SBA revision Flashcards
Amenorrhoea + High Oestradiol, High Prolactin
Low LH
Low FSH
Pregnancy
- Elevated oestradiol (secreted by placenta) , suppressed LH/FSH
Prolactin also rises in pregnancy
Causes of gynaecomastia?
Gynaecomastia describes an abnormal amount of breast tissue in males and is usually caused by an increased oestrogen:androgen ratio. It is important to differentiate the causes of galactorrhoea (due to the actions of prolactin on breast tissue) from those of gynaecomastia
Causes of gynaecomastia physiological: normal in puberty syndromes with androgen deficiency: Kallman's, Klinefelter's testicular failure: e.g. mumps liver disease testicular cancer e.g. seminoma secreting hCG ectopic tumour secretion hyperthyroidism haemodialysis drugs: see below
Drug causes of gynaecomastia spironolactone (most common drug cause) cimetidine digoxin cannabis finasteride gonadorelin analogues e.g. Goserelin, buserelin oestrogens, anabolic steroids Ramapril (rare) Thiazide diuretics (Rare)
Very rare drug causes of gynaecomastia tricyclics isoniazid calcium channel blockers heroin busulfan methyldopa
Drug cause sof Gynaecomastia?
spironolactone (most common drug cause) cimetidine digoxin cannabis finasteride gonadorelin analogues e.g. Goserelin, buserelin oestrogens, anabolic steroids
SBHG levels - what conditions decrease/increase it?
SHBG levels may be decreased in: Obesity Hypothyroidism Androgen use Nephrotic syndrome Cushing's disease, and Acromegaly. Levels may be increased in: Hepatic cirrhosis Hyperthyroidism, and Oestrogen use. SHBG levels fall when testosterone production increases, with oestrogens increasing SHBG synthesis in liver. Pregnancy leads to increased oestrogens and thus increases SHBG synthesis.
What are mirror movements and what syndrome are they seen in?
Mirror movements (for example, clicking the fingers of the right hand and seeing a similar involuntary movement in the left hand) are characteristic of X linked Kallmann’s syndrome.
Causes of hypergonadotrophic hypogonadism?
Causes of hypergonadotrophic hypogonadism (high FSH, low oestradiol)
Gonadal dysgenesis 45 XO (Turner syndrome)
Gonadal dysgenesis 46 XY (Swyer syndrome)
Gonadal dysgenesis 46 XX
Familial gonadal dysgenesis 17-hydroxylase deficiency
Galactosaemia
Ataxia telangiectasia
Myotonia dystrophica
Autoimmune disorders
Chemotherapy/radiation therapy (ovarian cytotoxicity)
Resistant ovary syndrome
Menopause, premature ovarian failure.
In the case of women who are taking the combined oral contraceptive pill, because of inhibition of the pituitary by raising concentrations of oestrogen, the secretion of FSH is inhibited.
What is Mendelson syndrome?
Mendelson’s syndrome is chemical pneumonitis caused by aspiration during anaesthesia, especially during pregnancy. Aspiration contents may include gastric juice, blood, bile, water or an association of them.
The risk of aspiration - Mendelson’s syndrome - can be reduced through appropriate anaesthetic measures (i.e. cricoid pressure) and through prior use of acid suppressant therapy. Pressure applied posteriorly through the cricoid cartilage can be utilised to occlude the oesophagus and reduce the risk of regurgitation during induction. In most adults, cricoid pressure would be reserved for rapid sequence induction (or any other situation where they were thought to be at high risk of aspiration). But in pregnancy they are felt to all be at high risk of aspiration, cricoid pressure is much more frequently used.
Why do you get hyperthyroidism in pregnancy?
Because B-HCG can mimic TSH
What is Omental Cake?
The diagnosis is omental carcinomatosis (cake), secondary to ovarian carcinoma.
There is extensive ascites filling the anterior abdomen. In addition there is abnormal soft tissue related to the omentum of the bowel. This is known as omental cake, which is commonly associated with ovarian carcinoma - this patient had a raised CA 125.
Other common associations are stomach and pancreatic carcinoma.
What is the Pearl Index?
