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Laura MRCOG Part 2 > 13) Gynaecological Problems - Other > Flashcards

13) Gynaecological Problems - Other Flashcards

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1
Q

Analgesia for outpatient hysteroscopy

A

NSAIDs 1 hour before appointment.
Don’t recommend opiates.
Intra-cervical or para-cervical LA if cervical dilatation required or hysteroscope >5mm.

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2
Q

Cervical preparation before outpatient hysteroscopy

A

No

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3
Q

Perforation risk during outpatient hysteroscopy

A

0.002-1.7%

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4
Q

Size of hysteroscope for outpatient hysteroscopy

A

2.7mm with 3-3.5mm sheath

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5
Q

Distension media for outpatient hysteroscopy

A

Normal saline (quicker, improved image quality and reduces vasovagal)

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6
Q

Dilatation before outpatient hysteroscopy

A

Not as routine

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7
Q

Benefit of local anaesthetic into cervical canal

A

Reduced vasovagal reactions

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8
Q

When to apply local anaesthetic to ectocervix?

A

If tenaculum to be used

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9
Q

Conscious sedation during outpatient hysteroscopy?

A

No

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10
Q

Standard technique for outpatient hysteroscopy

A

Vaginoscopy

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11
Q

Overall risk of serious complications from diagnostic hysteroscopy (under GA)

A

2 in 1000

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12
Q

Very rare risks of diagnostic hysteroscopy under GA

A

Death (3-8 per 100,000)

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13
Q

Rare risks of diagnostic hysteroscopy under GA

A

Damage to bladder/bowel/blood vessels.

Infertility.

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14
Q

Uncommon risks of diagnostic hysteroscopy under GA

A

Damage to uterus

Failure to gain entry

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15
Q

Frequent risks of diagnostic hysteroscopy under GA

A

Infection

Bleeding

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16
Q

Features of dextran 32%

A

High viscosity fluid.
Hypertonic.

Good visualisation in presence of blood.
Anaphylaxis. Crystallisation within scope. Small absorbed volumes led rapidly to heart failure.

Never used!!

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17
Q

Viscosity of modern distension fluids

A

Low

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18
Q

Which fluids are isotonic?

A

NaCl
Hartmanns
5% Mannitol

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19
Q

Which isotonic fluids contain electrolytes and which don’t?

A

NaCL and hartmanns contain electrolytes.

Mannitol doesn’t contain electrolytes.

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20
Q

When do you need fluid without electrolytes?

A

Monopolar operative hysteroscopy

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21
Q

Which fluids are hypotonic?

A

1.5% Glycine
3% Sorbitol
5% Dextrose

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22
Q

Which hypotonic fluids contain electrolytes/don’t?

A

None of them contain electrolytes

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23
Q

Risks of hypotonic fluids

A

In excess they will cause dilutional hypervolaemia (can lead to cardiac failure), hyponatremia & cerebral oedema.

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24
Q

What is classed as fluid overload?

A

> 1000mL using hypotonic solutions or >2500mL using isotonic solutions (but lower thresholds in people with comorbidities and fluid deficit threshold should be discussed with anaesthetist pre-procedure)

