Revision 3 Flashcards
Define premature menopause
<40 y/o
Result of primary ovarian insufficiency
Where is oestrogen produced in women of reproductive age?
Granulosa cells that surround follicles
When can a diagnosis of menopause be made without performing any investigations?
Women over 45 with typical symptoms
When does NICE recommend considering an FSH test for menopause? (1)
1) Women <40 with suspected premature menopause
2) Women <45 with menopausal symptoms or change in menstrual cycle
At what age does the progesterone depot injection become unsuitable?
≥45 y/o
What class of drug is clonidine?
Agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain
How is clonidine effective in menopausal symptoms?
Can be helpful for vasomotor symptoms and hot flushes:
- Lowers BP
- Reduces HR
Often used when there are contraindications to HRT.
What are the 2 significant progesterone classes used in HRT?
1) C19
2) C21
What are C19 progestogens derived from?
Testosterone –> help with reduced libido
What are C12 progestogens derived from?
Progesterone - may help with mood and acne
How long before major surgery should HRT be stopped?
4 weeks
What is premature ovarian insufficiency?
Menopause before the age of 40
Hypergonadotrophic hypogonadism
What will hormonal analysis show in premature ovarian insufficiency?
Low oestrogen & progesterone
High FSH & LH
What genetic condition can premature ovarian insufficiency be associated with?
Turners syndrome
How is premature ovarian insufficiency diagnosed?
Can be diagnosed in women;
a) younger than 40 years with typical menopausal symptoms
b) plus elevated FSH
The FSH needs to be persistently raised on two separate occasions separated by more than four weeks.
Mx of lichen sclerosus?
Potent topical steroid e.g. dermovate
Most common type of ovarian cancer?
Serous cystadenocarcinoma
What is management for cervical cancers that are still contained within the cervix with aim of sparing fertility?
Radical trachelectomy - removal of cervix, upper vagina and pelvic lymph nodes
If not breastfeeding, how soon after birth can the COCP be prescribed?
3 weeks postpartum
When can the COCP be given during breastfeeding?
If 6 weeks portpartum
Which POP has a 12 hour missed pill window?
Desogestrel
Is the nexplanon implant affected by enzyme inducers?
Yes
Is the Depo-Provera injection affected by enzyme inducers?
No
What is a key investigation in cases of erythema nodosum?
CXR
Sarcoidosis and TB are 2 important causes of erythema nodosum.
What is the most common infective cause of diarrhoea in HIV patients?
What is the mainstay of treatment?
Cryptosporidium
Supportive
What may a modified Ziehl-Neelsen stain (acid-fast stain) of the stool in cryptosporidium infection reveal?
Characteristic red cysts of Cryptosporidium
What should all men presenting with ED have checked?
Their morning testosterone
What is 1st line treatment of PCP?
Co-trimoxazole (trimethoprim + sulfamethoxazole)
What test should all patients with TB be offered?
HIV test - TB classified as ‘AIDS-defining illness’
1st line management of trichomonas vaginalis?
Oral metronidazole
What timeframe differs emergency contraception vs abortion?
<5 days is post-coital contraception (i.e. emergency contraception)
What phase of the menstrual cycle do women experience PMS?
Luteal phase
What is UKMEC for COCP for patients in wheelchair?
UKMEC 3
What drug can lead to false negative results on the urea breath test?
Abx used to treat H. pylori e.g. amoxicillin
It is recommended that patients should not have taken any antibiotics within 4 weeks prior to the test to ensure accurate results.
How soon after surgery can the COCP be restarted?
2 weeks after
What is the most common cause of pruritus vulvae?
irritant contact dermatitis (e.g. latex condoms, lubricants)
Investigation pathway in post-menopausal bleeding?
1) ≥55 y/o with PMB –> refer under 2ww
2) Referred for TV US to assess endometrial thickness
3) If thickness ≥4mm –> hysteroscopy with endometrial biopsy
4) Thickness <4mm has strong negative predictive value
Management of FGM in girls <18?
Report to police
When should admission to hospital be considered for N&V in pregnancy? (2)
1) Weight loss
and/or
2) Ketonuria
In early pregnancy, what type of ovarian cysts are common?
Corpus luteum cysts.
These usually resolve from the second trimester on wards.
What is the leading environmental contributor to PCOS?
Post-natal obesity
What 2 mechanisms can lead to excess androgen production in PCOS?
