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YEAR 5: Specialties (Laz) > Gynaecology > Flashcards

Gynaecology Flashcards

1
Q

What is used in the medical management of miscarriage?

A

Vaginal misoprostol
Bleeding should start within 24 hours

o If the bleeding has NOT started within 24 hours of treatment, contact a healthcare professional

o Inform patient about what to expect: vaginal bleeding, pain, diarrhoea and vomiting

pregnancy test after 3 weeks
NOTE: also give antiemetics and analgesia for the symptoms

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2
Q

What is the surgical management option for miscarriage?

A

Manual vacuum aspiration done under LA or surgical managemnt under GA

o Vaginal or sublingual misoprostol if often used to ripen the cervix to facilitate cervical dilatation for suction insertion

NOTE: surgical management of miscarriage requires anti-D in RhD-negative patients

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3
Q

Which tests should be requested in a patient with recurrent miscarriage?

A

Antiphospholipid antibodies (anticardiolipin and lupus anticoagulant)

Cytogenetic analysis of the products of conceptions and of both partners

Ultrasound scan for structural anomalies

Screen for thrombophilia (e.g. factor V Leiden)

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4
Q

How is antiphospholipid syndrome in pregnancy treated to reduce risk of miscarriage?

A

Low-dose aspirin + LMWH

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5
Q

What conditions need to be fulfilled for expectant management of ectopic pregnancy?

and what is it?

A

Size < 35 mm

Asymptomatic

No foetal heartbeat

Serum hCG < 1000 IU/L (may consider 1000-1500)

compatible if there is another intrauterine pregnancy

able to return for followup

Expectant management involves taking serial serum hCG measurements until the levels are undetectable

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6
Q

What is the medical management of ectopic pregnancy and what conditions need to be fulfilled for this option?

A

IM Methotrexate

No significant pain
Unruptured ectopic pregnancy with adnexal mass < 35 mm with no visible heartbeat
Serum B-hCG < 1500 iU/L
No intrauterine pregnancy (confirmed by USS)
Able to return for follow up

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7
Q

How should a patient be followed-up after medical management of ectopic pregnancy?

A

Serial serum hCG measurements on days 4 and 7 then once a week until negative

Don’t have sex during treatment

Don’t conceive for 3 months after treatment

Avoid alcohol and prolonged sun exposure

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8
Q

What conditions need to be fulfilled to consider surgical management of ectopic pregnancy?

A
  • Significant pain
  • Adnexal mass > 35 mm
  • Ectopic pregnancy with a foetal heartbeat visible on ultrasound scan
  • Serum b-HCG > 5000 iU/L
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9
Q

Describe the follow-up after salpingectomy (removal of fallopian tube) and salpingotomy (fallopian tube opened and closed).

A

Salpingectomy - urine pregnancy test at 3 weeks

Salpingotomy - 1 serum hCG per week until negative

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10
Q

Is anti-D required after ectopic pregnancy or miscarriage?

A

Only if they were managed surgically

NOTE: also required for all cases of molar pregnancy

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11
Q

What is the first line management option for molar pregnancy?

A

Suction curettage

Anti D prophylaxis

pregnancy test after 3/52

NOTE: methotrexate may be used as chemotherapy

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12
Q

What advice should be given to women who have had a molar pregnancy?

A

If receiving chemotherapy, do not get pregnant for 1 year

Do not conceive until follow-up is complete

Recommened barrier contraception until hCG normalised.

COCP and IUD can be used once hCG has normalised

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13
Q

Which investigations should be used in secondary amenorrhoea?

A 
Urinary or serum hCG (exclude pregnancy)
TFT
Gonadotrophins (low indicates hypothalamic cause, high indicates ovarian cause or turners)
Prolactin
Androgen (high in PCOS)
Oestradiol
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14
Q

What are the Rotterdam criteria for PCOS?

A

Oligo/anovulation

Clinical or biochemical hyperandrogenism

Polycystic ovaries on ultrasound

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15
Q

How should PMS be investigated?

A

Symptom diary for 2 cycles

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16
Q

What is management for PMS (conservative, moderate and severe)

A

Conservative - offer to all women regardless of severity:

  • Stress reduction
  • Alcohol and caffeine limitation
  • Smoking cessation
  • Regular exercise
  • Regular sleep
  • Regular, frequent (2-3 hourly) small balanced meals (inc complex carbs)
  • Offer pain relief if required - paracetamol or NSAIDS

Moderate - some impact on personal, social and professional life :

  • COCP = Yasmin. can be cyclical or continuous
  • Refer for CBT

Severe - causes withdrawal from social and professional activities and prevents normal functioning:

  • same as moderate PMS
  • SSRI ( can be continuous or just during the luteal phase. must monitor treatment response closely, esp regarding self harm and initially trial for 3 months)
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17
Q

Which investigation should be performed in all women with heavy menstrual bleeding?

A

FBC

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18
Q

What are the management options for menorrhagia of no known cause or menorrhagia caused by < 3 cm fibroids or adenomyosis?

A

1st line: LNG-IUS
2nd line non-hormonal: Tranexamic acid (antifibrinolytic) or NSAIDs (e.g. mefenamic acid)
2nd line hormonal: COCP or oral progestogens

Surgical:
Endometrial ablation
Hysterectomy

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19
Q

What are some medical management options for menorrhagia caused by fibroids > 3 cm?

A

Non-Hormonal: tranexamic acid, NSAIDs

Hormonal: Ulipristal acetate, LNG-IUS, COCP and cyclical oral progestogens

NOTE: ulipristal acetate carries a risk of liver injury

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20
Q

What are some surgical management options for fibroids > 3 cm?

A

Transcervical resection of fibroid (for submucosal) = hysteroscopic surgery

Myomectomy

Uterine artery embolisation

Hysterectomy

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21
Q

What are the 1st and 2nd line management options for dysmenorrhoea?

A

1st line: NSAIDs = mefenamic acid

2nd line: COCP

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22
Q

What are the three forms of emergency contraception and what is the window for taking them after UPSI?

