Gynae Flashcards
(827 cards)
1
Q
What age range is cervical cancer most commonly seen in?
A
35-44
2
Q
What are the two most common types of cervical cancer?
A
- Squamous cell carcinoma (80%)
2. Adenocarcinoma
3
Q
What is the most common cause of cervical cancer?
A
HPV
4
Q
What vaccination is given against cervical cancer?
A
HPV Vaccine
5
Q
At what age is the HPV vaccine given and why?
A
12-13 (hopefully before they become sexually active)
6
Q
Which strains of HPV are usually responsible for cervical cancer?
A
Type 16
Type 18
7
Q
How does HPV promote the development of cancer?
A
It produces two proteins that inhibit tumour suprrosor genes
8
Q
What cells make up the ectocervix?
A
Squamous cells
9
Q
What cells make up the endocervix?
A
Collumnar cells
10
Q
What is the squamocolumnar junction?
A
The junction at the cervix where the squamous cells transition into collumnar cells.
11
Q
Where is the squamocolumnar junction?
A
Location varies throughout life
12
Q
Why is the squamocolumnar junction the main target for HPV?
A
There is the largest turnover of cells there and so it can easily enter and remain
13
Q
When is the squamocolumnar junction cell turnover most active and why does this matter?
A
During puberty, therefore this is when people are most at risk of HPV
14
Q
What are the 3 categories of risk factor for cervical cancer?
A
- Increased risk of HPV
- Later detection of precancerous and cancerous changes (non-engagement with screening)
- Other risk factors
15
Q
What factors increase the risk of catching HPV?
A
- Early sexual activity
- Multiple sexual partners
- Sexual partners who have multiple partners
- Unprotected sex
16
Q
What are other risk factors for cervical cancer?
A
- Not attending smears
- Smoking
- HIV
- COCP > 5 years
- Multigravida
- Family history
- Exposure to diethylstilbestrol during fetal development
17
Q
What are the presenting symptoms of cervical cancer?
A
- Asymptomatic (screening)
- Abnormal vaginal bleeding (intermenstrual, postcoital, post-menopausal)
- Vaginal discharge
- Pelvic pain
- Dyspareunia
18
Q
How is suspected cervical cancer investigated?
A
Speculum examination
Swabs to exclude infection
Colposcopy
19
Q
What appearances on colposcopy may indicate cervical cancer?
A
Ulceration
Inflammation
Bleeding
Visible tumour
20
Q
What is dysplasia?
A
Premalignant change
21
Q
What is the grading system used to measure the level of dysplasia in the cervix?
A
CIN- Cervical intraepithelial neoplasia
22
Q
When is CIN decided?
A
At colposcopy (not cervical screening)
23
Q
What are the different grades of cervical cancer?
A
CIN I: Mild dysplasia (1/3 thickness of epithelial layer- likely to return to normal)
CIN II: Moderate dysplasia( 2/3 thickness of epithelial layer- likely to turn into cancer)
CIN III: Severe dysplasia (very likely to turn into cancer)
24
Q
What is CIN III otherwise known as?
A
Cervical carcinoma in situ
25
What does cervical screening involve?
Speculum examination and smear test to look for precancerous changes in the epithelial cells of the cervix
26
What is dyskaryosis?
Precancerous changes in cervical cells detected at smear
27
What is liquid based cytology?
The method of transporting the collected cervical cells: They are deposited from the brush into preservation fluid and taken to the lab to be examined under a microscope
28
What are smear cells tested for?
High-risk HPV- If not present the smear is considered negative/
29
What age women have smear tests and how frequently?
25-29 Every 3 years
| 50-64 Every 5 years
30
What are the exceptions to the cervical screening programme?
HIV+ve screened anually
Additional tests with previous CIN, immunocompromised
Pregnant women should wait until 12 weeks postpartum
31
What is cytology?
Diagnosing diseases by looking at single or small clusters of cells
32
What are the different options of cytology result?
```
Inadequate
Normal
Borderline changes
Low-grade dyskaryosis
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Possible invasive squamous cell carcinoma
Possible glandular neoplasia
```
33
What is the management of women who are HPV positive with normal cytology?
Repeat HPV test after 12 months
34
What is the management of woemn who are HPV positive with abnormal cytology on smear?
Refer to colposcopy
35
What is the management of women who have an inadequate sample on smear?
Repeat after at least 3 months
36
What is colposcopy?
When a colposcope is used to magnify the cervix, allowing the epithelial lining to be examined in detail
37
What is used in colposcopy to view abnormal cells?
Acetic acid--> causes abnormal cells to appear white (acetowhite)
Schiller's iodine test--> iodine solution stains healthy cells brown colour.
38
Why does acetic acid cause abnormal cells to appear white?
Pre-cancerous cells have more keratin so take up more acetic acid
39
What method can be used during colposcopy if abnormal cells are found?
LLETZ
| Cone biopsy
40
What is LLETZ?
Large loop excision of the transformation zone: When a loop of electrical wire is used to remove abnormal tissue of the cervix
41
What method is used during colposcopy to remove a larger area of abnormal tissue?
Cone biopsy
42
What does a cone biopsy involve?
Cone-shaped piece of cervix is removed using a scalpel and then sent for histology
43
What are the different stages of cervical cancer?
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
44
What is CGIN?
Cervical glandular intra-epithelial neoplasia (very high risk dysplasia)
45
What are the usual treatments of CIN/ 1a?
LLETZ or Cone biopsy
46
What is the treatment of stage 1B-2A cervical cancer?
Radical hysterectomy and removal or lymph nodes with chemo/ radiotherapy
47
What is the treatment of stage 2b-4a cervial cancer?
Chemotherapy and radiotherapy
48
What is the treatment of stage 4b cervical cancer?
Combo of surgery, radio, chemotherapy and palliative care
49
What is pelvic exenteration?
An operation which removes most or all of the pelvic organs that may be used in advanced cervical cancer
50
What is Bevacizumab?
A monoclonal antibody that may be used in combination with other chemotherapies in the treatment of cervical cancer
51
What strains of HPV does the vaccine protect against and what do they cause?
6 & 11= Genital warts
| 16&18 = Cervical cancer
52
What type of cancer makes up the majority of endometrial cancer?
Adenocarcinoma (80%)
53
What does endometrial cancer depend on to grow?
Oestrogen-dependent cancer
54
What is the diagnosis for any woman presenting with postmenopausal bleeding until proven otherwise?
Endometrial cancer
55
What is the key risk factor for endometrial cancer?
Increased exposure to unopposed oestrogen
56
What is endometrial hyperplasia?
Precancerous thickening of the endometrium
57
What percentage of cases of endometrial hyperplasia go on to become endometrial cancer?
<5%
58
What are the two types of endometrial hyperplasia?
Hyperplasia without atypia
| Atypical hyperplasia
59
How can endometrial hyperplasia be treated?
With progesterones:
- Mirena coil
- Oral progesterones
60
What is unopposed oestrogen?
Oestrogen without progesterone
61
What are the risk factors increase your exposure to unopposed oestrogen?
```
Increased age
Early onset menstruation
Late menopause
Oestrogen only HRT
No/ fewer pregnancies
Obesity
PCOS
Tamoxifen
```
62
Why does PCOS lead to an increased exposure to unopposed oestrogen?
There is a lack of ovulation so there is no luteal phase with the corpus luteum producing progesterone.
63
What should be offered to women with PCOS to decrease their exposure to unopposed oestrogen?
COCP
Mirena coil
Cyclical progesterones
64
Why is obesity a key risk factor for endometrial cancer?
Because adipose tissue is a source of oestrogen
65
Why is tamoxifen a risk factor for endometrial cancer?
It has an oestrogenic effect on the endometrium
66
What are additional risk factors for endometrial cancer not linked to unopposed oestrogen?
T2 Diabetes
| Lynch syndrome
67
What is lynch syndrome?
HNPCC--> Hereditary condition that increases risk of colon and endometrial cancer
68
Why does T2 diabetes increase the risk of endometrial cancer?
Increased production of insulin may stimulate the endometrial cells.
69
What are the protective factors against endometrial cancer?
COPC
Mirena coil
Increased pregnancies
Smoking
70
Why is smoking protective in endometrial cancer/
Anti-oestrogenic
71
What are the key presenting factors of endometrial cancer?
```
*Postmenopausal bleeding
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal discharge
Haematuria
Anaemia
Raised platelets
```
72
What 3 investigations are done to diagnose endometrial cancer?
1. TVUS for endometrial thickness
2. Pipelle biopsy
3. Hysteroscopy
73
What endometrial thickness would be a reg flag for cancer in post menopausal women?
>4mm
74
What is a pipelle biopsy?
Speculum examination where pipelle (thin tube) is inserted into uterus to take sample of endometrium
75
What are the different stages of endometrial cancer?
Stage 1: confined to uterus
Stage 2: Invades cervix
Stage 3: Invades ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond pelvis
76
How is endometrial cancer usually managed?
Total abdominal hysterectomy with bilateral salpinogo-oophorectomy (removal of uterus, cervix and adnexa)
77
What are the other treatment options for endometrial cancer?
Radical hysterectomy
Radiotherapy
Chemotherapy
Progesterone to slow progression
78
What does a radical hysterectomy involve?
Removal of uterus, cervix, adnexa, pelvic lymph nodes, surrounding tissues and top of vagina
79
Why do the majority of ovarian cancer cases present late?
Non-specific symptoms
80
What are the different types of ovarian cancer?
*Epithelial cell tumours
Dermoid cysts/ germ cell tumours
Sex cord-stromal tumours
Metastasis
81
What are teratomas?
Tumours that come from germ cells and may contain various tissue types.
82
How may germ cell tumours be recognised?
Raised alpha-fetoprotein and hCG
83
What is a Krukenberg tumour?
A metastasis in the ovary that has a characteristic signet-ring histology
84
What is the peak age for ovarian cancer?
60
85
What are the risk factors for ovarian cancer?
```
Age (60)
BRCA genes
Increased no of ovulations
Obesity
Smoking
Recurrent use of clomifene (infertility treatment)
Early onset periods
Late menopause
No pregnancies
```
86
What factors increase the risk of ovarian cancer?
Factors that increase the number of ovulations ( early onset periods, late menopause, no pregnancies)
87
What are the protective factors for ovarian cancer?
Factors that reduce the number of ovulations:
COPC
Breastfeeding
Pregnancy
88
How does ovarian cancer present?
Non- specific
- Abdominal bloating
- Early satiety
- Loss of appetite
- Pelvic pain
- Urinary symptoms
- Weight loss
- Abdominal/ pelvic mass
- Ascites
89
Where may you get referred pain in ovarian cancer and why?
Hip or groin pain due to ovarian mass pressing on obturator nerve
90
What red flag signs would cause direct referall to 2 week wait clinic?
Ascites
Pelvic mass
Abdominal mass
91
What investigations can be done to look for ovarian cancer?
```
CA125 blood test (>35)
Pelvic ultrasound
RMI
CT scan
Histology
Paracentesis
Germ cell tumour markers
```
92
What is RMI
Risk of malignancy index
93
What factors does RMI take into account?
Menopausal status
USS findings
CA125 level
94
What are causes of raised CA125?
```
Epithelial cell ovarian cancer
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
```
95
What are the stages of ovarian cancer?
Stage 1: Confined to ovary
Stage 2: Inside pelvis
Stage 3: Inside abdomen
Stage 4: Outside of abdomen
96
How is ovarian cancer managed?
With MDT using combination of surgery and chemotherapy
97
What is the most common type of vulval cancer?
90% squamous cell carcinomas
98
What are the risk factors for vulval cancer?
Advanced age (>75)
Immunosuppresssion
HPV infection
Lichen sclerosus
99
What is VIN?
Vulval intraepithelial neoplasia: premalignant condition affecting squamous epithelium of the skin
100
What is high grade squamous intraepithelial lesion?
Type of VIN associated with HPV infection (typically in women 35-50)
101
What is differentiated VIN?
Type of VIN associated with lichen sclerosus (typically in women 50-60)
102
What are the treatment options for VIN?
Watch & wait
Wide local excision
Imiquimod
Laser ablation
103
How does vulval cancer present?
```
Vulval lump--> usually on labia majora (irregular, fungugating)
Ulceration
Bleeding
Pain
Itching
Lymphadenopathy in groin
```
104
How is vulval cancer diagnosed?
2WW referral
Biopsy of lesion
Sentinel node biopsy
Imaging for staging
105
What are the management options for vulval cancer?
Wide local excision
Groin lymph node dissection
Chemotherapy
Radiotherapy
106
What two muscles is the pelvic floor made up of?
Levator ani
| Coccygeus
107
What 3 muscles make up the levator ani?
Pubococcygeus
Ileococcygeus
Puborectallis
108
What two holes are in the pelvic floor?
