AKT Flashcards
(529 cards)
1
Q
LIST UKMEC3 categories for COCP
A
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
2
Q
UKMEC 4 for COCP
A
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies (e.g. in SLE)
- Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
3
Q
UK MEc3 for POP
A
- Examples of UKMEC 3 conditions include
- active liver disease or past tumour
- liver enzyme inducers
- breast cancer more than 5 years ago
- undiagnosed vaginal bleeding
- ischaemic heart disease and stroke (initiation = UKMEC2)
4
Q
UKMEC4 for POP
A
- pregnancy
- breast cancer within the last 5 years
5
Q
UKMECs for pts on Lamotrigine
A
- UKMEC 3: COCP
2.UKMEC1:POP,IUS,IUD, DEPOT, implant
6
Q
UKMECs for pt phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
A
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS
7
Q
How much ethinydiestrol should be in a COCP if chosen for epileptic pt
A
minimum of 30 µg of ethinylestradiol.
8
Q
Postpartum cocntraception: when can POP be started
A
Anytime postpartum.
9
Q
How many days of extra precaution needed if POP started after 21 days postpartum
A
2 days
10
Q
Postpartum: how long is COCP contra-indicated in BREASTFEEDING mothers
A
<6 weeks postpartum- CI
6w-6months ukmec2
11
Q
True or false:COCP reduces breast milk production in lactating mothers
A
True
12
Q
For how many days should COCP not be used in a non-breastfeeding postpartum pt and why
A
21 days post partum - increased risk of VTE
13
Q
How many days of extra precaution needed if COCPis started 21 days postpartum
A
7 days extra precaution needed
14
Q
When can IUD be inserted after childbirth?
A
WITHIN 48hrs or after 4 weeks
15
Q
What are the criteria for LACTATIONA Amennhorea to be successful and what is the percentage
A
Exclusively breastfeeding, <6m postpartum, no return of periods. (98% effective)
16
Q
UKMEC3 for intrauterine devices iUS, IUD
A
- between 48 hours and 4 weeks postpartum (increased risk of perforation)
- initiation of method** in women with ovarian cancer
17
Q
UKMEC4 for IUD, IUS
A
- pregnancy
- current pelvic infection, puerperal sepsis, immediate post-septic abortion
- unexplained vaginal bleeding which is suspicious
- uterine fibroids or uterine anatomical abnormalities distorting the uterine cavity
18
Q
When should STIs be tested for before insertion of IUD/IUS
A
Chlamydia/gonnohorea in woman at risk of STI
If the woman requests it
19
Q
When should prophylactic abx be given prior to insertion of iud/ius
A
Women at risk of STI if testing has not been completed
20
Q
Which group of patients can never have oral contraception due to lack of effectiveness
A
gastric sleeve/bypass/duodenal switch
Also includes emergency contraception
21
Q
At what weight is COCP transdermal patch not effective
A
Above 90kg
22
Q
At what age is the COCP MEC2?
A
=/> 40 years
23
Q
AT WHAT AGE is the deposit provera UKMEC2?
A
> /=45 years
24
Q
True or False: The COCP may help preserve Bone mineral density in the peri-menopausal period
A
True
25
True or False: The COCP will make menopausal symptoms worse
False: COCP can make menopausal symptoms better
26
What dose of ethinyldiestrol is more suitable for women >40
<30 ug of ethinyldiestrol
27
When can women UNDER 50 stop non-hormonal contraceptives: IUD, Condoms, family planning
After 2 years of amennhorea
28
When can women 50 and ABOVE stop non0-hormonal contraception
AFTER 1 year of amennhorrea
29
Till what age can women continue the COCP till
Up to 50 years (49)
30
What contraceptive can a women aged 50 and above switch to from COCP?
Non hormonal or progesterone only method
31
What age can depot provera be continued till?
Up to 50 years (49)
32
What are the options for a woman aged 50 and above previously taking depot to switch contraception?
1. Switch to non-hormonal and then stop after 2 years of amenhorea
2. Switch to POP only method and stop as advised for progesterone only methods
33
How long can Implant, IUS and pOP be continued ?
Beyond 50 years
34
What are the options for a 50 year and above lady to stop POP, IUS, Implant?
1. Check FSH and stop after 1 YEAR if >30
2. Stop after 55 years if ammenhorrea
3. If ongoing bleeding investigate
35
UKMEC3 for nexplanon
ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2),
unexplained, suspicious vaginal bleeding,
past breast cancer,
severe liver cirrhosis,
liver cancer
36
UKMEC4 for nexplanon
current breast cancer
37
How long does nexplanon last
3 years
38
How can irregular/heavy bleeding from nexplanon be managed and what else must be done if this does not work
1. Add COCP
2. Do a speculum to check for STIs if ongoingbleeding
39
What are side effects associated with progesterone
headache, nausea, breast pain
40
Which medications can effect the effectiveness of nexplanon implant . What extra precautions are needed.
Enzyme inducers , anti-epileptics, rifampicin
1. SWITCH TO A method not effected by enzyme inducers OR use extra precautions 28 days after stopping treatment
41
How many days of extra precaution are needed if nexplanon is NOT inserted in DAY 1 -5 of cycle?
7 days extra precaution are
42
How many extra days precaution is needed if nexplanon is NOT inserted on DAY 1-5 of cycle
7 days extra precaution
43
What is the most common adverse effect of Nexplanon
Irregular/heavy bleeding from nexplanon
44
What is the most effective contraceptive
Nexplanon - 0.07/100 failure rate
45
2 advantages of Nexplanon
1. CAN Be inserted immediately after TOP
2. doesn't contain oestrogen so can be used if past history of thromboembolism, migraine etc
46
What are the types of emergency contraception available
Levonorgestrel, ulipristal acetate, IUD
47
What type of drug is urlipristal acetate and what is the mechanism of action
SELECTIVE Progesterone RECEPTOR MODULATOR
2. Inhibit ovulation
48
When can Ulipristal acetate be taken?
Up to 120hrs after UPSI
49
Can you take levonorgestrel and Ulipristal Acetate together?
NO
50
Can ulipristal acetate reduce the effectiveness of contraception?
Yes
51
When can hormonal contraception be restarted after taking Ulipristal acetate?
pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
52
Which patients should use ulipristal cautiously?
Asthmatics
53
How long does breastfeeding need to be delayed when taking Ulipristal acetate vs Levornogestrel
Ulipristal - delay 1 week
Levonorgestrel - can continue breastfeeding
54
Can ulipristal and levornogestrel be taken more than once in a cycle
Yes
55
What is the dose of ulipristal acetat
30mg
56
What is the mechanism of action of levornogestrel
Not fully understood. Stops ovulation and implantation
57
Up tlill when can Levornogestrel be taken and how effective is it
72hrs after UPS I 84% effective if taken in this time frame
58
When can hormonal contraception be restarted after-started after taking levornogestrel
Immediately
59
What is the dosing for levornogestrel?
1. 1.5mg if 70 OR BMO >26
60
How many people vomit after levornogestrel and when can a repeat dose be taken
Vomiting occurs in 1%
Take repeat dose if occurs within 3 hours of taking
61
What is the most effective emergency contraception?
IUD
62
How long after UPSI can IUD be inserted
5 days after UPSI and up to 5 days after ovulation
63
What is mechanism of action of IUD?
Inhibit implantation and fertilisation (spermicide)
64
How effective is IUD
99%
65
If pt wants to remove IUD after insertion for emergency contraception, how long should it be kept in
Until next period
66
What is the method of action of COCP
Inhibit ovulation
67
What is the method of action of POP (except desogestrel)
Thickens cervical mucous
68
What is the method of action of medroxyprogesterone acetate (depo provera)?
Primary: inhibits ovulation
Also: thickens cervical mucous
69
What is the method of action of implant?
Primary: inhibit ovulation Also
ALSO :thickens cervical mucous
70
What is the method of action of IUS
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
71
What is the method of action of desogestrel
Inhibits ovulation
72
Which COCP and dose would you start someone new to COCP on?
Ethinyloestrodiol 30 ug and levornogestrel 150 mcg (Microgynon 30) or Ethinylestrodio 30ug and Norethisterone 150ug
73
What are the 2 new COCP in the market?
Qlaira ad YAZ
74
What does COCP QLAIRA contain and what is the regimen
Contains estrodiol valerate and dinogest. 28 tablets (26 with both hormones and 2 inactive). Oestrogen dose slowly decreases a progesterone increases. Done to mimic a natural cycle
75
How much does qLAIRA Cost?
Approx £8
76
What are the missed dose rules for Qlaira ?
Works on a 12 hour interval.
