WOMENS HEALTH 2 - Breast, Gynae, Sexual Health Flashcards

Question

What are some immunotherapies and other drugs that can be used in teh treatmet of cancer 2

Answer 1

TRASTUZUMAB (herceptin) AND OTHER HER2 TARGETING THERAPIES. This drug binds to the Her-2 receptor which is over expressed in one third of all breast cancers. Her-2 expressing cancers have the worst prognosis of any breast cancer subtype and the use of trastuzumab helps to improve their survival substantially, to the extent that use of this drug neutralises the adverse effect of Her-2 expression. **Bisphosphonates** use

Answer 2

Oncologists will guide chemotherapy. Chemotherapy is used in one of three scenarios: Neoadjuvant therapy – intended to shrink the tumour before surgery Adjuvant chemotherapy – given after surgery to reduce recurrence Treatment of metastatic or recurrent breast cancer Chemotherapy - can cause infertility

Answer 3

younger women more likely whether its metastasised High Grade tumour **receptor status** HER2 negative (so cant treat with Herceptin) , and ER negative (so cant given then anti oestrogens like tamoxifen) - so can only give chemo!!

Answer 4

- Implants - Flap reconstruction, eg ○ use portion of **latissimus dorsi** and associated skin and fat tissue ○ **Transverse rectus abdominnus flap** (TRAM FLAP) ○ Deep **inferior epigastric perforator** flap = use Skin and subcut fat from the abdomen as free flap, Taking deep inferior epigastric atery and veins transplanted to breast cant do flap surgery in active smokers!

Answer 5

You can remember the notable locations that breast cancer metastasis occur using 2 Ls and 2 Bs: L – Lungs L – Liver B – Bones B – Brain TOM TIP: Breast cancer can spread to any region of the body. In patients with a metastatic tumour, regardless of where it is, the primary could be breast cancer. This is worth remembering, as you may be asked “where might this metastasis have originated” in an exam or OSCE scenario. If the patient is female, answering “breast cancer” will be a good answer. The other cancer that can spread practically anywhere, and may be less obvious, is melanoma (a type of skin cancer).

Answer 6

Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area. The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema). The lymphatic system also plays an important role in the immune system. Areas of lymphoedema are prone to infection. 15% -20% in total axilllary clearnace, 2-5% in Wide Local excision It is important to remember that you should avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery. This is because there is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.

Answer 7

There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include: Massage techniques to manually drain the lymphatic system (manual lymphatic drainage) Compression bandages Specific lymphoedema exercises to improve lymph drainage Weight loss if overweight Good skin care

Answer 8

use online risk calculuotrs, looks at age periods hormonal medication which family members that have been diagnosed and at what age CanRISK or IBIS 2 30% or higher lifetime risk is determined as high risk

Answer 9

Fibroadenoma Fibrocystic Breast Changes Breast Cysts General variation in nodularity, often premenstrual

Answer 10

Fibroadenomas are common benign tumours of stromal/epithelial breast duct tissue. They are more common in younger women, aged between 20 and 40 years. They respond to the female hormones (oestrogen and progesterone), which is why they are more common in younger women and often regress after menopause.

Answer 11

They are sometimes called a “breast mouse”, as they move around within the breast tissue. Painless Smooth Round Well circumscribed (well-defined borders) Firm Mobile (moves freely under the skin and above the chest wall) Usually up to 3cm diameter

Answer 12

1/3 will shrink. 1/3 will grow, 1/3 will stay the same Women are usually reassured and only advised to have surgical removal if they are large or prominent.

Answer 13

Breast cysts are benign, individual, fluid-filled lumps. They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period. They are an abnormal response of part of the breast to hormonal stimulation.

Answer 14

A breast cyst can be considered benign if it satisfies the following criteria: - the fluid is not blood stained - there is no residual lump - the same cyst does not continually refill - doesnt have an irregular/thickened wall If any of the above is not fulfilled, an intracystic cancer should be considered and appropriate investigation initiated.

Answer 15

On examination, breast cysts are: Smooth Well-circumscribed Mobile Possibly fluctuant -Fluctuance refers to being able to move fluid around within the lump using pressure during palpation

Answer 16

A breast abscess is a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a: *a progression from mastitis* Lactational abscess (associated with breastfeeding, - usually peripheral in the breast) Non-lactational abscess (unrelated to breastfeeding - usually associated with duct ectasia and therefore central.)

Answer 17

Smoking The presentation of mastitis or breast abscesses is usually acute, meaning the onset is within a few days. Mastitis with infection in the breast tissue presents with breast changes of: Nipple changes Purulent nipple discharge (pus from the nipple) Localised pain Tenderness Warmth Erythema (redness) Hardening of the skin or breast tissue Swelling The key feature that suggests a breast abscess is a swollen, fluctuant, tender lump within the breast.

Answer 18

Lactational mastitis caused by blockage of the ducts is managed conservatively, with **continued breastfeeding, expressing milk and breast massage**. Heat packs, warm showers and simple analgesia can help symptoms. NICE CKS recommends women with breast abscesses be referred urgently to a general surgeon for USS confirmation, and drainage and culture of the fluid from the abscess. Antibiotics **(flucloxacillin or erythromycin/clarithromycin** where there is penicillin allergy) are required where infection is suspected or symptoms do not improve.

Answer 19

Management of non-lactational mastitis involves: Analgesia Antibiotics Treatment for the underlying cause (e.g., eczema or candidal infection) Antibiotics for non-lactational mastitis need to be broad-spectrum. The NICE clinical knowledge summaries (last updated January 2021) recommend either: **Co-amoxiclav Erythromycin/clarithromycin (macrolides) plus metronidazole** (to cover anaerobes)

Answer 20

If redness/inflammation hasn’t improved after one antbx course - refer to a breast specialist on suspicion of cancer!

Answer 21

dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green.

Answer 22

Mammary duct ectasia occurs most frequently in perimenopausal women. Smoking is a significant risk factor. Presentation Mammary duct ectasia may present with: Nipple discharge Tenderness or pain Nipple retraction or inversion A breast lump (pressure on the lump may produce nipple discharge)

Answer 23

The initial priority is to exclude breast cancer, as they can present in similar ways. This involves triple assessment with: Clinical assessment (history and examination) Imaging (ultrasound, mammography and MRI) Histology (fine needle aspiration or core biopsy) Ductography – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct Nipple discharge cytology – examining the cells in a sample of the nipple discharge

Answer 24

Mammary duct ectasia may resolve without any treatment. It is not associated with an increased risk of cancer. Management depends on the individual patient: Reassurance after excluding cancer may be all that is required Symptomatic management of mastalgia (supportive bra and warm compresses) Antibiotics if infection is suspected or present Surgical excision of the affected duct (microdochectomy) may be required in problematic cases

Answer 25

This is an eczematous change of the nipple due to an underlying malignancy (invasive or in-situ) and should be suspected in apparent nipple eczema that does not resolve with two weeks of steroid/anti fungal cream

Answer 26

It is caused by the infiltration of tumours cells through the ducts onto the nipple surface where they infiltrate the epidermis. Treatment is by excision either as mastectomy or central (nipple excising) wide local excision.

Answer 27

intraductal papillomas are benign tumours, and are warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells.

Answer 28

Intraductal papillomas are often asymptomatic. They may be picked up incidentally on mammograms or ultrasound. They may present with: Nipple discharge (clear or blood-stained) Tenderness or pain A palpable lump Diagnosis Patients require triple assessment with: Clinical assessment (history and examination) Imaging (ultrasound, mammography and MRI) Histology (usually by core biopsy or vacuum-assisted biopsy)

Answer 29

Management Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.

Answer 30

upper vagina, cervix, uterus and fallopian tubes develop from the paramesonephric ducts (Mullerian ducts). These are a pair of passageways along the outside of the urogenital region that fuse and mature to become the uterus, fallopian tubes, cervix and upper third of the vagina. In a male fetus, anti-Mullerian hormone is produced, which suppresses the growth of the paramesonephric ducts, causing them to disappear.

Answer 31

A bicornuate uterus is where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance A bicornuate uterus may be associated with adverse pregnancy outcomes. However, successful pregnancies are generally expected. In most cases, no specific management is required. Typical complications include: Miscarriage Premature birth Malpresentation

Answer 32

Imperforate hymen is where the hymen at the entrance of the vagina is fully formed, without an opening. Imperforate hymen may be discovered when the girl starts to menstruate, and the menses are sealed in the vagina. This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding. An imperforate hymen can be diagnosed during a clinical examination. Treatment is with surgical incision to create an opening in the hymen.

