Gynaecology Flashcards
(316 cards)
1
Q
Define heavy menstrual bleeding
A
Excessive menstrual blood loss which has an adverse impact on a woman’s quality of life
2
Q
Give 3 causes of heavy menstrual bleeding
A
Fibroids Endometrial polyps Adenomyosis Pelvic infection Endometrial malignancy Anovulatory Ovulatory Clotting disorders
3
Q
How should heavy menstrual bleeding be assessed and investigated?
A
History
Examination - abdominal, bimanual
Blood tests - FBC, coagulation (if long history/FH), thyroid (if other signs/symptoms)
Biopsy (persistent intermenstrual, >45 treatment failure)
Imaging (palpable uterus, pelvic mass, treatment failure) - US
4
Q
How is heavy menstrual bleeding managed?
A
Pharmacological - non-hormonal (mefenamic acid, tranexamic acid), hormonal (pseudo-pregnancy, pseudo-menopause)
Surgical - endometrial ablation, hysterectomy
5
Q
What are mefenamic acid and tranexamic acid?
A
Mefenamic - prostaglandin synthase inhibitor, take during menses
Tranexamic - antifibrinolytic, take during menses
Reduce bleeding by 50% when taken in combination
6
Q
What are the pseudo-pregnancy medical hormonal management options for heavy menstrual bleeding?
A
COCP
Progestogens - systemic (POP, depo-provera, nexplanon), local (LNG-IUS/Mirena)
7
Q
What is the pseudo-menopause medical hormonal management option for heavy menstrual bleeding?
A
GnRH analogues (inhibit FH and LH release)
8
Q
What are the effects of progesterone receptor modulators?
A
Bind to progesterone receptor Act directly on endometrial blood vessels Induce amenorrhoea Shrink fibroids by 20-40% E.g. ulipristal acetate
9
Q
What 2 things must be noted when sending a sample from a hormone sensitive tissue to pathology?
A
Time in cycle
Hormonal preparations being taken by patient
10
Q
What does a Mirena coil do?
A
Thickens cervical mucus
Inhibits sperm from reaching egg
Thins uterine lining
11
Q
What can the Mirena coil be used for?
A
Small fibroids Adenomyosis Endometriosis Contraceptive Progesterone component of HRT
12
Q
What is contraindicated after endometrial ablation?
A
Pregnancy
13
Q
Define amenorrhoea. What are the 2 types?
A
Absent menses
Primary - failure to menstruate by 15 years of age
Secondary - established menses stop for ≥6 months in absence of pregnancy
14
Q
Define oligomenorrhoea
A
A cycle which is persistently greater than 35 days in length
15
Q
What are the common causes of primary amenorrhoea?
A
Physiological delay
Weight loss/anorexia/heavy exercise
PCOS
Imperforate hymen
16
Q
How is primary amenorrhoea assessed?
A
History - FH, weight, exercise, stress, sexual history
Examination - secondary sexual characteristics, Tanner staging
17
Q
How is amenorrhoea investigated?
A
Bloods - FSH, LH, oestradiol, prolactin, TFTs US Karyotype XR for bone age Cranial imaging
18
Q
What are the common causes of secondary amenorrhoea?
A
Pregnancy Lactation Menopause Weight loss/anorexia Heavy exercise Stress PCOS Hysterectomy Endometrial ablation Progestogen IUD
19
Q
What are the Rotterdam criteria for PCOS diagnosis?
A
Clinical or biochemical evidence of hyperandrogenism
Oligomenorrhoea/amenorrhoea
US features of PCOS
20
Q
What are the complications of PCOS?
A
Reduced fertility Insulin resistance and diabetes Hypertension Endometrial cancer Depression and mood swings Snoring and daytime drowsiness
21
Q
How is PCOS managed?
A
Education Weight loss and exercise Endometrial protection (progesterone) Fertility assistance Awareness and screening
22
Q
Define dysmenorrhoea
A
Excessive menstrual pain
23
Q
How is the pain of dysmenorrhoea described?
A
Cramping lower abdominal pain
Radiates to lower back and legs
Associated with GI symptoms and malaise
24
Q
Give 2 features of primary dysmenorrhoea
A
Begins with onset of ovulatory cycle
Typically occurs within first 2 years of menarche
Pain most severe on the day of/day prior to start of menstruation
25
What substance is implicated in primary dysmenorrhoea and how?
Prostaglandins
| Increases contractility of myometrium
26
How is primary dysmenorrhoea managed?
Discussion and reassurance
Transabdominal US
Medical therapy - prostaglandin synthesis inhibitors (NSAIDs), COCP, depot progestogens, LNG-IUS
27
When does secondary dysmenorrhoea occur and what are its causes?
Many years after menarche
| Pelvic pathology - endometriosis, adenomyosis, infection, fibroids
28
How is secondary dysmenorrhoea investigated and managed?
Genital tract swab (chlamydia)
Pelvic US (fibroids)
Laparoscopy (endometriosis)
Management depends on pathology
29
Define intermenstrual bleeding (IMB), post-coital bleeding (PCB) and post-menopausal bleeding (PMB)
IMB - bleeding between periods
PCB - bleeding after intercourse
PMB - bleeding >12 months after LMP
30
What are the causes of IMB and PCB?
```
Infection
Trauma
Polyp
Cervical ectropion
Malignancy
Contraception
Pregnancy
```
31
How are IMB/PCB investigated?
Cervical smear history
Speculum and bimanual examination - urgent colposcopy if cancer suspicion
STD screen
Urine pregnancy test
32
When is urgent gynaecology referral suitable for IMB/PCB?
Women >35 with >4 weeks of symptoms
33
When is routine gynaecology referral suitable for IMB/PCB?
Women <35 with >12 weeks of symptoms
| Single heavy episode of bleeding at any age
34
When is simple reassurance suitable for IMB/PCB?
Women <35 with normal examination and results
| Most will resolve within 6 months, consider changing hormonal contraception
35
What is the risk of cancer in post-menopausal bleeding?
5%
36
How is PMB investigated?
Transvaginal US
Biopsy if endometrial lining >3mm (non-HRT/CC-HRT users) or if EL >5mm (sequential HRT users)
Hysteroscopy/biopsy in tamoxifen users
37
What is the incidence of infertility and when should investigation start?
1 in 6
| After 1 year
38
Name 5 benign gynaecological conditions
```
Vulva - Bartholin cyst/abscess, lichen sclerosus, genital herpes
Cervix - ectopy, polyps
Uterus - fibroids, polyps
Fallopian tubes - PID, hydrosalpinx
Ovary - cysts
Endometriosis
```
39
How can a Bartholin gland abscess and cyst be differentiated?
Abscess - acute infection of the gland by bacteria, very painful
Cyst - chronic swelling after previous infection, painless
40
How are Bartholin gland abscesses/cysts managed?
Broad spectrum antibiotics
| Marsupialisation (GA) or word catheter (LA)
41
What is lichen sclerosus?
Autoimmune condition causing patchy thinned white skin which is especially common in postmenopausal women
42
Give 3 signs/symptoms of lichen sclerosus
```
Itching
Excoriation (can cause pain and painful sex)
Whitened vulval skin
Loss of labial and clitoral contours
Narrowed entry to vagina
```
43
How can a diagnosis of lichen sclerosus be confirmed and how is it managed?
Clinical diagnosis, biopsy can confirm
| Treatment - potent topical steroids (e.g. dermovate)
44
What are the signs/symptoms of genital herpes?
