Passmed textbook - Gynaecology Flashcards

Question

Which population is offered the smear test?.

Answer 1

Women of ages 25-65 25-49 years - every 3 years 50-64 years - every 5 years cervical screening cannot be offered to women over 64 unless A recent cervical cytology sample is abnormal They have not had a cervical screening test since 50 years of age and they request one Patients cannot self-refer past screening age Special situations women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears Women may undergo colposcopy in late first, or early second trimester, unless there is a clinical contraindication For low-grade changes, the assessment may be delayed until after delivery Women seen in early pregnancy may require a further assessment in the late second trimester

Answer 2

It is said that the best time to take a cervical smear is around mid-cycle Whilst there is limited evidence to support this it is still the current advice given out by the NHS A cervical sample should not be taken (unless you think the woman will not re-attend), if the woman: Is menstruating. Is less than 12 weeks postnatal. Is less 12 weeks after a termination of pregnancy, or miscarriage Has a vaginal discharge or pelvic infection — treat the infection and take the sample on another occasion

Answer 3

Place the brush into the cervix + rotate 5 times Take a sample from the whole of the transformation zone The transformation zone can be identified by visual inspection as there is a change in colour and texture from the pale, pink, shiny, smooth surface of the ectocervix to a reddish, granular appearance of the columnar cells that line the endocervical canal The position of the transformation zone may be affected by age and pregnancy Then swirl the brush into the sample bottle containing the preservative fluid 10 times There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC) Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid. Advantages of LBC reduced rate of inadequate smears increased sensitivity and specificity To take a cytology sample: Visualize the cervix (using a speculum) — if the cervix appears abnormal, suggesting possible malignancy arrange urgent referral (within 2 weeks) to a gynaecologist Note: there is no need for referral for colposcopy if there has been contact bleeding at the time a cervical sample is obtained (in the absence of other symptoms)

Answer 4

What used to happen Signs of dyskaryosis which may indicate cervical intraepithelial neoplasia Patients with mild dyskaryosis were further risk-stratified, i.e. as HPV is such a strong risk factor patients who were HPV negative could be treated as having normal result Now The NHS has moved to an HPV first system A sample is tested for high-risk strains of human papillomavirus (hrHPV) first Cytological examination is only performed if this is positive

Answer 5

If Negative hrHPV (high-risk strains of papillomavirus) return to routine recall unless Follow-up for borderline changes in endocervical cells Follow-up for incomplete excised cervical glandular epithelial neoplasia (CGIN)/ stratified mucin producing epithelial lesion (SMILE) or cervical cancer Test of Cure (TOC) pathway - individuals treated for CIN1, CIN2, CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community The untreated CIN1 pathway – Women with untreated CIN 1 must have a repeat Colposcopy and cytology test at 6 months

Answer 6

Subtotal hysterectomy (that still have a cervix) should continue in the National Cervical Screening Programme (NHSCSP) Women who have had a hysterectomy with CIN present are potentially at risk of developing vaginal intraepithelial neoplasia (VaIN) and invasive vaginal disease Total hysterectomy (no longer have a cervix) are not required to take part in the NHSCSP.

Answer 7

All women treated for CIN should be followed up for test of cure cervical cytology 6 months after treatment • If the sample is negative, borderline or low-grade, a reflex high-risk human papillomavirus (HR–HPV) test should be taken o HPV +ve - refer to colposcopy o HPV -ve should be recalled for repeated cytology in 3 years, irrespective of their age. • If the sample is high-grade dyskaryosis or invasive squamous carcinoma refer to colposcopy. An HR-HPV test is unecessary

Answer 8

Positive hrHPV • Samples are examined cytologically ``` Abnormal cytology → colposcopy this includes the following results: borderline changes in squamous or endocervical cells. low-grade dyskaryosi. high-grade dyskaryosis (moderate) high-grade dyskaryosis (severe) invasive squamous cell carcinom. glandular neoplasia ``` Normal cytology - Repeat test at 12 months if repeat test is hrHPV -ve → return to normal recall if the repeat test is still hrHPV +ve + cytology still normal → further repeat test 12 months late: If hrHPV -ve at 24 months → return to normal recall if hrHPV +ve at 24 months → colposcopy if inadequate sample at 24 months → colposcopy

Answer 9

Inadequate — this may be because the cervical sample: Was taken but the cervix was not fully visualized. Was taken in an inappropriate manner (for example, using an unapproved device). Contains insufficient cells. Contains an obscuring element (for example lubricant, inflammation, or blood). (when taking a cervical sample try not to use too much lubricant) Is incorrectly labelled. Negative — no abnormality is detected. Abnormal — the cervical samples may show: Borderline changes in squamous or endocervical cells. Low-grade dyskaryosis. High-grade dyskaryosis (moderate) High-grade dyskaryosis (severe) Invasive squamous cell carcinoma. Glandular neoplasia.

Answer 10

Sample is repeated in no less than 3 months Exception: Individuals who have inadequate cytology at the 24 month repeat test* - refer to colposcopy. *Positive hrHPV Normal cytology - Repeat test at 12 months if repeat test is hrHPV -ve → return to normal recall if the repeat test is still hrHPV +ve + cytology still normal → further repeat test 12 months late: If hrHPV -ve at 24 months → return to normal recall if hrHPV +ve at 24 months → colposcopy if inadequate sample at 24 months → colposcopy

Answer 11

On the ectocervix there is a transformation zone Stratified squamous epithelium meets the columnar epithelium of the cervical canal Elevated oestrogen levels (ovulatory phase, pregnancy, COCP use) result in larger area of columnar epithelium being present on the ectocervix Symptoms vaginal discharge PCB Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms

Answer 12

 All the genetic material comes from the father  An empty oocyte lacking maternal genes is fertilised  Commonly this arises from a single sperm duplicating within an empty ovum  Less often an empty ovum is fertilised by 2 sperm  There is no fetal tissue  46 XY or 46XX vaginal bleeding hyperemesis uterus size greater than expected for gestational age abnormally high serum hCG ultrasound: 'snow storm' appearance of mixed echogenicity

Answer 13

Short stature Turner's syndrome 45XO Prader Willi syndrome - Chr15 (loss of paternal gene, maternal gene is silenced by genomic imprinting) Noonan's syndrome ``` Normal stature PCOS Androgen insensitivity syndrome Kallman's syndrome Klinefelter's syndrome 47XXY ``` Kallmann syndrome is a condition characterized by delayed or absent puberty and an impaired sense of smell. This disorder is a form of hypogonadotropic hypogonadism, which is a condition resulting from a lack of production of certain hormones that direct sexual development Klinefelter syndrome may adversely affect testicular growth, resulting in smaller than normal testicles, which can lead to lower production of testosterone

Answer 14

Excessive pain during the menstrual period

Answer 15

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 (mefenamc acid, ibuprofen) - inhibit PG production* • COCP - 2nd line * e. Excessive endometrial prostaglandin production is thought to be partially responsible for primary dysmenorrhoea

Answer 16

``` Endometriosis Adenomyosis PID IUD Copper coils Mirena may help with dysmenorrhoea Fibroids ``` In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period

Answer 17

A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding lower abdominal pain typically the first symptom due to tubal spasm pain is usually constant and may be unilateral vaginal bleeding usually less than a normal period may be dark brown in colour history of recent amenorrhoea typically 6-8 weeks from the start of last period if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination dizziness, fainting or syncope symptoms of pregnancy e.g. breast tenderness

Answer 18

Examination findings abdominal tenderness cervical excitation (cervical motion tenderness) adnexal mass NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy A pelvic examination to check for cervical excitation is however recommended In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy

Answer 19

