Obstetrics and Gynaecology 1 Flashcards
(466 cards)
1
Q
What is a Miscarriage?
A
Loss of pregnancy before 24 weeks gestation
2
Q
What is an EARLY vs LATE Miscarriage?
A
Early miscarriage: 13- wksLate miscarriage: 13-24 wks
3
Q
What percentage of pregnancies end up as Miscarriages?
A
30%
4
Q
What are the RF for Miscarriages? (5 things)
A
- Age (both maternal + paternal like 35+)2. Black ethnicity3. Obesity4. Infection (e.g appendicitis)5. Anti-phospholipid syndrome
5
Q
What is the single most common cause of Miscarriages in 1st trimester?
A
Chromosomal abn
6
Q
What should you sus in with all women with bleeding in early pregnancy?
A
Miscarriage
7
Q
What are the classifications of Miscarriages? (5 things)
A
- Missed2. Threatened3. Inevitable4. Incomplete5. Complete
8
Q
What is a Missed Miscarriage?
A
Asymptomatic miscarriage
9
Q
What is a Threatened Miscarriage?
A
Ongoing viable pregnancy w Bleeding
10
Q
How long do symptoms of Threatened Miscarriage last?
A
Days / weeks
11
Q
What is an Inevitable Miscarriage? (2 things)
A
- Non-viable pregnancy w Bleeding2. Pregnancy tissue still in uterus
12
Q
What will an Inevitable Miscarriage become? (2 things)
A
Incomplete OR Complete miscarriage
13
Q
What is the difference between INCOMPLETE and COMPLETE Miscarriage?
A
Incomplete: still has some products of conception left (seen in US)Complete: all products of conception have been expelled + bleeding STOPPEDPlus Cervical Os still Open in Incomplete
14
Q
What are the CF of Miscarriages? (2 things)
A
- Bleeding2. Abd pain
15
Q
What is the blood like in Miscarriage?
A
Usually low volume
16
Q
What are the CF of Miscarriage if there is Excessive bleeding? (4 things)
A
Haemodynamic instability:1. Pale2. Tachycardia3. Hypotension4. Tachypnoea
17
Q
What are the CF of Miscarriage @ Abd examination? (2 things)
A
- Distension2. Localised tenderness
18
Q
What are the CF of Miscarriage @ Speculum examination? (3 things)
A
- Products of conception in Cervical canal2. Bleeding3. Cervical os (Open / Closed)
19
Q
What is the Cervial Os like in a MISSED Miscarriage?
A
Closed
20
Q
What is the Cervial Os like in a THREATENED Miscarriage?
A
Closed
21
Q
What is the Cervial Os like in an INEVITABLE Miscarriage?
A
Open
22
Q
What is the Cervial Os like in an INCOMPLETE Miscarriage?
A
Open
23
Q
What is the Cervial Os like in a COMPLETE Miscarriage?
A
Closed
24
Q
When is the only times the Cervical Os is OPEN in a Miscarriage? (2 things)
A
- Inevitable2. IncompleteOpeN iN iN
25
What are the CF of Miscarriage @ Bimanual examination? (2 things)
1. Uterine tenderness2. Adnexal masses / collections
26
What are some other Differential Dx of Miscarriage? (3 things)
1. Ectopic preg2. Hydatidiform mole3. Cancer (cervical / uterine)
27
Where should pt with sus Miscarriage be investigated?
EPAU
28
What investigation gives you a Definitive Dx of Miscarriage?
Transvaginal US
29
What will you NOT see in a Transvaginal US that will give you a Dx of Miscarriage?
Fetal Cardiac Activity
30
What weeks will you check for Fetal Cardiac Activity to check for Miscarriage Dx?
5.5 – 6 wks gestation
31
How can you calculate the weeks of gestation using US?
Crown Rump Length (CRL)
32
What are the measurements for a definitive Dx of MISSED Miscarriage? (2 things)
1. CRL: 7+ mm2. NO Fetal Cardiac Activity(both together)
33
Can you make a Dx of Missed Miscarriage if you have NO Fetal Cardiac Activity but the CRL is LESS than 7mm?
No, you have to repeat US 7 days later to confirm
34
What are the measurements for a definitive Dx of Empty Sac Miscarriage (aka Anembryonic Pregnancy? (2 things)
1. Mean Sac Diameter (MSD): 25+ mm2. NO Yolk Sac / Embryonic Pole (Fetal pole in pic)(both together)
35
Can you make a Dx of Empty Sac Miscarriage (aka Anembryonic Pregnancy if you have NO Yolk Sac / Embryonic Pole but the MSD is LESS than 25mm?
No, you have to repeat US 10-14 days later to confirm
36
What investigation can be done if US is not immediately available for Miscarriage?
Serum b-HCG blood test (helps Dx viable n non-viable pregnancy)
37
What other investigations can you do for bleeding women? (3 things)
1. FBC2. Blood group + Rhesus status3. Triple swabs + CRP (esp if pyrexial)
38
What is the Tx of for Threatened Miscarriages? (2 things)
1. Analgesia2. Vaginal micronised progesterone (400mg twice daily) (NICE 2021)
39
Who should have Vaginal Micronised Progesterone according to NICE 2021?
Woman who is:1. Pregnant (confirmed by scan)2. Bleeding3. Had a previous miscarriage(All 3)
40
What does Vaginal Micronised Progesterone do?
Helps preserve Threatened Miscarriage into Live Birth
41
If Fetal Cardiac Activity is confirmed while on Vaginal Micronised Progesterone, what should you do?
Continue VMP until 16 wks
42
What should you give if any type of Miscarriage pt (even threatened) is 12+ wks and Rhesus Negative?
Anti-D immunoglobulin
43
What is FIRST LINE management of Miscarriages?
Expectant (conservative) management (aka jus wait n let it come out naturally)
44
Who should be offered Expectant management of Miscarriage?
6- wks gestation w bleeding but NO pain
45
How long should you trial Expectant management for Miscarriages for?
7-14 days
46
If you do Expectant management of a miscarriage, and symptoms resolve within 7-14 days, what should the pt do next?
Pregnancy test @ 3 wks (if positive come bk)
47
What are the Advantages of Expectant Management of Miscarriage? (3 things)
1. Can go home2. No meds side fx3. No anaesthetic / surgery risk
48
What are the Disadvantages of Expectant Management of Miscarriage? (4 things)
1. Unpredictable timing2. Heavy bleeding + Pain @ passing POC (products of conception)3. Might not work4. Might need transfusion
49
What are the CI for Expectant management for Miscarriages? (4 things)
1. Infection2. Increased risk of haemorrhage (e.g coagulopathy)3. Hx of bad pregnancies4. Pt doesn’t want to
50
What are the MEDICAL management options for Miscarriages? (3 things)
1. Misoprostol (vaginal / oral) (vaginal is preffered)2. Analgesia (PRN)3. Anti-emetics (PRN)
51
What is Misoprostol? (2 things)
1. Synthetic prostaglandin that stimulates Cervical Ripening + Uterine contractions2. Used as Medical management for miscarriages
52
What should you give 24-48 hours before Misoprostol?
Mifepristone
53
What is Mifepristone?
Anti-progestational steroid (blocks progesterone)(progesterone helps pregnancy, remember dat lecturer said its PRO-GEST-erone)
54
What should you do after giving Misoprostol?
Pregnancy test @ 3 weeks
55
What happens if Pregancy test @ 3 wks after Misoprostol is still Positive?
Specialist review
56
What are the Advantages of Medical Management of Miscarriage? (2 things)
1. Can go home2. No anaesthetic / surgery risk
57
What are the Disadvantages of Medical Management of Miscarriage? (3 things)
1. Meds side fx: D+V2. Heavy bleeding + Pain @ passing POC (products of conception)3. Might not work (might need emergency surgical intervention)
58
What should you do if Expectant and Medical Management of Miscarriages fail?
Surgical management
59
What are the 2 main options for Surgical management of Miscarriages?
