WOMENS HEALTH Flashcards
ECTOPIC PREGNANCY
What is the epidemiology of ectopics?
What are some risk factors for ectopics?
ANATOMICAL FACTORS
- PID
- previous ectopic pregnancy
- tubal surgery
- endometriosis
NON-ANATOMICAL
- IVF
- IUD
- smoking
- POP contraception
- Diethylstilbestrol
ECTOPIC PREGNANCY
What is medical management?
What are the indications?
What indicates that it has worked?
- Single dose IM 50mg/m^2 methotrexate
- No significant pain, unruptured ectopic <35mm, no heartbeat, serum hCG <1500 (consider up to 5000IU/L) + able to return for follow up
- hCG levels at days 4 + 7 then weekly, <15% fall = ?another dose
MISCARRIAGE
What is the medical management of a miscarriage?
What is the follow up?
- PV/PO synthetic prostaglandin MISOPROSTOL
- Contact HCP if no bleeding in 24h
- Urinary beta-hCG 3w after to exclude ectopic or molar
TERMINATING PREGNANCY
What is the medical management of abortion?
- More appropriate in earlier pregnancy, <24w, <10w can be done at home
- MIFEPRISTONE (anti-progesterone) to halt pregnancy + relax cervix
- MISOPROSTOL (prostaglandin analogue) 24-48h after for contractions
TERMINATING PREGNANCY
What is done before surgical management of abortion?
- Cervical priming with mifepristone, misoprostol or osmotic dilators (>14w insert into cervix + gradually expand as absorb fluid to open cervical canal)
HYPEREMESIS
What is the inpatient management of hyperemesis gravidarum?
- Monitor U+Es
- NBM until tolerate PO = IV fluids + anti-emetics
- Vitamin supplements (incl. thiamine), may need artificial nutrition to prevent Wenicke-Korsakoff
- Thromboprophylaxis with TED stockings + LMWH
- Small + frequent meals when eating allowed
HYPEREMESIS
What is the community management of hyperemesis gravidarum?
- 1st line antiemetic = promethazine or cyclizine (anti-histamines)
- 2nd line = ondansetron (5-HT3 antagonist) or metoclopramide (dopamine antagonist)
PLACENTA PRAEVIA
What are some risk factors for placenta praevia?
- Embryos more likely to implant on lower segment scar from previous c-section
- Multiple pregnancy
- Multiparity
- Previous praevia
- Assisted conception
PLACENTAL ABRUPTION
What are the major risk factors for placental abruption?
What are some other risk factors?
- IUGR, pre-eclampsia or pre-existing HTN, maternal smoking + previous abruption
- Cocaine use, multiple pregnancy or high parity, trauma
ADHERED PLACENTA
What are some risk factors for a morbidly adhered placenta?
- Previous c-sections (placenta attaches to site)
- Myomectomy
- Surgical TOP
VASA PRAEVIA
What are some risk factors for vasa praevia?
- Placenta praevia
- Multiple pregnancy
- IVF pregnancy
- Bilobed placentas
PRE-ECLAMPSIA
What are the…
i) high risk
ii) moderate risk
factors for pre-eclampsia?
i) Pre-existing HTN, previous pre-eclampsia, CKD, autoimmune (SLE, T1DM)
ii) Nulliparity, multiple pregnancy, >10y pregnancy interval, FHx, >40y, BMI >35kg/m^2
PRE-ECLAMPSIA
What are the signs of pre-eclampsia?
- Raised BP + proteinuria are hallmarks
- Rapid weight gain, RUQ tenderness
- Ankle clonus (brisk reflexes normal in pregnancy but not clonus)
- Papilloedema if severe
HELLP
How does HELLP syndrome present?
➢ Nausea/vomiting
➢ Hypertension
➢ Brisk tendon reflexes
➢ RUQ/Epigastric pain
➢ General malaise/headache
➢ Oedema/bleeding
➢ Visual problems, jaundice
IUGR
What are some placental causes of IUGR?
- Abnormal trophoblast invasion (pre-eclampsia, placenta accreta)
- Infarction, abruption, location (praevia)
IUGR
What are some maternal causes of IUGR?
