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3rd year medicine > repro 2 > Flashcards

repro 2 Flashcards

1
Q

menstrual cycle phases?

A
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2
Q

hormones involved in mesntrual phases

A
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3
Q

which hormone triggers stroma and gland proliferation?

A

oestrogen

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4
Q

types of abnormal uterine bleeding (AUB)

A
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5
Q

causes of AUB?

A

cervical ectropion

pelvic inflammatory disease

endometritis

endometrial polyp

leiomyoma (fibroid)

leiomyosarcoma

adenomyosis

bleeding disorders

hyperplasia

cervical/endometrial cancer

atrophy (post-menopause)

DUB = anovulatory cycles/luteal phase defects

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6
Q

method of assessing endometrial hyperplasia?

indication for biopsy?

A

TVUS

indications for biopsy:

postmenopausal = endometrial thickness >4mm

premenopausal = >16mm

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7
Q

method of assessing polps or local thickening?

A

hysteroscopy

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8
Q

biopsy methods uterus

A

endometrial pipelle

* outpatient procedure, limited sample

dilatation and curretage

* most thorough sampling method

* can miss 5% of hyperplasias/cancers

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9
Q

disordered uterine bleeding (DUB)?

Ax?

A

abnormal uterine bleeding with no organic cause

most cases due to anovulatory cycles e.g. PCOS, hypothalamic dysfunction, thyroid disorders, hyperprolactinaemia

* commonest at either end of reproductive life

* corpus luteum does not form

rare cases due to luteal phase deficiency

* insufficient progesterone

* abnormal corpus luteum forms

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10
Q

anovulatory cycle pathophys

A

ovulation does not occur so endometrium continues to grow

glands appear cystically dilated (PCOS)

will break down irregularly i.e. oligomenorrhoea

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11
Q

endometritis?

Ax?

A

inflammatory cells in uterus

Ax

* gonorrhea + chlamydia (also TB, CMV, HSV)

* IUD

* postpartum (cause of secondary PPH)

* post-abortion

* post-curretage

* granulomatous (sarcoid, TB, foreign body)

* leiomyomata/polyps

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12
Q

endometritis rule?

A

infectious until proven otherwise (chlamdia, ghonorrhoea)

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13
Q

endometrial polyp s/s?

trigger?

risk?

A

common - usually asymptomatic but may present with bleeding

often occur during menopause

risk = almost always benign but endometrial carcinoma can present as a polyp

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14
Q

molar pregnancy types?

A

Complete mole

sperm combinies with egg which has lost its DNA

sperm then replicates forming 46 chromosome set

Only paternal DNA is present in complete mole

Partial mole

Egg fertilized by sperm which replicates itself yielding genotypes of 69, XXY (triploid)

partial moles have both paternal + maternal DNA

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15
Q

which mole is more dangerous?

A

complete mole - can develop into choriocarcinoma

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16
Q

myometrium Ax of AUB?

A

adenomyosis = endometrial glands and stroma in myometrium

* causes menorrhagia + dysmenorrhoea

leiomyoma = fibroids

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17
Q

leiomyoma symptoms?

growth?

risk?

A

menorrhagia

infetility

pain

growth is oestrogen dependent

very rarely can develop into leiomyosarcoma

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18
Q

what triggers ovulation?

A

LH surge (day 14)

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19
Q

when does progesterone peak?

A

day 21 of cycle

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20
Q

decidualisation?

A

progesterone-induced endometrial remodelling

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21
Q

normal menstruation

normal length of menstrual cycle?

A

usually lasts 4-6 days

mentrual flow peaks day 1-2

<80ml per menstruation

average 28 day cycle

between 21 to 35 days is normal

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22
Q

how many cases of AUB are DUB?

A

50%

so 50% have no organic cause

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23
Q

systemic disorders causing menorrhagia?

A

endocrine = hypothyroidism, diabetes, prolactin disorders

haemostasis = VWF, ITP, clotting dactor deficiency

liver disorders (clotting factorsO

renal disease

drugs - anticoagulants

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24
Q

PCOS symptoms?

complication?

A

oligomenorrhoea/amerneorrhoea

weight gain

facial hirsutism

facial acne

hair loss/thinning

associated with T2DM (insulin resistance), hypercholesterolaemia, hypertension, sleep apnoea

associated with increased risk of endometrial carcinoma

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25
Q

DUB subdivisions

A
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26
Q

Ix DUB?

A

diagnosis of exclusion

FBC - to assess Hb

Cervical smear (rule out cancer)

TSH

Coagulation screen

renal/liver function tests

Tranvaginal USS - endometrial thickness

hysteroscopy - fibroids and other pelvic masses

Endometrial sampling (pipelle, D+C)

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27
Q

Tx DUB?

A

Progestogens (synthetic progesterone)

Combined oral contraceptive pill

Anazol

GnRH analogues (low dose)

NSAIDs

Anti-fibrinolytics (tranexamic acid)

Capillary wall stabilisers

1st line for menorrhagia = IUS (Mirena)

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28
Q

infertility definition?

main causes?

A

Inability to conceive after 12 months regular intercourse without contraception

Sperm problems (30%)

Ovulation problems (25%)

Tubal problems (15%)

Uterine problems (10%)

Unexplained (20%)

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29
Q

advice for conception?

A

Woman should be taking 400mcg folic acid daily

Aim for a healthy BMI

Avoid smoking and excessive alcohol

Reduce stress

Aim for intercourse every 2-3 days

Avoid timing intercourse (i.e. timing with ovulation as can lead to increased stress and pressure on the relationship)

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30
Q

blood tests for infertility?

A

day 21 progesterone (>30 mmol/L)

TSH

anti-mullerian hormone (high levels good sign)

if oligo/amenorrhoeic:

LH (raised in PCOS), FSH, E2 levels

testosterone - SHBG, FAI

prolactin (hyperprolactinaemia can cause amenorrhoea)

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31
Q

PCOS blood results?