If 2 missed pills then emergency contraception be
Day 1- 17 : Take missed pill immediately and the next tablet at the usual time (even if
means taking two on same day)Continue with the tablet taking in the normal way
Abstain or use an additional contraceptive method for 9 days
Day 18-24 : Discard the rest of the packet. Start taking the Day 1 pill from a new packet immediately and continue taking these pills at the correct time.Abstain or use an additional contraceptive method for 9 days
Day 25-26: Take the missed tablet immediately and the next tablet at the usual time
(even if it means taking two tablets on the same day). Additional contraception is not necessary
Day 27-28: Discard the forgotten table and continue tablet taking in the normal way.
Additional contraception is not necessary
77
What is in the contraceptive YAz
20mcg ethinylestradiol with 3mg drospirenone is soon to be launched in the UK. In the US and Europe it is branded as Yaz and has an interesting 24/4 regime, as opposed to the normal 21/7 cycle. The idea is that a shorter pill-free interval is both better for patients with troublesome premenstrual symptoms and is also more effective at preventing ovulation. Studies have shown Yaz causes less pre-menstrual syndrome and blood loss reduced by 50-60%.
78
Give 4 examples of traditional POP
Micronor, Noriday, Nogeston, Femulen)
79
What s the brand name of a desogestrel pill
Cerazette
80
What are the rules for a missed dose of transitional POP and desogestrel
3 hours interval for traditional, 12 hours for desogestrel
If more than 3 hours late:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
81
What is the most common adverse effect of POP
Irregular vaginal bleeding
82
How many extra days of precaution needed if pop STARTED after day 5 of cycle
2 days
83
When is extra precaution not needed whilst switching directly from COCP to POP
If switching directly from end of COCP pack (day 21)
84
How is the POP taken
Take everyday of cycle
85
What should you do if D+V whilst taking POP
Use same rules as if pills were missed
86
Do antibiotics have an effect on POP
No unless enzyme inducers like rifampicin (may reduce effectiveness)
87
88
What is the fifth most common malignancy in females?
Ovarian cancer
89
At what peak age does ovarian cancer incidence occur?
60 years
90
What is the typical prognosis for ovarian cancer?
Generally poor due to late diagnosis
91
What percentage of ovarian cancers are epithelial in origin?
Around 90%
92
What percentage of ovarian cancer cases are due to serous carcinomas?
70-80%
93
Where is it increasingly recognized that many 'ovarian' cancers originate?
Distal end of the fallopian tube
94
What genetic mutations are significant risk factors for ovarian cancer?
Mutations of the BRCA1 or BRCA2 gene
95
What are some risk factors related to ovulation for ovarian cancer?
* Early menarche
* Late menopause
* Nulliparity
96
What are some common clinical features of ovarian cancer?
* Abdominal distension and bloating
* Abdominal and pelvic pain
* Urinary symptoms (e.g., urgency)
* Early satiety
* Diarrhea
97
What initial test does NICE recommend for ovarian cancer diagnosis?
CA125 test
98
What conditions may raise the CA125 level?
* Endometriosis
* Menstruation
* Benign ovarian cysts
* Other conditions
99
What CA125 level indicates the need for an urgent ultrasound scan?
35 IU/mL or greater
100
Should CA125 be used for screening asymptomatic women for ovarian cancer?
No
101
What is the usual method for diagnosing ovarian cancer?
Diagnostic laparotomy
102
What is the typical management approach for ovarian cancer?
Combination of surgery and platinum-based chemotherapy
103
What percentage of women present with advanced disease at diagnosis?
80%
104
What is the all-stage 5-year survival rate for ovarian cancer?
46%
105
106
In which demographic is endometrial cancer classically seen?
Post-menopausal women
## Footnote
Around 25% of cases occur before menopause
107
What is the typical prognosis for endometrial cancer?
Good prognosis due to early detection
108
List the risk factors for endometrial cancer.
* Excess oestrogen
* Nulliparity
* Early menarche
*Tamoxifen
*Hereditary non polyposis colorectal carcinoma
*Metabolic syndrome : PCOS, Diabetes m, obesity
109
What can reduce the risk of endometrial cancer in women taking oestrogen?
Addition of a progestogen
## Footnote
The risk is eliminated if a progestogen is given continuously
110
Name three metabolic conditions that are risk factors for endometrial cancer.
* Obesity
* Diabetes mellitus
*PCOS
111
What hereditary condition is associated with an increased risk of endometrial cancer?
Hereditary non-polyposis colorectal carcinoma
112
Identify a protective factor against endometrial cancer.
Multiparity
113
True or False: Smoking is a protective factor against endometrial cancer.
True
## Footnote
The reasons for this are unclear
114
What is the classic symptom of endometrial cancer?
Postmenopausal bleeding
115
What is the typical progression of postmenopausal bleeding in endometrial cancer?
Usually slight and intermittent initially before becoming heavier
116
What symptoms might premenopausal women experience with endometrial cancer?
Menorrhagia or intermenstrual bleeding
117
Is pain a common symptom of endometrial cancer?
No, pain is not common and typically signifies extensive disease
118
What should be done for all women >= 55 years presenting with postmenopausal bleeding?
Refer using the suspected cancer pathway
119
What is the first-line investigation for suspected endometrial cancer?
Trans-vaginal ultrasound
120
What endometrial thickness measurement has a high negative predictive value?
< 4 mm
121
What procedure is used for further investigation of endometrial cancer?
Hysteroscopy with endometrial biopsy
122
What is the mainstay of management for endometrial cancer?
Surgery
123
What surgical procedure is typically performed for localized endometrial cancer?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
124
What treatment may be given to patients with high-risk endometrial cancer post-surgery?
Postoperative radiotherapy
125
What type of therapy is sometimes used in frail elderly women not suitable for surgery?
Progestogen therapy
126
127
128
What is endometrial hyperplasia?
An abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle
## Footnote
A minority of patients with endometrial hyperplasia may develop endometrial cancer.
129
List the types of endometrial hyperplasia.
* simple
* complex
* simple atypical
* complex atypical
## Footnote
These classifications help in determining the management approach.
130
What is a common feature of endometrial hyperplasia?
Abnormal vaginal bleeding e.g. intermenstrual
## Footnote
This symptom can be a key indicator for diagnosis.
131
What is the management for simple endometrial hyperplasia without atypia?
High dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
## Footnote
Regular monitoring is essential to assess treatment effectiveness.
132
What is usually advised for endometrial hyperplasia with atypia?
Hysterectomy is usually advised
## Footnote
This is due to the higher risk of progression to cancer.
133
134
What percentage of cervical cancer cases occur in women under the age of 45?
Around 50%
135
What are the highest incidence rates for cervical cancer in the UK by age group?
People aged 25-29 years
136
What are the two main types of cervical cancer?
* Squamous cell cancer (80%)
* Adenocarcinoma (20%)
137
What features may indicate cervical cancer?
* Detected during routine cervical cancer screening
* Abnormal vaginal bleeding
* Vaginal discharge
138
What is the most important factor in the development of cervical cancer?
Human papillomavirus (HPV), particularly serotypes 16, 18 & 33
139
List some other risk factors for cervical cancer.
* Smoking
* Human immunodeficiency virus
* Early first intercourse
* Many sexual partners
* High parity
* Lower socioeconomic status
* Combined oral contraceptive pill
140
What oncogenes do HPV 16 & 18 produce?
* E6
* E7
141
What is the role of the E6 gene in cervical cancer?
Inhibits the p53 tumour suppressor gene
142
What is the role of the E7 gene in cervical cancer?
Inhibits RB suppressor gene
143
True or False: Cervical cancer can be detected during routine cervical cancer screening.
True
144
Fill in the blank: HPV 16 & 18 produce the oncogenes _______ and _______.
E6 and E7
145
What is vulval intraepithelial neoplasia (VIN)?
A pre-cancerous skin lesion of the vulva that may result in squamous skin cancer if untreated.
146
What is the average age of a woman affected by vulval intraepithelial neoplasia (VIN)?
Around 50 years
147
Name four risk factors associated with vulval intraepithelial neoplasia (VIN).
* Human papilloma virus 16 & 18
* Smoking
HSV 2
LICHEN SCLERSUS
148
What are some features of vulval intraepithelial neoplasia (VIN)?
* Itching
* Burning
* Raised, well-defined skin lesions
149
What is the purpose of a biopsy in the investigation of vulval intraepithelial neoplasia (VIN)?
To obtain a histological diagnosis
150
What types of biopsy can be used for vulval intraepithelial neoplasia (VIN)?
* Punch biopsy
* Excisional biopsy
151
What tests are used for HPV testing in vulval intraepithelial neoplasia (VIN)?
* PCR
* In situ hybridisation for high-risk HPV DNA
152
What are two topical therapies used in the management of vulval intraepithelial neoplasia (VIN)?
* Imiquimod
* 5-Fluorouracil
153
What is the aim of surgical interventions in vulval intraepithelial neoplasia (VIN)?
