Week 6 Flashcards

Question

How does Herpes simplex infection of the lower female genital tract present? How would you confirm the diagnosis?

Answer 1

- Genital HSV is highly stigmatised and poorly understood in the community. - Other human herpes viruses can cause genital ulceration (herpes zoster virus [HZV]; Epstein-Barr virus [EBV]). - Initial episodes may be severe, and treatment should never be delayed while waiting for a test result. - Most HSV is asymptomatic or mild enough that diagnosis is never sought. - f symptoms do appear, it can be days or years after HSV was first acquired. - More than 50% of primary genital infections are caused by HSV 1 in young people. - Recurrences are more common in the first year with HSV 2. - Severe and frequent recurrences may be treated with continuous suppressive or episodic antivirals.

Answer 2

**Other immediate management:** 1. Written information and support. 2. Regular analgesia 3. Topical lignocaine to reduce pain from erosions, fissures and ulcers 4. Urinating in a bath or shower relieves superficial dysuria. 5. Neuropathic bladder requires urgent catheterisation and referral. 6. Avoid intimate contact with partners until symptoms have resolved. 7. Routine sexual health screening 8. Use of barriers i.e., waterproof dressings. 9. HSV is not a notifiable disease. 10. Contact tracing is not recommended, but patients may need support if they wish to disclose to current or future sexual partners.

Answer 3

**Discharge Characteristics:** Trichomonal vaginitis is often associated with a frothy, yellow-green, or greyish vaginal discharge that has a strong, unpleasant odour. Candida vaginitis typically presents with a thick, white, "cottage cheese-like" discharge. It might not have a strong odour. **Itching and Irritation:** Some itching and irritation may be present in trichomonal vaginitis, but they are generally less severe compared to candida infections. Severe itching and burning sensations in the vaginal and vulvar areas are common symptoms of candida vaginitis.

Answer 4

**Treatment advice for Candida** - Intravaginal and oral azoles have similar efficacy – topical therapy provides quicker symptom relief but women generally prefer oral therapy. - Vulvar treatment alone is inadequate due to a vaginal reservoir – both sites should be treated. - The addition of hydrocortisone 1% cream may provide symptomatic relief. - No evidence that specific diets or use of probiotics influence recurrence. - Reconsider diagnosis if no response to therapy. - Oral azoles cannot be used in pregnancy. - No hepatic monitoring is required for fluconazole use at the above doses. **Other immediate management** - Avoid local irritants e.g., soap, bath oil, body wash, bubble bath, spermicide, vaginal lubricant and vaginal hygiene products. - Latex barrier contraception e.g., condoms can be damaged by antifungal vaginal creams or oil-based products. - Post-coital penile hypersensitivity to vaginal Candida colonisation is possible and responds to partner treatment Hydrocortisone 1% cream may provide symptomatic relief. Partners do not usually require treatment.

Answer 5

**Factors Predisposing to Recurrent Candida Vulvovaginitis:** 1. **Immunosuppression**: Conditions that weaken the immune system, such as HIV/AIDS, diabetes, and certain autoimmune disorders, can increase the risk of recurrent candida infections. 2. **Antibiotic Use**: Frequent or prolonged use of antibiotics can disrupt the balance of vaginal flora, allowing candida to overgrow. 3. **Hormonal Changes**: Fluctuations in hormone levels, such as those occurring during pregnancy, menstruation, or the use of oral contraceptives, can impact vaginal pH and make the environment more conducive to candida growth. 4. **Underlying Medical Conditions:** Conditions like uncontrolled diabetes, hormonal imbalances (e.g., polycystic ovary syndrome), and thyroid disorders can contribute to recurrent candida infections. 5. **Sexual Activity**: Although candida is not considered a sexually transmitted infection, sexual activity can introduce new organisms and disrupt the vaginal environment.

Answer 6

Vulvovaginitis is the general term which refers to many types of vaginal/vulva inflammation or infection. In prepubertal girls usually 2-8 years, non-specific vulvovaginitis is responsible for 25-75% of vulvovaginitis.

Answer 7

**Differential diagnosis** - If persistent, offensive or bloody discharge, consider the following: 1. **Threadworm** - if pruritus (vulval and/or perianal) is prominent especially at night. 2. **Foreign body** - if chronic vaginal discharge, intermittent bleeding, offensive odour. Toilet paper commonest foreign body. Refer to paediatric gynaecologist as required. 3. **Specific organisms** if discharge is profuse/offensive take an introital swab.

