All Flashcards
(195 cards)
1
Q
Contraindications to endometrial ablation
A
Previous classical Caesarean
Previous myomectomy
Desire for future fertility
Pre-malignancy or malignancy of the endometrium (therefore sample endometrium prior to procedure)
2
Q
Outcomes of a ablation?
A
40% amennorhoea after 12 months
70-90% lighter bleeding at 12 months
30% further treatment for HMB 12 months post procedure
3
Q
Complications of ablation?
A
Perforation with or without visceral injury. Bleeding Infection Haematometra Device failure Visceral burns
4
Q
Hypothalamic causes of secondary amenorrhea?
A
Low BMI Excessive exercise Head injury or cranial irradiation Hypothalamic lesions (craniopharyngioma or glioma) as the either compress hypothalamic tissue or block dopamine leading to hyperprolactinaemia Systemic disorders eg TB, sarcoidosis
5
Q
Pituitary causes of secondary amenorrhea
A
- Sheehans syndrome (prolonged severe hypotension secondary to major obstetric haemorrhage), pituitary in pregnancy is enlarged and sensitive to hypoxic insult.
- Prolactin secreting adenomas (micro if <1cm, macro if >1cm)
6
Q
Ovarian causes of secondary amenorrhea
A
- PCOS
2. POI
7
Q
Systemic causes of secondary amenorrhea
A
Renal failure Thyroid disease Cushing disease Liver disease Diabetes mellitus
8
Q
Drugs associated with secondary amenorrhea?
A
Domperidone
Metoclopromide
Phenothiazines
All are dopamine antagonists and therefor can result in hyperprolactinaemia
9
Q
Adrenal causes of secondary amenorrhea
A
- Virilizing adrenal tumours
2. Late onset CAH
10
Q
Examination in investigation of amenorrhea
A
General, BMI, secondary sexual characteristics.
Breast examination to look for excess hair growth and elicit galactorrhoea.
If a pituitary lesion is suspected then examination or visual fields looking for bitemporal hemianopia.
External genitalia and vaginal examination.
11
Q
Side effects of cabergoline?
A
Nausea Headache Postural hypotension Raynaud’s Aggression
12
Q
Pathophysiology of endometriosis
A
- Implantation theory/retrograde menstruation
- Coelomic metaplasia theory
- Embolisation theory (lymph or blood vessels)
13
Q
McCune Albright Syndrome triad
A
Polyostotic fibrous dysplasia
Cafe au lait skin lesions
Gonadotrophin independent (peripheral) precocious puberty
14
Q
Live birth dates with IUI compared to IVF
A
IUI 12%
IVF 32%
15
Q
Indications for pelvic +/- para-aortic lymph node dissection?
A
Tumour histology clear cell, serous, squamous or grad 2-3 endometriod.
Myometrial invasion >1/2
Isthmus-cervix extension
Tumour size >2cm
Extrauterine disease
16
Q
Is presacral neurectomy effective in management of endometriosis?
A
Yes for midline pain however it needs a high degree of skill and is potentially hazardous.
17
Q
When can aromatise inhibitors be used in endometriosis?
A
Only for those with rectovaginal endometriosis that is refractory to other medical or surgical treatment. Can be used in combination with a COCP or progestogen?
18
Q
Anti adhesion products used in endometriosis?
A
Oxidised regenerated cellulose - surgicel, prevents adhesion formation.
Polytetrafluoroethylene surgical membrane and hyaluronic acid products are effective in the context of pelvic surgery but not specifically studied in endometriosis.
Icodextrin has no benefit
19
Q
HRT in women with endometriosis?
A
Even for women who have had a hysterectomy, consider use of progesterone and oestrogen to limit disease reactivation and malignant transformation.
However need to balance the increased systemic risks of combined EP.
20
Q
Sex cord stromal tumours
A
Granulosa cell - malignant and slow growing
Theca cell - women >60 and oestrogen secreting
Fibroma
Sertoli-Leydig cell - rare and benign
21
Q
How long is the ovary viable for after torsion?
A
24-36 hours
Follow up of women who have undergone de-torsion suggests that ovarian function recovers.
22
Q
At what stage of oogenesis in the Fetus is development arrested?