- Chronic disease (HTN, cardiac, CKD)
- Substance abuse (cocaine, alcohol) smoking, previous SGA baby
- Autoimmune
- Low socioeconomic status
- > 40
IUGR
What are some foetal causes of IUGR?
- Genetic abnormalities (trisomies 13/18/21, Turner’s)
- Congenital infections (TORCH)
- Multiple pregnancy
IUGR
When would you be concerned about IUGR?
What would you do?
- SFH < 10th centile, slow or static growth or crossing centiles
- Refer for serial growth scans (USS) every 2w, umbilical artery doppler + amniotic fluid volume
- MCA doppler performed after 32w
OLIGOHYDRAMNIOS
What are some causes of oligohydramnios?
- PROM or SROM
- Renal agenesis (Potter’s syndrome) or non-functional kidneys
- Placental insufficiency (pre-eclampsia, post-term gestation) as blood redistributed to brain so reduced urine output
- Genetic anomalies
- Obstructive uropathy
POLYHYDRAMNIOS
What are the causes of polyhydramnios?
- Increased foetal urine production (maternal DM), twin-twin transfusion, foetal hydrops
- Foetal inability to swallow/absorb amniotic fluid (GI tract obstruction e.g. duodenal atresia, foetal neuro/muscular issues)
RHESUS DISEASE
What are some investigations for rhesus disease?
- Kleihauer test (check how much foetal blood > mother’s blood after event)
- All babies born to Rh-ve women should have cord blood at delivery for FBC, blood group + Direct Coombs (antiglobulin) test for antibodies on baby’s RBC
GESTATIONAL DIABETES
What is the pathophysiology of GDM?
- Increased insulin resistance due to placental production of anti-insulin hormones
- Allows post-prandial glucose peak to be higher for longer to spare glucose for foetus (main source of nutrients)
- If maternal pancreas cannot increase insulin production to combat this > GDM
GESTATIONAL DIABETES
What are the maternal risks of GDM?
- Pre-eclampsia
- DKA or hypos
- UTIs
- IHD
- Nephropathy, retinopathy
VTE IN PREGNANCY
What are the…
i) high
ii) intermediate
risk factors of VTE?
i) PMH of VTE, antenatal LMWH requirements, high-risk thrombophilia or low risk + FHx
ii) Smoking, parity >3, age >35, BMI >30, reduced mobility, multiple pregnancy, pre-eclampsia, gross varicose veins, IVF
VARICELLA ZOSTER
What is the management of chickenpox exposure in pregnancy?
- Any doubt in immunity, check for varicella zoster IgG
- ≤20w + not immune = VZIG within 10d
- > 20w + not immune = VZIG or aciclovir days 7–14 post-exposure
VARICELLA ZOSTER
What is the management of chickenpox infection in pregnancy?
- PO aciclovir if ≥20w + presents within 24h of rash onset
- <20w then consider
PROM
What are some risk factors for (P)PROM?
- Previous PROM/preterm
- Smoking
- Polyhydramnios
- Amniocentesis
PROM
What are some investigations for PROM?
- Sterile speculum 1st for pooling of amniotic fluid
- USS may show oligohydramnios if speculum normal
- Ferning test (cervical secretion on glass slide shows fern-pattern crystals)
- Test fluid for IGFBP-1 or PAMG-1
- CTG for foetus (tachycardia is suggestive of infection)
PROM
What is the management of PPROM?
- 1st line = IM corticosteroids if foetus <34w
- Prophylactic PO erythromycin given to prevent chorioamnionitis for 10d or until labour is established if within 10d
- Consider induction at 34w (trade off)
STAGES OF LABOUR
What are 7 important hormones in labour?
- Prostaglandins
- Oxytocin
- Oestrogen
- Beta-endorphins
- Adrenaline
- Prolactin
- Relaxin
STAGES OF LABOUR
What are the parts of the APGAR score?
Activity – absent 0, flexed arms + legs 1, active 2
Pulse – absent 0, <100bpm 1, >100bpm 2
Grimace – floppy 0, minimal response to stimulation 1, prompt response to stimulation 2
Appearance – blue 0, blue extremities 1, pink 2
Respiration – absent 0, slow + irregular 1, vigorous cry 2
STAGES OF LABOUR
What are the 6 cardinal movements of labour?