1. Manual vacuum aspiration (under LOCAL) (if 12- wks)2. Evacuation of Retained Products of Contraception (ERPC) (under GENERAL)
60
Who is Manual vacuum aspiration more suitable for?
Parous women (given birth b4)
61
What are the Indications for Surgical management of Miscarriage? (3 things)
1. Haemodynamically unstable2. Infected tissue3. Gestational trophoblastic disease
62
What are the Advantages of Surgical management of Miscarriage? (2 things)
1. Planned procedure (helps pt cope)2. Pt unconscious (under general)
63
What are the Disadvantages of Surgical management of Miscarriage? (7 things)
1. Infection (endometriosis)2. Bleeding3. Ashermen’s syndrome (scar tissue aka adhesions form inside uterus)4. Uterine perforation5. Bowel / bladder damage6. Retained POC (products of contraception)7. Anaesthetic risk
64
What is given before Surgical management of Miscarriage and why?
Misoprostol, to soften cervix
65
When can sexual intercourse resume after a miscarriage?
Once symptoms have completely settled
66
When can a pt start trying to conceive again after a miscarriage?
@ 4-8 wks bc that’s when menstruation will resume
67
What is a Recurrent miscarriage according to RCOG?
3+ consecutive pregnancies that end in miscarriage of fetus before 24 weeks gestation
68
What is the epidemiology of Recurrent Miscarriages?
1-2% women
69
What are the RF for Recurrent Miscarriages? (3 things)
1. Age2. No. of previous miscarriages3. Lifestyle (smoking / alcohol / caffeine)
70
The risk of miscarriage increases after each miscarriage... what is the risk of a 4th miscarriage after the 3rd one?
40%
71
What are the causes of Recurrent Miscarriages? (7 things)
1. Antiphospholipid syndrome2. Genetic factors (parental / embyronic chromosomal abn)3. Endocrine factors (DM / Thyroid / PCOS)4. Anatomical factors (uterine abn / cervical weakness)5. Infection (any severe infection / bacterial vaginosis)6. Inherited thrombophilia7. Idiopathic (esp older women)
72
What happens in Antiphospholipid syndrome?
Blood clots more
73
How can you get Antiphospholipid syndrome? (2 things)
1. Randomly2. Secondary to SLE
74
What percentage of Recurrent Miscarriage women have Antiphospholipid syndrome?
15%
75
What is the live birth rate for women with Antiphospholipid syndrome with no pharma intervention?
10% :( , but dw is treatable
76
What percentage of Recurrent Miscarriage couples have a Parental chromosomal abn being carried by one of the parents?
2-5%
77
What Parental chromosomal abn can be carried that cause Recurrent Miscarriages? (2 things)
1. Balanced reciprocal2. Robertsonian translocation
78
If DM and Thyroid disease are WELL controlled @ conception / during pregnancy is that calm?
Yh
79
What Uterine abn can cause Recurrent Miscarriages? (6 things)
1. Asherman's syndrome (adhesions of uterus)2. Fibroids3. Septate uterus (partition thru uterus)4. Unicornuate uterus (single horned uterus)5. Bicornuate uterus (heart shaped uterus)6. Didelphic uterus (double uterus)
80
How can Cervical weakness cause Recurrent Miscarriages?
Cervix effaces and dilates before term
81
When does Cervical weakness cause Miscarriage?
2nd trimester
82
How can Bacterial vaginosis cause Recurrent Miscarriages?
Infection in 1st trimester --\> 2nd trimester miscarriage
83
How is the Bacterial vaginosis cause of Recurrent Miscarriages prevented against?
Screening in 1st trimester + Tx if appropriate
84
What are the Inherited Thrombophilias that cause Recurrent Miscarriages? (4 things)
1. Factor V Leiden2. Prothrombin gene mutation3. Protein C/S deficiencies4. Antithrombin 3 deficiency
85
When do Inherited Thrombophilias cause Miscarriages?
2nd trimester
86
How do Inherited Thrombophilias cause Miscarriages?
Thrombosis of uteroplacental circulation
87
When should investigations be started for Recurrent Miscarriages? (2 things)
1. After 3+ 1st trimester miscarriages2. After 1+ 2nd trimester miscarriages
88
What different types of investigations can be done for Recurrent Miscarriages? (3 things)
1. Blood tests2. Genetic tests3. Imaging
89
What blood tests can be done for Recurrent Miscarriages? (2 things)
1. Antiphospholipid antibodies2. Inherited thrombophilia screen
90
How is a diagnosis of Antiphospholipid syndrome confirmed with blood tests? (3 things)
2 positive tests at least 12 weeks apart for either:1. Lupus Anticoagulant2. Anticardiolipin Antibodies3. Anti-B2-Glycoprotein Antibodies
91
What is checked for in an Inherited Thrombophilia Screen for Recurrent Miscarriages? (4 things)
1. Factor V Leiden2. Prothrombin gene mutation3. Protein C/S deficiencies4. Antithrombin 3 deficiency
92
What genetic tests can be done for Recurrent Miscarriages? (2 things)
1. Cytogenic analysis2. Parental peripheral blood karyotyping
93
What does Cytogenic analysis check for in Recurrent Miscarriages?
Chromosomal abn
94
What tissue is Cytogenic analysis done on in Recurrent Miscarriages?
Products of conception
95
When is Cytogenic analysis done for Recurrent Miscarriages?
After 3rd miscarriage + all ones after that
96
When should you do Parental peripheral blood karyotyping for Recurrent Miscarriages?
When Products of conception testing shows unbalanced structural chromosomal abn
97
Who is Parental peripheral blood karyotyping done on?
Both partners
98
What imaging can be done for Recurrent Miscarriages?
Pelvic US
99
What is a Pelvic US checking for in Recurrent Miscarriages?
Uterine anatomy
100
If you sus uterine abn in Pelvic US, what further investigations should you do to confirm Dx? (3 things)
1. Hysteroscopy2. Laparoscopy3. 3D Pelvic US
101
What should patients with Recurrent Miscarriages be referred for?
Specialist treatment
102
How should you manage a couple with abn Parental karyotypes?
Refer to clinical geneticist (genetic counselling)
103
Will surgical correction of Uterine abn (like septated uterus) change the pregnancy outcome?
No (no evidence on this so far)
104
Will surgical correction of Cervical weakness change pregnancy outcome?
Yes
105
What is the surgical treatment for Cervical weakness?
Cervical cerclage (suture used to close cervix)
106
What are the indications for Cervical cerclage? (3 things)
1. Poor obstetric Hx (3+ 2nd trimester miscarriages)2. Cervical shortening on US (25-mm before 24 wks + Hx of 2nd trimester miscarriage)3. Symptomatic + Premature Cervical dilatation + Exposed Fetal membranes in vagina
107
What are the complications of Cervical Cerclage? (3 things)
1. Bleeding2. Membrane rupture3. Stimulating uterine contractionsTherefore need senior involvement n counselling b4 decision
108
What should you offer women with Hx of 2nd trimester miscarriages + Sus cervical weakness who have NOT had Cervical cerclage?
Serial Cervical Sonographic Surveillance
109
What is the treatment for Recurrent Miscarriages caused by Antiphospholipid Syndrome? (2 things)
1. Low dose aspirin2. LMWH
110
What is the treatment for 2nd trimester Recurrent Miscarriages caused by Inherited Thrombophilias?
Heparin
111
What can you offer a woman with Unexplained Recurrent Miscarriages?
Preimplantation genetic screening + IVF (no evidence on this tho)
112
What is Heavy Menstrual Bleeding?
Excessive menstrual loss which interferes with a woman’s quality of life
113
What percentage of women experience Heavy Menstrual Bleeding?
3%
114
What age group of women are most affected by Heavy Menstrual Bleeding?
40-51 years old
115
What is the mnemonic used to divide the different causes of Heavy Menstrual Bleeding?
Palm-Coein
116
What does the PALM bit of the Palm-Coein mnemonic mean?