```
Urogenital hiatus (passage of urethra)
Rectal hiatus (passage of anal canal)
```
109
What is the pelvic outlet?
the inferior opening of the pelvis that is bounded by coccyx, the ischial tuberosities, and the pubis symphysis
110
What makes up the pelvic outlet?
Urogenital and anal triangles
111
What is the perineal body?
The fibrous node at the centre of the perineum that is the connecting point for many muscles
112
What is an episiotomy and why is it used in labour?
Horizontal cut, to avoid tearing of the perineal body
113
What is the function of the pelvic floor muscles?
Support abdominal and pelvic viscera
Resist intra-pelvic/ abdominal pressure
Urinary and faecal continence
114
What ligaments support the uterus?
Round ligament
Cardinal ligaments
Uterosacral ligament
115
Where do the round ligaments insert and therefore in what position does this keep the uterus?
Pass through the inguinal canal and insert on the labia majora, keeping uterus anteverted
116
What happens to the round ligaments during pregnancy?
They stretch and may cause pain. The uterus may be more floppy after birth
117
Where to the cardinal ligaments originate/ insert and therefore how to they support the uterus?
Arise from cervix and attach to lateral pelvic wall
118
Where do the uterosacral ligaments insert and therefore how do they support the uterus?
Attach cervix to the sacrum, supporting it posteriorly
119
What supports the inferior aspect of the uterus?
The pelvic floor: levator ani, perineal membrane and perineal body
120
What are the 3 categories of ligaments in the female reproductive tract?
Broad ligament
Uterine ligaments
Ovarian ligaments
121
What is the broad ligament?
A flat sheet of peritoneum that extends from the lateral pelvic walls to support all of the internal femal genitalia/
122
What are the 3 regions that make up the broad ligament?
Mesometrium
Mesovarium
Mesosalpinx
123
What is contained in the broad ligament?
The ovarian and uterine arteries
Ovarian ligament
Round ligament
Suspensory ovary ligament
124
What ligaments are associated with the ovary?
Ovarian ligament
| Suspensory ligament of ovary
125
What is pelvic organ prolapse?
The descent of pelvic organs into the vagina
126
What causes prolapse?
Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
127
What are the different types of prolapse?
Uterine
Vault
Rectocele
Cystocele
128
What is a vault prolapse and in which patients does it occur?
When the top of the vagina (the vault) descends into the vagina. Only occurs in women that have had a hysterectomy
129
What is a rectocele?
When the rectum prolapses forward into the vagina
130
How may a rectocele present?
Constipation due to faecal loading. (may have to press to open bowels)
Urinary retention
Palpable lump in vagina
131
Where is the defect in a rectocele?
The posterior vaginal wall
132
What is a cystocele?
When the bladder prolapses backwards into the vagina
133
Where is the defect in a cystocele?
Anterior vaginal wall
134
What is a cystourethrocele?
Prolapse of both the bladder and urethra
135
What are the risk factors for pelvic organ prolapse?
```
Multiple vaginal deliveries
Instrumental delivery
Prolonged or traumatic delivery
Obesity
Advanced age/ postmenopausal
COPD (chronic coughing)
Chronic constipation
Smoking
Tissue disorders
Hysterectomy
```
136
Why does chronic straining (e.g. COPD, constipation) increase the risk of prolapse?
Increases intra-abdominal pressure
137
How does prolapse usually present?
```
Dragging/ heavy sensation
Urinary symptoms
Bowel symptoms
Sexual dysfunction
Palpable lump/ mass
```
138
What are the urinary symptoms that should be taken in a history?
```
Incontinence (stress or urge)
Urgency
Frequency
Weak stream
Retention
Dysuria
Nocturia
```
139
What bowel symptoms should be taken in a history?
Constipation
Incontinence
Urgency
140
How do you examine a prolapse?
Abdominal exam to look for masses
Sim's speculum to examine vaginal walls (may need to lie left lateral)
Pelvic USS to look for mass
141
What are the different grades of uterine prolapse?
Grade 1= Uterus in upper part of vagina
Grade 2= Uterus descended to opening of vagina
Grade 3= Uterus protudes out vagina
Grade 4= Uterus completely out the vagina
142
What are the 3 management options for pelvic organ prolapse?
1. Conservative
2. Vaginal pessary
3. Surgery
143
What is the conservative management for prolapse?
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes
Vaginal oestrogen cream (reduce dryness and irritation)
144
What lifestyle changes are recommended for prolapse?
Weight loss
Reduced caffeine & alcohol intake
Reduce heavy lifting
Incontinence pads
145
What are the different types of pessaries that can be used?
```
Ring
Shelf
Gellhorn
Cube
Donut
Hodge
```
146
How often should pessaries be changed?
Every 4 months
147
What management is no longer recommended to treat prolapse?
Mesh repairs as they have a lot of complications and don't have good evidence as to effectiveness.
148
What are the two types of urinary incontinence?
Urge incontinence
| Stress incontinence
149
What is urge incontinence?
Overactivity of the detrusor muscle of the bladder
150
How does urge incontinence present?
Sudden urge to pass urine
Rush to the bathroom
Leaking before reaching bathroom
151
What is stress incontinence?
When increased pressure on the bladder overcomes the pelvic floor and sphincter muscles
152
How does stress incontinence usually present?
Urinary leakage when laughing, coughing, lifting or surprised
153
What is mixed incontinence?
Combination of urge and stress incontinence
154
What is overflow incontinence?
When chronic urinary retention (due to an obstruction) results in an overflow of urine without the urge to pass urine/
155
What can cause overflow incontinence?
Anticholinergics
Fibroids
Pelvic tumours
Neurological conditions (MS, Diabetic neuropathy, spinal cord injuries)
156
What are the risk factors for urinary incontinence?
```
Increased age
Previous pregnancies and vaginal deliveries
Increased BMI
Postmenopausal
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions
Cognitive impairment/ dementia
```
157
What modifiable risk factors can contribute to incontinence?
Caffeine consumption
Alcohol consumption
Medications
BMI
158
What should be assessed on examination of incontinence?
```
Pelvic tone
Prolapse
Atrophic vaginitis
Urethral diverticulum
Pelvic masses
Ask patient to cough to look for leakage from urethra
```
159
What is urethral diverticulum?
Where an outpouching forms next to the urethra which can get filled with urine during urination.
160
How is the strength of the pelvic muscles assessed?
Using bimanual examination and asking woman to squeeze against fingers
161
How is pelvic muscle tone graded?
```
Oxford grading system:
0= no contraction
1= faint contraction
2= weak
3= moderate with some resistance
4= good contraction
5= strong contraction
```
162
How is incontinence investigated?
```
Take thorough history
Bladder diary (>3 days)
Urine dipstick for infection
Bladder scan
Urodynamic testing
```
163
Why is a bladder scan done in incontinence investigations?
To measure the post- void residual bladder volume to assess for incomplete emptying
164
What is urodynamic testing?
Range of tests to assess presence and severity of urinary symptoms
165
What happens in urodynamic testing?
Catheters are inserted into bladder and rectum to measure and compare the pressures. The bladder is filled with liquid and measures are taken
166
What measures are taken in urodynamic testing?
```
Cystometry (detrusor muscle contraction/ pressure)
Uroflowmetry (flow rate)
Leak point pressure
Post-void residual bladder volume
Video urodynamic testing
```
167
What is the leak point pressure?
The point at which the bladder pressure results in leakage of urine
168
What is the management of stress incontinence?
Lifestyle modification
Pelvic floor excercises
Surgery
Duloxetine
169
What is the lifestyle management of stress incontinence?
Avoid caffiene, diuretics and overfilling the bladder
Avoid excessive or restricted fluid intake
Weight loss
170
What is duloxetine and what is its action?
SNRI antridepressant that increases activity of nerve that stimulated urethral sphincter, improving its function
171
What are the surgical options to treat stress incontinence?
Tension-free vaginal tape
Autologous sling
Colposuspension
Intramural urethral bulking
172
How long should ladies with stress incontinence try pelvic floor exercises before surgery is advised?
At least 3 months
173
What is the management of urge incontinence?
Bladder retraining
Anticholinergics
Mirabegron
Invasive procedures
174
What is the first line treatment for urge incontinence and what does it involve?
Bladder retraining: Gradually increasing time between voiding
175
What are the side effects of anticholinergic medications?
```
Dry mouth & eyes
Urinary retention
Constipation
Postural hypotension
Cognitive decline
Memory problems
Worsening of dementia
```
176
What is the most common anticholinergic used and what is its action?
Oxybutynin
| Block the action of acetylcholine which reduces abnormal bladder contractions/
177
What is Mirabegron and why would it be used instead of an anticholinergic?
Beta-3 agonist, similar to an antimuscarinic
| Less of an anticholinergic burden
178
When is Mirabegron contraindicated?
In uncontrolled hypertension as it increases blood pressure by stimulating sympathetic nervous system
179
What are the invasive third line options for treating overactive bladder?
Botulinium toxin (botox) injection
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion
180
What is amenorrhoea?
Lack of menstrual periods
181
What is primary amenorrhoea?
When the patient has never started periods
182
What are the causes of primary amenorrhoea?
```
Abnormal functioning of the hypothalamus or pituitary
Abnormal functioning of gonads
Structural pathology (imperforate hymen= when the hymen covers opening of the vagina)
```
183
What is secondary amenorrhoea?
When the patient has previously had periods that have now stopped (for >6months)
184
What are some causes of secondary amenorrhoea?
```
Pregnancy
Menopause
Physiological stress (excessive excercise, low BMI, chronic disease, psychosocial factors)
PCOS
Contraceptives
Premature ovarian insufficiency
Thyroid abnormalities
Prolactinoma
Cushing's syndrome
```
185
What are the different types of abnormal uterine bleeding?
```
Menorrhagia
Amenorrhea
Oligomenorrhoea
Post-menopausal bleeding
Post-coital bleeding
Dysmenorrhea
Dysfunctional uterine bleeding
```
186
What are the differential presentations in gynaecology?
```
Amenorrheoa
Irregular menstruation
Intermenstrual bleeding
Dysmenorrhoea
Menorrhagia
Postcoital bleeding
Pelvic pain
Vaginal discharge
Pruritus vulvae
```
187
What is oligomenorrhea?
Infrequent menstrual bleeding
188
What does irregular uterine bleeding indicate?
Annovulation of irregular ovulation
189
What are the causes of irregular menstruation?
```
Extremes of reproductive age
PCOS
Physiological stress
Medications
Hormonal imbalances
```
190
What are the key causes of intermenstrual bleeding?
```
Hormonal contraception
Cervical ectropion
Polpys
*Cervical, endometrial or vaginal cancer
STI's
Pregnancy
Ovulation
Medications
```
191
What is dysmenorrhoea?
Particularly painful periods
192
What are the causes of dysmenorrhoea?
```
Primary (no underlying pathology)
Endometriosis/ adenomyosis
Fibroids
PID
Copper coil
Cervical/ ovarian cancer
```
193
What is menorrhagia?
Heavy menstrual bleeding
194
What are the causes of menorrhagia?
```
Dysfunctional uterine bleeding
Extremes of reproductive age
Fibroids
Endometriosis/ adenomysosis
PID
Contraceptives (copper coil)
Anticoagulants
Bleeding disorders
Endocrine disorders
Connective tissue disorders
Endometrial hyperplasia
Cancer
(PCOS)
```
195
What is Dysfunctional uterine bleeding?
Bleeding with no identifiable cause
196
What are the key causes of postcoital bleeding?
```
Idiopathic
Cervical cancer, ectropion or infection
Trauma
Atrophic vaginitis
Polyps
Endometrial cancer
Vaginal cancer
```
197
What are some causes of pelvic pain?
```
UTI
Dysmenorrheoa
IBS
Ovarian cysts
Endometriosis
PID
Ectopic pregnancy
Appendicitis
Mittelshcmerz
Pelvic adhesions
Ovarian torsion
IBD
```
198
What may abnormal discharge indicate?
```
Bacterial vaginosis
Cadidiasis
STI's
Cervical ectropion
Polyps
Malignancy
pregnancy
Contraception
```
199
What is pruritis vulvae?
Itching of the vulva and vagina
200
What are the causes of pruritis vulvae?
```
Irritants (e.g. soap )
Atrophic vaginitis
Infections
Skin conditions
Malignancy
Stress
```
201
At what age is primary amenorrhoea defined?
13 with no other evidence of pubertal development
| 15 with other signs of puberty
202
When does puberty normally start in girls?
8-14
203
When does puberty normally start in boys?
9-15
204
What are the causes of primary amenorrhoea?
```
Hypogonadism (Hypogonadotropic hypogonadism
or Hypergonadotropic hypogonadism)
Kallman syndrome
Congenital adrenal hyperplasia
Androgen insensitivity syndrome
Structural pathology
```
205
What is hypogonadism?
Lack of oestrogen and testosterone
206
What is hypogonadotropic hypogonadism?
Deficiency of LH and FSH leading to oestrogen deficiency
207
What are the potential causes of hypogonadotropic hypogonadism?