Painful vesicular rash
Dysuria
Dyspareunia
45
How is genital herpes managed?
Oral aciclovir 400mg 3x/day for 5-10 days
Self care - oral analgesia, salt water application, vaseline/lidocaine (painful micturition), increase fluid intake to dilute urine, urinate in bath to reduce stinging
46
What is cervical ectropion?
Columnar cells from the cervical canal are everted to the cervix
47
What are the symptoms of cervical ectropion and how is it managed?
Symptoms - none, chronic discharge, PCB
| Treatment - cautery/cryotherapy/silver nitrate if symptomatic
48
What are the symptoms of cervical polyps and how are they managed?
Symptoms - none, PCB/PMB
| Treatment - avulsion if symptomatic
49
What are the correct medical terms for fibroids?
Leiomyomas
| Fibromyomas
50
What are fibroids?
Benign tumours of the myometrium
51
In what population are fibroids most common and faster growing?
Afro-Caribbean women
52
Why do fibroids grow during pregnancy and shrink after menopause?
Oestrogen dependent
53
Give 3 signs/symptoms of fibroids
Heavy menstrual bleeding
Abdominal swelling
Pressure symptoms - ureteric obstruction
Subfertility
Difficulties in pregnancy - miscarriage, red degeneration
Pain (torsion, degeneration)
Abdominal/pelvic mass
54
How are fibroids diagnosed?
Clinical suspicion confirmed by USS
| MRI may be needed to plan management
55
How are fibroids managed?
Conservative
Medical - control symptoms (heavy bleeding), before surgery (GnRH analogues, ulipristal acetate)
Surgical - hysterectomy, myomectomy (preservation of fertility)
Uterine artery embolisation - minimally invasive
56
What are the symptoms of endometrial polyps, how are they diagnosed and how are they managed?
Symptoms - PMB, IMB, HMB
Diagnosis - TVUS, hysteroscopy and biopsy
Treatment - polypectomy
57
What is PID?
Pelvic inflammatory disease - salpingitis, tubo-ovarian abscess
Ascending infection from cervix e.g. chlamydia
58
What are the complications of PID?
Infertility
Ectopic pregnancy
Chronic pelvic pain
59
What are the symptoms of PID?
```
Asymptomatic
Anorexia and general malaise
Lower abdominal pain
Deep dyspareunia
Variable discharge (often purulent)
PCB or IMB
```
60
What are the signs of PID?
```
Pyrexia
Tachycardia
Abdominal distension and tenderness, rebound and guarding
Very tender on vaginal examination
Discharge seen on speculum
```
61
What is Fitz-Hugh-Curtis syndrome?
Peri-hepatic inflammation causing RUQ tenderness in PID
62
What investigations should be carried out for suspected PID?
```
Urine pregnancy test
FBC and CRP (raised WCC and CRP)
MSU (exclude UTI)
Swabs (chlamydia)
Transvaginal USS (tubo-ovarian abscess)
Laparoscopy (uncertain, no improvement)
```
63
How is PID managed?
Empirical antibiotics when suspected - ceftriaxone 500mg IM stat, followed by oral doxycycline 100mg BD and metronidazole 400mg BD for 14 days
Pain refief - paracetamol, ibuprofen
Refer to GU medicine - further infection screening, contact tracing
64
What is hydrosalpinx?
A condition that occurs when the distal fallopian tube is blocked and fills with serous fluid
65
What are the symptoms of hydrosalpinx?
None
Pelvic pain
Subfertility
66
How is hydrosalpinx diagnosed and managed?
Diagnosis - suspected on TVU, laparoscopy, hysterosalpingogram (HSG)
Treatment - conservative (no symptoms), bilateral salpingectomy (pelvic pain), IVF for infertility
67
What are the 4 types of ovarian cyst?
Functional
Dermoid
Epithelial
Endometriotic
68
What are the symptoms of ovarian cysts?
None
Pelvic pain
Abdominal/pelvic swelling
69
How are ovarian cysts diagnosed and managed?
Diagnosis - US/CT/MRI, CA125/CEA/aFP/hCG
| Treatment - conservative (symptom free, <6cm), remove otherwise (cystectomy/oophorectomy)
70
What are the 2 types of functional cysts and how are they managed?
Follicular and luteal
| Avoid unnecessary intervention, will normally resolve in 6-12 weeks
71
What is endometriosis?
Oestrogen-dependent benign inflammatory disease characterised by ectopic endometrium, often accompanied by cysts and fibrosis
72
What are the 3 types of endometriosis
Superficial peritoneal lesion (minimal and mild)
Deep infiltrating lesion (moderate and severe)
Ovarian cysts (endometriomas)
73
What are the signs/symptoms of endometriosis?
```
None
Dysmenorrhoea
Dyspareunia
Pelvic pain
Subfertility
Fixed tender retroverted uterus
```
74
How is endometriosis investigated?
Suspected from history and exam
TVU, raised CA125
Laparoscopy and biopsy - gold standard
75
How is endometriosis managed?
```
Conservative (symptom free)
Medical - NSAIDs, progestogens, COCP, Mirena (symptom relief)
Prior to surgery - GnRH analogues
Surgical - cautery, cystectomy
IVF for infertility
```
76
What should be considered when assessing pelvic pain?
Lower abdominal pain
Acute - cyst torsion, PID, ectopic
Chronic - endometriosis, CPP
Is the pain cyclical and related to menstruation?
77
What are the symptoms of dysmenorrhoea?
Cramping lower abdominal pain
| Radiation to lower back and legs
78
What are the 2 types of dysmenorrhoea?
Primary - idiopathic, onset soon after start of ovulatory cycle due to increased prostaglandin
Secondary - years after menarche, due to pelvic pathology
79
What is vulvodynia?
Sensation of vulval burning/pain with no obvious skin problem due to hypersensitivity of vulval nerve fibres (e.g. post-herpetic neuralgia)
80
How is vulvodynia managed?
Low dose TCA (e.g. amitriptylline)
Lubricant
Vulval care advice
81
What is chronic pelvic pain syndrome?
Intermittent/constant lower abdominal pain for >6 months not occurring exclusively with menstruation or intercourse and not associated with pregnancy
82
How is CPP investigated?
Allow time to listen to patient
Rule out any gynaecological pathology
Consider - IBS, interstitial cystitis, MSK, psychological/social issues, past/ongoing sexual abuse
83
How is CPP managed?
Medication - antispasmodics (IBS), NSAIDs (MSK)
Referral - urology, gastroenterology, surgery
MDT - chronic pain, psychology, PT, psychosexual therapy, self-help groups
84
What is the incidence of cervical cancer?
Two peaks - 25-29 years, >80 years
85
What are the risk factors for cervical cancer?
```
HPV (high risk 16 and 18)
Smoking
Early onset of sexual activity
COCP use
Multiple sexual partners
Immunosuppression
```
86
How does HPV cause cervical cancer?
HPV releases proteins which bind to tumour suppressors, rendering cervical cells vulnerable to unchecked genetic changes
87
Outline the HPV vaccination programme
All girls aged 11-13
2 injections given at least 6 months apart
HPV 6, 11, 16 and 18 - protection against cervical, vulval, vaginal and anal cancer and genital warts
10 year protection
88
Outline the cervical screening programme
Aims to detect and treat abnormal changes in a woman's cervix which may develop into cervical cancer
25-65 year olds - 3 yearly until 50, 5 yearly from then on
89
What is the transformation zone of the cervix?
