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Final year > Woman's health > Flashcards

Woman's health Flashcards

1
Q

what hormonal change causes the shedding of the endometrium during menstruation? why does this change occur?

A

DECREASED PROGESTERONE: the thickened lining is supported by an increased blood supply owing to the progesterone being produced by the corpus luteum. if the follicle isnt fertilised the corpus luteum will fail and progesterone levels will fall

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2
Q

which hormone stimulates the release of LH and FHS from the pituitary? and where is this hormone released from?

A

GnRH from the hypothalamus

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3
Q

on which day in the menstrual cycle does each hormone peak?

A

oestrogen - day 12
LH and FSH - day 14
progesterone - day 21

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4
Q

LH and FSH induce follicular growth. these follicles produce which hormones and what is the effect of this?

A

oestradiol - increases LH in a +ve feedback loop and thickens endometrium

inhibin - inhibits FSH in a -ve feedback loop (so that only 1 follicle matures)

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5
Q

define pelvic inflammatory disease

A

inflammation of any pelvic organs: tubes, ovaries, uterus and peritoneum

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6
Q

what are the 3 most common causative organisms in PID?

A

chlamydia Trachomatis
Neisseria gonorhoea
mycoplasma

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7
Q 
the following presentation is classical of which gynae problem:
constant lower abdo. pain
purluent vaginal discharge
deep dyspareunia
pyrexia
A

PID

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8
Q

what clinical findings might be found on exam of a patient with PID?

A

purluent discharge
cervical excitation
blood

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9
Q

what Ix should be performed in ?PID including imaging?

A

BhCG
urine dip
high vaginal and endocervial swabs
chlamydia and gonorrhoea screening

Bloods: CRP, cultures (if febrile), U&E, FBC

pelvic USS

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10
Q

what are the complications of PID?

A

infertility (in as many as 20%)
increased risk of ectopic
chronic pelvic pain

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11
Q

what is that causes inflammation in endometriosis?

A

proliferation of endometrial tissue outside the uterus during the proliferative phase which cant drain so forms clots

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12
Q

what is adenomyosis and how does it present?

A

endometrial like tissue in the myometrium

presents v similar to endometriosis

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13
Q

the following presentation is classical of which gynae problem:
painful periods which starts before menstruation
deep dyspareunia
chronic pelvic pain

A

endometriosis

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14
Q

what finding might be found on examination in endometriosis

A 
on bimanual:
tenderness
palpable nodules
thickening of the adnexus
immobile and retroverted uterus (only in advanced cases and not always)
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15
Q

endometriosis is most common in which age category?

A

25-35

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16
Q

what is the first line imaging in endometriosis and what might be seen? what is the gold standard for diagnosis?

A

pelvic USS: endometriomas (large nodules) aka chocolate cysts

laparoscopy

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17
Q

‘since symptoms seem to regress in pregnancy and the menopause, treatment aims to mimic these states’

what condition does this statement refer to and how are pregnancy and the menopause mimicked for tx?

A

endometriosis

COCP - preg
progesterone - preg
GnRH analogues (e.g. Danazol) - menopause
IUS (Mirena) - preg

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18
Q

a woman reports a white discharge and vaginal itching. what is the most likely cause from this v short history? and what else might be noticed on exam of the vagina?

A

candidiasis

vulvitis - not always

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19
Q

a woman reports a really smelly grey/ white discharge. what is the most likely cause from this v short history? what might the smell remind one of? and what else might be noticed on cytology of the discharge?

A

bacterial vaginosis

fishy smell

CLUE CELLS - irregular bordered squamous epithelial cells

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20
Q

how does trichomonas vaginalis present? what might be seen on exam?

A

offensive yellow/green and frothy discharge

vulvovaginitis

strawberry cervix

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21
Q

define the menopause

A

no periods for 12 months

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22
Q

what change in hormone profile takes place during the menopause and why

A

increased LH and FHS (gonadatrophin hormones)
decreased oestrogen and progesterone (follicular hormones)

there are a finite number of follicles and these are now depleted

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23
Q

what are the two different types of HRT available to women and what are the indications for choosing them?