``` Risk factors damage to tubes (pelvic inflammatory disease, surgery) previous ectopic endometriosis IUCD progesterone only pill IVF (3% of pregnancies are ectopic) ```

Answer 20

``` Abdominal investigation Obs Urine pregnancy test Vaginal examination to test for cervical motion tenderness TVUS - investigation of choice ``` Bhcg After TVUSS if unable to locate the fetus (prefnancy of unknown origin) NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy A pelvic examination to check for cervical excitation is however recommended

Answer 21

``` Expectant mx - closely monitoring the patient over 48h • Size <35mm • Unruptured • Asymptomatic • No fetal heartbeat • Serum bhCG <1,000 IU/L ``` * If symptoms manifest or if bhCG levels rise again - intervention is performed * Expectant management is suitable if there is another intrauterine pregnancy ``` Medical mx - methotrexate only if the patient is wiling to attend follow up • Size <35mm • Unruptured • No significant pain • No fetal heartbeat • Serum bhCG <1,500 IU/L ``` • Medical management is not suitable if there is another intrauterine pregnancy ``` Surgical mx - salpingectomy or salpingotomy • Size >35mm • Unruptured/Ruptured • Pain • Visible fetal heartbeat • Serum bhCG >1,500 IU/L ``` • Surgical management is suitable if there is another intrauterine pregnancy

Answer 22

97% are tubal, with most in the ampulla Most dangerous in the isthmus Trophoblast invades the tubal wall - bleeding which may dislodge the embryo Natural history tubal abortion tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed tubal rupture (commonest are abortion + absorption)

Answer 23

classically seen in post-menopausal women Around 25% of cases occur before the menopause Usually carries a good prognosis due to early detection

Answer 24

Risk factors Obesity Nulliparity Early menarche, late menopause Unopposed oestrogen Addition of a progestogen to oestrogen reduces this risk (e.g. In HRT) Progestogen should be given continuously Diabetes mellitus Tamoxifen PCOS Hereditary non-polyposis colorectal carcinoma Protective factors Smoking COCP

Answer 25

Postmenopausal bleeding is the classic symptom premenopausal women Change intermenstrual bleeding Pain and discharge are unusual features

Answer 26

women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway TVUS - first-line investigation A normal endometrial thickness (< 4 mm) has a high negative predictive value Hysteroscopy with endometrial biopsy if endometrial thickness >4mm

Answer 27

Localised disease - total abdominal hysterectomy with bilateral salpingo-oophorectomy Patients with high-risk disease Post-operative radiotherapy Not suitable for surgery (e.g. frail elderly women) - progestogen therapy

Answer 28

Definition 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 Features Abnormal vaginal bleeding e.g. intermenstrual Management simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. LNG-IUD may be used atypia: hysterectomy

Answer 29

Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity Around 10% of women of a reproductive age have a degree of endometriosis.

Answer 30

Chronic pelvic pain Dysmenorrhoea - pain often starts days before bleeding Deep dyspareunia Subfertility Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements) on pelvic examination Reduced organ mobility Tender nodularity in the posterior vaginal fornix Visible vaginal endometriotic lesions

Answer 31

laparoscopy is the gold-standard investigation there is poor correlation between laparoscopic findings and severity of symptoms

Answer 32

Management depends on clinical features - NSAIDs and/or paracetamol - first-line treatments for symptomatic relief - if analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried If analgesia/hormonal treatment does not improve symptoms or if fertility is a priority the patient should be referred to secondary care. Secondary treatments include: GnRH analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels drug therapy unfortunately does not seem to have a significant impact on fertility rates surgery: some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Answer 33

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 34

Type 1 Clitoridectomy = Partial or total removal of the clitoris and/or the prepuce Type 2 Excision = Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora Type 3 Infibulation = Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris Type 4 All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

Answer 35

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 Low-grade fever Pain Vomiting Conservative management Rest and analgesia Should resolve within 4-7 days

Answer 36

In addition to routine diagnostic work up of abdominal pain, all female patients should undergo Urine pregnancy test Bimanual vaginal examination Consider abdominal + pelvic USS If diagnostic doubt - laparoscopy to assess suspected tubulo-ovarian pathology

Answer 37

``` Mittelschmerz Features Mid-cycle pain Sharp onset Little systemic disturance Recurrent episodes Settles over 24-48 hours ``` ``` Ix FBC - N USS - small quantity of free fluid --- Endometriosis Features Menstrual irregularity Infertility Pain Deep dyspareunia Complex disease - pelvic adhesion formation with episodes of intermittent small bowel obstruction Localised peritoneal inflammation from intra-abdominal bleeding Recurrent episodes are common ``` Ix USS - free fluid Laparoscopy - will show lesions ``` Management Usually managed medically Complex disease requires surgery Some pt may require formal colonic and rectal resections if these areas are involved --- ``` ``` Ovarian torsion Features Sudden onset of deep seated colicky abdominal pain Vomiting + distress Adnexial tenderness ``` Ix USS - free fluid Laparoscopy - diagnostic + therapeutic Management Laparoscopy ---- Ectopic gestation Features Symptoms of pregnancy without evidence of intrauterine gestation Presents as an emergency - evidence of rupture or impending rupture Open tubular ruptures - sudden onset abdominal pain + circulatory collapse small amount of vaginal discharge adnexal tenderness but should not perform adnexal palpation as there is a risk of rupture Ix elevated bhCG USS - no intrauterine pregnancy, intraabdominal free fluid Management Laparoscopy or laparotomy if haem unstable Salpingectomy or salpingotomy ---- PID Features Fever >38 Bilateral lower abdominal pain associated with vaginal discharge Dysuria RUQ discomfort - Peri-hepatic inflammation 2o to chlamydia (Fitz Hugh Syndrome) ``` Ix FBC - leukocytosis Pregnancy test - negative Amylase - N or slightly raised High vaginal + urethral swabs ``` Management Medical

Answer 38

FBC - Hb ``` Routine TVUS if symptoms suggest a structural or histological abnormality IMB PCB pelvic pain Pressure symptoms) Abnormal pelvic exam findings. ```

Answer 39

Does not require contraception Mefenamic acid 500 mg tds (NSAID) (particularly if there is dysmenorrhoea as well) or Tranexamic acid 1 g tds Both are started on the first day of the period Requires contraception, LNG-IUS (Mirena) - 1st line COCP - 2nd line long-acting progestogens (depo-provera) - 3rd line Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

Answer 40

Nausea Breast tenderness Fluid retention Weight gain

Answer 41

o Oestrogen only – endometrial cancer, ovarian cancer o Combined – breast cancer, ovarian cancer Increased risk of breast cancer increased by the addition of a progestogen the increased risk relates to the duration of use the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT increased risk with all HRT Risk of dying form breast cancer is not raised increased risk of endometrial cancer oestrogen by itself should not be given as HRT to women with a womb reduced by the addition of a progestogen but not eliminated completely the BNF states that the additional risk is eliminated if a progestogen is given continuously increased risk of ovarian cancer Risk increased with all HRT increased risk of venous thromboembolism increased by the addition of a progestogen transdermal HRT does not appear to increase the risk of VTE NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal) increased risk of stroke slightly increased risk with oral oestrogen HRT increased risk of coronary heart disease increased risk of ischaemic heart disease if taken more than 10 years after menopause

Answer 42

Most common between 8 + 12 weeks May persist up to 20 weeks ``` Associations Nulliparity multiple pregnancies trophoblastic disease hyperthyroidism obesity ``` Smoking = decreased incidence of hyperemesis

Answer 43

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) 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 44

5% pre-pregnancy weight loss and dehydration and electrolyte imbalance

Answer 45

Pregnancy-Unique Quantification of Emesis (PUQE)

Answer 46

admission may be needed for IV hydration antihistamines first-line Promethazine Cyclizine ondansetron and metoclopramide 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

Answer 47

Wernicke's encephalopathy central pontine myelinolysis Mallory-Weiss tear acute tubular necrosis fetal: small for gestational age, pre-term birth

Answer 48

Acute Urinary retention Long-term Enterocele Vaginal vault prolapse

Answer 49

Semen analysis Serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21. Interpretation of serum progestogen >30 nmol/l indicates ovulation 16-30 nmol/l repeat <16 nmol/l repeat, if consistently low refer to specialist

Answer 50

Affects around 1 in 7 couples Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years

Answer 51

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

Answer 52

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

Answer 53

51 years old Symptoms typically last for 4 years on average

Answer 54

12 months after the last period in women > 50 years 24 months after the last period in women < 50 years

Answer 55

Lifestyle modifications Hot flushes regular exercise, weight loss and reduce stress Sleep disturbance avoiding late evening exercise and maintaining good sleep hygiene Mood sleep, regular exercise and relaxation Cognitive symptoms regular exercise and good sleep hygiene Hormone replacement therapy (HRT) Non-hormone replacement therapy Vasomotor symptoms fluoxetine, citalopram or venlafaxine Vaginal dryness vaginal lubricant or moisturiser Psychological symptoms self-help groups, cognitive behaviour therapy or antidepressants Urogenital symptoms if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

Answer 56

* Any oestrogen-sensitive cancer * Current or past Breast cancer * Untreated endometrial hyperplasia * Undiagnosed vaginal bleeding * Hx of VTE * Current thrombophilia (AT-III, FV Leiden) * Severe liver disease * Pregnancy

Answer 57

For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment Vaginal oestrogen may be required long term Gradually reducing HRT is effective at limiting recurrence only in the short term In the long term, there is no difference in symptom control

Answer 58

Vasomotor symptoms - affects around 80% of women. Usually occur daily and may continue for up to 5 years hot flushes night sweats Urogenital changes - affects around 35% of women vaginal dryness and atrophy urinary frequency Psychological anxiety and depression may be seen - around 10% of women short-term memory impairment Longer term complications osteoporosis increased risk of ischaemic heart disease

Answer 59

uterine fibroids hypothyroidism intrauterine devices* Copper IUD IUS (mirena) is used to treat menorrhagia pelvic inflammatory disease bleeding disorders, e.g. von Willebrand disease dysfunctional uterine bleeding: menorrhagia in the absence of underlying pathology(accounts for approximately half of patients) anovulatory cycles: these are more common at the extremes of a women's reproductive life

Answer 60

