Gynae and Contraception

Question 1

Cervical Cancer

Answer 1

80% SCC, 20% adeno, highest rate 25-29yrs

RF - HPV 16/18/33, smoking, HIV, COCP, ^parity, early sex, many partners, low SES, FHx

= 50% <45yrs, abnormal PV bleeding, discharge, pelvic pain, pain in sex

FIGO Staging: 1) confined to cervix, 2) beyond cervix but not to pelvic wall 3) to pelvic wall 4) beyond pelvis or involves bladder/ rectum

-> hysterectomy +/- node clearance, cone biopsy to maintain fertility, radio and chemo for 1b+

Question 2

Cervical screening

Answer 2

25-49yrs: 3 yearly, 50-64yrs: 5 yearly

Pregnancy - delay to 3m postpartum
Virgin - can opt out

hrHPV tested first
- negative; return to normal recall
- positive; cytology

Cytology
- normal; test HPV again at 12mth, still high risk (normal cyt) test again at 24mth, colposcopy if still positive
- abnormal; colposcopy

Inadequate sample
- repeat at 3m, still inadequate then colposcopy

-> large loop excision of transformation zone, TOC pathway (repeat sample 6m after treat CIN)

Question 3

Endometrial Cancer

Answer 3

80% adeno, oestrogen-dependent

RF - (^oes) nulliparity, early menarche, late menopause, unopposed oes, obesity, DM, PCOS, tamoxifen, HNPCC
*Protective: mp, COCP, smoking

= post-menopausal bleeding

Inv - 2WW any 55yr+ with PMB, TV US (normal thickness <4mm), hysteroscopy with biopsy

-> total abdominal hysterectomy with bilateral salpingo-oophorectomy, post-op radio

Question 4

Endometrial Hyperplasia

Answer 4

Abnormal endometrial proliferation, 5% develop into cancer

Simple and no atypia -> high dose progestogens (IUS), repeat sample at 3m

Atypia -> hysterectomy

Question 5

Ovarian Cancer

Answer 5

RF - FHx (BRCA1/2), age, ^ovulations (early menarche, late menopause, np), obesity, smoking, clomifene
*Protective: COCP, pregnancy, breastfeeding

= 60yrs, bloating, satiety, weight loss, pelvic pain, mass, LUTS, diarrhea, hip/ groin pain (obturator nerve compression)

Inv - risk of malignancy index (menopausal status, US, Ca125), pelvic US, CT, diagnostic laparotomy

-> surgery and platinum chemo

^Ca125 in endometriosis, fibroids, benign cysts

Question 6

Vulval Cancer

Answer 6

90% SCC, mostly labia majora

RF - >65rys, IS, HPV, lichen sclerosis, VIN

= lump, ulcer, bleeding, itchy, inguinal nodes

Question 7

OHSS

Answer 7

Multiple luteinised cysts in ovaries after fertility treatment, ^VEGF, ^membrane permeability and loss of intravascular fluid

RF - gonadotropin, HCG, rarely clomifene

Mild: pain, bloating
Moderate - n+v, ascites on US
Severe: clinical ascites, v protein, ^Hct, oliguria
Critical: ARDS, tense ascites, anuria, VTE

Question 8

Trichomonas vaginalis

Answer 8

Flagellated protozoa, STI

= offensive yellow-green discharge, strawberry cervix, vulvovaginitis, urethritis in men

Inv - pH > 4.5

-> PO metronidazole 5-7d (or single dose)

Question 9

Emergency Contracpetion

Answer 9

Levonorgestrel
-Stops ovulation and implantation
-Take <72hrs of UPSI (1.5mg, double if BMI > 26)
-If vomit <3hrs must take again
-Can start hormonal contraception straight after

Ulipristal
-Inhibits ovulation
- Take <120hrs of UPSI (30mg)
-Start hormonal contraception 5days after
-Caution in severe asthma, don’t BF for 1wk

Copper IUD
- Best, offer to all women
- Take <5d of UPSI, if later then may fit <5d post-ovulation date