Junction between columnar epithelium of cervical canal and squamous epithelium of the outer cervix - location of dysplasia and carcinoma
90
If the cervix is visibly abnormal on speculum examination during a smear, what should be done?
Smear should not be taken as it is a screening test
| Diagnostic test required - biopsy (punch or LETZ)
91
What is colposcopy and what is it for?
Referral for - abnormal screening smear or suspicious symptoms/cerix appearance
Colposcope (microscope) used to visualise cervix on application of acetic acid which highlights abnormal cells for biopsy
92
What is CIN? What is the significance of staging?
Cervical intraepithelial neoplasia - abnormal, pre-cancerous cells
CIN 1 - low grade changes, given time to resolve
CIN 2 and 3 - high grade changes, treatment offered
93
How is CIN 2/3 managed?
Destructive - cold coagulation, cryotherapy
Excisional - LETZ, cold knife cone, laser excision
Follow up - 6 months smear
94
What subtypes of cervical cancer are there and which is the most common?
```
Squamous cell carcinoma (most common)
Adenocarcinoma
Adenosquamous carcinoma
Endometroid
Clear cell
Serous
Neuroendocrine (e.g. small cell)
```
95
How does cervical cancer present?
```
Vaginal bleeding
Sero-sanguineous offensive vaginal discharge
Obstructive renal failure
Supraclavicular lymphadenopathy
Asymptomatic
```
96
How should a woman with suspected cervical cancer be examined?
```
Supraclavicular palpation
Abdominal exam
Speculum
Bimanual
PR (assess parametrium)
Colposcopy
```
97
What is the parametrium?
Fibrous and fatty connective tissue that surrounds the uterus Separates the supravaginal portion of the cervix from the bladder
98
How should a woman with suspected cervical cancer be investigated?
Bloods - FBC, U&Es, LFTs
Biopsy - punch or LETZ
Imaging - MRI, CT, PET
99
What staging is used in cervical cancer?
FIGO staging
| Based on clinical examination - examination under anaesthetic/MRI, bloods and prognostic factors
100
What prognostic factors apply to cervical cancer?
Lymph node involvement
Lymphovascular space involvement
Parametrial extension
101
Outline FIGO staging for cervical cancer
Stage 1 - contained
Stage 2 - involves upper vagina/parametrium
Stage 3 - involves lower vagina/pelvic side wall/kidneys
Stage 4 - involves adjacent pelvic organs/distant organs
102
How is cervical cancer managed?
MDT discussion
Surgery - LETZ, trachelectomy, pelvic lymphadenectomy, hysterectomy
Chemotherapy and radiotherapy - cisplatin, external beam radiotherapy, vaginal vault brachytherapy
103
What is a trachelectomy?
Surgery for early stage cervical cancer that removes the cervix
Fertility sparing surgery as it does not remove the uterus meaning it may be possible to become pregnant in the future
104
How is advanced cervical cancer managed?
MDT - chemotherapy, radiotherapy, biologics
Guided by patient co-morbidity and wishes
Palliative medicine input
Nephrostomy/ureteric stent may be needed
105
What type of vulval cancers are there and which is the most common?
```
Squamous cell carcinoma (most common, 90%)
Adenocarcinoma
Melanoma
BCC
Sarcoma
Metastatic
```
106
What are the risk factors for vulval cancer?
```
VIN
HPV
Squamous metaplasia
Chronic skin conditions (e.g. lichen sclerosus)
Smoking
Immunosuppression
```
107
What are the 4 VIN types?
Usual - thickened, high nuclear:cytoplasmic ratio, nuclear atypia, abnormal mitotic figures
Warty - papillary configuration, multinucleate cells, koilocytes, dyskeratotic cells
Basaloid - flat surface, less differentiated, high nuclear:cytoplasmic ratio
Differentiated - thickened epidermis, enlarged keratinoctyes, surface parakeratosis
108
What pattern may disease follow in vulval cancer?
Multifocal
| Multicentric - vulva, vagina, cervix, perianal, anal, natal cleft
109
How does VIN present?
```
Pruritus
Pain
Ulceration
Leukoplakia
Lumps/warts
Asymptomatic - may be noticed on smear
```
110
What are the commonest sites affected by VIN?
Labia majora
Labia minora
Posterior fourchette
111
How can the appearance of VIN be described?
Variable
Red/white plaques
Papular, polypoid, verruciform
112
How is VIN diagnosed?
Biopsy - incisional or excision
113
How is high grade VIN managed?
Exclude invasive disease, relieve symptoms, eradicate HPV, reduce progression to invasive disease, preserve anatomy and function, sustain remission
Observe or excise (surgery, ablation)
114
What methods of ablation can be used in high grade VIN?
Chemical - imiquimod (immune response modifier, 2-3x/week for 16 weeks, side effects limit complicance)
Laser
Photodynamic therapy
115
What are the signs/symptoms of vulval cancer?
```
Lump
Pain
Bleeding
Discharge
Swollen leg
Groin lump
Mass
Ulceration
Colour changes
Elevation and irregularity of surface
Lower limb lymphoedema
```
116
What staging is used for vulval cancer?
FIGO staging
Depth of invasion measured from deepest point of tumour to epithelial-stromal junction
Nodal status critical in predicting survival
117
Outline FIGO staging for vulval cancer
Stage 1 - confined
Stage 2 - involves lower vagina/urethra/anus
Stage 3 - involves nodes
Stage 4 - involves upper vagina/urethra/bladder/anus/pelvic bone/higher pelvis
118
What is the 5 year survival of cervical and vulval cancer?
Cervical - 67%
| Vulval - 64%
119
How is vulval cancer managed?
Surgery - WLE, vulvectomy, inguinal lymphadenectomy
Reconstruction - grafts (split skin, full thickness), flaps (myocutaneous, fasciocutaneous, lotus petal)
Chemotherapy
Radiotherapy
120
What prognostic factors are applicable to vulval cancer?
```
Depth of involvement
Involvement of other structures
Histological sub type
Lymphovascular space invasion
Excision margins
Nodes
```
121
What are the complications of lymphadenectomy in vulval cancer?
```
Delayed wound healing
Infection
Wound breakdown
Lymphoedema
Recurrent infection (erysipelas)
```
122
What is erysipelas?
Relatively common bacterial infection of the superficial layer of the skin (upper dermis), extending to the superficial lymphatic vessels within the skin, characterized by a raised, well-defined, tender, bright red rash, typically on the face or legs, but which can occur anywhere on the skin
123
What are the types of ovarian cancer and what is the most common?
Epithelial (most common, 90%)
Germ cell (oocytes)
Stromal
Metastasis (Krukenburg - mucin-filled signet-ring cells)
124
What are the 2 types of epithelial ovarian cancer?
High grade serous - resembles fallopian tube mucosa, P53 mutations
Ovarian surface/Mullerian inclusion cysts - endometrioid, clear cell, mucinous, low grade serous
125
What are the 3 routes of ovarian cancer spread?
```
Direct extension (transcoelomic)
Exfoliation into peritoneal cavity
Lymphatic invasion
```
126
What are the risk factors for ovarian cancer?
```
Smoking
Low parity
Oral contraceptives
Infertility
Tubal ligation
Early menarche
Late menopause
```
127
What are the main genetic/familial causes of ovarian cancer?
