Obs and gynae Flashcards
What does obstetrics encompass?
health pre-pregnant, pregnant, childbirth and immediately after
What does gynae encompass?
Women’s health
What is gravidity?
number of times pregnant
What is parity?
number of times given birth to a foetus 24 wks+
Questions to ask in a gynae history?
menstruation/LMP (last menstrual period) = frequency, duration, heavy, pain, intermenstrual, postcoital, vaginal discharge, postmenopausal, clots; pain (colicky and felt in sacrum and groins could be uterine and ovarian tends to be in right iliac fossa down to front thigh of knee) associated symptoms; sex = activity, pain, contraception (problems, types, how long); obs hx (no. of children, problems with pregnancy and labour, outcome, puerperium, miscarriages/termiantions); GI and urinary symptoms (freq, nocturia, urgency, nocturnal enuresis, associations, dysuria, haematuria), incontinence, prolapse; FH; past medical and surgical; SH; DH; FH (GDM, pre-eclampsia)
Gynae examination?
appearance, weight, temp, bp, pulse, anaemia, jaundice, lymphadenopathy; breasts, abdo, vaginal (metal speculum warmed with lube – vulva and vaginal orifice for colour, ulcers, lumps, prolapses); digital pelvic exam (pt lie flat with ankles up to body with knees apart with left hand placed around pubic symphysis); uterus = size of small pear, size, consistency, regularity, mobility, tenderness, anteversion/retroversion; cervix = how hard, ulceration, bleeding, irregular, adnexa (attaches organs together) assessed for tenderness/size/masses, pouch of Douglas behind cervis and uterosacral ligaments palpable; Sims’ speculum for inspection of vaginal walls and prolapse (SEE PAGE 1 OF WOMEN’S HEALTH NOTES), can use DRE if posterior wall prolapse suspected; check abdo for tenderness (ascites and pregnancy)
Anatomy of the vulva?
has all entrances (vagina, urethra, clitoris, labia minora and fourchette) and around is labia majora and perineum; when hymen broken (tampons or intercourse) leaves tags at mouth of vagina
Anatomy of the vagina?
leads to uterus via cervix; muscular walls; lactobacilli keep acidic from puberty to menopause
Anatomy of the cervix?
mostly connective tissue and os in centre; circular in nulliparous but slit in parous women; mucin-secreting glands lube vagina
Anatomy of the uterus?
thick myometrium lined with columnar epithelium; uterosacral, round and broad ligaments hold in place; pouch of Douglas posteriorly; 14wks pregnant will fill pelvis; should be in anteverted position and can be bimanually palpated
Anatomy of the adnexae?
fallopian tubes, ovaries (in rectovaginal pouch) and associated connective tissue (parametria)
Some abnormalities of the gynae anatomy?
vaginal septae (partition in vagina), duplication of cervix/uterus; can diagnose bicornate uterus (divided uterus) by hysterosalpingogram and can cause recurrent miscarriage; may be unable to perforate hymen (primary amenorrhoea, lower abdo pain, swelling and pressure from haematocolops [built up menstrual blood]); small, thin ovaries found in Turner’s syndrome
Obstetric hx?
- Current – general things, gravidity and parity, LMP (last menstrual period and use this +40wks to give gestation), EDD (estimated date of delivery – 1st trimester scan ideal), irregular/long cycles and HRT all make EDD inaccurate, general health and symptoms, fetal movements >20wks, any problems, tests/scans
- Past hx – age (can give problems if older), all past (miscarriages, terminations and reason and normal; pre-eclampsia, GDM, preterm etc), antenatal problems, delivery/sex/weight/problems/date for past births; postnatal and neonatal life; difficulty with conception, smear hx, previous gynae problems, PMH in general; psych hx; surgical hx
- DH, FH, SH (drugs, alcohol, smoking, domestic violence)
How to work out EDD?
9 months and 10 days after LMP
What is symphysis fundal height and its measurements?
shows how much uterus grows during pregnancy (palpated in abdomen); should be halfway between pubic and umbilicus at 16wks, at umbilicus at 20-24wks, under ribs at 36wks
o Inaccurate when – bad hx, multiple, fibroids, polyhydramnios, maternal size, hydatidiform mole
o Check for stretch marks and noticeable linea nigra (after 1st trimester/13wks)
5 ways to assess foetus in uterus?
palpate orientation or baby, presentation (bit going to breach, mainly the head), engagement (how large the breach area is – measured in 5ths palpable); ascultate heart with doppler until 12wks then stethoscope; movement at 18-20wks and should increase then plateau at 32wks, every 20-40mins (if reduced then urgent and must let med team know – IUGR/stillbirth)
Anatomy of the breast?
- Nipple/areolar leads to lobule groupings via large then small ducts; lactiferous sinus just below surface of nipple and superficial fat protects lobules and ducts
- Proliferation of breast tissue occurs around ovulation every cycle
What is a mammography, it’s indications and results?
• Mammography (over 40s) – used for screening asymptomatic women, assess symptomatic, sensitivity 90%, follow up and surveillance for breast cancer survivors; 2 views (mediolateral oblique [MLO] which should show pectorals and tissue next to chest wall and craniocaudal [CC] which shows the gland and nipple centred)
o Things to check – pt identity, movement blur, nipple in profile, MLO (inframammary fold, pectoralis muscle to nipple, lower axilla), good exposure, CC have retromammary space
o Abnormals – asymmetrical densities, focal mass, parenchymal distortion, microcalcification, skin thickening, enlarged axillary nodes
o Symptomatic - <35yrs = examine, US; >35yrs = examine, bilateral mammogram and US
Ways to scan breast?
MRI with contrast and mammography
RFs for breast cancer?
> 35yrs first child, lobular carcinoma in situ (LCIS), alcohol (>40g/day harmful), ADH, HRT 5+yrs, oral contraceptive, obesity post menopause; BRCA1/2, CDH1 and Tp53 genes
Features of breast cancer?
painless lump (irregular, hard, fixed), nipple discharge, nipple in-drawing, skin tethering, indrawn nipple, older age
Diagnosis of breast cancer?
clinical score, imaging score, biopsy score (all 1-5)
Staging of breast cancer?
TMN (tumour size, mets and nodes) can also use Nottingham Prognostic Index
Subtypes and treatments of breast cancer?
Luminal A, Luminal B, HER2- and triple -ve; luminals can be ER+/-PR positive; treatments = endocrine (tamoxifen or ER+ve) for luminals, chemo for all but luminal A (for high risk) and HER2- use trastuzumab, ER +ve use bisphosphonates for high risk
Treatment for breast cancer?
radio and pre-op chemo (small tumour); mastectomy for large relative to breast size and position (medial more dangerous – can shrink with radio/chemo first) but more likely to recur, reconstruction; axillary surgery if glands involved (full clearance but partial if glands found to be normal), with glands removed may cause arm oedema as lymph no longer there to drain
High risk with breast cancer?
young age, ER-ve, HER-2+ve, high grade, node positive, Ki67 +ve, tumour size, high oncotype DX recurrence score
Tamoxifen SEs?
flushes, nausea, vaginal bleeding
What are aromatase inhibitors?
better than tamoxifen, inhibit aromatase enzyme for making androgens to oestrogen; no DVT or endometrial cancer risk like tamoxifen
Radiotherapy risks?
high rate of capsule formation, skin viability risk, wound healing, loss of elasticity, fat necrosis, fibrosis, implant extrusion
Reconstruction for breast cancer?
