PassMed Flashcards

Question

ovarian cyst rupture and mx

Answer 1

Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Answer 2

t has been known for a long time that the human papillomavirus (HPV) which infects the keratinocytes of the skin and mucous membranes is carcinogenic. There are dozens of strains of HPV. The most important to remember are: * **6 & 11:** causes genital warts * **16 & 18:** linked to a variety of cancers, most notably cervical cancer HPV infection is linked to: * over 99.7% of **cervical cancers** * HPV testing is now integral to cervical cancer screening * samples are first tested for HPV and only if they are positive is cytology then performed * around 85% of **anal cancers** * around 50% of **vulval and vaginal cancers** * around 20-30% of **mouth and throat cancers** It should of course be remembered that there are other risk factors important in developing cervical cancer such as smoking, combined oral contraceptive pill use and high parity. Immunisation A vaccination for HPV was introduced in the UK back in 2008. As you may remember the Department of Health initially chose Cervarix. This vaccine protected against HPV 16 & 18 but not 6 & 11. There was widespread criticism of this decision given the significant disease burden caused by genital warts. Eventually in 2012 Gardasil replaced Cervarix as the vaccine used. Gardasil protects against HPV 6, 11, 16 & 18. This was initially just given to girls but from September 2019 boys were given the vaccine as well. **All 12- and 13-year-olds (girls AND boys)** in school Year 8 are offered the human papillomavirus (HPV) vaccine. * the vaccine is normally given in school * information given to parents and available on the NHS website make it clear that the daughter may receive the vaccine against parental wishes * given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy HPV vaccination should also be offered to **men who have sex with men under the age of 45 to protect against anal, throat and penile cancers.** Injection site reactions are particularly common with HPV vaccines.

Answer 3

In urogenital prolapse there is descent of one of the pelvic organs resulting in protrusion on the vaginal walls. It probably affects around 40% of postmenopausal women Types Anterior vaginal wall: * **Cystocele:** bladder (may lead to stress incontinence) Urethrocele: urethra * **Cystourethrocele:** both bladder and urethra Posterior vaginal wall: * **Enterocele:** small intestine * **Rectocele**: rectum Apical vaginal wall * **Uterine prolapse:** uterus * **Vaginal vault prolapse:** roof of vagina (common after hysterectomy) Risk factors * increasing age * multiparity, vaginal deliveries * obesity * spina bifida Presentation * sensation of **pressure, heaviness, 'bearing-down'** * urinary symptoms: **incontinence, frequency, urgency** Management * **if asymptomatic and mild prolapse then no treatment needed** * conservative: weight loss, pelvic floor muscle exercises * ring pessary * surgery Surgical options * cystocele/cystourethrocele: anterior colporrhaphy, colposuspension * uterine prolapse: hysterectomy, sacrohysteropexy * rectocele: posterior colporrhaphy * vaginal vault: sacrocolpoplexy

Answer 4

Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females. Risk factors * advancing age * previous pregnancy and childbirth * high body mass index * hysterectomy * family history Classification * **overactive bladder (OAB)/urge incontinence:** due to detrusor overactivity * **stress incontinence:** leaking small amounts when coughing or laughing * **mixed incontinence:** both urge and stress * **overflow incontinence**: due to bladder outlet obstruction, e.g. due to prostate enlargement Initial investigation * **bladder diarie**s should be completed for a minimum of 3 days * **vaginal examination** to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises) * **urine dipstick and culture** * **urodynamic studies** Management depends on whether urge or stress UI is the predominant picture. If _urge incontinence_ is predominant: * **bladder retraining** (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) * bladder stabilising drugs: antimuscarinics are first-line. NICE recommend **oxybutynin** (immediate release), **tolterodine** (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women' * **mirabegron** (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients If _stress incontinence_ is predominant: * **pelvic floor muscle training:** NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months * **surgical procedures:** e.g. retropubic mid-urethral tape procedures * **duloxetine** may be offered to women if they decline surgical procedures * a combined noradrenaline and serotonin reuptake inhibitor * mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction

Answer 5

most common cause of vaginal discharge in women of reproductive age loss of lactobacilli → increase of anaerobic and BV-associated bacteria → proteolytic enzymes (vaginal peptides into malodorous amines) → rise in pH → **G. vaginalis and Atopobium vaginae** → exfoliate epithelial cells and biofilm development Diagnosis: * **grey-white discharge (fishy odour)** = _positive whiff test_ aka fishy odour when _KOH_ added to secretions * presence of **clue cells** on microscopy = epithelial cells studied with Gram-variable coccobacilli Tx: * symptomatic = **intravaginal metronidazole/clindamycin cream** can cause 2o infection in PID association with pre-term labour

Answer 6

**one-sided, lower abdominal pain associated with ovulation**. ## Footnote Usually **mid cycle pain.** Often sharp onset. Little systemic disturbance. May have recurrent episodes. Usually settles over 24-48 hours. Full blood count- usually normal Ultrasound- may show small quantity of free fluid Conservative pelvic discomfort, soft abdomen with mild suprapubic discomfort

Answer 7

Infection of uterus cavity alone spread of infection to pelvis cause = instrumentation of uterus or complication of pregnancy, chlamydia/gonorrhoea (BV, E. coli, staph may be implicated), common after C. section, also after miscarriage and ToP sx = p**ersistent heavy vaginal bleeding, pain** signs = tender uterus, cervical os open ix = cervical swabs, FBC tx = broad-spectrum abx, ERPC

