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Year 4 > Reproductive Health > Flashcards

Reproductive Health Flashcards

1
Q

Topics to discuss when taking a gynaecological history

A

HoPC - type, site of symptoms, timing, exacerbating/relieving factors, previous episodes, other symptoms
Ask about common symptoms - vaginal bleeding, abdo/pelvic pain, vaginal discharge
Menstrual history - frequency, duration, volume, date of LMP
PMHx - pregnancies, cervical smear, surgical history, previous gynae problems, previous STIs
DHx - contraception, HRT, recent abx, any other meds, known allergies
FHx - female cancers, diabetes, bleeding disorders
SHx - weight, occupation, home situation, smoking/alcohol, diet and exercise
Systems Review - urinary, bowel, fatigue, weight loss, abdo distentsion

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2
Q

Topics to discuss when taking an Obstetric history

A

Previous Obstetric Hx - term pregnancies (gestation, mode of delivery, gender, birth weight, complications, ART, care providers); other pregnancies not carried beyond 24wks (gestation, miscarriages, terminations, causes of miscarriage/stillbirth; if ectopic ask about site and management)
Current pregnancy - ask about folate, EDD, single/multiple pregnancy, Down’s syndrome screening, fetal abnormalities, placenta position
PMHx - abdo/pelvic surgery, mental health conditions, asthma, cf, epilepsy, htn, diabetes
DHx - allergies, enquire about any teratogenic drugs
FHx - heritable diseases
SHx - ask about thoughts of pregnancy, occupation, home circumstances, financial circumstances, smoking, domestic abuse

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3
Q

Sexual Health history taking

A

HOPC - type and site of symptoms, timing, previous episodes
Symptoms - vaginal bleeding, abdo/pelvic pain, vaginal discharge
Menstrual Hx - changes in menstruation can indicate infection
Sexual Contact History - relationship? contraception? timing of last sexual contact? partners in the last 3m? nature of relationship?
PMHx - previous STI, previous STI screens, cervical smears, previous gynae problems, surgical history, pregnancies, other medical conditions
DHx - contraception, HRT, recent abx use, allergies
SHx - smoking, alcohol, recreational drug use

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4
Q

Risk Factors for STIs

A

sexual contact with an HIV +ve partner
Engaging in sexual activities with a bisexual/homosexual man
Engaging in sexual activities with someone from an area of high HIV prevalence
IV drug use in patient/partner
paying/being paid for sex
Receiving blood transfusions/tattoos/piercings in environments where sterile equipment cannot be guaranteed
Unprotected sex
Having multiple sex partners
Having anonymous sex partners
Chemsex
Sexual assault
Immunosuppression

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5
Q

Signs and Symptoms of gynae disorders

A

vaginal discharge
vaginal bleeding
pelvic pain
urinary incontinence
prolapse
infertility
post-menopausal women
pain during intercourse - dyspareunia
dysuria

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6
Q

Causes of heavy periods

A

obesity, insulin resistance, thyroid problems, PCOS
uterine fibroids
polyps
adenomyosis
IUD - esp CuIUD
pregnancy complications
cancer
blood clotting disorders

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7
Q

Investigations for heavy menstrual bleeding

A

bed: examination, speculum
bloods: FBC, U&Es, TFTs, coagulation screen
imaging: USS
other: endometrial biopsy, hysteroscopy

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8
Q

Management of heavy menstrual bleeding

A

NSAIDs
tranexamic acid
oral contraceptives
oral progesterone, implant, LNG-IUS
GnRH can trigger menopause for a year/longer, to relieve symptoms

Endometrial ablation
Hysterectomy

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9
Q

Causes for painful periods

A

Endometriosis
PID
fibroids
adenomyosis
PCOS

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10
Q

Investigations for painful periods

A

internal examination
swabs for PID
uss for fibroids, endometriomas
laparoscopy for fibroids, endometriomas

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11
Q

Management of painful periods

A

Simple analgesia
Exercise
Contraceptive - COCP, POP, implant, LNG-IUS
GnRH
Endometrial ablation
Hysterectomy

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12
Q

Causes of irregular periods

A

PCOS
thyroid problems
puberty
start of the menopause
hormonal contraceptions
losing/gaining weight
stress and anxiety
exercising too much

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13
Q

Ix for irregular periods

A

bloods - fbc, tfts, hormone profile
uss

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14
Q

Mx of irregular periods

A

watchful waiting

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15
Q

Causes of absent periods

A

pregnancy
menopause
stress
PCOS
sudden weight loss
overweight
too much exercise
contraceptives

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16
Q

Ix for absent periods

A

pregnancy test
hormone profile
watchful waiting

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17
Q

Mx of absent periods

A

Not always required, reasons behind absent periods isn’t always pathological
treatment for the underlying cause is important

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18
Q

Causes of acute and chronic pelvic pain

A

constipation, ibs, UTIs, STIs, appendicitis, peritonitis
specifically in women - period pain, ovarian cysts, endometriosis, pelvic pain in pregnancy, could be something more serious (ectopic pregnancy, womb or ovarian cancer)

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19
Q

Ix for pelvic pain

A

swabs from vagina
urinalysis
fbc
uss

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20
Q

Mx of pelvic pain

A

Depends on the underlying cause
could be abx, analgesia, physiotherapy, some hormone treatments

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21
Q

Causes of dyspareunia

A

endometriosis, PID, uterine prolapse, retroverted uterus, uterine fibroids, cystitis, ibs, pelvic floor dysfunction, adenomyosis, haemorrhoids, ovarian cyst

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22
Q

Ix for dyspareunia

A

vaginal swabs
speculum examination
bloods - fbc, crp
uss

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23
Q

Mx of dyspareunia

A

depends on the underlying cause
hormonal treatments, antibiotics, analgesia
counseling or sex therapy

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24
Q

Causes of vaginal discharge

A

candida
bv
tv
chlamydia
gonorrhoea
PID
cervical cancer

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25
Q

Ix for vaginal discharge

A

vaginal swabs - vulvovaginal and high vaginal and potentially endocervical swabs
blood tests for hiv, hep b/c, syphilis serology
pregnancy tests
culture, microscopy, gram staining, sensitivity testing

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26
Q

Female Sterilisation - what is it?

A

a permanent method of sterilisation
prevents the egg from travelling along the Fallopian tubes to the sperm

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27
Q

Female Sterilisation - effectiveness?

A

Failure rate of 0.5%
LARC is much more reliable

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28
Q

Female Sterilisation - adv/disadv

A

+permanent
+no hormones
+no side effects

-difficult to reverse
-potential to regret
-periods can become heavier
-more likely to have an ectopic if pregnancy does occur
-not as easy or as effective as male sterilisation
-surgery risks
-no protection against STIs

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29
Q

Male Sterilisation - what is it?

A

permanent method of contraception
vasectomy
small operation to cut the end of the vas deferens tube - the tube that takes sperm from the testicles to the penis
sperm can no longer get into the semen

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30
Q

Male Sterilisation - effectiveness?

A

Very reliable, but not 100%
1 in 2500 men will become fertile again at some point in the future

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31
Q

Male Sterilisation - adv/disadv

A

+permanent
+easier to do than female sterilisation
+more effective than female sterilisation

-may take a few months before the semen is free from sperm
-it’s permanent, potential for regret
-no protection against STIs

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32
Q

What are the different stages of the menstrual cycle?

A

Menstrual cycle:
Follicular phase
Luteal phase

Uterine cycle:
Proliferative phase
Secretory phase
Menstrual phase

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33
Q

What is the follicular phase of the menstrual cycle?

