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4MB Medicine > Reproduction & Gynaecology > Flashcards

Reproduction & Gynaecology Flashcards

1
Q

Define primary amenorrhoea

A

Failure to have a period before age of 16

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2
Q

List aetiology/risk factors for primary amenorrhoea

A

Delayed puberty
Familial
Turner syndrome
Testicular feminisation

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3
Q

Define secondary amenorrhoea

A

Not had a period in 6 months in someone who previously has had a period

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4
Q

List aetiology/risk factors for secondary amenorrhoea

A 
HPO axis dysfunction (emotions, stress, weight loss/anorexia, high prolactin, pituitary tumour, Sheehan syndrome)
Polycystic ovarian syndrome
Ovarian tumours
Ovarian failure
Asherman syndrome (uterine adhesions following D+C)
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5
Q

What investigations would you do for secondary amenorrhoea?

A 
FSH (raised in premature ovarian failure)
LH, testosterone (raised in PCOS)
Prolactin
Thyroid function
MRI pituitary
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6
Q

Outline management of secondary amenorrhoea

A

Treat cause
GnRH injections
HRT
In vitro fertilisation/oocyte donation if wanting pregnancy

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7
Q

What is menorrhagia?

A

Increased menstrual blood loss (over 80ml per cycle) with prolonged menstrual flow

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8
Q

List local aetiology/risk factors for menorrhagia

A 
Anovulatory disorder
Adenomyosis
Polyps/fibroids
Malignancy
Pelvic inflammation
Endometriosis
Intrauterine contraception
Trauma
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9
Q

List systemic aetiology/risk factors for menorrhagia

A 
Hypothyroidism
Diabetes
Blood dyscrasia (vWD)
Anticoagulants
Dysfunctional uterine bleeding
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10
Q

What investigations would you do for menorrhagia?

A 
FBC
Thyroid function
Clotting studies
Renal and liver function
Transvaginal USS +/- endometrial biopsy (pipelle, hysteroscopy, D+C)
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11
Q

Outline management of menorrhagia

A

IUS 1st line if wanting contraception/no pregnancy
Antifibrinolytic (tranexamic acid)
Antiprostaglandin (mefenamic acid)
IM progestogen (northisterone)
Surgery (endometrial ablation, uterine artery ablation, hysterectomy)

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12
Q

What is dysmenorrhoea?

A

Painful periods with/without nausea or vomiting

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13
Q

Describe “primary” dysmenorrhoea

A

Painful periods in absence of organ pathology, often associated with anovulation
Occurs earlier in life
Crampy, back/groin ache, worse on days 1-3

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14
Q

Describe “secondary” dysmenorrhoea

A

Painful periods with associated pathology (fibroids, adenomyosis, endometriosis, PID, sepsis)
More constant pain, pain during sex

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15
Q

List aetiology/risk factors for intermenstrual bleeding

A 
Cervical polyps
Ectropion
Carcinoma (endometrial, cervical)
Vaginitis
IUD
"spotting" from hormonal contraception
Pregnancy
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16
Q

List aetiology/risk factors for post-coital bleeding

A 
Cervical trauma
Polyps
Carcinoma (endometrial, cervical, vaginal)
Cervicitis, vaginitis
Chlamydia
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17
Q

List aetiology/risk factors for post-menopausal bleeding

A 
Endometrial carcinoma
Vaginitis
Foreign bodies (pessaries)
Cervical/vulval carcinoma
Polyps
Oestrogen withdrawal
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18
Q

What is the most common ovulatory disorder?

A

Polycystic ovarian syndrome (PCOS)

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19
Q

List clinical features of PCOS

A 
Acne
Male-pattern baldness
Hirsutism
Acanthosis nigricans
Infertility
Insulin resistance
Central obesity
Amenorrhoea
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20
Q

What is the Rotterdam criteria for diagnosing PCOS?

A

2 of
Menstrual disturbance
12+ 9mm cysts on USS
Hyperandrogenism

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21
Q

What would hormone levels be like in PCOS?

A

Raised LH:FSH ratio
Raised testosterone
May have raised prolactin

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22
Q

Outline management of PCOS

A

Smoking cessation, weight loss
Treat diabetes/hypertension/hyperlipidemia
Metformin if insulin resistant esp if BMI over 25
Check for rubella immunity
Ovulation induction if wanting to conceive (clomifene, tamoxifen, gonadotropin injfections, laparoscopic ovarian drilling)

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23
Q

What is premenstrual syndrome?