Answer 8

Atrophic vaginitis often occurs in women who are **post-menopausal women.** It presents with **vaginal dryness, dyspareunia and occasional spotting**. On examination, the **vagina may appear pale and dry**. Treatment is with **vaginal lubricants and moisturisers** - if these do not help then **topical oestrogen cream** can be used. lack of oestrogen is cause MUST EXCLUDE MALIGNANCY (ENDOMETRIAL CANCER)

Answer 9

Vaginal candidiasis ('thrush') is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of ***Candida albicans***, with the remaining 20% being caused by other candida species. The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop: * diabetes mellitus * drugs: antibiotics, steroids * pregnancy * immunosuppression: HIV Features * **'cottage cheese', non-offensive discharge** * **vulvitis:** superficial dyspareunia, dysuria * itch * **vulval erythema, fissuring,** satellite lesions may be seen Investigations * a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis MANAGEMENT **Prescribe antifungal treatment** _Most women:_ * Local: **clotrimazole pessary or cream** (e.g. clotrimazole 500mg PV stat) * Oral: **itraconazole 200 mg PO BD** for 1 day or **fluconazole 150mg PO stat _(FLUCONAZOLE FIRST LINE)_** * _Girls aged 12-15 years_: consider prescribing **topical clotrimazole 1% or 2% applied 2-3 times per day** (do not prescribe intravaginal or oral antifungal) * _Pregnant women_: **intravaginal clotrimazole (**Do not use oral antifungals) * _If vulval symptoms_: **topical imidazole** (clotrimazole, ketoconazole) i**n addition to an oral or intravaginal antifungal** * NOTE: intravaginal clotrimazole (**Canesten**), oral fluconazole, topical clotrimazole → OTC **Advice** * Return if symptoms have not resolved in 7-14 days Avoid predisposing factors: * Wash the vulval area with a soap substitute - used externally and not more than once per day * Use simple emollient to moisturise vulval area * Consider probiotics (e.g. live yoghurts) orally or topically to relieve symptoms * Do not routinely treat asymptomatic sexual partner → Male partner could get candida balanitis **Summary** Either local or oral treatment o Local: **clotrimazole pessary or cream** (e.g. clotrimazole 500 mg PV stat) o Oral: **itraconazole 200mg PO BD** for 1 day or **fluconazole 150 mg PO stat** _Recurrent vaginal candidiasis_ * BASHH define recurrent vaginal candidiasis as **4 or more episodes per year** * compliance with previous treatment should be checked * confirm the diagnosis of candidiasis * **high vaginal swab for microscopy and culture** * consider a b**lood glucose test to exclude diabetes** * exclude differential diagnoses such as lichen sclerosus * consider the use of an **induction-maintenance regime** * induction: oral fluconazole *every 3 days for 3 doses* * maintenance: oral fluconazole *weekly for 6 months*

Answer 10

The **history of endometriosis, acute abdomen, and the pelvis filled with fluid** all point towards a rupture endometrioma.

Answer 11

It is recommended to use effective contraception until the following time: * 12 months after the last period in women \> 50 years * 24 months after the last period in women \< 50 years

Answer 12

Topical cyclical combined HRT HRT contraindicated Oestrogen patch Topical \> oral if migraine with aura If has a uterus → COMBINED Not combined if no uterus, or one of P+O already provided (e.g. mirena coil in situ giving P) Undiagnosed vaginal bleeding is a contraindication to HRT Patch has least side effects = do not have an increased risk of DVT compared oral oestrogen preparations

Answer 13

Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix (can be descending from local organs such as the appendix). RFs = young, poor, sexually active partially PFs = COCP, IUS Causative organisms * ***Chlamydia trachomatis** (MOST COMMON CAUSE)* * ***Neisseria gonorrhoeae*** * *Mycoplasma genitalium* * *Mycoplasma hominis* *Other causes = TOP, ERPC, laparoscopy and dye test and IUD (and/or complications of childbirth and miscarriage)* Features * lower abdominal pain/pelvic pain (constant, or intermittent) * fever (unusual in chronic infection) * deep dyspareunia * dysuria and menstrual irregularities may occur (intermenstrual/postcoital bleeding) * vaginal or cervical discharge * cervical excitation * adnexal discomfort Investigation * a **pregnancy test** should be done to exclude an ectopic pregnancy * **high vaginal swab** * these are often negative * screen for **Chlamydia** (NAAT on urine) and **Gonorrhoea** (NAATs of endocervcical/vulvovaginal swabs) Complications * **_perihepatitis (Fitz-Hugh Curtis Syndrome)_** * occurs in around 10% of cases * it is characterised by right upper quadrant pain and may be confused with cholecystitis * adhesions visible at laparoscopy between liver and anterior abdominal wall * **infertility** - the risk may be as high as 10-20% after a single episode * **chronic pelvic pain** * **ectopic pregnancy**

Answer 14

Cyclical (oestrogen daily, progesterone used for a few weeks in the cycle) = menopause not achieved (amenorrhoea less than a year) Continuous (P+O daily) = reached menopause (amenorrhoea \>1 year)

Answer 15

Insulin resistance -\> hyperinsulinaemia -\> androgen excess -\> arrest in antral follicular development -\> anovulation Metformin treats insulin resistance and hyperinsulinaemia, therefore allowing follicular development and subsequent ovulation

Answer 16

Clomifine FIRST LINE Metformin SECOND LINE

Answer 17

no secondary sexual characteristics RAISED GONADOTROPINS (FSH, LH)

Answer 18

Adenomyosis is characterized by the presence of endometrial tissue within the myometrium. It is more common in multiparous women towards the end of their reproductive years. Features (mainly asymptomatic) * DYSmenorrhoea (fibroids cause HMB) * menorrhagia * enlarged, **boggy** uterus Ix: **MRI** (US to aid) Management Medical treatment with the **progesterone IUS or the combined oral contraceptive pill** with or without **NSAIDs** may control the menorrhagia and dysmenorrhoea, but **hysterectomy is often required.** For some women, a **trial of GnRH analogue therapy** may determine if symptoms attributed to adenomyosis are likely to improve with hysterectomy. The condition is oestrogen dependent, but why it occurs is unknown. The effects on fertility are unclear. * GnRH agonists * hysterectomy