BRCA1 (chromosone 17q)
BRCA2 (chromosome 13q)
Lynch syndrome/HNPCC (mismatch repair genes)
Other undiscovered genes
128
Give 2 features suggestive of a familial ovarian cancer
```
Early onset breast cancer <50 years
Male breast cancer
Ashkenazi Jewish ancestry
Bilateral breast cancer
Multiple family members with breast/colon/ovarian/stomach/renal tract/endometrial/small bowel cancer
```
129
What is the risk of ovarian cancer in patient with BRCA mutation?
30%
130
What does risk reducing surgery for ovarian cancer involve and what is the risk reduction?
Prophylactic bilateral salpingo-oophorectomy (BSO)
Ovary RR - 96%
Breast RR - 53%
131
What are the signs/symptoms of ovarian cancer?
```
Vague and non-specific
Altered bowel habit
Abdominal pain/bloating
Feeling full quickly
Difficulty eating
Urinary/pelvic symptoms
Bowel obstruction
SOB
Abdominal distension
Upper abdominal mass
Pleural effusion
Nodules on vaginal exam
Paraneoplastic syndromes
```
132
How should suspected ovarian cancer be investigated?
USS
Bloods - CA125
Calculate risk of malignancy index (RMI)
CT - determines treatment and allows monitoring of response
133
What is CA125?
Glycoprotein antigen
Elevated in malignancy (ovarian, pancreas, breast, lung, colon) and benign conditions (menstruation, endometriosis, PID, pleural/pericardial effusion, recent laparotomy)
134
How is the risk of malignancy index (RMI) calculated?
USS (1/2/3) x menopausal status (pre/post) x CA125
135
What USS features are used in RMI calculation?
Multilocular
Solid areas
Ascites
Intra-abdominal metastasis
136
How is an ovarian cancer diagnosis confirmed?
Cytology - pleural/ascitic fluid
| Histology - biopsy
137
Outline FIGO staging for ovarian cancer
Stage 1 - ovaries/ascites/rupture
Stage 2 - involves uterus/fallopian tubes/other pelvic tissue
Stage 3 - involves retroperitoneal lymph nodes/microscopic beyond pelvis/peritoneal metastasis
Stage 4 - pleural effusion/abdominal involvement
138
What is the 5 year survival for ovarian and endometrial cancer?
Ovarian - 46%
| Endometrial - 79%
139
How is ovarian cancer managed?
Surgery - primary debulking, midline laparotomy, total abdominal hysterectomy (TAH), BSO, washings, omentectomy, appendicectomy, resection of peritoneum
Chemotherapy - neoadjuvant/adjuvant carboplatin and paclitaxel, biologics (anti-VEGF), hormonal (tamoxifen)
Fertility conservation - 9% recurrence risk in contralateral ovary
140
How does endometrial cancer present?
```
PMB
PCB
IMB
Altered menstrual pattern
Persistent vaginal discharge
```
141
What are the types of endometrial cancer and which is most common?
Adenocarcinoma (most common)
Sarcoma (e.g. leiomyosarcoma)
Uterine carcinosarcoma
142
What are the 2 types of adenocarcinoma of the endometrium?
Type 1 - oestrogen excess, endometroid, grade I-III
| Type 2 - no oestrogen excess, papillary serous or clear cell
143
What is the malignant potential of simple hyperplasia, complex hyperplasia and atypical hyperplasia of the endometrium?
Simple - 1-3%
Complex - 3-4%
Atypical - 23%
144
What are the risk factors for endometrial cancer?
```
Obesity
Physical inactivity
HRT
Diabetes
Metabolic syndrome
Unopposed oestrogen
Tamoxifen
Nulliparity
Longer menstrual lifespan
Genetics (HNPCC)
```
145
What is the difference between Lynch I and II syndromes?
I - site-specific colorectal cancer
| II - colorectal, endometrial, ovarian, stomach, hepatobiliary, brain, skin, upper urinary tract and small bowel cancers
146
What is the risk of endometrial cancer in a patient with Lynch II syndrome?
30-40%
147
How can risk of endometrial cancer be reduced in those genetically susceptible?
```
Reduce BMI
Avoid diabetes
Parity and COCP use
TVS and biopsy
Prophylactic hysterectomy (and BSO) when family is complete to eliminate risk
```
148
Outline the FIGO staging for endometrial cancer
Stage 1 - confined to uterus
Stage 2 - cervical stromal invasion, but not beyond uterus
Stage 3 - tumour outwith uterus
Stage 4 - invasion of bladder/bowel mucosa, distant metastasis
149
What investigations should be done in suspected endometrial cancer?
Basic bloods
Imaging - TVU (measure thickness of endometrium), MRI (assess for extra-uterine disease), CT/PET
Biopsy - pipelle, hysteroscopy
150
When should a biopsy be taken based on endometrial thickness in patients with PMB?
Thickness >3mm and not on HRT
Thickness >5mm and on sequential HRT
All tamoxifen users
151
How is endometrial cancer managed?
Early stage disease - total hysterectomy, BSO and washings; examine all peritoneal surfaces
Adjuvant - based on histopathology
Advanced disease - MDT discussion regarding surgery, chemotherapy, radiotherapy and hormonal treatment
Inoperable disease - histopathology important (ER/PR), palliative input
152
What are the uses and side-effects of radiotherapy in endometrial cancer?
Post-operative radiotherapy in high risk disease
Types - external beam or brachytherapy (vault insertions)
Side effects - proctitis, cystitis, lethargy, skin changes
153
Define subfertility
The inability of the couple to achieve pregnancy after 12 months of regular unprotected sexual intercourse
Primary or secondary (previous pregnancy)
154
Give 2 factors affecting fertility
Age (female)
Duration of sub-fertility
Timing of intercourse (needs to occur before ovulation, 2-3 times/week)
Weight (less likely if BMI <20 or >30)
155
Give 2 causes of infertility
```
Male factor (30%)
Ovulatory (25%)
Unexplained (25%)
Tubal (15%)
Endometriosis (5%)
```
156
What pre-conception health promotion advise can be given to couples?
```
Smoking cessation
Limit alcohol intake
Stop recreational drugs (e.g. anabolic steroids)
Weight loss/gain
Folic acid supplementation
```
157
How is male semen investigated?
Semen analysis - sample after 2-5 days abstinence; concentration (>15m/ml), motility (>40%), normal form (>4%), volume, vitality
158
Define azoospermia, oligospermia, asthenospermia and teratospermia
Azoospermia - absent sperm
Oligospermia - very few sperm
Asthenospermia - very immotile sperm
Teratospermia – abnormal morphology
159
What are the 3 ways in which male subfertility may occur?
Sperm transportation
Sperm production
Hypogonadotrophism
160
How should a subfertile male be assessed?
```
Semen analysis
History
Testicular examination
FSH levels
Karyotype (if no/few sperm)
```
161
What are the 3 types of azoospermia?
Obstructive - normal production/FSH and volume but no sperm in ejaculate due to blocked epididymis/vas or absent vas (test for CF)
Non-obstructive - testicular failure/increased FSH, small volume, biopsy and karyotype
Failure to stimulate spermatogenesis - hypogonadotrophic hypogonadism/low FSH
162
How is male subfertility managed?
IVF with ICSI (intra-cytoplasmic sperm injection) - better for obstructive azoospermia
Donor insemination - no quality sperm
163
What is the first thing which should be checked in a woman with suspected ovulatory subfertility and how?
Is she releasing an egg?
Regular cycle - check mid-luteal phase progesterone (day 21 of 28 day cycle)
Irregular/no cycle - unlikely to be releasing eggs
164
What is the WHO classification of anovulation?
