Womens health Flashcards
1
Q
What refers to the first trimester of pregnancy
A
0-12 weeks
2
Q
What is considered the second trimester
A
12-20/24 weeks
3
Q
What is considered a recurrent miscarriage
A
3 T1 or 2 T2
4
Q
What are the 3 main types of early pregnancy losses
A
Miscarriage
Ectopic pregnancy
Molar pregnancy
5
Q
What are the 5 risk factors for a miscarriage
A
- Age above 35yo
- Previous losses
- Maternal complications like bacterial or viral infections
- Medications and substances
- Environmental exposures e.g. radiation
6
Q
What are the 4 most likely causes of a T1 miscarriage
A
- Chromosomal abnormalities
- Maternal uterine abnormalities
- Trauma
- Subchorionic haematoma
7
Q
7 causes of a T2 loss
A
Infection
Uterine abnormalities
Cervical incompetence
Fetal abnormalities
Thrombophilias
Abruption
Rupture of the membranes
8
Q
What is the general presentation of a patient with a miscarriage
A
The patient might be shocked with large amounts of blood loss as well as liver-like clots that are a result of placental matter. The patient will also have some LAP as a result of the contractions
9
Q
What would you see on a specular exam in a miscarriage
A
There would be bleeding from the cervical os
10
Q
If there is uterine tenderness after a miscarriage what does that indicate
A
Sepsis
11
Q
What are the tests that can be done to check if it was a misscarrage
A
Pregnancy test
12
Q
What test should be done on a T2 miscarriage in conjunction with the pregnancy test
A
Dipstick to check for a UTI as the cause
13
Q
What is a threatened miscarriage
A
This is where there is a risk of miscarriage, as a result, there is variable bleeding with no products of conception and the cervical OS remains closed. On ultrasound the is a fetal heart rate
14
Q
What is a complete miscarriage
A
This is where there is complete loss of a fetus, the uterus on ultrasound is clear and there are no retained products of conception. The OS is closed and there is heavy bleeding as the fetus is evacuated
15
Q
What is an incomplete miscarriage
A
This is where there is heavy bleeding, the cervical os is still open because there is still passage of the material, and there is persistent pain as the material is being passed.
16
Q
What is a missed miscarriage (silent)
A
This is where there is no fetal heart rate and an intact gestational sac, the os is closed and there is no pain or bleeding
17
Q
What are the signs of a septic miscarriage
A
Bleeding with an offensive smell the os is open with some RPOC, often a lot of pain with peritonitis
18
Q
What are the 4 main types of management for a miscarriage and what are the specific interventions used
A
- Acute: Fluid resuscitation with counseling and support
- Expectant management: Watch them and wait
- Medical: Misoprostol for removal of RPOC
- Surgical: If there is active bleeding or if the patient has products of conception
19
Q
What is an ectopic pregnancy
A
This is where there is implantation of the blastocystic tissue anywhere except for the uterine cavity
20
Q
How would the symptoms of an ectopic pregnancy differ from those of a miscarriage
A
In a miscarriage there would be exessive bleeding vaginally whereas in an ectopic pregnancy the bleeding is internally
21
Q
What are the 4 major risk factors for an ectopic pregnancy
A
- Tubal damage often caused by PID
- Previous tubal surgery
- Previous ectopic pregnancy
- IUD
22
Q
What are the minor causes of an ectopic pregnancy 3
A
- Cigarette smoking
- Age over 35
- Multiple sexual partners because it increases the risk of PID
23
Q
What is the main presenting complaint of an ectopic pregnancy
A
Severe lower abdominal pain with some vomiting
24
Q
What are the general findings of the examination in an ectopic pregnancy
A
The patient will have a nongravid uterus with extreme excitation tenderness and an adnexal mass
25
What does the OS look like in an ectopic pregnancy
The Os will be closed with no products of conseption
26
What are the 3 factors that point to an ectopic pregnancy until proven otherwise
Positive pregnancy test
Shocked patient
Abdominal peritonism
27
Under 12 weeks what is required for a TOP
Any women over the age of 12 can ask for a TOP
28
What are the 4 conditions that allow for a TOP after 12 weeks and less than 20 weeks
1. Poses a physical risk to the mother
2. There is serious fetal anomaly
3. Pregnancy is due to rape or incest
4. There are very poor SES
29
Who needs to sign off on a TOP between 12 and 20 weeks
The patient, doctor and a witness
30
What are the 2 conditions that allow for a TOP after 20 weeks
1. If there is a significant risk to the mother's health
2. There is a significant abnormality that would not allow the baby to survive
31
How are TOPs done
0-9weeks: Medication is taken at home only with counseling
9-12 weeks: Medication is taken in the hospital to prevent complications.
