Gynaecology Flashcards
(103 cards)
1
Q
In a patient asking for emergency contraception, but they have severe asthma i.e. taking 25mg OD sertraline, 200 micrograms salbutamol inhaler PRN, beclomethasone 400 micrograms BD and formoterol 12 micrograms BD. What medication do you NOT give?
A
Ulipristal acetate
2
Q
What is the pearl index?
A
The Pearl Index is the most common technique used to describe the efficacy of a method of contraception. The Pearl Index describes the number of pregnancies that would be seen if one hundred women were to use the contraceptive method in question for one year. 0.2 = 2/1000/year.
3
Q
What is the treatment for a vaginal vault prolapse?
A
The treatment for vaginal vault prolapse is sacrocolpoplexy. This procedure suspends the vaginal apex to the sacral promontory. This support is usually afforded by the uterosacral ligaments.???? But this apparently uses mesh, so most appropriate may be sacrospinous fixation.
4
Q
What are the 3 main routes to gain access to the pelvic organs?
A
1) Abdominal route
2) Vaginal route
3) Laparoscopic surgery
5
Q
Explain how and when a diagnostic hysteroscopy may be completed.
A
How: Diagnostic hysteroscopy is when the uterine cavity is inspected with a rigid or flexible hysteroscope passed through the cervical canal. The uterine cavity is distended using carbon dioxide or saline. Anaesthetic options? Nothing, cervical local anaesthetic block, general anaesthetic.
When: Used as an adjunct to endometrial biopsy or if menstrual problems don’t respond to medical tx.
6
Q
What type of biopsy would we take when we want to examine the endometrium for carcinoma?
A
Pipelle biopsy
7
Q
How is a hysteroscopic surgery completed?
A
An operating hysteroscope is used (small instruments are passed down a parallel channel). Usual procedures involve TransCervical Resection of Endometrium (TCRE) or TransCervical Resection of Fibroids (TCRF) - if the fibroid is intracavity. Also for the removal of intracavity fibroids. Also for resection of the uterine septum. Usually, cutting diathermy and glycine irrigation fluid is used.
8
Q
What are the complications associated with hysteroscopic surgery?
A
- Uterine perforation + fluid overload - unusual in an experienced surgeon
- Usually minimal blood loss
- Sterility not ensured
9
Q
How is diagnostic laparoscopy performed?
A
Peritoneal cavity is insufflated with CO2 after passing a small hollow Veress needle through the abdominal wall. Trocar inserted through umbilicus (less damage to organs and major blood vessels). Laparoscope passed down trocar which enables visualisation of the pelvis.
10
Q
When may a diagnostic laparoscopy be performed?
A
Used to assess macroscopic pelvic disease in Mx of pelvic pain and dysmenorrhoea (endometriosis), infertility (lap+dye test to assess tubal integrity), suspected ectopic pregnancy and pelvic masses.
11
Q
How is laparoscopic surgery performed?
A
Multiple instruments to grasp and cut tissues are inserted through separate ports in the abdominal wall.
12
Q
What are the typical indications for laparoscopy?
A
Removal of adhesions, areas of endometriosis, removal of ectopic pregnancy.
13
Q
What are some advantages of laparoscopic surgery?
A
Better visualisation of tissues, faster post-op recovery, less pain, less blood loss, lower risk of infection, less heat loss, reduced hospital stay.
14
Q
What is the most common major gynaecological operation?
A
Hysterectomy
15
Q
Why are the fallopian tubes (bilateral salpingectomy) often removed when a hysterectomy is performed?
A
To reduce the risk of ovarian cancer as ovarian cancer often originates from the fimbral end of the fallopian tube (spreads along the peritoneal surface) and there is no use in having fallopian tubes with no uterus.
16
Q
Why are the ovaries removed in a hysterectomy (bilateral oophorectomy)?
A
Older women
Hx of cysts
17
Q
Why is hysterectomy perfomed?