A
Prophase 1 of meiosis
23
Q
Meiosis two of the secondary oocyte?
A
Follows immediately after meiosis 1. However it arrests in metaphase and remains here until fertilisation.
If the egg is penetrated by a spermatozoon this activates the egg and meiosis II is completed 3hrs later.
24
Q
Describe capacitation
A
Process that the spermatozoa must undergo to become competent to fertilise the oocyte.
Occurs within cervical mucus and involves removal of inhibitory mediators such as cholesterol from the sperm surface, tyrosine phosphorylation, and calcium ion influx.
25
Acrosome reaction
When a capacitated sperm passes through the cumulus cells surrounding the oocyte and the release of hydrolytic enzymes from the acrosome via exocytosis.
26
Which circumstance is it possible for a Fetus to have alloimmune thrombocytopenia? Ie what do the parents have to be?
Mother HPA-1a negative
Father HPA-1a positive
27
How long does it take for new sperm to be generated and reach the ejaculatory duct?
74 days
Therefore wait 3 months prior to repeating a semen analysis
28
Asthenospermia
Low total motility
29
Teratozoospermia
Low percentage of normal forms
30
Three investigations for tubal patency?
Hysterosalpingogram
HyCoSy - hysterosalpingocontrast sonography
Laparoscopy and tubal dye studies.
31
Mechanism of action of metformin?
Decreases hepatic glucose production, decreases intestinal absorption of glucose, and lowers free fatty acid concentrations thus reducing gluconeogenesis
32
Tests available to check correct veress needle placement?
Pressure check.
Saline check.
Hanging drop test.
Equal distension and tympanic sound to all quadrants after attaching gas.
33
What test is performed to look for fragile X syndrome?
FMR1 mutation testing
34
Autoimmune adrenal insufficiency is a cause of secondary amenorrhea. How is this tested for?
ACA (anti-adrenal) antibodies
21OH antibodies
35
Contraindications to bisphosphonate therapy
Oesophageal disorders
CKD (eGFR <30-35ml/min)
36
Non hormonal therapies for VMS?
All of the following have been shown to be superior to placebo in RCTs.
```
Gabapentin
Venlafaxine
Desvenlafaxine
Paroxetine
Fluoxetine
Citalopram
Escitalopram
```
Ie gabapentin and SSRIs
37
HRT and ovarian cancer risk?
Association remains uncertain. Potentially an increased risk of serous and endometriod subtypes but this is not consistent across studies.
38
Amsel criteria for BV?
```
At least three of;
Characteristic discharge
Clue cells on wet microscopy
pH >4.5
Fishy odour on adding alkali to slide
```
39
Which culture medium is used for growth of candida?
Sabouraud’s
40
Hepatitis B prophylaxis for a non-immune individual?
500IU of hepatitis B immunoglobulin within 7 days but ideally within the first 48 hours following exposure.
41
Vertical transmission risk of hepatitis C?
1-3% if HCV-RNA negative
4-6% if RNA positive
Not an indication for Caesarean section unless also HIV positive
42
Indicator diseases of AIDS?
```
Non-Hodgkin’s lymphoma
Kaposi’s sarcoma
CMV retinitis
Pneumocystis carinii pneumonia
Candida oesophagitis
Cerebral toxoplasmosis
```
43
Side effects of HAART for HIV?
Nausea, diarrhoea and lethargy are common.
Can be highly toxic and can cause lactic acidosis, hepatitis, peripheral neuropathy, and pancreatitis.
44
Four common causative agents in PID?
```
Chlamydia
Gonorrhoea
Mycoplasma genitalium
E.coli
Peptostreptococcus
```
45
Ulipristal acetate and emergency contraception?
Selective progesterone receptor modulator.
Most effective of the oral ECPs
Not available in NZ
Effective up to 5 days
30mg
46
Pelvic infection risk after insertion of IUD?
1/300 in the first 20 days following insertion
47
IUD and pregnancy?
Should exclude ectopic pregnancy and remove IUD.
50% spontaneous miscarriage rate.
Risk of APH, TPTL, and adherent placenta if left in situ.
48
Risks of vasectomy?
Infection
Hematoma
Localised swelling
Post vasectomy pain syndrome 3-8% (most likely due to a granuloma)
49
Dose of hormone in mirena?
