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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
Outline management of premenstrual syndrome
Support, psych counselling/CBT, family therapy Stress and relaxation techniques Pyridoxine may improve mood COCP Fluoxetine If cyclical mastalgia: reduce saturated fats, bromocriptine, danazol
26
What is menopause?
Cessation of menstrual periods following climacteric period (1 year of amenorrhoea)
27
Define premature, early and late menopause
Premature: before age of 40 Early: before age of 45 Late: after age of 54
28
List clinical features of menopause
``` 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) ```
29
What would you find on investigations for menopause?
Low oestrogen | High FSH and LH
30
Outline conservative management of menopause and medications used for menorrhagia
``` 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 ```
31
Outline HRT management for menopause
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
32
List contraindications to HRT
``` Oestrogen-dependent cancer Undiagnosed PV bleeding Abnormal LFT's Pregnancy Breastfeeding Phlebitis History of PE ```
33
List side effects of HRT
``` Weight gain Premenstrual syndrome VTE Breast cancer Ovarian cancer Gallbladder disease Increased risk of CV event after 10 years ```
34
What is the typical gestation cut-off for termination of pregnancy?
24 weeks
35
State the criteria of the Abortion Act, A-F, for termination of pregnancy
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
36
What investigations would you do for termination of pregnancy?
``` Counselling to make sure of patient's decision Pregnancy test USS, fundal height Screen for STI (Chlamydia) Discuss future contraception Check rhesus status ```
37
Outline medical management of termination of pregnancy
``` 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 ```
38
Outline surgical management of termination of pregnancy
``` If 6-12w Vacuum aspiration D&C Prime with misoprostol Warn about future risk of miscarriage, failure, haemorrhage, infection, uterine rupture/perforation ```
39
Describe the different types of miscarriage
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
40
List aetiology/risk factors for miscarriage
``` PCOS Low progesterone Bacterial vaginosis Familial Abnormal uterus Antiphospholipid syndrome Thrombophilia Alloimmunity ```
41
What investigations would you do for miscarriage?
US scan Speculum/PV exam FBC, BHCG levels
42
Outline management of miscarriage
Emotional support Treat haemodynamic compromise Largely conservative Misoprostol may be used to expel products
43
What is ectopic pregnancy?
Implantation occurs outwith uterus, usually in ampulla of fallopian tube
44
List aetiology/risk factors for ectopic pregnancy
``` Salpingitis Previous surgery Previous ectopic Endometriosis Old IUCD POP use ```
45
List clinical features of ectopic pregnancy
``` Abdo pain Bleeding Peritonism Shoulder tip pain Fainting Pallor Nausea, vomiting ```
46
What investigations would you do for ectopic pregnancy?
FBC, U+E, glucose BHCG levels (double after 48h) US scan
47
Outline management of ectopic pregnancy
Laparotomy if in shock/unstable, otherwise laporoscopy +/- salpingectomy Methotrexate for small early ectopic with low BHCG Expectant management
48
What happens in gestational trophoblastic disease?
Non-viable trophoblastic tissue forms from fertilised ovum i.e. no foetus Usually genetically paternal but has 46XX karyotype
49
What are "complete" and "partial" hydatidiform moles?
Complete: egg without DNA fertilised, no foetus results Partial: haploid egg fertilised, triploidy, may have foetus
50
List aetiology/risk factors for hydatidiform mole
Extremes of child-bearing age Previous mole Non-Caucasians
51
List clinical features of hydatidiform mole
``` Early miscarriage Pass "grape-like" clusters Hyperemesis Bleeding Dyspnoea ```
52
What would investigations show in hydatidiform mole?
USS snowstorm appearance Appears large for dates Increased bHCG
53
Outline management of hydatidiform mole
Suction removal Avoid pregnancy for 1 year Monitor bHCG
54
What is chorionic haematoma?
Pooling of blood between endometrium and embyro
55
When is a couple infertility defined as being infertile?
Inability to achieve pregnancy after 12 hours of UPSI
56
List aetiology/risk factors for infertility
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
57
What investigations would you do for infertility?
``` 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 ```
58
Outline management of infertility
Lifestyle: intercourse 2-3x/w, stop smoking, reduce alcohol, BMI less than 30 Treat hormonal causes Assisted fertilisation
59
List the main assisted fertilisation techniques used for infertilitiy
``` Donor sperm insemination ICSI (inject sperm into egg) Sperm aspirate + ICSI IUI (inseminate uterus) IVF ```
60
List some side effects of IVF
``` Multiple birth Pre-eclampsia Pregnancy-induced hypertension Genetic defects Low birthweight Prematurity Perinatal mortality ```
61
List aetiology/risk factors for male infertility
``` 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 ```
62
List clinical features of male infertility
``` Reduced testicular volume (less than 15ml) Loss of secondary sexual characteristics Gynaecomastia Scrotal swelling Prostatitis ```
63
What would you analyse/look for from normal semen for male infertility?
