Gynae Flashcards
(188 cards)
1
Q
Menstrual cycle - HPO axis
A
*Effect of oestrogen on pituitary hormones switches when concentration increases beyond a threshold
2
Q
What are the 2 phases of the menstrual cycle?
A
Follicular phase and luteal phase
3
Q
How long does follicular phase last?
A
From day 1 of menstrual cycle up to ovulation (approx 14 days)
4
Q
What happens during follicular phase?
A
LH and FSH stimulates growth of follicles in the ovaries.
Follicular growth produces oestrogen -> oestrogen builds endometrium
5
Q
What are the LH and FSH levels during follicular phase?
A
Oestrogen release from follicle is gradually increasing - whilst it is still low, LH and FSH production is inhibited thus decrease
Once oestrogen past critical threshold, positive feedback effect and surge in LH and FSH (LH much higher)
6
Q
What does surge in LH trigger?
A
Ovulation
7
Q
What happens in ovulation?
A
A maure egg is released from the ovary
8
Q
What happens during luteal phase?
A
Follicle that has released its egg becomes corpus luteum –> progesterone release
Progesterone maintains endometrial lining
9
Q
Why does endometrial lining break down?
A
No implantation + corpus luteum is out of progesterone (has enough for 14 days)
10
Q
Differentials for bleeding + abdo pain in early pregnancy
A
- Ectopic pregnancy
- Miscarriage
11
Q
Ectopic pregnancy
A
Implantation of a conceptus outside uterine cavity
12
Q
Ectopic pregnancy clinical features
A
- Lower abdo pain (often to one side)
- PV bleeding
13
Q
Ectopic pregnancy RFs
A
- Previous abdo/pelvic surgery (adhesions)
- IUD
- PID
- Assisted conception
- Progesterone only pill
14
Q
Ectopic pregnancy Ix
A
- Urien B-hCG
- TV USS (empty uterus, free fluid in pouch of Douglas)
- Serum B-hCG
15
Q
Ectopic pregnancy Mx - 3 categories
A
Expectant
Medical
Surgical
16
Q
When to consider expectant management for ectopic pregnancy?
A
- Clinically stable
- Pain free
- Ectopic ≤ 35mm w/o heartbeat
- Serum hCG ≤ 1000IU/L
- Able to return for follow up
17
Q
Expectant mx for ectopic pregnancy
A
- Repeat serum hCG on days 2, 4, 7
- Ensure downtrending - ≥15% drop on e/ occasion
18
Q
When to consider medical management for ectopic pregnancy?
A
- Significant pain
- Ectopic ≤ 35mm w/o heartbeat
- Serum hCG ≤ 1500IU/L
- No intrauterine pregnancy
- Able to return to follow up
19
Q
Medical Mx ectopic pregnancy
A
IM Methotrexate
20
Q
Management of ectopic pregnancy
hCG 1500-5000 w/o heartbeat
A
Offer either medical or surgical
21
Q
When to consider surgical mx for ectopic pregnancy?
A
- Significant pain
- Ectopic >35mm
- Ectopic with hearbeat
- hCG ≥ 5000IU/L
22
Q
Surgical Mx of Ectopic pregnancy
A
Salpingectomy
(affected fallopian tube removed)
+ anti D prophylaxis for anti D-ve mums
23
Q
How long after methotrexate should you wait to conceive?
A
At least 3/12
24
Q
Ruptured ectopic pregnancy Mx
A
Definitive:
Diagnostic laparoscopy w/ views towards laparoscopic salpingectomy
- Admit pt to ward
- Escalate to gynae seniors
- A to E approach (2x large bore cannulae + G&S +/- IV Hartmanns)
- Consent pt for surgery
- Speak to ER theatre team
- On call anaesthetist to see pt
- Prep pt for surgery (NBM, cross match 4 units blood)
25
Miscarriage
Pregnancy ending spontaneously before 24 weeks gestation
26
What are the 5 types of miscarriage?
* Threatened
* Inevitable
* Incomplete
* Complete
* Missed
27
What are the USS and clinical findings of each of a threatened miscarriage?