Answer 33

A condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors. It is an X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics.

Answer 34

are genetically male, with XY sex chromosomes. However, the absent response to testosterone and the conversion of additional androgens to estrogen result in a female phenotype externally. Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue. Patients will have testes in the inguinal canal, that produce antimullerian hormone, which prevents males form developing upper vagina, uterus, cervix and fallopian tubes.

Answer 35

lack of pubic hair, facial hair and male type muscle development. Patients tend to be slightly taller than the female average. Patients are infertile, and there is an increased risk of testicular cancer unless the testes are removed. Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea.

Answer 36

1. Raised LH Increased LH results from the lack of negative feedback due to ineffective testosterone action, leading to higher stimulation of the testes. 2. Normal or Raised FSH FSH may be normal or elevated due to the absence of feedback from testosterone and inhibin, as the Sertoli cells are not effectively stimulated. 3. Normal or Raised Testosterone Levels: Testes produce normal or elevated testosterone, but body tissues cannot respond to it due to androgen receptor insensitivity. 4. Raised Estrogen Levels: Elevated estrogen occurs from the conversion of excess testosterone to estradiol, contributing to the development of some secondary female characteristics

Answer 37

where there the cells have a partial response to androgens. This presents with more ambiguous signs and symptoms, such as a micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics.

Answer 38

Bilateral orchidectomy (removal of the testes) to avoid testicular tumours Oestrogen therapy Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length Generally, patients are raised as female, but this is sensitive and tailored to the individual. They are offered support and counselling to help them understand the condition and promote their psychological, social and sexual wellbeing.

Answer 39

- A retrospective diagnosis made after a woman has had no periods for 12 months - It is defined as a permanent end to menstruation - Menopause is the point at which menstruation stops

Answer 40

- Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. - Postmenopausal describes the period from 12 months after the final menstrual period onwards. - Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.

Answer 41

- It is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle - Oestrogen and progesterone levels are low - LH and FSH levels are high in response to an absence of negative feedback from oestrogen

Answer 42

- In the ovaries the process of primordial follicles maturing is into primary and secondary follicles is always occurring - At the start of the menstrual cycle FSH stimulates the further development of secondary follicles - As the follicles grow the **granulosa cells** that surround them secrete increasing amounts of oestrogen

Answer 43

- The menopause begins with a decline in the development of ovarian follicles - Without the growth and development of the follicles there is reduced production of oestrogen - This results in increasing levels of LH and FSH as oestrogen has a negative feedback on these hormones in the pituitary gland

Answer 44

- Falling follicular development means ovulation does not occur (anovulation) - Without oestrogen the endometrium does not develop leading to a lack of menstruation (Amenorrhoea) - The low levels of oestrogen lead to the perimenopausal symptoms

Answer 45

- Hot flushes - Emotional lability or low mood - Premenstrual syndrome - Irregular periods - Joint pains - Heavier or lighter periods - Vaginal dryness and atrophy - Reduced libido

Answer 46

- CVD - Osteoporosis - Pelvic organ collapse - Urinary incontinence

Answer 47

- Symptoms without blood test - Use FSH blood test in women under 40 or aged 40-45 with menopausal symptoms - FSH levels >40iu/l (and associated with amenorrhoea for >4 months). This will be taken on 2 blood samples taken **4-6 weeks apart.**

Answer 48

- Two years after the last menstrual period in women under 50 - One year after the last menstrual period in women over 50

Answer 49

Hormone replacement therapy (HRT) Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors Testosterone can be used to treat reduced libido (usually as a gel or cream) Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT), Vaginal moisturisers, such as Sylk, Replens and YES like Epaderm or Diprobase

Answer 50

Clonidine which is a alpha-2 agonist NICE guidelines advise that menopausal women suffering from vasomotor symptoms can be given a selective serotonin uptake inhibitor (SSRI) such as fluoxetine

Answer 51

Premature ovarian insufficiency: hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to **women until the age of 51 years* Reducing vasomotor symptoms such as hot flushes and night sweats Improving symptoms such as low mood, decreased libido, poor sleep and joint pain Reducing risk of osteoporosis in women under 60 years

Answer 52

Women with a uterus require endometrial protection with progesterone (in addition to oestrogen) The primary purpose of adding progesterone is to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen. whereas women without a uterus can have oestrogen-only HRT.

Answer 53

Women that still have periods should go on **cyclical HRT, with cyclical progesterone** and regular breakthrough bleeds. Postmenopausal women with a uterus and more than 12 months without periods should go on **continuous combined HRT**.

Answer 54

- Breast and endometrial cancer - Angina - Increased risk of VTE with oral pill - Women are not at increased risk under 50

Answer 55

Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or myocardial infarction Pregnancy

Answer 56

- When endometrial tissue (tissue that lines the uterus) grows in the **Myometrium** (the muscular layer of the uterus) - It is more common in later reproductive years and those that have had several pregnancies

Answer 57

Painful periods (dysmenorrhoea) Heavy periods (menorrhagia) Pain during intercourse (dyspareunia) It may also present with infertility or pregnancy related complications. 1/3 of patients will be asymptomatic

Answer 58

- An enlarged tender uterus that will feel mores soft than a uterus containing fibroids heavy periods, with an **enlarged and boggy** uterus. Adenomyosis is when endometrial tissue becomes embedded within the myometrium.

Answer 59

transvaginal ultrasound - The gold standard is a histological examination of the uterus after a hysterectomy

Answer 60

- Tranexamic acid when there is no associated pain (antifibrinolytic so reduces bleeding) - Mefenamic acid where there is associated pain (NSAID reduces bleeding and pain)

Answer 61

Mirena coil (first line) Combined oral contraceptive pill Cyclical oral progestogens

Answer 62

- Infertility - Miscarriage - Preterm birth - Small for gestational age - Preterm premature rupture of membranes - Malpresentation - Need for caesarean section - Postpartum haemorrhage

Answer 63

- It is where adhesions (sometimes called synechiae) form within the uterus following **damage** to the uterus Endometrial curettage (scraping) can damage the basal layer of the endometrium

Answer 64

Usually Asherman’s syndrome occurs after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth) can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).

Answer 65

- The damage endometrium forms scar tissue which connects areas of the uterus that are not usually connected - These adhesions may bind the uterine walls together or the endocervix sealing it shut - These adhesions form physical obstructions and distort the pelvic organs

Answer 66

- Secondary amenorrhoea *(as the adhesion tissue does not respond to oestrogen)* - Significantly lighter periods - Dysmenorrhoea - Infertility Adhesions may be found incidentally during hysteroscopy. Asymptomatic adhesions are not classified as Asherman’s syndrome.

Answer 67

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions Hysterosalpingography, where contrast is injected into the uterus and imaged with x-rays Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed MRI scan **Management is dissecting the adhesions during hysteroscopy**

Answer 68

a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. Can affect foreskin and glans of the penis

Answer 69

Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo. Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears: “Porcelain-white” in colour Shiny Tight Thin Slightly raised There may be papules or plaques

Answer 70

The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms: Itching Soreness and pain possibly worse at night Skin tightness Painful sex (superficial dyspareunia) Erosions Fissures The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus - worsened by tight underwear, and urinary incontinence

Answer 71

- Topical potent steroids (dermovate) used long term and reduce the risk of malignancy

Answer 72

Squamous cell carcinoma of the vulva

Answer 73

Is the dryness and atrophy of the vaginal mucosa related to a lack of oestrogen The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections. can also be referred to as genitourinary syndrome of menopause

Answer 74

Oestrogen also helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence. Weak or brittle bones

Answer 75

Itching Dryness Dyspareunia (discomfort or pain during sex) Bleeding due to localised inflammation consider it in older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse. *Specifcially ask symptoms of vaginal dryness and discomfort!!*

Answer 76

Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES. Topical oestrogen - Estriol Cream or pessaries - Estradiol Tablets or a ring

Answer 77

Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. Women should be monitored at least annually, with a view of stopping treatment whenever possible.

Answer 78

Around 90% are squamous cell carcinomas. Advanced age (particularly over 75 years) Immunosuppression Human papillomavirus (HPV) infection Lichen sclerosus .

Answer 79

It's a type of premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer High grade squamous intraepithelial lesion is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years. Differentiated VIN is an alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years).