A

women might want/ need HRT if they have a premature menopause or if they suffer badly from the symptoms

a women with a uterus should have combined therapy (oestrogen and progesterone)

a women without a uterus should have oestrogen only

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24
Q

the are the risks associated with HRT?

A 
VTE
breast cancer
endometrial cancer
gall bladder disease
vascular disease
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25
Q

the definition of heavy menstrual bleeding has changed this year from what to what?

A

old: >80ml of blood lost per menses
new: any amount of bleeding that significantly interferes with a patients life

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26
Q

what are the causes of heavy menstrual bleeding?

A 
uterine fibroids
coagulopathy 
pelvic malignancies 
thyroid disorders (particularly hypo)
PID
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27
Q

if a woman with heavy menstrual bleeding wants to try for children, what should the medical mx be?

what if she also wants contraception?

A 
tranexamic acid (anti-fibrinolytic) during periods (1st line) 
mefenamic acid (NSAID) during periods

COCP
Mirena

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28
Q

what are the two categories for amenorrhoea and define them?

A

primary - absence of onset of menses by age 14 in the absence of secondary sexual characteristics OR by 16 with secondary sexual characteristics

secondary - absence of periods for >6months in a woman who previously had them

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29
Q

a 17 year old girl has not started their periods. what is your differential?

A

Turners
congenital adrenal hyperplasia
congenital malformation of the genital tract

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30
Q

what is an ovarian cyst? and what are the two types?

A

benign epithelial neoplasia on the ovaries

  1. serous cystadenoma (most common)
  2. mucinous cystadenoma
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31
Q

what are the possible presentations of ovarian cysts?

A 
can be asymptomatic
any pressure effects
swollen adbo. +/- palpable mass
lower abdo pain
dysparenuria

RUPTURE: peritonitis and shock

TORSION: sudden onset deep colicky pain

Meigs syndrome

1) benign ovarian tumour
2) ascites
3) Pleural effusion

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32
Q

what is the common name for leiomyomas?

A

fibroids

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33
Q

what is a uterine fibroid?

A

leiomyoma: benign smooth muscle tumour arising form myometrium of the uterus

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34
Q

what kind of bleeding might you expect with uterine fibroids?

A

HMB most common

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35
Q

what is the medical management of fibroids?

A

COCP
tranexemic acid
GnRH analogues for short term reduction

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36
Q

‘red degeneration’ is a rare complication of what gynae problem ? describe it and when it happens

A

haemorrhage of fibroid
more common in pregnancy as some fibroids grow too quickly for their blood supply to support them

n/b most fibroids dont actually grow during pregnancy and those that do tend to return to normal size after delivery

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37
Q

a woman comes in with lower abdo pain

on exam she has adnexal tenderness

the USS shows free fluid in the pelvis

this is a classical presentation of which condition?

A

torsion of an ovarian cysts

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38
Q

a young woman presents with post coital bleeding and some discharge

imaging shows redness around the os

what is the most likely diagnosis? what is less likely but needs ruling out? how is that done?

A

cervical ectropion

cervical cancer - smear +/- colposcopy

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39
Q

whats the difference between PCO and PCOS and when does one lead to the other?

A

PCO - 20% of women have enlarged follicles on their ovaries

PCOS - only 5% have the syndrome (characterised by hyperandrogenaemia)

women with PCO are likely to develop the syndrome with increasing weight

40
Q

how is a diagnosis of PCOS made?

A

diagnosis of exclusion because we don’t understand the pathophysiology
2 / 3 of the following:

  1. polycystic ovaries on USS (>12 enlarged follicles)
  2. oligo / anovulation
  3. clinical OR biochemical evidence of hyperandrogenaemia
41
Q

what are the different ways PCOS can present?

A

subfertility

hyperandrogenaemia

42
Q

what Ix should be done a woman with ?PCOS to screen for a common coplication?

A

OGGT - 50% of PCOS women develop DMTII and 30% develop gestational diabetes

43
Q

how do hormone profiles change in PCOS?

A

normally FSH is higher than LH (because it has more letters in it)

in PCOS, LH will be higher

raised prolactin and testosterone

44
Q

1st line mx for PCOS?

A

weight loss and exercise

45
Q

what is the role of clomifene in managing PCOS?