A

Premenstrual change in mood or physical state

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24
Q

List clinical features of premenstrual syndrome

A 
Tension, irritability
Depression
Bloating
Breast tenderness
Carb craving
Headache
Reduced libido
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25
Q

Outline management of premenstrual syndrome

A

Support, psych counselling/CBT, family therapy
Stress and relaxation techniques
Pyridoxine may improve mood
COCP
Fluoxetine
If cyclical mastalgia: reduce saturated fats, bromocriptine, danazol

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26
Q

What is menopause?

A

Cessation of menstrual periods following climacteric period (1 year of amenorrhoea)

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27
Q

Define premature, early and late menopause

A

Premature: before age of 40
Early: before age of 45
Late: after age of 54

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28
Q

List clinical features of menopause

A 
Menstrual irregularity
Sweats, hot flushes
Palpitations
Insomnia
Joint ache
Vaginal dryness
Low libido
Mood swings
Anxiety
Bleeding
Late symptoms (frequency, dry hair/skin, breast atrophy, osteoporosis)
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29
Q

What would you find on investigations for menopause?

A

Low oestrogen

High FSH and LH

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30
Q

Outline conservative management of menopause and medications used for menorrhagia

A 
Reduce caffeine, weight loss
Wear lighter clothes
Oestrogen if vaginal dryness
Mefenamic acid to reduce uterine blood flow
Tranexamic acid to reduce clots
Progesterone injections
IUS if wanting contraception
Endometrial ablation
Hysterectomy
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31
Q

Outline HRT management for menopause

A

Cyclical if perimenopausal, continuous if postmenopausal
Oestrogen-only if had hysterectomy, otherwise combined oestrogen-progesterone
Start if greater than 1 year since last menstrual period

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32
Q

List contraindications to HRT

A 
Oestrogen-dependent cancer
Undiagnosed PV bleeding
Abnormal LFT's
Pregnancy
Breastfeeding
Phlebitis
History of PE
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33
Q

List side effects of HRT

A 
Weight gain
Premenstrual syndrome
VTE
Breast cancer
Ovarian cancer
Gallbladder disease
Increased risk of CV event after 10 years
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34
Q

What is the typical gestation cut-off for termination of pregnancy?

A

24 weeks

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35
Q

State the criteria of the Abortion Act, A-F, for termination of pregnancy

A

A: risk to mother’s life if pregnancy continues
B: termination necessary to prevent grave injury to health of the woman
C: continuance risks injury to health of woman, foetus is less than 24w
D: continuance risks injury to health of existing children, foetus is less than 24w
E: risk of child being seriously handicapped or suffer physical/mental abnormality
F: emergency termination necessary to prevent grave injury

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36
Q

What investigations would you do for termination of pregnancy?

A 
Counselling to make sure of patient's decision
Pregnancy test
USS, fundal height
Screen for STI (Chlamydia)
Discuss future contraception
Check rhesus status
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37
Q

Outline medical management of termination of pregnancy

A 
Oral mifepristone (disimplant foetus) + PV misoprostol (expulsion) 48h later
Misoprostol may be done at home if early termination
If late, give misoprostol every 3h up to maximum of 5 in 24h
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38
Q

Outline surgical management of termination of pregnancy

A 
If 6-12w
Vacuum aspiration
D&C
Prime with misoprostol
Warn about future risk of miscarriage, failure, haemorrhage, infection, uterine rupture/perforation
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39
Q

Describe the different types of miscarriage

A

Threatened: bleeding, no product, closed os, continued pregnancy
Inevitable: bleeding, visible products, open os
Complete: bleed, product in vagina, closed os
Missed: pregnancy in-situ but no foetal heartbeat

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40
Q

List aetiology/risk factors for miscarriage

A 
PCOS
Low progesterone
Bacterial vaginosis
Familial
Abnormal uterus
Antiphospholipid syndrome
Thrombophilia
Alloimmunity
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41
Q

What investigations would you do for miscarriage?

A

US scan
Speculum/PV exam
FBC, BHCG levels

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42
Q

Outline management of miscarriage

A

Emotional support
Treat haemodynamic compromise
Largely conservative
Misoprostol may be used to expel products

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43
Q

What is ectopic pregnancy?

A

Implantation occurs outwith uterus, usually in ampulla of fallopian tube

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44
Q

List aetiology/risk factors for ectopic pregnancy

A 
Salpingitis
Previous surgery
Previous ectopic
Endometriosis
Old IUCD
POP use
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45
Q

List clinical features of ectopic pregnancy

A 
Abdo pain
Bleeding
Peritonism
Shoulder tip pain
Fainting
Pallor
Nausea, vomiting
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46
Q

What investigations would you do for ectopic pregnancy?