A
- Menstrual disorders
- Endometriosis
- Fibroids
- Chronic PID
- Prolapse
- Pelvic malignancy
- Typically last resort
18
Q
What are the different types of hysterectomy?
A
1) Total abdominal hysterectomy
2) Subtotal hysterectomy
3) Vaginal hysterectomy
4) Laparoscopic hysterectomy (laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy)
5) Wertheim’s (radical) hysterectomy
19
Q
What are the indications for Total Abdominal Hysterectomy?
A
Malignancy - ovarian or endometrial (in conjunction with laparotomy)
Very large or immobile uterus
When abdominal inspection is required
20
Q
What are the indications for Subtotal hysterectomy?
A
When you don’t want to damage the ureters or bladder?
21
Q
What is a disadvantage of the subtotal hysterectomy?
A
- Still worried about cervical cancer as cervix remains in the pt
- Contraindicated in patients with abnormal smear Hx
- May still have menstrual spotting after if small amounts of endometrium remain in the cervical canal
22
Q
What are indications for vaginal hysterectomy?
A
Uterine prolapse. Moderate enlargement of uterus?.
23
Q
What are the advantages of vaginal hysterectomy?
A
Lower morbidity, quicker recovery, lower risk infection, blood loss etc. Least invasive.
24
Q
How might a subtotal hysterectomy be completed?
A
Performed laparoscopically and uterine body removed from the peritoneal cavity using a morcellator instrument.
25
Why must uterine morcellation be undertaken with care in pts \>40 with abnormal bleeding?
Underlying unsuspected endometrial malignancy could be present and spread through morcellation. Should check pathology of the endometrium pre-operatively by performing a pipelle biopsy.
26
What is a Wertheim's (radical) hysterectomy?
- Removal of parametrium
- Upper 3rd vagina
- Pelvic lymph nodes
- Usually for stage 1a(ii)-2a cervical carcinoma
- If completed vaginally is called 'Schauta's radical hysterectomy'
27
What are the immediate complications of hysterectomy?
Haemorrhage, bladder or ureteric injury
28
What are the post-operative complications of hysterectomy?
Venous thromboembolism (use prophylactic low molecular weight heparin)
Pain
Retention
Infection of urine, wounds, chest infection (use prophylactic/broad spec Abx)
Pelvic haematoma
29
What are the long-term complications of hysterectomy?
Prolapse
Genuine stress incontinence
Premature menopause
Pain
Psychosexual problems
30
How is evacuation of retained products of conception completed?
- Cervix is dilated
- Suction curette removes the retained non-viable fetus or placental tissue (surgical therapeutic abortion \<12 weeks is similar)
31
What are the operations for cervical intraepithelial neoplasia (CIN)?
1) Large loop excision of the transformation zone (LLETZ)
2) Cone biopsy
32
What is LLETZ surgery?
Large Loop Excision of the Transformation Zone - cutting diathermy, under local anaesthetic is used to remove the transformation zone of the cervix where the cervical intraepithelial neoplasia is present.
Complications: Risk of subsequent preterm delivery is slightly increased
33
What is Cone biopsy surgery?
Removes the transformation zone of the cervix and most of the endocervix by making a circular cut with a scalpel or loop diathermy in the cervix. Used to stage early cervical carcinoma + is sufficient tx for stage 1a(i) disease. General or epidural/spinal anaesthetic is required.
Complications: Risk of subsequent preterm delivery is increased due to the increased cervical damage.
34
What are the main operations for fibroids?
Myomectomy - transcervical removal of fibroids or abdominal (laparoscopic or open)
Hysterectomy
Uterine artery embolisation
35
What are the risks of myomectomy?
Adhesion formation
Uterine rupture during labour
Perioperative haemorrhage
Spread of unsuspected leiomyosarcoma during laparoscopic morcellation
36
What are the risks of uterine artery embolisation?
Effect on fertility
Pregnancy complications
37
How is uterine artery embolisation carried out?