either implants or autologous (latissimus dorsi, gluteal muscle – but can interfere with physical activity/job); stick on nipples, nipple tattoos, new nipples constructed from skin
Treatment for breast cancer mets?
hormonal treatments, bisphosphonates, densoumab, chemo (CMF, doxorubicin, taxanes, Herceptin)
Types of breast lumps and management?
benign breast change (puberty to menopause, tender and painful, cyclical variation, rubbery feel, leave and reassure), fibroadenoma (usually puberty, smooth, mobile, non-tender, leave unless enlarging/tender/atypical), cyst (35-55yrs, usually multiple, feel cystic usually, aspirate), sebaceous cyst, papilloma (dilated ductal system, usually benign yet remove, multiple means breast cancer risk), fat necrosis, mastitis/abscess (breast sepsis, pyrexia and flu-like, respond to abx, staph aureus; if chronic and periductal then excise duct), cancer, sarcoma/lymphoma/mets, implant related, duct ectasia (asymptomatic, nipple discharge, bloody discharge, nipple inversion, menopause; breast duct becomes blocked from duct narrowing and breast widening), can get benign cyclical breast pain (record diary; management = reassure, NSAIDs PRN, low fat, correct fitting bra)
What is paget’s disease of the nipple?
malignant cells infiltrate epidermis via mammary duct epithelium; thickened skin results
S+Ss of paget’s?
unilateral usually, usually nipple, eczematous change, itching, erythema, scales, erosions, discharge, bleeding; can indicate breast cancer
Treatment of paget’s?
treat as cancer but can be more conservative if need be
Overview of normal menstruation?
investigate if none by 16 or no signs by 14yrs; first start of puberty is growth spurt; controlled by hypothalamic-pituitary-ovarian axis; pulsatile gonadotrophin-releasing hormone get Pituitary to release FSH and LH which stimulate ovaries to make oestrogen and progesterone that -ve feedback; <16yrs, >45yrs menopause, <8 days, blood loss <80mL, cycle length 23-35 days, no intermenstrual bleeding; monthly bleeding from hormonal changes, length = start of one to start of other
Day 1-4 of menstruation?
menstruation; cycle lengths vary; soon after menarche and menopause will be irregular (also HRT)
Days 4-13 of menstrual cycle?
GnRH pulses increase levels of LH and FSH which stimulate development of primary follicle in ovary; follicle makes oestradiol and inhibin which suppress FSH secretion in -ve feedback so only one egg and follicle matures; oestradiol rises and +ve feedback to cause LH secretion and surge (36 hours after ovulation occurs); oestradiol also develops endometrium (endometrial proliferation), cervical mucous receptive to sperm, mucous stringy and white
Days 14-28 of menstruation?
oestrogen level high enough to stimulate LH and ovulation; primary follicle then forms corpus luteum and produces progesterone and endometrium ready for implantation (secretory phase); cervical mucous hostile to sperm; corpus luteum broken down so hormones low, spiral arteries constrict, endometrium sloughs off (normal loss 20-80mL over 2-7 days)
Menopause overview?
ovaries don’t develop follicles; no -ve feedback so gonadotrophin levels rise and so periods stop
How to postpone menopause?
use norethisterone 3 days before period or take 2 packets combined pill consecutively without break
What is secondary amenorrhoea?
periods stop >6 months
Hx to ask for menstruation?
duration, cycle, heaviness (clots, protection, flooding); pain, premenstrual tension, infertility worries and details, cancer phobia, interference with QOL, duration and relation to cycle; social and work
Examination for menstruation?
sclera, palms, gingiva, thyroid, abdo; specific = vulva, vaginal, cervix, uterus (fibroids and adenomyosis), adnexae
Diseases that can lead to abnormal menstruation?
thyroid disease (temp intolerance, hair consistency, lethargy), clotting disorder, anti-clotting/blood thinning drugs
What is intermenstrual bleeding and causes?
bleeding clearly between cycles and menses; fall in oestrogen levels; other causes = cervical polyps, ectropion (columnar epithelium migrating to front of os), carcinoma, cervicitis, HRT, IUCD, chlamydia, pregnancy
What is endometrial proliferation and how to treat?
continuous high oestrogen (obesity) can make it hyperplastic and can cause irregular heavy bleeding; treat = address cause, Mirena coil, can lead to endometrial carcinoma
What is pyometra?
uterus distended by pus from salpingitis; drain uterus and treat cause
What is haematometra?
uterus filled with blood from obstruction; rare (imperforate hymen, carcinoma, stenosis
What is endometrial tuberculosis and treatment?
rare; blood borne and affects fallopians first; menstrual pain and disorders if active, salpingitis; exclude lung disease; check up scans and RIPE treatment
What is abnormal uterine bleeding?
abnormal in vol, regularity, timing, non-menstrual (PCB, IMB, PMB)
What is menorrhagia?
excessive bleeding in normal cycle (80mL
Causes of menorrhagia?
endometrial haemostasis (balance between fibrin deposition and platelet aggregation with platelet inhibition and fibrinolysis), uterine prostaglandin levels, uterine polyps, fibroids (irregular enlargement of uterus), chronic pelvic infection, ovarian tumours, malignancy, adenomyosis (endometrium breaks through to myometrium – 40yrs, with endometriosis and fibroids)
S+Ss of menorrhagia?
absent, painful, reg, heavy menstruation, uterus can be enlarged and tender
Investigations for menorrhagia?
Hb, coagulation, TFT, transvaginal US, endometrial biopsy (if endometrium thicker >10mm, polyps, women >40 with recent menorrhagia to exclude malignancy), not responding to treatment use hysteroscope, smear hx, STI screen
Treatment for menorrhagia?
first line progesterone IUD (too much = amenorrhoea), second = antifibrinolytics (tranexamic acid – inhibits plasminogen activator), NSAIDs (mefenamic acid – inhibits COX and blocks PGE2 receptors), combined OC (all reduce blood loss) or IUD, others are IM/oral progesterone like norethisterone (least effective in luteal phase so use 5-25 day, best for anovulatory and chaotic bleeding), gonadotrophin-releasing hormones (danazol – stops sex steroid production); polyps resected under anaesthesia, endometrial ablation for older women (reduces fertility; if heavy, not expecting amenorrhoea, completed family, uterus less than 12 wks size), transcervical resection of endometrium/fibroid; myomectomy = removal of fibroids from myometrium; hysterectomy = last resort for abnormal uterine bleeding; uterine artery embolization for menorrhagia from fibroids who want to keep uterus
Irregular menstruation causes?
anovulatory cycles (absence of ovulation and luteal phase and varying menstruation), pelvic pathology (fibroids, uterine/cervical polyps, adenomyosis, ovarian cysts, chronic infection)
Investigations for irregular menstruation?
menorrhagia?, Hb, malignancy?, US for women >35 and where treatment failed, biopsy if endometrium thickened
Treatment for irregular menstruation?
drugs (IUS, combined OC pill), cervical polyp excised and surgery same as menorrhagia but ablative less useful
Amenorrhoea primary and oligomenorrhoea definitions?
primary = not occurred by 16yrs; oligomenorrhoea = occurs every 35 days-6 months
Causes of amenorrhoea?
pregnancy, menopause, pathological with hypothalamus, pituitary, thyroid (hypo/hyper), adrenals (congenital adrenal hyperplasia), ovary (ovarian insufficiency), uterus, outflow tract, drugs causing = progestogens, GnRH analogues, antipsychotics, Turner’s; secondary causes = premature menopause, polycystic ovary syndrome (PCOS), hyperprolactinaemia, hypothalamic-pituitary-ovarian (delayed from stress etc), pregnancy, Asherman’s syndrome (uterine adhesions)
Causes of hyperprolactinaemia?
pituitary hyperplasia, benign adenomas (use bromocriptine or surgery), tumours and Sheehan’s syndrome, thyroid, premature menopause, Turner’s syndrome, imperforate hymen (membrane partially covering vagina) and transverse vaginal septum obstruct menstrual flow (accumulates in vagina/uterus – surgery), also cervical stenosis (stops blood from uterus)
Tests for amenorrhoea?
pregnancy test, serum free androgen index (high in PCOS), FSH/LH low for hypothalamic-pituitary-ovarian, prolactin, TFT, testosterone (secreting tumour)
Treatment for amenorrhoea?
