Women's Health

Question 1

Describe the physiology of a period

Answer 1

Follicular phase (1-13): oestrogen rises, development of Graafian follicle, D13 LH surge due to high oestrogen, ovulation (14) Graafian ruptures and releases oocyte (remaining follicular become corpus luteum)
Period (1-4) progesterone withdrawal due to loss of corpus luteum; proliferative (5-14) endometrial proliferation (oestrogen).
Luteal (15-28): corpus luteum producing progesterone (oestrogen and inhibin), spontaneously regresses D28 - LH / FSH rise
Secretory (15-28): glands secreting glycogen / glycoproteins, myometrial contraction inhibited (progesterone)

(Different cycle length is caused by variable follicular phases, luteal phase is always 14 days; to assess ovulation measure progesterone (peaks 7d post ovulation) 7d before cycle ends)

Question 2

What needs to be included in an obstetrics history

Answer 2

History: gestational age, gravidity + parity, presenting complaint, foetal movements, rule out UTI + pre eclampsia, systemic screen, current pregnancy (scans, growth, placental position, supplements), previous pregnancies (how many, incomplete, gestation, method, weight, complications), gynae history, PMH, drug, family, social
Risk factors are mostly the same for most conditions: over 40, MBI >35, first pregnancy, multiple pregnancy, over 10y since last, autoimmune conditions, diabetes

Question 3

What are the normal physiological changes in pregnancy, how long are the trimesters

Answer 3

Normal physiological changes in pregnancy:
Cardio: cardiac output increases 40% (HR and stroke volume), large uterus can lead to impaired venous return (oedema), red cells + plasma increase (Hb + platelets falls)
Blood pressure in pregnancy: blood pressure falls in first trimester until 20-24w (any hypertension before 20w is preexisting, after 20w becomes pregnancy induced_

Resp: pulmonary ventilation + tidal volume increase (more than O2 required can lead to fall in pCO2)

Urinary: GFR + blood flow increase, salt + water absorption increased, small proteinuria + glycosuria normal

Biochemical: calcium requirements increase (increased Gut absorption), serum calcium + phosphate falls

Trimesters: 1st conception to 12w, 2nd 13-27, 3rd 28-40

Question 4

Describe the stages of labour

Answer 4

Latent phase: irregular contractions, mucoid plug, 6 hours - 3 days, cervix is effacing and thinning - up to 4cm, paracetamol
Effacement: muscle fibres retract, cervix becomes accessible, cervix then dilates
Up to 3cm dilation, 0.5cm an hour
Active phase (2nd phase, still 1st stage): regular contractions, progression, dilates up to 10cm
2nd: up until the baby is delivered, nulliparous up to 2h, multiparous up to 3h
3rd: further pushing until the placenta has been delivered (syntocinon and gentle cord traction if necessary), up to 30m

(Diagnosis of labour: show (mucus plug to stop infection), rupture of membranes, regular + painful contractions, dilated on examination
Preterm prelabour rupture of membranes: assess for fluid in the posterior vault, IGF1 binding protein1 test)

Question 5

Describe induction of labour and the bishop score

Answer 5

Induction of labour: bishop score (cervical position / consistency / effacement / dilation, foetal station) (>8 no intervention), >6 amniotomy +/- oxytocin (not oxytocin alone), <=6 vaginal prostaglandin E2 / misoprostol / balloon catheter if risk of hyperstimulation or previous c section

(In order, only do if others fail) membrane sweep, vaginal prostaglandin E2, misoprostol, oxytocin, amniotomy (artificial rupture), cervical ripening balloon.

Question 6

Describe how to read and a healthy CTG

Answer 6

CTG: measures foetal HR and contractions (/10m), assess with DR C BRaVADO: define risk, contractions, baseline rate, variability, accelerations, decelerations, overall

HR 110-160, variability 5-25, accelerations (increase of 15bpm for more than 15s - reassuring, should happen with contractions), decelerations (only early not concerning)

Question 7

Why does labour fail to progress, how is it managed

Answer 7

Failure to progress - 4Ps: power (hypotonia / not pushing hard enough), passage (pelvic inlet / outlet), passenger (position, attitude, head size), psyche of mum

Vaginal examination, CTG

Augmentation (artificial rupture, syntocinon), instruments, caesarean
Instrumental indication - FORCEP B: fully dilated cervix, OP / OA position, ruptured membranes, cephalic presentation, engaged presenting part, pain relief, bladder empty (catheterization)

Question 8

Describe breech position, OP position, vaginal birth after c section

Answer 8

Breech presentation: leave before 36w, external cephalic version offered 36w if nulliparous or 37w multiparous, still breech mum decides c section or vaginal
RF: uterine malformations (fibroids), placenta praevia, poly / oligohydramnios, foetal abnormality, prematurity
Vaginal birth after caesarean: fine if single lower segment - planned vaginal at +37w, if multiple or classical Cs not suitable for vaginal due to risk of uterine rupture
OP position: head may spontaneously rotate, labour longer and more painful, Kielland’s forceps best instrument, often have urge to push earlier

Question 9

Describe the Apgar score

Answer 9

Apgar score used to assess health immediately (1-5m) after birth, 0-10; 7-10 healthy, 4-6 may need attention, 0-3 critical condition → NICU
Appearance (skin colour): 0 all blue / pale, 1 pink but blue extremities, 2 all pink
Pulse: 0 no HR, 1 <100, 2 >100
Grimace (reflex irritability): 0 no response, 1 grimace / feeble cry, 2 vigorous cry / active withdrawal. Initiate by stroking back / sole of feet
Activity: 0 no tone, 1 some flexion of limbs, 2 active / well flexes
Respiration: 0 no breathing, 1 irregular / gasping, 2 strong