```
Hypopituitarism
Hypothalamus or pituitary damage
Chronic conditions
Excessive exercise/ dieting
Constitutional delay in growth and development
Endocrine disorders
Kallman syndrome
```
208
What is Hypergonadotropic hypogonadism?
When the gonads fail to respond to the stimulation from gonadotrophins
209
What are the gonadotropin hormoness?
LH & FSH
210
What are the causes of Hypergonadotropic hypogonadism?
Damage to gonads (torsion, cancer, infection)
Congenital absence of ovaries
Turner's syndrome
211
What is Kallman syndrome?
Genetic condition that causes hypogonadotrophic hypogonadism, with failure to start puberty
212
What is congenital adrenal hyperplasia?
A congenital condition causing the underproduction of cortisone and aldosterone and the overproduction of androgens from birth.
213
What is androgen insensitivity syndrome?
Condition where tissues are unable to respond androgen hormones (testosterone) so male characteristics do not develo, resulting in a female phenotype with male internal pelvic organs.
214
What is the aims of assessment of primary amenorrhoea?
Look for evidence of puberty and assess for possible underlying causes
215
What are the conditions for investigating primary amenorrhoea?
No evidence of pubertal changes at 13 or some evidence of puberty with no progression after 2 years
216
What are the initial steps in the assessment of primary amenorrhoea?
Detailed history
| Examine height, weight, stage of development and features of underlying conditions
217
What are the initial investigations into primary amenorrhoea?
Assess for underlying conditions
Hormonal blood tests
Genetic testing
Imaging
218
What investigations would be done to look for underlying conditions in primary amenorrhoea?
- FBC/ ferritin (anaemia)
- U&E's (kidney disease)
- Anti-TTG, anti- EMA
219
What investigations would be done to look for hormonal abnormalities in primary amenorrhoea?
```
FSH/ LH
Thyroid function
Insulin-like growth factor 1 (GH deficiency)
Prolactin
Testosterone
```
220
What imaging can be done to look into primary amenorrhoea?
Wrist X-ray to assess bone age
Pelvic ultrasound
MRI brain (pituitary pathology)
221
How is primary amenorrhoea?
Treat cause:
- Hormone replacement
- Reassurance and observation
- Weight gain/ stress reduction
- Manage chronic/ endocrine condition
- Pulsatile GnRH
- COCP
222
What is the definition of secondary amenorrhea?
No menstruation for >3months after previously regular periods
OR >6 months after previous irregular periods
223
What are the main causes of secondary amenorrhea?
```
Pregnancy
Menopause
Hormonal contraception
Hypothalamic/ pituitary/ thyroid/ uterine pathology
PCOS
Hyperprolactinaemia
Physiological/ psychological stress
```
224
Why does physiological/ psychological stress cause amenorrhoea?
In circumstances where the body may not be fit for pregnancy, the hypothalamus reduces the production of GnRH, leading to hypogonadotropic hypogonadism.
225
What is the main cause of hyperprolactinaemia and why does it cause amenorrhoea?
Pituitary adenoma secreting prolactin.
| High prolactin levels have negative feedback on the hypothalamus, reducing its release of GnRH/
226
How is secondary amenorrhoea investigated?
History+ examination
Hormonal blood tests
USS pelvis (PCOS)
227
What hormonal blood tests are done to look into secondary amenorrhoea?
```
HcG to rule out pregnancy
LH/ FSH
Prolactin
TSH, T3/T4
Testostrone
```
228
How is secondary amenorrhoea managed?
Treat cause (may need replacement hormones)
229
What are patients with amenorrhoea associated with low oestrogen levels at risk of?
Osteoporosis
230
What is PMS and at what stage of the menstrual cycle does it occur?
Pre-menstrual syndrome
| Luteal phase
231
What are management options for severe PMS?
```
Lifestyle changes
COCP
SSRI antidepressants
CBT
Oestrogen patches
GnRH analogues
Hysterectomy
```
232
How much blood to women typically lose per menstural period?
40ml
233
How many ml of blood is counted as menorrhagia?
>80ml
| In practice: changing pads 1-2 hours, bleeding >7days, passing large clots
234
What investigations are performed first line in menorrhagia?
Speculum and bimanual examination
| FBC (Anaemia)
235
What would you be looking for with a speculum examination in menorrhagia?
Fibroids
Ascites
Cancer
236
When would an outpatient hysteroscopy be arranged for menorrhagia?
Suspected submucosal fibroids
Suspected endometrial hyperplasia/ cancer
Persistent intermenstrual bleeding
237
When would a pelvic/ transvaginal USS be arranged for menorrhagia?
Possible large fibroids
Possible adenomyosis
Examination difficult to interpret (obesity)
Hysteroscopy declined
238
What additional tests can be done into menorrhagia after examination?
```
Hysteroscopy
USS
Swabs
Coagulation screen
Ferritin
Thyroid function tests
```
239
How is menorrhagia managed?
Manage underlying pathology
1. Mirena coil
2. COPC
3. Cyclical oral progesterones
4. If contraception not acceptable: TXA
5. If all else fails: Endometrial ablation/ hysterectomy
240
What is TXA and how does it work?
Transexamic acid: antifibronlytic that reduces bleeding
241
What are fibroids?
Benign tumours of the smooth muscle of the uterus
242
What percentage of older women have fibroids?
40-60%
243
What reaction to fibroids have to oestrogen?
Oestrogen-sensitive so grow in response
244
What are the 4 types of fibroid?
Intramural
Subserosal
Submucosal
Pedunculated
245
Where are intramural fibroids located?
Within the myometrium
246
Where are subserosal fibroids located?
Just below the outer layer of the uterus, filling the abdominal cavity
247
Where are submucosal fibroids located?
Just below the endometrium
248
What are pedunculated fibroids?
Those on a stalk, often invading the uterine space
249
How might fibroids present?
```
Asymptomatic
Menorrhagia
Prolonged menstruation
Abdominal pain (wores on menstruation)
Bloating/ fullness in abdomen
Urinary/ bowl symptoms due to pressure
Deep dyspareunia
Reduced dertility
```
250
What may abdominal/ bimanual examination reveal with suspected fibroids?
Palpable mass or enlarged firm uterus
251
Why may fibroids cause heavy/ prolonged menstrual bleeding?
May put pressure against endometrium
May prevent uterus from contracting properly to stop bleeding
May stimulate growth of blood vessels
May increase surface area of endometrium leading to more tissue loss
252
What investigations are done to confirm fibroids?
Hysteroscopy
Pelvic USS
MRI scanning
253
What is the medical management for fibroids <3cm?
1. Mirena coil
2. NSAIDS/ TXA
3. COCP
4. Cyclical oral progesterones
254
What are the surgical options for smaller fibroids?
Endometrial ablation
Resection
Hysterectomy
255
What are the medical management options for fibroids >3cm?
Symptomatic management (NSAIDS/ TXA)
Mirena coil
COCP
Cyclical oral progesterones
256
What are the surgical options for fibroids >3cm?
Uterine artery embolisation
Myomectomy
Hysterectomy
257
What is myomectomy?
Surgical removal of fibroids
258
What might be used to reduce the size of fibroids before surgery?
GnRH agonists (Zoladex, Prostap) to reduce the amount of oestrogen maintaining the fibroid
259
What is uterine artery embolisation?
When a catheter is inserted into the femoral artery and X-ray guided to the fibroid where particles are injected to block the arterial supply to the fibroid
260
What is laparoscopic vs laparotomy surgery?
```
Laparoscopic= key-hole
Laparotomy= surgical incision
```
261
What are the complications of fibroids?
```
Heavy menstrual bleeding
Reduced fertility
Pregnancy complications
Constipation
UTI/ Urinary outflow obsrtuction
Red degeneration
Torsion
```
262
What is red degeneration of fibroids?
Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply (usually during pregnancy), presenting with severe abdominal pain, fever, tachycardia and vomiting.
263
What is the treatment for red degeneration?
Supportive with rest, fluids and analgesia.
264
What is endometriosis?
When endometrial tissue grows outside the uterus
265
What is adenomyosis?
Endometrial tissue within the myometrium
266
What are the main symptoms of endometriosis?
```
Cyclical pelvic pain
Deep dyspareunia
Dysmenorrhoea
Infertility
Cyclic bleeding in stool/ urine
```
267
What is deep dyspareunia?
Pain on deep sexual intercourse
268
Why is pelvic pain the main symptom of endometriosis?
During menstruation, the ectopic endomatrial tissue also sheds its lining and bleeds, causing irritation and inflammation of the tissues
269
What complication can localised bleeding and inflammation lead to in endometriosis?
Adhesions (scar tissue that binds organs together).
| Can cause chronic, non-cyclic pain
270
What may examination reveal in endometriosis?
Visible endometrial tissue in the vagina on speculum examination
Fixed cervix
Tenderness in vagina, cervix or adnexa
271
How is endometriosis diagnosed?
Pelvic USS
| Laparoscopic surgery with biopsy of lesions
272
What is the initial management of endometriosis?
Establish diagnosis with clear explanation
| Analgesia for pain (NSAIDs/ paracetamol
273
What management options can be tried before definitie laparoscopic diagnosis of endometriosis?
```
COPC
POP
Medroxyprogesterone acetate injection
Implant
Mirena
GnRH agonist
```
274
What are the surgical management options of endometriosis?
Laparoscopic surgery to excise/ ablate tissue and adhesions
| Hysterectomy
275
What is used to treat cyclical pain in endometriosis and why?
- Hormonal contraceptives to stop ovulation and reduce endometrial thickening/
- Induce menopause-like state with GnRH agonists.
276
In which women is adenomyosis more common?
Older women
| Multiparous women
277
How does adenomyosis present?
Dysmenorrhoea (painful periods)
Menorrhagia (heavy periods)
Dyspareunia (painful intercourse
278
How is adenomyosis diagnosed?
Examination (enlarged, tender uterus)
TVUS = 1st line
MRI/ abdominal USS
Histological examination after hysterectomy= gold standard
279
How is adenomyosis managed?
* Same as for heavy menstrual bleeding:
1. Contraception
2. TXA/ Mefenamic acid
280
What are the complications of adenomyosis associated with pregnancy?
```
Infertility
Miscarriage
Preterm birth
Small for gestational age
Preterm premature rupture of membranes
Malpresentation
Need for caesarean section
Postpartum haemorrhage
```
281
What is cervical ectropion?
When the columnar epithelium of the endocervix extends out to the ectocervix and is visible
282
How does cervical ectropion usually present and why?
With postcoital bleeding as the endocervical cells are more fragile and prone to trauma.
283
What are the risk factors for cervical ectropion?
Higher oestrogen levels:
- Younger women
- COCP use
- Pregnancy
284
What is the transformation zone?
The border between the columnar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix
285
How else might cervical ectropion present?
Increased discharge
Bleeding
Dyspareunia
286
When would ectropion be treated and how?
If there is problematic bleeding, it can be cauterised with silver nitrate or cold coagulation during colposcopy.
287
What is classified as the menopause?
When a woman has had no periods for 12 months
288
What is the average age of menopause?
51
289
What is perimenopause?
The time around the menopause, where the woman may be experiencing symptoms and irregular periods
290
What time period is the perimenopause?
The time leading up to the last period and the 12 months afterwards
291
What is classified as premature menopause?
Menopause before age 40.
292
What causes menopause?
Lack of ovarian follicular function, resulting in low oestrogen & progesterone and high LH and FSH
293
What are the symptoms of perimenopause?
```
Hot flushes
Emotional instability/ low mood
Premenstrual syndrome
Irregular periods/ change in quantity
Joint pains
Vaginal dryness/ atrophy
Reduced libido
```
294
What are the risks of the lack of oestrogen caused by menopause?
Cardiovascular disease
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
295
What blood test can be used to help diagnose menopause and when would it be necessary?
FSH blood test:
Women <40 with suspected premature menopause
Women 40-45 with symptoms or change in cycle
296
How long should women continue to use contraception after their last menstrual period?
2 years if <50
| 1 year if >50
297
What are vasomotor symptoms?
Those that occur due to the constriction/ dilation of blood vessels (e.g. hot flushes, night sweats, palpitations, BP changes)
298
How long to perimenopausal vasomotor symptoms usually last?
2-5 years
299
What are the treatment options for symptomatic menopause?
```
None
HRT
Tibolone
Clonidine
CBT
SSRI's
Testosterone
Vaginal oestrogen
Vaginal mousturisers
```
300
What is the cause of premature menopause?
Premature ovarian insufficiency
301
What causes Premature ovarian insufficiency?
Hypergonadotropic hypogonadism:
- Idiopathic
- Latrogenic
- Autoimmune
- Genetic
- Infections
302
How is Premature ovarian insufficiency diagnosed?
Women <40 presenting with typical menopausal symptoms and elevated FSH on two consecutive occasions
303
How is premature ovarian insufficiency managed?