To achieve complete removal of dysplastic areas while preserving normal anatomy and function as much as possible.
154
Name a surgical technique used in the management of vulval intraepithelial neoplasia (VIN).
* Wide local excision
* Laser ablation
* Partial vulvectomy
155
What does follow-up and surveillance for vulval intraepithelial neoplasia (VIN) involve?
Regular monitoring with repeat colposcopy and biopsy if recurrence or progression is suspected.
156
157
What percentage of vulval cancers are squamous cell carcinomas?
Around 80%
## Footnote
This statistic highlights the most common type of vulval cancer.
158
What is the typical age demographic for vulval cancer diagnosis?
Women over the age of 65 years
## Footnote
This indicates that vulval cancer is more prevalent in older women.
159
How many cases of vulval cancer are diagnosed in the UK each year?
Around 1,200 cases
## Footnote
This statistic shows the rarity of vulval cancer.
160
Name a risk factor for vulval cancer.
* Human papilloma virus (HPV) infection
* Vulval intraepithelial neoplasia (VIN)
* Immunosuppression
* Lichen sclerosus
## Footnote
These factors increase the likelihood of developing vulval cancer.
161
What are common features of vulval cancer?
* Lump or ulcer on the labia majora
* Inguinal lymphadenopathy
* May be associated with itching, irritation
## Footnote
These symptoms can help in identifying vulval cancer.
162
True or False: Vulval cancer is common among young women.
False
## Footnote
Vulval cancer is relatively rare and primarily affects older women.
163
Fill in the blank: Most vulval cancers are _______.
squamous cell carcinomas
## Footnote
This term refers to the predominant type of vulval cancer.
164
What is inguinal lymphadenopathy in relation to vulval cancer?
A feature that may indicate the presence of vulval cancer
## Footnote
It refers to swollen lymph nodes in the groin area.
165
What are fibroids?
Benign smooth muscle tumours of the uterus
## Footnote
They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
166
In which demographic are fibroids more common?
Afro-Caribbean women
## Footnote
Rare before puberty and develop in response to oestrogen.
167
What are some symptoms of fibroids?
Asymptomatic, menorrhagia, iron-deficiency anaemia, bulk-related symptoms, lower abdominal pain, bloating, urinary symptoms, subfertility
## Footnote
Rare features include polycythaemia secondary to autonomous production of erythropoietin.
168
What is the most common diagnostic tool for fibroids?
Transvaginal ultrasound
169
What is the management for asymptomatic fibroids?
No treatment needed other than periodic review to monitor size and growth
170
What treatment options are available for menorrhagia secondary to fibroids?
* Levonorgestrel intrauterine system (LNG-IUS)
* NSAIDs (e.g. mefenamic acid)
* Tranexamic acid
* Combined oral contraceptive pill
* Oral progestogen
* Injectable progestogen
## Footnote
LNG-IUS is useful if the woman also requires contraception but cannot be used if there is distortion of the uterine cavity.
171
What are some medical treatments to shrink/remove fibroids?
* GnRH agonists
* Ulipristal acetate (not currently used due to liver toxicity concerns)
## Footnote
GnRH agonists may reduce fibroid size but are typically for short-term treatment due to side effects like menopausal symptoms and loss of bone mineral density.
172
What are the surgical options for fibroid treatment?
* Myomectomy (abdominally, laparoscopically, or hysteroscopically)
* Hysteroscopic endometrial ablation
* Hysterectomy
* Uterine artery embolization
173
What is the prognosis for fibroids after menopause?
Fibroids generally regress after menopause
174
What complications can arise from fibroids?
* Subfertility
* Iron-deficiency anaemia
* Red degeneration (haemorrhage into tumour during pregnancy)
## Footnote
Some complications such as subfertility and iron-deficiency anaemia have been mentioned previously.
175
What is the upper limit for termination of pregnancy as per the 1990 amendment to the Abortion Act?
24 weeks gestation
## Footnote
The original limit was 28 weeks gestation before the amendment.
176
How many registered medical practitioners must sign a legal document for an abortion?
Two registered medical practitioners (or one in an emergency)
## Footnote
This is a requirement under the current abortion law.
177
Who is allowed to perform an abortion according to the law?
Only a registered medical practitioner
## Footnote
The procedure must take place in an NHS hospital or licensed premises.
178
What prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks' gestation?
Anti-D prophylaxis
## Footnote
This is crucial to prevent Rh sensitization.
179
What is mifepristone commonly referred to as?
RU486
## Footnote
It is an anti-progestogen used in medical abortions.
180
What follows the administration of mifepristone in a medical abortion?
Prostaglandins (e.g. misoprostol)
## Footnote
This is done 48 hours later to stimulate uterine contractions.
181
What is a multi-level pregnancy test?
A pregnancy test that detects the level of hCG
## Footnote
It is required in 2 weeks to confirm that the pregnancy has ended.
182
List three surgical options for abortion.
* Manual vacuum aspiration (MVA)
* Electric vacuum aspiration (EVA)
* Dilatation and evacuation (D&E)
## Footnote
These are transcervical procedures used to end a pregnancy.
183
What is cervical priming in the context of surgical abortion?
Use of misoprostol +/- mifepristone before procedures
## Footnote
This helps prepare the cervix for surgery.
184
What types of anesthesia may be offered to women undergoing surgical abortion?
* Local anaesthesia alone
* Conscious sedation with local anaesthesia
* Deep sedation
* General anaesthesia
## Footnote
The choice depends on the procedure and patient preference.
185
According to NICE, what is recommended regarding the choice of abortion procedure up to 23+6 weeks' gestation?
Women should be offered a choice between medical or surgical abortion
## Footnote
Patient decision aids are usually provided to help with informed decision-making.
186
True or False: After 9 weeks, medical abortions become more common.
False
## Footnote
Medical abortions become less common due to factors like the likelihood of seeing products of conception.
187
What must a person believe to not be guilty of an offence under the law relating to abortion?
That the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk
## Footnote
This includes risks to the physical or mental health of the pregnant woman or existing children.
188
Fill in the blank: The 1967 Abortion Act allows termination if there is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be _______.
seriously handicapped
## Footnote
This clause is part of the criteria for legal abortion.
189
What exceptions exist where the limits of the Abortion Act do not apply?
*continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family;
*or that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;
*or that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated;
* there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
## Footnote
These exceptions allow for termination beyond the specified limits. (24 weeks)
190
191
What is the minimum days of abstinence required before performing a semen analysis?
3 days
## Footnote
The analysis can also be performed after a maximum of 5 days of abstinence.
192
What is the maximum time frame for delivering a semen sample to the lab?
1 hour
## Footnote
Timely delivery is crucial for accurate analysis.
193
What is the minimum volume of semen considered normal?
> 1.5 ml
194
What is the minimum pH level for a normal semen analysis?
> 7.2
195
What is the minimum sperm concentration for normal semen results?
> 15 million / ml
196
What percentage of normal forms is required for sperm morphology?
> 4%
197
What is the minimum percentage of progressive motility considered normal?
> 32%
198
What is the minimum percentage of live spermatozoa required for normal vitality?
> 58%
199
Define recurrent miscarriage and give 6 causes
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women
Causes
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
200
201
What does premenstrual syndrome (PMS) describe?
The emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle
202
When does PMS occur?
In the presence of ovulatory menstrual cycles
203
At what life stages does PMS not occur?
* Prior to puberty
* During pregnancy
* After menopause
204
What are some emotional symptoms of PMS?
* Anxiety
* Stress
* Fatigue
* Mood swings
205
What are some physical symptoms of PMS?
* Bloating
* Breast pain
206
How can mild PMS symptoms be managed?
With lifestyle advice
207
What specific lifestyle advice is recommended for mild PMS symptoms?
* Regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates
* General advice on sleep, exercise, smoking, and alcohol
208
What type of medication may benefit moderate PMS symptoms?
A new-generation combined oral contraceptive pill (COCP)
209
Give an example of a COCP that may benefit moderate PMS symptoms.
Yasmin (drospirenone 3 mg and ethinylestradiol 0.030 mg)
210
What treatment may be beneficial for severe PMS symptoms?
A selective serotonin reuptake inhibitor (SSRI)
211
How may SSRIs be taken for PMS treatment?
* Continuously
* Just during the luteal phase (e.g., days 15-28 of the menstrual cycle)
212
What is premature ovarian insufficiency?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
## Footnote
Occurs in around 1 in 100 women.
213
What are some causes of premature menopause?
* Idiopathic
* Family history
* Bilateral oophorectomy
* Hysterectomy with preservation of ovaries
* Radiotherapy
* Chemotherapy
* Infection (e.g. mumps)
* Autoimmune disorders
* Resistant ovary syndrome (due to FSH receptor abnormalities)
## Footnote
Idiopathic is the most common cause.