Question 10

Describe cord prolapse and its management

Answer 10

Cord prolapse (rare): cord is presenting - exposure leads to vasospasm, significant risk of mortality from hypoxia - on all fours until surgery, terbutaline (tocolytic) reduces contractions
To prevent hypoxic ischemic encephalopathy - therapeutic cooling neonate to 33.5-34.5 for 72h, slows metabolic rate, increases cerebral perfusion and allows recovery

Question 11

Shoulder dystocia, RF, management, complications

Answer 11

Shoulder dystocia: head comes out and anterior shoulder stuck behind pubic symphysis, significant risk of baby and mum mortality (haemorrhage, hypoxia, cerebral palsy)
Risk factors: big babies and maternal diabetes, maternal obesity, after 40w, induction
Management: tell mum stop pushing, mcroberts position (flat on back, knees to shoulders, push on suprapubic) - most resolve, episiotomy, rotate and grab post arm
Complications: brachial plexus injury (Erb’s palsy - shoulder adducted and I rotated), cerebral palsy, hypoxic-ischaemic encephalopathy, mortality, PPH

Question 12

Postpartum haemorrhage - definition, causes, RF

Answer 12

Postpartum haemorrhage: primary within 24h, blood loss >500ml in vaginal, >1000 c section
Four T causes: Tone - uterus not contracted, Tissue - placenta left in, Trauma - tears, Thrombin - check clotting. Atony by far the most common cause
Degrees of tears: 1 - perineal skin, 2nd - fascia and perineal muscles, 3rd - anal sphincter (A/B <50%/>50% external, C internal), 4th - anal epithelium
Risk factors: big baby, nulliparity / grand multiparity, infection, operation, shoulder dystocia

Question 13

Management of postpartum haemorrhage

Answer 13

Management: ABCDE assessment, IV warmed crystalloid, uterus compression (catheterise). Otherwise: treat cause, syntocinon (oxytocin analogue) helps placenta separate, ergometrine stimulates uterine contraction (don’t give HTN), carboprost (prostaglandin - not asthmatics), misoprostol, tranexamic acid for everyone. Surgery (after medical) - intrauterine balloon (bakri catheter) FL if atony, ligation, hysterectomy in severe

Question 14

Describe secondary postpartum haemorrhaeg

Answer 14

Secondary PPH (24h - 12w after): endometritis, retained products, subinvolution of implantation site, pseudoaneurysms, arteriovenous malformations

Question 15

Describe Rhesus incompatibility

Answer 15

Rhesus: occurs in Rh-negative mums having Rh-positive babies, mum does not have the antigens so sees baby’s RBCs as foreign, IgG antibodies produced. Sensitisation occurs when blood is exposed - childbirth, so usually affects second baby. Causes haemolytic anaemia in baby (antibodies cross the placenta), jaundice, potential brain damage and death. Give anti-D immunoglobulin in pregnancy at 28 and 34w. Treat baby with exchange transfusion, phototherapy

In abortion still need antiD after 10w

Question 16

What is the most common infection in preterm births

Answer 16

Group B strep most common severe infection in neonatal period (20-40% carry), can cause sepsis + meningitis. Signs: fever, poor feeding, irritable, lethargy, breathing issues
Benzypenicillin used as prophylaxis and treatment, prophylaxis for all preterm + previous, all women in labour with temp > 38

Question 17

How is preterm premature rupture of membranes managed

Answer 17

Preterm premature rupture of membranes: admission, obs for chorioamnionitis, erythromycin for 10d, steroids after 24w (respiratory distress), delivery considered at 34w
Speculum exam (amniotic fluid in posterior vault), test fluid for PAMG-1 or IGF binding 1
CTG, tocography, TVUS, cervico-vaginal fibronectin swab

Question 18

Describe reduced foetal movements, investigations and risks

Answer 18

Reduced foetal movements: should start at 18-20w (latest 24) and increase until 32w, reduced are concerning that it is compensation for hypoxia (stillbirth / foetal growth restriction), should not reduce - mothers opinion
Investigations: doppler for HR, no HR immediate US, HR present CTG for 20m
Risks: anterior placenta / anterior position / obesity (less aware), alcohol / sedatives, oliog + polyhydramnios, small foetus

Question 19

Ectopic pregnancy - presentation, investigations, management

Answer 19

Ectopic (6-8w): abdominal pain, vaginal bleeding, shoulder pain, pain on passing urine / poo, n+v, dizziness, lower back / pelvic pain. May not think pregnant - missed periods
Risk factors: previous, smoking, over 35, previous tubal damage (PID, STIs, sterilisation), IUD / IUS

Transvaginal US - see gestational sac elsewhere, empty uterus, pseudo sac in uterus (no foetal pole or HR). Measure bHCG + pregnancy test. 95% tubal

Treatment depends on size (<35mm) and bHCG (<1500). Conservative if small and no HR - monitor HCG until <20. Medical - IM methotrexate, monitor HCG and toxicity. Surgical if HR / too big / HCG >5000 or any complications (ruptured fallopian = emergency), laparoscopic salpingectomy or salpingostomy (preserves tubes)

Question 20

How is pregnancy of unknown location investigated

Answer 20

Pregnancy of unknown location - measure bHCG and repeat after 48h, <63% rise - intrauterine, rise of >63% - ectopic, fall >50% - miscarriage