A

FBC, U+E, glucose
BHCG levels (double after 48h)
US scan

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47
Q

Outline management of ectopic pregnancy

A

Laparotomy if in shock/unstable, otherwise laporoscopy
+/- salpingectomy
Methotrexate for small early ectopic with low BHCG
Expectant management

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48
Q

What happens in gestational trophoblastic disease?

A

Non-viable trophoblastic tissue forms from fertilised ovum i.e. no foetus
Usually genetically paternal but has 46XX karyotype

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49
Q

What are “complete” and “partial” hydatidiform moles?

A

Complete: egg without DNA fertilised, no foetus results
Partial: haploid egg fertilised, triploidy, may have foetus

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50
Q

List aetiology/risk factors for hydatidiform mole

A

Extremes of child-bearing age
Previous mole
Non-Caucasians

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51
Q

List clinical features of hydatidiform mole

A 
Early miscarriage
Pass "grape-like" clusters
Hyperemesis
Bleeding
Dyspnoea
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52
Q

What would investigations show in hydatidiform mole?

A

USS snowstorm appearance
Appears large for dates
Increased bHCG

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53
Q

Outline management of hydatidiform mole

A

Suction removal
Avoid pregnancy for 1 year
Monitor bHCG

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54
Q

What is chorionic haematoma?

A

Pooling of blood between endometrium and embyro

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55
Q

When is a couple infertility defined as being infertile?

A

Inability to achieve pregnancy after 12 hours of UPSI

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56
Q

List aetiology/risk factors for infertility

A

Male: low quality sperm, varicocele, obstruction
Female: anovulation, tubal damage/failure of egg and sperm to meet, endometriosis
Altered mood
Infections
Poor sexual technique
Infrequent UPSI

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57
Q

What investigations would you do for infertility?

A 
Examine both genitalia, abdomen, pelvis
Mestrual and sexual history
Rubella check, STI screen
Hormone levels (mid-luteal progesterone, day 5 FSH/LH, thyroid, prolactin)
MRI pituitary
Hysterosalpingogram
Semen analysis
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58
Q

Outline management of infertility

A

Lifestyle: intercourse 2-3x/w, stop smoking, reduce alcohol, BMI less than 30
Treat hormonal causes
Assisted fertilisation

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59
Q

List the main assisted fertilisation techniques used for infertilitiy

A 
Donor sperm insemination
ICSI (inject sperm into egg)
Sperm aspirate + ICSI
IUI (inseminate uterus)
IVF
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60
Q

List some side effects of IVF

A 
Multiple birth
Pre-eclampsia
Pregnancy-induced hypertension
Genetic defects
Low birthweight
Prematurity
Perinatal mortality
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61
Q

List aetiology/risk factors for male infertility

A 
Idiopathic oligo/azoospermia
Teratozoospermia
Non-obstructive (cryptorchidism, radiation, tumour, cannabis, Klinefelter's)
Obstructive (CF, infection, vasectomy)
Pituitary tumour
Steroid use
Cushing's syndrome
Congenital adrenal hyperplasia
Androgen insensitivity
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62
Q

List clinical features of male infertility

A 
Reduced testicular volume (less than 15ml)
Loss of secondary sexual characteristics
Gynaecomastia
Scrotal swelling
Prostatitis
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63
Q

What would you analyse/look for from normal semen for male infertility?

A 
Volume (norm over 2ml)
Count (over 20 million per ml)
Greater than 50% motility
Greater than 30% normal morphology
Examine 2 specimens preferably 3 months apart, transferred fresh and avoiding temp less than 15 or greater than 38
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64
Q

What investigations other than semen analysis would you do for male infertility?

A

Plasma FSH to distinguish from 1’ and 2’ testicular failure
Testosterone, LH levels
Testicular biopsy
Scrotal scan

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65
Q

Outline management of male infertility

A 
Avoid lubricants, tight pants, hot baths/saunas
IUI (25% successful)
ICSI (30% successful)
Sperm aspirate (up to 95% successful)
Donor sperm
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66
Q

List some natural methods of contraception/estimating fertility

A

Fertile 6 days prior to and 2 days after ovulation
Cervical mucus clear + sticky when fertile, dry at ovulation, thick when non-fertile
Basal body temp rises by 0.3’C after ovulation
Hormone levels (day 21 progesterone)
High soft open cervix when fertile, low firm closed cervix when infertile
Breastfeeding (exclusively, less than 6/12 postnatal, amenorrhoeic)

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67
Q

List the main long-acting contraception methods used

A

Depo injection
Implant
IUD, IUS
Sterilisation

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68
Q

How does the Depo injection work?

