Passmedicine - Gynaecology Flashcards
(472 cards)
1
Q
After giving birth on what day to women require contraception?
A
Day 21
2
Q
When can the POP be used in the post-partum?
A
Anytime
3
Q
If you start the POP on day 21 post-partum, do you require additional contraception for any amount of time?
A
Yes - 2 days
4
Q
Is POP okay to use whilst breastfeeding?
A
Yes (small amount enters milk but this does not harm infant)
5
Q
When can the COCP be used after giving birth?
A
UKMEC 4 (completely contraindicated) <6w post-partum UKMEC2 if breast feeding 6w-6m post-partum
6
Q
What affect can the COCP have on lactating mothers?
A
May reduce breast milk production
7
Q
When can the IUS/IUD be inserted after birth?
A
Within 48h of birth or after 4 weeks
8
Q
How effective is the lactational amenorrhoea method at preventing pregnancy?
A
98% if woman is fully breast feeding + amenorrhoeic + <6m post-partum
9
Q
What is an inter-pregnancy interval of <12m between childbirth and conceiving again associated with?
A
Increased risk of preterm birth, low birth weight and small for gestational age babies
10
Q
When can the progesterone only implant be inserted after birth?
A
Any time
11
Q
How common is infertility?
A
Affects 1 in 7 coples
12
Q
What are the causes of infertility?
A
Male factor 30% Unexplained 20% Ovulation failure 20% Tubal damage 15% Others 15%
13
Q
What are the two basic initial tests you should do for infertility?
A
Semen analysis
Serum progesterone 7 days prior to next expected period
14
Q
What is the average length of a cycle?
A
28 days
15
Q
On the average cycle, when should you do a serum progesterone?
A
21st day
16
Q
How should you interpret a serum progesterone?
A
<16nmol/l - repeat, if consistently low refer to specialist
16-30nmol/l - repeat
>30nmol/l - ovulation has occured
17
Q
What advice can you give couples trying to conceive?
A
Take folic acid
Maintain BMI 20-25
Have regular unprotected vaginal intercourse every 2-3 days
Smoking/drinking advice
18
Q
Follow ovulation does basal temperature increase or decrease?
A
Increase
19
Q
If a cervical smear comes back as borderline/mild dyskaryosis what happens?
A
Original sample tested for HPV:
-ve: returns to routine recall
+ve: referred for colposcopy
20
Q
If a cervical smear comes back as moderate dyskaryosis what happens?
A
Consistent with CIN II - refer for urgent colposcopy within 2w
21
Q
If a cervical smear comes back as severe dyskaryosis what happens?
A
Consistent with CIN III
Refer for urgent colposcopy within 2w
22
Q
If a cervical smear comes back as suspected invasive cancer what happens?
A
Refer for urgent colposcopy within 2w
23
Q
If cervical smear comes back as inadequate what action is taken?
A
Repeat smear - if persistent (3 inadequate samples), assess via colposcopy
24
Q
How are women treated for CIN 1-3 reassessed?
A
Invited 6m after treatment for test of cure with repeat cytology in the community
25
What are the oncogenic subtypes of HPV associated with cervical cancer?
HPV 16, 18, 33
26
What are the different types of miscarriage?
```
Threatened
Missed
Inevitable
Incomplete
Complete
```
27
How does threatened miscarriage present?
Painless vaginal bleeding before 24w
Usually lighter than a period
Cervical os is closed
28
When do threatened miscarriages typically occur?
6-9 weeks
29
What is a missed miscarriage?
Gestational sac contains dead foetus before 20w without the symptoms of expulsion
30
How does a missed miscarriage present?
Light vaginal bleeding/discharge + symptoms of pregnancy may disappear
Not usually painful
Cervical os is closed
31
What is the description 'blighted ovum' or 'anembyronic pregnancy' used to describe?
Gestational sac >25mm + no embyronic/fetal part can be seen
32
How does inevitable miscarriage present?
Heavy bleeding with clots + pain
| Cervical os is open
33
What occurs in an incomplete miscarriage?
Not all products of conception have been expelled
34
How does incomplete miscarriage tend to present?
Pain + vaginal bleeding
| Cervical os is open
35
In routine diagnostic workup for abdominal pain, what examinations and tests should be done in all females?
Bimanual vaginal examination
Urine pregnancy test
Consider abdominal + pelvic USS
36
If after investigation of abdominal pain in a female, diagnostic doubt remains what investigation may be good for assessing suspected tubulo-ovarian pathology?
Laparoscopy
37
What are gynae causes of abdominal pain?
```
Mittelschmerz
Endometriosis
Ovarian torsion
Ectopic gestation
PID
```
38
When do you get pain in Mittelschmzer?
Midcycle
39
Describe the pain experienced in Mittelschmzer?
Sharp onset
Little systemic disturbance
Usually settles over 24-48h but may be recurrent
40
How do you investigate suspected Mittelschmzer?
FBC - usually normal
| US - may show small quantity of free fluid
41
How do you manage Mittelschmzer?
Conservatively
42
How does endometriosis typically present?
Dysmenorrhoea (pain often days before period starts)
Subfertility
Chronic pelvic pain
Deep dyspareuina
43
What may occur in complex endometriosis?
Pelvic adhesions --> episodes of intermittent small bowel obstruction
44
What can intra-abdominal bleeding in endometriosis lead to?
Localised peritoneal inflammation
45
What can you see on investigation of endometriosis?
US - free fluid
| Laparoscopy - lesions
46
How does ovarian torsion tend to present?
Sudden onset of deep unilateral colicky abdominal pain
Nausea, vomiting and distress
Onset my coincide with exercise
VE - unilateral tender adnexal mass
47
What might you see on investigation of ovarian torsion?
US - free fluid, whirlpool sign
| Laparoscopy is diagnostic + therapeutic
48
How do you manage ovarian torsion?
Laparoscopy
49
How can ectopic pregnancy present?
1. symptoms of pregnancy without intrauterine gestation
| 2. emergency with rupture/impending rupture
50
How does ectopic pregnancy rupture present?
Sudden onset abdominal pain, circulatory collapse
Adnexial tenderness
Shoulder tip pain
51
What investigations should you do for suspected ectopic pregnancy + what will they show?
US - no intrauterine pregnancy, may show free fluid in abdomen
b-HCG elevated
52
How does PID tend to present?
Bilateral lower abdominal pain, vaginal/cervical discharge, deep dyspareunia
Dysuria + menstrual irregularities may be present
Fever
Cervical excitation on ex
53
What is Fitz Hugh Curtis syndrome?
Peri-hepatic inflammation secondary to chlamydia leading to RUQ discomfort
54
What investigations should you do for suspected PID and what will they show?
FBC - leucocytosis
Pregnancy test
Amylase - normal/slightly raised
High vaginal + urethral swabs
55
What causes Mittleschmerz?
Very small amounts of fluid released during ovulation
56
What is the medical term for heavy menstrual bleeding?
Menorrhagia
57
How did menorrhagia used to be defined?
Blood loss >80ml per menses
58
How is menorrhagia defined now?
