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Gynaecology Flashcards

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1
Q

what is used to treat dysmenorrhoea

A

NSAID - Mefenamic Acid

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2
Q

What medical management treat Menorrhagia

A 
Mirena Coil (IUS) 
Antifibrinolytics - Tranexamic Acid 
NSAIDS - Mefenamic Acid 
COCP
Progestogens - Norethisterone 
Gonadothrophins
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3
Q

What surgical management can treat Menorrhagia

A

Endometrial Ablation
Uterine Artery Embolisation
Hysterectomy

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4
Q

What can cause Primary Amenorrhoea

A

Turners Syndrome
Androgen Insensitivity Syndrome (make sure to examine external genitalia
Absent Uterus and Vaginal Agenesis
Malnutrition

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5
Q

When should you investigate Primary Amenorrhoea

A

at 14 with no breast development, or at 16

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6
Q

What causes Secondary Amenorrhoea

A

Ovarian Failure-Surgery, Radiotherapy, Chemotherapy and X chromsome disorders
Hypothalamic-Pituitary-Ovarian Axis Malfunction - Exercise, Stress and Weight Loss
Hyperprolactaemia- Hypothyroidism, renal/liver failure, drugs, pituitary tumours
Ovarian Caurses- PCOS and Ovarian Tumours
Uterine Causes - Pregnancy and Ashermans Syndrome

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7
Q

Treatment for Amenorrhoea

A

Manage cause - eg hypothyroidism, tumours, PCOS etc.
Ovarian failure - no treatment give HRT
Manage Lifestyle for axis dysfunction - gain weight, reduce exercise and reduce stress
Clomifene can encourage ovulation

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8
Q

COCP components

A

Ethinylestradiol + Norethisterone or Levonorgestrel

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9
Q

What gene mutation can increase risk of fibroids

A

Fumarate Hydratase (can also cause benign smooth muscle tumours of the skin and increase risk of renal cancer)

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10
Q

What is a fibroid

A

It is a benign smooth muscle tumour

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11
Q

What are the 4 types of Fibroids

A

Subserosal
Submucosal
Pedunculated
Intramural

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12
Q

What is a subserosal fibroid

A

A fibroid in the uterine wall bulging out under the visceral peritonium

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13
Q

What is a submucosal fibroid

A

A fibroid under the endometrium

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14
Q

What is an intramural fibroid

A

A fibroid in the muscular wall of the uterus

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15
Q

What is a pedunculated fibroid

A

A fibroid attached to the uterine wall by a peduncle

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16
Q

What are fibroids associated with

A

FH
increasing age
Afro-Caribbean
Gene mutation - Fumarate Hydratase

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17
Q

What are fibroids dependent on

A

Oestrogen

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18
Q

What causes fibroids to increase in size

A

Pregnancy or COCP

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19
Q

What causes fibroids to atrophy

A

Menopause

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20
Q

What are the symptoms of fibroids

A 
asymptomatic
menorrhagia and anaemia
pain
Abdominal mass if large 
Fertility problems
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21
Q

What investigations are used for fibroids

A

US or Hysterscopy

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22
Q

Treatment of fibroids

A

No treatment if asymptomatic
If causing menorrhagia but no other symptoms - IUS
GnRH or Ullipristal Acetate can be used to shrink fibroids prior to surgery but not long term use
Myomectomy - to remove fibroids
uterine artery embolisation
Hysterectomy - only if women has finished family

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23
Q

What can be used to medically shrink fibroids before surgery

A

GnRH or Ullipristal Acetate

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24
Q

What is red degeneration

A

(most common in pregnancy) When a fibroid outgrows its blood supply, or torsion of fibroid and its blood supply - leads to thrombosis of vessels and venous engorgement and inflammation:
Symptoms: Abdominal pain, vomiting, low grade fever
US aids diagnosis
treatment: expectant (bed rest and analgesia) relsolves 4-7 days