Answer 19

Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space Epidemiology * occurs in approximately 1/200 pregnancies Cause - not known but associated factors: * proteinuric hypertension * cocaine use * multiparity * maternal trauma * increasing maternal age * current smoker * pre-eclampsia * transverse lie * *A** for **A**bruption previously; * *B** for **B**lood pressure (i.e. hypertension or pre-eclampsia); * *R** for **R**uptured membranes, either premature or prolonged; * *U** for **U**terine injury (i.e. trauma to the abdomen); * *P** for **P**olyhydramnios; * *T** for **T**wins or multiple gestation; * *I** for **I**nfection in the uterus, especially chorioamnionitis; * *O** for **O**lder age (i.e. aged over 35 years old); * *N** for **N**arcotic use (i.e. cocaine and amphetamines, as well as smoking) Clinical features * shock out of keeping with visible loss * pain constant * tender, tense uterus * normal lie and presentation * fetal heart: absent/distressed * coagulation problems * beware pre-eclampsia, DIC, anuria

Answer 20

Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment. If **low-lying placenta** at the **20-week** scan: * rescan at **34 weeks** * no need to limit activity or intercourse unless they bleed * if still present at 34 weeks and grade I/II then scan **every 2 weeks** * final ultrasound at **36-37 weeks** to determine the method of delivery * elective caesarean section for **grades III/IV between 37-38 weeks** * if **grade I then a trial of vaginal delivery may be offered** * if a woman with known placenta praevia goes into labour prior to the elective caesarean section an emergency caesarean section should be performed due to the risk of post-partum haemorrhage Placenta praevia with bleeding * admit * ABC approach to stabilise the woman * **if not able to stabilise → emergency caesarean section** * **if in labour or term reached → emergency caesarean section** Prognosis * death is now extremely rare * major cause of death in women with placenta praevia is now **PPH**

Answer 21

Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space Management Fetus alive and **\< 36 weeks** * fetal distress: immediate caesarean * **no fetal distress: ADMIT, observe closely, steroids, no tocolysis, threshold to deliver depends on gestation** Fetus alive and \> 36 weeks * fetal distress: immediate caesarean * no fetal distress: _deliver vaginally_ **Fetus dead** * **induce vaginal delivery** Complications Maternal * shock * DIC * renal failure * PPH Fetal * IUGR * hypoxia * death Prognosis * associated with **high perinatal mortality rate** * responsible for **15% of perinatal deaths**

Answer 22

Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage. Risk factors * previous caesarean section * placenta praevia Strictly speaking, there are 3 different types of placenta accreta, depending on the degree of invasion although this is quite small print: * accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis * increta: chorionic villi invade into the myometrium * percreta: chorionic villi invade through the perimetrium

Answer 23

**Magnesium sulphat**e is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following: * should be given once a decision to deliver has been made * in eclampsia an **IV bolus of 4g over 5-10 minutes** should be given **followed by an infusion of 1g / hour** * _urine output, reflexes, respiratory rate and oxygen saturations_ should be monitored during treatment * respiratory depression can occur: **calcium gluconate** is the first-line treatment for magnesium sulphate induced respiratory depression * treatment should continue for **24 hours after last seizure or delivery** (around 40% of seizures occur post-partum) Other important aspects of treating severe pre-eclampsia/eclampsia include **fluid restriction** to avoid the potentially serious consequences of fluid overload

Answer 24

If suspicion of ovarian cancer but there is an abdominal or pelvic mass, CA125 and US test can be bypassed and the patient directly referred to gynaecology

Answer 25

* squamous cell cancer (80%) * adenocarcinoma (20%)

Answer 26

* may be detected during routine cervical cancer screening * abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding * vaginal discharge

Answer 27

* smoking * human immunodeficiency virus * early first intercourse, many sexual partners * high parity * lower socioeconomic status * combined oral contraceptive pill\*

Answer 28

Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer RFs = **unopposed oestrogen (e.g. tamoxifen)** Types * simple * complex * simple atypical * complex atypical Features * abnormal vaginal bleeding e.g. intermenstrual Management * _simple endometrial hyperplasia without atypia:_ **lose weight** + **high dose progestogens with repeat sampling in 3-4 months**. The **levonorgestrel intra-uterine system** may be used (oral progestogens are second line) * _atypia:_ **hysterectomy +/- bilateral salpingo-oophorectomy** is usually advised

Answer 29

referring all patients with secondary dysmenorrhoea to gynaecology for investigation.

Answer 30

In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible. Features * pain typically starts **just before or within a few hours of the period starting** * **suprapubic cramping pains** which may **radiate to the back or down the thigh** Management * NSAIDs such as _mefenamic acid and ibuprofen_ are effective in up to 80% of women. They work by inhibiting prostaglandin production * _combined oral contraceptive pills_ are used second line

Answer 31

Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually start**s 3-4 days before the onset of the period.** Causes include: * endometriosis * adenomyosis * pelvic inflammatory disease * intrauterine devices\* * fibroids

Answer 32

**The only effective treatment for large fibroids causing problems with fertility is myomectomy** if the woman wishes to conceive in the future Myomectomy, which involves surgically removing the fibroid from the uterus is currently the only form of treatment for fibroids which has sufficient evidence of improving fertility. This is most likely to be successful for submucosal fibroids which reduce fertility evonorgestrel-releasing IUS and tranexamic acid provide symptomatic relief but will not impact on fertility making them inappropriate. Additionally, this fibroid is rather large making medical treatment likely ineffective.