USS
* Intrauterine pregnancy with heartbeat
Clinical
* Vaginal bleeding
* Abdominal pain
* Closed os
28
What are the USS and clinical findings of each of an inevitable miscarriage?
USS
* Intrauterine pregnancy without heartbeat
Clinical
* Vaginal bleeding
* Abdominal pain
* Open cervical os
29
What are the USS and clinical findings of each of an incomplete miscarriage?
USS
* Retained products of conception
Clinical
* Vaginal bleeding
* Abdominal pain
* Open os
* Visible products of conception
30
What are the USS and clinical findings of each of a complete miscarriage?
USS
* Empty uterus
* Needs to have previously been visualised on USS
Clinical
* Resolved PV bleed
* Closed os
31
What are the USS and clinical findings of each of a missed miscarriage?
USS
* Intrauterine pregnancy without heartbeat
Clinical
* Asymptomatic
32
Miscarriage Ix
Bedside
* Urinary pregnancy test
* Speculum + bimanual
* TVUSS
33
Threatened miscarriage Mx
Monitoring
34
Miscarriage Mx (3)
Expectant, medical, surgical
35
Miscarriage expectant mx
* Wait for bleeding and pain to resolve in 7-14 days
* Pregnancy test after 3 weeks
Rescan if pain and bleeding -
* Not started
* Persisting/worsening
36
Miscarriage medical mx
* Vaginal misoprostol
* Pain relief
* Anti-emetics
+ Pregnancy test after 3 weeks
37
Medical miscarriage safety netting
* Vaginal bleeding
* Pain
* Diarrhoea
* Vomiting
* 10% failure rate
38
Miscarriage surgical Mx
* Manual vacuum aspiration
* Local anaesthetic
* Surgical mx in theatre
* GA
* More advanced misc!
* + offer Anti D prophylaxis
39
Recurrent miscarriage
3 or more consecutive miscarriages
40
Increased risk of miscarriages
* Thyroid disease
* Uterine anomaly
* e.g., fibroid
* Chromosomal abnormality
* Blood clotting disorder
* Antiphospholipid syndrome
41
Recurrent miscarriage Ix
Bedside
* TVUSS
Bloods
* TFTs
* Thrombophilia screen
* Antiphospholipid syndrome screen
* Cytogenetic analysis
* Individual and partner
42
Antiphospholipid syndrome triad
* Recurrent miscarriage
* Venous thromboembolism
* Thrombocytopaenia (low platelets)
43
What are the 2 blood tests done in antiphospholipid syndrome screen?
Lupus anticoagulant
Anticardiolipin antipodies
44
Antiphospholipid syndrome Mx
* Low dose aspirin
* LMWH in future pregnancies
45
Termination of pregnancy options
Medical
Surgical
46
What time frame (gestation) can medical TOP be considered?
Before 24 weeks (from last menstrual period)
47
Medical mx for TOP
\<10 weeks - can be done at home
10-12 weeks - either :)
13-23+6 in clinic
1. **Mifepristone**, then
2. **Misoprostol**
48
How does Mifepristone work?
Anti-progestogen - precipitate break down of endometrial lining and conceptus to come out with it
49
How does misoprostol work?
Prostaglandin analogue stimulates uterine contractions
50
When can feticide be considered in TOP?
From 21+6 weeks to ensure no signs of life once born
51
Surgical mx of TOP
\<14 weeks
* Suction curettage
* Can be done under GA
* Insertion of vacuum tube via cervix + curettage to remove any remaining pregnancy tissue
14 - 23+6 weeks
* Dilation & evacuation
* GA in theatre
* Similar to suction curettage but use of forceps to remove larger tissue
52
Gestational trophoblastic disease / molar pregnancy
Spectrum of tumours and tumour-like conditions characterised by proliferation of pregnancy-associated trophoblastic tissue
/ pt:
A molar pregnancy is when there's a problem with a fertilised egg, which means a baby and a placenta do not develop the way they should after conception. A molar pregnancy is not viable.