Answer 80

Vulval cancer may present with symptoms of: Vulval lump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin

Answer 81

Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral. Biopsy of the lesion Sentinel node biopsy to demonstrate lymph node spread Further imaging for staging Management Wide local excision to remove the cancer Groin lymph node dissection Chemotherapy Radiotherapy

Answer 82

A Bartholin's cyst is a small, fluid-filled cyst that is caused by an obstructed Bartholin's gland duct Bartholin's cysts typically are painful and soft on examination.

Answer 83

- 80% are squamous cell carcinomas - Adenocarcinoma - Rarely small cell cancer

Answer 84

- It is a sexually transmitted infection that can cause anal, vulval, vaginal, penis, mouth and throat cancers - HPV proteins e6 and e7 inhibit tumour suppressor genes p53(e6) and pRb(e7)

Answer 85

Type 16 and type 18. There is no treatment for HPV most resolve spontaneously

Answer 86

Early sexual activity Increased number of sexual partners Sexual partners who have had more partners Not using condoms

Answer 87

HPV infection Smoking HIV (patients with HIV are offered yearly smear tests) Combined contraceptive pill use for more than five years Increased number of full-term pregnancies Family history Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)

Answer 88

- Many paitents are asymptomatic and picked up on screening - Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) - Vaginal discharge - Pelvic pain - Dyspareunia (pain or discomfort with sex)

Answer 89

Ulceration Inflammation Bleeding Visible tumour Patients should be referred for a colposcopy

Answer 90

it is a grading system for the level of dysplasia in the cells of the cervix CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated CIN III: severe dysplasia, very likely to progress to cancer if untreated CIN III is sometimes called cervical carcinoma in situ.

Answer 91

- A cervical smear test which is a collection of cells for the cervix - Cells are examined under a microscope for precancerous changes (**Dyskaryosis**) This method is called **liquid-based cytology**

Answer 92

Every three years aged 25 – 49 Every five years aged 50 – 64

Answer 93

Women with HIV are screened annually Women over 65 may request a smear if they have not had one since aged 50 Women with previous CIN may require additional tests (e.g. test of cure after treatment) Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant) Pregnant women due a routine smear should wait until 12 weeks post-partum

Answer 94

Inadequate sample – repeat the smear after at least three months HPV negative – continue routine screening HPV positive with normal cytology – repeat the HPV test after 12 months, (if positive still after 24 months - refer for colp, if now hrHPV negative at 24 months then return to normal recall HPV positive with abnormal cytology – refer for colposcopy

Answer 95

FIGO staging Stage 1: Confined to the cervix Stage 2: Invades the uterus or upper 2/3 of the vagina Stage 3: Invades the pelvic wall or lower 1/3 of the vagina Stage 4: Invades the bladder, rectum or beyond the pelvis

Answer 96

cervical intraepithelial dysplasia - Laser ablation IA1 (stromal invasion ≤3 mm): Fertility-sparing: Cone biopsy (LLETZ or cold knife) with clear margins. Non-fertility-sparing: Hysterectomy. IA2 (stromal invasion >3 mm but ≤5 mm): Fertility-sparing: Radical trachelectomy + pelvic lymphadenectomy. Non-fertility-sparing: Radical hysterectomy + pelvic lymphadenectomy. IB1 (tumor ≤2 cm): Fertility-sparing: Radical trachelectomy + pelvic lymphadenectomy. Non-fertility-sparing: Radical hysterectomy + pelvic lymphadenectomy. IB2-IB3 (tumor >2 cm): Preferred: Radical hysterectomy + pelvic lymphadenectomy. Adjuvant chemoradiotherapy if high-risk features (e.g., lymph node involvement, positive margins).

Answer 97

Stages II–IV (Locally Advanced and Advanced Disease) IIA–IIB (spread beyond uterus but limited to pelvis): Primary treatment: Chemoradiotherapy (cisplatin-based) with external beam radiotherapy (EBRT) and brachytherapy. III–IVA (further local spread): Chemoradiotherapy (cisplatin-based) + EBRT and brachytherapy. Consider exenterative surgery for isolated pelvic recurrence.

Answer 98

Bevacizumab (avastin) r. It targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels.

Answer 99

Needs to be given to boys and girls before they become sexually active **Gardasil** protects against strains 6, 11, 16 and 18: Strains 6 and 11 cause genital warts Strains 16 and 18 cause cervical cancer

Answer 100

Endometrial Cancer 80% of cases are adenocarcinomas It is an **oestrogen dependant cancer** meaning that oestrogen stimulates the growth of endometrial cancer cells

Answer 101

- Post menopausal women with bleeding

Answer 102

- Endometrial hyperplasia is a precancerous condition involving thickening of the endometrium - Treated by a specialist using progestogens, with either: Intrauterine system (e.g. Mirena coil) Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)

Answer 103

***think - mostly oestrogen related***!! Unopposed oestrogen (oestrogen without progesterone) Increased age Earlier onset of menstruation Late menopause Oestrogen only hormone replacement therapy No or fewer pregnancies Obesity Polycystic ovarian syndrome Tamoxifen - *(While it acts as an estrogen antagonist in breast tissue, it has estrogen-like effects on the endometrium)* HNPCC/Lynch syndrome is a strong risk factor for endometrial cancer

Answer 104

- Fat tissue is a source of oestrogen as it produces aromatase which converts androgens

Answer 105

Insulin may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer. PCOS is also associated with insulin resistance and increased insulin production. Insulin resistance further adds to the risk of endometrial cancer in women with PCOS.

Answer 106

- Combined pill - Mirena coil - Increased pregnancies - Cigarette smoking Oestrogen may be metabolised differently in smokers Smokers tend to be leaner, meaning they have less adipose tissue and aromatase enzyme Smoking destroys oocytes (eggs), resulting in an earlier menopause

Answer 107

**postmenopausal bleeding** Postcoital bleeding Intermenstrual bleeding Unusually heavy menstrual bleeding Abnormal vaginal discharge Haematuria Anaemia Raised platelet count

Answer 108

- Postmenopausal bleeding (12 months after last period) Transvaginal ultrasound in women over 55 with: - Unexplained vaginal discharge - Visible haematuria plus raised platelets anaemia or raised glucose levels

Answer 109

- Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause) Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer It involves a speculum examination and inserting a thin tube (pipelle) through the cervix into the uterus. This small tube fills with a sample of endometrial tissue that can be examined for signs of endometrial hyperplasia or cancer hysteroscopy with endometrial biopsy

Answer 110

Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis

Answer 111

- Stage 1 and 2 is a total abdominal hysterectomy **with bilateral salpingo-oophorectomy** Radiotherapy Chemotherapy Progesterone may be used as a hormonal treatment to slow the progression of the cancer

Answer 112

It is estimated that they are present in 25% of women with abnormal vaginal bleeding No definitive cause of endometrial polyps is known, but they appear to be affected by hormone levels and grow in response to circulating estrogen. Risk factors include obesity, high blood pressure and a history of cervical polyps.[3] Taking tamoxifen or hormone replacement therapy can also increase the risk of uterine polyps

Answer 113

Removal by curettage or operative hysteroscopy. (All polyps removed should be examined histologically.)

Answer 114

- By 13 years when there is no other evidence of pubertal development - By 15 years of age where there are other signs of puberty, such as breast bud development

Answer 115

Hypogonadism Kallman Syndrome Congenital Adrenal Hyperplasia Androgen Insensitivity Syndrome Structural Pathology - eg Imperforate Hymen

Answer 116

Hypogonadotropic hypogonadism: a deficiency of LH and FSH Hypergonadotropic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)

Answer 117

No menstruation more than 3 months after regular periods Consider assessment and investigation after three to six months. In women with previously infrequent irregular periods, consider investigating after six to twelve months.

Answer 118

Pregnancy is the most common cause Menopause and premature ovarian failure Hormonal contraception (e.g. IUS or POP) Hypothalamic or pituitary pathology Ovarian causes such as polycystic ovarian syndrome Uterine pathology such as Asherman’s syndrome Thyroid pathology - *Hypothyroidism: Can cause amenorrhea by increasing prolactin production, which can prevent ovulation. Hypothyroidism can also lead to pituitary gland enlargement. Hyperthyroidism: Can cause menstrual irregularities, including amenorrhea.* Hyperprolactinaemia

Answer 119

Excessive exercise (e.g. athletes) Low body weight and eating disorders Chronic disease Psychological stress

Answer 120

- As prolactin inhibits the production of GnRH

Answer 121

Osteoporosis Ensure adequate vitamin D and calcium intake Hormone replacement therapy or the combined oral contraceptive pill

Answer 122

Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus. A lump of endometrial tissue outside the uterus is described as an endometrioma Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.