``` Threatened miscarriage • Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6-9 weeks • Mild symptoms of bleeding • Little/no pain • FH is present • Cervical os is closed ``` ``` Inevitable miscarriage • Heavy bleeding with clots • Pain • Cervical os is open • Pregnancy will not continue – will proceed to incomplete/complete miscarriage ``` Missed (delayed) miscarriage • Fetus is dead but retained • Also described as early fetal demise/empty sac/blighted ovum o a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion o blighted ovum/anembryonic pregnancy = when the gestational sac is >25mm and no embryonic/fetal part can be seen • Mother may have light vaginal bleeding/discharge and the symptoms of pregnancy which disappear • Pain is not usually a feature • Uterus is small for dates • Pregnancy test can remain positive for several days/weeks • Hx of threatened miscarriage + persistent dark-brown discharge • Early pregnancy symptoms may have decreased or stopped Incomplete miscarriage – passage of products of conception but uterus not empty on USS Pain and vaginal bleeding Cervical os is open Products of conception are partially expelled Many incomplete miscarriages can be unrecognised missed miscarriages ``` Complete miscarriage • Hx of confirmed IU pregnancy • Heavy bleeding + clots • Passage of products of conception • Empty uterus on USS – no pregnancy tissue in the uterine cavity ```

Answer 61

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 85% of spontaneous miscarriages occur in the 1st trimester The risk falls rapidly with advancing gestation

Answer 62

Expectant - 1st line - Wait for 7-14 days unless Increased risk of haemorrhage (late first trimester or coagulopathies or unable to have a blood transfusion) Previous adverse +/or traumatic experience associated with pregnancy (stillbirth, miscarriage, APH) Evidence of infection Medical - Vaginal misopostol PG analogue - binds to endometrial cells - causes strong myometrial contractions leading to the expulsion of tissue - Contact Dr if bleeding hasn't started in 24h - Should be given w anti-emetics + pain relief ``` Surgical - vacuum aspiration (suction curettage) LA as an OP - Surgical management in theatre (evacuation of retained products of conception) GA ```

Answer 63

The 5th most common malignancy in females Peak age of incidence - 60 years Carries a poor prognosis due to late dx RF - FHx - BRCA1 or BRCA2 - Many ovulations - early menarches, late menopause, nulliparity Protective factors - COCP - Having many pregnancies 80% of women have advanced disease at presentation the all stage 5-year survival is 46%

Answer 64

90% of ovarian cancers - epithelial in origin with 70-80% of cases being due to serous carcinomas Distal end of the fallopian tube is often the site of origin of many 'ovarian' cancers

Answer 65

Abdominal distension and bloating Abdominal and pelvic pain Urinary symptoms e.g. Urgency Early satiety Diarrhoea

Answer 66

CA125 Done initially If the CA125 is raised (35 IU/mL or greater) --> urgent ultrasound scan of the abdomen and pelvis should be ordered Should not be used for screening for ovarian cancer in asymptomatic women Other causes of increased CA125 Endometriosis menstruation benign ovarian cysts Ultrasound Diagnosis is difficult and usually involves diagnostic laparotomy

Answer 67

usually a combination of surgery and platinum-based chemotherapy

Answer 68

Physiological cysts Benign germ cell tumours Benign epithelial tumours Benign sex cord stromal tumours Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy

Answer 69

Follicular cysts - commonest type of ovarian cyst - due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle - commonly regress after several menstrual cycles Corpus luteum cyst - during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears - If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst - more likely to present with intraperitoneal bleeding than follicular cysts

Answer 70

Dermoid cyst - also called mature cystic teratomas - Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth - Most common benign ovarian tumour in woman under the age of 30 years - Median age of diagnosis is 30 years old - Bilateral in 10-20% - Usually asymptomatic - Torsion is more likely than with other ovarian tumours

Answer 71

Arise from the ovarian surface epithelium Serous cystadenoma - the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma) - bilateral in around 20% Mucinous cystadenoma - second most common benign epithelial tumour - large and may become massive - if ruptures may cause pseudomyxoma peritonei

Answer 72

USS - Initial imaging modality for suspected ovarian cysts/tumours Cyst can be either Simple - unilocular - more likely to be physiological or benign Complex - multilocular - more likely to be malignant Premenopausal women - Conservative mx in younger women (esp. if < 35 years) as malignancy is less common - Small cyst (e.g. < 5 cm) + 'simple' Highly likely to be benign A repeat ultrasound should be arranged for 8-12 weeks Referral considered if it persists Postmenopausal women Physiological cysts are unlikely Any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment

Answer 73

- Complication seen in some forms of infertility treatment - up to 1/3 of women who are having IVF may experience a mild form of OHSS - occurs in <1% of all women undergoing ovarian induction - Multiple luteinized cysts within ovaries - ovarian enlargement with multiple cystic spaces - high levels of oestrogen, progesterone, vasoactive substances (e.g. VEGF) - Increased membrane permeability - loss of fluid from the intravascular compartment - fluid shift from the intravascular to the extra-vascular space - can be life-threatening if not identifies and managed promptly Can result in multiple life-threatening complications - Hypovolaemic shock - Acute renal failure - Venous or arterial thromboembolism Seen after - Gonadotrophin treatment - hcg treatment - clomifene therapy (rarely)

Answer 74

Mild - Abdominal pain - Abdominal bloating Moderate - Abdominal pain - Abdominal bloating - N+V - USS evidence of ascites Severe - Abdominal pain - Abdominal bloating - N+V - USS evidence of ascites - Clinical evidence of ascites - Oliguria - Hct >45% - Hypoproteinaemia Critical - Abdominal pain - Abdominal bloating - N+V - USS evidence of ascites - Clinical evidence of ascites - Tense ascites - Anuria - Hct >45% - Hypoproteinaemia - Thromboembolism - ARDS

Answer 75

Ovarian torsion Partial or complete torsion of the ovary on it's supporting ligaments that may in turn compromise the blood supply Adnexal torsion If the fallopian tube is also involved

Answer 76

Ovarian mass: present in around 90% of cases of torsion Being of a reproductive age Pregnancy Ovarian hyperstimulation syndrome

Answer 77

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

Answer 78

USS Free fluid Whirlpool sign Laparoscopy Both diagnostic and therapeutic

Answer 79

Surface derived tumours Germ cell tumours Sex cord-stromal tumours Metastasis

Answer 80

Account for around 65% of ovarian tumours, including the greatest number of malignant tumours. Serous cystadenoma - Benign - Most common benign ovarian tumour, often bilateral - Cyst lined by ciliated cells (similar to Fallopian tube) Serous cystadenocarcinoma - Malignant - Often bilateral - Psammoma bodies seen (collection of calcium) Mucinous cystadenoma - Benign - Cyst lined by mucous-secreting epithelium (similar to endocervix) Mucinous cystadenocarcinoma - Malignant - May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause of pseudomyxoma peritonei ) Brenner tumour - Benign - Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium - Typically have 'coffee bean' nuclei.

Answer 81

These are more common in adolescent girls Account for 15-20% of tumours Similar cancer types to those seen in the testicle Dysgerminoma - Malignant - Most common malignant germ cell tumour - Histological appearance similar to that of testicular seminoma - Associated with Turner's syndrome - Typically secrete hCG and LDH Teratoma - Mature teratoma (dermoid cyst) - most common - benign - Immature teratoma: malignant - Account for 90% of germ cell tumours - Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue Yolk sac tumour - Malignant - Typically secrete AFP - Schiller-Duval bodies on histology are pathognomonic Choriocarcinoma - Malignant - Rare tumour that is part of the spectrum gestational trophoblastic disease - Typically have increased hCG levels - Often characterised by early haematogenous spread to the lungs

Answer 82

Represent around 3-5% of ovarian tumours Often produce hormones ``` Granulosa cell tumour - Malignant - Produces oestrogen leading to Precocious puberty in children Endometrial hyperplasia in adults - Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells) ``` Sertoli-Leydig cell tumour - Benign - Produces androgens → masculinizing effects - Associated with Peutz-Jegher syndrome Fibroma - Benign - Associated with Meigs' syndrome (triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor) - Solid tumour consisting of bundles of spindle-shaped fibroblasts - Typically occur around the menopause, classically causing a pulling sensation in the pelvis

Answer 83

Account for around 5% of tumours Krukenberg tumour - Malignant - Metastases from a GIT tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma

Answer 84

For couples who have ovulation disorders Ovulation disorders are the cause of infertility in approx 25% of couples who have difficulty conceiving naturally

Answer 85

``` Early follicular phase Increase in (GnRH) pulse frequency --> increases the release of FSH + LH --> stimulation + development of multiple ovarian follicles Usually only one of which will become the dominant ovulatory follicle in that menstrual cycle ``` Mid-follicular phase FSH gradually stimulates estradiol production Estradiol produces a negative feedback loop on the hypothalamus + pituitary gland --> suppression of FSH and LH concentrations Luteal phase, Switch from negative to positive feedback of estradiol --> surge of LH secretion --> follicular rupture + ovulation If there is an alteration in this fine balance which may lead to irregular or complete anovulation https://cdn.britannica.com/07/55707-050-5927EDFB/changes-woman-cycle.jpg

Answer 86

There are three main categories of anovulation: Class 1 Hypogonadotropic hypogonadal anovulation Notably hypothalamic amenorrhoea (5-10% of women) Class 2 Normogonadotropic normoestrogenic anovulation PCOS (80% of cases) Class 3 hypergonadotropic hypoestrogenic anovulation POI (5-10% of cases) In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive

Answer 87

To induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development, and this is to ultimately lead to a singleton pregnancy, which tends to be far lower risk and therefore preferable

Answer 88

Exercise and weight loss First-line treatment for patients with PCOS ovulation can spontaneously return with even a modest 5% weight loss --- Clomiphene citrate While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women) Mechanism of action: clomiphene is a selective estrogen receptor modulator (SERMs) --> acts primarily at the hypothalamus --> blocks the negative feedback effect of estrogens --> increase in GnRH pulse frequency --> FSH and LH production --> stimulating ovarian follicular development Side effects: hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%) --- Gonadotropin therapy - Used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism - For women with PCOS it is only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial This is because the Increased risk of multi-follicular development + subsequent multiple pregnancy Increased risk of OHSS Mechanism of action: pulsatile GnRH therapy involves - IV GnRH via IV infusion pump (or less frequently SC) --> endogenous FSH + LH production --> subsequent follicular development

Answer 89

Depending on the severity, the management includes: Fluid and electrolyte replacement Anti-coagulation therapy Abdominal ascitic paracentesis Pregnancy termination to prevent further hormonal imbalances

Answer 90

Can result in multiple life-threatening complications - Hypovolaemic shock - Acute renal failure - Venous or arterial thromboembolism

Answer 91

Infection and inflammation of the upper female genital tract including the uterus, fallopian tubes, ovaries and the surrounding peritoneum It is usually the result of ascending infection from the endocervix

Answer 92

Causative organisms Chlamydia trachomatis + the most common cause Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis

Answer 93

``` Lower abdominal pain fever deep dyspareunia dysuria and menstrual irregularities may occur vaginal or cervical discharge cervical excitation ```

Answer 94

Pregnancy test to exclude an ectopic pregnancy High vaginal swab These are often negative Screen for Chlamydia and Gonorrhoea

Answer 95

• Start Abx before swabs if you suspect PID o Do not delay abx while waiting for the results o Broad-spectrum abx treatment to cover C. trachomatis, N. gonorrhoea, anaerobic infection is recommended ``` outpatient • First line (all 3) o IM ceftriaxone 1g single dose and o Doxycycline 100mg PO BD 14 days and o Metronidazole 400mg BD 14 days ``` Inpatient – if pyrexial (>38) or septic o IV ceftriaxone 2g OD + IV doxycycline 100mg BD followed by o PO Doxycycline 100mg BD + PO Metronidazole 400mg BD for a total of 14 days