A

elevated LH

hyperprolactinaemia

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32
Q

what is the most accurate marker of ovarian reserve?

A

anti-mullerian hormone (high levels = good)

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33
Q

non-blood test Ix for infertility?

A

US pelvis - look for polycystic ovaries or structural abnormalities in uterus

Hysterosalpingogram - patency of fallopian tubes

Laparoscopy and dye test - tubal patency, adhesions and endometriosis

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34
Q

Tx anovulation?

A

1st line = clomifene

2nd line = letrozele

low dose GnRH in women resistant to clomifene

ovarian drilling in PCOS

metformin can also be used in PCOS

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35
Q

Tx tubal factors infertility?

A

tubal cannulation during HSG

laparoscopy to remove adhesions or endometriosis

IVF

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36
Q

Tx uterine factors infertility?

A

surgery to remove polyps, adhesions, structural abnrmalities

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37
Q

normal semen parameters

nomenclature?

A

Sperm conc should be >15

Motility >32

Morphology >4

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38
Q

Tx sperm problems infertility?

A

Surgical sperm retrieval - blockage of vas deferens

Surgical correction of obstruction of vas deferens

Intrauterine insemination

ICSI - injecting sperm directly into the cytoplasm of egg (useful when significant motility issues, low sperm count)

Donor insemination

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39
Q

ART eligibility?

A

Stable relationship 2y (incl same sex)

Female <40 y/o

Female BMI 18.5-30

Non-smokers

No biological child

No illegal/abusive substances (incl methadone)

Neither Partner sterilised

Duration unexplained infertility 2y

Up to 3 cycles of tx

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40
Q

complications of IVF?

A

Failure

Multiple pregnancy

Ectopic pregnancy

Ovarian hyperstimulation syndrome

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41
Q

ovarian hyperstimulation syndrome s/s?

A

Abdominal pain + bloating

vomiting + diarrhoea

Hypotension (hypovolaemia)

Ascites

Pleural effusion

Renal failure

Peritonitis from rupturing follicles releasing blood

Prothrombotic state (risk of DVT and PE)

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42
Q

Tx OHSS?

A

oral fluids

monitor urine output (hypovolaemia)

LMWH (to prevent DVT/PE)

paracentesis if req

IV colloids (albumin)

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43
Q

types of miscarriage

A

missed = foetus no longer alive but no symptoms

threatened = vaginal bleeding with closed cervical os + foetus alive

inevitable = vaginal bleeding + open cervical os

incomplete = RPOC

complete = full miscarriage with no RPOC

anembryonic pregnancy = gestational sac present but no embryo

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44
Q

miscarriage symptoms?

Dx?

A

positive UPT

bleeding primary symptom (more than cramps)

Dx = TVUS 1st line for diagnosiing miscarriage

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45
Q

things to look for in TVUS miscarriage?

A

Mean gestational sac diameter

Foetal pole and CRL

Foetal heartbeat

foetal heartbeat expected once CRL >7mm

when CRL <7mm without a heartbeat, scan repeated after at least 1 week to ensure heartbeat develops

when CRL >7mm without foetal heartbeat, scan repeated after one week before confirming non-viable pregnancy

Foetal pole expected once the mean gestational sac diameter >25mm

when >25mm but no foetal pole, scan is repeated after one week before confirming an anembryonic pregnancy

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46
Q

speculum exam to assess stage of miscarriage?

A

Is the os closed? (threatened miscarriage)

Open? (inevitable miscarriage)

Products already in vagina and os is closed? (complete miscarriage)

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47
Q

RPOC complications?

symptoms?

Tx?

A

cervical shock

* cramps

* nausea/vomiting

* collapse

* sweating

resolves if products removed from cervix

* resus with IV fluids

* uterotonics may be required

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48
Q

Ax miscarriage?

A

Embryonic abnormality - chromosomal

Immune cause - anti phospholipid syndrome (APS)

Infections - CMV, rubella, toxoplasmosis, listeria

Severe emotional upsets/stress

Iatrogenic loss (after chorionic villus sampling causing infection or uterine irritability)

Associations - heavy smoking, cocaine, alcohol misuse

Uncontrolled diabetes

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49
Q

signs of miscarriage on TVUS

anemebryonic pregnancy?

A

miscarriage = no heartbeat + foetal pole >7mm

anamebryonic = gestational sac >25mm, no foetal pole

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50
Q

management of miscarriage <6 weeks gestation?

A

Women <6 weeks presenting with bleeding can be managed expectantly (they must be in no pain and have no risk factors e.g. previous ectopic)

Expectant management = waiting for miscarriage without investigations or treatment

Ultrasound unlikely to be helpful as pregnancy too small to be seen

Repeat UPT is performed after 7-10 days

If negative, a miscrriage can be confirmed

If bleeding continues or pain occurs = referral

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51
Q

management of miscarriage >6 weeks gestation?

A

Ultrasound scan - confirm location and viability of pregnancy

Essential to exclude ectopic pregnancy!!!

3 main options for management:

* Expectant (do nothing and await spontaneous miscarriage)

1st line in women without risk

repeat UPT after 3 weeks to confirm complete miscarriage

* Medical (misoprostol)

* Surgical

manual vacuum (LA) <10 weeks gestation

electric vacuum (GA)

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52
Q

misoprostol?

S/E?

A

prostaglandin analogue (used for medical management miscarriage)

* heavier bleeding

* pain

* vomiting

* diarrhoea

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53
Q

important to remember surgical management miscarriage?

A

anti-rhesus D for rhesus neg women!!

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54
Q

recurrent miscarriage?

Ax?

A

3 consecutive 1st trim miscarriages OR

one 2nd trim miscarriage

Ax = idiopathic (older women), APS, uterine abnormalities e.g. fibroids, hereditary thrombophillias, chronic histiolytic intervillositis (NK cells in uterus), diabetes, untreated thyroid, SLE

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55
Q

APS?

Tx?