A

FSH rises, stimulates ovarian follicles
Ovarian follicle that fully matures will produce large amounts of oestrogen
Large amounts of oestrogen will result in endometrial thickening, thinning of cervical mucus to allow sperm to enter, inhibition of LH by the pituitary gland
Eventually, when oestrogen gets to the threshold level, stimulates LH production (around 12 days)
The follicle ruptures and releases an oocyte, matures into an ovum, is released into the peritoneal space and taken to the fallopian tube

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34
Q

What is the luteal phase of the menstrual cycle?

A

Once ovulation has occurred, LH and FSH stimulate the Graafian follicle to develop into a corpus luteum - this produces progesterone
These increased levels of progesterone causes the endometrium to become receptive to implantation of the blastocyst, negative feedback causes decreased LH and FSH, an increase in the woman’s basal body temp.
Levels of FSH LH fall, the corpus luteum degenerates. As this happens, the progesterone is stopped being produced. Falling levels of progesterone triggers menstruation and the whole cycle begins again

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35
Q

What is the proliferative phase of the uterine cycle?

A

the endometrium is exposed to increasing levels of oestrogen as a result of FSH and LH
oestrogen stimulates repair and growth of the functional endometrial layer - allowing recovery from the recent menstruation

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36
Q

what is the secretory phase of the uterine layer?

A

begins once ovulation has occurred
driven by progesterone, results in secretion of various substances by the endometrial glands
ensures the uterus is a welcoming environment for the embryo to implant

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37
Q

What is the menstrual phase of the uterine cycle?

A

at the ned of the luteal phase, the corpus luteum degenerates and this results in decreased progesterone production
decreasing levels of progesterone causes the spiral arteries in the functional endometrium to contract
loss of blood supply causes the functional endometrium to become ischaemic and necrotic - the functional endometrium is shed and exits through the vagina as menstruation

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38
Q

Polycystic Ovary Syndrome - pathophysiology

A

excess androgen production - usually due to excess LH production or hyperinsulinaemia and insulin resistance
“cysts” found in women with PCOS are immature follicles which have had their ovulation phase arrested due to elevated baseline of LH and lack of LH surge causing ovulation

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39
Q

Polycystic Ovary Syndrome - risk factors

A

obesity
diabetes mellitus
family history of PCOS
premature adrenarche - early onset of pubic hair

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40
Q

Polycystic Ovary Syndrome - s/s

A

hirsutism, infertility, acne, menstrual cycle disturbance, obesity and weight gain, alopecia, depression and other psychological disorders
htn, acanthosis nigricans

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41
Q

Polycystic Ovary Syndrome - ix

A

bedside: urine hcg, capillary blood glucose
bloods: fbc, u&e, crp, testosterone, sex hormone-binding globulin, lh and fsh, oral glucose tolerance test, lipid screen, tfts, prolactin
imaging: pelvic ultrasound scan (shows “cysts” on the ovaries and/or increased ovarian volume), but it can exist without polycystic ovaries

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42
Q

Polycystic Ovary Syndrome - Rotterdam criteria

A

Two of three criteria must be met to make a diagnosis of PCOS
*imaging: polycystic ovaries on ultrasound
*oligo- or anovulation, or oligo- or amenorrhoea
*hyperandrogenism: clinical and/or biochemical changes

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43
Q

Polycystic Ovary Syndrome - mx

A

goals are to restoration of regular menses to reduce the risk of endometrial hyperplasia; weight loss and preventing insulin resistance/diabetes; restoring fertility; treatment of hirsutism/acne
lifestyle: weight loss, regular exercise, diet
pharmological: COCP, “anti-androgens”, metformin, orlistat, eflornithine hydrochloride

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44
Q

Polycystic Ovary Syndrome - cx

A

infertility
higher incidence of pregnancy complications
higher risk of endometrial hyperplasia and endometrial cancer
higher cardiovascular risk profile
higher risk of psychological complications

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45
Q

Fibroids - patho

A

benign tumours arising from the myometrium
most common type fo pelvic tumour, usually arising in women of child-bearing age
hormone driven growths, maintained by high levels of oestrogen and progesterone

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46
Q

Fibroids - Risk Factors

A

risk is decreased by pregnancy, progesterone only contraceptives appear to do the same
increased by early age of puberty, increasing age, obesity, ethnicity (black females)

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47
Q

Fibroids - s/s

A

menorrhagia, abdominal swelling, pelvic pain, dyspareunia, dysmenorrhoea, urinary/bowel symptoms

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48
Q

Fibroids - ix

A

transvaginal ultrasound is the initial diagnostic modality of choice
may require an FBC and a pelvic MRI +/- hysteroscopy

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49
Q

Fibroids - mx

A

depends on the presenting symptoms of the patient
menorrhagia is the most common problem so mx focuses on treating heavy periods - IUS, NSAIDs, tranexamic acid and/or the COCP
surgical intervention with myomectomy or hysterectomy can be considered

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50
Q

Fibroids - cx

A

divided into pregnancy and non-pregnancy

pregnancy:
infertility, malpresentation, placental abruption, intrauterine growth restriction, preterm labour

non-pregnancy:
prolapsed fibroid, anaemia, endocrine effects (polycythaemia, hypercalcaemia, hyperprolactinaemia)

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51
Q

Endometriosis - patho

A

extrauterine implantation and growth of endometrial tissue
chronic and debilitating condition
deposits are most frequently on pelvic structures, ovaries are most affected
adenomyosis - specifically refers to deposits of endometrial tissue in the myometrium
endometriomas - cystic structures developing on the ovaries, often referred to as chocolate cysts due to the appearance of contained, old, altered blood
causes are unknown

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52
Q

Endometriosis - causes

A

cause is unknown although there are some theories
*metaplastic conversion of other tissues has been suggested and could explain why deposits are seen in seemingly anatomically distinct positions
*lymphatic or haematogenous spread has been suggested as endometriosis may develop in remote regions of the body

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53
Q

Endometriosis - Risk Factors

A

early menarche
late menopause
nulliparity
delayed childbearing
short menstrual cycle
family history
white ethnicity

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54
Q

Endometriosis - s/s

A

chronic pelvic pain
dysmenorrhoea
irregular periods
dyspareunia
dyschezia (difficulty pooping)
blaoting, nausea
LUTS
infertility/sub-fertility

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55
Q

Endometriosis - ix

A

laparoscopy is considered the gold-standard in the diagnosis of endometriosis
USS, MRI, laparoscopy may be used in ix and diagnosis of endo
Additional investigation to exclude urinary and STIs

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56
Q

Endometriosis - Conservative Mx

A

pain management - paracetamol +/- NSAIDs
hormonal therapies can reduce pain experienced (COCP, POP, LNG-IUS, implant)
psychological support

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57
Q

Endometriosis - Surgical Mx

A

surgery may be indicated
diagnostic laparoscopy will be used for therapeutic intervention too
peritoneal endometriosis and uncomplicated endometriomas may be treated
excision or ablation can be used
hormonal treatment may be advised to sustain benefit of surgery
hysterectomy may be an option

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58
Q

Uterine Polyps - patho

A

growths attached to the inner wall of the uterus that expand into the uterus
also known as endometrial polyps

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59
Q

Uterine Polyps - s/s

A

vaginal bleeding after menopause
bleeding between periods
frequent, unpredictable periods whose lengths and heaviness vary
very heavy periods
infertility
some may even have no symptoms

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60
Q

Uterine Polyps - ix

A

transvaginal ultrasound
hysteroscopy
endometrial biopsy

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61
Q

Uterine Polyps - mx

A

watchful waiting - may resolve on their own
hormonal medications
surgical removal

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62
Q

Endometrial Hyperplasia - patho

A

precancerous condition in which there is an irregular thickening of the uterine lining

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63
Q

Endometrial Hyperplasia - s/s

A

heavy periods
longer periods
intermenstrual bleeding
short menstrual cycles
post menopausal bleeding
anaemia - due to heavy menstrual bleeding

