Quick revise Flashcards

1
Q

Glycolysis

A

Occurs int he cytosol of cells

Glucose (C6) – > Pyruvate (2 x C3)

–> Acetyl-coA which can enter the citric acid cycle.

Net ATP gain = 2 ATP (4 produced, 2 used).

NADH plus H+ produced = 2 molecules per glucose.

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2
Q

pelvic floor muscles

A

coccygeus (back)

levator ani (lat to med)
iliococcygeus
pubococcygeus
puborectalis

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3
Q

Obesity and EC

A

LNG-EC – double dose if BMI>26 or >70kg

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4
Q

Bosentan

A

used to treat pulmonary arterial hypertension

ERA – endothelial receptor antagonist

decreases prog and eostro levels in contra

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5
Q

VTE risk and progesterones

A

Doubles the risk (9-10 in 10,000)

Baseline VTE risk = 2 in 10,000
Pregnancy & puerperium = 20 in 10,000

Lower risk progestogens (6 in 10,000)
Levonogestrel
Norethisterone
Norgestimate

Moderate risk progestogens (8 in 10,000)
Etonogestrel
Norelgestromin

Higher risk progestogens (10 in 10,000)
Desogestrel
Gestodene
Drospirenone

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6
Q

What oestrogen does zoely and qlaria use

A

oestradiol valerate

Zeoly: Nomegestrol acetate progestin
Qlaria: Dienogest progestin

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7
Q

First line COCP

A

A monophasic COC containing
20 - 35 micrograms of ethinylestradiol
norethisterone or levonorgestrel

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8
Q

Dianette components

A

Ethinylestradiol 35
Cyproterone acetate 2000

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9
Q

UKMEC Known BRCA1/2 mutation

A

CHC: UKMEC 3
All other hormonal forms UKMEC 2

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10
Q

Filshie clip

A

Titanium clip lined with silicone

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11
Q

UKMEC Hx of bariatric surgery

A

All 1 other than CHC

BMI <30 = 1
BMI 30-34 =2
BMI >34 = 3

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12
Q

UKMEC Organ transplant

A

a) Complicated: graft failure (acute or
chronic), rejection, cardiac allograft vasculopathy
Coils UKMEC 3 initiation/ 2 continuation
CHC UKMEC 3

b) Uncomplicated
UKMEC 2 for all

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13
Q

UKMEC CVD
RFs
Known dislipidaemia
Cardiomyopathy
AF
QT

A

RF multiple:
DMPA and CHC: UKMEC 3
All other methods (other than copper):UKMEC 2

Known dislipidaemia
UKMEC 2 (other than copper)

Cardiomyopathy
Normal cardiac fx: CHC UKMEC 2, all UKMEC 1
Impaired cardiac fx: CHC UKMEC 4, all UKMEC 2

AF
CHC UKMEC 4, Copper UKMEC 1, rest UKMEC 2

Known long QT
Coils UKMEC 3 initiation/ 1 continuation
DMPA and CHC UKMEC 2

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14
Q

IIH UKMEC

A

CHC 2, rest 1

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15
Q

GC VS CT infectivity

A

Single episode of UPSI

M->F spread
GC: 60-80% (40% with condom) 40/60/80
CT: 10% transmission rate (75% concordance within partners, condoms reduce by 40%)

F->M spread
GC: 20% (5% with condom)
CT: 10% same as above

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16
Q

Men symptoms and complications GC

A

Only 5-10% asymptomatic

Typical incubation of 2-5 days (up to 14)

Urethral discharge in 80%, typically profuse and purulent; dysuria in 50%

Complications are rare
(1) Infection of the median raphe (line down middle of scrotum -> perineum)
(2) Tysonitis – swollen parafrenal gland/s
(3) Meatal gland abscess / peri-urethral cellulitis/ abscess -> strictures and fistulae if left
(4) Epididymitis in <1%

Note: MSM: FVU, pharyngeal and rectal swabs all recommended even if no history of RAI