HRT for ovarian failure; diet, stress management and psych and some drugs
Causes of postcoital bleeding?
cervical ectropions (glandular cells inside cervix present on outside from eversion – discharge, postcoital bleeding and aka cervical erosion, columnar epithelium around os of endocervix = red), benign polyps, invasive CC
Investigations for postcoital bleeding?
cervix and smear
Treatment for postcoital bleeding?
ectropion frozen with cryotherapy, colposcopy used
Dysmenorrhoea pathophysiology and definition?
high prostaglandins in endometrium, from contraction/uterine ischaemia, painful periods and can have N+V; primary with no organic cause
Treatments for dysmenorrhoea?
pain use NSAIDs (mefenamic acid) or ovulation suppression (combined pill), pelvic pathology if this doesn’t work (secondary)
Secondary causes of dysmenorrhoea?
deep dyspareunia (pain on intercourse/penetration) and menorrhagia, pelvic US, fibroids, adenomyosis, endometriosis, pelvic inflammatory disease, ovarian tumours
What is precocious puberty?
menstruation <10yrs; rare and usually no pathology; stop sexual development
Causes of precocious puberty?
= meningitis, CNS tumours, hydrocephaly, ovarian, adrenal tumours
Treatment for precocious puberty?
GnRH agonists
What is McCune-Albright syndrome?
bone and ovarian cysts, café-au-lait spots and precocious puberty
Causes of ambiguous development?
congenital adrenal hyperplasia (AR inherited); ACTH gives high androgen production (enlarged clitoris, amenorrhoea)
Treatment for ambiguous development?
cortisol and mineralcorticoid replacement
What is premenstrual syndrome?
95% have psych, behavioural, physical symptoms and 5% debilitating before menstruation; behaviour = irritable, aggressive, depressed; others = bloated, minor GI upset, breast pain, headache
Treatment for premenstrual syndrome?
SSRIs, 100mcg oestrogen HRT, GnRH agonists, sometimes CBT, diet, exercise; total hysterectomy may be indicated
What is postmenopausal bleeding?
> 1yr after last period
Causes of PMB?
endometrial carcinoma, vaginitis, foreign bodies, carcinoma of cervix/vagina, endometrial/cervical polyps, oestrogen withdrawal; consider bleeding from other areas
When to take endometrial sample?
unexpected bleeding patterns with HRT, over 45yrs and PMB
What are uterine fibroids?
benign tumours of myometrium, whorls of smooth muscle cells with collagen
Risks for fibroids?
menopause, Afro-caribbean, FH (reduce with OC pill); types = intramural, subserosal, submucosal; growth = oestrogen dependent (stop growing after menopause and can be slow), 50% asymptomatic and more from site than size
S+Ss of fibroids?
menorrhagia, dysmenorrhoea, frequency and retention (large and on bladder), fertility reduced (tubal ostia blocked), pedunculated fibroids (grows on stalk-like growth – peduncle) can have torsion (pain); may be felt abdo, press on bladder (urinary retention), veins (varicose)
What is red degeneration with fibroids?
pain, tenderness, haemorrhage, necrosis, common in pregnancy and can cause severe pain, N+V; premature labour, malpresentations and obstructed labour; thrombosis of capsular veins leading to engorgement and inflammation
What is cystic degeneration of fibroids?
fibroid soft and partly liquefied
Investigations for fibroids?
MRI diagnostic, hysteroscopy/hysterosalpingogram for uterine cavity distortion, Hb low (bleeding) or high (high EPO); size
Treatment for fibroids?
don’t use HRT (can increase size); asymptomatic nothing needed; GnRH (max 6 months – temporary amenorrhoea and fibroid shrinkage; goserelin), ulipristal acetate (induces amenorrhoea and is a selective progesterone receptor modulator; only for a few months to shrink them) small resected (myomectomy – treat failed but reproductive function needed), adhesions in surgery reduce fertility, hysterectomy (only cure), uterine artery embolization to reduce fibroids
Endometritis causes?
secondary to STI, complication of surgery, foreign material in IUD, malignancy; uterus tender
Treatment of endometritis?
abx and evacuation of retained products of conception
What are intrauterine polyps?
benign tumours in uterus (disordered apoptosis and regrowth of endometrium); most endometrial but some submucosal; 40-50yrs, in post-menopause = tamoxifen
S+Ss of intrauterine polyps?
menorrhagia and IMB
Investigations of intrauterine polyps?
US or hysteroscopy
Treatment for intrauterine polyps?
Resection of polyp
Haematometra definition and causes?
menstrual blood in uterus from outflow obstruction; from fibrosis, cone biopsy or carcinoma of cervical canal
Types of congenital malformations?
; Mullerian ducts don’t fuse at 9 wks (total = 2 uteruses), renal problems, malpresentations, preterm labour, recurrent miscarriage, retained placenta
Endometrial carcinoma overview?
most common genital tract cancer (mostly adenocarcinoma of columnar endometrial gland cells); 60yrs
Risks for endometrial carcinoma?
oestrogen:progesterone ratio, HT, DM, obesity, PCOS, nulliparity (never done a pregnancy past 20wks), late menopause, ovarian granulosa cell tumours, tamoxifen
S+Ss of endometrial carcinoma?
oestrogen causes cystic hyperplasia/menstrual abnormalities or PMB, irregular/IMB in premenopausal, atrophic vaginitis (post-menopausal bleeding)
Investigations of endometrial carcinoma?
surgical staging; US (thickness >4mm), endometrial biopsy, hysteroscopy, FBC, renal function, glucose, ECG, most are stage 1
Bad prognosis indicators for endometrial carcinoma?
high age/stage, deep, myometrial spread, higher grade, adenosquamous pathology
Treatment for endometrial carcinoma?
uterus preserved then progestogens and 6 monthly endometrial biopsy, otherwise hysterectomy and bilateral salpingo-oophorectomy, vaginal vault when bad prognosis, can use adjuvant radio
Types of gynae sarcomas?
leiomyosarcomas (malignant fibroids), endometrial stromal tumours (perimenopausal women) and mixed Mullerian tumours (with PMB)
Benign cervical disorders?
cervical ectropion (red ring around os as endocervix epithelium migrated to ectocervix; from puberty, combined pill and pregnancy, prone to bleeding, excess mucous and infection, no treatment but can stop pill or diathermy), acute cervicitis (rare from STI), chronic cervicitis = usually ectropion, discharge, cryotherapy with/out abx, can mask neoplastic change on smear; cervical polyps (>40yrs, asymptomatic or cause IMB/PCB; if small avulse, endocervical epithelium; hysteroscopy to exclude IU polyps); Nabothian follicles (squamous epithelium over endocervical cells, treatment not needed unless symptoms)
Cervical intraepithelial neoplasia overview?
atypical cells in squamous epithelium, pre-invasive stage of cancer; 1-3 grade, histology diagnose (dyskaryosis – high false +ves and -ves); 1 = atypical cells in low 1/3rd of lower epithelium, 2 = 2/3rds, 3 = full thickness; peak age = 25-29
Risks for cervical intraepithelial neoplasia?