Question 10

COCP

Answer 10

Started in first 5 days of cycle = immediate protection (If not, 7 days of condoms)

MOA - inhibits ovulation

+fertility returns when stopped, v risk of ovarian and endometrial cancer, v CRC, v PID, lighter period

-blood clots, heart attacks, strokes, breast and cervical cancer, affected by Abx (rifampicin)

*sex in pill free period is only safe if start next pack on time

Contra
UKMEC 3 - BMI>35, >35yrs + smoking <15, VTE in first degree <45yrs, HTN, immobility, BRCA, gallbladder disease, DM for >20yrs
UKMEC 4 - >35yrs + smoking >15, migraine with aura, VTE, IHD, BF <6wks postpartum, major surgery, APLS, current breast cancer

Question 11

COCP: Missed Pill

Answer 11

Missed if 24 hours late

2) 1) take last pill asap, no barrier needed

2+) take last pill asap, barrier until 7 in a row
Week 1 - emergency contraception if sex in pill free/ first week
Week 2 - no additional need
Week 3 - finish pills in pack and start next, omit pill free interval

Question 12

Implant

Answer 12

Nexplanon, subdermal implant, lasts 3yrs, most effective contraception

MOA - inhibits ovulation, thicken mucus

Inserted in first 5 days of cycle = immediate protection (If not, 7 days of condoms)

SE: irregular/ heavy bleeding (? +COCP), headache, nausea, breast pain, reduced by antiepileptic/ rifampicin

Contra
UKMEC 3 - IHD, vaginal bleeding, past breast cancer, severe liver disease
UKMEC 4 - current breast cancer

Question 13

POP

Answer 13

Same time every day no pill free period

MOA - thickens cervical mucus

Started in first 5 days of cycle = immediate protection (If not, 2 days of condoms)

+antibiotics don’t affect it

-irregular bleeding, d+v, breast cancer, ovarian cysts

Contra - severe liver disease, breast cancer, preg

Missed pill
<3hrs late (12 for desogestrel): cont as normal
>3hrs late: take it asap, 2 days barrier

Question 14

Injectable Contraception

Answer 14

Depo provera, medroxyprogesterone acetate, IM 12wkly (<14 without barrier)

MOA - inhibits ovulation

SE: cannot be reversed once given, delay in fertility <12m, irregular bleeding, weight gain, OP

Contra - current breast cancer

Question 15

IUD and IUS

Answer 15

IUD
- v sperm motility and survival
- works immediately
- last 5 or 10yrs

IUS
- v endometrial proliferation, thickens mucus
- reliable after 7 days
- Mirena 5yrs (4 as HRT), jaydess 3yrs

SE: heavier longer periods (IUD), uterine perf (^if BF), ectopic, PID in first 20d, expulsion

Question 16

Bacterial Vaginosis

Answer 16

Overgrowth of anaerobes e.g., Gardnerella Vaginalis, fall in lactobacilli (produce lactic acid) so pH rises

= fishy, thin white discharge

Inv - pH > 4.5, microscopy (clue cells), whiff test

-> symptomatic only, PO metro (5-7d or single) or topical metro/ clindamycin

Comp - prem, v BW, CA if pregnant

Question 17

Adenomyosis

Answer 17

Endometrial tissue within the myometrium

RF - multiparous, later in reproductive years

= painful heavy periods, large boggy uterus

Inv - TV US

-> GnRH agonists, uterine artery embolisation, hysterectomy definitive, TX for heavy bleeding

Question 18

Amenorrhoea

Answer 18

Primary: no period by 15yrs (normal 2nd characteristics) or 13yrs (no 2nd)

Secondary: cessation of periods for 3-6m if previously regular, or 6-12m if irregular

Inv - excl pregnancy, FBC, U&E, TFTs, coeliac screen, gonadotrophins (low = hypothlamic, raised = ovarian problem/ gonadal dysgenesis), prolactin, androgen, oestrodiol