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17
Q

Women symptoms and complications GC

A

Women ~50% symptomatic vs asymptomatic

When present, symptoms usually appear within 10 days

Increased vaginal discharge, which again may be purulent, most common symptom
Dysuria without frequency, lower abdominal discomfort and less often IMB/ menorrhagia

Complications are rare
(1) Inflamed paraurethral (Skene) glands
(2) Bartholin’s abscess
(3) PID may develop in 10-20% of cases if left untreated

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18
Q

GC rectal

A

usually asymptomatic but can cause discharge (12%), pain or itching

In women: + rectal GC, + correlation with length of infection suggests transmucosal spread to rectal infection, with anal intercourse thought to be attributable in only ~10%

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19
Q

GC pharyngeal

A

asymptomatic in >90% of cases with almost 100% spontaneous clearance in 3 /12

Strongest association with disseminated infection

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20
Q

GC Conjunctival infection

A

Conjunctival infection in adults is rare and can present with purulent discharge and -> keratitis and blindness

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21
Q

GC disseminated infection

A

Occurs in <1%

4 x more likely in women, especially if recent menstruation, in pregnancy, and pharyngeal infection (which is likely to have been asymptomatic)

Skin signs in 67% - ‘gonococcal dermatitis’ – petechiae, necrotic pustules usually at extremities

Tenosynovitis in ~ 1/3 of cases -> migratory arthralgia

Rarely: endocarditis, hepatitis, meningitis

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22
Q

GC microscopy endocervical vs urethral vs proctoscopic

A

Endocervical microscopy sensitivity of only 45% - not routinely recommended for asymptomatic but should be performed if symptoms

Microscopy of urethral smears has good sensitivity for those with symptoms (95%) so is recommended -> POC diagnosis and treatment facilitation
Sensitivity less good for asymptomatic (65%) therefore not recommended here

Proctoscopy and microscopy 75% sensitivity&raquo_space;> blind swab microscopy only 40% sensitivity

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23
Q

Listeria

A

non-spore forming Facultative anaerobe

GRAM POSITIVE bacilli

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24
Q

obligate anaerobes

A

If you are asked about obligate anaerobes you are likely dealing with either:

Clostridium gram positive

Bacteroides (also called Prevotella) gram negative

Actinomyces not appropriately classified : Actinomyces mostly facultative, one strain is an obligate anaerobe