HPV, more sexual contacts, virus proteins inactivate tumour suppressor genes, smoking, immunocompromise; refer for colposcopy if risk (visualise cervix and paint with acetic acid to see dense white areas of risk and take biopsies; abnormal looking vessels indicate invasive carcinoma); grade 2/3 = excision with cutting diathermy (large loop excision of the transition zone [LLETZ], usually during colposcopy high cure rate
Prevention for cervical intraepithelial neoplasia?
HPV vaccination (only protects against some strains)
Smear overview?
visualise with speculum; suspicious areas identified and scrape off squamo-columnar transitional zone of cervix for chlamydia and HPV; 3 yearly 25-50yrs, 5yearly until 64yrs
S+Ss cervical cancer?
PCB, offensive vaginal discharge, IMB/PMB and later stages uraemia, haematuria, rectal bleeding, pain, ulcer/mass visible, altered bowel habit (blood borne spread = late feature); tumour spread to parametrium, vagina and pelvic side wall, cervical smear +ve, weight loss, ureteric obstruction, vesicovaginal fistula
Diagnosis for cervical cancer?
bimanual examination (cervix rough and hard, cervix fixed), tumour biopsy, staging from vaginal and rectal exam, cystoscopy (bowel), MRI/PET for tumour size and mets, bloods; colposcopy
Treatment for cervical cancer?
stage 1a with cone biopsy, up to stage 2 with surgery/chemo/radio, sometimes radical abdo hysterectomy (pelvic node clearance, parametrium, upper vagina) or radical trachelectomy (keep fertility), palliative radio for bone pain/haemorrhage; death usually uraemia from ureteric obstruction
HPV vaccine protection and who eligible?
offered at 12yrs to kids; for prevention only mainly against HPV 6 and 11; don’t prevent all cancers; HPV strong cervical cancer risk
Risks from ovarian masses?
• Silent masses and detected when large (>5cm); rupture of cyst = peritonitis; epithelial tumours mostly in postmenopause, histology of borderline malignancy
Common ovarian neoplasms?
cystadenoma/adenocarcinoma (mucinous cystadenoma v large and less common), exclude pseudomyxoma peritonei and appendiceal tumour; also endometrial carcinoma and clear cell carcinoma (rarer but poorer prognosis – associated with endometriosis)
S+Ss of ovarian masses?
asymptomatic, chronic pain, dyspareunia, cyclical pain, acute pain (torsion [rare] and bleeding), irregular bleeding, abdo swelling, hormonal effects, discharge
What is a dermoid cyst?
common benign in premenopausal women, bilateral, large and asymptomatic
What is dysgerminoma?
most common ovarian malignant; granulosa cell tumours malignant but slow in postmenopausal, lots of oestrogen and inhibin; ovary common mets site for breast and GI
What is endometrioma?
blood-filled cysts in ovaries; OC pill prevents follicular and lutein cysts
What is ovarian cancer overview?
low 5yr survival; most >50yrs and most are epithelial carcinomas
Risks for ovarian cancer?
early menarche, late menopause, nulliparity, smoking, obesity, asbestos, BRCA1/2 or HNPCC (offered yearly transvaginal US and CA 125 screening)
Protective factors against ovarian cancers?
pregnancy, lactation and OC pill
S+Ss ovarian cancer?
mostly absent/vague (70% stage 3/4), persistent abdo distension, early satiety, loss of appetite, pelvic/abdo pain, increased urinary frequency, IBS, cachexia, abdo/pelvic mass, ascites, weight loss, bloating
Investigations of ovarian cancers?
breasts palpated, staging surgical and histology, CA125 levels in >50 with symptoms, US abdo/pelvis, <40yrs alpha fetoprotein and hCG, CT/MRI staging, FBC, TVS
Treatment for ovarian cancer?
total hysterectomy, bilateral salpingo-oopherectomy, partial omentectomy, carboplatin for 1c and above, radio only for dysgerminomas, chemo post-op
Poor prognosis for ovarian cancers?
later stage, poorly differentiated, clear cell tumours, slow chemo response
N+V treatment for ovarian cancers?
60% with advanced; from opiates, metabolic causes, vagal stimulation, psych; use = anticholinergics, antihistamines, dopamine agonists, 5HT-3 agonists (ondansetron)
Bowel obstruction for ovarian cancers?
metoclopramide, stool softeners, enemas, cyclizine (total obstruction), hyoscine (spasm)
Definition for sexual function?
important for arousal, plateau, orgasm, resolution; also emotional, physical, biological, psychological, sexual stimuli and drive all important too
What is hypoactive sexual desire disorder (HSDD)?
loss of libido and sexual desire, affects personal relationships and causes distress; mainly from psychosexual
Organic causes of HSDD?
menopause, depression, chemo, radio
Hx for HSDD?
start?, normal sexual function?, different to partner’s beliefs?, relationship problems?
Treatment for HSDD?
testosterone and psychosexual counselling
Causes of dyspareunia?
superficial = infections, skin conditions (lichen sclerosis); can be deep; treat the cause (lubricants, local anaesthetic gel); if don’t treat can become fearful and avoid
What is vaginsmus?
difficult for woman to be penetrated even if want to
What causes vaginsmus and treatment?
contraction of the thigh adductors and pelvic floor muscles; exclude vaginal septae (anatomical); treatment = vaginal dilators, relaxation techniques and her own fingers
What is vulvodynia?
burning pain in absence of visible findings or neuro disorder
Treatment for vulvodynia?
physio, psychosexual, pain management, first-line = pelvic floor exercises, internal and external perineal massage, topical anaesthetic; can use tricyclic antidepressants and gabapentin
What is Peyronie’s disease?
fibrous scar tissue on penis causing painful, curved erections; non-cancerous
Treatment for Peyronie’s disease?
verapamil oral, interferon injections (breaks down fibrous tissue)
What is hypospadias?
congenital and urethral meatus not at tip but along shaft instead
Treatment for hypospadias?
surgery
Aspermia definition?
lack of semen when ejaculating or antegrade ejaculation; associated with infertility
Causes of aspermia?
hormonal level change, infection, spinal cord injury, diabetes, anti-hypertensives, alcohol, radiation, chemo, congenital
Treatment for aspermia?
either treat cause (infection) or offer artificial conception (ICSI/IVF etc)
What is anejaculation?
– inability to ejaculate semen (orgasmic/anorgasmic); prostate and seminal ducts fail to release semen
Treatment for anejaculation?
Artificial insemination
Common symptoms for vulval/vaginal disorders?
itching, soreness, burning, superficial dyspareunia
What is pruritus vulvae?
may be general or localised; local = infection, vaginal discharge, allergies to washing powder, vulval dystrophy; obesity and incontinence exacerbate, autoimmune?