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64
Q

Endometrial Hyperplasia - Risk Factors

A

early menarche
nulliparity
diagnosed with infertility
late menopause
obese
tamoxifen
prescription oestrogen without progesterone

diabetes
PCOS
thyroid disease
gallbladder disease
lynch syndrome
cowden syndrome
oestrogen secreting tumour
family history of cancer

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65
Q

Endometrial Hyperplasia - ix

A

pelvic examination
transvaginal ultrasound
biopsy
hysteroscopy

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66
Q

Endometrial Hyperplasia - mx

A

hormonal contraception
LNG-IUS
hysterectomy may be considered

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67
Q

Pre-Menstrual Dysphoric Disorder - patho

A

Condition similar to PMS that also happens in the week or two before your period starts as hormone levels begin to fall after ovulation

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68
Q

Pre-Menstrual Dysphoric Disorder - s/s

A

lasting irritability or anger that may affect other people
feelings of sadness or despair, even thoughts of suicide
feelings of tension or anxiety
panic attacks
mood swings, crying often
lack of interest in daily activities and relationships
trouble thinking and focusing
tiredness or low energy
food cravings or binge eating
trouble sleeping
feeling out of control
physical symptoms - cramps, bloating, breast tenderness, headaches, joint/muscle pain

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69
Q

Pre-Menstrual Dysphoric Disorder - diagnosis

A

Must have 5 or more PMDD symptoms, including one mood-related symptom

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70
Q

Pre-Menstrual Dysphoric Disorder - mx

A

SSRIs
contraceptives
paracetamol +/- NSAIDs
stress management, relaxation techniques
healthy changes - diet and exercise
safety netting - feel unsafe, thinking of harming yourself or others, seek further help

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71
Q

Menopause -patho

A

natural cessation of menstruation due to loss of ovarian follicular activity
occurs between the ages of 45-55, mean age 51

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72
Q

What is premature menopause?

A

when menopause occurs prior to the age of 40

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73
Q

What is perimenopause?

A

occurs prior to menopause and is characterised by an irregular menstrual cycle and vasomotor symptoms

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74
Q

What is post-menopause?

A

The time after periods have ceased for 12m

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75
Q

Menopause - physiology

A

number of follicles falls with each menstrual cycle
as the oocytes fall, there’s a fall in follicular activity - causing a marked reduction in oestrogen and inhibin. Negative feedback on the pituitary is alleviated, results in higher amounts of LH and FSH
decrease in oestrogen results in vasomotor symptoms (flushing, sweats)
estradiol production falls, results in amenorrhoea
changes result in a permanently lowered level of oestrogen and high levels of FSH and LH

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76
Q

Menopause - s/s

A

menstrual irregularity
vasomotor symptoms - common, first symptoms noticed, last for a median duration of 7 years, hot flushes and night sweats in particular
urogenital symptoms - vaginal dryness, dyspareunia, UTIs
other - anxiety/depression, difficulty concentrating, sleep disturbance, reduced libido, musculoskeletal pains

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77
Q

Menopause - diagnosis

A

over the age of 45, diagnosis can be made in women with:
*perimenopause based on vasomotor symptoms and irregular periods
*menopause in women who have not had a period for at least 12m and are not using hormonal contraception
*menopause based on symptoms in women without a uterus

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78
Q

Menopause - HRT

A

can help with symptoms of menopause

women with a uterus are given combined oestrogen and progesterone HRT
women without a uterus are given oestrogen only HRT

topical HRT is also available; typically used to help with vaginal dryness

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79
Q

Menopause - HRT - adv/disadv

A

breast cancer - combined HRT is associated with an increased risk
ovarian cancer - small increased risk
VTE - increased risk with oral HRT
stroke - increased risk with oral oestrogen

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80
Q

Menopause - mx

A

lifestyle modifications - exercise can help, weight loss can be advised, good sleep hygiene

contraception - HRT will not act as contraception, may be fertile for one/two years after their last period, should use contraception to cover this period

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81
Q

Causes of post-menopausal bleeding?

A

atrophic vaginitis
endometrial atrophy
cervical or womb polyps
endometrial hyperplasia
less commonly - it can be caused by cancer (e.g. ovarian and womb)

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82
Q

Investigations for post-menopausal bleeding

A

transvaginal ultrasound
speculum examination
hysteroscopy with biopsy
bimanual examination
bloods

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83
Q

Management of post menopausal bleeding

A

Depends on the cause

cervical polyps- surgical removal
vaginal or endometrial atrophy- may not need treatment; oestrogen creams/pessaries
endometrial hyperplasia- may be offered no treatment, hormonal treatment or total hysterectomy
HRT side effect - changing medications
womb cancer - total hysterectomy recommended with radio/chemotherapy, hormone therapy, often a combination of treatments

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84
Q

Urinary Incontinence - s/s

A

involuntary leakage of urine

o/e - leakage with “stress test”, pelvic organ prolapse, pelvic floor contraction, other pelvic pathology

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85
Q

Urinary Incontinence - causes

A

UTIs
overactive bladder
genuine stress incontinence
retention with overflow

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86
Q

Urinary Incontinence - Types

A

Stress incontinence
Urgency incontinence
Mixed incontinence
Overflow incontinence

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87
Q

Stress Urinary Incontinence - patho/risk factors

A

Incontinence occurs secondary to a rise in intra-abdominal pressure - triggered by coughing, sneezing, exertion

RFs:
age; pregnancy and vaginal delivery, constipation, obesity, family history

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88
Q

Urinary Incontinence - ix

A

identify the underlying type of UI
hx and examination
bedside: urine dip +/- MSU, bladder scan
patient-based assessments: bladder diaries, quality of life assessments
urodynamic testing

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89
Q

Stress Urinary Incontinence - mx

A

lifestyle - consistent fluid, not excess or insufficient; pelvic floor muscle training; specialist care
surgical: colposuspension, autologous rectus fascial sling
duloxetine may be offered second line

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90
Q

Urgency Urinary Incontinence - patho

A

characterised by the urge to pass urine associated with involuntary leakage
occurs secondary to an overactive bladder
occurs due to detrusor muscle overactivity that leads to involuntary contractions of the bladder
usually idiopathic; but can be secondary to some neurological disorders

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91
Q

Urgency Urinary Incontinence - mx

A

lifestyle - consistent fluid intake, reduce caffeine, weight loss
bladder training - 6wks; trains the bladder to tolerate larger volumes of urine; attempt to hold the urine for gradually increasing lengths of time
pharmacological - anticholinergic therapy can be used - oxybutynin 1st line

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92
Q

Overflow Urinary Incontinence - patho

A

happens when someone is unable to empty their bladder; incontinence occurs when the bladder is too full
can be secondary to physical obstruction (prolapse, fibroids, following pelvic surgery) or underactivity of the detrusor muscle (peripheral neuropathy, MS, antimuscarinics)

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93
Q

Overflow Urinary Incontinence - mx

A

all patients should be managed under a urogynaecologist/uro/gynaecologist
obstruction may require surgical treatment
catheterisation may be considered when pathology cannot be corrected

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94
Q

Duloxetine for urinary incontinence
dosage
drug class
contra indications
side effects

A

40mg BD, then assessed for benefit and tolerability after 2-4wks

Serotonin and noradrenaline re-uptake inhibitor

allergic reaction, glaucoma, kidney/liver impairment, taking other medications for depression

dry mouth, headache, dizziness, nausea, sexual dysfunction, reported increased risk of suicide

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95
Q

Oxybutynin for urinary incontinence
dosage
drug class
contraindications
side effects

A

5mg TDS
Antimuscarinic
glaucoma, GI obstruction, MA, ileus, pyloric stenosis
diarrhoea, dry mouth, dizziness, headache, constipation, vision disorders, urinary retention, confusion

