Gynaecology Flashcards
(249 cards)
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
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
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)
4
Q
How is antiphospholipid syndrome in pregnancy treated to reduce risk of miscarriage?
A
Low-dose aspirin + LMWH
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
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
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
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
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
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
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
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
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
14
Q
What are the Rotterdam criteria for PCOS?
A
Oligo/anovulation
Clinical or biochemical hyperandrogenism
Polycystic ovaries on ultrasound
15
Q
How should PMS be investigated?
A
Symptom diary for 2 cycles
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)
17
Q
Which investigation should be performed in all women with heavy menstrual bleeding?
A
FBC
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
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
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
21
Q
What are the 1st and 2nd line management options for dysmenorrhoea?
A
1st line: NSAIDs = mefenamic acid
2nd line: COCP
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
23
Q
How long after taking emergency contraception must it be repeated if the patient vomits?
A
2 hours
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
25
How do periods tend to change with the COCP?
Usually makes periods regular, lighter and less painful
26
How long before an elective operation should the COCP be stopped?
4 weeks
27
How should a patient on the COCP who has missed 1 pill be counselled?
Take last pill
28
How should a patient on the COCP who has missed 2 pills be managed?
* 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
29
Aside from emergency contraception, what else should be offered to women coming in asking for emergency contraception?
STI screen
Long-acting contraception
NOTE: this should be discussed with all TOP (termination of pregnancy) patients as well
30
Describe how progesterone-only pills should be taken.
1 pill at the same time every day with no pill-free week
31
Which POP has longer leeway with regards to taking the next dose?
Cerazette (desorgestrel) - 12 hours
32
How should you advice a patient who is >12 hours late to take her cerazette?
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
33
What is the main side-effect associated with POPs?
Irregular menstrual bleeding
34
Describe how the combined hormonal transdermal patch should be used?
Apply patch for 3 weeks (replacing at the end of every week)
Take 1 week off (withdrawal bleed)
35
What benefit does the transdermal patch have over the COCP?
No increased risk of clots
36
Describe how the combined hormonal ring is used.
Flexible ring inserted into the vagina
| Worn vaginally for 21 days followed by a 7-day hormone-free period
37
How long does the mirena last?
3 or 5 years
38
How do periods tend to change with mirena?
They become lighter and less painful
39
List some side-effects of mirena.
Acne
Breast tenderness
Mood disturbance
Headache
40
What is Jaydess?
Smaller form of LNG-IUS that is effective for contraception but not for treating heavy periods
Lasts 2 years
Easier to put in
41
How long does nexplanon last?
3 years
42
How long does depo-provera last?
12 weeks
43
What are some important side-effects of depo-provera?
Weight gain (only form of contraception with proven link)
May take up to 6-12 months for fertility to return
44
How long does the copper coil last?
5 or 10 years
45
What are some side-effects of the copper coil?
Heavy, painful periods
Expulsion
Infection
46
How long do all LARCs take to be effective?
1 week
Except copper coil
47
How is female sterilisation performed at laparoscopy?
Occlude Fallopian tubes with Filshie clips
48
What advice should be given to women who have had a laparoscopic sterilisation?
Additional contraception should be used until the first period after the procedure
49
What is hysteroscopic sterilisation?
Insert expanding springs into the tubal ostia via a hysteroscope
This induces fibrosis over 3 months
Additional contraception should be used during this time
50
Which drugs are used in the medical termination of pregnancy?
Mifepristone - progesterone receptor antagonist
Misoprostol (after 48 hours) - prostaglandin analogue
NOTE: pain relief should also be provided
51
Where should medical TOP take place?
< 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
52
What extra treatment may be required in TOP over 21 +6 weeks?
Intracardiac KCl injection (feticide) = eliminates the possibility of aborted fetus showing any signs of life
53
What are the surgical management options for TOP?
Vacuum aspiration (< 14 weeks)
Dilatation and Evacuation (D&E) > 14 weeks
54
What additional management should you discuss with all TOP patients?
Long-acting reversible contraception (copper IUD, mirena, nexplanon)
55
How many doctors need to sign a form to agree to TOP?
2
56
Which investigations should you request for subfertility?
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
57
Which tests are used to assess ovarian reserve?
Anti-Mullerian hormone (AMH)
Antral follicle count (AFC)
58
How can tubal patency be assessed?