Methods of contraception are compared by the Pearl index.
A high Pearl index stands for a high chance of unintentionally getting pregnant; a low value for a low chance.
The Pearl index will be determined by the number of unintentional pregnancies related to 100 women years. For example, 100 women can use contraception for one year each with the method that is going to be examined. If three pregnancies occur during this period in this group, the Pearl index will be 3.0.
To give some examples, the Pearl index of condoms is 3-12 and that of the OCP is 0.1 to 1.
Hyperthyroidism in pregnancy?
Mx?
Graves’ disease is the commonest cause of hyperthyroidism in pregnancy, and the incidence is roughly 1 in 500 to 1 in 2,000.
Radio-iodine is absolutely contraindicated in pregnancy due to the risk to the fetal thyroid.
The most appropriate treatment is carbimazole/Propylthiouracil and as both drugs cross the placenta the minimal dose of each should be used so as to render the patient euthyroid. It needs careful monitoring of TFTs and dose adjustment.
Both carbimazole and PTU are excreted in small amounts in breast milk. Usually they are of no consequence and breast feeding is not absolutely contraindicated however it is obviously not ideal to take either whilst breastfeeding.
Testicular tumour age groups?
The main differentiating factor here is the age of the patient. Teratomas are tumours that more commonly occur in patients of the age group 20-30 and seminomas in the age group 30-50.
Features of infants of diabetic mothers?
Hypoglycaemia (as the fetus has been exposed to high circulating glucose levels resulting in the insulin hypersecretion and hence macrosomia) Congenital abnormalities Talipes Congenital heart defects Polycythaemia Hypocalcaemia Birth injuries/shoulder dystocia.
A 22-year-old man returned from a trip to West Africa two days ago. He is complaining of multiple painful ulcers on his penis. He admits to having unprotected sex with a local woman a few days before he left the country.
On examination there are multiple ulcers on his penis, they have a purulent base and bleed when they are touched, the edges are undermined. He has left sided inguinal lymphadenopathy.
- Chancroid (gram -ve Haemophilus ducreyi)
- Common in tropics, incubation period 3-10days
- Tx: Abx eg. Cipro + STI screen
Other causes of ulcers:
- LGV (chlamydia trachomatis) - PC usually solitary ulcer that may be painless, and can be associated with urethritis and proctitis
- HSV/HZV - both also present with multiple painful ulcers, but incubation period typically longer
- Primary syphilis (Painless, indurated)
Which Hep is most common in gays?
HBV - Especially as it is more transmissable by sex than HCV
Von Willebrand’s disease?
Von Willebrand’s disease is the most common hereditary bleeding disorder with autosomal dominant inheritance.
It is caused by a deficiency of von Willebrand factor, which causes platelets to adhere to the blood vessel wall and to each other.
The coagulation profile depends on the subtype of vWD but in the most common (and mild) cases it will show:
Normal platelet count
Prolonged bleeding time
Normal (slightly prolonged) APTT, and
Normal PT.
Diagnosis is confirmed with reduced ristocetin co-factor or reduced vWF factor concentrations.
Because factor VIII is bound to vWF while inactive in circulation it is possible to have relatively reduced factor VIII too, which can prolong the APTT in addition to bleeding time.
In haemophilia A (an isolated defect in factor VIII) there would be a very prolonged APTT with normal vWF levels. Bleeding time would be less abnormal.
Haemophilia B : F9 deficiency (X-linked)
Post-partum thyroiditis?
Tends to occur within the three months of delivery followed by a hypothyroid phase at three to six months, followed by spontaneous recovery in one third of cases. In the remaining two-thirds, a single-phase pattern or the reverse occurs.
Management is centred on symptomatic treatment using beta-blockers for relief of tremor or anxiety, and observation for the development of persistent hypo- or hyperthyroidism.
Carbimazole and propylthiouracil (PTU) are thyroid peroxidase inhibitors. They are used in thyrotoxicosis however post-partum thyroiditis is usually transient, therefore symptomatic treatment (with beta-blockers) should be enough.