214
What are common features of premature ovarian insufficiency?
* Climacteric symptoms (hot flushes, night sweats)
* Infertility
* Secondary amenorrhoea
* Raised FSH and LH levels (e.g. FSH > 30 IU/L)
* Low oestradiol (e.g. < 100 pmol/l)
## Footnote
Elevated FSH levels should be demonstrated on 2 blood samples taken 4-6 weeks apart.
215
What symptoms are associated with climacteric in premature ovarian insufficiency?
Hot flushes and night sweats
## Footnote
Symptoms are similar to those of the normal climacteric.
216
What is the management for premature ovarian insufficiency?
Hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of 51 years
## Footnote
HRT does not provide contraception in case spontaneous ovarian activity resumes.
217
Fill in the blank: Elevated FSH levels should be demonstrated on ______ taken 4-6 weeks apart.
2 blood samples
218
True or False: Hysterectomy with preservation of the ovaries can advance the age of menopause.
True
219
What is the average age of menopause?
51 years
220
Fill in the blank: Resistant ovary syndrome is due to ______ abnormalities.
FSH receptor
221
What is polycystic ovary syndrome (PCOS)?
A complex condition of ovarian dysfunction affecting 5-20% of women of reproductive age
222
What are common features of PCOS?
* Subfertility and infertility
* Menstrual disturbances: oligomenorrhoea and amenorrhoea
* Hirsutism and acne (due to hyperandrogenism)
* Obesity
* Acanthosis nigricans (due to insulin resistance)
223
Which hormonal levels are typically seen in PCOS?
* Hyperinsulinaemia
* High levels of luteinizing hormone (LH)
224
What is the significance of the LH:FSH ratio in PCOS?
Raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis
225
What investigations are useful for diagnosing PCOS?
* Pelvic ultrasound for multiple cysts
* FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)
* Check for impaired glucose tolerance
226
What are the Rotterdam criteria for diagnosing PCOS?
Diagnosis can be made if 2 of the following 3 are present:
* Infrequent or no ovulation (no menstruation)
* Clinical and/or biochemical signs of hyperandrogenism
* Polycystic ovaries on ultrasound (≥ 12 follicles or increased ovarian volume > 10 cm³)
227
What does a pelvic ultrasound show in PCOS?
Multiple cysts on the ovaries
228
How can testosterone levels present in women with PCOS?
Testosterone may be normal or mildly elevated; if markedly raised, consider other causes
229
What is SHBG and how is it affected in PCOS?
SHBG is normal to low in women with PCOS
230
What should be done before making a formal diagnosis of PCOS?
Perform investigations to exclude other conditions
231
True or False: Acanthosis nigricans is associated with insulin resistance in PCOS.
True
232
Fill in the blank: The aetiology of PCOS is not fully ______.
understood
233
What does pelvic inflammatory disease (PID) describe?
Infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries, and the surrounding peritoneum
## Footnote
PID usually results from ascending infection from the endocervix.
234
What is the most common causative organism of PID?
Chlamydia trachomatis
## Footnote
Other causative organisms include Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis.
235
List some features of pelvic inflammatory disease (PID).
* Lower abdominal pain
* Fever
* Deep dyspareunia
* Dysuria
* Menstrual irregularities
* Vaginal or cervical discharge
* Cervical excitation
236
What investigation should be done to exclude an ectopic pregnancy in suspected PID?
A pregnancy test
## Footnote
Other investigations include a high vaginal swab, which is often negative, and screening for Chlamydia and Gonorrhoea.
237
What is the first-line management for PID?
Stat IM ceftriaxone + followed by 14 days of oral doxycycline + oral metronidazole
## Footnote
This regimen is preferred to avoid systemic fluoroquinolones where possible.
238
What is the second-line management for PID?
Oral ofloxacin + oral metronidazole
239
According to RCOG guidelines, what should be considered in mild cases of PID regarding intrauterine contraceptive devices?
Intrauterine contraceptive devices may be left in
## Footnote
The more recent BASHH guidelines suggest that removal of the IUD should be considered for better short-term clinical outcomes.
240
What is perihepatitis, also known as Fitz-Hugh Curtis Syndrome, and how common is it in PID cases?
It occurs in around 10% of cases and is characterized by right upper quadrant pain
## Footnote
Perihepatitis may be confused with cholecystitis.
241
What are some potential complications of PID?
* Infertility (risk may be as high as 10-20% after a single episode)
* Chronic pelvic pain
* Ectopic pregnancy
242
True or False: Dysuria is a common feature of pelvic inflammatory disease (PID).
True
243
Fill in the blank: PID is usually the result of _______ infection from the endocervix.
[ascending]
244
What hormone's pulse frequency increases during the early follicular phase to stimulate FSH and LH release?
Gonadotropin-releasing hormone (GnRH)
245
What does FSH stimulate in the mid-follicular phase?
Estradiol production
246
What type of feedback does estradiol produce on the hypothalamus and pituitary gland in the mid-follicular phase?
Negative feedback
247
What is the unique switch in feedback mechanism of estradiol during the luteal phase?
From negative to positive feedback
248
What does the surge of LH secretion during the luteal phase lead to?
Follicular rupture and ovulation
249
What are the three main categories of anovulation?
* Class 1: Hypogonadotropic hypogonadal anovulation-notably hypothalamic amenorrhoea (5-10% of women)
* Class 2: Normogonadotropic normoestrogenic anovulation-polycystic ovary syndrome (80% of cases)
* Class 3: Hypergonadotropic hypoestrogenic anovulation-premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
250
What is the percentage of women affected by Class 1 anovulation?
5-10%
251
What condition is associated with Class 2 anovulation affecting 80% of cases?
Polycystic ovary syndrome (PCOS)
252
What is typically required for conception in Class 3 anovulation?
In-vitro fertilisation (IVF) with donor oocytes
253
What is the ideal goal of ovulation induction?
Induce mono-follicular development and subsequent ovulation
254
What is the first-line treatment for patients with polycystic ovarian syndrome?
Exercise and weight loss
255
What effect can a modest 5% weight loss have on women with PCOS?
Ovulation can spontaneously return
256
What is the first-line medical therapy for patients with PCOS according to UptoDate?
Letrozole
257
What is the mechanism of action of letrozole?
Aromatase inhibitor that increases FSH production
258
What are the side effects associated with letrozole?
* Fatigue (20%)
* Dizziness (10%)
259
What percentage of women with PCOS respond to clomiphene citrate treatment?
80%
260
What is the mechanism of action of clomiphene citrate?
Selective estrogen receptor modulator (SERM) that blocks negative feedback of estrogens
261
What are the side effects of clomiphene citrate?
* Hot flushes (30%)
* Abdominal distention and pain (5%)
* Nausea and vomiting (2%)
262
What therapy is primarily used for women with Class 1 ovulatory dysfunction?
Gonadotropin therapy
263
What is the risk associated with gonadotropin therapy for women with PCOS?
Higher risk of multi-follicular development and multiple pregnancy
264
What is the potential life-threatening side effect of ovulation induction?
Ovarian hyperstimulation syndrome (OHSS)
265
What are the potential complications of ovarian hyperstimulation syndrome (OHSS)?
* Hypovolaemic shock
* Acute renal failure
* Venous or arterial thromboembolism
266
What is the risk percentage of severe OHSS occurring in women undergoing ovarian induction?
Less than 1%
267
What are the management strategies for severe OHSS?
* Fluid and electrolyte replacement
* Anti-coagulation therapy
* Abdominal ascitic paracentesis
* Pregnancy termination
268
269
What is the initial imaging modality for suspected ovarian cysts/tumours?
Ultrasound
270
How are ovarian cysts classified in ultrasound reports?
Cysts are classified as either simple or complex
## Footnote
Simple cysts are unilocular and more likely to be physiological or benign, while complex cysts are multilocular and more likely to be malignant.
271
What factors influence the management of ovarian cysts?
The age of the patient and whether the patient is symptomatic
272
Why is the diagnosis of ovarian cancer often delayed?
Due to a vague presentation
273
What approach may be taken for premenopausal women with ovarian cysts?
A conservative approach may be taken, especially if < 35 years
274
What is the likelihood of malignancy in premenopausal women with small simple cysts (< 5 cm)?
Highly likely to be benign
275
What should be arranged if a small simple cyst in a premenopausal woman persists?
A repeat ultrasound should be arranged for 8-12 weeks and referral considered
276
What is true about physiological cysts in postmenopausal women?
By definition, physiological cysts are unlikely
277
What should be done for any postmenopausal woman with an ovarian cyst?
She should be referred to gynaecology for assessment
278
What are the main types of benign ovarian cysts?
Physiological cysts, benign germ cell tumours, benign epithelial tumours, benign sex cord stromal tumours
279
What should be done with complex ovarian cysts?