Hysterosalpingography (HSG) either by X-ray or ultrasound (HyCoSy)
Laparoscopy and dye (lap and dye)
59
List some medical management options for subfertility.
Ovarian induction (clomiphene)
Intrauterine insemination
Donor insemination
IVF
60
List some surgical management options for subfertility.
Operative laparoscopy to treat disease and restore anatomy (e.g. adhesions, endometriosis, cyst)
Myomectomy (if fibroids)
Tubal surgery
Laparoscopic ovarian drilling (PCOS)
61
What is cyclical HRT?
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)
62
What is continuous HRT?
Take oestrogen and progesterone every day
63
Which patient groups are cyclical and continuous HRT recommended for?
Cyclical - perimenopausal
Continuous - postmenopausal
64
What are the possible routes of administration of HRT?
Oral
Transdermal
Vaginal (if predominantly vaginal symptoms)
NOTE: transdermal HRT will avoid hepatic metabolism so isn't associated with VTE/cardiovascular risks
65
What are the main benefits of HRT?
Improved vasomotor symptoms, sleep and performance
Prevention of osteoporosis
Improved genital tract symptoms (dryness, dyspareunia)
66
What are the main side-effects and risks of HRT?
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
67
List some absolute contraindications for HRT.
Pregnancy
Breast cancer
Endometrial cancer
Uncontrolled HTN
Current VTE
Thrombophilia
68
List some non-hormonal treatments for menopause.
Alpha agonists (clonidine)
Beta-blockers (propanolol)
SSRIs (fluoxetine) - for vasomotor and mood symptoms
CBT - mood
Symptomatic: lubricants, osteoporosis treatments
69
What investigation is used to diagnose premature ovarian insufficiency?
2 x FSH results > 30 IU/L
70
How should the osteoporosis be managed in patients with premature ovarian insufficiency?
Regular DEXA scans every few years
All patients should be recommended HRT
71
Which lifestyle measures could help lessen the symptoms of menopause?
stop smoking
reduce alcohol consumptions
Regular exercise
Weight loss
Reduce stress
Sleep hygiene
72
How is bacterial vaginosis treated?
Metronidazole for 5 days BD
avoid douching and excessive genital washing
Alternative: clindamycin
73
How is vulvovaginal candidiasis treated?
Intravaginal/pessary clotrimazole (canestan duo)
Alternative: oral antifungal (fluconazole)
Pregnancy: topical treatments ONLY
74
How is trichomonas vaginalis treated?
Metronidazole
IMPORTANT: male contacts will also need treatment as this is an STI
75
How is chlamydia managed?
Doxycycline or azithromycin
Contact tracing and treatment
76
How is gonorrhoea managed?
IM ceftriaxone 1 g
With single dose oral azithromycin and doxycycline
77
Which tests should be done in a patient with PID?
Test for chlamydia and gonorrhoea (swabs)
78
Which antibiotic regimen is recommended for PID?
Ceftriaxone 500 mg IM
Doxycycline 100 mg BD for 14 days
Metronidazole 400 mg BD for 14 days
Alternative: ofloxacin + metronidazole
79
How should sexual contacts of someone with PID be treated?
Single dose azithromycin 1 g
80
List some investigations that may be used in syphilis.
Serology
Dark field microscopy or PCR
Non-treponemal: rapid plasma reagin (RPR) or VDRL
Treponemal: EIA, treponema pallidum particle or haemagglutination assay (TPPA/TPHA)
81
How is syphilis treated?
IM Benzathine penicillin
82
What are some indication for elective C-section in women with HIV in pregnancy?
Detectable HIV viral load >50
HCV coinfection
PROM
83
How should urinary incontinence be investigated?
Bladder diaries for at least 3 days
Vaginal examination (check for pelvic organ prolapse and control of pelvic floor muscles)
Urine dipstick and culture
84
List the steps in the management of urge incontinence.
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)
85
List the steps in the management of stress incontinence.
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
86
List some conservative and medical approaches to managing vaginal prolapse.
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)
87
Which investigation would help confirm a diagnosis of ovarian torsion?
Pelvic USS (may show free fluid, whirlpool sign, oedematous ovary)
88
How should an asymptomatic ovarian cyst be managed?
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
89
What long-term side-effect is associated with GnRH analogue use?
Osteoporosis
90
What is the gold-standard investigation for endometriosis?
Diagnostic laparoscopy
Look out for 'powder burn spots' on the pelvic peritoneum
91
Outline the management options for endometriosis.