A

try to manage weight first either with lifestyle change or with orlistat

anti-oestrogen drug that tricks the pituitary into thinking that there is low oestrogen so it produces more LH and FSH (pro-ovulatory)

46
Q

a woman cant get pregnant. male factor is normal. there are no structural abnormalities. what is most likely to be the problem and what the causes of this?

A

annovualtion

PCOS
hypothalamic hypogonadism (reduced GnRH causes amenorrhoea - common in athletes/ models / anorexics)
Thyroid disease (over or overactive)
hyperprolactinaemia

47
Q

what are the causes of post coital bleeding

A 
cervical trauma
cervical polyps
endometrial carcinoma
cervicitis
vaginitis
48
Q

vaginitis is more common in which patient group and why?

A

older

low oestrogen

49
Q

ten weeks into pregnancy, what is the recommended action in terms of ante natal care? what is the purpose of this and what will happen?

A

Booking visit to identify risk factors and determine EDD

dating scan
BP and urinalysis
FBC - particularly for Hb
blood group
Rhesus status
screen for infections
downs syndrome screening
lifestyle advice
50
Q

which protein is produced by the developing foetus? how is this useful clinically?

A

AFP - alpha-feto protein

high AFP occurs in

  • NTD
  • adbo wall defects
  • multiple pregnancy

low AFP occurs in

  • downs syndrome
  • trisomy 18
  • maternal diabetes

remember Decreased in Downs and Diabetes

51
Q

define miscarriage

A

loss of pregnancy BEFORE 24 WEEKS

52
Q

how does a miscarriage present typlically?

A

PV bleeding +/- cramping abdo pain

loss of symptoms of pregnancy

53
Q

what kind of miscarriage does this describe?

no symptoms
scan shows empty sac
cervix is closed

A

missed / silent

54
Q

what kind of miscarriage does this describe?

painful bleeding at 20 weeks
cervix is open on exam
products in the urterus

A

inevitable

55
Q

what kind of pain would you expect with a threatened miscarriage?

A

painless abdo pain

56
Q

in which patients should conservative (expectant) mx of miscarriage definitely be used as 1st line?

A

any women who is at increased risk of trauma
infection
previous adverse / traumatic pregnancy

57
Q

what is the medication given for miscarriage with retained products? and what additional mx steps should be taken

A

misoprostol (PV or orally)
also give antiemetics and analgesia
repete pregnancy test after 3 weeks

58
Q

in expectant mx of miscarriage, what follow up is required?

A

repete TVUSS after 2 weeks

59
Q

for which patients is surgical mx of miscarriage recommended?

A

haemodynamically unstable

infected retained tissue

60
Q

define ectopic pregnancy

A

fertilised ovum implants outside the uterus

61
Q

where is the most common place to find an ectopic pregnancy?

A

98% tubal (most of these in the ampulla)

62
Q

what are the predisposing factors for ectopics?

A

anything that hinders passage of fertilised egg toward uterine cavity:

PID - tubal damage / scarring
tubal surgery
endometriosis
progesterone only pill -> reduced motility of tubes

IVF

63
Q

when do ectopics most commonly present?

A

5-14 weeks

64
Q

typically, how will an ectopic present in terms of pain?

A

unilateral abdo pain
on exam, unilateral cervical excitation

shoulder tip pain if ruptured into peritoneum

65
Q

how can B-HCG be used to inform about ectopics?

A

get base line and repete after 48 hrs

a rise of >66% suggests INTER-UTERINE preg.

a sub-optimal rise is an indiction of ectopic NOT a diagnosis

66
Q

why is there a sub optimal increase in B-HCG in ectopics?

A

B-HCG is produced by the placenta. in ectopics the placenta is not going to be as healthy so wont make as much as it should

67
Q

why do a FBC in ?ectopic ?

A

checking Hb to see if it is leaking

68
Q

when is expectant management of ectopic appropriate?

A 
clinically stable
minimal symptoms
hCG is decreasing
the embryo is <3cm
SAFETY NETTING safely communicated
69
Q

for how long should contraception be used after medical management of ectopic? why?