Tests for pruritus vulvae?
smear, examination, vaginal and vulval swabs, diabetes and thyroid disease?, biopsy, vulval dermatitis = ferritin
Treatment for pruritus vulvae?
treat cause, avoid sensitizers, usually not successful, topical steroids
What are lichen disorders of vulvae?
chronic inflammatory skin with severe intractable pruritus (mainly night)
What is lichen simplex?
labia majora inflamed and thickened, stress, low iron; vulval biopsy, avoid irritants and antihistamines
What is lichen planus?
affect mucosa of mouth and GU tract (flat, papular, purple lesions); autoimmune; treat = potent steroid creams
What is lichen sclerosis?
vulval epithelium thin and collagen loss; autoimmune; discomfort, pain, dyspareunia, carcinoma in 5%; use ultra-potent topical steroids
What is leukoplakia?
white patches due to skin thickening and hypertrophy; itchy and analysed to see if pre-malignant
Treatment for leukoplakia?
topical corticosteroids, psoralens with UV phototherapy, methotrexate and ciclosporin
What is vulvovaginitis and treatment?
unknown cause, inflammatory; shiny erythematous patches with/out petechiae; intravaginal clindamycin cream and hydrocortisone to vulva
What is vulvitis?
inflammation from infection (candida, herpes, chemicals) and often with discharge
What is vulvar dysaethesia/pain?
provoked or spontaneous (burning pain more common in older); associated = PMH of GU infections, previous OC, psychosexual
Treatment for vulvar dysaethesia?
Amitriptyline or gabapentin
Vulval infections?
herpes simplex, vulval warts, syphilis, donovanosis can affect vulva; candidiasis (diabetics, obese, immunocompromised, pregnant), may need antifungals
What is Bartholin’s gland cyst/abscess?
blockage and infection with staph or E coli (glands under labia minora and make lubricant during sexual excitement); painful red with large tender swelling, can get vaginal cysts
Treatment of Bartholin gland cysts?
incision and drainage by marsupialisation
What is vaginal adenosis?
columnar epithelium in squamous of the vagina, can resolve spontaneously or into clear cell carcinoma
What is vulval intraepithelial neoplasia and associations?
usually warty, basaloid, mixed, 35-55yrs, reddening, whitening, pigmentation, plaques, papules, erosions, nodules, hyperkeratosis; associated = HPV, CIN, smoking, immunosuppression, warty/basaloid squamous cell carcinoma; differentiated type rare and with lichen sclerosis, risk of progression is higher, pruritus and pain
Treatment of vulval intraepithelial neoplasia?
local excision
Vulval carcinoma associations?
> 60yrs; most squamous cell (others are melanomas/basal cell); association = lichen sclerosis, immunosuppression, smoking, Paget’s disease of vulva
S+Ss of vulval carcinoma?
pruritus, bleeding, discharge, mass, large inguinal lymph nodes; staging surgically and histology
Treatment of vulval carcinoma?
stage 1 is wide local excision, others are that with groin lymphadenectomy, may use pre-op radiotherapy
Vulval malignancy S+Ss?
secondary malignancy from cervix, endometrium and vulva (primary rare); older women and squamous; bleeding, discharge, mass
Vulval malignancy treatment?
intravaginal radio/radical surgery; survival 50% for 5 yrs
Vaginal cancer overview?
very rare if primary; most squamous and older women and upper 1/3rd; associated with CIN, pelvic radio, long-term inflammation (pessaries/procidentia = complete uterus prolapse)
Vaginal cancer S+Ss and treatment?
S+Ss = bleeding; treat = radio, poor prognosis
What is urethrocele?
lower anterior vaginal wall and urethra
What is cystocele?
upper anterior vaginal wall and bladder
What is apical prolapse?
uterus, cervix and upper vagina
What is enterocele?
upper posterior wall of vagina
What is rectocele?
lower posterior wall of vagina and anterior wall of rectum; these are all the areas involved in the prolapse (vagina/uterus beyond anatomical confines from weakness from support)
Risk for prolapse?
vaginal delivery, pregnancy, Ehlers-Danlos, menopause, obesity, chronic cough, constipation, heavy lifting, pelvic mass/surgery
3 degrees of prolapse?
first = prolapse halfway to introitus, second = to introitus, third = outside of vagina
S+Ss of prolapse?
usually asymptomatic, dragging sensation/lump, worse at end of day/standing, severe = interferes with sex, ulcerates, bleeds, cystourethrocele can cause urinary frequency, stress incontinence, back ache, tenesmus
Investigations for prolapse?
examine abdo, exclude polyps and masses, vaginal cysts, pelvic US, urodynamic testing if incontinent, Sims speculum
Prevention of prolapse?
pelvic floor exercises, avoidance of excessive long 2nd stage, weight reduction, stop smoking, physio
Treatment of prolapse?
pessaries (women unfit for surgery – artificial pelvic floor, ring most common and changed 6-9months, can cause urinary retention, pain or infection); vaginal hysterectomy for uterovaginal prolapse; hysteropexy (resuspension of prolapsed uterus) for uterine prolapse; sacrocolpopexy (lifts the vagina up using metal mesh) for vaginal vault prolapse; hysterectomy best treatment if severe and untreatable but can leave vault (where cervix was) and this can prolapse
Best pelvic US?
transvaginal is best, homogeneity, low intensity echoes, linear central shadow = normal; 20mm endometrium = investigated, tamoxifen thickens it
Main causes of incontinence?
overactive bladder (increase in detrusor) or increased intra-abdo pressure (stress incontinence)
History for incontinence?
daytime voids (4-7), nocturia, nocturnal enuresis, urgency and voiding difficulties, incomplete emptying, bladder pain, dysuria, haematuria, UTI, prolapse, bowel movement abnormal, ADLs
What is stress incontinence?
Urethral sphincter weakness
Causes of stress incontinence?
pregnancy, prolonged labour, forceps delivery, obesity, age
S+Ss of incontinence?
frequency, urgency, urge incontinence, faecal incontinence, cysto/urethrocele
Investigations of stress incontinence?
urine dipstick, cystometry, test pelvic floor strength, urinalysis, imaging (US), urodynamics, cystoscopy, MSU
Treatment of stress incontinence?
lose weight, pelvic floor exercises for 3 months, vaginal cones/sponges, duloxetine for moderate/severe, surgery after everything else (tension-free vaginal tape/trans-obturator tape)
Overactive bladder definition?
urgency without incontinence (can be urge urinary incontinence too), frequency, nocturia without infection, leak at orgasm, childhood enuresis
Overactive bladder causes?
detrusor overactivity, idiopathic, MS, spinal cord injury, postmenopause
Overactive bladder treatment?
reduce fluid, avoid caffeine, bladder training (education, timed voiding and positive reinforcement), anticholinergics (suppress detrusor), oestrogen, Botox (weakens muscle), neuromodulation/sacral nerve stimulation
Acute urinary retention causes?
childbirth, surgery, drugs (anticholinergics), retroverted gravid uterus, pelvic masses and neuro; mimics stress incontinence, leaking from bladder overflow
Acute urinary retention investigations?
US or catheter after micturition
Acute urinary retention treatment?
catheter for 48hrs, ISC (intermittent self catheterisation)
Painful bladder syndrome definition and S+Ss?
suprapubic pain from bladder filling, frequency with no UTI; interstitial cystitis from painful bladder filling with cystoscopic and histological
Treatment of painful bladder syndrome?
diet changes, bladder training, TCAs, analgesics, intravesical infusion of drugs, surgery
Endometriosis defintion?