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25
What is an ovarian cyst
A fluid filled sac on or in the ovary
26
What are the two broad groups of ovarian cysts
Functional Cysts or Neoplastic Cysts
27
What are the types of Functional cysts
Caused by disruption to normal cyclic activity | there are follicular cysts or luteal cysts (Associated with PCOS
28
What are the types of Neoplastic cysts
Mature cystic Teratomas Endometriomas Malignant ovarian tumours
29
What are the symptoms of Ovarian cysts
Most are asymptomatic But if they are they cause: dull, aching pain, dyspareunia and feeling of pressure, (pain may be cyclical if . endometrioma)
30
What are the 3 complications of ovarian cysts
Haemorrhage/Bleeding Torsion Rupture
31
What symptoms do you get with ovarian cyst complications
3s's: Severe, Sudden, Sharp pain In Torsion: pain, vomiting and low grade fever In Rupture: Signs of shock: high HR, low BP and haemoperitonium (causes shoulder pain)
32
What investigations would you do for someone with ovarian cysts
TVS or AUS if indefinite do a MRI Screen for CA125 Gold standard for type of cyst is US guided biopsy/aspiration or histological analysis on removal
33
What is the treatment of cysts in pre-menopausal women
Try and preserve womens fertility wherever possible If cyst under <5cm, non malignant or asymptomatic- Observe and don't surgically treat If cyst over 5cm, malignant or symptomatic perform laparoscopic ovarian cystectomy or oopherectomy
34
What is the treatment of cysts in post-menopausal women
Calcualate risk of malignancy index - CA125, menopause status and US findings Low risk, under <5cm can be managed with observation and CA125 High risk of malignancy, >5cm or causing complications - bilateral laproscopic oopherectomy and staging
35
What is the treatment of ruptured cysts
``` Uncomplicated Rupture (clinically stable): expectant management and NSAIDS Complicated Rupture: cyst that is haemorraging severely - give IV fluids or blood transfusion (treat symptoms of shock) surgery may be needed to remove cyst or ovary and stop bleeding ```
36
What is the treatment of torsion
Laproscopic surgery may be needed since lack of blood flow can damage ovaries
37
What is an ectopic pregnancy and where is most common?
A fertilised ovum outside the uterine cavity and is most common in the ampulla of the fallopian tube
38
What are the predisposing factors of Ectopic Pregancy?
``` Damage to fallopian tubes (PID and prev. surgery) Previous ectopic endometriosis Smoking POP or IUCD IVF or subfertility Tube Ligation ```
39
What are the symptoms of ectopic
``` Bleeding Nausea/Vomiting +/- Diarrhoea Abdominal Pain - can be non specific L abdo pain but classically unilateral Fainting/ Dizziness Amemorrhoea for 6- 8 weeks Shoulder pain - from haemoperitoneum ```
40
What are the signs on bilateral vaginal examination for Ectopic Pregnancy
``` Adnexal Tenderness (DONT palpate for adnexal mass could cause rupture) Cervical motion tenderness/ Excitation ```
41
What signs my you find on examination on ovarian cysts
May be normal if cyst small or woman obese | Acute presentation e.g rupture: pelvic mass, tenderness, peritonsim, bleeding cervival excitation and adnexal tenderness
42
What are the investigations for ectopic pregnancy
``` TVS for location of ectopic pregnancy Progesterone levels (lower in ectopic) hCG leveles (lower in ectopic as rise more slowly) ```
43
What are the three types of management for an ectopic pregnancy
Expectant/Observant Medical Management Surgical Management
44
What is the criteria for expectant/observant management of ectopic pregnancy
asymptomatic/ very mild symptoms | clinically stable
45
What is done in expectant/observant management ectopic pregnancy
Watch hCG levels fall. If they fall at an unacceptable rate precede to active intervention
46
What is the criteria for first line medical management ectopic pregnancy
hCG < 1500 (if hCG <5000 can choose surgical or medical intervention as long as all other criteria is met) no significant pain adnexal mass <3.5cm and no fetal heart beat No intrauterine pregnancy on scan
47
What is medical management of ectopic pregnancy
One dose Methotrexate (observe on day 4 and 7 if hCG has fallen by <15% give second dose) REMEMBER: ensure they are on reliable contraception for 3 months after as its teratogenic Analgesia can help with the pain
48
What is the criteria for surgical intervention
hCG >5000 (if hCG under <5000 but all criteria met below precede to surgical management not medical) significant pain adnexal mass >3.5cm and a fetal heart beat No intrauterine pregnancy
49
What is surgical management of ectopic pregnancy
Salpingectomy if other fallopian tube is healthy | Salpingostomy if other fallopian tube is unhealthy to preserve fertility
50
What is the definition of endometriosis
Endometrial tissue present outside the uterus hormonally driven by oestrogen
51
What is the commonest location of endometriosis
Endometrioma (chocolate cyst)
52
What is the cause of endometriosis
Unknown: But 3 theories: 1. Retrograde menstruation causes adhesions, growth and invasion 2. Metaplasia of Mesothelial tissue e.g nose and lungs 3. Immunity impairment: retrograde endometrial cells fail to be destroyed by immune response
53
What are the symptoms of endometriosis
``` Some people may be asymptomatic Cyclical Constant chronic pain from adhesions causing chronic inflammation Dysmennorhoea Deep Dyspareunia ( due to involvement of uterosacral ligaments) Dysuria Dyschezia Sub-fertility ```
54
What would you find on examination of endometriosis
May be no findings Speculum: may reveal cervical and vaginal lesions Bimanual examination: Fixed Retroverted uterus, Adrenal masses or tenderness and tender nodules over Uterosacral ligaments
55
What investigations would you carry out for endometriosis
TVS may show endometrioma but little else MRI is useful for bowel involvement CA125 may be raised Gold Standard is Laparoscopy for biopsy
56
What is the treatment for endometriosis
``` Medical Management Pain relief: NSAIDs e.g. Mefenamic Acid 1st line: COCP or Mirena (IUS) 2nd Line: Progestogen e.g Norethisterone 3rd line: GnRH analogues with HRT therapy Surgical Intervention: Laproscopy using ablation and excision to destroy endometriosis Hysterectomy last resort ```
57
What cancers predominantly lead to vaginal cancer
``` Primary Vaginal cancer is rare Most commonly due to metatastic spread from: Vulva Uterus Cervix ```