Answer 33

An **abortion is the expulsion of the products of conception before 24 weeks.** The term miscarriage is used often to avoid any misunderstandings Epidemiology * **15-20%** of diagnosed pregnancies will miscarry in early pregnancies * non-development of the blastocyst within 14 days occurs in up to 50% of conceptions * recurrent spontaneous miscarriage affects 1% of women

Answer 34

**In miscarriages the I's are open - inevitable and incomplete.** Threatened miscarriage * painless vaginal bleeding occurring **before 24 weeks**, but typically occurs at **6 - 9 weeks** * the bleeding is often **less than menstruation** * cervical os is **closed** * complicates up to 25% of all pregnancies * **Foetal HR present** Missed (delayed) miscarriage * a gestational sac which contains a **dead fetus** before 20 weeks **without the symptoms of expulsion** * mother may have **light vaginal bleeding / discharge** and the s**ymptoms of pregnancy which disappear.** _Pain is not usually a feature_ * cervical os is **closed** * when the gestational sac is **\> 25 mm** and **no embryonic/fetal part** can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy' Inevitable miscarriage * **heavy bleeding** with **clots** and **pain** * cervical os is **open** Incomplete miscarriage * **not all products** of conception have been expelled * **pain** and vaginal **bleeding** * cervical os is **open**

Answer 35

The latest edition (11th) of the Oxford Handbook of Clinical Specialties says that the medical management of a 2nd (mid)-trimester miscarriage uses mifepristone (an antiprogestogen) to prime, and then 24-48h start misoprostol and admit mifepristone now, misprostol at home vaginal bleeding, nausea, vomiting → anti-emetics and analgesics

Answer 36

Recurrent miscarriage is defined as _3 or more consecutive spontaneous abortions._ It occurs in around 1% of women Causes * **antiphospholipid syndrome (MOST COMMON CAUSE)** * endocrine disorders: poorly controlled **diabetes mellitus/thyroid** disorders. **Polycystic ovarian syndrome** * uterine abnormality: e.g. uterine septum * parental chromosomal abnormalities * **smoking**

Answer 37

Common disorder, ovarian dysfunction associated with hyperandrogenism and polycystic ovarian morphology Path – LH + hyperinsulinaemia leads to increased ovarian androgen production Genetics are implicated RF – FHx, obesity, insulin resistance, HTN, AI, thyroid disease Most common endocrinopathy of women of reproductive age, affecting up to 10%

Answer 38

* pelvic ultrasound: multiple cysts on the ovaries * FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes * check for impaired glucose tolerance

Answer 39

Therefore inducing a withdrawal bleed every 3-4 months or preventing proliferation of the endometrium is recommended. This can be achieved with a cyclical oral progestogen (e.g. medroxyprogesterone) for at least 12 days a month, a combined oral contraceptive (COC), or levonorgestrel-releasing intrauterine system (LNG-IUS). Fertility → REFER TO FERTILITY SERVICES * As this woman has a known cause of infertility in the form of PCOS, she should be referred immediately to fertility services for consideration of further treatment. NICE recommends that these women be offered clomifene citrate or metformin, or a combination of the two, as first-line treatment. If this proves unsuccessful, laparoscopic ovarian drilling or gonadotrophins may be considered.

Answer 40

Cyproterone acetate + ethinylestradiol, used in PCOS complicated by hirsutism and acne (also acts as contraception)

Answer 41

**Clomiphene -** 1st line in women with a normal BMI (selective oestrogen receptor modulator) Can induce ovulation if subfertility is an issue; used for up to 6 months Increased risk of multiple pregnancy Given with/without **metformin** (usually added after 3 failed cycles with clomiphene)

Answer 42

Increased peripheral insulin sensitivity The majority of patients with polycystic ovarian syndrome have a degree of insulin resistence which in turn can lead to complicated changes in the hypothalamic-pituitary-ovarian axis. PCOS --\> insulin resistance --\> androgen excess --\> arrest in antral follicular development --\> anovulation.

Answer 43

A complete hydatidiform mole occurs when all of the genetic material comes from the father. There will be no foetal parts present * vaginal bleeding * uterus size greater than expected for gestational age * abnormally high serum hCG → hyperemesis gravid arum and thyrotoxicosis * ultrasound: 'snow storm' appearance of mixed echogenicity = solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes * Morning sickness can be more severe in molar pregnancies Diagnosis should be confirmed with histology after evacuation

Answer 44

A complete hydatidiform mole occurs when all of the genetic material comes from the father. There will be no foetal parts present and snowstorm appearance is seen on ultrasound. Vaginal bleeding early in pregnancy is often the presenting feature. Incomplete hydatidiform mole occurs due to two sets of paternal chromosomes and one set of maternal chromosomes. There are often foetal parts present and snowstorm appearance is not seen on ultrasound.

Answer 45

Amenorrhoea may be divided into: * _primary:_ defined as the failure to establish menstruation by **15 years** of age in girls with normal secondary sexual characteristics (such as breast development), or by **13 years** of age in girls with no secondary sexual characteristics * _secondary_: cessation of menstruation for **3-6 months** in women with previously normal and regular menses, or **6-12 months** in women with previous oligomenorrhoea

Answer 46

Imperforate hymen An **imperforate hymen** is a [congenital disorder](https://en.wikipedia.org/wiki/Congenital_disorder) where a [hymen](https://en.wikipedia.org/wiki/Hymen) without an opening completely obstructs the [vagina](https://en.wikipedia.org/wiki/Vagina). It is caused by a failure of the hymen to perforate during [fetal development](https://en.wikipedia.org/wiki/Prenatal_development). It is most often diagnosed in adolescent girls when menstrual blood accumulates in the vagina and sometimes also in the [uterus](https://en.wikipedia.org/wiki/Uterus). It is treated by surgical incision of the hymen. **CYCLICAL PAIN** **BLUISH BULGING MEMBRANE O/E** ted by surgical incision of the hymen. The above history suggests there is an obstruction to menstrual flow (since other secondary sexual characteristics have developed and due to the cyclical abdominal pain).

