Gynae notes Flashcards
(740 cards)
1
Q
What are fibroids?
A
Benign tumours of the smooth muscle of the uterus.
2
Q
Are fibroids oestrogen sensitive?
A
Yes: they grow in response to oestrogen
3
Q
What ethnic group most commonly suffer with fibroids?
A
Black women
4
Q
What are the features of uterine fibroids?
A
May be asymptomatic. OR: menorrhagia, bulk related symptoms (lower abdo pain which is worse during menstruation, cramps, bloating pain, urinary symptoms), subfertility, dyspareunia
5
Q
What is the link between fibroids and polycythaemia?
A
Fibroids can cause polycythaemia as they may sometimes produce EPO.
6
Q
How are fibroids diagnosed?
A
Transvaginal ultrasound or Hysteroscopy
7
Q
What is the management of asymptomatic fibroids?
A
No treatment other than periodic review to monitor size and growth
8
Q
What is the management of menorrhagia secondary to fibroids?
A
Levonorgestrel intrauterine system (Mirena: 1st line) , NSAIDs (mefenamic acid), TXA, COC, oral progestogen, injectable progestogen
9
Q
When is Mirena coil contraindicated in women with fibroids?
A
If there is distortion of the uterine cavity
10
Q
What is the medical treatment of shrinking fibroids (often prior to surgery)?
A
GnRH agonists
11
Q
What are the s/e of GnRH agonists?
A
Menopausal symptoms + loss of bone mineral density
12
Q
What is the surgical treatment of fibroids?
A
Myomectomy, hysteroscopic endometrial ablation, hysterectomy, uterine artery embolisation
13
Q
What are potential complications of fibroids?
A
Subfertility, iron deficiency anaemia, pregnancy complications, constipation, urinary issues, red degeneration of the fibroid, torsion of the fibroid
14
Q
What is red degeneration of fibroids?
A
Ischaemia, infarction and necrosis of a fibroid due to disrupted blood supply. Occurs during pregnancy
15
Q
What is an intramural fibroid?
A
Fibroid within the myometrium. As they grow can change shape and distort the uterus
16
Q
What is a subserosal fibroid?
A
Just below the outer layer of the uterus: can grow very large and fill the abdominal cavity
17
Q
What is a submucosal fibroid?
A
Just below the lining of the uterus (endometrium)
18
Q
What is a pedunculated fibroid?
A
On a stalk
19
Q
What is found on abdominal and bimanual examination of someone with fibroids?
A
Palpable pelvic mass or enlarged firm non tender uterus
20
Q
Up to what size, is the management of fibroids the same as with heavy menstrual bleeding?
A
3cm
21
Q
What are examples of GnRH agonists?
A
Goserelin (zoladex), leuprorelin (prostap)
22
Q
How is uterine artery embolisation done, and what condition is it done for?
A
Large fibroids. Interventional radiologists insert a catheter into an artery, usually femoral. Passed into the uterine artery under xray guidance. Particles insert that block the arterial supply to the fibroid: causes them to shrink
23
Q
What treatment can improve fertility of patients with fibroids?
A
Myomectomy
24
Q
What malignant change can occur with fibroids?
A
To leiomyosarcoma (very rarely)
25
What trimesters of pregnancy does red degeneration of fibroids typically occur?
2nd and 3rd
26
How does red degeneration of fibroids present?
Severe abdominal pain, low grade fever, tachycardia, vomiting
27
Why does red degeneration of fibroids occur in pregnancy?
Fibroid enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. Or, kinking in blood vessels as the uterus changes shape.
28
How is red degeneration treated?
Rest + analgesia
29
What can ovarian cysts be grouped into?
Physiological, benign germ cell tumors, benign epithelial tumours, benign sex cord tumours, complex
30
What further investigation should be undertaken with complex ovarian cysts?
Biopsy to exclude malignancy
31
What are the types of physiological ovarian cyst?
Follicular + corpus leteum
32
What is the commonest type of ovarian cyst?
Follicular cyst
33
Why do follicular cysts form?
Forms due to non-rupture of the dominant follicle or failure of atresia in non dominant follicle
34
How does a corpus luteum cyst form?
If the corpus luteum doesn't break down properly, and fills with blood/fluid
35
What is the features of a dermoid cyst?
Mature cystic teratomas: lined with epithelial tissue and thus may contain skin appendages, hair, and teeth
36
What risk does dermoid cysts carry?
Torsion
37
What is the most common benign ovarian tumour in young women?
Dermoid cyst (mature cystic teratoma)
38
Where do benign epithelial tumours arise from?
The ovarian surface epithelium
39
What are the two types of benign epithelial tumours?
Serous and mucinous cystadenoma
40
What is the most common benign epithelial tumour?
Serous cystadenoma: bears resemble to serous carcinoma
41
What is the most common type of ovarian cancer?
Serous carcinoma
42
How can multiple ovarian cysts present on imaging?
'String of pearls'
43
Why might women with multiple ovarian cysts not be diagnosed with PCOS?
They must have other features of the condition: requires 2 of anovulation, hyperandrogenism, polycystic kidneys on US
44
What is the presentation of ovarian cysts?
Generally asymptomatic (often found incidentally on pelvic ultrasound). Can have vague symptoms of pelvic pain, bloating, fullness of abdomen
45
When might ovarian cysts present with acute pelvic pain?
If there is ovarian torsion, haemorrhage, or rupture
46
What complication can mucinous cystadenoma have?
Can become huge and take up lots of space in the pelvis and abdomen
47
What are signs during a hx that an ovarian cyst might be malignant?
Abdominal bloating, reduced appetite, early satiety, weight loss, urinary symptoms, pain, ascites, lymphadenopathy
48
What are risk factors of ovarian malignancy?
Age, post menopause, increased number of ovulations, obesity, HRT, smoking, FHx + BRCA1/2
49
What is the correlation between ovulation and ovarian cancer?
The higher the number of ovulations, the higher the risk of ovarian cancer. Thus, affected by age at menarche, menopause, number of pregnancies, use of COC
50
When does a cyst not require any further investigations (other than ultrasound)?
Premenopausal w/ simple ovarian cyst which is less than 5cm on US
51
What blood test is done to help identify a malignant ovarian cyst?
CA125
52
What tumour markers should be checked in women under 40 with a complex ovarian mass, and why?
Identify a possible germ cell tumour. Check LDH, alpha-fetoprotein, HCG
53
Why would CA125 be raised?
- epithelial cell ovarian cancer
- endometriosis
- fibroids
- adenomyosis
- pelvic infection
- liver disease
- pregnancy
54
What is the Risk of malignancy index made up of, and why is it used?
Estimates risk of an ovarian mass being malignant. Takes into account menopausal status, ultrasound findings, CA125 level
55
What is the management of ovarian cyst that is possible ovarian cancer?
2 week wait
56
What is the management of possible dermoid cysts?
Referral to gynaecologist for further investigation + consideration of pregnancy
57
What is the management of simple ovarian cyst in premenopausal women?
- <5cm: will resolve. No further management
- 5-7cm: routine referral, yearly ultrasound monitoring
- >7cm: MRI/surgical evaluation
58
What is the management of ovarian cysts in post menopausal women?
Dependent on CA125 result: if raised, 2 week wait. If not raised, monitor with ultrasound. Always refer to gynae
59
What surgical intervention is done for ovarian cysts?
Removal (ovarian cystectomy), possibly alongside affected ovary (oopherectomy)
60
What are possible complications of ovarian cysts?
Torsion, haemorrhage, rupture
61
What is Meig's syndrome?
Triad of ovarian fibroma (type of ovarian cyst), pleural effusion, ascites
62
What popular does Meig's syndrome typically occur in?
Older women
63
What is the management of Meig's syndrome?
Removal of ovarian fibroma; this resolves other symptoms
64
What is ovarian torsion?
Partial or complete torsion of the ovary on it's supporting ligaments that can compromise the blood supply
65
What is adnexal torsion?
Torsion of the ovary involving the fallopian tube
66
What are risk factors of ovarian torsion?
Ovarian mass, being of reproductive age, pregnancy, ovarian hyperstimulation syndrome, benign tumours
67
What size does a ovarian mass tend to be to be a RF for ovarian torsion?
5cm or more
68
Why might ovarian torsion occur in young girls before menarche?
Due to having longer infundibulopelvic ligaments that twist more easily
69
What is the features of ovarian torsion?
Sudden onset unilateral severe pelvic pain. Constant, progressively worse, associated with nausea and vomiting. May have fever
70
What is seen on examination of ovarian torsion?
Localised tenderness, may be palpable mass
71
What is the first line investigation in ovarian torsion?
Pelvic ultrasound
72
What sign is seen on ultrasound in ovarian torsion? What else is seen?
Whirlpool sign + free fluid in the pelvis
73
What is the definitive diagnostic tool in ovarian torsion?
Laproscopy
74
What is the management of ovarian torsion?
Laproscopic torsion to 'detorsion' or do an ooporectomy
75
What are possible complications of ovarian torsion?
When a necrotic ovary is not removed, may lead to infection, development of an abscess, lead to sepsis. MAy also rupture, leading to peritonitis and adhesions
76
What is lichen sclerosus?
Chronic inflammatory skin condition that typically affects the labia, perineum, and perianal skin in women
77
How does Lichen sclerosus typically present on examination?
With patches of shiny, 'porcelain white' skin: white plaques on genitalia. May be associated fissures, cracks or haemorrhages under the skin
78
What is the population most affected by lichen sclerosus?
Elderly women
79
What type of condition is lichen sclerosus, and what is it likely to be associated with?
Autoimmune condition: associated with diabetes, alopecia, hypothyroid, vitiligo
80
What is the typical features of Lichen Sclerosus?
Vulval itching, and skin changes to the vulva. Soreness + pain, possible worse at night, skin tightness, painful sex (superficial dyspareunia), erosions, fissures
81
What is Koebner phenomenom?
When signs/symptoms of a condition are made worse by friction to the skin
82
What is the potential critical complication of lichen sclerosus?
Squamous cell carcinoma of the vulva
83
How is lichen sclerosus diagnosed?
Generally clinically, can do a vulval biopsy to confirm
84
What is the management of lichen sclerosus?
Potent topical steroids (Clobetasol propionate 0.05%: dermovate). Also emoillients
85
What is primary amenorrhoea?
A patient who has never developed periods
86
What are the 3 possible causes (categories) of primary amenorrhoea?
- abnormal functioning of the hypothalamus or pituitary gland (hypogonadotropic hypogonadism)
- abnormal functioning of the gonads (hypergonadotropic hypogonadism)
- imperforate hymen or other structural issue
87
What are differentials of secondary amenorrhoea?
Pregnancy, menopause, physiological stress, PCOS, medications, premature ovarian insufficiency, thyroid hormone abnormalities (hypo or hyper), excessive prolactin (eg, prolactinoma), Cushing's syndrome
88
What are key differentials or intermenstrual bleeding?
- Cancer (cervical and other)
- hormonal contraception
- cervical ectropion
- STI
- endometrial polyps
- vaginal pathology
- pregnancy
- ovulation
- medications
89
What are differential dx of dysmenorrhoea?
- primary (no underlying cause)
- endometriosis or adenomyosis
- fibroids
- PID
- copper coil
- cervical or ovarian cancer
90
What are the differential dx of menorrhagia?