A

Levonorgestral (Levonelle) - 72 hours

Ulipristal Acetate (EllaOne) - 120 hours

Copper IUD - 120 hours

NOTE: levonorgestrel and ulipristal should NOT be taken together, but both can be used more than once in a single cycle

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23
Q

How long after taking emergency contraception must it be repeated if the patient vomits?

A

2 hours

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24
Q

What are the main side-effects and risks of the COCP?

A

Side-Effects: headache, nausea, breast tenderness

Risks: VTE, breast and cervical cancer, stroke, ischaemic heart disease

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25
Q

How do periods tend to change with the COCP?

A

Usually makes periods regular, lighter and less painful

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26
Q

How long before an elective operation should the COCP be stopped?

A

4 weeks

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27
Q

How should a patient on the COCP who has missed 1 pill be counselled?

A

Take last pill

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28
Q

How should a patient on the COCP who has missed 2 pills be managed?

A
  • Use condoms until pill has been taken correctly for 7 days in a row
  • 2 Missed in Week 1: consider emergency contraception
  • 2 Missed in Week 2: no need for emergency contraception
  • 2 Missed in Week 3: finish pills in current pack and start the new pack immediately with no pill-free break
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29
Q

Aside from emergency contraception, what else should be offered to women coming in asking for emergency contraception?

A

STI screen

Long-acting contraception

NOTE: this should be discussed with all TOP (termination of pregnancy) patients as well

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30
Q

Describe how progesterone-only pills should be taken.

A

1 pill at the same time every day with no pill-free week

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31
Q

Which POP has longer leeway with regards to taking the next dose?

A

Cerazette (desorgestrel) - 12 hours

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32
Q

How should you advice a patient who is >12 hours late to take her cerazette?

A

Take the missed pill ASAP and continue with the rest of the pack

Use extra precautions (condoms) until pill taking has been re-established for 48 hours

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33
Q

What is the main side-effect associated with POPs?

A

Irregular menstrual bleeding

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34
Q

Describe how the combined hormonal transdermal patch should be used?

A

Apply patch for 3 weeks (replacing at the end of every week)

Take 1 week off (withdrawal bleed)

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35
Q

What benefit does the transdermal patch have over the COCP?

A

No increased risk of clots

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36
Q

Describe how the combined hormonal ring is used.

A

Flexible ring inserted into the vagina

Worn vaginally for 21 days followed by a 7-day hormone-free period

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37
Q

How long does the mirena last?

A

3 or 5 years

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38
Q

How do periods tend to change with mirena?

A

They become lighter and less painful

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39
Q

List some side-effects of mirena.

A

Acne
Breast tenderness
Mood disturbance
Headache

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40
Q

What is Jaydess?

A

Smaller form of LNG-IUS that is effective for contraception but not for treating heavy periods

Lasts 2 years

Easier to put in

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41
Q

How long does nexplanon last?

A

3 years

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42
Q

How long does depo-provera last?

A

12 weeks

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43
Q

What are some important side-effects of depo-provera?

A

Weight gain (only form of contraception with proven link)

May take up to 6-12 months for fertility to return

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44
Q

How long does the copper coil last?

A

5 or 10 years

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45
Q

What are some side-effects of the copper coil?

A

Heavy, painful periods

Expulsion

Infection

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46
Q

How long do all LARCs take to be effective?

A

1 week

Except copper coil

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47
Q

How is female sterilisation performed at laparoscopy?

A

Occlude Fallopian tubes with Filshie clips

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48
Q

What advice should be given to women who have had a laparoscopic sterilisation?

A

Additional contraception should be used until the first period after the procedure

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49
Q

What is hysteroscopic sterilisation?

A

Insert expanding springs into the tubal ostia via a hysteroscope

This induces fibrosis over 3 months

Additional contraception should be used during this time

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50
Q

Which drugs are used in the medical termination of pregnancy?

A

Mifepristone - progesterone receptor antagonist

Misoprostol (after 48 hours) - prostaglandin analogue

NOTE: pain relief should also be provided

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51
Q

Where should medical TOP take place?

A

< 9 weeks = can be done at home if easy access to follow-up, perform urine pregnancy test after 3 weeks

> 9 weeks = done in clinical setting (higher risk of bleeding/discomfort), repeated misoprostol may be needed every 3 hours

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52
Q

What extra treatment may be required in TOP over 21 +6 weeks?

A

Intracardiac KCl injection (feticide) = eliminates the possibility of aborted fetus showing any signs of life

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53
Q

What are the surgical management options for TOP?

A

Vacuum aspiration (< 14 weeks)

Dilatation and Evacuation (D&E) > 14 weeks

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54
Q

What additional management should you discuss with all TOP patients?

A

Long-acting reversible contraception (copper IUD, mirena, nexplanon)

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55
Q

How many doctors need to sign a form to agree to TOP?

A

2

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56
Q

Which investigations should you request for subfertility?

A
  1. Blood hormone profile:
    - FSH, LH, oestrodial levels (day 2-3)
    - Anti-mullerian hormone (AMH) = assess ovarian reserve (doesn’t change in response to gonadotrophins)
    - Mid-luteal progesterone = 1 week before period, to confirm ovulation
    - If irregular menstraul cycle = TFTs, Prolactin and Testosterone
  2. STI screen = HIV, hep b and c screening if ART is being considerred
  3. TVUSS
    - assessment of pelvic anatomy
    - antral follicle count (important parameter of ovarial reserve: <4 = poor, 16+ = good)
  4. Tubal assessment
    - hysterosalpingography (HSG) using x-ray or USS or a laparoscopy and dye
    - if there are risk factors for tubal damae (pid, ectopic pregnancy r endometriosis)
  5. Semen analysis
    - 2 tests 3 months apart
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57
Q

Which tests are used to assess ovarian reserve?

A

Anti-Mullerian hormone (AMH)

Antral follicle count (AFC)

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58
Q

How can tubal patency be assessed?