52mg levonorgestrel
50
Time to return to fertility for mirena?
As early as 1 month.
| 97% have menses within 3 months.
51
Time to return of fertility for jadelle/implanon?
Ovulation can occur as early as 7-14 days
52
NZ current abortion rate?
Statistics from 2017.
13.7/1000 women age 15-44 years.
Overall numbers were 13,285 in 2017.
53
Teenage abortion rate in NZ?
9.2/1000 for 15-19 year olds
Significant reduction since 2007 where it was 26.7/1000
54
Regimen for medical abortion prior to 63 days?
```
Mifepristone 200mg
Misoprostol 800mcg (24-28 hours later)
```
RANZCOG guidelines say safe to give miso at home at this gestation and should be administered bucally.
55
Factors increasing risk of progression of HPV infection in the context of cervical cancer?
Cigarette smoking (risk of squamous carcinoma but not of adenocarcinoma).
>5 term pregnancies
Early age at first full term pregnancy
Immune deficiency
Oral contraceptive use >5yrs
Do-infection with other sexually transmitted diseases
56
HPV types included in gardasil 9?
```
6
11
16
18
31
33
45
52
58
```
57
Predicted reduction in cervical cancer from new screening programme?
31-36% for unvaccinated women
| 24-29% for vaccinated women
58
HPV vaccine is made from?
Virus like proteins
Do not contain live, attenuated or killed virus
59
Indications to perform a cone biopsy?
Unable to visualise the upper limit of the transformation zone and the woman has a high grade abnormality
Unsatisfactory colposcopy and review of cytology confirms high grade abnormalities
Suspected presence of an additional glandular abnormality
Suspicion of an early invasive cancer
60
A radical hysterectomy involves removal of?
Uterus, cervix, upper 1/3-1/2 of vagina, and parametrium (round, broad, cardinal and uterosacral ligaments).
Tubes and ovaries are not routinely removed unless they look normal or the woman is postmenopausal.
61
Differentials for cervical smear report of possible high grade infra-epithelial neoplasia?
```
CIN
Invasive cervical cancer
VIN
VAIN
Immature squamous metaplasia
Active HPV infection
Inflammation/infection
Squamous cell carcinoma in situ
```
62
Malignancies associated with lynch syndrome?
```
Colorectal (predominantly right sided)
Endometrial
Ovarian
Stomach
Small bowel
Hepatobiliary
Renal pelvis
Ureter
Brain
Sebaceous
```
63
Amsterdam II criteria?
Three or more relatives with genetic syndrome cancers Eg Lynch, one of whom is first degree.
Involve at least two generations.
One or more cancers diagnosed prior to 50 yrs age.
Sensitivity of 22% but specificity of 98%
64
What structures are removed in a radical vulvectomy?
Entire vulva down to the level of the deep fascia of the thigh, the periosteum of the pubis and the inferior fascia of the urogenjtal diaphragm.
65
Further investigations you may need to consider if you diagnose a mucinous borderline tumour?
Gastroscopy
Colonoscopy
Intestinal subtype is associated with pseudomyxoma peritoneui and appendices neoplasm.
66
Which malignancies are associated with Peutz-Jeghers syndrome?
Sex cord stromal tumours
Adenoma malignum
67
High risk features of borderline tumours?
Invasive implants
DNA aneuploidy
Higher stage disease
Micropapillary projections in a serous tumour
68
Prognosis of borderline tumours?
>97% survival at 5 years
69
Epidemiological factors most protective against developing ovarian Ca?
COCP use - RR 30% for every 5 years of use
High parity - 25% risk reduction after one child and 20% with subsequent births. Breastfeeding also associated with risk reduction of 20% for every year of breastfeeding.
Age - premenopausal women less likely
70
RMI>200
Referral to gynae oncology
| Sensitivity of 78% and specificity of 87% for malignancy
71
Indications for referral for genetic testing for BRCA?
3 or more relatives on one side of the family with breast or ovarian ca, or ovarian/bowel/uterine.
Known BRCA or lunch in affected members
2 or more relatives and bilateral breast Ca
Male breast Ca
Breast and ovarian Ca in same person
Breast cancer <45 years
72
Sensitivity of pipelle endometrial biopsy?