58
What cells does primary vaginal cancer most commonly originate from and what location?
Vaginal cancer is most commonly squamous and most commonly found in the upper 1/3 of the vagina
59
What is the most common symptom of vaginal cancer
Bleeding
60
What are the associations with vaginal cancer
older women Previous CIN (cervical intraepithelial neoplasia) Previous Radiotherapy Long term vaginal inflammation from pessaries and uterine prolapse HPV related
61
What is the treatment and prognosis of vaginal cancer
Radiotherapy and prognosis is generally poor
62
What should be done for patients presenting with unexplained vulva lumps
They should be referred immediately
63
What cell type does vulva cancer originate from
90% squamous | Other types: Melanoma, Basal Cell and Bartholins Cyst Carcinoma
64
What is the most common symptom of vulva cancer
Persistent Lump or non healing lesion Vulval itching and soreness Bleeding Pain on passing urine
65
What is VIN
Vulva Intraepithelial Neoplasia
66
How does VIN present
White patches surrounded areas of inflammation which may be itchy
67
What should be done for VIN
Surveillance and Biopsy
68
What is the most common cause of VIN
HPV
69
What is the treatment for vulva cancer
Surgery - radial/conservative (partial/total vulvectomy) Chemotherapy Radiotherapy
70
What is CIN
Cervical Intraepithelial Neoplasia - The pre invasive phase of cervical cancer
71
Where does CIN occur and what cell type does it most commonly occur to
the basal layer of the transformation zone | the immature squamous epithelium
72
What are the stage of CIN
CIN1- neoplasia of lower 1/3 of basal layer thickness CIN2- neoplasia of < lower 2/3 of basal layer thickness CIN3- neoplasia of > lower 2/3 of basal layer thickness Carcinoma in Situ - full thickness
73
What is the expectations of CIN1
Most will regress (60%) to normal within 2yrs
74
What are the expectations of CIN2, 3 and Carcinoma in situ
Less likely to regress - a significant amount will develop into invasive squamous carcinoma of the cervix
75
What HPV types are associated with CIN
16, 18, 31 and 33 main ones (15 all together known)
76
What is the screening criteria for cervical cancer
Sexually active women aged 25-64 3 yrs for women aged 25-50 5yrs for women over 50-64
77
What is the process for screening for cervical cancer
Cervical Smear - cells looked under microscope for dyskaryosis
78
What is the process for women with borderline/mild cervical dyskaryosis
Perform HPV test is +ve send for colposcopy
79
What is the process for women with moderate/severe cervical dyskaryosis
Send straight for colposcopy
80
Risk factors for CIN
``` Type of HPV Early age of intercourse Increased number of sexual partners Not using condoms Increased exposure time to HPV Immunocompromised- HIV, transplant, immunosuppressed Smoking ```
81
What is an example of primary prevention of CIN
HPV Vaccination is primary prevention
82
How is CIN investigated using Colposcopy
1. Cervix is examined | 2. Transformation zone is painted with acetic acid (5%) neoplastic cells take more up so abnormal areas are highlighted
83
How is CIN managed
Large Loop Excision of Transformation Zone (LLETZ) - CIN1 (low grade) - should regress without treatment offer 6 month colposcopy and LLETZ if persistant - >CIN1 (high grade) - spontaneous regression much less likely - excision with LLETZ recommended if high risk HPV after LLETZ - offer 6 monthly smears
84
What age groups is Cervical Cancer common in
Two peaks of incidence 30-39 >70
85
What is the biggest risk factor for cervical cancer
HPV - Early age of intercourse, Multiple sexual partners, STDs, smoking, Previous CIN, multiparity
86
What are the signs and symptoms of cervical cancer
``` Vaginal bleeding - especially post coital (post menopausal in older women) Smelly watery discharge Dysuria Vaginal discomfort Advanced Disease: - Constipation - Ureteric obstruction and haematuria - Heavy vaginal bleeding - Weight Loss ```
87
What would be found on examination of cervical cancer
Bimanual Examination: hard and rough cervix Speculum Examination: irregular mass and bleeding on contact Colposcopy: high/dense uptake of acetic acid, irregular cervix surface
88
Investigations of cervical cancer
LLETZ for biopsy is contraindicated as it causes heavy bleeding FBC, U&Es and LFTs CT abdomen and pelvis, MRI of pelvis - can help staging Cystopscopy and Hysteroscopy - EUA can help staging
89
What are the stages of cervical cancer
``` Stage 1a: Confined to cervix (microscopic) Stage 1b: Confined to cervix (macroscopic) Stage 2a: Spread to upper 2/3 of vagina Stage 2b: Spread to parametria Stage 3a: Spread to lower 1/3 of vagina Stage 3b: Spread to pelvic wall Stage 4a: Spread to bladder and bowel Stage 4b: Spread to distant organs ```
90
How is cervical cancer treated
Stage 1: Radial Trachylectomy (can lead to incompetent cervix) Hysterectomy (wider excision margins) Stage 2+ - Radiotherapy - Chemotherapy - Palliative Care
91
What are the complications of treatment for radical hysterectomy and lymphadenectomy
Radical Hysterectomy: bleeding, infection, VTE, bladder injury Radiotherapy: acute bladder and bowel dysfunction, vaginal stenosis, shortening and dryness
92
What is the most common histological type of endometrial cancer
Adenocarcinoma
93
What is the cause of endometrial cancer
Related to the exposure to oestrogen unopposed by progesterone
94
What age group does endometrial cancer most commonly occur in
postmenopausal women
95
What are the most common signs/symptoms of endometrial cancer
POSTMENOPAUSAL BLEEDING Vaginal watery discharge or pyometra Before menopause: intermenstrual bleeding or heavier menstrual bleeding Less common: Abdo pain, dyspareunia Late disease: Back pain, tiredness, loss of appetite, weight loss
96
What are the risk factors for endometrial cancer
``` HTN, obesity and T2DM Early menarche Late Menopause Nulliparity Oestrogen only HRT PCOS Breast Cancer Genetic Predisposition (Lynch 2 syndrome) Tamoxifen ```
97
What are protective factors of endometrial cancer
COCP | Parity
98
What investigations are used in endometrial cancer
Examination may be normal in early disease TVS - endometrial thickness >4mm Hysteroscopy - biopsy - staging/histology and diagnosis CT/MRI - help per-op staging
99
What are the stages for endometrial cancer
1. in body of uterus 2. in body of cervix 3. extending out of uterus but not beyond pelvis 4. extending beyond pelvis e.g bladder and bowel