A

Hysterosalpingography (HSG) either by X-ray or ultrasound (HyCoSy)

Laparoscopy and dye (lap and dye)

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59
Q

List some medical management options for subfertility.

A

Ovarian induction (clomiphene)

Intrauterine insemination

Donor insemination

IVF

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60
Q

List some surgical management options for subfertility.

A

Operative laparoscopy to treat disease and restore anatomy (e.g. adhesions, endometriosis, cyst)

Myomectomy (if fibroids)

Tubal surgery

Laparoscopic ovarian drilling (PCOS)

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61
Q

What is cyclical HRT?

A

Either 1 monthly or 3 monthly

Take oestrogen every day

Take progesterone for last 14 days of time period (during which withdrawal bleed will happen)

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62
Q

What is continuous HRT?

A

Take oestrogen and progesterone every day

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63
Q

Which patient groups are cyclical and continuous HRT recommended for?

A

Cyclical - perimenopausal

Continuous - postmenopausal

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64
Q

What are the possible routes of administration of HRT?

A

Oral

Transdermal

Vaginal (if predominantly vaginal symptoms)

NOTE: transdermal HRT will avoid hepatic metabolism so isn’t associated with VTE/cardiovascular risks

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65
Q

What are the main benefits of HRT?

A

Improved vasomotor symptoms, sleep and performance

Prevention of osteoporosis

Improved genital tract symptoms (dryness, dyspareunia)

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66
Q

What are the main side-effects and risks of HRT?

A

Side-Effects: breast tenderness, headaches, mood swings, fluid retention

Risks: breast cancer, cardiovascular disease, VTE

NOTE: cardiovascular risk is decreased in younger women and increased in older women

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67
Q

List some absolute contraindications for HRT.

A

Pregnancy

Breast cancer

Endometrial cancer

Uncontrolled HTN

Current VTE

Thrombophilia

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68
Q

List some non-hormonal treatments for menopause.

A

Alpha agonists (clonidine)

Beta-blockers (propanolol)

SSRIs (fluoxetine) - for vasomotor and mood symptoms

CBT - mood

Symptomatic: lubricants, osteoporosis treatments

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69
Q

What investigation is used to diagnose premature ovarian insufficiency?

A

2 x FSH results > 30 IU/L

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70
Q

How should the osteoporosis be managed in patients with premature ovarian insufficiency?

A

Regular DEXA scans every few years

All patients should be recommended HRT

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71
Q

Which lifestyle measures could help lessen the symptoms of menopause?

A

stop smoking
reduce alcohol consumptions
Regular exercise

Weight loss

Reduce stress

Sleep hygiene

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72
Q

How is bacterial vaginosis treated?

A

Metronidazole for 5 days BD

avoid douching and excessive genital washing

Alternative: clindamycin

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73
Q

How is vulvovaginal candidiasis treated?

A

Intravaginal/pessary clotrimazole (canestan duo)

Alternative: oral antifungal (fluconazole)

Pregnancy: topical treatments ONLY

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74
Q

How is trichomonas vaginalis treated?

A

Metronidazole

IMPORTANT: male contacts will also need treatment as this is an STI

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75
Q

How is chlamydia managed?

A

Doxycycline or azithromycin

Contact tracing and treatment

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76
Q

How is gonorrhoea managed?

A

IM ceftriaxone 1 g

With single dose oral azithromycin and doxycycline

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77
Q

Which tests should be done in a patient with PID?

A

Test for chlamydia and gonorrhoea (swabs)

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78
Q

Which antibiotic regimen is recommended for PID?

A

Ceftriaxone 500 mg IM

Doxycycline 100 mg BD for 14 days

Metronidazole 400 mg BD for 14 days

Alternative: ofloxacin + metronidazole

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79
Q

How should sexual contacts of someone with PID be treated?

A

Single dose azithromycin 1 g

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80
Q

List some investigations that may be used in syphilis.

A

Serology
Dark field microscopy or PCR

Non-treponemal: rapid plasma reagin (RPR) or VDRL

Treponemal: EIA, treponema pallidum particle or haemagglutination assay (TPPA/TPHA)

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81
Q

How is syphilis treated?

A

IM Benzathine penicillin

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82
Q

What are some indication for elective C-section in women with HIV in pregnancy?

A

Detectable HIV viral load >50

HCV coinfection

PROM

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83
Q

How should urinary incontinence be investigated?

A

Bladder diaries for at least 3 days

Vaginal examination (check for pelvic organ prolapse and control of pelvic floor muscles)

Urine dipstick and culture

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84
Q

List the steps in the management of urge incontinence.

A

1 - bladder retraining for 6 weeks

2 - bladder stabilising drugs (e.g. oxybutynin, tolteridone) se - blurred vision, dry mouth, constipation, urinary retention

3 - mirabegron (for elderly)

4 - surgical (botox injection, percutaneous tibial nerve stimulation, sacral nerve stimulation)

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85
Q

List the steps in the management of stress incontinence.

A

1 - pelvic floor muscle training for 8 contractions, 3 times a day for 3 months

Medical - duloxetine (enhances sphincter tone) - se is nausea

Surgical - retropubic midurethral tape, bulking, autologous fascial slings, Burch colposuspension, periurethral injection

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86
Q

List some conservative and medical approaches to managing vaginal prolapse.

A

Lifestyle - lose weight if BMI > 30kg/m^2, avoid heavy lifting, prevent/treat constipation

Pelvic floor exercises - 16 week course

Oestrogens (pill, patch, cream) - helps symptom relief if woman also has signs of vaginal atrophy

Vaginal ring pessary (replaced every 6 months)

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87
Q

Which investigation would help confirm a diagnosis of ovarian torsion?

A

Pelvic USS (may show free fluid, whirlpool sign, oedematous ovary)

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88
Q

How should an asymptomatic ovarian cyst be managed?