Answer 123

No genes have been found, but there does seem to be a genetic link retrograde menstruation - endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum. Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus during the development of the fetus, and later develop into ectopic endometrial tissue. endometrial cells may through the lymphatic system, Cells outside the uterus under go metaplasic to become endometrial cells Early menopause Family history Low body mass index (BMI) Smoking White ethnicity

Answer 124

During menstruation, as the endometrial tissue in the uterus sheds its lining and bleeds, - **leads to irritation and inflammation of the tissues around the sites of endometriosis** This results in the cyclical, dull, heavy or burning pain that occurs during menstruation in patients with endometriosis. Deposits of endometriosis in the bladder or bowel can lead to blood in the urine or stools.

Answer 125

Inflammation causes damage and development of scar tissue that binds the organs together Adhesions lead to a chronic, non-cyclical pain that can be sharp, stabbing or pulling and associated with nausea. Adhesions around the ovaries and fallopian tubes, can block the release of eggs or kink the fallopian tubes and obstruct the route to the uterus. Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.

Answer 126

Endometriosis can be asymptomatic in some cases, or present with a number of symptoms: Cyclical abdominal or pelvic pain Deep dyspareunia (pain on deep sexual intercourse) Dysmenorrhoea (painful periods) Infertility Cyclical bleeding from other sites, such as haematuria There can also be cyclical symptoms relating to other areas affected by the endometriosis: For the pain to be chronic in nature, it must be cyclical or continuous for **over six months** 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 and visible vaginal endometriotic lesions may be seen If an endometrioma ruptures, it will cause sudden intense pain

Answer 127

look for **nitrites on urine dip** to distinguish present in UTI but not edometriosis! (where blood and protein will be present on urine dip in endometriosis) - ***Some has had antbx for UTI symptoms, that appear to go away as pain is cyclical***, only for it to return again the next month - might not actually be UTI can be on bowel, lung, bladder, fallopian tubes, - so think of it as a differential if symptoms are recurrnet ?

Answer 128

Examination may reveal: Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix A fixed cervix on bimanual examination Tenderness in the vagina, cervix and adnexa US - can pick up chocolate cysts, but not always reliable MRI - can pick up endometrioma Patients with suspected endometriosis need referral to a gynecologist for laparoscopy. Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms. If an endometrioma ruptures, it will cause sudden intense pain

Answer 129

Stage 1: Small superficial lesions Stage 2: Mild, but deeper lesions than stage 1 Stage 3: Deeper lesions, with lesions on the ovaries and mild adhesions Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions

Answer 130

Establishing a diagnosis Providing a clear explanation Listening to the patient, establishing their ideas, concerns and expectations and building a partnership Analgesia as required for pain (NSAIDs and paracetamol first line)

Answer 131

Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy: Combined oral contractive pill, which can be used back to back without a pill-free period if helpful Progesterone only pill (Desogesterol) Medroxyprogesterone acetate injection (e.g. Depo-Provera) Mirena coil GnRH agonists - induce a menopause-like state, eg **goserelin (Zoladex) or leuprorelin (Prostap).** (they block ostrogen and progesterone) (hard core, so can give tibolone to reduce risk of osteroporosis) *Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening.* If symptoms improve with hormonal therapies - it shows its endometriosis can also start on antispasmodics to help w IBS symptoms

Answer 132

Laparoscopic surgery can be used to excise or ablate the ectopic endometrial tissue urgery can be used to dissect the adhesions and attempt to return the anatomy to normal. Hysterectomy and bilateral salpingo-opherectomy is the final surgical option. During the procedure, the surgeon will attempt to remove as much of the endometriosis as possible. The surgery can lead help with infertility due to endometriosis

Answer 133

Benign smooth muscle tumours of the uterine myometrium. They are also called uterine leiomyomas. They are very common, affecting 40-60% of women in later reproductive years, and are more common in black women compared with other ethnic groups.

Answer 134

Oestrogen.

Answer 135

Fibroids are classified according tot heir position in the uterine wall, for example: Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity. Submucosal means just below the lining of the uterus (the endometrium). Pedunculated means on a stalk.

Answer 136

Intramural - fibroids confined to the myometrium.

Answer 137

1. Obesity. 2. Early menarche. 3. Family history. 4. Increasing age.

Answer 138

1. Pain. 2. Infertility/sub-fertility. 3. Menorrhagia. 4. Pressure symptoms e.g. urinary frequency if pressing on bladder. 5. Can cause iron deficiency anaemia -> lethargy and pallor. Bloating or feeling full in the abdomen Deep dyspareunia (pain during intercourse) Can be asymptomateic

Answer 139

Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus Investigations Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. Pelvic ultrasound is the investigation of choice for larger fibroids. MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids. | 2. Hysteroscopy.

Answer 140

NICE guidelines on fibroids are included within the heavy menstrual bleeding guideline from 2018. For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding: Mirena coil (1st line) – fibroids must be less than 3cm with **no distortion of the uterus** If fibroids are large enough to distort the uterus - Mirena is CI, **give COCP** Symptomatic management with NSAIDs and tranexamic acid Combined oral contraceptive Cyclical oral progestogens

Answer 141

Uterine artery embolisation GnRH agonists, such as goserelin (Zoladex) (reduce oestrogen and progesterone) (they block ostrogen and progesterone) (hard core, so can give tibolone to reduce risk of osteroporosis) - - very strong and can bring about menopausal symptonms or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery. Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery). Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids. Endometrial ablation can be used to destroy the endometrium Hysterectomy involves removing the uterus and fibroids.

Answer 142

Heavy menstrual bleeding, often with iron deficiency anaemia Reduced fertility Pregnancy complications, such as miscarriages, premature labour and obstructive delivery Constipation Urinary outflow obstruction and urinary tract infections Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.

Answer 143

1. Endometrial polyps. 2. Cancer. 3. Endometriosis/adenomyosis. 4. Chronic PID.

Answer 144

- A type of tumour that grows like a pregnancy inside the uterus - This is called a molar pregnancy

Answer 145

- **Partial mole**: when two sperm cells fertilise a normal ovum at the same time and it has 3 sets of chromones called a haploid cell - **Complete mole**: when two sperm fertilise and ovum that contains no genetic material

Answer 146

**Will behave like a normal pregnancy** Indications will be: - More severe morning sickness - Vaginal bleeding - Increased enlargement of uterus - Abnormally high hCG - Thyrotoxicosis as hCG can mimic TSH Low TSH, and High Thyroxine **Ultrasound will show snowstorm appearance of the pregnancy**

Answer 147

- Evacuation of the uterus - Monitoring of hCG levels - Can metastasise so maybe chemo required

Answer 148

Galactorrhoea refers to breast milk production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone prolactin. Prolactin is produced in the anterior pituitary gland. It is also produced in other organs, such as the breast and prostate

Answer 149

Idiopathic (no cause can be found) Prolactinomas (hormone-secreting pituitary tumours) Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome Medications, particularly dopamine antagonists (i.e., antipsychotic medications) - **as dopamine inhibits prolactin!** *Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to suppress prolactin secretion.*

Answer 150

This may be associated with multiple endocrine neoplasia (MEN) type 1, an autosomal dominant genetic condition. Prolactinomas can be: Microprolactinomas – smaller than 10 mm Macroprolactinomas – larger than 10 mm

Answer 151

Macroadenomas can have adverse effects relating to their size: Headaches Bitemporal hemianopia (loss of the outer visual fields in both eyes Symptoms of increased prolactin: Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with: Menstrual irregularities, particularly amenorrhoea (absent periods) Reduced libido (low sex drive) Erectile dysfunction (in men) Gynaecomastia (in men)

Answer 152

Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms of hyperprolactinaemia. They block prolactin secretion and improve symptoms. Trans-sphenoidal surgical removal of the pituitary tumour

Answer 153

- It has very non-specific symptoms more than 70% of patients present when it has spread beyond the pelvis

Answer 154

- Epithelial cell tumours (most common) - Germ cell tumours they are associated with ovarian torsion and can cause raised ** alpha fetoprotein** and **hCG** - Sex cord-stromal tumours They may also be a metastasis called a **krukenberg tumour** usually from a GI tumour. They produce **signet ring cells** on histology