Question 19

Causes of Amenorrhoea

Answer 19

Primary:
Gonadal dysgenesis (Turner’s)
Imperforate hymen
Anorexia (functional hypothalamic)
Congenital adrenal hyperplasia

Secondary:
Excessive exercise/ stress (hypothalamic)
PCOS
High prolactin, high thyroid
Premature ovarian failure
Sheehan’s
Ashermann’s (IU adhesions)

Question 20

Cervical Ectropion

Answer 20

Larger area of columnar epithelium on the ectocervix (transformation zone, squamous - columnar)

RF - ^oestrogen e.g., COCP, pregnancy

= discharge, post-coital bleeding

-> ablation (cold coag) if troublesome symptoms

Question 21

Dysmenorrhoea

Answer 21

Excessive pain during periods

Primary
50% of women, no pathology
= pain alongside period, suprapubic cramping
-> NSAIDs (mefenamic, ibuprofen), COCP 2nd

Secondary
Develops years after menarche
Causes - endometriosis, adeno, PIDs, IUD, fibroid
= pain starts 3-4 days before period
-> refer to gynae

Question 22

Endometriosis

Answer 22

Growth of ectopic endometrial tissue outside the uterine cavity

Causes - unknown, retrograde flow or embryonic cells outside of uterus during development?

= chronic pelvic pain, 2nd dysmenorrhea, subfertility, deep pain in sex, LUTS, painful stool
*Exam; tender nodular posterior fornix, reduced organ mobility

Inv - laparoscopy

-> NSAIDs +/- paracetamol, COCP or injection 2nd, refer to hosp, GnRH analogues (pseudo-menopause), lap excision and adhesiolysis if want to conceive

Question 23

Fibroid Degeneration

Answer 23

Uterine fibroids are sensitive to oestrogen so grow during pregnancy, eventually outgrow their blood supply

= T1/2, low grade fever, pain, vomiting

-> rest, pain relief, resolves <1wk

Question 24

Menorrhagia

Answer 24

No set amount, what is excessive for her

Causes - dysfunctional uterine bleeding (50%), anovulatory cycles, fibroids, hypothyroid, IUD, PIDs, vWD

Inv - all get FBC, TV US

-> if requires contraception use IUS, not then mefenamic or tranexamic acid

Question 25

HRT: Side Effects

Answer 25

Small dose of oestrogen (+ progesterone if uterus) to alleviate menopausal symptoms SE: nausea, tender breasts, fluid retention, weight gain, stroke, IHD (if >10yrs since menopause) Progestogen = VTE, breast cancer (normal 5yrs after stopping) Oestrogen = endometrial cancer Contra - breast cancer, any oestrogen-sensitive cancer, bleeding, endometrial hyperplasia

Question 26

Infertility

Answer 26

1 in 7 couples, 84% should conceive in 1yr Inv - semen analysis, day 21/ 7d before period serum progesterone (normal >30, repeat 16-30, refer <16) -> folic acid, BMI 20-25, sex every 2-3d

Question 27

Menopause

Answer 27

51yrs average, symptoms for 5 years, due to low oestrogen = change in period length, hot flush, night swets, dryness, atrophy, urinary frequency, anxiety, depression, STM issue, OP, IHD -> contraception for 12m after LMP if >50yrs or 24m <50yrs, exercise and weight loss, sleep hygiene, HRT

Question 28

Miscarriage

Answer 28

<24wks, usually 6-9wks Threatened: painless bleed, os closed Inevitable: heavy bleeding, pain, os open Missed: dead fetus in sac, light bleed, os closed -> expect, if not then PO mifepristone, PO/PV misoprostol at 48hrs Incomplete: not expelled, pain, bleeding, os open -> expect, if not then single dose misoprostol