A

Releases synthetic progesterone
Inhibits ovulation, thickens cervical mucus, thins endometrium
Injected every 12 weeks

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69
Q

When should the Depo injection be started?

A

Start day 1-5 of cycle

Beyond day 5, use condoms for 7 days prior to start

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70
Q

List some contraindications of Depo injection

A

Pregnancy
Undiagnosed PV bleed
Liver disease
Cardiac disease

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71
Q

List side effects of Depo injection

A

Increased appetite and weight
Delayed return to fertility
Osteoporosis
Irregular bleeding

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72
Q

How does the implant work?

A

Subdermal rod contains progesterone
Inhibits ovulation, thickens cervical mucus, thins endometrium
Surgically inserted 8mm above medial epicondyle of elbow
Lasts up to 3 years

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73
Q

When should the implant be started?

A

Start day 1-5
On or before day 21 if post-partum
Beyond day 5, use condoms for 7 days prior

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74
Q

List some contraindications to the implant

A

Heart disease/stroke
Unexplained PV bleeding
Past breast cancer
Liver disease (cirrhosis, cancer)

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75
Q

List side effects of the implant

A

Irregular, heavy periods
Weight gain
Acne

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76
Q

How does the IUD work?

A

Intrauterine copper coil toxic to sperm
Prevents fertilisation, creases endometrial inflammation
Lasts 5-10 years

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77
Q

When should the IUD be started?

A

Start day 1-7

Beyond day 7, start as long as certain not pregnant

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78
Q

List some contraindications to the IUD and IUS

A

Pelvic infection
Abnormal uterine anatomy
Molar pregnancy
Cancer/undiagnosed PV bleed

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79
Q

List side effects of the IUD

A 
Heavy periods
Pain
Discomfort on insertion
Expulsion
Perforation
STI
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80
Q

How does the IUS work?

A

T-shaped intrauterine device
Releases progesterone,
Inhibits ovulation, thickens cervical mucus, thins endometrium
Lasts 3-5 years

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81
Q

When should the IUS be started?

A

Start day 1-7

Beyond day 7, start as long as certain not pregnant

82
Q

List side effects of the IUS

A

Lighter less frequent periods
Infection
Expulsion

83
Q

What sterilisation procedures may be offered to males and females?

A

Male: vasectomy
Female: laporoscopic tubal occlusion

84
Q

How long does it take sperm stores to be used up following vasectomy?

A

3 months

85
Q

How does combined oral contraception (COC) work?

A

Pill, patch, ring
Releases oestrogen and progesterone
Inhibits ovulation, thickens cervical mucus, thins endometrium

86
Q

When should COC be started? How are they taken?

A

Start up to day 5
Beyond day 5, use condoms for 7 days prior
Take pill each day for 21 days, then pill-free week
Patch 1 week, replace patch and wear for 2 weeks, 4th week patch-free
Ring for 21 days, then ring-free week

87
Q

How long can the COC patch/ring be taken out for and still be effective?

A

48 hours

88
Q

If someone misses a COC pill, what should they do?

A

Take a pill ASAP and continue pack as normal

89
Q

If someone misses more than one COC pill, what should they do?

A

Take a pill ASAP and continue pack as normal and use condoms for 7 days

90
Q

List some contraindications for COC pill

A

BMI over 35 and smoker
Migraine with aura
History of VTE, thrombophilia
Liver disease

91
Q

List side effects of COC pill

A

Hypertension
Breast and cervical cancer
Drug interactions

92
Q

How does the progesterone only pill (POP) work?

A

Releases progesterone

Inhibits ovulation, thickens cervical mucus, thins endometrium

93
Q

When should the POP be started?

A

Start any time of cycle

Take at same time every day/within 3 or 12 hours (depending on generation) of last dose

94
Q

If someone misses a POP, what should they do?

A

Condom required for 48h if it has been more than 3h or 12h depending on generation of pill

95
Q

List side effects of POP

A 
Breast tenderness
Skin changes
Headache
Ovarian cysts
VTE
Bleeding
96
Q

What are the different methods of emergency contraception and when can they be used?

