Gynaecology

Question 1

Describe menopause, its symptoms, and management

Answer 1

Menopause is the cessation of a normal menstrual cycle in old age typically occurring at 50yrs of age, requires 1yr without periods. Problems are related to falling oestrogen levels.

Symptoms:

• Menstrual irregularity as cycles become anovulatory, before stopping
• Vasomotor disturbance e.g. Sweats, palpitations, and hot flushes (Brief, nasty, and may occur every few minutes, disrupting life and sleep)
• Atrophy of oestrogen-dependent tissues (genitalia, breasts) and skin. Vaginal dryness can lead to recurrent vaginal and urinary infection, dyspareunia, traumatic bleeding, stress incontinence and prolapse.
• Osteoporosis, the menopause accelerates bone loss which predisposes to fracture of femur neck, radius and vertebrae in later life

Management:

• Rule out other causes I.e. Thyroid and psychiatric problems. 2 FSH levels greater than 30IU/L is suggestive of menopause, test unreliable if patient on exogenous oestrogens.
• Hot flushes may respond to clonidine or HRT.
• HRT reduces symptoms of menopause but increases risk of breast and endometrial cancer and if long term increases risk of ovarian cancer. Also raises VTE risk, contraindicated if previous PE, unopposed oestrogen increases risk of endometrial cancer.

Question 2

Describe Ovarian tumours, presentations, red flag symptoms, and management

Answer 2

94% are benign, they are usually cystic. 24% of all ovarian tumours are functional cysts e.g. Enlarged or persistent follicular or corpus luteum cysts. Most common type of tumour is epithelial, followed by germ cell (e.g. Teratomas in young women), and stormal.

6% are malignant and 5% of these are cystadenomas that have become malignant. Serous cystadenomas are papillary growths tat may be so prolific that the cyst appears solid. They are commonest in women aged 30-40 and about 30% are bilateral and 30% are malignant. Mucinous cystadenomas are the commonest large ovarian tumours, they are filled with mutinous material and may be multilocular. They are commonest in the 30-50 group and about 5% are malignant.

Presentation: asymptomatic, swollen abdomen +/- dull palpable mass, pressure effects on bladder causing urinary frequency, rupture +/- local Peritonism, Ascites, torsion, endocrine or metastatic effects.

Red flag symptoms:

• bloating, abdominal distension
• early satiety
• loss of appetite
• unexplained weight loss
• change of bowel habit
• fatigue
• onset of IBS like symptoms after 50years
• urinary frequency or urgency
• abdominal or pelvic pain

Management:

• consider ultrasound
• if pelvic mass or abdominal distension refer under 2 week wait.
• check ca-125, AFP, B-HCG (AFP + bHCG marker of Germ cell tumour)
• if less than 40yrs if CA-125 greater than 35IU/mL arrange urgent abdominal and pelvis ultrasound and if suggestive of ovarian cancer refer under 2-week wait rule
• Tumour debunking and Chemotherapy (Carboplatin + Paclitaxel)

Question 3

Describe Ovarian Torsion, it’s causes, presentation, and management.

Answer 3

Rotation of the ovary at its peddle to such a degree as to occlude the ovarian artery/vein.

Causes: usually due to the development of an ovarian mass.

Presentation: Sudden onset of sharp and usually unilateral lower abdominal pain, accompanied by nausea and vomiting in 70%.

Management:

• Doppler ultrasound may help diagnosis.
• surgical treatment include laparoscopy to uncool the tossed ovary and oophoropexy to fixate the ovary which is likely to twist again.

Question 4

What are some causes of vaginal discharge?

Answer 4

Non-offensive discharge may be physiological (pregnancy, sexual arousal, puberty, pill). Most discharges are smelly, itchy and due to infection:

Causes:

• Bacterial vaginosis
• Thrush (candida)
• trichomoniasis
• Gonorrhoea

Question 5

Describe Pelvic Inflammatory Disease, its symptoms, and management.

Answer 5

Pelvic infection of the upper female reproductive system. Infections commonly affect the Fallopian tubes (salpingitis) and may involve the ovaries and parametria. 90% are sexually acquired mostly chlamydia. Untreated can lead to infertility (10-20%), ectopic pregnancy, chronic pelvic pain and cancer.