• Presence/growth of endometrium tissue out of uterus, driven by oestrogen; 30-45yrs and nulliparous
Endometriosis S+Ss?
pelvis/ovaries, inflammation, progressive fibrosis, adhesions with pain, dysuria, dysmenorrhoea before menstruation, deep dyspareunia, subfertility, pain on defecation (dyschezia), menstrual problems, tenderness/thickening behind uterus, bleeding at area of tissue, cyclical pain
Causes of endometriosis?
Retrograde menstruation?
Investigation of endometriosis?
laparoscopy with biopsy (active/red lesions on peritoneum, if white/brown then less active, extensive adhesions means more severe), transvaginal US, MRI (excludes adenomyosis), American fertility society grading system, bimanual exam = fixed retroverted uterus, tender nodes over uterosacral ligaments
Treatment of endometriosis?
asymptomatic don’t need treating, analgesia (NSAIDs), OC pill (without break) or GnRH analogues (danazol – temporary menopause so bone demineralisation so <6months, mirena), IUS (less pain and dysmenorrhoea), scissors, laser or bipolar diathermy for lesions, surgery to dissect lesions, hysterectomy last resort; problems post-op = chronic pain (difficult to treat and need a specialist), consider other non-gynae problems (IBS etc), analgesia to treat (GnRH analogues, opiates, gabapentin if neuropathic)
Chronic pelvic pain definition?
• Intermittent/chronic pain in lower abdo/pelvis >6months; not just menstruation/intercourse
Investigation of chronic pelvic pain?
psych evaluation, tansvaginal US, MRI, laparoscopy
S+Ss of chronic pelvic pain?
IBS/interstitial cystitis (endometriosis/adenomyosis), depression, sleep disorder
Treatment of chronic pelvic pain?
cyclical pain with OC pill/GnRH analogue, counselling, psychotherapy, amitriptyline, gabapentin
Risks for candidiasis?
pregnant, diabetes, abx, steroids
S+Ss for candidiasis?
non-offensive discharge, vulval irritation, itching, superficial dyspareunia, dysuria; diagnose = culture
Treatment for candidiasis?
imidazoles (clotrimazole) or oral fluconazole
Bacterial vaginosis definition?
normal lactobacilli replaced by anaerobes and Gardnerella
S+Ss of bacterial vaginosis?
grey-white discharge, fishy odour, regular sex partners, concurrent STIs, child sexual abuse; diagnose = high pH, clue cells
Treatment of bacterial vaginosis?
metronidazole or clindamycin cream
Risks for bacterial vaginosis?
preterm labour, intra-amniotic infection, post-termination sepsis, HIV susceptible
Chlamydia S+Ss?
usually asymptomatic, urethritis, vaginal discharge, pelvic infection (subfertility/chronic pelvic pain/PID), Reiter’s syndrome
Investigations of chlamydia?
nucleic acid amplification
Treatment of chlamydia?
azithromycin/doxycycline
Gonorrhoea S+Ss?
asymptomatic, vaginal discharge, urethritis, bartholinitis, cervicitis, bacteraemia, monoseptic arthritis, PID
Investigations and treatment of gonorrohoea?
culture, endocervical swabs; treat = ceftriaxone
Genital warts definition?
from HSV2; virus dormant in dorsal root ganglia
Genital warts S+Ss?
multiple small painful vesicles and ulcers around introitus, vulvitis, lymphadenopathy, dysuria, systemic flu symptoms, attacks = less painful with tingling before
Genital herpes investigation and treatment?
examination and viral swabs; treat = acyclovir for severe, strong analgesia
Syphilis S+Ss?
solitary painless vulval ulcer (first), then wks after rash, flu symptoms, warty genital growth, tertiary rare but AR, dementia, tabes dorsalis
Syphilis investigation and treatment?
syphilis EIA; treat = parenteral penicillin
Trichomoniasis S+Ss?
offensive grey-green fishy discharge, vulval irritation, superficial dyspareunia, asymptomatic
Trichomoniasis investigation and treatment?
wet film microscopy; treat = metronidazole
Endometritis definition?
untreated can spread to pelvis, fallopians and ovaries; from complication of pregnancy/instrumentation of uterus (C-section, miscarriage, abortion); chlamydia and gonococcus
Endometritis S+Ss?
heavy vaginal bleeding and offensive discharge, lower abdo pain, tender uterus
Endometritis investigations and treatment?
swabs and FBC; treat = broad-spectrum abx, evacuation of retained products of conception
Acute pelvic infection/PID?
– upper genital tract infection with dense pelvic adhesions and obstructed fallopian tubes if persists
PID causes?
ascending infection from endocervix (STI, uterine instrument, post-partum) or from descent (appendix)
PID S+Ss?
chronic lower abdo pain, dysmenorrhoea, deep dyspareunia, heavy/irregular menstruation, chronic vaginal discharge, subfertility, similar to endometriosis, fever
PID investigations?
= laparoscopy (diagnosis uncertain), MC+S, endocervical swabs for chlamydia/gonorrhoea, FBC, CRP, blood cultures, TVS if abscess suspected
PID treatment?
analgesics, abx (ceftriaxone +/- doxycycline if high risk), salpingectomy, contact tracing
PID complications?
tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome, recurrent PID, ectopic, subfertility
Vaginal discharge normal physiology?
increases in ovulation, pregnancy and OC pill
Vaginal discharge causes?
exposure of columnar epithelium in adenomyosis and ectropion, bacterial vaginosis and candidiasis, foreign body (offensive), cervical carcinoma (bloody), fallopian tube carcinoma (watery)
Atrophic vaginitis definition and overview?
low oestrogen and before menarche, during lactation and after menopause, treat with oestrogen cream, HRT
What is contact tracing?
notify sexual partners of individual diagnosed with HIV/AIDS; public health duty and should be anonymous/confidential of who the sexual partner is
What are triple swabs?
for symptomatic; endocervical NAAT swab, a high-vaginal charcoal media swab and an endocervical charcoal media swab
Subfertile definition?
conception not happened after 1yr unprotected sex (either primary or secondary [had a previous terminage/miscarriage])
Subfertile causes?
anovulation, inadequate sperm, fallopian tube damage, defective implantation, unexplained, endometriosis, male causes, >35yrs predisoposes; regular cycles = ovulatory (higher serum progesterone in mid-luteal phase means ovulation)
What is infertile?
Both partners have fertility problems
History for infertility?
age, duration of subfertility; previous pregnancies/children; menstrual hx; pelvic pain; STI hx; previous surgery; smoking; drinking; medical hx; sex hx and problems during; male = undescended testes, mumps, drugs, smoking, alcohol
Examination and investigation for fertility?
BMI, endocrine disorder signs, exclude pelvic pathology, cervical smear; invest = chlamydia, hormonal profiling, TSH, prolactin, testosterone, MMR vaccine, semen analysis, mid-luteal progesterone (ovulation); TVS, hysterosalpingogram (and with contrast), laparoscopy and dye = gold standard for tube patency
Polycystic ovary syndrome definition?
transvag US with multiple small follicles in enlarged ovary (12+); most cases of anovulatory infertility
S+Ss of PCOS?
irregular periods, hirsutism (acne/more body hair/raised testosterone), disordered LH, peripheral insulin resistance, more androgens, obese, oligo/amenorrhoea, anovulation
Investigations of PCOS?
FSH, prolactin, TSH (all for anovulation), testosterone (hirsutism), LH, US, screening for diabetes and lipids
Increased risk for PCOS?