13-20 weeks: A mini labour is preformed in the hospital
After 20 weeks: Manual vacuum and aspiration is done or a doalation an curettage
32
What are the medications used in a TOP
Mifepristone followed by Misoprostol 48h later
33
What are some of the reasons that rape is so common in South Africa
1. Poverty
2. Lack of employment
3. Strongly patriarchal society
4. Lack of police and justice
5. Societal norms
6. High level of drugs and alcohol abuse
7. Poor infrastructure e.g. lights in informal settlements
8. Limited child care opportunities
34
Define rape
Sexual penetration of an orifice without a person's permission
35
Define consent
Consent is the voluntary uncoerced agreement to an act
36
What are some of the factors that can invalidate a statement of consent 7
1. If force or intimidation is used to gain consent
2. If there is a threat of harm or property
3. If there is an abuse of a power dynamic
4. If it obtained under false pretenses
5. If the person if the person is unable to understand the nature of the act e.g. they are under the influence
6. If the person is mentally disabled
7. Below the age of 12
37
Define sexual assault
Any person that unlawfully or intentionally sexually violates another person
38
What are the 3 situations in which sexual assault can be claimed
1. contact between the genitals of one person and any other body part of a person, animal or object
2. Contact between the mouth of one person and the genitals of another person
3. Forced masturbation
39
Does sex with a child over the age o 12 count as rape
Yes if the person they are having sex with is over the age of 16 then it is considered statutory rape
40
What is secondary trauma
This is where a victim of a traumatic event has to undergo the trauma of having to report the crime to someone who does not believe them and makes them feel as though it is their fault
41
What are the 4 principles of empowerment
1. Safety: It is vital to make the survive feel as though they are safe
2. Restoring control: This extends to the environment, persons body and other situation
3. Ongoing support: Dont let them leave without them knowing where to go next
4. Respect
42
What are the 5 steps that should be taken when you find out that someone has been raped
1. Check the patient's HIV status
2. If they are negative at the time of the test then start them on post-exposure prophylaxis
3. Test for syphilis, hep b
4. Treat for STI using a syndromic approach
5. Give emergency contraception
43
What are some of the reasons that a victim does not report rape 5
1. The perpetrator is often someone that the person knows
2. There is an enormous stigma around rape
3. There is often unprofessional behavior around how rape is handled by the police and healthcare workers
4. There is a very low conviction rate
5. Victims can feel shame and guilt
44
What are the forms of violence that fall under the IPV act in RSA 8
1. Psychological abuse
2. Physical violence
3. Damage to property
4. Stalking
5. Rape
6. Any form of harassment
7. Entry into a residence without permission
8. Any form of intimidation
45
What are the types of psychological abuse that constitute IPV
1. Coercive behaviour
2. Controlling behavior
3. Exposing children to domestic violence
4. Related personal abuse
5. Spiritual abuse
6. Humiliation
7. Jealocy
8. Threatening to harm a pet
9. Exposing sexual orientation
10. Threatening selfharm
46
Who is the most likely victim of IPV
Women in rural areas
46
What are the 4 stages in the cycle of violence
1. Honeymoon phase when everything is good and the person promises to change
2. Tension: This is where there are constant insults and threats of violence
3. Explosion: This is where there is an act of violence
4. Break.
47
What are some of the reasons that victims of IPV do not report 7
1. They do not know that this is what is happening to them
2. They are economically dependant on the perpetrator
3. They have no where to go after
4. They have been gaslight into believing that this is what they deserve
5. They have children with the abuser
6. System failures
7. They are too afraid to report them
48
What are the 6 R to handling a IPV situation?