Answer 155

Risk factors: - Age (peaks age 60) - BRCA1 and BRCA2 genes (consider the family history) - Increased number of ovulations - Obesity - Smoking - Recurrent use of clomifene -medication used to treat infertility in women who do not ovulate Protective factors: - Combined contraceptive pill - Breastfeeding - Pregnancy Later onset of periods (menarche) Early menopause

Answer 156

Abdominal bloating Early satiety (feeling full after eating) Loss of appetite Pelvic pain Urinary symptoms (frequency / urgency) Weight loss Abdominal or pelvic mass Ascites Especially pain in older women ***Ovarian cancer can present with urinary symptoms due to pressure effects from the tumour.*** Can cause hip or groin pain due to compression on the **obturator nerve** Suspect ovarian cancer in any woman **>= 50 years of age presenting with symptoms suggestive of irritable bowel syndrome** in the last 12 months. IBS rarely presents for the first time in this age group

Answer 157

- Ascites - Pelvic mass - Abdominal mass

Answer 158

- Raised CA125 blood test - more signifitcant in post menopausal women - Pelvic ultrasound

Answer 159

CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125: Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy Menstruation is **not** a cause of raised Ca125

Answer 160

Stage 1: Confined to the ovary Stage 2: Spread past the ovary but inside the pelvis Stage 3: Spread past the pelvis but inside the abdomen Stage 4: Spread outside the abdomen (distant metastasis) *(confined to…OPAM …. ovary, pelvis, Abdo, metastasised)*

Answer 161

Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.

Answer 162

An ovarian cyst is a fluid-filled sac that develops on an ovary. - Are very common in premenopausal women and are normally benign - Postmenopausal cysts are more concerning for malignancy and need further investigations Either functional or pathological

Answer 163

Functional Cysts - either one of Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist. Corpus luteum cysts occur when the corpus luteum fails to break down and instead fills with fluid Pathological cysts are caused by abnormal cell growth and are not related to the menstrual cycle. They can develop before and after the menopause. Pathological cysts develop from either the cells used to create eggs or the cells that cover the outer part of the ovary. They can sometimes burst, twist or grow very large and block the blood supply to the ovaries.

Answer 164

Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans. Can cause Pelvic pain Bloating Fullness in the abdomen A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas) Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.

Answer 165

Abdominal bloating Reduce appetite Early satiety Weight loss Urinary symptoms Pain Ascites Lymphadenopathy Assess for risk factors for ovarian malignancy: Age Postmenopause Increased number of ovulations Obesity Hormone replacement therapy Smoking Breastfeeding (protective) Family history and BRCA1 and BRCA2 genes

Answer 166

Estimates the risk of an ovarian mass being malignant, taking account of three things: Menopausal status Ultrasound findings CA125 level Post menopausal and CA125 level = more than 2000 - high risk of being sinister - so need a staging C

Answer 167

Simple ovarian cysts in premenopausal women can be managed based on their size: Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan . 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring. More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.

Answer 168

Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.

Answer 169

surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).W

Answer 170

Complications Consider complications when patients present with acute onset pain. The main complications are: Torsion Hemorrhage into the cyst Rupture, with bleeding into the peritoneum Meig’s Syndrome: involves a triad of Ovarian fibroma (a type of benign ovarian tumor) Pleural effusion Ascites

Answer 171

Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue/ligaments , fallopian tube and blood supply (the adnexa).

Answer 172

Can be spontaneous usually due to an ovarian mass larger than 5cm eg **cyst or a tumour**. More likely to occur with benign tumours. Pregancy younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily. Ovulation induction - *hormonal therapy to stimulate egg development and release, or ovulation.*

Answer 173

- Sudden onset constant severe unilateral pelvic pain associated with nausea and vomiting - Pain is not always severe and can come and go - On examination there will be localised tenderness there may be a palpable mass absence does exclude the diagnosis

Answer 174

Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, Will show a **whirlpool sign, free fluid** in pelvis and oedema of the ovary Definitive diagnosis is made with laparoscopic surgery

Answer 175

Emergency laparoscopy to uncoil twisted ovary + fixation

Answer 176

- Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions. - Can cause infertility and menopause if only ovary

Answer 177

The key causes of intermenstrual bleeding are: Hormonal contraception Cervical ectropion, polyps or cancer Sexually transmitted infection Endometrial polyps or cancer Vaginal pathology, including cancers Pregnancy Ovulation can cause spotting in some women Medications, such as SSRIs and anticoagulants

Answer 178

the cells from the 'inside' of the cervical canal, known as glandular cells (or columnar epithelium), are present on the 'outside' of the vaginal portion of the cervix. Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms

Answer 179

Ectropion's are more common when taking the pill, in pregnancy and during puberty.

Answer 180

consists of the luteal stage and the follicular stage. **Follicular** FSH stimulates development of secondary follicles, as these grow the **granulosa cells around them secrete oestrogen** One follicle will develop further than the others becoming the dominant follicle. A spike in LH just before ovulation causes the dominant follicle to release the ovum from the ovary. **luteal phase** the collapsed follicle becomes the corpus luteum, which secretes progesterone which maintains the uterine lining, and oestrogen. If fertilized the embryo secretes hCG, without this the corpus luteum degenerates leading to a fall in progesterone and oestrogen levels. The drop in these hormone levels causes the endometrium to break down and menstruation to occur.

Answer 181

Menorrhagia refers to heavy menstrual bleeding. This can be caused by: Dysfunctional uterine bleeding (no identifiable cause) Extremes of reproductive age Fibroids Endometriosis and adenomyosis Pelvic inflammatory disease (infection) Contraceptives, particularly the copper coil Anticoagulant medications Bleeding disorders (e.g. Von Willebrand disease) Endocrine disorders (diabetes and hypothyroidism) Endometrial hyperplasia or cancer Polycystic ovarian syndrome

Answer 182

1. Ectopic pregnancy. 2. Miscarriage. 3. Ovarian cyst rupture/haemorrhage/torsion.

Answer 183

1. PID. 2. Abscess. 3. Ovarian cyst rupture/haemorrhage/torsion.

Answer 184

1. Appendicitis. 2. Constipation. 3. Bowel obstruction.

Answer 185

1. UTI. 2. Renal stones. 3. Urinary retention.

Answer 186

1. Endometriosis/adenomyosis. 2. Fibroids. 3. Adhesions. 4. PID. 5. Ovarian cysts.

Answer 187

1. IBS. 2. Constipation. 3. Inflammatory bowel.

Answer 188

1. Pelvic USS -> fibroids, ovarian cysts, endometriosis. 2. Laparoscopy -> endometriosis, adhesions. 3. Hysteroscopy -> fibroids. 4. MRI -> adhesions, adenomyosis, fibroids. 5. STI screen.

Answer 189

Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix

Answer 190

Endometritis is inflammation of the endometrium Salpingitis is inflammation of the fallopian tubes Oophoritis is inflammation of the ovaries Peritonitis is inflammation of the peritoneal membrane

Answer 191

Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections: **Neisseria gonorrhoeae** tends to produce more severe PID - *most common* Chlamydia trachomatis Mycoplasma genitalium Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as: Gardnerella vaginalis (associated with bacterial vaginosis) Haemophilus influenzae Escherichia coli

Answer 192

There risk factors for pelvic inflammatory disease are the same as any other sexually transmitted infection: Not using barrier contraception Multiple sexual partners Younger age Existing sexually transmitted infections Previous pelvic inflammatory disease Intrauterine device (e.g. copper coil)

Answer 193

Women may present with symptoms of: Pelvic or lower abdominal pain - **BILATERAL** Abnormal vaginal discharge Abnormal bleeding (intermenstrual or postcoital) Pain during sex (dyspareunia) Fever Dysuria Bimanual Examination findings may reveal: Pelvic tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge Patients may have a fever and other signs of sepsis.

Answer 194

NAAT swabs for gonorrhoea and chlamydia NAAT swabs for Mycoplasma genitalium if available HIV test Syphilis test A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis. A pregnancy test to exclude an ectopic pregnancy. Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.

Answer 195

Refer to GUM service, and contact tracing Antibiotics : **Empiric treatment should be initiated while awaiting the results of screening** for Chlamydia trachomatis and Neisseria gonorrhoea, as delayed treatment can lead to serious complications like infertility or ectopic pregnancy. Ceftriaxone covers Neisseria gonorrhoea, doxycycline covers Chlamydia trachomatis, and metronidazole provides coverage for anaerobic bacteria and Trichomonas vaginalis, which can be involved in mixed infections. IM ceftriaxone 1g (to cover gonorrhoea) Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium) Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis) Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.

