Gynaecology Flashcards
(202 cards)
1
Q
What is the average blood loss per menstrual cycle?
A
30-40ml
2
Q
What are some systemic causes of menorrhagia?
A
Hypothyroidism
Chronic liver disease
Blood thinning drugs
Bleeding disorders (e.g. Von Willebrands)
3
Q
What are some local causes of menorrhagia?
A
Vulval/vaginal/cervical cancer or malignancy IUCD DUB Fibroids Endometriosis Adenomyosis Endometrial polyp/malignancy PID Granulosa ovarian tumours
4
Q
What is the commonest cause of menorrhagia?
A
Dysfunctional Uterine Bleeding (DUB)
5
Q
What is DUB?
A
Heavy and/or irregular bleeding with no underlying pelvic pathology
6
Q
What are the two commonest underlying causes of DUB?
A
Anovulatory cycles - often post-menarche or peri-menopause
Poor quality eggs leading to poor quality corpus luteums and luteal phase defects
7
Q
What are the different medical management option for DUB?
A
Mirena IUS
Tranexamic acid
Mefenamic acid (not as effective as tranexamic)
COCP
Progestogens (depo-provera or oral norethisterone)
If anovulatory cycles, try COCP to regulate. If not, try tranxeamic acid. PATIENT CHOICE is important.
8
Q
What are the surgical options for DUB?
A
Endometrial ablation
Hysterectomy
9
Q
How many and for how long should medical management of DUB be done before considering surgical options?
A
Trial of 2 different options both for at least 3 months
10
Q
What are some long term complications of endometrial ablation?
A
Decreases fertility
May lead to placenta percreta if do concieve
11
Q
Woman presents with intensely itchy white vaginal discharge. Vulva sore and red.
A
Thrush
12
Q
What is the organism causing thrush?
A
Candida Albicans (yeast)
13
Q
How is thrush treated?
A
Topical clotrimazole 500mg pessary + cream
OR
Oral fluconazole 150mg stat
14
Q
Woman presents with watery, grey, fishy discharge. Vaginal pH >4,5. Clue cells seen on HVS.
A
Bacterial Vaginosis
15
Q
What causes bacterial vaginosis?
A
Overgrowth of normal vagina flora - Gardnerella vaginalis, mobiluncus, anaerobes
16
Q
How is bacterial vaginosis treated?
A
Metronidazole 400 mg BD (7 days)
17
Q
What chlamydia serovars cause genital infection?
A
Serovars D-K
A-C cause trachoma. L-lymphogranuloma
18
Q
How does chlamydia present in females?
A
Asymptomatic. Post coital/intermenstrual bleeding. Lower abdominal pain. Dyspareunia. Mucopurluent cervicitis.
19
Q
How does chlamydia present in males?
A
Urethral discharge, dysuria, urethritis, epididimo-orchitis
20
Q
How is chlamydia/gonorrhoea diagnosed?
A
Combined test for both organisms
Females - HVS for PCR/NAATs
Males - first void urine for PCR/NAATs
21
Q
How is chlamydia treated?
A
Azithromycin 1g stat
If allergic, doxycycline 100mg BD (7 days)
22
Q
What are some complications of untreated chlamydia?
A
PID, pelvic pain, sexually acquired reactive arthritis, Fitz-Hugh-Curtis syndrome.
23
Q
How is pelvic inflammatory disease treated?
A
Metronidazole 400mg BD and Ofloxacin 400mg BD (14 days)
24
Q
How does gonorrhoea present in men and women?
A
Asymptomatic, altered/urethral discharge, dysuria
25
How is gonorrhoea treated?
IM ceftriaxone 500mg and oral azithromycin 1g stat
26
What is the causative organism of syphilis?
Treponema Pallidum
27
How does primary syphilis present?
Chancre - indurated, firm papule, with raised edge. Usually heals itself without treatment.
28
How does secondary syphilis present?
Maculopapular rash and flu like symptoms. Occurs when the organism is in the blood stream.
29
How does tertiary syphilis present?
Neuological/cardiovacular complications
30
How is syphilis diagnosed?
If lesion present - swab lesion for PCR
| If none present - bloods
31
What blood tests are done to diagnose syphilis?
Combined IgG and IgM ELISA test (IgM positive in active infection)
TPPA (stays positive for life even if syphilis treated)
VDRL and RPR (non-specific tests of inflammation. Useful for assessing response to treatment)
32
How is syphilis treated?