A volume of blood the women considers to be excessive
59
What investigations should be done for menorrhagia?
FBC in all women
Consider TVU in those with symptoms (e.g. IMB/PCB, pelvic pain...) suggestive of a structural /histological abnormality or abnormal pelvic Ex
60
What is the first line treatment for a women with menorrhagia who does not require contraception?
Mefenamic acid 500mg tds (if painful) or tranezamic acid 1g tds (if painless) started on the first day of period
61
If mefenamic/tranexamic acid don't work to manage a pts menorrhagia what is the next step?
Try other drug whilst awaiting referral
62
What is the first line treatment for a women with menorrhagia who does require contraception?
IUS (mirena)
63
What is the second and third line treatment for a women with menorrhagia who does require contraception?
2nd: COCP
3rd: long acting progesterone
64
What drug can be used as a short term option to rapidly stop heavy menstrual bleeding?
Norethisterone 5mg
65
At what age is ovarian torsion most common?
Reproductive age
66
What is a typical history of someone presenting with an ectopic pregnancy?
6-8w history of amenorrhoea with lower abdominal pain, + vaginal bleeding
67
What two features are sometimes seen in ectopic pregnancy?
Shoulder tip pain
| Cervical excitation
68
In women what is the most common cause of pelvic pain?
Primary dysmenorrhoea
69
What things may cause pelvic pain?
```
Primary dysmenorrhoea
Ectopic pregnancy
UTI
Appendicitis
PID
Ovarian torsion
Miscarriage
Endometriosis
IBS
Ovarian cyst
Urogenital prolapse
```
70
How does appendicitis tend to present?
```
Pain in central abdomen --> RIF
Anorexia, low grade fever
Tenderness in RIF
Tachycardia
Rovsing's sign
```
71
What is Rovsing's sign?
More pain in RIF than LIF when palpating LIF
72
How does IBS tend to present?
Abdominal pain
Bloating
Change in bowel habit
Lethargy, nausea, backache, bladder symptoms may be present
73
How does ovarian cyst tend to present?
Unilateral dull ache which may be intermittent/only occur during intercourse
74
What happening to an ovarian cyst may lead to severe abdominal pain?
Torsion or rupture
75
What symptoms may large ovarian cysts cause?
Abdominal swelling or pressure effects on the bladder
76
Who is urogenital prolapse seen in?
Older women
77
What are the features of urogenital prolapse?
Sensation of pressure, heaviness, bearing down
| Incontinence, frequency, urgency
78
How does tranexamic acid work?
Plasminogen activator inhibit that acts as an anti-fibrinolytic
79
In what age group do most cases of endometrial cancer occur?
Post-menopausal women
80
What is the prognosis of endometrial cancer?
Usually good as it is usually detected early
81
What are RFs for endometrial cancer?
```
Obesity
Nulliparity
Early menarche
Late menopause
Unopposed oestrogen
DM
Tamoxifen
PCOS
HNPCC
```
82
How can you avoid giving unopposed oestrogen to a women with a womb?
Add in progesterone when giving HRT
83
What is the classic symptom associated with endometrial cancer?
PMB
84
How might a women who is premenopausal present with endometrial cancer?
Change in intermenstrual bleeding
85
How is PMB investigated?
Women => 55 with PMB should be referred using the suspected cancer pathway
1st line Ix: TVU - normal endometrial thickness (<4mm) has high -ve predictive value
Hysteroscopy with endometrial biopsy if >4mm
86
How is localised endometrial cancer treated?
Total abdominal hysterectomy + bilateral salphino-oophorectomy
87
How is localised HIGH RISK endometrial cancer treated?
TAH + BSO + post-op radio
88
What treatment may be used for endometrial cancer in frail elderly women not suitable for surgery?
Progesterone therapy
89
PMB = ? until proven otherwise
Endometrial cancer
90
What are causes of menorrhagia?
```
Dysfunctional uterine bleeding
Anovulatory cycles
Uterine fibroids
Hypothyroidism
IUD (Cu coil)
PID
Bleeding disorders,e.g. vWB
```
91
What is dysfunctional uterine bleeding?
Menorrhagia in the absence of underlying pathology
92
When are anovulatory cycles most common?
Extremes of a women's reproductive life
93
What is endometriosis?
Growth of ectopic endometrial tissue outside the uterine cavity
94
How common is endometriosis?
Affects 10% of women of a reproductive age
95
What non-gynae symptoms can those with endometriosis get?
Urinary symptoms, e.g. dysuria, urgency, haematuria
| Dyzchezia (painful bowel movements)
96
What do you see in pelvic examination in those with endometriosis?
Reduced organ mobility
Tender nodularity in posterior vaginal fornix
Visible vaginal endometriotic lesions may be seen
97
What is the gold standard investigation for endometriosis?
Laparoscopy
98
What can be done for endometriosis in primary care?
Not much, if pt has significant symptoms she should be referred for definitive diagnosis
99
How is endometriosis managed?
1st line: NSAIDs/Paracetamol
2nd line: hormonal treatments, e.g. COCP, progesterones
3rd line/if trying for children: refer to secondary care for GnRH analogues, surgery
100
How do GnRH analogues work in treating endometriosis?
Induce a pseudomenopause due to low oestrogen lvels
101
What surgery may be offered for severe endometriosis?
Laparoscopic excision
| Laser treatment of endometriotic ovarian cysts
102
Is endometriosis oestrogen dependent or independent?
Dependent - starts after menarche and regresses after menopause
103
How should the COCP be used in those with endometriosis?
Back to back with no pill free interval
104
What contraceptive is not suitable for those with endometriosis?
Cu coil as it makes periods painful and longer
105
What causes the lower abdominal pain in ectopic pregnancy?
Tubal spasm
106
Describe the pain in ectopic pregnancy?
Lower abdominal
Unilateral
Constant
107
What symptoms can peritoneal bleeding in ectopic pregnancy cause?
Shoulder tip pain and pain on defaecation or urination
108
Apart from vaginal bleeding and lower abdominal pain what other symptoms may you see in ectopic pregnancy?
Symptoms of pregnancy, e.g. breast tenderness
| Circulatory collapse in ruptured ectopic, e.g. syncope, dizziness
109
What findings may you see on examination in ectopic pregnancy?
Abdominal tenderness
Cervical excitation
Adnexal mass - do not examine for adnexal mass as this may increase chance of rupture (do check for cervical excitation)
110
In case of pregnancy of unknown location what can point towards a diagnosis of ectopic pregnancy?
Serum bHCG >1, 500
111
What is the medical treatment for an ectopic pregnancy?
Methotrexate
112
What is the surgical treatment for ectopic pregnancy?
Salpingectomy unless they have other RFs for inferility, e.g. contralateral tube damage - then offer salpinotomy
113
What is the average age to go through menopause?
51
114
When should women nearing the menopause use contraception up until?
12m after last period if >50
| 24m after last period if <50
115
What is PID?
Infection and inflammation of the female pelvic organs (uterus, fallopian tubes, ovaries, surrounding peritoneum)
116
What tends to cause PID?