A

anti-phospholipid antibodies, hypercoagulable state

associated with thrombosis and recurrent miscarriage

Tx = LDA + LMWH

(check for past medical history of DVT)

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56
Q

common hereditary thrombophillias?

comps?

A

factor V Leiden (most common)

factor II (prothrombin)

protein S deficiency

recurrent miscarriage

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57
Q

Ix recurrent miscarriage?

Tx?

A

Antiphospholipid antibodies

Testing for hereditary thrombophilias

Pelvic ultrasound (uterine abnormalities, fibroids)

Genetic testing of products of conception/parents

for APS = LDA + LMWH

for unexplained cases = progesterone pessary

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58
Q

incomplete miscarriage?

Tx?

A

RRPOC remain in uterus after miscarriage = risk of infection!!

Tx = medical (misoprostol) or surgical management

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59
Q

most common site ectopic? other sites?

risk factors?

A

most common site = ampulla

other sites = other fallopian tube areas, ovary, peritoneum, liver, cervix, c-section scar

risk factors

* previous ectopic

* previous PID

* surgery to fallopian tubes

* IUD

* older age

* smoking

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60
Q

s/s ectopic pregnancy?

A

Pain > bleeding

Constant lower abdominal pain in right or left iliac fossa

Missed period

Vaginal bleeding

Lower abdominal tenderness

Cervical motion tenderness (pain when moving cervix during bimanual examination)

Dizziness or syncope (collapse)

Shoulder tip pain (peritonitis)

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61
Q

ectopic pregnancy Ix?

A

FBC, BHCG (levels should not double)

TVUS gold standard for ectopic!! - blob sign, tubal ring sign

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62
Q

pregnancy of unknown location?

A

basically ectopic but not visible on USS

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63
Q

Tx ectopic pregnancy?

A

depends on presentation!

if acutely unwell (BHCG >5000, >35mm, rupture, pain, visible heartbeat)

laparoscopic salpingectomy 1st line - remember anti-D

(salpingotomy if damage to other tube)

medical management (patient well, BHCG<5000, <35mm, unruptured)

methotrexate IM to buttock

conservative management (unruptured, <35mm, no heartbeat, no pain, HCG <1500)

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64
Q

methotrexate ectopic S/E?
remember to advise?

A

vaginal bleeding, nausea + vom, abdominal pain, stomatitis (inflammation of mouth)

woman advised not to get pregnant for 3 months (teratogenic)

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65
Q

presentation PUL?

Dx?

Tx?

A

amenorrhoea + abdominal pain with no evidence of pregnancy in uterus, fallopian tube, cervix, c-section scar or abdominal cavity

Dx = HCG - repated after 48 hours

Tx = can be managed conservatively, but if persistent = methotrexate

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66
Q

molar pregnancy s/s?

Dx?

Tx?

A

Hyperemesis

Vaginal bleeding (grape-like tissue)

Hyperthyroidism (thyrotoxicosis - hCG can mimic TSH)

Early onset pre-eclampsia

Size of uterus bigger for stage of pregnancy

Rare cases - SOB (embolisation of molar tissue to lungs) or brain (seizures)

Dx = snow storm appaerance on USS

Tx = surgical

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67
Q

implantation bleeding?

A

common, occurs approx 10 days post-ovulation (once egg implanted in endometrium)

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68
Q

chorionic haematoma?

s/s?

Tx?

A

Pooling of blood between endometrium and embryo due to separation

S/s = bleeding, cramping, threatened miscarriage

Tx = usually self-limiting and resolve

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69
Q

cervical causes of bleeding in early pregnancy?

A

ectropion

Infections - chlamydia, gonococcus

Malignancy (very rare)

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70
Q

vaginal causes of bleeding in early pregnancy?

Tx?

A

Infections = trichomoniasis (strawberry vagina), bacterial vaginosis, chlamydia

Malignancy - ulcers, rare

Forgotten tampon

BV + trich = metronidazole

chlamydia = erythromycin/amxocicillin (CANNOY give doxycycline in pregnancy)

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71
Q

DDx pain in pregnancy?

A

miscarriage (bleeding > pain)

extopic (pain > bleeding)

tosion of ovarian cyst, end of 1st trimester when uterus climbs out of pelvis into abdomen

intra-abdominal bleeding from cyst rupture

UTI, appedncitis

vaginal infections, PID

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72
Q

when is anti-D given?

A

28 weeks

and after any sensitising event

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73
Q

hyperemesis gravidarum?

complications?

Dx?

Tx?

A

excessive vomiting

comps = dehydration (ketosis), electrolyte imbalance, weight loss, altered liver function (50%)

Dx = of exlcusion

Tx = fluids + electrolyte replacment

1st line antiemetic = cyclizine

2nd line = metoclopramide

steroids in protracted condition or evidence of weight loss

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74
Q

complication metoclopramide?

Tx?

A

oculogyric crisis

tx = atropine

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75
Q

types urinary incontinence?

risk factors?

A

Stress incontinence

Urge incontinence

Mixed incontinence

Overflow incontinence

risk factors = women, older, obesity, smoking, kidney disease, diabetes

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76
Q

overactive bladder syndrome?

A

Urgency (with or without urge incontinence) with frequency and nocturia

Absence of pathology that could explain these symptoms

Wet OAB = urge incontinence represent

Dry OAB = incontinence absent

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77
Q

mixed urinary incontinince?

A

urgency + stress incontinence (coughing, sneezing)

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78
Q

exam urinary incontinence?

A

palpable bladder?

External genitalia - atrophic vaginitis

Vaginal - prolapse (50% of SUI patients), malignancy, fistula

Rectal - tone, masses

Neurological - reflexes, sensory, motor

Standing or supine stress test

urinanalysis, post-redisual, bladder diary

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79
Q

Tx ladder OAB?

A

bladder drill

oxybutynin (antimuscarinic)

botox

surgery

when antimuscarinics contraindicated = mirabegron (B3 receptor agonist)

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80
Q

lifestyke advice urinary incontinence?

