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
DUB subdivisions
26
Ix DUB?
**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)
27
Tx DUB?
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)
28
infertility definition? main causes?
Inability to conceive after 12 months regular intercourse without contraception Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%)
29
advice for conception?
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)
30
blood tests for infertility?
**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)
31
PCOS blood results?
elevated LH hyperprolactinaemia
32
what is the most accurate marker of ovarian reserve?
anti-mullerian hormone (high levels = good)
33
non-blood test Ix for infertility?
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**
34
Tx anovulation?
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
35
Tx tubal factors infertility?
tubal cannulation during HSG laparoscopy to remove adhesions or endometriosis IVF
36
Tx uterine factors infertility?
surgery to remove polyps, adhesions, structural abnrmalities
37
normal semen parameters nomenclature?
Sperm conc should be \>15 Motility \>32 Morphology \>4
38
Tx sperm problems infertility?
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
39
ART eligibility?
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
40
complications of IVF?
Failure Multiple pregnancy Ectopic pregnancy **Ovarian hyperstimulation syndrome**
41
ovarian hyperstimulation syndrome s/s?
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)
42
Tx OHSS?
oral fluids monitor urine output (hypovolaemia) LMWH (to prevent DVT/PE) paracentesis if req IV colloids (albumin)
43
types of miscarriage
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
44
miscarriage symptoms? Dx?
positive UPT bleeding primary symptom (more than cramps) **Dx = TVUS 1st line for diagnosiing miscarriage**
45
things to look for in TVUS miscarriage?
**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**
46
speculum exam to assess stage of miscarriage?
Is the os closed? (threatened miscarriage) Open? (inevitable miscarriage) Products already in vagina and os is closed? (complete miscarriage)
47
RPOC complications? symptoms? Tx?
**cervical shock** \* cramps \* nausea/vomiting \* collapse \* sweating **resolves if products removed from cervix** \* resus with IV fluids \* uterotonics may be required
48
Ax miscarriage?
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
49
signs of miscarriage on TVUS anemebryonic pregnancy?
miscarriage = no heartbeat + foetal pole \>7mm anamebryonic = gestational sac \>25mm, no foetal pole
50
management of miscarriage \<6 weeks gestation?
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
51
management of miscarriage \>6 weeks gestation?
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)
52
misoprostol? S/E?
prostaglandin analogue (used for medical management miscarriage) \* heavier bleeding \* pain \* vomiting \* diarrhoea
53
important to remember surgical management miscarriage?
anti-rhesus D for rhesus neg women!!
54
recurrent miscarriage? Ax?
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**
55
APS? Tx?
anti-phospholipid antibodies, hypercoagulable state associated with **thrombosis** and **recurrent miscarriage** Tx = LDA + LMWH (check for past medical history of DVT)
56
common hereditary thrombophillias? comps?
factor V Leiden (most common) factor II (prothrombin) protein S deficiency recurrent miscarriage
57
Ix recurrent miscarriage? Tx?
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
58
incomplete miscarriage? Tx?
RRPOC remain in uterus after miscarriage = **risk of infection!!** Tx = medical (**misoprostol**) or surgical management
59
most common site ectopic? other sites? risk factors?
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**
60
s/s ectopic pregnancy?
**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)**
61
ectopic pregnancy Ix?
FBC, BHCG (levels should not double) **TVUS gold standard for ectopic!!** - blob sign, tubal ring sign
62
pregnancy of unknown location?
basically ectopic but not visible on USS
63
Tx ectopic pregnancy?
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)
64
methotrexate ectopic S/E? remember to advise?
vaginal bleeding, nausea + vom, abdominal pain, **stomatitis (inflammation of mouth)** woman advised not to get pregnant for 3 months (teratogenic)
65
presentation PUL? Dx? Tx?
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**
66
molar pregnancy s/s? Dx? Tx?
**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
67
implantation bleeding?
common, occurs approx 10 days post-ovulation (once egg implanted in endometrium)
68
chorionic haematoma? s/s? Tx?
Pooling of blood between endometrium and embryo due to separation S/s = bleeding, cramping, threatened miscarriage Tx = usually self-limiting and resolve
69
cervical causes of bleeding in early pregnancy?
**ectropion** Infections - chlamydia, gonococcus Malignancy (very rare)
70
vaginal causes of bleeding in early pregnancy? Tx?
