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Year 5 > Repro 1 > Flashcards

Repro 1 Flashcards

1
Q

Atrophic vaginitis

A

Dryness and atrophy of the vaginal mucosa due to lack of oestrogen, symptom of menopause. The mucosa becomes thinner, less elastic and more dry. Changes to the vaginal pH (becomes more alkaline) and microbial flora that contribute to localised infection. Lack of oestrogen can cause pelvic organ prolapse and stress incontinence

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2
Q

Atropic vaginitis symptoms

A
  • Itching
  • Dryness
  • Dyspareunia
  • Bleeding due to localised inflammation (post-coital bleeding)
  • Recurrent UTI, stress incontinence or pelvic organ prolapse
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3
Q

Atropic vaginitis examination

A
  • Pale mucosa
  • Thin skin
  • Reduced skin folds
  • Erythema and inflammation
  • Dryness
  • Sparse pubic hair
  • Narrow introitus, loss of vaginal rugae (folds)
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4
Q

Atropic vaginitis management

A
  • Vaginal lubricants help with symptoms of dryness. Use moisturisers regularly
  • Estriol (oestrogen cream), applied using an applicator (syringe) at bedtime
  • Oestrogen rings or pressaries
  • Systemic HRT if other menopause symptoms
  • Contraindications of topical oestrogen include breast cancer, angina and VTE
  • Ix: clinical examination with speculum if tolerated, may do swabs if suspect infection
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5
Q

Anaemia in pregnancy

A

Increase in plasma volume causes haemodilution. Red cell mass does increase but not enough

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6
Q

Definition and screening for anaemia

A
  1. In non-pregnancy patients, the female lower limit of normal Hb is 115-120.
  2. FBC is taken at booking – if Hb is <110g/L, this suggests anaemia prior to pregnancy.
  3. FBC is then repeated at 28 weeks – if Hb is <105g/L this suggests anaemia.
  4. Women are offered haemoglobinopathy screening at the booking clinic for thalassaemia and sickle cell disease
  5. Additional testing can take place in the presence of symptoms suggestive of anaemia, including tiredness, lethargy, dizziness or fainting
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7
Q

Causes and diagnosis for anaemia in pregnancy

A
  • The commonest cause is iron deficiency anaemia then folate deficiency.
  • Normal MCV suggests physiological anaemia due to increased plasma volume
  • Conditions such as haemolytic anaemia, sickle-cell disease, thalassaemia and hereditary spherocytosis can also increase the risk of folate deficiency.
  • Non-haematological causes of anaemia (less common) include CKD, autoimmune conditions and coeliac disease
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8
Q

Folic acid and pregnancy

A
  1. All women planning pregnancy should be advised to take folate supplements 400mcg daily pre-conceptually and continue until 12 weeks to prevent neural tube defects/ other abnormalities.
  2. Women who are at high risk for neural tube defects should take high dose (5mg) folic acid (women with spina bifida, previous baby affected by any NTD, diabetes, anticonvulsant use, obesity, haematological conditions).
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9
Q

Iron deficient anaemia in pregnancy

A
  • Additional tests include serum iron, serum ferritin and total iron binding capacity
  • Iron supplementation should be prescribed for women with confirmed IDA in addition to iron rich diet (red meat, green leafy vegetables). It usually takes 2-3 weeks to increase Hb, but symptoms may improve earlier.
  • IV iron can be considered as an alternative when oral iron is not tolerated, when Hb levels are not improving despite therapy, or if a more rapid increase in Hb is required (diagnosis is late in pregnancy, pre-op).
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10
Q

Postpartum anaemia

A
  • Patients at risk of anaemia include an estimated blood loss at delivery >500ml or any patient who is anaemic (Hb <105) in the 3rd trimester / the start of labour.
  • In cases where Hb is found to be <100g/L postnatally, oral iron should be commenced for at least 3 months
  • Blood transfusion guidelines suggest Hb <70g/L as a threshold for transfusion, however if a woman is symptomatic between 71-80g/L transfusion may need to be considered.
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11
Q

Pregnancy screening for anaemia and cut offs for iron

A

When are pregnant women screened for anaemia: the booking visit (8-10 weeks) and at 28 weeks

Cut offs for iron therapy
- First trimester- <110 g/L
- Second/third trimester- <105 g/L
- Postpartum- <100 g/L