53
Molar pregnancy presentation
* Irregular PV bleeding
* Hyperemesis gravidarum
* HUGE amount of hCG produced
* Large for date uterus
* Mass growing way quicker than usual preg would
* HTN
54
Complete mole aetiology
2 sperm (23X x2), or 1 sperm (23X) fuse with an **empty egg** (containing no genetic material)
If 1 sperm, then it duplicates itself -\> overall 46 XX fertilised egg -\> all the genetic material purely male -\> overdose male chromosomes -\> excessive growth
55
Partial mole aetiology
2 normal sperm (23X x2) or 1 sperm with full set of chromosomes (46XY) fuses with **normal egg (23X)**
--\> 69XXY
Huge abundance of chromosomes in fertilised egg --\> overdose of chromosomal material from male partner --\> excessive growth
56
Molar pregnancy Ix
Bedside
* Urinary pregnancy test
Bloods
* Serum hCG
* out of proportion w gestation
* FBC + G&S
* Likely need surgical intervention
* TFT
* excess bHCG can affect thyroids
Imaging
* TVUSS
* Bunch of grapes/
* Snowstorm appearance - complete
57
Molar pregnancy mx
* Suction curettage
* GTD centre follow up
* Serial quantitative beta-HCG
If gestational trophoblastic neoplasia
* Chemotherapy at GTD centre
58
Heavy menstrual bleeding Ddx
* Endometriosis
* Adenomyosis
* Fibroids
* IUD
* Endometrial hyperplasia
59
Menorrhagia Ix
TVUSS
\*Diagnostic laparoscopy
60
Endometriosis
Endometrial tissue outside the uterine cavity
61
Endometriosis presentation
* Cyclical (or chronic) pelvic pain
* Dysemnorrhea
* Deep dyspareunia
* IMB
* Haematuria
* Painful bowel movement
* Chronic fatigue
62
Endometriosis Ix
* USS
* Diagnostic laparoscopy
63
Endometriosis Mx
Medical
* NSAIDs
* Mefenamic acid
* COCP/IUS
* GnRH agonists
* Goserelin
Surgical
* Ablation or excision
* Fertility-sparing
* Hysterectomy with bilateral salpingo-oophorectomy
www.endo.org.uk - Endometriosis UK
64
Adenomyosis
Endometrial tissue is found deep within myometrium
65
Adenomyosis Mx
Medical
* Tranexamic acid
* NSAID
* Mefenamic acid
* **IUS
Surgical
* Uterine artery ablation
* Endometrial ablation
* Hysterectomy
66
Fibroids
Benign tumour of the uterine smooth muscle (myometrium)
- oestrogen sensitive
67
Fibroid presentation
* Menorrhagia
* Urinary frequency
* Back pain
* Bloating
* ±pelvic mass o/e
68
What are the different types of fibroids?
* Submucosal
* Intramural
* Subserosal
* Pedunculated
69
Fibroids Mx
Fibroid \<3cm
* 1st line: LNG-IUS
* reduces menstrual blood loss, some studies showed a reduction in uterine fibroids size
* 2nd line
* Non-hormonal: Tranexamic acid (if no dysmen), or mefenamic acid (if dysmen)
* Hormonal: Other contraception
* 3rd line -\> Specialty referral
* Endometrial ablation
* Hysterectomy
Fibroid ≥3cm
* Specialist referral
* Whilst ^ awaiting: Tranexamic acid ± mefenamic acid
In 2ndry care
* Pharmacological treatment — hormonal (LNG-IUS, CHC, or cyclical oral progestogens) or non-hormonal (NSAIDs or tranexamic acid)
* Uterine artery embolization.
* Surgery - transcervical resection of fibroids, myomectomy, hysterectomy, or endometrial ablation
70
Causes of irregular periods
* Raised prolactin
* Disturbed thyroid function
* Severe anaemia
* Contraception
* PCOS
71
What criteria is used to define PCOS?
Rotterdam criteria
72
What is needed to diagnose PCOS?