Answer 47

Androgen insensitivity syndrome is an **X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype.** Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome Features * 'primary amennorhoea' * undescended testes causing groin swellings * breast development may occur as a result of conversion of testosterone to oestradiol Diagnosis * buccal smear or chromosomal analysis to reveal 46XY genotype Management * counselling - raise child as female * bilateral orchidectomy (increased risk of testicular cancer due to undescended testes) * oestrogen therapy

Answer 48

Androgen insensitivity syndrome is an X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome Features * 'primary amennorhoea' * undescended testes causing groin swellings * breast development may occur as a result of conversion of testosterone to oestradiol Diagnosis * buccal smear or chromosomal analysis to reveal 46XY genotype Management * counselling - raise child as female * bilateral orchidectomy (increased risk of testicular cancer due to undescended testes) * oestrogen therapy

Answer 49

* miscarriage * **ectopic pregnancy** * the most 'important' cause as missed ectopics can be potentially life-threatening * implantation bleeding * a diagnosis of exclusion * miscellaneous conditions * cervical ectropion * vaginitis * trauma * polyps

Answer 50

* no identifiable pathology is found in around 50% of cases * cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill * cervicitis e.g. secondary to *Chlamydia* * cervical cancer * polyps * trauma

Answer 51

Positive pregnancy test AND any of the following: * pain and abdominal tenderness * pelvic tenderness * cervical motion tenderness BECAUSE IT CAN BE ECTOPIC

Answer 52

Long term: * enterocoele * vaginal vault prolapse Short term: * urinary retention

Answer 53

* he most common cause of postmenopausal bleeding is **vaginal atrophy**: The thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding * **HRT (hormone replacement therapy**) is also a common cause of postmenopausal bleeding: Periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding * **Endometrial hyperplasia**, an abnormal thickening of the endometrium and a precursor for endometrial carcinoma: Risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes * **Endometrial cancer:** Although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently * **Cervical cancer:** It is important to obtain a full record of prior cervical screening programme attendance * **Ovarian cancer:** Can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours * **Vaginal cancer:** Uncommon but can present with postmenopausal bleeding * Other uncommon causes include **trauma, vulval cancer and bleeding disorders**

Answer 54

* nausea * breast tenderness * fluid retention and weight gain

Answer 55

* NICE guidelines state that **women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer¹** * A thorough history is necessary: Enquire about timing, consistency and quantity of the bleeding, as well as a full gynaecological and obstetric history. It is especially important to ask about risk factors for endometrial cancer and to establish a menstrual timeline from menarche to menopause. A full drug history including HRT use should be sought. Red flag symptoms for gynaecological cancer should be enquired about¹ * A vaginal and a full abdominal examination should be performed: Looking for any masses or abnormalities within the abdomen or felt from within the vagina, as well as a speculum visualisation of the walls of the vagina and cervix. Blood or discharge may be seen * Immediate testing could include a urine dipstick to look for haematuria or infection, a full blood count to look for anaemia or a bleeding disorder, as well as CA-125 levels * For those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice: The endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is \<5mm. However, it may miss some pathology and if clinical suspicion is high, further testing is required * A definitive diagnosis of endometrial cancer can be achieved by an endometrial biopsy: This can either be taken during hysteroscopy or by an aspiration (pipelle) biopsy, where a thin flexible tube is inserted into the uterus via a speculum to remove cells for testing * Imaging in secondary care could include a CT or MRI of the uterus, pelvis and abdomen * Women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer

Answer 56

Risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes * In the case of endometrial hyperplasia, usually **dilatation and curettage** is performed to remove the excess endometrial tissue

Answer 57

Associations * more common in **Afro-Caribbean women** * rare before puberty, develop **IRT oestrogen** Features * **may be asymptomatic** * menorrhagia * may result in iron-deficiency **anaemia** * **lower abdominal pain:** cramping pains, often during menstruation * bloating * urinary symptoms, e.g. frequency, may occur with larger fibroids * subfertility * rare features: * **polycythaemia** secondary to autonomous production of erythropoietin

Answer 58

GnRH agonists not for large fibroids

Answer 59

Fibroids generally regress after the menopause. Some of the complications such as subfertility and iron-deficiency anaemia have been mentioned previously. Other complications * **red degeneration** - **h**emorrhagic infarction of the uterine leiomyoma, - commonly occurs during pregnancy → low grade fever, pain and vomiting → rest and analgesia resolve within 4-6 days

Answer 60

Delayed puberty with short stature * Turner's syndrome * Prader-Willi syndrome * Noonan's syndrome Delayed puberty with normal stature * polycystic ovarian syndrome * androgen insensitivity * Kallman's syndrome * Klinefelter's syndrome

Answer 61

Ovarian torsion may be defined as the partial or complete torsion of the ovary on it's supporting ligaments that may in turn compromise the blood supply. If the fallopian tube is also involved then it is referred to as adnexal torsion. Risk factors * ovarian mass: present in around 90% of cases of torsion * being of a reproductive age * pregnancy * ovarian hyperstimulation syndrome Features * Usually the sudden onset of deep-seated colicky abdominal pain. * Associated with vomiting and distress * fever may be seen in a minority (possibly secondary to adnexal necrosis) * Vaginal examination may reveal adnexial tenderness **Ultrasound** may show **_free fluid or a whirlpool sign._** **Laparoscopy i**s usually both diagnostic and therapeutic.