A

Levonelle within 72h of UPSI
ellaOne within 120h of UPSI
IUD within 120h of UPSI

97
Q

List aetiology/risk factors for pruritis vulvae

A 
Skin disease (psoriasis, lichen planus)
Infection
Vaginal discharge
Infestation (scabies, lice, threadworm)
Lichen sclerosus
Leukoplakia
Cancer
Obesity and incontinence may exacerbate symptoms
98
Q

Outline management of pruritis vulvae

A 
Reassurance
Avoid nylon, chemicals, soap
Dry genitals with hairdryer
Short-course topical steroid (betametasone)
Oral antipruritic (promethazine)
99
Q

What is lichen sclerosus?

A

Elastic tissue turns to collagen after middle age (rarely before puberty)

100
Q

List clinical features of lichen sclerosus

A

Bruised red purpura in younger
White, flat, shiny “hourglass” shape lesions in older
Intense itch

101
Q

Which drug is used for lichen sclerosus?

A

Clobetasol propionate

102
Q

Vulval intraepithelial neoplasia (VIN) usually occurs in younger women. True/False?

A

True

Squamous carcinoma of vulva develops/arises de novo in elderly

103
Q

Which virus is often associated with VIN?

A

HPV

104
Q

List clinical features of vulval carcinoma

A 
White areas with surrounding inflammation
Lump
Indurated ulcer
Pain
Bleeding
105
Q

Which stain is used to detect vulval carcinoma and how does it stain?

A

Acetic acid stains affected area white

106
Q

Outline management of vulval carcinoma

A

Imiquimod cream may be effective
Wide local excision
Nodal excision if greater than 2cm width and 1mm depth
Radical vulvectomy (wide excision + inguinal gland removal)

107
Q

List aetiology/risk factors for vulval lumps

A 
Varicose veins
Sebaceous cysts
Keratoacanthoma
Viral warts
Syphilis
Bartholin's cyst/abscess
Uterine prolapse, polyp
Hernia
Carcinoma
108
Q

What is a Bartholin’s cyst/abscess?

A

Gland lying under labia minora that secretes lubricating mucus during sexual excitation becomes blocked/infected

109
Q

List clinical features of a Bartholin’s cyst/abscess

A

Blocked cyst: painless
Infected abscess: painful, cannot sit
Very swollen hot red labium

110
Q

Outline management of Bartholin’s cyst/abscess

A 
Incise and drain abscess
Exclude STI (Gonorrhoea)
111
Q

What is cervical ectropion?

A

Endocervical (columnar) epithelium extends over ectocervical (squamous) epithelium

112
Q

List clinical features of cervical ectropion

A

Red ring around cervical os
Bleeding
Excess mucus
Infection

113
Q

List aetiology/risk factors for cervical ectropion

A

Puberty hormones
COC pill
Pregnancy

114
Q

Outline management of cervical ectropion

A

Cautery if nuisance/symptomatic

Otherwise leave alone

115
Q

List aetiology/risk factors for cervical cancer

A 
HPV strains 16, 18, 31, 33, 45
Long-term COC pill use
High parity
Many sexual partners
HIV, immunosuppression
Smoking
116
Q

List clinical features for cervical cancer

A 
PV bleeding
Brown/blood -stained discharge
Contact bleeding (friable epithelium)
Pelvic pain
Haematuria
117
Q

What is the normal cervical screening schedule?

A

3-yearly for 25-49 yo

5-yearly for 50-64 yo

118
Q

List next steps if a cervical smear was found to show borderline/mild dyskaryosis, moderate dyskaryosis, severe dyskaryosis or inadequate result

A

Borderline/mild: test for HPV, if +ve refer to colposcopy, if -ve go back to normal screening
Moderate/severe: colposcopy within 2 weeks
Inadequate: repeat smear, if 3 inadequate smears refer to colposcopy

119
Q

Describe cervical intraepithelial neoplasia (CIN) I, II and III

A

CIN I: basal 1/3, increased mitosis, mature surface cells, abnormal nuclei
CIN II: middle 1/3, abnormal mitosis
CIN III: full thickness, abnormal mitosis and cells

120
Q

Outline management of CIN

A

LLETZ destruction
Cryotherapy/laser/cold coagulation may also be sured for CIN II
6-month follow-up for test of cure
If small volume invasive carcinoma found, can do potentially curative cone biopsy

121
Q

Cervical cancer is usually squamous carcinoma. True/False?