* Oligo/anovulation
* \>2 years
* Hyperandrogenism
* Clinical: weight gain, hirutism, acne
* Biochemical: Increased testosterone
* Polycystic ovaries on USS
* (≥12 in one ovary measuring 2-9mm)
73
PCOS Ix
Bloods
* LH (often raised) and FSH (often normal - raised in ova failure, low in hypothalamic disease)
* **High LH**:FSH
* Total testosterone
* Normal/elevated
* Calculate free androgen index from total testosterone - physiologically active testosterone: normal to raised
* Sex hormone binding globulin (SHBG)
* low
* Prolactin
* Rule out hyperprolactinaemia
* TFTs
* Rule out thyroid dysfunction
* Cortisol
* Rule out cushings
Imaging
* TVUSS
74
PCOS Mx
Symptomatic
* Weight loss
* Acne
* COCP
* ±Topical retinoid
* Co-cyprindiol
* Hirsutism
* COCP
* Facial hirsutism: topical eflornithine
Menstruation
* Prolonged amenorrhea (less than one period every three months)
* progestogen (such as medroxyprogesterone) to induce withdrawal bleed, then
* Refer for a transvaginal ultrasound to assess endometrial thickness
* If abnormal, biopsy referral
* If normal --\>
* COCP
* IUS/IUD
Subfertility
* Weight loss
* Smoking cessation
* Clomiphene
* Stimulates ovulation
* Metformin
* Stimulates ovulation
* 2nd line in clomiphene resistance
* Laparoscopic ovarian drilling
* May help release some eggs
Moreover
* Offer screening for impaired glucose tolerance and type 2 diabetes
* Offer screening for CVD RFs: HTN, lipid levels
75
Infertility Ix
Bedside
* General exam: hirsutismm, acne (PCOS)
* Abdo exam: mass (ova cyst)
* Pelvic exa, (PID, endometriosis)
* BMI
Bloods
* FBC (IDA)
* Mid luteal phase progesterone (high in fertile individuals)
* To confirm ovulation
* Chlamydia screen
If irreg cycles: gonadotrophin (FSH & LH)
* TFTs (thyroid dysfunction)
* Prolactin (hypeerprolactinaemia)
* AMH (not on NHS)
Imaging
* TVUSS
Others
* Semen analysis
76
Primary amenorrhea Mx
* Refer to 2ndry care to rule out causes
* Gynae
* Endo if hyperprolactinaemia, thyroid disease, or features of androgen excess
* Manage amenorrhoea caused by weight loss, excessive exercise, stress, chronic illness
* Reduce exercise, incr calorie intake
* Dietitian
* Psych (if ED)
* CBT
* Osteoporosis risk mx
* Vit D + Ca
* Consider HRT if amenorrhea persists \>12 months
Healthy lifestyle + weight bearing exercise
77
Premature ovarian failure
Occurrence of menopause under the age of 40. 1% of women.
78
Premature ovarian failure Ix
**DIAGNOSIS: 2x FSH results \>30 (4-6 weeks apart)**
* Day 2 FSH, LH, Oestradiol
* **FSH & LH raised**
* ****FSH very high as your body produces high levels to try to stimulate your ovaries
* Oestrogen low
* Testosterone level
* Rule out PCOS
* TFTs
* Rule out thyroid dysfunction
* Prolactin
* Rule out prolactinaemia
* Antral follicle count or anti-mullerian hormone (test of Ovarian reserve - produced by ovaries and levels drop nearer to menopause)
* Semen analysis
79
Premature ovarian insufficiency Mx
Definitive
* COCP (if needing contraception), or
* Combined progesterone and oestrogen cyclical HRT
Additional
* ±ca and vit D
Having children
* Permanent early menopause will affect your ability to have children naturally.
* 1 in 10 POI w/o known cause still get pregnant
* You may still be able to have children by using IVF and donated eggs from another woman, or using your own eggs if you had some stored.
* Surrogacy (surrogacy UK) and adoption (Adoption UK) may also be options for you.