Answer 62

Uterine fibroids are sensitive to **oestrogen** and can therefore grow during **pregnancy.** If growth outstrips their blood supply, they can undergo red or 'carneous' degeneration. This usually presents with **low-grade fever, pain and vomiting**. The condition is usually managed conservatively with **rest and analgesia** and should **resolve within 4-7 days.**

Answer 63

* lower abdominal pain * fever * deep dyspareunia * dysuria and menstrual irregularities may occur * vaginal or cervical discharge * cervical excitation Investigation * a pregnancy test should be done to exclude an ectopic pregnancy * high vaginal swab * these are often negative * screen for Chlamydia and Gonorrhoea

Answer 64

* oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole * RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that *' Removal of the IUD should be considered and may be associated with better short term clinical outcomes'*

Answer 65

**Perihepatitis (Fitz-Hugh Curtis Syndrome)** * occurs in around 10% of cases * it is characterised by right upper quadrant pain and may be confused with cholecystitis infertility - the risk may be as high as 10-20% after a single episode Chronic pelvic pain Ectopic pregnancy

Answer 66

Initial investigations * exclude pregnancy with urinary or serum bHCG * full blood count, urea & electrolytes, coeliac screen, thyroid function tests * gonadotrophins * low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) * raised if gonadal dysgenesis (e.g. Turner's syndrome) * prolactin * androgen levels * raised levels may be seen in PCOS * oestradiol

Answer 67

Management * _primary amenorrhoea:_ * **investigate and treat any underlying cause** * with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner's syndrome) are likely to benefit from **hormone replacement therap**y (e.g. to prevent osteoporosis etC) * _secondary amenorrhoea_ * **exclude pregnancy, lactation, and menopause** (in women 40 years of age or older) * treat the underlying cause

Answer 68

imperforate hymen

Answer 69

Female genital mutilation (FGM) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.

Answer 70

* if FGM is confirmed in a girl under 18 years of age (either o/e or because the patients or parents says it has been done within 1 month of confirmation) reporting to the police is mandatory and this must be within 1 month of confirmation * Contact child protection services * Refer to secondary care for further investigation

Answer 71

Whilst the majority of women experience nausea (previously termed 'morning sickness') during the early stages of pregnancy it can become problematic in a minority of cases. The Royal College of Obstetricians and Gynaecologists (RCOG) now use the term 'nausea and vomiting of pregnancy' **(NVP)** to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition. It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between **8 and 12 weeks but may persist up to 20 weeks\*.** Associations * multiple pregnancies * trophoblastic disease * hyperthyroidism * nulliparity * obesity **Smoking** is associated with a decreased incidence of hyperemesis.

Answer 72

NICE Clinical Knowledges Summaries recommend considering admission in the following situations: * Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics * Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics * A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection) They also recommend having a lower threshold for admitting to hospital if the woman has a co-existing condition (for example diabetes) which may be adversely affected by nausea and vomiting.

Answer 73

The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis hyperemesis gravidarum: * 5% pre-pregnancy weight loss * dehydration * electrolyte imbalance Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis **(PUQE)** score can be used to classify the severity of NVP. Ix: **hypochloraemic, hyponatraemia with elevated urea and raised ketones** **metabolic alkalosis but acidosis if very severe (increased ketones aka ketosis)**

Answer 74

Management * antihistamines should be used first-line (BNF suggests **_promethazine/prochlorperazine**_ _**as first-line_**). Cyclizine is also recommended by Clinical Knowledge Summaries (CKS) * **ondansetron and metoclopramide** may be used _second-line_ * _metoclopramide may cause extrapyramidal side effects_ * **ginger and P6 (wrist) acupressure**: CKS suggest these can be tried but there is little evidence of benefit * admission may be needed for **IV hydration** Complications * Wernicke's encephalopathy * Mallory-Weiss tear * central pontine myelinolysis * acute tubular necrosis * fetal: small for gestational age, pre-term birth

Answer 75

reducing the upper limit from 28 weeks gestation to 24 weeks\* Key points * two registered medical practitioners must sign a legal document (in an emergency only one is needed) * only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise The method used to terminate pregnancy depend upon gestation * _less than 9 weeks_: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions * _less than 13 weeks_: surgical dilation and suction of uterine contents * _more than 15 week_s: surgical dilation and evacuation of uterine contents or late medical abortion (induces 'mini-labour')

Answer 76

* **Oral mifepristone** first to ripen cervix and also sensitise myometrium for prostaglandin analogues and then **misoprostol vaginally** 48 hours later which is the analogue for expulsion of pregnancy tissue

Answer 77

M rules include: * Irregular, solid tumour. * Ascites. * At least 4 papillary structures. * Irregular multilocular solid tumour with largest diameter ≥100 mm. * Very strong blood flow (on doppler) Women with any of the 'M rules' present should be referred to the gynaecology oncology department. As the patient has a multiloculated cyst with a strong blood flow, she should be referred to the gynaecology oncology service for biopsy.

Answer 78

Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS

Answer 79

intestinal obstruction, Crohn’s

Answer 80

***Rokitansky*** nodule or dermoid plug refers to a solid ***protuberance***projecting from an ovarian ***cyst*** in the context of mature ***cystic*** teratoma.