Symptoms: 60% asymptomatic. dyspareunia, irregular mentstruation. Patients with salpingitis may be most unwell, with pain, fever, and spasm of lower abdominal muscles. Cervicitis present with profuse, purulent or bloody vaginal discharge. Endometritis presents with heavy menstrual loss.

Management:

• swab and treat any infection
• trace sexual partners
• PO Ofloxacin + POl Metronidazole OR IM Ceftriaxone + PO Doxycycline + PO Metronidazole.
• In mild cases of PID intrauterine devices may be left in but otherwise consider removal.

Question 6

Describe Miscarriages and the different types and symptoms.

Answer 6

Miscarriage is the loss if a pregnancy before 24weeks gestation. Most present with bleeding PV. Pregnancy tests remain +ve several days after foetal death.20% of all pregnancy.

Types + Symptoms:

• Threatened miscarriage, symptoms are mild and the cervical os is closed. Rest is advised but probably does not help, 75% will settle. It is associated with risk of subsequent preterm rupture of membranes (PROM) and preterm delivery so book mother at a hospital with good neonatal facilities.
• inevitable miscarriage, symptoms are severe and the os is open, if most of the products have already been passed, it is an incomplete miscarriage. If bleeding is profuse consider ergometrine 0.5mg IM. If there is unacceptable pain or bleeding arrange evacuation of retained products of conception (ERPC).
• Missed miscarriage, the foetus dies but is retained. There has usually been bleeding and the uterus is small for dates. Mifepristone and misoprostol may be used to induce uterine evacuation but 50% require surgical evacuation.

Question 7

Describe Cervical Ectropion and its treatment.

Answer 7

A normal phenomenon, there is a red ring around the os because the endocervical epithelium has extended its territory over the paler epithelium of the ectocervix. Ectropions extend temporarily under hormonal influence during puberty, with combined pill, and during pregnancy. As columnar epithelium is soft and glandular, Ectropion is prone to bleeding, to excess mucus production, and to infection.

Treatment: Cryocautery will treat these if they are a nuisance, otherwise no treatment is required.

Question 8

Describe Cervical Screening, why we do it, how we do it, and details on screening process.

Answer 8

Why we do it:
Cervical cancer has a pre-invasive phase: Cervical Intra-epithelial Neoplasia (CIN). CIN I affects the lower basal third of the cervical epithelium and its associated with oncogene can HPV 6 + 11, and commonly regresses (57%). CIN II affects less than 2/3 of the epithelium and is more associated with more oncogenic types HPV 16 + 18 and is less likely to regress (43%). CIN III affects more than 2/3 or full thickness epithelium and is more associated with more oncogenic types HPV 16 + 18 and is less likely to regress (32%). A significant number of CIN II + III develop into invasive squamous carcinoma of the cervix.

How we do it:
Smear tests collect cervical cells for microscopy for dyskaryosis, abnormalities which reflect CIN. A smear identifies women who need cervical biopsy. The degree of dyskaryosis approximates to the severity of CIN. Moderate dyskaryosis and above require referral for colposcopy.

Screening Process:
1st smear at aged 25, then 3 yearly until 49, then 5 yearly from 50-64. HIV+ve women should have annual smears. Depending on results, depends on treatment and repeat.

Question 9

Describe Bacterial Vaginosis, its symptoms and management.

Answer 9

There is increased risk of preterm labour, intra-amniotic infection in pregnancy.

Symptoms: Mostly asymptomatic, may present with vaginal discharge with fishy odour, vaginal pH is greater than 4.5. The vagina is not inflamed and priorities is uncommon.

Management:
-culture, treated with metronidazole 2g PO once or 400mg BD PO for 5 days if pregnant.

Question 10

What are some causes of postcoital bleeding?

Answer 10

• unidentifiable in 50%
• cervical ectropion is most common identifiable cause. More common in women on COOP
• cervicitis secondary to chlamydia
• cervical cancer
• polyps
• trauma

Question 11

Describe Polycystic Ovarian Syndrome (PCOS), its symptoms, tests, and management.

