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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
the definition of heavy menstrual bleeding has changed this year from what to what?
old: >80ml of blood lost per menses new: any amount of bleeding that significantly interferes with a patients life
26
what are the causes of heavy menstrual bleeding?
``` uterine fibroids coagulopathy pelvic malignancies thyroid disorders (particularly hypo) PID ```
27
if a woman with heavy menstrual bleeding wants to try for children, what should the medical mx be? what if she also wants contraception?
``` tranexamic acid (anti-fibrinolytic) during periods (1st line) mefenamic acid (NSAID) during periods ``` COCP Mirena
28
what are the two categories for amenorrhoea and define them?
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
29
a 17 year old girl has not started their periods. what is your differential?
Turners congenital adrenal hyperplasia congenital malformation of the genital tract
30
what is an ovarian cyst? and what are the two types?
benign epithelial neoplasia on the ovaries 1. serous cystadenoma (most common) 2. mucinous cystadenoma
31
what are the possible presentations of ovarian cysts?
``` 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
32
what is the common name for leiomyomas?
fibroids
33
what is a uterine fibroid?
leiomyoma: benign smooth muscle tumour arising form myometrium of the uterus
34
what kind of bleeding might you expect with uterine fibroids?
HMB most common
35
what is the medical management of fibroids?
COCP tranexemic acid GnRH analogues for short term reduction
36
'red degeneration' is a rare complication of what gynae problem ? describe it and when it happens
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
37
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?
torsion of an ovarian cysts
38
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?
cervical ectropion cervical cancer - smear +/- colposcopy
39
whats the difference between PCO and PCOS and when does one lead to the other?
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
how is a diagnosis of PCOS made?
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
what are the different ways PCOS can present?
subfertility | hyperandrogenaemia
42
what Ix should be done a woman with ?PCOS to screen for a common coplication?
OGGT - 50% of PCOS women develop DMTII and 30% develop gestational diabetes
43
how do hormone profiles change in PCOS?
normally FSH is higher than LH (because it has more letters in it) in PCOS, LH will be higher raised prolactin and testosterone
44
1st line mx for PCOS?
weight loss and exercise
45
what is the role of clomifene in managing PCOS?
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
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?
annovualtion PCOS hypothalamic hypogonadism (reduced GnRH causes amenorrhoea - common in athletes/ models / anorexics) Thyroid disease (over or overactive) hyperprolactinaemia
47
what are the causes of post coital bleeding
``` cervical trauma cervical polyps endometrial carcinoma cervicitis vaginitis ```
48
vaginitis is more common in which patient group and why?
older low oestrogen
49
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?
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
which protein is produced by the developing foetus? how is this useful clinically?
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
define miscarriage
loss of pregnancy BEFORE 24 WEEKS
52
how does a miscarriage present typlically?
PV bleeding +/- cramping abdo pain | loss of symptoms of pregnancy
53
what kind of miscarriage does this describe? no symptoms scan shows empty sac cervix is closed
missed / silent
54
what kind of miscarriage does this describe? painful bleeding at 20 weeks cervix is open on exam products in the urterus
inevitable
55
what kind of pain would you expect with a threatened miscarriage?
painless abdo pain
56
in which patients should conservative (expectant) mx of miscarriage definitely be used as 1st line?
any women who is at increased risk of trauma infection previous adverse / traumatic pregnancy
57
what is the medication given for miscarriage with retained products? and what additional mx steps should be taken
misoprostol (PV or orally) also give antiemetics and analgesia repete pregnancy test after 3 weeks
58
in expectant mx of miscarriage, what follow up is required?
repete TVUSS after 2 weeks
59
for which patients is surgical mx of miscarriage recommended?
haemodynamically unstable | infected retained tissue
60
define ectopic pregnancy
fertilised ovum implants outside the uterus
61
where is the most common place to find an ectopic pregnancy?
98% tubal (most of these in the ampulla)
62
what are the predisposing factors for ectopics?
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
when do ectopics most commonly present?
