Gynaecology 2 Flashcards by John Darlington

List some absolute contraindications to the combined oral contraception pill:

Migraine with aura

BMI >35 + Smoker >15

Breast feeding until 6 weeks postpartum

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What are the treatment options for endometrial fibroids and which is an absolute contraindication for pregnancy?

Medical:

Tranexamic acid
Ulipristal acetate (progesterone receptor modulator)
GnRH analogies

Surgical: 
- Myomectomy 
- Hysteroscopic resection 
- Uterine artery embolization 
- Endometrial ablation 
`
***endometrial ablation is an absolute contraindication

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What is the management for an ectopic pregnancy where the patient is unstable?

Laparoscopic salinpingectomy

Laproscopic Salinpingotomy
- where only the ectopic is removed

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Which type of HRT has a better impact on lipid levels?

Oral

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What are some absolute contraindications to HRT?

Liver disease

Thromboembolic disease

Recurrent DVTs

Previous breast cancer

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Which ligament provides the greatest degree of support to the uterus?

Cardinal ligament

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What is part of the malignancy risk index for ovarian cancers?

Menopause status
Ca125
Ultrasound findings

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What are the symptoms of lichen sclerosus?

Vulva itch

White discoloration

thinning

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What is the management of endometriosis?

1st line:

NSAIDs
Contraceptive pill (COCP and Progesterone only)

If not working or fertility is of concern then referral to secondary centre:
- GnRH analogies

Surgical:

Ablation of ectopic tissue
resection of endometriosis tissue
Adhesiolysis

Definitive:

hysterectomy
Bilateral salpingectomy (stop oestrogen production)

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What are the main causes of vaginal discharge?

Vaginal infection:

Candida infection
Bacterial vaginosis
Trichomonas Vaginalis

Cervical infection:

chlamydia
gonorrhoea

Other::

cervical ectropion
retained products of conception
retained tampon

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What treatment can be given to patients with endometriosis to improve chances of successful fertilisation?

clomiphene

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On a biopsy of endometriosis - what might histology show?

Endometrial stroma

Endometrial glands

Hemosiderin laden macrophages

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List 3 things which may block the fallopian tubes preventing pregnancy:

Endometriosis

PID
- adhesions

Hydrosalpinx

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What factors need to be discussed for IVF?

Success rate

limited amount of times on NHS
- 3 times

Alternatives
- such as adoption

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Where are the most common places for endometriosis to develop endometrial tissue on?

Ovaries

Uterosacral ligament

Pouch of Douglas

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What are some differentials for endometriosis?

PID

IBD

Primary dysmenorrhoea

Fibroids

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What are some surgical options for endometriosis?

Surgical ablation

Surgical resection

Adhesiolysis
- can be used surgically to improve outcomes for pregnancy

Bilateral salpingo-oophorectomy

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What are the three groups of of hypothalamus, pituitary and ovarian dysfunction causing infertility in women?

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Hypothamic- pituitary failure (low FSH, LH)
- anorexia
- Kalmann’s syndrome
- Pituitary adenoma
Hypothamic pituitary ovarian dysfunction
- PCOS
Ovarian failure
- Premature ovarian failure
- Turner’s syndrome
- chemotherapy

What tests are done to asses tubal patency?

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Hysterosalpingogram
- this is done as a day case where the radioactive dye is injected into the uterus and should be seen to take the shape of the uterus and the across the fallopian tubes.

If it doesn’t then the female is referred on for:
- laparoscopic blue dye test

What are some medical and surgical options for infertility in PCOS?

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Medical:

clomiphene
risk of multiple pregnancy
risk of ovarian hyperstimulation
Metformin
GnRH pulsatile

Surgical:

laparoscopic ovarian drilling
increases FSH and reduces androgens

If on a sperm analysis there is seen to be aspermia (no sperm or semen) then what has most likely occurred and how is this investigated for?

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Retrograde ejaculation

Investigations:
- Post ejaculation urine analysis

List some causes of menorrhagia:

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Idiopathic

Endocrine:

Hypothyroidism
Unopposed oestrogen (obesity, Liver disease)

Structural:

fibroids
polyps

Others:

clotting disorders
PID
Endometrial cancer (rare pre menopause)

What are some red flags for menorrhagia which warrant further investigation?

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Post coital bleeding

Intermenstrual bleeding

Dyspareunia

Pain discomfort/ compressional pain

What important topic needs to be discussed when deciding on particular surgeries for heavy menstruation?