``` 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 ```
64
What investigations other than semen analysis would you do for male infertility?
Plasma FSH to distinguish from 1' and 2' testicular failure Testosterone, LH levels Testicular biopsy Scrotal scan
65
Outline management of male infertility
``` Avoid lubricants, tight pants, hot baths/saunas IUI (25% successful) ICSI (30% successful) Sperm aspirate (up to 95% successful) Donor sperm ```
66
List some natural methods of contraception/estimating fertility
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)
67
List the main long-acting contraception methods used
Depo injection Implant IUD, IUS Sterilisation
68
How does the Depo injection work?
Releases synthetic progesterone Inhibits ovulation, thickens cervical mucus, thins endometrium Injected every 12 weeks
69
When should the Depo injection be started?
Start day 1-5 of cycle | Beyond day 5, use condoms for 7 days prior to start
70
List some contraindications of Depo injection
Pregnancy Undiagnosed PV bleed Liver disease Cardiac disease
71
List side effects of Depo injection
Increased appetite and weight Delayed return to fertility Osteoporosis Irregular bleeding
72
How does the implant work?
Subdermal rod contains progesterone Inhibits ovulation, thickens cervical mucus, thins endometrium Surgically inserted 8mm above medial epicondyle of elbow Lasts up to 3 years
73
When should the implant be started?
Start day 1-5 On or before day 21 if post-partum Beyond day 5, use condoms for 7 days prior
74
List some contraindications to the implant
Heart disease/stroke Unexplained PV bleeding Past breast cancer Liver disease (cirrhosis, cancer)
75
List side effects of the implant
Irregular, heavy periods Weight gain Acne
76
How does the IUD work?
Intrauterine copper coil toxic to sperm Prevents fertilisation, creases endometrial inflammation Lasts 5-10 years
77
When should the IUD be started?
Start day 1-7 | Beyond day 7, start as long as certain not pregnant
78
List some contraindications to the IUD and IUS
Pelvic infection Abnormal uterine anatomy Molar pregnancy Cancer/undiagnosed PV bleed
79
List side effects of the IUD
``` Heavy periods Pain Discomfort on insertion Expulsion Perforation STI ```
80
How does the IUS work?
T-shaped intrauterine device Releases progesterone, Inhibits ovulation, thickens cervical mucus, thins endometrium Lasts 3-5 years
81
When should the IUS be started?
Start day 1-7 | Beyond day 7, start as long as certain not pregnant
82
List side effects of the IUS
Lighter less frequent periods Infection Expulsion
83
What sterilisation procedures may be offered to males and females?
Male: vasectomy Female: laporoscopic tubal occlusion
84
How long does it take sperm stores to be used up following vasectomy?
3 months
85
How does combined oral contraception (COC) work?
Pill, patch, ring Releases oestrogen and progesterone Inhibits ovulation, thickens cervical mucus, thins endometrium
86
When should COC be started? How are they taken?
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
How long can the COC patch/ring be taken out for and still be effective?
48 hours
88
If someone misses a COC pill, what should they do?
Take a pill ASAP and continue pack as normal
89
If someone misses more than one COC pill, what should they do?
Take a pill ASAP and continue pack as normal and use condoms for 7 days
90
List some contraindications for COC pill
BMI over 35 and smoker Migraine with aura History of VTE, thrombophilia Liver disease
91
List side effects of COC pill
Hypertension Breast and cervical cancer Drug interactions
92
How does the progesterone only pill (POP) work?
Releases progesterone | Inhibits ovulation, thickens cervical mucus, thins endometrium
93
When should the POP be started?
Start any time of cycle | Take at same time every day/within 3 or 12 hours (depending on generation) of last dose
94
If someone misses a POP, what should they do?
Condom required for 48h if it has been more than 3h or 12h depending on generation of pill
95
List side effects of POP
``` Breast tenderness Skin changes Headache Ovarian cysts VTE Bleeding ```
96
What are the different methods of emergency contraception and when can they be used?
Levonelle within 72h of UPSI ellaOne within 120h of UPSI IUD within 120h of UPSI
97
List aetiology/risk factors for pruritis vulvae
``` Skin disease (psoriasis, lichen planus) Infection Vaginal discharge Infestation (scabies, lice, threadworm) Lichen sclerosus Leukoplakia Cancer Obesity and incontinence may exacerbate symptoms ```
98
Outline management of pruritis vulvae
``` Reassurance Avoid nylon, chemicals, soap Dry genitals with hairdryer Short-course topical steroid (betametasone) Oral antipruritic (promethazine) ```
99
What is lichen sclerosus?