Answer 96

Perihepatitis (Fitz-Hugh Curtis Syndrome) 10% of cases RUQ pain, 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 97

Primary dysmenorrhoea

Answer 98

Primary dysmenorrhoea - commonest ``` Ectopic pregnancy o 6-8 weeks amenorrhoea with lower abdominal pain o Later develops vaginal bleeding o Shoulder tip pain o Cervical excitation ``` UTI o Dysuria o Frequency o Suprapubic burning secondary to cystitis Appendicitis o Pain initially in the central abdomen before localising to the RIF o Tenderness in RIF o Rovsing's sign - more pain in RIF than LIF when palpating LIF o Anorexia o Tachycardia o Low-grade pyrexia ``` PID o Pelvic pain o Fever o Deep dyspareunia o Vaginal discharge o Dysuria o Menstrual irregularities may occur o Cervical excitation on examination ``` Ovarian torsion o Sudden onset unilateral lower abdominal pain o May coincide with exercise o N+V are common o Unilateral, tender adnexal mass on examination Miscarriage o Vaginal bleeding following a period of amenorrhoea o Crampy lower abdominal pain

Answer 99

``` Endometriosis o Chronic pelvic pain o Secondary Dysmenorrhoea - pain often starts days before bleeding as opposed to primary dysmenorrhoea where pains starts pain typically just before or within a few hours of the period starting o Deep dyspareunia o Subfertility ``` IBS o Extremely common o Abdominal pain, bloating, change in bowel habit o Lethargy, Nausea, Backache, bladder symptoms Ovarian cyst o Unilateral dull ache o Intermittent or might only occur during intercourse o Severe abdominal pain with torsion or rupture o Abdominal swelling or pressure effects on the bladder (larger cysts) Urogenital prolapse o Older women o Sensation of pressure/heaviness/bearing down o Urinary symptoms - incontinence, frequency, urgency

Answer 100

Both hyperinsulinaemia and high levels of LH are seen and there appears to be some overlap with the metabolic syndrome subfertility and infertility menstrual disturbances: oligomenorrhea and amenorrhoea hirsutism, acne (due to hyperandrogenism) obesity acanthosis nigricans (due to insulin resistance)

Answer 101

o pelvic ultrasound: multiple cysts on the ovaries o FSH, LH, prolactin, TSH, and testosterone are useful investigations (ix for infertility) 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 o Check for impaired glucose tolerance

Answer 102

General o Weight loss if appropriate o COCP - regulate cycle + induce a monthly bleed Hirsutism and acne o COCP - Third generation COC which has fewer androgenic effects Co-cyprindiol which has an anti-androgen action Increased risk of venous thromboembolism No response to COCP --> topical eflornithine Infertility o Weight loss if appropriate (1st line) o Clomiphene (2nd line or 1st line in women with normal BMI)  Should not be used for >6 months o Metformin  May be used instead or together with clomiphene to improve pregnancy rates  Usually added after 3 failed cycles with clomiphene  Warn women about side-effects  Metformin is not recommended in pregnancy o Gonadotrophins (3rd line) There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene - women should have US monitoring during treatment Metformin is also used, either combined with clomifene or alone, particularly in patients who are obese *work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion

Answer 103

``` o no identifiable pathology is found in around 50% of cases o cervical ectropion Most common identifiable cause (33% of cases) More common in women on the COCP o Cervicitis e.g. secondary to Chlamydia o cervical cancer o polyps o trauma ```

Answer 104

Vaginal bleeding occurring after twelve months of amenorrhoea, in women at the age where the menopause can be expected Can also occur in younger women who have experienced premature menopause or POI Postmenopausal bleeding is usually benign, however, endometrial malignancy should be ruled out with urgency

Answer 105

o Vaginal atrophy - commonest cause Thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause o HRT Also a common cause Periods or spotting can continue in some women taking HRT for many months with no pathological cause Endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding o Endometrial hyperplasia An abnormal thickening of the endometrium Precursor for endometrial carcinoma RF - obesity, unopposed oestrogen use, tamoxifen use, PCOS and diabetes o Endometrial cancer 10% of patients with postmenopausal bleeding have endometrial cancer 90% of patients with endometrial cancer present with postmenopausal bleeding Must be ruled out urgently o Cervical cancer Obtain a full record of prior cervical screening programme attendance o Ovarian cancer Especially oestrogen-secreting (theca cell) tumours (granulosa cell tumour) o Vaginal cancer Uncommon but can present with postmenopausal bleeding o Other uncommon causes include trauma, vulval cancer and bleeding disorders

Answer 106

Women over the > 55 with postmenopausal bleeding -> 2 week wait for USS for endometrial cancer History taking o Timing, consistency and quantity of the bleeding o Full gynaecological and obstetric history o RF for endometrial cancer o Establish a menstrual timeline from menarche to menopause o Full drug history including HRT use o Red flag symptoms for gynaecological cancer should be enquired about Examination o A vaginal and a full abdominal examination Look for any masses or abnormalities within the abdomen or felt from within the vagina, o Speculum visualisation of the walls of the vagina and cervix Blood or discharge may be seen ``` Immediate testing o Urine dipstick Haematuria Infection o FBC anaemia or a bleeding disorder o CA-125 levels ``` For those referred on a cancer pathway within two weeks: o TVUS The endometrial lining thickness is assessed <3-mm cut-off has high sensitivity for detecting endometrial cancer and can identify women with PMB who are highly unlikely to have endometrial cancer, thereby avoiding more invasive endometrial biopsy Some centres use 4 mm or even 5 mm as a cut-off for endometrial biopsy. However, it may miss some pathology and if clinical suspicion is high, further testing is required o Endometrial biopsy Definitive diagnosis of endometrial cancer Taken during hysteroscopy or by an aspiration (pipelle) biopsy Pipelle biopsy --> thin flexible tube is inserted into the uterus via a speculum to remove cells for testing Imaging in secondary care o 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 107

Once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding o Vaginal atrophy Topical oestrogens Lifestyle changes - Lubrication HRT can also be used o HRT Different HRT preparations can be used to try to reduce this o Endometrial hyperplasia Dilatation + curettage To remove the excess endometrial tissue

Answer 108

nausea/vomiting tiredness musculoskeletal pains

Answer 109

The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years It occurs in around 1 in 100 women.

Answer 110

Idiopathic - the most common cause Family history bilateral oophorectomy Hysterectomy with preservation of the ovaries - advances the age of menopause radiotherapy chemotherapy infection: e.g. mumps autoimmune disorders resistant ovary syndrome: due to FSH receptor abnormalities genetic endocrine

Answer 111

Similar to those of the normal climacteric but the actual presenting problem may differ ``` o Climacteric symptoms: hot flushes, night sweats infertility o secondary amenorrhoea o raised FSH, LH levels e.g. FSH > 40 iu/l o low oestradiol e.g. < 100 pmol/l ```

Answer 112

The emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle. Only occurs in the presence of ovulatory menstrual cycles - it doesn't occur prior to puberty, during pregnancy or after the menopause.