(For fibroids). With the patient under conscious sedation and local anaesthesia, a catheter is inserted into the femoral artery (bilateral catheters are sometimes used). Fluoroscopic guidance is used to manipulate the catheter into the uterine artery. Small embolisation particles/sclerosing agents are injected through the catheter into the arteries supplying the fibroids, with the aim of causing thrombosis and consequent fibroid infarction.
38
What are the complications associated with gynaecological surgery?
Short-term: Bleeding - haemorrhage, pain
Longer-term: Infection - sepsis, paralytic ileus, bowel obstruction, bowel perforation, urinary retention, VTE, PE
39
How can we reduce the risk of thromboembolism in and after gynaecological surgery?
Stop COCP 4 weeks prior to major surgery
If not stopped -\> use low molecular weight heparin
Mobilise women early after surgery
Give thromboembolic disease stockings
Keep hydrated
Keep patient warm during surgery
40
How can we reduce the risk of infection in and after gynaecological surgery?
Prophylactic Abx
41
How would we go about a septic screen in a patient presenting with a fever of 38.5C one day after surgery?
Hx - find out about recent infection symptoms, consider anaesthetic/intubation etc
Exam - general - examine wound sites, respiratory
Ix: Obs, ABCDE, Swab everything, Septic 6, Broad spectrum Abx depending on local policy, Oxygen, Fluids, Urine output, Blood cultures, Lactate
42
What is the condition where you have intrauterine adhesions?
Asherman's syndrome
43
What are the different surgical options for repair of pelvic organ prolapse?
• A pelvic floor repair if you have prolapse of the anterior or posterior walls of the vagina
(cystocele or rectocele); this is where the walls of your vagina are tightened up to support the
pelvic organs. This is usually done through your vagina so you do not need a cut in your abdomen.
• Operations that aim to lift up and attach your uterus or vagina to a bone towards the sacrum or the sacrospinous ligament (sacrocolpopexy or sacrospinous fixation). These
may be done by keyhole surgery.
• A vaginal hysterectomy (removal of the uterus) is sometimes performed for uterine prolapse.
Your gynaecologist might recommend that this be performed at the same time as a pelvic
floor repair.
• Closing off your vagina (colpocleisis) may be considered but only if you are in very poor medical
health or if you have had several operations previously that have been unsuccessful. Vaginal
intercourse is no longer possible after this operation.
44
How is an anterior repair for a cystocele specifically completed?
Excision of prolapsed vaginal wall and plication of bladder base and fascia. Vagina wall excision is then closed.
45
How is an posterior repair for a rectocele specifically completed?
Levator ani plicated between vaginal wall and rectum.
46
What are the complications of anterior repair and posterior repair operations?
Retention of urine, overtightening of the vagina
47
What is the surgical tx for urinary stress incontinence?
Burch colposuspension - dissection through an abdominal incision in the extraperitoneal space over bladder and anterior vaginal wall. The vaginal wall on either side of the bladder neck is hitched up to the iliopectineal ligament on either side of the symphysis pubis with non-absorbable sutures.
Intramural Bulking agents
Silicone
Carbon-coated zirconium beads
Hyaluronic acid
Artificial urinary sphincter
48
What is the tx for urinary stress incontinence before surgery?
Conservative: Avoid caffeine: reduces detrusor over activity and pressure
Weight loss if BMI \>30
Fluid intake 1.5L/day
PFMT pelvic floor muscle training
Supervised
3 months
8 contractions 3x a day
Medical: Duloxetine
SNRI
Enhances striated sphincter activity in the urethra
NOT 1st line
80% side effects: nausea and dizziness
Vaginal atrophy: topical oestrogen
49
What is the conservative management for urge urinary incontinence?
Lifestyle
Avoid caffeine: reduces detrusor over activity and pressure
Weight loss if BMI \>30
Fluid intake 1.5L/day
Medications
Vaginal atrophy: topical oestrogen
Bladder retraining
6 weeks minimum
Void 1.5 hours to 2 hours a day
Input 1.5L/24 hours
Pelvic floor exercises
50
What is the medical management for urge urinary incontinece?