95-99% sensitive for endometrial cancer if hyperplasia/cancer is >50% of cavity
73
What is attrition bias?
When members of the original cohort are lost or excluded after the outcome has occurred.
Trials need to document withdrawals, losses to follow up, protocol deviations, and exclusions.
74
What is prevalence?
A measurement of all individuals affected by a disease at a particular time
75
Incidence?
Measurement of the number of new individuals who contract a disease during a particular period of time
76
Types of observational studies?
Cohort - prospective or retrospective
Case control
Cross sectional
77
Difference between parametric and non-parametric tests?
Parametric tests can be performed on normally distributed data.
Non parametric tests are used when the data is skewed. This is the same circumstance when a median is more relevant than a mean.
78
How is a standard error calculated?
The standard deviation of the sample is divided by the square root of the number of observations in the sample.
79
How is a confidence interval calculated?
The sample mean +/- 1.96x the standard error for a 95% confidence interval
80
Branches of the anterior division of the internal iliac artery
```
Uterine
Umbilical
Inferior vesical
Middle rectal
Obturator
Inferior gluteal
Internal pudendal
```
81
Tips to identify uterine artery off anterior internal iliac artery?
Uterine artery originates 6cm distal from the bifurcation of the common iliac.
Follow the obliterated umbilical artery as it will always lead backwards to the uterine.
Ligate medial to lateral to avoid the ureter
82
Which distension media should be used for hysteroscopy with monopolar diathermy?
Hypertonic solution such as glycine or sorbitol as it is non conducting
83
How is vapourisation of tissues achieved?
Cut
Non-contact
84
How is fulguration achieved?
Coag
Non-contact
85
How is dessication achieved?
Cut or coag
Contact
86
What is the estimated rate of serious complications at laparoscopic surgery?
3-8/1000
87
Physical properties and physiological effects of household current?
Low frequency alternating current
Neuromuscular stimulation and potential cardiac arrest.
Rapid tissue heating at entry and exit points leading to severe burns
88
Physiological effects and physical properties of electrosurgery?
High frequency alternating current 400-500kHz
Prevents neuromuscular stimulation.
“Burning” the controlled ability to cut and coagulate
89
Benefits of vaginal hysterectomy over laparoscopic based on nieboer et al Cochrane review findings
Shorter operations
| Lower rate of substantial bleeding
90
Benefits of vaginal hysterectomy over abdominal hysterectomy based on nieboer te et al Cochrane review?
Shorter hospital stay
Quicker return to normal activities
Fewer episodes of post op fever
Fewer infections
91
How is a free androgen index calculated?
Total testosterone divided by SHBG x 100
92
Anticipated effect of ovarian electrocautery on women with PCOS?
Over 60% normalisation of SHBG and androgens for up to 20 years.
Demonstrated in a long term cohort study
93
Definition of metabolic syndrome
```
Elevated BP > 130/85
Increased waist circumference >88cm
Elevated fasting blood glucose levels
Reduced HDL cholesterol
Elevated triglyceride levels
```
94
Urinary tract anomalies associated with mullerian anomalies
Duplex collecting system
Pelvic or horseshoe kidney
Renal agenesis
95
Features of a dysgerminoma
2% ovarian neoplasms and 75% occur in adolescents and young adults.
May develop within a gonadoastoma in an XY female
Growth is usually rapid therefore presentation is with abdominal enlargement and pain due to rupture with haemoperitoneum or torsion.
If tumour is hormonally active then menstrual irregularities may occur.
Elevated LDH
96
Mechanism of action of mirena?
Levonorgestrel leads to changes in the endometrium such as pseudo-decidualisation, glandular atrophy, leukocytic infiltration and a decrease in glandular and stromal mitoses.
Ultimately thins and stabilises myometrium
97
Regression rate hyperplasia without atypia with observation alone?
74.2%-81%
98
Regression rate of hyperplasia without atypia when treated with progestogens?
89-96%
99
Regression rates of hyperplasia without atypia at six months of mirena and PO progestogerone?
Mirena = 100%
| PO progesterone = 64%
100
Risk of lymph node metastasis in 1B Vulval cancers?