Answer 113

``` Emotional symptoms include: anxiety stress fatigue mood swings ``` Physical symptoms bloating breast pain

Answer 114

Mild symptoms o Lifestyle advice o Advice on sleep, exercise, smoking and alcohol o Specific advice - regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates Moderate symptoms o New-generation COCP Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg) Severe symptoms o SSRI Taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)

Answer 115

3 or more consecutive spontaneous abortions occurs in around 1% of women Causes - antiphospholipid syndrome - endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders - PCOS - uterine abnormality: e.g. uterine septum - parental chromosomal abnormalities - smoking

Answer 116

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

 Semen volume – >1.5 ml  pH - >7.2  sperm concentration – >15 million spermatozoa per ml  total sperm number - >39 million spermatozoa per ejaculate or more  total motility (progressive motility + non-progressive motility) - >40% motile, >32% progressively motile  vitality - >58% live spermatozoa  sperm morphology (normal forms) >4%

Answer 118

Current law based on he 1967 Abortion Act In 1990 the upper limit changed from 28w to 24w But these limits do not apply in cases where - it is necessary to save the life of the woman - there is evidence of extreme fetal abnormality - there is risk of serious physical or mental injury to the woman - Two registered medical practitioners must sign a legal document - In an emergency only one is needed - Only a registered medical practitioner must perform an abortion - Abortion must be performed in an NHS hospital or a licensed premise - 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 119

<9 weeks - mifepristone* + PG (48H later to stimulate uterine contractions) <13 weeks - surgical dilation + suction of uterine contents >15 weeks - surgical dilation + evacuation of uterine contents or late medical abortion (induces mini-labour) * mifepristone - Anti-progestogen - Often referred to as RU486

Answer 120

``` advancing age previous pregnancy and childbirth high body mass index hysterectomy family history ```

Answer 121

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

Answer 122

bladder diaries 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

Answer 123

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. - 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

Answer 124

pelvic floor muscle training: 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 - MOA: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction

Answer 125

descent of one of the pelvic organs resulting in protrusion on the vaginal wall affects around 40% postmenopausal women ``` RF increasing age multiparity, vaginal deliveries obesity spina bifida ```

Answer 126

cystocele, cystourethrocele rectocele uterine prolapse less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)

Answer 127

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, vaginal sacrospinous hysteropexy, Manchester repair, colpocleisis rectocele: posterior colporrhaphy vaginal vault prolapse - sacrocolpopexy, vaginal sacrospnous fixation, colpoclesis

Answer 128

Fibroids are benign smooth muscle tumours of the myometrium They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years more common in Afro-Caribbean women rare before puberty, develop in response to oestrogen

Answer 129

- may be asymptomatic - menorrhagia 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 130

Asymptomatic fibroids no treatment is needed other than periodic review to monitor size and growth Management of menorrhagia secondary to fibroids - NSAIDs e.g. mefenamic acid - tranexamic acid LNG-IUS useful if the woman also requires contraception cannot be used if there is distortion of the uterine cavity - COCP - oral progestogen - injectable progestogen ``` Treatment to shrink/remove fibroids Medical - GnRH agonists o May reduce the size of the fibroid o Typically useful for short-term treatment ``` - Ulipristal acetate o SPRM (selective progesterone receptor modulator) with predominantly inhibitory action o Shrinks fibroids, reduced bleeding – Inhibits cell proliferation inducing apoptosis o Should only be used for intermittent treatment of moderate to severe uterine fibroid symptoms before menopause and when surgical procedures (including uterine fibroid embolisation) are not suitable or have failed o Reports of serious liver injury  Perform LFTs at least once monthly  Stop treatment if transaminase levels are >2 x the upper limit of normal  Repeat LFTs 2 and 4 weeks after stopping treatment ``` surgical o myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically o hysteroscopic endometrial ablation o hysterectomy o uterine artery embolization ```

Answer 131

Fibroids generally regress after the menopause. Subfertility Iron-deficiency anaemia red degeneration - haemorrhage into tumour - commonly occurs during pregnancy

Answer 132

Candida albicans (80%) the remaining 20% of cses are caused by other candida species

Answer 133

diabetes mellitus drugs: antibiotics, steroids pregnancy immunosuppression: HIV

Answer 134

- 'cottage cheese', non-offensive discharge - vulvitis: superficial dyspareunia, dysuria - itch - vulval erythema - fissuring - satellite lesions

Answer 135

Investigations a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis Management - Local or oral treatment Local treatments: - Clotrimazole pessary Oral treatments: - Itraconazole or fluconazole If pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Answer 136

Definition: 4 or more episodes per year Investigations: Check compliance with previous treatment Confirm the diagnosis High vaginal swab for microscopy and culture Consider a blood glucose test to exclude diabetes Exclude differential diagnoses such as lichen sclerosus Management: - 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 137

``` Physiological Candida - Cottage cheese discharge - Non-offensive - Vulvitis - Itch ``` Trichomonas vaginallis - Yellow/green frothy discharge - Offensive - Vulvovaginitis - Strawberry cervix Bacterial vaginosis - White/grey fishy discharge - Offensive - Thin

Answer 138

Gonorrhoea Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms ectropion foreign body cervical cancer

Answer 139

Around 80% are squamous cell carcinomas | Most cases occur in women over the age of 65 years

Answer 140

``` Age Human papilloma virus (HPV) infection Vulval intraepithelial neoplasia (VIN) Immunosuppression Lichen sclerosus ```

Answer 141

- lump or ulcer on the labia majora - inguinal lymphadenopathy - itching, irritation

Answer 142

In any patient presenting with urinary incontinence or increased urinary frequency, urinalysis should always be the first investigation to rule out a urinary tract infection (UTI) or diabetes mellitus In patients over 65 years old, urinalysis is not performed to assess for UTIs as asymptomatic bacteriuria is common in this population and therefore urinalysis will not be reliable. As this patient is below 65 years old, urinalysis should be performed.

Answer 143

otential adverse effects irregular vaginal bleeding is the most common problem Starting the POP if commenced up to and including day 5 of the cycle --> immediate protection Otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days if switching from a COCP gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21) Taking the POP should be taken at the same time every day, without a pill-free break (unlike the COC) Missed pills (Micronor, Noriday, Nogeston, Femulen) --> if < 3 hours* late: continue as normal *for Cerazette (desogestrel) a 12 hour period is allowed if > 3 hours*: Take the missed pill as soon as possible - if >1 missed, only 1 should be taken Continue with the rest of the pack Extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours o If UPSI after missed pill + within 48h of restarting the POP – EC Other potential problems DV: continue taking POP but assume pills have been missed - see above antibiotics: have no effect on the POP** liver enzyme inducers may reduce the effectiveness Other information discussion on STIs - POP does not offer protection against STIs **unless the antibiotic alters the P450 enzyme system, for example, rifampicin