Elastic tissue turns to collagen after middle age (rarely before puberty)
100
List clinical features of lichen sclerosus
Bruised red purpura in younger White, flat, shiny "hourglass" shape lesions in older Intense itch
101
Which drug is used for lichen sclerosus?
Clobetasol propionate
102
Vulval intraepithelial neoplasia (VIN) usually occurs in younger women. True/False?
True | Squamous carcinoma of vulva develops/arises de novo in elderly
103
Which virus is often associated with VIN?
HPV
104
List clinical features of vulval carcinoma
``` White areas with surrounding inflammation Lump Indurated ulcer Pain Bleeding ```
105
Which stain is used to detect vulval carcinoma and how does it stain?
Acetic acid stains affected area white
106
Outline management of vulval carcinoma
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
List aetiology/risk factors for vulval lumps
``` Varicose veins Sebaceous cysts Keratoacanthoma Viral warts Syphilis Bartholin's cyst/abscess Uterine prolapse, polyp Hernia Carcinoma ```
108
What is a Bartholin's cyst/abscess?
Gland lying under labia minora that secretes lubricating mucus during sexual excitation becomes blocked/infected
109
List clinical features of a Bartholin's cyst/abscess
Blocked cyst: painless Infected abscess: painful, cannot sit Very swollen hot red labium
110
Outline management of Bartholin's cyst/abscess
``` Incise and drain abscess Exclude STI (Gonorrhoea) ```
111
What is cervical ectropion?
Endocervical (columnar) epithelium extends over ectocervical (squamous) epithelium
112
List clinical features of cervical ectropion
Red ring around cervical os Bleeding Excess mucus Infection
113
List aetiology/risk factors for cervical ectropion
Puberty hormones COC pill Pregnancy
114
Outline management of cervical ectropion
Cautery if nuisance/symptomatic | Otherwise leave alone
115
List aetiology/risk factors for cervical cancer
``` HPV strains 16, 18, 31, 33, 45 Long-term COC pill use High parity Many sexual partners HIV, immunosuppression Smoking ```
116
List clinical features for cervical cancer
``` PV bleeding Brown/blood -stained discharge Contact bleeding (friable epithelium) Pelvic pain Haematuria ```
117
What is the normal cervical screening schedule?
3-yearly for 25-49 yo | 5-yearly for 50-64 yo
118
List next steps if a cervical smear was found to show borderline/mild dyskaryosis, moderate dyskaryosis, severe dyskaryosis or inadequate result
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
Describe cervical intraepithelial neoplasia (CIN) I, II and III
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
Outline management of CIN
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
Cervical cancer is usually squamous carcinoma. True/False?
True
122
Describe stage 1a1, 1a2, 1b, 2, 3 and 4 cervical cancer
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
Outline management of cervical cancer
Cone excision if stage 1a1 Radical hysterectomy + pelvic lymphadenopathy Radiotherapy if stage 1a2 Chemoradiation for stage 2/3/4 (cisplatin, carboplatin, paclitaxel)
124
Endometritis is common. True/False?
False | Uncommon unless barrier is broken (acidic vaginal pH, cervical mucus)
125
List aetiology/risk factors for endometritis
``` Miscarriage Termination of pregnancy Childbirth IUCD insertion Surgery Rising infection ```
126
List clinical features for endometritis
Lower abdo pain Fever Uterine tenderness on bimanual exam
127
Outline management of endometritis
Doxycycline + metronidazole for 7 days
128
What are uterine leiomyomas?
Benign smooth muscle fibroids very common in over 40 year-olds Start as lumps in uterine wall, grow out and lie under peritoneum
129
List aetiology/risk factors for uterine fibroids
Oestrogen-dependent (enlarge in pregnancy, COCP, atrophy after menopause) Mutation in gene for fumarate hydratase Renal cell cancer
130
List clinical features of uterine fibroids
``` Asymptomatic Menorrhagia, heavy prolonged periods Infertility/subfertility Pelvic pain, tenderness Abdo mass if large fibroid ```
131
Outline management of uterine fibroids
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
What is leiomyosarcoma?
Most common malignant smooth muscle tumour of the uterus, usually affecting over 50 year-olds
133
What is the morphology of leiomyosarcoma on histology?