A

simple and small (<50 mm diameter) = likely to be physiological and likely to resolve within 3 menstrual cycles. do not require follow up.

simple of 50-70mm diameter = yearly ultrasound follow up

> 70mm diameter = require further imaging i.e MRI or surgical intervention (laparoscopic cystectomy)
- if the mass is large with solid components (e.g dermoid cyst) may need laparotomy

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89
Q

What long-term side-effect is associated with GnRH analogue use?

A

Osteoporosis

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90
Q

What is the gold-standard investigation for endometriosis?

A

Diagnostic laparoscopy

Look out for ‘powder burn spots’ on the pelvic peritoneum

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91
Q

Outline the management options for endometriosis.

A

1st line symptomatic relief: NSAIDs and/or paracetamol

COCP and progestogens (e.g. LNG-IUS)

GnRH analogues

Surgery (laparoscopic excision or ablation) - may improve fertility

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92
Q

Which investigations would be considered in a patient with chronic pelvic pain?

A

Genital tract swab

Pelvic USS

MRI

Laparoscopy (gold standard)

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93
Q

How should a woman with cyclical pelvic pain and no abnormalities on USS or pelvic examination be treated?

A

Therapeutic trial of hormonal treatment to suppress ovarian function for 3-6 months (COCP, LNG-IUS, progestogens, GnRH analogues)

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94
Q

Which investigations should be performed in a patient with post-coital bleeding/intermenstrual bleeding?

A

Speculum

Smear

Swabs for STIs

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95
Q

How might cervical ectropion be treated?

A

Change from oestrogen-based contraceptives

Cervical ablation (cryocautery)

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96
Q

Which investigations are useful for suspected endometrial polyps?

A

TVUSS

Hysteroscopy (and saline infusion sonography)

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97
Q

How are endometrial polyp managed?

A

Some small polyps resolve spontaneously

Polypectomy may be recommended to relieve AUB symptoms and optimise fertility

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98
Q

How is Asherman’s syndrome managed?

A

Surgical breakdown of intrauterine adhesions

2 cycles of cyclical oral oestrogen and progesterone given after to aid endometrial proliferation

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99
Q

List some examples of GnRH analogues.

A

Triptorelin, goserelin, buserelin

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100
Q

What are the main treatment options for heavy menstrual bleeding?

A

LNG-IUS

Tranexamic acid

Mefenamic acid

COCP

101
Q

Name two medical treatments that can reduce the size of fibroids.

A

Injectable GnRH agonist

Ulipristal acetate

102
Q

Why can’t GnRH analogues be used for longer than 6 months?

A

Causes osteoporosis

103
Q

List some surgical and radiological options for the treatment of fibroids.

A

Myomectomy

Hysterectomy

Transcervical resection of fibroid

Uterine artery embolisation

MRgFUS

Endometrial ablation

104
Q

Which types of fibroids may be removed via a hysteroscopic approach?

A

Submucosal fibroids

105
Q

Describe the examination and imaging findings seen in adenomyosis.

A

Bulky and boggy uterus

TVUSS: haemorrhage-filled, distended endometrial glands

MRI (BEST INVESTIGATION)

106
Q

How is adenomyosis treated?

A

Long-acting reversible contraceptives containing progestin (e.g. LNG-IUS)

Hysterectomy (only definitive management)

107
Q

How is lichen planus treated?

A

High dose topical steroids

108
Q

How is lichen sclerosus treated?

A

good skin care - soap substitiute, emollient and avoid irritants

Strong steroid ointments (clobetasol proprionate for 3 months then review)

Biopsy may be considered if it fails to respond to treatment

109
Q

How is Bartholin’s cysts managed?

A

if small and asx = conservative = warm compression

if symptomatic and large =

  • Marsupialisation (The internal aspect of the cyst is sutured to the outside of the cyst to create a window so that the cyst does not reform), elective procedure under GA , Abx also given
  • outpatient catheter drainage (insert a tiny catheter into incision, stays for 4-6 weeks, under LA)
110
Q

How is vaginismus treated?

A

Vaginal dilators (little evidence to show efficacy)

Encourage self-exploration and stretching of the vagina

Explore patient anxieties and psychosocial factors

111
Q

What must you always do with cases of FGM?

A

Document in the hospital notes

If < 18 years, refer to police and social services

Explore whether other children are at risk

112
Q

Which procedure is performed to reverse FGM?

A

Deinfibulation

113
Q

Which investigations are used for suspected ovarian cancer?

A

TVUSS

CA125

114
Q

What are the components of the Risk Malignancy Index (RMI) for ovarian masses?

A

Menopausal status

Appearance on TVUSS

CA125

115
Q

What level of CA125 in a woman complaining of lower abdominal pain would warrant an urgent ultrasound scan?

A

> 35 IU/mL

116
Q

Which surgical treatment is usually recommended for ovarian cancer?

A

Total abdominal hysterectomy with BSO

NOTE: platinum-based chemotherapy may also be recommended after surgery

117
Q

List some drugs that are used in chemotherapy for ovarian cancer.

A

1st line: platinum-based chemotherapy (carboplatin)

Paclitaxel

Bevacizumab (anti-VEGF)

118
Q

Which forms of contraception are unaffected by EIDs?

A

Copper IUD

Mirena IUS

Depo-Provera

119
Q

Which forms of contraception work by inhibiting ovulation?

A

COCP

Desorgestrel (cerazette)

Depo-Provera

Nexplanon

120
Q

Which forms of contraception work by a different mechanism other than inhibition of ovulation?

A

POP - thickens cervical mucus

Copper IUD - spermicide + reduces implantation

Mirena IUS - prevents endometrial proliferation + thickens cervical mucus

121
Q

List some risk factors for endometrial cancer.

A

oestrogen exposure: nulliparity, early menarche, late menopause, unopposed oestrogen (negated by taking progesterone too)

obesity

diabetes mellitus

tamoxifen

polycystic ovarian syndrome

hereditary non-polyposis colorectal carcinoma

122
Q

How is endometrial cancer usually managed?

A

Total abdominal hysterectomy with BSO

Frail elderly women may be given progestogen therapy

123
Q

How long should the use of contraception continue for in perimenopausal women?