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
92
Which investigations would be considered in a patient with chronic pelvic pain?
Genital tract swab
Pelvic USS
MRI
Laparoscopy (gold standard)
93
How should a woman with cyclical pelvic pain and no abnormalities on USS or pelvic examination be treated?
Therapeutic trial of hormonal treatment to suppress ovarian function for 3-6 months (COCP, LNG-IUS, progestogens, GnRH analogues)
94
Which investigations should be performed in a patient with post-coital bleeding/intermenstrual bleeding?
Speculum
Smear
Swabs for STIs
95
How might cervical ectropion be treated?
Change from oestrogen-based contraceptives
Cervical ablation (cryocautery)
96
Which investigations are useful for suspected endometrial polyps?
TVUSS
Hysteroscopy (and saline infusion sonography)
97
How are endometrial polyp managed?
Some small polyps resolve spontaneously
Polypectomy may be recommended to relieve AUB symptoms and optimise fertility
98
How is Asherman's syndrome managed?
Surgical breakdown of intrauterine adhesions
2 cycles of cyclical oral oestrogen and progesterone given after to aid endometrial proliferation
99
List some examples of GnRH analogues.
Triptorelin, goserelin, buserelin
100
What are the main treatment options for heavy menstrual bleeding?
LNG-IUS
Tranexamic acid
Mefenamic acid
COCP
101
Name two medical treatments that can reduce the size of fibroids.
Injectable GnRH agonist
Ulipristal acetate
102
Why can't GnRH analogues be used for longer than 6 months?
Causes osteoporosis
103
List some surgical and radiological options for the treatment of fibroids.
Myomectomy
Hysterectomy
Transcervical resection of fibroid
Uterine artery embolisation
MRgFUS
Endometrial ablation
104
Which types of fibroids may be removed via a hysteroscopic approach?
Submucosal fibroids
105
Describe the examination and imaging findings seen in adenomyosis.
Bulky and boggy uterus
TVUSS: haemorrhage-filled, distended endometrial glands
MRI (BEST INVESTIGATION)
106
How is adenomyosis treated?
Long-acting reversible contraceptives containing progestin (e.g. LNG-IUS)
Hysterectomy (only definitive management)
107
How is lichen planus treated?
High dose topical steroids
108
How is lichen sclerosus treated?
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
How is Bartholin's cysts managed?
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
How is vaginismus treated?
Vaginal dilators (little evidence to show efficacy)
Encourage self-exploration and stretching of the vagina
Explore patient anxieties and psychosocial factors
111
What must you always do with cases of FGM?
Document in the hospital notes
If < 18 years, refer to police and social services
Explore whether other children are at risk
112
Which procedure is performed to reverse FGM?
Deinfibulation
113
Which investigations are used for suspected ovarian cancer?
TVUSS
CA125
114
What are the components of the Risk Malignancy Index (RMI) for ovarian masses?
Menopausal status
Appearance on TVUSS
CA125
115
What level of CA125 in a woman complaining of lower abdominal pain would warrant an urgent ultrasound scan?
> 35 IU/mL
116
Which surgical treatment is usually recommended for ovarian cancer?
Total abdominal hysterectomy with BSO
NOTE: platinum-based chemotherapy may also be recommended after surgery
117
List some drugs that are used in chemotherapy for ovarian cancer.
1st line: platinum-based chemotherapy (carboplatin)
Paclitaxel
Bevacizumab (anti-VEGF)
118
Which forms of contraception are unaffected by EIDs?
Copper IUD
Mirena IUS
Depo-Provera
119
Which forms of contraception work by inhibiting ovulation?
COCP
Desorgestrel (cerazette)
Depo-Provera
Nexplanon
120
Which forms of contraception work by a different mechanism other than inhibition of ovulation?
POP - thickens cervical mucus
Copper IUD - spermicide + reduces implantation
Mirena IUS - prevents endometrial proliferation + thickens cervical mucus
121
List some risk factors for endometrial cancer.
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
How is endometrial cancer usually managed?
Total abdominal hysterectomy with BSO
Frail elderly women may be given progestogen therapy
123
How long should the use of contraception continue for in perimenopausal women?
< 50 = for 2 years after the last menstrual period
> 50 = for 1 year after the last menstrual period
124
How long would you expect a urine pregnancy test to stay positive for after a termination of pregnancy?