Question 21

How is miscarriage investigated, what are the types and how are they managed

Answer 21

Miscarriage (early before 12w, late 12-24w). Different categories: missed (no symptoms), threatened (bleeding but closed cervix), inevitable (bleeding + open cervix), incomplete (retained products), complete, anembryonic (sac but no embryo)

HR should be present once the crown rump length is 7mm, present = viable

Conservative: up to 6w, no risk factors, repeat pregnancy test in 3w, <35mm
Medical - misoprostol (vaginal) (prostaglandin analogue) and analgesia. Surgical - manual / electric vacuum

Recurrent = 3 consecutive. Caused by age, antiphospholipid S, uterine abnormalities, endocrine disorders (DM, thyroid, PCOS), smoking

Question 22

Describe abortions

Answer 22

Abortion (before 24w): medical - mifepristone (antiprogestogen) followed by misoprostol (prostaglandin) 48h later, pregnancy 2w later to confirm; surgical - cervical priming (misoprostol, mifepristone) and transcervical vacuum aspiration or dilatation and evacuation
Women decide method, antiD given to rhesus negative after 10w

Question 23

Describe molar pregnancy

Answer 23

Molar: fertilisation occurs incorrectly with 2 sperms / egg with no DNA, instead of embryo many fluid filled cysts (non C tumour), high bHCG + echobright / snowstorm on US, evacuate uterus, small risk of choriocarcinoma. Symptoms bleeding, N+V, preeclampsia, abdominal swelling

Question 24

Describe placenta + vasa praevia

Answer 24

Placenta praevia: not in the upper segment, major - reached os, minor encroaching, risk of haemorrhage. RF: previous, C section
US at 20 / 32 / 36w. Minor often resolve, steroids 34-36w to mature lungs, C section at 37w

Vasa praevia: vessels are exposed in the membranes instead of the placenta. Management same^

Question 25

Describe placental abruption and morbidly adherent placenta

Answer 25

Placental abruption: separation from wall before birth, severe constant abdominal pain, bleeding, foetal distress (CTG), woody abdomen
Emergency - manage like major haemorrhage, if stable steroids and observe, foetal distress - deliver vaginally if possible / emergency Cs

Morbidly adherent placenta - placenta penetrates myometrium; accreta - at, increta - in, percreta - past. Diagnosed with US + MRI. C section, likely transfusion, percreta may require hysterectomy

Question 26

Preeclampsia - definition, investigations and management

Answer 26

Preeclampsia, new hypertension with end organ dysfunction - proteinuria: headache, visual changes, peripheral + pulmonary oedema, upper abdominal pain, brisk reflexes, n+v

Diagnosis: >140/90 and proteinuria (protein/albumin:creatinine) / organ dysfunction (LFTS, creatinine, thrombocytopenia, seizures) / placental dysfunction (PGrowthFac)

Aspirin given from 12w as prophylaxis in high risk, labetalol first line (nifedipine, methyldopa), fluid restriction, monitor bloods / urine output / foetal growth and wellbeing
Delivery if >34w, give MgSO4 / betamethasone / dexamethasone

Question 27

Describe HELLP syndrome

Answer 27

HELLP syndrome (severest complications): haemolysis, elevated liver enzymes, low platelets. Risk of damage to liver / kidneys / blood vessels, haemorrhage, stroke, placental abruption, foetal distress, still birth
Delivery when possible, blood transfusion, labetalol

Question 28

Eclampsia, definition, management

Answer 28

Eclampsia - seizures unrelated to previous condition (all seizures until proven otherwise), treat like preeclampsia and IV magnesium sulphate for seizures (need up to 24h post). 50% of cases occur after birth and 40% seizures
Magnesium sulphate IV bolus 4g then 1g/hour- need to monitor resp rate and reflexes (can lead to resp depression + cardiac arrest), give calcium gluconate for resp depression

Question 29

Obstetric cholestasis - presentation, risk, management

Answer 29

Obstetric cholestasis: fatigue, dark urine, pale greasy stools, jaundice, pruritus of soles and palms. Intrahepatic (conjugated), genetics, hormonal, impaired bile flow leads to build up
Abnormal LFTs and raised bile acids. Give ursodeoxycholic acid + vit K, emollient
Increases risk of: preterm, foetal distress, still birth (rare). Induction of labour 37w
28w onwards, small risk of still birth, increased in south asian

Question 30

Describe disseminated intravascular coagulation, presentation and management

Answer 30

Disseminated intravascular coagulation (DIC): widespread uncontrolled activation of clotting throughout body (and bleeding), activated by infections / placental problems / child birth

Presentation: prolonged vaginal bleeding, easy bruising, blood in urine / stools, clot formation (purpura) → organ dysfunction (confusion, SOB, chest pain, kidney dysfunction)

Find and treat cause, heparin / TXA, supportive (blood transfusions, IV fluids)

Common causes: abruption, amniotic fluid embolism, preeclampsia, HELLP, intrauterine death, sepsis, postpartum haemorrhage, trauma

Question 31

Describe antepartum haemorrhage

Answer 31

Antepartum haemorrhage - after 24w: 40% no identifiable cause, placenta previa / abruption / vasa, non placental (fibroids, polyps, cervical cancer, ectropion), trauma, infection
Minor: <50ml, major 50-1000, massive >1000.