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96
Q

Uterovaginal Prolapse - anatomy

A

ligaments involved - round, ovarian, broad ligaments; uterosacral ligament most important in preventing prolapse

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97
Q

Uterovaginal Prolapse - Risk Factors

A

trauma during childbirth
multiple vaginal births
obesity
chronic coughing or straining
chronic constipation

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98
Q

Uterovaginal Prolapse - patho

A

incomplete prolapse - uterus drops part way down into the vagina, creates a bulge
complete prolapse - uterus slips down and protrudes out of the vagina

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99
Q

Uterovaginal Prolapse - s/s

A

symp- heaviness or pressure in pelvis; pelvic pain; abdominal or lower back pain; dyspareunia; recurrent UTIs; urinary incontinence; symptoms worsened by prolonged standing or walking (added pressure on muscles by gravity)

o/e - protrusion of tissue at opening of vagina (in complete prolapse); excessive vaginal discharge

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100
Q

Cystocele - patho/anatomy

A

supportive tissues around the bladder and vaginal wall weaken and stretch, allowing bladder and vaginal wall to fall into the vaginal canal

anterior vaginal prolapse

s/s - difficulty starting urine stream, incomplete emptying of the bladder, frequency/urgency or urination, may have stress incontinence

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101
Q

Rectocele - patho/anatomy

A

prolapse where supportive wall of tissue between rectum and vaginal wall weakens; the front wall of the rectum sags and bulges into the vagina

posterior vaginal prolapse

s/s- difficulty with bowel movements, sensation of rectal pressure, tenesmus

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102
Q

Uterovaginal Prolapse - ix

A

Pelvic examination

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103
Q

Uterovaginal Prolapse - mx

A

kegel exercises to strengthen pelvic floor muscles
vaginal pessary to hold the uterus in place
hysterectomy
sacrohysteropexy - resuspension of the prolapsed uterus using a mesh sling

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104
Q

Pelvic Inflammatory Disease - patho

A

infection of the upper female genital tract; polymicrobial
endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis

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105
Q

Pelvic Inflammatory Disease - risk factors

A

<25 years of age
risky sexual behaviour
earlier age at first intercourse
increasing number of sexual partners
previous STI
uterine instrumentation - surgical TOP for example
post partum endometriosis

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106
Q

Pelvic Inflammatory Disease - s/s

A

symp- lower abdominal or pelvic pain, chills, deep dyspareunia, dysuria, nausea or vomiting, IMB/PCB

o/e- fever, abnormal cervical discharge or bleeding, cervical friability, abnormal vaginal odour, ecchymosis (erythema) and swelling, diffuse tenderness, RUQ tenderness (perihepatic space may be involved)
cervical motion tenderness, adnexal tenderness, uterine tenderness

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107
Q

Pelvic Inflammatory Disease - ix

A

uss - transvaginal if tubo-ovarian abscess is suspected
swabs for STIs
screen for other STIs

FBC, CRP

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108
Q

Pelvic Inflammatory Disease - mx

A

Ceftriazone 1g stat dose
Doxycycline 400mg
Metronidazole 400mg
for 14 days

109
Q

Pelvic Inflammatory Disease - complications

A

infertility
ectopic pregnancy
Fitz-Hugh Curtis syndrome - infection of liver with multiple peritoneal adhesions

110
Q

Ovarian Cyst -patho

A

fluid-filled sac/s within an ovary

111
Q

Ruptured Ovarian Cyst - s/s

A

unilateral lower abdominal/pelvic pain
sudden onsent, usually after physical activity
may have signs of ‘acute abdomen/shock’

112
Q

Ruptured Ovarian Cyst - Risk Factors

A

endometrioma
dermoid cyst
bleeding diathesis - increased susceptibility to bleeding/bruising
anticoagulation

113
Q

Ruptured Ovarian Cyst - ix

A

pelvic ultrasound - will find free fluid usually in the rectouterine pouch

114
Q

Ruptured Ovarian Cyst - mx

A

haemodynamically stable - conservative symptom management

haemodynamically unstable - laparoscopy for haemorrhage control

115
Q

Ovarian Torsion - patho

A

xy

116
Q

Ovarian Torsion - s/s

A

unilateral lower abdominal/pelvic pain
sudden onset
nausea/vomiting

117
Q

Ovarian Torsion - ix

A

pelvic ultrasound with Doppler - enlarged ovary with decreased blood

118
Q

Ovarian Torsion - mx

A

detorsion if ovary is viable

119
Q

Acute Pelvic Pain - differentials

A

APP in a woman of reproductive age with a +ve pregnancy test is an ectopic pregnancy until proven otherwise
miscarriage
PID
ovarian cyst - torsion, haemorrhage, rupture
torsion of fallopian tube, salpingo-ovarian abscess
endometriosis
1` dysmenorrhoea
non-gynaecological cause (appendicitis, IBS/IBD, mesenteric adenitis, diverticulitis, UTI, MSK)

120
Q

Acute Pelvic Pain - hx

A

Pain - SQITARS
LMP
contraception
recent UPSI
risk factors for an EP - PID, ART
vaginal discharge, bleeding
bowel symptoms
urinary symptoms
precipitating factors

121
Q

Acute Pelvic Pain - ix

A

o/e - haemodynamically stable? acute abdomen? pelvic (discharge, cervical excitation, adnexal tenderness, masses?)

hCG
MSU
triple swabs (high vaginal, cervical and endocervical)
FBC, G&S, CRP,pelvic USS - TV or abdo
abdominal X-ray, CT, MRI as appropriate
diagnostic laparoscopy

122
Q

Acute Pelvic Pain - mx

A

resuscitate if necessary
analgesia
specific treatment will depend on the cause
avoid unnecessary laparoscopy

123
Q

Chronic Pelvic Pain - patho

A

Intermittent or constant pelvic pain in the lower abdomen or pelvis of at least 6m duration, not occurring with menstruation or intercourse, not associated with pregnancy
severe enough to cause functional disability or require treatment

124
Q

Chronic Pelvic Pain - causes

A

endometriosis
adenomyosis
adhesions
chronic PID
fibroids

IBS, constipation, hernia, interstitial cystitis, calculi, fibromyalgia, nerve entrapment, neuropathic pain

125
Q

Chronic Pelvic Pain - ix

A

as for acute pelvic pain

126
Q

Chronic Pelvic Pain - mx

A

analgesia
hormonal treatments
surgical option of hysterectomy, limited role but can be helpful

127
Q

Pelvic Pain in Pregnancy - causes

A

pregnancy-related pelvic girdle pain

128
Q

Pelvic Girdle Pain - s/s

A

pain in the pubic region, lower back, hips, groin, thighs or knees
clicking or grinding in the pelvic area
pain made worse by movement

129
Q

Pelvic Girdle Pain - mx

A

stay active
rest well
good posture
physiotherapy
warm baths
hydrotherapy
support belt or crutches
simple analgesia

130
Q

Early Pregnancy Complications

A

miscarriage
molar pregnancy
ectopic pregnancy
pregnancy of unknown location
hyperemesis gravidarum

131
Q

Molar Pregnancy - patho

A

a hydatidiform mole is type of tumour that grows like a pregnancy inside the uterus
two types: complete mole and partial mole

132
Q

Molar Pregnancy - complete mole

A

occurs when two sperm cells fertilise an ovum that contains no genetic material
the sperm combine genetic material and the cells divide and grow in to a tumour
no fetal material will form

133
Q

Molar Pregnancy - partial mole

A

occurs when two sperm cells fertilise a normal ovum containing its own genetic material
new cell has three sets of chromosomes
cell dividies and multiplies into a partial mole tumour
some fetal material may form