- Engagement + descent
- Flexion
- Internal rotation
- Extension (crowning)
- Restitution/external rotation
- Expulsion
FAILURE TO PROGRESS
How would you manage failure to progress in the third stage of labour?
What are the indications for management?
- IM oxytocin to cause uterus contraction to expel placenta
- Cord clamp + careful cord traction to guide placenta out
- Haemorrhage or >60m delay in physiological management (delay in active Mx is >30m)
BREECH
What are some causes/risk factors for breech presentation?
- Idiopathic
- Prematurity as baby may not have turned itself yet
- Previous breech
- Uterine abnormalities (bicornuate uterus), fibroids
- Placenta praevia
- Foetal abnormalities (CNS malformation
- Multiple pregnancy
- Poly/oligohydramnios
CORD PROLAPSE
What are some risk factors for cord prolapse?
- Prematurity
- Polyhydramnios
- Long umbilical cord
- Malpresentation (Footling breech + transverse lie)
- Multiparity + multiple pregnancy
- Placenta praevia
CORD PROLAPSE
What is the management of cord prolapse?
- 999/emergency buzzer, neonatal team
- Fill bladder with 500ml warmed saline via catheter (elevate presenting foetal part + lift off cord)
- Left lateral position with head down or knee-chest position
- Presenting part pushed back into uterus to prevent compression
- Avoid handling cord > vasospasm
- Tocolytics like terbutaline (SABA) to abolish contractions if delivery not imminently available
SHOULDER DYSTOCIA
What are some risk factors for shoulder dystocia?
- Macrosomia
- Maternal DM
- High maternal BMI
- Cephalopelvic disproportion
- Post-maturity
- Previous shoulder dystocia
SHOULDER DYSTOCIA
What is the management of shoulder dystocia?
HELPERR[R] –
- Help (call with emergency buzzer, obs, neonates)
- Evaluate for episiotomy (enlarge opening)
- Legs = McRobert’s
- Pressure = suprapubic
- Enter = pelvis for rotation
- Remove = posterior arm
- Replace = head in vagina + deliver by section (Zavanelli)
PERINEAL TEARS
What is the classification of perineal tears?
- 1st degree = limited to superficial skin of perineum
- 2nd degree = above PLUS perineal muscles (includes episiotomy)
- 3rd degree = above PLUS anal sphincter involvement
- 4th degree = above PLUS injury to rectal mucosa
PERINEAL TEARS
How are third degree tears further classified?
- 3A = <50% of external anal sphincter thickness torn
- 3B = >50% of EAS thickness torn
- 3C = EAS + internal anal sphincter torn
PPH
What is a primary postpartum haemorrhage (PPH)?
Primary = loss of >500ml blood in the first 24h after delivery
- Minor = 500–1000ml estimated blood loss
- Major = >1000ml, clinically in shock
PPH
What are the primary causes of PPH?
Primary (4Ts)–
- Tone (uterine atony = most common)
- Trauma (perineal tear)
- Tissue (retained products)
- Thrombin (clotting issue e.g. DIC in pre-eclampsia)
PPH
What are some preventative measures to reduce risk and consequences of PPH?
- Treat anaemia during antenatal period
- Empty bladder (?catheter) as full bladder reduces uterine contractions
- Active Mx of third stage (IM oxytocin)
- IV TXA during c-section in third stage of labour if high risk
PPH
What is the role of medical management in PPH?
What is the medical management of PPH?
- All stimulate uterine contractions
- IV syntocinon
- IV/IM ergometrine, C/I in HTN as vasoconstrictor (can combine with syntocinon as syntometrine)
- IM carboprost, caution in asthma (prostaglandin analogue)
- Sublingual misoprostol (prostaglandin analogue)
HYPEREMESIS
What are some associations of hyperemesis gravidarum?
- nulliparity,
- hyperthyroid,
- obesity,
- decreased in smokers
PPH
What is a secondary postpartum haemorrhage (PPH)?