Long acting injectable penicillins
33
What organism causes genital warts?
HPV 6 & 11
34
How are genital warts treated?
Cryotherapy or Podophyllin toxin
35
What causes genital herpes?
Herpes Simplex Virus I and II
36
How does genital herpes present?
Painful, multiple small vesicles that are easily deroofed. May be dysuria, discharge, lymphadenopathy
37
How is genital herpes diagnosed?
Swab for PCR
38
How is genital herpes treated?
Aciclovir 200mg 5 times a day for 5 days
| Subsequent attack - aciclovir cream
39
Woman presents with frothy green, offensive discharge. Strawberry cervix. HVS shows flagellae motion of organism.
Trichomonas vaginalis - single celled protozoal parasite
40
How is trichomonas vaginalis treated?
Metronidazole 400mg BD (7days)
| Treat partners even if asymptomatic as can be carriers
41
Woman has itching, inflammation in pubic area. Black 'powder' seen in underwear.
Pubic lice
42
How are pubic lice treated?
Malathion lotion
43
Where is the target of HIV virus?
CD4+ receptors
44
How does HIV affect the immune system?
Reduces circulation and proliferation of CD4+ cells
Reduces activity of CD8+ cells
Reduces anitbody class switching
45
What are the implications of HIV affecting the immune system?
Increased susceptibility to viral, fungal and bacterial infections as well as infection induced cancers
46
What is a normal CD4+ count?
500-1600 cells/mm2
47
At what CD4+ count is there a risk of opportunistic infection?
200 cells/mm2 and less
48
When does primary HIV infection occur?
Around 2-4 weeks after contracting HIV
49
What are the symptoms of primary HIV infection?
fever, maculopapular rash, myalgia, pharyngitis
50
What are the 3 broad areas of AIDS?
Opportunistic infections, constitutional symptoms and AIDS related cancers
51
Name 3 AIDS related cancers
Kaposi's sarcoma, Burkitts lymphoma, Cervical cancer (all virally driven)
52
How is HIV treated?
Highly active anti-retroviral treatments (HAART)
| Combination of 3 drugs from 2 classes
53
When is post-exposure prophylaxis given?
Taken within 72 hours of exposure for 28 days
54
What measures should be taken for a HIV +ve male to conceive?
Sperm washing + IUI/IVF
| Timed UPSI with HAART +/- PrEP
55
What measures should be taken for a HIV +ve female to conceive?
Self-insemination
| Timed UPSI with HAART
56
Should HIV+ve women take HAART during pregnancy?
Yes as risk of HIV greater to the baby than the medications
57
What factors affect whether a HIV+ve women has a vaginal delivery or a c-section?
Viral load (<50 vaginal birth is safe)
CD4+ count (>350 vaginal birth is safe)
Previous obstetric history
58
Should newborns be given antiretrovirals?
YES - babies should receive PEP within 4 hours of delivery and continue for 28 days
59
What is the histology of the ectocervix?
Stratified squamous epithelium
60
What is the histology of the endocervix?
Simple columnar epithelium
61
What is the transitional zone of the cervix?
The squamo-columnar junction between the endocervix and ectocervix
62
What is cervicitis?
Inflammation of the cervix
63
How does cervicitis present?
Asymptomatic/ discharge, dyspareunia, intermenstrual bleeding, post-coital bleeding
64
What are some causes of cervicitis?
STIs, allergies (e.g. latex), BV
65
What is a cervical ectropion?
When the endocervical columnar epithelium extends over the stratified sqaumous epithelium of the ectocervix
66
How does a cervical ectropion present?
Bleeding (intermenstrual, post coital), excess mucus, infections
67
How is a cervical ectropion treated?
Silver nitrate cautery
68
What are cervical polyps?
Pedunculated benign tumours of endocervix
69
What is cervical intraepithelial neoplasia?
Pre invasive stage of cancer, occurring at transitional zone
70
What is CIN I?
Basal 1/3rd of epithelium has abnormal cells
71
What is CIN II?
Basal 2/3rd of epithelium has abnormal cells
72
What is CIN III?
Full thickness of epithelium has abnormal cells
73
What is seen histologically in CIN?
Delay in differentiation, nuclear abnormalities, excess mitosis, koiliocytosis
74
How is CIN I managed?