4 weeks
125
What are the risks associated with intrauterine contraceptive devices?
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
Define secondary amenorrhoea.
Cessation of menstruation for 6 months in a woman who was previously menstruating
127
What is shoulder tip pain in a gynaecology patient suggestive of?
Peritoneal bleeding (e.g. ruptured ectopic)
128
What are the UKMEC4 contraindications for the COCP?
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
Define primary amenorrhoea.
When a girl fails to menstruate by 16 years of age.
130
Define oligomenorrhoea.
Irregular periods with intervals of > 35 days with only 4-9 periods per year
131
List some causes of recurrent miscarriage.
Antiphospholipid syndrome
Thrombophilia
Cervical abnormalities
Uterine malformations
Foetal chromosomal abnormalities
132
What is the incidence of ectopic pregnancy?
1% of pregnancies
133
List some risk factors for ectopic pregnancy.
PID
Previous ectopic (inc risk by 10%)
Smoking
Increased maternal age
Abdominal surgery
IVF
Endometriosis
IUD
134
What percentage of couples will conceive within a year?
85%
135
Which forms of contraception are not affected by enzyme-inducing drugs?
LNG-IUS
Copper IUD
Depo-Provera
136
When should alternative contraception be started in a patient who is currently reliant on lactational amenorrhoea?
6 months
Or if menses occur or if breastfeeding is reduced
137
What is section C of the UK abortion law?
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
For how long are eggs fertilisable after ovulation?
12-24 hours
139
At what point do you start investigating subfertility?
After 1 year of failing to conceive naturally
140
Outline the steps in IVF.
Pituitary downregulation
Controlled ovarian stimulation
Inhibition of premature ovulation
hCG trigger
Egg collection
Fertilisation
Embryo culture
Embryo transfer
Luteal phase support
141
What are some features of a high risk ovarian cyst (high risk of cancer)?
High CA125
Complex, bilateral, multinodular
> 5 cm
142
Describe how bhCG changes in an ectopic pregnancy.
It will plateau
NOTE: a fall in bhCG suggests miscarriage
143
How is an ectopic pregnancy managed surgically?
Salpingectomy
Salpingotomy (if the opposite Fallopian tube is damaged)
144
Describe how GnRH, FSH and LH levels change around menopause.
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
Define premature ovarian insufficiency.
Menopause occurring before the age of 40 years
146
List some causes of premature ovarian insufficiency.
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
List some immediate, intermediate and long-term effects of menopause.
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
Which STIs can be tested using NAAT of vulvovaginal swab?
Gonorrhoea
Chlamydia
TV
149
What is the most common cause of abnormal vaginal discharge?
BV
150
Which criteria are used to diagnose BV?
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
Where else might you consider taking swabs from in a patient with a suspected STI?
Oral cavity
Rectum
152
Which organisms are most commonly implicated in PID?
Chlamydia (MOST COMMON)
Gonorrhoea
Mycoplasma genitalium and vaginal microflora
153
What might you do in a patient with PID and an IUD in situ?
Consider removing the IUD (if symptoms haven't improved in a few days)
154
What is the test of choice for HSV?
PCR
155
List some treatment options for genital warts.
Cryotherapy (liquid nitrogen ablation)
Topical (podophyllotoxin, imiquimod)
NOTE: treatment is optional because the lesions are benign
156
How often should HIV-positive women have cervical smears?
Annually
157
What types of muscle make up the urethral sphincter?
Internal = smooth muscle
External = striated muscle
NOTE: these are under sympathetic and somatic control
158
List some risk factors for stress incontinence.
Multiparity
Forceps delivery
Long labour
High birthweight
Age
Obesity
Connective tissue disease
Chronic cough
159
How is a urodynamic test performed?
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
What are the three levels of supporting structures for the uterus, vagina and other pelvic organs?
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
What are the two types of posterior vaginal wall prolapse?
Enterocele - upper 1/3 of the vagina
Rectocele - lower 2/3 of the vagina
162
Describe the stages of uterine prolapse.
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
Name and describe a few different types of procedures for pelvic organ prolapse.
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
List some examples of functional ovarian cysts.
Follicular cyst
Corpus luteal cyst
Theca luteal cyst (associated with pregnancy)
*More common in younger women*
165
List some examples of epithelial ovarian cysts.
Serous cystadenoma
Mucinous cystadenoma
Brenner tumour
*More common in older women*
166
List some examples of sex cord stromal cysts.