Group 1 - hypothalamic pituitary failure
Group 2 - hypothalamic pituitary ovarian axis dysfunction
Group 3 - ovarian failure
165
How common is group 1 anovulation, give an example and how does it present?
Uncommon (5-10%)
E.g. hypogonadotrophic hypogonadism
Amenorrhoea, low gonadotrophins and oestrogen
166
What are the causes of group 1 anovulation?
Hypothalamic - idiopathic, weight, stress, exercise; craniopharyngioma, Kallman syndrome
Pituitary - tumour; Sheehan syndrome, cerebral radiotherapy
167
How is group 1 anovulation managed?
Increase BMI and decrease exercise
GnRH agonist - pump, limited, mono-ovulation
FSH/LH - problems with ovarian hyperstimulation (multiple pregnancy)
168
How common is group 2 anovulation, give an example and how does it present?
Commonest (80-85%)
E.g. PCOS
Hyperprolactinaemia, thyroid/adrenal dysfunction
169
What are the Rotterdam criteria for anovulatory infertility in PCOS?
1. Biochemical/clinical evidence of androgen excess
2. Amenorrhoea/oligomenorrhoea
3. TVUS features of PCOS
170
How is anovulatory infertility in PCOS managed?
Weight loss
Drug therapy - clomifene (SERM, increases FSH, induces ovulation), letrozole (aromatase inhibitor, increases FSH), metformin, FSH injection
Ovarian drilling (miscarriage risk)
Assisted reproductive technology - IVF
171
What are the complications of clomifene therapy for anovulatory infertility in PCOS?
Increased multiple pregnancy - not an issue for letrozole as one follicle is stimulated
Increased ovarian cancer risk (>12 months use)
172
What is ovarian hyperstimulation?
Ovaries over-respond to gonadotrophin injections and release vasoactive products
173
What are the complications of ovarian hyperstimulation?
Thrombosis
Renal dysfunction
Liver dysfunction
ARDS
174
What causes group 3 anovulatory infertility?
Premature ovarian insufficiency - idiopathic (premature ovarian failure), autoimmune, ovarian chemotherapy/radiation/surgery, chromosomal (Turner syndrome)
175
What do bloods show in group 3 anovulatory infertility?
```
Increased FSH
Decreased oestrogen (menopausal levels)
```
176
How is group 3 anovulatory infertility managed?
May have functional Graafian follicles in ovary - can conceive without treatment
Assisted conception - IVF and oocyte donation
177
What causes tubal subfertility?
Problems with ovum pick-up or transport
| PID, endometriosis
178
What 2 features of a history are suggestive of tubal subfertility?
Previous infection
| Ectopic pregnancy
179
How should suspected tubal infertility be investigated?
```
Chlamydia
TVUS
Hystero-salpingo-gram (HSG)
Hysterosalpingo-contrast-ultrasonography (Hy-Co-Sy)
Laparoscopy and dye test
```
180
How is tubal subfertility managed?
IVF
| Salpingesctomy/clipping if hydrosalpinx
181
How is endometriosis related subfertility managed?
Medical - symptom relief only, all effective drugs are anti-fertility
Surgical - diathermy, ovarian cystectomy
IVF
182
How is unexplained subfertility managed?
Full history and investigations
| IVF
183
What assisted reproductive technology options are there?
Ovulation induction - intrauterine insemination (IUI)
IVF - intra-cytoplasmic sperm injections (ICSI)
Donor sperm/eggs +/- IVF
184
What are the eligibility criteria for IVF in Scotland?
```
Co-habiting in a stable relationship >2 years
<42 years of age
BMI >18.5 and <30
Both partners non-smokers
At least one partner with no child
Not sterilised
```
185
What is the average age of menopause?
52 years
186
Outline the histology of an infant ovary
Filled with primordial follicles which contain oocytes (female germ cells)
Halted in prophase I of meiosis until puberty
187
Outline the process of folliculogenesis
Recruitment of primordial follicles
FSH - proliferation of granulosa cells and arrangement of theca cells around follicle
Primordial follicles -> primary follicles -> antral follicles -> 1 dominant follicle which releases an oocyte in response to LH
188
What are the causes of menopause?
```
Normal process of ageing
Surgical removal of ovaries
Radio/chemotherapy
Hysterectomy
Smoking
Deletions of X chromosome
```
189
How should a patient <45 years old in whom menopause has began be investigated?
FSH levels
| Genetic testing
190
Give 3 symptoms of menopause
```
Vasomotor - hot flushes, night sweats
Vulvo-vaginal dryness
Sleep disturbance
Mood disturbance
Sexual dysfunction
```
191
What change occurs to the vaginal epithelium in menopause?
Change from thick layer of mature superficial cells in high oestrogen environment to thin layer in low oestrogen environment
192
Give 3 changes to the urogenital tract in menopause and their consequences
Atrophic ovary and tubes
Fibroids shrink
Vagina lining becomes thin, low secretions and pH - vaginal dryness, dyspareunia, relationship breakdown, discomfort, bleeding
Atrophic urethral mucosa - frequency, dysuria, incontinence, recurrent UTI
Decreased tone and blood supply to pelvic floor - uterovaginal prolapse
Atrophic external genitalia
193
How does menopause affect mood/sleep/cognition?
```
Depression
Irritability
Anxiety
Poor memory
Sleep disturbance
Alzheimer's
```
194
What are the options for hormone replacement therapy in menopause?
```
Tablets
Implants
IUS
Gel
Patches
Pessaries
Vaginal rings
Creams
```
195
What hormones need to be replaced in menopause and why?
Oestrogen and progesterone (reduce risk of endometrial cancer)
196
How are the urinary symptoms of menopause managed?
Weight reduction
Pelvic floor muscle training
Bladder training
Antimuscarinics
197
How is osteoporosis risk assessed in menopause?
Assess fracture possibility - FRAX
| Prevention - falls, mobility, nutrition
198
What effect does HRT have on risk of CHD in menopause?
Reduces CHD by 50% if commenced within 10 years of menopause
199
What treatment options are there for flushing in menopause other than HRT?
Prescribed - clonidine, gabapentin, SSRI
Alternative - acupuncture, lifestyle, stellate ganglion blockade
Non-prescribed - vitamin E, evening primrose oil, phytoestrogens, black cohosh
CBT
200
Give 3 side effects of clonidine
```
Headache
Constipation
Dry mouth
Dry eyes
Impotence
Drowsiness
Confusion
Gynaecomastia
Hallucinations
Paraesthesia)
Dizziness
Nausea and vomiting
postural hypotension
Hair loss (alopecia)
Peripheral vasoconstriction
Decreased Libido
Depressed mood
```
201
Outline the micturition cycle which maintains continence
1 - bladder fills; detrusor muscle relaxes, urethral sphincter and pelvic floor contract
2 - first sensation to void; bladder half full, urination voluntarily inhibited until appropriate time
3 - normal desire to void
4 - micturition; detrusor muscle contracts, pelvic floor relaxes
202
What are the 3 types of urinary incontinence?
Urgency/overactive bladder
Mixed
Stress - anatomical defect in urethral support or sphincter muscle weakness
203
Which type of urinary incontinence is the most common? What causes it?
Stress
| Increased intra-abdominal pressure
204
Give 3 causes of urge incontinence/overactive bladder
```
Neurological - Parkinsons, stroke, MS, cognitive function
Mobility
Constipation
Previous surgery
Acute UTI
Caffeine
Alcohol
Bladder abnormalities - tumours, stones
High urine output - medication, excess fluid, diabetes, poor kidney function
```
205
Give 5 risk factors for urinary incontinence
```
Pregnancy
Parity
Pelvic surgery/radiation
Pelvic prolapse and repair
Race
Family history
Anatomical/neurological abnormalities
Drugs
Menopause
Cognitive impairment
UTI
Increased intra-abdominal pressure
Obesity
Co-morbidities
Age
```
206
How might urinary incontinence affect a patient's quality of life?