- dysfunctional uterine bleeding (no identifiable cause)
- extremes of reproductive age
- fibroids
- endometriosis + adenomyosis
- PID
- contraceptives, particularly the copper coil
- anticoagulant medication
- bleeding disorders
- endocrine disorders
- connective tissue disorders
- PCOS
91
What are differential diagnosis of post coital bleeding?
- cervical cancer, ectropion, infection
- trauma
- atrophic vaginitis
- polyps
- endometrial cancer
- vaginal cancer
92
What is pruritus vulvae?
Itching of the vulva and vagina
93
What are differential dx of pruritus vulvae?
- irritants such as soaps etc
- atrophic vaginitis
- infections such as thrush, pubic lice
- vulval malignancy
- skin conditions: eczema, lichen sclerosus
- pregnancy related vaginal discharged
- stress
94
What is endometriosis?
Growth of ectopic endometrial tissue outside of the uterine cavity
95
What is an endometrioma?
A lump of endometrial tissue outside the uterus
96
What is the symptoms of endometriosis?
Cyclical abdominal or pelvic pain, deep dyspareunia, dysmenorrhoea, infertility, cyclical bleeding from other sites such as haematuria. Can also be urinary or bowel symptoms
97
What causes the pelvic pain experienced in endometriosis?
Cells of endometrial tissue outside the uterus respond to hormones the same way endometrial tissue in the uterus does. During menstruation, this tissue sheds and bleeds, causing irritation and inflammation of tissues in the body
98
Why might chronic, non cyclical pain develop in endometriosis?
Due to adhesions developing
99
What may be found on examination of endometriosis?
Endometrial tissue visible in the vagina, fixed cervix on bimanual examination, tenderness in the vagina, cervix, adnexa
100
What is the gold standard for diagnosis of endometriosis?
Laproscopic surgery. Definitive dx can be made via a biopsy of a lesion during laparoscopy. However, there is poor correlation between laproscopic findings and severity of symptoms
101
What are the first line recommended tx for symptomatic relief of endometriosis?
NSAIDs +/- paracetamol
102
What is second line treatment for symptomatic relief of endometriosis?
COCP or progestogens. Then implant, then coil, then GnRH agonists
103
What is the surgical treatment of endometriosis?
Laproscopic surgery to excise/ablate tissue and remove adhesions. Hysterectomy is the only definitive tx
104
What treatment should be carried out for women with endometriosis who are trying to concieve?
Laproscopic excision or ablation. Ovarian cystectomy for endometriomas also recommended.
105
What are the 4 stages of endometriosis?
1: small superficial lesions
2: mild, but deeper
3: deeper lesions, with lesions on ovaries and mild adhesions
4: deep and large lesions affecting ovaries, with extensive adhesions
106
What is adenomyosis?
Presence of endometrial tissue within the myometrium
107
Which patients is adenomyosis more common in?
Those in later reproductive years, and those who are multiparous
108
What are the features of adenomyosis?
Dysmenorrhoea, menorrhagia, enlarged boggy uterus. Some women will have infertility or pregnancy related complications
109
What is the first line investigation of adenomyosis?
Transvaginal ultrasound
110
What is the gold standard diagnosis of adenomyosis?
Histological examination of the uterus after a hysterectomy (though obviously this isn't always suitable!)
111
What is the type of treatment pathway that NICE recommends for adenomyosis?
The same as for heavy menstrual bleeding
112
What is the treatment for heavy menstrual bleeding where contraception is not required?
Mefanamic acid or TXA. Start both on first day of period
113
What is TXA MoA in heavy menstrual bleeding?
Antifibrinolytic: reduces bleeding
114
What is the management of heavy menstrual bleeding when contraception is required?
Mirena is first line. Then COCP, then long acting progestogens
115
What surgery can be considered in severe adenomyosis?
Endometrial ablation, uterine artery embolisation, hysterectomy
116
What compx is associated with adenomyosis in pregnancy?
Infertility, miscarriage, preterm birth, SGA, preterm premature ruptue of membranes, malpresentation, need for C-section, PPH
117
What population is most commonly affected by cervical cancer?
Younger women within their reproductive years
118
What is the most common type of cervical cancer?
Squamous cell carcinoma
119
What virus is cervical cancer strongly associated with?
Human papillomavirus
120
What type of HPV are responsible for most cervical cancers?
16 and 18
121
How does infection with HPV lead to cervical cancer?
HPV produces proteins that inhibit tumour suppressor genes.
122
What are the features of cervical cancer?
abnormal vaginal bleeding (post coital, intermenstrual or post menopausal), vaginal discharge, pelvic pain, dyspareunia
123
Other than infection with HPV, what are risk factors for cervical cancer?
Smoking, HIV, early first intercourse, many sexual partners, high parity, lower socioeconomic status, COC, not engaging with screening, family history
124
What HPV strains are non carcinogenic, and associated with genital warts?
6 and 11
125
How do cervical cells that are infected with HPV appear on histology? What name is given to them when infected?
Koilocytes. Enlarged nucleus that stains darker, irregular nuclear membrane contour, perinuclear halo may be seen
126
What is first line investigation of cervical cancer? What signs suggest further investigation required?
Examination with speculum, swabs to exclude infection. Further investigation if ulceration, inflammation, bleeding, visible tumour
127
What investigation can diagnose cervical cancer?
Colposcopy
128
What is the grading system used for cervical cancer?
CIN: cervical intraepithelial neoplasia for level of dysplasia.
129
What are the CIN stages?
1: mild dysplasia, affecting 1/3 thickness, likely to return to normal
2: moderate dysplasia, affecting 2/3rd thickness, likely to progress to cancer
3: severe dysplasia, will progress to cancer
130
How are smears tested in the NHS in the cervical screening programme?
HPV first system: sample tested for high risk strains of HPV first, and then cytological examination performed if this is positive.
131
What is dyskaryosis?
When cells are abnormal on a cervical screening sample
132
Who is offered cervical screening?
Women between 25 and 64
133
How often is cervical screening done?
- 25-49: 3 yearly
- 50-64: 5 yearly
Cannot self refer
134
How is cervical screening affected by pregnancy?
Pregnancy is delayed until 3 months post partum unless missed screening or previous abnormal screens.
135
How does HIV affect cervical screening?
Women are screened annually
136
How is cervical screening done?
he test consists of a speculum examination and collection of cells from the cervix using a small brush. The cells are deposited from the brush into a preservation fluid. This fluid is transported to a lab where the cells are examined under a microscope for precancerous changes (dyskaryosis). This way of transporting the cells is called liquid-based cytology.
137
What else may be detected on cervical screening?
BV, candidiasis, and trichomoniasis
138
What occurs if a cervical screening comes back as HPV positive with abnormal cytology?
Refer for colposcopy
139
What happens if a cervical screening is HPV positive with normal cytology?
Repeat HPV test after 12 months. If when repeated and still positive and normal, do another test in another year. If at 24 months positive and normal: colposcopy.
140
What is the management of a cervical screening sample that is 'inadequate'?
Repeat in 3 months. If two in a row are inadequate: colposcopy
141
Is borderline changes included in women who are called for colposcopy after cervical screening?
Yes: all recalled if anything but completely normal
142
What is a colposcopy?
Magnifies the cervix and allows the epithelial lining to be magnified in detail
143
What stains are used in colposcopy to identify abnormal areas?
Acetic acid + iodine solution
144
Why is acetic acid used during colposcopy?
Stain that makes abnormal cells appear white: helps identify cancerous cells
145
Why is iodine used during colposcopy?
Schiller’s iodine test involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain
146
How are tissue samples obtained during a colposcopy?
Punch biopsy or large loop excision of the transformation zone (LLETZ)
147
What is LLETZ?
Loop biopsy done in cervical cancer diagnosis.It involves using a loop of wire with electrical current (diathermy) to remove abnormal epithelial tissue on the cervix. The electrical current cauterises the tissue and stops bleeding.
148
What is a cone biopsy?
Treatment for cervical intraepithelial neoplasia + early stage cervical cancer. Under general anaesthetic, a cone shaped piece of the cervix is removed using a scalpel
149
What are the main risks of a cone biopsy?
Pain, bleeding, infection, scar formation with stenosis of the cervix, increased future risk of miscarriage and premature labour
150
What staging is used for cervical cancer?
FIGO
151
What are the 4 FIGO stages?
1a: confined to the cervix (<7mm)
1b: confined to cervix (>7mm)
2: invades uterus or upper 2/3 of vagina
3: invades pelvic wall or lower 1/3 of vagina
4: invades bladder, rectum or beyong pelvis
152
What is the treatment of CIN?
LLETZ
153
What is the management of stage 1a cervical cancer?
Gold standard: hysterectomy +/- lymph node clearance.
For patients wanting to maintain fertility, a cone margin with negative margins
154
What is the treatment of stage 1B cervical cancer?
Radical hysterectomy + removal of lymph nodes with chemo and radiotherapy
155
What is the treatment of stage 2 and 3 cervical cancer?
Radiation with concurrent chemotherapy
156
What is the treatment of stage 4 cervical cancer?
Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
157
What is pelvic exenteration?
Operation used in advanced cervical cancer: involves removal of most pelvic organs
158
What is the role of bevacizumab in cervical cancer tx?
May be used to treat metastatic or recurrent cancer. Stops the development of new blood vessels
159
What is the current guidance for HPV vaccines?
Given to all girls and boys before they become sexually active
160
Which strains of HPV cause genital warts?
6 and 11
161
What is cervical ectropium?
On the ectocervix, there is a transformation zone where the stratified squamous epithelium meets columnar epithelium of the cervical canal. The columnar epithelium becomes present and visible on the ectovervix
162
What is risk factors for cervical ectropium?
Elevated oestrogen levels: ovulatory phase, pregnancy, combined oral contraceptive pill use
163
What are possible features of cervical ectropium?
Vaginal discharge, post coital bleeding
164
What is the treatment of troublesome cervical ectropiums?
Cryotherapy
165
How does the hypothalamic pituitary gonadal axis work?
Hypothalamus releases GnRH, stimultes the anterior pituitary to release LH and FSH. LH and FSH stimulate development of follicles in the ovaries. Theca granulosa cells around the follicles secrete oestrogen: oestrogen has a negative feedback affect on the hypothalamus
166
What is the most prevalent and active version of oestrogen?
17-beta oestradiol
166
What is oestrogen
A steroid sex hormone produced by the ovaries in response to LH and FSH
167
What does oestrogen stimulate?
Acts on tissues with oestrogen receptors to promote female secondary sexual characteristics. Stimulates: breast tissue development, growth and development of the female sex organs, blood vessel development in the uterus, development of the endometrium
168
What produces progesterone?
Corpus luteum after ovulation, and in pregnancy produced by the placenta from 10 weeks gestaiton onwards
169
What is the role of progesterone?
Acts on tissues that have previously been stimulated by oestrogen. Acts to thicken and maintain the endometrium, thicken the cervical mucus, increase body temperature
170
Why do overweight children tend to enter puberty at an earlier age?
Aromatase is an enzyme found in adipose (fat) tissue, that is important in the creation of oestrogen. Therefore, the more adipose tissue present, the higher the quantity of the enzyme responsible for oestrogen creation.
171
What are the two phases of the menstrual cycle?