Answer 8

Lichen sclerosus is a chronic inflammatory disease of unknown cause that is characterized by white, atrophic plaques with intense pruritus affecting the skin, nails, hair, and/or mucous membranes. It most commonly affects the anogenital area and often occurs in postmenopausal women. Although the condition is benign, it is associated with an increased risk of squamous cell carcinoma. Lichen sclerosus is diagnosed clinically and should be confirmed via punch biopsy in adults, which can concurrently screen for squamous cell carcinoma. Treatment primarily consists of superpotent topical steroids but may also include surgical excision in steroid-refractory disease. **Treatment of Lichen Sclerosis** - **First-line**: superpotent topical steroids (clobetasol, sometimes betamethasone) - **Second-line**: topical calcineurin inhibitors (e.g., tacrolimus) - If necessary, surgical excision

Answer 9

**Investigations of Heavy Menstrual Bleeding** Clinical examination should include a routine CST. A full blood examination should be performed if anaemia is suspected or a serum ferritin to detect iron deficiency. As a coagulopathy such as Von Willebrand disease is a possible cause in the adolescent woman, a coagulation screen or platelet function tests should be performed when appropriate. Other tests such as thyroid function tests, renal investigations or autoantibodies such as lupus coagulant should be performed if organic disease is suspected. A transvaginal ultrasound (except in the adolescent woman) will aid in excluding pelvic causes of heavy bleeding. Hysteroscopy with dilation and curettage or endometrial biopsy, or laparoscopy if there is associated pain, will be diagnostic but not curative for HMB.

Answer 10

**Medical Management:** 1. **NSAIDs**: NSAIDs like ibuprofen can help reduce menstrual bleeding and pain. 2. **Hormonal Birth Control**: Options like combination oral contraceptives, hormonal IUDs, or the contraceptive implant can help regulate and lighten periods. 3. **Tranexamic Acid**: This medication helps reduce bleeding by promoting clot formation. 4. **Progestin Therapy**: Progestin-only methods, like birth control pills, injections, or hormonal IUDs, can help regulate and reduce bleeding. **Surgical Management:** If medical treatment isn't effective or appropriate, surgical options may be considered, including: 1. **Endometrial Ablation**: This procedure removes or destroys the lining of the uterus to reduce menstrual bleeding. 2. **Hysterectomy**: In severe cases, when other treatments fail or aren't appropriate, a hysterectomy (removal of the uterus) may be considered.

Answer 11

**Dilation and curettage** A gynecological procedure in which the cervix is dilated and tissue is removed from the uterus using a curette. May be performed for therapeutic purposes (e.g., spontaneous or induced abortions at < 13 weeks' gestation, molar pregnancies, removal of uterine masses) or diagnostic purposes (e.g., obtaining uterine tissue samples for histological examination).

Answer 12

1. Infertility 2. Iron deficiency anemia (due to heavy menstrual bleeding) 3. Fibroid torsion - A pedunculated subserosal fibroid may twist and become necrotic, which presents with acute pelvic pain. 4. Thromboembolism - Large leiomyomas may compress the vena cava. 5. Very rare: malignant transformation to uterine leiomyosarcoma

Answer 13

Differential Diagnosis: 1. **Uterine Fibroids (leiomyomas)**: These benign growths in the muscular wall of the uterus can cause menorrhagia and an enlarged uterus. 2. **Adenomyosis**: This condition involves the abnormal growth of endometrial tissue into the uterine muscle, leading to heavy and painful periods, as well as an enlarged uterus. 3. **Endometrial Hyperplasia:** A condition characterized by excessive growth of the uterine lining, which can cause heavy bleeding. It can sometimes progress to endometrial cancer. 4. **Endometrial Polyps**: Small growths in the uterine lining can cause heavy bleeding. 5. **Uterine Cancer/Endometrial Carcinoma**: Although less common, uterine cancer can cause abnormal bleeding and an enlarged uterus.

Answer 14

Gestational trophoblastic disease includes both benign and malignant proliferations of placental cells. At the benign end of the spectrum, there’s hydatidiform mole, also called molar pregnancy; while at the malignant end, there’s gestational trophoblastic neoplasia, which includes choriocarcinoma and trophoblastic tumors.

Answer 15

‘Total’ means with the cervix and ‘sub-total’ means without the cervix.

Answer 16

Anovulatory dysfunctional bleeding, also known as anovulatory bleeding or abnormal uterine bleeding (AUB), refers to irregular or abnormal bleeding from the uterus that occurs due to anovulation, which is the absence of ovulation in a menstrual cycle. Ovulation is the process where an egg is released from the ovaries, and it plays a key role in regulating the menstrual cycle. During a normal menstrual cycle, the uterine lining (endometrium) builds up in preparation for a potential pregnancy. If ovulation occurs and the egg is not fertilized, hormonal changes lead to the shedding of the uterine lining, resulting in a menstrual period. However, when ovulation doesn't occur, hormonal imbalances can disrupt the typical menstrual cycle, leading to various types of abnormal bleeding patterns.