Answer 196

perihepatitis (Fitz-Hugh Curtis Syndrome) occurs in around 10% of cases it is characterised by right upper quadrant pain and may be confused with cholecystitis# get Hepatic adhesions with abdominal wall infertility - the risk may be as high as 10-20% after a single episode chronic pelvic pain ectopic pregnancy

Answer 197

multiple ovarian cysts, infertility, oligomenorrhea, - irregular, infrequent menstrual periods hyperandrogenism - the effects of high levels of androgens insulin resistance.

Answer 198

The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features: Oligoovulation or anovulation, presenting with irregular or absent menstrual periods Hyperandrogenism, characterized by hirsutism and acne Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3) IMPORTANT

Answer 199

Origin unclear, but basically inappropriate signaling to the hypothalamus and pituitary. PCOS is characterized by a “steady state” of chronically **elevated LH and chronically suppressed FSH levels**, instead of their cyclic rise and fall in a normal menstrual cycle * Increased LH stimulates ovaries to increase production of androgens. (testosterone), which perpetuateds chronic anovulation. * As a result of suppressed FSH, new follicular growth is continuously stimulated but not to the point of full maturation and ovulation (corpus lutea and corpus albicans are rarely detected).

Answer 200

Insulin resistance is a crucial part of PCOS. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS.

Answer 201

Oligomenorrhoea or amenorrhoea Infertility Obesity (in about 70% of patients with PCOS) Hirsutism Acne Hair loss in a male pattern Also: Insulin resistance and diabetes Acanthosis nigricans - thickened, rough skin, found in the axilla and elbow - due to **hyperinsulinaemia/insulin resistance** Depression and anxiety Sexual problems

Answer 202

Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids Ovarian or adrenal tumours that secrete androgens Cushing’s syndrome Congenital adrenal hyperplasia

Answer 203

Pelvic US - would see string of pearls criteria Investigations - FSH low - LH high - Ultrasound - see string of pearls criteria - High testosterone - Low Sex hormone binding Globulin Normal or raised osteogen levels 12 or more developing follicles in one ovary , volume more than 10cm^3

Answer 204

Raised luteinising hormone Raised LH to FSH ratio (high LH compared with FSH) Raised testosterone Raised insulin Normal or raised oestrogen levels 12 or more developing follicles in one ovary Ovarian volume of more than 10cm3 Pelvic ultrasound is not reliable in adolescents for the diagnosis of PCOS.

Answer 205

Weight loss Low glycaemic index, calorie-controlled diet Exercise Smoking cessation Antihypertensive medications where required Statins where indicated (QRISK >10%) Weight loss is really important Orlistat may be used to help weight loss in women with a BMI above 30. Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.

Answer 206

Women with polycystic ovarian syndrome have several risk factors for endometrial cancer: Obesity Diabetes Insulin resistance Amenorrhoea Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. Options for reducing the risk of endometrial hyperplasia and endometrial cancer are: Mirena coil for continuous endometrial protection Inducing a withdrawal bleed at least every 3 – 4 months with either: Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) Combined oral contraceptive pill

Answer 207

Weight loss may improve the symptoms of hirsutism. Women are likely to have already explored options for hair removal, such as waxing, shaving and plucking. **Co-cyprindiol (Dianette)** is a combined oral contraceptive pill licensed for the treatment of hirsutism and acne. Co-cyprindiol significantly increases the risk of VTE - stop after 3 months Other standard treatments for acne include: Topical adapalene (a retinoid) Oral tetracycline antibiotics (e.g. lymecycline)

Answer 208

Pelvic organ prolapse refers to the descent of pelvic organs into the vagina. Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.

Answer 209

- Uterine - Vault - Rectocele - Cystocele

Answer 210

- When a women has had a hysterectomy and no longer have a uterus - The top of the vagina (the vault) descends into the vagina

Answer 211

- They are caused by weakness in the **posterior vaginal wall** - This allows the rectum to prolapse forward into the vagina

Answer 212

- They are associated with constipation and women can develop faecal loading in the part of the rectum that has prolapsed - The loading of faeces causes urinary retention due to compression on the urethra and a palpable lump in the vagina that can be pushed backwards

Answer 213

- Caused by a defect in the **anterior vaginal wall** allowing the bladder to prolapse backwards into the vagina - Can also happen with the urethra (urethrocele) and a combined one is called a cystourethrocele

Answer 214

- Multiple vaginal deliveries - Prolonged traumatic delivery - Age - Obesity - Coughing/constipation strain - Menopause

Answer 215

A feeling of “something coming down” in the vagina A dragging or heavy sensation in the pelvis **Urinary symptoms**, such as incontinence, urgency, frequency, weak stream and retention **Bowel symptoms**, such as constipation, incontinence and urgency **Sexual dysfunction**, such as pain, altered sensation and reduced enjoyment

Answer 216

- Dorsal and left lateral position - A **Sim's speculum** would be used to support opposing vaginal wall to one being examined

Answer 217

Physiotherapy (pelvic floor exercises) Weight loss Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations Vaginal oestrogen cream

Answer 218

Vaginal pessaries -->inserted into the vagina to provide extra support to the pelvic organs. Types **Ring pessaries** are a ring shape, and sit around the cervix holding the uterus up **Shelf and Gellhorn** pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards **Cube** pessaries are a cube shape **Donut** pessaries consist of a thick ring, similar to a doughnut **Hodge** pessaries are almost rectangular. ***Can't fit pessaries if there is an infection (aka thrush) or history of vaginal ulceration*** Surgery

Answer 219

A sacrocolpopexy is an operation to treat a prolapse of the vaginal vault (top of the vagina/front passage) in women who have had a hysterectomy (removal of womb) using a strip of synthetic mesh to lift the top of the vagina and hold it in place.

Answer 220

Uterine prolapse is where the uterus itself descends into the vagina.

Answer 221

Grade 0: Normal Grade 1: The lowest part is more than 1cm above the introitus Grade 2: The lowest part is within 1cm of the introitus (above or below) Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended Grade 4: Full descent with eversion of the vagina

Answer 222

When bladder half full, **stimulates stretch receptors in bladder wall** ===> Send impulses to the sacral spinal chord, at levels S2 and S3 - PELVIC SHPLANIC NERVE, these signals then go up to micturition centre in the pons

Answer 223

**Micturition reflex** Activation of pelvic splanchnic nerve S2-S4 cause the detrusor muscles to CONTRACT - *at sacral micturition centre,* ***Onuf's Nucleus*** - When the detrusor muscle contract, the change in bladder shape pulls open the internal urethral sphincter - is **made of smooth muscle** **Micturition reflex** also decreases motor nerve stimulation to the external sphincter allowing it to relax as well. At this point, urination should occur, but why don't just wet ourselves every time the bladder is half full?

Answer 224

At this point we should just wee ourselves every time the bladder is half full, however at this point, the **PONTINE STORAGE CENTRE OVERIDES MICURITION RELFEX** It does this by activating SYMPATHETIC, **HYPOGASTIRC NERVES T10 - L2**, that cause DETROUSER RELAXATION, and BLADDER NECK CONTRACTION

Answer 225

- Urge incontinence: - Stress incontinence - Mixed incontinence: Overflow incontinence (neurogenic bladder):

Answer 226

- **Diabetes** - **Bladder cancer** - **Parkinson's** - **Multiple sclerosis** - **Prostatectomy** - **Hysterectomy**

Answer 227

Sudden urge to urinate because of an "overactive bladder", followed immediately by involuntary urination typically due to an uninhibited detrusor muscle that contracts randomly. Usually associated with urinary tract infections. Inflammation may trigger the detrusor muscle.

Answer 228

Increased abdominal pressure overwhelms the sphincter muscles and allows urine to leak out. Causes include pregnancy and exertion, like sneezing, coughing, laughing.