Question 29

Types of Ovarian Cysts

Answer 29

Physiological (functional) Cysts - Follicular: most common, dominant follicle didn't rupture, regress in mths - Corpus luteum: hasn't broken down, fills with blood or fluid Benign Germ Cell Tumour - Dermoid cyst (teratoma): most common benign tumour <30yrs, hair/ teeth (Rotikansky protuberance), ^torsion Benign Epithelial Tumour - Serous cystadenoma - Mucinous cystadenoma: large, pseudomyxoma peritonei Inv - biopsy any complex (multi-loculated) or post-menopausal to excl. cancer

Question 30

Ovarian Torsion

Answer 30

Torsion of the ovary around its supporting ligaments, may compromise blood supply RF - ovarian mass, reproductive age, pregnancy, OHSS = sudden severe abdo pain, n+v, distress, fever, adnexial tenderness Inv - US (whirlpool sign) -> laparoscopy

Question 31

PID

Answer 31

Infection and inflammation of the female pelvic organs Causes - ascending infection from ectocervix e.g., chlamydia, gonorrhea, mycoplasma = lower abdo pain, fever, deep pain in sex, discharge, cervical excitation Inv - exclude pregnancy, high swab (often neg), STI screen -> low threshold, IM ceftriaxone + 14d doxy + metro, or ofloxacin + metro, consider removing IUD Comp - Fitz Hugh Curtis (perihepatitis, RUQ pain), infertility, ectopic, chronic pain

Question 32

PCOS

Answer 32

High insulin and high LH = subfertility, oligomenorrhea, hirsutism, acne, acanthosis nigricans, obesity Inv - ^LH:FSH, TFTs, prolactin, T, v SHBG, IGT, pelvic US Rotterdam criteria (2 of 3) - infrequent or anovulation - clinical or biochemical signs of high androgens - PCO on US (12+ follicles)

Question 33

PCOS: Management

Answer 33

-> weight loss, COCP (regulate period, hirsutism), top eflornithine 2nd for hirsutism, clomifene for fertility, may add metformin

Question 34

PMB Causes

Answer 34

Vaginal atrophy - most common, thin/ dry/ inflamed walls -> topical oestrogen HRT Trauma Endometrial hyperplasia Endometrial, cervical, ovarian, vulval cancer

Question 35

Premature ovarian Insufficiency

Answer 35

Onset of menopause <40yrs Causes - idiopathic (FHx), radio, chemo, bilateral oophorectomy, mumps, AI disorders Inv - ^FSH (2 samples, 4-6wks apart), ^LH, v oestradiol -> HRT or COCP until 51yrs

Question 36

Premenstrual syndrome

Answer 36

Emotional and physical symptoms during the luteal phase = anxiety, stress, fatigue, mood swings, bloating, breast pain -> lifestyle (regular, frequent, balanced meals, complex carbs), COCP, SSRI if severe

Question 37

Abortion

Answer 37

Two registered practitioners must sign, one performs, <24wks only (unless risk) Medical (<10wks, at home) -> mifepristone (anti progestogen), misoprostol (PG) 48hrs after, multi-level pregnancy test in 2wks (hCG) Surgical -> Manual/ electric vacuum aspiration, dilatation and evacuation (may prime cervix with medical) *Anti-D if RhD negative have abortion >10wks

Question 38

Urinary Incontinence

Answer 38

RF - age, prev pregnancy/ childbirth, fat, hysterectomy, FHx Overactive bladder/ urge - detrusor overactivity -> 6wk bladder retraining, oxybutynin/ tolterodine/ darifenacin Stress - leaking when laughing or coughing -> 3m pelvic floor training, retropubic mid-urethral tape, duloxetine (SNRI) if no surgery Mixed - both of the above Overflow - due to bladder outlet obstruction

Question 39

Urogenital Prolapse

Answer 39

Descent of pelvic organs causing protrusion on the vaginal walls Cystocele, uterine, rectocele etc. RF - age, weight, mp, obesity, spina bifida = sensation of dragging/ pressure, incontinence, frequency, urgency -> treat symptomatic, weight loss, pelvic floor exercises, ring pessary, surgery (colporrhaphy, hysterectomy)