Answer 17

Chronic anovulation can lead to irregular bleeding, prolonged unopposed estrogen stimulation of the endometrium, and increased risk of endometrial cancer. Causes include polycystic ovary syndrome, uncontrolled diabetes mellitus, thyroid dysfunction, hyperprolactinemia, and use of antipsychotics or antiepileptics.

Answer 18

A hydatidiform mole, also known as a molar pregnancy, is a rare condition where abnormal placental tissue grows in the uterus instead of a healthy fetus. Hydatidiform mole (HM) is one of a group of diseases that develop from abnormal proliferation of trophoblast and are classified as gestational trophoblastic disease (GTD). The two distinct types of HM, complete mole and partial mole, have different karyotypes, gross and microscopic histopathology, clinical presentations, and prognoses. Management is similar but with some differences. Treatment involves surgical removal of the molar pregnancy followed by surveillance of serial human chorionic gonadotropin (hCG) levels to confirm resolution of disease or to identify development of gestational trophoblastic neoplasia (GTN), which includes invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Although GTN is the invasive or metastatic form of GTD, it has an excellent cure rate with chemotherapy.

Answer 19

**Hydatidiform mole: Treatment** 1. **Uterine dilation and evacuation (D&E)** - Complete moles have a 20% risk of becoming invasive and a 2% risk of developing into choriocarcinoma. Therefore, complete evacuation of the uterine cavity is the mainstay of treatment. 2. **Monitor β-HCG levels**: until within reference range (usually 8–12 weeks) 3. **Chemotherapy** (usually methotrexate) if unresolved, as indicated by either of the following: - β-HCG values do not decrease. - Features of malignant GTN on histology or imaging

Answer 20

Emergency contraception (EC) refers to measures taken to prevent pregnancy within 5 days of unprotected intercourse or contraception failure (e.g., condom breakage, missed oral contraceptives).

Answer 21

**General Principles** - Most effective when taken within 3 days of unprotected intercourse (ulipristal acetate can be taken within 5 days). - Does not disrupt embryo implantation or already established pregnancies. - Significantly less effective in obese (BMI ≥ 30 kg/m2) or overweight (BMI 25–29.9 kg/m2) individuals.

Answer 22

**Primary dysmenorrhea** - **Definition**: recurrent lower abdominal pain shortly before or during menstruation (in the absence of pathologic findings that could account for those symptoms) - **Epidemiology**: Prevalence up to 90% (most common gynecologic condition), Manifests during adolescence (typically within three years of menarche) - **Etiology**: The etiology of primary dysmenorrhea is not completely understood. Associated with some risk factors (e.g., early menarche, nulliparity, smoking, obesity, positive family history) - **Pathophysiology**: increased endometrial prostaglandin (PGF2 alpha) production leads to vasoconstriction/ischemia and stronger, sustained uterine contractions (to prevent blood loss).

Answer 23

**Secondary dysmenorrhea** - **Definition**: recurrent lower abdominal pain shortly before or during menstruation that is due to an underlying condition - **Epidemiology**: May begin later in life than primary dysmenorrhea, Commonly affects female individuals ≥ 25 years of age. - **Diagnostics** 1. CBC with differential (rules out infection) 2. Urinalysis (rules out UTIs) 3. β-hCG (rules out ectopic pregnancy), 4. Gonococcal/chlamydial swabs (rule out STDs and PID) 5. Pelvic ultrasound

Answer 24

Secondary dysmenorrhea refers to menstrual pain that is caused by an underlying medical condition, unlike primary dysmenorrhea which occurs without any identifiable underlying cause. Secondary dysmenorrhea tends to develop later in life and often presents with more severe and persistent symptoms than primary dysmenorrhea.

Answer 25

**Pain Hx** - SOCRATES **Management**: If organic factors have been excluded and the pain is not due to a physical condition, the management of dyspareunia might involve addressing psychological, emotional, or relational factors that could contribute to the pain.

Answer 26

Pregnancy is a stress for women with cardiac diseases because: 1. Cardiac output increases by 40% during pregnancy due to increase in stroke volume and heart rate 2. Cardiac output also increases soon after delivery because of tonic uterine contraction and relief from aorto-caval compression 3. These changes are not tolerated by a heart that is compromised by disease 4. Anaemia, infection, bleeding, hypertension, pre-eclampsia, GDM can further complicate cardiac disease in pregnancy

Answer 27

**Presentation:** 1. Leg pain discomfort, swelling, tenderness, pyrexia, erythema, raised WCC 2. Dyspnoea, Collapse, Chest pain, 3. Haemoptysis, Raised JVP, Focal signs in the chest **Investigations:** 1. Thrombophilia screen- congenital and acquired 2. FBC, U and E, LFT, Coagulation screen 3. Imaging- Leg USS- Compression or Duplex 4. For PE- ECG, Chest X Ray, ABG, V/Q Scan, CT angiography/MRI