1. Realise: Self realisation of what the patient is telling you, that abuse is happening
2. Recognise: Recognise what the victim is saying in a supportive way
3. Relevant clinical exam
4. Risk assessment: See if there is a risk of femicide
5. Risk plan
6. Refer them to an NGO or social worker
49
What is the first step to take if you suspect abuse
Ask the patient if there is any abuse
50
Do your report the abuse of an adult patient
No becuase it is disempowering to the patient and it may place the patient at significant risk
51
What are the types of abnormal vaginal bleeding 5
1. Irregular bleeding patterns
2. Heavier than usual bleeding
3. A bleeding duration that is longer than usual
4. Intermenstral bleeding
5. Post-coital bleeding
52
What are the possible structural and non-structural causes of abnormal vaginal bleeding
PALM-COINE
Structural causes:
1. Polyps
2. Adenomosis
3. Leiomyoma
4. Malignancy
Non structural causes:
1. Coagulopathies
2. Ovulatory disorders
3. Endometriosis
4. Iatogenic causes
5. Non classified
53
What is Adenomyosis
This is where endometrial tissue invades the muscle tissue causing disruption to the normal structure
54
What are the most likely causes of regular heavy menstral bleeding
1. Adenomyosis
2. Leiomyoma
3. Coagulopathies
4. Endometrial causes
5. Iatogenic
55
What are the most likely causes of irregular heavy menstral bleeding
1. Polyps
2. Ovulatory dysfunction
3. Malignancy
4. Iatogenic
POMI
56
How does adenomyosis occur
It is thought that in a previously pregnant women the placenta disrupts the endo myometrial junction allowing for the infiltration of the endometrial cells
57
What are the 2 main symptoms of adenomyosis
Chronic pelvic pain and because of the increase in the amount of endometrial tissue there is heavy menstation
58
What does the uterus feel like when Uterine Fibroids are present
On bimanual palpation the uterus is larger than usual and globular in feeling
59
What is the possible treatment options for adenomyosis
Hysterectomy
60
What are the possible treatment options for a patient with adenomyosis that wants to still get pregnant
The patient would need to be put on strong analgesia and then COC to decrease the uterine growth
61
How do coagulopathies lead to increased or heavy menstrations
In the prosess of menstration there is tearing of the small blood vessels that supply the endometrium if the patient has a coagulopathy then they are unable to seal off these vessels
62
What are the possible treatment options for patients that have a coagulopathy causing heavy menstration
The patient can be given COC to decrease the thickness and the frequency of menstration and then also procoagulopathic drugs to help them clot
63
What causes a primary disorder of endometrial hemostasis
This is where there is an issue with a specific prostaglandin factor in the coagulation cascade and so there is and inability for the bleeding to seas
63
What are uterine polyps
These are hyperplastic growths of the endometrial glands and stroma of the endometrium
64
What are the diagnostic test that is used to test for polyps
US and the gold standard is a hysteroscopy
65
Which hormonal axis causes irregular heavy menstral bleeding
Hypothalamo-pituitary-ovaqrian axis
66
What is the primary aetiology of PCOS
The failure of follicles to mature and ovulate (anovulation) is central to PCOS. The HPO axis becomes imbalanced, leading to elevated LH and androgens, reduced FSH, and improper follicle maturation, which then prevents ovulation.