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25
primordial germ cells
Early in development at the time of gastrulation a small group of cells are "put aside" -- primordial germ cells. The cells migrate initially through the primitive streak (at gastrulation) into the posterior endoderm that forms the hindgut from there later into the genital ridge VIA VITILLINE DUCT that will be the site of the developing gonad.
26
whats formed from the urogenital ridge
from int mesoderm Gonads ductal system primordial germ cells (primitive streak, ORIGIN YOLK SAC)
27
quadruple screening
Hcg Quad UE3 Inhibin A aFP 14+3 - 20 Amniocentesis
28
comb screening
Comb Hcg Imaging Papp A 10-14 CVS <1:150 low risk
29
Likelihood Ratios
LR+ = Sensitivity / (1 - Specificity) LR- = (1- Sensitivity) / Specificity
30
Actinomyces
Gram positive anaerobe “Sulphur granules with filamentous organisms” seen on histopathology review
31
Treatment of partners of PID
doxycycline 100mg BD 7/7
31
first line for treatment of confirmed mycoplasma associated PID
moxifloxacin current partners should also be tested +/- treated for M gen as per result 
32
Theca Lutein cysts
Form of functional ovarian cyst associated with pregnancy  Seen as large, (almost always) bilateral, multiple ovarian cysts   Differential diagnosis: OHSS Mucinous ovarian malignancy  Highly associated with GTD Present in >20% of molar pregnancies  Following evacuation of a molar pregnancy typically self-resolve within 2-4 months   More likely to occur if: GTD Ovulation induction/ clomiphene > natural conception  Multi-fetal pregnancies Patient with pre-existing PCOS or type 2 diabetes   Rarely found in typical/ uncomplicated pregnancies   In these rare reports the cyst(s) have been seen to spontaneously resolve following delivery  Not commonly associated with torsion (<2%) 
33
Krukenberg tumours
GI tumours to the ovary (typically from stomach cancer)
34
Germ cell tumours: ovarian
More common in younger women, contain extraembryonic elements of germ cell layers 2nd most common form of ovarian neoplasm (making up ~15% of cases) Arise from cells of the germ cell layers, younger demographic Can be benign or malignant Usually unilateral (can be bilateral in minority) Most common benign germ cell tumour = mature teratoma (“dermoid cyst”) Most common malignant germ cell tumour = dysgerminoma >>Dysgerminoma is more common in those with abnormal karyotypes (e.g. 45 XO Turner’s) >>Contains syncytiotrophoblast cells -> raised hCG Other malignant forms = immature teratoma (younger patients), yolk sac tumours >>Both of these may secrete aFP (majority of yolk sac secrete AFP >> ~1/3 immature teratomas) NB: Gonadoblastoma is very rare form of ovarian neoplasm with mixed germ cell and sex cord origins Typically begin as a benign growth, but strongly associated with dysgerminoma (malignant)
35
dysgerminoma
Most common malignant germ cell tumour Dysgerminoma is more common in those with abnormal karyotypes (e.g. 45 XO Turner’s) Contains syncytiotrophoblast cells à raised hCG
36
Sex cord stromal ovarian tumours:
Significantly less common, secrete hormones <5% Derived from sex cords of the developing gonads (granulosa cells/ stroma, theca cells/ fibroblasts) 3 types: (1) Fibromas and thecomas – typically benign (2) Granulosa cell tumours – most common type of SCST and are malignant (3) Sertoli-Leydig tumours – either
37
Granulosa cell tumours
<5% of ovarian tumours but >95% of sex cord stromal ovarian tumours Generally produce oestrogen Can occur in adulthood (most commonly) or pre-puberty (rare); can cause oestrogenic symptoms Juvenile granulosa cell tumours may be associated with precocious puberty Post-menopausal granulosa cell tumours may be associated with post-menopausal bleeding 90% present early, at stage 1, and are generally managed surgically Majority of cases have a mutation in FOXL2 (required for ovarian differentiation)
38
Meig’s syndrome/ triad
Fibroma – benign and always non-secretory Ascites Pleural effusion Ovarian fibroma
39
Mmx SUI
Duloxetine 40mg BD Selective serotonin and noradrenaline reuptake inhibitor/ SSNRI Theory: increases serotonin and noradrenaline level within Onuf’s nucleus (S2-S4) à Increased activity of pudendal nerve à improved tone of external urethral sphincter and therefore improvement in function