```
Exercise
Sleep
Employment
Emotions
Relationships
Socialising
Self with
Travel
Holidays
```
207
Give 3 symptoms to ask about when urinary incontinence is suspected
```
Stress incontinence
Frequency
Urgency
Urge incontinence
Nocturia
Enuresis
Haematuria
Dysuria
Voiding problems
Pain
Prolapse symptoms
```
208
How should a patient with suspected urinary incontinence be examined?
Abdominal/bimanual examination - masses, palpable bladder, pelvic floor tone
Vaginal examination - speculum, cervix/vaginal vault, check walls (prolapse, atrophy, fistula, ulceration), urine leakage on coughing
209
What investigations can be done for suspected urinary incontinence?
Urinalysis +/- culture - UTI, haematuria, diabetes
Bladder diary - 3 days minimum, in/out/time of leak
Cystoscopy and renal tract imaging
Urodynamic testing
210
What is urodynamics, why might it be carried out and which patients are suitable?
Dynamic study of bladder function - uroflowmetry measures flow and filling/voiding cystometry measures pressures
Why - obtain diagnosis, choose operation, predict complications
Who - failed conservative management/prior surgery, prior to surgery, treatment complications, suspected voiding problem
211
How is urinary incontinence managed?
Conservative - education, lifestyle changes (avoid caffeine/alcohol/carbonated drinks, weight loss, smoking cessation, treat cough/constipation), PT (pelvic floor exercises), bladder retraining (relearning higher cortical control of detrusor, empty bladder to strict hourly schedule and increase gradually)
Medical - antibiotics, anticholinergics (e.g. oxybutynin, inhibits contraction), B3 agonists (increase relaxation), duloxetine
Surgical
212
What is the success rate of conservative urinary continence management and what patients would not be suitable for this?
Cure in 75-85%
Not suitable if - haematuria, infection, pain, difficulty voiding, tried and failed, patient unable/unwilling to engage, no facilities
213
What are the side effects of anticholinergics for overactive bladder urinary incontinence and how is treatment managed?
Side effects - dry mouth, dry eyes, constipation
| 4-6 weeks needed to assess response, trial withdrawal every 3-4 months if successful
214
How does duloxetine work for treating stress urinary incontinence and what are its side effects?
Stimulated pudendal nerve which increases sphincter contraction
Side effects - GI disturbance, dry mouth, headache, suicidal ideation
215
How can an overactive bladder be managed surgically?
Detrusor botox injections
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion
216
How can an stress urinary incontinence be managed surgically?
Synthetic tapes/mid-urethral sling
Colposuspension
Biological slings
Intramural bulking agents
217
Define uterovaginal prolapse
Protrusion of the uterus and/or vagina beyond normal anatomical confines
Often involves bladder, urethra, rectum and bowel
218
What is the pelvic floor?
Muscular and fascial structures which provide support to the pelvic viscera and external openings of the vagina, urethra and rectum
219
What structures support the uterus and cervix/upper vagina?
Uterus - vaginal walls, transverse cervical ligaments, round and broad ligaments
Cervix and upper vagina - transverse cervical ligaments, uterosacral ligaments
220
Give 3 risk factors for uterovaginal prolapse
Increasing age
Menopause
Vaginal delivery - direct trauma (avulsion of levator ani/ligaments via forceps), pudendal nerve damage (against bony pelvis)
Increased parity
Raised intra-abdominal pressure - obesity, chronic cough/constipation
Abnormal collagen metabolism
221
What are the symptoms of uterovaginal prolapse?
```
Asymptomatic
Sensation of pressure/fullness/heaviness
Sensation of bulge/something coming down which is worse at the end of the day and better on lying down
Bleeding/discharge
Backache
Dyspareunia
Urinary incontinence/frequency/urgency
Need to manually reduce before voiding
Constipation/straining
Faecal incontinence/urgency
Incomplete faecal evacuation
```
222
How should a patient with suspected uterovaginal prolapse be examined?
Vaginal examination - speculum, cervix/vaginal vault, check walls for descent/atrophy/ulceration, ask patient to cough
Abdominal/bimanual examination - masses
223
How are uterovaginal prolapses graded?
Pelvic organ prolapse quantification (POPQ) - based on position of most distal portion during straining
224
Outline the pelvic organ prolapse quantification used for grading uterovaginal prolapses
Stage 0 - no prolapse
Stage 1 - >1cm above hymenal ring
Stage 2 - extends from 1cm above to 1cm below hymenal ring
Stage 3 - extends >1cm below hymenal ring
Stage 4 - vagina completely everted (complete procidentia)
225
How are prolapses classified anatomically according to site of the defect and pelvic viscera that are involved?
Cystocele - bladder protrudes (anterior)
Urethrocele - descent of the lower anterior vaginal wall where the urethra sits
Rectocele - rectum protrudes (posterior)
Enterocele - upper posterior vaginal wall (fornix) and pouch of Douglas, contains small bowel
Uterine prolapse - uterus into vagina
Vaginal vault prolapse - following hysterectomy
226
What is the commonest type of prolapse?
Prolapse of upper anterior vaginal wall and bladder (cystocele)
227
What are the 3 degrees of uterine prolapse?
1st - cervix does not pass outside introitus
2nd - cervix protrudes beyond introitus
3rd - total prolapse
228
How are prolapses managed?
Conservative - none, lifestyle (weight, smoking), PT (pelvic floor exercises), pessaries, vaginal oestrogen
Surgical - vaginal, abdominal
229
What factors will influence management of a patient with prolapse?
```
Severity of symptoms
Impact on quality of life
Age/parity/future plans
Sexual activity
Presence of smoking or obesity
Urinary symptoms
Other gynaecological issues (e.g. menorrhagia)
```
230
Where is a ring pessary placed?
Between posterior aspect of symphysis pubis and posterior fornix of vagina
231
Name 3 types of pessary
```
Ring
Shelf
Gelhorn
Hodge (correction of uterine retroversion)
Cube (if difficulty retaining others)
Donut (if difficulty retaining others)
```
232
Give 3 complications of pessaries
```
Interfere with sexual intercourse
Ulceration
Infection
Difficulty and discomfort on insertion/removal
Fistula can occur if neglected
```
233
What are the surgical management options for prolapse?
Anterior compartment defect (cyctocele) - anterior colporrhaphy
Posterior (rectocele) - posterior colporrhaphy
Uterovaginal prolapse - hysterectomy, Manchester repair, sacrohysteropexy
Vaginal vault prolapse - sacrospinous ligament fixation, sarcocolpopexy
Vaginal closure - colpocleisis
234
What are the indications for prolapse sugery?
Pessaries failed
Patient request for definitive treatment
Prolapse combined with urinary/faecal incontinence
235
What are the complications of prolapse surgery?
Anterior - dyspareunia, incontinence, failure, recurrence
| Posterior - dyspareunia
236
How can prolapse be prevented?
```
Weight reduction
Treatment of constipation/cough
Smoking cessation
Avoidance of heavy lifting
Pelvic floor exercises
Good intrapartum care - avoid unnecessary instrumentation/prolonged labour
```
237
What are the 3 gynaecological emergencies?