Infections = trichomoniasis (strawberry vagina), bacterial vaginosis, chlamydia Malignancy - ulcers, rare Forgotten tampon BV + trich = metronidazole chlamydia = erythromycin/amxocicillin (**CANNOY give doxycycline in pregnancy**)
71
DDx pain in pregnancy?
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
72
when is anti-D given?
28 weeks and after any sensitising event
73
hyperemesis gravidarum? complications? Dx? Tx?
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**
74
complication metoclopramide? Tx?
oculogyric crisis tx = atropine
75
types urinary incontinence? risk factors?
Stress incontinence Urge incontinence Mixed incontinence Overflow incontinence risk factors = women, older, obesity, smoking, kidney disease, diabetes
76
overactive bladder syndrome?
**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
77
mixed urinary incontinince?
urgency + stress incontinence (coughing, sneezing)
78
exam urinary incontinence?
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
79
Tx ladder OAB?
bladder drill **oxybutynin** (antimuscarinic) botox surgery when antimuscarinics contraindicated = **mirabegron** (B3 receptor agonist)
80
lifestyke advice urinary incontinence?
weigtht loss stop smoking reduce caffeine
81
S/E antimuscarinics e.g. oxybutynin?
Dry mouth Constipation Blurred vision Somnolence (type of anticholinergic)
82
clinical Ix urinary incontinence?
cystometry post residual (abnormal \>150) urinalysis
83
overflow incontinence Ax? Dx? Tx?
Ax = obstruction of urethra (prostate), poor contractile bladder muscle Dx = PVR Tx = **stop anticholinergics** alpha-blocker for BPH
84
Tx SUI?
Weight loss, smoking, reduce caffeine, avoid excessive fluid intake **Physio - pelvic floor** Pessaries **Drugs - duloxetine** surgical = vaginal tape, injections, obturator appraoch
85
pelvic prolapse compartments?
anterior = cystocele middle/apical = uterine/enterocele posterior = rectocele
86
classification uterovaginal prolapse?
1st degree = in vagina 2nd degree = at interoitus 3rd degree = outside vagina 4th = procidentia (entirely outside vagina)
87
cystocele s/s? uterine/enterocele? rectocele?
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**
88
POP-Q?
Pelvic organ prolapse quantification system (POP-Q) If site is above hymen - assigned negative number If site prolapses below hymen - assigned positive number
89
risk factors vaginal prolapse?
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
90
Tx vaginal prolapse?
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
91
prevention of ovulation? prevention of fertilsation? prevention of implantation?
ovulation = COCP, depo povera, implant, ring, patch. mini pill fertilisation = IUD/IUS, POP + barrier methods implantation = IUD (secondary action)
92
copper coil? use? S/E?
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)
93
IUS? use? S/E?
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
Nexplanon? lasts how long? main side effect?
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
how to take COCP
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
risks of COCP?
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
absolute contraindications COCP? relative contraindications?
migraine with aura (**sparkles are not an aur****a**) breast cancer history of DVT/PE liver disease relative = smoking, \>35, hypertension, breastfeeding
98
1st line Tx PCOS?
COCP
99
s/s COCP?
Nausea Spots (can worsen acne in some people) Bleeding Breast tenderness
100
POP? mechanism of action? how to take?
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
when is implant/DMPA effective?
immediately if day 1-5 of period if any other time - condoms for 7 days
102
contraindications of POP and nexplanon?
breast cancer
103
missed POP guidance?
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
depo provera/sayana press? mechanism? benefit? Side effects?
injection suppresses ovulation benefit = isnt affected by enzyme inducing drugs S/E = **weight gain**, nausea, spots, bleeding, headaches, **osteoporosis**
105
diaphragm use?
Must leave for at least 6 hours after sex
106
sterilisation techniques?
vasectomy + tubal ligation
107
when can you not give ellaone? instead? when is this effective?
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
how long after ellaone can you begin taking POP?
5 days after
109
copper coil mechanism of action?
prevents fertilsation
110
ellaone v levonelle
ellaone= 5 days post intercourse levonella = 3 days
111
normal vaginal flora? normal ph?
**lactobacillus (gram +ve rods)** other organisms = GBS, candida, strep viridans normal pH = acidic (4-4.5)
112
candida infection Ax? risk factors? S/s? Dx? Tx?
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
typical "spotty" appearance of candida balantitis
114
purulent discharge typical of gonorrhoea infection
115
gonorrhoea gram stain appearance?
gram -ve intracellular diplococci
116
where does gonorrhoea infect? Dx? Tx?