8%
101
Five proven benefits of HRT
Reduction in vasomotor symptoms
Reduction in vaginal dryness and dyspareunia
Improved quality of life
Reduction in colorectal cancer risk
Reduction in all cause mortality
Reduction in the risk of hip fracture and osteoporosis
102
HRT use after 60 years is associated with?
Increased risk of stroke when used >60 years or >10yrs post menopause
Increased risk of breast cancer with prolonged use past 5 years
Increased risk of coronary artery disease
103
Mechanism of action of letrozole?
Aromatise inhibitor.
| Suppresses ovarian secretion of estradiol and therefore reduced negative feedback on the hypothalamus.
104
Side effects of bromocriptine?
GI disturbance
| Hypotension
105
Chance of regression or microprolactinoma with pregnancy/breastfeeding?
40%
106
Side effects of Clomiphene?
Abdominal distension
Breast tenderness
Nausea and vomiting
- all due to high estrogen
Hot flushes due to LH
107
Markers of critical OHSS?
```
Tense ascites/large hydrothorax
Haematocrjt >0.55
WCC >25
Oliguria or anuria
VTE
ARDS
```
108
How do dopamine agonists work in preventing OHSS?
Reduce the expression of VEGF receptors
109
Estimated rate of serious complications at laparoscopy?
3-8/1000
110
Electro surgical waveform needed to achieve dessication of tissue?
Cut or coag
| Contact with tissue
111
What is fulgaration and how is it achieved?
Action of electrical arcs on tissue leading to superficial tissue destruction and large amounts of carbonisation.
Caused by coagulation setting and non-contact
112
Vessels from which the ureter derives it’s blood supply?
```
Ureteric branch from renal artery
Gonadal artery
Internal iliac -> inferior vesical
Uterine
Vesical
```
113
Causes of CA 125
| Elevation?
```
Fibroids
Adenomyosis
Endometriosis
PID
Acute cyst events
```
```
TB
Cirrhosis
Hepatitis
Pancreatitis
Peritonitis
Pleuritis
Other primary tumours with metastases to the peritoneum
```
114
What percentage of ovarian cancer is related to a genetic syndrome?
10%
115
What is denonvilliers fascia?
Rectovaginal septum that is the posterior equivalent of the pubocervical fascia. Extends from vaginal apex to the perineal body
116
Duloxetine?
SNRI
Only pharmacological management option for stress urinary incontinence.
Acts in the spinal cord where it increases pudendal nerve activity and therefore increases urethral sphincter closure.
20mg bd
117
How is a burch colposuspension performed?
Two non-absorbable sutures are places through the full thickness of the paravaginal fascia at each side of the bladder neck.
Each is then attached to the iliopectineal ligament 3-4cm from the midline of the pubic bone.
118
Differential diagnoses for urge and occasional stress incontinence?
```
UTI
Vulvovaginal atrophy
Spinal cord lesion
Overactive bladder syndrome
Multiple sclerosis
Pelvic mass
Peripheral neuropathy
Temporary causes such as diuretics, caffeine, alcohol
```
119
What are the benefits of TV mesh as per evidence?
Probable benefit for repair success and longevity for anterior compartment.
No benefit for repair success and longevity for vault or posterior compartment.
Possible benefit for severe prolapse, particularly after a failed primary procedure.
120
What are the complications associated with transvaginal mesh?
```
Mesh exposure/erosion
Vaginal stricture/scarring
Fistula
Dyspareunia
Unprovoked pelvic pain at rest
Pain symptoms that may not completely resolve with mesh removal
```
121
Caution with TV mesh implants in which patients?
Primary prolapse cases
Younger patients <50
Postmenopausal patients who are unable to use Ovestin cream
Chronic pelvic pain
Lesser grades of prolapse
Posterior compartment prolapse without significant apical descent
122
Centres involved in micturition?
Cerebral - voluntary inhibition
Brain stem - pontine micturition centre
Supra-sacral - sympathetic supply
Sacral - parasympathetic supply
123
Innervation of the levator ani?
Nerve to levator ani (S4)
Pudendal nerve (S2-4) - inferior rectal and perineal branches
124
Mechanisms of levator ani injury?