Follicular phase and luteal phase
172
What is the follicular phase of the menstrual cycle?
From the start of menstruation to the moment of ovulation (first 14 days of a 28 day cycle)
173
What is the luteal phase of the menstrual cycle?
From ovulation to the start of menstruation (final 14 days of the cycle)
174
What is the process of development of primordial follicles?
They develop into primary and secondary follicles, independent of the menstrual cycle. Once they reach secondary follicle, they have FSH receptors, and require external stimulation from FSH
175
What occurs in the proliferative phase?
GnRH stimulate LH and FSH, thus follicle growth. As follicles grow, oestradiol secreted, which has negative feedback on FSH; thus only one follicle becomes dominant. Oestradiol rise also causes cervical mucus to be more permeable. LH continues to rise, and spikes 36 hrs before ovulation. The follicle releases the egg.
176
What occurs in the luteal phase?
Follicle becomes the corpus luteum; this produces oestradiol and progesterone, which maintains the endometrial lining. If there is fertilisation, the embryo releases HCG, and maintains the corpus luteum. If there is no fertilisation, corpus luteum degenerates and stops producing oestrogen and progesterone. This causes the endometrium to break down, and menstruation to occur, and negative feedback ceases, and LH and FSH rises
177
What occurs in menstruation?
The superficial and middle layers of the endometrium separate from the basal layer. Tissue is brokwn down inside the uterus
178
What is the average amount of blood women lose during menstruation?
40ml
179
What qualifies as excessive menstrual blood loss?
More than 80ml
180
What investigations are done in heavy menstrual bleeding?
Pelvic examination with speculum and bimanual. FBC to look for iron deficiency anaemia. Consider thyroid function tests, swabs if evidence of infection
181
When should a patient with heavy menstrual bleeding be arranged to go to outpatient hyesteroscopy?
Suspected submucosal fibroids, suspected endometrial pathology, persistent IMB
182
When should a patient with heavy menstrual bleeding be arranged to have pelvic/transvaginal ultrasound?
Any patients with symptoms (eg, pelvic pain, pressure symptoms). Possible large pelvic mass, adenomyosis
183
What can be used as a short term option for rapidly stopping heavy menstrual bleeding?
Norethisterone 5mg
184
What are the final treatment options for heavy menstrual bleeding where medical management has failed?
Endometrial ablationa nd hysterectomy
185
What is the key differential dx for postmenopausal bleeding?
Endometrial cancer
186
What is the most common type of endometrial cancer?
Adenocarcinoma
187
Is endometrial cancer oestrogen dependent or independent?
Dependent
188
What are risk factors for endometrial cancer?
Excess oestrogen (nulliparity, early menarche, late menopause, unopposed oestrogen), metabolic syndrome (PCOS, DM, obese), tamoxifen
189
What genetic condition can increase the risk of endometrial cancer?
HNPCC/Lynch syndrome
190
What are protective factors for endometrial cancer?
Multiparity, COC, smoking (who knows why lol
191
What are the key features of endometrial cancer?
Post menopausal bleeding. Pain is uncommon, as is discharge
192
What is the management of any women over 55 years old who present with post menopausal bleeding?
Refer using the suspected cancer pathway
193
What is the first investigation for women with suspected endometrial cancer? What is a reassuring feature?
Trans-vaginal ultrasound. Normal thickness has high negative predictive factor
194
What is the management of endometrial cancer?
Surgery: localised disease with total abdominal hysterectomy with bilateral salpingo-oopherectomy. High risk disease may also have postoperative radiotherapy
195
What is the treatment for women with endometrial cancer who may not be suitable for surgery?
Progestogen therapy
196
What is endometrial hyperplasia?
Precancerous condition involving thickening of the endometrium. Most cases return to normal
197
What is the treatment of endometrial hyperplasia?
Progestogens: intrauterine system (mirena) or continuous oral progestogens
198
Why does PCOS increase the risk of endometrial cancer?
High levels of unopposed oestrogen due to a lack of ovulation. Corpus luteum less likely to be formed and produce progesterone. Thus endometrial lining has more exposure to unexposed oestrogen
199
What cancer are women with PCOS more at risk of?
Endometrial cancer
200
What protected against endometrial cancer should women with PCOS have?
COC pill, intrauterine system (Mirena), cyclical progestogens
201
Why is obesity such a high risk factor for endometrial cancer?
Adipose tissue is a source of oestrogen: adipose tissue is the primary source of oestrogen in post menopausal women. It contains aromatase which is an enzyme which converts androgens into oestrogen.
202
How does tamoxifen affect the risk of endometrial cancer?
Tamoxifen has an anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium. This increase the risk of endometrial cancer.
203
What is normal endometrial thickness post menopause?
<4mm
204
What biopsy is highly sensitive for endometrial cancer?
Pipelle biopsy
205
What is the management of any endometrial hyperplasia with atypia?
Hysterectomy
206
What is a Krukenberg tumour?
Metastasis in the ovary, usually from a GI tract cancer
207
How do Krukenberg tumours typically present on histology?
Signet ring cells
208
What are risk factors for ovarian cancer?
Older age, BRCA1/2, increased number of ovulations (early menarche, late menopause), obesity, smoking, recurrent use of clomifene
209
What are protective factors for ovarian cancer?
COC pill, breast feeding, pregnancy
210
What are the typical symptoms of ovarian cancer?
Vague, non specific symptoms. Can include: abdominal bloating, early satiety, loss of appetite, pelvic pain, urinary symptoms, weight loss, abdominal or pelvic mass, ascites
211
Why might an ovarian mass cause referred hip or groin pain?
Due to the obturator nerve being pressed on
212
When should a 2-week-wait be referred for in potential ovarian cancer?
Ascites, pelvic mass (unless clearly due to fibroids), abdominal mass
213
What are the initial investigations for potential ovarian cancer in primary care?
CA125, referral for pelvic ultrasound
214
What is the risk of malignancy index?
Estimates the risk of an ovarian mass being malignant. Takes into account menopausal status, ultrasound findings, CA125 level
215
What investigations should be done for women under 40 years old with a complex ovarian mass?
Investigations for a possible germ cell tumour: aFP, HCG
216
What level means CA125 is raised?
35 IU/mL or greater
217
What is the management of ovarian cancer?
Combination of surgery and platinum based chemotherapy
218
What is PMS?
The emotional and physical symptoms that women experience in the luteal phase
219
What is the management of mild PMS?
Lifestyle advice, and also regular, frequent small balanced meals rich in complex carbohydrates
220
What is the management of moderate PMS?
New generation COCP (eg, Yasmin)
221
What is the management of severe PMS?
SSRI (taken continuously or during the luteal phase)
222
What causes PMS?
The fluctuation of oestrogen and progesterone during the menstrual cycle
223
What helps to diagnose PMS?
Symptom diary spanning 2 menstrual cycle (and should demonstrate cyclical symptoms). Definitive diagnosis via GnRH analogues, and seeing if this eradicates symptoms
224
What can help manage the physical symptoms of PMS (breast swelling, water retention, bloating)?
Spironolactone
225
What can help treat cyclical breast pain?
Danazole and tamoxifen
226
What are risk factors for incontinence?
Advancing age, previous pregnancy and childbirth, high BMI, hysterectomy, FHx, post menopausal, pelvic organ prolapse, neurological conditions, cognitive impairment and dementia
227
What causes urge incontinence?
Caused by overactivity of the detrusor muscle of the bladder
228
What is the typical presentation of urge incontinence?
- suddenly feeling the urge to pass urine
- rushing to the bathroom and not arriving before urination occurs
229
What causes stress incontinence?
Due to weak pelvic floor and sphincter muscles, which allows urine to leak at times of increased pressure on the bladder
230
What is the presentation of stress incontinence?
Urinary leakage when laughing, coughing, or surprised
231
What is overflow incontinence?
Chronic urinary retention due to an obstruction of the outflow of urine. Incontinence occurs without the urge to pass urine
232
What can cause overflow incontinence?
Anticholinergic medications, fibroids, pelvic tumours, neurological conditions such as MS, diabetic neuropathy, and spinal cord injuries
233
Which gender is overflow incontinence more common in?
Men
234
What is the investigation from a woman with suspected overflow incontinence?
Urodynamic testing
235
What is functional incontinence?
When someone can't get to the toilet due to physical inability, such as disability
236
What is establish when taking a hx of urinary incontinence?
- hx: establish triggers
- modifiable lifestyle factors: caffeine, alcohol, medications, BMI
- establish severity
237
What should be assessed in a physical examination in urinary incontinence?
- pelvic tone: do a bimanual and ask the woman to squeeze
- examine for pelvic organ prolapse, atrophic vaginitis, urethral diverticulum, pelvic massess
- ask patient to cough, watch for leakage
238
What are the investigations for urinary incontinence?
- bladder diary
- urine dipstick testing
- post void residual bladder emptying scan
- urodynamic testing
239
How long should a bladder diary be kept in urinary incontinence?
at least 3 days, with a mix of work and leisure
240
When is urodynamic testing done?
To investigate patients with urge incontinence not responding to first line medical treatments, difficulties urinating, urinary retention, previous surgery or unclear dx
241
What is urodynamic testing?
A catheter is inserted into the rectum and into the bladder. They measure the pressures in both to compare. The bladder is filled with liquid, and various measures are taken
242
What measures are taken during urodynamic tests?
- cystometry
- uroflowmetry
- leak point pressure
- post void residual bladder volume tests
- video urodynamic testing
243
How do patients need to prepare for urodynamic testing?
Stop taking any anticholinergic and bladder related medications around 5 days before
244
What is the management of stress incontinence?
- lifestyle
- supervised pelvic floor exercises for at least 3 months
- surgery
- duloextine (second line)
245
What are surgical options for stress incontinence?
- tension free vaginal tape (mesh sling)
- autologous sling procedures
- colposuspension
- intramural urethral bulking
246
What is the first line management of urge incontinence?
Bladder retraining for at least 6 weeks
247
What medication is given in urge incontinence?
Anticholinergic: oxybutynin, tolterodin
248
What is a C/I for anticholinergic medications?
Can lead to cognitive decline, memory problems, and worsening of dementia
249
What are anticholinergic side effects?
Dry mouth, dry eyes, urinary retention, constipation, postural hypotension
250
What are invasive options for management of urge incontinence?
Boulinum toxin type A, percutaneous sacral nerve stimulation, urinary diversion
251
What is an alternative to anticholinergics in urge incontinence in older patients?
Mirabegron (beta-3 agonist)
252
What are the potential types of prolapse?
Cystocele, rectocele, uterine prolapse, urethrocele, enterocele
253
What is a uterine prolapse?
Where the uterus itself descends into the vagina
254
What is a vault prolapse?
When a woman who has had a hysterectomy, has the top of the vagina (the vault) descend into the vagina
255
What is a rectocele?
The rectum prolapses forwards into the vagina
256
What wall is there a defect in with rectoceles?
Posterior vaginal wall
257
What condition is associated with rectoceles, and how do women 'self manage' it?
Constipation and can develop into faecal loading. Women may use their fingers to press the lump backwards, which allows them to open their bowels
258
What wall is there a defect in with cystoceles?
Anterior vaginal wall
259
What is a cystocele?
Bladder prolapses backwards into the vahina
260
What is a cystourethrocele?