Due to 1 or both:
1) Excess LH production
2) Hyperinsulinemia and insulin resistance
How can hyperinsulinemia and insulin resistance lead to excess androgen production?
Excess insulin in the blood promotes androgen production by the ovaries.
Hyperinsulinemia may stimulate the ovary to over-produce testosterone and prevent the follicles from growing normally to release eggs. This causes the ovaries to become polycystic.
Most women with PCOS have “cysts” found on their ovaries. What are these cysts?
These are immature follicles which have had their ovulation phase arrested.
Cause of cysts in PCOS?
This occurs due to an elevated baseline of LH and lack of LH surge (as in a normal menstrual cycle).
What criteria is used for making a diagnosis of PCOS?
Rotterdam criteria
What is the Rotterdam Criteria?
A diagnosis requires at least 2 of the 3 key features:
1) Hyperandrogenism, characterised by hirsutism and acne
2) Polycystic ovaries on US
3) Oligoovulation or anovulation, presenting with irregular or absent menstrual periods
What is the most common symptom of PCOS?
Hirsutism
Role of sex hormone binding globulin (SHBG)?
SHBG normally binds to androgens and suppresses their function.
SHBG levels in PCOS?
Low
How are insulin and androgens related?
1) Insulin promotes release of androgens from ovaries and adrenal glands
2) Insulin suppresses SHBG production by liver - results in rise in androgens
How will testosterone be affected in PCOS?
Raised
How will LH to FSH ratio be affected in PCOS?
Raised (LH high compared to FSH)
(Remember, LH high in PCOS but FSH high in premature ovarian failure).
How will LH be affected in PCOS?
Raised
How will insulin be affected in PCOS?
Raised
Gold standard investigation for visualising the ovaries?
TV US
What is the screening test of choice for diabetes in patients with PCOS?
2-hour 75g oral glucose tolerance test (OGTT).
What OGTT result implies an impaired fasting glucose?
Fasting glucose of 6.1-6.9
What OGTT result implies an impaired glucose tolerance?
7.8 to 11.1 2 hours after
What drug may be used to help weight loss in women with a BMI above 30?
Orlistat
What class of drug is orlistat?
Lipase inhibitor
Why can PCOS increase risk of endometrial cancer?
1) Women with PCOS do not ovulate (or ovulate infrequently)
2) Therefore do not produce sufficient progesterone due to no corpus luteum
3) They continue to produce oestrogen and do not experience regular menstruation.
4) Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation.
5) Endometrial hyperplasia and significant risk of endometrial cancer
What is the most common complication of PCOS?
Inferility
What endometrial thickness needs a referral to exclude endometrial hyperplasia or cancer in PCOS?
> 10mm
Options for reducing the risk of endometrial hyperplasia and endometrial cancer in PCOS?
1) mirena coil for continuous protection
2) inducing withdrawal bleed every 3 months:
- COCP
- cyclical progestogens e.g. medroxyprogesterone acetate
What is licensed for the treatment of hirsutism and acne in PCOS?
Co-cyprindiol (Dianette) –> a COCP
What are the 2 types of functional ovarian cysts?
1) follicular cysts (most common)
2) corpus luteum cysts
When are corpus luteum cysts typically seen?
Early pregnancy
What type of ovarian cyst can become huge, taking up lots of space in the pelvis and abdomen?
Mucinous cystadenoma
What type of ovarian cyst is associated with ovarian torsion?
Dermoid cyst/germ cell tumour (teratoma)
Give 2 types of sex cord-stromal tumours?
1) Sertoli-Leydig cell tumours
2) Granulosa cells tumours
Premenopausal women with a simple ovarian cyst less than what size do not need further investigations?
<5cm on US
What tumour markers are required for women under 40 with a complex ovarian mass?
LDH
hCG
AFP
How are cysts in postmenopausal women managed?
Need to get Ca-125 –> 2ww referral if raised
What is Meig’s syndrome? What is the triad of symptoms?
A triad of:
1) pleural effusion
2) ovarian cyst (fibroma)
3) ascites
What is most common cause of ovarian torsion?
Usually due to an ovarian mass larger than 5cm e.g. cyst or tumour
Is ovarian torsion more likely to occur with benign or malignant tumours?
Benign
Definitive diagnosis of ovarian torsion?
Laparoscopic surgery
Why is pelvic US not reliable for PCOS diagnosis in adolescents?