Avulsion
Irreversible over-distension leading to micro-trauma
Necrosis and damage to the pudendal nerve and sacral plexus
125
Diagnosing a levator ani muscle injury?
1. Larger genital hiatus
2. Distance between two puborectalis attachments of >3.5 finger widths
3. Ultrasound - puborectalis to side wall attachment not seen on all three central slices
4. MRI - hypersignal of puborectalis, thinning or thickening, rupture of muscular insertion
126
Reducing risk of pelvic floor injury at vaginal delivery?
Ventouse > forceps if clinically appropriate
Pudendal or epidural to relax the pelvic floor
Prevention of OASIS
Avoid a prolonged second stage
Counsel re large fetal size/head circumference
Pelvic floor exercises during and after pregnancy
127
What is an abdominal sacro-colpopexy?
Apical suspension of the vault with a permanent mesh fixed to the longitudinal ligament of the sacrum.
Attached to anterior and posterior aspects of the vault
128
Where should sutures be placed for a sacrospinous fixation?
1.5-2cm medial to the ischial spines
Can be done bilaterally but commonly unilateral on the RHS
129
Frequency of anterior compartment prolapse after sacrospinous fixation?
8-30%
130
Theory behind hot flashes?
Increase in pulsatile release of FSH.
Narrowed thermoregulatory zone. Inappropriate peripheral vasodilatation with increased digital cutaneous blood flow.
Perspiration leads to rapid heat loss and a decrease in core body temperature below normal.
Estrogen administration restores the thermoneutral zone to normal
131
What type of drug is teriparatide?
Recombinant parathyroid hormone
132
Postmenopausal adrenal function?
Progesterone synthesis decreases or is absent (main supply corpus luteum).
DHEA and DHEAS decrease with age
Androstenedione is produced and peripherally converted to estrone as well as testosterone.
If high cortisol (eg stress) then low androstenedione = hot flashes, accelerated bone loss
133
Drugs that can cause hot flashes?
Anti hypertensives and anti depressants as at high doses they can affect vascular reactivity
134
What marks the early menopause transition?
Persistent difference of 7 days or more in length of consecutive cycles
135
Late menopause is marked by?
Periods of amenorrhea of 60 days or more, frequent anovulation, and the onset of perimenopausal symptoms
136
Menopausal symptoms that are likely to improve with HRT?
Vasomotor
Vaginal dryness
Sleep disturbance
Joint symptoms
137
First line management for women with menopausal symptoms?
```
Life style changes including:
Stress reduction
Regular exercise
Optimal weight management
Appropriate diet
Avoidance of smoking, excessive alcohol and caffeine
```
138
HRT reduction in VMS compared with placebo?
87% reduction
139
HRT and cholecystitis?
Increased risk with 12 extra cases per 1000 women per 5 years
140
Transdermal HRT is preferred for which women?
Migraine
Abnormal LFTs
Increased risk of VTE
No increased risk of stroke >60 years with transdermal 50microgram or less dose
141
RANZCOG recommended monitoring while on HRT?
Review after 6 months of commencing therapy
General health, breast check and mammogram every 2 years
Check cervical screening is up to date
Bone densiometry when indicated
Investigate any unexpected vaginal bleeding after 6 months of therapy
142
Which drugs should be avoided in women on tamoxifen with breast Ca?
Paroxetine
Fluoxetine
Gabapentin is a good choice for these women
143
Benefits of HRT?
```
Decreased risk of fragility fracture
Decreased risk of colorectal cancer
Reduction in all cause mortality
Improved quality of life
87% reduction in vasomotor symptoms compared to placebo
```
144
Endometrial cancer risk in women on tamoxifen postmenopausal?
RR 4.01
Incidence 2-3/1000/year
145
What are the names of the two trials that show HRT is not supported in breast cancer survivors?
HABITS
| Stockholm
146
Aromatase inhibitors and osteoporosis?
Increased risk
Regular bone mineral density measurements
If drug therapy is needed bisphosphonates are first line
147
Medical history for a woman consulting for HRT?
Gynae - LMP, bleeding pattern, past surgery, current HRT use, need for contraception?