They should be biopsied to exclude malignancy
280
What is the commonest type of ovarian cyst?
Follicular cysts
281
What causes follicular cysts?
Non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
282
How do follicular cysts typically behave over time?
They commonly regress after several menstrual cycles
283
What is a corpus luteum cyst?
A cyst that forms when the corpus luteum fills with blood or fluid instead of breaking down
284
What is more likely to occur with a corpus luteum cyst compared to follicular cysts?
Intraperitoneal bleeding
285
What is a dermoid cyst also known as?
Mature cystic teratomas
286
What can dermoid cysts contain?
Skin appendages, hair, and teeth
287
What is the median age of diagnosis for dermoid cysts?
30 years old
288
What percentage of dermoid cysts are bilateral?
10-20%
289
What is the most common benign epithelial tumour?
Serous cystadenoma
290
In which demographic are serous cystadenomas typically seen?
Middle-aged women
291
What is the typical imaging appearance of serous cystadenomas?
Thin-walled, anechoic or low-level echo cyst; may have thin septations
292
What is the second most common benign epithelial tumour?
Mucinous cystadenoma
293
What symptoms may present with mucinous cystadenomas?
Abdominal distension, discomfort, or pressure symptoms
294
What is a potential complication if a mucinous cystadenoma ruptures?
Pseudomyxoma peritonei
295
Fill in the blank: Serous cystadenomas are usually _____ or _____ with thin walls.
unilocular, multilocular
296
True or False: Dermoid cysts are usually symptomatic.
False
297
What is a characteristic feature of mucinous cystadenomas on ultrasound imaging?
Multiloculated cyst with varying echogenicity due to mucin content
298
What are the types of benign ovarian germ cell tumours
Dermoid cyst
299
What are the 2 types of benign epithelial ovarian tumours
- Mucinous cytsadenoma
- Serous cystadenoma
300
301
What is a threatened miscarriage?
Painless vaginal bleeding occurring before 24 weeks, typically at 6 - 9 weeks.
## Footnote
The bleeding is often less than menstruation and complicates up to 25% of all pregnancies.
302
What are the characteristics of a threatened miscarriage?
Cervical os is closed and bleeding is less than menstruation.
## Footnote
Occurs before 24 weeks of pregnancy.
303
What defines a missed (delayed) miscarriage?
A gestational sac containing a dead fetus before 20 weeks without the symptoms of expulsion.
## Footnote
May involve light vaginal bleeding/discharge and disappearance of pregnancy symptoms. Pain is not usually a feature.
304
What is a 'blighted ovum' or 'anembryonic pregnancy'?
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen.
## Footnote
This occurs in the context of a missed (delayed) miscarriage.
305
What are the symptoms of an inevitable miscarriage?
Heavy bleeding with clots and pain.
## Footnote
Cervical os is open.
306
What characterizes an incomplete miscarriage?
Not all products of conception have been expelled, accompanied by pain and vaginal bleeding.
## Footnote
Cervical os is open.
307
What are the phases of the menstrual cycle?
Menstruation, Follicular phase, Ovulation, Luteal phase
## Footnote
Menstruation (Days 1-4), Follicular phase (Days 5-13), Ovulation (Day 14), Luteal phase (Days 15-28)
308
What occurs during the Follicular phase (Days 5-13)?
Development of follicles, one follicle becomes dominant
## Footnote
Follicular phase is also known as the proliferative phase.
309
What changes occur in the endometrium during the Follicular phase?
Proliferation of endometrium
## Footnote
This occurs under the influence of estrogen, particularly oestradiol.
310
What triggers ovulation in the menstrual cycle?
Acute release of LH due to high levels of oestradiol
## Footnote
This happens when the egg has matured.
311
What is the role of the corpus luteum during the Luteal phase?
Secretes progesterone
## Footnote
The corpus luteum forms after ovulation and is responsible for maintaining the uterine lining.
312
What happens to the corpus luteum if fertilization does not occur?
Degenerates and progesterone levels fall
## Footnote
This leads to the onset of menstruation.
313
What is the cervical mucus like during the Follicular phase?
Thick and forms a plug across the external os
## Footnote
This helps to prevent sperm from entering the uterus.
314
What changes occur in cervical mucus just prior to ovulation?
Becomes clear, low viscosity, and stretchy
## Footnote
This quality is termed spinnbarkeit.
315
What happens to basal body temperature during the Follicular phase?
Falls prior to ovulation
## Footnote
This is due to the influence of oestradiol.
316
What occurs to basal body temperature after ovulation?
Rises in response to higher progesterone levels
## Footnote
This rise is an indicator of the luteal phase.
317
What hormone levels rise during the Luteal phase?
Progesterone and oestradiol
## Footnote
Progesterone is secreted by the corpus luteum.
318
6 Causes of mennhoragia , and current definition
Menorrhagia: causes
Menorrhagia was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The assessment and management of heavy periods has therefore shifted towards what the woman considers to be excessive and aims to improve quality of life measures.
Causes
1. dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
2. anovulatory cycles: these are more common at the extremes of a women's reproductive life
3. uterine fibroids
4. hypothyroidism
5. intrauterine devices*
6. pelvic inflammatory disease
7. bleeding disorders, e.g. von Willebrand disease
*this refers to normal copper coils. Note that the intrauterine system (Mirena) is used to treat menorrhagia
319
320
What is the average age for women in the UK to go through menopause?
51 years old
## Footnote
Menopause marks the end of menstrual cycles.
321
What is the climacteric?
The period prior to menopause where women may experience symptoms as ovarian function starts to fail
## Footnote
Symptoms can include hot flashes, mood changes, and sleep disturbances.
322
When is effective contraception recommended for women over 50?
12 months after the last period
## Footnote
This is to prevent unintended pregnancies during the transition to menopause.
323
When is effective contraception recommended for women under 50?
24 months after the last period
## Footnote
The extended period accounts for potentially longer fertility windows.
324
What is menopause?
Permanent cessation of menstruation due to loss of follicular activity.
325
How is menopause diagnosed?
Clinical diagnosis usually made when a woman has not had a period for 12 months.
326
What percentage of postmenopausal women experience menopausal symptoms?
Roughly 75%.
327
How long do menopausal symptoms typically last?
Typically last for 7 years but may vary.
328
What are the three categories of menopause management?
* Lifestyle modifications
* Hormone replacement therapy (HRT)
* Non-hormone replacement therapy
329
What lifestyle modifications can help with hot flushes?
Regular exercise, weight loss, and reduce stress.
330
What can help with sleep disturbances during menopause?
Avoiding late evening exercise and maintaining good sleep hygiene.
331
What lifestyle changes can improve mood during menopause?
Sleep, regular exercise, and relaxation.
332
What is the recommended management for cognitive symptoms during menopause?
Regular exercise and good sleep hygiene.
333
What are the contraindications for hormone replacement therapy (HRT)?
* Current or past breast cancer
* Any oestrogen-sensitive cancer
* Undiagnosed vaginal bleeding
* Untreated endometrial hyperplasia
334
What percentage of women are treated with HRT for menopausal symptoms?
Roughly 10%.
335
What is the risk associated with unopposed oestrogens in women with a uterus?
Increased risk of endometrial cancer.
336
What type of HRT is given to women without a uterus?
Oestrogen alone, either orally or in a transdermal patch.
337
What are the risks associated with HRT treatment?
* Venous thromboembolism
* Stroke
* Coronary heart disease
* Breast cancer
* Ovarian cancer
338
What medications can be used for vasomotor symptoms as a non-HRT management?
Fluoxetine, citalopram, or venlafaxine.
339
What can be used to treat vaginal dryness?
Vaginal lubricant or moisturiser.
340
What are some options for managing psychological symptoms during menopause?
* Self-help groups
* Cognitive behaviour therapy
* Antidepressants
341
What should be prescribed for urogenital atrophy?
Vaginal oestrogen.
342
How long may HRT be required for managing vasomotor symptoms?
2-5 years.
343
What is important to tell women when stopping HRT?
Gradually reducing HRT is effective at limiting recurrence only in the short term.
344
When should a woman be referred to secondary care for menopause management?
If treatment has been ineffective, ongoing side effects, or unexplained bleeding.
345
What percentage of couples will conceive within 1 year of having regular sex?
84%
## Footnote
This statistic highlights the typical conception rates for couples trying to conceive.
346
What are the main causes of infertility?
* Male factor: 30%
* Unexplained: 20%
* Ovulation failure: 20%
* Tubal damage: 15%
* Other causes: 15%
## Footnote
These percentages indicate the distribution of infertility causes among couples.
347
What is the first basic investigation for infertility?
Semen analysis
## Footnote
This test is crucial for assessing male fertility.
348
When should serum progesterone be measured in a typical 28-day cycle?
7 days prior to expected next period, typically on day 21
## Footnote
This timing is important for accurately assessing ovulation.