A

< 50 = for 2 years after the last menstrual period

> 50 = for 1 year after the last menstrual period

124
Q

How long would you expect a urine pregnancy test to stay positive for after a termination of pregnancy?

A

4 weeks

125
Q

What are the risks associated with intrauterine contraceptive devices?

A

Uterine perforation (2 in 1000)

Ectopic pregnancy (relative not absolute)

Infection (in first 20 days)

Expulsion (risk is 1 in 20)

Abnormal bleeding (IUS: initial frequent bleeding and spotting followed by intermittent light menses; IUD: heavier, longer and more painful)

126
Q

Define secondary amenorrhoea.

A

Cessation of menstruation for 6 months in a woman who was previously menstruating

127
Q

What is shoulder tip pain in a gynaecology patient suggestive of?

A

Peritoneal bleeding (e.g. ruptured ectopic)

128
Q

What are the UKMEC4 contraindications for the COCP?

A

more than 35 years old and smoking more than 15 cigarettes/day

migraine with aura

history of thromboembolic disease or thrombogenic mutation

history of stroke or ischaemic heart disease

breast feeding < 6 weeks post-partum

uncontrolled hypertension

current breast cancer

major surgery with prolonged immobilisation

129
Q

Define primary amenorrhoea.

A

When a girl fails to menstruate by 16 years of age.

130
Q

Define oligomenorrhoea.

A

Irregular periods with intervals of > 35 days with only 4-9 periods per year

131
Q

List some causes of recurrent miscarriage.

A

Antiphospholipid syndrome

Thrombophilia

Cervical abnormalities

Uterine malformations

Foetal chromosomal abnormalities

132
Q

What is the incidence of ectopic pregnancy?

A

1% of pregnancies

133
Q

List some risk factors for ectopic pregnancy.

A

PID

Previous ectopic (inc risk by 10%)

Smoking

Increased maternal age

Abdominal surgery

IVF

Endometriosis

IUD

134
Q

What percentage of couples will conceive within a year?

A

85%

135
Q

Which forms of contraception are not affected by enzyme-inducing drugs?

A

LNG-IUS

Copper IUD

Depo-Provera

136
Q

When should alternative contraception be started in a patient who is currently reliant on lactational amenorrhoea?

A

6 months

Or if menses occur or if breastfeeding is reduced

137
Q

What is section C of the UK abortion law?

A

Pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman

138
Q

For how long are eggs fertilisable after ovulation?

A

12-24 hours

139
Q

At what point do you start investigating subfertility?

A

After 1 year of failing to conceive naturally

140
Q

Outline the steps in IVF.

A

Pituitary downregulation

Controlled ovarian stimulation

Inhibition of premature ovulation

hCG trigger

Egg collection

Fertilisation

Embryo culture

Embryo transfer

Luteal phase support

141
Q

What are some features of a high risk ovarian cyst (high risk of cancer)?

A

High CA125

Complex, bilateral, multinodular

> 5 cm

142
Q

Describe how bhCG changes in an ectopic pregnancy.

A

It will plateau

NOTE: a fall in bhCG suggests miscarriage

143
Q

How is an ectopic pregnancy managed surgically?

A

Salpingectomy

Salpingotomy (if the opposite Fallopian tube is damaged)

144
Q

Describe how GnRH, FSH and LH levels change around menopause.

A

GnRH pulsatility increases

FSH and LH increases

NOTE: inhibin A, which is produced by follicles, will decline leading to reduced negative feedback on the hypothalamus and pituitary

145
Q

Define premature ovarian insufficiency.

A

Menopause occurring before the age of 40 years

146
Q

List some causes of premature ovarian insufficiency.

A

Chromosomal abnormalities (e.g. Turner’s syndrome, fragile X)

Autoimmune disease (e.g. hypothyroidism, Addison’s, myasthenia gravis)

Enzyme deficiencies (e.g. galactosaemia, 17a-hydroxylase deficiency)

Chemotherapy or radiotherapy

Infections (e.g. TB, mumps, malaria, varicella)

147
Q

List some immediate, intermediate and long-term effects of menopause.

A

Immediate: flushes, sweats, mood swings, loss of concentration, reduced libido

Intermediate: vaginal dryness, dyspareunia, urinary urgency, urogenital prolapse, recurrent UTI

Long-term: osteoporosis, cardiovascular disease, dementia

148
Q

Which STIs can be tested using NAAT of vulvovaginal swab?

A

Gonorrhoea

Chlamydia

TV

149
Q

What is the most common cause of abnormal vaginal discharge?

A

BV

150
Q

Which criteria are used to diagnose BV?

A

Amsel’s criteria (grey white discharge, pH >4.5, whiff test = strong fish odour when 10% KOH is added to sample of discharge and presence of clue cells on microscopy)

151
Q

Where else might you consider taking swabs from in a patient with a suspected STI?

A

Oral cavity

Rectum

152
Q

Which organisms are most commonly implicated in PID?

A

Chlamydia (MOST COMMON)

Gonorrhoea

Mycoplasma genitalium and vaginal microflora

153
Q

What might you do in a patient with PID and an IUD in situ?

A

Consider removing the IUD (if symptoms haven’t improved in a few days)

154
Q

What is the test of choice for HSV?

A

PCR

155
Q

List some treatment options for genital warts.

A

Cryotherapy (liquid nitrogen ablation)

Topical (podophyllotoxin, imiquimod)

NOTE: treatment is optional because the lesions are benign

156
Q

How often should HIV-positive women have cervical smears?

A

Annually

157
Q

What types of muscle make up the urethral sphincter?

A

Internal = smooth muscle

External = striated muscle

NOTE: these are under sympathetic and somatic control

158
Q

List some risk factors for stress incontinence.

A

Multiparity

Forceps delivery

Long labour

High birthweight

Age

Obesity

Connective tissue disease

Chronic cough

159
Q

How is a urodynamic test performed?