Structural causes of Heavy Menstrual Bleeding:P – PolypA – AdenomyosisL – Leiomyoma (Fibroid)M – Malignancy / hyperplasia
117
What does the COEIN bit of the Palm-Coein mnemonic mean?
Non-structural causes of Heavy Menstrual Bleeding:C – CoagulopathyO – Ovulatory dysfunctionE – EndometrialI – IatrogenicN – Not yet classified
118
What are the main risk factors for Heavy Menstrual Bleeding? (2 things)
1. Age2. Obesity
119
What are the CF of Heavy Menstrual Bleeding? (3 things)
1. Bleeding2. Fatigue3. SOB (if associated anaemia)
120
What are you looking for @ examination of Heavy Menstrual Bleeding patient? (4 things)
1. Pallor (anaemia)2. Palpable uterus / pelvic mass3. Inflamed cervix / cervical polyp / tumour4. Vaginal tumour
121
What are you suspecting if a Heavy Menstrual Bleeding patient has an irregular uterus @ examination?
Fibroids
122
What are you suspecting if a Heavy Menstrual Bleeding patient has a tender uterus / cervical excitation @ examination? (2 things)
1. Adenomyosis2. Endometriosis
123
What are the differential diagnoses for Heavy Menstrual Bleeding? (9 things)
1. Pregnancy2. Endometrial / cervical polyps3. Adenomyosis4. Fibroids5. Malignancy / endometrial hyperplasia6. Coagulopathy7. Ovarian dysfunction8. Iatrogenic causes9. Endometriosis
124
What are the CF of Endometrial / cervical polyps? (3 things)
1. Intermenstrual bleeding2. Post-coital bleeding3. NOT associated w dysmenorrhea (painful periods)
125
What are the CF of Adenomyosis? (2 things)
1. Dysmenorrhea2. Bulky uterus (@ exam)
126
What are the CF of Fibroids? (2 things)
1. Hx of pressure symptoms (e.g urinary frequency)2. Bulky uterus (@ exam)
127
What is the most common Coagulopathy to cause Heavy Menstrual Bleeding?
Von Willebrand’s disease
128
What are the CF of Von Willebrand’s disease? (5 things)
1. HMB since menarche2. PPH Hx3. Surgical / dental related bleeding (bleeding gums)4. Easy bruising / epistaxis5. Bleeding disorder FHx
129
What should you consider for pt w Von Willebrand’s disease?
Warfarin (anti-coagulant)
130
What are the most common causes of Ovarian dysfunction? (2 things)
1. PCOS2. Hypothyroidism
131
What are the iatrogenic causes of HMB? (2 things)
1. Contraceptive hormones2. Copper IUD
132
What percentage of all HMB does Endometriosis represent?
Less than 5%
133
What investigations should you do for HMB? (5 things)
1. Urine pregnancy test2. FBC3. TFT4. Hormone tests (e.g if sus PCOS)5. Coag screen (+ check for Von Willebrand’s) if sus
134
Why should you do a FBC for HMB?
Anaemia presents after 120ml menstrual blood loss
135
When should you do a TFT for HMB?
If has other signs of hypothyroidism
136
What imaging should you do for HMB?
Transvaginal US
137
What is a Transvaginal US useful for?
Checking endometrium / ovaries
138
When should you for a Transvaginal US in HMB? (2 things)
1. Uterus / pelvic mass palpable @ exam2. Pharmacological tx failed
139
When should you do a Cervical smear in HMB?
If hasn’t had routine ones done
140
What investigation should you for HMB if sus infection?
High vaginal / endocervical swabs
141
What biopsy can be done for HMB?
Pipelle endometrial biopsy
142
When should you do a Pipelle endometrial biopsy in HMB? (3 things)
1. Persistent intermenstrual bleeding2. 45+ age3. Pharmacological tx failed
143
When should you do a Hysteroscopy / Endometrial biopsy for HMB?
US identifies pathology / is inconclusive
144
What is the aim of management of HMB?
Improve woman’s quality of life (rather than specific reduction in blood loss volume)
145
When considering HMB management options, what should you discuss with the patient?
Impact on fertility
146
What is the management approach for HMB when there is no sus pathology?
3 tiered approach
147
What is the 3 tiered approach for HMB?
1. Levonorgestral-releasing intrauterine system (LNG-IUS)2. Tranexamic acid / Mefanamic acid / COCP3. Progesterone only: Oral Norethisterone / Depo / Implant
148
What does Levonorgestral-releasing intrauterine system (LNG-IUS) also act as?
Contraceptive
149
How long is Levonorgestral-releasing intrauterine system (LNG-IUS) licenced for treatment?
5 years
150
How does Levonorgestral-releasing intrauterine system (LNG-IUS) work? (2 things)
1. Thins endometrium2. Shrinks fibroids
151
What does the woman’s choice to use Tranexamic acid / Mefanamic acid / COCP depend on?
Her wishes for fertility
152
When should Tranexamic acid be used?
Only during menses to reduce bleeding
153
Does Tranexamic acid have an effect on fertility?
No
154
What is a pro for using Mefanamic acid?
Is an NSAID = offers analgesia for dysmenorrhoea
155
When should Mefanamic acid be used?
Only during menses to reduce bleeding
156
Does Mefanamic acid have an effect on fertility?
No
157
Does Oral Norethisterone work as a contraceptive?
No
158
Do Depo / Implant progesterone work as a contraceptive?
Yes
159
What are the main Surgical management options for HMB? (2 things)
1. Endometrial ablation2. Hysterectomy
160
What are some other Surgical management options only for HMB caused by fibroids? (2 things)
1. Myomectomy2. Uterine artery embolization
161
What is Endometrial ablation?
Lining of uterus obliterated
162
Who is Endometrial ablation suitable for?
Women who no longer wish to conceive
163
By how much does Endometrial ablation reduce HMB?
Up to 80%
164
Where can Endometrial ablation be performed?
Outpatient using local anaesthetic
165
What is the only definitive treatment for HMB?
Hysterectomy
166
What does Hysterectomy offer? (2 things)
1. Amenorrhoea2. End to fertility
167
What are the types of Hysterectomy performed? (2 things)
1. Subtotal (partial)2. Total
168
What is Subtotal (partial) Hysterectomy?
Removal of uterus but NOT cervix
169
What is Total Hysterectomy?
Removal of uterus and cervix
170
What openings can Hysterectomy be performed via? (2 things)
1. Abdominal incision2. Vagina
171
What is the most common gynaecological disorder?
Dysmenorrhoea
172
What is Dysmenorrhoea?
Painful periods
173
What are the pathophysiological steps of Dysmenorrhoea? (5 steps)
1. Absence of fertilisation2. Corpus luteum regresses3. Decline in oestrogen + progesterone prod4. Endometrial cells release Prostaglandin5. Excess prostaglandin release --\> primary dysmenorrhoea
174
What are main actions of Prostaglandins on the uterus? (2 things)
1. Spiral artery vasospasm (--\> ischaemic necrosis + endometrium shedding)2. Increased myometrial contractions
175
What are the RF for primary dysmenorrhoea? (5 things)
1. Early menarche2. Long menstrual phase3. Heavy periods4. Smoking5. Nuliparity
176
Where is the pain of dysmenorrhoea?
Lower abd / pelvic pain
177
Where can the pain of dysmenorrhoea radiate to? (2 things)
1. Lower back2. Ant thigh
178
What is the quality of the pain of dysmenorrhoea?
Crampy
179
How long does the pain of dysmenorrhoea last for and when does it occur?
48-72 hours during menstrual period
180
When is the pain of dysmenorrhoea worse?
At menses onset
181
What other symptoms can come w dysmenorrhoea? (5 things)
1. Nausea2. Dizziness3. Malaise4. Vomiting5. Diarrhoea
182
What signs might you find @ examination of a pt w dysmenorrhoea?