A

True

122
Q

Describe stage 1a1, 1a2, 1b, 2, 3 and 4 cervical cancer

A

1a1: depth up to 3mm, width up to 7mm
1a2: depth up to 5mm, width up to 7mm
1b: confined to cervix
2: spread to upper 2/3 vagina, adjacent organs
3: spread to lower 1/3 vagina, pelvic wall
4: spread to rectum/bladder, distant organs

123
Q

Outline management of cervical cancer

A

Cone excision if stage 1a1
Radical hysterectomy + pelvic lymphadenopathy
Radiotherapy if stage 1a2
Chemoradiation for stage 2/3/4 (cisplatin, carboplatin, paclitaxel)

124
Q

Endometritis is common. True/False?

A

False

Uncommon unless barrier is broken (acidic vaginal pH, cervical mucus)

125
Q

List aetiology/risk factors for endometritis

A 
Miscarriage
Termination of pregnancy
Childbirth
IUCD insertion
Surgery
Rising infection
126
Q

List clinical features for endometritis

A

Lower abdo pain
Fever
Uterine tenderness on bimanual exam

127
Q

Outline management of endometritis

A

Doxycycline + metronidazole for 7 days

128
Q

What are uterine leiomyomas?

A

Benign smooth muscle fibroids very common in over 40 year-olds
Start as lumps in uterine wall, grow out and lie under peritoneum

129
Q

List aetiology/risk factors for uterine fibroids

A

Oestrogen-dependent (enlarge in pregnancy, COCP, atrophy after menopause)
Mutation in gene for fumarate hydratase
Renal cell cancer

130
Q

List clinical features of uterine fibroids

A 
Asymptomatic
Menorrhagia, heavy prolonged periods
Infertility/subfertility
Pelvic pain, tenderness
Abdo mass if large fibroid
131
Q

Outline management of uterine fibroids

A

Expectant if asymptomatic
Hysterectomy if family complete
Myomectomy if wanting family + subfertile
IUS may reduce fibroid size
GnRH analogue prior to surgery to reduce size (goserelin)

132
Q

What is leiomyosarcoma?

A

Most common malignant smooth muscle tumour of the uterus, usually affecting over 50 year-olds

133
Q

What is the morphology of leiomyosarcoma on histology?

A

Spindle-cell morphology

134
Q

Describe simple, complex and atypical endometrial hyperplasia

A

Simple: generalised, dilated glands, normal cytology
Complex: focal, crowded glands, normal cytology
Atypical: focal, crowded glands, abnormal cytology

135
Q

Describe the histopathology of endometrial carcinoma

A

Most are adenocarcinoma presenting after menopause
Relative oestrogen excess unopposed by progesterone
Type 1 (mucinos, endometroid) from atypical hyperplasia
Type 2 (serous, clear cell) from serous intraepithelial carcinoma (STIC)

136
Q

List aetiology/risk factors for endometrial carcinoma

A 
Obesity
Functioning ovarian tumour
Family/personal history of breast/ovarian/colorectal cancer (Lynch syndrome)
Nulliparity
Early menarche
Late menopause
Diabetes
HRT
Polycystic ovaries
137
Q

List clinical features of endometrial carcinoma

A

Postmenopausal bleeding, initially scanty and watery that becomes heavy and painful

138
Q

What investigations would you do for endometrial carcinoma?

A

Transvaginal USS to measure thickness (abnormal if above 4mm)
Pipelle biopsy
Hysteroscopy
Staging

139
Q

Outline management of endometrial carcinoma

A

Total hysterectomy + bilateral salpingo-oophorectomy

High dose progestogen in advanced disease

140
Q

What is endometriosis?

A

Foci of endometrial glandular tissue outwith the uterine cavity (e.g. ovary, rectovaginal pouch, uterosacral ligament, peritoneum)

141
Q

What is adenomyosis?

A

Endometrial tissue found in uterine wall muscle

142
Q

List aetiology/risk factors for endometriosis

A 
Cell rest
Retrograde menstruation
Long-term IUCD + tampon use
Genetics
Autoantibodies
143
Q

List clinical features of endometriosis

A 
Pelvic pain (typically cyclical)
Dysmenorrhoea
Dyspareunia
Pain on defecation, IBS-like symptoms
Infertility
144
Q

What investigations would you do for endometriosis?

A

PV exam (typically fixed retroverted uterus)
Nodules on uterosacral ligaments
Enlarged boggy tender uterus if adenomyosis
Laparoscopy shows cysts, peritoneal deposits
Chocolate cysts on ovarian USS

145
Q

Outline management of endometriosis

A

Leave if asymptomatic, mutual/group support
Analgesia, NSAID’s, stress reduction
COCP low-dose, progestogens/IUS/danazol
GnRH analogue
Surgical excision of endometriotic tissue
Total hysterectomy + bilateral salpingo-oophorectomy if no wishes for fertility

146
Q

How does pelvic prolapse arise?