67
Which hormone in PCOS causes the viriliization and hisuitism
Testorone
68
Why does the LH surge for ovulation to occur not occur in PCOS
This is because the LH levels are chronically high
69
Why are the ovaries in PCOS patients known as polycystic
This is because there are multiple follicales that develop but then are not released as there is no LH surge
70
What are the short term complications of PCOS
Oligomenorrhoea
Infertility
Hirsutism
71
What are the long term complications of PCOS
Obecity
Insulin resistance
Hypercholestrolemia
Raised BP
Endometrial cancer
72
What are 2 iatogenic causes of heavy regular periods
1. Copper IUD
2. Anticoagulant threopy
73
What is the most likely cause of a heavy menstration in a patient that has been on contraception for at least 6 months
Break through bleed
74
What is the most likely cause of irregular abnormal bleeding
Hormonal methods of contraception
75
Define menopause
This is the cessation of menses for at least 12 months
76
What is the normal pattern in postmenstrual bleeding
Irregular
77
What 5 most common causes of PMB
1. Genital atrophy as a result of decreased estrogen
2. Malignancies
3. Polyps
4. Endometrial hyperplasia
5. Iatrogenic causes
GEM PI
78
What causes the bleeding in a patient that has atrophy of the genital tract
There 2 possible mechanisms:
1. There is thinning of the tissue and a decrease in lubrication and so in intercourse there is significant damage that can occur
2. There is thinning and shrinking of the uterus causing the uterine walls to rub against one another and so causing bleeding
79
What is the main driver for the formation of polyps in a patient that has undergone menapause
Exessive adipose tissue
80
What does the genital tract of a post menuposal women look like
It looks pale and atrophied as it degenerates
81
What is the transitional zone
It is the area between the prepubertal columnar squamous junction and the one established in puberty
82
What are the 4 risk factors that predispose someone to mutations in the transitional zone of the cervix
1. Smoking
2. HIV infection
3. Increased estrogen exposure
4. HPV
83
What are the 2 types of HPV that predisposes a person to cervical cancer
16 and 18
84
How often should women be screened for cervical cancer
They should be screened every 10 years except if they have HIV then it should be done every 3 years
85
What are the 5 different types of endothelia changes from least significant to the most significant
1. ASCUS [Atypical squamous cells of unknown significance]
2. LSIL [Low grade intraepithelial lesion]
3. ASCH [Atypical squamous cell where HSIL can not be excluded]
4. HSIL [High grade intraepithelial lesion]
5. Squamous carcinoma
86
What is an AGC cell
This is an atypical glandular cell
87
What is the appropriate test done on a cervix that looks visibly abnormal
Do a punch biopsy
88
What are the 3 main alternatives that can be done instead of a normal pap smear
1. Liquid based cytology
2. HPV testing
3. Visual inspection with acetic acid
89
How do you know whether a cone biopsy or a LLETZ should be done
The extent of the invasion is not known and is micro invasion can be ruled out [Cone biopsy is worse]
90
What are the signs of cervical cancer
Abnormal bleeding
Offensive discharge
Pain
Rectovaginal fistula
91
Who should get a diagnostic pap smear
Patients that present with abnormal vaginal bleeding, pain and discharge
92
What is meant by exophytic
This is when the lesion is fungating
93
What is meant by endophytic
This is when a lesion is ulcerating
94
What is considered a FIGO 1A and 1B
1A is when the lesion is less than 5mm deep and 1B is where the lesion is more than 5mm deep
95
What is considered a FIGO 2A and 2B
2A is the upper 2/3 of the vagina and 2B is insolvent of the parametrium
96
What is considered a FIGO 3A 3B and 3C
3A is the lower 1/3 of the vagina and then 3B is the when there is extension into the pelvic wall 3C Is lymph node involvement
97
What is considered a FIGO 4A and 4B
4A is involvement of the bladder and the bowel and 4B is distant ments
98
What is the most common presentation of endometrial cancer
Postmenopausal bleeding
99
What is the most common precipitant for endometrial cancers
Exessive estrogen exposure
100
What are the 2 main factors that increase the levels of estrogen exposure throughout life
1. Increased adipose tissue
2. Wide estrogen window
101
What are the 4 main ways that there can be an increase in the oestrogen window
1. If there is early menstral onset
2. Few or no pregnancies as it decreases the no. of cycles
3. PCOS
4. HRT
102
What are the 2 protective factors in preventing endometrial cancer
1. Pregnancies
2. Hormonal contraceptives
103
What are the 2 chemicals produced by the resident bacteria in the vagina that help to maintain the microbiome and so prevent the growth of pathogenic bacteria