Answer 144

``` Irregular, solid tumour. Ascites. At least 4 papillary structures. Irregular multilocular solid tumour with largest diameter ≥100 mm. Very strong blood flow. ``` Refer to gynae for biopsy of cyst

Answer 145

50-70mm in diameter - yearly TVUS | <50mm in diameter - no follow up, likely to be physiological, almost always resolve within 3 menstrual cycles

Answer 146

Transformation zone Endocervical curettage is used when at colposcopy the transformation zone (the area most at risk of pre-cancerous changes) cannot be visualised. A curette is inserted into the cervical canal to remove cells which can be examined in the lab. Although this patient may undergo cervical curettage, colposcopy should be performed first.

Answer 147

if the couple have not conceived after 6 months of regular unprotected vaginal sexual intercourse. Surgical options such as laparoscopic adhesiolysis may improve fertility rates in patients with mild-moderate disease.

Answer 148

Weight gain Irregular bleeding Delayed return to fertility Increased risk of osteoporosis

Answer 149

Associated with dermoid cysts (teratomas) The inner lining of every mature cystic teratoma contains single or multiple white shiny masses projecting from the wall toward the centre of the cysts. When hair, other dermal appendages, bone and teeth are present, they usually arise from this protuberance. This protuberance is referred to as the Rokitansky protuberance

Answer 150

solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes (also known as 'snow-storm' appearance)

Answer 151

Thyrotoxicosis | Hog has a structural resemblance to TSH

Answer 152

MOONTA Street ``` Menarchy extremes Obesity Oestrogen Nulliparity Tamoxifen Age35+ Smoking ```

Answer 153

All of them work by inhibiting ovulation except the POP and the intrauterine device + system. Progesterone only methods all increase cervical mucus thickening The implantable rod contains the hormone progesterone and the hormone will be slowly released into the systemic circulation. This typically lasts 3 years before replacement. Its primary function is to inhibit ovulation as progesterone inhibits the secretion of FSH and LH from the pituitary. While the rod also has an additional effect of increasing the thickness of mucous within the cervical lining, this is not the predominant mode of action of the rod. Increasing cervical mucous thickening is also caused by the progesterone-only pill. Decreasing sperm viability is the main mechanism of action of the intrauterine copper device. The intrauterine system predominantly provides contraception by providing exerting local progesterone onto the uterine lining. This prevents the proliferation of the uterine lining and prevents implantation of the ovum.

Answer 154

``` Women with HIV should be offered cervical screening at dx Cervical screening (hrHPV) should then be offered annually for screening ``` Their management will follow the protocols for primary hrHPV testing in all other aspects other than the frequency of screening

Answer 155

Suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.

Answer 156

Other POPs - consider missed if more than 3 hours late Desogestrel - considered missed if more than 12 hours late POP needed if missed pill + UPSI within 48 h of restarting POP

Answer 157

Early menopause - cessation of ovarian function between the ages of 40-45 Premature ovarian failure - cessation of ovarian function <40

Answer 158

T2DM | PCOS

Answer 159

Smoking | COCP

Answer 160

COCP protects against Ovarian and endometrial cancer COCP increases the risk of breast and cervical cancer ``` COCP = Causes Outside Cancers Predominantly Outside = breast + cervix Inside = endometrial and ovarian ``` COCP stops ovulation + endometrial thickening (therefore protects against ovarian and endometrial cancer) COCO orevents babies + prevents ‘baby-maker’ cancers (endometrial, ovarian)

Answer 161

Omitting the pill-free interval is advised if 2 or more pills are missed in week 3 of a packet If 2 pills missed in week 3, finish the pills in the current pack and start new pack immediately, omitting pill-free interval

Answer 162

IA Gold standard - hysterectomy +/- lymph node clearance If wanting to maintain fertility - cone biopsy with negative margins A2 - nodal evaluation, radical trachelectomy (also prserves fertility) IB B1 radiotherapy + concurrent chemo B2 radical hysterectomy with pelvic node dissection II, III Radiation with concurrent chemo IV Radiation and or chemo IVB palliative chemo Recurrent disease Chemoradiation or radiation

Answer 163

When it is 24 hours after it should have been taken E.g. once 72 hours have passed since the last pill was taken, 2 pills have been missed

Answer 164

If more than 7 consecutive pills are missed

Answer 165

If she has taken 7 consecutive pills on the week prior to the interval the COCP would theoretically be effective if given 7 days on 7 days off.