100
What is the treatment for endometrial cancer?
Depends on stage and function of patient 1. early stage - total hysterectomy with salpingo-oopherectomy (open or laproscopic) +/- Removal of lymph nodes +/- adjuvant radiotherapy 2. advanced stage - radiotherapy to control bleeding and high dose progesterone can help with palliation of symptoms
101
What is the commonest origin of ovarian cancer
epithelial
102
Why does ovarian cancer present late
vague symptoms and insidious outset
103
What is the cause of ovarian cancer
evidence shows fallopian tubes play a role in development
104
What are the most common risk factors of ovarian cancer
nulliparity early menarche late menopause genetic predisposition e.g lynch 2 syndrome and BRACA 1 & 2
105
What is protective for ovarian cancer
COCP parity and breastfeeding tube ligation
106
What can ovarian cancer be mistaken as due to similar symptoms
IBS or diverticular disease
107
What are the symptoms of ovarian cancer
``` Bloating unexplained weight loss, loss of appetite and early satiety Change in bowel habit Change in urinary symptoms e.g frequency/urgency Abdominal pain Palpable pelvic mass Vaginal pain fatigue ```
108
What may be found on examination in ovarian cancer
Fixed abdo/pelvic mass Ascites Pleural effusion Supra-clavicular lymph node enlargement
109
What in investigations may be performed for supsected ovarian cancer
``` FBC, U&Es and LFTs Tumour Markers - CA125 CXR - pleural effusion, lung metastises TVS MRI/CT - for staging and metastises eg liver Ascites or pleural fluid sampling ```
110
What are the treatments for ovarian cancer
Full stage laparotomy - hysterectomy, bilateral salpingo-oopherectomy, omentectomy, para-aortic and pelvic lymphectomy, peritoneal washing Adjuvant Chemotherapy recommended after surgery in all other than low grade stage 1 disease Advanced disease: chemotherapy can be used for palliative treatment of symptoms *young women try and spare fertility in early disease e.g saving the other ovary
111
What are the two most common types of thrush and which is more difficult to treat
Candida Albicans 95% | Candida Glabrata 5% - more difficult to treat
112
What is the typical presentation of thrush
Vulva and Vagina - redness, itchiness, soreness and fissures Disharge - non offensive and resembles white curds like cottage cheese
113
What are the risk factors for candida
``` Diabetes Pregnancy` Abx Steroids Immunodefficiency Contraception ```
114
What is the diagnosis of candida
MC&S - mycelia and spores
115
What is the treatment for candida
``` Topical treatment - clotrimazole Oral treatment - fluconazole Resistant C. Glabrata - imidazole Pregnant tropical treatment only Recurrent infection maintenance dose of treatment ```
116
What sort of disease is lichen sclerosis
Autoimmune
117
What occurs in lichen sclerosis
Elastic tissue turns to collagen
118
What are the symptoms of lichen sclerosis
Pruritis Soreness Fissures Bruised red purpuric signs e.g blood filled blisters, ulcers bruises Eventually the vulva will turn white, flat and shiny as well as atrophy May see typical hourglass shape around vagina and anius
119
What is a major risk for lichen sclerosis patients
may be premalignant leading to Vulva cancer
120
What is the treatment for lichen scelerosis
Topical steroids Clobetasol Propionate
121
What does trichomonas vaginalis present with
Yellow/green frothy and thin fishy smelling discharge Vaginitis - swelling, soreness, redness of vagina and surrounding area Strawberry Cervix Dysuria ans Dyspareunia
122
How is trichomaniasis diagnosed
Wet films - motile pearl shaped, flagellated protozoa | Exclude Gonorrhoea as they often co-exist
123
What is trichomonas vaginalis
a parasite
124
What is the treatment for trichomaniasis
Metronidazole | Treat partner as well!!!
125
What is bacterial vaginosis caused by
an imbalance of bacterial flora and anaerobe overgrowth
126
What are the common symptoms of bacterial vaginosis
Thin grey/off white discharge with fishy odour | Vaginitis and pruritus is uncommon (more likely trichomonas)
127
What can bacterial vaginosis increase your risk of
preterm labour intra-amniotic infection increased HIV susceptibility Post termination sepsis
128
How do you diagnose bacterial vaginosis
mix with 10% potassium hydroxide - whiff of ammonia | Cultures/wet film - clue cells
129
What are clue cells
Epithelial cells coated with bacteria - giving stippled appearance
130
What is the treatment for bacterial vaginosis
Metronidazole (PV gel or oral) only treat partner if necessary not STI
131
What are common causes of vaginal discharge in children
Infection from faecal floral (associated with alkalinity from lack of oestrogen) due to poor hygiene Staph and Strep infections may cause pus Exclude foreign bodies by PR and vaginal exam Exclude sexual abuse Threadworms may cause pruritus
132
What would you do to examine a child with vaginal discharge
PR and vagina exam + vaginal swabs and smears MSU sample XR/US for prolonged discharge
133
How would you manage a child with vaginal discharge
Offer hygiene advice Offer Abx if needed e.g erythromycin Maybe try oestrogen cream
134
What are the symptoms of chlamydia
Often asymptomatic Dysuria and Dyspareunia Intermenstrual Bleeding or post coital bleeding Abnormal Vaginal Discharge
135
What has been introduced to reduce the prevalence of chlamydia
The National Chlamydia Screening Programme | 16-24 yrs yearly screening self administered kit or to those with +ve partners any age
136
What are the complications of chlamydia
PID - Ectopic pregnancy and Infertility | Pregnancy - cam cause PROMS and premature labour as well as neonatal conjunctivitis and pneumonia
137
How is Chlamydia diagnosed
Vaginal Swab/urine sample - Nucleotide Acid Amplification Test (NAAT)
138
How would you treat Chlamydia
Doxycycline or Azithromycin | azythromycin if pregnant
139
What is essential for successful treatment of Chlamydia and Gonorrhoea
Treating the partner | And abstaining from intercourse until both partners are treated
140
What is gonorrhoea
A gram negative diplococci
141
What is a current problem with gonorrhoea
It is becoming increasingly antibiotic resistant
142
What is the presentation of gonorrhoea
Dysuria and Dyspareunia Abdominal Pain Post coital bleeding or Intermenstrual Bleeding Abnormal Discharge - may be green/yellow
143
What are the complications of gonorrhoea