Expectant management - repeat smear in 12 months
75
How is CIN II/III managed?
Cold coagulation
| LLETZ (if suspicious of malignancy do this)
76
What is a complication of LLETZ?
Can lead to preterm labour (due to cervical insufficiency) - favour cold coagulation in women who have not completed their families
77
What type of cervical cancer is commonest?
Squamous cell (from ectocervix)
78
How does cervical cancer present?
Abnormal bleeding (PCB, IMB, brown stained discharge), pelvic pain, urinary infections
79
What is the main viral driver of cervical cancer?
HPV - mainly types `16, 18 and 33
80
What are some risk factor for cervical cancer?
HPV, smoking, HIV, early intercourse, many sexual partners, high parity, low socioeconomic status, COCP
81
How is early stage cervical cancer treated?
Surgery - dependent on extent and need to preserve fertility
82
How are stages IB-IV of cervical cancer treated?
Platinum based chemotherapy, radical radiotherapy and vaginal brachytherapy
83
How often do women aged 25-49 need a smear?
Every 3 years
84
How often do women aged 50-64 need a smear?
Every 5 years
85
If a smear comes back borderline, what should be done?
Repeat the smear test
86
If a smear comes back unsatisfactory sample, what should be done?
Repeat the smear test
87
If a smear comes back low grade dyskaryosis, what should be done?
Repeat the smear test
88
After 3 unsatisfactory samples on smear test, what is the next step?
Routine colposcopy (<8 weeks)
89
After 3 borderline samples on smear test, what is the next step?
Routine colposcopy (<8 weeks)
90
After 2 low grade dyskaryosis samples on smear test, what is the next step?
Routine colposcopy (<8 weeks)
91
If a smear comes back as high grade dyskaryosis, what should be done?
Urgent colposcopy (<4 weeks)
92
If a smear comes back as invasive dyskaryosis what should be done?
Urgent colposcopy with suspicion of malignancy (<2 weeks)
93
If CIN is treated, when should the next smear test be?
6 months time - do cytology and HPV for 'test of cure'
94
What is the commonest histological type of primary ovarian tumour?
Serous
95
What are dermoid cysts?
Benign cystic teratomas - totipotent. May contain hair, teeth, bone etc. Can be asymptomatic.
96
What may rupture of a dermoid cyst cause?
Acute chemical peritonitis
97
What is struma ovarii?
Type of teratoma containing thyroid tissue which may result in hyperthyroidism
98
What is the triad of Meig's Syndrome?
Ovarian tumour, ascites and pleural effusion
99
What cancers metastasise to the ovary?
Breast, pancreas and GI
100
What are some risk factors for ovarian cancer?
Increased age, nulliparity, early menarche, late menopause, family history
101
How does the COCP affect ovarian cancer risk?
COCP is protective against ovarian cancer
102
How does ovarian cancer present?
May be asymptomatic
| Bloating, abdominal mass, early satiety, urinary frequency, change of bowel habit, weight loss, fatigue.
103
What should be checked if history and examination raises suspicion of ovarian cancer?
CA-125
104
What level of CA-125 warrants an ultrasound?
≥ 35
105
How is risk of malignancy index (RMI) calculated?
RMI = menopausal status X ca-125 X USS score
106
What RMI should patients be referred to a specialist?
RMI ≥250
107
How is early ovarian cancer treated?
Surgery - TH, BSO, omental/lymph node biopsy for staging.
| Adjuvant chemotherapy if high grade tumour
108
How is advanced ovarian cancer treated?
Primary debulking surgery
Neo/adjuvant chemotherapy with platinum based agent
RELAPSES - if platinum sensitive, use chemo again. If resistant, use tamoxifen/letrozole
109
What are the muscles of the pelvic floor?
```
Levator ani (pubococcygeus, puborectalis, iliococcygeus)
Coccygeus
```
110
What nerves supply the muscles of the pelvic floor?
```
Pudendal nerve (S2,3,4)
Nerve to levator ani (S4)
```
111
What are the symptoms of pelvic organ prolapse?
```
'Something coming down'
Urinary symptoms (hesitancy, poor flow, frequency, urge)
Bowel symptoms (constipation, dyschezia)
Sexual symptoms
```
112
What are risk factors for pelvic organ prolapse?