349
What serum progestogen level indicates ovulation?
> 30 nmol/l
## Footnote
This level suggests that ovulation has occurred.
350
What should be done if serum progestogen levels are consistently low?
Refer to specialist
## Footnote
Low levels may indicate a need for further evaluation and intervention.
351
What is the recommended daily dose of folic acid for women before conception?
0.4 mg per day
## Footnote
This supplementation helps reduce the risk of neural tube defects.
352
What is the recommended daily dose of folic acid for women with specific risk factors?
5 mg per day
## Footnote
This higher dose is for women with a history of neural tube defects, those on anti-epileptic medication, or with diabetes.
353
What is the recommended BMI range for women trying to conceive?
20-25
## Footnote
Maintaining a healthy BMI is important for fertility.
354
How often should couples engage in sexual intercourse when trying to conceive?
Every 2 to 3 days
## Footnote
Regular intercourse increases the chances of conception.
355
True or False: Smoking and drinking advice is part of infertility counselling.
True
## Footnote
Lifestyle factors such as smoking and drinking can affect fertility.
356
What are common side effects of hormone replacement therapy (HRT)?
Nausea, breast tenderness, fluid retention and weight gain
## Footnote
These side effects can vary among individuals and may require monitoring.
357
What is the increased risk of breast cancer associated with HRT?
Increased by the addition of a progestogen; relative risk of 1.26 at 5 years in the WHI study
## Footnote
The risk is related to the duration of use and declines after stopping HRT.
358
How does the risk of breast cancer change after stopping HRT?
The risk begins to decline and reaches the same level as in women who have never taken HRT by 5 years
## Footnote
This indicates the reversibility of the risk associated with HRT.
359
What is the recommendation regarding oestrogen as HRT for women with a womb?
Oestrogen by itself should not be given; a progestogen should be added
## Footnote
This is to reduce the risk of endometrial cancer.
360
What happens to the risk of endometrial cancer when a progestogen is added to HRT?
It is reduced but not completely eliminated
## Footnote
The BNF states that the additional risk is eliminated if a progestogen is given continuously.
361
What is the relationship between progestogen and the risk of venous thromboembolism (VTE) with HRT?
The risk is increased by the addition of a progestogen; transdermal HRT does not appear to increase the risk
## Footnote
NICE recommends referring high-risk women to haematology before starting treatment.
362
What other risks are associated with hormone replacement therapy?
* Increased risk of stroke
* Increased risk of ischaemic heart disease if taken more than 10 years after menopause
## Footnote
These risks highlight the need for careful patient selection and monitoring.
363
What is hyperemesis gravidarum most common between?
8 and 12 weeks
## Footnote
It may persist up to 20 weeks.
364
List four risk factors for hyperemesis gravidarum.
* Increased levels of beta-hCG
* Multiple pregnancies
* Trophoblastic disease
* Nulliparity
* Obesity
* Family or personal history of NVP
365
True or False: Smoking is associated with an increased incidence of hyperemesis.
False
## Footnote
Smoking is associated with a decreased incidence of hyperemesis.
366
What are the NICE referral criteria for nausea and vomiting in pregnancy?
* Continued nausea and vomiting unable to keep down liquids or oral antiemetics
* Continued nausea and vomiting with ketonuria and/or weight loss greater than 5% of body weight despite treatment
* Confirmed or suspected comorbidity
367
What triad is present for the diagnosis of hyperemesis gravidarum?
* 5% pre-pregnancy weight loss
* Dehydration
* Electrolyte imbalance
368
What validated scoring system can classify the severity of NVP?
Pregnancy-Unique Quantification of Emesis (PUQE) score
369
List three simple management measures for hyperemesis gravidarum.
* Rest and avoid triggers
* Bland, plain food, particularly in the morning
* Ginger
370
Name two first-line medications for hyperemesis gravidarum.
* Oral cyclizine
* Oral promethazine
371
What combination drug is commonly used for NVP?
Doxylamine/pyridoxine
## Footnote
Pyridoxine monotherapy is commonly used outside of the UK but is not recommended in RCOG guidelines.
372
What are the second-line medications for hyperemesis gravidarum?
* Oral ondansetron
* Oral metoclopramide
* Oral domperidone
373
What is a potential risk associated with ondansetron during the first trimester?
Small increased risk of the baby having a cleft lip/palate
374
What should be discussed with pregnant women if ondansetron is used?
Risks associated with ondansetron
375
Why should metoclopramide not be used for more than 5 days?
It may cause extrapyramidal side effects
376
What is used for rehydration in hyperemesis gravidarum?
Normal saline with added potassium
377
List three complications that women with hyperemesis gravidarum may develop.
* Dehydration
* Weight loss
* Electrolyte imbalances
378
What other complications are associated with hyperemesis gravidarum?
* Acute kidney injury
* Wernicke's encephalopathy
* Mallory-Weiss tear
* Venous thromboembolism
* Fetal outcome
379
True or False: Studies show significant evidence of adverse outcomes for birth weight with mild-moderate symptoms.
False
## Footnote
Studies generally show little evidence of adverse outcomes.
380
What may severe NVP linked to multiple admissions result in?
A small increase in preterm birth and low birth weight
381
What should be performed in all women with heavy menstrual bleeding?
A full blood count should be performed
## Footnote
This is to assess for anemia and other blood-related issues.
382
When should a routine transvaginal ultrasound scan be arranged for heavy menstrual bleeding?
If symptoms suggest a structural or histological abnormality, such as intermenstrual or postcoital bleeding, pelvic pain, and/or pressure symptoms
## Footnote
Other indications include abnormal pelvic exam findings.
383
What is the first-line treatment for heavy menstrual bleeding that does not require contraception?
Either mefenamic acid 500 mg tds (esp if dysmenorrhea as well) or tranexamic acid 1 g tds
## Footnote
Both treatments should be started on the first day of the period.
384
What should be done if there is no improvement in heavy menstrual bleeding after initial treatment?
Try another drug while awaiting referral
## Footnote
This allows for further management options to be explored.
385
What are the first-line options for heavy menstrual bleeding that requires contraception?
Options include:
* Intrauterine system (Mirena)
* Combined oral contraceptive pill
* Long-acting progestogens
## Footnote
These options help in managing both bleeding and contraception.
386
What short-term option can be used to rapidly stop heavy menstrual bleeding?
Norethisterone 5 mg tds
## Footnote
This is typically used for quick management of heavy bleeding.
387
388
389
What are uterine fibroids sensitive to?
Oestrogen
390
What can happen to uterine fibroids during pregnancy?
They can grow
391
What occurs if the growth of fibroids outstrips their blood supply?
They can undergo red or 'carneous' degeneration
392
What are the typical symptoms of fibroid degeneration?
Low-grade fever, pain, and vomiting
393
How is fibroid degeneration usually managed?
Conservatively with rest and analgesia
394
What is the typical duration for resolution of fibroid degeneration?
4-7 days
395
Fill in the blank: Uterine fibroids can undergo _______ degeneration if their growth exceeds blood supply.
red or 'carneous'
396
True or False: Fibroid degeneration usually resolves within 10 days.
False
397
What does FGM stand for?
Female genital mutilation
398
What is the definition of female genital mutilation?
All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
399
What is Type 1 FGM?
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
400
What is Type 2 FGM?
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
401
What is Type 3 FGM?
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
402
What is Type 4 FGM?
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
403
What is endometriosis?
A common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity.
404
What percentage of women of reproductive age are affected by endometriosis?
Around 10%.
405
List the clinical features of endometriosis.
* Chronic pelvic pain
* Secondary dysmenorrhoea- pain starts days before bleeding
* Deep dyspareunia
*subfertility
406
What is secondary dysmenorrhoea?
Painful menstruation that is often linked to an underlying condition, such as endometriosis.
407
When does pain often start in relation to bleeding in endometriosis?
Days before bleeding.
408
What are some non-gynaecological symptoms associated with endometriosis?
* Urinary symptoms (e.g. dysuria, urgency, haematuria)
* Dyschezia (painful bowel movements)
409
What findings may be observed during a pelvic examination in a patient with endometriosis?
* Reduced organ mobility
* Tender nodularity in the posterior vaginal fornix
* Visible vaginal endometriotic lesions
410
What is the gold-standard investigation for endometriosis?
Laparoscopy.
411
What should be done if a patient has significant symptoms of endometriosis?
The patient should be referred for a definitive diagnosis.
412
What are the recommended first-line treatments for symptomatic relief of endometriosis?
* NSAIDs
* Paracetamol
413
What hormonal treatments may be tried if analgesia does not help in endometriosis management?
* Combined oral contraceptive pill
* Progestogens (e.g. medroxyprogesterone acetate)
414
If analgesia or hormonal treatment does not improve symptoms, what should be considered next?
Referral to secondary care.