Secondary = excessive blood loss from genital tract between 24h–12w after delivery (can result in Sheehan’s syndrome)
HELLP
what are the risk factors for HELLP?
➢ White ethnicity
➢ Maternal age >35 yrs.
➢ Obesity
➢ Chronic hypertension
➢ DM
➢ Autoimmune disorders
➢ Abnormal placentation and multiple gestation
➢ Previous pregnancy with preeclampsia
FOETAL HYDROPS
what is the pathophysiology?
an imbalance of interstitial fluid production and inadequate lymphatic return. This can result from congestive heart failure, obstructed lymphatic flow, or decreased plasma osmotic pressure.
FOETAL HYDROPS
what are the causes of non-immune foetal hydrops
- severe anaemia (parvovirus B19, thalassaemia, G6PD)
- cardiac abnormalities
- chromosomal abnormalities (trisomies 13, 18 and 21)
- genetic conditions
- other infections (toxoplasmosis, rubella, CMV, varicella)
- structural abnormalities (CCAM, diaphragmatic hernia)
- twin-to-twin transfusion syndrome
- chorioangioma
FOETAL HYDROPS
what is the management?
depends on the cause
- anaemia = in-utero blood transfusion
- pleural effusions/CCAM = shunt
- twin-to-twin transfusion syndrome = laser photocoagulation of placental anastomoses
- cardiac arrhythmias = maternal digoxin + flecanide
UTEROPLACENTAL INSUFFICIENCY
what are the causes of uteroplacental insufficiency?
➢Abnormal trophoblast invasion:
▪ Pre-eclampsia
▪ Placenta accreta
➢ Abruption
➢ Infarction
➢ Placenta previa
➢ Tumor: chorioangiomas
➢ Abnormal umbilical cord or cord insertion (i.e., two vessel cord)
➢ Maternal diabetes
➢ Maternal hypertension
➢ Anemia
➢ Smoking
➢ Drug abuse (cocaine, heroin, methamphetamine)
➢ Antiphospholipid syndrome
➢ Renal disease
➢ Advanced age
UTEROPLACENTAL INSUFFICIENCY
what is the presentation?
➢ Depending on the cause
➢ Mother may notice uterus is smaller than previous pregnancies
➢ Fetus may be moving less than expected
➢ IUGR
➢ Vaginal bleeding or preterm labor contractions (i.e., during placental abruption)
PUERPERAL INFECTION
what is it defined as?
Temperature of above 38 degrees Celsius in the first 14 days following delivery.
PUERPERAL INFECTION
what is the management?
➢ Supportive (analgesics/NSAIDS, wound care, ice packs…)
➢ Antibiotics (for endometritis – IV clindamycin and gentamicin until >24hrs afebrile)
➢ Surgical (drain abscess, secondary repair of wound, drainage of hematomas…)
OBSTRUCTED LABOUR
What are the different types of causes of obstructed labour?
- Power (most common)
- Passage
- Passenger
- Psyche (maternal exhaustion in second stage)
CHORIONIC VILLUS SAMPLING
when is chorionic villus sampling performed?
Usually between 10-13 weeks
AMNIOCENTESIS
When is amniocentesis performed?
from 15 weeks onwards
CHLAMYDIA IN PREGNANCY
what is the management?
- azithromycin 1g OD followed by 500mg orally OD for 2 days
- erythromycin 500mg QD for 7 days
- amoxicillin 500mg TD for 7 days
GONORRHOEA IN PREGNANCY?
what is the management?
500mg ceftriaxone IM single dose
SYPHILIS IN PREGNANCY
what is the management?
penicillin
TRICH VAGINALIS IN PREGNANCY
what is the management?
metronidazole
UTIs IN PREGNANCY
what are the treatments?
- Oral antibiotics
- Asymptomatic bacteriuria: 3 days
- Cystitis 7 days - nitrofurantoin (avoid in 3rd trimester)
- amoxicillin (only once sensitivities known)
- cefalexin
UTIs IN PREGNANCY
what is the management of pyelonephritis?
antibiotics (IV) for 10-14 days
- Pyelonephritis needs IV antibiotics until pyrexia settles and vomiting stops. IV fluids and antipyretics too.