Ascending infection from the endocervix
117
What is the most common cause of PID?
Chlamydia trachomatis
118
What are other causes of PID?
Neisseria gonorrhoea
Mycoplasma genitalium
Mycoplasma hominis
119
What investigations should be done for suspected PID?
Pregnancy test to exclude ectopic
High vaginal swabs
Screen for chlamydia/gonorrheoa
120
Why is there a low threshold for treating PID?
Difficulty in making diagnosis
| Potential complications of untreated PID are severe
121
How is PID managed?
Oral olofaxin + oral metronidazole
OR
IM ceftriazone + oral doxycyline + oral metronidazole
122
Should IUDs be removed in PID?
If mild might be okay to leave, but evidence suggests removal may be better
123
What are complications of PID?
Fitz Hugh Curtis syndrome
Infertility
Chronic pelvic pain
Ectopic pregnancy
124
What is the risk of infertility after a single episode of PID?
10-20%
125
Give e.g.s of minor symptoms of pregnancy?
N/V
Tiredness
MSK pains
126
What is UTI in pregnancy associated with?
Premature birth (inflammatory mediators trigger pre-term labour by irritating neck of uterus + cervix)
127
Why do pregnant ladies get lower back pain?
Due to increased laxity in SI joints due to release of hormone relaxin
Increased mechanical load
128
How common is PCOS in women of reproductive age?
5-20%
129
High levels of what two hormones are seen in PCOS?
Insulin
| LH
130
What is the general management of PCOS?
Wt loss
| COCP may regulate cycle+ induce a monthly bleed
131
What drugs may be used to treat hirsutism/acne in PCOS?
COCP
Topical eflornithine
Spirnolactone, flutamide, finasteride under specialist supervision
132
What is the management of infertility in PCOS?
Wt loss
Under specialist supervision - clomifene/metformin or combo of both
Gonadotrophins
133
How does clomifene work?
Occupies hypothalamic oestrogen receptors without activating them, this interferes with binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion
134
How is PCOS diagnosed?
When 2/3 of the following are present:
1. Polycystic ovary on USS/increased ovarian volume
2. Infrequent periods (>35d apart) or no ovulation
3. Clinical/biochemical signs of hyperandrogenism/elevated levels of total/free testosterone
135
What is the pathophysiology of PCOS?
Increased LH and insulin --> increased androgen production which disrupts folliculogenesis --> excess small ovarian follicles + irregular/absent ovulation + hirsutism
136
What are complications of PCOS?
```
T2DM
Obesity
Subfertility
Miscarriage
Endometrial cancer
```
137
When is clomifene given?
Days 2-6 of cycle to initiate follicular maturation
138
How many uses of clomifene are you allowed?
6
139
What does clomifene increase the risk of?
Multiple pregnancy
140
What are the pros and cons of using metformin for PCOS?
Pros - increases effectiveness of clomifene in clomifene-resistant women, treats hirsutism, reduces risk of gestational diabetes + early miscarriages
Con - less effective than clomifene
141
What are second line treatments for infertility in PCOS?
Ovarian diathermy
| Gonadotrophin induction
142
How does gonadotrophin induction work?
Daily s/c injection of recombinant/purified FSH + or LH
This stimulates follicular growth which is monitored by USS
Once follicle is big enough, ovulation is stimulated by injection of hCG or LH
143
What is the 3rd line treatment option for infertility in those with PCOS?
IVF
144
How should women taking COCP for control of PCOS symptoms take the pill?
Back to back with 3/4 bleeds a year to protect the endometrium
145
Who does atrophic vaginitis tend to affect?
Post menopausal women
146
How does atrophic vaginitis tend to pesent?
Vaginal dryness, pain, itching, dyspareunia, occasional spotting
147
What might atrophic vaginitis look like o/e?
Pale, dry
148
How is atrophic vaginitis treated?
Vaginal lubricants and moisturisers
| 2nd line: topical oestrogen cream
149
Define endometrial hyperplasia
Abnormal proliferation of the endometrium in excess of normal proliferation that occurs during the menstrual cycle
150
What are the types of endometrial hyperplasia
Simple
Complex
Simple atypical
Complex atypical
151
What do a minority of pts with endometrial hyperplasia go on to develop?
Endometrial cancer
152
What are the features of endometrial hyperplasia
Abnormal vaginal bleeding, e.g. IMB
153
How do you manage simple endometrial hyperplasia without atypica?
High dose progestogens with repeat sampling in 3-4 months (IUS may be used)
154
How do you manage atypical endometrial hyperplasia?
Hysterectomy
155
What are the types of benign ovarian cysts?
Physiological cysts
Benign germ cell tumours
Benign epithelial tumours
Benign sex cord stromal tumours
156
What kind of ovarian cysts should be biopsied to exclude malignancy?
Complex (i.e. multi-loculated) ovarian cysts
157
What are the commonest types of ovarian cysts?
Follicular cysts
158
What are the two functional/physiological cysts?
Follicular cysts
| Corpus luteum cysts
159
What causes a follicular cyst?
Non-rupture of a dominant follicle or failure of atresia in a non-dominant follicle
160
Do follicular cysts go away?
Commonly regress after several menstrual cycles
161
What is a corpeus luteum cyst?
If pregnancy doesn't occur the corpus luteum usually breaks down + disappears
If it doesn't it may fill with blood/fluid to form a corpus luteum cyst
162
What are corpus luteum cysts more likely to present with when compared to follicular cysts?
Intraperitoneal bleeding
163
Give an example of a benign germ cell tumour that may affect the ovary
Dermoid cyst
164
What is the other name for dermoid cysts?
Mature cystic teratomas
165
What is the appearance of dermoid cysts?
Epithelial lined, may contain skin appendages, hair + teeth
166
What is the most common benign ovarian tumour in women under 30?
Dermoid cyst
167
How do dermoid cysts in the ovary tend to present?
Usually asymptomatic but increase risk of torsion
168
What tissue do benign epithelial tumours of the ovary develop from?
Ovarian surface epithelium
169
Give e.g.s of two benign epithelial tumours of the ovary
Serous cystadenoma
| Mucinous cystadenoma
170
What is the most common benign epithelial tumour?
Serous cystadenoma
171
What cancer does serous cystadenoma of the ovary bear resemblance to?
Serous carcinoma of ovary
172
If mucinous cystadenoma of the ovary ruptures what can it cause?
Pseudomyxoma peritoni
173
What are the 3 features of Meig's syndrome?
Benign ovarian tumour (usually fibroma)
Ascites
Pleural effusion
174
What test should you order for a women who has had heavy bleeding since her period started?
Coagulation screen
175
What is a Rokitansky protuberance?
The inner lining of a mature cystic teratoma has single/multiple white shiny masses projecting from the wall to the centre of the cyst and this is where the hair, bone, teeth etc. grows from
176
What occurs in urogenital prolapse?
Descent of one of the pelvic organs --> protrusion on the vaginal walls
177
How common is urogenital prolapse?
Affects 40% of post-menopausal women
178
What are the types of urogenital prolapse?