40
Mirabegron
Beta-3 adrenoreceptor agonist à detrusor relaxation/ reduced voiding
41
Wilson and Jungner Criteria for Screening Tests (1968)
We must have knowledge of the disease (3) >> care (condition important) >> (sub Clinical) recognisable asypm latent / early symptomatic stage >> (course) natural course of the condition understood We must have knowledge of the proposed test (3) >> (approp) Suitable >> (acceptable) Acceptable to pop >> (always going) Continuous (not just a 'once and for all' project) We must have an effective treatment for the disease (3) >> (dose) Accepted treatment >> (diagnosis and rx faciliteis ) Facilities for diagnosis and treatment available >> (deal who) Agreed policy on whom to treat The screening must be cost appropriate (1) >> B Balance cost. Costs of case finding economically balanced ABCD A - Test Approp, acceptable, always going B - Cost Balance cost C - disease Care, subClinical, course D- treatment Dose, diagnosis fac, deal who gets it
42
% that hpv is responsible for cancers
>90% of cases of anal cancer, >40% of cases of penile/ vulval cancers >99% of cervical cancer (16 and 18 responsible for >70% of cervical cancers)
43
Chemicals applied to cervix at colp
Acetic acid; neoplastic cells w higher nuclear:cytoplasmic ratio --> white (“acetowhite”) Iodine solution; normal tissue à brown, neoplastic cells are glycogen deficient and do not stain brown
44
CINs
CIN = Cervical Intra-epithelial Neoplasia of the squamous cells of the external cervix CIN 1 (low-grade or mild dysplasia) – 1/3 thickness of surface layer affected; starts at base >>> CIN 1 = “HPV infection correlate” and NOT pre-cancerous condition by definition >>> Usually resolves if HPV clears >>> CIN 1 = repeat colposcopy should be arranged for further testing in 12 months CIN 2 and 3 are high grade changes - 20% of high grade changes (CIN 2+3) progress to cervical cancer. pre-cancerous condition.
45
CIN 2
moderate – 2/3 thickness of surface layer is affected; starts at base Up to 5% progress to cervical cancer if not treated appropriately For CIN 2 some cases (~40%) will self resolve but this can take up to 2 years Excisional treatment is usually offered for CIN 2 (LLETZ) Conservative management > excision may be appropriate if <2 quadrants of the cervix are effected, as long as the patient is agreeable to follow up If patients want conservative management they should be followed up with 6 monthly colposcopy until resolution (maximum of 2 years) If persistent CIN 2 at 2 years then excision should be recommended
46
CIN 3
high-grade or severe dysplasia – full thickness of surface layer is affected Highest rates of progression to cervical cancer (up to 30% progression) For CIN 3 excision is always recommended (LLETZ) If CIN completely excised à follow up smear with ‘test of cure’ for high risk HPV strains in 6 months If this TOC is negative for high risk HPV strains à discharge to 3 yearly recall
47
CGIN
Cervical Glandular Intra-epithelial Neoplasia; glandular cells within the endocervical canal Most strongly associated with HPV type 18 May be more difficult to achieve clear margins/ have higher recurrence risk – skip lesions Cone biopsy >> LLETZ usually given as treatment (need to get deeper into endocervical canal) If CGIN is completely excised -> follow up smear with ‘test of cure’ for high risk HPV strains is recommended at 6 and 18 months following treatment If both of these TOCs are negative for high risk HPV strains -> discharge to 3 yearly recall
48
BV on gram stain
Absence of polymorphs (pus cells) Use of Hay-Ison Gram-stain method for scoring: Grade 0 – epithelial cells with no bacteria Grade 1/ normal – epithelial cells with lactobacilli dominant Grade 2/ intermediate – epithelial cells w some lactobacilli and mixed bacteria Grade 3/BV consistent – epithelial cells w mixed bacteria and few/ absent lacto Grade 4 – epithelial cells with gram + cocci only (typically streptococci)
49
Spironolactone MOA