Prolapse of both the bladder and the urethra
261
What are risk factors for pelvic organ prolapse?
Weak and stretched muscles and ligaments. RF: multiple vaginal deliveries, instrumental/prolonged/traumatic delivery, advanced age, post menopausal, obesity, chronic respiratory disease causing coughing, chronic constipation causing straining
262
What are the typical symptoms of prolapse?
Something 'dragging down' in the vagina, heavy sensation in the pelvis, urinary symptoms (LUTS), bowel symptoms, sexual dysfunction
263
What should be done in an examination for prolapse?
Empty bowel and bladder before examination. Multiple positions attempted: dorsal and left lateral position. Can use Sim's speculum. Ask patient to bear down/cough
264
What is the scale used to assess severity of uterine prolapse?
POP-q
265
What is the introitus?
The external opening of the vaginal canal
266
What is a prolapse referred to if it extends beyond the introitus?
Uterine procidentia
267
What is grade 0 uterine prolapse?
Normal
268
What is grade1 uterine prolapse?
Lowest part is more than 1cm above introitus
269
What is grade 2 uterine prolapse?
Lowest part is within 1cm of the introitus
270
What is grade 3 uterine prolapse?
Lowest part is more than 1 cm below the introitus but not fully descended
271
What is grade 3 uterine prolapse?
Full descent with eversion of the vagina
272
What are conservative management strategies for uterine prolapse?
Physiotherapy, weight loss, lifestyle changes, treatment of related symptoms, vaginal oestrogen cream
273
What are the different types of Pessary? (5)
Ring, shelf, cube, donut, hodge
274
What is the definitive treatment of uterine prolapse?
Surgery
275
What is the controversy related to mesh repairs of uterine prolapse?
Chronic pain, altered sensation, dyspareunia, abnormal bleeding, urinary/bowel problems
276
What is a fistula definition?
Abnormal connection between two epithelial surfaces
277
What are the symptoms of a enterovesicular fistula?
Pathological connection between the bowel and bladder. Can result in frequent UTIs, and passage of gas from the urethra during urination
278
What are the most common types of vulval cancers?
Squamous cell carcinomas
279
What are risk factors for vulval cancer?
Advanced age, immunosuppression, HPV, lichen sclerosus
280
What is vulval intraepithelial neoplasia?
A premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer
281
What type of vulvar intraepithelial neoplasia is associated with HPV infection?
High grade squamous intraepithelial lesion: tends to be associated with younger women
282
What type of vulval intraepithelial neoplasia tends to be associated with lichen sclerosus?
Differentiated vulval intrapeithelial neoplasia
283
How is vulval intraepithelial neoplasia diagnosed?
Biopsy
284
How is vulvar intraepithelial neoplasia treated?
Watch and wait, wide local excision, imiquimod cream, laser ablation
285
What is the most common location for vulval cancer?
Labia majora
286
How does vulval cancer present?
Vulval lump, ulceration, bleeding, pain, itching, lymphadenopathy in the groin
287
How might a lesion of vulval cancer present on the labia majora?
Irregular mass, fungating lesion, ulceration, bleeding
288
How is vulval cancer diagnosed?
Biopsy, sentinel lymph node biopsy, further imaging for staging (CT abdomen and pelvis)
289
What is a complete hydatidiform mole?
Benign tumour of trophoblastic material
290
How does a hydatidiform mole form?
Occurs when an empty egg is fertilised by a single sperm that then duplicates its own DNA, hence all 46 chromosomes are of the paternal origin
291
What are the features of a hydatidiform mole?
Bleeding in the first or early second trimester, exaggerated symptoms of pregnancy (hyperemesis), uterus large for dates, very high hCG levels, HTN and hyperthyroidism may be seen
292
Why might hyperthyroidism be seen in hydatidiform mole?
hCG can mimic TSH
293
What is the management of complete hydatidiform mole?
Urgent referral to specialist centre: evacuation of the uterus is performed. Must also be on effective contraception for the next 12 months
294
What a potential complication of a hydatidiform mole?
May develop a choriocarcinoma
295
What is a partial mole?
A normal haploid egg that has been fertilised by 2 sperms, or by one with duplication of paternal chromosomes
296
What is seen on a ultrasound in complete hydatidiform mole?
'Snow storm' appearance
297
Is there any fetal material in a complete vs partial mole?
Complete mole: no fetal material
Partial mole: some fetal material
298
What is atrophic vaginitis?
Dryness and atrophy of the vaginal mucosa due to a lack of oestrogen
299
When does atrophic vaginitis typically occur?
When women enter the menopause
300
What is the pathophysiology of atrophic vaginitis?
Normally, oestrogen keeps the epithelial lining of the vagina and urinary tract thick, elastic and producing secretions. However, when women enter the menopause, it becomes thinner, less elastic and more dry and prone to inflammation
301
What is the typical presentation of atrophic vaginitis?
Itching, dryness, dyspareunia, bleeding due to localised inflammation
302
What is seen on examination in atrophic vaginitis?
Pale mucosa, thin skin, reduced skin folds, erythema, inflammation, dryness, sparse pubic hair
303
What conditions should make you consider atrophic vaginitis and treatment with topical oestrogen?
Recurrent UTIs, stress incontinence, pelvic organ prolapse
304
What is the treatment for atrophic vaginitis?
- vaginal lubricants
- topical oestrogen: cream, tablets, pessaries
305
What is required for a dx of menopause?
Retrospective dx, after a woman has had no periods for 12 months
306
What is perimenopause?
The time around menopause where the woman may experience vasomotor symptoms and irregular periods; this is 12 months after the last menstrual period
307
What age is premature menopause?
Prior to 40
308
What causes premature menopause?
Premature ovarian insufficiency
309
What causes menopause?
Lack of ovarian follicular function, resulting in low oestrogen and progesterone, and high FSH and LH (due to no negative feedback)
310
What is the pathophysiology of the menopause?
- decline in development of the ovarian follicles
- reduced production of oestrogen
- LH and FSH levels rise (oestrogen has a negative affect on the pituitary)
- ovulation doesn't occur due to lack of developing follicles
- low oestrogen means the endometrium doesn't develop, leading to lack of menstruation
311
What are peri menopausal symptoms?
Hot flushes, emotional lability, premenstrual syndrome, irregular periods, joint pains, heavier/lighter periods, vaginal dryness and atrophy, reduced libido
312
What conditions does a lack of oestrogen increase the risk of?
CVD, stroke, osteoporosis, pelvic organ prolapse, urinary incontinence
313
How is menopause and perimenopause diagnosed?
In women over 45: no additional testing required
In women less than 45: FSH blood test. Must do 2, 4-6 weeks apart
314
How long after menopause should women use contraception?
2 years after last period in women under 50, 1 year in women over 50
315
What is considered good contraception options for women approaching the menopause?
Barrier methods, mirena/copper coil, progesterone only pill or implant, progesterone depot injection
316
Why are menopausal women not recommended to use the COCP?
Due to risk of VTE
317
What is key side effects of the progesterone depot injection?
Weight gain, reduced bone mineral density
318
What are the options for management of perimenopausal symptoms?
HRT, CBT, SSRI, testosterone for reduced libido, vaginal oestrogen and moisturisers, clonidine, tibolone
319
What are contraindications to menopause management with HRT?
Current or past breast cancer, oestrogen sensitive cancer, undiagnosed vaginal bleeding, untreated endometrial hyperplasia
320
Why should women with a uterus not be given unopposed oestrogen as a treatment for menopause?
Increased risk of endometrial cancer
321
What are the increased risks associated with combined HRT?
Venous VTE, coronary heart disease, breast cancer, ovarian cancer
322
What is there an increased risk of with oestrogen HRT?
Stroke
323
What is the strongest indication for starting HRT?
Vasomotor symptoms such as flushing, insomnia and headaches
324
If women take HRT for premature menopause, when should it be taken until, and why?
Take until 50 years, due to the risk of oesteoporosis
325
What is tibolone?
A synthetic compound with oestrogenic, progestogenic and andogenic activity: used as HRT
326
If a woman is at risk of VTE, but still wants HRT, how should it be given?
Transdermal: doesn't increase risk
327
What are side effects of HRT?
Nausea, breast tenderness, fluid retention and weight gain
328
How does HRT affect risk of breast cancer?
Increased risk, and increased by the addition of a progestogen. Duration of taking HRT also increases risk
329
When does risk of breast cancer return to 'normal' after HRT is stopped?
5 years
330
Which women can go on cyclical HRT?
Those who are still having periods, can have cyclical progesterone, and regular breakthrough bleeds
331
How is progesterone delievered in HRT?
Oral, transdermal, or mirena
332
What weeks of pregnancy is hyperemesis gravidarum most common between, and when can it persist until?
Between 8 and 12, can persist up to 20
333
What are risk factors for hyperemesis gravidarum?
Increased bHCG (multiple pregnancies, trophoblastic disease), nulliparity, obesity, FHx or personal hx
334
What decreases the incidence of hyperemesis?
Smoking !
335
When should someone be admitted with hyperemesis gravidarum?
- unable to keep down liquids or oral anti emetics
- ketonuira and/or weight loss (greater than 5% body weight), despite treatment with oral antiemetics
- confirmed or suspected comorbidity
336
What is the (recommended) triad of hyperemesis gravidarum?
5% pre pregnancy weight loss, dehydration, electrolyte imbalance
337
What is a validated scoring system for hyperemesis gravidarum?
PUQE (pregnancy-unique quantification of emesis)
338
What are first line medications for hyperemesis?
antihistamines: oral cyclizine or promethazine. Can also give prochlopromazine
339
What are second line medications for hyperemesis gravidarum?
Oral ondanestron, metaclopramide or domperidone
340
What are potential s/e of ondanestron during first trimester?
Risk of baby having cleft lip/palate
341
What are potential complications of hyperemesis gravidarum?
AKI, Wernicke's, oesophagitis, Mallory-Weiss tear, VTE, fetal outcome
342
What is Ashermans syndrome?
Where there is adhesions within the uterus, usually following damage
343
What causes Ashermans syndrome?
Occurs after pregnancy related D+C, uterine surgery, or several pelvic infections
344
Why might endometrial curettage lead to Ashermans?
It damages the basal layer of the endometrium; the damaged tissue then heals abnormally, leaving scar tissues and adhesions
345
Are asymptomatic adhesions counted as Ashermans?
No
346
What is the presentation of Ashermans?
- typically following recent D+C, uterine surgery or endometriosis with: secondary amenorrhoea (absent periods), lighter periods, dysmenorrhoea, infertility
347
What is the gold standard for diagnosis of Ashermans?
Hysteroscopy. Can also do MRI
348
How is Ashermans managed?
Dissecting the adhesions during hysteroscopy, though reoccurence is common
349
What are the causes of premature ovarian insufficiency?
Most commonly idiopathic (may be FHx), bilateral oopherectomy, radiotherapy, chemotherapy, infection (mumps, eg), autoimmune disorders, resistant ovary disorder (FSH receptor abnormalitieS)
350
What is the differentiation between a microadenoma and macroadenoma?
Micro <1cm, macro >1cm
351
What is the most common type of pituitary adenoma?
Prolactinoma
352
What are the features of prolactinomas in women?
Amenorrhoea, infertility, galactorrhoea, osteoporosis
353
What are the features of prolactinomas in men?