Uterine tenderness
183
What is special about diagnosing primary dysmenorrhoea?
It is a diagnosis of exclusion: so you have to exclude causes of SECONDARY dysmenorrhoea
184
What are the causes of secondary dysmenorrhoea to exclude? (4 things)
1. Endometriosis2. Adenomyosis3. Pelvic inflamm disease4. Adhesions
185
What investigations are needed for primary dysmenorrhoea dx?
None
186
What scenarios would make you do some investigations in sus primary dysmenorrhoea? (2 things)
1. Pt = high risk for STI --\> do high vaginal swab / endocervical swabs2. Pelvic mass palpated @ exam --\> transvaginal US (TVS) for further investigation
187
What is the aim of management in primary dysmenorrhoea?
Symptomatic improvement (bc ders no pathology to treat)
188
What lifestyle advice would you give a pt w primary dysmenorrhoea?
Stop smoking
189
What is the FIRST line pharmacological tx for primary dysmenorrhoea? (2 things)
1. NSAIDs (ibuprofen / naproxen / mefenamic acid)2. +/- paracetamol
190
Why do NSAIDs work to treat primary dysmenorrhoea?
They inhibit prostaglandin production (which we said is the cause of primary dysmenorrhoea)
191
What is the SECOND line pharmacological tx for primary dysmenorrhoea?
Trial of hormonal contraception (3-6 month trial)
192
What pill is used first line for hormonal contraception trial tx of primary dysmenorrhoea?
Monophasic combines oral contraceptive pill
193
What else can be used for hormonal contraception trial tx of primary dysmenorrhoea?
Intrauterine system (e.g Mirena coil)
194
What are some non pharmacological tx options for primary dysmenorrhoea? (2 things)
1. Local heat application (water bottles / heat patch)2. Transcutaneous Electrical Nerve Stimulation (TENS)
195
How do you classify Amenorrhoea?
Primary and Secondary
196
What is Primary Amenorrhoea? (2 things)
Failure to start menses (aka no menarche) in:1. 16+ yr w secondary sexual characteristics (e.g pubic hair / breast dev)2. 14+ yr w NO secondary sexual characteristics
197
What is Secondary Amenorrhoea?
Periods stop for 6+ months (after menarche obv)
198
What is Oligomenorrhoea? (2 things)
1. Irregular periods w intervals of 35+ days2. +/- Less than 9 periods / year
199
What are the titles of the causes of Amenorrhoea? (3 things)
1. Hypothalamic causes2. Pituitary causes3. Ovarian / Genital causes
200
How does clartation of the Hypothalamus cause Amenorrhoea? (3 steps)
1. Reduced GnRH secretion2. Reduces pulsatile release of LH + FSH from Ant Pit3. Anovulation
201
What are the Hypothalamic causes of Amenorrhoea? (3 things)
1. Anorexia nervosa2. Extreme exercise3. Stress
202
How does clartation of the Pituitary gland cause Amenorrhoea? (2 steps)
1. Reduced release of LH + FSH from Ant Pit2. Anovulation
203
What are the Pituitary causes of Amenorrhoea? (3 things)
1. Prolactinoma2. Pituitary adenoma3. Sheehan's syndrome
204
How do Prolactinomas cause Amenorrhoea? (4 steps)
1. High levels of prolactin released2. Prolactin inhibits GnRH sec3. Reduces pulsatile release of LH + FSH from Ant Pit4. Anovulation
205
What is Sheehan's syndrome?
Post-partum pituitary necrosis (secondary to massive obstetric haemorrhage)
206
What are the Ovarian / Genital causes of Amenorrhoea? (3 things)
1. PCOS2. Ovarian failure3. Ashermann's syndrome
207
Does PCOS more commonly cause Amenorrhoea or Oligomenorrhoea?
Oligomenorrhoea
208
What is Ovarian failure?
Premature ovarian insuffiency (aka menopause before age of 40)
209
What are the CF of Ovarian failure?
Menopause symptoms like hot / night sweats
210
What do hormone profile tests show in Ovarian failure? (2 things)
1. Low oestrogen2. High FSH
211
What is Ashermann's syndrome?
Damage to basal layer of endometrium --\> intrauterine adhesions
212
What causes Ashermann's syndrome?
Damage to uterus from Surgical management of miscarriage
213
What are the most common causes of Oligomenorrhoea? (7 things)
1. PCOS2. Contraceptive / hormonal tx3. Perimenopause4. Hypo / Hyperthyroidism5. DM6. Eating disorders / excessive exercise7. Medications
214
How can Hypothyroidism cause Oligomenorrhoea? (4 steps)
1. Decreased T3/T42. TRH upregulated3. Stimulates Prolactin secretion4. LH / FSH inhibited
215
How can Hyperthyroidism cause Oligomenorrhoea? (4 steps)
1. High T3/T42. Increased Sex Hormone Binding Globulin (SHBG)3. Reduced ratio of free / bound oesteadiol4. LH spike not triggered
216
What medications can cause Oligomenorrhoea? (2 things)
1. Anti-psychotics2. Anti-epileptics
217
What investigations should you do for Amenorrhoea / Oligomenorrhoea? (5 things)
1. Pregnancy test2. Bloods3. Karyotyping4. US5. Progesterone challenge test
218
What bloods should you do for Amenorrhoea / Oligomenorrhoea? (4 things)
1. TFT2. Prolactin3. FSH / LH / Oestradiol / Progesterone / Testosterone4. 17 hydroxyprogesterone (to check for Congenital adrenal hyperplasia)
219
Why would you do Karyotyping for Amenorrhoea / Oligomenorrhoea?
If sus genetic abn
220
Why would you do US for Amenorrhoea / Oligomenorrhoea?
To visualise ovaries / pelvic anatomy
221
What is the Progesterone challenge test?
Giving progesterone to see if bleeding will start
222
What does the Progesterone challenge test show? (2 things)
1. If bleeding starts: suggests adeq levels of oestrogen but NO ovulation = PCOS2. If no bleeding: suggests LOW levels of oestrogen / outflow obstruction
223
What are the titles of Tx for Amenorrhoea / Oligomenorrhoea? (7 things)
1. Regulating periods2. Hormone replacement3. Symptom control4. Lifestyle advice5. Tx underlying disorder (aka thyroid disease)6. Improving fertility (clomifene / metformin / IVF)7. Surgery
224
How do you Regulate periods to treat Amenorrhoea / Oligomenorrhoea? (2 things)
1. COCP / POP2. Intrauterine system (IUS) (for irregular periods)
225
What is another benefit of using COCP / POP to treat Amenorrhoea / Oligomenorrhoea?
Keeps lining of womb thin --\> reduces long term risk endometrial cancer
226
Who should receive Hormone replacement as Tx for Amenorrhoea / Oligomenorrhoea?
Women w Ovarian Failure
227
What is Hormone replacement tx for Amenorrhoea / Oligomenorrhoea?
Cyclic hormone replacement therapy w Oestrogen (+ progesterone if they have a uterus)
228
What are the benefits of Hormone replacement as treatment in Amenorrhoea / Oligomenorrhoea? (3 things)
1. Treats menopause symptoms2. Decreases CVS risk3. Maintains bone density (prevents osteoporosis)
229
What is also recommended alongside Hormone replacement tx for Amenorrhoea / Oligomenorrhoea?
Calcium + Vit D supplementation
230
What types of Symptom control are available for Amenorrhoea / Oligomenorrhoea? (2 things)
1. Excessive hair growth (from PCOS): Certain COCP types e.g Yasmin2. Acne: Abx / topical tx
231
What Lifestyle advice options could you give for Amenorrhoea / Oligomenorrhoea? (2 things)
1. Eating disorders / excessive exercise: sort it out m82. PCOS: weight loss
232
What are the Surgical Mx options for Amenorrhoea / Oligomenorrhoea? (2 things)
1. Trans-sphenoidal removal of Pit tumour2. Surgery for genital tract abn
233
What is Endometrial cancer?