Antimuscarinics : act on smooth muscle
Solifenacin
Tolterodine
Oxybutynin (don't give in elderly due to risk of falls)
Mirabegron (B3 adreneoreceptor agonist)
Side effects: constipation, dry mouth, blurred vision, drowsiness
Link to Alzheimers over 65
51
What are the additional tx for urge urinary incontinence after conservative and medications?
Botulinum toxin A
Decreases incontinence episodes, frequency and urgency
Risks of urinary retention and recurrent UTIS (need for ISC)
100-200 units
6 months
Neuromodulation
Percutaneous sacral nerve stimulation
Alternative to Botox if unable to perform ISC
12 sessions weekly (30 minutes)
52
What are the surgical tx for urge urinary incontinence?
Reconstructive surgery
10% refractory to medical treatment
Augmentation cystoplasty
Ileum 25cm to replace dissected bladder
Side effects: incomplete voiding, straining, self catheterisation
5% adenocarcinoma
Urinary diversion
Ileal conduit
Into abdominal stoma
53
What are the Ix for urinary incontinence?
Urine dipstick
Residual urine
Bladder diary (3 days)
Urodynamics
Cystoscopy
54
Why do we do urodynamics testing?
For diagnosis
To determine if more stress or urgency as this will change management
To investigate problems with voiding
55
How is urodynamic testing carried out?
1) Uroflowmetry - measures how much urine is in your bladder and how fast the urine comes out, also known as flow rate. You wee into a special commode.
2) Postvoid residual measurement - measures how much urine is left in your bladder after you urinate. If you have 100–150 milliliters of urine or more left in your bladder, your bladder is not emptying completely. This test can be conducted with an ultrasound NIH external link or by feeding a catheter into your bladder to drain and measure remaining urine.
3) Cystometric test - measures:
- how much urine your bladder can hold
- how much pressure builds up inside your bladder as it stores urine
- how full your bladder is when you start feeling the urge to urinate
First, a catheter is used to empty your bladder completely. Then a special, smaller catheter is placed in the bladder. This catheter has a pressure-measuring device called a manometer. Another catheter may be placed in the rectum or vagina to record pressure there.
Once you completely empty your bladder, it is filled slowly with warm water. You’ll be asked to describe how the bladder feels and when you feel the need to start urinating. When you start feeling that urge, the volume of water and the bladder pressure are recorded.
You may be asked to cough or strain during this procedure to see if the bladder pressure changes or if you leak urine.
A cystometric test can also identify if your bladder contracts when it’s not supposed to.
56
What are RF for thromboembolic events in gynaecological surgery?
Moderate (Anti-embolus stockings + subcutaneous heparin)
Surgery \>30 mins
Obesity
Gross varicose veins
Current infection
Prior immobility
Major current illness
High (use LMWH prophylaxis for 5 days or until mobile)
Cancer surgery
Prolonged surgery
Hx DVT/thrombophilia
\>=3 moderate risk factors above
57
What drugs are contraindicated for Ulipristal Acetate use as emergency contraception?
Drugs that induce hepatic enzyme activity (e.g. carbamazepine, eslicarbazepine acetate, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John's wort, topiramate and, above all, rifabutin and rifampicin), and possibly also griseofulvin. Also drugs that reduce hepatic activity such as itraconazole may increase plasma concentrations for longer.
58
Is keppra (levetiracetam) a contra-indication for Ulipristal Acetate?
No - it is not an enzyme inducer. There are no contraindications for it's use.
59
When can Levonelle (Levonorgestrel) be used?
It can be used within 72 hours (12-24 hours preferably), 1.5mg dose.
60
How effective is Levonelle (Levonorgestrel)?
Levonorgestrel is thought to prevent: up to 95% of pregnancies if taken within 24 hours. up to 85% if taken within 25-48 hours. up to 58% if taken within 49-72 hours.
61
When can Ulipristal Acetate be used as emergency contraception?
5 days /120 hrs after coitus. 30mg one dose. Not used if patient is on enzyme inducing drugs or asthmatic + needing glucocorticoids.