Answer 229

Due to either - Obstruction due to blockage in urine flow or Ineffective detrusor muscle. ==> **Detrusor cant contract properly so the bladder doesn’t empty** properly In both cases, **leads to urine build up, to the point that the bladder is so full that urine dribbles/leaks** out through sphincters Obstruction - - eg benign prostatic hyperplasia, Ineffective detrusor = Diabetes (neurogenic bladder) Multiple sclerosis, Spinal chord injury

Answer 230

- Urge incontinence: **frequent urination, especially at night** - Stress incontinence: **urinary leakage with pressure applied to the abdomen** - Overflow incontinence: **weak or intermittent stream or hesitancy**

Answer 231

Urinalysis (MSU) Frequency volume chart (FVC) Residual urine measurement (RU) Questionnaire (ePAQ) In patients with urinary incontinence, make sure to rule out a UTI and diabetes mellitus

Answer 232

A questionnaire regarding urinary, bowel, vaginal and sexual symptoms.

Answer 233

Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line - **Anticholinergic medication**, for example, oxybutynin, tolterodine and solifenacin - but ***WORSENING IN DEMENTIA AND CAN CAUSE POSTURAL HYPOTENSION*** - **B3 adrenergic agonist: mirabegron** - increases BP though

Answer 234

- **Avoiding caffeine, diuretics and overfilling of the bladder** - **Avoid excessive or restricted fluid intake** - **Weight loss** (if appropriate) - **Supervised pelvic floor exercises** for at **least three months** before considering surgery - **Pessary** - *It is a firm ring that presses against the wall of the vagina and urethra to help decrease urine leakage.* duloxetine may be offered to women if they decline surgical procedures a combined noradrenaline and serotonin reuptake inhibitor mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced

Answer 235

- Typically occurs in 30-60 year olds - M>F - More than 50% lifetime risk of recurrence once you've had them Common: lifetime incidence up to 15%

Answer 236

**high salt intake** **male Sex** - *testosterone - increased oxalate* **Stone forming food** **Metabolic** - Hypercalcaemia, Hyperparathyroidism **Drugs** - *loop diuretics*

Answer 237

chocolate, rhubarb, spinach, tea, and most nuts are high in oxalate, and colas are high in phosphate

Answer 238

Calcium-based stones they account for 80%. Having a raised serum calcium and low urine output are key risk factors for calcium collecting into a stone

Answer 239

1. Uric Acid (red brown colour, not visible on xray (make up 5-10% of stones) 2. Struvite, from bacteria *(associated with infection)* - forms dirty white stones, visible on xray (2-10%) 3. Cystine - yellow/light pink coloured (1%)

Answer 240

Kidney stones form when your urine contains more crystal-forming substances — such as calcium, oxalate and uric acid — than the fluid in your urine can dilute. Urine is a combination of solvent and solutes If solvent is low (dehydration) or there are high levels of solute (hypercalcaemia) then it is more likely a kidney stone will form.

Answer 241

- **Acute, severe flank pain (renal colic)** - Classically ‘loin to groin’ pain - Pain lasts minutes to hours and occurs in spasms (with intervals of no pain or dull ache) - Fluctuating in severity as the stone moves and settles - **Nausea and vomiting** Pain is not relieved - **Urinary urgency or frequency** - **Haematuria:** microsopic or macroscopic Flank/ renal angle tenderness Left and right lumbar region pain Fever (if sepsis)

Answer 242

Urine dipstick can show blood, leukocytes, nitrates FBC check kidney function and calcium levels **X-ray can show calcium based stones but not uric** Negative pregnancy test **XRAY IS FIRST LINE IMAGING FOR RENAL STONES**

Answer 243

Non contrast CT scan of kidney, ureters and bladder (CT KUB) . ***Should be performed within 14 hours of admission*** ^^**For non pregnant adult** Renal ultrasound for pregnant adult or child May use ultrasound if radiation needs to be avoided

Answer 244

- **Watchful waiting**: stones <5mm should pass spontaneously and followed up in clinic - **Medical expulsive therapy (MET):** Alpha-blocker, e.g. **tamsulosin**, for ureteric stones 5-10mm to help passage. Not indicated for renal stones. - ***it helps relax muscles in the ureter, and can increase the flow of urine**

Answer 245

- **IV fluids and anti-emetics** - **Analgesia**: an NSAID by any route is considered first-line; - **IV DICLOFENAC** - IV paracetamol is used if NSAIDs are contraindicated or ineffective - **Antibiotics**: if infection is present

Answer 246

Extracorporeal shockwave lithotripsy (ESWL) Ureteroscopy (URS): Percutaneous nephrolithotomy (PCNL):

Answer 247

Extracorporeal shock wave lithotripsy (ESWL): utilises **high energy ultrasound waves** to break the stone into tiny fragments; uncomfortable, requires analgesia and can cause organ injury. Contraindicated in pregnancy due to risk to the foetus (perform URS instead) **if stones are <5mm, then watchful waiting**

Answer 248

Ureteroscopy (URS): pass a ureteroscope through the urethra and bladder up to the ureter (retrograde) and retrieve the stone or fragment it with intracorporeal lithotripsy

Answer 249

Percutaneous nephrolithotomy (PCNL): accessing the renal collecting system percutaneously via a surgical incision in the back for intracorporeal lithotripsy or stone fragmentation *(not used for ureteric stones)*

Answer 250

- **Increase oral fluids** - **Reduce dietary salt intake** - **Reduce intake of oxalate-rich foods for calcium stones** (e.g. spinach, nuts, rhubarb, tea) - **Reduce intake of urate- rich foods for uric acid stones** (e.g. kidney, liver, sardines) - **Limit dietary protein**

Answer 251

Potassium citrate, **Thiazide diuretics** (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium

Answer 252

• Pelviureteric junction/ureteropelvic junction – where the renal pelvis connects to the ureter • Pelvic brim – where the ureter crosses over the pelvic brim and the bifurcation of the common iliac arteries • Vesicoureteric junction/ureterovesicular junction – where the ureter connects to the urinary bladder Kidney stones of

Answer 253

Anovaginal or rectovaginal fistula is a hole joining the anus or rectum to the vagina. A colovaginal fistula joins the space in the colon to that in the vagina. A urinary tract fistula is an abnormal opening in the urinary tract or an abnormal connection between the urinary tract and another organ

Answer 254

Disease: Infections including an anorectal abscess Crohn's and UC Surgical treatment and Radiotherapy Trauma - Childbirth and rape

Answer 255

- It refers to an overgrowth of bacteria in the vagina specifically **anaerobic bacteria** - It is not **Sexually transmitted** MOST COMMON CAUSE OF VAGINITIS IN YOUNG WOMEN

Answer 256

Loss of lactobacilli which produce lactic acid and keep the vaginal pH low Gardnerella vaginalis (most common) Mycoplasma hominis Prevotella species

Answer 257

- Multiple sexual partners - Excessive vaginal cleaning - soaps and douching - Recent antibiotics - Smoking - Copper coil

Answer 258

Fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.

Answer 259

- Test vaginal pH anything above 4.5 is bad - charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.

Answer 260

Clue cells

Answer 261

Metronidazole - AVOID ALCOHOL Or clindamycin but is less effective

Answer 262

It increases risk of **STI** - Also can cause problems in pregnancy Miscarriage Preterm delivery Premature rupture of membranes Chorioamnionitis Low birth weight Postpartum endometritis

Answer 263

Vaginal candidiasis is commonly referred to as “thrush”. It refers to vaginal infection with a yeast of the Candida family. The most common is Candida albicans

Answer 264

Candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora. Symptoms: Vulval itch Vulval soreness Vaginal discharge Superficial dyspareunia External dysuria Erythema Fissuring Discharge, typically curdy but may be thin. Non-offensive. White 'curdy' vaginal discharge with pH <4.5 is likely to be candidiasis

Answer 265

Complicated candidiasis: Severe symptoms (by subjective assessment) Pregnancy Recurrent vulvovaginal candidiasis (at least 4 episodes per year) Non-albicans species Abnormal host (e.g. hyperoestrogenic state, diabetes mellitus, immunosuppression)

Answer 266

Microscopy and culture is standard for symptomatic women Vaginal swab should be taken from the anterior fornix . Erythematous plaques with satellite lesions are noted on examination. White 'curdy' vaginal discharge with pH <4.5 is likely to be candidiasis (for the following: Gram or wet film examination Direct plating to solid fungal media. Speciation to albicans/non-albicans is essential if complicated disease suspected/present

Answer 267

Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).

Answer 268

Treatment of candidiasis is with antifungal medications. These can be delivered in several ways: Oral fluconazole single-dose is first-line for non-pregnant women with vaginal thrush Clotrimazole intravaginal pessary = an effective antifungal treatment for vulvovaginal candidiasis but is typically used when oral fluconazole is contraindicated, such as during pregnancy. Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.