Ectopic pregnancy
Miscarriage
Post-operative/intra-abdominal bleeding
238
How common are abortions?
25% of all pregnancies end in abortion
| 1 in 3 people will have had an abortion by 45 years of age
239
What is the national set up for abortion in Scotland?
Medical abortion up to 18 weeks
Surgical procedures up to 13 weeks
>18 weeks - access funded abortion care in England
240
What are the 2 types of abortion?
Medical - at home or inpatient
Surgical - local or general anaesthetic
Same as miscarriage management
241
How is medical abortion achieved?
Mifepristone 200mg - anti-progesterone taken orally in clinic
Misoprostol 800mcg - taken 24-48 hours later, vaginal/buccal/sublingual, prostaglandin analogue, can be taken at home
242
What are the inclusion criteria for taking misoprostol at home for a medical abortion?
Clinic for the first drug (mifepristone)
Fulfils the criteria set out in the Abortion Act 1967
16 years +
No significant medical conditions or contraindications to medical abortion
243
What should a woman undergoing medical abortion expect?
Will experience vaginal bleeding (heavy with clots, up to 2 weeks) and lower abdominal pain (cramping) 2-3 hours after misoprotsol usually completing within 4 hours
Simple analgesia and hot water bottle may be used during this time
244
What should a woman undergoing surgical abortion expect?
Day case
Will need to be fasted and have an adult escort for GA
Symptoms - minimal abdominal pain, 1 week of vaginal bleeding
245
What additional things should be considered in a patient undergoing abortion?
Contraception - needed 5 days after, most can start on day of
Antibiotic prophylaxis may be required
Anti D IgG may be required if medical >10 weeks or surgical
Cervical screening status
Sexual health screen
Female genital mutilation
246
What are the complications of abortion?
```
Failure to end pregnancy
Retained tissue
Infection
Haemorrhage
Cervical tear (late medical)
Uterine perforation (late medical)
```
247
What are the risk factors for long term psychological issues following abortion?
Possible long term psychological risk factors:
Previous / current mental health problems
Pressure to have abortion
Unsure of decision / ambivalent about abortion
Unsupportive partner / limited social support
Belonging to a religious, social or cultural groups
248
What are crisis pregnany centres?
Some CPCs do not provide impartial pregnancy decision-making support
Many have a specific anti-abortion agenda
249
Give 3 contraindications to medical abortion
```
Long term corticosteroids
Severe asthma
Adrenal insufficiency
Clotting disorders
Porphyria
Sickle cell
High cholesterol
Hypertension
```
250
Give 2 contraindications to surgical abortion
```
BMI 40
BMI 35 with comorbidities
Anaesthetic complications
Difficulty accessing cervix e.g. tumor
Gestational trophoblastic disease IP rather DS
```
251
When should medical attention be sought following an abortion?
Very heavy bleeding - soaking >2 pads/hour for 2 consecutive hours, symptoms of anaemia (dizziness, SOB, palpitations, fatigue)
Persistent bleeding/pain
Offensive vaginal discharge
High fever/systemically unwell
252
What should be covered in the history of a patient who has recently had an abortion and is bleeding?
```
Assess bleeding
Type of abortion and process
Associated symptoms
Contraception
STI screen
Prophylactic antibiotics
```
253
What is the differential diagnosis for bleeding after abortion?
Incomplete abortion
Endometritis
Uterine perforation
Contraception side-effect
254
What is RPOC?
Retained products of conception
| Placental/fetal tissue left inside uterus
255
How is RPOC diagnosed?
History - persistent pain/bleeding, may have infection
| USS - endometrial cavity filled with irregular vascular material
256
How is RPOC managed?
Expectant - watch and wait
Medical - further misoprostol dose
Surgical - evacuation
257
What is endometritis?
Infection of the lining of the uterus occurring within the first few days of abortion
258
Give 3 signs/symptoms of endometritis
```
Persistent lower abdominal pain / tenderness
Pain with intercourse (deep dyspareunia)
Persistent bleeding
Offensive vaginal discharge
Fever
Cervical motion tenderness
```
259
How is endometritis managed?
Broad spectrum antibiotics (local PID guideline)
Analgesia
If septic - admit, IV antibiotics, IV fluids
If retained tissue - empty uterus ASAP
260
When does uterine perforation after abortion usually present and how?
Usually recognised and managed at time of procedure
| If not, may present up to 48 hours later with abdominal pain and bleeding
261
How is uterine perforation after abortion managed?
Laparoscopy/lamarotomy and repair
262
What affect does abortion have on future fertility and risk of breast cancer?
None
263
What should be asked in a consultation where a woman has requested a pregnancy test?
LMP
Unprotected sexual intercourse
Contraception
How would they feel if it were positive
264
What should be asked in a consultation where a woman has a positive pregnancy test and does not want to be pregnant?
LMP/ gestation calculation
Medical & sexual history
Past and current mental health illness
Assess STI risk and screen
Explore feelings about pregnancy/reasons for abortion
Ask if sure about decision/check for ambivalence
Assess risk of coercion (gender based violence)
Check support (partner/friends/relatives)
Ask about beliefs about abortion in general
Outline options (parenting, abortion, adoption)
Outline different abortion methods
Discuss/prescribe contraception
Explain how to access abortion service
Refer and sign Certificate A (optional)
Offer post abortion review
265
What are the legal implications of having a conscientious objection to abortion as a doctor?
Abortion Act 1967
Doctors have a legal & professional right to opt out of participating in abortion care
As long as the woman can still access an abortion
Unless one is needed to save life/prevent serious harm
GMC: Personal beliefs and medical practice (2013)
Doctors may practise medicine in accordance with their beliefs, provided that they do not:
treat patients unfairly
deny patients access to appropriate medical treatment or services
cause patients distress
GMC: Good Medical Practice (2013)
You must explain to patients if you have a conscientious objection to a particular procedure
Tell them about their right to see another doctor
Make sure they have enough information to exercise their right
266
What is the potential impact of conscientious objection of abortion?
Patients seeking abortion - feel judged and/or stigmatised, decision may be influenced by doctor, trust in doctor may be eroded
Medical colleagues - increased workload
Colleagues with objections - feel judged/stigmatised
Abortion service provision - care limited/compromised if too many opt out
Medical profession - trust undermined, reputation damaged
267
What routine asymptomatic STI testing is available for men and woman?
Men - urine (chlamydia, gonorrhoea), blood (HIV, syphilis)
| Women - self-take vaginal swab (chlamydia, gonorrhoea), blood (HIV, syphilis)
268
What type of test is used for chlamydia and gonorrhoea and how is the sample taken?
Nucleic acid amplification testing (NAAT) - dual PCR, orange tube with swab which snaps
Women - low vaginal swab
Men - first pass urine
Extra-genital - pharynx, rectal
269
How is HSV tested for?
Viral PCR vial with fluid
Plain swab used to obtain fluid from ulcer and then transferred to fluid in vial which is shaken
Also tests for syphilis
270
How are BBV tested for?
```
9ml EDTA (large/2 small purple top) tube to virology
Tests for - HIV and syphilis, hepatitis B and C in high risk groups
```
271
What is a window period?
The period of time when a person may be infected but the test is not yet positive depending on type of infection and test
Important that patients are not falsely reassured by a negative result when they may still have an infection and therefore pass it on unknowingly
272
What is the window period for HIV?
4 weeks (8 weeks if high risk)
273
How might partner notification occur?