PID - ectopic pregnancy and infertility Bartholins Abscess Disseminated Gonorrhoea
144
What is the presentation of disseminated Gonorrhoea
Fever Migratory Polyathalgia Pustular Rash Septic Arthritis
145
How is gonorrhoea diagnosed
Vaginal Swab, can also rectal, pharyngeal or urethral swab Swabs sent for Nucleotide Acid Amplification Testing If it comes back +ve send for MC&S due to increased Abx resistance - on film will see gram negative stain diplococci
146
What is the treatment of Gonorrhoea
Ceftriaxone IM plus Azithromycin PO
147
What are the complications associated with gonorrhoea and pregnancy
PROMs Preterm Delivery Chorioamniotitis - intra amniotic infection Baby - ophthalmia neonatorum
148
What is pruritus vulvae and what can cause it
Vaginal itch Causes - Infections, Allergy, Skin Disease, infestations (e.g pubic lice, scabies), obesity Treat cause
149
What is pelvic inflammatory disease
Infection of the upper genital tract
150
What is the most common cause of PID
Ascending infections from the endocervix e.g STIs, Uterine instrumentation (hysteroscopy, insertion of IUCD and TOP), Post partum Descending infections from infected organs (appendicitis)
151
Which STIs contribute the most to PID
Main cause Chlamydia | Gonorrhoea
152
What are the risk factors for PID
<25, multiple sexual partners, previous STI
153
What is protective for PID
COCP and barrier contraception
154
What is the presentation of PID
``` Abdominal pain - constant or intermittent Deep Dyspareunia Abnormal Vaginal Discharge Post coital or intermenstrual bleeding Dysmenorrhoea and/or fever ```
155
What would you find on examination of PID
Abnormal vaginal discharge Cervival excitation/ cervical motion tenderness Adnexal Tenderness Fever (afebrile in mild/chronic PID)
156
What investigations do you want to do for someone with PID
Vulvovaginal/ Endocervical Swabs If acutely unwell - FBC, U&Es, CRP and Blood cultures for SEPSIS TVS - if tubo-ovarian abscess is suspected
157
What are the complications of PID
Ectopic Pregnancy and Infertility Tubo- Ovarian Abscess and Hydrosalpinges - needs draining laparoscopically Fitz-Hugh-Curtis Syndrome (liver capsule inflammation)
158
What is the treatment for PID
Outpatients - if well IM Ceftriaxone + PO Doxycycline and PO Metronidazole Inpatients Same but IV
159
What does chronic PID lead to
Fibrosis and Adhesions between Pelvic Organs and tubes may fill with liquid or pus Similar symptoms to PID but may also have menorrhagia
160
What could be a differential for symptoms similar to PID and how would you differential between the two
Endometriosis Laparoscopy
161
Are Abx helpful in chronic PID
No
162
What three things does PCOS comprise of
Hyperandrogenism Oligomenorrhoea Polycystic ovaries - >12 cysts or ovarian . mass greater than 10cm3
163
What other differentials cause symptoms similar to PCOS
Congenital Adrenal Hyperplasia | Cushings
164
Whats causes PCOS
unknown but it leads to increased production of androgens by the ovaries including increased oestrogen and testosterone production
165
What is PCOS associated with
``` Obesity HTN Hyperlipidaemia T2DM Sleep Apnoea Insulin resistance leading to hyperinsulinaemia - darkened skin in skin flexures and neck ```
166
Long term complications of PCOS
T2DM and Gestational Diabetes Endometrial Cancer Cardiovascular Disease
167
What is the presentation of PCOS
Hursuitism Acne Oligomenorrhoea Subfertility
168
How is PCOS diagnosed
Rotterdam Criteria: 2 of the 3 following - 1. Oligomenorrhoea/ anovulation 2. Clinical features and blood tests (increased testosterone) showing hyperandrogenism 3. Polycystic ovaries on US - >12 cysts or ovarian mass >10cm3 Rule out other causes of irregular cycles: e.g hypothyroisism, hyperprolactaemia, androgen secreting tumours, congenital adrenal hyperplasia
169
How is PCOS managed
Lifestyle changes: 1st line: Weight loss and Exercise Find and treat associations - HTN, T2DM, Hyperlipidaemia Don't want to get pregnant? : COCP - to help regulate periods and protect against endometrial cancer Metformin - for T2DM and help fertility Want to get pregnant? Clomefene can help with fertility Metformin Ovarian Drilling can help fertility if medical interventions do not help Anti androgens e.g cyproterone to help with facial hair and acne
170
What is a prolapse
When the supporting pelvic structures weaken causing the pelvic organs to bulge into the vagina The weakness may be congenital
171
What are the risks associated with prolapse
``` Prolonged labour trauma from instrumental delivery lack of pelvic floor exercises postnatally obesity constipation chronic cough ```
172
What are the main 4 types of prolapse
Cystocele Enterocele Rectocele Uterine Prolapse
173
What is a cystocele prolapse and what symptoms may it present with
``` The bladder bulging into the anterior wall of the vagina May cause: Increased frequency and urgency Urinary retention Incomplete Bladder emptying ```
174
What is a rectocele prolapse and what symptoms may it present with
The rectum bulging into the posterior wall of the vagina May cause: Constipation Difficulty Defficating
175
What is a enterocele
Small bowel bulging into top of the vagina
176
What is a uterine prolapse
Uterus bulging down into vagina
177
Why is a 3rd degree uterine prolapse with cystocele a danger to health
It can lead to obstruction of the urethra
178
What are the 4 grades of prolapse
1st degree - lowest part of prolapse extends to level half way down vagina 2nd degree - lowest part of prolapse extends to level of vaginal introitus 3rd degree - lowest part of prolapse extends through introitus and out of vagina 4th degree - procidentia - uterus lies outside vagina
179
What are the general symptoms of prolapse
Discomfort and dragging sensation Dyspareunia Back Ache
180
What examination would you perform to confirm prolapse
May do a bimanual Speculum Exam! - Woman lies laterally and Sims speculum is used to look at anterior and posterior walls If no prolapse present ask woman to cough or stand
181
How can you prevent prolpase
Pelvic floor exercises, lower parity
182
How can you manage prolapse
Conservative - mild - weight loss, pelvic floor exercises/physiotherapy, quitting smoking and stopping straining Pessaries - women unsuitable/ decline surgery, affects sexual function, needs changing every 6months, post menopausal women give oestrogen cream to prevent vaginal erosion Surgery - Sacrospinous Fixation treatment for prolapse of uterus and vault of vagina
183