Cystocele, cystourethrocele
Rectocele
Uterine prolapse
Urethrocele, enterocele
179
What is an enterocele?
Herniation of the pouch of Douglas, incl. the small intestine into the vagina
180
What are RFs for urogenital prolapse?
```
Increasing age
Multiparity
Vaginal deliveries
Obesity
Spina bifida
```
181
How is asymptomatic mild urogenital prolapse managed?
No treatment req.
182
What are conservative managements for urogenital prolapse?
Wt loss
| PFMT
183
What other treatments are available for urogenital prolapse?
Ring pessary
| Surgery
184
What surgeries are available for cystocele/cystourethrocele?
Anterior colporrhaphy/colposuspension
185
What surgeries are available for uterine prolapse?
Hysterectomy, sacrophysteropexy
186
What surgeries are available for rectocele?
Posterior colporrhaphy
187
What is sacrocolpoplexy?
Suspending the vaginal apex to the sacral promontory
188
What are the two kinds of amenorrhoea?
Primary
| Secondary
189
What is primary amenorrhoea?
Failure to start menses by 16y
190
What is secondary amenorrhoea?
Cessation of established, regular menstruation for 6m or longer (12m in those with previous oligomenorrhoea)
191
What are causes of primary amenorrhoea?
```
Constitutional delay
Turner's syndrome
Testicular feminisation syndrome
Kallmann syndrome
Congenital adrenal hyperplasia
Congenital malformations of the genital tract (e.g. imperforate hymen, mullerian agenesis, transverse vaginal septae)
```
192
What are causes of secondary amenorrhoea?
```
Hypothalamic amenorrhoea (e.g. stress/excessive exercise)
PCOS
Hyperprolactinaemia
Premature ovarian failure
Thyrotoxicosis
Sheehan's syndrome
Asherman's syndrome
Contraception
Lactational amenorrhoea
```
193
What is Asherman's syndrome?
Intrauterine adhesions
194
How do you investigate amenorrhoea?
```
Urinary/serum bHCG to exclude pregnancy
Gonadotrophins: low levels indicate hypothalamic cause, raised levels indicate ovarian problem
Prolactin
Androgen levels: raised in PCOS
Oestradiol
TFTs
```
195
What thyroid problem can cause amenorrhoea?
Thyrotoxicosis or hypothyroidism
196
What % of the population does urinary incontinence affect?
4-5%
197
Who is urinary incontinence most common in?
Elderly females
198
What are RFs for urinary incontinence?
```
Advancing age
Prev pregnancy + childbirth
High BMI
Hysterectomy
FH
```
199
What are the types of urinary incontinence?
Overactive bladder/urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
200
What causes overactive bladder/urge incontinence?
Detrusor overactivity
201
How does stress incontinence present?
Leaking small amounts of urine when laughing/coughing
202
What is mixed incontinence?
Urge and stress incontinence
203
What causes overflow incontinence?
Bladder outlet obstruction, e.g. prostate enlargement
204
How should urinary incontinence be investigated?
Bladder diaries for at least 3d
Vaginal ex to rule out POP + ability to contact PFMs
Urine dipstick + culture
Urodynamic studies
205
What is the initial management for urge incontinence?
Bladder retraining (min 6w)
206
What are other treatments for urge incontiennce?
First line: anti-muscarinics (e.g. oxybutinin, tolterodine, darifenacin)
207
What drug can be used in frail pts for urge incontiennce?
Mirabegron
| Avoid oxybutinin in frail older women
208
What is the initial management for stress incontinence?
PFMT (8 contractions 3x day for 3m)
209
What surgical procedures can be done for stress incontinence?
Retropubic mid-urethral tape procedures
210
What are fibroids?
Benign smooth muscle tumours of the uterus
211
What race tend to get fibroids more often?
Afro-caribbean women
212
What are the features of fibroids?
May be asymptomatic
Menorrhagia
Crampy lower abdominal pain often during period
Bloating
Urinary symptoms, e.g. frequency with larger fibroids
Subfertility
213
How do you diagnose fibroids?
TVU
214
How are fibroids managed?
Symptomatically - IUS first line
Other options: tranexamic acid, COC
GnRH agonists may reduce fibroid size in short term
Surgery sometimes needed
215
What surgeries may be used for fibroids?
Myomectomy, hysteroscopic endometrial ablation, hysterectomy, uterine artery embolisation
216
What are complications of fibroids?
Red degeneration (haemorrhage into tumour, commonly occurs during pregnancy)
217
Define premature ovarian failure
Onset of menopausal symptoms + elevated gonadotrophins before age 40
218
What are causes of premature ovarian failure?
Idiopathic (most common)
Chemotherapy
Autoimmune
Radiation
219
What are features of premature ovarian failure?
Same as menopause (hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH, LH)
220
Define dysmenorrhoea
Excessive pain during the menstrual period
221
What are the two types of dysmenorrhoea
Primary
| Secondary
222
What is primary dysmenorrhoea?
There is no underlying pelvic pathology
223
How common is primary dysmenorrhoea?
Affects 50% of women
224
What is thought to be related to primary dysmenorrhoea?
Excessive endometrial prostaglandin production
225
What are the features of primary dysmenorrhoea?
Pain just before/within a few hours of period starting
| Suprapubic cramping which can radiate to back or down thigh
226
How is dysmenorrhoea managed?
NSAIDs (e.g. mefenamic acid/ibuprofen)
| COCP second line
227
What is secondary dysmenorrhoea?
Is due to underlying pathology
228
When does the pain for secondary dysmenorrhoea tend to start?
3-4 days before the onset of the period
229
What are causes of secondary dysmenorrhoea?
```
Endometriosis
Adenomyosis
PID
IUD
Fibroids
```
230
What should be involved in the management of all women with secondary dysmenorrhoea?
Refer to gynae for investigation
231
What is hyperemesis gravidarum thought to be related to?
Raised bHCG levels
232
When is hyperemesis gravidarum most common?
Between 8 and 20 weeks
233
What things are associated with hyperemesis gravidarum?
```
Multiple pregnancies
Trophoblastic disease
Hyperthyroidism
Nulliparity
Obesity
```
234
What thing is associated with decreased incidence of hyperemesis gravidarum?
Smoking
235
When should you consider admission for nausea and vomiting in pregnancy?
Continued N+V + unable to keep liquids or oral antiemetics down
Continued N+ V with ketonuria +/or wt loss (>5% body wt), despite oral antiemetics
Confirmed/suspected co-morb (e.g. unable to tolerate antibiotics for a UTI)
236
For which individuals should you have a lower threshold for admitting with N+V during pregnancy?
Those with conditions that may be adversely affected by N+V, e.g. DM
237
What triad is used for the diagnosis of hyperemesis gravidarum?
5% pre-pregnancy wt loss
Dehydration
Electrolyte imbalance
238
What scoring system can be used to classify the severity of NVP?
Pregnancy-Unique Quantification of Emesis
239
How is hyperemesis gravidarum managed?