UTIs IN PREGNANCY
what are the antenatal risk factors for UTIs?
- previous infection
- renal stones
- diabetes mellitus
- immunosuppression
- polycystic kidneys
- congenital abnormalites of renal tract
- neuropathic bladder
ANAEMIA + PREGNANCY
what are the cut offs for the normal ranges of haemoglobin during pregnancy?
1st trimester = <110g/L
2nd/3rd trimester = <105g/L
Postpartum = <100g/L
PREMATURE LABOUR
how can premature labour be prevented?
- vaginal progesterone gel/pessary (if cervical length <25mm on vaginal USS at 16-24 weeks)
- cervical cerclage (if cervical length <25mm on vaginal USS at 16-24 weeks and have had previous premature birth or cervical trauma)
- rescue cervical cerclage offered at 16-27+6 weeks when there is cervical dilatation without ROM
PREMATURE LABOUR
what medications can stop uterine contractions?
when are they used?
- nifedipine or atosiban
- used between 24-33+6 weeks
- used to delay delivery and buy time for further foetal development, administration of steroids or transfer to a more specialist unit
- only used as a short term measure (<48 hours)
FIBROIDS
What are some risk factors for fibroids?
- Afro-Caribbean
- Obesity
- Early menarche
- FHx
- Increasing age (until menopause)
ADENOMYOSIS
What is the initial management of adenomyosis?
if pt does NOT want contraception
- anti-fibrinolytic = TRANEXAMIC ACID (when there is no associated pain)
- NSAID = MEFANAMIC ACID (when there is associated pain)
if pt does want contraception
- 1st line = mirena coil
- COCP
- cyclical oral progestogens
other options (considered by specialist)
- GnRH analogues
- endometrial ablation
- uterine artery embolism
- hysterectomy
ENDOMETRIOSIS
What are some risk factors for endometriosis?
- Early menarche,
- late menopause,
- obstruction to vaginal outflow (imperforate hymen)
ENDOMETRIOSIS
What is the initial management of endometriosis?
- NSAIDs ± paracetamol first line for Sx relief
- COCP triphasing (can’t take for longer as if not irregular bleeding
- POP like medroxyprogesterone acetate
- GnRH analogues to “induce” menopause, reversible, quicker than triphasing but need HRT + only short-term as risk of osteoporosis
PCOS
How does insulin resistance contribute to PCOS?
- Insulin resistance = pancreas produces more insulin
- Insulin mimics action of insulin-like growth factor 1 which augments androgen production by theca cells in response to LH
- Higher insulin = higher androgens (testosterone)
PCOS
How does high insulin levels contribute to PCOS?
- Insulin suppresses sex hormone-binding globulin (SHBG) produced by liver which normally binds to androgens + suppresses their function further promoting hyperandrogenism
- Also contribute to halting development of follicles in ovaries > anovulation + multiple partially developed follicles (polycystic ovaries)
PCOS
What are the 3 main presenting features of PCOS?
- Hyperandrogenism
- Insulin resistance
- Oligo or amenorrhoea + sub/infertility
PCOS
How does insulin resistance present?
- Obesity, acanthosis nigricans (thickened, rough skin often axilla + elbows with velvety texture), psychological Sx
PCOS
What diagnostic criteria is used in PCOS?
Rotterdam criteria (≥2) –
- Oligo- or anovulation (may present as oligo- or amenorrhoea)
- Hyperandrogenism (biochemical or clinical)
- Polycystic ovaries (≥12) or ovarian volume >10cm^3 on USS
PCOS
What hormone tests may be used in PCOS?
- Testosterone (raised)
- SHBG (low)
- LH (raised) + raised LH:FSH ratio (LH>FSH)
- Prolactin (normal), TFTs (exclude causes)
CERVICAL CANCER
What genes may be implicated in cervical cancer?
- P53 + pRb are tumour suppressor genes
- HPV produces two oncoproteins (E6 + E7)
- E6 inhibits P53, E7 inhibits pRB
CERVICAL CANCER
What is the cervical cancer screening?