Spindle-cell morphology
134
Describe simple, complex and atypical endometrial hyperplasia
Simple: generalised, dilated glands, normal cytology Complex: focal, crowded glands, normal cytology Atypical: focal, crowded glands, abnormal cytology
135
Describe the histopathology of endometrial carcinoma
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
List aetiology/risk factors for endometrial carcinoma
``` Obesity Functioning ovarian tumour Family/personal history of breast/ovarian/colorectal cancer (Lynch syndrome) Nulliparity Early menarche Late menopause Diabetes HRT Polycystic ovaries ```
137
List clinical features of endometrial carcinoma
Postmenopausal bleeding, initially scanty and watery that becomes heavy and painful
138
What investigations would you do for endometrial carcinoma?
Transvaginal USS to measure thickness (abnormal if above 4mm) Pipelle biopsy Hysteroscopy Staging
139
Outline management of endometrial carcinoma
Total hysterectomy + bilateral salpingo-oophorectomy | High dose progestogen in advanced disease
140
What is endometriosis?
Foci of endometrial glandular tissue outwith the uterine cavity (e.g. ovary, rectovaginal pouch, uterosacral ligament, peritoneum)
141
What is adenomyosis?
Endometrial tissue found in uterine wall muscle
142
List aetiology/risk factors for endometriosis
``` Cell rest Retrograde menstruation Long-term IUCD + tampon use Genetics Autoantibodies ```
143
List clinical features of endometriosis
``` Pelvic pain (typically cyclical) Dysmenorrhoea Dyspareunia Pain on defecation, IBS-like symptoms Infertility ```
144
What investigations would you do for endometriosis?
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
Outline management of endometriosis
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
How does pelvic prolapse arise?
Weakness of pelvic floor support structures causes pelvic organs to sag into vagina
147
What is a cystocele and its clinical features?
Upper anterior vaginal wall bulge causes bladder sag | Frequency, dysuria
148
What is a urethrocele and its clinical features?
Lower anterior vaginal wall bulge causes displaced urethra | Stress incontinence
149
What is a rectocele and its clinical features?
Middle posterior vaginal wall bulge due to weak levator ani causes rectal sag Hernia
150
What is an enterocele?
Upper posterior anterior vaginal wall bulge causes sag of bowel loop from pouch of Douglas
151
What are the different degrees of uterine prolapse?
1' uterus in vagina 2' uterus at introitus 3' uterus outside vagina 4' uterus completely outside vagina
152
List clinical features of pelvic prolapse
Dragging sensation Urinary symptoms Difficult defecation Dyspareunia
153
What investigations would you do for pelvic prolapse?
Examine vaginal wall in left lateral position using Sim's speculum Urodynamic studies POPQ strain + rest test
154
Outline management of pelvic prolapse
Weight loss, stop smoking, stop straining, physiotherapy Topical oestrogen if postmenopausal Treat incontinence Surgical repair Ring pessary if very frail/temporary relief
155
Who is typically affected by ovarian tumours?
Usually over 50 year-olds and those who are nulliparous/low parity
156
List clinical features of ovarian tumours
``` Asymptomatic Abdo swelling +/- palpable mass Urinary symptoms Peritonitis/shock if rupture of cyst Ascites Ovarian torsion Virilsation Menstrual irregularity Post-menopausal bleeding ```
157
What are functional ovarian cysts?
Enlarged/persistent follicular (commonest) or corpus luteal cysts related to ovulation Very common, rarely greater than 5cm, usually resolve spontaneously
158
Which ovarian tumour is the commonest benign epithelial tumour?
Serous cysts
159
Rupture of which ovarian cysts can typically cause pseudomyxoma peritonii?
Mucinous cysts
160
Which ovarian tumour is associated with Meig's syndrome (and what is the clinical triad of Meig's syndrome)
Fibromas | Meig's syndrome: pleural effusion, right-sided, benign ovarian fibroma
161
What are the two main sex-cord ovarian tumours and what do they secrete?
Granulosa cell tumours (secrete oestrogen) | Theca cell tumours (secrete androgens)
162
What is the usual histopathological subtype of ovarian carcinoma?
Serous carcinoma
163
List aetiology/risk factors for ovarian carcinoma
``` Familial BRCA mutation Late menopause Nulliparity HRT ```
164
List clinical features of ovarian carcinoma
``` Abdo pain Bloating Discomfort Reduced appetite Thrombosis/DVT ```
165
What investigations would you do for ovarian carcinoma?