5-14 weeks
64
typically, how will an ectopic present in terms of pain?
unilateral abdo pain on exam, unilateral cervical excitation shoulder tip pain if ruptured into peritoneum
65
how can B-HCG be used to inform about ectopics?
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
why is there a sub optimal increase in B-HCG in ectopics?
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
why do a FBC in ?ectopic ?
checking Hb to see if it is leaking
68
when is expectant management of ectopic appropriate?
``` clinically stable minimal symptoms hCG is decreasing the embryo is <3cm SAFETY NETTING safely communicated ```
69
for how long should contraception be used after medical management of ectopic? why?
3 months methotrexate is teratogenic
70
what medication is used in the medical mx of ectopic preg? when is it given?
methotrexate IM 50mg | repete B-HCG after 4-7 days and repete methotrexate if not falling
71
what are the causes of folate deficiency?
methotrexate alcohol excess PREGNANCY phenytoin (for epilepsy)
72
other than NTDs, what can folate deficiency cause in pregnancy?
macrocytic megoblastic anaemia
73
what is the normal dose of folate for women trying to conceive and for how long should they take it?
400micrograms until 12th week
74
women who are considered 'high risk' should take what dose of folate during pregnancy? what is considered high risk?
5mg (until 12th week) ``` diabetes anti-epileptic medication e.g. phenytoin previous NTD coeliac disease BMI>30 thalassaemia ```
75
which factors increase risk of hyperemisis gravidarum?
main ones: multiple pregnancy trophoblastic disease nulliparity obesity hyperthyroidism
76
when would you admit in hyperemisis gravidarum?
if they cant tolerate oral fluids
77
which medications are indicated in hyperemisis gravidarum?
anti-histerminess (promethazine) metoclopramide IV fluids if needed
78
what are the complications of hyperemisis gravidarum?
AKI mallory weis tear Wernike's encephalopathy
79
what is the pathophys of obstetric cholestasis?
abnormal liver reaction to cholestatic effects of oestrogen
80
in obstetric cholestasis, where is the pruritis?
truck, limbs (incl. hans and feet)
81
what additional symptoms can co-exist with obs cholestasis?
dark urine, epigastric pain, steatorrhoea
82
when does obs cholestasis occur?
3d trimester
83
how do LFTs change inconjunction with obs cholestasis?
the rise in LFTs can be AFTER the onset of itching
84
if obs cholestasis is suspected, what should the mx be?
``` foetal growth scan every 2 weeks and IOL at 37 weeks Ursodeoxycholic acid vit K anti-histermines topical emollients ```
85
what are the complications for obs cholestasis?
``` maternal: vit K deficiency PPH infection increased risk in future pregnancies ``` ``` foetal: pre-term labour still birth IUD iatrogenic prematurity ```
86
what normally happens to BP in pregnancy and why?
drops in 2nd trimester due to decreased vascular resistance
87
what normally happens to urine protein levels in pregnancy?
some protein excreted but less than 300mg in 24 hours
88
what is the clinical definition of pre-eclampsia ?
new onset hypertension (>140/90) proteinuria (>300mg in 24 hours) after 20 weeks
89
what are the risk factors for pre-eclampsia?
``` HIGH: previous pre-eclampsia multiple gestation CKD diabetes ``` ``` LOW: primips age>40 BMI>35 family history ```
90
how does pre-eclampsia present?
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
what Ixs can help differentiate pre-eclampsia from pregnancy induced hypertension before proteinuria occurs?
raised uric acid low platlets high Hb
92
what does the protein : creatinine ratio tell us about pregnant women with high blood pressure?
if >30mg/nmol then this confirms significant proteinuria which indicates pre-eclampsia
93
what are the complications of pre-eclampsia?
grand mal seizures cerebrovascular accidents (due to failure of cerebral blood flow HELLP syndrome
94
how are patients with risk factors for pre-eclampsia managed?
aspirin 75mg from 12 weeks gestation
95
if pre-eclampsia is moderate or severe, how is it managed?
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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