The Daisy Network – a support group for women with premature ovarian failure
80
Premature ovarian insufficiency
Consequences
* Increased risk hypothyroid disease
* Osteoporosis
* Sexual dysfunction (due to dyspareunia from vaginal dryness)
* Insomnia (due to hot flushes)
81
Premature ovarian failure
Advice for assisted conception
Donor oocyte IVF
82
Lifestyle + Non-hormonal/symptomatic menopause Mx
Lifestyle
* Regular exercise + weight loss (if applicable)
* Wearing lighter clothing/layers of clothing
* Turning down central heating/sleeping in a cooler room
* Using fans
* Reducing stress
* Avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol)
Non hormonal/symptom Mx
* Vasor motor syx
* SSRIs, e.g.. fluoxetine, citalopram
* Clonidine (an alpha-2 adrenergic receptor agonist)
* Mood disorder
* Self help
* CBT
* Dyspareunia
* Lubrication
R/v after 3 months then annually thereafter
83
What are the 2 formulations of HRT?
* Oestrogen only
* Combined (O+P)
84
When would you use E only HRT?
Women without a womb
(Increased risk endometrial Ca)
85
Continuous v cyclical combined HRT
* If pt has intermittent periods = Cyclical
* No periods for \>12/12 = continuous
86
Pros of HRT
* Improved vasomotor syx
* Prevent osteoporosis
* Improved genital syx
87
Cons of using HRT
* Increased risk breast Ca
* O+P
* Increased risk CVD
* Increased risk VTE
88
SE of HRT PILL v patch
Pill incr risk VTE
89
Emergency contraception
1. 3 types
2. How long each can be used for
3. Efficacy
4. Any caveats/ special notes
* IUD Copper coil
1. Up to 5 days/120h after UPSI or expected ovulation date
2. 99%
* Ulipristal actetate/ Ellaone 30mg
1. Up to 5 days/120h after UPSI
2. 85%
3. Repeat if vomit within 3h + caution for asthmatics
* Levonorgesterel / Levonelle 1500mcg
1. Up to 3 days/72h after UPSI
2. 95% within 24h then 58% up till 72h
3. Double dose if \>70kg or BMI \>26 + repeat if vomit within 2h
90
How does the COCP work?
Prevents ovulation
91
How does COCP affect periods?
Makes them lighter
92
Return to fertility on COCP
Upon stopping
93
Absolute contraindications for COCP
* Breast cancer
* Migraine w aura
* VTE
* ≥35 and ≥15 cigarettes a day
94
How does POP work?
Thickens cervical mucus
95
POP affect on periods
May get irreg bleeding
96
What are the different types of LARC?
* Coil
* IUS
* IUD
* Implant
* Depot injection
97
What hormone does the IUS have?
Levonorgestrel
98
How long does the IUS last?
3-5 years
99
How does the IUS work?
Prevents fertilisation
thickens the mucus from the cervix (opening of the womb), making it harder for sperm to move through
100
How does IUS affect periods?
Lighter periods -\> amenorrhoea
101
How long does the IUD work?
5-10 years
102
How does the IUD work?
Sterile inflammation
(release copper ions, which are toxic to sperm.)
103
How does IUD affect periods?
Heavier + more painful
104
What type of hormone is used in depot injection?
Depo-provera = medroxyprogesterone acetate (progestin)
105
How long does the implant last?
3 years
106
What type of hormone(s) is/are in the implant? How does the implant work?
Progesterone only. Prevents ovulation (and fertilisation - thickens cervical mucus)
107
Implant SE
Irregular bleeding
108
How does the implant effect periods?
Irregular periods
109
Return to fertility on implant
Rapid
110
How long does depot last?
12-14 weeks (3 months ish)
111
Main side effect of depot
Weight gain
112
Return to fertility on depot
Delayed
113
How does patch application work?
Weekly patches applied for 3 weeks, with 1 week off (withdrawal bleed)
114
Problems with patch
Adherence (to skin)
Skin sensitivity
115
Ovarian Ca Presentation
* Abdominal bloating
* Loss of appetite
* Pelvic/abdo pain
* Constipation/diarrhoea
* Urinary problems
* PMB
* **Pelvic mass**
* **Ascites**
116
Ovarian Ca RFs
* Age
* FHx
* Many ovulations (early menarche, late menopause, nulliparity)
* Smoking
* Obesity
117
Ovarian Ca Ix
* Abdo exam
* TVUSS
* Ca125
* CT/MRI
* For staging
118
Ovarian Ca Mx
* Total hysterectomy with bilateral salpingo-oophorectomy
* Platinum based chemo
* F/u
119
Which ovarian mass has solid components on USS?