mineralocorticoid receptor antagonists (non selective - can bind to androgen and progesterone receptors) Reduces NA absorption (water follows NA by osmosis) Reduces K secretion Both in DT (principal cells) (Reduces H+ secretion in CT - alpha intercal --> decrease in PH) K sparing Drosperinone is derived from 17alpha spironolacton HYPERkalemia, HYPOnatremia, HYPOtension
50
Ectopic measurements
FP NO MSD >=25mm on TV - 2nd opinion <25MM on TV - rescan 7/7 TA always 2nd scan 14/7 FP YES CRL >=7 -2nd opinion <7 - rescan 7/7 TA always 2nd scan 14/7
51
How does oestrogen interact with RAAS
Stimulates synthesis of angoitensinogen (the precursor to Ang I) But downregs ACE (so Ang 1 not converted to Ang 2) - reduces inflammatory response.
52
Congenital adrenal hyperplasia
21 hydroxylase 17 less common Needed for corticosteroid and mineralocorticoid production. But not needed for progesterone and androgen. --> so steroid synthesis is directed towards making androgens REDUCED cortisol: high ACTH, prog, androgens. (due to neg feedback on pituitary) --> androgens dominate over oestogen --> male like genitalia, precesious puberty and virualization. REDUCED aldosterone: salt and water wasting. (hypotension, hyponatremia, hypERkalemia) INCREASED 17OH progesterone. <200 no CAH 200-800 ACTH stimulation test > 800 CAH dx XX: Uterus, vagina, fallopian tube and ovaries. XY: go through puberty earlier Rx: steroids
53
Levator ani arterial and nerve supply
A: inferior gluteal N pudendal, perineal and inferior rectal (S3/4)
54
Posterior vs anterior pituitary originates:
Posterior pituitary - neural tube ectoderm Anterior pituitary- surface ectoderm epithelial tissue of nasal cavity --> Rathke’s pouch --> anterior pituitary
55
Layers of adrenal gland cortex
glomerulosa GC fasciculata MC reticularis Androgens
56
Plasma ACTH and cortisol in adrenal insufficiency
Plasma ACTH: A low serum cortisol with an elevated plasma ACTH hormone level indicates Addison’s disease as it suggests a primary insufficiency of the adrenal gland. On the other hand, if there is a low serum cortisol accompanied by a normal or low ACTH level, this would suggest a secondary cause of adrenal insufficiency.
57
(Addison disease)
adrenocortical insufficiency primary adrenal insufficiency Acute (crisis) or chronic Adrenal cortex gets progressively damaged ZG: low aldosterone - low NA, high K, low BP, acidosis. ZF: low cortisol - high ACH and MSH - hyperpigmentation in joints Rarely ZR affected: decreased sex drive and hair in women. Causes AI (unsure why) TB Met carcinoma
58
Cushing’s syndrome,
increased cortisol levels ACTH dep: cortisol excess is driven by ACTH, either from the pituitary or ectopic sources. ** pituitary adenoma ** (( ACTH-dependent types (and some adrenal cancers) --> elevated androgens. )) ACTH indep: cortisol excess is independent of ACTH. Includes exogenous causes (consumption of cortisol) and adrenal lesions (adenomas, carcinomas). Ix (1) 24-hour urinary cortisol --> high = cushings (2)plasma acth LOW ACTH indep HIGH ACTH dep (3A) ACTH indep (low plasma ACTH) --> CT adrenal gland (3B) ACTH dep (high plasma ACTH) --> Dex suppresion test ACTH suppressed by hd dexamethazone - Pit source (MRI PITUITARY) ACTH unsuppressed - Ectopic source.
59
hyper- aldosteronism
Primary = conns Adrenal adenoma Secondary high aldosterone, high renin RA stenosis / HF etc
60
phaeochromocytoma
a rare neuroendocrine tumour of the adrenal glands - chromaffin cells It can present with palpitations, diaphoresis, pallor, and paroxysmal hypertension Diagnosed by increased levels of metanephrines and normetanephrines.
61
paraganglioma (PPGL).
PPGLs are rare neuroendocrine tumours arising from neural crest-derived cells of the sympathetic and parasympathetic nervous systems. results from excessive production of catecholamines by the chromaffin cells located in the extra-adrenal sympathetic paraganglia, typically in the abdomen and pelvis. PPGL can be sporadic, it can also form part of hereditary syndromes, such as Von Hippel–Lindau syndrome, multiple endocrine neoplasia-type 2 (MEN-2) and neurofibromatosis type 1 (NF1) – all of which have autosomal dominant patterns of inheritance. High blood pressure, headache
62
Hypoaldosteronism causes