What is Female Genital Mutilation/Genital Cutting
The partial or total removal of female external genitalia for no medical reason, it is a form of child abuse in the UK
184
What countries are highly associated with FGM
Africa, India and Indonesia
185
What are the reasons for FGM
``` Social and community acceptance Family Honour Status Seen as a woman's right of passage to preserve virginity Respect ```
186
What are the 4 stages of FGM
Stage 1 - cliteroidectomy - partial or total Stage 2 - Excision of the clitoris and labia minor +/- removal of labia majora Stage 3 - Infibulation - narrowing of the vaginal orifice by sealing +/- removal of clitoris Stage 4 - other - any other form of harm, scraping, incising, piercing and pricking
187
What are the acute complications of FGM
``` Blood loss Sepsis Death Infection - HIV, Hepatitis, Tetanus Urinary Retention Pain ```
188
What are the long term complications of FGM
``` emotional trauma chronic pain amenorrhoea anorgasmia apareunia increased risk of C-section fear of child birth Sexual dysfunction Subfertility UTIs and urinary retention ```
189
What is the management of FGM
Defibulation - favourably preconception but can be done during pregnancy up to 20 weeks or 1st stage labour If not possible before birth make sure she is in a specialist obstetric unit with a planned labour
190
When should investigations begin for subfertility
1 year after trying or eariler if known pathology affecting fertility
191
What are the causes of subfertility
``` Fibroids Endometriosis Age (greater/or equal to 35) PID and STIs previous surgery Anovulation - PCOS, Turners, Hyperprolactaemia, Ovarian failure, Hypopituitrism, Hypothalmic-pituitary-ovarian axis Ovarian Reserve - premature ovarian failure Tubal factors Male factors Obesity Smoking and Alcohol Medication Rubella Low frequency of intercourse ```
192
What investigations would you do for subfertility
Key investigation: Measure Progesterone: 7 days before period (mid luteal phase) Calculate: (last day of cycle - 7 days) usually around 21 ``` STI screening Ovarian Reserve testing: LH and FSH TVS and hysteroscopy Hyster-salpingogram Laproscopy and Dye test - gold standard for assessing tubal patency ```
193
What lifestyle management can be performed for subfertility
``` Weight loss or gain Regular exercise or reducing exercise reducing stress Quitting smoking Reducing alcohol Increasing frequency of intercourse ```
194
What management can help stimulate ovulation in subfertility
Clomifene Ovarian Drilling - only in PCOS Gonadotrophins Metfromin - in PCOS however not licensed
195
What surgical management can help subfertility
Tubal Catheterisation | Laproscopic ablation of adhesions in endometriosis and Ashermans Syndrome
196
What is Ashermans Syndrome and what can cause it
``` Intrauterine adhesions Causes: Dilation & Curettage (D&C) (scraping Rx for abortion) PID Endometriosis Infection e.g genital TB ```
197
What is IVF used for
``` Tubal disease Male factor subfertility Endometriosis Age affected fertility Clomifene resistance unexplained subfertility for greater than 2 years ```
198
What increases success of IVF
``` Not smoking Lower BMI Lower age Length of subfertility Lower Anti mullarian Hormone (AMH) Salpingectomy for Hydrosalpinges ```
199
What is the process of IVF
1. Ovarian Stimulation and Monitoring 2. Egg Collection 3. Insemination 4. Fertilisation 5. Embryo Culture 6. Embryo Transfer 7. Luteal support - 2 weeks of progesterone 8. Pregnancy Test
200
Why are only 1-2 eggs transferred in IVF
To prevent multiple pregnancy
201
What is the NHS criteria for IVF
``` Generally no children already Non smoker BMI <30 Age 45 and under Not requiring donor gametes ```
202
What Assisted fertility options are there
``` Donor Insemination Intrauterine Insemination In Vitro Fertilisation Intracytoplasmic sperm injection In vitro maturation ```
203
What are common causes of male infertility
Most common - oligoasthenoteratozoospermia Testicular cancer Drugs, smoking and alcohol Varicoceles Azoospermia - can be pretesticular, obstructive, non-obstructive Immunological Coital problems e.g. erectile dysfunction Cystic Fibrosis Androgen Insensitivity Syndrome Hypoandrogenism
204
What investigations would you do for male infertility
Semen Analysis: count, motility and morphology ``` Testicular examination Rectal Exam - Prostate General appearance and external male genitalia Testosterone levels testicular US and biopsy ```
205
How can male subfertility be treated
Lifestyle changes: quit smoking, diet, exercise, avoid tight underwear and heated seats, cute down alcohol Itrauterine insemination or Intracytoplasmic Sperm Injection for men with low/mild subfertility IVF Azoospermia - donor insemination Surgery for obstruction, varicocele Gonadotrophins, Clomifene, Testoterone Replacement therapy
206
Abortion Act 1967 - Allow termination if:
A. the mothers life is at risk B. it is necessary to prevent grave physical/mental harm to the mother C. continuance of pregnancy risks greater physical/mental harm to mother than termination D. continuance of pregnancy risks greater physical/mental harm to existing children than termination E. there is a substantial risk the child will be born with physical/mental abnormalities causing the child to be severely handicapped
207
Who must be present to sign the certificate of abortion
2 doctors
208
Which 2 parts of the abortion act can only allow termination of the fetus up to 24 weeks
C. continuance of pregnancy risks greater physical/mental harm to mother than termination D. continuance of pregnancy risks greater physical/mental harm to existing children than termination
209
Before termination of pregnancy what should you offer
Screening of STIs Contraception advice Antibiotic Prophylaxis: for post op infection e.g metronidazole or azithromycin
210
What two types of treatment should be offered for Termination of Pregnancy (TOP) and up to what date
Medical and Surgical | Up to 24 weeks
211
What is the medical management of TOP
Antiprogestogen - Mifepristone | Prostoglandin (24hrs later) - Misoprostol
212
What is the surgical management of TOP
Prostoglandin - Misoprostol pre op to prime/dilate the cervix Vacuum/Suction - can be performed up to 15 weeks Dilation and Evacuation - using surgical forceps
213
What is the menopause
The time of waining fertility leading up to last period
214
When is the menopause said to have happened
12 months after last period