1st line: antihistamines, e.g. promethazine, cyclizine
2nd line: onansetron, metoclompramide
Ginger and P6 (wrist) acupressure can be used (little evidence for these)
Admission for IV hydration
240
What is the issue with giving metoclompramide?
EPS
241
What are complications of hyperemesis gravidarum?
```
Wernicke's encepahlopathy
Mallory-Weiss tear
Central pontine myelinolysis
Acute tubular necrosis
Fetal - small for gestational age, pre-term birth
```
242
What is the peak age to get ovarian cancer?
60 years old
243
What are the most common ovarian tumours/
Epithelial ones, most are serous carcinomas
244
Lately it has been recognise that what weird place is often the site of origin of many ovarian cancers?
The distal end of the fallopian tube
245
What are RFs for ovarian cancer?
BRCA1/2 mutation
| Many ovulations, e.g. early menarche, late menopause, nulliparity
246
What are the clinical features of ovarian cancer?
```
Abdominal distension + bloating
Abdominal + pelvic pain
Urinary symptoms, e.g. urgency
Early satiety
Diarrhoea
```
247
What is the initial test for ovarian cancer?
CA125
248
What things can raise CA125 besides ovarian cancer?
Endometriosis
Menstruation
Benign ovarian cysts
249
What level of CA125 would indicate a need for further investigation?
Raised (35IU/ml or greater)
250
What should you do if CA125 is raised?
Urgent US of abdomen + pelvis
251
How is ovarian cancer generally diagnosed?
Diagnostic laparotomy
252
How is ovarian cancer usually managed?
Surgery + platinum based chemo
253
What is a common complication of open myomectomy?
Adhesions most common
| Bladder injury + uterine perforation can also occur but they are less common
254
What are predisposing factors for candidiasis?
DM
Drugs - steroids, antibiotics
Pregnancy
Immunosupression - HIV, iatrogenic
255
What are the features of vaginal candidiasis?
Cottage cheese, non-offensive discharge
Vulvitis - dyspareunia, dysuria
Itch
Vulval erythema, fissuring, satellite lesions may be seen
256
How do you investigate suspected candidiasis?
Don't usually need to if clinical features are consistent with candidiasis
Can do high vaginal swab if unsure
257
How do you manage thrush?
Local Rx: clotrimazole pessary
| Oral: itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
258
How do you treat thrush in pregnancy?
Local treatments only (creams/pessaries)
259
Define recurrent vaginal candidiasis
4+ episodes per year
260
How do you manage recurrent vaginal candidiasis?
Check compliance with Rx
Confirm initial diagnosis - high vaginal swab, exclude ddx, e.g. lichen sclerosus
Exclude predisposing factors
consider use of induction-maintenance regimen (daily treatment for a week followed by maintenance treatment weekly for 6m)
261
What is the discharge of thrush like?
White, curdy with pH <4.5
262
What causes thrush?
Candida albicans
263
What test can you do to confirm menopause?
FSH - this is very raised in menopausal pts
264
What causes menopause?
Loss of follicular activity
265
How is menopause diagnosed?
Usually in primary care after the cessation of periods
266
What % of women will get menopausal symptoms?
75%
267
How long do menopausal symptoms generally last for?
7 years
268
What lifestyle modifications may help with hot flushes associated with menopause?
Regular exercise, weight loss, stress reduction
269
What lifestyle modifications may help with sleep disturbance associated with menopause?
Avoiding late evening exercise, maintaining good sleep hygiene
270
What lifestyle modifications may help with mood problems associated with menopause?
Sleep, regular exercise, relaxation
271
What lifestyle modifications may help with cognitive symptoms associated with menopause?
Regular exercise, good sleep hygiene
272
What are contraindications for HRT?
Current/past breast cancer
Any oestrogen sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
273
What are is the big difference in giving HRT for a women with and without a womb?
Womb - must give progesterone with oestrogen
| No womb - can give unopposed oestrogen
274
What are the risks of HRT?
```
VTE for oral HRT
Stroke for oral HRT
Coronary heart disease
Breast cancer
Ovarian cancer
```
275
What are the ways women with no womb can be given HRT?
Oestrogen either orally or in a transdermal patch
276
What are the ways women with a womb can be given HRT?
Oral or transdermal combined HRT
277
What are non-HRT treatments to help with vasomotor symptoms?
Fluoxetine, citalopram, venlafaxine
278
What are non-HRT treatments to help with vaginal dryness?
Vaginal lubricant or moisturiser
279
What are non-HRT treatments to help with psychological symptoms?
Self help groups
CBT
Antidepressants
280
What are non-HRT treatments to help with urogenital symptoms?
Vaginal oestrogen if suffering from urogenital atrophy
281
How long may HRT need to be used for vasomotor symptoms?
2-5y (should make regular attempts to come off it)
282
Does stopping HRT gradually help with recurrence?
Limits recurrence in the short term only
283
When should a women be referred to secondary care for management of her menopausal symptoms?
If treatment in primary care has been ineffective or if there are ongoing side effects or unexplained bleeding
284
What is the initial imaging used for ovarian cysts/tumours?
USS
285
What will an USS report about an ovarian cyst/tumour?
Simple - unilocular (more likely to be benign/physiological)
| Complex - multilocular (more likely to be malignant)
286
What is your approach to the management of an ovarian mass in someone who is premenopausal?
Conservative approach in women <35y
Cyst is small + simple on USS likely to be benign
Repeat USS in 8-12w + referral if it persists
287
What is your approach to the management of an ovarian mass in someone who is postmenopausal?
Physiological cysts unlikely
| Regardless of size/nature of cyst refer to gynae for assessment
288
How does rupture ovarian cyst tend to present?
Sudden onset unilateral pelvic pain precipitated by intercourse/strenuous activity
289
What may you see on USS in an ovarian cyst rupture?
Free fluid in the abdomen
290
What are side effects of HRT?
Nausea
Breast tenderness
Fluid retention + wt gain
291
What are potential complications of HRT?
Increased risk of:
- Breast cancer (only during use + for 5y after use)
- Endometrial cancer (reduced by addition of progesterone)
- VTE
- Stroke
- IHD
292
What may indicate a need for a biopsy to exclude endometrial cancer in a women who is premenopausal?
Persistent IMB in someone =<45 + treatment failure/ineffective treatment
293
How does rupture endometrioma present?
Sudden intense pain
| Pelvis will be filled with fluid
294
What are potential common long term complications of hysterectomy?
Enterocele
Vaginal vault prolapse
Urinary retention
295
Give an example of what can be used as the progesterone component of HRT
Mirena (IUS)
| Licensed up to 4y use
296
What is the classic exam history of ectopic pregnancy rupture?
Amenorrhoea
Abdominal pain
Vaginal bleeding
Shoulder tip pain
297
What is adenomyosis?
Endometrial tissue in the myometrium
298
Who is adenomyosis most common in?
Multiparous women towards end of their reproductive years
299
What are the features of adenomyosis?
Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus
300
What is the management of adenomyosis?
GnRH agonists
| Hysterectomy - definitive
301
What are the commonest causes of vaginal discharge?