Answer 81

Where the initial serum bHCG level is \<1,500 IU per ml, serial bHCG measurements may be required (48 hours apart): * Where there is an increase in serum bHCG \>63%, the woman is likely to have a developing intrauterine pregnancy. * Where there is a decrease in serum bHCG \>50%, the pregnancy is unlikely to continue. * In the case of unstable serial bHCG measurements, there may be an ectopic pregnancy.

Answer 82

AMH, serum analysis, day 21 serum progesterone and hysterosalpingogram, USS High AMH also in PCOS

Answer 83

* 2 prior C sections * Previous Classical C sections * Abdominal/pelvic/vaginal surgery * Previous uterine rupture or less than 18 months from previous delivery done less likely when: * Placental problems, abnormal position, multiple * Uterine scar rupture if vaginal, vaginal can end up emergency C-section anyway, might hysterectomy

Answer 84

Utrogestan HRT very common to use as good side effect profile but not much Progesterone cover so risk of endometrial cancer from unopposed oestrogen - mirena coil is second line

Answer 85

EXTRAPYRAMIDAL SIDE EFFECTS (resting tremor and increased upper limb tone)

Answer 86

* two registered medical practitioners must sign a legal document (in an emergency only one is needed) * only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise upper limit is 24 weeks GA

Answer 87

* **less than 9 weeks:** mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions * **less than 13 weeks:** surgical dilation and suction of uterine contents * **more than 15 weeks:** surgical dilation and evacuation of uterine contents or late medical abortion (induces 'mini-labour')

Answer 88

* *that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or* * *that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or* * *that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or* * *that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.*

Answer 89

Infection (10%)

Answer 90

The whirl pool sign in this case refers to an ovarian torsion, it may also be seen when bowel twists on itself causing a volvulus. Other features you may see on the _ultrasound scan_ is an enlarged ovary seen in the midline with free pelvic fluid. If a _doppler scan_ is also done, you may see little on no ovarian venous flow with absent or reversed diastolic flow.

Answer 91

Primary dysmenorrhoea

Answer 92

'Beads-on-a-string' sign refers to a finding in chronic salpingitis, with mural nodules appearing as 'beads' and the relatively-thin wall appearing as 'string'.

Answer 93

Fibroids will often appear as hypoechoic masses.

Answer 94

The female genital mutilation Act 2003 advises that all forms of female genital cutting/modification for non-medical reasons is illegal and cannot be performed under any circumstances. It is illegal to perform such procedures however not illegal to discuss it. Inform the medical team and the police (report all known causes of FGM in under-18s to the police, either by calling 101 or through existing local routes) inform safeguarding team

Answer 95

GnRH agonists (-RELINs) = Leuprorelin, triptorelin

Answer 96

Turner's syndrome Prader-Willi syndrome Noonan's syndrome

Answer 97

PCOS Androgen insensitivity Kallman's syndrome Klinefelter's syndrome

Answer 98

Normal ovulation requires the close functioning of a number of positive and negative feedback loops between the hypothalamus, pituitary gland and ovaries. * The early follicular phase requires an increase in gonadotropin-releasing hormone (GnRH) pulse frequency which increases the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH), to allow for stimulation and development of multiple ovarian follicles, and usually only one of which will become the dominant ovulatory follicle in that menstrual cycle. * In the mid-follicular phase, FSH gradually stimulates estradiol production, following which estradiol itself produces a negative feedback loop on the hypothalamus and pituitary gland to suppress FSH and LH concentrations. * In the luteal phase, there is a unique switch from negative to positive feedback of estradiol, resulting in a surge of LH secretion and this leads to subsequent follicular rupture and ovulation. It is the unique balance of hormones and their feedback loops which leads to normal ovulation with each menstrual cycle, however with each class of ovulatory dysfunction, there is an alteration in this fine balance which may lead to irregular or complete anovulation.

Answer 99

Class 1 (hypongonadtropic hypogonadal anovulation) = hypothalamic amenorrhoea Class 2 (normogonadotropic normoestrogenic anovulation) = PCOS (80% cases) Class 3 (hypergonadotropic hypoestrogenic anovulation) = POI → ovulation induction unsuccessful → IVF with done oocytes to conceive required

Answer 100

Exercise and weight loss * 1st line for PCOS (overweight/obese women) Letrozole * 1st line for PCOS over clomiphene citrate. * Aromatase inhibitor → reduce -ve feedback caused by oestrogen to pituitary gland → increase in FSH for follicular development * higher rate of mono-follicular development * side effects = fatigue, dizziness Clomiphene citrate * SERM → acts on hypothalamus → increase GnRH → increase FSH + LH → follicular development * 2nd line PCOS * side effects = hot flushes, abdominal distension and pain, N+V Gonadotropin therapy * for class 1 ovulatory dysfunction * risk of multi-follicular development and subsequent multiple pregnancy much higher * higher risk of OHSS * GnRH IV infusion pump → endogenous FSH + LH production → follicular development

Answer 101

Kallmann syndrome is a congenital form of **hypogonadotropic hypogonadism**, caused by an abnormally functioning hypothalamus. blood results would show **low GnRH, FSH, and LH.** Exam questions also often mention an **_absence of the sense of smell,_** which can be seen in Kallmann syndrome.

Answer 102

congenital condition in which the gonads are atypically developed, and may be functionless. This can be seen in syndromes such as Turner's syndrome Due to the abnormal gonads, androgens are not produced in response to FSH and LH from the anterior pituitary gland. This results in the **underdevelopment of secondary sexual characteristics,** and in females will cause **primary amenorrhoea.** **FSH and LH levels will continue to remain high due** to the absence of negative feedback from oestrogen on the hypothalamus.