Hormone replacement therapy until at least normal menopausal age, to reduce risks of osteoporosis, cardiovascular risks etc.
304
What are the two options of HRT for women with premature ovarian insufficiency?
Traditional HRT
| COCP
305
What is HRT?
Hormone replacement therapy- giving exogenous oestrogen to alliviate menopausal symptoms
306
In what women should progesterone be given along with oestrogen and why?
Those with a uterus to prevent endometrial hyperplasia and cancer
307
What can unopposed oestrogen do to the endometrium?
cause endometrial hyperplasia, increasing the risk of cancer
308
What HRT therapy would women without a uterus be given?
Oestrogen only
309
What HRT therapy would women that still have periods be given?
Cyclical HRT with cyclical progesterone and breakthrough bleeds
310
What HRT therapy would women with a uterus and >12 months without periods be given?
Continuous combined HRT
311
What are the non-hormonal treatment options for menopausal symptoms?
```
Lifestyle changes
CBT
Clonidine
SSRI's
Venlafaxine
Gabapentin
```
312
What lifestyle changes may improve menopausal symptoms?
Diet, exercise, weight loss, stop smoking, reduce alcohol, reduce caffeine, reduce stress
313
What is Clonidine?
Agonist of alpha-adrenergic and imidazoline receptors in the brain.
314
What is the action of Clonidine?
Lowers blood pressure and heart rate, and can reduce hot flushes and other vasomotor symptoms
315
What are some common side effects of Clonidine?
Dry mouth
Headaches
Dizziness
Fatigue
316
What are the indications for HRT?
- Replacing hormones in premature ovarian insufficiency
- Reducing vasomotor symptoms
- Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
- Reducing risk of osteoporosis in women under 60 years
317
What are the risks of HRT?
Increased risk of:
- Breast cancer
- Endometrial cancer
- VTE
- Stroke
- Coronary artery disease
318
In which women do the risks of HRT not apply?
- Not increased risk compared to other women <50
- No risk of endometrial cancer in those without a uterus
- No risk of coronary artery disease with oestrogen-only HRT
319
What are the contraindications to HRT?
```
Undiagnosed abnormal bleeding
Endometrial hyperplasia/ cancer
Breast cancer
Uncontrolled hypertension
Venous thromboembolism
Liver disease
Active angina or MI
Pregnancy
```
320
What is assessed before starting HRT?
```
Full Hx for contraindications
FH for risk of cancer/ VTE
BMI
BP
Screening is up to date
```
321
What are the 3 steps to consider when choosing HRT formulation?
Step 1: Are the symptoms local or systemic?
Step 2: Does she have a uterus?
Step 3: Have they had a period in the last 12 months?
322
What is given if the woman has local symptoms?
Topical treatments (e.g. topical oestrogen cream or tablets)
323
What are the two options for delivering systemic oestrogen?
Oral (tablet)
| Transdermal (patches or gels)
324
What are the 3 options for delivering progesterone?
Oral
Transdermal
Intrauterine system (Mirena coil)
325
What are progestogens?
Any chemicals that target and stimulate progesterone receptors
326
What are progestins?
Synthetic progesterones
327
What are the 2 classes of progesterone used in HRT?
C19 and C21, can be sweitched if woman is having side effects
328
What is the best way of delivering oestrogen and why?
Via patches due to the decreased rrisk of VTE
329
What is the best way of delivering progesterone and why?
With and IUD
Has added benefits of contraception and treating HMP
Will not experience progestogenic side effects
330
What is tibolone?
A synthetic steroid that stimulates oestrogen and progesterone receptors, used as a form of continuous combined HRT.
331
After how long on HRT should there be a follow up and how long should women persist to allow it to work/ side effects to reside?
3 months
332
What are the oestrogenic side effects of HRT?
```
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
```
333
What are the progestogenic side effects of HRT?
```
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
```
334
What is PCOS?
Polycystic ovarian syndome
335
What are the characteristic features of PCOS?
```
Ovarian cysts
Infertility
Oligomenorrhea/ amenorrhoea
Hyperandrogenism
Insulin resistance
```
336
What is oligoovulation?
Irregular, infrequent ovulation
337
What is hirsutism?
The growth of thick, dark hair (often on the face)
338
What is the diagnostic criteria for PCOS?
2 out of 3:
- Oligoovulation/ Anovulation
- Hyperandrogenism
- Polycystic ovaries on USS
339
How would oligoovulation/ anovulation present?
Irregular or absent periods
340
What are the effects of hyperandrogenism?
Hirsutism and acne
341
What is the Rotterdam criteria?
The criteria for making a diagnosis of PCOS
342
How does PCOS usually present?
```
Infrequent/ absent menstruation
Infertility
Obesity
Hirsutism
Acne
Hair growth in male pattern
```
343
What additional features may also be found in PCOS?
```
Insulin resistance/ diabetes
Acanthosis nigricans
Cardiovascular disease
Hypercholesterolaemia
Endometrial hyperplasia/ cancer
Obstructive sleep apnoea
Depression/ anxiety
Sexual problems
```
344
What is acanthosis nigricans?
Thick, rough skin usually in the axilla and elbows that occurs with insulin resistance
345
What are other causes of hirsutism?
Medications
Ovarian/ adrenal tumours
Cushing's syndrome
Congenital adrenal hyperplasia
346
What happens to insulin levels with insulin resistance?
The pancreas produces more in order to get a response
347
What effects does insulin have in PCOS?
- Promotes the release of androgens from the ovaries and adrenal glands
- Supresses SHBG production in the liver, therefore promoting hyperandrogenism
348
What is SHBG and what is its action?
Sex hormone-binding globulin/ Binds to androgens and suppresses their function.
349
What do higher levels of insulin result in?
Higher levels of androgens (e.g. testosterone)
| Halting development of follicles in the ovaries
350
What does reduced follicle develop cause?
Annovulation
| Multiple partially developed follicles (seen as polycystic ovaries on scan)
351
What investigations are done into PCOS?
Blood tests
Pelvic or transvaginal ultrasound
OGTT for diabetes
352
What blood tests are done to diagnose PCOS?
```
Testosterone
SHBG (Sex hormone-binding globulin)
LH
FSH
Prolactin
TSH
```
353
What would hormonal blood tests typically show in PCOS?
Raised LH
Raised LH:FSH ratio
Raised testosterone
Raised insulin
354
What imaging is the gold standard for visualising the ovaries?
TVUS
355
What may be seen on USS of PCOS?
'String of pearl' appearance of follicles around the ovary
356
What is the diagnostic criteria for PCOS on USS?
- 12 or more developing follicles in one ovary
| - Ovarian volume of >10cm^3
357
What are the key risks associates with PCOS?
Obesity
T2 Diabetes
Hypercholesterolaemia
Cardiovascular disease
358
How can the risks associated with PCOS be reduced?
```
Weight loss
Low GI, calorie-controlled diet
Exercise
Smoking cessation
Antihypertensives
Statins
```
359
What is the main management of PCOS and why?
Weight loss- alone can restore fertility and regular menstrution, improve insulin resistance and reduce other symptoms
360
What medication can be used to help weight loss in women with BMI over 30?
Orlistat (lipase inhibitor that stops absorption of fat in intestines)
361
What cancer are women with PCOS more at risk of and why?
```
Endometrial cancer:
-Amenorrhoea means they don't produce sufficient progesterone, resulting in endometrial hyperplasia
Also have other RF's=
-Obesity
-Diabetes
-Insulin resistance
```
362
At what endometrial thickness would women need to be referred for a biopsy to exclude endometrial hyperplasia/ cancer?
>10mm
363
What are the options for reducing the risk of endomtrial cancer in women with PCOS?
- Mirena coil (continuous protection)
| - Inducing a withdrawal bleed every 3-4 months with cyclical progesterones of COPC
364
How can infertility be managed in PCOS?
Weight loss
Clomifene
Laparoscopic ovarian drilling
IVF
365
What is the action of Clomifene?
Stimulates the release of gonadotropins, leading to the development of follicles and initiating ovulation
366
How is hirsutism managed in PCOS?
Weight loss
COPC: Co-cyprindiol= has anti-androgenic effect
Topical eflornithine
367
What is the risk of co-cyprindol and therefore how long should it be used for?
Increased risk of VTE so is stopped after 3 months
368
How is acne managed in PCOS?
COPC
| Topical, retinoids, antibiotics or azelaic acid
369
What are functional ovarian cysts?
Fluid-filled sacs that relate to the fluctuating hormones of the menstrual cycle
370
In which women are ovarian cysts more a cause for concern?
Postmenopausal women
371
How are ovarian cysts usually diagnosed?
Found incidentally on pelvic USS
372
How may ovarian cysts presents?
- Usually asymptomatic
- Pelvic pain
- Bloating/ fullness
- Palpable mass
- May have acute pelvic pain if there is a complications
373
What are the two types of functional cysts?
Follicular cycsts
| Corpus luteum cysts
374
What are follicular cysts?
When the developing follicle fails to rupture and release the egg, a cyst can persist
375
What is the most common ovarian cyst?
Follicular cyst
376
What are corpus luteum cysts?
Cysts that occur when the corpus luterum fails to break down and instead fills with fluid
377
What are other types of ovarian cyst?
```
Serous cystadenoma
Mucinous cystadenoma
Endometrioma
Dermoid cyst/ germ cell tyous
Sex cord-stromal tumours
```
378
What investigations are done into ovarian cysts?
USS
| CA125 tumour marker
379
What is the management of a <5cm simple cyst in premenopausal women?
No action required- will resolve in 3 cycles
380
What is the management of a 5-7cm simple cyst in premenopausal women?
Routine referal to gynaecology and yearly USS monitoring
381
What is the management of a <7cm simple cyst in premenopausal women?
MRI scan or surgical evaluation
382
What is the management of cysts in postmenopausal women?
If there is raised CA125, 2WW referral to gynaecology
| If simple <5cm, USS monitoring every 4-6 months
383
What is the management of persistent or enlarging cysts?
Laparoscopic surgical intervention (ovarian cystectomy with possible oophorectomy)
384
What are the main complications of ovarian cysts?
Torsion
Haemorrhage into cyst
Rupture
385
What is Meig's syndrome?
Triad of:
- Ovarian fibroma (benign ovarian tumour)
- Pleural effusion
- Ascites
386
What is ovarian torsion?
When the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply
387
What is the main causes of ovarian torsion?
- An ovarian mass >5cm (e.g. cyst or tumour)
| - Before menarche when the infundibulopelvic ligaments are longer
388
What is the main presenting feature of ovarian torsion?
Sudden onset severe unilateral pelvic pain that gets progressively worse and is associated with nausea and vomiting
389
What would be found on examination of ovarian torsion?
Localised tenderness with possible palpable mass
390
How is ovarian torsion diagnosed?
Pelvic USS or TVUS
391
What is found on USS of ovarian torsion?
'Whirlpool sign'
Free fluid in pelvis
Oedema of ovary
392
How is a definitive diagnosis of ovarian torsion made?
Laparoscopic surgery
393
What is the management of ovarian surgery?
Emergency laparoscopic surgery to either untwist it (detorsion) or remove it (oophorectomy)
394
What are the complications of ovarian torsion?
Ischaemia and necrosis to the ovary
If not removed, infection which can lead to an abscess and sepsis. If it ruptures it can result in peritonitis and adhesions.
395
What is Asherman's syndrome?
Where adhesions form within the uterus and cause symptoms
396
When does Asherman's syndrome usually occur?
After pregnancy-related dilation and curettage
397
What is D&C and when would it be performed?
Dilation and curettage: dilating cervix and scraping uterine lining to treat retained products of conception or after uterine surgery or infection
398
What is endometrial curettage and what are the complications?
Scraping the endometrium, which can damage the basal layer and cause adhesions
399
What may uterine adhesions cause?
May bind uterine walls together or seal the endocervix shut, leading to physical obstructions and distortion that can cause infertility, frequent miscarriages and menstrual abnormalities
400
What is the typical presentation of Asherman's syndrome?
Presents following recent D&C, uterine surgery or endometritis with:
- Secondary amenorrhoea
- Lighter periods
- Dysmenorrhoea
- Infertiity
401
How is Asherman's syndrome diagnosed?
Hysteroscopy =GS
Hysterosalpingography
Sonohysterography
MRU scan
402
How is Asherman's syndrome managed?
Dissection of adhesions during hysteroscopy
403
What are Nabothian cysts?
Fluid-filled cysts on the surface of the cervix
404
Why do nabothian cysts develop?
When the squamous epithelium of the ectocervix covers the mucus-secreting columnar epithelium of the endocervix, the mucus becomes trapped and forms a cyst.
405
What us atrophic vaginitis?
Dryness and atrophy of the vaginal mucosa related to lack of oestrogen
406
In what women does atrophic vaginitis occur?
Women entering menopause
407
What happens to the epithelial lining of the vagina in response to oestrogen?