A

weigtht loss

stop smoking

reduce caffeine

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81
Q

S/E antimuscarinics e.g. oxybutynin?

A

Dry mouth

Constipation

Blurred vision

Somnolence

(type of anticholinergic)

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82
Q

clinical Ix urinary incontinence?

A

cystometry

post residual (abnormal >150)

urinalysis

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83
Q

overflow incontinence Ax?

Dx?

Tx?

A

Ax = obstruction of urethra (prostate), poor contractile bladder muscle

Dx = PVR

Tx = stop anticholinergics

alpha-blocker for BPH

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84
Q

Tx SUI?

A

Weight loss, smoking, reduce caffeine, avoid excessive fluid intake

Physio - pelvic floor

Pessaries

Drugs - duloxetine

surgical = vaginal tape, injections, obturator appraoch

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85
Q

pelvic prolapse compartments?

A

anterior = cystocele

middle/apical = uterine/enterocele

posterior = rectocele

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86
Q

classification uterovaginal prolapse?

A

1st degree = in vagina

2nd degree = at interoitus

3rd degree = outside vagina

4th = procidentia (entirely outside vagina)

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87
Q

cystocele s/s?

uterine/enterocele?

rectocele?

A

cystocele = bulging, pressure, “mass”, difficulty voiding, incomplete emptying, difficulty inserting tampon, pain with intercourse

uterine/enterocele = same as cystocele

rectocele = bulging, pressure, “mass”, difficulty defecating, difficulty inserting tampon, splitting vaginal wall/perineum

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88
Q

POP-Q?

A

Pelvic organ prolapse quantification system (POP-Q)

If site is above hymen - assigned negative number

If site prolapses below hymen - assigned positive number

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89
Q

risk factors vaginal prolapse?

A

Aging

Pelvic surgery e.g. prior hysterectomy

Menopause and hypoestrogenism

Loss of muscle tone

Multiple vaginal births

Obesity

Chronic constipation, coughing, heavy lifting

Uterine fibroids

Family history

Connective tissue disorders such as marfans

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90
Q

Tx vaginal prolapse?

A

conservative = avoid heavy lifting, weight loss, stop smoking, vaginal oestrogens (only if atrophic vaginitis)

pelvic floor exercises

pessaries in women unfit for surgery

surgery e.g. sacrospinous fixation, Manchester repair

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91
Q

prevention of ovulation?

prevention of fertilsation?

prevention of implantation?

A

ovulation = COCP, depo povera, implant, ring, patch. mini pill

fertilisation = IUD/IUS, POP + barrier methods

implantation = IUD (secondary action)

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92
Q

copper coil?

use?

S/E?

A

Can last up to 10 years (if inserted >40 y/o, can be kept in til menopause)

Non-hormonal (might be only reliable method for women after breast cancer)

Can be used as emergency contraception

Often makes periods heavier, longer and more painful (NSAIDs like ibuprofen can help)

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93
Q

IUS?

use?

S/E?

A

e.g. Mirena

1st line Tx for menorrhagia, endometriosis etc

S/E = irregular bleeding, 50% amenorrhoea

systemic hormones very low so hormonal side effects rarely a problem

94
Q

Nexplanon?

lasts how long?

main side effect?

A

arm implant - most effective of all contraceptive methods

safe for most women (progesterone only)

lasts 3 years

main side effect = prolonged PV bleeding (can be controlled by COCP on top of implant)

95
Q

how to take COCP

A

Start in first 5 days of period

Or

At any time in cycle + condoms 7 days

Take daily for 21 days followed by 7 day break (bit outdated now)

Continuous use (off licence lol)

If you have a bleed, come off it for 4 days then start again

96
Q

risks of COCP?

A

Venous thrombosis

Arterial thrombosis

hypertension (must check BP every 3 months then annually)

increased risk breast + cervical cancer

(but protective against endometrial + ovarian cancer)

97
Q

absolute contraindications COCP?

relative contraindications?

A

migraine with aura (sparkles are not an aura)

breast cancer

history of DVT/PE

liver disease

relative = smoking, >35, hypertension, breastfeeding

98
Q

1st line Tx PCOS?

A

COCP

99
Q

s/s COCP?

A

Nausea

Spots (can worsen acne in some people)

Bleeding

Breast tenderness

100
Q

POP?

mechanism of action?

how to take?

A

main is cerelle

mechanism = inhbitis ovulation

others do not - prevent fertilisation by thickening cervical mucus

Day 1-5 of period

Or

Anytime in cycle

+ condoms 2 for days

101
Q

when is implant/DMPA effective?

A

immediately if day 1-5 of period

if any other time - condoms for 7 days

102
Q

contraindications of POP and nexplanon?

A

breast cancer

103
Q

missed POP guidance?

A

Take pill at same time every day

If late taking pill, only really matters if more than 12 hours late

If >12 hours late, won’t work for 2 days

104
Q

depo provera/sayana press?

mechanism?

benefit?

Side effects?

A

injection

suppresses ovulation

benefit = isnt affected by enzyme inducing drugs

S/E = weight gain, nausea, spots, bleeding, headaches, osteoporosis

105
Q

diaphragm use?

A

Must leave for at least 6 hours after sex

106
Q

sterilisation techniques?

A

vasectomy + tubal ligation

107
Q

when can you not give ellaone?

instead?

when is this effective?

A

Can’t give ella one if been taking anything containing progesterone e.g. CHC, mini pill

instead = copper coil

Coil effective immediately if 1-5 day in cycle

If any other time, use condoms for 7 days

108
Q

how long after ellaone can you begin taking POP?

A

5 days after

109
Q

copper coil mechanism of action?

A

prevents fertilsation

110
Q

ellaone v levonelle

A

ellaone= 5 days post intercourse

levonella = 3 days

111
Q

normal vaginal flora?

normal ph?

A

lactobacillus (gram +ve rods)

other organisms = GBS, candida, strep viridans

normal pH = acidic (4-4.5)

112
Q

candida infection Ax?

risk factors?

S/s?

Dx?

Tx?

