Women's Health Flashcards
Describe the physiology of a period
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)
What needs to be included in an obstetrics history
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
What are the normal physiological changes in pregnancy, how long are the trimesters
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
Describe the stages of labour
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)
Describe induction of labour and the bishop score
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.
Describe how to read and a healthy CTG
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)
Why does labour fail to progress, how is it managed
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)
Describe breech position, OP position, vaginal birth after c section
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
Describe the Apgar score
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
Describe cord prolapse and its management
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
Shoulder dystocia, RF, management, complications
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
Postpartum haemorrhage - definition, causes, RF
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
Management of postpartum haemorrhage
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
Describe secondary postpartum haemorrhaeg
Secondary PPH (24h - 12w after): endometritis, retained products, subinvolution of implantation site, pseudoaneurysms, arteriovenous malformations
Describe Rhesus incompatibility
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
What is the most common infection in preterm births
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
How is preterm premature rupture of membranes managed
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
Describe reduced foetal movements, investigations and risks
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
Ectopic pregnancy - presentation, investigations, management
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)
How is pregnancy of unknown location investigated
Pregnancy of unknown location - measure bHCG and repeat after 48h, <63% rise - intrauterine, rise of >63% - ectopic, fall >50% - miscarriage
How is miscarriage investigated, what are the types and how are they managed
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
Describe abortions
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
Describe molar pregnancy
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
Describe placenta + vasa praevia
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^
Describe placental abruption and morbidly adherent placenta
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
Preeclampsia - definition, investigations and management
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
Describe HELLP syndrome
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
Eclampsia, definition, management
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
Obstetric cholestasis - presentation, risk, management
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
Describe disseminated intravascular coagulation, presentation and management
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
Describe antepartum haemorrhage
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.
Describe gestational diabetes, investigations. management and complications
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
Describe management of preexisting diabetes in pregnancy
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
Describe STIs in pregnancy
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
Describe hyperemesis gravidarum, diagnosis and management
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
Describe oligo and polyhydramnios
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
Describe the antenatal scans and visits
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
What should patients receive during the antenatal period
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
Describe management of exposure to chicken pox in pregnancy
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
Management of UTIs, thrush, STIs in pregnancy
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
Describe contraception following birth
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
Describe postpartum thyroiditis and puerperal pyrexia
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
Describe the effects of rubella and syphilllis on a neonate
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
Describe TORCH infections
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)
What are common non-obstetric complications for the mum following birth
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
Cervical cancer - presentation, investigations, management, RF
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
Describe HPV, screening and investigations
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
Endometrial cancer - presentation, investigations, management, RF
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))
Ovarian cancer - presentation + complications, investigations, management and risk factors
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)
Describe vulval cancer
Vulval cancer, 90% squamous cell: lump, ulceration, bleeding, pain, pruritus. Biopsy and excision
Fibroid uterus - presentation, investigations, management, complication
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
Describe polyps and cervical ectropion
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)
Describe atrophic vaginitis
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
Describe endometriosis, presentation + exam, investigations, management
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
Describe adenomyosis, presentation, investigations, management
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
PCOS - criteria and investigations
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
PCOS - presentation and management
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
Ovarian cysts - presentation, investigations, management
Complications / risk
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)
Ovarian torsion - presentation, investigations, management
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
Describe premature ovarian insufficiency, investigations, management
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
Describe lichen sclerosis
Lichen sclerosus: AI derm condition, chronic inflammation - porcelain-white skin, itchy. 5% become vulval SCC
Topical steroids + emollient
Amenorrhoea - causes, investigations
Sheehan’s + asherman’s
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
What are the causes of irregular menstrual bleeding
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
Causes and management of dysmenorrhoea
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
Causes and management of menorrhagia
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
Causes of post coital bleeding, pelvic pain, discharge
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
What common medications are not given / given in pregnancy and breastfeeding
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
Describe HRT
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
Describe mastitis, breast abscess, fibroadenoma, fibroadenosis (fibrocystic), fat necrosis
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
Describe duct ectasia, duct papilloma, galactocele, galactorrhoea
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
Screening and referral for breast cancer
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)
Breast cancer presentation, investigations, management
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)
Types and pathophysiology of breast cancer
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
Describe Paget’s disease of nipple
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
Describe COCP pill, contraindications, what to do if missed pill
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
Describe the POP pills, what to do when missed
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
Describe IUS, implant, depo injections and IUD
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
Describe emergency contraception
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
Describe contraception around menopause
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