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25
Factors that increase the risk of fluid absorption
``` High intrauterine distension pressures Low mean arterial pressure Deep myometrial penetration Prolonged Surgery Rsection of large vascular myxomas Large uterine cavities ```
26
In which women are complications more likely?
Premenopausal women and those with cardiovascular/renal disease
27
Risks of isotonic fluids
Don't cause hyponatremia but can cause hypervolaemia
28
Measures to reduce fluid absorption
- Pre-op GnRH analogues in premenopausal women before hysteroscopic fibroid resection. - Intracervical injection of dilute vasopressin before dilatation - Intrauterine pressure as low as possible and lower than MAP
29
How to manage fluid overload?
Strict fluid balance monitoring Catheter Electrolytes Fluid restriction/diuretics If symptomatic - 3% hypertonic saline
30
How often should fluid deficit be measured throughout hysteroscopy?
Every 10 minutes
31
Incidence of gender variance in population
0.01-1%
32
Where should patients with gender dysphoria be referred?
Adults - GIC | Children - GIDS
33
What can GPs do whilst awaiting referral to GIC?
Bridging prescriptions with advice from gender specialist
34
Eligibility criteria for gender treatments
- Persistent and well documented gender dysphoria - Capacity - Significant medical or mental health concerns controlled - Achievable plan that has already been implemented or is about to be
35
Option for adolescents with gender dysphoria
GnRH analogues
36
Cross-sex hormone therapy for adults
- GnRH analogues to suppress innate sex hormones | - "Add-back" of oestrogen or testosterone
37
Percentage improvement in gender dysphoria with cross sex hormone therapy
80%
38
What blood test monitoring required for people on cross-sex hormone therapy?
BP, FBC, U&E, LFT, Fasting blood glucose, lipid profile, thyroid, oestrogen, testosterone, prolactin. Every 6 months for 3 years and then yearly if stable.
39
Oestrogen used in M->F hormonal treatment
Estradiol (bio-identical) 1-6mg/day
40
Target serum estradiol levels during hormonal therapy
Upper level of follicular phase oestrogen
41
Effect of adrenal androgens in M->F hormonal therapy
Androstenedione and DHEA not suppressed. Low potency but can be converted to testosterone/DHT. - if need to prevent this can use finasteride, or use cyproterone/spironolactone.
42
Mechanism of action of finasteride
5a-reductase inhibitor
43
VTE in transgender women
Estradiol doesn't increase the risk but if risk factors for VTE then give transdermal.
44
Liver in transgender women
Oestrogen causes obstructive liver dysfunction - if present use topical instead of oral.
45
Breast cancer in transgender women
Same risk as background male population but should receive breast screening (transmit also eligible if breast tissue still remaining)
46
Risk of testosterone treatment in transmen
Induces production of EPO --> Polycythaemia --> CVA. Ensure testosterone near lower end of normal before next dose and can use venesection if polycythaemia occurs.
47
When to recommend hysterectomy in transmen and what monitoring if they decline?
After 4-5 years of testosterone. | 2 yearly ultrasound assessment if not.
48
Eligibility for gender reassignment surgery
12m living in gender role and 12m of continuous endocrine treatment
49
Effect of gender treatment on fertility
- Surgery will lead to irreversible sterility. - Oestrogen reversible reduction in testicular volume + poor quality semen - Testosterone reversible amenorrhoea and may affect follicular function.
50
Contraception during gender treatment
Transgender men on testosterone treatment should still use barrier contraception if required as risk of pregnancy (even if GnRH analogues) and testosterone is teratogenic.
51
When should gamete storage be performed?
Ideally offered pre-hormones, but if already using then interrupt for 3m
52
Duration of gamete storage
10 years usually. Extended to 55 years for transgender individuals.
53
Effect of testosterone on ovaries
Cortical and theca thickening similar to PCOS
54
Preferred route for hysterectomy in transmen and why?
Vaginal/laparoscopic to minimise scarring of abdomen in case it becomes donor site for phalloplasty
55
Implications of Gender Recognition Certificate
New hospital records in new name. Must then be no disclosure in medical records to patient's former gender or any treatments, unless consent has been obtained.
56
Prevalence of HIV in transwomen
19%
57
Percentage of women undertaking >150 minutes of exercises each week
59%
58
Proportion of women reporting an adverse effect of menstruation on athletic performance
2/3
59
Energy balance
45kcal/kg fat free mass/day
60
Consequences of chronic low energy availability
RED-S | Syndrome of consequences including metabolism, bone health, immunity, CVS, psychological, menstrual and reproductive
61
What is the "female athlete triad"?
Menstrual dysfunction, impaired bone health, sub fertility.
62
Proportion of amenorrhoea in general population/athletes
5% general population 65% long distance runners 79% ballet dancers
63
At what level of energy availability is LH pulsatility disrupted?
20-25 kcal/kg
64
Proportion of athletes with delayed menarche
7% athletes overall, 22% in high risk sports (average delay 4y in gymnasts)
65
What is the effect of intense exercise on sub fertility?
>1h/day with energy expenditure >6kcal/min - 6 x increased risk
66
IVF outcomes in those with intense exercise
40% less likely to achieve live birth 3 x increased risk cycle cancellation 2 x increased risk miscarriage
67
Exercise and miscarriage
HIT around implantation may increase risk miscarriage
68
Proportion of athletes with clinical eating disorders
47%
69
BMD difference in RED-S
10-20% lower BMD
70
Prevalence of urinary incontinence in athletes
36% (3 x more likely than sedentary controls) | 2 x more likely during training than competition
71
Current diagnostic criteria for low EA
BMI <17.5 or recent weight loss >10% over 1 month
72
Investigations in low EA
low LH, low FSH, low estradiol, normal testosterone. Low AMH. Polycystic ovaries on USS>
73
Diagnosis of osteoporosis in athletes
Z score <2 (<2.5 normal population)
74
Management of RED-S
Increase energy intake or reduce expenditure. | Increase calorie intake by 300-600 per day with target BMI >18.5
75
When to say someone with RED-S can't compete and can't train?
Eating disorder Serious medical condition related to low EA Extreme weight loss techniques resulting in dehydration/life threatening condition Severe ECG abnormalities
76
When to say someone with RED-S can train and compete fully?
``` Healthy eating Appropriate EA Healthy endocrine function Normal BMD Healthy MSK system ```
77
Medical management involved in RED-S
- Transdermal oestrogen with progestogen after 12m conservative management - Barrier contraceptives - Calcium supplementation 1.5g
78
Which drugs are prohibited by doping agency?
SERM Clomifene GH (LH/hCG in males but not females)
79
Improvement in incontinence after PFE in sportswomen
70%
80
Pre-treatment if ART used in sportswomen
Oestrogen

Laura MRCOG Part 2 (56 decks)

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