Cancer of lining of uterus
234
What type of cancer is Endometrial cancer usually?
Adenocarcinoma (80%)
235
Endometrial cancer is an WHAT-dependant cancer? What does this mean?
Oestrogen-dependant cancerOestrogen stimulates the growth of endometrial cancer cells
236
What is the precursor precancerous condition to Endometrial condition?
Endometrial hyperplasia
237
What percentage of Endometrial hyperplasia goes on to become Endometrial cancer?
5%
238
What are the 2 types of Endometrial hyperplasia?
1. Hyperplasia without atypia2. Atypical hyperplasia (more likely to progress to cancer)
239
What is the Tx for Endometrial hyperplasia? (2 things)
Progestogens:1. Intrauterine system (e.g Mirena coil)2. Continuous oral progestogens (e.g levonorgestrel)
240
What is the cause of Endometrial cancer?
Exposure to Unopposed oestrogen (aka oestrogen without progesterone)
241
What are the RF for Endometrial cancer? (7 things)
1. Age2. Early menarche / Late menopause3. Oestrogen only HRT4. Nuliparity5. Obesity6. PCOS7. Tamoxifen
242
How does PCOS increase risk of Endometrial cancer?
Usually: Ovulation --\> Corpus luteum formed --\> CL produces Progesterone (which opposes oestrogen)In PCOS: Anovulation = so all this doesn't happen
243
How do you protect the Endometrium in women with PCOS? (3 things)
1. COCP2. Intrauterine system (e.g Mirena coil)3. Cyclical progestogens (to induce a withdrawal bleed)
244
Why is Obesity a RF for Endometrial cancer?
Adipose tissue (fat) = source of oestrogen
245
How does Adipose tissue increase Oestrogen in body? (2 things)
1. Adipose tissue contains Aromatase2. Aromatase converts androgens (aka testosterone) --\> Oestrogen
246
Why is Tamoxifen a RF for Endometrial cancer?
Has oestrogenic effect on Endometrial (while has anti-oestrogenic effect on breast tissue)
247
What are the Protective Factors vs Endometrial Cancer? (4 things)
1. COCP2. Mirena coil3. Increased pregnancies4. Smoking
248
What is the main CF of Endometrial cancer that means it is Endometrial cancer unless proven otherwise?
Postmenopausal bleeding
249
What percentage of Endometrial cancer pt have PMB?
75-90%
250
What percentage of women w PMB do NOT have Endometrial cancer?
90%
251
What other CF can Endometrial cancer present with? (4 things)
1. Clear / white vaginal discharge2. Abn cervical smear3. Abd pain (advanced / metastatic)4. Weight loss (advanced / metastatic)
252
What are you checking for in an Abd examination of sus Endometrial cancer?
Abd / pelvic masses
253
What are you checking for in a Speculum examination of sus Endometrial cancer? (2 things)
1. Vulval / vaginal atrophy2. Cervical lesions
254
What are you assessing in an Abd examination of sus Endometrial cancer?
Size + axis of uterus b4 endometrial sampling
255
What are some DDx that present similarly to Endometrial cancer (aka PMB)? (3 things)
1. Vulval atrophy / pre-malignant vulval conditions2. Cervical polyps / cancer3. Endometrial hyperplasia / polyps / atrophy
256
What is the FIRST line investigation for sus Endometrial cancer?
Transvaginal US
257
What do the majority (96%) of Endometrial cancer pt show on the Transvaginal US?
Endometrial thickness of 5+ mm
258
What investigation should you do if you see Endometrial thickness of 4+ mm in Transvaginal US?
Endometrial biopsy
259
What other investigation can you do for sus Endometrial cancer apart from TUS and biopsy?
Hysteroscopy
260
Once Endometrial cancer is confirmed, what investigation should you do next and why?
CT / MRI for staging
261
What staging system is used for Endometrial cancer?
International Federation of Gynaecology and Obstetrics (FIGO)
262
What are the stages of Endometrial cancer in the FIGO system? (4 stages)
1. Stage 1: Confined to uterus2. Stage 2: Invades cervix3. Stage 3: Invades ovaries / fallopian tubes / vagina / lymph nodes4. Stage 4: Invades bladder / rectum / beyond pelvis
263
What are the Tx options for Stage 1 and 2 Endometrial cancer?
Total abdominal hysterectomy (TAH) with Bilateral salpingo-oophorectomy (BSO)(aka removing uterus, cervix and adnexa)
264
What are the Tx options for Stage 1 and 2 Endometrial cancer? (2 things)
1. Maximal de-bulking surgery (if possible)2. Chemo + Radio
265
What can be given to Endometrial cancer patients to slow progression of cancer?
Progesterone
266
What is Endometriosis?
Condition where there is Ectopic endometrial tissue OUTSIDE uterus
267
What is Adenomyosis?
Endometrial tissue in myometrium (muscle layer of uterus)
268
What is the main age group for Endometriosis?
25-40 yrs
269
Is the pathophysiology of Endometriosis clear?
No
270
What is the Retrograde Menstruation theory for Endometriosis? (2 steps)
1. Endometrial cells travel backwards from uterine cavity --\> Fallopian tubes --\> Pelvis / Peritoneum2. Endometrial cells seed + grow here
271
What is another theory for Endometriosis pathophysiology?
Endometrial cells travel through lymphatic system (same way as cancer spreads)
272
What is endometrial tissue sensitive to?
Oestrogen
273
During menstruation, what happens to the ectopic endometrial tissue?
Bleeds, just like normal endometrial tissue
274
What does the bleeding of ectopic endometrial tissue cause? (2 things)
1. Pain2. Bloating / distension @ ectopic sites
275
What can repeated bleeding and inflammation at ectopic sites lead to?
Scarring --\> Adhesions
276
When are the symptoms of endometriosis reduced? (2 things)
1. Pregnancy2. Menopause
277
What are the RF for Endometriosis? (6 things)
1. Early menarche2. FHx Endometriosis3. Short menstrual cycles4. Long duration of menstrual bleeding5. Heavy menstrual bleeding6. Defects in uterus / fallopian tubes
278
What are the CF of Endometriosis?
1. Pelvic / abdominal pain (cyclic)2. Dyspareunia (pain @ intercourse)3. Dysmenorrhoea4. Infertility5. Dysuria / Dyschezia6. Cyclic bleeding @ other sites (e.g haematuria)
279
What examinations can you do for sus Endometriosis? (2 things)
1. Bimanual examination2. Speculum examination
280
What might you find @ examination of sus Endometriosis? (3 things)
1. Endometrial tissue visible in vagina (esp post fornix)2. Fixed retroverted cervix3. Tenderness in vagina / cervix / adnexa
281
What does an enlarged, tender, boggy uterus indicate?
Adenomysosis
282
What are some DDx that present similarly to Endometriosis? (4 things)
1. PID2. Ectopic pregnancy3. Fibroids4. IBS
283
How does PID present similarly to Endometriosis? (3 things)
1. Pelvic pain2. Dyspareunia3. Abn / heavy bleeding
284
How does Ectopic pregnancy present similarly to Endometriosis? (4 things)
1. Pelvic pain2. Dyspareunia3. Abn / heavy bleeding4. Collapse
285
How does Fibroids present similarly to Endometriosis? (4 things)
1. Pelvic pain2. Long duration of menstrual bleeding3. Heavy menstrual bleeding4. Bloating / feeling of a mass
286
How does IBS present similarly to Endometriosis? (3 things)
1. Abd pain2. Dyspareunia3. Bloating
287
What is the GOLD standard investigation for sus Endometriosis?
Laparoscopy
288
What are the typical findings of Endometriosis on Laparoscopy? (4 things)
1. Endometriotic lesions (see pic)2. Chocolate cysts (endometriosis of ovaries)3. Peritoneal deposits4. Adhesions
289
What are the benefits of doing a Laparoscopy for sus Endometriosis? (2 things)
1. Take biopsy (for definitive dx)2. Surgically remove deposits (can improve symptoms)
290
What other investigation can be done for sus Endometriosis?