Physiological
Candida
Trichomonas vaginalis
Bacterial vaginosis
302
What are less common causes of vaginal discharge?
```
Gonorrhoea
Chlamydia
Ectropion
Foreign body
Cervical cancer
```
303
What are the key features of trichomas vaginalis infection?
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
pH >4.5
304
What is the discharge of BV like?
Offensive, thin, white/grey, fishy discharge
305
Define recurrent miscarriage
3+ consecutive spontaneous abortions
306
What are causes of recurrent miscarriages?
```
Antiphospholipid syndrome
Endocrine disorders (poorly controlled DM/thyroid dx/PCOS)
Uterine abnormality, e.g. uterine septum
Parental chromosomal abnormalities
Smoking
```
307
What is the most reliable test to confirm ovulation?
Day 21 progesterone
308
When does serum progesterone peak?
7 days after ovulation (nb luteal phase is always 14 days, so peaks always 7 days before period)
309
What are the stages of ovarian cancer?
Stage 1 - confined to ovaries
Stage 2 - local spread within pelvis
Stage 3 - spread beyond pelvis into abdomen
Stage 4 - distant mets
310
What kind of spread is most common in ovarian cancer?
Local spread
311
What is Sheehan's syndrome?
Reduction in function of pituitary gland following ischaemic necrosis due to hypovolaemic shock following birth
312
What are features of Sheehan's syndrome?
Amenorrhoea, problems with milk production, hypothyroidism
| Symptoms can be varied + take sometimes take years to develop
313
Define FGM
All procedures involving partial/total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons
314
What is type 1 FGM
Clitoridectomy
315
What is type 2 FGM
Partial/total clitoridectomy + removal of labia minora +/- excision of labia majora
316
What is type 3 FGM
Narrowing of vaginal orifice with creation of a covering seal by cutting + appositioning the labia minor +/- labia majora +/- clitoridectomy
INFIBULATION
317
What is type 4 FGM
All other harmful procedures to the female genitalia, e.g. pricking, piercing, incising, scraping, cauterization
318
Is reinfibulation legal?
NO
319
What are non-gynae causes of lower abdominal pain in women?
```
Appendicitis
UTI
Constipation
IBS
Gallstones
```
320
What are menstrual related causes of lower abdominal pain in women?
Dysmenorrhoea
Endometriosis
Mittelschmerz
321
What are gynae causes of lower abdominal pain in women?
```
PID
Ovarian torsion
Uterine rupture (e.g. with IUS/IUD in situ)
```
322
What are pregnancy related causes of lower abdominal pain?
```
Ectopic pregnancy
Spontaneous abortion
Placental abruption
Premature labour
Pre-eclampsia
```
323
How does metformin work in treating some of the symptoms of PCOS?
Increases peripheral insulin resistance
324
What is a risk factor for endometrial hyperplasia?
Tamoxifen use (unopposed oestrogen stimulates endometrial growth)
Progesterone usually stimulates shedding of this tissue
Obesity
PCOS
DM
325
How does tamoxifen work?
Used in oestrogen receptor +ve breast cancer (in breast has anti-oestrogen effects, in endometrium has pro-oestrogen effects)
326
What is the only effective treatment for someone with large fibroids causing problems who is wanting to conceive?
Myomectomy
327
Who is offered cervical screening?
Women aged 25 to 64
328
How often are women screened for cervical cancer?
25-49y: 3yrly
| 50-64y: 5yrly
329
Which women may opt out of cervical cancer screening?
Those who have never been sexually active as they have a very low risk
330
Can you do a cervical screen on a pregnant women?
You can if missed screening or previously abnormal smears but usually delayed until 3m post-partum
331
What is the method of cervical screening?
Liquid based cytology
332
When is theoretically the best time to take a cervical smear?
Mid cycle
333
What women may require cervical screening more often?
Those who are immunosupressed
334
What is the mechanism of action of oxytbutinin?
Anti-muscarinic
335
How many small (<3cm) uterine fibroids not distorting the uterine cavity be managed?
Medically, e.g. IUS, tranexamic acid, COCP
336
What are the majority of vulval cancers?
SCC
337
Over what age do most cases of vulval cancers occur?
65y
338
What are risk factors for vulval cancer?
HPV infection
VIN
Immunosupression
Lichen sclerosus
339
What are features of vulval cancer?
Lump/ulcer on labia majora
Often ulcerated
Itching/irritation may occur
340
What is the appearance of a VIN?
White/plaque like
| Don't tend to ulcerate
341
In which cases when someone has an ectopic pregnancy but is haemodyamically stable should they be treated wth surgery as opposed to just methotrexate?
If a foetal heartbeat is present
342
Do lesbians require cervical screening?
Yes - HPV can be transmitted during lesbian sex
343
What is the screening programme for ovarian cancer?
There is NO screening for ovarian cancer currently
344
Why does a urine dipstick need to be done in all women presenting with urinary incontinence?
Rule out UTI/DM
345
How often should women with HIV be screened for cervical cancer and how should this be done?
Yearly cervical cytology
346
Why do women with HIV require more frequent cervical cancer screening?
They are at increased risk of CIN due to decrease immune response + clearance of HPV
(Even if effectively treated with antiretrovirals)
347
What is ovarian hyperstimulation syndrome a complication of?
Some infertility treatments
348
What is the pathophysiology of ovarian hyperstimulation syndrome?
Presence of multiple lutenized cysts --> high levels of oestrogen, progesterone + also vasoactive substances, e.g. VEGF --> increased membrane permeability + loss of fluid from the intravascular compartment
349
What therapies cause the most ovarian hyperstimulation syndrome?
Gonadotrophin
hCG treatment
IVF (1/3rd get it)
350
What is the criteria for mild OHS?
Abdominal pain
| Abdominal bloating
351
What is the criteria for moderate OHS?
Mild criteria +
NV
US evidence of ascites
352
What is the criteria for severe OHS?
```
Moderate criteria +
Clinical evidence of ascites
Oliguria
Haematocrit >45%
Hypoproteinaemia
```
353
What is the criteria for critical OHS?
```
Severe criteria +
TE
ARDS
Anuria
Tense ascites
```
354
Name 2 protective factors for endometrial cancer
COCP use
| Smoking
355
What is post-coital bleeding?
Vaginal bleeding after sexual intercourse
356
What are causes of PCB?
```
Idiopathic 50%
Cervical ectropion in 33%
Cervicitis e.g. secondary to chlamydia
Cervical cancer
Polyps
Trauma
```
357
What is the most common identifiable cause of PCB?
Cervical ectropion
358
What women are more at risk of developing a cervical ectropion?
Those on the COC
359
What are features of PCOS?
Subfertility/infertility
Menstrual disturbances, e.g. amenorrhoea/oligomenorrhoea
Hirsutism/acne (hyperandrogenism)
Obesity
Acanthosis nigricans (insulin resistance)
360
What investigations should be done for suspected PCOS?
Pelvic USS: multiple cysts on ovaries
FSH, LH (LH:FSH ratio), prolactin (raised/normal), TSH, testosterone (normal/raised)
Check for impaired glucose tolerance
361
What drug can mask the symptoms of PCOS?