Question 32

Describe gestational diabetes, investigations. management and complications

Answer 32

Gestational diabetes - fasting >5.6, 2h >7.8: 2/3 trimester + did not have diabetes before. OGTT between 24-28w (13-14w and self monitoring earlier if had before). 1-2w trial of diet + exercise (fasting <7) - fail metformin, insulin (fasting >7 or complications); given 2w for each step to see improvements

(More blood sugar produced + placental hormones increase insulin resistance, those with predisposing factors can’t produce enough insulin (age, FHx, obesity, PCOS, multiP))

Complications: macrosomia (large) + shoulder dystocia (+ trauma), preterm birth, preeclampsia, hypoglycaemia + respiratory distress at birth, infection. Risk correlates to HbA1c

Question 33

Describe management of preexisting diabetes in pregnancy

Answer 33

Preexisting diabetes: BMI <27, only metformin / insulin, folic acid 5mg pre to 12w, aspirin 12w monitor renal function and retinopathy (screening)
Can get worse in T2/3, hypo in T1, risk of DKA in hyperemesis and steroids
Self monitoring - fasting, pre + post meals, bedtime; fasting 5.3, 1h post meal 7.8, 2h 6.4

Question 34

Describe STIs in pregnancy

Answer 34

STIs in pregnancy: all can be transmitted to babies without correct antibiotics. C+G: preterm birth, conjunctivitis + respiratory. Syphilis: preterm, stillbirth, congenital disabilities (developmental, organ). Herpes: brain + organ damage, death. Hep B / C, HIV

Question 35

Describe hyperemesis gravidarum, diagnosis and management

Answer 35

Hyperemesis gravidarum: 2-20w, 5% pre-pregnancy weight loss, dehydration, electrolyte imbalance
Diagnosis: 5% weight loss, dehydration, electrolyte imbalance. Pregnancy unique quantification of emesis (PUQE) score
Rest, avoid triggers, bland food + ginger. Cyclizine / promethazine (antihistamine), doxylamine with pyridoxine, metoclopramide severe. Severe - IV hydration with normal saline with added potassium. Hospital admission if ketonuria or weight loss (>5%) despite treatment
Thiamine deficiency common, dextrose not given as increases demand

Question 36

Describe oligo and polyhydramnios

Answer 36

Oligohydramnios - <500ml at 32-36w: premature ROM, potter sequence (renal agenesis + pulmonary hypoplasia), intrauterine growth restriction, pre eclampsia
Complications: abnormal lie, poor respiratory development

Polyhydramnios: diabetes, foetal GI, twins+, foetal hydrops, swallowing disorders (oesophageal atresia)
Measure with US amniotic fluid index (above 95th) or maximum pool depth
Complications: preterm delivery, malpresentation, postpartum haemorrhage, GORD

Question 37

Describe the antenatal scans and visits

Answer 37

8-12w booking / check up: BP, urine dipstick, BMI, bloods (FBC, rhesus, haemoglobinopathies, hep B + syphilis + HIV + rubella, urine culture)
10-13+6: early scan for date and multiple pregnancy
11-13+6: Down’s + nuchal translucency. (if they book later quadruple (+ inhibin A) at 15-20
18-20+6: anomaly scan
28w (25w primiparous) onwards routine care every 3w: BP, urine dipstick, symphysis fundal height. Second screen for anaemia + atypical RBCs. First dose of anti-D

Question 38

What should patients receive during the antenatal period

Answer 38

Influenza and pertussis vaccines offered 16-32w
All pregnant women should take vit D 400IU daily throughout pregnancy, folic acid before - 12w (400micro if healthy, 5mg if risk factors of neural tube defects)
Iron supplementation for low Hb: <110 g/L first T, <105 S/T, <100 postpartum (115 non pregnant)

Ace / ARB need to be stopped - labetalol, DOACs + warfarin contraindicated - LMW heparin

Question 39

Describe management of exposure to chicken pox in pregnancy

Answer 39

Exposure to chickenpox in pregnancy (without varicella antibodies) can be dangerous to mum (pneumonitis) and child
Foetal VS: skin scarring, microcephaly, eye defects, limb hypoplasia, learning difficulties; also shingles in infancy, neonatal varicella

<=20w: VZ IG (works 10d post exposure), >20w: aciclovir and ZVIG (no rash) 7-14d post
VZIG not effective once rash has started, aciclovir given within 24h of rash

Question 40

Management of UTIs, thrush, STIs in pregnancy

Answer 40

UTI in pregnancy: treat aggressively and specifically as risk of ascending infection, preterm delivery and IU growth restriction. Low threshold for MSU. treat for 7d

No nitrofurantoin in 3rd trimester (neonatal haemolysis), trimethoprim teratogenic in 1st
Immediate Abx whilst awaiting MSU - nitro / amoxicillin / cephalexin

Thrush: no oral fluconazole - clotrimazole pessary

Chlamydia: azithromycin / erythromycin / amoxicillin. Syphilis: IM penicillins / ceftriaxone

Question 41

Describe contraception following birth

Answer 41

Contraception not needed for first 21d, COCP contraindicated first 6w whilst breastfeeding
Lactational amenorrhoea is 98% effective for 6m - need to be fully breastfeeding
Progesterone safe to start at any time
IUS / IUD can be inserted in first 48h or after 4w

Question 42

Describe postpartum thyroiditis and puerperal pyrexia

Answer 42

Postpartum thyroiditis (autoantibodies, usually self resolving), 3 stages: thyrotoxicosis (treat with propranolol), hypothyroidism (thyroxine), return to normal function. High recurrence rate