A

Ax = most are candida albicans

risk factors = recent antibiotics, high oestrogen, diabetes, immunocomproised patients

S/s = intensely itchy, white vaginal discharge

Dx = HVS

Tx = clotrimazole cream –> oral fluconazole

(non-albicans likely to be azole resistant)

113
Q
A

typical “spotty” appearance of candida balantitis

114
Q
A

purulent discharge typical of gonorrhoea infection

115
Q

gonorrhoea gram stain appearance?

A

gram -ve intracellular diplococci

116
Q

where does gonorrhoea infect?

Dx?

Tx?

A

urethra, rectum thorat, eyes, endocervix (in females)

Dx = miscroscopy (endocervical NOT HVS, purulent discharge in males), culture, NAATs (more sensitivity than culture, only needs VVS)

Tx = ceftriaxone

117
Q

chlamydia infects?

gram appearance?

serological groupings?

Tx?

A

urethra, rectum, throat, eyes, endocervix

does not gram stain!!

serovars A-C = trachoma (eye)

serovars D-K = genital

serovars L1-L3 = lymphogranuloma venereum

Tx = doxycyline (azithromycin in pregnancy)

118
Q

LGV?

S/s?

A

chlamydia infection

painless genital lesion + regional lymphadenopathy

painful bowel movements (or painful anal sex)

bloody stools

119
Q

NAATs?

how are they taken?

A

tests for gonorrhoea and chlamydia (more sensitive than culture)

females = VVS (can be self-taken)

males = first pass urine (i.e. not MSSU like UTI)

120
Q

Trichomonas vaginalis?

transmission?

S/s?

Dx?

Tx?

A

protozoal parasite

STD

s/s females = itching, greenish fishy discharge

males = itching, discharge from penis

Dx = HVS for miscroscopy

Tx = oral metronidazole

(treat partners as well as notoriously difficult to diagnose)

121
Q

bacterial vaginosis?

Dx?

Tx?

complications BV?

A

technically imbalance rathe than infection (absence of lactobacilli)

Dx = positive whiff test (fishy) + wet mount miscroscopy, will show absence of lacobasilli + prescence of clue cells (look fluffy)

Tx = metronidazole 7 days

complications = endometritis, PROM, preterm delivery

122
Q

syphillis Ax?

stages?

Dx?

Tx?

A

treponema pallidum

4 stage illness:

stage 1 = chancre (will heal without Tx)

stage 2 = snail track mouth ulcers, generalised rash, flu-like symptoms

stage 3 (latent) = no symptoms, multiplication

stage 4 (late stage) = cardiovascular + neurovascular complications

Dx = cannot be gram stained or cultured

primary = dark field miscoscopy, PCR, IgM

seondary + tertiary = serology

Tx = IM benzylpenicillin

(if allergic = doxycyline/erythromycin 14 days)

123
Q

Tx syphillis?

A

early syphillis

IM benzylpenicillin single dose

(if allergic = doxycycline/erythromycin 14 days)

late syphillis

IM benzylpenicillin (2 doses)

allergic = doxycycline 28 days

124
Q

Dx?

Tx?

A

genital herpes (HSV2)

Tx = aciclovir

125
Q

Tx pubic lice (pthirus pubis)

A

malathion lotion

126
Q

abortion legal til?

management after 20 weeks?

A

Abortion is legal up to 24 weeks

>20 weeks = purely surgical

127
Q

what has to be completed for every abortion in UK?

A

HSA1 form has to be completed for every abortion in the UK

2 doctors sign (clause A-E)

1 doctor signs (if emergency clauses F+G)

All abortions perfomred in UK must be reproted to CMO via HSA4

Most abortions fall under clause C (risk to physical or mental health of mother)

128
Q

conscientious objection abortion?

A

does not apply in emergency situations

should not delay or prevent patient’s access to care

should not apply to indirect tasks associated with abortion i.e. administrative, supervision of staff

129
Q

when is uterus palpable?

A

12 weeks

130
Q

medical abortion?

timing?

A

Mifepristone 200mg PO 1st + prostaglandins

Misoprostol 800mcg PV/SL - 2nd (24-48 hours after taking mifepristone)

<12 weeks gestation = can self-administer

2nd dose misoprostol if >10 weeks

>12 weeks = inpatient procedure

>20 weeks = purely surgical management

131
Q

early medical abortion at home?

A

Contents of pack:

Mifepristone 200mg

Misoprostol 800mcg (PV or SL) + additional dose 400mcg

(additional dose for those who do not experience bleeding within 4 hours, or who are over 10 weeks)

Anti-emetic, analgesia, antibiotics

Contraception (6/12 POP)

132
Q

surgical abortion available until?

types?

A

availible up to 14 weeks in scotland

<14 weeks = electric vacuum aspiration (GA), manual vacuum aspiration (up to 10 weeks - LA)

>14 weeks = Dilation and evacuation

133
Q

complications of abortion?

A

haemorrhage

failed/incomplete abortion

infection

uterine perforation (surgical risk only)

cervical trauma (surgical risk only) - reduced with cervical ripening (misoprostol)

134
Q

prophylaxis at time of abortion to reduce complications?

A

antibiotics (7 days doxycycline + 2days azithroycin)

rhesus anti-D

VTE prophylaxis - LMWH if smoker, BMI, previous embolus

135
Q

contraception after abortion?

A

Can be started at/soon after abortion

Immediately effective if started on day of abortion or within 5 days

If started after 5 days, efficacy depends on method:

2 days for POP

7 days for CHC/DMPA/SDI/LNG-IUS

136
Q

IUD after abortion?

COCP/POP?

A

IUD can be inserted immediately after STOP/MTOP once expulsion of pregnancy confirmed

COCP/POP can be started any time after MTOP/STOP including on day of mife/miso

137
Q

follow-up abortion?

A

No formal follow-up after surgical abortion or in-hospital abortion where passage of PoC confirmed

After EMAH = UPT performed at least 2 weeks after abortion

138
Q

history STI?