Fibroma
Thecoma
167
In which subset of women would a transabdominal USS be preferred over a transvaginal USS?
Women who have never been sexually active
168
List some tumour markers used for ovarian cysts.
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
What size of functional ovarial cyst is considered pathological?
> 3 cm
NOTE: normal ovulatory follicles can reach 2.5 cm
170
When do corpus luteal cysts tend to form?
After ovulation
May cause pain due to rupture or haemorrhage late in the cycle
171
What are some examples of inflammatory ovarian cysts?
Tubo-Ovarian Abscess
Endometrioma
172
What is Meig syndrome?
Triad of fibroma, pleural effusion and ascites
173
How can thecomas manifest?
They secrete oestrogen
Usually present after menopause
May have features of excess oestrogen (e.g. PMB)
Associated with endometrial carcinoma
174
What is the prevalence of endometriosis?
10% of women of reproductive age
NOTE: it resolves after menopause
175
Define chronic pelvic pain.
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
What is a nabothian follicle?
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
List some causes of cervical stenosis.
Usually iatrogenic
E.g. due to cone biopsy, LLETZ or endometrial ablation
178
Define Asherman syndrome.
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
Name and briefly describe the three types of fibroid degeneration.
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
What is the difference between the epithelium of the vulval vestibule and the labia majora/minora?
Vestibule: non-keratinised, non-pigmented squamous epithelium
Labia: keratinised, pigmented squamous epithelium
181
Which ducts are present in the vulval vestibule?
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
What are some key differences between the labia majora and the labia minora?
Majora: adipose tissue, covered by skin containing follicles, sebaceous glands and sweat glands
Minora: no adipose tissue, no hair follicles, contains sebaceous follicles
183
In which patient groups is vulvovaginal candidiasis uncommon?
Prepubescent
Postmenopausal
Consider diabetes mellitus or other underlying predisposing factor
184
What is lichen planus?
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
Outline the expectant management of a miscarriage - incomplete, inevitable
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
What does the finding of free fluid in a patient with an ectopic pregnancy suggest?
It has ruptured
They will need surgical management
187
How should patients who have been treated for gestational trophoblastic disease be followed up?
Refer to trophoblastic screening centre
Follow-up is individualised
Depends on the bhCG at 56 days from the pregnancy event
188
When do products of conception need to be sent for histological assessment?
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
Which measures can help improve fertility in patients with PCOS?
Weight loss
Clomiphene
Metformin
190
What measure is recommended to reduce the risk of endometrial hyperplasia in PCOS?
Hormonal therapy (e.g. norethistrone) to induce a period at least 4 times per year
191
List some absolute contraindications for the COCP.
< 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
What prophylactic medication should be given to any patient having surgical management of miscarriage or TOP?
Prophylactic antibiotics
193
Describe the impact of surgical management of miscarriage and TOP on future reproductive potential.
No impact on fertility and risk of ectopic pregnancy
194
Outline the FIGO stages of endometrial cancer.
1 - confined to uterus
2 - confined to uterus + cervix
3 - invades through cervix/uterus
4 - bowel/bladder involvement or distant metastases
195
Outline the FIGO stages of ovarian cancer.
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
Outline the FIGO stages of cervical cancer.
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
What advice would you give to a patient who has had a salpingectomy for an ectopic pregnancy about future contraception and pregnancy?
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
What are the 7 sections of the UK Abortion Act?
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
Where can pregnancies be terminated?
Marie Stopes centre
British Pregnancy Advisory Service
200
Describe some symptoms of Asherman's syndrome.
Reduction or absence of bleeding
Deep dyspareunia
201
What is a radical hysterectomy?
It is a total hysterectomy + BSO + removal of upper half of the vagina, uterus, parametrium
This is done for cervical cancer
202
What mid-luteal progesterone level is suggestive of ovulation?