Patient initiated
| Provider initiated - anonymous text message service
274
What is the window period for chlamydia and gonorrhoea?
2 weeks
275
What is the window period for hepatitis B and C?
B - 3 months
| C - 4 weeks to 3 months
276
What is the window period for syphilis?
3 months
277
What contraceptive options are available?
Long acting and reversible - implant, injection, intrauterine (hormonal, non-hormonal)
Long acting and permanent - vasectomy, sterilisation
Short acting - hormonal pills/patches/rings, condoms (male, female), diaphragm
278
What is the contraceptive implant, how does it work and what are its side-effects?
Small flexible rod lying under the skin of the upper arm
Contains progestogen - stops ovulation, thickens mucus, thins lining
3 year duration
0.05% failure
Side-effects - unpredictable bleeding
279
What is the contraceptive injection, how does it work and what are its side-effects?
```
Injection into buttock or abdomen
Contains progestogen
Given every 13 weeks
6% failure
Side-effects - irregular bleeding, weight gain, reduced BMD, 1 year after stopping for ovulation to be normal
```
280
What is the hormonal intrauterine device, how does it work and what are its side-effects?
Progestogen
3-5 years duration
0.2% failure
Side-effects - lighter/stopped periods, irregular bleeding in first 6 months
281
What is the non-hormonal intrauterine device, how does it work and what are its side-effects?
Copper - kills sperm, stops implantation, thickens mucus
5-10 year duration
0.8% failure
Side-effects - heavier more painful periods
282
What are the combined hormonal contraceptive options, how do they work and what are their side-effects?
Oestrogen and progestogen - pill, patch, ring; inhibits ovulation, thickens mucus, thins lining
21 days on, 7 days off
Reduced effectiveness if missing, vomiting or diarrhoea
9% failure
Reduced bleeding and period pain
Risks - VTE/PE, contraindicated in migraine, increased risk of breast cancer
283
What is the progestogen only pill, how does it work and what are its side-effects?
Progestogen (e.g. cerelle)
Take daily without breaks
9% failure
Can be used in smokers, >35 year olds, breastfeeding or CI to oestrogen
Side-effects - break through bleeding, amenorrhoea
284
Outline sterilisation as a contraceptive option
Tubes cut/sealed/blocked - fallopian tube in women (GA), vas deferens in men (LA)
Women 0.5% failure, men 0.1% failure
Permanent
Will not improve periods
285
What is the failure rate of condoms (typical use)?
18%
286
What are the most and least effective contraceptive options?
```
Implant
Male sterilisation
LND-IUS
Female sterilisation
Cu-IUD
Injection
CHC/POP
Condoms
None
```
287
Outline the use of emergency contraception
If method has failed/been forgotten
Free from GP/chemist/Sandyford
Gold standard is copper intrauterine device within 5 days of unprotected sex/predicted ovulation
Oral hormonal - ullipristal acetate (ellaOne) up to 120 hours after sex, levonorgestrel (levonelle) up to 72 hours after sex
288
What is FGM
Procedure that involves partial or total removal of the external female genitalia, or other injury to the female genitals
For non medical reasons
289
Give 3 risk factors for STIs
Young age (less than 25, but especially less than 20) – especially cisgender women
Not in a monogamous relationship
Multiple sexual partners or recent change of sexual partner
Non use of barrier methods of contraception
Ethnicity for some STIs eg. hepatitis B in Asians, gonorrhoea and trichomonas in black Carribeans, HIV in Black Africans
Sexual orientation – men who have sex with men (MSM)
Residence in metropolitan areas
290
What is the most common bacterial STI in the UK?
Chlamydia
291
What are the signs/symptoms of chlamydia in women?
```
80% asymptomatic
PCB/IMB
Purulent discharge
Lower abdominal pain
Proctitis
Cervicitis
Cervical contact bleeding
Pelvic infection
```
292
What are the signs/symptoms of chlamydia in men?
```
50% asymptomatic
Urethral discharge
Dysuria
Testicular/epididymal pain
Proctitis
```
293
How is chlamydia managed?
Doxycycline 100mg for 7 days
| Erythromycin 500mg for 14 days if pregnant/breastfeeding
294
What are the complications of chlamydia?
Pelvic inflammatory disease - increasing risk of infertility, ectopic pregnancy and chronic pelvic pain with repeated infections.
Epididymitis.
Reactive arthritis
Fitz-Hugh Curtis syndrome
295
What are the risks of chlamydia in pregnancy?
Neonatal conjunctivitis in 30-50%, less commonly pneumonitis
Low birth weight
Post-partum endometritis
296
What are the signs/symptoms of gonorrhoea in women?
Cervical infection asymptomatic in 70%
Vaginal discharge
Low abdominal pain
297
What are the signs/symptoms of gonorrhoea in men?
Urethral discharge
Dysuria
Rectal infection
298
How is gonorrhoea managed?
Ceftriaxone 1g
299
What are the complications of gonorrhoea for men and women?
Women - PID, bartholinitis, endometritis
| Men - epididymitis, infection of penile glands (Tyson’s glands)
300
How does HSV present?
70-80% asymptomatic
Primary infection - febrile illness of 5-7 days, dysuria, painful lymphadenopathy, neuropathic pain, genital blisters, ulcers, fissures
301
What are the complications of HSV?
Urinary retention, constipation, rarely aseptic meningitis
Recurrent infections tend to be milder and resolve within 3-4 days
Risk of symptomatic recurrences greater in patients who have type 2 HSV, who have a severe first episode and who are immunocompromised
302
How is HSV managed?
Primary - acyclovir 400mg TID for 5 days, simple analgesia, salt bath
Recurrence - acyclovir 800mg TID for 2 days
303
What organism causes syphilis?
Treponema pallidum
304
What are the symptoms of syphilis?
Indurated anogenital/oral ulcer - may be painless or painful
305
How is syphilis diagnosed?
Syphilis serology
Swab of lesion for PCR testing
Dark ground microscopy (of fluid from lesion) in specialist sexual health services
306
How is syphilis managed?
Benzathine penicillin 2.4 mu IM (early)
307
What are the complications of syphilis?
Neurosyphilis (usually a late complication but may occur earlier if immune suppressed)
Cardiovascular syphilis (late complication)
Gummata
308
What is a gumma?
A small soft swelling which is characteristic of the late stages of syphilis and occurs in the connective tissue of the liver, brain, testes, and heart
309
What causes anogenital warts?
HPV (types 6 and 11)
310
What are the symptoms of anogenital warts?
Warts around sites of trauma (e.g. introitus in women, penis in men)
Genital lumps which can itch and bleed
311
How are anogenital warts diagnosed?
Clinical appearance
| Biopsy should be done if atypical appearance
312
How are anogenital warts managed?
Podophyllotoxin cream/solution
Imiquimod
Cryotherapy
313
How can anogenital warts be prevented?
HPV vaccination (6, 11, 16, 18) to all women at school and all MSM <45 years old
314
Give 3 causes of discharge
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Physiological
STI - gonorrhoea, chlamydia
Candida
Bacterial vaginosis
Trichomonas vaginalis (STI)
Allergic reaction/dermatosis
```
315
How do candida, BV and TV differ in type of discharge and treatment?
Candida - thick, white, itchy, sore; anti-fungal (e.g. clotrimazole)
BV - thin, grey, watery, fishy, burning; metronidazole
TV - thin, frothy, yellow, fishy, itchy, sore, dysuria, vaginitis; metronidazole
316
What is the normal vaginal pH?
3.5-4.5