(1) hyporenin hypoaldosteronism both low - diabetic nephropathy, nsaids (2) non-hyporenin hypoaldost renin n/high aldosterone low ACEi Chronic heparin Primary adrenal insufficiency Genetic (3) Aldosterone resistance Renin n/h aldosterone n/h Aldosterone receptor antagonists Trimethoprim/ sulfamethoxazole Genetic disorders
63
which mutations have been linked to increasing quinolone resistance in GC
mutations in gyrA and gyrB)
64
epithelial ovarian tumour - types/ semicirc
80% Serous (high G and low G) Endometroid (assoc with endometriosis) MUcinous = Unilat i Circle = clear cell (rare but v aggresssive)
65
Three germ cell ovairian tumours  
15% (1) Mature teratoma - benign, dermoid cyst (2) dysgerminoma - malig Most common malignant germ cell tumour. raised hCG more common in those with abnormal karyotypes (e.g. 45 XO Turner’s) (3) immature teratoma - malig secrete aFP
66
Sex cell ovarian tumours; three types
(1) Fibromas and thecomas – typically benign Fibroma = meigs syndrome (2) ****Granulosa cell tumours – most common type of SCST and are malignant**** Produce oestrogen - PMB, precious puberty. FOXL2 (3) Sertoli-Leydig tumours – either
67
LS % to vulval SCC
5% risk
68
Wickham’s striae
shiny flat topped papules with “white lacy lines” mucosal LP
69
LP vs LS
LS Does not affect vaginal walls White and flat lesions 5% risk vulval scc LP Affects vaginal walls Red and raised Wickham’s striae - mucousal lesions Lesions else where Lower risk of vulval squamous cell carcinoma of <3%
70
LP and the Ps
Skin lesions 6Ps Puritic Polygonal Purple Planar Papule Plaque
71
FGM types
Type I – Clitoridectomy Partial/ total removal of clitoris/ prepuce Type II – Excision Partial/ total removal of clitoris and the inner labia +/- outer labia Type III – Infibulation Narrowing of the vaginal opening by creating a covering seal. The seal is formed by cutting and repositioning the inner or outer labia, with or without removal of the clitoris.. Type IV – Other
72
Solifenacin
Selective and competitive M3 antimuscarinic agent
73
What do they look for on cytology
(1) DYSKARYOSIS: high nuclear: cytoplasmic ratio (hyperchromatic nucleu) (2)POILKILOCYTOSIS: Abnormal shape (3) KOILIOCYTOSIS: Abnormal density (bigger nucleus)
74
HPV associated with CGIN
HPV type 18 TOC at 6 and 18 months following treatment (rather than others just 6 months)
75
Breast screening
50 - 70, 3 yearly (First invitation should be received before 53rd birthday) It is recommended that breast screening for trans women should continue beyond the age of 70 if oestradiol continues to be used Mammograms require at least 2 x-rays to be taken of each breast Mammograms interpreted using standardised BI-RADS system
76
Breast cancer
Most common ca in women in uk Types: 1. Invasive ductal carcinoma (IDC) makes up 80%
77
Significant family hx of breast ca: definition and tests
1st degree male relative diagnosed with breast cancer at any age 1st degree female relative diagnosed with breast cancer at <40 years 1st degree relative with bilateral breast cancer first diagnosed <50 years 2 x 1st degree relatives diagnosed with breast cancer at any age 1 x 1st degree and 1 x 2nd degree relative diagnosed with breast OR ovarian cancer at any age 3 x 2nd degree relatives diagnosed with breast cancer at any age ----> specialist referral for genetic testing (BRCA 1, BRCA 2 and TP53 genes)
78
Prognosis of breast cancer based on receptor status
Oestrogen receptors (present in 70-80%) Progesterone receptors >>>> Hormone sensitive (ER + PR +) cancers have more favourable prognoses Suitable for treatment with SERM agents (e.g. Tamoxifen) during follow up if ER + HER2 (human epidermal growth factor receptor 2) receptors Triple negative (no receptors)
79
MEN with BRCA (1 or 2)
mutations the risk of breast cancer is between 1.2-8% Also have double the risk of prostate cancer compared to male baseline risk (10% -> 20%)
80
BRCA 1 and 2
BRCA mutations are responsible for >90% of inherited breast (and ovarian) cancers BRCA1 – highest risk Long arm of chromosome 17, ***triple neg breast cancers (Aggressive, difficult to treat and poorer prognosis) Lifetime risk breast ca 70% Ovarian ca 45% BRCA 2 – lower risk Long arm of chromosome 13, Lifetime risk of breast ca is 40% Ovarian cancer is 15%