Child birth - big babies, multiple pregnancy, prolonged labour
Increased age, obesity, smoking, heavy lifting
113
What is a urethrocele?
Anterior inferior prolapse of the urethra
114
What is a cystocele?
Anterior superior prolapse of the bladder
115
What is an enterocele?
Posterior superior prolapse of the bowel via pouch of douglas
116
What is a rectocele?
Posterior inferior prolapse of the rectum
117
What is a procidentia?
Grade III uterine prolpase where the majority of the uterus is in the vagina
118
What are some conservative management options for pelvic organ prolapse?
Lose weight, stop smoking, reduce constipation, bladder/defecation techniques. Pelvic floor physiotherapy.
Pessaries (ring, cube, shelf, gelhorn)
119
What is the medical management of pelvic organ prolapse?
Vaginal oestrogens (used if symptomatic atrophic vaginitis)
120
What are the surgical management options for pelvic organ prolapse?
Anterior/posterior repair
Sacrospinous fixation (vaginal vault prolapse)
Laparoscopic hysteropexxy (uterine prolapse)
Colpocleisis
121
Which gynaecological cancers is the COCP protective in?
Endometrial and Ovarian
122
Which gynaecological cancers is the COCP a risk factor for?
Breast and Cervical
123
How long is the time frame to take Levonelle for emergency contraception?
Within 72 hours
124
How long is the time frame to take Ullipristal (EllaOne)?
Within 120 hours
125
How long is the time frame to have an IUCD inserted for emergency contraception?
Within 120 hours of UPSI or ovulation
126
If a traditional POP is missed by up to 3 hours, what advice should you give?
Take pill. No action required.
127
If a traditional POP is missed by more than 3 hours, what advice should you give?
Take pill as soon as possible. If more than one has been missed just take one pill.
Continue rest of pack as normal.
Use condoms until 48 hours after pilltaking
128
The same advice applies for cerazette as it does for traditional POPs, but what is the time frame?
12 hours
129
What advice would you recommend for a patient using the contraceptive patch who has forgotten to change her patch for less than 48 hours?
Change patch immediately
| No extra precautions needed
130
What advice would you recommend for a patient using the contraceptive patch who has forgotten to change her patch for more than 48 hours?
Change patch immediately
Extra precautions for 7 days
Emergency contraception if had unprotected sex in last 5 days
131
Which contraception may cause a delay in return to fertility?
Injection
132
How long after insertion is a copper IUD effective?
Immediately
133
How long after starting a POP is it effective (not day 1 of period)?
2 days
134
How long after starting COC, injection, implant, IUS (not on day 1 of period) are they effective?
7 days
135
What hormone do you check for ovulation?
Mid-luteal progesterone (cycle length-7days)
136
What is the primary mode of action of the COCP?
Inhibits ovulation
137
What is the primary mode of action of the POP?
Thickens cervical mucus
138
What is the primary mode of action of the injection?
Inhibits ovulation
139
What is the primary mode of action of the implant?
Inhibits ovulation
140
What is the primary mode of action of the IUCD?
Decreases sperm motility and survival
141
What is the primary mode of action of the IUS?
Prevents endometrial proliferation
142
If one pill of the COCP is missed at any time in the cycle, what should you do?
Take the last pill then continue taking the rest of the pack as normal
No additional protection required
143
If 2 or more pills of the COCP are missed, what should the woman take?
Take the last pill, leave any earlier missed pills and continue taking pills one each day
144
If two or more pills are missed in the first week of the cycle and the woman has had sex, what should you consider?
Emergency contraception
145
If two or more pills are missed in the second week of the cycle, what extra precautions do you need to take?
No extra precautions
146
If two or more pills are missed in the 3rd week of the cycle, what should you recommend?
Omit the pill free interval
147
How long after giving birth do you not need contraception?
Up to 21 days
148
Where is an implant inserted?
Sub-dermally, non-dominant arm
149
When should the COCP be stopped before surgery?
4 weeks before surgery
150
When can the COCP be restarted after surgery?
2 weeks
151
What is the most effective emergency contraception?
Copper IUD
152
What is the first line management of fibroids?
Mirena IUS
153
Painless vaginal bleeding before 24 weeks, cervical os closed, fetal heart detected
Threatened miscarriage
154
USS shows intrauterine sac with no fetal pole. cervical Os closed
Missed miscarriage
155
8 weeks pregnant, heavy bleeding with clots, fetal heartbeat present, os is open
Inevitable miscarriage
156
Bleeding, fetal heart absent, cervical os open
Incomplete miscarriage
157
Bleeding, fetal hear absent, cervical os closed
Complete miscarriage
158
What is Sheehans syndrome?