134
Q

Molar Pregnancy - s/s

A

cessation of periods
more severe morning sickness
vaginal bleeding
increased enlargement of the uterus
abnormally high hCG
thyrotoxicosis

uss- snowstorm appearance of the pregnancy

135
Q

Molar Pregnancy - ix

A

examination
bhCG
bloods: TFTs
imaging: ultrasound

diagnosis is confirmed with histology of the mole after evacuation

136
Q

Molar Pregnancy - mx

A

evacuation of the uterus, contents sent for histological examination to confirm molar pregnancy
referred to a gestational trophoblastic disease centre for mx and f-up
hCG levels are monitored until they return to normal
mole can metastasise and may require systemic chemotherapy

137
Q

Ectopic Pregnancy - patho

A

implantation of a conceptus outside the uterine cavity
93-95% tubal; the remainder are in CS scars, interstitial, abdominal, ovarian, cervical

138
Q

Ectopic Pregnancy - s/s

A

often asymptomatic
amenorrhoea (6-8wks)
pain (lower abdominal, often mild/vague, classically unilateral)
vaginal bleeding (usually small amount, often brown)
diarrhoea and vomiting
dizziness, light headedness
shoulder tip pain - diaphragmatic irritation - haemoperitoneum
collapse, if ruptured

signs- often no signs
normal size uterus; cervical excitation and adnexal tenderness occasionally; adnexal mass rarely; peritonism due to intra-abdominal blood if ruptured

139
Q

Ectopic Pregnancy - Risk Factors

A

history of infertility or assisted conception
history of PID
endometriosis
pelvic or tubal surgery
previous ectopic
iucd, ius, progesterone based contraception
smoking

140
Q

Ectopic Pregnancy - ix

A

tvs/uss - establish location
serum progesterone - establish whether a pregnancy is failing
serum hCG and repeat after 48hrs
laparoscopy - gold standard but only used when is necessary

141
Q

Ectopic Pregnancy - mx

A

unruptured, small and stable - conservative mx, go away on its own
unruptured, large and stable - surgical or medical mx preferred
all ruptured require surgery

142
Q

What is conservative management with regards to an ectopic pregnancy?

A

if bHCG is <1500 and falling; patient is asymptomatic; <1.5cm
will dissolve itself

143
Q

What is the medical management with regards to an ectopic pregnancy?

A

1.5-3.5cm; 1500-5000bHCG; no cardiac activity
will require methotrexate
15mg per m^2

will require reliable contraception for 3m after as methotrexate is teratogenic

144
Q

What is the surgical management with regards to an ectopic pregnancy?

A

laparoscopy to take out the ectopic and stabilise the patient
if there is cardiac activity; large >3.5cm; bHCG >5000; ruptured

145
Q

What happens after giving methotrexate?

A

pt will need bloods: FBC, LFTs - they need to be stable

146
Q

What follow up will be required after methotrexate for an ectopic?

A

follow up bHCG; more than 50% decline in a week
follow up until it is less than 15

147
Q

Hyperemesis Gravidarum -patho

A

excessive vomiting
rare (1:1000)

148
Q

Hyperemesis Gravidarum - Risk Factors

A

multiple pregnancies
molar pregnancy - due top higher amount of hCG

149
Q

Hyperemesis Gravidarum - s/s

A

1st trimester - intractable vomiting (inability to keep food or fluid down) with a triad of
1. >5% weight loss
2. dehydration
3. electrolyte imbalance

muscle wasting
ptyalism (inability to swallow saliva)
hypovolaemia
behaviour disorders
haematemesis (MWTs)

150
Q

Hyperemesis Gravidarum - ix

A

urinalysis
MSU
FBC
U&Es
LFTs
USS for reassurance and to exclude multiple and molar pregnancies

151
Q

Hyperemesis Gravidarum - mx

A

admission if not tolerating oral fluid for IV fluids (NaCl or Hartmann’s) - avoid gluocse as it can precipitate Wernicke’s encephalopathy
Daily U&es, replace K+ when necessary
Keep nil by mouth for 24hr the nintroduce light diet as tolerated
Antiemetics - cyclizine 50mg/8hr or promethazine

152
Q

Hyperemesis Gravidarum - complications

A

Maternal risks:
*liver and renal failure
*hyponatraemia and rapid reversal of hyponatraemia -> central pontine myelinolysis
*thiamine deficiency may lead to Wernicke’s encephalopathy

Fetal risks:
*FGR theoretically possible though most fetal outcome is normal
*fetal death may ensue in cases with Wernicke’s encephalopathy

153
Q

Miscarriage - defintion

A

spontaneous loss of pregnancy before 24wks of gestation
around 10-24% of clinically recognised pregnancies end in miscarriage

154
Q

Miscarriage - Risk Factors

A

fetal chromosomal abnormalities
maternal and paternal age
infection
appendicitis with surgical mx and anaesthesia
poorly controlled diabetes and thyroid disease
PCOS
hx of miscarriage
smoking
obesity
stress

155
Q

Miscarriage - s/s

A

PV bleeding
abdominal pain

156
Q

Miscarriage - classification

A

Missed
Threatened
Inevitable
Incomplete
Complete

157
Q

Missed Miscarriage - cervical os
ultrasound
description

A

closed
non-viable pregnancy
no abdominal pain or bleeding

diagnosed on a scan

158
Q

Threatened Miscarriage - cervical os
ultrasound
description

A

closed
viable pregnancy
vaginal bleeding

159
Q

Inevitable Miscarriage - cervical os
ultrasound
description

A

open
non-viable pregnancy
bleeding and/or abdominal pain

160
Q

Incomplete Miscarriage - cervical os
ultrasound
description

A

open
some remaining products of conception
partial expulsion of products of conception

lining of uterus >15mm

161
Q

Complete Miscarriage - cervical os
ultrasound
description

A

closed
no products of conception
all products of conception passed and bleeding ceased

lining of uterus <15mm

162
Q

Miscarriage - types of treatment

A

expectant, medical or surgical

163
Q

Threatened Miscarriage - treatment

A

in a viable pregnancy where the patient wishes to continue, symptoms should be monitored
if stable, pt advised to return if symptoms worsen or do not settle after 14d. analgesia, written information, contact details and safety netting advice should be given
vaginal micronised progesterone 400mg BD if had a previous miscarriage

164
Q

What is expectant management with regards to a miscarriage?

A

offered 1st line and trialled for 7-14d for missed or incomplete miscarriage
most women need no further medical intervention
if symptoms settle at 7-14 days, should take a pregnancy test at 3wks - if positive return to obstetric care

165
Q

What is medical management with regards to miscarriage?

A

mx of missed or incomplete miscarriage is vaginal or oral misoprostol - synthetic prostaglandin; stimulates uterine contraction
analgesia and anti-emetics PRN
pregnancy test advised at three weeks - positive requires specialist review

166
Q

What is the surgical management with regards to miscarriage?

A

mx of incomplete or missed miscarriage is typically indicated where expectant or medical management fails
two options:
*manual vacuum aspiration (LA)
*surgical management (GA)
Anti-D should be offered to women who are rhesus negative undergoing surgical management

167
Q

What is the psychosocial management with regards to a miscarriage?

A

Common area impacted following the loss of a pregnancy
grief, mourning, depression and anxiety are common following miscarriage
counselling and additional support should be offered where necessary

168
Q

What follow-up should be offered following a miscarriage?