It becomes thicker, more elastic and produces secretions
408
What happens to the vaginal mucosa as oestrogen levels fall?
It becomes thinner, less elastic and more dry making it more prone to inflammation
409
How does atrophic vaginitis present?
Itching
Dryness
Dyspareunia
Bleeding caused by localised inflammation
410
What are the effects of reduced oestrogen on menopausal women?
atrophic vaginitis
Pelvic organ prolapse and stress incontinence due to lack of oestrogen maintaining connective tissue
Increased infections due to change in vaginal pH and microbial flora
411
What will examination of atrophic vaginitis show?
```
Pale mucosa
Thin skin
Reduced skin folds
Erythema
Inflammation
Dryness
Sparse pubic hair
```
412
How can atrophic vaginitis be managed?
```
Vaginal lubricants
Topical oestrogen (cream, pessaries, tablets, ring)
```
413
What are Bartholin's glands?
The pair of glands on either side of the vaginal opening
414
What is a Bartholin's cyst?
When Bartholin's gland gets blocked and the gland swells and becomes tender
415
What happends when a Bartholin's cyst becomes infected?
It forms a Bartholin's abscess (red, hot tender abscess draining pus)
416
How are Bartholin's cysts managed?
Usually resolve with good hygeine, analgesia and warm compresses
417
How are Bartholin's abscesses managed?
Antibiotics
| May need surgical intervention
418
What is lichen sclerosus?
Chronic inflammatory skin condition that presents with patches of shiny white skin
419
Where is most affected by lichen sclerosus?
The labia, perineum and perianal skin
420
What causes lichen sclerosus?
Autoimmune condition
421
What is the typical presentation of lichen sclerosis?
Women aged 45-60
Vulval itching
Vulva skin changes
422
What is the Koebner phenomenon?
When the signs and symptoms are made worse by friction to the skin
423
What are other potential symptoms of lichen sclerosus?
```
Itching
Soreness and pain
Skin tightness
Superficial dyspareunia
Erosions
Fissures
```
424
What is the appearance of lichen sclerosus?
```
'Porcelain-white' colour
Shiny
Tight
Thin
Slightly raised
May be fissures, cracks, erosions and plaques
```
425
How is lichen sclerosus managed?
```
Topical steroids (Clobetasol propionate/ Dermovate)
Emollients
```
426
What are the complications of lichen sclerosus?
5% risk of developing squamous cell carcinoma of vulva
Pain/ discomfort
Sexual dysfunction
Bleeding
427
What is FGM?
Female genital mutliation
428
Where is FGM most commonly practiced?
```
African countries (Somalia most common) , Ethiopia, sudan,
Yemen, Kurdistan, Indonesia, Asia
```
429
What are the 4 types of FGM?
1: Removal or part/ all of clitoris
2: Removal or clitoris and labia minora and/or majora
3: Narrowing/ closing of vaginal orifice
4: all other unecessary procedures to the female genitalia
430
What risk factors should be looked out for to identify cases of FGM?
- Coming from community that practices FGM
- Having relatives affected by FGM
- Declining examintaion of cervical screening
431
What are the immediate complications of FGM?
```
Pain
Bleeding
Infection
Swelling
Urinary retention
Urethral damage and incontinence
```
432
What are the long term complications of FGM?
```
Vaginal/ pelvic infections
UTI's
Dysmenorrhea
Dyspareunia/ sexual dysfunction
Infertility/ pregnancy complications
Psychological issues/ depression
```
433
How is FGM managed?
- Mandatory reporting of all cases under 18 to the police (and social services, paeds, specialty FGM services, counselling)
- Educate about the legality and consequences
- In patients >18 use risk assessment tool as to whether to report.
- De-infibulation (corrects closure of vaginal orifice)
434
What are the main congenital structural abnormalities of the reproductive tract?
Bicornuate uterus
Imperforate hymen
Transverse vaginal septae
Vaginal hypoplasia and agenesis
435
In embryological development, where do the upper vagina, cervix, uterus and fallopian tubes develop from?
The paramesonephric (Mullerian) ducts
436
Why do males not develop a uterus?
Anti-Mullerian hormone
437
What is a bicornuate uterus?
When there are two horns to the uterus, giving it a heart shaped appearance
438
What are the potential complications of a bicronuate uterus?
Miscarriage
Premature birth
Malpresentation
439
What is imperforate hymen?
Where the hymen is fully formed without opening and covers the opening of the vagina
440
When will imperforate hymen be discovered?
When the female starts the menstruate and the menses are sealed in the vagina
441
What is the presentation of imperforate hymen?
Cyclical pelvic pain and cramping without vaginal bleeding
442
What is the diagnosis and treatment of imperforate hymen?
```
Diagnosis= clinical examination
Treatment= surgical incision
```
443
What happens if imperforate hymen is not treated?
Retrograde menstruation which leads to endometriosis
444
What is transverse vaginal septae?
When there is a wall of tissue running horizontally across the vagina, either perforate or imperforate (sealed or with a hole)
445
How will perforate transverse vaginal septae present?
Difficulty with intercourse of tampon use
446
How will imperforate transverse vaginal septae present?
Cyclical pelvic symptoms without menstruation
447
How is transverse vaginal septae diagnosed?
Examination
USS
MRI
448
How is transverse vaginal septae treated?
Surgical correction
449
What is vaginal hypoplasia?
An abnormally small vagina
450
What is vaginal agenesis?
An absent vagina
451
What causes vaginal hypoplasia/ agenesis?
Failure of the Mullerian ducts to develop properly
452
What is androgen insensitivity syndrome?
Where cells are unable to respond to androgen hormones due to lack of androgen receptors
453
What causes androgen insensitivity syndrome?
X-linked recessive genetic condition
454
What happens to the excess androgens in androgen insensitivity syndrome?
They are converted into oestrogen
455
What is the genotype/ phenotype of patients with androgen insensitivity syndrome?
Genetically male (XY chromosome) with female external phenotype due to lack of androgens.
456
How does androgen insensitivity syndrome present?
Inguinal hernias in infancy
| Primary amenorrhoea at puberty
457
What will be the results of hormone tests in androgen insensitivity syndrome?
Raised LH
Normal/ raised FSh
Normal/ raised testosterone
Raised oestrogen
458
How is androgen insensitivity syndrome managed?
```
MDT
Bilateral orchidectomy to avoid testicular tumours
Oestrogen therapy
Vaginal dilators/ therapy
Support/ counselling
```
459
How long should a couple try to conceive before investigating for infertility?
12 months
460
How many couple struggle to conceive naturally?
1 in 7
461
After how long of trying to conceive should investigation for infertility be initiated in women over 35 ?
6 months
462
What are the causes of infertility?
```
Sperm problems (30%)
Ovulation problems (25%)
Tubal problems (15%)
Uterine problems (10%)
Unexplained (20%)
```
463
What general advice is given to couples trying to get pregnant?
- Take 400mcg folic acid dily
- Aim for healthy BMI
- Avoid smoking and excessive drinking
- Reduce stress
- Aim for intercourse every 2-3 days
- Avoid timing intercourse and it leads to increased stress
464
What are the initial infertility investigations performed in primary care?
```
BMU
Chlamydia screen
Semen analysis
Female hormonal testing
Rubella immunity
```
465
What does female hormone testing involve when investigating infertility?
- Serum LH/ FSH day 2-5
- Serum progesterone on day 21
- Anti-Mullerian hormone
- Thyroid function tests
- Prolactin
466
What do high FSH levels indicate?
That there is poor ovarian reserve so the pituitary gland is producing extra FSH to try to stimulate follicular development
467
What might high LH levels indicate?
PCOS
468
What does a low level of progesterone on day 21 indicate?
That ovulation has not occurred so there is no corpus luteum secreting it
469
What hormone is the most accurate marker of ovarian reserve and why?
Anti-Mullerian hormone: released by the granulosa cells in the follicles and falls as eggs are depleted
470
What other infertility investigations may be completed in secondary care?
USS pelvis for polycystic ovaries/ structural abnormalities
Hysterosalpingogram
Laparoscopy and dye test to look at patency of fallopian tubes/ endometriosis/ adhesions
471
What is Hysterosalpingogram?
X-ray looking at the shape of the uterus and patency of the fallopian tubes
472
What are the treatment options when anovulation is the cause of infertility?
```
Weight loss
Clomifene (stimulates ovulation)
Letrozole
Gonadotropins
Ovarian driling
Metformin for insulin insensitivity/ obesity in PCOS
```
473
What is clomifene?
An anti-oestrogen given on days 2-6 of the menstrual cycle to stop the negative feedback of oestrogen on the hypothalamus, resulting in greater release of GnRH and therefore FSH and LH
474
What is ovarian drilling?
Laparoscopic surgery where multiple holes are drilling into the ovaries to improve the hormonal profile
475
What are management options when tubal factors are the cause of infertility?
Tubal cannulation
Laparoscopy to remove adhesions/ endometriosis
IVF
476
What management options are used when uterine factors are the cause of infertility?
Surgery to correct polyps, adhesions or structural abnormalities
477
How is male factor infertility assessed?
Semen analysis
478
What instructions should men be given when providing a sperm sample?
```
Abstain from ejaculation for at least 3 days
Avoid hot baths/ tight underwear
Attempt to catch full sample
Deliver sample within one hour
Keep sample warm
```
479
What lifestyle factors may affect the results of semen analysis & quality/ quantity of sperm?
```
Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine
```
480
When is a repeat sperm sample taken with borderline and abnormal results?
Borderline- after 3 months
| Abnormal- 2-4 weeks
481
What things does semen analysis look for and what are the normal results?
```
Semen volume (>1.5ml)
Semen pH (>7.2)
Concentration of sperm (>15 million per ml)
Total number of sperm (>39 million)
Motility of sperm (>40% are mobile)
Vitality of sperm (>58% are active
Percentage of normal sperm (>4%)
```
482
What is polyspermia?
High number of sperm in a semen sample (>250 million per ml)
483
What is normospermia?
Normal characteristics of sperm in sample
484
What is oligospermia?
Reduced number of sperm in semen sample
485
How can oligospermia be classified?
Mild (10-15 million/ ml)
Moderate (5-10 million/ml)
Severe (<5 million/ ml)
486
What is cryptozoospermia?
Very few sperm in the semen sample (<1 million/ml)
487
What is azoospermia?
Abscence of sperm in the semen
488
What causes pre-testicular infertility?
Hypogonadotrophic hypogonadism causing low levels of testosterone needed for sperm production
489
What are the causes of Hypogonadotrophic hypogonadism in males?
- Pituitary/ hypothalamic pathology
- Suppression due to stress/ chronic conditions/ hyperprolactinaemia
- Kallman syndrome
490
What are the testicular causes of infertility?
```
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
Genetic/ congenital disorders
```
491
What are post-testicular causes of infertility?
Obstruction caused by:
- Damage from trauma/ surgery/ cancer
- Ejaculatory duct obstruction
- Retrografe ejaculation
- Scarring from epididymitis (chlamydia)
- Abscence of vas deferens (Cystic fibrosis)
- Young's syndrome
492
What initial investigations are done into male factor infertility?
```
Semen analysis
History
Examination
Repeat sample
USS testes
```
493
What further investigations may to considered to look into male factor infertility?
```
Hormonal analysis (FSH/LH/ Testosterone)
Genetic testing
Imaging
Vasography
Testicular biopsy
```
494
What are the management options for male factor infertility?
```
Surgical sperm retrieval
Surgical correction
Intra-uterine insemination
Intracytoplasmic sperm injection
Donor insemination
```
495
What is surgical sperm retrieval and when is it used?
When there is a blockage somewhere along the vas deferens preventing the sperm from being ejaculated, a needle and syringe is used to collect sperm directly from the epididymis
496
What is intra-uterine insemination?
Collecting and seperating out high-quality sperm and injecting them directly into the uterus
497
What is intracytoplasmic sperm injection?
Injecting sperm directly into the cytoplasm of an egg
498
When might intrauterine insemination (IUI) be used instead of IVF?
Donor sperm for same-sex couples
HIV (To avoid unprotected sex)
Practical issues with vaginal sex
499
What is the success rate of each cycle of IVF?
25-30%
500
What does one cycle of IVF involve?
Single episode of ovarian stimulation and collection of oocytes. May produce several embryos which can be transferred seperately in multiple attempts at pregnancy
501
What happens to embryos that are not used immediately?
They are frozen to be used at a later date
502
What are the steps involved in IVF?
```
Suppressing menstrual cycle
Ovarian stimulation
Oocyte collection
Insemination/ Intracytoplasmic sperm injection
Embryo culture
Embryo transfer
```
503
What are the two methods of suppressing the natural menstrual cycle in IVF?
GnRH agonists
| GnRH antagonists
504
What happens if a GnRH agonist is used?
An injection of GnRH agonist is given in the luteal phase (day 21) to stimulate the pituitary gland to secrete large amounts of FSH and LH, which causes negative feedback to supress the natural production of GnRH and stop the menstrual cycle
505
What happens for the GnRH antagonist protocol?