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12
Q

BV in pregnancy

A
  • BV is treated in pregnancy because it can be associated with miscarriages and preterm labour, low birth weight and chorioamnionitis
  • During pregnancy treatment options include topical Clindamycin cream ; some units use oral Metronidazole
  • In gynaecology, BV is treated by Metronidazole 400 MG BD for 7 days.
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13
Q

Overview of BV

A
  • pH of vaginal fluid is elevated above 4.5 and up to 6.0
  • When levels of lactobacillus drop and other bacteria like Gardnerella vaginalis and Prevotella spp rise
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14
Q

Risk factors for BV

A
  • Vaginal douching
  • Receptive cunnilingus
  • Black race
  • Recent change of sex partner
  • Smoking
  • Presence of an STI e.g. chlamydia or herpes
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15
Q

BV: clinical presentation

A
  • Offensive, fishy smelling vaginal discharge.
  • Not associated with soreness, itching or irritation
  • Many women (50%) are asymptomatic
  • Signs: thin, white, homogenous discharge coating the walls of the vagina and the vestibule
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16
Q

Amsels criteria

A

Diagnosis: based on Amsel’s criteria or the Hay/Ison criteria

Amsel’s criteria: At least three of the four criteria are present for the diagnosis to be confirmed.
- Thin, white, homogeneous discharge
- Clue cells on microscopy of wet mount
- pH of vaginal fluid >4.5
- Release of a fishy odour on adding alkali (10% KOH)

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17
Q

Treatment for BV

A
  • Who to treat: Symptomatic women, Women undergoing some type of surgical procedure
  • Metronidazole 400mg twice daily for 5-7 days. OR
  • Metronidazole 2g single dose. OR
  • Intravaginal metronidazole gel (0.75%) once daily for 5 days. OR
  • Intravaginal clindamycin cream (2%) once daily for 7 days
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18
Q

Bartholins abscess symptoms

A
  • A tender lump on one side of the vagina where the ducts are situated.
  • Surrounding area that looks red, swollen and hot to touch. Can get lymphadenopathy
  • Discomfort and/or pain that is worse when pressure isapplied e.g. when sitting or walking and during sexual intercourse.
  • Pus oozing from the abscess (sometimes foul smelling).
  • Discomfort when passing urine (stinging sensation).
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19
Q

Bartholin glands

A
  • Located bilaterally at the posterior introitus and drain through ducts that empty into the vestibule
  • The Bartholins gland has a long duct, when this gets blocked it’s a Bartholins cysts. When the cyst is infected its Bartholin’s abscess
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20
Q

Bartholins abscess presentation

A
  • Polymicrobial- Neisseria gonorrhoea is the most common agent, Chylamydia trachomatis can also cause it
  • May present acutely and require surgical drainage
  • May discharge spontaneously and resolve without surgical intervention
  • Can reoccur on the same or contralateral site
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21
Q

Bartholins abscess treatment and diagnosis

A
  • Investigations: confirm with US
  • Symptomatic: warm salt water to relieve pain
  • Cyst can be aspirated with a needle, reoccurrence rate is high
  • An abscess requires surgical intervention in order to drain it
  • Word catheter- a tiny catheter inserted under local anaesthetic inorder to drain it
  • Marsupialisation- an insiscion is made into the abscess and after drainage the internal aspect of the cyst wall is sutured to the skin to form a pouch, reduce recurrence
  • Small abscesses <3cm can be cured with antibiotics
22
Q

Functional ovarian cysts

A
  • These include follicular, theca and corpus luteal cysts. Diagnosed when the cyst is over 30mm.
  • They are also called “physiological cysts” and rarely grow over 100mm.
  • Asymptomatic women with small (less than 50 mm diameter) simple ovarian cysts do not require follow-up as these cysts resolve within 3 menstrual cycles.
  • Women with simple ovarian cysts of 50–70 mm should have yearly ultrasound follow-up. >7mm should be considered for either further imaging (MRI) or surgical intervention.
  • Theca luteal cysts are usually bilateral and are associated with pregnancy, particularly twins and molar
23
Q

Functional cysts- Follicular cysts

A
  • Most common type of ovarian cysts
  • Due to non rupture of the dominant follicle or failure of atresia in a non dominant follicle
  • Commonly regress after several menstrual cycles
24
Q

Functional cysts- corpus luteum cysts

A
  • During the menstrual cysle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If it doesn’t it may fill with blood or fluid and form a corpus luteal cysts
  • More likely to present with intraperitoneal bleeding than follicular cysts
25
Q