A

Bladder is filled with warm saline whilst pressure recordings are taken and the patient is sitting on a commode that records leakage

Urinary catheter - measures pressure in the bladder

Rectal catheter - measures pressure in the rectum

160
Q

What are the three levels of supporting structures for the uterus, vagina and other pelvic organs?

A

Level 1 (apical) - uterosacral ligaments attaching the cervix to the sacrum (defect causes vaginal vault prolapse)

Level 2 - fascia around the vagina (defect causes vaginal wall prolapse)

Level 3 - fascia of the posterior vagina attached to the perineal body (defect causes lower posterior vaginal wall prolapse)

161
Q

What are the two types of posterior vaginal wall prolapse?

A

Enterocele - upper 1/3 of the vagina

Rectocele - lower 2/3 of the vagina

162
Q

Describe the stages of uterine prolapse.

A

Stage I – the uterus is in the upper half of the vagina

Stage II – the uterus has descended nearly to the opening of the vagina

Stage III – the uterus protrudes out of the vagina

Stage IV – the uterus is completely out of the vagina.

163
Q

Name and describe a few different types of procedures for pelvic organ prolapse.

A

Colporrhaphy - used for anterior and posterior vaginal wall prolapse (stitches are placed to strengthen the vagina)

Sacrocolpopexy - used for vaginal vault prolapse and enterocele (mesh is attached from the prolapsed wall to the sacrum)

Sacrohysteropexy - used in women who want to avoid hysterectomy (mesh is attached to the cervix and the sacrum)

164
Q

List some examples of functional ovarian cysts.

A

Follicular cyst

Corpus luteal cyst

Theca luteal cyst (associated with pregnancy)

More common in younger women

165
Q

List some examples of epithelial ovarian cysts.

A

Serous cystadenoma

Mucinous cystadenoma

Brenner tumour

More common in older women

166
Q

List some examples of sex cord stromal cysts.

A

Fibroma

Thecoma

167
Q

In which subset of women would a transabdominal USS be preferred over a transvaginal USS?

A

Women who have never been sexually active

168
Q

List some tumour markers used for ovarian cysts.

A

CA125: epithelial ovarian cancer (CA19-9 is likely to also be raised)

Inhibin: granulosa cell tumours

bhCG: dysgerminoma, choriocarcinoma

AFP: endodermal yolk sac, immature teratoma

169
Q

What size of functional ovarial cyst is considered pathological?

A

> 3 cm

NOTE: normal ovulatory follicles can reach 2.5 cm

170
Q

When do corpus luteal cysts tend to form?

A

After ovulation

May cause pain due to rupture or haemorrhage late in the cycle

171
Q

What are some examples of inflammatory ovarian cysts?

A

Tubo-Ovarian Abscess

Endometrioma

172
Q

What is Meig syndrome?

A

Triad of fibroma, pleural effusion and ascites

173
Q

How can thecomas manifest?

A

They secrete oestrogen

Usually present after menopause

May have features of excess oestrogen (e.g. PMB)

Associated with endometrial carcinoma

174
Q

What is the prevalence of endometriosis?

A

10% of women of reproductive age

NOTE: it resolves after menopause

175
Q

Define chronic pelvic pain.

A

Intermittent or constant pain in the lower abdomen or pelvis of a woman of at least 6 months duration, NOT occurring exclusively with menstruation (dysmenorrhoea) or intercourse (dyspareunia) and not associated with pregnancy

176
Q

What is a nabothian follicle?

A

Benign lesion of the cervix formed when columnar glands of the transformation zone become sealed over, forming small, mucous-filled cysts on the ectocervix

177
Q

List some causes of cervical stenosis.

A

Usually iatrogenic

E.g. due to cone biopsy, LLETZ or endometrial ablation

178
Q

Define Asherman syndrome.

A

Fibrosis and adhesion formation within the endometrial cavity following irreversible damage of the single layer thick basal endometrium (does not allow normal regeneration of the endometrium)

179
Q

Name and briefly describe the three types of fibroid degeneration.

A

Red - haemorrhage and central necrosis usually occurring in pregnancy and presenting acutely

Hyaline - asymptomatic softening and liquefaction of the fibroid

Cystic - asymptomatic central necrosis leaving cystic spaces at the centre. Becomes calcified.

180
Q

What is the difference between the epithelium of the vulval vestibule and the labia majora/minora?

A

Vestibule: non-keratinised, non-pigmented squamous epithelium

Labia: keratinised, pigmented squamous epithelium

181
Q

Which ducts are present in the vulval vestibule?

A

Minor vestibular glands

Skene’s glands

Bartholin’s glands (major)

NOTE: major and minor vestibular glands contain mucus-secreting acini with ducts lined by transitional epithelium

182
Q

What are some key differences between the labia majora and the labia minora?

A

Majora: adipose tissue, covered by skin containing follicles, sebaceous glands and sweat glands

Minora: no adipose tissue, no hair follicles, contains sebaceous follicles

183
Q

In which patient groups is vulvovaginal candidiasis uncommon?

A

Prepubescent

Postmenopausal

Consider diabetes mellitus or other underlying predisposing factor

184
Q

What is lichen planus?

A

Autoimmune disorder affecting 1-2% of the population (particularly > 40 years) affecting the skin, genitalia and oral and GI mucosa

Presents with itching, superficial dyspareunia, cobweb lesions in mouth and genital lesions

185
Q

Outline the expectant management of a miscarriage - incomplete, inevitable

A

go home and wait for 7-14 days for the miscarriage to complete spontaneously

warn them to expect heavier bleeding with clots

If bleeding and pain resolves in this time period, advise taking a pregnancy test after 3 weeks

If bleeding unmanageable, come back to A&E

186
Q

What does the finding of free fluid in a patient with an ectopic pregnancy suggest?

A

It has ruptured

They will need surgical management

187
Q

How should patients who have been treated for gestational trophoblastic disease be followed up?

A

Refer to trophoblastic screening centre

Follow-up is individualised

Depends on the bhCG at 56 days from the pregnancy event

188
Q

When do products of conception need to be sent for histological assessment?