Puerperal pyrexia >38 in first 14d, causes: endometritis (most common), UTI, wound infection, mastitis, VTE
Endometritis: hospital admission - IV clindamycin + gentamicin

Question 43

Describe the effects of rubella and syphilllis on a neonate

Answer 43

Rubella in pregnancy: cataracts, deaf, cardiac abnormalities. Jaundice, hepatosplenomegaly, microcephaly, reduced IQ

Syphilis: rhinitis, saddle nose, sensorineural deafness. Hutchinson’s incisors. Hepatosplenomegaly, lymphadenopathy, anaemia, jaundice

Question 44

Describe TORCH infections

Answer 44

TORCH infections (viruses) can be transmitted from mum to foetus and have significant consequences
Toxoplasmosis: hydrocephalus, intracranial calcifications, chorioretinitis
Rubella: deafness, heart defects, cataracts, intellectual disabilities
Cytomegalovirus: hearing loss, intellectual disabilities, developmental delay
Herpes: severe neurological damage and death. Give antiviral, lesions in birth - c section
Other: syphilis (deaf, hydrocephalus, meningitis), varicella zoster (cataracts + chorioretinitis, intellectual, limb hypoplasia) (mum - pneumonitis, encephalitis), parvovirus (hydrops fetalis - HF, anaemia, stillbirth)

Question 45

What are common non-obstetric complications for the mum following birth

Answer 45

Sepsis, eclampsia, VTE, post dural puncture headache, urinary retention, baby blues + postnatal depression, psychosis, PTSD
Post dural puncture headache: worse on sitting / standing, neck stiffness, photophobia; lying flat, simple analgesia, fluids + caffeine, epidural blood patch
70% maternal deaths postnatal, cardiac (thrombosis / thromboembolism) + neurological most common up to 6w, maternal suicide most common at 1y

Question 46

Cervical cancer - presentation, investigations, management, RF

Answer 46

Cervical cancer (80% squamous C carcinoma, most common cause HPV): postcoital / any abnormal bleeding, vaginal discharge, pelvic pain, dyspareunia. Refer to colposcopy (stain and punch biopsy), cone biopsy / hysterectomy + node clearance (1A), hysterectomy + C/R (1B-2A), 2B+ chemo and radio
RF: HPV, smoking, HIV, many partners, high parity, COCP

Question 47

Describe HPV, screening and investigations

Answer 47

HPV can cause all organ cancers involved in sex, over 100 strains, type 16 + 18 responsible for 70% of cancers. Vaccine but no treatment, usually resolve if not immunoS. Screen every 3y from 25, 5 from 50. +HPV but normal cytology repeat in 12m (3 in a row refer to colposcopy), inadequate sample - repeat + 2 in a row - colposcopy

Cervical intraepithelial neoplasia (CIN), grading system for premalignant change: I ⅓ of epithelium should resolve, II ⅔ likely to progress if untreated, III very likely

Question 48

Endometrial cancer - presentation, investigations, management, RF

Answer 48

Endometrial cancer, 80% adenocarcinoma, oestrogen dependent: postmenopausal bleeding, other abnormal bleeding, haematuria, anaemia.

Vaginal US, pipelle biopsy, hysteroscopy + biopsy

Stage 1 + 2: total hysterectomy + bilateral salpingo-oophorectomy + lymphadenectomy, 3+ radio and chemo, progesterone slows progression

(Risk factors - exposure to oestrogen: age, early menarche / late menopause, oestrogen only, no pregnancies, obesity, POCS (obesity, DM), tamoxifen. Protective: multiparity, COCP, smoking?

Endometrial hyperplasia = premalignant, 5% become cancer, give progesterones (mirena)

Most common gynae cancer, only one increasing in incidence - due to rising obesity levels (unopposed oestrogen following menopause))

Question 49

Ovarian cancer - presentation + complications, investigations, management and risk factors

Answer 49

Ovarian 70% present too late: many different types - epithelial cell tumours most common;

vague symptoms: bloating, loss of appetite, pain, urinary / GI.
Complications: hirsutism (increased test), amenorrhoea, ovarian torsion, rupture, thyrotoxicosis

CA125 blood test, pelvic US, CT, histology.

Surgery (hysterectomy and bilateral S-O +/- other deposits) and platinum based chemo if required

RF: BRCA1+2, many ovulations (early menarche, late menopause, nulliparity)

Question 50

Describe vulval cancer

Answer 50

Vulval cancer, 90% squamous cell: lump, ulceration, bleeding, pain, pruritus. Biopsy and excision

Question 51

Fibroid uterus - presentation, investigations, management, complication

Answer 51

Fibroid uterus: benign tumours of smooth muscle, 50% perimenopause, oestrogen sensitive
Presentation often asymptomatic, menorrhagia, prolonged bleeding, abdo pain, bloating, urinary / bowel. Examination, hysteroscopy, pelvic US, MRI before surgery
Management: symptomatic (<3cm): mirena, mefenamic + tranexamic acid, COCP / POP. >3cm: goserelin / leuprorelin (GnRH agonist) pre surgery to shrink, endometrial ablation, myomectomy, uterine artery embolisation, hysterectomy
Red degeneration; ischaemia → necrosis of fibroid, common in pregnancy (grows rapid): severe pain, low grade fever, tachycardia, vomiting. Supportive management