Impotence, loss of libido, galactorrhoea
354
How are prolactinomas (/pituitary adenoma) diagnosed?
MRI
355
How are prolactinomas typically treated?
Dopamine agonists (eg, cabergoline, bromocriptine) which inhibit release of prolactin
356
What surgery is typically done for prolactinomas/ pituitary adenomas?
Trans-sphenoidal approach
357
What is the function of prolactin?
Stimulates breast development and milk production. Also decreases GnRH pulsalitity, and blocks action of LH on the ovary or testus
358
What increases the secretion of prolactin?
TRH, pregnancy, oestrogen, breastfeeding, sleep, stress, drugs (metoclopramide, antipsychotics)
359
What is pelvic inflammatory disease?
Inflammation and infection of the organs of the pelvis, due to infection spreading up through the cervix
360
What is the most common cause of pelvic inflammatory disease?
Chlamydia trachomatis
361
What typically presents with a severe course of pelvic inflammatory disease?
Neisseria gonorrhoeae, mycoplasma genitalium, mycoplasma hominis
362
What are the features of PID?
Lower abdominal pain, fever, deep dyspareunia, dysuria and menstrual irregularities, vaginal or cervical discharge, cervical excitation, abnormal bleeding
363
What are the risk factors for PID?
Not using barrier contraception, multiple sexual partners, younger age, existing STIs, previous PID, intrauterine device
364
What investigations should be done for PID?
- NAAT swabs for gonorrhoea + chlamydia (often negative)
- HIV + syphilis test
- high vaginal swab for BV, candidiasis and trichomoniasis
- pregnancy test to exclude ectopic pregnancy
- ESR +CRP
- check for pus cells on swabs from vagina/endocervix
365
What is the treatment for pelvic inflammatory disease?
Dependent on BASHH guidelines. Example: oral doxycycline, oral metronidazole, IM cetriaxone
366
What are potential complications of PID?
Sepsis, abscess, infertility, chronic pelvic pain, ectopic pregnancy, Fitz-Hugh-Curtis syndrome
367
What is Fitz-Hugh-Curtis syndrome?
Complication of PID, where inflammation and infection has spread to the liver capsule, leading to adhesions.
368
What must healthcare professionals do if they encounter FGM?
Report to the police
369
What is type 1 FGM?
Removal of part or all of the clitoris
370
What is type 2 FGM?
Removal of all of the clitoris and labia minora. Also may remove labia majora
371
What is type 3 FGM?
Narrowing or closing the vaginal orifice (infibulation)
372
What are scenarios where the risk fo FGM must be considered?
- pregnant women with FGM with possible female child
- siblings or daughters of women with FGM
- extended trips to areas where FGM is practised
- women that decline examination or cervical screening
373
What structure does most of the female genital structures develop from?
The mullerian ducts
374
What makes female embryological structures 'disappear' in men?
anti-mullerian hormone
375
What is bicornuate uterus?
'Heart shaped' uterus, where there are 2 horns.
376
How is bicornuate uterus dx?
Ultrasound
377
What is imperforate hymen?
Where the hymen at the entrance of the vagina is fully formed, without an opening
378
How does imperforate hymen typically present?
Teenager with primary amenorrhoea, who has cyclical pain
379
What is the treatment of an imperforate hymen?
Surgical incision
380
What is transverse vaginal septum?
A condition where there is a septum running transversely across the vagina. It can be perforate or imperforate
381
What is the treatment and possible complications of transverse vaginal septae?
Surgery. Vaginal stenosis and recurrence of the septae
382
What is vaginal hypoplasia and agenesis?
Vaginal hypoplasia: abnormally small vagina
Vaginal agenesis: absent vagina
383
What causes vaginal hypoplasia and agenesis?
Failure of the mullerian ducts to develop properly
384
What is the management of vaginal hypoplasia and agenesis?
Management may involve the use of a vaginal dilator over a prolonged period to create an adequate vaginal size. Alternatively, vaginal surgery may be necessary.
385
What is oligoovulation?
Irregular, infrequent ovulation
386
What is hirsutism?
The growth of thick dark hair, often in a male pattern
387
What diagnostic criteria is used for PCOS?
Rotterdam criteria
388
What are the 3 key features of the Rotterdam Criteria?
Oligoovulation/anovulation (irregular/absent menstrual periods), hyperandrogenism (hirsutism and acne), polcystic ovaries on ultrasound
389
How many of the rotterdam criteria is required for PCOS dx?
2 out of 3
390
What are features of PCOS?
Oligomenorrhoea/amenorrhoea, infertility, obesity, hirsutism, acne, hair loss in a male pattern, acanthosis nigricans
391
What levels of hormones are observed to be high in PCOS?
Insulin and LH
392
What skin condition is seen in PCOS?
Acanthosis nigricans
393
What other conditions are more common in PCOS?
Insulin resistance/diabetes, CVD, hypercholesterolaemia, endometrial hyperplasia and cancer, obstructive sleep apnoea, depression, anxiety, sexual probems
394
What are differential diagnosis of hirsutism?
- ovarian or adrenal tumours that secrete androgens
- cushings
- congenital adrenal hyperplasia
- medications (phenytoin, corticosteroids, testosterone, anabolic steroids)
395
How does insulin resistance relate to PCOS?
Hyperinsulinaemia occurs, leads to the release of more androgens (such as testosterone). Insulin also suppresses sex hormone binding globulin produced by the liver, which usually suppresses androgens. Therefore, reduced SHBG further promotes hyperandrogenism. High insulin leads to halted development of follicles in the ovaries.
396
What investigations should be done on a woman with queried PCOS?
Pelvic ultrasound, FSH, LH, prolactin, TSH, testosterone, sex hormone binding globulin
397
What LH:FSH ratio is seen in PCOS?
Raised LH:FSH ratio
398
What levels of testosterone and SHBG are seen in women with PCOS?
Testosterone: normal/slightly raised
SHBG: normal to low
399
What is seen on ultrasound in PCOS?
- string of pearls appearance (follicles arranged around the periphery of the ovary)
400
What is the diagnostic criteria for ultrasound in PCOS?
- 12 or more developing follicles in one ovary
- ovarian volume of more than 10cm^3
401
How should diabetes be diagnosed in patients with PCOS?
Oral glucose tolerance test
402
What is the general management in PCOS to control potential compx?
Weight loss, low glycaemia index, exercise, smoking cessation, antiHTN medications, statins
403
What may be given to PCOS patients to aid weight loss?
Orlistat
404
What is orlistat, and when is it given in PCOS?
Women with a BMI >30. It is a lipase inhibitor that stops the absorption of fat in the intestines
405
Why do women with PCOS have an increased risk of endometrial cancer?
These patients frequently ovulate, but do not have a corpus luteum to produce progesterone. Therefore, the endometrial lining continues to proliferate and not shed, so there is unopposed oestrogen
406
What additional investigations should be done in women with PCOS with extended gaps between periods?
Pelvic ultrasound to assess the endometrial thickness: may then need a biopsy to exclude hyperplasia or cancer
407
How can the risk of endometrial hyperplasia and endometrial cancer be reduced in PCOS patients?
Mirena coil (continuous protection) or inducing a withdrawal bleed with COCP or cyclical progestogens
408
How is hirsutism managed in PCOS patients?
COCP: often co-cyprindiol (dianette) which has an anti-androgenic effect
409
What is first line management of fertility in PCOS patients?
Weight reduction
410
What management can be used for infertility in PCOS?
Clomifene, metofirmin, laparoscopic ovarian drilling, IVF
411
How can ovarian drilling improve fertility in patients with PCOS?
The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
412
How can increasing GnRH pulse frequency increase change of pregnancy?
Increases the release of FSH and LH hormone, makes it more likely that multiple follicles will develop, and one will become dominant
413
What type of ovulatory disorder occurs in PCOS?
Normogonadotropic normoestrogenic anovulation
414
What is the most common type of ovulation disorder?
Normogonadotropic normoestrogenic anovulation
415
What type of ovulatory disorder is premature ovarian insufficiency?
Hypergonadotropic hypoestrogenic anovulation
416
What is first line medical therapy in PCOS?
Letrozole
417
How does letrozole aid fertility?
It is an aromatase inhibitor, reducing the negative feedback by estrogens to the pituitary gland, so more FSH is produced, and more follicles develop
418
Why is letrozole generally preferable to clomifene in fertility?
Has higher rates of mono-follicular development, has higher rates of live birth
419
How does clomifene work in fertility treatment?
Selective estrogen receptor modulator, which blocks the negative feedback of oestrogens at the hypothalamus. Increases GnRH pulse frequency, increases follicular development
420
What is ovarian hyperstimulation syndrome?
Ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift into the extra vascular space. This can cause hypovolaemic shock, acute renal failure, VTE
421
What is a potentially life threatening side effect of ovulation induction?
Ovarian hyperstimulation syndrome
422
What is the management of ovarian hyperstimulation syndrome?
Fluid and electrolyte replacement, anti-coagulation therapy, pregnancy termination, monitoring urine output, LMWH, ascitic fluid removal
423
Why is there fluid movement in ovarian hyperstimulation syndrome?
Due to the granulosa cells of the follicles releasing vascular endothelial growth factor, which increases the permeability.
424
What are risk factors for ovarian hyperstimulation syndrome?
Younger age, lower bmi, PCOS, raised oestrogen during ovarian stimulation
425
What sorts of fertility tx is ovarian hyperstimulation syndrome most commonly seen in?
hCG or gonadotropin treatment
426
What are features of ovarian hyperstimulation syndrome?
Abdominal pain, bloating, N+V, diarrhoea, hypotension, hypovolaemia, ascites, pleural effusions, renal failure, peritonitis, prothrombotic state
427
Why is haematocrit measured in ovarian hyperstimulation syndrome?
Can be used to assess the volume of fluid in the intravascular space. Raised haematocrit can indicate dehydration, indicates there is less fluid in the intravascular space
428
When should investigation and referral for infertility be initiated?
When a couple has been trying to concieve without success for 12 months, and 6 months if the woman is older than 35
429
What is the most common cause of infertility for couples?
Sperm problems, though most couples have a mix of male and female causes
430
What supplement should women take whilst trying to fall pregnant?
400mcg folic acid daily
431
What are the basic investigations for infertility?
Semen analysis and serum progesterone 7 days prior to expected next period (day 21 typically)
432
What is the interpretation of serum progestogen tests during infertility investigations?
<16 repeat and if consistently low refer to specialist, and if >30 indicates ovulation
433
What is the most accurate marker of ovarian reserve?
Anti-Mullerian hormone
434
What scan can be done to assess the shape of the uterus and the patency of the fallopian tubes?
Hysterosalpingogram
435
What is the process of a hysterosalpingogram?
A small tube is inserted into the cervix. A contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes. Xray images are taken, and the contrast shows up on the xray giving an outline of the uterus and tubes. If the dye does not fill one of the tubes, this will be seen on an xray and suggests a tubal obstruction.
436
When should semen analysis be undertaken?
After a minimum of 3 days and a maximum of 5 days abstinence
437
What is intrauterine insemination?
Process of introducing sperm directly into the uterus
438
What causes most cases of thrush?
Candida albicans
439
What are predisposing factors for thrush?