Answer 11

At least two of hyperandrogenism, oligo-ovulation, and polycystic ovaries on US. It is common, 5-20% of premenopausal women.

Symptoms: Subfertility (miscarriage) and infertility, Menstrual disturbances (oligomenorrhea and amenorhoea), hirsutism, acne, obesity, acanthosis nigricans

Tests: TVS shows multiple peripherally allocated follicles 3-5mm, string of pearls appearance, usually bilateral.
-FSH, LH, Prolactin (normal/mildly elevated consider alternative diagnosis if markedly raised), TSH (exclude thyroid dysfunction), and testosterone (normal/mildly elevated consider alternative diagnosis if markedly raised)are useful investigations. Check for impaired glucose tolerance.

Management:

• advise smoking avoidance
• encourage weight loss and excercise to increase insulin sensitivity
• Metformin improves insulin sensitivity, menstrual disturbance and ovulated function
• Co-cypindiol (Contains cyproterone an anti androgen) may be more effective in controlling acne and hirsutism than COCP. Spironolactone and fin astride may be used under specialist supervision to manage hirsutism.
• Clomifene is useful (in combination with Metformin) to stimulate ovulation.
• ovarian drilling Can help with fertility

Question 12

Describe Amenorrhoea, it’s causes, and investigations.

Answer 12

May be divided into primary (failure to start menses by age of 16yrs) or secondary (cessation of established, regular menstruation for 6 months or longer.

Primary causes: Turners syndrome, testicular feminisation, congenital adrenal hyperplasia, congenital malformation of the genital tract e.g. Imperforate hymen, transverse septum, cervical stenosis.

Secondary causes:

• pregnancy/lactation
• hypothalamic Amenorrhoea (stress, excessive exercise)
• PCOS
• hyperprolactinaemia
• premature ovarian failure
• thyrotoxicosis/hypothyroidism
• sheehans syndrome
• ashermans syndrome

Investigations:

• exclude pregnancy with urinary or serum bHCG
• gonadotrophins, low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem
• prolactin if raised MRI pituitary
• androgen levels, may be raised in PCOS
• oestadiol
• TFT

Question 13

Describe Menorrhagia, it’s causes, investigations, and management.

Answer 13

Increased menstrual blood loss typically more then 80ml/cycle but rarely measured. Occurs in 1in20 women. Ask about flooding, clots, and anaemia symptoms.

Causes: In girls pregnancy and dysfunctional uterine bleeding (diagnosis of exclusion occurs in anovulatory cycle at extremes of reproductive life) are likely. With increasing age think of ICUDs, fibroids, endometriosis, pelvic infection, polyps, hypothyroidism. In perimenopausal women think endometrial carcinoma. Ask about general bleeding issues due to von willebrands.

Investigations: Examination (enlarged uterus = fibroids, tender uterus = Adenomyosis) Speculum (?polyps), FBC, TFT, Coagulation, pelvic ultrasound.

Management:

• for those wanting contraception as well progesterone-containing IUS e.g. Mirena, should be 1st line treatment.
• 2nd line recommended drugs are anti-fibrinolytic E.g. Tranexamic acid and antiprostglandins. E.g. Mefenamic acid.
• 3rd line are progestogens or norethisterone.
• surgical options include endometrial resection suitable for women who have completed their families and who have less than 10wk size uterus and fibroids less than 3cm. For those wishing to retain fertility who have fibroids more than 3cm may need it from uterine artery embolisation or myomectomy.

Question 14

What are some contraindications of COCP?

Answer 14

• Age over 35 and smoking more than 15/day
• consistently elevated systolic BP over 160, Diastolic over 95 or vascular disease
• less than 6 months postpartum if breastfeeding
• major surgery with prolonged immobilisation
• secondary Raynaud’s disease (with lupus anticoagulant)
• SLE with +ve or unknown anti-phospholipid
• Current VTE or history of VTE
• Migraine headaches with aura at any age
• current breast cancer
• Multiple risk factors for arterial cardiovascular disease
• cirrhosis.

Question 15

Describe Ectopic Pregnancy, its symptoms, and management.

Answer 15

Implantation of a fertilised ovum outside the uterus 97% are tubal. Consider ectopic in a sexually active woman with abdominal pain, bleeding, fainting, or diarrhoea and vomiting.

