Gynae

Question 1

Total contraindications for COCP

Answer 1

more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation

Question 2

Management for PCOS

Answer 2

Weight reduction
COCP - helps with managing hirsutism
infertility - weight loss, clomphiene (anti-oestrogen, reduces negative feedback on hypothalamus and pituitary, given on day 2 to 6 of cycle to help follicular development), metformin, gonadotrophin, ovarian diathermy, IVF

S/E of gonadotrophin stimulation = increased risk of multiple pregnancy, OHSS (bloating, abdo pain, vomiting, decreased urine output, ovarian torsion, if severe hypovolaemia, electrolyte imbalance, thromboembolism, ascites, pulmonary oedema)

Question 3

PCOS features:

Answer 3

Increased LH (increased androgens) and insulin (due to resistance, which also increases androgen production)
Excess small ovarian follicles on USS - polycystic ovaries
Obesity
acne
hirstuism
Oligo/amenorrhoea

Ix:
FSH is normal
Anti-mullerian hormone is high

Question 4

causes of anovulation

Answer 4

PCOS
Pregnancy
Hypothalamic hypogonadism (in anorexia, women on diets, athletes, stress)
Kallmann’s syndrome - Gnrh neurones don’t develop (also have anosmia)
Hyperprolactinaemia (usually adenoma or hyperplasia of pituitary –> treat with bromocriptine or cabergoline = Dopamine agonists)
Piuituary damage e.g Sheehan’s syndrome post partum or from tumours
Primary ovarian insufficiency (E2, inhibit lowered, FSH and LH massivly raised, no AMH as no follicles)
Hypo/hyperthyroid

Question 5

Dermoid Cysts

Answer 5

Type of mature teratoma - germ cell tumours
Cyst with normal body tissue in it - hair, teeth, skin etc
Has Rokitansky protuberance
Higher risk of torsion than other cysts

Question 6

Follicular cyst

Answer 6

Most common type of cyst
Caused by non-rupture of the dominant follicle or failure of a non dominant follicle atresia (regression)
Should regress in a few cycles

Question 7

Serous Cystaednoma/ Carcinoma

Answer 7

Ovarian tumour
Serous carcinoma = most common malignancy
Made up of columnar epithelium
Affects women aged 30-40

Question 8

Mucinous Cystadenoma

Answer 8

Mucin secreting cells, like those from endocervical mucosa
Or can be intestinal type –> metastasis from appendix causing pseudomyxoma peritonea
Secretes oestrogen

Question 9

Ectopic pregnancy symptoms

Answer 9

A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding

lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm

vaginal bleeding: usually less than a normal period, may be dark brown in colour

history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion

Abdominal tenderness
Cervical excitation

peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination

Question 10

Causes of free fluid in the pouch of douglas

Answer 10

Ruptured ectopic
PID
Tubo-ovarian abscess
Hydratidform mole

Question 11

whirlpool sigh

Answer 11

Ovarian torsion

Question 12

Endometriosis signs

Answer 12

chronic pelvic pain
dysmenorrhoea - pain often starts days before bleeding
deep dyspareunia
subfertility
non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Question 13

COCP increases risk of which 2 cancers

Answer 13

Breast

Cervical

Question 14

COCP decreases the risk of which 2 cancers

Answer 14

Ovarian

Endometrial

Question 15

How long until the COCP is affective if not first day of period

Answer 15

Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS

Question 16

How long until POP is effective if not first day of period

Answer 16

Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS

Question 17

Symptoms of a ruptured ovarian cyst

Answer 17

sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity
Ultrasound shows free fluid in the pelvic cavity.

Question 18

Symptoms of a ovarian torsion

Answer 18

sharp unilateral pain often associated with nausea and vomiting.
There is a tender palpable adnexal mass on bimanual exam.
Ultrasound shows an enlarged, oedematous ovary with impaired blood flow.

Question 19

Features of adenomyolysis

Answer 19

dysmenorrhoea
menorrhagia
enlarged, boggy uterus

Question 20

Treatment for adenomyolysis

Answer 20

Gnrh agonists

Hysterectomy

Question 21

how long can you use levonorgestrel for, how does it work

Answer 21

72hrs

its a progesterone so inhibits ovulation and increases cervical mucus

Question 22

What is Ella one and how long can you use it for

Answer 22

Ulipristal acetate

up to 5 days

Question 23

What can you use for emergency contraception that isn’t a pill, and when is it effective

Answer 23

IUD (copper)

5 days after unprotected sex or up to 5 days after likely last ovulation date

Question 24

When do you have to stop the COCP for surgery and when can you start it again

Answer 24

Stop 4 weeks before

start 2 weeks after surgery

Question 25

what does atrophic vaginitis present with

Answer 25

``` dryness pain (dyspareunia), some spotting Pale and dry vagina ```

Question 26

Rx atrophic vaginitis

Answer 26

Give topical oestrogen cream | use lube and moisturisers

Question 27

Missed POP pill - Micronor, Noriday, Nogeston, Femulen Missed POP Pill - Cerazette (desogestel) What do you do?

Answer 27

Traditionals -less than 3 hours, take it and continue as normal More than 3 hours late - take next pill ASAP then continue as normal with rest of pack, use condoms for 48 hours Cerazette is 12 hours instead of 3

Question 28

Symptoms of Ovarian Cancer

Answer 28

``` abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea ```

Question 29

Ix for ovarian Cancer

Answer 29

Ca125 If raised >35, urgent USS of the abdomen and pelvis Diagnostic laparotomy

Question 30

Most common ovarian cancer & what type of cell

Answer 30

Serous Carcinoma, Epithelial

Question 31

Risk factors for ovarian cancer What commonly used medication decreases the risk

Answer 31

BRCA1 and 2 Many ovulations - early menarche, late menopause, nuliparity COCP decreases risk

Question 32

Causes of menorrhagia

Answer 32

dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients PAINFUL, normal cycle Endometriosis Adenomyolysis PID PAINLESS, normal cycle: FIbroids bleeding disorders, e.g. von Willebrand disease Consider endometrial cancer and polyps Long cycle >35 days or Short cycle <21 days anovulatory cycles: these are more common at the extremes of a women's reproductive life Consider prolonged COCP course Other hypothyroidism intrauterine devices - copper coil

Question 33

Stress incotinence treatment

Answer 33

pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months surgical procedures: e.g. retropubic mid-urethral tape procedures Colposuspension Sling procedures Intramural bulking agents

Question 34

Urge incotinence treatment

Answer 34

``` reduce caffeine, intake, weight bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs: antimuscarinics are first-line. ``` NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women' mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients Overactive bladder can be treated with botulin trigger point injections, percutaneous sacral & posterior tubular nerve stimulation

Question 35

what is linked with cervical ectropion, and what are the symptoms

Answer 35

Oestrogen - COCP, pregnancy etc --> increases columnar epithelium at the transition zone of the cervix Causes post coital bleeding and PV discharge

Question 36

Risk factors for cervical cancer

Answer 36

``` smoking human immunodeficiency virus early first intercourse, many sexual partners high parity lower socioeconomic status combined oral contraceptive pill* ```

Question 37

What section of the menstrual cycle is variable?

Answer 37

The follicular phase of the menstrual cycle can be variable, however, the luteal phase (after ovulation) remains constant at 14 days.

Question 38

uterus big for gestational age, hyperemesis and PV bleeding | Dx?

Answer 38

Hydratidform mole

Question 39

Rx for hydratidform mole

Answer 39

ERPC, Serial monitoring of bHCG in specialist centre methotrexate if rising stagnant BHCG avoid pregnancy for 6m

Question 40

how long should pregnacy be avoided for after a molar pregnancy

Answer 40

6m

Question 41

woman presents with pyrexia, tachycardia, lower abdo tenderness, offensive discharge, uterine and adenexal tenderness after her C section. What is it and what do you do?

Answer 41

Endometritis, | broad spec Abx

Question 42

If a woman has post-coital bleeding, what should be ruled out, and what are other causes

Answer 42

Cervical Cancer Cervical ectropion Cervical polyp vaginal trauma vaginal atrophy

Question 43

what causes a strawberry cervix and frothy/thin green/yellow offensive discharge with itching, soreness etc

Answer 43

Trichomonas Vaginals

Question 44

what happens to fibroids in pregnancy and what are the symptoms

Answer 44

``` red degeneration (coagulative necrosis Pain,uterine tenderness ```

Question 45

what happens to fibroids post-menopausal

Answer 45

Often regression | Calcification

Question 46

was is the risk malignancy index used for and what does it involve

Answer 46

USS enopausal status Serum Ca125

Question 47

what are the symptoms of ovarian cancer

Answer 47

Bloating feeling full/early saitey or loss of apetite pelvic/abdo pain Increased urgency and frequency of urination Similar to IBS - but IBS shouldn't present in an older woman

Question 48

what genes increase risk of ovarian cancer

Answer 48

BRCA1+2 | HNPCC

Question 49

what is the treatment for a bartholin cyst/abscess

Answer 49

Incision, drainage and marzupilisation

Question 50

FIGO staging general overview of stages (ovarian)

Answer 50

1 - in the ovaries (a if 1 ovary, b if 2, c if ruptured capsule/positive periotneal washings/positive ascities) 2- Into the pelvis - fallopian tube, uterus 3- abdominal disease/LN (omentum, SI, peritoneum) 4- beyond the abdomen - lung, liver

Question 51

what are the signs of asherman's syndrome

Answer 51

``` Menstural distubrances (often amenorrhoea) cyclical abdominal pain Subfertility ```

Question 52

Gold standard for diagnosing endomeriosis

Answer 52

Laproscopy

Question 53

Mittelschmerz

Answer 53

``` Usually mid cycle pain. Often sharp onset. Little systemic disturbance. May have recurrent episodes. Usually settles over 24-48 hours. ```