Diabetes, antibiotics + steroids, pregnancy, immunosuppression (eg, HIV)
440
What investigations are required for thrush?
High vaginal swab is not routinely indicated if the clinical features are consistent with thrush
441
What is the first line management of thrush (and dose)
Oral fluclonazole (150mg)
442
What can be added to oral fluclonazole if vulval symptoms in thrush?
Topical imidazole
443
What is the definition of recurrent vaginal candidiasis?
4 or more episodes per year
444
What blood test should be done in women with recurrent thrush?
Diabetes
445
What is the important differential diagnosis in recurrent vaginal candidiasis?
Lichen Sclerosus
446
What is the management of recurrent thrush?
Induction maintenance regime of fluclonazole: induction = a dose per day for 3 days, then once a week for 6 months
447
What causes bacterial vaginosis?
Overgrowth of bacteria in the vagina, specifically anaerobic bacteria. Caused by the loss of lactobacilli
448
Why are lactobacilli important in the vagina, and how do they link with BV?
Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5). When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply. This can lead to BV.
449
What anaerobic bacteria is most commonly associated with BV?
Gardnerella vaginalis
450
What are risk factors for BV?
Multiple sexual partners, excessive vaginal cleaning, recent abx, smoking, copper coil
451
Is itching, irritation or pain seen with BV?
No
452
What investigations should be done in suspected BV?
Speculum exam can confirm the typical discharge, and do a high vaginal swab to exclude other STDs. This is not always required
453
What pH is typically seen in BV?
Above 4.5
454
What is seen on microscopy in BV?
'Clue cells' (epithelial cells from the cervix that have bacteria stuck inside them, usually gardnerella vaginalis)
455
What is the treatment for BV, if it requires it? What is the course?
Metronidazole, as it specifically targets anaerobic bacteria. Taken for 5-7 days
456
What should patients taking metronidazole be told to avoid?
Alcohol: can cause N+V, flushing and rarely shock + angioedema
457
What does BV increase the risk of?
Catching other STDs such as chlamydia, gonorrhoea, and HIV
458
What complications is BV associated with in pregnancy?
Miscarriage, preterm delivery, PROMs, chorioamnionitis, low birth weight
459
What are features of trichomonas vaginalis?
Offensive, rellow/green, frothy discharge. Vulvovaginitis, strawverry cervix, pH >4.5
460
What is the treatment of trichomonas?
Oral metronidazole
461
What is trichomonas (as a bacteria-y thing-y rather than the disease lol)
A protozoan, a single celled organism with flagella
462
Where does trichomonas lie in women and men?
Women: vagina
Men: urethra
463
What conditions does trichomonas increase the risk of?
HIV, BV, cervical cancer, PID, pregnancy related complications
464
How is trichomonas diagnosed?
Standard charcoal swab with microscopy, from the posterior fornix of the vagina (behind the cervix)
465
What is the most common STD in the UK?
Chlamydia
466
What type of bacteria is chlamydia trachomatis?
Gram negative, and is intracellular organism (enters and replicates within cells before rupturing and preading)
467
Are more men or women asymptomatic with chlamydia?
Women
468
What is the national chlamydia screening programme?
Aims to screen every sexually active person under 25 annually, or when they change their sexual partner
469
How soon after should someone who has tested positive for chlamydia be tested again? Why?
Within 3 months, to ensure they haven't contracted chlamydia again, rather than checking the tx worked
470
What STDs/bacteria do charcoal swabs check for?
BV, candidiasis, gonorrhoea, trichomonas vaginalis, GBS
471
What is NAAT testing used to diagnose?
Chlamydia and gonorrhoea
472
What is the preference of swab location in NAAT testing in women?
Preference is endocervical, then vulvovaginal, then urine
473
What testing is done for chlamydia?
NAAT, with a preference for endocervical. Traditional cell culture isn't used.
474
When should chlamydia testing be carried out after a potential exposure?
2 weeks
475
If a woman does present with chlamydia, what would the symptoms be?
Abnormal vaginal discharge, pelvic pain, abnormal bleeding, painful sex, painful urination
476
What is the presentation of chlamydia in men?
Urethral discharge or discomfort, painful urination, epididymo-orchitis, reactive arthritis
477
How might rectal chlamydia present?
Discomfort, discharge, bleeding, change in bowel habits
478
What age is chlamydia screening offered between?
15-24 years
479
What might be seen on examination in chlamydia in women?
Pelvic or abdominal tenderness, cervical motion tenderness (excitation), inflamed cervix, discharge
480
What is first line treatment for uncomplicated chlamydia and dosage?
Doxycycline 100mg twice a day for 7 days
481
What is the treatment of chlamydia if pregnant? Why cannot doxy be used?
Azithromycin, erythromycin or amoxicillin. Doxy contraindicated in pregnancy
482
When is test of cure (testing after treatment of STI) recommended in chlamydia?
If rectal, pregnancy or persistent symptoms
483
What are potential complications of chlamydia infection?
Epididymitis, PID, endometriosis, ectopic pregnancies, infertility, reactive arthritis, perihepatitis
484
What is lymphogranuloma venereum?
Condition that affects the lymphoid tissue around the site of infection with chlamydia
485
What population is most likely to be affected by lymphogranuloma venereum?
MSM or immunosuppressed with HIV
486
What is the presentation course of lymphogranuloma venerueum?
1: small painless pustule which later forms an ulcer
2: painful inguinal lymphadenopathy
3: proctocolitis (inflammation of the rectum and colon, presents with anal pain, tenesmus, discharge)
487
What is the likely cause of proctocolitis in a man with HIV?
Chlamydia infection leading to lymphogranuloma venereum
488
What is the treatment of lymphogranuloma venereum?
21 days of doxy
489
What are triple swabs in GUM?
a NAAT swab, high vaginal charcoal media swab, and a endocervical charcoal media swab
490
What bacteria causes gonorrhoea, and what type of bacteria is it?
Neisseria gonorrhoeae, gram negative diplococcus
491
What type of tissue does gonorrhoea infect?
Mucous membranes with columnar epithelium, such as the endocervix, urethra, rectum, conjunctiva, pharynx
492
What STD has a particular issue with abx resistance?
Gonorrhoea
493
Are more men or women asymptomatic for gonorrhoea?
More men (90%)
494
How does gonorrhoea present in women?
Odourless purulent discharge (green or yellow), dysuria, pelvic pain
495
How does gonorrhoea present in men?
Odourless purulent discharge, dysuria, testicular pain or swelling
496
How is gonorrhoea diagnosed?
NAAT test, and a standard endocervical swab for MC&S
497
What is the current first line treatment for gonorrhoea?
IM ceftriaxone 1g
498
What is the treatment of gonorrhoea if the patient is needle-phobic?
Oral cefixime 400mg + oral azithromycin 2g
499
What can be added to first line gonorrhoea treatment if the sensitivities are known?
Ciprofloxacin
500
Is test of cure done in gonorrhoea?
Yes, due to the very high abx resistance
501
What is a key complication of gonorrhoea if transmitted to a neonate?
Gonococcal conjunctivitis: in a neonate this is an emergency and can be associated with sepsis, perforation of the eye and blindness
502
What are possible local complications of gonorrhoea?
Urethral strictures, epididymitis and salpingitis
503
What is the most common cause of septic arthritis in young adults?
Gonococcal infection
504
What is the triad of disseminated gonococcal infection?
Tenosynovitis, migratory polyarthritis (arthritis that moves between joints), dermatitis
505
What nerve does HSV become latent in with genital herpes?
Sacral nerve ganglia
506
What nerve does HSV become latent in with cold sores?
Trigeminal nerve ganglion
507
What type of HSV is most associated with cold sores?
HSV-1
508
How is herpes simplex virus spread?
Through direct contact with affected mucous membranes or viral shedding in mucous secretions. Can be spread even when asymptomatic
509
How does genital herpes present?
Ulcers or blistering lesions in the genital area, neuropathic type pain (tingling, burning, shooting), flu like symptoms, dysuria, inguinal lymphadenopathy
510
After encountering the initial virus, when is the first episode of genital herpes?
Within 2 weeks. This is usually the most severe episode
511
How is genital herpes diagnosed?
Clinically or with a viral PCR/NAAT swab
512
What is the treatment of genital herpes?
Aciclovir
513
What is the general measures for managing genital herpes?
Saline bathing, analgesia, topical anaesthetic agents (eg, lidocaine)
514
What is the advice if primary genital herpes is contracted after 28 weeks in pregnancy?
Aciclovir + c-section to reduce risk of neonatal infectin
515
When is herpes most risky during pregnancy?
If they encounter the virus for the first time, as there are no antibodies passed onto the baby
516
What causes syphilis?
Treponema pallidum
517
What are the features of primary syphilis infection?
Chancre (painless lesion at site of sexual contact), local non tender lymphadenopathy
518
What are secondary features of syphilis?
Systemic symptoms (fevers, lymphadenopathy), rash on trunk, palms, soles, buccal 'snail track' ulcers, condylomata lata (painless warty lesions on the genitalia)
519
What are tertiary features of syphilis?
Gummas (granulomatous lesions of the skin and bones), ascending aortic aneurysms, general paralysis, neurological complications
520
When does the secondary stage of syphilis occur?
6-10 weeks after infection
521
How does neurosyphilis present?
Headache, altered behaviour, dementia, ocular syphilis, paralysis, sensory impairment, argyll robertson pupil
522
What is argyll-robertson pupil?
Specific finding in neurosyphilis: a constricted pupil that accomodates when focusing on a near object, but doesn't react to light. Often called 'prostitutes pupil' (accomodates but doesn't react)
523
How is syphilis tested?
Antibody testing to T.pallidum
524
How is syphilis confirmed?
Samples from sites of infection confirmed with dark field microscopy, PCR
525
What are additional tests done for syphilis, and what are their challenges?
RPR (rapid plasma reagin) and venereal disease research laboratory (VDRL). They test for quantity of antibodies being produced. This test is non-specific but sensitive, so there are some false positives
526
What is the first line treatment for syphillis?
IM benpen
527
What causes genital warts?
HPV, particularly types 6 and 11
528
What are the features of genital warts?
Small fleshy protuberances which are slightly pigmented, may bleed or itch
529
What is the treatment of solitary, keratinised warts?
Cryotherapy
530
What is the treatment of multiple, non-keratinised warts?
Topical agents (podophyllum)
531
What condition does genital warts predispose to?
cervical cancer
532
What type of pathogen is HIV?
RNA retrovirus
533
What is the most common type of HIV?
HIV-1
534
What cells does HIV destroy?
CD4 t-helper cells
535
What are AIDS defining illnesses?
Kaposi's sarcoma pneumocystis jirovecii pneumonia (PCP), CMV infection, oesophageal or bronchial candidiasis, lymphomas, TB
536
What is the main test for HIV in the UK?
Fourth generation laboratory test
537
What does the fourth generation lab test for HIV check for?
antibodies to HIV and the p24 antigen
538
What window is required for a diagnosis of HIV with a fourth generation lab test?
45 days
539
What is the window period for point of care HIV tests?
90 days
540
What do HIV point of care tests check for?
ONLY HIV antibodies via ELISA and confirmatory Western Blot Assay
541
What are the symptoms of HIV seroconversion?
Sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhoea, maculopapular rash, mouth ulcers
542
What is the p24 antigen in HIV?