1. Hydrogen peroxide
2. Lactic acid
104
Define pelvic inflamatory disease
This is where bacteria pass past the endocervix causing infection that involves the endometrium, fallopian tubes and ovaries
105
How does PID develop into peritonism
This occurs if there is rupture of the tubo-ovarian complex
106
What are the 8 main risk factors for PID
1. Early age of intercourse
2. Being less than 25yo
3. High no. of sexual partners
4. Low parity
5. Low SES
6. Bacterial vaginosis
7. Previous PID
8. Insertion of a IUD
107
What are the most common causal organisms in PID
It is normally a polymicrobial infection
1. Nesseria gonorrhoea
2. Chlamydia trachomoatis
3. Mycoplasma genitalium
4. Anaerobic bacteria
108
What is salpingitis
This is inflammation of the fallopian tubes
109
What are the 4 stages of PID
1. Early salpingitis - With moderate pain and discharge
2. Late salpingitis - Pelvic peritonitis
3. Tubo-ovarian complex
4. Peritonitis caused by the rupture of a tubo-ovarian complex
110
What are the main signs of PID in patients
1. Pain in the lower abdomen
2. Foul smelling discharge
3. Abnormal vaginal bleeding
4. Fever
5. Urinary symptoms like frequency
111
What is Fitz Hugh Cutis syndrome
Fitz-Hugh-Curtis syndrome is inflammation of the liver capsule with adhesion formation resulting in right upper quadrant pain
112
What are the possible differentials for PID?
1. Appendicitis
2. Ovarian torsion or cyst rupture
3. UTI
4. Ectopic pregnancy
113
What are the general treatment options for PID in each stage
1. Oral antibiotics to treat the infection
2.Admission to the ward with antibiotics
3 and 4. IV antibiotics and then surgery if there is no improvement
114
What are the 4 common causal pathogens for chronic PID
1. Genital TB
2. Schistosomiasis
3. Actinomycosis
4. Chlamydia trachomatis
115
What are the common presenting complaints of a patient with chronic PID
1. Weight loss
2. Low grade fever
3. Lower abdominal pain
4. Pain on intercourse
116
What are the common causes of damage to the microbiome of the vagina
1. STI
2. Antibiotics
3. Douching
4. Low estrogen
5. Foreign bodies
117
What is leucorrhoea
This is the normal white, yellow discharge from the vagina
118
What are the associated symptoms that are common with vaginal discharge syndromes
1. Burning on urination
2. Dyspareunia
3. Itching
4. Spotting
119
What are the non-infectious causes of VDS
1. Post-menopausal vaginal atrophy
2. Foreign bodies
3. Douching
120
What are the infectious causes of Vulva- vaginitis
1. Candidiasis
2. Bacterial vaginosis
3. Trichomoniasis
121
What are the common causes of cervicitis
1. Gonorrhoea
2. Mycoplasma
3. Chlamydia
122
What are the 2 main causes of vaginal atrophy
1. Menopause
2. When antiestrogen drugs are given in patients with cancer
123
What does the discharge look like in a patient with vulvovaginal atrophy
Watery discharge
124
What are some of the common symptoms in vulvovaginal atrophy
1. Spotting
2. Dyspareunia
3. Frequent UTI
125
What is the other name for anogenital warts
Conodylomata acuminata
126
What is the common viral cause of anogenital warts
HPV 6 and 11
127
What are the typical medical treatments for warts
Podophyllin
Imiquimod
Tri-chloroacetic acid
128
What is the treatment for larger warts
1. Electrocautery
2. Excision
3. Lazer
129
What is the viral cause of genital herpes
HSV 1 and 2
130
What are the 3 types of infection that can occur in HPV
1. Primary infection: Primary infection is generally the most severe form of infection as there are no antibodies against the infection
2. Reinfection after the primary infection: Here the symptoms are generally less severe as the patient has some antibodies from the initial infection
3. Recurrent infections: This occurs in an immunosuppressed patient where there is recurring infections
131
How is genital herpes generally diagnosed
1. Cultured from the fluid in the vesicles
2. Viral PCR from the vesicles
3. HSV antibody testing
132
What is the medical treatment given to patients with HSV
Acyclovir
133
Define chronic pelvic pain
Non-cyclical pain for 6 months or more
134
What are the 5 most common causes of Chronic pelvic pain
1. Endometriosis
2. Pelvic adhesions caused by PID
3. Pelvic varicosities [Pelvic congetion]
4. Painful bladder syndrome
5. IBS
135
What is endometriosis
This is where endometrial tissue forms in the wrong area like outside of the uterine cavity
136
What are the common symptoms of endometriosis
1. Severe dysmenorrhoea [Pain that is cyclical]
2. Dysparuria
137
What is the general treatment for endometriosis
1. Potent analgesia
2. Hormonal contraception to decrease the endometrial tissue growth
138
What is the best contraceptive method for a patient with endometriosis
Depot
139
What are the medication options that are given to a patient who would like to fall pregnant?