Answer 28

**Causes of Hypothyroidism** 1. Hashimoto’s thyroiditis 2. Atrophic thyroiditis 3. Congenital absence of thyroid 4. Thyroidectomy, radioiodine therapy, drugs ( Lithium, iodine) 5. Pituitary failure

Answer 29

**Adenomyosis** - **Definition**: benign disease characterized by the occurrence of endometrial tissue within the myometrium due to hyperplasia of the endometrial basal layer - **Epidemiology**: peak incidence at 35–50 years - **Aetiology**: The exact etiology is unknown, though some risk factors have been identified: Endometriosis, Uterine fibroids, Parity - **Clinical features**: 1. May be asymptomatic 2. Dysmenorrhea 3. Abnormal uterine bleeding 4. Chronic pelvic pain, aggravated during menses 5. Globular, uniformly enlarged uterus that is soft but tender on palpation

Answer 30

**Clinical features** **Maternal** 1. Fever (> 38 °C or > 100°F) 2. Tachycardia > 120/min 3. Uterine tenderness, pelvic pain 4. Malodorous and purulent amniotic fluid, vaginal discharge 5. Premature contractions, PROM **Fetal** tachycardia > 160/min in cardiotocography

Answer 31

- Prostaglandins getting into gut = diarrhoea - N&V - pain - Syncope = retrograde blood getting into peritoneum causing irritation and vagal stimualtion - Should take the mefanamic acid at the onset of her period (when prostaglandins released) **Management** - Education re : correct use of NSAIDs - COCP to regulate periods & reduce prostaglandin production & skip periods & can time Mefenamic acid use

Answer 32

1. MEC Cat 1 – eg. 20yo F wanting COCP 2. Cat 2 – eg. 20yo F wanting IUD 3. Cat 3 – eg. BMI >35 & COCP – risk of thromboembolism 4. Cat 4 – eg. COCP past VTE or migraine with aura (risk of stroke very high)

Answer 33

For hormonal IUDs, add the same contraindications as implants (eg breast cancer, severe liver disease)

Answer 34

**Implanon** * Flexible 4cm subdermal rod * Contains desogestrel (a progestogen) * Inserted under skin of inner upper arm

Answer 35

**Progestogen IUDs** * Progestogen containing: – Mirena® – Lasts 5 years (longer if only used for menstrual management) – Initial frequent bleeding (3-6 months) followed by very little bleeding for most women – Very low incidence “progestogen” side effects

Answer 36

**Copper containing IUDs** – Copper T Standard – lasts 10 years – Copper T Short – lasts 5 years – Load 375® - lasts 5 years (formerly Multiload®) * 40-50% chance of heavier or more painful periods

Answer 37

* “Skipping bleeds” is encouraged!! – Take active tablets, skip inactive ones until a withdrawal bleed is desired * Regular withdrawal bleed once every 3 months, OR * When any breakthrough bleeding occurs, have 4-7 inactive pills then continue active pills again

Answer 38

1. Levonorgestrel 1.5g within 4 days 2. Ulipristal 30mg within 5 days 3. Copper IUD – within 5 days

Answer 39

1. Discuss medical vs surgical options 2. Discuss risks of termination and risks of continuing pregnancy 3. Discuss contraception 4. Offer STI screening

Answer 40

**Possible complications of termination** 1. Infection – uncommon 2. Heavy bleeding – more likely with medical 3. Perforation – more likely with surgical; very uncommon 4. Incomplete expulsion – more likely with medical **Rare risks – mostly preventable** 1. Rhesus isoimmunisation 2. Anaesthetic complications 3. Missed ectopic pregnancy

Answer 41

**How effective is the combined pill?** Patients understandably want to know how effective contraception is and this is often a major factor in their decision as to which type of contraception they want to use. As a result, it’s useful to know some basic statistics on efficacy. However, if you’re unsure, signpost the patient to a reliable source and don’t guess! Explain to the patient that the effectiveness of the pill depends on compliance. However, if the pill is used correctly, it is 99% effective. “If you take the combined pill at the appropriate time each day and don’t miss pills, it is 99% effective at preventing pregnancy.”

Answer 42

**Risks of the combined pill** 1. **Venous thromboembolism** - “There is a small increase in the risk of developing clots in your legs and lungs. There is also a small increase in the risk of having a heart attack or a stroke. If you have had any of these conditions in the past, then you should not use the pill. The risk of developing these conditions is increased if you smoke regularly, have a high BMI or if you are immobile for a long period of time.” 2. **Breast cancer** - “Research has shown that there is a small increased risk of breast cancer compared to people who are taking non-hormonal contraception. The risk reduces with time after stopping the pill.” 3. **Cervical cancer** - “Research has also shown that there is a small increased risk of developing cervical cancer with longer use of the combined oral contraceptive.”