Daily subcutaneous injections of a GnRH antagonist are given starting from day 5-6 of ovarian stimulation to supress the body releasing LH and therefore supressing normal ovulation
506
Why is it necessary to supress the natural menstrual cycle in IVF?
If the gonadotropins weren't supressed, ovulation would occur and follicles would be released before it is possible to collect them
507
What does ovarian stimulation involve?
Using medications to promote the development of multiple follicles in the ovaries:
1. Sub-cut FSH injections from day 2-12
2. Monitoring the development of follicles with TVUS
3. Trigger injection: When there are enough follicles of adequate size, stop FSH and hCG injection given to stimulate final maturation of follicles.
508
How are oocytes collected?
Under sedation with the guidance of TVUS. Needle inserted through vaginal wall into each ovary to aspirate follicular fluid which contains the mature oocytes.
509
How are oocytes then inseminated?
Male produces semen sample and sperm and egg mixed in culture medium
510
Why do thousands of sperm need to be combined with each oocyte?
To produce enough enzymes for a sperm to penetrate the corona radiata and zona pellucide
511
What happens once the oocyte has been inseminated?
The fertilised eggs are left in an incubator for 2-5 and observed until the reach the blastocyst stage of development when the highest quality embryos are selected for transfer/
512
How are embryos transferred?
Catheter placed into the uterus. Single embryo is injected and the catheter is removed.
513
How long after egg collection is a pregnancy test performed?
Around day 16
514
What needs to be given from the time of oocyte collection until 8-10 weeks gestation and why?
Progesterone suppositories to mimic the progesterone that would be released from the corpus luteum in a normal pregnancy
515
What are the main complications of IVF?
```
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
Pain/ bleeding/ infection during egg collection
```
516
What is OHSS?
Ovarian hyperstimulation syndrome
517
What triggers OHSS?
The hCG trigger injection given 36 hours before oocyte collection--> HCG stimulates the release of vascular endothelial growth factor (VEGF) which increases vascular permiability and causes the ovaries to swell
518
What are the risk factors for OHSS?
```
Younger age
Low BMI
Raised anti-Mullerian hormone
Higher antral follicle count
PCOS
Raised oestrogen levels
```
519
How is OHSS prevented?
During gonadotropic stimulation, they are monitored with serum oestrogen levels and USS
520
How may OHSS present?
```
Abdominal pain/ bloating
N&V
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from ruptured follicles
Prothrombotic state
```
521
How is the severity of OHSS determined?
Based on clinical features:
Mild= abdo pain/ bloating
Moderate= N&V/ ascites
Severes= Ascites, oliguria, low albumin, high potassium
Critical= tense ascites, anuria, thromboembolism, acute respiratory distress
522
How is OHSS managed?
```
Supportive:
Oral fluids
Monitor urine output
LMWH
Ascitic fluid removal
IV colloids
```
523
What are the key methods of contraception?
```
Natural family planning
Barrier methods
COPC
POP
Copper coil
Mirena coil
Implant
Progesterone injection
Surgery (sterilisation/ vasectomy
Emergency contraception
```
524
What are the 4 levels used to assess the risk of different contraceptions in individuals?
```
UKMEC1= No restriction
UKMEC2= Benefits outweigh risk
UKMEC3= Risks outweigh benefits
UKMEC4= Unacceptable risk
```
525
Which are the most reliable methods of contraception with typical use?
Surgery
Coils
Progesterone implant
526
What contraception should be avoided in women with breast cancer?
Hormonal contraception: use copper coil or barrier methods
527
What contraception should be avoided in women with cervical or endometrial cancer?
IUD
528
What contraception should be avoided in women with Wilson's disease?
Copper coil
529
What specific risk factors would cause you to avoid the COCP?
```
Uncontrolled hypertension
Migraine with aura
History of VTE
>35 and smoking >15 per day
Major surgery with prolonged immobility
Vascular disease/ stroke
Ischaemic heart disease/ cardiomyopathy /atrial fibrillation
Liver cirrhosis/ tumours
SLE/ Antiphospholipid syndrome
```
530
How long after the last period should post menopausal be on contraception?
2 years if <50
| 1 year if >50
531
Why should the progesterone injection not be given to women over 50?
It increases the risk of osteoporosis
532
What are the different barrier methods of contraception?
Condoms
Diaphragms/ cervical caps
Dental dams
533
How effective are condoms?
98% with perfect use
| 82% with typical use
534
What should be avoided when using condoms?
Oil-based condoms as they can damage the latex
535
How should diaphragms be used?
Silicone cup fitted over cervix before having sex and left for at least 6 hours afterwards. Should be used with spermicide gel
536
What are dental dams used for?
During oral sex to provide a barrier between the mouth and vulva, vagina and anus to prevent infection
537
How effective is the COCP?
99% with perfect use
| 91% with typical use
538
How does the COCP prevent pregnancy?
1. Prevents ovulation
2. Progesterone thickens cervical mucus
3. Progesterone inhibits proliferation of endometrium reducing risk of successful implantation
539
How does the COCP prevent ovulation?
Negative feedback effect on hypothalamus and anterior pituitary suppresses the release of GnRH, LH and FSH, preventing ovulation
540
What happens to the endometrium when taking the combined pill?
It is maintained in a stable state
541
What happens to the endometrium when the pill is stopped?
It breaks down and sheds, leading to a withdrawal bleed
542
What are the two types of COCP?
Monophasic pills
| Multiphasic pills
543
What are monphasic pills?
Contain the same amount of hormone in each pill
544
What are multiphasic pills?
Contain varying amounts of hormone to match normal cyclical changes more closely
545
What is the first line COPC and why?
Microgynon (monophasic with 7 inactive pills)
| Lower risk of VTE
546
What type of oestrogen and progesterone do the first line COCP's contain?
```
Oestrogen= ethinylestradiol
Progesterone= Levonorgestrel or norethisterone
```
547
What type of COCP's are first line for PMS and why ?
Those containing drosipernone (e.g. Yasmin) as it has anti-mineralocorticoid and anti-androgen activity so can help with bloating, water retention and mood changes
548
What type of COCP's are first line for acne and hirsutism and why?
Those containing cyproterone acetate (e.g. Dianette) as it has anti-androgen effects
549
What are the 3 most common regimes used when taking the COCP?
1. 21 days on, 7 days off
2. 63 days on (3 packs) and 7 days off
3. Continuous use
550
What are the main side effects of taking the COCP?
- Unscheduled bleeding
- Breast pain/ tenderness
- Mood changes/ depression
- Headaches
- Hypertension
551
What are the main risks of taking the COCP?
- VTE
- Increased risk of breast/ cervical cancer
- MI/ stroke
552
What are the benefits of taking the COCP?
- Contraception
- Rapid return of fertility after stopping
- Improvement in PMS, menorrhagia, dysmenorrhoea
- Reduced risk of endometrial, ovarian and colon cancer
- Reduced risk of benign ovarian cysts
553
What are the contraindications to taking the COCP? (UKMEC 4)
- Uncontrolled hypertension
- Migraine with aura
- History of VTE
- >35 smoking >15 cigarettes a day
- Major surgery with prolonged immobility
- Vascular disease/ stroke
- IHD/ Cardiomyopathy/ AF
- Liver cirrhosis/ Liver tumours
- SLE/ Antiphospholipid syndrome
554
What factor makes the risk of taking the COCP UKMEC3?
BMI > 35
555
At what stage in the cycle should the COCP be started and why?
Day 1 of cycle as this offers protection straight away
556
What should be used if the COCP is started after day 5 of the cycle?
Extra contraception for 7 days
557
What should happen if switching between COCPs?
Finish one pack then immediately start the new one without a pill free period
558
What should happen if switching from a POP to a COCP?
7 days of contraception used
559
What should be discussed when prescribing the COCP?
```
Different options including LARC
Contraindications
Adverse effects
Instructions
Factors that impact efficacy
STI protection
Safeguarding concerns
```
560
What contraindications should be screened for when prescribing the pill?
```
Age
BMI
BP
Smoking status
PMH (migraine, VTE, Cancer, Cardiovascular disease, SLE)
FH (VTE, breast cancer)
```
561
What is classified as missing one pill?
More than 24 hours late (48 hours since last pill taken)
562
What should the woman do if one pill is missed?
- Take missed pill ASAP (even if that means 2 in one day)
| - No extra protection required
563
What should the woman do if more than one pill is missed?
- Take most recent missed pill ASAP
| - Additional contraception until have taken pill for 7 days straight
564
What should the woman do if she missed more than one pill during day 1-7 in the packet?
Need emergency contraception of had unprotected sex
565
What should the woman do if she missed more than one pill during day 8-14 in the packet?
If day 1-7 was fully compliant need no emergency contraception
566
What should the woman do if she missed more than one pill during day 15-21 in the packet?
No emergency contraception needed if days 1-14 were fully compliant but should go back-back with next pack of pills
567
In theory, in what cycle of pill usage will women be protected if taken perfectly?
7 days on, 7 days off
568
What can reduce the effectiveness of the pill?
Vomiting
Diarrhoea
Certain medications
569
When should the COCP be stopped?
4 weeks before a major operation or any procedure that requires the lower limb to be immobilised
Age 50
570
How is the POP taken?
Continuously
571
How effective is the POP?
99% with effective use
| 91% with perfect use
572
Des the COCP or POP have more contraindications/ risks?
POP has far fewer contraindications & risks
573
What are the 2 types of POP?
Traditional (e.g. Norgeston, Noriday)
| Desogestrerl-only pill
574
When is considered a 'missed pill' when taking the traditional progesterone-only pill?
If it is >3 hours late
575
When is considered a missed pill when taking the desogestrel-only pill?
>12 hours late
576
How does the traditional progesterone-only pill work?
Thickens cervical mucus
Alters endometrium to make implantation less successful
Reduces ciliary action in fallopian tubes
577
How does the Desogestrel pill work?
Inhibits ovulation
578
At what points in the cycle does starting the POP mean the woman is protected immediately?
Day 1-5
579
For how long is additional contraception required if the POP is started at other times in the cycle and why?
48 hours (takes 48 hours for cervical mucus to thicken enough to prevent sperm entering uterus)
580
How long does it take for the POP vs the COCP to become effective and why?
POP- 48 hours for cervical mucus to thicken enough to prevent sperm entering uterus
COCP- 7 days to inhibit ovulation
581
Can the POP/ COCP be taken even if there is a risk of pregnancy?
POP- Yes
| COCP- Must rule out pregnancy first
582
What should happen when switching between POPs?
No extra protection required
583
What should happen when switching from a COCP to a POP?
Should aim to change on day 1-7 after finishing COCP pack with no extra protection required.
If switching immediately, need to use contraception for first 48 hours of POP
584
What are the main adverse effects of the POP?
Unscheduled bleeding
Breast tenderness
Headaches
Acne
585
After how long does unscheduled bleeding usually settle?
3 months (should investigate for other causes after this)
586
What changes to bleeding schedule may the POP have and how many women do these effect?
20% No bleeding
40% regular bleeding
40% irregular, prolonged or troublesome bleeding
587
What can the POP make you more at risk of?
Ovarian cysts
Ectopic pregnancy
Breast cancer
588
What should happen if a POP is missed?
Take the pill ASAP and continue the next pill at the usual time, with extra contraception for 48 hours
589
What is the Progesterone-only injection also known as?
Depot medroxyprogesterone acetate (DMPA)
590
How frequently is the progesterone-only injection given?
12-13 week intervals
591
How is the progesterone-only injection given?
IM or Sub-cut injection of medroxyprogesterone acetate
592
How effective is the progesterone-only injection?
99% with perfect use
| 94% with imperfect use (forgetting to book injection)
593
How long can it take for fertility to return after stopping injections?
Up to 12 months
594
What are the two versions of progesterone-only injection used in the UK?
```
Depo-Provera (IM)
Sayana Press (self-injected sub cut)
```
595
What are the UKMEC 4 and UKMEC 3 contraindications to the progesterone-only injection?
```
UKMEC4: Active breast cancer
UKMEC3: Ischaemic heart disease/ stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
```
596
What is the main risk factor of the progesterone-only injection and therefore in which women should this be considered?
Osteoporosis
| Older women and patients on steroids (for asthma/ inflammatory conditions)
597
What is the mechanism of action of the progesterone-only injection?
Inhibits ovulation by inhibiting FSH secretion by the pituitary gland
(Also thickens cervical mucus and alters the endometrium to make implantation less successful)
598
When should the progesterone-only injection be given to offer immediate protection?
Day 1-5
599
If the progesterone-only injection is given after day 5 of the menstrual cycle, how long should additional contraception be used?
7 days
600
What are the main sides effects of the progesterone-only injection?
```
Changes to bleeding schedule (may become highly irregular but usually stops altogether after 1 year)
Weight gain
Acne
Reduced libido
Mood changes
Headaches
Flushes
Hair loss
Skin reactions at injection site
```
601
What is the biggest risk of the progesterone-only injection and why?