A

query deep dyspareunia (upper genital tract infection e.g. PID, endometritis)

characteristics of vaginal discharge

query urianry/bowel symptoms

date of LMP

contraceptive use

sexual history - no. of partners in last 6 months

139
Q

standard STI screen?

A

chlamydia, gonorrhoea, HIV, syphillis

140
Q

HIV?

pathophys?

CD4 level to aim for?

A

RNA retrovirus

attacks helper T cells

CD4 >500

141
Q

HIV symptoms?

A

onset 2-4 weeks after infection

S/s = fever, rash (maculopapular), myalgia, pharyngitis, headache/aseptic meningitis

then latent stage

then late stage - AIDS = oppurtunistic infections and cancers

142
Q

most important oppurtunistic infection HIV?

organism?

CD4 threshold?

S/s?

Dx?

Tx?

Prophylaxis?

A

pneumocystis pneumonia (PCP)

Ax = pneumocystis jiroveci (fungus)

CD4 <200

S/s = dry cough, SOB, insidious onset

Dx = CXR may be normal, BAL + PCR

Tx = high dose co-trimoxazole

prophylaxis when CD4 <200 = low dose co-trimox

143
Q

cerebral toxoplasmosis Ax?

CD4 threshold?

S/s?

Dx?

Tx?

A

toxoplasma gondii

CD4 <150

S/s: cerebral abscesses, chorioretinitis, headache, fever, focal neurology, seizures, raised ICP

Dx = MRI (cerebral abscesses)

Tx = co-trimoxaxole?

144
Q

CMV CD4?

complications?

symptoms?

screening?

A

CD4 <150

causes retinitis, colitis + oesophagitis

S/s = vision loss, floaters, abdominal pain, diarrhoea, PR bleeding

opthalmic screening for all individuals CD4 <50

145
Q

HIV-induced neurocognitive imapirment?

Dx?

A

reduced short term memory + motor dysfucntion

Dx = MRI (enlarged ventricles + deep sulci i.e. atrophy)

146
Q

progressive multifocal leukoencephalopathy (PML) Ax?

CD4?

S/s?

A

organism = JC virus

CD4 <100

S/s = rapid!!, focal neurology, confusion, personality change

147
Q

skin infections HIV?

A

herpes zoster = mutlidermatomal, recurrent

herpes simplex = extensive ulceration, tumour-like, aciclovir resistant

HPV = extensive + resistant to Tx

148
Q

AIDS oppurtunistic infections?

A

PCP

Tuberculosis

cerebral toxoplasmosis

CMV

progressive multifocal leukoencephalopathy

149
Q

HIV associated wasting?

Ax?

A

Slim’s disease

Ax = chronic immune activation, anorexia, malabsoprtion/diarrhoea (CMV)

150
Q

AIDS-related cancers?

A

Kaposi’s sarcoma

non-Hodgkin’s lymphoma (Burkitts)

cervical cancer

151
Q

Kaposi’s sarcoma Ax?

S/s?

Tx?

A

organism = human herpes virus 8 (HHV8)

S/s = cutaneous lesions, mucosal lesions, visceral lesions

Tx = anti-retrovirals, liquid nitrogen, systemic chemo

152
Q

Burkitt’s lymphoma Ax?

Type of cancer?

S/s?

Tx?

A

Ax = EBV

non-Hodgkins lymphoma (AIDS-related)

S/s = B symptoms (weight loss, night sweats, fever), bone marrow involvement, CNS involvement

Tx = antiretrovirals

153
Q

non-AIDS symptomatic HIV?

A

Mucosal candidiasis

Seborrhoeic dermatitis

Diarrhoea

Fatigue

Worsening psoriasis

Lymphadenopathy

Parotitis

Neuroligcal presentations = polyneurpathy, monenuritis multiplex, aseptic meningitis

Haematological = leukolymphopenias, thrombocytopenia

154
Q

transmission HIV?

A

sexual contact

injected drugs

infected blood products

mother to child

155
Q

high prevelance areas HIV?

A

Sub-saharan africa

Caribbean

Thailand

156
Q

Lab markers HIV?

A

Viral RNA is first marker to become positive

Second is p24 protein

Antibody can take 3 months to become detectable in blood

157
Q

types antiretroviral drugs?

HAART?

A

Reverse transcriptase inhibitors

Integrase inhibitors

Protease inhibitors

Entry inhibitors

HAART example = Atripla

158
Q

prognosis HIV?

A

life expectancy with treatment essentially normal

159
Q

HAART toxicity?

A

GI side-effects (protease inhibitors) = transaminitis, fulminant hepatitis

Skin = rash, hypersensitivity, SJS

CNS = mood, psychosis

Renal toxicity = proximal renal tubulopathies, nephrolithiasis

Bone = osteomalacia

CVS - increased MI risk

Haematology - anaemia

160
Q

post-exposure prophylaxis HIV?

A

within 72 hours

antiretroviral Tx for 4 weeks e.g. tenofevir

161
Q

prevention of mother to child transmission HIV?

A

HAART during pregnancy

c-section if detected viral load

2-4 weeks antiretroviral for neonate

exclusive formula feeding

162
Q

Dx?

Ix?

Tx?

A

Extopic pregnancy

Ix = TVUS gold standard, FBC, G+S

Tx = laparoscopic salpingectomy

163
Q

Dx?

on USS, see cyst

A

likely ovarian torsion

164
Q

ovarian torsion Ax?

premenopausal vs postmenopausal

Tx ovarian torsion?

A

Ax = dermoid cyst (any cyst >5cm really)

premenopausal = likely benign

postmenopausal = likely malignant

Tx = deterosion, oophrectomy

165
Q

rebound + guarding

Rovsing’s positive

A

Dx = appendicitis

166
Q

Dx?

Ix?

Ax?

Tx?

A

classic presentation cyst rupture

Ix = FBC, CRP, G+S, USS

Ax = can be spontaneous, or after sex/trauma

Tx = conservative, stop bleeding, resus

167
Q

Dx?