415
What are GnRH analogues used for in the treatment of endometriosis?
They induce a 'pseudomenopause' due to low oestrogen levels.
416
Does drug therapy significantly impact fertility rates in endometriosis?
No, it does not seem to have a significant impact.
417
What surgical options may be considered for women with endometriosis who have not responded to medical treatment?
Surgery may be an option.
418
What does NICE recommend for women trying to conceive who have endometriosis?
Laparoscopic excision or ablation of endometriosis plus adhesiolysis.
419
What is recommended for endometriomas during surgery in women with endometriosis?
Ovarian cystectomy.
420
421
What is a common examination finding in ectopic pregnancy?
abdominal tenderness
## Footnote
Abdominal tenderness is often noted during physical examination of a patient suspected to have an ectopic pregnancy.
422
What does cervical excitation indicate in the context of ectopic pregnancy?
cervical motion tenderness
## Footnote
Cervical excitation, or cervical motion tenderness, is a sign that may suggest an ectopic pregnancy during examination.
423
What does NICE advise regarding the examination for an adnexal mass in suspected ectopic pregnancy?
NOT to examine for an adnexal mass
## Footnote
NICE advises against examining for an adnexal mass due to the increased risk of rupturing the pregnancy.
424
What examination is recommended by NICE for ectopic pregnancy?
a pelvic examination to check for cervical excitation
## Footnote
Despite the advice against examining for an adnexal mass, a pelvic examination for cervical excitation is still recommended.
425
In cases of pregnancy of unknown location, what serum bHCG level suggests an ectopic pregnancy?
>1,500
## Footnote
Serum bHCG levels greater than 1,500 are indicative of a potential ectopic pregnancy when the location of the pregnancy is unknown.
426
What is dyspareunia?
Pain during or after sexual intercourse.
427
How can dyspareunia be classified?
According to where the pain is felt.
428
What is a cause of superficial dyspareunia related to sexual arousal?
Lack of sexual arousal.
429
What condition may cause superficial dyspareunia due to hormonal changes?
Vaginal atrophy (e.g. post-menopausal).
430
Which infections can lead to superficial dyspareunia?
* Vaginitis secondary to infection (e.g. Candida, Trichomonas)
* Painful episiotomy scar
* Vaginismus.
431
What are some causes of deep dyspareunia?
* Pelvic inflammatory disease
* Endometriosis
* Cervicitis secondary to infection (e.g. Chlamydia)
* Prolapsed ovaries in the pouch of Douglas
* Adenomyosis
* Fixed retroverted uterus.
432
Fill in the blank: Superficial dyspareunia can be caused by _______.
[Lack of sexual arousal]
433
True or False: Vaginismus is a cause of deep dyspareunia.
False.
434
What type of dyspareunia is caused by pelvic inflammatory disease?
Deep dyspareunia.
435
Fill in the blank: A painful episiotomy scar can lead to _______.
[Superficial dyspareunia]
436
What is primary dysmenorrhoea?
A condition with no underlying pelvic pathology affecting up to 50% of menstruating women.
437
When does primary dysmenorrhoea typically appear?
Within 1-2 years of menarche.
438
What is thought to be partially responsible for primary dysmenorrhoea?
Excessive endometrial prostaglandin production.
439
When does pain typically start in primary dysmenorrhoea?
Just before or within a few hours of the period starting.
440
What type of pain is associated with primary dysmenorrhoea?
Suprapubic cramping pains that may radiate to the back or down the thigh.
441
What is the first-line management for primary dysmenorrhoea?
NSAIDs such as mefenamic acid and ibuprofen.
442
What is the effectiveness of NSAIDs in managing primary dysmenorrhoea?
Effective in up to 80% of women.
443
How do NSAIDs work in the treatment of primary dysmenorrhoea?
By inhibiting prostaglandin production.
444
What is used as a second-line treatment for primary dysmenorrhoea?
Combined oral contraceptive pills.
445
What is secondary dysmenorrhoea?
Dysmenorrhoea that develops many years after menarche due to underlying pathology.
446
When does pain typically start in secondary dysmenorrhoea?
3-4 days before the onset of the period.
447
List some causes of secondary dysmenorrhoea.
* Endometriosis
* Adenomyosis
* Pelvic inflammatory disease
* Intrauterine devices
* Fibroids
448
What does NICE recommend for patients with secondary dysmenorrhoea?
Referring all patients to gynaecology for investigation.
449
What is cervical ectropion?
A condition where the stratified squamous epithelium meets the columnar epithelium on the ectocervix.
450
What causes an increase in columnar epithelium on the ectocervix?
Elevated oestrogen levels during the ovulatory phase, pregnancy, or combined oral contraceptive pill use.
451
What are two common features of cervical ectropion?
* Vaginal discharge
* Post-coital bleeding
452
When is ablative treatment indicated for cervical ectropion?
Only used for troublesome symptoms.
453
Fill in the blank: Elevated _______ levels can lead to cervical ectropion.
[oestrogen]
454
True or False: Cervical ectropion is characterized by the presence of only stratified squamous epithelium on the ectocervix.
False
455
What is an example of an ablative treatment for cervical ectropion?
'Cold coagulation'
456
What is a common reason women in early pregnancy seek medical attention?
Bleeding in the first trimester
## Footnote
Bleeding can indicate various conditions, including miscarriage or ectopic pregnancy.
457
What are the main differential diagnoses for bleeding in the first trimester?
* Miscarriage
* Ectopic pregnancy
* Implantation bleeding
* Cervical ectropion
* Vaginitis
* Trauma
* Polyps
* Miscellaneous conditions
## Footnote
Ectopic pregnancy is particularly important as it can be life-threatening.
458
When should a woman with a positive pregnancy test and concerning symptoms be referred to an early pregnancy assessment service?
Immediately if she has:
* Pain and abdominal tenderness
* Pelvic tenderness
* Cervical motion tenderness
## Footnote
These symptoms suggest a possible ectopic pregnancy.
459
What is the management guideline for women with bleeding if the pregnancy is greater than or equal to 6 weeks gestation?
They should be referred to an early pregnancy assessment service
## Footnote
This applies if the gestation is uncertain or confirmed to be more than 6 weeks.
460
What is the most important investigation for identifying the location of the pregnancy in cases of bleeding?
Transvaginal ultrasound scan
## Footnote
It helps determine the presence of a fetal pole and heartbeat.
461
What should be done if a woman has bleeding and the pregnancy is less than 6 weeks gestation but has no pain or risk factors for ectopic pregnancy?
They can be managed expectantly
## Footnote
Women should be advised to return if bleeding continues or pain develops.
462
What follow-up actions should women take if they experience bleeding and are less than 6 weeks pregnant?
* Return if bleeding continues or pain develops
* Repeat a urine pregnancy test after 7-10 days
* Return if the test is positive
* A negative test indicates miscarriage
## Footnote
This approach helps monitor the situation safely.
463
What is more common in presentations to gynaecology: Bartholin's abscess or Bartholin's cyst?
Bartholin's abscess
## Footnote
Bartholin's abscess is three times more common than the cyst due to the asymptomatic nature of cysts.
464
What is the typical size and characteristics of Bartholin's cysts?
1-3 cm in diameter, usually unilateral, soft, painless lump
## Footnote
The Bartholin's glands should not be palpable in health.
465
How can a Bartholin's cyst be best examined?
Felt between a finger at the posterior vaginal introitus and a thumb lateral to the labium
## Footnote
This examination reveals the soft lump characteristic of a cyst.
466
What are the risk factors for developing Bartholin's cyst?
Poorly understood, but incidence increases with age up to menopause, and having one cyst is a risk factor for another
## Footnote
Only 10% of cysts occurred in women over age 40 in one study.
467
What is the general intervention for asymptomatic Bartholin's cysts?
No intervention required
## Footnote
Some gynaecologists advocate incision and drainage with biopsy for older women to exclude carcinoma.
468
What treatments are recommended for symptomatic or disfiguring Bartholin's cysts?
Incision and drainage or marsupialisation
## Footnote
Marsupialisation is thought to be more effective at preventing recurrence.
469
What is marsupialisation?
Creating a new orifice for glandular secretions by incising the gland, everting it, and suturing the epithelial lining against the skin
## Footnote
This procedure is longer and more invasive than simple drainage.
470
True or False: Antibiotics are recommended for Bartholin's cyst without evidence of abscess.
False
## Footnote
There is no place for antibiotic use in this setting.
471
What does assisted reproductive technologies refer to?
Techniques and procedures performed to achieve pregnancy including intrauterine insemination, IVF, intra-cytoplasmic sperm injection, donor insemination, egg donation, pre-gestational testing, and surrogacy.
472
What is intrauterine insemination?
The process of introducing sperm directly into the uterus.
473
In which cases is intrauterine insemination typically used?