A

Material obtained from medical or surgical management of ALL failed pregnancies should be sent for histological analysis to exclude trophoblastic disease

NOTE: this does NOT include terminations

189
Q

Which measures can help improve fertility in patients with PCOS?

A

Weight loss

Clomiphene

Metformin

190
Q

What measure is recommended to reduce the risk of endometrial hyperplasia in PCOS?

A

Hormonal therapy (e.g. norethistrone) to induce a period at least 4 times per year

191
Q

List some absolute contraindications for the COCP.

A

< 6 wks postpartum

Smoker over the age of 35 (>15 cigarettes per day)

Hypertension (systolic > 160mmHg or diastolic > 100mmHg)

Current of past history of venous thromboembolism (VTE)

Ischemic heart disease

History of cerebrovascular accident

Complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis)

Migraine with aura

Breast cancer (current)

Diabetes with retinopathy/nephropathy/neuropathy

Severe cirrhosis

Liver tumour (adenoma or hepatoma)

192
Q

What prophylactic medication should be given to any patient having surgical management of miscarriage or TOP?

A

Prophylactic antibiotics

193
Q

Describe the impact of surgical management of miscarriage and TOP on future reproductive potential.

A

No impact on fertility and risk of ectopic pregnancy

194
Q

Outline the FIGO stages of endometrial cancer.

A

1 - confined to uterus

2 - confined to uterus + cervix

3 - invades through cervix/uterus

4 - bowel/bladder involvement or distant metastases

195
Q

Outline the FIGO stages of ovarian cancer.

A

1 - confined to the ovaries

2 - beyond the ovaries but confined to pelvis

3 - beyond the pelvis but confined to the abdomen

4 - beyond the abdomen

196
Q

Outline the FIGO stages of cervical cancer.

A

1 - cervix only

2 - extends into upper vagina but not pelvic wall

3 - extends to lower vagina/pelvic wall or causing ureteric obstruction

4 - invasion of bladder or rectal mucosa

197
Q

What advice would you give to a patient who has had a salpingectomy for an ectopic pregnancy about future contraception and pregnancy?

A

Avoid intrauterine devices

Avoid POP (associated with increased risk of ectopic)

Get an early TVUSS whenever you next get pregnant to rule out ectopic

198
Q

What are the 7 sections of the UK Abortion Act?

A

A - continuance RISKS THE LIFE of the pregnant woman more than if the pregnancy was terminated

B - termination is necessary to prevent GRAVE PERMANENT INJURY to mental/physical health of woman

C - not exceeded 24 weeks and continuation involves GREATER RISK to physical/mental health of woman than termination

D - not exceeded 24 weeks and continuation involves RISK TO EXISTING CHILD(ren)’s mental/physical health

E - substantial risk that if the child were born it would be SERIOUSLY HANDICAPPED

F - to SAVE THE LIFE of the pregnant woman

G - prevent GRAVE PERMANENT INJURY to the woman

199
Q

Where can pregnancies be terminated?

A

Marie Stopes centre

British Pregnancy Advisory Service

200
Q

Describe some symptoms of Asherman’s syndrome.

A

Reduction or absence of bleeding

Deep dyspareunia

201
Q

What is a radical hysterectomy?

A

It is a total hysterectomy + BSO + removal of upper half of the vagina, uterus, parametrium

This is done for cervical cancer

202
Q

What mid-luteal progesterone level is suggestive of ovulation?

A

> 30 nM/L

203
Q

how to manage a threatened miscarriage (vaginal bleeding and a confirmed intrauterine pregnancy with a foetal heart beat)

A

Return for further assessment if the bleeding gets worse or persists beyond 14 days

Continue routine antenatal care if the bleeding stops

Anti-D not needed if bleeding stops < 12 weeks

204
Q

Offer repeat scan if after the period of expectant management the bleeding and pain:

A

 Has not started (suggests miscarriage has not begun) –> may need medical/surgical

 Persisting and/or increasing (suggesting incomplete miscarriage)  may need medical surgical

205
Q

what is the failure rate for medical management of miscarriage

A

10%

206
Q

what are some risk factors for miscarriage

A

advanced maternal age, previous miscarriages, uterine or cervical anomalies

207
Q

what to reassure miscarriage pts

A

it is common and under reported - 1 in 5 pregnanies
the risk increases with age
most of the time there is no cause

208
Q

psychological support for miscarriage

A

o Having a single miscarriage does not affect future pregnancies

miscarriageassociation.co.uk –> information about finding counselling

209
Q

investigation for miscarriage

A 
ABCDE
basic obs
abdominal exam
speculum and bimanual
TVUSS
FBC and group and save
210
Q

investigation for ectopic pregnancy

A 
ABCDE
pregnancy test 
abdominal exam
bimanual and speculum
TVUSS
serial hCG to guide management
211
Q

Support groups for ectopic

A

the Ectopic Pregnancy Trust

212
Q

risk factor for molar pregnancy

A

o Extremes of ages: teenagers and > 40 years

o Previous molar pregnancy

213
Q

investigation for molar pregnancy

A

• Serum hCG > 100,000 IU/L  much higher than would be expected in a normal pregnancy
• Pelvic USS
o Complete mole: snow-storm/swiss-cheese sign of uterine cavity, absence of fetal parts, thecal lutein cysts
o Partial mole: small placenta with partial fetal development, oligohydramnios
 50% accuracy for partial moles
 If live embryo, do not intervene
• Histological diagnosis is gold-standard

214
Q

follow up for molar pregnancy

A

referral to the trophoblastic screening centre to monitor pregnancy hormone levels

Serum and urine hCG every 2 weeks until levels are normal
 If complete mole: continue every month for 6 months
• If it takes > 2 months for a normal reading, continue for 6 months after a normal reading
• Increased risk of chemo
 If partial mole: continue until normal reading  2 more measurements  if normal, discharge

215
Q

counselling levonorgestrel

A

it vomit within 2-3 hours , repeat dose
can be used more than once in a menstrual cycle
stops ovulation and inhibits implantation

