin’s glands situated?

A

Next to the entrance of hte vagina

430
Q

What size are the bartholin’s glands normally?

A

The size of a pea

431
Q

What is a bartholin’s abscess?

A

Infection + enlargement of the bartholin’s glands

432
Q

How can a bartholin’s abscess be treated?

A

Antibiotics
Insertion of a word catheter
Surgery - marsupialization

433
Q

What are the three types of management of a miscarriage?

A

Expectant
Medical
Surgical

434
Q

What does expectant management of a miscarriage involve?

A

Waiting for a spontaneous miscarriage

Waiting 7-14d for miscarriage to complete spontaneously

435
Q

What is involved in medical management of a miscarriage?

A

Vaginal misoprostol
Anti-emetics, analgesia
Contact dr if bleeding
hasn’t started in 24h

436
Q

How does misoprostol work?

A

Prostaglandin analogue

Binds to myometrial cells –> strong myometrial contractions –> expulsion of tissue

437
Q

When is medical management of miscarriage prefered?

A

High risk of haemorrhaging (e.g. late first trimester)

Evidence of infection or prev. adverse experiences

438
Q

What are the main two ways to surgically manage a miscarriage?

A

Vacuum aspiration (suction curettage) under LA or surgical management in theatre

439
Q

When might you opt for a surgical management of miscarriage?

A

If evidence of infection, e.g. going into shock

Increased risk of haemorrhage

440
Q

How are most miscarriages managed first line?

A

Expectant management

441
Q

For patients opting for medical management of an ectopic pregnancy what must they agree to?

A

Attending follow up

442
Q

When does fibroid degeneration commonly occur?

A

During pregnancy

443
Q

By how much does smoking increase your risk of getting cervical cancer?

A

2x

444
Q

What is premenstrual syndrome?

A

The emotional and physical symptoms women may experience prior to menstruation

445
Q

What are common premenstrual syndrome symptoms?

A 
Anxiety
Stress
Fatigue
Mood swings
Bloating
Irritability
Depression 
Mastalgia
446
Q

What is involved in the management of PMS?

A

Lifestyle advice - healthy diet, exercise, reduction in stress levels, regular sleep
More severe symptoms - COC, SSRI

447
Q

What are risk factors for ectopic pregnancy?

A 
Damage to tubes (e.g. salphinitis, surgery)
Prev. ectopic
Endometriosis
IUD
POP
IVF
448
Q

What staging system is used for cervical cancer?

A

FIGO

449
Q

What is FIGO IA?

A

Confined to cervix only visible by microscopy + less than 7mm wide:
A1: <3mm deep
A2: 3-5mm deep

450
Q

What is FIGO IB?

A

Confined to cervix, clinically visible or larger than 7mm wide:
B1 <4cm
B2 >4cm

451
Q

What is FIGO II?

A

Extension of tumour beyond cervix but not to pelvic wall
A = upper two thirds of vagina
B = parametrial involvement

452
Q

What is FIGO III?

A

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

453
Q

What is FIGO IV?

A

Extension of tumour beyond the pelvis/involvement of the bladder/rectum
A = bladder or rectum involvement
B = distant mets outside pelvis

454
Q

How is stage IA cervical cancer managed?

A

Gold standard: hysterectomy +/- lymph node clearance

For those wanting to maintain fertility: cone biopsy with negative margins and follow up can be done

455
Q

What are other treatment options for IA2 cervical cancer?

A

Node evaluation must be performed

Radial trachelectomy

456
Q

How is stage IB cervical cancer managed?

A

B1: radio (brachy/EBR) + chemo (cisplatin)
B2: radical hysterectomy + pelvic node dissection

457
Q

How is stage II and III cervical cancer managed?

A

Radio + chemo

If hydronephrosis consider nephrostomy

458
Q

How is stage IV ovarian cancer managed?

A

Radiation +/or chemo

Palliative chemo best for IVB

459
Q

How is recurrent ovarian cancer managed?

A

Primary surgical treatment - offer chemo/radio

Primary radio treatment - offer surgery

460
Q

What are complications of surgery for ovarian cancer?

A

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

461
Q

What are complications of radiotherapy for ovarian cancer?

A

Short-term: diarrhoea, vaginal bleeding, radiation burns, pains on micturition, tiredness/weakness
long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema

462
Q

What ovarian tumour is associated with endometrial hyperplasia?

A

Granulosa cell tumour

463
Q

When should methotrexate be the first line for management of an ectopic pregnancy?

A 
Small (<35mm)
Unruptured
No visible heart beat
Serum bHCG <1500 IU/L
No interuterine pregnancy 
No pain
464
Q

How does methorexate work in treating ectopic pregnancies?

A

It is an antimetabolite chemotherapeutic drug, it interferes with DNA synthesis + disrupts cell multiplication

465
Q

When can you use expectant management for an ectopic pregnancy (watchful waiting)?

A

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

466
Q

What are the investigations of choice for suspected ectopic pregnancy?

A

Pregnancy test

TVU

467
Q

What does expectant management of an ectopic pregnancy invoolve?

A

Closely monitoring the pt over 48h and if bHCG levels rise again or symptoms manifest intervention is performed

468
Q

What is the criteria for using surgical management for ectopic pregnancies?

A 
Size >35mm
Can be ruptured
Severe pain 
Visible fetal heart beat
Serum bHCG >1500IU/L
469
Q

What types of management of ectopic pregnancies are compatible with another intrauterine pregnancy?

A

Surgical + expectant

470
Q

What is a typical history of vesicovaginal fistula?

A

Continuous dribbling incontinence after prolonged labour from an area of limited obstetric services

471
Q

What is the risk malignancy index for ovarian cancer based off of?

A

US findings
Menopausal status
CA125 levels

472
Q

What is the best imaging technique for diagnosing adenymosis?

A

MRI

Reproduction (28 decks)

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