- Sexually active women 25–64 (triennially 25–50, 5y 50–64) smear test
- Exceptions = HIV pts screened annually, women with previous CIN may require additional tests
OVARIAN CANCER
What are the 4 types of ovarian cancer?
- Epithelial cell tumours (85–90%)
- Germ cell tumours (common in women <35)
- Sex cord-stromal tumours (rare)
- Metastatic tumours
OVARIAN CANCER
What are some types of epithelial cell tumours?
- Serous carcinoma (#1)
- Endometrioid, clear cell, mucinous + undifferentiated tumours too
OVARIAN CANCER
What are sex-cord stromal tumours?
- Arise from stroma (connective tissue) or sex cords (embryonic structures associated with the follicles)
- Sertoli-Leydig + granulosa cell tumours
OVARIAN CANCER
What are metastatic tumours?
- Secondary tumours
- Krukenberg = metastasis in ovary, usually from GI (stomach) > CLASSIC “SIGNET-RING” CELLS ON HISTOLOGY
OVARIAN CANCER
What are some risk factors of ovarian cancer?
Unopposed oestrogen + increased # of ovulations –
- Early menarche
- Late menopause
- Increased age
- Endometriosis
- Obesity + smoking
Genetics (BRCA1/2, HNPCC/lynch syndrome)
OVARIAN CANCER
Hence, what are some protective factors of ovarian cancer?
- COCP
- Early menopause
- Breast feeding
- Childbearing
OVARIAN CANCER
How is the risk of malignancy index calculated?
- Menopausal status = 1 (pre) or 3 (post)
- Pelvic USS findings = 1 (1 feature) or 3 (>1 feature)
- CA-125 levels IU/mL as marker for epithelial cell ovarian cancer
OVARIAN CANCER
What can cause falsely elevated CA-125 levels?
- Endometriosis
- Fibroids + adenomyosis
- Pelvic infection
- Pregnancy
- Benign cysts
OVARIAN CYST
What are the 4 types of ovarian cysts?
- Functional (physiological)
- Benign epithelial neoplasms
- Benign germ cell neoplasms
- Benign sex-cord stromal neoplasms
OVARIAN CYST
What are the three types of functional cysts?
- Follicular (most common)
- Corpus luteum
- Theca lutein
OVARIAN CYST
What are corpus luteum cysts?
When are they seen?
- Corpus luteum fails to breakdown, may fill with fluid or blood
- May burst causing intraperitoneal bleeding
- Early pregnancy
OVARIAN CYST
What are theca lutein cysts?
Association?
- Stimulates growth of follicular theca cells so usually bilateral as resting follicles on both sides
- Overstimulation of hCG (multiple + molar pregnancy as hCG v high)
OVARIAN CYST
What are some features of neoplastic cysts?
- Often complex
- > 10cm
- Irregular borders
- Internal septations appearing multi-locular
- Heterogenous fluid
OVARIAN CYST
What are the 2 benign epithelial neoplasms?
- Serous cystadenoma (most common epithelial tumour)
- Mucinous cystadenoma
OVARIAN CYST
How does serous cystadenoma present?
- May be bilateral, filled with watery fluid, 30–50y
OVARIAN CYST
How does mucinous cystadenoma present?
- Often very large + contain mucus-like fluid
- Pseudomyxoma peritonei where abdo cavity fills with gelatinous mucin secretions if rupture
- 30–40y
OVARIAN CYST
What is an example of sex cord-stromal neoplasms?
- Fibromas (small, solid benign fibrous tissue tumour)
- Associated with Meig’s syndrome
OVARIAN CYST
What are some risk factors of ovarian cysts?
- Obesity, tamoxifen, early menarche, infertility
- Dermoid cysts = most common in young women, can run in families
- Epithelial cysts = most common in post-menopausal (?malignant)
OVARIAN CYST
What are the germ cell tumour markers?
- Lactate dehydrogenase
- Alpha-fetoprotein
- Human chorionic gonadotropin
OVARIAN CYST
What is the management of simple cysts in pre-menopausal women?
- Small <5cm = likely to resolve within 3 cycles, no follow up
- Mod 5–7cm = routine gynae referral + yearly USS
- Large >7cm = ?MRI + surgical evaluation
OVARIAN CYST
What is the management of post-menopausal women presenting with an ovarian cyst?