A

there are numerous information leaflets and support groups to provide additional avenues for information
sex- can resume once symptoms have settled completely
wish to conceive- menstruation tends to resume at 4-8wks, give routine pre-conception advice
do not wish to conceive- discuss and offer suitable contraceptive options

169
Q

Recurrent Miscarriages - defintion

A

three or more consecutive, spontaneous miscarriages occurring in the 1st trimester with the same biological father, which may or may not follow a successful birth

170
Q

Recurrent Miscarriages - Risk Factors

A

advanced maternal age
increasing number of miscarriages

171
Q

Recurrent Miscarriages - causes

A

antiphospholipid syndrome (APS)
genetic
fetal chromosomal abnormalities
anatomical abnormalities
fibroids
thrombophilic disorders
infection
endocrine disorders
cervical weakness
immune dysfunction

172
Q

Recurrent Miscarriages - ix

A

parental blood for karyotyping
cytogenetic analysis of products of conception at the time of miscarriage
pelvic uss
thrombophilia screening
lupus anticoagulant
anticardiolipin antibodies

173
Q

Recurrent Miscarriages - mx

A

sometimes no treatment is offered; 75% chance of a succesful pregnancy next time if miscarriage was unexplained
should be seen in a dedicated clinic
surgical intervention for intrauterine abnormalities or fibroids may be helpful
antiphospholipid syndrome - combination of aspirin and heparin when viability of fetus is confirmed
cervical cerclage may be offered

174
Q

Molar Pregnancy - s/s

A

It behaves like a normal pregnancy so periods will stop and the hormonal changes will occur
a few things can indicated a molar pregnancy vs a normal pregnancy:
*more severe morning sickness
*vaginal bleeding
*increased enlargement of the uterus
*abnormally high hCG
*thyrotoxicosis (because hCG can mimic TSH and stimulate the thyroid to produce more t3 and 4)

175
Q

Molar Pregnancy - ix

A

Ultrasound (of the pelvis) - will show a characteristic ‘snowstorm appearance’ of the pregnancy
histology of the mole after evacuation provides definitive diagnosis

176
Q

Molar Pregnancy - mx

A

evacuation of the uterus to remove the mole
products of conception will be sent for histological examination
referral to a gestational trophoblastic disease centre for mx and follow-up
hCG monitoring until they return to monitoring

occasionally the mole can metastasise and the patient may require systemic chemotherapy

177
Q

Pregnancy of Unknown Location - patho

A

the situation when the pregnancy test is positive but there are no signs of intrauterine pregnancy or an extrauterine pregnancy via transvaginal ultrasound
can be:
1. too small to be seen on scan because it is earlier than 6wks
2. has passed and will be a miscarriage
3. is outside of the womb but cannot see it on a scan, this is an ectopic pregnancy

178
Q

Pregnancy of Unknown Location - s/s

A

may be asymptomatic
abdo pain
vaginal bleeding

179
Q

Pregnancy of Unknown Location - ix

A

Transvaginal ultrasound
bhCG monitoring, serial monitoring to assess pregnancy
repeat ultrasound

180
Q

Pregnancy of Unknown Location - mx

A

Depends on the underlying cause
1. small intrauterine embryo - continue with regular antenatal care
2. miscarriage - depending on type of miscarriage mx will change, expectant vs medical vs surgical mx
3. ectopic - expectant vs medical vs surgical - depends on size, rupture, bhCG etc

181
Q

Legal requirements for an abortion

A

1967 Abortion Act and 1990 Human Fertilisation and Embryology Act

182
Q

Up to what age is an abortion legal?

A

24 weeks

183
Q

What are the criteria required to justify the decision to proceed with an abortion?

A

An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental wellbeing of a) the woman and/or b) existing children of the family

the threshold for when the risk of continuing the pregnancy outweighs the risk of termination is a matter of clinical judgement and opinion of the medical practitioners

184
Q

What are the criteria required to abort a pregnancy at any time?

A
  • continuing the pregnancy is likely to risk the life of the woman
  • terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
  • there is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
185
Q

What are the legal requirement for an abortion (with regards to the doctors required etc)?

A
  • two registered medical practitioners must sign to agree abortion is indicated
  • it must be carried out by a registered medical practitioner in an NHS hospital or approved premise
186
Q

What pre-abortion care is provided?

A

-many services are accessed by self-referral pathways
women should be offered counselling and information to help decision making from a trained practitioner
informed consent is essential

187
Q

What is a medical abortion?

A

it is the most appropriate earlier in pregnancy, but can be used at any gestation
involves two drugs: mifepristone (anti-progestogen) and misoprostol (prostaglandin analogue) 1-2 days later

188
Q

Mifepristone for abortions

A

anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix

189
Q

Misoprostol in abortions

A

prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them
prostaglandins soften the cervix and stimulate uterine contractions
from 10wks gestation, additional misoprostol doses are required until expulsion

190
Q

Anti-D prophylaxis in medical TOP

A

rhesus negative women with a gestational age of 10wk+ having a medical TOP should have anti-D prophylaxis

191
Q

What is a surgical abortion?

A

surgical abortion can be performed, depending on preference and gestational age, under LA, LA+sedation, and GA

192
Q

Prior to a surgical TOP?

A

medications are used for cervical priming - this softens and dilates the cervix
misoprostol, mifepristone or osmotic dilators are used

193
Q

What is an osmotic dilator?

A

Device inserted into the cervix that gradually expands as it absorbs fluid, therefore opening the cervical canal

194
Q

What are the options for surgical TOP?

A
  1. cervical dilatation and suction of the contents of the uterus (usually up to 14wks)
  2. cervical dilatation and evacuation using forceps (14-24wks)
195
Q

Anti-D prophylaxis in surgical TOP?

A

rhesus negative women having a surgical TOP should have anti-D prophylaxis
NICE suggests it should be considered in women less than 10wks gestation

196
Q

What should women expect post-abortion?

A

vaginal bleeding and intermittent abdominal crmaping for up to two weeks after the procedure
urine pregnancy test completed 3wks after the abortion to confirm it is complete
contraception is discussed and started where appropriate
support and counselling is offered

197
Q

Complications of TOP

A

bleeding
pain
infection
failure of the abortion
damage to the cervix, uterus, other structures

198
Q

What to discuss with a patient when counselling about contraception

A

-different options available
-suitability (including assessing contraindications and risks)
-effectiveness
-mechanism of action
-instruction on use

worth mentioning that all forms of contraception are available free in the UK on the NHS

199
Q

Key Methods of Contraception

A

-natural family planning [rhythm method]
-barrier methods [condoms]
-combined contraceptive pills
-progesterone-only pills
-coils [mirena or copper]
-progestogen injection
-progestogen implant
-surgery [sterilisation or vasaectomy]

emergency contracpetion is available after unprotected intercourse, however it should not be relied upon as a regular method of contraception

200
Q

UK Medical Eligibility Criteria

A

FSRH has UKMEC guidelines from 2016 to categorise the risks of starting different methods of contraception in different individuals
UKMEC 1 - no restriction in use, minimal risk
UKMEC 2 - benefits generally outweigh the risks
UKMEC 3 - risks generally outweigh the benefits
UKMEC 4 - unacceptable risk, typically this means the method is contraindicated

201
Q

Explaining Effectiveness with regards to contraception

A

Effectiveness is expressed as a percentage
99% effective means that is an average person used this method correctly with a regular partner for a single year they would only have a 1% chance of pregnancy

202
Q

Perfect use vs typical use with regards to contraception

A

this is especially important with methods such as natural family planning, condoms, and the pill, effectiveness is very user-dependent

203
Q

What are some specific risk factors for contraception?