62
Why can Ulipristal not be used in asthmatics for emergency contraception?
Use in women with severe asthma insufficiently controlled by oral glucocorticoids is not recommended. Ulipristal acetate has a steroid structure and acts as a selective progesterone receptor modulator with predominantly inhibitory effects on the progesterone receptor. Reduces the effect of glucocorticoids? Worsening asthma?
63
What questions must a doctor ask of a young woman coming in for emergency contraception?
They must establish the details of what happened. Age of partner? Regular or casual partner? Did you know them? Was alcohol involved? Was drugs involved? Were you forced? Did you use protection? Are you on contraception? Is this the first time this has happened? Has this happened before? Do your parents know?
64
What is the management for a young woman coming in for emergency contraception?
1) Emergency contraception
2) Ongoing contraception
3) STI screen +/- Abx
4) Safeguarding/Information
65
How does Levonorgestrel work?
1) Inhibits ovulation
2) Thickens cervical mucus - creating a physical barrier between sperm and egg meeting/sperm from entering uterus
3) Thins the endometrium - preventing implantation of the pregnancy
66
What are likely differentials for menorrhagia?
1) FIBROIDS
2) Endometriosis
3) Cervical/endometrial polyp
4) Dysfunctional uterine bleeding
5) PID
6) IUD - first 6 months
7) Endometrial carcinoma
8) Contraception?
Non gynae: Blood dyscrasia? (von Willebrand), hypothyroidism
67
What are the 3 ways of managing a Breech presentation?
1) External Cephalic Version - ctg and scan, then lie on bed and trained drs and midwives press on tummy and then get you to sit up (gravity), which will hopefully cause baby to turn into a head down first position. Give Anti-D Ig. Give terbutaline if tense and contracting.
2) Elective c-section
3) Elective vaginal breech delivery \*NO INDUCTION of labour, EPIDURAL may increase risk, continuous fetal monitoring\*
68
When do we offer ECV to mothers with a breech baby?
36 weeks for primips, 37 weeks for multiparous women
69
What stage of pregnancy do women create a birth plan?
34 weeks
70
What are the risks of a vaginal breech delivery?
Increased risk of fetal death, head entrapment, cerebral palsy, healthcare professionals also have less experience currently
71
What are the risks of a C-section?
Increased immediate complications for mother, risk of complications in future pregnancy, including the risks of opting for VBAC, the increased risk of complications at repeat caesarean section and the risk of an abnormally invasive placenta.
For subsequent pregnancies, having had a planned caesarean (compared with planned vaginal) birth causesa three-fold increase in uterine scarring; more than half of all women with at least one prior caesareansection have another.25The risks of blood transfusion, endometritis, hysterectomy and death are increasedin women with a previous caesarean section (irrespective of whether they attempt a VBAC) whencompared with those who have previously delivered vaginally.22The risk of scar rupture during attemptedvaginal birth after one caesarean section is approximately 0.5%.22,26,27In developing countries, particularlywhere birth outside hospital is usual and access to healthcare is poor, the effect on maternal outcomes islikely to be considerably greater.28A further maternal issue is that of placenta praevia and placenta accreta,29or abnormally invasiveplacentation, for which prior caesarean delivery is the principal risk factor. The risk of abnormally invasiveplacentation increases from 0.31% with one prior caesarean section to 2.33% with four30and the incidenceis rising. The risk is higher after elective compared with emergency caesarean section.31 This complicationcan lead to massive haemorrhage, hysterectomy, urinary tract injury and maternal death.
72
What is the efficacy of ulipristal acetate (ella1)?
Around 98-99% - more effective within the 72-120 hr window than Levonelle
73
What are the 4 stages of endometriosis?
Stage 1 or minimal: There a few small implants or small wounds or lesions. They may be found on your organs or the tissue lining your pelvis or abdomen. There’s little to no scar tissue.
Stage 2 or mild: There are more implants than in stage 1. They’re also deeper in the tissue, and there may be some scar tissue.