Osteoporosis --> Oestrogen helps maintain bone mineral density in women so suppressing the development of the follicles reduces the amount of oestrogen produced
602
Which two side effects are unique to the progesterone-only injection?
Weight gain
| Osteoporosis
603
What are the benefits of the progesterone-only injection?
Improves dysmenorrhoea
Improves endometriosis symptoms
Reduces risk of endometrial and ovarian cancer
Reduces the severity of sickle cell crisis
604
Where the the progestogen-only implant placed?
Upper arm, beneath skin and above subcutaneous fat
605
How long does the progestogen-only implant last before it needs replacing?
3 years
606
How effective is the progestogen-only implant ?
99%
607
What is the only contraindication for the progestogen-only implant?
Active breast cancer
608
What is the name of the implant used in the UK and what does it contain?
Nexplanon, contains 68mg of etonogestrel
609
How does the progestogen-only implant work?
Inhibits ovulation
Thickens cervical mucus
Makes endometrium less accepting of implantation
610
What point of the cycle does inserting the implant offer immediate protection and what should happen if its inserted after this?
Day 1-5= immediate protection
| After this, need 7 days extra contraception
611
What are the benefits of the implant ?
```
Effective contraception
Can improve dysmenorrhoea
Can make periods lighter/ stop
No need to remember to take pills
Doesn't cause weight gain
No effect on bone mineral density
No increase in thrombosis risk
```
612
What are the drawbacks of the implant?
Requires minor operation which may have complications
Can worsen acne
No STI protection
May cause problematic bleeding
Can become impalpable or deeply implanted
613
What changes to bleeding pattern may occur with the implant and how many women does this effect?
1/3 infrequent bleeding
1/3 frequent or prolonged bleeding
1/5 no bleeding
614
What should be given to help ease problematic bleeding when using a progesterone-only form of contraception?
COCP for 3 months to help settle the bleeding
615
What is LARC?
Long-acting reversible contraception
616
What are the two types of IUD?
Copper coil
| Levonorgestrel intrauterine system (LNG-IUS) - Mirena
617
How effective are coils?
99%
618
How soon after removal of coils does fertility return?
Immediately
619
What do IUD and IUS refer to?
```
IUD= Copper coil
IUS= Mirena coil
```
620
What are the contraindications to coils?
```
PID/ Infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (fibroids)
```
621
What should be screened for before coil insertion?
Chlamydia
| Gonorrhoea
622
What happens during coil insertion?
Bimanual examination to check size/ position of uterus
Speculum insertion to fit device
Forceps stabilise cervix while device is inserted
Record BP and HR during
623
How long after coil insertion should women be seen and why?
3-6 weeks to check the threads and ensure coil is in place
624
What are the risks associated with coil insertion?
```
Bleeding
Pain on insertion
Vasovagal reactions
Uterine perforation
PID
Expulsion
```
625
What needs to happen before the coil can be removed?
Women need to abstain from sex/ use condoms for 7 days
626
What needs to be excluded when coil threads can't be seen or palpated?
Expulsion
Pregnancy
Uterine perforation
627
What investigations would be carried out if coil threads can't be seen/ palpated?
USS
Abdo/ pelvic xray
Hysteroscopy or laparoscopic surgery may be required
628
For how long can the copper coil be inserted?
5-10 years
629
When is the copper coil contraindicated?
Wilson's disease
630
How does the copper coil work?
Copper is toxic to the ovum and sperm
| Alters endometrium to make it less accepting of implantation
631
What are the benefits of the IUD?
Reliable contraception
Effective immediately at any time of cycle
Contains no hormones so no risk of VTE/ cancer
632
What are the drawbacks of the IUD?
```
Risks of procedure
Can cause heavy/ intermenstrual bleeding
May have pelvic pain
No protection against STI's
Increased risk of ectopic pregnancies
5% fall out
```
633
What are the 4 types of IUS?
Mirena
Levosert
Kyleena
Jaydess
634
How long can the mirena coil be inserted?
5 years (4 years as HRT)
635
For what reasons can the mirena coil be used?
Contraception
Menorrhagia
HRT
636
How does the mirena coil work?
Releases progesterone (levonorgestrel) into local area to thicken mucus, alter endometrium and inhibit ovulation in some women/
637
Up to what day of the menstrual cycle can the LNG-IUS be inserted without the need for additional contraception?
Day 7
638
What are the benefits of the LNG-IUS?
```
Can make periods lighter/ stop
May improve dysmenorrhoea or pelvic pain
No effect on bone mineral density
No increase in thrombosis risk
No restrictions for obese patients
Has additional uses
```
639
What are the drawbacks of the LNG-IUS?
```
Risks of procedure
Can cause spotting/ irregular bleeding
May cause pelvic pain
No protection against STI's
Increased risk of ectopic pregnancies
Increased risk of ovarian cysts
Systemic absorption may cause side effects
5% fall out
```
640
How long does irregular bleeding usually go on for when the LNG-IUS is inserted?
Around 6 months
641
What may be found incidentally during a smear test in women with an IUD?
Actinomyces-like organisms (don't require treatment)
642
What are the 3 options for emergency contraception?
Levonorgestrel
Ulipristal
Copper coil
643
What is UPSI?
Unprotected sexual intercourse
644
How long after intercourse should Levonorgestrel be taken?
Within 72 hours
645
How long after intercourse should Ulipristal be taken?
Within 120 hours
646
How long after intercourse can the coil be inserted as emergency contraception?
Within 5 days of UPSI or within 5 days of estimated date of ovulation
647
What is the most effective form of emergency contraception?
Copper coil
648
What can the two oral methods of contraception be affected by?
BMI
Enzyme-inducing drugs
Malabsorption
649
Why is the copper coil the most effective form of contraception?
It is toxic to the ovum and sperm, and inhibits implantation
650
What may copper coil insertion cause?
Pelvic inflammatory disease
651
For how long should the coil be kept in if used as emergency contraception?
Until at least the next period (though can be kept in as long-term contraception)
652
What is Levonorgestrel?
A type of progesterone (used in the IUS or as emergency contraception)
653
What dose of Levonorgestrel is used as emergency contraception?
1.5mg as single dose
| 3mg in women >70kg or BMI>26
654
What is the common side effects of taking Levonorgestrel as emergency contraception?
Nausea and vomiting (need to take another dose if vomit within 3 hours)
655
What is Ulipristal?
A selective progesterone receptor modulator used as emergency contraception
656
What is Ulipristal better known as?
EllaOne
657
What are the notable restrictions to taking Ulipristal?
Avoid breastfeeding for 1 week
| Should be avoided in those with severe asthma
658
What is the female sterilisation procedure?
Tubal occlusion
659
What happens during tubal occlusion?
Clips are used to occlude the fallopian tubes using laparoscopy under general anaesthesia
660
What other options are there for female sterilisation?
Tube tying, cutting or removal
661
What is the male sterilisation procedure?
Vasectomy
662
What does a vasectomy involve?
Cutting the vas deferens, to prevent the sperm travelling from the testes to join the ejaculated fluid
663
What must happen after a vasectomy before it can be relied upon as contraception?
Semen testing 12 weeks after to confirm absence of semen
664
When can children under 16 make decisions about their own treatment?
When they are deemed to have Gillick competence
665
What is Gillick competence?
Judging whether the understanding/ intelligence of a child is sufficient to consent to treatment.
666
What are the Frazer guidelines?
Specific guidelines for providing contraception to patients under 16 without parental input/ consent
667
What criteria is included in the Frazer guideline?
1. Mature/ intelligent enough to understand treatment
2. Can't be persuaded to discuss with parents
3. Likely to have intercourse regardless
4. Physical/ mental health will suffer without treatment
5. It's in their best interests
668
What is bacterial vaginosis?
(BV) Overgrowth of anaerobic bacteria in the vagina
669
What causes bacterial vaginosis?
Loss of lactobacilli (friendly bacteria) in the vagina
670
What is the main component of healthy vaginal bacterial flora?
Lactobacilli
671
What is the action of Lactobacilli?
Produce lactic acid that keeps the vaginal pH low (<4.5) and prevents other bacteria from overgrowing
672
Why does an absence of lactobacilli enable anaerobic bacteria to multiply in the vagina?
Lactobacilli produce lactic acid which creates an acidic environment, so when there are reduced numbers the pH rises and the alkaline environment enables anaerobic bacteria to multiply
673
What can BV increase the risk of in women?
Developing STI's
674
What are some examples of anaerobic bacteria associated with BV?
Gardnerella vaginalis
Mycoplasma hominis
Prevotella
675
What are the main risk factors for developing bacterial vaginosis?
```
Multiple sexual partners
Excessive vaginal cleaning
Recent antibiotics
Smoking
Copper coil
```
676
Is BV sexually transmitted?
No
677
What factors can reduce your risk of BV?
COCP
| Using condoms effectively
678
How does bacterial vaginosis present?
(Half asymptomatic)
-
Fishy-smelling watery grey/ white discharge
679
How is BV investigated?
- Speculum examination to confirm typical discharge
- Vaginal pH test with swab and pH paper
- High vaginal swab to rule out other causes
680
What does BV look like on microsopy?
'Clue cells'- Epithelial cells from the cervix that have bacteria stuck inside them
681
How is BV managed?
```
If asymptomatic needs no treatment, and may resolve itself.
Metronidazole antibiotic (orally or by vaginal gel)
Provide advice on how to avoid in future (e.g. cleaning)
```
682
What should be avoided when taking Metronidazole?
Alcohol (can cause N&V, flushing etc)
683
What are the potential complications of BV?
Increases risk of catching STI's
| Can cause pregnancy complications
684
What is vaginal candidiasis more commonly known as?
Thrush (or candida)
685
What is the most common cause of vaginal candidiasis?
Candida albicans (type of fungus/ yeast)
686
What happens after the candida colonises the vagina?
It may not cause symtoms until the right environment occurs
687
What changes to environment can cause candida to progress to infection?
During pregnancy
| After treatment with broad-spectrum antibiotics
688
What are the risk factors for developing vaginal candidiasis?
Increased oestrogen (e.g. pregnancy)
Poorly controlled diabetes
Immunosuppression
Broad-spectrum antibiotics
689
What are the symptoms of vaginal candidiasis?
Thick, white discharge (no odour)
| Vulval/ vaginal itching/ irritation/ discomfort
690
How is vaginal candidiasis investigated?
(Treatment often started based on presentation)
Test vaginal pH
Charcoal swab with microscopy can confirm dignosis
691
What are the treatment options for candidiasis?
Antifungals:
- Cream
- Pessary
- Oral tablets
692
What is the usual antifungal medication used to treat vaginal candidiasis?
Clotrimazole
693
What OTC treatment is often used to treat thrush?
Canesten Duo (contains fluconazole tablet and clotrimazole cream)
694
What should women be advised when using antifungal creams/ pessaries?
That they can damage latex condoms so should use alternative contraceptions for at least 5 days after use
695
What is the most common STI in the UK?
Chlamydia
696
What kind of organism is chlamydia trachomatis?
Gram-negative bacteria
697
How does chlamydia spread in the body?
It is an intracellular organism that enters and replicated in cells before rupturing and spreading to other cells
698
What are the risk factors for catching chlamydia?
Young
Sexually active
Having multiple partners
699
What percentage of chlamydia cases are asymptomatic?
50% in men
| 75% in women
700
What does the National Chlamydia Screening Programme aim for?
To screen every sexually active person <25 for chlamydia annually or when changing sexual partners
To re-test positive cases after 3 months
701
What is tested on an STI screen (as a minimum)?
Chlamydia
Gonorrhoea
Syphilis
HIV
702
What are the two types of swab used in sexual health testing?
Charcoal swabs
| Nucleic acid amplification test (NAAT) swabs
703
What do charcoal swabs allow to be tested for?
Microscopy
Culture
Sensitivities
704
What type of swabbing can charcoal swabs be used for?
Endocervical swabs
| High vaginal swabs
705
What conditions can charcoal swabs confirm?
BV
Candidasis
Gonorrhoeae
Trichomonas vaginalis
706
What does NAAT look for?
The DNA/ RNA of an organism
707
What conditions can NAAT confirm?
Chlamydia
| Gonorrhoea
708
What type of swabbing can be done with NAAT swab?
Vulvovaginal swab
Endocervical swab
First-catch urine sample
(Rectal and pharyngeal)
709
If gonorrhoea is proven on a NAAT, what needs to happen?
An endocervical charcoal swab must be done to look for microscopy, culture and sensitivities
710
If chlamydia is symptomatic, how might it present in women?
```
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding
Painful sex
Painful urination
```
711
If chlamydia is symptomatic, how might it present in men?
Urethral discharge/ discomfort
Painful urination
Epididymo-orchitis
Reactive arthritis
712
What should be considered if sexually active patients are presenting with anorectal symptoms (discomfort, discharge, bleeding, change in bowel habits)?