Question 40

Uterine Fibroids

Answer 40

Benign smooth muscle tumours of the uterus RF - black, later reproductive years = lower abdo pain, heavy periods, urinary symptoms, bloating, sub-fertility, polycythaemia Inv - TV US -> monitor growth, treat if symptoms, IUS or mefenamic acid for bleeding, GnRH agonist to shrink (menopause symp, v bone density), surgery (myomectomy, hysteroscopic endometrial ablation, hysterectomy), uterine artery embolization Prog - regress after menopause

Question 41

Candidiasis

Answer 41

Thrush, candidia albicans RF - DM, Abx, steroids, pregnancy, HIV = cottage cheese discharge, no smell, itchy, red, dysuria Inv - clinical, high vaginal swab, glucose -> PO fluconazole single dose, clotrimazole pessary if preg Recurrent - 4+ in 1yr, check compliance, high swab (M&C), glucose -> induction-maintenance (PO fluconazole 6m)

Question 42

Chlamydia

Answer 42

Most common STI in UK (1 in 10 F), intracellular pathogen, chlamydia trachomatis Screening open to all 15-24yrs = aymp, dysuria, cervicitis, urethral discharge (m) Inv - NAAT to diagnose (urine for M, vulvovaginal swab for F) 2wks post-exposure -> 7d doxycycline, if pregnant use stat azithromycin/ erythromycin/ amoxicillin, partner notification (past 6mths) Comp - epididymitis, PID, endometritis, ^ectopic, infertility, reactive arthritis

Question 43

Mycoplasma Genitalium

Answer 43

Common cause of non-gonococcal urethritis Same treatment and investigation as chlamydia -> test for macrolide resistance, do test of cure

Question 44

Contraception >40yrs

Answer 44

Non-hormonal - stop <50yrs if 2yr no period or >50yrs if 1yr no period COCP - UKMEC2 40yrs+ - continue to 50 years then switch to POP or non hormonal Depo - UKMEC2 >45yrs - continue to 50yrs then switch to POP or non hormonal Implant / POP / IUS - stop taking at 55yrs or if amenorrhoeic with FSH>30 WOMEN WITH GASTRIC SLEEVE OR BYPASS CANNOT HAVE ORAL METHODS EVER

Question 45

Contraception transgender or non binary

Answer 45

If assigned female at birth and have uterus - Testosterone is not a contraceptive - Do not use any with oestrogen in (progesterone okay) Assigned male at birth - Condoms needed

Question 46

Contraception young people

Answer 46

Nexplanon best Avoid Depo due to v bone mineral density IUS/ IUD are UKMEC2 <20yrs

Question 47

Postpartum Contraception

Answer 47

Need it after day 21 POP - can start at any time - 2 days barrier if after day 21 COCP - do not use <21d due to VTE, UKMEC4 if BF <6wks, UKMEC2 if BF 6wk-6m - 7 days barrier after day 21 IUD/S - insert <48hrs or >4wks postpartum LAM - 98% effective in first 6m if full breastfeeding and no periods

Question 48

Ectopic Pregnancy

Answer 48

Implantation of a fertilised ovum outside the uterus, 97% tubal (^ampulla), isthmus most dangerous RF - tubal damage (PID/ surgery), prev ectopic, endometriosis, POP, IUD, IVF = 6-8wks, lower abdo pain, dark bleeding, shoulder pain, dizzy, cervical excitation, adnexal mass Inv - preg test, NO DVE (rupture), hCG>150, TV US

Question 49

Ectopic: Management

Answer 49

-> EPAU Expectant - <35mm, not ruptured, no symptoms, no heartbeat, hCG <1000 -> monitor 48hrs, hCG levels Medical - <35mm, not ruptured, no sig pain, no heartbeat, hCG <1500 -> methotrexate, must attend follow-up Surgical - >35mm, rupture, pain, visible heartbeat, hCG >5000 -> salpingectomy, salpingotomy if RF for infertility (1 in 5 unsuccessful)