DM2, gestational diabetes, endometrial cancer (rf for this = obesity, HT, DM, PCOS, tamoxifen, late menopause)
Treatment of PCOS?
diet, weight loss, exercise, OC pill (to menstruate to protect endometrium), cyproterone acetate (hirsutism), eflornithine (for facial hirsutism), clomifene (first line ovulation induction - <6months, blocks oestrogen receptors in hypothalamus and pituitary, assess with transvag US for ovarian response and endometrial thickness), metformin, laparoscopic ovarian diathermy and gonadotrophins are all good 2nd line ovulation treatments (increases perinatal complication rates), cyproterone for anti-androgen
Long-term risk of PCOS?
GDM, T2DM, CVD, endometrial cancer
What is hypothalamic hypogonadism?
low GnRH causing amenorrhoea
Risks for hypothalamic hypogonadism?
anorexia, diets, athletes, stress, benign tumours or hyperplasia of pituitary cells, PCOS, hypothyroidism, psychotropics
Treatment for hypothalamic hypogonadism?
increase weight, CT, bromocriptine/cabergoline (dopamine inhibits prolactin that reduces GnRH)
What is premature ovarian failure?
anovulation so donor eggs needed for pregnancy; hyper/hypothyroid can reduce fertility
Premature ovarian failure treatment?
health advice, risk of multiple pregnancy with ovulation induction and folic acid, normal weight, no smoking
What is ovarian hyperstimulation syndrome?
gonadotrophins overstimulate follicles (large and painful); common in IVF
Risks for ovarian hyperstimulation syndrome?
gonadotrophin stimulation, <35yrs, previous OHSS, polycystic ovaries
Prevention for OSS?
= low gonadotrophin dose, US monitoring
Complications for OSS?
hypovolaemia, electrolyte disturbance, ascites, thromboembolism, pulmonary oedema
Male subfertility risks?
idiopathic oligospermia, asthenozoospermia, alcohol, smoking, drugs, industrial chemicals, varicocele, infections, mumps, orchitis, testicular abnormalities, obstruction to delivery, hypothalamic problems, hyperprolactinaemia, retrograde ejaculation
Male subfertility examination?
body form, gynaecomastia, orchidometer (orchitis), rectal exam
Male subfertility investigations?
semen analysis repeated 12wks later if abnormal, high FSH and LH with low testosterone means primary testicular failure, azoospermia and no vas deferens check for CF, testosterone and FSH for androgen deficiency
Treatment of male subfertility?
lifestyle changes, loose clothing and testicular cooling, hypogonadotrophic hypogonadism (2x FSH and LH 6-12 months), may need intrauterine insemination
Disorders of fertilisation overview?
pelvic inflammatory disease most common form of tubal damage (hx pelvic pain, vaginal discharge, abnormal menstruation, asymptomatic), endometriosis, pelvic surgery (adhesions), sometimes cervical cancer and sexual problems
Disorders of fertilisation S+Ss?
Usually asymptomatic
Investigation of disorders of fertilisation?
laparoscopy and dye test for fallopians, hysteroscopy, hysterosalpingogram (shape of uterus and patency of fallopians); ovarian reserve testing (FSH, antral follicle count, antimullerian hormone); use IVF and ICSI
What is intrauterine insemination?
washed sperm injected into uterus after gonadotrophin ovulation induction, for unexplained subfertility, cervical, sexual and male factors, tubes should be patent
Ways to induce ovulation?
weight loss/gain; clomifene citrate (50mg 2-6days of cycle; anti-oestrogen; menopause symptoms; only for 6-12 cycles; follicular monitoring for hyperstimulation); laparoscopic ovarian drilling (PCOS only; aim to reduce LH and increase -ve feedback); gonadotrophins (if clomifene resistance; injected; expensive); metformin (PCOS, not licensed)
What is IVF and the steps for it?
success higher in <36, need normal ovarian reserve (no ovarian failure – test with antimullerian hormone), get multiple follicular development with 2wks daily FSH+LH (GnRH analogue to stop LH surge and stop premature ovulation), eggs collected under IV sedation with US and incubated with washed sperm to growth medium until cleavage/blastocyst, progesterone 4-8wks in gestation
ICSI definition?
for male subfertility but can be surgically retrieved; inject sperm into egg cytoplasm; preimplantation genetic diagnosis to test for defects; surrogate?
ICSI complications?
superovulation and higher ectopic rates
Donor insemination definition?
male can’t donate sperm (azoospermia), high risk genetic disorder, HIV transmission
Intrauterine insemination definition?
mild male subfertility, coital difficulties, unexplained, same-sex couples; can be combined with ovarian stimulation
In vitro maturation definition?
immature eggs collected from ovaries and matured before ICSI; reduces risk of ovulation stimulation drugs and hyperstimulation (PCOS)
Ooplasmic transfer definition?
– 2 mothers; one for nucleus and other for mtDNA and cytoplasm
What makes contraception less effective?
small bowel disease and malabsorption for oral, IBD higher osteoporosis (<18yrs), breast feeding (98% stops pregnancy), women <50 advised to continue contraception up to 2yrs after last period; non-compliance
When to avoid combined hormonal contraception?
venous disease/heart disease RF; arterial disease; liver disease; cancer; previous pregnancy complications; hepatic enzyme-inducing drugs; avoid if migraines as risk of ischaemic strokes (especially if with aura)
Prevention in place of contraception?
• Important to have sex education in schools, condoms (don’t use oil based lubes), femidom, cap over cervix, cervical sponges, spermicide used with a barrier; aim to not have sex 6 days prior to ovulation to 2 days after (cervical mucous should be clear and slippery before ovulation and then sticky and tacky – no sex when slippery to 3 days after tacky); Persona use urine sticks measure oestorgen-3-gluconoride + LH, give her a green/amber/red light when not ovulating and can have sex, use 8 times per cycle and v effective
How does the combined OC pill work?
ve feedback on gonadotrophin release and inhibits ovulation; thin endometrium and thicken cervical mucous, 1 tablet daily for 3ks then stop for a week, vaginal bleeding at end of each packet (determined by progesterone used), some contain ethinyloestradiol (same O+P dose) or oestradiol valerate (natural O and synthetic P – 26 pill days then 2 free)
What is the OC pill for?
menarche-menopause, stop recurrent simple ovarian cysts
Things to note with the combined pill?
diarrhoea (reduced absorption), vomits 2hrs after taking take another, broad spectrum abx use condoms as well, liver enzyme inducing drugs use more oestrogen, forgotten pill taken asap, pill stopped 4wk before major surgery
SEs of the combined pill?
nausea, headaches, breast tenderness
What is the combined transdermal patch?
releases ethinyloestradiol then norelgestromin (progestogen); new patch weekly for 3wks then week break
What is the combined vaginal ring?
daily ethinyloestradiol and etonogestrel; same rule as patch; don’t remove during intercourse
What is the progestrogen-only pill and how does it work?
levonorgestrel or norethisterone; every day without a break at same time; makes cervical mucous hostile to sperm and inhibits ovulation in 50%, not affected by broad-spectrum
SEs of progesteron only pill?
vaginal spotting, weight gain, mastalgia, pre-menstrual symptoms
What is depo-provera and noristerat?
medroxyprogesterone acetate IM 3 months
SEs of the depo injection?
irregular bleeding in 1st wks then amenorrhoea, bone density increases, noristerat as short-term interim
What is the nexoplanon?