81
Patients with identified BRCA mutation who do NOT wish to undertake risk reducing surgery
offered annual screening with MRI and/ or mammography as per their age 25-39 MRI 40-50 MRI plus mam 51-71 mamm +/- MRI
82
Li Fraumeni syndrome
= Transcription factor p53 (TP53) mutation The most frequently identified genetic mutation across all cancer types Identified in ~30% of all breast cancer cases Most TP53 mutations are acquired -> spontaneous cancer cases (NOT inherited/familial - but is AD) Tested if breast ca <30, adrenocortical carcinoma, early onset GI ca People with known TP53 gene mutation should have breast cancer screening annually via MRI: From age 20+. Mammography not recommended for people with TP53 mutations (NICE)
83
Bowel screening
Offered to people of all genders between ages of 50 – 74 years Home FIT kit --> looks for traces of blood in the stool à if + invited for further tests (colonoscopy) Invited to take part routinely every 2 years After age 75 you can request a kit every 2 years if you wish to continue with the screening
84
Lynch syndrome (Hereditary Non-Polyposis Colorectal Cancer HNPCC):
AD ~3% of colorectal cancer due to Lynch syndrome Implicated genes – MLH1, MSH2, MSH6 and PMS2 Screening colonoscopy every 2 years, from 25 Lynch syndrome increases risk of Endometrial ca Ovarian ca No screening is recommended for gynaecological cancers with Lynch syndrome >>If confirmed Lynch syndrome, risk reducing surgery (TAHBSO) can be considered Usually recommended after the age of 35 (with add-back HRT cover) Limited evidence linking Lynch syndrome and breast cancer; no additional screening recommended
85
AAA screening
From 65 for men Trans women will have similar AAA risk levels to cis men and should consider requesting screening if not registered as male with their GPs (not routinely invited) No AAA Small AAA (3 – 4.4 cm) – annual monitoring USS Medium AAA (5.4 – 5.4cm) – USS every 3 months Large AAA (5.5cm +) - prophylactic repair
86
CAH
21-hydroxylase deficiency Autosomal recessive genetic inheritance via chromosome 6 Classical: ambiguous genitalia +/- adrenal crisis at birth Non: milder - early pubertal changes (secondary to androgen excess) or absent/ irregular menses 17-hydroxyprogesterone HIGH --> should be measured in the follicular phase and will be raised in CAH. 8AM d 1-5 --> Testosterone can be normal or high --> If 17- hydroxyprogesterone is borderline, it will have to be confirmed by an ACTH stimulation test to diagnose CAH.
87
Hymenal origin
Endoderm (from the urogenital sinus epithelium)
88
Embryological development of vagina
Müllerian ducts --> inferior/ fused structure --> uterus, cervix and upper 1/3 vagina Urogenital sinus --> lower 2/3 of the vagina develop from the (sinovaginal bulbs - fuse to form vaginal plate) --- both of these are from intermediate mesoderm--- ---Happens at about 10 weeks Entire process is complete by 20 weeks of gestation (think: in time for anatomy scan!) ---
89
MRKH
Primary ammenorrhoea (make up 15% of primary) Absent vagina (upper 2/3 and cervix) Non-functioning uterus Normal ovaries! T1: above T2: other assoc (40%-50%) Renal tract (most commonly!) Hearing difficulties (middle ear) Bone effects (fused or absent vertebrae)
90
Androgen insensitivity syndrome (previously testicular feminisation syndrome)
46XY genotype Defective androgen receptors Phenotypic females, often tall and without pubic hair due to lack of androgenic stimulation Present with primary amenorrhoea Testes should be removed to prevent gonadoblastoma
91
diethylstilboestrol (DES)
Drug has been discontinued since 1971 Previous oestrogenic compound used for management of recurrent miscarriage Exposure associated with Vaginal adenosis T shaped uterus
92
Congenital anomalies of the cervix;
(1) Cervical agenesis Can occur in isolation or alongside uterine/ vaginal agenesis (MRKH syndrome) Incomplete or failed development of the Mullerian/paramesonephric ducts Primary amenorrhoea If isolated cervical agenesis -> development of heamatometra (2) Cervical duplication/ didelphys Most commonly in association with uterine didelphys Does not typically interrupt menses Failed fusion of Mullerian/paramesonephric ducts