Question 52

Describe polyps and cervical ectropion

Answer 52

Polyps: endometrial tissue hyperplasia (associated with cancer) (fibroids are muscle), usually only symptom is bleeding, benign, oestrogen sensitive, risk of infertility. TVUS, hysteroscopy + biopsy
<1cm and asymptomatic conservative management; symptomatic: hormonal contraceptives, TXA; majority should get polypectomy especially if post menopausal or wanting children

Cervical ectropion: endocervix (velvet red, columnar) extends to ectocervix (strat squam), visible on speculum, more prone to trauma - post coital bleeding, oestrogen sensitive (younger, H con)
Often asymptomatic, discharge, pain and blood - sex
Usually resolves, cauterisation (cold, silver nitrate)

Question 53

Describe atrophic vaginitis

Answer 53

Atrophic vaginitis: lack of oestrogen (menopause), mucosa thin / dry / less elastic, pH + flora change, increased risk of prolapse and incontinence
Itchy, dry, dyspareunia, bleeding. Exam: pale, less skin folds / hair, inflammation
Lubricants (sylk), topical oestrogen: oestriol cream / pessary, estradiol tablet / ring

Question 54

Describe endometriosis, presentation + exam, investigations, management

Answer 54

Endometriosis - unknown aetiology: endometrial tissue out of the uterus → irritation + inflammation, bleeding can lead to adhesions + scarring (chronic noncyclic pain)

Classically: dyspareunia, dysmenorrhoea (starting before bleeding), chronic pelvic pain. Cyclical, deep pain, depending on site blood in urine + stools

Exam: commonly normal, fixed retroverted cervix, tender, visible endom lesions.

Investigations: pelvic US, laparoscopic biopsy (gold)

Analgesia FL (para + ibu), hormonal (combined, mini, mirena), GnRH agonist, surgery

Question 55

Describe adenomyosis, presentation, investigations, management

Answer 55

Adenomyosis: endometrial tissue in the uterus myometrium, more common in older + multiparous, presentation similar to endometriosis (no blood elsewhere), boggy uterus (enlarged)
Trans V US, MRI
Mirena, combined, progesterone. No contraception: Txa, mefenamic acid (NSAID that reduces bleeding). GnRH - zoladex, uterine artery embolisation, hysterectomy

Question 56

PCOS - criteria and investigations

Answer 56

PCOS (rotterdam criteria - ⅔): multiple cysts, oligoovulation / oligomenorrhoea, hyperandrogenism
Diagnosis: ^ LH, ^ LH:FSH, (^) test, V sex hormone binding globulin, high insulin / resistance. Pelvic US (FL), transV US (GS)
On US: 12+ follicles on one ovary / volume >10cm3, “String of pearls”, unopposed oestrogen - endometrial thickness

Question 57

PCOS - presentation and management

Answer 57

Presentation: hirsutism (body hair, balding, acne), irregular menstruation, infertility, 70% obese, mood changes
Lifestyle + weight loss, COCP / mirena / progesterone, clomifene or letrozole for infertility, topical eflornithine for hirsutism, metformin, tamoxifen
Letrozole (aromatase inhibitor) reduced oestrogen production from androgens and increases FSH and makes endometrium more receptive

Question 58

Ovarian cysts - presentation, investigations, management
Complications / risk

Answer 58

Usually premenopause (follciular most common), bloating, pelvic pain, large are palpable
US (<5cm leave, 5-7 monitor, >7cm remove)
Small chance that they are premalignant - bigger = worse; 40+ complex (multi-loculated) cysts should be biopsied and LDH, alpha fetoprotein, HCG

Signs of malignancy: weight loss, urinary symptoms, ascites, lymphadenopathy
Ruptured: sharp unilateral pain (usually following exercise / sex), US shows free fluid in pelvic cavity, normal examination unless severe
Can cause torsion - (dermoid most likely, also most common under 30)

Question 59

Ovarian torsion - presentation, investigations, management

Answer 59

Ovarian torsion: ovary twists and blood supply is cut off.

Sudden + severe lower abdo pain, N+V, fever.

Need imaging quickly - TV / abdo US, laparoscopic - look and treat

Causes: cysts / masses, pregnancy, vigorous exercise, abdo trauma

Question 60

Describe premature ovarian insufficiency, investigations, management

Answer 60

Premature ovarian insufficiency - loss of ovarian function (fertility, oestrogen, progesterone) before 40: hypergonadotropic hypogonadism - ^ LH ^ FSH V oestrogen. Diagnose with repeated FSH

Symptoms due to low oestrogen (menopausal). Give HRT

Question 61

Describe lichen sclerosis

Answer 61

Lichen sclerosus: AI derm condition, chronic inflammation - porcelain-white skin, itchy. 5% become vulval SCC
Topical steroids + emollient

Question 62

Amenorrhoea - causes, investigations
Sheehan’s + asherman’s

Answer 62

Amenorrhea: primary: hypogonadotropic / hypergonadotropic hypogonadism, imperforate hymen, structural; secondary: pregnancy, menopause, physiological stress (exercise, low weight), PCOS, medications, thyroid, premature ovarian insufficiency, prolactinoma, Cushing’s
Raised FSH + LH - gonadal dysgenesis / ovarian issue, low FSH + LH - hypothalamic cause
Sheehan’s S: hypopituitarism caused by ischaemic necrosis (blood loss + shock) - agalactorrhoea, amenorrhoea, hypothyroidism + hypoadrenalism
Asherman’s S: intrauterine adhesions due to scarring, endometrium does not respond normally to oestrogen, amenorrhoea, miscarriages, infertility