Ix?

Ax?

Tx?

A

Dx = PID

Ix = FBC, CRP, LFT (Fitz-Hugh Curtis), genital swabs

Ax = chlamydia, gonorrhoea, IUD, anaerobes

Tx = 14 days metronidazole + doxycycline, remove IUD

168
Q

complications PID?

A

infertility

chronic pelvic pain

ectopic pregnancy

169
Q

management acute PV bleed?

A

tranexamic acid + resus

170
Q

bartholin’s abscess Tx?

A

conservative

broad spectrum antibiotics

incision + drainage

171
Q

vaginismus?

A

Body’s automatic reaction to vaginal penetration - whenever penetration is attempted, vaginal muscles tighten on their own

172
Q

menopause?

A

no periods >12 months

173
Q

premature ovarian insufficiency?

early menopause?

A

POI = <40 y/o

early menopause = 40-44

174
Q

symptoms menopause

A

Mood swings

Night sweats

Hot flushes

Weight gain

Dry skin/hair

Aches and pains

Insomnia

Depression

Brain fog

Loss of sex drive

175
Q

Dx early menopause/atypical menopause?

A

FSH levels 2 x 6 weeks apart = indicated in women >45 with atypical symptoms, women 40-45 with menopausal symptoms

FSH, E2, TFT, glucose, prolactin, FAI = in women <40

check chromosomes and exclude autoimmune disorders in women <35

176
Q

Tx menopause?

A

HRT

lifestyle = phytooestrogens, regular exercise, no smoking, limit alcohol + caffeine

environmental = cool ambient temperature, intelligent fabrics, cooling scarf

non-hormonal Tx = black kohosh, sage, SSRIs/SNRIs

177
Q

benefits HRT?

risks?

contraindications?

A

benefits = symptom relief, reduces risk of osteoporosis + cardiovascular disease

risks = breast cancer, VTE, increased CVD>60 y/o

contraindications = history of breast cancer, coronary heart disease, TIA/stroke, unexplained vaginal bleeding, liver disease

178
Q

HRT principles

A
179
Q

POI Tx?

early menopause Tx?

A

POI <40

HRT til average age of menopause ~51

CHC continuously could be considered as alternative?

Continue with contraception

Early menopause 40-44

HRT til average age of menopause ~51

180
Q

indications for transdermal HRT?

benefits?

A

Individual preference

Poor symptom control with oral HRT

Increased VTE risk

High blood pressure

benefits = no associated risk of VTE, better for symptom control, less CVD risks

181
Q

side effects of COCP/HRT

A
182
Q

perimenopausal contraception?

A

Age <40 = continue contraception

Age 40-49 - contraception can be stopped:

2 years after last NATURAL period OR 2 years after 2 results of FSH > 30 IU/I taken 6 weeks apart

Age >50 contraception can be stopped:

1 year after last natural period OR 1 year after 1 result of FSH >30 IU/I

Age >55 contraception can be stopped even if still having periods

183
Q

vulvo-vaginal atrophy?

Tx?

A

complication of menopause

Tx = vaginal oestrogen (can be used in addition to HRT)

184
Q

how long must wait to test for chlamydia?

A

14 days following exposure (incubation period)

185
Q

Tx gonorrhoea?

A

1st line = ceftriaxone 1g IM

2nd line = cefixime 400mg oral plus azithromycin 2g (only if IM injection is contra-indicated or refused by patient)

186
Q

complications gonorrhoea?

A

lower genital tract = bartholinitis, tysonitis, periurethral abscess, rectal abscess, epididymitis, urethral stricture

upper genital tract = endometritis, PID, hydrosalpinx, infertility, ectopic pregnancy, prostatitis

187
Q

Behcet’s disease symptoms?

A

genital ulcers

mouth ulcers

red painful eyes + blurred vision

acne-like spots

headaches

painful swollen joints

188
Q

primary syphillis incubation period?

A

approx a month until chancre appears

189
Q

symptoms secondary syphillis?

A

Skin (macular, follicular or pustular rash on palms + soles)

Lesions of mucous membranes - SNAIL TRACK

Generalised lymphadenopathy

Fever, sore throat, malaise

Anterior uveitis

Cranial nerve lesions

Condylomata lata (most highly infectious lesion in syphilis, exudes a serum teeming with treponemes)

190
Q

Dx?

Tx?

A

HPV

Tx = podophyllotoxin, imiquimod, cryotherapy

191
Q

Meigs syndrome?

Tx?

A

Triad

Benign ovarian tumour (most common is ovarian fibroma)

+ Ascites

+ Pleural effusion

Tx = resolves after removal of tumour

192
Q

red flag symptoms ovarian cancer?

A

new onset IBS >50

Bloating

Early satiety

Reduced appetite

193
Q

Ix ovarian masses?

A

MRI in young women

Ca125 (>30), AFP, LDH, HCG

ovarian masses with low RMI = MRI (esp in young women)

high RMI = CT

194
Q

RMI score?

A

Ca125 x USS x menopausal status

<30 = low

30-200 = intermediate

>200 = ¾ chance

195
Q

smear test recall?

A
196
Q

smear test screening age?

A

24-65

every 5 years

197
Q

HPV vaccine?

A

6, 11, 16 + 18

198
Q

epithelium ectocervix?

endocervix?

transformation zone?

A

ecto = stratified squamous epithelium

endo = columnar epithelium

TZ = mix of columnar and squamous

199
Q

cervicitis?

Ax?

Dx?

complication?

A

inflammation of cervix

Ax - chlamydia, herpes

Dx = lymphocytes in cervix

coplication = can lead to infertility

200
Q

what increases risk of cervical cancer x3?

A

smoking!

201
Q

whats this?

A

Koilocytes = epithelial cells that have been infected by HPV

202
Q

whats this?

A

squamous cell carcinoma - keratin swirls

203
Q

time line HPV infection

A

HPV infection –> high grade CIN = 6 months - 3 years

High grade CIN → invasive cancer = 5-20 years

204
Q

CIN3?