Symptoms: Typical presentation is a woman with a history of 6-8wks amenorrhoea who presents with constant lower abdominal pain (may be unilateral) and later develops vaginal bleeding. If perforation peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination. On examination there is abdominal tenderness, cervical excitation, there may be an adnexal mass but NICE recommend not examine due to increased risk of rupturing pregnancy.

Management:

• ABCDE is the patient stable ?ruptured ectopic
• dipstick test bHCG for pregnancy, Blood bHCG
• ultrasound, if bHCG is greater than 6000 and an interuterine gestational sac is not seen probability of ectopic is high. Normally bHCG doubles over 48hrs, it may plateau in ectopic.
• laparotomy if ruptured and unstable, laparoscopy plus salpingectomy
• Methotrexate is sometimes used for small early ectopics (less than 3.5cm in greatest diameter, bHCG less than 3000, minimal symptoms) Visualisation of foetal heart is contraindication. 75% of women get some abdominal pain with treatment and admission and observation may be needed to ensure pain isn’t related to rupture.
• Some tubal pregnancies end themselves without any problem so conservative management may be an option in those without acute symptoms, and with falling bHCG levels that are less than 1000 initially. 88% successfully resolve if bHCG less than 1000. Twice weekly follow up.

Question 16

Describe Endometrial Cancer, its risk factors, its symptoms, investigations, and management.

Answer 16

Post menopausal bleeding is endometrial cancer until proven otherwise.

Risk factors: Obesity, unopposed oestrogen, functioning ovarian tumour, FHx of breast, ovary or colon cancer, nulliparity, late menopause, early menarche, diabetes Mellitus, tamoxifen, pelvic irradiation, polycystic ovaries.

Symptoms: Postmenopausal bleeding, premenopausal women may have a change in bleeding e.g. Intermenstrual bleeding.

Investigations: Transvaginal ultrasound, normal endometrial thickness is less than 5mm. Hysteroscopy with endometrial biopsy. CT Staging

Management:

• Localised disease treated with abdominal hysterectomy with bilateral salpingectomy-oophorectomy. Patient with high-risk disease may have post operative radiotherapy.
• Progestogen therapy is sometimes used in frail elderly women not suitable for surgery

Question 17

Describe Endometriosis, it’s features, investigations, and management.

Answer 17

A common condition characterised by growth of endometrial tissue outside of the uterine cavity. Classified as Adenomyosis if in the uterine wall (more often associated with pelvic surgery). It causes fibrosis and adhesions.

Feature: Chronic cyclical pelvic pain, dysmenorrhea (pain often starts days before bleeding), deep dyspareunia, Subfertility. Less commonly urinary symptoms e.g. Dysuria, urgent, and dyschezia(painful Bowel movements), GI-upset (differential in IBS). Examination may show immobile retroverte uterus.

Investigations: Laparoscopy + biopsy is the gold-standard (consider empirical treatment first 3-6 months unless infertility is main issue)

Management:

• NSAIDs and other analgesia for pain relief
• COCP 9wks back to back then 1wk off
• If insufficient or contraindicated progestogens may be used, oral or intrauterine (mirena)
• GnRH analogues can be used to induce a pseudo menopause state. HRT can be used to treat menopausal symptoms
• Surgical excision, or ablation can help reduce pain, relapse is common (shown to improve pregnancy rates)

Question 18

Describe the normal menstrual cycle.

Answer 18

Pulsatile production of GnRH by the hypothalamus stimulates the pituitary to produce the gonadotrophins LH and FSH. These stimulate the ovary to produce oestrogen and progesterone.

In the first 4 days of the menstrual cycle FSH levels are high, stimulating the development of a primary follicle in the ovary. The follicle produces oestrogen, which stimulates the development of a glandular ‘proliferative’ endometrium and of cervical mucus which is receptive to sperm.

Around the 14th day oestrogen levels becomes high enough to stimulate a surge of LH. This stimulates ovulation. Having released the ovum, the primary follicle forms a corpus luteum and starts to produce progesterone. under this influence the endometrial lining is prepared for implantation and enters the secretory phase.