Stage 3 or moderate: There are many deep implants. You may also have small endometriomas on one or both ovaries, and thick bands of scar tissue called adhesions.
Stage 4 or severe: This is the most widespread. You have many deep implants and thick adhesions. There are also large endometriomas on one or both ovaries.
74
What is the treatment for endometriomas?
Laparoscopic drainage of endometrioma and removal
75
What is the aetiology of endometriosis?
Oestrogen dependent
Retrograde menstruation and spread via mechanical, lymphatic and blood-borne means
Implantation may increase in women with weakened immune system
Endometriosis deposits are neuro- and angio-genic leading to increased density of adjacent nerve fibres and hence pain
Genetics
Less popular theory: metaplasia of coleomic cells
76
What are the presenting signs and sx of endometriosis?
Dysmenorrhoea
Chronic pelvic pain
Deep dyspareunia
Subfertility
Cyclical bowel/bladder sx
Dyschezia
Dysuria
None
77
What are the signs of severe endometriosis?
Cyclical haematuria
Rectal bleeding
Bleeding from the umbilicus
78
What are the differential diagnoses for a picture of:
Dysmenorrhoea
Chronic pelvic pain
Deep dyspareunia
Endometriosis
Adenomyosis
Chronic PID
Chronic pelvic pain
IBS
79
What are common findings of clinical examination for endometriosis?
Tenderness on vaginal examination
Thickening behind uterus / adnexa
Retroverted uterus
Immobile uterus (endometriotic adhesions)
Rectovaginal nodule of endometriosis (DRE)
80
What are common sites of endometriosis?
Uterine fundus
Uterosacral ligaments
Pelvic side walls
Ovaries
Colon
81
What are the appearances of endometriosis in the pelvis?
Black powder burn spots (mild)
Red dots
White area of scarring (mild)
Large raised black and red vesicles
Adhesions (severe)
Chocolate cysts (severe)
82
What are the Ix for an endometriosis picture?
TVUS - to visualise endometriomas
Laparoscopy +/- biopsy - diagnostic test
Clinical evidence of bowel/bladder involvement: MRI +/- IV pyelogram and barium studies
Serum Ca-125 (raised)
83
What is the tx for endometriosis?
Medical:
Oral analgesia - NSAIDS, paracetomal
In women not trying to conceive:
COCP
Progestogen - POP pill, depo provera (mimics pregnancy)
GnRH analogues (mimics menopause - +/- HRT + screening for OP - only use for 6months/2yrs)
IUS
Surgical:
Laparoscopic Scissors/laser/bipolar diathermy - destroy endometriotic lesions (good for pain and subfertility)
Laparoscopic Dissection of adhesions
Laparoscopic drainage and removal of ovarian endometriomas
Hysterectomy with bilateral salpingo-oopherectomy (last resort and if family complete - may require HRT
84
What is the best option for a couple presenting with infertility - the female partner has severe endometriosis of the fallopian tubes.
IVF
85
What is the tx for acute PID?
Painkillers
IM ceftriaxone
Doxycycline and metronidazole
If febrile admit for IV therapy
If no improvement, review diagnosis after 24 hrs + perform laparoscopy - pt may have a pelvic abscess (will not respond to Abx - requires drainage)
Tx sexual partners
86
What are the complications of PID?
Formation pelvic abscess
Chronic PID
Chronic pelvic pain
Subfertility
Ectopic pregnancy
Pyosalpinx
Tubal obstruction
87
What are the investigations for PID?
Endocervical swabs for chlamydia and gonorrhoea
Blood cultures if fever
WBC
CRP (elevated)
Pelvic ultrasound - excludes abscess or ovarian cyst
TVUS (chronic - fluid collections in fallopian tubes/surrounding adhesions)
Laparoscopy with fimbrial biopsy and culture
88
How can acute PID lead to chronic PID?
- Persisting infection
- Tx failure
- Reinfection through sexual partners
89
What are the features of chronic PID?
Dense pelvic adhesions
Hydrosalpinx
Pyosalpinx
Obstructed fallopian tubes
Causing: cervical excitation, adnexal discomfort
90
What is the tx for chronic PID?