A viral core protein that appears early in the blood as viral RNA levels rise
543
If a combination test for HIV is positive, what is the next step?
Repeat to confirm the diagnosis
544
When should HIV testing be done in asymptomatic patients?
4 weeks after exposure, but offer a repeat test at 12 weeks
545
How is a severe HIV seroconversion related to HIV prognosis?
If severe, then associated with poor long term prognosis
546
What is the monitoring method of HIV?
CD4 cell count and HIV RNA per ml of blood (viral load)
547
What is the normal CD4 count range in healthy patients?
500-1200 cells/mm3 is normal range
548
What CD4 cell count puts a patient at risk of opportunistic infections?
Under 200 cells/mm3
549
What is the treatment of HIV?
Antiretroviral therapy
550
When should antiretroviral therapy by started?
Start as soon as the patient is diagnosed with HIV
551
What is a typical antiretroviral drug regime in HIV?
Two nucleoside reverse transcriptase inhibitors (tenofovir and emtricitabine) and a protease inhibitor or a non-nucleoside reverse transcriptase inhibitors
552
What are the treatment aims in HIV?
Achieve a normal CD4 count and undetectable viral load
553
What prophylactic treatment is given to all HIV patients with a low CD4 count?
Prophylactic co-trimoxazole to protect against PCP
554
How frequently is cervical smears performed in patients with HIV?
Annually: HIV increases the risk of HPV and cervical cancer
555
What is the relationship between HIV and CVD?
HIV infection increases the risk of developing cardiovascular disease: requires close monitoring of cardiovascular risk factors + statins
556
What is the management of mothers with HIV who are giving birth?
Dependent on viral load. IF <50 copies/ml then normal vaginal delivery, if >50 consider pre-labour c-section, if >400 pre-labour c-section recommended
557
What is given as an infusion during labour and delivery if a mother has a very high HIV viral load, or viral load is unknown?
IV zidovudine
558
What prophylaxis is given to a baby after birth if mother has HIV?
Low risk: zidovudine
High risk: zidovudine, lamivudine, nevirapine
559
Is breast feeding allowed in HIV positive mothers?
Generally avoided
560
What is the current regime of post exposure prophylaxis for HIV?
28 days of emtricitabine /tenofovir (truvada) and raltegravir
561
What is given in pre exposure prophylaxis in HIV?
emtricitabine/tenofovir (truvada)
562
What is the most common opportunistic infection in AIDS?
PCP
563
What are the features of PCP?
Dyspnoea, dry cough, fever, very few chest signs
564
What is a common complication of PCP?
Pneumothorax
565
What is seen on investigation in PCP?
- exercise induced desaturations
- CXR: may be normal, or lobar consolidation, or bilateral interstitial pulmonary infiltrates
- sputum culture: can see characteristic cysts
566
What is the tx of PCP?
Co-trimoxazole
567
What focal neurological lesions might be seen in AIDs?
Toxoplasmosis, primary CNS lymphoma
568
What is seen on head CT in HIV toxoplasmosis?
Single or multiple ring enhancing lesions
569
What is Kaposi's sarcoma?
Caused by HHV-8, presents as purple papules or plaques on the skin or mucosa, that may later ulcerate. Resp involvement can lead to haemoptysis or PE
570
What is ectopic pregnancy?
When the pregnancy is implanted outside the uterus
571
What are risk factors for ectopic pregnancy?
Damage to tubes (PID, surgery), previous ectopic, endometriosis, IUCD, progesterone only pill, IVF
572
When does ectopic pregnancies typically present?
6-8 weeks gestation
573
What are the classic features of ectopic pregnancy?
Missed period, constant lower abdominal pain in the LIF/RIF, vaginal bleeding, lower abdominal or pelvic tenderness, cervical motion tenderness. Can have dizziness/syncope due to blood loss, or shoulder tip pain due to peritonitis
574
What are the features of lower abdominal pain in ectopic pregnancy?
Constant, unilateral
575
What bHCG levels are seen in ectopic pregnancy?
>1,500
576
Why is there bleeding in ectopic pregnancy?
Trophoblast invades the tubal wall, producing bleeding which may dislodge the embyro
577
What is the investigation of choice in ectopic?
Transvaginal ultrasound
578
What are the three types of management of an ectopic pregnancy?
Expectant, medical and surgical
579
What will be seen on an ultrasound in ectopic pregnancy?
A mass that moves seperately to the ovary, empty uterus, fluid in the uterus
580
What is expectant management of an ectopic?
Awaiting natural termination. Closely monitor the B-hCG levels over 48 hours
581
What are the features of an expectant management ectopic pregnancy?
<35 mm, unruptured, asymptomatic, no fetal heartbeat, <1000 b-hCG
582
What is the medical management of an ectopic pregnancy?
Give methotrexate (IM); highly teratogenic
583
What are the features of an ectopic pregnancy that is managed medically?
<35mm, unruptured, no significant pain, HCG <5000, confirmed absence of intrauterine pregnancy on ultrasound, no fetal heartbeat
584
What is first line surgical management of an ectopic pregnancy?
Salpingectomy
585
When is a salpingotomy done instead of salpingectomy in ectopics?
If there are other fertility RF that means losing the fallopian tube would be an issue
586
What is a negative of salpingotomy for ectopic management?
1 in 5 women require further treatment with methotrexate/salpingectomy
587
What are the features of an ecoptic pregnancy that is treated surgically?
>35 mm, can be ruptured, pain, visible heartbeat, HCG >5000
588
What prophylaxis is given to women having a surgical treatment of an ectopic?
Anti- rhesus D prophylaxis
589
What is pregnancy of unknown location?
When a woman has a positive pregnancy test, but no evidence of a pregnancy on the ultrasound scan
590
How should b-HCG change in an intrauterine pregnancy?
Should double every 48 hours
591
What produces hCG in pregnancy?
Syncytiotrophoblast
592
A b-hCG rise of more xx% in 48 hours indicates an intrauterine pregnancy
63%
593
When should a pregnancy be visible on an ultrasound scan? (b-HCG levels)
>1500 IU/L
594
A b-hCG fall of more than xx% in 48 hours indicates a miscarriage
50%
595
What is an early miscarriage?
Before 12 weeks gestation
596
What is late miscarriage?
12 and 24 weeks
597
What is a threatened miscarriage?
Vaginal bleeding with a closed cervix and a fetus that is alive
598
What is an inevitable miscarriage?
Vaginal bleeding with an open cervix
599
What is an incomplete miscarriage?
Retained products of conception remain in the uterus after the miscarriage
600
How is a miscarriage diagnosed?
Transvaginal ultrasound
601
The presence of what indicates a viable pregnancy?
Fetal heartbeat
602
What are the three sequential features a sonographer looks for in early pregnancy on a ultrasound?
Mean gestational sac diameter, fetal pole and crown-rump length, fetal heartbeat
603
When is a fetal heartbeat expected?
Once the crown-rump length is >7mm
604
If there is a crown rump length of <7mm on ultrasound, and no heartbeat, what is the management?
Scan repeated after a week to confirm non-viable pregnancy
605
What is the fetal pole on ultrasound?
First direct imaging manifestation of the fetus
606
When is a fetal pole expected to be seen on ultrasound?
When the mean gestational sac diameter is 25mm or more. If at that length and no fetal pole, anembryonic pregnancy
607
How can women with a miscarriage at less than 6 weeks be managed?
Expectant. Do a repeat pregnancy test after 7-10 days
608
What should be done for a woman a positive pregnancy test, more than 6 weeks gestation, and bleeding?
Referral to early preganncy assessment unit. Ultrasound performed
609
What is first line management for women with >6 weeks miscarriage with no RF for heavy bleeding or infection?
Expectant. Repeat pregnancy test 3 weeks after bleeding and pain settles
610
What is medical management of miscarriage?
Misoprostol via vaginal suppository or oral dose
611
How does misoprostol work?
It is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. These soften the cervix and stimulate uterine contractions
612
What is surgical management of miscarriage?
Manual vacuum aspiration (local anaesthetic) or electric vacuum aspiration (general). Give misoprostol as well for both
613
When is manual vacuum aspiration done for miscarriage?
IF less than 10 weeks gestation, and more appropriate for parous women
614
What is the management of incomplete miscarriage?
Misoprostol or surgical management
615
What is classified as recurrent miscarriage?
3 or more consecutive miscarriages
616
What are differentials for recurrent miscarriage?
Idiopathic, antiphospholipid syndrome, hereditary thrombophilias, uterine abnormalities, genetic factors in parents, diabetes, SLE, untreated thyroid disease, chronic histiocytic
617
What is antiphospholipid syndrome?
Antiphospholipid antibodies, where the blood is prone to clotting
618
What are symptoms of antiphospholipid syndrome?
Thrombosis, recurrent miscarriage
619
How can the risk of miscarriage be reduced in antiphospholipid syndrome?
Low dose aspirin, LMWH
620
What is chronic histiocytic intervillositis?
Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes
621
When do miscarriages due to chronic histiocytic intervillositis tend to occur?
In the second trimester
622
What investigaitons should be undertaken in recurrent miscarriage?
anti phospholipid antibodies, testing for hereditary thrombophilias, pelvic ultrasound, genetic testing on parents
623
What are the main differentials of bleeding in the first trimester?
Miscarriage, ectopic pregnancy, implantation bleeding, miscellaneous (trauma, ectorpion, polyps)
624
What is the first line investigation in post menopausal bleeding and why?
Ultrasound, for endometrial cancer. Want endometrium to be <5mm
625
How is the natural menstrual cycle suppressed in IVF?
either GnRH agonists or GnRH antagonist
626
Why is GnRH agonists given to suppress the natural menstrual cycle in IVF?
Given in the luteal phase, to stimulate the pituitary to produce large amounts of LH and FSH. This gives negative feedback to the hypothalamus
627
Why does the natural menstrual cycle need to be suppressed in IVF?
Ovulation would occur, and the follicles would be released before it is possible to collect them
628
What is given and why for ovarian stimulation in IVF?
FSH Sub cut injections. This helps develop the follicles. Then, hCG injection is give, and stimulates the final maturation of the follicles for collection (similar to LH surge)
629
How are eggs collected in IVF?
Via a needle under ultrasound guidance
630
What happens after eggs are removed in IVF?
Insemination (either via mixing, or intracytoplasmic sperm injection). Eggs are then cultured for 3-5 days, and then transfered into the uterus
631
When is a pregnancy test done in IVF?
Around day 16
632
What suppository is used in the first 2 months of IVF pregnancy and why?
Progesterone, to mimic the progesterone that would be released by the corpus luteum
633
What is intrauterine insemination?
Introducing sperm directly into the uterus. Done when there are mechanical issues with sex, HIV positive
634
What factors can cause a poor quality sperm sample?
Hot baths, tight underwear, smoking, alcohol, raised BMI, caffeine
635
What can cause pre testicular causes of infertility?
Kallman syndrome, suppression due to stress/chronic conditions, pathology of pituitary gland
636
What can cause testicular cause male infertility?
Mumps, undescended testes, trauma, radiotherapy, chemotherapy, cancer
637
What are genetic conditions that cause defective or absent sperm?
Klinefelters, Y chromosome deletions
638
What are possible post testicular causes of infertility?