Medical - including VTE, breast cancer, CVD including HTN, diabetes, osteoporosis, depression, recurrent UTI, thyroid and liver disease
Family history - CVD, CVA, osteoporosis, dementia, cancer
Smoking
Alcohol
Current meds
Social history
148
What is the dose of tibolone?
2.5mg daily Po
149
Dose of gabapentin for HRT?
300-900mg/day
150
Four categories of menopausal symptoms?
Vasomotor
Psychological
General physical
Urogenital/sexual
151
Disadvantages of oral oestrogen for HRT?
Increased risk of VTE
Increased risk of cholelithiasis
Increased SHBG = decreased testosterone
Increased TBG = therefore if hypothyroidism May need to increase thyroxine dose
Administration of a total higher dose
152
Disadvantages of transdermal oestrogen HRT?
Patches can cause skin irritation and rarely an allergic reaction
Gel can be sticky and inconvenient
Occasionally poorly absorbed
Women may forget to change 2x weekly patch
153
What non hormonal methods have evidence to support efficacy for management of menopausal symptoms?
```
SSRI/SNRI
Clonidine
Gabapentin
Hypnosis
CBT
Stellate ganglion blockade
```
All improve vasomotor symptoms
154
Advice re androgen therapy for low sexual desire?
Transdermal cream or pellets
Treatment effects may take 6-8 weeks
Stop if no benefit by 6 months
Side effects of excessive dosage include masculinisation
155
Risks for women taking HRT after 60?
Increased risk of CVA if >60 or greater than 10 years post menopause. 8 more cases per 10,000 women.
Increased risk of breast cancer with prolonged HRT use >5 years. 8 more cases per 10,000 women.
Increased risk of coronary artery disease
Increased risk of thrombosis. 6 extra PE and 18 extra DVT
156
Disadvantage of lifestyle changes for management of hot flashes?
Minimal effect on frequency of symptoms but may reduce severity of tolerability
157
Does gabapentin improve vaginal symptoms related to menopause?
No
But equal to HRT in management of VMS
158
Side effects of tibolone?
Headache
Acne
Increased hair growth
Irregular bleeding
159
Advantages of tibolone in LIFT trial
Reduction in vasomotor symptoms
Endometrial protection
Improved vulvovaginal atrophy
No increase in risk of VTE, breast Ca, endometrial Ca or CV disease.
Increased risk of stroke however of 2.19
160
How do oral bisphosphonates work?
Prevent osteoclast action.
Eg alendronate, risendronate.
161
Estrogen causes the environment of the vagina to be?
Glycogen rich
Glycogen then gets broken down to lactic acid causing the pH of the vagina to be <4.5
162
Properties of lactobacilli?
Prevent long term colonisation of the vagina by adhering to vaginal epithelial cells
Produce lactic acid
Produce hydrogen peroxide
Produce bacteriocins
163
Bacteria that predominate in BV?
Gardnerella
Prevotella
Mycoplasma hominis
164
Treatment of recurrent episodes of candida?
Recurrent episodes = >4/year
Fluconazole 100mg Po weekly for six months
165
Features of disseminated gonococcal infection?
Arthritis
Skin lesions
Endocarditis
Meningitis
166
Treatment for herpes?
Treat any primary episode regardless of timing of onset.
Valaciclovir 500mg Po bd for 7/7 or aciclovir 400mg po tds for 7/7.
Only treat recurrent episodes if during pro drone or 24 hours of lesion onset. Valaciclovir 500mg op be for 3/7 or aciclovir 800mg Po tds for 2/7
167
In utero features of congenital syphillis?
Hydrops
(Skin thickening, Polyhydramnios, Placental thickening, Serious cavity effusions)
Hepatomegaly
Splenomegaly
Can also cause IUD and preterm birth
168
What is antibiotic stewardship?
Strategies to improve the use of antimicrobials:
Enhance patient outcomes
Decrease resistance
Decrease unnecessary costs
169
Four key features of innate immunity?
Complement cascade
Cytokines
Anatomical barriers
Leukocytes
169
PEACH study?
Effectiveness of antibiotics in PIS and preventing long term complications.
Women were treated with cefoxitin and doxycycline and pregnancy rates at three years were similar or higher than the generally population
169
Medical considerations for a patient presenting with rape?