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
Outline management of ovarian carcinoma
Prophylactic oophorectomy in older women with hysterectomy/BRCA mutation Surgical excision if benign Debulking surgery +/- chemotherapy (paclitaxlel, carboplatin)
167
Which organisms make up the normal vaginal flora?`
Lactobacullus Group B Strep Candida spp
168
List aetiology/risk factors for vaginal thrush
``` Candida albicans Recent antibiotic use High oestrogen Poorly controlled diabetes Pregnancy Contraceptive Steroids, immunodeficiency ```
169
List clinical features of vaginal thrush
Intensely itchy vagina "cottage-cheese"/curd-like white discharge Red fissured painful vulva
170
Vaginal thrush is not always sexually transmitted. True/False?
True
171
What investigations would you do for vaginal thrush?
Clinical diagnosis High vaginal swab (endocervical) Microscopy and culture
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Outline management of vaginal thrush
``` Topical clotrimazole (pessary) Oral fluconazole (CI in breastfeeding) Nystatin/imidazole for other strains ```
173
List aetiology/risk factors for bacterial vaginosis
Altered anaerobic floral overgrowth Gardnerella vaginalis Mycoplasma Mobiluncus
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List clinical features of bacterial vaginosis
Thin, watery, fish-smelling discharge Uninflamed vagina Ammonia wiff when mixed with potassium Increased risk of preterm labour, intrauterine infection and HIV
175
What investigations would you do for bacterial vaginosis?
Wet microscopy shows clue cells | Vaginal pH over 4.5
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Outline management of bacterial vaginosis
Oral metronidazole | Clindamycin cream if not able to take metrondiazole
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What is trichomoniasis?
STI caused by trichomonas vaginalis, a protozoal parasite
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List clinical features of trichomoniasis
Vaginitis | Thin, bubbly discharge
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What investigations would you do for trichomoniasis?
Motile flagellae seen on wet microscopy of high vaginal swab
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Outline management of trichomoniasis
Oral metronidazole Treat partner too Vaginal acidificaton with boric acid if allergic
181
What is chlamydia?
Commonest STI, caused by chlamydia trachomatis (obligate intracellular bacteria)
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What are the different subtypes of chlamydia and their clinical sequelae?
Serovars A-C: trachoma in eye Serovars D-K: genital infection Serovars L1-L3: lymphogranuloma venereum
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List clinical features of chlamydia
Infects cervix, rectum, urethra, throat, eyes PV bleeding Lower abdo pain Dyspareunia Dysuria Discharge Inguinal lymphadenopathy and ulceration in LGV
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What investigations would you do for chlamydia?
First-pass early morning urine PCR Endocervical swab Free chlamydia tests in pharmacies for 16-24yo
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Outline management of chlamydia
Oral azithromycin/doxycycline for 7 days | 3 weeks' treatment if LGV
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Which organism causes gonorrhoea and what does it look like?
Neisseira gonorrhoea | Gram -ve diplococcus
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List clinical features of gonorrhoea
Urethral pus + dysuria White discharge Tenesmus Proctitis
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What investigations would you do for gonorrhoea?
Urethral smear for gram stain + selective agar culture First-pass urine PCR Endocervical swab Nucleic acid amplification test (NAATs)
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Outline management of gonorrhoea
``` IM ceftriaxone Oral azithromycin (for chlamydia protection) ```
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Which virus causes genital warts?
HPV 6, 11
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Outline management of genital warts
Cryotherapy Podophyllotoxin Vaccination
192
Which organism causes syphilis?
Treponema pallidum
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List clinical features of primary syphilis
Macule at site of sexual contact develops into painless, infectious chancre
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List clinical features of secondary syphilis
Ulcers Generalised rash on palms and soles Flu-like illness Enlarged lymph nodes
195
List clinical features of tertiary syphilis
Follows latentn period Granulomas Relatively asymptomatic
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List clinical features of late syphilis
Cardiac and neuro compromise (aneurysms, CN palsy, psychosis etc.)
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What investigations would you for syphilis?
Dark ground microscopy of chancre fluid Non-specific antibody to monitor response to treatment (VDRL, RPR) Specific antibody (TPPA, TPHA) Syphilis ELISA IgG/IgM
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Outline management of syphilis
Penicillin injection | Oral erythromycin if pregnant
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List aetiology/risk factors for salpingitis
``` Usually sexually-acquired (chlamydia) Childbirth IUCD POP use Intestinal tract spread (appendicitis) ```
200
List clinical features of salpingitis
``` Pain Fever Lower abdo spasms Profuse/purulent/bloody discharge Suprapubic tenderness Peritoneum Cervical excitation ```
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What investigations would you do for salpingitis?
Endocervical + urethral swabs | Blood cultures
202
Outline management of salpingitis
IV ceftriaxone + oral doxycycline | Step down to metronidazole + doxycycline

4MB Medicine (19 decks)

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