Pelvic US(Usually unremarkable tho and will be referred to gynae for Laparoscopy)
291
What does NICE recommend instead of using a staging system for Endometriosis?
Detailed documentation of endometriosis
292
What are the 3 components of Mx of Endometriosis?
1. Pain2. Hormonal3. Surgical
293
How do you manage the pain of Endometriosis?
Analgesia / NSAIDS (follow analgesia ladder)
294
What is a benefit of Hormonal Mx of Endometriosis?
Can be tried even before definitive Dx with laparoscopy
295
What are the options for Hormonal Mx of Endometriosis? (5 things)
1. COCP2. POP (Norethisterone)3. Depo-Provera injection4. IUD (Mirena coil)5. GnRH agonists
296
How do COCP / POP / Depo / IUD work to manage Endometriosis? (3 steps)
1. Suppresses ovulation2. Causes atrophy of endometriosis lesions3. Reduces symptoms
297
How do GnRH agonists work to manage Endometriosis? (3 steps)
1. Induce menopause-like state2. Female sex hormones reduced3. Reduces symptoms
298
What are the side fx of using menopause-like inducing meds like GnRH agonists? (3 things)
1. Hot flushes2. Night sweats3. Osteoporosis
299
What are the Surgical Mx options of Endometriosis? (2 things)
1. Laparoscopy2. Hysterectomy
300
What can be done in Laparoscopic Tx of Endometriosis? (3 things)
1. Excision2. Ablation3. Adhesiolysis
301
What is the benefit of Laparoscopic Tx over Hormonal Tx of Endometriosis?
Laparoscopic Tx can improve fertility
302
When is Hysterectomy a better option than Laparoscopic Tx of Endometriosis?
Beh relapses (which almost always occur after laparoscopic tx)
303
What is PID?
Infection of Upper genital tract in females
304
What organs does PID affect? (3 things)
1. Uterus2. Fallopian tubes3. Ovaries
305
What age group is PID most common in?
15-24 yrs
306
What is the general cause of PID?
Spread of bac infection from vagina / cervix upwards
307
What are the most common organisms that cause PID? (3 things)
STI's:1. Neisseria gonorrhoea2. Chlamydia trachomatis3. Mycoplasm genitalium
308
Which organism causes the most severe PID?
Neisseria gonorrhoea
309
What are the RF for PID? (5 things)
1. Sexually active (esp without protection)2. Recent partner change3. Age 15-244. Hx of STIs / PID5. IUD
310
What are the CF of PID? (7 things)
1. Fever (advanced)2. Pelvic / lower abd pain3. Dyspareunia (pain @ intercourse)4. Post-coital bleeding5. Abn discharge (purulent / foul smelling)6. Menstrual abn (menorrhagia / dysmenorrhoea)7. Dysuria
311
What are the CF of PID @ examination? (4 things)
1. Palpable mass2. Pelvic / cervical tenderness3. Inflamm cervix4. Purulent discharge
312
What are some differential Dx that present similarly to PID? (4 things)
1. Endometriosis2. Ectopic pregnancy3. Ruptured ovarian cyst4. UTI
313
What investigations should be done for sus PID? (6 things)
1. Endocervical (NAAT) swabs2. Full STI screen3. Urine dipstick / MSU4. Pregnancy test (to exclude ectopic pregnancy)5. Inflamm markers (CRP / ESR) (raised)6. Transvaginal US7. Laparoscopy
314
What are you testing for in Endocervical (NAAT) swabs? (3 things)
1. Gonorrhoea2. Chlamydia3. Mycoplasm genitalium
315
What are you testing for in a Full STI screen? (5 things)
1. HIV2. Syphilis3. Gonorrhoea4. Chlamydia5. Mycoplasm genitalium
316
What is the point of a Urine dipstick / MSU in sus PID?
To exclude UTI's
317
When are Transvaginal US / Laparoscopy indicated in sus PID?
Severe cases where there is diagnostic uncertainty
318
What is the point of Laparoscopy for investigating PID? (2 things)
1. Observe gross inflamm changes2. Peritoneal biopsy
319
What is the Tx for PID?
14 day broad spec abx course (w good anaerobic coverage)
320
When should abx course for PID be started?
Immediately, even before swabs results are back
321
What are the abx options for PID? (2 things)
1. Doxycycline + Ceftriaxone + Metronidazole2. Ofloxacin + Metronidazole
322
How should you manage pain in PID?
Paracetamol
323
What are signs the pt has severe PID / needs further Tx? (3 things)
1. Sepsis signs2. Pelvic abscess3. Pregnant
324
What further treatment is given to patients with severe PID who are admitted?
IV abx
325
What is the Tx when a Pelvic abscess develops in PID?
Drainage (by interventional radiologist / surgeon)
326
What are the complications of PID? (6 things)
1. Sepsis2. Abscess3. Infertility (10%)4. Chronic pelvic pain5. Ectopic pregnancy6. Fitz-Hugh-Curtis syndrome
327
Why is the risk of Ectopic pregnancy increased after having PID?
Bc narrowing + scarring of fallopian tubes
328
What is Fitz-Hugh-Curtis syndrome? (2 steps)
1. Inf of liver capsule (aka Glisson's capsule)2. Leads to adhesions between Liver + peritoneum
329
What are the CF of Fitz-Hugh-Curtis syndrome? (2 things)
1. RUQ pain2. Referred R shoulder pain (if diaphragm irritated)
330
What is used to visualise and treat adhesions of Fitz-Hugh-Curtis syndrome?
Laparoscopy (adhesiolysis)
331
What is an Ectopic Pregnancy?
Pregnancy implanted outside uterus
332
Where is the most common implantation site of an Ectopic pregnancy?
Fallopian tube
333
What is the prevalence of Ectopic pregnancies in the UK?
1/80 pregnancies
334
What are the RF for an Ectopic Pregnancy? (6 things)
1. Previous EP2. Previous PID3. Previous of surgery to fallopian tubes4. IUD5. Age6. Smoking
335
When do the CF of EP normally present?
6-8 weeks gestation
336
What are the CF of EP? (4 things)
1. Pain (lower abd / pelvic)2. Vaginal bleeding3. Amenorrhoea (aka missed period)4. Shoulder pain
337
What are the CF of EP @ examination? (2 things)
1. Lower abd / pelvic tenderness2. Cervical motion tenderness (pain @ moving cervix @ bimanual exam)
338
What is the difference between Vaginal and Intra-abd bleeding in EP?
1. Vaginal: Uterine cavity breakdown bc not enough β-HCG2. Intra-abd: Ruptured EP
339
How will a pt present with a Ruptured EP?
Haemodynamically unstable
340
Why might someone with EP present with Shoulder pain?
Blood in peritoneal cavity irritates diaphragm --\> referred shoulder pain
341
What are some differential Dx that present similarly to EP? (6 things)
1. Miscarriage2. Ovarian cyst haemorrhage / torsion / rupture3. PID4. UTI5. Appendicitis6. Diverticulitis
342
What is the first important investigation for sus EP?
Pregnancy test (β-HCG test)
343
What investigation should be performed if the Pregnancy test in sus EP is positive?
Pelvic US
344
What should be offered if no pregnancy is seen on the Pelvic US?
Transvaginal US
345
What is the term used to describe a positive pregnancy test but NO pregnancy seen on US?
Pregnancy of Uknown Location (PUL)
346
What are the 3 main differentials of PUL?
1. Very early intrauterine pregnancy2. Miscarriage3. EP
347
What investigation should you do for PUL?
Serum β-HCG
348
What Serum β-HCG levels are considered EP?
1500+ iU
349
What investigation should be done to confirm the diagnosis of EP when Serum β-HCG levels are 1500+?
Diagnostic laparoscopy
350
What investigation should be done if Serum β-HCG levels are below 1500 and pt is stable?