```
Emergency contraception
Hepatitis B vaccination
HIV post exposure prophylaxis if within 72hours
Tetanus
Antibiotics if bitten
Hepatitis A if anal rape
Antibiotic prophylaxis for STIs
```
170
Incubation period for vulvovaginal HPV/warts?
2 weeks to 18 months
May have an initial latent phase where no signs or symptoms are exhibited or may be unaware of a primary episode.
171
What commonly used drugs depress sperm quantity and quality?
```
Opioids
Chemotherapy
Nitrofurantoin
Spironolactone
Anabolic and corticosteroids
Anti-fungal agents
Finasteride
```
172
Anatomy of the inferior epigastric artery?
Arises from the external iliac artery and anastomoses superiority with the superior epigastric artery.
Origin is superior and medial to the inguinal ligament and ascends in an oblique path along the medial border of the deep inguinal ring then punctures the transversals fascia and ascends to enter the rectus sheath just beneath the arcuate line
173
How is the inferior epigastric artery identified?
Medial to the entry of the round ligament into the inguinal canal
Identify the obliterated umbilical arteries as the inferior epigastric artery lies lateral to these
174
Why is primary hypogonadism in males more likely to be associated with decreased sperm production than testosterone production?
Diseases usually damage the seminiferous tubules to a greater degree than the Leydig cells.
Gynaecomastia is common due to testicular aromatase activity leading to an increased conversion of testosterone to estradiol.
175
Guiding principles of cross border reproductive care?
Health and safety - eg multiple pregnancies, infectious diseases risk
Autonomy
Equity
176
Circumstances where surrogacy May be appropriate?
Where uterine factors are the cause of infertility
Serious maternal medical conditions of high risk if pregnant eg pulmonary hypertension provided the woman is still fit enough to look after the child following delivery
Multiple failed IVF cycles
Multiple miscarriages
177
In statistics, what is a significance level?
The probability of rejecting the null hypothesis when it is true.
178
Branches of the external iliac artery?
Inferior epigastric
| Deep circumflex -> femoral
179
Posterior branch of the internal iliac artery gives off which vessels?
Iliolumbar
Lateral sacral
Superior gluteal
180
The retropubic space is also known as?
The space of retzius
181
What is the single most important factor to reduce injury from primary trocar placements?
Intra-abdominal pressure
Ideally 20-25mmHg
182
Circumstances where a Palmer’s point entry should be considered?
Suspected or known periumbilical adhesions
Previous umbilical hernia
After three failed insufflation attempts at the umbilicus
Morbid obesity or very thin women (or Hasson)
183
When is written consent required?
Patient will be under GA
Participation in any research
Procedure is experimental
Significant risk of adverse effects to the patient
184
Mechanisms of electro surgical injuries?
```
Insulation failure
Lateral thermal spread
Direct application
Direct coupling
Capacitive coupling
Return electrode or alternative site burns
```
185
What is capacitive coupling?
Electric current is transferred from one conductor, through intact insulation to another conductive material without direct contact.
Example is combination metal/plastic ports
186
What is coaptation?
Contact with tissue leads to dissipation of heat over a wide area.
More diffuse and gentle heating and sealing of small to medium vessels
187
What to consider regarding prophylactic BSO during hysterectomy for benign conditions?
Risk of developing ovarian cancer
Risk factors for CVD, osteoporosis, dementia and depression
Absolute and relative contraindications to HRT
188
What are the four domains of the consensus bundle for prevention of surgical site infections?
Readiness
Recognition and prevention
Response
Reporting and systems learning
189
What does the WASHING pneumonic stand for?
```
W = weight
A = antibiotic resistant skin flora (MRSA)
S = smoking cessation
H = hygiene, skin preparation
I = immune deficiency status
N = nutritional status
G = glycemic control
```
190
What are the three different types of surgical site infections?
Superficial incisional
Deep incisional
Organ or space
191
What is the lifetime incidence of invasive cervical cancer in Australia?
1/162
192
What is the incidence of precocious puberty in girls?
1/5000-10,000
193
Colposcopic appearance of VIN?
White area with prominent surface and clearly defined border
Red macular area with velvety surface
Dark papular area, generally multi focal with dark brown pigmentation
Papillomatous white/grey rough surface with visible capillaries