Germ cell tumour
120
Post menopausal bleed Ddx
* Endometrial ca
* Hyperplasia w/o malignancy
* Benign endometrial polyps
* Cervical polyps
* Vaginal atrophy
* Vulval atrophy
121
Endometrial Ca Presentation
* Post menopausal bleeding
122
Endometrial ca RF
* Obesity
* More oestrogen released from subcutaneous fat
* Oestrogen-only HRT
* Tamoxifen
* Oestrogenic effect on uterus
* Nulliparous
* PCOS
123
Endometrial Ca Ix
* TVUSS
* Normal endometrial lining \<4mm post menopause, \<10mm pre men
* Pipelle biopsy
* Hysteroscopy if cant be performed
* CT/MRI
* Staging
124
Endometrial Ca Mx
Low grade tumour/atypical endothelial hyperplasia (not quite malignant)
* High dose progestogen
Otherwise
* Total hysterectomy with BSO
125
Cervical Ca Presentation
* Post coital bleeding
* Intermentsrual bleeding
126
Cervical Ca RFs
* HIV
* Prev HPV
* Smoking
* Multiple sexual partners
* Prolonged use of COCP
127
Cervical Ca screening - which HPVs are looked for?
HPV 16/18
128
How does cervical screening work?
Smear taken -\> test sample for HPV 16/18
If +ve, looked at under microscope for cytology -cervical intra-epithelial neoplasia (CIN)
129
Cervical Ca screening outcomes
Inadequate smear: Repeat in 3/12 -\> inadequate smear -\> colposcopy
HPV -ve: Routine recall (3 years)
HPV +ve & cytology normal: 1 year recall
HPV+ve & abnormal cytology (dyskariosis): colposcopy & biopsy
130
What is the cervical screening schedule?
25 - 49: Every 3 years
50 - 64: Every 5 years
65 and above: Only if 1 of last 3 tests were abnormal
131
Cervical ca screening biopsy results and mx
1) Normal
2) CIN1
3) CIN 2
4) CIN 3
5) CGIN
(Cervical Glandular Intra-epithelial Neoplasia)
1. Routine recall
2. 12 month recall
3. - 5. Removal of cells - LLETZ (large loop excision of the transformation zone) + cervical screening (test of cure) after 6/12
132
!Cervical Ca vax
For Human papillomavirus (HPV) - Gardasil
6, 11, 16, 18
HP6+11= genital warts
16+18 = cervical ca
*Offered to all y9 school children (12-13)*
133
Cervical ca Ix
* Vaginal + sepc exam
* Cervical smear
* only if overdue
* Vaginal swabs
* Biopsy
* Colposcopy
134
Cervical ca Mx
Depends on staging
* Surgical
* hysterectomy
* cone biopsy w negative markers
* Radiotherapy
* Chemotherapy
* cisplatin
135
Pelvic inflammatory disease
Ascending infection of the female reproductive tract
136
PID Ix
Bedside
* Bimanial + speculum
* Cervical excitation
* Endocervical swab
* For chlamydia and gonorrhoea
* High vaginal swab
* Anaerobes
Bloods
* FBC -\> WBC
* CRP
* Blood culture
Imaging
* TVUSS
* Check for development of tubo-ovarian abscess
137
PID Mx
! IM Ceftriaxone 500mg STAT + PO Doxycycline 100mg BD 14 days + PO Metronidazole 400mg BD 14 days
(If pen allergic: PO Ofloxacin + Metronidazole 14 days)
* Consider IUD removal
* STI screen
* Contact tracing
* Counsel about subfertility
138
Vaginal d/c
* Cottage cheese w/o foul smell + itchy vulva -\> Candida albicans (thrush)
* Fish-grey d/c -\> bacterial vaginosis
* Yellow-green w/ pain -\> trichomonas vaginalis
* White/yellow/grey foul -\> Chlamydia trachomatis
139
Most common reason for foul vaginal d/c in children?