COCP
362
Define PMB
Vaginal bleeding after 12m of amenorrhoea
363
What is the most common cause of PMB?
Vaginal atrophy
364
What is vaginal atrophy?
Thinning, drying and inflammation of the walls of the vagina due to a reduction in oestrogen after menopause
365
What drug can cause PMB?
HRT (with no pathological cause or due to long-term oestrogen causing endometrial hyperplasia)
366
What things can present with PMB?
```
Vaginal atrophy
HRT use
Endometrial hyperplasia
Endometrial cancer
Cervical cancer
Ovarian cancer (esp. oestrogen secreting (theca cell) tumours
Vaginal cancer
Rarer: trauma, vulval cancer, bleeding disorders
```
367
What are the guidelines for investigating PMB?
If >55 + PMB --> investigate within 2w by TVU to rule out endometrial cancer
368
What examinations should be done in PMB?
Vaginal
Abdominal
Speculum
Check for masses, abnormalities in abdomen/pelvis
369
What other investigations might you do for PMB?
Urine dipstick (haematuria/infection)
FBC (anaemia/bleeding disorders)
CA125
370
What is an acceptable depth of endometrial in someone who is post-menopausal?
<5mm
371
How is a definitive diagnosis of endometrial cancer made?
Endometrial biopsy
372
How is endometrial biopsy carried out?
Hysteroscopy with biopsy
or
Aspiration (pipelle) biopsy - thin flexible tube inserted into uterus via speculum to remove cells for testing
373
What additional imaging may be done in suspected endometrial cancer in secondary care?
CT/MRI uterus, pelvis, abdomen
374
How might PMB due to endometrial hyperplasia be managed?
Dilation + curettage to remove excess endometrial tissue
375
What is Amsel's criteria used for?
Diagnosis of BV
376
What is Amsel's criteria?
3/4 points should be present:
- Thin, white homogenous discharge
- Clue cells on microscopy - stippled vaginal epithelial cells
- Vaginal pH >4.5
- Positive whiff test
377
What is a whiff test?
Addition of K hydroxide --> fishy odour in BV
378
How is BV treated?
Oral metronidazole
379
How is trichomonas vaginalis treated?
Oral metronidazole 5-7 days or one off 2g dose
380
How is gonorrhoea treated?
IM ceftriaxone 1g
381
Define miscarriage
Expulsion of products of conception before 24w
382
What factors are associated with an increased risk of miscarriage?
```
Increased maternal age
Smoking in pregnancy
Consuming alcohol
Recreational drug use
High caffeine intake
Obesity
Infections/food poisoning
Health conditions, e.g. thyroid problems, severe HTN, uncontrolled DM
Medicines, e.g. ibuprofen, methotrexate, retinoids
Unusual shape/structure of womb
Cervical incompetence
```
383
Define complex ovarian cyst
One that is multiloculated or contains a solid mass
| These are malignant until proven otherwise
384
What investigations should be done when you find a complex ovarian cyst on USS?
CA125, aFP, bHCG
| Book for elective cystectomy
385
What kind of HRT regimens should be used in perimenopausal women and why?
Cyclical as it provides a predictable withdraw bleed (continuous regimens cause unpredictable bleeding)
Can give continuous if LMP >1y ago or if has been on cyclical HRT >1y
386
How can you confirm a miscarriage?
Diagnosed on US if there is no cardiac activity +
| - Crown rump length is greater than 7mm OR gestational sack is greater than 25mm
387
What is a cervical ectropion?
Elevated oestrogen levels --> larger area of columnar epithelium on the ectocervix
388
What is the transformation zone on the cervix?
Area on cervical canal where the stratified squamous epithelium meets the columnar epithelium
389
How might cervical ectropion present?
Vaginal discharge
| PCB
390
Are cervical ectropions treated?
Only if they cause troublesome symptoms
391
How might a cervical ectropion be treated?
Ablative treatment, e.g. cold coagulation
392
What things predispose to cervical ectropion?
Ovulatory phase
Pregnancy
COC
393
What are risk factors for miscarriage?
```
Age (>35)
Prev. miscarriages (2+)
Chronic conditions, e.g. uncontrolled DM
Uterine/cervical problems
Smoking, alcohol, illicit drug use
Over/under wt
Invasive prenatal testing, e.g. CVS, amniocentesis
```
394
What is the risk of miscarriage in:
a. a 35 year old
b. a 40 year old
c. a 45 year old?
a. 20%
b. 40%
c. 80%
395
What kind of uterine/cervical problems can predispose to miscarriage?
Mullerian duct anomalies
| Large cone cervical biopsies
396
How do NSAIDs work to help with pain?
Inhibit prostoglandin synthesis
397
What is the main clinical indication for starting HRT?
Vasomotor symptoms
398
What are the reasons someone should take continuous and NOT cyclical HRT?
1. They have taken cyclical for at least 1 year
2. It has been 1 year since their LMP
3. If has been 2 years since their LMP + they are <40 years old
399
What are long term complications of PCOS?
```
Subfertility
DM
Stroke and TIA
CAD
Obstructive sleep apnoea
Endometrial cancer
```
400
What is the tumour marker for pancreatic cancer?
CA 19-9
401
What is the tumour marker for bowel cancer?
CEA
402
What is the tumour marker for liver cancer and germ cell tumours (e.g. testicular)?
AFP
403
What is a tumour marker for breast cancer?
HER2
404
What are causes of delayed puberty with short stature?
Turner's syndrome
Prader-Willi syndrome
Noonan syndrome
405
What are causes of delayed puberty wtih normal stature?
PCOS
Androgen insensitivity
Kallman's syndrme
Klinefelter's syndrome
406
What are the two ways primary amenorrhoea can be diagnosed?
No period by age 14 + no secondary sexual characteristics
| No period by 16 + secondary sexual characteristics
407
What is constitutional delay?
Late bloomer - has secondary sexual characteristics
408
How would imperforate hymen present?
Cyclical pain + blueish bulging membrane oe
409
What are the features of transverse vaginal septae?
Cyclical pain + retrograde menstruation
410
What occurs in kallmann syndrome?
Failure to secrete GnRH
411
Where is the most common place for an ectopic pregnancy?
Ampulla of fallopian tube
412
Where is the most dangerous place to get an ectopic pregnancy?
Isthmus (increased risk of rupture)
413
When should you refer a couple to an infertility clinic?
After 1 year of trying (regular (every 2-3d) unprotected vaginal sex)
414
When should you consider earlier refer to the infertility clinic?
Female - age >35, amenorrhoea, prev. pelvic surgery, prev. STI, abnormal genital ex
Male - prev. surgery on genitalia, prev. STI, varicocele, significant systemic illness, abnormal genital ex
415
How is Meig's syndrome managed?
Drainage of pleural effusion + ascites
| Surgery to remove tumour
416
What is the GMC guidance on FGM?
Report all known cases of FGM under 18 to the police
417
In which age group is the highest incidence of cervical cancer?
25-29yos
418
What are the two types of cervical cancer?