Rectal chlamydia or lymphogranuloma venereum
713
What may be found on examination of chlamydia?
Pelvic/ abdominal tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
714
How is chlamydia diagnosed?
NAAT:
| Vulvovaginal/ endocervical/ urethral/ rectal/ pharyngeal swab or first-catch urine sample
715
What is the first-line treatment for uncomplicated chlamydia?
Doxycycline 100mg
| Twice a day for 7 days
716
When would doxycycline be contraindicated as chlamydia treatment?
In pregnancy and breastfeeding
717
What should happen when someone is being treated for chlamydia?
- They should abstain from sex until treatment is complete
| - They should be referred to GUM for contact tracing
718
What are the main complications of infection with chlamydia?
```
PID
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lyphogranuloma venereum
Reactive arthritis
```
719
What are the pregnancy complications of chlamydia?
```
Preterm delivery
PROM
Low birth weight
Postpartum endometritis
Neonatal infection
```
720
What is lymphogranuloma venereum?
Condition that affects the lymphoid tissue around site of chlamydia infection
721
What are the 3 stages of lymphogranuloma venereum?
```
Primary= Painless ulcer
Secondary= Lymphadenitis
Tertiary= Inflammation of rectum and anus (may cause tenesmus)
```
722
What is tenesmus?
The feeling of needing to empty the bowels when they are empty
723
How is lymphogranuloma venereum treated?
21 days Doxycycline
724
What is chlamydial conjunctivitis?
Chlamydia infection of the conjunctiva of the eye (usually happens when genital fluid comes in contact with the eye)
725
What kind of organism is gonorrhoea?
Gram-negatie diplococcus bacteria
726
How does gonorrhoea cause infection?
Infects mucous membranes with a columnar epithelium (e.g. endocervix) and then spreads via contact with the mucous secretions from these infected areas
727
What is the concern with gonorrhoea treatment?
There is a high level of antibiotic resistance and the traditional things used to treat it can no longer be used
728
What percentage of presentations are symptomatic with gonorrhoea?
90% men
| 50% women
729
How may gonorrhoea present in women?
Odourless purulent discharge (may be green/ yellow)
Dysuria
Pelvic pain
730
How may gonorrhoea present in men?
Odourless purulent discharge (may be green/ yellow)
Dysuria
Testicular pain/ swelling
731
How is gonorrhoea diagnosed?
NAAT to detect the RNA or DNA
| Charcoal swab for microscopy, culture and antibiotic sensitivities to guide antibiotic treatment
732
What is the first-line treatment for uncomplicated gonorrhoeal infections if sensitivities are not known?
Single dose of IM Ceftriaxone 1g
733
What is the first-line treatment for uncomplicated gonorrhoeal infections if sensitivities are known?
Single dose of oral Ciprofloxacin 500mg
734
After how long should patients treated for gonorrhoea have a test of cure?
72 hours after treatment for culture
7 days after treatment for RNA NAT
14 days after for DNA NAAT
735
What are the complications of gonorrhoea?
```
PID
Chronic pelvic pain
Infertility
Epididymo-orchitis
Prostatitis
Conjunctivitis
Urethral strictures
Disseminated gonococcal nfection
Skin lesions
```
736
What is a key complication of neonatal gonorrhoea passed down from the mother?
Ophthalmia neonatorum (gonococcal conjunctivitis)- medical emergency associated with sepsis and blindness
737
What is disseminated gonococcal infection?
Complication of untreated gonococcal infection where bacteria spreads to skin and joints
738
What is PID?
Pelvic inflammatory disease
739
What causes PID?
Infection spreading up through the cervix
740
What are the kay complications of PID?
Tubular infertility
| Chronic pelvic pain
741
What are the 3 most common causes of PID?
Gonorrhoea
Chlamydia
Mycoplasma genitalium
742
What are non-sexually transmitted causes of PID?
Gardnerella vaginalis
Haemophilus influenzae
E. coli (UTI)
743
What are the risk factors for PID?
Same as any other STI:
- Not using barrier contraception
- Multiple partners
- Young age
- Existing STI's
- Previous PID
- IUD
744
How may PID present?
```
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding
Dyspareunia
Fever
Dysuria
```
745
What may examination of PID reveal?
Pelvic tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
746
How is PID investigated?
NAAT swabs for gonorrhoea, chlamydia and Mycoplasma genitalium
HIV test
Syphilis test
High vaginal swab for bacterial vaginosis, candidiasis and trichomoniasis
Microscopy to look for pus cells
Inflammatory markers
747
How is PID managed?
Refer to GUM for contact tracing
| Empirial antibiotics started before confirmation, followed by necessary local antibiotic regime
748
What is a typical regime for the treatment of PID ?
1. Single dose of IM ceftriaxone (for gonorrhoea)
2. 14 Dyas Doxyccycline (for chlamydia/ mycoplasma genitalium)
3. 14 days Metronidazole (for garnerella vaginalis)
749
What are the complications of PID?
```
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis Syndrome
```
750
What is Fitz-Hugh-Curtis Syndrome?
Complication of PID that causes inflammation of the liver capsule, leading to adhesions between the liver and peritoneum.
751
What is Trichomonas vaginalis?
A type of parasite spread through sexual intercourse
752
What type of organism is trichomonas vaginalis?
Protozoan, single-celled organism with flagella (parasite)
753
Where does trichomonas live in infected men/ women?
```
Men= Urethra
Women= Vagina
```
754
What can Trichomonas vaginalis increase the risk of?
```
Contracting HIV
Bacterial vaginosis
Cervical cancer
PID
Pregnancy-related complications
```
755
How does Trichomonas vaginalis present?
```
50 % asymptomatic
50% non specific syptoms:
- Vaginal discharge
-Itching
-Dysuria
-Dyspareunia
-Balanitis
```
756
What is the typical description of discharge with Trichomonas vaginalis?
Frothy, yellow- green discharge with fishy smell
757
What may examination reveal with Trichomonas vaginalis?
'Strawberry cervix' (inflammation with tiny haemorrhages)
| Raised vaginal pH
758
How can Trichomonas vaginalis be diagnosed?
Standard charcoal swab with microscopy
759
How is Trichomonas vaginalis managed?
GUM referral
| Treat with Metronidazole
760
What is Mycoplasma genitalium?
STI that causes non-gonococcal urethritis
761
What is the key feature of Mycoplasma genitalium?
Urethritis
762
How does MG present?
Most are asymptomatic
| May present similarly to chlamydia
763
How is MG diagnosed?
NAAT from first urine sample (men) or vaginal swab (women)
764
How is MG treated?
Doxycycline for 7 days followed by Azithromycin
765
What is HSV?
The herpes simplex virus
766
What is HSV most commonly responsible for?
```
Cold sores (herpes labialis)
Genital herpes
```
767
What are the two most common strains of herpes?
HSV-1
| HSV-2
768
What happens after initial infection with herpes?
The virus becomes latent in the associated sensory nerve ganglia
769
Which nerve ganglia does the herpes virus usually live in with cold sores?
Trigeminal nerve ganglion
770
Which nerve ganglia does the herpes virus usually live in with genital herpes?
Sacral nerve ganglia
771
What else can the HSV cause?
Apthous ulcers
Herpes keratitis
Herpetic whitlow
772
How is HSV spread?
Direct contact with affected mucous membranes or viral shedding in mucous secretions
773
When is asymptomatic viral shedding most common?
In the first 12 months of infection
774
What is HSV-1 most associated with?
Cold sores
775
When is HSV-1 usually contracted?
In childhood (before 5)
776
When does HSV-1 usually reactivate?
In times of stress
777
What is HSV-2 most associated with?
Genital herpes
778
What are the main symptoms of initial genital herpes infection?
```
May be asymptomatic
Ulcers or lesions to the genitals
Neuropathic pain
Flu-like symptoms
Dysuria
Inguinal lymphadenopathy
```
779
How long do symptoms last with initial infection and do they get better or worse with recurrent infections?
3 weeks
| Milder and more quickly resolved with recurrent infections
780
How is herpes diagnosed?
History to try to establish source of infection
Clinical diagnosis with history/ examination findings
May do viral PCR from lesion to confirm
781
How is herpes managed?
Aciclovir
| Symptomatic management
782
What is the main complication of genital herpes during pregnancy?
Risk of neonatal herpes simplex infection contraction during labour or delivery
783
How is primary genital herpes contracted before 28 weeks gestation managed?
Aciclovir followed by prophylactic aciclovir starting from 36 weeks
(may need C-section is symptoms are present)
784
How is primary genital herpes contracted after 28 weeks gestation managed?
Aciclovir followed immediately by regular prophylactic aciclovir
C-section
785
How is recurrent genital herpes managed in pregnancy?
Consider prophylactic aciclovir from 36 weeks
786
What causes Syphilis?
Treponema pallidum bacteria
787
What is the incubation period between infection and symptoms with syphilis?
21 days
788
How can syphilis be contracted?
Through oral, vaginal or anal sex
Vertical transmission
IV drug use
Blood transfusions/ transplants
789
What are the 5 stages of syphilis?
```
Primary
Secondary
Latent
Tertiary
Neurosyphilis
```
790
What is primary syphilis?
A painless ulcer (chancre) at the original site of infection
791
What is secondary syphilis?
Systemic symptoms that resolve after 3-12 weeks
792
What is latent syphilis?
When symptoms disappear and the patient becomes asymptomatic despite being infected.
793
After how long does it become late latent syphilis instead of early latent syphilis?
After 2 years
794
What is tertiary syphilis?
When many years after initial infection, syphilis may affect many organs of the body
795
What is neurosyphilis?
When the infection involves the CNS and presents with neurological symptoms
796
How does primary syphilis present?
Painless genital ulcer that resolves in 3-8 weeks
| Local lymphadenopathy
797
How does secondary syphilis present?
```
Maculopapular rash
Condylomata lata (wart)
Low-grade fever
Lymphadenopathy
Alopecia
Oral lesions
```
798
How may tertiary syphilis present?
Gummatous lesions
Aortic aneurysms
Neurosyphilis
799
How may neurosyphilis present?
```
Headache
Altered behavious
Dementia
Tabes dorsalis
Ocular syphilis
Paralysis
Sensory impairment
```
800
What is the specific finding found in neurosyphilis?
Argyll-Robertson pupil: constricted pupil that accommodates when focusing on a near object but does not react to light
801
How is syphilis
| diagnosed?
Antibodies for antibodies to T. pallidum
802
How is syphilis managed?
GUM
| Single deep IM dose of penicillin
803
What comes first, HIV or AIDS?
AIDS= acquired immunodeficiency syndrome that comes as HIV progresses
804
What type of organism is HIV?
RNA retrovirus
805
What is the mechanism of HIV?
Enters and destroys CD4-T helper cells
806
How is HIV transmitted?
Unprotected sex
Vertical transmission
Exposure to infected blood or bodiliy fluids
807
What is the course of HIV?
Inital flu-like infection, then asymptomatic until progresses to immunodeficiency
808
What causes AIDS-defining illnesses?
When the CD4 count drops to a level that allows for opportunistic infections
809
What are some examples of AIDS- defining illnesses?
```
Kaposi's sarcoma
PCP (pneumonia)
Cytomegalovirus
Candidiasis
Lymphomas
Tuberculosis
```
810
For up to how long after infection can HIV antibody tests remain negative and why?
Up to 3 months as it taes this long to develop antibodies to the virus
811
Who should be screened for HIV?
Practically everyone admitted to hospital and especially those with risk factors
812
How is HIV screened for?
Antibody blood test
813
How is HIV monitored?
CD4 count
814
What is the normal CD4 rage?
500-1200 cells
815
What range of CD4 cells indicated end-stage HIV?
<200 cells
816
How can you assess the HIV viral load?
PCR testing for HIV RNA
817
How is HIV treated?
ART
818
What is ART?
Antiretroviral therapy
819
What does ART involve?
Tailored treatment that aims to achieve normal CD4 count and undetectable viral load
820
What is HAART?
Highly active anti-retrovirus therapy medication
821
What are the medications used in HAART therapy?
Protease inhibitors
Integrase inhibitors
Nucleoside reverse transcriptase inhibitors
Non-nucleoside reverse transcriptase inhibitors
Entry inhibitors
822
What additional management should be used to treat those with HIV?
Prophylactic septrin to protect against PCP
Monitoring of cardiovascular health
Yearly cervical smears
Vaccinations
823
How can you prevent HIV transmission during birth if there is a high viral load?
C-section and IV zidovudine
| Baby given Zidovudine for 4 weeks
824
Should mothers with HIV breastfeed?
NO
825
What can be used to prevent HIV developing?
PEP (post-exposure prophylaxis)
826
How soon after potential exposure should PEP e given?
<72 hours
827
What does PEP involve?
A combination of ART therapy ( Truvafa and raltegravir for 28 days)