Vulvovaginitis
140
HSV presentation
* White lesion on labia
* painful urination
141
HSV Mx
Lesion
* Topical aciclovir
Suppression
* Oral aciclovir
142
Trichomonas vaginalis presentation
frothy yellow/green d/c + dyspareunia and strawberry cervic
143
Syphilis Presentation
Primary syphilis
* Chancre - painless lesions on genitals or mouth
* Lymphadenopathy
144
2 main types of urinary incontinence
1. Urge incontinence
2. Stress incontinence
* Bladder unable to close itself fully so when incr intra-abdo pressure, you get leakage
145
Urge incontinence Mx
1. Discuss diet + fluid intake + bladder retraining (6 weeks)
2. Anticholinergics
* Tolterodine
* This over oxybutynin in frail elderly
* Oxybutynin
3. Beta 3 agonist
* Mirabegranon
4. Surgical
* Botox injection
* Percutaneous nerve stimulation
* Sacral nerve stimulation
146
Stress incontinece Mx
Lifestyle changes
* Reducing caffeine intake — this may improve symptoms of urgency and frequency but not incontinence.
* Fluid intake — advise the woman to avoid drinking either excessive amounts, or reduced amounts, of fluid each day.
* Weight loss if the woman's body mass index is 30 kg/m2 or greater. For more information, see the CKS topic on Obesity.
* Smoking if this is appropriate — for more information, see the CKS topic on Smoking cessation.
1. Pelvic floor excercises (min 3 months)
- at least 8 contractions x 3/day
- squeezy app
2. Duloxetine
* Only 2nd line if pt doesn't want surgical mx
* Awful side effects :(
3. Surgical procedures
* Intramural urethral bulking agent
* Autologous rectus fascial sling
* Burch colposuspension
147
What is the cause of constant urinary dribbling?
vesicovaginal fistula
148
Urinary incontinence Ix
* Bladder diary
* Min 3 days
* Urodynamic testing
149
Urodynamics - what does unprovoked pressure peaks with urinary leakage indicate?
Overactive bladder secondary to detrusor overactivity
150
Pelvic organ prolapse Mx
Conservative
* Losing weight if BMI\>30
* Minimise heavy lifting
* Preventing/treating constipation
* **Pelvic floor muscle training**
Medical
* Pessary
Surgical
Urocele
* Anterior wall repair
Vault prolapse
* sacrocolpoplexy
Uterine prolapse
* Vaginal hysterectomy
Rectocele
* Posterior wall repair
151
What scoring system is used to assess severity of pelvic organ prolapse?
POP Q
152
Turner's syndrome presentation
Teenager presenting
* Short
* No signs development of secondary sexual characteristics
* Widely spaced nipples
* Systolic murmur under L clavicle
153
Turner's syndrome/primary amenorrhoea Ix
* FSH/LH
* Raised due to negative feedback to try compensate for lack of oestrogen/progesterone
154
Which Ix confirms Tuner's?
Karotyping
155
Imperforate hymen presentation
* Cyclical pain
* Developed 2ndry sexual characteristics
156
What to do if you come across FGM?
Under 18 - police
18 and over - safeguarding lead
157
Most common cause Azoospermia
Mumps orchitis
158
Azoospermia Mx for getting pregnant
ICSI - Intracytoplasmic sperm injection
| (Type of IVF)
159
Blocked fallopian tubes Mx for getting pregnant
IVF
160
Ovarian cyst mx
* Women with small (less than 50 mm diameter) simple ovarian cysts
* Women with simple ovarian cysts of 50–70 mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.
* If surgery, lap removal
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What size is classed as a small ovarian cyst?
\<50mm
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What is the management for a small simple ovarian cyst?
Generally do not require follow-up as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles.
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\>70mm simple ovarian cyst Mx
Surgical intervention - laparoscopic removal
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Which ovarian cyst contains hair and teeth?
(Mature cystic) Teratoma
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Which ovarian cyst shows ground glass appearance on USS?