COC and Provera can be given as they are fast-reversing
140
What is chronic PID
This is where acute PID is not treated leading to severe adhesions as the body tries to wall off the infection
141
What is the most significant finding on bimanual palpation
The patient will have a fixed uterus where it is non-mobile due to the adhesions present
142
What are the key features that allow you to make a diagnosis of chronic PID
1. There is chronic non-cyclic pain
2. The patient has had previous PID
3. The uterus is non-mobile
143
What are some of the neuromodulatory drugs that can help with chronic pain management
1. Amitriptyline
2. Pregabalin
144
What are the common pathological causes of a mass in the pelvis
1. Fibroids
2. Ovarian cysts
3. Ovarian cancer
145
What are fibroids
They are benign growths of the uterine wall that are composed of smooth muscle
146
What are the risk factors for fibroids
1. Black women are more at risk
2. Obesity
147
How do fibroids cause heavy bleeding
The fibroids are increasing the surface area in the uterus thus causing more uterine deposition
148
How do fibroids cause infertility
Cervical fibroids block off openings near the fallopian tube thus preventing entry of the sperm. The placenta can also form over the fibroids, causing the placenta to rupture
149
What causes pain in fibroids
Fibroids are generally not painful but pain can be caused by:
1. Hyaline degeneration
2. Torsion of a fibroid peduncle
3. Prolapse of a peduncle out of the cervix
4. Red degeneration
5. Sacromatous changes
150
What is red degeneration
Red degeneration is a complication of uterine fibroids that occurs when the fibroid's blood supply is disrupted, resulting in ischemia, infarction, and necrosis often as a result of pregnancy
151
What is the definition of menopause
Cessation of menstruation for 12 consecutive months
152
What is the average age of menopause and what is the age range that it normally occurs in
Average is 51 and normally occurs between 49-55
153
What are the general signs that a patient is perimenopausal
1. Menstrual irregularities
2. Hot flashes
3. Night sweats
4. Muscle and joint pain
5. Breast tenderness
6. Insomnia and mood changes
154
What are the contraindications for menopausal hormone therapies
Breast cancers
Previous thromboembolic
Thrombophilias
Undiagnosed abnormal uterine bleeding
Cardiovascular disease
155
What is the risk with giving unopposed oestrogen treatments
This does not allow the endometrium to shed and rather allows it to proliferate unchecked this unchecked proliferation allows for increased risk of dysplastic changes that cause the formation of cancers
156
What are the 2 main types of breast cancers
Ductal carcinomas [Most common] and lobular carcinomas
157
When inspecting the breast what are the things that you are looking for
1. Size
2. Symmetry
3. Conture
4. Colour
5. Nipple
158
Define sexual health
This means that one can have safe sex, free from violence or coersion and where there is free consent
159
Define trauma
Truama is a specific event that overrides the nervous system and alters the way that memories are saved
160
What are the 3 main types of female sexual disorders
1. Sexual interest disorders
2. Genetopelvic pain
3. Female orgasm disorders
161
What are the 4 steps in adressing sexual functioning according to the PLISSIT model
1. Permission: Encourage the patient to discuss sexual concerns by creating a safe, nonjudgmental environment.
2. Limited infromation: Provide specific, relevant information related to the patient’s concerns or condition.
3. Specific sigestions: Offer practical strategies or behavioral modifications to address the sexual concerns.
4. Intensive theropy: Refer for in-depth therapy when issues are beyond the scope of general care or require specialized treatment.