Pelvic US should not be used for the diagnosis of PCOS in those with a gynaecological age of < 8 years (i.e. < 8 years post menarche) due to the high incidence of multi-follicular ovaries in this life stage.
What is typically used 1st line for infertility in PCOS? (after weight loss)
Clomifene
How manysamples are needed to diagnose premature ovarian failure?
2
What type of ovarian cyst can cause pseudomyxoma peritonei if it ruptures?
Mucinous cystadenoma
What is the most most common type of epithelial cell ovarian tumour?
Serous cystadenoma
What bloods are indicated in PCOS?
- FSH
- LH
- Testosterone
- SHBG
- TSH
Which gene mutation confers the highest risk for ovarian cancer?
BRCA1
Referral for suspected ovarian cancer if there is a palpable pelvic mass?
CA125 and US test can be bypassed and the patient directly referred to gynaecology (urgently)
What is the Rokitansky protuberance?
The inner lining of every mature cystic teratoma contains single or multiple white shiny masses projecting from the wall toward the centre of the cysts.
When hair, other dermal appendages, bone and teeth are present, they usually arise from this protuberance. This protuberance is referred to as the Rokitansky protuberance.
What is the most common type of ovarian pathology associated with Meigs’ syndrome?
Fibroma
What is the most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst (teratoma)
What is the most common cause of ovarian enlargement in women of a reproductive age?
Follicular cyst
In what 2 conditions is cervical excitation found?
1) PID
2) Ectopic pregnancy
What is a vault prolapse?
Occurs in women who have had a hysterectomy.
The top of the vagina (the vault) descends into the vaginal canal due to a loss of support.
What is used to assist examination in pelvic organ prolapse?
A Sim’s speculum (U shaped) - can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined.
What system is used to grade uterine prolapses?
Pelvic organ prolapse quantification (POP-Q)
Describe grade 0-4 of the POP-Q
Grade 0 - nothing
Grade 1 - lowest part is >1cm above the introitus
Grade 2 - lowest part is within 1cm of introitus (above or below)
Grade 3 - lowest part is >1cm below introitus, but not fully descended
Grade 4 - full descent with eversion of vagina
What can a prolapse extending beyond the introitus be referred to as?
uterine procidentia
What can be prescribed alongside vaginal pessaries to reduce irritation & erosion?
Oestrogen cream
What is overflow incontinence?
Occurs when there is chronic urinary retention due to an obstruction to the outflow of urine.
E.g. due to fibroids, pelvic tumours, anticholinergic medications, MS, spinal cord injuries, diabetic neuropathy.
Is overflow incontinence more common in men or women?
Men
What happens if a woman presents with overflow incontinence?
Referral for urodynamic testing and specialist management.
How is the strength of the pelvic muscle contractions graded?
Using the modified Oxford grading system
What investigations can be done in urinary incontinence?
(4)
1) Bladder diary
2) Urine dipstick e.g. UTI
3) Post-voidal residual bladder volume
4) Urodynamic studies
How soon before urodynamic tests should patients stop taking any anticholinergic and bladder related medications?
5 days before
What outcome measures are taken in urodynamic tests?
1) Cystometry
2) Uroflowmetry
3) Leak point pressure
4) Post-void residual bladder volume
What is cystometry?
Measure of detrusor muscle contraction and pressure
What does management of STRESS incontinence involve?
1) Lifestyle:
- avoid caffeine, diuretics, overfilling of bladder
2) Weight loss
3) Pelvic floor exercises
4) Surgery
5) Duloxetine (if surgery is less preferred)
Which drug is prescribed in stress incontinence if surgery is not preferred?
Duloxetine (SNRI)
How long must pelvic floor exercises be done before considering surgery in stress incontinence?
At least 3 months and supervised.
Women should aim for at least eight contractions, three times daily.
Stepwise mx of urge incontinence/overactive bladder?
1) Bladder retraining (for at least 6 weeks)
2) Anticholinergics e.g. oxybutynin
3) Mirabegron (alternative to anticholinergics)
4) Surgery
When would mirabegron be used as an alternative medical treatment for urge incontinence?
Has less anticholinergic burden
1st line management for urge incontinence?
Bladder retraining
Contraindication of mirabegron?
Uncontrolled HTN
Mirabegron works as a beta-3 agonist, stimulating the SNS, leading to raised BP.
This can lead to a hypertensive crisis and an increased risk of TIA and stroke.
What must be monitired regularly during treatment with mirabegron?
BP