- Risk of malignancy index calculation
- Simple cysts <5cm + normal CA-125 = monitor with 4–6m USS
- Complex cyst or raised CA-125 = 2ww gynae oncology referral
ENDOMETRIAL CANCER
What are some risk factors for endometrial cancer?
Unopposed oestrogen –
- Obesity (adipose tissue contains aromatase)
- Nulliparous
- Early menarche
- Late menopause
- Oestrogen-only HRT
- Tamoxifen
- PCOS
- Increased age
- T2DM
- HNPCC (Lynch syndrome)
ENDOMETRIAL CANCER
What are some protective factors for endometrial cancer?
- COCP
- Mirena coil
- Multiparity
- Cigarette smoking (Seem to have anti-oestrogenic effect)
ENDOMETRIAL POLYP
What are some risk factors of endometrial polyps?
- Being peri or post-menopausal
- HTN
- Obesity
- Tamoxifen
VULVAL CANCER
What is the management of VIN?
- Biopsy to Dx
- Watch + wait with close follow up
- Wide local excision to surgically remove lesion
- Imiquimod cream or laser ablation
MENOPAUSE
What contraception is suitable in older women?
How do hormonal contraceptives affect the menopause?
- UKMEC1 = barrier, IUS/IUD, POP, long-acting progesterone (<45), sterilisation
- UKMEC2 = COCP after 40 used until 50, try ones with levonorgestrel or norethisterone as lower VTE risk
- They don’t but may mask Sx
MENOPAUSE
What is the management of menopause in more severe cases?
- HRT first-line for vaso-motor Sx as most effective
- Clonidine (alpha adrenergic receptor agonist) second line with low-dose antidepressants like venlafaxine (not C/I in breast cancer Tx) or fluoxetine
- CBT
- Vaginal oestrogen cream/tablets + moisturisers for dryness
MENOPAUSE
What is the mechanism of action of clonidine?
- Alpha-adrenergic receptor agonist
HRT
What are the side effects associated with oestrogen?
- Nausea,
- bloating,
- headaches,
- breast swelling or tenderness,
- leg cramps
ATROPHIC VAGINITIS
What is the pathophysiology of atrophic vaginitis?
- Epithelial lining of vagina + urinary tract responds to oestrogen by becoming thicker, more elastic + producing secretions so reduced oestrogen has opposite effect
- Tissue more prone to inflammation + changes in vaginal pH + microbial flora that contribute to localised infections
ATROPHIC VAGINITIS
What are some risk factors for atrophic vaginitis?
- Menopause
- Oophorectomy
- Anti-oestrogen (tamoxifen, anastrozole)
URINARY INCONTINENCE
What causes urge incontinence/OAB?
- Overactivity + involuntary contractions of the detrusor muscle
URINARY INCONTINENCE
What are some causes of overflow incontinence?
- Anticholinergics
- Fibroids
- Pelvic tumours
- BPH (men)
- Neuro (damage, MS, diabetic neuropathy, spinal cord injuries)
URINARY INCONTINENCE
What is the stepwise management of urge incontinence/OAB?
- 1st line = bladder retraining (6w gradually increasing time between voiding)
- 1st line drugs = anti-muscarinics (oxybutynin, tolterodine, darifenacin)
- Mirabegron (beta-3-adrenergic agonist) if anti-muscarinics not tolerated
- specialist referral for botox injections + surgery
URINARY INCONTINENCE
What is the mechanism of action of anti-muscarinics?
- Parasympathetic so Pissing = decreases need to urinate + spasms
URINARY INCONTINENCE
What is the mechanism of action of beta-3-adrenergic agonists?
- Sympathetic so Storage = relaxes detrusor + increases bladder capacity
URINARY INCONTINENCE
What are the surgical interventions for stress incontinence?
- Colposuspension
- Tension free vaginal tape (TVT)
- Autologous sling procedures (TVT but strip of fascia from abdo wall)
PELVIC ORGAN PROLAPSE
What are some risk factors of pelvic organ prolapse?