If the ovum is not fertilised the corpus luteum breaks down and hormone levels fall. This causes spiral arteries in the in the uterine endothelial lining to constict and the lining sloughs hence mensturation.

Normal menstruation lasts 2-7 days and normal blood loss is 20-80ml.

Question 19

Describe Stress Incontinence and it’s management.

Answer 19

Involuntary voiding of small quantities of urine with rises in intra-abdominal pressure e.g. sneezing, laughing, coughing. It is commoner in women.

Management:

• exclude UTI and Diabetes.
• Optimise BMI
• Pelvic floor exercises with physiotherapy
• Duloxetine (SNRI) 40mg/12hr PO can reduce stress incontinence.
• surgery for severe stress symptoms resistant to drug or conservative treatment e.g. synthetic slings, mid urethral tension free tape.

Question 20

Describe Vaginal Prolapse, the types, it’s causes, symptoms, and management.

Answer 20

A prolapse occurs when weakness of the supporting structure allows the pelvic organs to sag within the vagina.

Types: rectocele, cystocele, urethrocele, antrocele, vault

Causes: May be congenital but usually due to stretching at childbirth. Weakness is exacerbated by menopausal atrophy and coughing and straining.

Symptoms: Dragging sensation, worse by day. Cystitis, frequency, stress incontinence, difficulty in defecation may occur if rectocele.

Management:

• weight loss, stop smoking, stop straining (aim to reduce intrabdominal pressure)
• pelvic floor excercises
• if severe treat surgically e.g. Anterior or posterior wall repair.

Question 21

Describe Lichen Sclerosus, its symptoms and management.

Answer 21

An inflammatory condition which usually affects the genitali and is more common in elderly females. It leads to atrophy of the epidermis with white plaques forming

Symptoms: White genital plagues, itch

Management:
-topical steroids and emollients

Question 22

Describe Molar Pregancy, its symptoms, investigations, and management

Answer 22

A gestational trophoblastic disease which grows into a mass (hydatiform mole) in the uterus that has swollen proliferating chorionic villi. The villi grow in clusters that resemble grapes.

Symptoms: Heavy vaginal bleeding, large uterus, Hyperemesis, hypertension. Symptoms of hyperthyroidism

Investigations: Ultrasound shows snowstorm effect in uterus large for dates, bHCG is very high.

Management:
-evacuation of products by uterine suction or surgical curettage.

Question 23

Describe Genital Warts, its symptoms, and management.

Answer 23

Caused by HPV especially types 6 and 11.

Symptoms: small 2-5mm fleshy protuberances which are slight pigmented, may bleed or itch

Management:

• topical podophyllum or cryotherapy depend on location. Solitary keratinised warts respond better to cryotherapy where as multiple non-keratinised warts are best treated topically
• imiquimod may be used second line

Question 24

Describe Bartholin’s abscess and its management.

Answer 24

Bartholins gland and ducts lie under the labia minora. They secrete thin lubricating mucus during sexual excitation. If the duct blocks a painless cyst forms. This may become infected resulting in an extremely painful Fluctuant abscess, (unable to sit down), it is hugely swollen and hot red labium is seen.

Management:
-incision and drainage, marsupialisation.

Question 25

Describe Choriocarinoma, its symptoms and management.

Answer 25

Malignant gesational trophoblastic disease. Associated with increased HCG level. Often characterised by early haemotgenous spread to the lungs.

Symptoms: Persistent PV bleeding in pregnancy or even after miscarriage, following molar pregnancy

Management:
-chemotherapy based on methotrexate.

Question 26

What are the 15 principles of a consultation with a women who wants/is considering an abortion?

Answer 26

• Last menstrual period/ work out gestation
• Outline options
• sure of decision / ambivalence
• contraception/sexual/medical/drug/ allergy history
• STI testing
• how to access abortion service
• outline different methods and risks
• arrange ongoing contraception
• arrange post abortion review
• referral letter/abortion form HSA1 form
• explore reasons for wanting abortion
• risk of coercion?
• history of mental health illness?
• check support
• beliefs about abortion in general

Question 27

What are the types of contraception available?