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
chlamydia infects? gram appearance? serological groupings? Tx?
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
LGV? S/s?
chlamydia infection painless genital lesion + regional lymphadenopathy painful bowel movements (or painful anal sex) bloody stools
119
NAATs? how are they taken?
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
Trichomonas vaginalis? transmission? S/s? Dx? Tx?
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
bacterial vaginosis? Dx? Tx? complications BV?
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
syphillis Ax? stages? Dx? Tx?
**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
Tx syphillis?
early syphillis IM benzylpenicillin single dose (if allergic = doxycycline/erythromycin 14 days) late syphillis IM benzylpenicillin (2 doses) allergic = doxycycline 28 days
124
Dx? Tx?
genital herpes (HSV2) Tx = aciclovir
125
Tx pubic lice (pthirus pubis)
malathion lotion
126
abortion legal til? management after 20 weeks?
Abortion is legal up to 24 weeks \>20 weeks = purely surgical
127
what has to be completed for every abortion in UK?
**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
conscientious objection abortion?
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
when is uterus palpable?
12 weeks
130
medical abortion? timing?
**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
early medical abortion at home?
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
surgical abortion available until? types?
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
complications of abortion?
haemorrhage failed/incomplete abortion infection uterine perforation (surgical risk only) cervical trauma (surgical risk only) - reduced with cervical ripening (misoprostol)
134
prophylaxis at time of abortion to reduce complications?
antibiotics (7 days doxycycline + 2days azithroycin) rhesus anti-D VTE prophylaxis - LMWH if smoker, BMI, previous embolus
135
contraception after abortion?
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
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IUD after abortion? COCP/POP?
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
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follow-up abortion?
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
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history STI?
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
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standard STI screen?
chlamydia, gonorrhoea, HIV, syphillis
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HIV? pathophys? CD4 level to aim for?
RNA retrovirus attacks helper T cells CD4 \>500
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HIV symptoms?
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
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most important oppurtunistic infection HIV? organism? CD4 threshold? S/s? Dx? Tx? Prophylaxis?
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
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cerebral toxoplasmosis Ax? CD4 threshold? S/s? Dx? Tx?
toxoplasma gondii CD4 \<150 S/s: **cerebral abscesses, chorioretinitis**, headache, fever, focal neurology, **seizures**, raised ICP Dx = MRI (cerebral abscesses) Tx = co-trimoxaxole?
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CMV CD4? complications? symptoms? screening?
CD4 \<150 causes **retinitis, colitis + oesophagitis** S/s = vision loss, floaters, abdominal pain, diarrhoea, PR bleeding opthalmic screening for all individuals CD4 \<50
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HIV-induced neurocognitive imapirment? Dx?
reduced short term memory + motor dysfucntion Dx = MRI (enlarged ventricles + deep sulci i.e. **atrophy**)
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progressive multifocal leukoencephalopathy (PML) Ax? CD4? S/s?
organism = JC virus CD4 \<100 S/s = rapid!!, focal neurology, confusion, **personality change**
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skin infections HIV?
herpes zoster = mutlidermatomal, recurrent herpes simplex = extensive ulceration, tumour-like, **aciclovir resistant** HPV = extensive + resistant to Tx
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AIDS oppurtunistic infections?
PCP Tuberculosis cerebral toxoplasmosis CMV progressive multifocal leukoencephalopathy
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HIV associated wasting? Ax?
Slim's disease Ax = chronic immune activation, anorexia, malabsoprtion/diarrhoea (CMV)
150
AIDS-related cancers?
Kaposi's sarcoma non-Hodgkin's lymphoma (Burkitts) cervical cancer
151
Kaposi's sarcoma Ax? S/s? Tx?
organism = human herpes virus 8 (HHV8) S/s = cutaneous lesions, mucosal lesions, visceral lesions Tx = **anti-retrovirals**, liquid nitrogen, systemic chemo
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Burkitt's lymphoma Ax? Type of cancer? S/s? Tx?
Ax = EBV non-Hodgkins lymphoma (AIDS-related) S/s = B symptoms (weight loss, night sweats, fever), bone marrow involvement, CNS involvement Tx = **antiretrovirals**
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non-AIDS symptomatic HIV?