Question 63

What are the causes of irregular menstrual bleeding

Answer 63

Irregular menstruation: PCOS, stress, medications, hormonal

Irregular bleeding CAME LIPO: coagulopathy, adenomyosis, malignancy, endometrial, leiomyoma (fibroids), iatrogenic, polyps, ovulatory

Intermenstrual . postcoital bleeding red flag for cervical cancer, also: polyps, cervical ectropion, hormonal contraception, STIs, vaginal pathology, ovulation (spotting healthy), meds
Meds: contraception (progesterone most), SSRIs, antipsychotics, anticoagulants

Post menopausal bleeding RF for endometrial cancer

Question 64

Causes and management of dysmenorrhoea

Answer 64

Dysmenorrhoea (extreme pain): primary (idiopathic), endometriosis, adenomyosis, fibroids, PID, IUD, cancer
Primary within 1-2y of menarche - mefenamic acid (NSAID), COCP. Secondary pain 3-4 days before period - referral

Question 65

Causes and management of menorrhagia

Answer 65

Menorrhagia (heavy): dysfunctional uterine bleeding (idiopathic), extremes of age, fibroids, endo, adeno, PID, contraception, clotting disorders, endocrine (diabetes, hypoT), PCOS, cancer, meds
Treatment: hormonal (mirena FL, combined, long acting progesterones), TXA, mefenamic acid. Surgery - ablation (= infertility), hysteroscopy / hysterectomy, embolisation
Examination, FBC, TV US

Question 66

Causes of post coital bleeding, pelvic pain, discharge

Answer 66

Post coital bleeding, red flag for all cancers, also: trauma, atrophic vaginitis, polyps

Pelvic pain: UTI, periods, IBS, ovarian cysts, endometriosis, PID, ectopic P, appendicitis, Mittelschmerz (painful ovulation), adhesions, ovarian torsion, IBD

Discharge: bacterial vaginosis, candidiasis, STI, foreign body, cervical ectropion, polyps, malignancy, pregnancy, contraception, ovulation

Question 67

What common medications are not given / given in pregnancy and breastfeeding

Answer 67

Lamotrigine (and levetiracetam) safest antiepileptic, valproate and carbamazepine both teratogenic (all safe in breastfeeding). Also avoided other psychiatric: lithium, benzos, clozapine.
Aspirin contraindicated in pregnancy due to risk of Reye’s syndrome (encephalopathy + hepatic)
Other: rarer antibiotics, carbimazole, methotrexate, sulfonylureas, amiodarone, statins
SSRI in third trimester increase risk of persistent pulmonary hypertension of newborn

Avoided in pregnancy: aspirin, Lithium, Carbimazole, Tetracyclines, Ciprofloxacin, fluconazole, Methotrexate, Amiodarone, Benzodiazepines, Sulphonylureas, sulphonamides

Question 68

Describe HRT

Answer 68

HRT - combined or oestrogen only (no uterus)
Sequential HRT initially in perimenopause to induce bleeds, after 1y of no bleeding can have continuous combined. Irregular bleeding common up to 6m after starting
Risk: breast cancer (if progesterone), endometrial C, VTE (transdermal no effect) - stroke and IHD
Progesterone to be used 14d every 4w (sequential) or continuous; POP pill as well as progesterone in HRT or just mirena (4y) provides contraception and progesterone
Transdermal indications: gastric upset, migraine / epilepsy, increased risk of VTE, hypertension, patient choice
Don’t want HRT can give SSRI (fluoxetine) or clonidine for vasomotor

Question 69

Describe mastitis, breast abscess, fibroadenoma, fibroadenosis (fibrocystic), fat necrosis

Answer 69

Mastitis - infectious vs non: symptoms do not resolve within 24h after milk removal, infected nipple fissure, bacterial culture in severe. Painful, tender, red + hot, fever, malaise. Becomes abscess
FL continue breastfeeding, analgesia, warm compress. Abx: flucloxacillin 10d (continue BF)
Periductal mastitis common in smokers, recurrent infections, co-amoxiclav

Abscess: red + hot tender swelling (including skin), recent mastitis, IV flucloxacillin + drainage

Fibroadenoma: ‘breast mice’ - discrete, non tender, highly mobile, under 30. >3cm conservative Mx, 3+ surgical excision

Fibroadenosis / fibrocystic: lumpy, painful, middle aged, may worsen prior to menstruation

Fat necrosis: usually obese, following trauma, firm and round → hard irregular

Question 70

Describe duct ectasia, duct papilloma, galactocele, galactorrhoea

Answer 70

Duct ectasia (50+): dilatation and shortening of large ducts, tender lump around areola, +/- green / brown discharge. Duct shortening can cause slit like retraction. Conservative Mx, if bothering patient microdochectomy (young) / total duct excision (old)
Can rupture and cause local inflammation - plasma cell mastitis

Duct papilloma: epithelial proliferation in large ducts, hyperplastic not malignant, bloody discharge

Galactocele: stopped breastfeeding, blocked duct, firm + mobile, below areola

Galactorrhoea (milk without baby, prolactin): amenorrhea; men: impotence, loss of libido
Prolactinoma, oestrogens, acromegaly, PCOS, primary hypothyroidism (high TSH), antipsychotics / dopamine agonists. Treat cause

Question 71

Screening and referral for breast cancer

Answer 71

Mammography screening: 50+ every 3 years, up to 70 (have to arrange their own), 2 planes x ray, US as well for lumps (cystic vs solid), HRT make more dense + glandular (difficult like younger)
Early referral, annual: first degree before 40 / male / bilateral under 50, 2 first degree, 3 second degree; high risk genes MRI annually