> 30 nM/L
203
how to manage a threatened miscarriage (vaginal bleeding and a confirmed intrauterine pregnancy with a foetal heart beat)
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
Offer repeat scan if after the period of expectant management the bleeding and pain:
Has not started (suggests miscarriage has not begun) --> may need medical/surgical
Persisting and/or increasing (suggesting incomplete miscarriage) may need medical surgical
205
what is the failure rate for medical management of miscarriage
10%
206
what are some risk factors for miscarriage
advanced maternal age, previous miscarriages, uterine or cervical anomalies
207
what to reassure miscarriage pts
it is common and under reported - 1 in 5 pregnanies
the risk increases with age
most of the time there is no cause
208
psychological support for miscarriage
o Having a single miscarriage does not affect future pregnancies
miscarriageassociation.co.uk --> information about finding counselling
209
investigation for miscarriage
```
ABCDE
basic obs
abdominal exam
speculum and bimanual
TVUSS
FBC and group and save
```
210
investigation for ectopic pregnancy
```
ABCDE
pregnancy test
abdominal exam
bimanual and speculum
TVUSS
serial hCG to guide management
```
211
Support groups for ectopic
the Ectopic Pregnancy Trust
212
risk factor for molar pregnancy
o Extremes of ages: teenagers and > 40 years
| o Previous molar pregnancy
213
investigation for molar pregnancy
• 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
follow up for molar pregnancy
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
counselling levonorgestrel
it vomit within 2-3 hours , repeat dose
can be used more than once in a menstrual cycle
stops ovulation and inhibits implantation
216
counselling ulipristal acetate
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
investigations for pcos
```
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
management for pcos
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
support for TOP
o Counselling service at the abortion clinic
| o Organisations such as the FPA, Brook (for under 25s), British Pregnancy Advisory Service
220
safety net for abortion
* 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
investigations for ovarian hyperstimulation syndrome
FBC, CRP, U&Es (hyponatremia and hypokalaemia), serum osmolality, LFTs, coagulation profile
Haematocrit is useful to assess intravascular volume - raised
Ultrasound scan
222
management for ovarian hyperstimulation syndrome
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
management for prematue ovarian insufficiency
HRT or COCP
| must continue treatment until at least age of natural menopause (51)
224
follow up for menopause
refer to specialist, review at 3 months and then annually
225
risk factors for bacterial vaginosis
douching, black women, new sexual partner
226
risk factors for vulvovaginal candidiasis
poorly controlled DM
immunosuppresion
antibiotics
227
investigations for thrush
bimanual
speculum
high vaginal swab --> microscopy/culture
228
advice fror thrush
• Advise: return if symptoms not resolved in 7-14 days
avoid perfumed soaps/douching/tight-fitting clothes, use emollient
consider probiotics
229
investigations for trichomonas vaginalis
speculum - strawberry cervix
NAAT of vulvaginal swab
full STI screen
230
follow up for PID
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
lifestyle measures for incontinence
avoid cafeniated drinks, avoid drinking excess/reduced amounts of fluids, lose weight if u big, stop smoking
232
s/sx of asherman syndrome
● Reduced/absent menstrual bleeding
● Subfertility
● Recurrent miscarriage
233
ix of asherman syndrome
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
atrophic vaginitis symptoms
vaginal dryness and mild itching
dyspareunia
vaginal discharge
235
management of atrophic vaginitis
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
How is Bartholin's abscess managed?
conservative: warm compression and analgesia)
Incision, drainage and marsupialisation (Under GA)
broad spectrum abx
recommenend STI screen
237
risk factors for bartholins cyst/abscess
nulliparous, child bearing age, previous bartholin cyst
238
endometriosis risk factors
fhx, nulliparous, early menopause
239
investigations for endometriosis
pregnancy test (rule out ectopic)
abdominal exam
pelvic exam - fixed retroverted uterus, uterosacral ligament thickening
diagnostic laparoscopy
240
risk factors for fibroids
nulliparous, obesity, afr caribbean
241
investigations for fibroids
pelvic exam
FBC
TVUSS
242
support for fgm
national fgm centre
243
ix for ovarian cyst
pregnancy test
TVUSS
crp, esr
tumour markers
244
how to treat high grade cin
large loop excision of transformation zone - under LA, takes 15 mins
inc risk of midtrimester loss and preterm delivery
245
investigation for cervical cancer
pelvic exam
colposcopy
biopsy
mri of abdomen and pelvis to check for spread
246
fertility-sparing tx for cervical cancer
radical trachelectomy -
247
ix for endometrial cancer
women >55 with PMB should be referred to suspected cancer referral
speculum and bimanual
TVUSS - >4mm --> refer for hysteroscopy and biopsy
248
vulvar cancer s/sx
lump or ulcer
bleeding
discharge
ulcerated lesion - well demarcated, raised
249
vulvar cancer tx
vulvar excision
sentinel lymph node biopsy
radiotherapy