SSC
| Adenocarcinoma
419
How might cervical cancer present?
1. Screening
| 2. Abnormal vaginal bleeding (PCB, IMB PMB) or vaginal discharge
420
What are the risk factors for cervical cancer?
```
Infection with HPV 16, 18, 33
Smoking
HIV
Early first intercourse, many sexual partners
High parity
Lower socioeconomic status
COCP
```
421
Why are HPV 16 and 18 oncogenic?
They produce the oncogenes E6 and E7
E6 inhibits p53 tumour supressor gene
E7 inhibits RB supressor gene
422
For which people would you advise to try having regular unprotected sex for 2 years prior to IVF?
Those with unexplained infertility, mild endometriosis, mild male factor infertility
423
Define ovarian torsion
Complete/partial torsion of the ovary on it's supporting ligaments that may in turn compromise the blood supply
424
What is an adnexal torsion?
Ovarian torsion where the fallopian tube is also involved
425
What are risk factors for ovarian torsion?
Ovarian mass (present in 90% cases of ovarian torsion)
Being of reproductive age
Pregnancy
Ovarian hyperstimulation syndrome
426
Why do fibroids grow during pregnancy?
Because they are oestrogen sensitive
427
What causes red degeneration of a fibroid?
If their growth outstrips their blood supply they degenerate
428
How does red degeneration tend to present?
Low grade fever
Pain
Vomiting
429
Where are the bartholin's glands situated?
Next to the entrance of hte vagina
430
What size are the bartholin's glands normally?
The size of a pea
431
What is a bartholin's abscess?
Infection + enlargement of the bartholin's glands
432
How can a bartholin's abscess be treated?
Antibiotics
Insertion of a word catheter
Surgery - marsupialization
433
What are the three types of management of a miscarriage?
Expectant
Medical
Surgical
434
What does expectant management of a miscarriage involve?
Waiting for a spontaneous miscarriage
| Waiting 7-14d for miscarriage to complete spontaneously
435
What is involved in medical management of a miscarriage?
Vaginal misoprostol
Anti-emetics, analgesia
Contact dr if bleeding
hasn't started in 24h
436
How does misoprostol work?
Prostaglandin analogue
| Binds to myometrial cells --> strong myometrial contractions --> expulsion of tissue
437
When is medical management of miscarriage prefered?
High risk of haemorrhaging (e.g. late first trimester)
| Evidence of infection or prev. adverse experiences
438
What are the main two ways to surgically manage a miscarriage?
Vacuum aspiration (suction curettage) under LA or surgical management in theatre
439
When might you opt for a surgical management of miscarriage?
If evidence of infection, e.g. going into shock
| Increased risk of haemorrhage
440
How are most miscarriages managed first line?
Expectant management
441
For patients opting for medical management of an ectopic pregnancy what must they agree to?
Attending follow up
442
When does fibroid degeneration commonly occur?
During pregnancy
443
By how much does smoking increase your risk of getting cervical cancer?
2x
444
What is premenstrual syndrome?
The emotional and physical symptoms women may experience prior to menstruation
445
What are common premenstrual syndrome symptoms?
```
Anxiety
Stress
Fatigue
Mood swings
Bloating
Irritability
Depression
Mastalgia
```
446
What is involved in the management of PMS?
Lifestyle advice - healthy diet, exercise, reduction in stress levels, regular sleep
More severe symptoms - COC, SSRI
447
What are risk factors for ectopic pregnancy?
```
Damage to tubes (e.g. salphinitis, surgery)
Prev. ectopic
Endometriosis
IUD
POP
IVF
```
448
What staging system is used for cervical cancer?
FIGO
449
What is FIGO IA?
Confined to cervix only visible by microscopy + less than 7mm wide:
A1: <3mm deep
A2: 3-5mm deep
450
What is FIGO IB?
Confined to cervix, clinically visible or larger than 7mm wide:
B1 <4cm
B2 >4cm
451
What is FIGO II?
Extension of tumour beyond cervix but not to pelvic wall
A = upper two thirds of vagina
B = parametrial involvement
452
What is FIGO III?
Extension of tumour beyond cervix + to the pelvic wall
A = lower third of vagina
B = pelvic side
OR any tumour causing hydronephrosis/non-functioning kidney
453
What is FIGO IV?
Extension of tumour beyond the pelvis/involvement of the bladder/rectum
A = bladder or rectum involvement
B = distant mets outside pelvis
454
How is stage IA cervical cancer managed?
Gold standard: hysterectomy +/- lymph node clearance
| For those wanting to maintain fertility: cone biopsy with negative margins and follow up can be done
455
What are other treatment options for IA2 cervical cancer?
Node evaluation must be performed
| Radial trachelectomy
456
How is stage IB cervical cancer managed?
B1: radio (brachy/EBR) + chemo (cisplatin)
B2: radical hysterectomy + pelvic node dissection
457
How is stage II and III cervical cancer managed?
Radio + chemo
| If hydronephrosis consider nephrostomy
458
How is stage IV ovarian cancer managed?
Radiation +/or chemo
| Palliative chemo best for IVB
459
How is recurrent ovarian cancer managed?
Primary surgical treatment - offer chemo/radio
| Primary radio treatment - offer surgery
460
What are complications of surgery for ovarian cancer?
Bleeding, damage to local structures, infection, anaesthetic risk etc.
Cone biopsies + radical trachelectomy may increase risk of preterm birth
Radical hysterectomy may lead to ureteral fistula
461
What are complications of radiotherapy for ovarian cancer?
Short-term: diarrhoea, vaginal bleeding, radiation burns, pains on micturition, tiredness/weakness
long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
462
What ovarian tumour is associated with endometrial hyperplasia?
Granulosa cell tumour
463
When should methotrexate be the first line for management of an ectopic pregnancy?
```
Small (<35mm)
Unruptured
No visible heart beat
Serum bHCG <1500 IU/L
No interuterine pregnancy
No pain
```
464
How does methorexate work in treating ectopic pregnancies?
It is an antimetabolite chemotherapeutic drug, it interferes with DNA synthesis + disrupts cell multiplication
465
When can you use expectant management for an ectopic pregnancy (watchful waiting)?
1) An unruptured embryo
2) <30mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <200IU/L and declining
466
What are the investigations of choice for suspected ectopic pregnancy?
Pregnancy test
| TVU
467
What does expectant management of an ectopic pregnancy invoolve?
Closely monitoring the pt over 48h and if bHCG levels rise again or symptoms manifest intervention is performed
468
What is the criteria for using surgical management for ectopic pregnancies?
```
Size >35mm
Can be ruptured
Severe pain
Visible fetal heart beat
Serum bHCG >1500IU/L
```
469
What types of management of ectopic pregnancies are compatible with another intrauterine pregnancy?
Surgical + expectant
470
What is a typical history of vesicovaginal fistula?
Continuous dribbling incontinence after prolonged labour from an area of limited obstetric services
471
What is the risk malignancy index for ovarian cancer based off of?
US findings
Menopausal status
CA125 levels
472
What is the best imaging technique for diagnosing adenymosis?
MRI