Answer 166

PMH of endometriosis Acute abdomen Pelvis filled with fluid

Answer 167

``` Cervical cancer (>IA2)= radical hysterectomy with lymphadenectomy Endometrial cancer = Hysterectomy with bilateral salpingo-oophorectomy with or without lymphadenectomy Ovarian cancer = Hysterectomy with bilateral salpingo-oophorectomy with lymphadenectomy, omentectomy ``` Just seems you remove the adjacent organ for each pelvic cancer!

Answer 168

Stress = duloxetine (SNRI - can causse nausea, dizziness, insomnia) Urge = oxygutynin, tolterodine, solifenacin (antimuscatinics, 1st line), mirabegron (β3 agonist, 2nd line)

Answer 169

Mirena (LGN-IUS)

Answer 170

FSH LH normal or raised | AMH high due to anovilation

Answer 171

POP can be commenced immediately after delivery an intrauterine device can be fitted during a caesarean section (ideally within 10 minutes of the passage of the placenta), once the wound is closed it is advised to wait 4-6 weeks post-partum before having it inserted vaginally COCP CI -can suppress milk production and increase risk of DVT Prior to Day 21 postpartum no contraceptive methods are required. In non-breastfeeding women, ovulation may occur as early as Day 28. As sperm can survive for up to 7 days in the female genital tract, contraceptive protection is required from Day 21 onwards if pregnancy is to be avoided.

Answer 172

The serum progesterone level will peak 7 days after ovulation has occurred. The length of the follicular phase of the menstrual cycle can be variable, however, the luteal phase (after ovulation) remains constant at 14 days. Therefore, in a 35-day cycle, given that the luteal phase always lasts for 14 days, the follicular phase will be 21 days (ovulating on day 21). Therefore, the progesterone level will be expected to peak on day 28. In simple terms, measure serum progesterone 7 days prior to expected next period (for 28-day cycle: 28 - 7 = 21. For 35-day cycle: 35 - 7= 28)

Answer 173

If primary 1st line NSAIDs e.g. mefanemic acid 2if NSAIDs contraindicated - paracetamol If treatment with NSAIDs fails, combination of NSAIDs + paracetamol can be tried If secondary Refer all patients to gynae for investigation If pt doesnt have plans to conceive + no contraindications to hormonal contraception - COCP

Answer 174

Mirena LNG IUS

Answer 175

Women with suspected adenomyosis 1.3.13 Offer transvaginal ultrasound (in preference to transabdominal ultrasound or MRI) to women with HMB who have: significant dysmenorrhoea (period pain) or a bulky, tender uterus on examination that suggests adenomyosis. [2018] 1. 3.14 If a woman declines transvaginal ultrasound or it is not suitable for her, consider transabdominal ultrasound or MRI, explaining the limitations of these techniques. [2018]' https: //www.nice.org.uk/guidance/ng88/chapter/recommendations

Answer 176

Cyclical abdominal pain, pelvic pain, dysmenorrhoea, dyspareunia and subfertility

Answer 177

CHIMP: Continuation (likely to continue sex with or without advice) Health (physical or mental health compromised if not given treatment) Interest (Advice is in their best interest) Maturity (mature to understand nature of treatment) Persuasion (can't be persuaded to tell parents)

Answer 178

Risk malignancy index Used to aassess prognosis in ovarian cancer RMI = US * menopause status * CA125 (U/ml) US: no findings = 1 point, 1 finding = 2 points, 2-5 findings = 3 points Pre-menopause = 1 point, post-menopause = 3 points CA125 = actual level US findings: - multilocular cyst - ascites - mets - bilateral cysts - solid area RMI =/<200 = low/moderate risk RMI >200 = high risk, sensitivity 87%, specificity 97% https://www.mdcalc.com/risk-malignancy-index-rmi-ovarian-cancer Also, CA125 and US are not specific and should not be used as screening test i.e. in asymptomatic patients. Ovarian cancer also does not have an identified precursor lesion.

Answer 179

If two pills are missed, between days 8-14 of the cycle, no emergency contraception is required, as long as the previous 7 days of COCP have been taken This woman has missed 2 doses of the COCP. Provided the first 7 doses of the COCP are taken at the correct date and time, if 2 consecutive doses are missed between days 8-14 of the menstrual cycle, emergency contraception is not required. This woman has missed doses on days 8 and 9 of her menstrual cycle and has since restarted her medication on day 10. Therefore emergency contraception is not needed. Important -> However, until 7 consecutive days of the COCP are taken, women are at risk of becoming pregnant, and therefore barrier contraception or abstaining from sex is advised.

Answer 180

until 7 consecutive days of the COCP are taken, women are at risk of becoming pregnant

Answer 181

Stresssss - Pelvisss (floor exercise) Stressed -> Duloxetine (SNRI) Urge - urge to breath oxygen - Oxybuynin Urrrrrrge - RRRetraining of bladder STRESS incontinence, tell them to relaxxx - sounds like Duloxxx(etine) Duloxitine- Du 'locks it in'- keeps your pee locked in, so treats stress incontinence.

Answer 182

Granulosa cell tumours secrete oestrogen

Answer 183

The correct answer is GnRH analogues injections. These drugs can be used to manage endometriosis when the combined oral contraceptive pill (COCP) and NSAIDs such as ibuprofen have failed. Their beneficial effects are thought to be due to a pseudo-menopause induced by the high circulating levels of GnRH.

Answer 184

IUD - immediately contraceptive depot - 7 days contraceptive implant - 7 days intrauterine system - 7 days POP - 2 days COCP - 5 days

Answer 185

1. Clomiphene – ovulation induction – stimulate FSH & LH release > development and maturation of ovarian follicle > corpeus luteum development >pregnancy 2. 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 186

Endometriosis | Peritonitis

Answer 187

distorted uterine anatomy | including insertion of a copper IUD as emergency contraception.

Answer 188

within 5 days after the first unprotected sexual intercourse in a cycle or within 5 days of the earliest estimated date of ovulation whichever is later

Answer 189

The dose should be doubled to 3mg levonorgestrel for those with a BMI >26 kg/m2 or weight over 70kg.

Answer 190

Breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions with levonorgestrel and so levonorgestrel is more appropriate for this patient.

Answer 191

Treat for candida albicans oral fluconazole 150 mg as a single dose first-line clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated Important to rule out chlamydia and gonorrhoea in this age group, especially given their high prevalence, however, remember that 70% of chlamydia is asymptomatic in women, and the majority of gonorrhoea is also asymptomatic

Answer 192

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 blood 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 193

Serous carcinoma

Answer 194

follicular cyst

Answer 195

Intra-peritoneal bleed

Answer 196

Day 1 of the menstrual cycle is typically the preferred day to start a COCP regimen, as it ensures immediate protection from pregnancy. However, it is not the earliest option in this scenario.

Answer 197

Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception

Answer 198

Intrauterine copper coil should not be used as this can occasionally worsen dysmenorrhoea and can induce menorrhagia as well. While this is a long-acting contraceptive, it often causes heavy menstrual bleeding. It should therefore be avoided in those with a history of heavy menstrual bleeding.

Answer 199

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.

Answer 200

Regardless of the length of the individual's menstrual cycle - the progesterone levels should be carried out 7 days before the end of the cycle, so will, therefore, vary from individual to individual.

Answer 201

Ovulation = 35-14 = day 21 Midluteal progesterone = 35-7 or 21+7 = day 28

Answer 202

Mirena coil | 4 years

Answer 203

Clomifene is the traditional first-line drug used to induce ovulation in women with PCOS. It works by antagonising oestrogen receptors in the hypothalamus and pituitary, thus increasing the release of LH and FSH via negative feedback. This induces ovulation.

Answer 204

Gonadotropins are recognised second-line management options for inducing ovulation. A daily subcutaneous injection of FSH/LH is given to stimulate multiple follicles in the ovaries. Ovulation is then triggered by a single hCG injection of 5000–10,000 IU intramuscularly when the follicles are 15–18 mm in size.

Answer 205

Trichomonas vaginalis --> 5 or 7 day course of PO metronidazole Neisseria gonorrhoea --> single dose of IM ceftriaxone (if sensitivity is not known) or a single dose of oral ciprofloxacin (if sensitivity is known and the organism is sensitive) Chlamydia trachomatis - oral azithromycin (single dose) or oral doxycycline (for 7 days)

Answer 206

'Boobs, Pubes, Grow, Flow'

Answer 207

vaginal misoprostol Coagulopathy is a contra-indication to expectant management, but not medical management.

Answer 208

Test the pH of the discharge is, again, not required given the characteristic signs and symptoms of candidiasis. Testing pH may be done to differentiate candidiasis from bacterial vaginosis. In bacterial vaginosis, the pH is above 4.5

Answer 209

It is thought to work by increasing serotonin and norepinephrine levels in the pudendal motor nucleus of the sacral spinal segments, thereby increasing urethral muscular tone and closure pressure.

Answer 210

The most appropriate answer is therefore tranexamic acid, a plasminogen activator inhibitor that acts as an anti-fibrinolytic to prevent heavy menstrual bleeding.

Answer 211

• precautions should still be taken with enzyme inducing antibiotics such as rifampicin The BNF states that: 'effectiveness of oral progestogen-only preparations is not affected by antibacterials that do not induce liver enzymes'. Ciprofloxacin is a cytochrome P450 (CYP450) inhibitor, not an inducer. This means that the efficacy of this patient's contraception is not affected and she does not need to use additional barrier contraception. If she were taking rifampicin, an alternative choice for meningococcal contact prophylaxis, she should also use barrier contraception during and for four weeks after cessation of treatment as this drug is a potent enzyme inducer and therefore can decrease the plasma concentration and efficacy of contraceptive pills.

Answer 212

3Ps for Ectropions: Pregnancy; Pill (COCP); Puberty

Answer 213

an infected nipple fissure, symptoms not improving after 12-24 hours despite effective milk removal and/or breast milk culture positive.

Answer 214

Whiff test - a sample of discharge is taken, and mixed with potassium hydroxide. If positive, the result smell fishy. Clue cells - epithelial cells from the vagina that have a load of bacteria stuck to their surface, so the edges look fuzzy. positive in BV

Answer 215

Clomifene is the traditional first-line ovulation induction drug used. As an antioestrogen, it works by blocking oestrogen receptors in the hypothalamus and pituitary and increasing the release of LH and follicle stimulating hormone (FSH), which are inhibited by oestrogen. It is only given on days 2 to 6 of each cycle to initiate follicular maturation. If no follicles develop then the dose can be increased from 50mg/day to 100mg/day and finally 150mg/day in subsequent cycles. It is limited to 6 months use and increases the risk of multiple pregnancy to 11%.

Answer 216

Gonadotropin induction involves a daily subcutaneous injection of recombinant or purified urinary FSH and/or LH. This stimulates follicular growth and is monitored by ultrasound. Once a follicle has reached approximately 17mm in size, the process of ovulation is artificially stimulated by injection of hCG or LH.

Answer 217

PCOS --> insulin resistance --> androgen excess --> arrest in antral follicular development --> anovulation. Metformin increases peripheral insulin sensitivity

Answer 218

Tamoxifen is used for oestrogen receptor-positive breast cancer, in the breast, it has anti-oestrogenic effects. However, on the endometrium, it has pro-oestrogenic effects. This effect, if unopposed by progesterone, can result in endometrial hyperplasia.

Passmed textbook - Gynaecology Flashcards

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