Answer 27

Injectable contraceptives
Implantable contraceptive
Intrauterine contraceptive devices
Intrauterine contraceptive system
Combined oral contraceptives
Progestogen only contraceptives

Question 28

Describe Intrauterine Contraceptive Devices, their mode of action, and potential side-effects.

Answer 28

Also known as the coil, usually mean copper intrauterine devices. Most need changing every 5-10yrs. Can also be used as emergency contraception if inserted within 120h of unprotected sex. Require STD screen before insertion or use prophylactic azithromycin 1g PO. Insertion of IUCDs may provoke ‘cervical shock’ have atropine and resuscitation equipment to hand.

Mode of action: it works by preventing fertilisation by causing decreased sperm motility and survival.

Side-effects:

• IUDs make periods heavier, longer and more painful
• expulsion in nulliparous or distorted uterus (fibroids) risk is 1/20 and most likely to occur in first 3 months.
• Associated with increased risk of PID in first 20days.
• risk of perforation on insertion 2/1000

Question 29

Describe Intrauterine systems, their mode of action, and side-effects.

Answer 29

IUD carrying hormones. Usually levonorgestrel-releasing (mirena). Used in the management of menorrhagia, may also benefit endometriosis, Adenomyosis, fibroids. Can be relied upon 7 days after insertion. Last around 5 years.

Mode of action: Prevents endometrial proliferation and causes cervical mucous thickening.

Side-effects:

• IUS associated with initial frequent uterine bleeding and spotting, but later intermittent light me see with less pain and some become amenorrhoeic.
• Uterine perforations 2/1000 insertions.
• Increased risk of PID in first 20days

Question 30

Describe Implantable Contraceptives, their mode of action, and side-effectss.

Answer 30

Progesterone implants give up to 3 years contraception. Typically inserted in non-dominant arm just overlying the tricep. Doesn’t contain oestrogen so can be used if past history of VTE, migraine etc. Can be inserted immediately following a termination of pregnancy. Additional contraception needed for first 7 days if not inserted on day 1-5 of a woman’s menstrual cycle.

Mode of action: It inhibits ovulation and thickens mucus

Side-effects:

• irregular/heavy bleeding
• Progestogen effects e.g. Headache, nausea, breast pain
• efficacy reduced with enzyme inducing drugs.
• relative contraindicated in IHD, stroke, unexplained suspicious vaginal bleeding, previous breast cancer, severe liver cirrhosis, positive Antiphospholipid.
• complete contradiction if current breast cancer.

Question 31

Describe Injectable Contraceptives, their mode of action, and side effects.

Answer 31

Depo Provera is the main injectable used in UK. It contained medroxyprogesterone acetate given IM every 12wks. Use condoms for first 7days of first and late injections.

Mode of action: Inhibits ovulation. (Secondary effects include cervical mucus thickening and endometrial thinning).

Side-effects:

• irregular bleeding
• weight gain
• potential increased risk of osteoporosis
• not quickly reversible and fertility returns after a varying time.
• contraindicated in pregnancy, breast cancer, undiagnosed vaginal bleeding, acute liver disease, severe cardiac disease.

Question 32

What are the types of emergency contraception?

Answer 32

Copper IUD, and two methods of emergency hormonal contraception.

Levonorgestrel e.g. Levonelle: Should be taken as soon as possible and must be taken within 72hrs of unprotected sexual intercourse. Safe and well tolerated. Vomiting occurs in 1%, should be repeated if vomitting occurs within 2hours.

Ulipirstal e.g. EllaOne: a progesterone receptor modulator taken no later than 120hours after intercourse. May interfere with the contraception and so barrier methods should be used during this 5 day period.

Question 33

Describe Progestogen-only Contraceptive, it’s mode of action, and side-effects.

Answer 33

Also known as mini-pill e.g. Cerazette (desogestrel). Take everyday +/-3h to be effective without pill free break. If missed pill or pill not started within day 1-5 of menstrual cycle 48hours additional contraception needed.

Mode of action: Thickens cervical mucus

Side-effects:

• Liver enzyme inducers may reduce effectiveness
• UKMEC 3 active liver disease, past tumour, previous breast cancer, undiagnosed vaginal bleeding.
• UKMEC 4 Pregancy, breast cancer within 5 years.