215
What causes the symptoms of the menopause
Falling oestrogen levels
216
What are the symptoms of the menopause
Change in periods- periods become irregular (oligmenorrhoea) and make become heavier or lighter Vasomotor symptoms -sweats, palpitations and hot flushes Atrophy of oestrogen dependent areas - breasts and genitalia, vagina dryness and bleeding, dyspareunia, increased risk of UTIs, prolapse and stress incontinence Increased risk of Osteoporosis Mood Changes/Irritability/Memory loss/Difficulty concentrating
217
What bones are at risk of fracture after menopause
Radius Femur Neck Vertebrae
218
What conservative management can help menopause
Exercise and Diet
219
What investigations can be done for the menopause
Rule out other causes of symptoms - Thyroid TFTs and Psychiatry FSH - two consecutive readings over 30 2 weeks apart(not recommended by NICE)
220
What can help the menorrhagia in the menopause
Mirena Coil
221
What contraception advice should be offered to women in the menopause
use contraception for a year after amennorhoea in women over 50 and for 2 years under 50
222
What HRT would you you give women without a uterus
Oestrogen only HRT
223
What HRT would you give a woman with a uterus
Combined HRT e.g estridol and norethisterone
224
Why should women with a uterus take combined HRT
unopposed oestrogen is a major risk factor for endometrial cancer
225
What are the two types of HRT treatment routines and what criteria decides which one you take
Cyclical HRT: women with menopausal symptoms still having periods or haven't had a period within a year (progesterone only take for part of cycle) Combined Continuous HRT: women who are post menopausal
226
Can HRT be used as contraception
NO
227
What are the contrindications of HRT
``` Oestrogen dependent cancer past pulmonary embolism undiagnosed PV bleed pregnancy and breastfeeding raised LFTs ```
228
What are the SE of HRT
``` bloating fluid retention nausea breast tenderness headache leg cramps progestogens can cause depression/mood swings, acne and back ache ```
229
What are the benefit of HRT
reduced vasomotor symptoms improves urogenital and sexual function reduces risk of osteoporotic fractures reduces risk of colorectal cancer
230
What are the risks of HRT
``` increased risk of breast cancer increased risk of VTE slight increased risk of stroke increased risk of gallbladder disease increased risk of endometrial cancer in oestrogen only HRT ```
231
What would be used 1st line for osteoporosis but no other symptoms of menopause
NOT HRT use calcium and vit D Bisphosphates
232
What are alternatives of HRT
SSRIs e.g. cloridene for vasomotor symptoms | Oestrogen cream or lubricants for vaginal dryness
233
What is the definition of a miscarriage
Loss of pregnancy before 24 weeks gestation
234
What are the 5 types of miscarriage
``` Threatened Inevitable Incomplete Complete Septic Missed ```
235
What is a threatened miscarriage
Mild symptoms of pain and bleeding but os remains closed (75% will resolve)
236
What is an inevitable miscarriage
More severe symptoms of pain and bleeding and os is open, uterine content will pass into the vagina
237
What is an incomplete miscarriage
Some products of the uterus still remain in the uterus
238
What is a complete miscarriage
All products of the pregnancy have been passed and the os is now closed
239
What is a septic pregnancy and how may a patient present
Products of the pregnancy have become infected in the uterus causing endometritis Woman may present with adnexal tenderness, fever and offensive vaginal discharge
240
What is a missed miscarriage
Fetus has died in the uterus but os remains closed, woman may present with no symptoms or symptoms of pain and bleeding
241
How is a missed miscarriage diagnosed
TVS will show no fetal HR
242
What are the symptoms of a miscarriage
Abdomial Pain Cramping Bleeding PROMS
243
What should you note on examination of a miscarriage
The source of bleeding - is it uterus or cervical lesions Quantify the bleeding - are they haemodynamically stable Is the os open or closed Is there evidence of products of conception Is pain worse than period Does the uterus size match pregnancy dates
244
What investigations should be performed for miscarriage
bhCG - these will begin to fall but pregnancy will stay +ve for few days after miscarriage TVS - rule out ectopic Laproscopy if ectopic
245
What initial assessment should be performed before miscarriage management
ABCDE
246
What are the three types of miscarriage management
Expectant Medical Surgical
247
Who is most appropriate for expectant miscarriage management
Women with mild bleeding who have undergone an incomplete miscarriage less appropriate for missed
248
What is medical management of missed miscarriage
prostoglandin (Misoprostol) appropriate for missed miscarriage
249
Who should undergo surgical management for miscarriage and what does it entail
Severe symptoms of bleeding, infection or significant retained products from pregnancy Prime cervix with prostoglandins e.g Misoprostol Followed by D&E or Suction (<15 weeks)
250
What is the definition of recurrent miscarriage
Loss of 3 consecutive pregnancies before 24 weeks gestation
251
What are the causes of recurrent miscarriage
- increases with age - antiphospholipid syndome - treat with heparin and aspirin - Endocrine disorders e.g diabetes, thyroid - Thrombophillia - treat with heparin - Incompetent Cervix - Chromosomal abnormalities - Infection - Uterine abnormalities e.g bicornuate or unicornuate uterus
252
What investigations should be performed for recurrent miscarriage
``` antiphospholipid antibodies thrombophillia screening karyotyping and genetic counselling Pelvic US Diabetic testing and TFTs ```
253
What maintains urinary continence
External Sphincter and Pelvic floor muscles
254
What occurs in micturition
External Sphincter and pelvic floor muscles relax and detrusor muscle contracts
255
What is the definition of stress incontinence
Involuntary leakage of urine due to increased stress/pressure usually due to exercise, coughing, sneezing and heavy lifting
256
What causes stress incontinence
``` External sphincter weakness Pregnancy Oestrogen deficency after menopause Congenital Surgery Radiotherapy ```
257
What investigations should be performed in stress incontinence
Urinalysis - to Exclude UTI and diabetes Frequency/Volume charts will be normal Urodynamics
258
What is the management of stress incontinence