Post partum hypopituitarism following PPH
159
What is Meigs syndrome?
Fibroma, ascites, pleural effusion
160
What are the management options for PMS?
Lifestyle - healthy diet, exercise, good sleep
| Medical - COCP, SSRIs
161
What is the gold standard investigation for endometriosis?
Laparoscopy
162
What are medical management options for symptomatic relief of endometriosis?
NSAIDs, paractamol
| COCP, progestogens
163
What are secondary treatments for endometriosis?
```
GnRh analogues (induce pseudomenopause)
Laparoscopic excision/laser of cysts
```
164
What is the commonest complication of TOP?
Infection
165
Where is the commonest site of ectopic pregnancy?
Ampulla of uterine tube
166
What ovarian tumour is associated with endometrial hyperplasia?
Granulosa cell tumours
167
What is the commonest benign ovarian tumour in under 35s?
Teratoma
168
How should post-menopausal women with atypical endometrial hyperplasia be managed?
Total hysterectomy +BSO
169
'Free pelvic fluid and whirlpool sign'
Ovarian torsion
170
What is Ashermans syndrome?
Adhesions following D&C
171
When is contraception required in the menopause in women over 50?
For at least 12 months after the last period
172
When is contraception required in the menopause in women under 50?
For at least 24 months after the last period
173
What is the imaging of choice for adenomyosis?
MRI pelvis
174
What is the average age of menopause?
51
175
What is early menopause defined as?
Before 45
176
What is premature menopause defined as?
Before 40
177
What is late menopause defined as?
After 54
178
What are symptoms of menopause?
Hot flushes, night sweats, palpitations, insomnia, joint aches, headaches, mood swings, vaginal dryness, decreased libido, DUB
179
What are conservative management options for menopause?
Diet, weight loss, exercise, caffeine reduction, sleeo hygiene
180
How can menorrhagia be managed in menopause?
Tranexamic acid, progestogens, IUS, endometrial abltation, hysterectomy
181
What HRT is given to women with a uterus?
Combined HRT (oestrogen and progestogen)
182
What HRT is given to women without a uterus?
Oestrogen only HRT
183
What regime of HRT do peri-menopausal women get?
Cyclical
184
What regime of HRT do post-menopausal get?
Either cyclical or continuous but continuous preferred as no withdrawal bleeds
185
What is an alternative to HRT?
Tibolone
186
Who can take tibolone?
Post menopausal women who have not had periods for at least 12 months
187
How can HRT be given?
Patches, tablets, IUS
| Vaginal oestrogens can be given as creams, pessarys, rings
188
What are side effects of HRT?
Bloating, breast tenderness, headache, acne, weight gain, bleeding
189
What are the risks of HRT?
Increased risk of breast and endometrial cancer, VTE, stroke and IHD. Risk goes away once HRT stopped
190
What can be used for the vasomotor symptoms of menopause?
SSRIs, venlafaxine, clonidine
191
What are the legal gestation limits of termination of pregnancy?
Socially - 23+6 weeks
| Fetal anomaly - any gestation
192
What is the limit of TOP in Nhs Tayside?
18 weeks and 6 days
193
What is considered an early medical termination?
Up to 9 weeks
194
What is considered a late medical termination?
9-12 weeks
195
What is considered a mid-trimester medical termination?
12-24 weeks
196
What are the two main stages of a medical termination?
Anti-progesterone (oral mifepristone)
| 24-48hrs later PV/oral prostaglandin (misoprostol)
197
Which patients have the option to complete the second part of a medical termination at home?
Early terminations (<9 weeks)
198
What surgical termination procedure is done in Scotland?
Vacuum aspiration
199
How is vacuum aspiration carried out?
Cervical priming with PV prostaglandin
| GA, electrical vacuum aspiration
200
What are complications of TOP?
Pain, infection, haemorrhage, cervical trauma, failure
201
What are important aftercare considerations in TOP?
Follow up urinary pregnancy test in 2-3 weeks
Anti-D
Seeking help & support counselling
Contraception
202
Which specialist carries out uterine artery embolization?
Radiologist