Question 34

Describe Turner’s Syndrome, its symptoms, and management.

Answer 34

Also known as gonadal dysgenesis, is a condition in which a female is partly or completely missing an X chromosome I.e. 45XO. There is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and crohn’s disease.

Symptoms: Short stature, webbed neck, low-set ears, low posterior hairline, short stature, lymphoedema in neonates, primary amenorrhoea, hypo plastic breasts, wide carrying angle, high arched palate, short fourth metacarpal, coarctation of aorta, left heart defects e.g. Bicuspid valve +/- AS. Single horse-shoe kidney, increased renal cyst formation, renal artery stenosis.

Management: Somatropin can help with short stature. If hypogonadic, HRT can start at 13yrs.

Question 35

Describe Fibroids, it’s risk factors, symptoms, investigations

Answer 35

Benign monoclonal tumour of smooth muscle also known as leiomyoma. Typically present at 30-50yrs, they are stimulated by oestrogen and progesterone. Classified on position I.e. Intramural, submucosal, extramural.

Risk factors: obesity, non-Caucasian, early menarche, late menopause, infertility

Symptoms: asymptomatic, or menorrhagia, dysmenorrhea, pressure effects (bloating, incontinence), pelvic pain, bulky uterus, inter-menstrual bleeding.

Investigations: TVS, hysteroscopy and endometrial biopsy.

Management:

• watch and wait if asymptomatic
• NSAIDS + tranexamic acid
• COCP or other hormonal contraceptive
• surgical, GnRH before hysterectomy, myomectomy, endometrial abalation, uterine artery ligation.
• beware red-degeneration in pregnancy

Question 36

What are the rules surrounding missed pills with the COCP?

Answer 36

Need 9 missed days to allow ovulation.

If one pill is missed anywhere in the pack then the missed pull should be taken immediately even if it means two pills in one day and then the pack should be continued as normal and non additional contraception is needed.

If two pills are missed then the last pull should be taken immediately even if it means two pills in one day but earlier missed pills should be taken as usual and additional precautions such as condoms should be used for 7 days.

If the pills were missed in the first week of a pack emergency contraception should be considered.

If the pills were missed in the second week of a pack no emergency contraception is needed as long as the first week was uninterrupted.

If pills are missed in the third week of a pack the next pack should be started without a pack and emergency contraception is not required.

Question 37

Describe Cyst Accident, its symptoms, investigations and management.

Answer 37

Ruptured ovarian cysts are a common cause of acute pelvic pain in premenopausal women.

Symptoms: Afebrile, acute pelvic pain, rebound tenderness.

Investigations: USS, thin wall remnants of cysts if haemorrhagic clot may adhere to cyst wall mimicking nodule.

Management:

• analgesia manage conservatively unless shock in ruptured haemorrhagic cyst.
• If shock consider surgical investigation.

Question 38

Describe Dysmenorrhea, the types and causes, and management.

Answer 38

Painful periods +/- nausea and vomiting.

Primary Dysmenorrhoea: is pain without organ pathology. Often starting with anovulatory cycles after the menarche. It is crampy with ache in the back or groin and worse during the first day or 2. Excess prostaglandins cause painful uterine contractions, producing ischaemic pain.

Secondary Dysmennorhea: Associated with pathology e.g. Adenomyosis, endometriosis, chronic sepsis (e.g. Chlamydial infection), fibroids.

Management:

• treatment of cause if secondary, IUCDs increase pain whereas as mirena reduces it.
• In primary, NSAIDs inhibit prostaglandins e.g. Mefenamic acid 500mg TDS during menstruation. Paracetamol is good alternative.
• COCP can help with ovulatory pain
• Smooth muscles antispasmodiscs e.g. Alverine or hyoscine butylbromide may help.

Question 39

Describe Meigs’ syndrome

Answer 39

Three cardinal features are:

• benign ovarian tumour
• ascites
• pleural effusion

Question 40

Describe Cervical Shock

Answer 40

A Triad of Hypotension, Bradycardia and PV Bleeding. Often due to incomplete miscarriage with products of conception in the Cervical Os leading to vagal stimulation.