A

Weakness of pelvic floor support structures causes pelvic organs to sag into vagina

147
Q

What is a cystocele and its clinical features?

A

Upper anterior vaginal wall bulge causes bladder sag

Frequency, dysuria

148
Q

What is a urethrocele and its clinical features?

A

Lower anterior vaginal wall bulge causes displaced urethra

Stress incontinence

149
Q

What is a rectocele and its clinical features?

A

Middle posterior vaginal wall bulge due to weak levator ani causes rectal sag
Hernia

150
Q

What is an enterocele?

A

Upper posterior anterior vaginal wall bulge causes sag of bowel loop from pouch of Douglas

151
Q

What are the different degrees of uterine prolapse?

A

1’ uterus in vagina
2’ uterus at introitus
3’ uterus outside vagina
4’ uterus completely outside vagina

152
Q

List clinical features of pelvic prolapse

A

Dragging sensation
Urinary symptoms
Difficult defecation
Dyspareunia

153
Q

What investigations would you do for pelvic prolapse?

A

Examine vaginal wall in left lateral position using Sim’s speculum
Urodynamic studies
POPQ strain + rest test

154
Q

Outline management of pelvic prolapse

A

Weight loss, stop smoking, stop straining, physiotherapy
Topical oestrogen if postmenopausal
Treat incontinence
Surgical repair
Ring pessary if very frail/temporary relief

155
Q

Who is typically affected by ovarian tumours?

A

Usually over 50 year-olds and those who are nulliparous/low parity

156
Q

List clinical features of ovarian tumours

A 
Asymptomatic
Abdo swelling +/- palpable mass
Urinary symptoms
Peritonitis/shock if rupture of cyst
Ascites
Ovarian torsion
Virilsation
Menstrual irregularity
Post-menopausal bleeding
157
Q

What are functional ovarian cysts?

A

Enlarged/persistent follicular (commonest) or corpus luteal cysts related to ovulation
Very common, rarely greater than 5cm, usually resolve spontaneously

158
Q

Which ovarian tumour is the commonest benign epithelial tumour?

A

Serous cysts

159
Q

Rupture of which ovarian cysts can typically cause pseudomyxoma peritonii?

A

Mucinous cysts

160
Q

Which ovarian tumour is associated with Meig’s syndrome (and what is the clinical triad of Meig’s syndrome)

A

Fibromas

Meig’s syndrome: pleural effusion, right-sided, benign ovarian fibroma

161
Q

What are the two main sex-cord ovarian tumours and what do they secrete?

A

Granulosa cell tumours (secrete oestrogen)

Theca cell tumours (secrete androgens)

162
Q

What is the usual histopathological subtype of ovarian carcinoma?

A

Serous carcinoma

163
Q

List aetiology/risk factors for ovarian carcinoma

A 
Familial
BRCA mutation
Late menopause
Nulliparity
HRT
164
Q

List clinical features of ovarian carcinoma

A 
Abdo pain
Bloating
Discomfort
Reduced appetite
Thrombosis/DVT
165
Q

What investigations would you do for ovarian carcinoma?

A

CA-125
CEA may be raised in GI mets
USS, CT, biopsy
Risk of malignancy index: US score x CA-125 level x menopausal status

166
Q

Outline management of ovarian carcinoma

A

Prophylactic oophorectomy in older women with hysterectomy/BRCA mutation
Surgical excision if benign
Debulking surgery +/- chemotherapy (paclitaxlel, carboplatin)

167
Q

Which organisms make up the normal vaginal flora?`

A

Lactobacullus
Group B Strep
Candida spp

168
Q

List aetiology/risk factors for vaginal thrush

A 
Candida albicans
Recent antibiotic use
High oestrogen
Poorly controlled diabetes
Pregnancy
Contraceptive
Steroids, immunodeficiency
169
Q

List clinical features of vaginal thrush

A

Intensely itchy vagina
“cottage-cheese”/curd-like white discharge
Red fissured painful vulva

170
Q

Vaginal thrush is not always sexually transmitted. True/False?

A

True

171
Q

What investigations would you do for vaginal thrush?