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If they have completed their family

endometrial ablation
hysterectomy

What are some risk factors for fibroids?

``` African Early menarche / late menarche Advancing age Nulliparity Obesity (oestrogen driven) ``` *oestrogen driven so very similar risk factors for breast cancer

What are the typical symptoms of fibroids and list two complications of fibroids:

``` Usually asymptomatic Menorrhagia Intermenstrual bleeding Abdominal fullness Abdominal pain ``` Complications: - fibroid torsion (pedunculated twists on itself causing necrosis) - Red degeneration (usually seen in pregnancy) -infertility and pregnancy complications (pre-term, malrotation, placenta previa, spontaneous miscarriage)

What surgical options are available for fibroids to when wanting to preserve fertility?

Myomectomy Uterine artery embolism

What is the risk factors for an ectopic pregnancy?

Previous ectopic PID Previous Tubal surgery - scarring IUD Smoking >35 years old

Where is an ectopic most likely to implant?

Ampulla of the tubes *97% are tubal pregnancy

Why do you get shoulder tip pain in an ectopic?

Blood/ fluid can move up through the intra-abdominal cavity and irritate the diaphragm

What is the diagnostic test of choice for a suspected ectopic and if it is negative what are the next investigations?

TVS is diagnostic test of choice. If it is negative then a Beta- hCG level should be conducted over 48 hours. - increased >63% = intrauterine pregnancy - halved = miscarriage - stayed the same = ectopic Laparoscopy can be done if there is still uncertainty

How is the methotrexate for a medical management of an ectopic given, what are the indications and how is it followed up?

IM injection - followed up 4 and 7 days later looking for <15% drop in bhCG, if not dropped 2nd dose can be given. Indications: - stable patient - b- hCG <1500iU - no heart beat - <35mm

When is premature menopause and what are some causes?

<40 years old is premature. **Average age in UK is 52 Primary ovarian failure Turner's syndrome Iatrogenic Hypothyroidism Addison's disease

What are some differentials for the symptoms of menopause?

Night sweats: - leukaemia - lymphoma - TB Libido: - depression Joint aches: - OA

What are some of the complications of menopause?

Psychological effect Osteoporosis Recurrent UTIs Accidental pregnancy

What are the forms HRT can be given, which is usually advised and why?

``` Oral Transdermal patches Gels Implants Nasal spray ``` Parental is usually preferred as has lower risk of DVT *any non-oral type

Which women should receive the continuous and sequential HRT?

``` Periods stopped (menopause) = continuous ``` Period stopped but symptomatic (climatic) = sequential

What are the alternatives to HRT:

Flushes: - SSRIs - Clonidine - Gabapentin Topical lubricants CBT

What are the main types of urinary incontinence in females and list some risk factors:

Stress incontinence - Obesity - Pregnancies/ births - Chronic cough - Smoking - increasing age * note these are same risk factors for prolapses Urge incontinence: - caffeine/ alcohol use - Excessive fluid intake - Neurological conditions (MS, Parkinson's) - Bladder tumour

What are some differentials for urinary incontinence and list some initial investigations that should be done along with some specialist ones:

Differentials: - diabetes - diabetes insipidus - Excessive fluid intake - repetitive UTIs - Functional/ passive incontinence - Prolapse Investigations: - urinalysis (glucose? UTI?) - bladder diary - post void residual volume (too much left tells you the bladder isn't emptying correctly) Specialist test: - cytometry (measurement of pressures - bladder should be relaxing) - Uroflowmetry

What are the treatments of urinary incontinence?

Stress: - weight loss - reduced fluid/ caffeine intake - Pelvic floor exercises (Kegel exercises) - Urethral sling operation - Duloxetine (increases sphincter tone) Urge incontinence: - lifestyle - bladder retraining - Anti-muscarines (oxybutynin) - Beta - 3 agonists (increased sphincter tone) - botulism injection - sacral nerve stimulation

What are some risk factors for prolapse?

``` Parity - especially instrumental delivery Smoking Age -reduced oestrogen Pelvic surgery Connective tissue disease ```

What is the management of ovarian cysts and what does the RMI score consist of?

Pre-menopausse: <5cm: discharge >5cm Dermoid Endometrial cyst - cystectomy Post- menopausal: Low RMI: Follow up Intermediate/ high RMI: - Bilateral oopherectomy + salpingectomy +/- Hysterectomy depending on histological analysis of the cyst

Gynaecology 2 Flashcards

(43 cards)