Radioactive iodine is used in thyrotoxicosis that has not responded to PTU or carbimazole. Lugol’s iodine is part of the treatment of a thyrotoxic storm, in which the patient would be much more clinically unwell and is not the diangosis here.
Epilepsy & pregnancy
In pregnancy total plasma concentrations of anticonvulsants fall, so the dose may need to be increased.
Lamotrigine is probably the best choice of antieptileptic for generalised epilepsy in women of child-bearing age. It doesn’t have any major known teratogenic effects but it cannot conclusively be said to be safe. She should receive high-dose folate supplements.
Screening with alpha fetoprotein (AFP) and second trimester ultrasound are required. Vitamin K should be given to the mother prior to delivery.
APS antibodies?
Anticardiolipin antibodies may be found.
Venous thrombi occur more often if lupus anticoagulant is positive and arterial thrombi if IgG or IgM antiphospholipid antibody are positive. Long term warfarin is indicated.
SERMs?
Raloxifene is the first of the so-called selective oestrogen receptor modulators.
There are fundamentally two types of oestrogen receptor, alpha and beta, distributed at locations such as breast, uterus, bone and in the vasculature.
Raloxifene acts as an oestrogen agonist at some sites, for example, bone to increase mineralisation, but acts as an antagonist at other sites, for example, uterus/breast (preventing endometrial/breast hyperplasia).
It differs from tamoxifen in this regard, because tamoxifen (another SERM) acts as a partial agonist at the endometrium, so can promote endometrial hyperplasia.
- Clomifene is also a SERM
Tamoxifen:
In breast tissue, the drug acts as an antagonist at the oestrogen receptor although it acts as an agonist at other tissues in the body such as the endometrium. Since oestrogen receptor positive breast cancers require the action of oestrogen on the neoplastic cells to grow, blockade at the level of the receptor by tamoxifen reduces the risk of neoplastic transformation or tumour growth. However, in the endometrium, tamoxifen is an agonist at oestrogen receptors and this has the potential to promote carcinomatous growth. For this reason, use of tamoxifen is generally restricted to a maximum of five years to reduce the likelihood of endometrial cancer.
Another site where tamoxifen acts as an agonist is at bone. The effect of activation of oestrogen receptors on bone is to inhibit osteoclast activity and so it acts as a bone density protector and reduces the incidence of osteoporosis.
When in prostate cancer based on PSA would hormonal therapy be indicated?
Hormonal therapy not routinely recommended for men with prostate cancer who have a biochemical relapse unless they have:
- Symptomatic local disease progression
- Any proven mets
- PSA doubling time
Haematuria one stop clinic?
In the haematuria clinic the following tests are carried out:
Urine for microscopy, culture and sensitivity - to rule out an infection as the cause of the bleeding.
Urine cytology - high grade bladder cancer will show malignant cells on cytology.
Cystoscopy (flexible) - endoscopic procedure to visualise the bladder mucosa in order to identify bladder lesions or stones.
Ultrasound of the renal tract - to identify any renal tumours.
What is Fournier’s gangrene?
Fournier’s gangrene is a true urological emergency. Early recognition and surgical debridement is the key to successful treatment.
Fournier’s gangrene is a necrotising fasciitis of the perineum which can rapidly spread to the skin of the entire scrotum and penis (1-2 cm/h). Mortality is high and averages 20-30%.
Risk factors include
Diabetes mellitus (most common)
Alcohol dependence
Immunosuppressive therapy
Longstanding steroid therapy
Malnutrition
HIV
Extremes of age and
Low socio-economic status.
Cellulitis is a non-necrotising inflammation of the skin and subcutaneous tissues, a process related to acute infection that does not involve the fascia or muscles.
A scrotal abscess presents in a similar way to Fournier’s gangrene and often requires surgical intervention to drain the abscess. On examination there is tenderness and swelling but no signs of rapid spread of infection or necrosis.
Causes of elevated Ca125
Causes of an elevated CA 125 include: Ovarian cancer Endometrial cancer Tumours of the pancreas, GI tract, lung and breast Benign gynaecological disease, such as cysts and endometriosis Early pregnancy Follicular phase of menstrual cycle, and Cirrhosis or hepatitis.