Another Serum β-HCG after 48 hours
351
What are the HCG levels expected to do every 48 hours in a VIABLE pregnancy?
Double every 48 hours
352
What are the HCG levels expected to do every 48 hours in a Miscarriage?
Halve every 48 hours
353
What should you do if the HCG levels doesn't double / halve every 48 hours and was initially below 1500?
Can't exclude EP so manage accordingly
354
How could you exclude a differential of UTI in sus EP?
Urinalysis
355
What are the Mx options for EP? (3 things)
1. Expectant (await natural termination)2. Medical (methotrexate)3. Surgical (salpingectomy / salpingotomy)
356
What are the criteria for Expectant Mx of EP? (6 things)
1. Follow up possible to ensure successful termination2. EP needs to be unruptured3. Adnexal mass less than 35mm4. No visible heartbeat5. No significant pain6. HCG level below 1500
357
What are the criteria for Medical (MTX) management of EP? (2 things)
Same as Expectant except:1. HCG level below 50002. Confirmed absence of IU pregnancy on US
358
How does the Methotrexate work for Medical Mx of EP?
MTX = Anti-folate cytotoxic agent --\> disrupts Folate dependant cell division of developing foetus
359
How do you ensure the Methotrexate is working for EP Mx?
Measure HCG levels regularly (supposed to decline by 15+ % by day 5)
360
What should you do if the HCG levels aren't declining properly after you Methotrexate EP Mx?
Give repeat dose
361
What are the Advantages of Medical Mx with MTX for EP? (2 things)
1. Avoid surgical complications2. Pt can go home after injection
362
What are the Side Fx of MTX as Medical Mx for EP? (9 things)
1. N+V2. Stomatitis (mouth infamm)3. Abd pain4. Myelosuppression5. Renal dysfunction6. Hepatitis7. Vaginal bleeding8. Teratogenesis9. Failure of Tx
363
What are the criteria for Surgical Mx of EP? (4 things)
1. Pain2. Adnexal mass 35+ mm3. Visible heartbeat4. HCG level 5000+
364
What is the most common surgical procedure for EP Mx?
Laparoscopic salpingectomy (remove ectopic + tube it's in)
365
When would you do a Salpingotomy instead of Salpingectomy for EP Mx? (2 points)
1. If other tube is damaged bc infection / disease / surgery2. This is to preserve the EP tube to preserve future fertility
366
If you do a Salpingotomy instead of Salpingectomy, what should you do you need to do?
1. HCG follow up until it reaches below 52. To ensure no residual trophoblast
367
What is the disadvantage of doing a Salpingotomy instead of a Salpingectomy for EP Mx?
Risk of recurrent EP in salvaged tube
368
What are the Advantages of Surgical Mx of EP? (2 things)
1. Reassurance that gonna be treated for defo2. High success rate
369
What are the Disadvantages of Surgical Mx of EP? (2 things)
1. Anaesthesia risk2. Damaging nearby structures3. DVT / PE / Haemorrhage / Infection4. Tx failure (salpingotomy)
370
What do all Rhesus Negative women who receive Surgical Mx for EP need to be offered?
Anti-D prophylaxis
371
What age group does Cervical Cancer tend to affect more?
Young women (in reproductive years)
372
What is the most common type of Cervical Cancer?
Squamous cell carcinoma (80%)
373
What is the second most common type of Cervical Cancer?
Adenocarcinoma
374
What is the most common cause of Cervical Cancer?
HPV (STI)
375
What is the pathophysiology of HPV causing Cervical Cancer? (4 points)
1. HPV produces 2 proteins: E6 + E72. E6 inhibits p53 (tumour suppressor gene)3. E7 inhibits pRb (tumour suppressor gene)4. Therefore: HPV promotes cancer dev by inhibiting tumour suppressor genes
376
What strains of HPV are responsible for 70% of Cervical Cancers? (2 things)
1. Type 162. Type 18
377
What are the RF for Cervical Cancer? (6 things)
1. HPV (main)2. Smoking3. HIV4. COCP use for 5+ years5. High number of full-term pregnancies6. FHx
378
What are the RF for catching HPV? (4 things)
1. Early sexual activity2. High no. of partners3. Partners who have had more partners4. Not using condoms
379
What are the CF of Cervical Cancer? (5 things)
1. Asymptomatic (detected @ routine smear)2. Pelvic pain3. Dyspareunia (pain @ intercourse)4. Abn vaginal bleeding (intermenstrual / postcoital / post-menopausal)5. Vaginal discharge
380
Why is it hard to diagnose Cervical Cancer from symptoms alone?
Symptoms are non-specific, and usually NOT caused by Cervical Cancer
381
What investigation should be done for sus Cervical Cancer?
Speculum examination
382
What can be done during a Speculum examination in sus Cervical Cancer and why?
Swabs to exclude infection
383
What abn appearances of the cervix warrant an Urgent Cancer Referral for Colposcopy? (4 things)
1. Ulceration2. Inflamm3. Bleeding4. Visible tumour
384
What are you aiming to diagnose / exclude @ Colposcopy?
CIN aka Cervical Intraepithelial Neoplasia
385
## FootnoteWhat is CIN?
A grading system for the level of dysplasia (aka premalignant changes) in cervical cells
386
What are the CIN grades?
* CIN I = mild dysplasia* CIN II = moderate dysplasia* CIN III = severe dysplasia
387
What does CIN I (aka mild dysplasia) mean? (2 things)
1. Dysplasia affecting 1/3 thickness of epithelial layer2. Likely to return normal w/o tx
388
What does CIN II (aka moderate dysplasia) mean? (2 things)
1. Dysplasia affecting 2/3 thickness of epithelial layer2. Likely to progress to cancer if left untreated
389
What does CIN III (aka severe dysplasia) mean?
Very likely to progress to cancer if untreated
390
What are the aims of the screening programme for Cervical Cancer?
Pick up precancerous changes in cervix epithelium
391
How often are the different age groups of women screened for Cervical Cancer?
1. Age 25-49: every 3 years2. Age 50-64: every 5 years
392
What are the exceptions to the Cervical Cancer screening program? (5 things)
1. HIV pt: Screen anually2. 65+ yrs: Can request smear if not had one since 50 yrs old3. Hx of CIN: May require additional tests (e.g to test for cure after tx)4. Immunocompromised pt: Additional screening5. Pregnant: Must wait 12 wks post-partum
393
What does the screening for Cervical Cancer involve?
Smear test
394
How is a smear test done for Cervical Cancer screening?
1. Speculum examination + collect cervical cells w small brush2. Cells sent to lab
395
Who can do the smear test for Cervical Cancer screening?
Practice nurse
396
What are smear samples tested for before the cells are examined?
High-risk HPV
397
What happens next depending on the result of the High-risk HPV testing on the smear sample?
* HPV negative = cells NOT examined --\> continue routine screening* HPV positive = cells examined (cytology)
398
What happens next depending on the cytology of the HPV positive smear?
* Normal cytology: repeat HPV test after 12 months* Abn cytology: refer for colposcopy
399
How are abn areas of cervix differentiated in Colposcopy?
Using stains
400
What are the different stains used in Colposcopy? (2 things)
1. Acetic acid2. Iodine
401
What will you see in Colposcopy with Acetic Acid?
Abn cells = white (called acetowhite)
402
What will you see in Colposcopy with Iodine?
1. Healthy cells = brown2. (Abn areas won't stain)
403
How can you get a tissue sample during Colposcopy? (2 things)
1. Punch biopsy2. Large Loop Excision of the Transformational Zone (LLETZ)
404
What anaesthetic can LLETZ done under?
Local
405
What does LLETZ involve?
Using loop of wire w electrical current (diathermy) to remove abn epithelial cervix tissue
406
What are the side fx of LLETZ? (3 things)
1. Bleeding2. Abn discharge3. Increased risk of Preterm labour
407
What should be avoided after LLETZ and why? (2 things)
1. Intercourse2. Tampon use(to reduce infection risk)
408
What staging system is used for Cervical Cancer?