Endometrioma/chocolate cysts
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Recovery time post-hysterectomy
* Vaginal or laparoscopic hysterectomy: 1- 4 days inpt
* Abdominal hysterectomy: up to 5 days inpt
* GP r/v 4-6 weeks
* hosp if complicates
* 6 to 8 weeks to fully recover after abdominal hysterectomy
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PMS Mx
+ r/v after 2/12 + keeping syx diary
Mild
* Lifestyle advice
* Regular, frequent, small meals rich in complex carbs
* Reg exercise
* Reg sleep
* Stress reduction
* Alcohol reduction
* Smoking cessation
* Paracetamol or NSAIDs for pain
Moderate
* Combined oral contraceptive pill
* CBT referral
Severe
* SSRI
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Why are COCPs used for PMS?
they suppress ovulation, which is thought to contribute to PMS
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Contraception prior to sterilisation
Use until the day of operation and up until next period after surgery
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What is a nodule on the uterosacral ligament indicative of?
Endometriosis
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What does high vaginal swab (HVS) test for?
BV + candidiasis
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What do endocervical swabs test for?
Gonorrohoea and chlamydia
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Bartholin's cyst presentation
painless fluid-filled lump near the opening of the vagina
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Bartholin's abscess presentation
acutely painful large swelling near the opening of the vagina
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Atrophic vaginitis presentation
* Vaginal dryness
* Vaginal burning (inflammation)
* Postcoital bleed
* Dyspareunia
* Dysuria
* Urinary frequency
* Urinary incontinence
vulvar and vaginal tissues are red, thin, friable, with a loss of rugae and loss of normal anatomy
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Lichen sclerosus
Patches on the skin that are usually:
* **itchy**
* white
* smooth or crinkled
* easily damaged – they may bleed or hurt if rubbed or scratched
vulvar tissue is usually thin and white but may be red and inflamed
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How long after simple lap surgery can a pt go home?
4hrs
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Bulky uterus ddx
* Fibroid
* Menorrhagia
* Adenomyosis
* Dysmenorrhea +menorrhagia
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Asherman's syndrome
Characterised by uterine adhesions
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What are the 4 types of Female Genital Mutilation (FGM)?
Type 1 - clitoridectomy (partial or total)
Type 2 - clitoridectomy (partial or total) + removal of labia minora +/- removal of labia majoria
Type 3 - infibulation - narrowing of vaginal opening either by stitching or by using labia to form a seal
Type 4 - any other type, e.g., piercing, stabbing, burning, etc.
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Bartholin cyst and abscess Mx
Asymptomatic cyst
* Warm compress/siltz bath
* ±Antibiotic cover
Abscess
* Marsupialisation
* The cyst is first opened with a cut and the fluid is drained out. The edges of the skin are then stitched to create a small "kangaroo pouch", which allows any further fluid to drain out.
* Takes 10-15mins
* GA usually
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Uterine artery embolisation explanation
Involves injecting (cannulating the femoral artery) small particles into the blood vessels which supply blood to the uterus/womb. The aim is to block the blood supply to the fibroids/adenomyosis to relieve symptoms and reduce their size.
may potentially allow them to retain their fertility.
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Myomectomy
surgery to remove the fibroids from the wall of your womb - usually approached from the abdomen
may potentially allow them to retain their fertility.
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Endometrial ablation explanation
Endometrial ablation is a procedure to remove a thin layer of tissue (endometrium) that lines the uterus. But it is only done on women who do not plan to have any children in the future - use of contraception.
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How does the LNG IUS work?
The LNG-IUS works primarily by thickening the cervical mucus and changing the endometrial lining. Thick cervical mucus obstructs the passage of sperm through the cervix. High concentrations of progestins are produced in the endometrium; this progestin-dominant effect allows the endometrium to remain thin and nonproliferate.
(Feedback loop where high levels prog is inhibitory for GnRH and LH/FSH prod = no/low oestr and prog prod - tho prog is released from external source. Oest needed for build up of wall)
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What can premature ovarian insufficiency be caused by?
* chromosome abnormalities – such as in women with Turner syndrome
* an autoimmune disease – where the immune system starts attacking body tissues
* Ca trx
* certain infections, such as tuberculosis, malaria and mumps – but this is very rare
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BV Mx
PO metronidazole
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Fibroids Complx
* Red degeneration
* Insufficient blood supply can cause haemorrhage and necrosis often during **pregnancy**
* Torsion of pedunculated fibroid