A

carcinoma in situ

205
Q

CIN?

occurs where?

Dx?

S/s?

A

Pre-invasive stage of cervical cancer - dysplasia of squamous cells

Occurs at transformation zone

Not visible to naked eye - detectable by cervical screening

s/s = asymptomatic

206
Q

histology CIN?

A

Delay in maturation/differentiation - immature basal cells occupying large proportion of epithelium

Nuclear abnormalities = hyperchromasia (nucleus super dark), increased nucleocytoplasmic ratio (i.e. massive nucleus), pleomorphism (lots of variation in nuclear size and shape)

Excess mitotic activity i.e. above basal layers

Koilocytosis (indicating HPV infection) often present

207
Q

CIN 1 vs 2 vs 3?

when is it classed as carcinoma?

A

CIN1 = basal ⅓ of epithelium occupied by abnormal cells

CIN2 = abnormal cells extend to middle ⅓

CIN3 = abnormal cells occupy full thickness of epithelium

Even a single cell breaking through basement membrane makes it carcinoma

208
Q

cervical squamous cell carcinoma Ax?

S/s?

A

develops from pre-existing CIN

S/s

* post-coital/PMB/IMB

* pelvic pain

* haematuria/UTIs

* acute renal failure

209
Q

spread squamous cell carcinoma?

A
210
Q

is this SCC well-differentiated or poorly differentiated?

A

well-differentiated = keratin swirls

211
Q

Cervical glandular intraepithelial neoplasia (CGIN)?

A

pre-invasive phase of endocervical adenocarcinoma

212
Q

endocarvical adenocarcinoma?

precursor?

Epidemiology?

A

less common than SCC

precursor = CGIN

epidemiology = higher socioeconomic class, later onset sexual activity, smoking, HPV 18

213
Q

HPV driven diseases - other than CIN/SCC?

A

Vulvar intraepithelial neoplasia (VIN)

Vaginal intraepithelial neoplasia (VaIN)

Anal intraepithelial neoplasia (AIN)

214
Q

Types of Vulvar intraepithelial neoplasia (VIN)?

A

2 types

VIN of usual type - precursor of SCC (HPV-driven)

Differentiated VIN (dVIN) - precursor of vulval SCC but not associated with HPV

* higher risk of malignancy than HPV-driven!!

* often background inflammatory skin disease like lichen sclerosus

215
Q

vulvar invasive squamous carcinoma epidemiology?

S/s?

Ax?

most important prognostic factor?

Tx?

A

elderly women

s/s = ulcer

can arise from normal epihtelium or VIN

most important prognostic factor = spread to inguinal nodes

Tx = radical vulvectomy +/- inguinal lymphadenopathy

216
Q

vulvar paget’s disease s/s?

features?

Tx?

A

s/s = crusting rash (sharp demarcation), itchy, painful

tumour cells contain mucin - rarely cancerous

Tx = excision

217
Q

is ca125 specific to ovarian cancer?

A

absolutely not - can be raised in ovulation, pregnancy, endometriosis, fibroids, SLE, sarcoidosis, cirrhosis, pericarditis, pancreatitis

218
Q

when to suspect primary ovarian mass?

A

if Ca125:CEA >25

219
Q

AFP raised in?

HCG?

LDH?

A

Alpha foeto-protein - raised in yolk sac tumour

HCG - raised in choriocarcinoma

LDH - raised in dysgerminoma

220
Q

malignant features ovarian mass?

A

multiloculated

solid areas

bilateral

acites

metastasis

221
Q

endometriosis presentation?

examination?

A

Severe dysmenorrhoea/premenstrual pain

Dyspareunia (painful intercourse)

Associated with sub-fertility

Acute abdomen if ruptures

examination = tender

222
Q

Tx borderline ovarian tumours?

A

young women = unilateral oophrectomy/cystectomy

postmenopausal = pelvic clearance

223
Q

ovarian cancer Tx?

type of chemo?

A

1a cancer = surgery only

early stage = surgery followed by adjuvant chemo

advanced = neoadjuvant chemo followed by surgery

chemo = cisplatin + paclitaxel

224
Q

signet ring histology ovary?

A

Krukenberg tumour = metastasis from stomach

Ca125:CEA <25

225
Q

complex atypical endometrial hyperplasia?

A

precursor to endometrial carcinoma

226
Q

endometrial carcinoma epidemiology?

types?

A

peak 50-60 years

if <40, consider underlying condition e.g. PCOS or Lynch syndrome

2 types

* endometroid carcinoma = precursor is atypical hyperplasia

* serous carcinoma = precursor is serous intraepithelial carcinoma

227
Q

endometrial cancer presents with?

type 1 tumours?

type 2?

A

post-menopausal bleeding

Type 1 tumours (80%) = endometrioid + mucinous

* releated to oestrogen

* precursor = atypical hyperplasia

* associated with Lynch syndrome

Type 2 tumours = serous and clear cell

* not associated with ostrogen

* affect elderly women

* precursor = serous endometrial intraepithelial carcinoma

* TP53 mutation

* much more aggressive than type 1 tumours

228
Q

risk factors endometrial cancer?

A

obesity

PCOS

Lynch syndrome

229
Q

staging endometrial cancer?

Tx?

A

1a = <50% of myometrium

1b = >50% myometrium (completely within myometrium)

2 = extends to cervix

3a = serosa of uterus or adnexae

3b = invades vagina

3c = para-aortic lymph nodes

4 = bladder/bowel + distant metastases

Tx = hysterectomy + chemo/radiotherapy

230
Q

grading endometrial carcinoma?

A

Grade 1 = <5% solid growth

Grade 2 = 6-50% solid growth

Grade 3 = >50% solid growth

231
Q

most common uterine sarcoma?

s/s?

A

leiomyosarcoma

s/s = abnormal vaginal bleeding, palpable pelvic mass, pelvic pain

3rd year medicine (13 decks)

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