93
Congenital anomalies of the uterus
Mullerian anomalies have an incidence of between 1-3%
94
What % of 1st and 2nd trimester miscarriage is linked to mullerian anomalies
~15% of recurrent first trimester miscarriage patient cohort have one, and ~25% of those who have had a second trimester miscarriage)
95
Strassman metroplasty
Operation done on bicornuate uterus if recurrent preg loss
96
uterine anomalies associated with vaginal septum
uterine didelphys - vaginal septum in 75% of cases Septate uterus - less assoc
97
When do females have max number of oocytes
20 weeks gestation
98
Causes of high inhibin levels
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Inhibin levels
Tend to be inhibin B levels measured. Granulosa cell tumours (inhibin B 60 fold increase, 90-100%) Mucinous epithelial ovarian tumours. (55%) Assessing infertility issues: Inhibin B levels can be used to assess ovarian reserve and it is suggested that levels can also predict the success of ovulation-inducing drugs Day 3 of the cycle!
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ospemifene
SERM for vaginal atropy in people not suitable for oestrogen
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Testosterone levels in women in 20s compared to women in 40s
A women in her mid 40s has approx. half as much circulating testosterone as a woman in her 20s
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Prevalence of OP in older men/ women
1 in 3 older women 1 in 5 older men (Peak in 20s, BMD begins to reduce from age 30)
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When is rate of BMD loss greatest in women
1 year prior to menopause --> 2 years following menopause
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DXA T score and Z score
T score = comparison of BMD to average of young person (aged 20-29) of the same sex Normal T score = +1 to -1 Osteopenia T score = -1 to -2.5 Osteoporosis T score = <-2.5  Z score = compared BMD to people of the same age and gender
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Drug therapy known to impact BMD
PPI SSRIs Medroxyprogesterone acetate (long term/significant history of use in particular) Aromatase inhibitors Thiazolidinediones Most anticonvulsants
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Vitamin D sources
But between October and early March we do not make enough vitamin D from sunlight. Vitamin D is also found in a small number of foods: oily fish – such as salmon, sardines, herring and mackerel red meat liver (avoid liver if you are pregnant) egg yolks fortified foods – such as some fat spreads and breakfast cereals
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Special populations that should take vit D
OP (BMS rec 1000units) Pregnant/ people in gen - 400 IU (10mcg) Trans and non binary - OTC 400 IU (10mcg)
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Macrolide resistance what mutations
40% 23sRNA mutations Azithromycin
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M Gen shape
Flask like shape with tip covered with surface proteins MgpB, MgpC. Complex for adherence. Remember Mgen as a little tiny independent (self-replicating) woman at 23 (23sRNA Azithromycin resistance) years shes doing her MCB (MgpB, MgpC) to become a gp. She is single (sDNA). She has curly hair (round). Shes so small she cant have memb bound organelles. She DNA gaf.
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normal ph vag
3.5-4.5
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BV organisms
Gardenella (small gram neg) Mobillinus Provotella M hominus Atropobium vaginalis
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The Hay/Ison criteria
grade 1 (Normal): Lactobacillus morphotypes predominate grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli
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Metronidazole
BV and TV: 400mg PO for 7/7 (or 2g stat) Small - enters by diffusion into protozoans and anarebes - reduced to 5-nitromadazole (free radicals) - binds to DNA = reduces dna synthesis Note: Disulfiram reaction and increase lithium toxicity Ritonavir!!!
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