1) Analgesics
2) Abx - ceftriaxone, doxycycline, metronidazole
3) Adhesiolysis
4) Salpingectomy
91
What are some causes of vaginal discharge?
Infection: Candidiasis (white cottage cheese + itch); BV (fishy odour, thin grey); Trichomoniasis; Gonorrhoea (green); Chlamydia (yellow, strong odor); HSV
Foreign body: malodorous
Atrophic vaginitis
Ectropion/erosion
Polyp
Cervical carcinoma - usually with abnormal vaginal bleeding too
92
What are the Ix for a Bartholin's cyst?
Ix: Obs, FBC - WBC, CRP
Microscopy and culture of abscess material - sterile /polymicrobial
In women over 40, biopsy of vulval lesion - may be a bartholin gland cancer
93
What are the examinations for a Bartholin's cyst?
Pelvic examination + feel for inguinal lymphadenopathy
Lump examination - looking for M rules of lumps - tethering to local structures, irregular outline, firm, non-fluid filled
94
What are the differentials for a Bartholin's cyst?
Mucous cyst
Vulval haematoma
Vulval fibroma
Vulval lipoma
Cyst of canal of Nuck
Epidermal inclusion cyst
Malignant lesion of Bartholin's gland
Genital/vulval warts (condylomata acuminata)
Vulval carcinoma
Vulval intraepithelial neoplasia
Congenital vaginal cyst
95
What is the tx for Bartholin's cyst?
Asymptomatic - conservative management - wash with warm water only
soak with warm flannel
warm compresses
sitz baths
Symptomatic -
Medical treatment - Broad spectrum Abx - trimethoprim/sulfamexazole or amoxicillin/clavulanate + clindamycin
Surgical tx - Marsupialisation
Catheter drainage - word catheter
Bartholin's abscess -
Conservative management +/- incision and drainage
Broad spec Abx
After infection/inflammation controlled: Marsupialisation/catheter drainage
96
What is VIN?
Vulval intraepithelial neoplasia (premalignant condition of the vulva).
Divided into 2 types: usual and differentiated.
Usual is most common - can be warty, basaloid or mixed - more common in women 35-55. HPV, CIN, cigarette smoking and chronic immunosuppression are RF.
97
What is the tx for VIN?
Conservative: Emollients
Medical: mild topical steroid
Surgical: local surgical excision - relieves sx, confirms histology and excludes invasive disease.
98
What are the Ix for vulval carcinoma?
Bloods: FBC, U&E, G&S
Imaging: CXR
Other: ECG
Biopsy of lesion
99
How do the progesterone implants work as contraceptives?
Both versions slowly releases the progestogen hormone etonogestrel. They are typically inserted in the proximal non-dominant arm, just overlying the tricep. The main mechanism of action is preventing ovulation. They also work by thickening the cervical mucus.
Implanon has been replaced by nexplanon - (newer - better - more superficial insertion)
100
What is the most effective form of contraception?
The contraceptive implant (nexplanon)
Has a failure rate of 0.7/1000
101
What are the adverse effects, drug interactions and contraindications to the contraceptive implant (Nexplanon)?
Adverse effects
## Footnote
irregular/heavy bleeding is the main problem: this is sometimes managed using a co-prescription of the combined oral contraceptive pill. It should be remembered to do a speculum exam/STI check if the bleeding continues
'progestogen effects': headache, nausea, breast pain
Interactions
enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon
the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
Contraindications
UKMEC 3\*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer
UKMEC 4\*\*: current breast cancer
102
Explain how tamoxifen can cause endometrial hyperplasia?
Tamoxifen is used for **oestrogen receptor-positive breast cancer**, in the breast, it has **anti-oestrogenic effects**. However, on the endometrium, it has **pro-oestrogenic effects**. This effect, if unopposed by progesterone, can result in **endometrial hyperplasia.**
103
What is the vaginal pH in bacterial vaginosis infection?
Alkaline