* Cervical scarring
* Poor sperm count
* Poor sperm mobility
* Difficulty with penetrative sexual intercourse
* Couples with HIV positive and negative partners.
474
How is sperm prepared for intrauterine insemination?
Sperm is collected via masturbation, then 'washed' and filtered to form a concentrated specimen.
475
What is the recommendation regarding intrauterine insemination for patients with unexplained infertility?
It is not recommended.
476
What does IVF stand for?
In vitro fertilisation.
477
What is the primary goal of IVF?
To stimulate egg production, collect eggs, and fertilise them with harvested sperm in vitro.
478
What is a traditional method of IVF?
Placing the egg and sperm in a dish where the sperm must penetrate the egg.
479
What is intra-cytoplasmic sperm injection?
A method where sperm is inserted directly into the egg cytoplasm using a micropipette.
480
What is the significance of using intra-cytoplasmic sperm injection?
It allows fertilisation in cases of severely compromised sperm mobility or difficult egg penetration.
481
What happens to the fertilised embryo in IVF?
It is reintroduced into the uterus of the child-carrying party.
482
What is the success rate of IVF in women over 44 years?
2%.
483
What does IVF allow for regarding genetic disorders?
Screening of embryos for specific genetic disorders using pre-implantation genetic diagnosis.
484
What are some examples of conditions that can be tested through IVF?
* Alpha thalassaemia
* Early-onset dementia
* Motor neurone disease with an identified genetic cause
* Huntingdon's disease.
485
What are the risks associated with pre-implantation genetic diagnosis?
Risk of damage to embryos tested and possibility that all embryos carry the condition.
486
What is surrogacy?
The process of a third party carrying a foetus for another couple.
487
In which situations might surrogacy be considered?
* Couples without a uterus
* Those with uterine abnormalities
* Individuals who have suffered multiple miscarriages or failed IVF implantations.
488
What is the distinction between 'full' and 'partial' surrogacy?
* Full surrogacy: surrogate not genetically related to the foetus
* Partial surrogacy: surrogate's egg is fertilised and re-implanted.
489
What legal advice is recommended for patients pursuing surrogacy?
Seek legal counsel prior to commencing the procedure.
490
In surrogacy who is the legal mother of the child?
It can be a highly controversial reproductive technology as, by law, the party giving birth to the child is its legal mother. Patients pursuing this option are strongly advised to seek legal counsel prior to commencing the procedure.
491
492
Alpha
493
What is Alpha-fetoprotein (AFP)?
A protein produced by the developing fetus
## Footnote
AFP is often measured in maternal blood during pregnancy.
494
What conditions can lead to increased levels of AFP?
* Neural tube defects (meningocele, myelomeningocele, anencephaly)
* Abdominal wall defects (omphalocele, gastroschisis)
* Multiple pregnancy
## Footnote
Elevated AFP levels can indicate potential fetal abnormalities.
495
What conditions are associated with decreased levels of AFP?
* Down's syndrome
* Trisomy 18
* Maternal diabetes mellitus
## Footnote
Low levels of AFP can suggest chromosomal abnormalities or maternal health issues.
496
What do NICE recommend regarding vitamin D for pregnant women?
'All women should be informed at the booking appointment about the importance for their own and their baby's health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding.'
497
What is the recommended daily intake of vitamin D for pregnant and breastfeeding women?
10 micrograms of vitamin D per day.
498
What supplement is suggested for pregnant women to meet their vitamin D needs?
Healthy Start multivitamin supplement.
499
When was the advice for pregnant and breastfeeding women to take vitamin D confirmed?
2012.
500
Who advised that all pregnant and breastfeeding women should take a daily vitamin D supplement?
The Chief Medical Officer.
501
What is the purpose of taking vitamin D during pregnancy and breastfeeding?
To ensure the mother's requirements for vitamin D are met and to build adequate fetal stores for early infancy.
502
Which groups of women should take particular care regarding vitamin D intake?
Women at risk, such as those who are Asian, obese, or have a poor diet.
503
True or False: It is not necessary for pregnant women to maintain adequate vitamin D stores.
False.
504
Fill in the blank: Pregnant and breastfeeding women are advised to take _______ micrograms of vitamin D daily.
10
505
What are the NICE recommendations for antenatal visits in the first pregnancy if uncomplicated?
10 antenatal visits
## Footnote
These visits are crucial for monitoring the health of the mother and fetus.
506
How many antenatal visits are recommended for subsequent pregnancies if uncomplicated?
7 antenatal visits
## Footnote
This is a reduction compared to the first pregnancy.
507
Do women need to see a consultant if the pregnancy is uncomplicated?
No
## Footnote
Routine care can be managed by primary healthcare providers.
508
What is the recommended timing for the booking visit?
8 - 12 weeks (ideally < 10 weeks)
## Footnote
This visit is essential for initial assessments.
509
What general information is provided during the booking visit?
Diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
## Footnote
This information helps promote a healthy pregnancy.
510
What tests are included in the booking bloods/urine?
* FBC
* Blood group
* Rhesus status
* Red cell alloantibodies
* Haemoglobinopathies
* Hepatitis B
* Syphilis
* HIV test offered to all women
* Urine culture for asymptomatic bacteriuria
## Footnote
These tests are vital for screening and managing potential health issues.
511
What is the purpose of the early scan at 10 - 13+6 weeks?
Confirm dates and exclude multiple pregnancy
## Footnote
Accurate dating is crucial for prenatal care.
512
When is Down's syndrome screening performed?
11 - 13+6 weeks
## Footnote
This includes a nuchal scan.
513
What routine care is performed at 16 weeks?
Information on anomaly and blood results; BP and urine dipstick check
## Footnote
If Hb < 11 g/dl, consider iron.
514
What is the purpose of the anomaly scan at 18 - 20+6 weeks?
To check for physical abnormalities in the fetus
## Footnote
This scan is a critical part of prenatal care.
515
What routine care is conducted at 25 weeks for primiparous women?
BP, urine dipstick, symphysis-fundal height (SFH)
## Footnote
Monitoring growth and health is essential at this stage.
516
What additional care is provided at 28 weeks?
* BP
* Urine dipstick
* SFH
* Second screen for anaemia and atypical red cell alloantibodies
* If Hb < 10.5 g/dl, consider iron
* First dose of anti-D prophylaxis to rhesus negative women
## Footnote
This is crucial for managing maternal and fetal health.
517
What routine care is performed at 31 weeks for primiparous women?
Routine care as above
## Footnote
Similar assessments are repeated to ensure ongoing health.
518
What additional information is provided at 34 weeks?
Information on labour and birth plan; second dose of anti-D prophylaxis to rhesus negative women
## Footnote
This is important for preparing for delivery.
519
What routine check is performed at 36 weeks?
Check presentation and offer external cephalic version if indicated
## Footnote
This helps address potential delivery complications.
520
What information is discussed at 38 weeks?
Routine care as above
## Footnote
Continuation of monitoring and preparation for birth.
521
What is discussed at 40 weeks for primiparous women?
Discussion about options for prolonged pregnancy
## Footnote
Important for planning next steps if pregnancy goes beyond term.
522
What is discussed at 41 weeks?
Discuss labour plans and possibility of induction
## Footnote
Preparing for delivery is critical at this stage.
523
What conditions should women be offered screening for during pregnancy?
* Anaemia
* Bacteriuria
* Blood group, Rhesus status and anti-red cell antibodies
* Down's syndrome
* Fetal anomalies
* Hepatitis B
* HIV
* Neural tube defects
* Risk factors for pre-eclampsia
* Syphilis
## Footnote
These screenings are important to ensure maternal and fetal health during pregnancy.
524
Which screenings should be offered depending on the history of the woman?
* Placenta praevia
* Psychiatric illness
* Sickle cell disease
* Tay-Sachs disease
* Thalassaemia
## Footnote
These conditions may require additional monitoring or interventions based on individual patient history.
525
True or False: Women should be offered screening for bacterial vaginosis during pregnancy.
False
## Footnote
Bacterial vaginosis is not recommended for screening in pregnancy.
526
Fill in the blank: Women should NOT be offered screening for _______ during pregnancy.
Chlamydia
## Footnote
Chlamydia screening is not routinely recommended for pregnant women.
527
List 7 conditions that women should NOT be screened for during pregnancy.
* Cytomegalovirus
* Fragile X
* Hepatitis C
*Bacterial vaginosis
*Chlamydia
*Group B Streptococcus
*Toxoplasmosis
## Footnote
These conditions do not have recommended screening protocols in pregnancy.
528
What is one of the conditions screened for that relates to fetal development?
Neural tube defects
## Footnote
Screening for neural tube defects is crucial for early detection and management.
529
What condition related to infections is screened for during pregnancy?
HIV
## Footnote
Screening for HIV is essential to prevent transmission to the fetus.