40mm rod of etonogestrel into upper arm and lasts 3yrs
Types of emergency contraception?
levonelle has levonorgestrel (take in 24hrs), affects sperm and endometrial receptivity; ulipristal is selective progesterone receptor modulator prevents/delays ovulation, if IUD inserted then stops implantation and can be inserted 5 days after sex
Types of barrier contraception?
diaphragms and caps before sex and 6hours after; also use with spermicide (nonoxynol-9)
How to use IUCD?
screen for STD/prophylactic abx before; use immediately after TOP/miscarriage for 4wks
Types of IUCD and indications?
copper (prevent fertilisation; more ectopic/PID risk) or progesterone like Mirena/Jaydess (change cervical mucous and uterotubal fluid so no sperm migration, can be used for menorrhagia and dysmenorrhoea)
Complications of IUCD?
low failure and SEs; can perforate uterus, be expelled, PID association, dysmenorrhoea/menorrhagia
Female sterilisation types?
use of clips and applied laparoscopically; other is transcervical sterilisation (microinserts into proximal tubal lumen); confirm 3months later by hysertosalpingogram
Vasectomy definition?
more effective and ligation and removal of small section of vas deferens (confirm by azoospermia in 2 sperm samples up to 6months)
Complications of female sterilisation?
failure, infection and chronic pain; make sure consent properly and that they know it’s permanent and won’t regret later (reversibility 50% effective and not on NHS)
Progesterone changes in pregnancy?
from corpus luteum til 35 days post-conception then by placenta causes smooth muscle excitability, raises body temp
Oestrogen changes in pregnancy?
increase breast and nipple growth, water retention and protein synthesis
Thyroxine changes in pregnancy?
increase thyroid from more colloid made
Prolactin changes in pregnancy?
from pituitary increases
Uterus changes in pregnancy?
late in pregnancy cervical collagen reduces and vaginal discharge from cervical ectopy, cell desquamation, more mucous
Cardiac output changes in pregnancy?
increased stroke volume and pulse rate; bp mainly diastolic falls in 2nd trimester; increased venous pressure so may get varicose from venous dilation (increase in renin and angiotensin)
What is aorto-caval compression?
from uterus when on back which reduces CO significantly; put woman on her left side tilting 15 degrees on side
Other changes in pregnancy?
ventilation increases, gut motility decreases, micturition frequently common, palmar erythema, spider naevi, striae
Minor symptoms in pregnancy in 1st 12wks?
amenorrhoea, nausea, vomiting, bladder irritability, breasts engorge, nipples large, Montgomery’s tubercles prominent, increased vulval vascularity, cervix softens, uterine globular, temp rises (37.8)
Other symptoms in pregnancy?
Headaches, palpitations and fainting – dilated peripheral circ; stand slowly and drink; Urinary frequency – exclude UTI, fetal head pressure on bladder, GFR increases; abdo pain; SOB; constipation – gut motility low, fluid and fibre, avoid stimulant laxatives, piles common, rest with feet up and stockings; GORD – pyloric sphincter relaxation from progesterone, foetus pressing on GI, pillows, other GORD treatment; MSK – symphysis pubis dysfunction, analgesia and physio; carpal tunnel syndrome – from fluid retention; itchy/rashes – common (pruritic eruption of pregnancy/PEP), 35wks+, emollients and weak topical steroids; ankle oedema – very common, measure BP, check protein (pre-eclampsia) and DVT usually harmless and elevate feet; leg cramps – raise foot 20cm in bed, sometimes restless leg syndrome harder to treat; chloasma – dark pigmentation on face; nausea/vomiting – starts by 4wks and usually declines, small meals, low stress
What is hyperemesis gravidarum?
• Persistent vomiting causing weight loss and ketosis in pregnancy; v rare; higher in multiple, molar pregnancy, previous HG
S+Ss hyperemesis?
can’t keep F+D down, weight low, nutritional deficiency, dehydration, hypovolaemia, tachycardia, postural hypotension, electrolyte disturbance with hypokalaemia, hyponatraemic shock, polyneuritis, behaviour disorder, haematemesis (Mallory-Weiss), ptyalism (can’t swallow saliva), spitting
Tests hyperemesis?
urine dip (ketones and UTI), U+Es, FBC (raised haematocrit), albumin low, transaminases abnormal, TFTs abnormal
Treatment hyperemesis?
hospital if oral anti-emetics not working; fluid replacement; don’t use glucose (wernicke’s encephalopathy – use folic acid and thiamine), daily U+Es; anti-emetics (promethazine, cyclizine, metoclopramide and ondansetron if these fail) use corticosteroids if these fail; high risk of VTE so stockings and thromboprophylaxis
Problems with sickle cell disease for pregnant women?
pregnancy worsens anaemia (crises and acute chest syndrome increased); advise on cold intolerance, hypoxia, dehydration
Advice for sickle cell disease?
genetic counselling for child and test partner; echo to exclude pulmonary hypertension, bp, urinalysis, U+Es, LFTs, retinal screening, iron overload screening
Treatment for sickle cell disease?
daily penicillin, update vaccines (more at risk to infections), 5mg folic acid OD; prenatal testing and tell medical team before so they can prepare; 12wks give aspirin 75mg OD so no pre-eclampsia, TEDs in hosp; regular testing as seen above at visits
S+Ss of crises in sickle cell disease and management?
fever, severe pain, chest pain, SOB; fluids, opiates and O2; delivery 38-40wks, monitor foetus and maternal sats, 7 days thromboprophylaxis after (progesterone contraception)
Increased risk for cardiac disease in pregnancy?
risk increased from pulmonary hypertension, effect on haemodynamics, NHYA functional class I-IV and cyanosis present, arrhythmias, TIA, HF, left tract outflow tract obstruction, low EF
Advice for pulmonary HT in pregnant?
25-40% mortality, advise against pregnancy, Eisenmenger’s etc
Advice for congenital HD in pregnant?
uncorrected can mean IUGR (intrauterine growth restriction), get foetal echo
Marfan’s advice for pregnant?
risk of aortic dissection, offer root replacement pre-pregnancy
Mitral stenosis advice for pregant
dyspnoea, orthopnoea, PND risks and treat AF and pulmonary oedema
Arrhythmias advice for pregnant?
exclude anaemia and hyperthyroidism, SVT treat with adenosine
Artificial valves advice for pregnant?
warfarin can harm foetus and heparin could mean valve thrombosis, can have LMWH
Cardiac failure management for pregnant?
diuretics, vasodilators, B-blockers and inotropes then ACEI once delivered
Management of cardiac disease in pregnancy?
prevent anaemia, obesity, smoking, treat hypertension, echo, HF = admission; O2 and drugs to hand for labour, vaginal delivery aim for, epidurals safe if no hypotension, avoid fluids and ergometrine (use oxytocin)
Psych things to avoid and reasons during pregnancy?
avoid paroxetine, fluoxetine and citalopram but SSRIs fine (same for ante/postnatal depression); try to avoid valproate as mood stabiliser (lamotrigine and carbamazepine have lower chance of NTD); lithium is teratogenic, deffo stop it during labour, don’t breastfeed; higher incidence of foetal abnormalities in schizophrenic; avoid benzos for foetal withdrawal and cleft lip/palate
Problems during pregnancy from anaemia?
can increase risk of postpartum haemorrhage (PPH – when uterus cannot tense from muscle fibres to restrict in size post-birth and knot itself and cervix cuts off), infection, HF severity
Definition of anaemia during pregnancy?
<150g/L and steepest decline in 20wks