A

*breast cancer - avoid all hormonal contraception and opt for a copper coil or barrier methods
*cervical or endometrial cancer - avoid the Mirena coil
*Wilson’s disease - avoid the copper coil

204
Q

Specific risk factors for the combined contraceptive pill (UKMEC4)

A

uncontrolled hypertension (particularly >=160/>=100)
migraine with aura
history of VTE
aged over 35 smoking more than 15 cigarettes a day
major surgery with prolonged immobility
vascular disease or stroke
ischaemic heart disease, cardiomyopathy, or atrial fibrillation
liver cirrhosis and liver tumours
systemic lupus erythematosus and antiphospholipid syndrome

205
Q

Contraception in older and perimenopausal women

A

after their last period, contraception is required for 2 years in women under 50 and 1 year in women over 50
HRT doesn’t prevent pregnancy and extra contraception
the COCP can be used up to age 50, can treat perimenopausal symptoms
Depo-Provera should be stopped before 50 due to risk of osteoporosis

206
Q

Choice of contraception under 20

A

combined and progestogen only pills are unaffected by age
progestogen only implant us a good choice of LARC
progestogen injection is UKMEC2 due to reduced bone mineral density
Coils are UKMEC2 as they have a higher rate of expulsion

207
Q

Contraception after Childbirth

A

fertility is not considered to return until 21 days after giving birth, but after 21 days contraception is needed
the progestogen-only pill/implant can be used any time after birth and during breastfeeding
COCP avoided in breastfeeding
IUD/IUS inserted within 48hr or after 4wks

208
Q

What are the benefits of pregnancy planning?

A

allows people to attain their desired number of children, if any, and to determine the spacing of their pregnancies
it is achieved through use of contraceptive methods and the treatment of infertility
+lowers maternal ill health and number of pregnancy related deaths
+reduces the need for unsafe abortion and reduces HIV transmissions from mothers to newborns

209
Q

How to take a history from a couple presenting with infertility

A

Explore conception history - open questions about how they’ve been trying to get pregnant, how long, previous contraception
Address ICE
Pregnancy history - previous pregnancies? outcome of pregnancies? assisted reproductive techniques? mode of delivery? baby’s health outcome?
Menstrual history - regular cycles? LMP? pain?
Sexual history - how often having UPSI? any pain/bleeding? ask about previous STIs and treatment?
Systemic enquiry - screen for other symptoms in other systems
PMHx - specifically ask about smears, vaccinations, allergies
DHx - prescribed and OTC? folic acid in particular
FHx - genetic problems? haemoglobinopathies? early menopause?
SHx - smoking, alcohol, recreational drug use, diet, exercise, occupation
Partner history - a full history from the partner is required

210
Q

Primary vs Secondary failure to conceive?

A

Primary - female pt has never conceived before
Secondary - pt has conceived previously, irrespective of how the pregnancy developed, but is now struggling to conceive again

211
Q

Four basic conditions required for pregnancy

A
  1. egg must be produced: failure to release an egg is known as ‘anovulation’
  2. adequate sperm must be released: a sperm sample may be required as part of further investigations
  3. the sperm and egg must form an embryo: sexual, cervical and/or problems with the fallopian tube may prevent the sperm from reaching the egg
  4. the embryo must implant: the incidence of defective implantation is unknown
212
Q

Lifestyle issues associated with infertility

A

substance use (smoking tobacco, other tobacco products, marijuana use, heavy drinking, illegal drugs) reduces fertility
hypertension changes the shape of sperm and reduces fertility
being underweight and having very little amounts of body fat are associated with ovarian dysfunction and infertility in women
sedentary or excessive exercising can impact fertility
anxiety and depression
nutrition
high scrotal temperature (tight clothing, hot baths)
caffeine consumption

213
Q

Female factor infertility - main categories

A

Disorders of ovulation
Tubal causes
Uterine/peritoneal causes

214
Q

Female factory infertility - Disorders of ovulation

A

Group I (hypothalamic-pituitary failure) - hypogonadotropic hypogonadism; a failure to produce the required amount of LH and FSH, results in anovulation

Group II (hypothalamic-pituitary-ovulation dysfunction) - occurs as a result of polycystic ovary syndrome, the most common cause of female infertility

Group III (ovarian failure) - hypergonadotropic hypogonadism; normal hypothalamic and pituitary function but insufficient numbers of follicles within the ovary; less oestrogen produced and follicles do not develop fully; results in anovulatory cycles

Sheehan’s syndrome - ischaemic necrosis of the pituitary causes hypopituitarism; occurs as a result of severe hypotension or haemorrhagic shock secondary to massive PPH

Hyperprolactinaemia - inhibits both FSH and LH secretion, leads to menstrual dysfunction and galactorrhoea

Pituitary tumours - tumour displaces/destroys normal tissue and can affect production of FSH and LH

215
Q

Female factor infertility - Tubal causes

A

fallopian tubes are delicate and are more susceptible to damage
most common cause of tubal damage is PID
others include: previous sterilisation, endometriosis, previous pelvic surgery

216
Q

Female factor infertility - uterine/peritoneal causes

A

Most prevalent is endometriosis, causes inflammation and adhesions in the pelvis, can distort pelvic anatomy
others include: cervical mucus dysfunction/defect, previous pelvic or cervical surgery, uterine fibroids, Asherman’s syndrome, previous abdominal infections which have resulted in adhesions, congenital abnormalities

217
Q

Female factor infertility - other causes

A

unexplained
genetic factors
immune factors and systemic illnesses
medications: chemotherapy and cytotoxic agents
lifestyle factors: smoking, excessive alcohol, obesity

218
Q

Female factor infertility - 1` care ix

A

should be commenced after 1y in couples who have not conceived despite regular UPSI
-mid-luteal phase progesterone to assess ovulation
-chlamydia screening
-testing for susceptibility to rubella (protects the baby, prevents harm to the baby and having to terminate the pregnancy)
-serum progesterone
-gonadotrophins
-thyroid function tests
-prolactin

219
Q

Female factor infertility - referral to 2` care
(women less than 36yoa)

A

Referral should be considered in hx, ex, ix are normal in both partners and the couple have not conceived after 1 year

220
Q

Female factor infertility - when to consider an earlier referral to 2` care

A

-age 36+ (after 6m)
-amenorrhoea or oligomenorrhoea
-previous abdominal or pelvic surgery
-previous PID
-previous STI
-abnormal pelvic examination
-known reason for infertility (e.g. previous cancer treatment)

221
Q

Female factor infertility - 2` care ix

A

Tubal patency tests:
hysterosalpingography (screens for tubal occlusion) HSG
or diagnostic laparoscopy and dye - tubal and other pelvic abnormalities can be assessed simultaneously

222
Q

Female factor infertility - lifestyle mx

A

weight management - aim for 19-25kg/m2 BMI
psychological stress management

223
Q

Female factor infertility - medical mx

A

clomiphene 50mg OD for 5 days (anti-oestrogen drug) for induction of ovulation (e.g. anovulation in PCOS); gonadotrophins can be considered if no response to clomiphene (as an injection. risk of multiple pregnancies, ovarian hyperstimulation syndrome)

pulsatile gonadotrophin-releasing hormone can induce ovulation

dopamine agonists may be used for ovulatory disorders that are 2` to raised prolactin

IVF is next option. Artificial insemination.