A

3 months

methotrexate is teratogenic

70
Q

what medication is used in the medical mx of ectopic preg? when is it given?

A

methotrexate IM 50mg

repete B-HCG after 4-7 days and repete methotrexate if not falling

71
Q

what are the causes of folate deficiency?

A

methotrexate
alcohol excess
PREGNANCY
phenytoin (for epilepsy)

72
Q

other than NTDs, what can folate deficiency cause in pregnancy?

A

macrocytic megoblastic anaemia

73
Q

what is the normal dose of folate for women trying to conceive and for how long should they take it?

A

400micrograms until 12th week

74
Q

women who are considered ‘high risk’ should take what dose of folate during pregnancy? what is considered high risk?

A

5mg (until 12th week)

diabetes
anti-epileptic medication e.g. phenytoin
previous NTD
coeliac disease
BMI>30
thalassaemia
75
Q

which factors increase risk of hyperemisis gravidarum?

A

main ones:
multiple pregnancy
trophoblastic disease

nulliparity
obesity
hyperthyroidism

76
Q

when would you admit in hyperemisis gravidarum?

A

if they cant tolerate oral fluids

77
Q

which medications are indicated in hyperemisis gravidarum?

A

anti-histerminess (promethazine)
metoclopramide
IV fluids if needed

78
Q

what are the complications of hyperemisis gravidarum?

A

AKI
mallory weis tear
Wernike’s encephalopathy

79
Q

what is the pathophys of obstetric cholestasis?

A

abnormal liver reaction to cholestatic effects of oestrogen

80
Q

in obstetric cholestasis, where is the pruritis?

A

truck, limbs (incl. hans and feet)

81
Q

what additional symptoms can co-exist with obs cholestasis?

A

dark urine, epigastric pain, steatorrhoea

82
Q

when does obs cholestasis occur?

A

3d trimester

83
Q

how do LFTs change inconjunction with obs cholestasis?

A

the rise in LFTs can be AFTER the onset of itching

84
Q

if obs cholestasis is suspected, what should the mx be?

A 
foetal growth scan every 2 weeks and IOL at 37 weeks
Ursodeoxycholic acid
vit K
anti-histermines
topical emollients
85
Q

what are the complications for obs cholestasis?

A 
maternal:
vit K deficiency 
PPH
infection
increased risk in future pregnancies
foetal:
pre-term labour
still birth
IUD
iatrogenic prematurity
86
Q

what normally happens to BP in pregnancy and why?

A

drops in 2nd trimester due to decreased vascular resistance

87
Q

what normally happens to urine protein levels in pregnancy?

A

some protein excreted but less than 300mg in 24 hours

88
Q

what is the clinical definition of pre-eclampsia ?

A

new onset hypertension (>140/90)
proteinuria (>300mg in 24 hours)
after 20 weeks

89
Q

what are the risk factors for pre-eclampsia?

A 
HIGH:
previous pre-eclampsia
multiple gestation
CKD
diabetes
LOW:
primips
age>40
BMI>35
family history
90
Q

how does pre-eclampsia present?

A

varied presentation

hypertension or proteinuria on screening

if there are symptoms then it's serious: 
headaches
visual disturbance
excessive weight gain (due to fluid)
epigastric pain
slow growth
91
Q

what Ixs can help differentiate pre-eclampsia from pregnancy induced hypertension before proteinuria occurs?

A

raised uric acid
low platlets
high Hb

92
Q

what does the protein : creatinine ratio tell us about pregnant women with high blood pressure?

A

if >30mg/nmol then this confirms significant proteinuria which indicates pre-eclampsia

93
Q

what are the complications of pre-eclampsia?

A

grand mal seizures
cerebrovascular accidents (due to failure of cerebral blood flow
HELLP syndrome

94
Q

how are patients with risk factors for pre-eclampsia managed?

A

aspirin 75mg from 12 weeks gestation

95
Q

if pre-eclampsia is moderate or severe, how is it managed?

A

labetolol (1st line)
nifedipine (2nd line)

MgSO4 IV if very severe and deliver baby asap

deliver at 36 weeks having administered steroids

post-nataly - stay in hospital for monitoring and follow up at 6-8 weeks after delivery

Final year (4 decks)

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