Answer 103

'For people with unexplained infertility, mild endometriosis or 'mild male factor infertility', who are having regular unprotected sexual intercourse: do not routinely offer intrauterine insemination, either with or without ovarian stimulation (exceptional circumstances include, for example, when people have social, cultural or religious objections to IVF) advise them to try to conceive for a **total of 2 years** (this can include up to 1 year before their fertility investigations) before IVF will be considered'.

Answer 104

Causes * male factor 30% * unexplained 20% * ovulation failure 20% * tubal damage 15% * other causes 15%

Answer 105

semen analysis _serum progesterone_ **7 days prior to expected next period.** For a typical 28 day cycle, this is done on **day 21.**

Answer 106

semen analysis _serum progesterone_ **7 days prior to expected next period.** For a typical 28 day cycle, this is done on **day 21.**

Answer 107

Key counselling points * folic acid * aim for BMI 20-25 * advise regular sexual intercourse every 2 to 3 days * smoking/drinking advice

Answer 108

Postpartum hypopituarism = reduction of pituitary gland function following ischaemic necrosis due to hypovolaemia shock following birth amenorrhoea, problems with milk production, hypothyroidism

Answer 109

* nausea * breast tenderness * fluid retention and weight gain

Answer 110

If a uterine fibroid is less than 3cm in size, and not distorting the uterine cavity, medical treatment can be tried (e.g. IUS, tranexamic acid, COCP etc)

Answer 111

secondary amenorrhoea (hypothalamic hypogonadism) low levels of body fat → hypothalamus releases less GRH → hypogonadism

Answer 112

Congenital adrenal hyperplasia

Answer 113

Up to 4 weeks After this time, a positive test requires investigation, as the abortion may have been unsuccessful or she may have persistent trophoblastic tissue that requires management.

Answer 114

Transdermal HRT

Answer 115

abdominal pain, bloating, change in bowel habits A 27-year-old woman complains of spasmodic pains in the left iliac fossa. These pains have been present for the past six months and sometimes radiate to the back. She often feels bloated, particularly around her period. She describes her bowels as being 'stubborn' but does not take a regular laxative. Vaginal and abdominal examination is unremarkable.

Answer 116

Semen analysis should be performed after a **minimum of 3 days** and a **maximum of 5 days abstinence.** The sample needs to be delivered to the lab **within 1 hour**

Answer 117

* volume \> 1.5 ml * pH \> 7.2 * sperm concentration \> 15 million / ml * morphology \> 4% normal forms * motility \> 32% progressive motility * vitality \> 58% live spermatozoa

Answer 118

A repeat confirmatory test should therefore be undertaken. This should be postponed for **3 months** after the initial analysis to allow time for the cycle of spermatozoa formation to be completed. **immediate recheck** should only be performed if there is gross spermatozoa deficiency (azoospermia or severe oligozoospermia - defined as a sperm concentration of \<5 million per ml)

Answer 119

* Complete miscarriage is a spontaneous abortion with expulsion of the entire fetus through the cervix. * Pain and uterine contractions **stop** after fetus has been expelled. * Diagnosis: **U/S shows an empty uterus**

Answer 120

* **painless vaginal bleeding** occurring before 24 weeks, but typically occurs at 6 - 9 weeks * the bleeding is often less than menstruation * **cervical os is closed** * complicates up to 25% of all pregnancies

Answer 121

* a gestational sac which contains a dead fetus **before 20 weeks without the symptoms of expulsion** * mother may have **light vaginal bleeding / discharge** and the symptoms of pregnancy which **disappear.** P_ain is not usually a feature_ * **cervical os is closed** * when the gestational sac is **\> 25 mm** and **no embryonic/fetal part can be seen** it is sometimes described as a _'blighted ovum' or 'anembryonic pregnancy'_

Answer 122

* heavy bleeding with clots and pain * cervical os is open

Answer 123

* not all products of conception have been expelled * pain and vaginal bleeding * cervical os is open

Answer 124

Endometriomas, also known as chocolate cysts or endometriotic cysts, are **a localised form of endometriosis and are usually within the ovary**. A 30-year-old woman is brought into the emergency department in intense pain. She has a past medical history of endometriosis, and it is one week since her last period. On ultrasound scan there is free fluid in the pelvis. What is the cause of her acute abdomen?

Answer 125

vesicovaginal fistulae feature = continuous dribbling incontinence ix = urinary dye study identifies presence of a fistula

Answer 126

Endometrioid, mucinous, secretory, serous and clear cell 

Answer 127

* **List some risk factors for endometrial cancer.** Obesity  Nulliparity  Early menarche and late menopause  Unopposed oestrogen therapy  Diabetes mellitus  Tamoxifen  PCOS  HNPCC – hereditary non-polyposis colorectal carcinoma

Answer 128

Smoking COCP

Answer 129

* (anti-oestrogen in breast, oestrogen in uterus)

Answer 130

for facial hirsutism but has **limited utility if the excess hair is more widespread** **also for acne**

Answer 131

TWIN PREGNANCY

Answer 132

obesity and nulliparity

Answer 133

Age, previous miscarriages, chronic conditions (uncontrolled diabetes), uterine/cervical problems (mullein duct problems, cervical cone biopsies), smoking and illicit drugs, weight, invasive prenatal

Answer 134

enterocoele and vaginal vault prolapse. (urinary prolapse is an ACUTE problem)

Answer 135

urgent surgical evacuation of products of conception is required to minimise further blood loss. Dilation and curettage is a common and controlled method of uterine evacuation.

Answer 136

Some situations are better managed with medically or surgically. NICE list the following: * increased risk of haemorrhage * she is in the late first trimester * if she has coagulopathies or is unable to have a blood transfusion * previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) * evidence of infection

PassMed Flashcards

(179 cards)