Conservative- weight loss, manage comorbidities, pelvic floor exercises Medical management - Dulotexine rarely used Surgical management - tension free vaginal tape
259
What is urge incontinence
Involuntary leakage of urine with the strong desire to pass urine, presents with increased frequency and nocturia (overactive bladder syndrome)
260
What are the symptoms of urge incontinence
Increased frequency nocturia may worsen in the cold
261
What are the causes of urge incontinence
MS Spina bifida Idiopathic Surgery
262
What investigations should be performed for urge incontinence
Urinalysis - Exclude UTI and diabetes Frequency/Volume charts will show increased frequency and nocturia Urodynamics - are diagnostic! will show involuntary detrusor contraction
263
What is the management of of urge incontinence
Conservative - cut down alcohol, caffeine and carbonated drinks, bladder retraining to suppress urge, avoid excessive fluid intake Medical management: Anticholinergic- Oxybutinin (dont use in old patients can increase risk of falls) Botulinum Toxin injections into detrusor muscle Surgical management last resort
264
What is overflow incontinence and how is it managed
Caused by bladder insult or injury | Management: Catheterise
265
What is mixed urinary incontinence and how should it be treat
Mixture of stress and urge incontinence | Treat the predominant one first
266
What are the forms of barrier contraception
``` Condoms Caps Cervical Sponges Female condoms Spermcide Also protect against most UTIs ```
267
What are the forms of fertility awareness/natural methods of contraception
Menstrual cycle monitoring Cervical mucus monitoring Basal body temperature monitoring Lactational amenorrhoea - natures contraception
268
What is the IUCD? - How long does it last - What are the symptoms and risks - Can it be used as a emergency contraception?
Intrauterine Copper Device - it lasts 5-10 years - it can cause dysmenorrhoea and menorrhagia - it can increase risk of ectopic and PID Yes it can be used as emergency contraception
269
What is the IUS? - How long does it last - What symptoms can it relieve - What risks are lower using the IUS instead of IUCD - What can the IUS be used to treat - Can it be used as emergency contraception?
Intrauterine System - it lasts around 5 years - it can relieve symptoms of menorrhagia and dysmenorrhoea by making periods lighter or cause amenorrhoea - Can cause irregular bleeding - the IUS has lower risks of ectopic and PID - the IUS can be used to treat endometriosis and menorrhagia - the IUS cannot be used as emergency contraception
270
What are the types of emergency contraception
The IUCD - 120hrs or up to 5 days after earliest ovulation Ullipristal Acetate - 120 hrs Levonorgestrel - 72 hrs
271
What are the reasons to avoid the COCP
``` CVD Increased BMI Past/Current VTE and family Hx Migraines Oestrogen reliant cancers (breast cancer) Liver disease ```
272
What are the risks of the COCP
increased risk of: stroke, VTE, breast and cervical cancer
273
What are the SE of the COCP
Mood swings, bloating, breast tenderness, headaches
274
What are the benefits of COCP
Improves acne, protects against endometrial, ovarian and bowel cancer, helps reduce symptoms of menorrhagia and dysmenorrhoea
275
What are the different types of progesterone only contraception
Progestogen only pill The depot injection The implant
276
What are the SE of POP
Most common: Irregular menstrual bleeding | Depression, acne, back ache. increased risk of ectopic
277
What are the SE of depot
Weight gain, osteoporosis
278
What are the SE of the implant
irregular or frequent or prolonged periods
279
What are reasons to avoid POP
Current breast cancer liver disease SLE with antiphospholipid syndrome new sympttoms of migraine, stroke etc while taking POP
280
What are the two types of sterilisation
Tubal ligation - women (difficult to reverse) | Vasectomy - men (safer can be reversed takes up to 3 months to work to use up sperm stores
281
Where is the most appropraite place to insert implant contraception
Non dominant arm, subdermal layer
282
What is defined as premature ovarian failure
40 years
283
What is the best tool to diagnose Adenomyosis
MRI pelvis
284
If there have been 3 inadequate cervical smears what should be the next step
Refer for colposcopy
285
What is oxybutinin
An Anticholinergic - antimuscarinic
286
Should HIV positive women breastfeed
No
287
What is Mittelschmerz
Cause of mid cycle pain caused by a small amount of fluid released mid ovulation, often sharp onset and settles after 24-48 hrs
288
What is the most common cause of post coital bleeding
Cervical Ectropian
289
What are the rules for missed pill POP
Traditional POP - take within 3 hrs of normal time Desogesterel - taken within 12 hrs of normal time If missed outside time frame take missed pill and use safety measures for 48hrs e.g condoms
290
What is a bartholins cyst
Blockage of the bartholins gland leading to a fluid filled sac Causes unilateral swelling and perineal tenderness
291
What is the treatment of bartholins cyst
Marsupialisation
292
What is Adenomyosis
Presence of endometrial tissue in the myometrium - it causes uterine enlargement
293
What is adenomyosis associated with
Endometriosis | Fibroids
294
As growth of endometrial tissue is oestrogen dependent when would it subside
After menopause - no oestrogen
295
What symptoms would you get in adenomyosis
Menorrhagia | Dysmenorrhoea
296
What would you find on examination of someone with adenomyosis
Tender Uterus
297
How would you manage adenomyosis
Non- hormonal: pain relief: mefanamic acid, Antifibrinolytics e.g tranexamic acid Hormonal: COCP, POP, IUS
298
What causes continuous dribbling go urine
Vesicovaginal Fistula
299
What are causes of Menorrhagia
``` Fibroids Endometriosis Polyps Endometrial Hyperplasia PID PCOS Coagulation Problems Infection (irregular, heavy bleeding) ```
300
What is in the risk of malignancy index (RMI)
CA125 x USS score x Menopause status
301
When is a woman most likely to conceive
Last day - 14
302
What should pregnent women avoid in pregnancy
``` Vitamin A - strong link with congenital abnormality Soft Cheeses -Listeria Cold Meats Raw Eggs which aren't fully boiled - Salmonella Liver Shell Fish - Listeria & Salmonella Tuna - Mercury Cat Litter - Toxoplasmosis ```
303
What amount of folic acid should normal pregnant women take
400 micrograms

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