Dermoid cysts

A
  • Most common ovarian tumour in women aged 20-40 years. The peak incidence is at 20 years.
  • 10% are bilateral and rarely malignant
  • It contains tissue from all three embryonic germ cell layers (epithelial, mesenchymal and stromal).
  • Diagnosis: ultrasound scan; an MRI useful if uncertainty.
  • Astruma ovariiis a rare form of monodermal teratoma that contains mostly thyroid tissue, which may cause hyperthyroidism.
  • Treatment: surgical (cystectomy or oophorectomy), particularly if more than 50mm as can tort
  • Usually asymptomatic. Torsion more likely than with other ovarian tumours
  • Also called mature cystic teratomas, usually lined with epithelial tissue so may contain skin appendages, hair and teeth
  • Benign germ cell tumour
26
Q

Endometriotic cysts (endometrioma)

A
  • Arises from the ectopic endometrial tissue. It contains thick, brown, tar-like fluid, “chocolate cyst.” Endometriomas are often densely adherent to surrounding structures, such as the peritoneum, fallopian tubes, and bowel.
  • Endometriomas can be associated with endometriosis and be bilateral
  • Endometriosis like symptoms including dyspareunia and/or subfertility.
  • Surgical treatment (cystectomy)
  • The other procedure is a cyst aspiration, can cause recurrence and adhesion formation
  • Expectant management: Endometrioma <4cm and the patient is asymptomatic
27
Q

Serous cystadenoma

A
  • the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
  • bilateral in around 20%
  • Arises from the ovarian surface epithelium
28
Q

Mucinous cystadenoma

A
  • second most common benign epithelial tumour
  • they are typically large and may become massive
  • if ruptures may cause pseudomyxoma peritonei
  • Arises from the ovarian surface epithelium
29
Q

Ovarian cyst accidents

A
  • Ovarian cyst accidents includecyst rupture, haemorrhage and torsion.
  • Rupture of an ovarian cyst occurs in women of reproductive age.
  • Most women with a ruptured ovarian cyst may be managed with observation, analgesics, and rest, but some women require surgery. Surgical management is usually required for rupture of a dermoid cyst.
  • A bleed into a cyst can cause acute onset pain from peritoneal stretching. This gradually settles over time. The management is like that of a ruptured ovarian cyst.
  • Ovariantorsionis when an ovary twists around its own ligaments. More likely if large cyst. Can include fallopian tube
  • Treatment for ovarian torsion is usually surgical involving either untwisting the ovary (and removing the cyst) or removing the affected ovary and tube (if gangrenous).
30
Q

Breast cancer screening

A
  • Offered to women between 50-70
  • Woman are offered a mammogram every 3 years
  • After 70 can make their own appointments for mammograms
31
Q

Candidiasis risk factors and definition

A

Thrush is an extremely common condition, 80% are caused by Candida albicans

Risk factors: Diabetes mellitus, Drugs (antibiotics, steroids), Pregnancy, Immunosuppression (HIV)

32
Q

Candidiasis features

A
  • ‘Cottage cheese’ non offensive discharge
  • Vulvitis: superficial dyspareunia, dysuria
  • Itch, burning sensation
  • Vulval erythema, fissuring, satellite lesions may be seen
33
Q

Candidiasis investigations and management

A

Investigations- often a clinical diagnosis, though a high vaginal swab can be used

Management
- Oral fluconazole 150 mg as a single dose first-line
- Clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
- If there are vulval symptoms, topical imidazole in addition to an oral or intravaginal antifungal
- If pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

34
Q

Recurrent vaginal candidiasis

A
  • Recurrent vaginal candidiasis is >4 symptomatic episodes a year with at least 2 episodes confirmed by microscopy or culture when symptomatic
  • Compliance with previous treatment should be checked
  • Confirm the diagnosis of candidiasis- high vaginal swab for microscopy and culture, consider a blood glucose test to exclude diabetes
  • Exclude differential diagnoses such as lichen sclerosus
  • Consider the use of an induction-maintenance regime, induction: oral fluconazole every 3 days for 3 doses, maintenance: oral fluconazole weekly for 6 months
35
Q

Cervical screening programme

A
  • 25-49: every 3 years
  • 50-64: every 5 years
  • Detects HPV then cervical cytology
36
Q

Management of results: negative hrHPV

A

Return to normal recall unless:

  • the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
  • the untreated CIN1 pathway
  • follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
  • follow-up for borderline changes in endocervical cells
37
Q

Management of results: positive hrHPV

A
  • Samples are examined cytologically
  • If the cytology is abnormal -> colposcopy stained with 5% acetic acid
38
Q

Management of results: if the cytology is normal but HPV)

A

the test is repeated at 12 months

  • if the repeat test is now hrHPV -ve → return to normal recall
  • if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
  • If hrHPV -ve at 24 months → return to normal recall
  • if hrHPV +ve at 24 months (i.e. 3 positive tests) → colposcopy
39
Q

Management of results: if the sample is inadequate

A
  • repeat the sample within 3 months
  • if two consecutive inadequate samples then → colposcopy
40
Q

Follow up for CIN1, CIN2, CIN3

A

Individuals who’ve been treated for CIN1, CIN2 or CIN3 should be invited 6 months after treatment for a test of cure. Repeat cervical sample in the community.

41
Q

Treatment of CIN

A
  • Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic.
  • Cryotherapy- in low grade CIN
  • Hysterectomy- persistent disease in women nearing/after menopause or after LETZ
42
Q

Cervical screening: exceptions for routine screening

A
  • All women aged 25 to 64 with renal failure requiring dialysis, who have never been screened must have cervical cytology performed at diagnosis.
  • Newly diagnosed HIV- Annual cytology should be performed with an initial colposcopy
  • In organ transplant recipients: These patients should be assessed by cytology, HPV testing (within the context of the NHSCSP), colposcopy, vulvoscopy, and biopsy where indicated at least every six months
43
Q

HPV strains cancer and vaccine

A

cervical cancer is mostly caused by HPV 16,18 which cause 70% of cervical cancer

HPV vaccine
- Offered to all 12-13 year old, cut cervical cancer by 90%
- Current brand: Gardasil 9 covers HPV 6, 11, 16, 18, 31, 33. 45, 52

44
Q

Malignant disease of the cervix investigations

A
  • To confirm the diagnosis, the tumour is biopsied.
  • To stage the disease, vaginal and rectal examination is used to asses the size of the lesion and parametrial or rectal invasion.
  • Unless it is clearly small, examination under anaesthetic is performed. Cystoscopy detects bladder involvement and MRI detects tumour size, spread and LN involvement.
  • To assess the patient’s fitness for surgery, a CXR, FBC, U&Es are checked. These may be abnormal with advanced disease. Blood is cross-matched before surgery
45
Q

CIN categories

A
  • A precancer
  • CIN 1 – changes only in lower 1/3rd of squamous epithelium, low grade, high chance of spontaneous regression
  • CIN 2 and 3 – changes in lower 2/3 rd and whole of the squamous epithelium respectively. Higher grade abnormality, regression rates are lower.
  • CIN 2 – regression rate is 50% to 60%, therefore in nulliparous women conservative management can be offered with more regular surveillance.
  • CIN 3 – treatment options offered as further progression leads to cancer.
46
Q

Chlamydia

A
  • Risk factors: age <25, non barrier contraception, co-infection with another STI
  • The most prevalent STI
  • Causative agent is Chylamydia trachomatis. An obligate intracellular parasite. 70% of infected women and 50% of infected men no obvious symptoms
47
Q

Chlamydia symptoms

A
  • Female: Usually asymptomatic, Dysuria (most common symptom), Fever, Offensive vaginal discharge, Lower abdominal pain
  • Male: Usually either presents with unilateral epidydimal-orchitis or dysuria with urethral discharge
48
Q

Reiters syndrome- more common in males

A
  • Reactive arthritis – urethritis, conjunctivitis and arthritis
  • Remember with the mnemonic of can’t see, can’t wee and can’t even climb a tree
49
Q

Chlamydia investigations and complications

A
  • Urine test or urethral swab/ vulvovaginal swab
  • Better to use swabs
  • Analysed with NAAT
  • Complications: PID, Epididymitis, Reactive arthritis
50
Q

Chlamydia management

A
  • Doxycycline 100mg BD 7 days or azithromycin 1g single dose are the 1 line options for treatment of chlamydia
  • If pregnant then azithromycin, erythromycin or amoxicillin are used
  • NAAT should be repeated 2 weeks later or cultures >72 hours after antibiotics given to test for adequate treatment of infection
  • Contact tracing: last 6 months. If male urethral symptoms last 4 weeks

Year 5 (24 decks)

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