- Age
- BMI
- Multiparity (vaginal)
- Spina bifida
- Pelvic surgery
- Menopause
PELVIC ORGAN PROLAPSE
What is the management for pelvic organ prolapse?
- Conservative = pelvic floor exercises, weight loss + diet changes
- Vaginal pessary = ring (preferred as can have sex), shelf or Gellhorn
- Surgery (symptomatic or severe like outside vagina, ulcerated, failed Mx)
DYSMENORRHOEA
What is the management of primary dysmenorrhoea?
- NSAIDs like mefenamic acid during menstruation
- COCP second line
ASHERMAN’S SYNDROME
What is the management of Asherman’s syndrome?
- Hysterosalpingography = contrast injected into uterus + XR
- Sonohysterography = uterus filled with fluid + pelvic USS
- Hysteroscopy gold standard + can dissect adhesions (recurrence after common)
ENDOMETRIOSIS
What are some protective factors?
Multiparity + COCP
HRT
What are the side effects associated with progesterone?
Mood swings,
fluid retention,
weight gain,
acne
greasy skin
HYDATIDIFORM MOLE
What is a complete mole?
- Diploid trophoblast cells
- Empty egg + sperm that duplicates DNA (all genetic material comes from father)
- 46 chromosomes
- No foetal tissue
HYDATIDIFORM MOLE
What is a partial mole?
- Triploid (69XXX, 69XXY) trophoblast cells
- 2 sperm fertilise 1 egg
- Some recognisable foetal tissue
HYDATIDIFORM MOLE
What is an invasive mole?
What is the significance of this?
- When a complete mole invades the myometrium
- Metaplastic potential to evolve into a choriocarcinoma
HYDATIDIFORM MOLE
What are some risk factors for hydatidiform mole?
- Extremes of reproductive age
- Previous molar pregnancy
- Multiple pregnancies
- Asian women
- OCP
PELVIC INFLAMMATORY DISEASE
What are the STI causes of PID?
- N. gonorrhoea (tends to be more severe),
- chlamydia trachomatis (most common),
- Mycoplasma genitalium
PID
What might you look for on microscopy in PID?
What is the relevance?
- Pus cells on swabs from vagina or endocervix
- Absence is useful to exclude PID
PELVIC INFLAMMATORY DISEASE
What is the management of PID?
- 1g stat IM ceftriaxone (gonorrhoea)
- 100mg BD doxycycline for 14d (chlamydia + MG)
- Metronidazole 400mg BD for 14d (Gardnerella)
- GUM referral for specialist Mx + contact tracing
- Hospital admission for IV Abx if signs of sepsis or pregnant
- Pelvic abscess > drainage
PELVIC INFLAMMATORY DISEASE
What are the non-infective causes of PID?
- Post-partum (retained tissue),
- uterine instrumentation (hysteroscopy, IUCD),
- descended from other organs (appendicitis)
PELVIC INFLAMMATORY DISEASE
What are the non-STI infective causes of PID?
Gardnerella vaginalis,
H. influenzae,
E. coli.
GENITAL TRACT FISTULA
what are the causes of genital tract fistulas?
injury (primarily in childbirth),
surgery,
infection
radiation.
CERVICAL CANCER SCREENING
when is screening offered?
25-49yrs = every 3 years
50-64yrs = every 5 years
not offered to people over 64yrs
URINARY INCONTINENCE
What are some side effects of anti-muscarinics?
- “Can’t see, spit, pee or shit” > caution in elderly as falls esp oxybutynin immediate release in frail
URINARY INCONTINENCE
What is a caution of beta-3-adrenergic agonists?
- C/I in uncontrolled HTN as stimulates SNS to increase BP, can lead to hypertensive crisis so monitor BP
DYSMENORRHOEA
What is secondary dysmenorrhoea?
Secondary to endometriosis, adenomyosis, fibroids, PID, IUDs, cancer
CERVICAL CANCER
what are the risk factors for cervical cancer?
- HPV
- multiple sexual partners
- younger age at first intercourse
- non-attendance at smears
- immunosuppression
- oral contraceptives
- higher parity
- tobacco use
- deprivation