Damage to testicles due to trauma/cancer/surgery, ejaculatory duct obstruction, retrograde ejaculation, scarring (eg from STD), vas deferens absence (CF)
639
What act is the current law surrounding abortion based on?
The 1967 abortion act, 1990 ammendment
640
What must be given a woman who is rhesus D negative and having an abortion after 10 weeks?
anti-d prophylaxis
641
What is given for a medical abortion?
mifepristone, followed by misoprostol 48 hours later
642
What is required 2 weeks after a medical abortion?
a multi-level pregnancy test (detect level of hCG)
643
What are the surgical options for an abortion?
Vacuum aspiration, electric vacuum aspiration, dilatation and evacuation (D&E)
644
How is the cervix primed for a surgical abortion?
Misoprostol +/- mifepristone
645
What are the 4 levels or contraception?
UKMEC 1-4, which is UK Medical Eligibility Criteria. It categorises risks of contraception
646
What is UKMEC 1 contraception, vs UKMEC 4?
No restriction in use (1) and unacceptable risk (4)
647
In contraception, what does 99% effective mean?
if an average person used this method of contraception correctly with a regular partner for a single year, they would only have a 1% chance of pregnancy.
648
What contraception should be avoided for those with Wilson's disease?
Copper coil
649
What contraception should be avoided in those with breast cancer?
Hormonal contraception
650
What contraception should be avoided in cervical/endometrial cancer?
Intrauterine system
651
What are specific risk factors for COCP?
Uncontrolled HTN, migraine with aura, hx of VTE, aged >35 smoking >15 cigarettes per day, major surgery with immobility, vascular disease or stroke, ischaemic heart disease/cardiomyopathy/AF, liver cirrhosis, SLE, Anti-phospholipid syndrome
652
How long is contraception required after the last period?
2 years if under 50, 1 year if older
653
What are concerns around progesterone only injection in v young/v old women?
Bone mineral density issues: risk of osteoporosis in older women
654
How does the COCP prevent pregnancy?
Prevent ovulation, thicken cervical mucus, stops endometrial proliferation (reduces chance of successful implantation)
655
What are monophasic vs multiphasic COCP?
- monophasic: same amount of hormone in each pill
- multiphasic: varying amount of hormones
656
What form is oestrogen in COCP?
ethinylestradiol
657
What are first line COCPs, and why?
Pill with levonorgesterol or norethisterone (microgynon or lesotrin). Lower risk of VTE.
658
What is used in premenstrual cycle?
Yasmin (ethinylestradiol and drospirenone), continuous use
659
What COCPs are used for acne and hirstuim, and why?
Dianette, as it contains cyproterone acetate, which is anti-androgenic and reduces acne/hirstuism
660
What is the possible s/e of dianette?
Very high risk of VTE.
661
What are potential s/e and risks of COCP?
Unscheduled bleeding, breast pain and tenderness, mood changes/depression, headaches, HTN, VTE, small risk of breast + cervical cancer, MI/stroke
662
When is the pill UKMEC3?
For women above BMI of 35
663
When will the pill be immediately effective and not required additional contraception?
If taken up to day 5 of the menstrual cycle
664
What is needed if the pill is started after day 5 of the menstrual cycle?
Additional contraception for 7 days
665
How should women switch between COCPs?
Finish one pack, then immediately start the next without a pill free period
666
How do women switch between traditional progesterone only pill and COCP?
Can switch any time in the pack, but need 7 days additional contraception
667
When does missing a pill count as 'missing'?
More than 24 hours rate
668
If one pill is missed, and there is less than 72 hours since last pill is taken, what should be done?
Take missed pill ASAP (even if two on one day). No extra protection needed
669
If more than one pill is missed, and there is more than 72 hours since last pill taken, what should be done? And they have NOT had sex.
Take most recent missed pill asap, even if two on one day. Additional contraception needed for 7 days
670
If a woman missed more than one pill, and had sex, what should be done?
If day 1-7: need emergency contraception
If day 8-14: no emergency contraception needed
If day 15-21: no emergency contraception needed, but go back to back with next pack, miss pill free period
671
When should the pill be stopped before major operation?
4 weeks
672
Can COCP be taken in BRCA1/2?
UKMEC3
673
What is the only absolute contraindication to progestogen only pill?
Active breast cancer
674
What are the two types of POP?
Traditional (norgeston), desogestrel only pill (creazette)
675
When is traditional progestogen only pill considered a missed pill?
3 hours
676
When is desogestrel only pill considered a missed dose?
12 hours
677
How does traditional progestogen only pills work?
Thicken cervical mucus, alter endometrium and make it more difficult to implant, reduce ciliary action
678
How does desogestrel pill work?
Inhibits ovulation, thicken cervical mucus, alter endometrium, reduce cilary action in fallopian tubes
679
If the POP is started day 1-5 of the cycle, what is required?
Nothing: immediate protection
680
If the POP is started after day 5 of the cycle, what is required?
Additional contraception for 48 hours
681
How does a woman switch between COCP to POP?
- have taken COCP for more than 7 days consistently (no break week), or on days 1-2 of hormone free period then fine
- If days 3-7 of hormone free or days 1-7 of COCP, depends on if they had unprotected sex between hormone free 1-3. If yes, take COCP until 7 days consecutive. If no, 48 hours additional contraception
682
What are side effects of POP?
Unscheduled bleeding, breast tenderness, headaches, acne, small risk of ectopic, ovarian cysts
683
If a women on POP has unpredictable bleeding for >3 months, what should be done?
Further investigations, as usually settles
684
What should be done if missed pill of POP
Take pill ASAP, additional contraception for next 48 hours
685
When is emergency contraception required if missed POP pill?
If had sex since missing pill or within 48 hours of restarting
686
How often is the progestogen only injection given?
12-13 weeks
687
How does depot injection affect fertility?
Can take up to a year for fertility to return
688
How does the depot injection work?
Mainly via inhibiting ovulation, by inhibiting FSH secretion by the pituitary gland, preventing development of follicle. Also thickens mucus, and alters endometrium
689
When will a woman need additional contraception if starting the depo injection?
If starting after day 5 of the cycle, need contraception for first 7 days
690
What are possible s/e of the depot injection?
- irregular bleeding: most women will eventually stop bleeding
- weight gain
- acne
- mood changes
- headaches
- flushes
- hair loss (alopecia)
691
What are unique s/e to depot injection?
Weight gain and osteoporosis
692
Why does the depot injection cause osteoporosis?
Suppressing the development of follicles reduces the amount of oestrogen produced, and this can lead to decreased bone mineral density.
693
What other conditions can the depot injection improve the symptoms of?
Endometriosis and sickle cell crisis
694
How long does the implant last for?
3 years
695
What is the only UKMEC for the progestogen only implant?
Active breast cancer
696
What implant is used in the UK, and what does it contain?
Nexplanon is the implant used in the UK. It contains 68mg of etonogestrel.
697
How does the progestogen implant work?
Inhibits ovulation, thickens cervical mucus, alters the endometrium
698
What are the specific additional contraception requirements when starting the implant?
Inserting the implant on day 1 to 5 of the menstrual cycle provides immediate protection. Insertion after day 5 of the menstrual cycle requires seven days of extra contraception
699
How is the implant inserted?
- 1/3 of the way up upper arm, medial side
- lidocaine used
- special device used to insert, beneath skin and above subcutaneous fat
700
What are the benefits of the implant?
- can improve dysmenorrhoea
- no weight gain or effects on bone mineral density
- no increased risk of thrombosis
- no restrictions on obese patients
701
What are the possible drawbacks of the implants?
- requires a minor operation
- can worsen acne
- can cause problematic bleeding
- implants can become impalpable or deeply implanted
702
What is the investigation done if a impalpable implant is being located?
Ultrasound or xray; nexplanon adds barium sulphate to make it radio-opaque
703
How is problematic bleeding with the implant mananaged?
COCP for 3 months
704
What is the most effective form of contraception?
The implant
705
What are progestogen effects?
Headache, nausea, breast pain
706
What is the MoA of the IUD?
Creates a hostile environment for pregnancy
707
What is the MoA of the IUS?
Contains progestogen which is slowly released into the uterus
708
What are contraindications for IUD/IUS?
PID or infection, immunosuppression, pregnancy, unexplained bleeding, pelvic cancer, uterine cavity distortion
709
What screening is done before insertion of IUD/IUS?
Chlamydia and gonorrhoea
710
What are risks relating to the insertion of the coil?
Bleeding, pain on insertion, PID, uterine perforation, vasovagal reactions (dizziness, bradycardia, arrhythmias)
711
How long do women need to abstain from sex for/use condoms before IUD/IUS removal?
7 daus
712
What must be excluded if coil threads cannot be seen or palpated?
Expulsion, pregnancy, uterine perforation
713
What is first line investigation for non visible threads in IUS/IUD?
Ultrasound
714
How can a coil be retrieved if non visible threads?
Hysteroscopy or laparoscopic surgery
715
How long does the copper coil last?
5-10 years, dependent on device
716
What are the benefits of the copper coil?
Reliable contraception, can be inserted at any time and is immediately effective, no hormones contained, can reduce risk of endometrial and cervical cancer
717
How long does the mirena work?
5 years
718
What other conditions is mirena used for?
Menorrhagia and HRT
719
What is the requirements if the mirena is inserted in the first 7 days of the menstrual cycle?
None
720
What are the additional requirements if the mirena is inserted after day 7 of the menstrual cycle?
Exclude pregnancy, and extra contraception for 7 days
721
What are drawbacks of the IUS?
- pelvic pain
- increased risk of ectopics
- increased incidence of ovarian cysts
- systemic absorption --> acne, headaches, breast tenderness
722
What might be seen on smears in women with IUD/IUS?
Actinomyces-like organisms are often discovered incidentally during smear tests in women with an intrauterine device (coil). These do not require treatment unless they are symptomatic.
723
What are the three options for emergency contraception?
Levonorgestrel, ulipristal, copper coil
724
How long can levonorgestrel taken after UPSI?
72 hours
725
How long can ulipristal be taken within UPSI?
120 hours
726
How long after UPSI can the copper coil be inserted?
Within 5 days of UPSI, or within 5 days of ovulation
727
What is the most effective form of emergency contraception?
Copper coil
728
What factors can reduce the effectiveness of oral methods of emergency contraception?
BMI, enzyme inducing drugs, malabsorption
729
Can oral emergency contraception be used more than once per cycle?
Yes
730
What is levonorgestrel?
The hormone used in oral emergency contraception, or in the IUS
731
How does levonorgestrel work in emergency contraception?
Prevents/delays ovulation
732
What is the dosage of levonorgestrel in emergency contraception?
1.5mg single dose, or 30mg if >70kg or BMI >26
733
What is ulipristal?
Selective progesterone receptor modulator, also known as ellaone
734
Can COCP or POP be started straight after taking levonorgestrel?
Yes
735
Can COCP or POP be started immediately after ulipristal?
No: wait 5 days
736
What is a contraindication for ulipristal (ellaone)
Breastfeeding and severe asthma
737
If doing natural family planning, what are major clinical indicators of fertility?
Changes in cervical mucous, in the cervix, in the basal body temp
738
How is female sterilisation performed?
Tubal occlusion using Filshie clips
739
How is male sterilisation performed?
Vastectomy: cutting the vas deferens. Can be done under local.