224
Q

Female factor infertility - surgical mx

A

tubal microsurgery (tubal catheterisation or cannulation) in women with mild tubal disease
laparoscopy for excision or ablation of endometriosis
lap ovarian drilling may be considered if no response to clomiphene
lap ovarian cystectomy if endometriomas
lap salpingectomy in presence of hydrosalpinx

225
Q

Male factor infertility - broad categories of causes

A
  1. primary spermatogenic failure
  2. genetics
  3. obstructive azoospermia
  4. varicocele
  5. hypogonadism
  6. other
226
Q

Male factor infertility - primary spermatogenic failure - definition

A

Defined by NICE as ‘any spermatogenic abnormality caused by a condition other than hypothalamic pituitary disease’

227
Q

Male factor infertility - primary spermatogenic failure - congenital causes

A

absence of testes
cryptorchidism - absence of at least one testicle from the scrotum/undescended testicle
genetic abnormalities

228
Q

Male factor infertility -primary spermatogenic failure - acquired causes

A

testicular trauma/torsion
mumps
orchitis
testicular tumour
systemic disease (e.g. liver cirrhosis)
varicocele
cytotoxic agents

229
Q

Male factor infertility -primary spermatogenic failure - other causes

A

idiopathic

230
Q

Male factor infertility - genetic causes

A

Klinefelter’s syndrome: 47 XXY karyotype
Kallmann syndrome leading to a hypogonadotropic hypogonadism
Androgen insensitivity syndrome (karyotype of XY, but phenotypically female)

231
Q

Male factor infertility - obstructive azoospermia - definition

A

bilateral obstruction of the seminal ducts leading to a total absence of sperm in semen

232
Q

Male factor infertility - obstructive azoospermia - causes

A

absent vas deferens
post-infection
post-surgery
congenital abnormalities
cystic fibrosis

233
Q

Male factor infertility - varicocele

A

found in 25% of men with abnormal semen analysis
pathophysiology linking varicocele with infertility is unclear, potentially due to increased scrotal temperature

234
Q

Male factor infertility - primary hypogonadism

A

hypergonadotropic hypogonadism due to testicular failure

235
Q

Male factor infertility - secondary hypogonadism

A

hypogonadotropic hypogonadism due to reduced gonadotrophin-releasing hormone and/or FSH/LH scretion

236
Q

Male factor infertility - androgenic insensitivity

A

end organ resistance to gonadotrophins

237
Q

Male factor infertility - other causes

A

Medications - chemotherapy and cytotoxic agents, sulfasalazine, anabolic steroids

Psychological factors - ejaculation disorders or erectile dysfunction

Lifestyle factors - smoking, obesity, excessive alcohol, illicit drug use

238
Q

Male factor infertility - history taking

A

full medical, sexual and social history, with particular interest in:
-length of time trying to conceive
-frequency and type of sexual intercourse
-children born to the man
-ejaculatory or erectile dysfunction
-medications (sulfasalazine, chemotherapy, anabolic steroids)
-PMHx (mumps, STIs, testicular trauma, undescended testes, systemic disease [e.g. liver cirrhosis, diabetes], prior surgery [e.g. orchidopexy])
FHx (i.e. cystic fibrosis)
SHx (smoking, alcohol intake, exercise, diet, occupation)

239
Q

Male factor infertility - examination

A

-BMI calculation
-genital exam (position of urethral meatus, structural abnormalities of the penis; testicular volume and consistency, varicocele, hernia, undescended testes)
-check for signs of hypogonadism: gynaecomastia, lack of body hair growth, reduction in muscle mass
-look for signs of anabolic steroid use

240
Q

Male factor infertility - 1` care ix

A

Semen analysis
results should be compared to WHO reference values
-if results of 1st are abnormal, repeat testing is offered 3m after 1st test
-if results are normal, no further tests required

Chlamydia testing

241
Q

Male factor infertility - referral to 2` care

A

Referral is required after two abnormal semen analysis results

242
Q

Male factor infertility - when is an earlier referral to 2` care warranted

A

If the following are present:
-previous genital pathology
-previous urogenital surgery
-previous STI
-varicocele
-significant systemic illness
-abnormal genital examination
-known reason for infertility (e.g. previous cancer treatment)

243
Q

Male factor infertility - 2` care ix

A

genetic testing
sperm culture
endocrine tests - FSH and testosterone
imaging of the urogenital tract
testicular biopsy

244
Q

Male factor infertility - lifestyle mx

A

weight management
psychological stress management
lifestyle advice - smoking and alcohol cessation

245
Q

Male factor infertility - medical mx

A

hypogonadotropic hypogonadism - gonadotrophin drugs should be offered

246
Q

Male factor infertility - surgical mx

A

If obstructive azoospermia then surgical correction can be offered

247
Q

What women’s health-related screening programmes exist?

A

Breast screening - mammogram for women aged 50-71
Cervical screening - cervical smears for women aged 25-64

248
Q

What is a cervical smear?

A

During the appt, a small sample of cells are taken from the cervix
The sample is checked for specific types of HPV that can cause changes to the cells of the cervix; these are called ‘high risk’ types of HPV
If it is found, the sample is sent to histology to check for any cellular changes - this can be treated before it progresses to cervical cancer

249
Q

What is a mammogram?

A

A breast X-ray to look for any lumps/signs of early breast cancer that are too small to feel or see
A patient will have 4 mammograms taken, 2 for each breast during the appt
Each breast will be squeezed between two pieces of plastic to keep it still while the xrays are being taken

250
Q

What happens if a cervical smear comes back with HPV positive, with no abnormal cell changes?

A

invited for screening in another year and a year later, if HPV still positive then will be asked for a colposcopy

251
Q

What happens if a cervical smear comes back with HPV positive, with abnormal cell changes?

A

Get a colposcopy

252
Q

What is a colposcopy?

A

A test to take a closer look at your cervix; a microscope is used to look at the cervix in greater detail; a small sample of cells may be taken from the cervix [a biopsy]

253
Q

What are the risk factors for cervical cancer?

A

*early age of first intercourse
*higher number of sexual partners
*HPV infection
*lower socioeconomic group
*smoking
*partner with prostatic or penile cancer

254
Q

What is Cervical Intraepithelial Neoplasia [CIN]?

A

squamous cell carcinoma of the cervix exist in a pre-malignant state
CIN describes any changes to cervical epithelial cells pre-malignancy
Can be low grade or high grade

255
Q

What is CIN 1?

A

Deeper third of cells show abnormal cytoplasmic and nuclear maturation
++nuclear to cytoplasmic ratio
Loss of polarity
++mitotic figures
Hyperchromatic nuclei

256
Q

What is CIN 2?

A

Up to 2/3 of epithelium shows abnormalities

257
Q

What is CIN 3?

A

More than 2/3 of epithelium shows abnormalities

258
Q

What, on colposcopy, would raise suspicion of cervical cancer or pre-malignant changes to the cervix?

A

*intense acetowhite, pale on iodine staining
*mosaicism and punctuation due to atypical vessel formation
*raised or ulcerated surface

259
Q

Endometrial Hyperplasia - pathophysiology

A

It is a pre-malignant condition which can lead to cancer if left untreated
Most often caused by unopposed oestrogen

260
Q

Endometrial Hyperplasia - Risk Factors

A

Having irregular periods
Having an ovulation periods
Obesity
PCOS
tamoxifen
Nulliparity
Early menarche, late menopause
Post-menopausal women

261
Q

Endometrial Hyperplasia - S/S

A

Heavy periods
Long periods
Intermenstrual bleeding
Post menopausal women
Anaemia - due to heavy bleeding

262
Q

Endometrial Hyperplasia - Ix

A

Transvaginal ultrasound
Hysteroscopy with biopsy and histology is gold standard for diagnosis

263
Q

Endometrial Hyperplasia - Mx

A

Medical - progesterone either oral continuous or local IUS
Atypical hyperplasia is typically managed with a total hysterectomy due to likelihood of it progressing to cancer

264
Q

CIN - s/s

A

There aren’t always signs/symptoms associated with CIN that’s why it’s important to get screened for cervical cancer regularly

265
Q

CIN - ix

A

Biopsy will have been taken and sent for histology in order to get a diagnosis of CIN

266
Q

CIN - mx

A

If abnormal cells are seen during colposcopy then they may be removed during the procedure
LLETZ may be a procedure undertaken to remove CIN

267
Q

CIN - what is LLETZ?

A

Large Loop Excision of the Transformation Zone (LLETZ)
Diathermy is used to remove the abnormal cells from the cervix

268
Q

Lichen Sclerosus et Atrophicus - patho

A

chronic inflammatory skin disease
cause is unknown

269
Q

Lichen Sclerosus et Atrophicus - s/s

A

itchy and painful patches of thin, white, wrinkled-looking skin - in women, typically on the vulva and/or the skin around the anus
painful intercourse and difficulty on urinating

Year 4 (8 decks)

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