FIGO(International Federation of Gynaecology and Obstetrics)
409
What are the FIGO stages of Cervical Cancer?
* Stage 1: Confined to cervix* Stage 2: Invades uterus / upper 2/3 of vagina* Stage 3: Invades pelvic wall / lower 1/3 of vagina* Stage 4: Invades bladder / rectum / beyond pelvis
410
What are the Mx options for CIN / Early stage 1A Cervical Cancer? (2 things)
1. LLETZ2. Cone biopsy
411
What is Cone biopsy?
Tx for CIN / Early Stage 1A Cervical Cancer
412
What anaesthetic is Cone biopsy done under?
General
413
What does Cone biopsy involve? (2 steps)
1. Cone shaped piece of cervix removed w Scalpel2. Sample sent for histology to assess for malignancy
414
What are the side fx of Cone biopsy? (5 things)
1. Pain2. Bleeding3. Inf4. Scar formation w Stenosis of cervix5. Increased risk of Miscarriage / Premature labour
415
What are the Mx options for Stage 1B / 2A Cervical Cancer? (4 things)
1. Radical hysterectomy2. Removal of local lymph nodes3. Chemo4. Radio
416
What are the Mx options for 2B - 4A Cervical Cancer? (2 things)
1. Chemo2. Radio
417
What are the Mx options for 4B Cervical Cancer? (4 things)
1. Surgery2. Radio3. Chemo4. Palliative care
418
What is the Surgical Mx option for 4B Cervical Cancer?
Pelvic extenteration
419
What is removed in Pelvic exenteration? (7 things)
Most / All pelvic organs:1. Vagina2. Cervix3. Uterus4. Fallopian tubes5. Ovaries6. Bladder7. Rectum
420
Why are early detection and screening programmes for Cervical Cancer so important? (2 points)
* 5 year survival of Stage 1A: 98%* 5 year survival of Stage 4: 15%
421
What chemo is used for Cervical Cancer?
Bevacizuman (Avastin)
422
What is Bevacizumab (Avastin)?
Monoclonal antibody
423
What types of Cervical Cancer is Bevacizumab (Avastin) used for? (2 things)
1. Metastatic2. Recurrent
424
What does Bevacizumab (Avastin) target?
Vascular Endothelial Growth Factor A (VEGF-A) --\> responsible for new blood vessel dev(so dis tx stops dis)
425
What vaccine is used to protect against HPV?
Gardasil
426
When should Gardasil vaccine be given to people?
When they're kids before they're sexually active
427
What strains of HPV does Gardasil protect against? (4 things)
6, 11, 16, 18
428
What are the HPV strains 6, 11, 16 and 18 responsible for? (2 things)
1. 6 + 11 = Genital warts2. 16 + 18 = Cervical Cancer
429
What proportion of couples fail to conceive naturally?
01-Jul
430
After trying to conceive for how long should investigations and referrals for infertility be started? (2 options)
1. 12 months2. 6 months if: woman 35+ yrs
431
What are the causes of infertility? (5 things)
1. Sperm (30%)2. Ovulation (20%)3. Tubal (15%)4. Uterine (10%)5. Unexplained (20%)
432
What is some general advice for infertility? (5 things)
1. Woman takes 400mcg folic acid daily2. Have healthy BMI3. X Smoking / Alcohol4. Reduce stress (fx libido + relationship)5. Intercourse every 2-3 days
433
What initial investigations should you do in primary care for infertility? (5 things)
1. BMI2. Chlamydia screening3. Semen analysis4. Female hormone testing5. Rubella immunity in mother
434
What does a LOW BMI suggest the cause of infertility is?
Anovulation
435
What does a HIGH BMI suggest the cause of infertility is?
PCOS
436
What does Female hormone testing involve? (5 things)
1. Serum LH + FSH2. Serum progesterone3. Anti-Mullerian hormone4. TFTs (if symptoms suggest dis)5. Prolactin (when symptoms of galactorrhoea / amenorrhoea)
437
Why should you check Prolactin in infertility?
Hyperprolactinaemia causes anovulation
438
Which day range is Serum LH + FSH checked?
Day 2-5
439
Which day is Serum progesterone checked?
Day 21(or 7 days b4 end of cycle if not 28 day cycle)
440
What does High FSH suggest?
Poor ovarian reserve (aka number of follicles left in ovaries)
441
What explains the High FSH in poor ovarian reserve?
Pit gland prod extra FSH in attempt to stimulate follicular dev
442
What does Low LH suggest?
PCOS
443
What does a rise in Progesterone @ day 21 indicate? (2 things)
1. Ovulation has occurred2. Corpus luteum formed + started secreting progesterone
444
When in the cycle can Anti-Mullerian hormone be tested for?
Anytime
445
What is Anti-Mullerian hormone a marker for?
Most accurate marker of ovarian reserve
446
What is Anti-Mullerian hormone released by?
Granulosa cells in follicles
447
What does Low Anti-Mullerian hormone suggest?
Eggs are depleted
448
What further investigations should you for infertility in Secondary care? (3 things)
1. US Pelvis2. Hysterosalpingogram3. Laparoscopy + Dye test
449
What are you looking for in a US Pelvis of infertility? (2 things)
1. PCOS2. Structural abn in uterus
450
What are you looking for in a Hysterosalpingogram of infertility?
Fallopian tube patency
451
What are you looking for in a Laparoscopy + Dye test of infertility? (3 things)
1. Fallopian tube patency2. Adhesions3. Endometriosis
452
What is a benefit of a Hysterosalpingogram?
Can do Tubal cannulation during it --\> opens up tube --\> restores fertility
453
What is a risk of having a Hysterosalpingogram?
Infection
454
What precautions are taken with Hysterosalpingogram to reduce risk of infection? (2 things)
1. Prophylactic abx2. Chlamydia + Gonorrhoea screening b4 hand
455
What is a benefit of a Laparoscopy?
Can treat adhesions / endometriosis on the job
456
What are the management options for infertility caused by ANOVULATION? (6 things)
1. Weight loss (if overweight +/- PCOS)2. Clomifene3. Letrozole (instead of clomifene)4. Gonadotropins (if resistant to clomifene)5. Ovarian drilling (if PCOS)6. Metformin (for insulin sensitivity / obesity related to PCOS)
457
What drug class in Clomifene?
Anti-oestrogen (selective oestrogen receptor modulator)
458
What day range is Clomifene given?
Days 2-6 of menstrual cycle
459
What are the physiological steps of Clomifene in restoring fertility? (4 steps)
1. Stops negative feedback of oestrogen on hypothalamus2. Increased GnRH release3. Increased FSH + LH4. Ovulation
460
What are the physiological steps of Ovarian drilling in restoring fertility? (3 steps)
1. Multiple holes drilled in ovaries using diathermy / laser (@ laparoscopy)2. Womans hormone profile improved3. Regular ovulation
461
What are the management options for infertility caused by TUBAL DEFECTS? (3 things)
1. Tubal cannulation @ hysterosalpingogram2. Laparoscopy to remove adhesions / endometriosis3. IVF
462
What is the management option for infertility caused by Uterine DEFECTS?
Surgery to correct polyps / adhesions / structural abn
463
What are the management options for infertility caused by Sperm defects? (5 things)
1. Surgical sperm retrieval2. Surgical correction of vas deferens obst3. Intra-uterine insemination4. Intracytoplasmic sperm infection (ICSI)5. Donor insemination
464
What does Intra-uterine insemination involve? (2 steps)
1. Collecting + separating high quality sperm2. Injecting them directly into uterus
465
What does Intracytoplasmic sperm injection (ICSI) involve? (2 steps)
1. Injecting sperm directly into cytoplasm of egg (which then becomes embyro)2. Embryo injected into uterus
466
When is Intracytoplasmic sperm injection (ICSI) useful? (2 things)
1. Sperm motility issues2. Low sperm count