Mucosal candidiasis Seborrhoeic dermatitis Diarrhoea Fatigue Worsening psoriasis Lymphadenopathy Parotitis Neuroligcal presentations = polyneurpathy, monenuritis multiplex, aseptic meningitis Haematological = leukolymphopenias, thrombocytopenia
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transmission HIV?
sexual contact injected drugs infected blood products mother to child
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high prevelance areas HIV?
Sub-saharan africa Caribbean Thailand
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Lab markers HIV?
Viral RNA is first marker to become positive Second is **p24 protein** Antibody can take **3 months** to become detectable in blood
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types antiretroviral drugs? HAART?
Reverse transcriptase inhibitors Integrase inhibitors Protease inhibitors Entry inhibitors HAART example = Atripla
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prognosis HIV?
life expectancy with treatment essentially normal
159
HAART toxicity?
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
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post-exposure prophylaxis HIV?
**within 72 hours** antiretroviral Tx for 4 weeks e.g. **tenofevir**
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prevention of mother to child transmission HIV?
HAART during pregnancy c-section if detected viral load 2-4 weeks antiretroviral for neonate **exclusive formula feeding**
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Dx? Ix? Tx?
Extopic pregnancy Ix = **TVUS gold standard**, FBC, G+S Tx = **laparoscopic salpingectomy**
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Dx? on USS, see cyst
likely ovarian torsion
164
ovarian torsion Ax? premenopausal vs postmenopausal Tx ovarian torsion?
Ax = **dermoid cyst** (any cyst \>5cm really) premenopausal = likely benign postmenopausal = likely malignant Tx = deterosion, oophrectomy
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rebound + guarding Rovsing's positive
Dx = appendicitis
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Dx? Ix? Ax? Tx?
classic presentation cyst rupture Ix = FBC, CRP, G+S, USS Ax = can be spontaneous, or after sex/trauma Tx = conservative, stop bleeding, resus
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Dx? Ix? Ax? Tx?
Dx = PID Ix = FBC, CRP, LFT (Fitz-Hugh Curtis), genital swabs Ax = chlamydia, gonorrhoea, IUD, anaerobes Tx = 14 days metronidazole + doxycycline, remove IUD
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complications PID?
infertility chronic pelvic pain ectopic pregnancy
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management acute PV bleed?
tranexamic acid + resus
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bartholin's abscess Tx?
conservative broad spectrum antibiotics incision + drainage
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vaginismus?
Body’s automatic reaction to vaginal penetration - whenever penetration is attempted, vaginal muscles tighten on their own
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menopause?
no periods \>12 months
173
premature ovarian insufficiency? early menopause?
POI = \<40 y/o early menopause = 40-44
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symptoms menopause
Mood swings Night sweats Hot flushes Weight gain Dry skin/hair Aches and pains Insomnia Depression Brain fog Loss of sex drive
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Dx early menopause/atypical menopause?
**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
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Tx menopause?
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
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benefits HRT? risks? contraindications?
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
HRT principles
179
POI Tx? early menopause Tx?
**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
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indications for **transdermal** HRT? benefits?
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
side effects of COCP/HRT
182
perimenopausal contraception?
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
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vulvo-vaginal atrophy? Tx?
complication of menopause Tx = **vaginal oestrogen** (can be used in addition to HRT)
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how long must wait to test for chlamydia?
14 days following exposure (incubation period)
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Tx gonorrhoea?
1st line = ceftriaxone 1g IM 2nd line = cefixime 400mg oral plus azithromycin 2g (only if IM injection is contra-indicated or refused by patient)
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complications gonorrhoea?
lower genital tract = bartholinitis, tysonitis, periurethral abscess, rectal abscess, epididymitis, urethral stricture upper genital tract = endometritis, PID, hydrosalpinx, infertility, ectopic pregnancy, prostatitis
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Behcet's disease symptoms?
genital ulcers mouth ulcers red painful eyes + blurred vision acne-like spots headaches painful swollen joints
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primary syphillis incubation period?
approx a month until chancre appears
189
symptoms secondary syphillis?
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
Dx? Tx?
HPV Tx = podophyllotoxin, imiquimod, cryotherapy
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Meigs syndrome? Tx?
**Triad** Benign ovarian tumour (most common is ovarian fibroma) + Ascites + Pleural effusion Tx = resolves after removal of tumour
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red flag symptoms ovarian cancer?
new onset IBS \>50 Bloating Early satiety Reduced appetite
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Ix ovarian masses?
**MRI in young women** Ca125 (\>30), AFP, LDH, HCG ovarian masses with low RMI = MRI (esp in young women) high RMI = CT
194
RMI score?