216
Q

counselling ulipristal acetate

A

if vomit within 3 hours - repeat dose

May reduce efficacy of hormonal contraception  use barrier method for 5 days
 Can be used >1 in a menstrual cycle
 Caution if severe asthma
 Delay breastfeeding for 1 week after taking ulipristal

217
Q

investigations for pcos

A 
serum total and free testosterone
serum LH and FSH
OGTT
monitor CVD risk
- BMI
- fasting lipid panel
- blood pressure 
pelvic ultrasound
rotterdam consensus criteria
218
Q

management for pcos

A

Lifestyle advice

  • Dietary modification and exercise if at increased risk of developing T2DM and cardiovascular disease
  • Weight reduction if appropriate

Menstrual function

  • COCP to regulate menstruation
  • Cyclical oral progesterone - regulae withdrawal bleed (should happen at least every 3-4 months)

Treatment of hirsuitism/androgenic symptoms

  • eflornithine cream
  • cyproterone aceate
  • co-copyrindol COCP
  • metformin
219
Q

support for TOP

A

o Counselling service at the abortion clinic

o Organisations such as the FPA, Brook (for under 25s), British Pregnancy Advisory Service

220
Q

safety net for abortion

A
  • Can experience some discomfort and vaginal bleeding for up to 2 weeks
  • Return to clinic if heavy bleeding, severe pain, smelly vaginal discharge, fever or ongoing signs of pregnancy such as nausea or sore breasts
  • Clinic gives 24 hour helpline for concerns
221
Q

investigations for ovarian hyperstimulation syndrome

A

 FBC, CRP, U&Es (hyponatremia and hypokalaemia), serum osmolality, LFTs, coagulation profile
 Haematocrit is useful to assess intravascular volume - raised
 Ultrasound scan

222
Q

management for ovarian hyperstimulation syndrome

A

mild-moderate = outpatient
–> analgesia (avoid NSAIDS), antiemetics, LMWH

admission if unable to achieve pain conrol, cant maintain adequate fluid intake due to nausea, signs of worsening OHSS despite outpt therapy –> fluid replacement, paracentesis if severe abdo distension and pain, sob and resp compromise 2ary to ascites

223
Q

management for prematue ovarian insufficiency

A

HRT or COCP

must continue treatment until at least age of natural menopause (51)

224
Q

follow up for menopause

A

refer to specialist, review at 3 months and then annually

225
Q

risk factors for bacterial vaginosis

A

douching, black women, new sexual partner

226
Q

risk factors for vulvovaginal candidiasis

A

poorly controlled DM
immunosuppresion
antibiotics

227
Q

investigations for thrush

A

bimanual
speculum
high vaginal swab –> microscopy/culture

228
Q

advice fror thrush

A

• Advise: return if symptoms not resolved in 7-14 days

avoid perfumed soaps/douching/tight-fitting clothes, use emollient

consider probiotics

229
Q

investigations for trichomonas vaginalis

A

speculum - strawberry cervix
NAAT of vulvaginal swab
full STI screen

230
Q

follow up for PID

A

if treated as outpatien –> return in 72 hours to assess response
if no improvement, admit for IV antibiotics
further follow up in 2-4 weeks to ensure resolution, reitierae importance of STIs, and reassure that if compliant, fertility is not affected

231
Q

lifestyle measures for incontinence

A

avoid cafeniated drinks, avoid drinking excess/reduced amounts of fluids, lose weight if u big, stop smoking

232
Q

s/sx of asherman syndrome

A

● Reduced/absent menstrual bleeding
● Subfertility
● Recurrent miscarriage

233
Q

ix of asherman syndrome

A

hysteroscopy - gold standard

● Saline infusion sonohysterogram (SIS) may be done first if low suspicion of Asherman’s
- Thin endometrial lining (<4mm) is suggestive of Asherman’s

234
Q

atrophic vaginitis symptoms

A

vaginal dryness and mild itching
dyspareunia
vaginal discharge

235
Q

management of atrophic vaginitis

A

o Mild:
 Vaginal lubricant and moisturisers
 Can improve coital comfort and increase vaginal comfort

o If severe:
 topical vaginal oestrogen, oestrogen-containing vaginal pessaries

236
Q

How is Bartholin’s abscess managed?

A

conservative: warm compression and analgesia)

Incision, drainage and marsupialisation (Under GA)

broad spectrum abx

recommenend STI screen

237
Q

risk factors for bartholins cyst/abscess

A

nulliparous, child bearing age, previous bartholin cyst

238
Q

endometriosis risk factors

A

fhx, nulliparous, early menopause

239
Q

investigations for endometriosis

A

pregnancy test (rule out ectopic)
abdominal exam
pelvic exam - fixed retroverted uterus, uterosacral ligament thickening
diagnostic laparoscopy

240
Q

risk factors for fibroids

A

nulliparous, obesity, afr caribbean

241
Q

investigations for fibroids

A

pelvic exam
FBC
TVUSS

242
Q

support for fgm

A

national fgm centre

243
Q

ix for ovarian cyst

A

pregnancy test
TVUSS
crp, esr
tumour markers

244
Q

how to treat high grade cin

A

large loop excision of transformation zone - under LA, takes 15 mins

inc risk of midtrimester loss and preterm delivery

245
Q

investigation for cervical cancer

A

pelvic exam
colposcopy
biopsy
mri of abdomen and pelvis to check for spread

246
Q

fertility-sparing tx for cervical cancer

A

radical trachelectomy -

247
Q

ix for endometrial cancer

A

women >55 with PMB should be referred to suspected cancer referral

speculum and bimanual

TVUSS - >4mm –> refer for hysteroscopy and biopsy

248
Q

vulvar cancer s/sx

A

lump or ulcer
bleeding
discharge

ulcerated lesion - well demarcated, raised

249
Q

vulvar cancer tx

A

vulvar excision
sentinel lymph node biopsy
radiotherapy

YEAR 5: Specialties (Laz) (19 decks)

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