Breast referral:
2 week pathway: 30+ unexplained lump (breast or axilla) +/- pain, 50+ unilateral discharge / retraction / other concerning changes, any age with lump and skin changes, Paget’s
Non urgent: under 30 with unexplained lump +/- pain (even if clinically suggestive of non cancer)

Question 72

Breast cancer presentation, investigations, management

Answer 72

painless lump, skin distortion, bloody discharge, nipple inversion, axillary lymphadenopathy, ulceration. RF: family history, prolonged oestrogen

Triple assessment: clinical assessment, US + mammography, core biopsy (standard) / fine needle aspiration / vacuum biopsy / open biopsy. Sentinel lymph node biopsy in surgery
3+ lymph nodes with metastasis indicates full node clearance

Surgery (wide local excision / mastectomy), axillary node clearance, radiotherapy (everyone following surgery), chemo for metastasis. Presurgery, non palpable nodes: axillary US, sentinel NB; palpable: axillary node clearance
Mastectomy: DCIS >4cm, multifocal, central; Wide local: DCIS <4cm, solitary, peripheral

If oestrogen receptors: Tamoxifen in premenopausal, anastrozole / letrozole / exemestane (aromatase inhibitors) for post. Her2: trastuzumab
Tamoxifen = selective oestrogen receptors modulator (antagonist in breasts), (agonist in endometrium and bones) (VTE, endo C, menopausal). Aromataseinhibitor = reduce peripheral synthesis of oestrogen (joints, osteoporosis, CVD, menopausal)

Question 73

Types and pathophysiology of breast cancer

Answer 73

Invasive ductal carcinoma most common (some from DCIS), inflammatory (raised WCC / CRP / Ca15-3), paget’s, tubular, lobular, non special type+ triple negative, mucinous

5% familial (but up to 80% lifetime risk), invasive ductal carcinomas most common, - from ductal carcinoma in situ, oestrogen receptor in 70% (good prognosis)
Her-2 (trastuzumab), triple negative very bad prognosis (BRCA1+2, FEC-D chemo)

Contraindication for all types of hormonal contraception

Question 74

Describe Paget’s disease of nipple

Answer 74

Paget’s: eczematous (crusty, weeping) change of nipple due to underlying carcinoma, suspect if eczema on nipple does not resolve with 2 weeks steroid / antifungal. 90% have invasive carcinoma (10% DCIS)
Pagets = nipple → areola, eczema = areola → nipple. Punch biopsy, mamm, US

Question 75

Describe COCP pill, contraindications, what to do if missed pill

Answer 75

Combined pill: O+P, inhibits ovulation (LF, FSH, GnRH), classically take 21:7 / newer is 3 packets then 4d off or take continuously until bleed then 4d off, increased risk VTE / stroke / breast (slight) + cervical cancer, decreased risk ovarian + endometrial cancer. Works after 7d

Contraindications; class 3: 35 +, smoking 15/d, BMI > 35, BRCA1/2, hypertension, wheelchair; class 4 (absolute): 35+ and 15 cigs/d, migraine with aura, history of stroke etc, breastfeeding 6w post birth, uncontrolled hypertension, antiphospholipid, long term diabetes

1 missed pill, take 2 next day. 2 missed pills - take missed as well; in first week / switching to CP from POP, other contraception for 7d, emergency contraception if unprotected. If 2 pills missed in second week no extra; in third week omit pill free interval
If going to have surgery stop 4w before and commence 2w after

Question 76

Describe the POP pills, what to do when missed

Answer 76

POP (norethisterone): thickens cervical mucus (barrier), taken daily - 3h window, increased menstrual irregularities, slight increase in breast cancer. Works after 2d
Desogestrel pill: inhibits ovulation as well as thickening mucus. Newest and preferred as 12 hour window to take compared to 3h for others
Most women tolerate very well but some it just doesn’t suit and bleeds never stop
Missed pill, condoms for 2d then covered

Question 77

Describe IUS, implant, depo injections and IUD

Answer 77

IUS (mirena): progesterone local (prevents endometrial proliferation, thickens mucus), less risk, menstrual benefits. 7d

Implant (nexplanon): ovulation + mucus, into non dominant arm subdermal, most effective long term, last 3y, no oestrogen, can be inserted immediately - additional contraception needed for 7d
Common side effect - unscheduled bleeding, give COCP

Depo-Provera (progesterone) injection lasts up to 12w and can take several months for body to return to normal fertility. 7d to start. Less popular due to increased risk of osteoporosis

Copper IUD: inhibits sperm motility + survival (implantation), painful + menstruation irregularities

Question 78

Describe emergency contraception

Answer 78

ulipristal acetate (ellaone) up until 120h after, levonorgestrel up to 72h
Ulipristal 30mg, contraindicated in severe asthma, reduced effectiveness of hormonal contraception (wait 5d) + breastfeeding delayed for a week
Levonorgestrel 1.5mg, 3mg for obese, vomited within 3h - repeat dose, safe with other contraception

Question 79

Describe contraception around menopause

Answer 79

Contraception in older women: COCP to be stopped at 50 and UKMEC2 after 40, depo stopped at 50 + UKMEC2 at 45, others not contraindicated, can stop after 1y of amenorrhea over 50, 2y under 50
Mirena ideal as provides HRT along with oestrogen patch