**Ca125 x USS x menopausal status** \<30 = low 30-200 = intermediate \>200 = ¾ chance
195
smear test recall?
196
smear test screening age?
24-65 every 5 years
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HPV vaccine?
6, 11, 16 + 18
198
epithelium ectocervix? endocervix? transformation zone?
ecto = stratified squamous epithelium endo = columnar epithelium TZ = mix of columnar and squamous
199
cervicitis? Ax? Dx? complication?
inflammation of cervix Ax - chlamydia, herpes Dx = lymphocytes in cervix coplication = **can lead to infertility**
200
what increases risk of cervical cancer x3?
smoking!
201
whats this?
Koilocytes = epithelial cells that have been infected by HPV
202
whats this?
squamous cell carcinoma - keratin swirls
203
time line HPV infection
HPV infection --\> high grade CIN = 6 months - 3 years High grade CIN → invasive cancer = 5-20 years
204
CIN3?
carcinoma in situ
205
CIN? occurs where? Dx? S/s?
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
histology CIN?
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
CIN 1 vs 2 vs 3? when is it classed as carcinoma?
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
cervical squamous cell carcinoma Ax? S/s?
develops from pre-existing CIN S/s \* post-coital/PMB/IMB \* pelvic pain \* haematuria/UTIs \* acute renal failure
209
spread squamous cell carcinoma?
210
is this SCC well-differentiated or poorly differentiated?
well-differentiated = keratin swirls
211
Cervical glandular intraepithelial neoplasia (CGIN)?
pre-invasive phase of endocervical **adenocarcinoma**
212
endocarvical adenocarcinoma? precursor? Epidemiology?
less common than SCC precursor = CGIN epidemiology = higher socioeconomic class, later onset sexual activity, smoking, **HPV 18**
213
HPV driven diseases - other than CIN/SCC?
Vulvar intraepithelial neoplasia (VIN) Vaginal intraepithelial neoplasia (VaIN) Anal intraepithelial neoplasia (AIN)
214
Types of Vulvar intraepithelial neoplasia (VIN)?
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
vulvar invasive squamous carcinoma epidemiology? S/s? Ax? most important prognostic factor? Tx?
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
vulvar paget's disease s/s? features? Tx?
s/s = crusting rash (sharp demarcation), itchy, painful tumour cells contain mucin - **rarely cancerous** Tx = excision
217
is ca125 specific to ovarian cancer?
absolutely not - can be raised in ovulation, pregnancy, endometriosis, fibroids, SLE, sarcoidosis, cirrhosis, pericarditis, pancreatitis
218
when to suspect primary ovarian mass?
if Ca125:CEA \>25
219
AFP raised in? HCG? LDH?
Alpha foeto-protein - raised in yolk sac tumour HCG - raised in choriocarcinoma LDH - raised in dysgerminoma
220
malignant features ovarian mass?
multiloculated solid areas bilateral acites metastasis
221
endometriosis presentation? examination?
Severe dysmenorrhoea/premenstrual pain Dyspareunia (painful intercourse) Associated with sub-fertility Acute abdomen if ruptures examination = tender
222
Tx borderline ovarian tumours?
young women = unilateral oophrectomy/cystectomy postmenopausal = pelvic clearance
223
ovarian cancer Tx? type of chemo?
1a cancer = surgery only early stage = surgery followed by adjuvant chemo advanced = neoadjuvant chemo followed by surgery chemo = cisplatin + paclitaxel
224
signet ring histology ovary?
Krukenberg tumour = metastasis from stomach Ca125:CEA \<25
225
complex atypical endometrial hyperplasia?
precursor to endometrial carcinoma
226
endometrial carcinoma epidemiology? types?
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
endometrial cancer presents with? type 1 tumours? type 2?
post-menopausal bleeding Type 1 tumours (80%) = endometrioid + mucinous \* releated to **oestrogen** \* precursor = **atypical hyperplasia** \* associated with **L****ynch 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
risk factors endometrial cancer?
obesity PCOS Lynch syndrome
229
staging endometrial cancer? Tx?
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
grading endometrial carcinoma?
Grade 1 = \<5% solid growth Grade 2 = 6-50% solid growth Grade 3 = \>50% solid growth
231
most common uterine sarcoma? s/s?
leiomyosarcoma s/s = abnormal vaginal bleeding, palpable pelvic mass, pelvic pain