A

Clinical diagnosis
High vaginal swab (endocervical)
Microscopy and culture

172
Q

Outline management of vaginal thrush

A 
Topical clotrimazole (pessary)
Oral fluconazole (CI in breastfeeding)
Nystatin/imidazole for other strains
173
Q

List aetiology/risk factors for bacterial vaginosis

A

Altered anaerobic floral overgrowth
Gardnerella vaginalis
Mycoplasma
Mobiluncus

174
Q

List clinical features of bacterial vaginosis

A

Thin, watery, fish-smelling discharge
Uninflamed vagina
Ammonia wiff when mixed with potassium
Increased risk of preterm labour, intrauterine infection and HIV

175
Q

What investigations would you do for bacterial vaginosis?

A

Wet microscopy shows clue cells

Vaginal pH over 4.5

176
Q

Outline management of bacterial vaginosis

A

Oral metronidazole

Clindamycin cream if not able to take metrondiazole

177
Q

What is trichomoniasis?

A

STI caused by trichomonas vaginalis, a protozoal parasite

178
Q

List clinical features of trichomoniasis

A

Vaginitis

Thin, bubbly discharge

179
Q

What investigations would you do for trichomoniasis?

A

Motile flagellae seen on wet microscopy of high vaginal swab

180
Q

Outline management of trichomoniasis

A

Oral metronidazole
Treat partner too
Vaginal acidificaton with boric acid if allergic

181
Q

What is chlamydia?

A

Commonest STI, caused by chlamydia trachomatis (obligate intracellular bacteria)

182
Q

What are the different subtypes of chlamydia and their clinical sequelae?

A

Serovars A-C: trachoma in eye
Serovars D-K: genital infection
Serovars L1-L3: lymphogranuloma venereum

183
Q

List clinical features of chlamydia

A

Infects cervix, rectum, urethra, throat, eyes
PV bleeding
Lower abdo pain
Dyspareunia
Dysuria
Discharge
Inguinal lymphadenopathy and ulceration in LGV

184
Q

What investigations would you do for chlamydia?

A

First-pass early morning urine PCR
Endocervical swab
Free chlamydia tests in pharmacies for 16-24yo

185
Q

Outline management of chlamydia

A

Oral azithromycin/doxycycline for 7 days

3 weeks’ treatment if LGV

186
Q

Which organism causes gonorrhoea and what does it look like?

A

Neisseira gonorrhoea

Gram -ve diplococcus

187
Q

List clinical features of gonorrhoea

A

Urethral pus + dysuria
White discharge
Tenesmus
Proctitis

188
Q

What investigations would you do for gonorrhoea?

A

Urethral smear for gram stain + selective agar culture
First-pass urine PCR
Endocervical swab
Nucleic acid amplification test (NAATs)

189
Q

Outline management of gonorrhoea

A 
IM ceftriaxone
Oral azithromycin (for chlamydia protection)
190
Q

Which virus causes genital warts?

A

HPV 6, 11

191
Q

Outline management of genital warts

A

Cryotherapy
Podophyllotoxin
Vaccination

192
Q

Which organism causes syphilis?

A

Treponema pallidum

193
Q

List clinical features of primary syphilis

A

Macule at site of sexual contact develops into painless, infectious chancre

194
Q

List clinical features of secondary syphilis

A

Ulcers
Generalised rash on palms and soles
Flu-like illness
Enlarged lymph nodes

195
Q

List clinical features of tertiary syphilis

A

Follows latentn period
Granulomas
Relatively asymptomatic

196
Q

List clinical features of late syphilis

A

Cardiac and neuro compromise (aneurysms, CN palsy, psychosis etc.)

197
Q

What investigations would you for syphilis?

A

Dark ground microscopy of chancre fluid
Non-specific antibody to monitor response to treatment (VDRL, RPR)
Specific antibody (TPPA, TPHA)
Syphilis ELISA IgG/IgM

198
Q

Outline management of syphilis

A

Penicillin injection

Oral erythromycin if pregnant

199
Q

List aetiology/risk factors for salpingitis

A 
Usually sexually-acquired (chlamydia)
Childbirth
IUCD
POP use
Intestinal tract spread (appendicitis)
200
Q

List clinical features of salpingitis

A 
Pain
Fever
Lower abdo spasms
Profuse/purulent/bloody discharge
Suprapubic tenderness
Peritoneum
Cervical excitation
201
Q

What investigations would you do for salpingitis?

A

Endocervical + urethral swabs

Blood cultures

202
Q

Outline management of salpingitis

A

IV ceftriaxone + oral doxycycline

Step down to metronidazole + doxycycline

4MB Medicine (19 decks)

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