Answer 269

fluconazole 150mg should be repeated after 3 days If oral treatment is contra-indicated repeat a single dose pessary after 3 days Low-potency corticosteroids are also thought to improve symptomatic relief in conjunction with antifungal therapy

Answer 270

Chlamydia trachomatis A gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. More common in female

Answer 271

Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding (intermenstrual or postcoital) Painful sex (dyspareunia) Painful urination (dysuria) can be yellow, odourless vaginal discharge. **Asymptomatic** in 50% of cases

Answer 272

Aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner First catch urine sample for NAAT

Answer 273

The order of preference in women for STI testing is endocervical, vulvovaginal and finally first catch urine (FCU). This is based on patient preference. In men, FCU is the specimen of choice. Treating empirically for all STI’s is recommended by WHO when services are not available, or if the patient refused to be seen at GUM clinic.

Answer 274

100mg of doxycycline twice a day for 7 days

Answer 275

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known . Azithromycin can be used for both the treatment of gonorrhoea & chlamydia

Answer 276

Near patient test Microscopy of gram stained smears of genital secretions looking for gram negative diplococci within cytoplasm of polymorphs Culture on **Gonococcus agar** Male - urethra Female - endocervix Rectum

Answer 277

Nucleic Acid Amplification Tests (NAAT) High specificity and sensitivity Female Self-collected vaginal swab Endocervical swab Male – first void urine

Answer 278

Syphilis is caused by bacteria called Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria.

Answer 279

The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection. The incubation period between the initial infection and symptoms is 21 days on average.

Answer 280

A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy

Answer 281

ypically starts after the chancre has healed, with symptoms of: Maculopapular rash **Condylomata lata** (grey wart-like lesions around the genitals and anus) Low-grade fever **Painless Lymphadenopathy** Altered sensation Alopecia (localised hair loss) Oral lesions

Answer 282

Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test or Samples from sites of infection can be tested to confirm the presence of T. pallidum with: Dark field microscopy Polymerase chain reaction (PCR)

Answer 283

. As with all sexually transmitted infections, patients need: Full screening for other STIs Advice about avoiding sexual activity until treated Contact tracing Prevention of future infections A single deep **intramuscular dose of benzathine benzylpenicillin (penicillin)** is the standard treatment for syphilis.

Answer 284

a bacteria that causes non-gonococcal urethritis. Most common cause of a NGU after Chlamydia, it's an STI

Answer 285

Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. Urethritis is a key feature. Mycoplasma genitalium infection may lead to: Urethritis Epididymitis Cervicitis Endometritis Pelvic inflammatory disease Reactive arthritis Preterm delivery in pregnancy Tubal infertility

Answer 286

Traditional cultures are not helpful in isolating MG, as it is a very slow-growing organism. Therefore, testing involves nucleic acid amplification tests (NAAT) to look specifically for the DNA or RNA if the bacteria. First urine sample in the morning for men Vaginal swabs (can be self-taken) for women The guideline recommends checking every positive sample for macrolide resistance, as there is developing problems with antibiotic resistance, particularly with azithromycin. (a marcolide)

Answer 287

recommend a course of doxycycline followed by azithromycin for uncomplicated genital infections: Doxycycline 100mg twice daily for 7 days then; Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides) Moxifloxacin is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).

Answer 288

Sexually acquired reactive arthritis seronegative spondyloarthropathies. sterile inflammation of the synovial membranes, fascia and tendons triggered by an infection at a distal site. Reiters syndrome encompasses the classic triad Conjunctivitis Arthritis Urethritis

Answer 289

Chlamydia trachomatis: This has the strongest association with SARA and has been identified in up to two-thirds of cases. Neisseria gonorrhoeae: This is associated in up to 16% of cases and distinct from its role in septic arthritis Mycoplasma genitalium: This is a well-recognised cause of urethritis but has only been identified in the joints in a few cases, so its arthritogenic potential is not yet fully known. Sexual transmission of enteric pathogens triggering SARA has been reported Shigella outbreaks

Answer 290

It causes bloody diarrhoea, abdominal cramps and fever. Shigella can produce the Shiga toxin, which can cause haemolytic uraemic syndrome. Mostly self limiting diarrhoea

Answer 291

Treatment of severe cases is with azithromycin or ciprofloxacin. but Mostly self limiting diarrhoea

Answer 292

Post-exposure prophylaxis (PEP) can be used after exposure to reduce the risk of transmission of HIV PEP involves a combination of ART therapy. The current regime is emtricitabine/tenofovir (Truvada) and raltegravirm **for 4 weeks**

Answer 293

In known positive HIV patients, when HIV Viral load is unknown or detectable for: Insertive and Receptive Anal Sex Receptive Vaginal sex (consider in insertive vaginal sex) If HIV status isn't known, and from a country with high prevalence or high risk group : Receptive anal sex Consider PEP for insertive anal sex.

Answer 294

The herpes simplex virus (HSV) is commonly responsible for both cold sores (herpes labialis) and genital herpes. There are two main strains, HSV-1 and HSV-2. After an initial infection, the virus becomes latent in the associated sensory nerve ganglia. Typically this is the trigeminal nerve ganglion with cold sores and the sacral nerve ganglia with genital herpes.

Answer 295

Signs and symptoms include: Ulcers or blistering lesions affecting the genital area Neuropathic type pain (tingling, burning or shooting) Flu-like symptoms (e.g. fatigue and headaches) Dysuria (painful urination) Inguinal lymphadenopathy Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.

Answer 296

Ask about sexual contacts, including those with cold sores, to establish a possible source of transmission. They may have caught the infection from someone unaware they are infected and not experiencing any symptoms. The diagnosis can be made clinically based on the history and examination findings. A viral PCR swab from a lesion can confirm the diagnosis and causative organism.

Answer 297

Aciclovir is used to treat genital herpes. Primary genital herpes contracted before 28 weeks gestation is treated with aciclovir during the initial infection. This is followed by regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery Primary genital herpes contracted after 28 weeks gestation is treated with aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. Caesarean section is recommended in all cases to reduce the risk of neonatal infection.

Answer 298

General inspection Palpate inguinal lymph nodes Perform palpation of the vaginal walls Perform palpation of the vaginal fornices Perform palpation of the cervix and assess for cervical motion tenderness Bimanually palpate the uterus Bimanually palpate the adnexa

Answer 299

Menorrhagia is defined as abnormally heavy or prolonged menstrual bleeding, used to be typically exceeding 80 milliliters per cycle or lasting more than 7 days. now, The definition of menorrhagia has changed to reflect the woman's subjective experience rather than trying to quantify blood loss - its any amount of bleeding that a women considers to be excessive Dysmenorrhoea refers to painful menstrual cramps, either primary (without an underlying condition) or secondary (due to conditions like endometriosis or fibroids).

Answer 300

no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche Management NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production combined oral contraceptive pills are used second line

Answer 301

Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts **3-4 days before the onset of the period.**

Answer 302

endometriosis adenomyosis pelvic inflammatory disease copper coil fibroids NICE recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation, giving ibuprofen

Answer 303

Pelvic examination with a speculum and bimanual This is mainly to assess for fibroids, ascites and cancers. Full blood count should be performed in all women with heavy menstrual bleeding, to look for iron deficiency anaemia. Outpatient hysteroscopy should be arranged if there is: Suspected submucosal fibroids Suspected endometrial pathology, such as endometrial hyperplasia or cancer Persistent intermenstrual bleeding Pelvic and transvaginal ultrasound should be arranged if the is: Possible large fibroids (palpable pelvic mass) Possible adenomyosis (associated pelvic pain or tenderness on examination) Examination is difficult to interpret (e.g. obesity) Hysteroscopy is declined

Answer 304

When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with: Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding) Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

Answer 305

Management when contraception is wanted or acceptable: Mirena coil (first line) Combined oral contraceptive pill - as long as not CI, Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism) Progesterone only contraception may also be tried, as it can suppress menstruation. This could be the progesterone-only pill or a long-acting progesterone (e.g. depo injection or implant). Referral to secondary care for further investigation and management is indicated if treatment is unsuccessful, symptoms are severe or there are large fibroids (more than 3 cm).

Answer 306

The final options when medical management has failed are endometrial ablation and hysterectomy. Endometrial ablation involves destroying the endometrium. (now been replaced with balloon thermal dilation, safer and faster)

Answer 307

It can be inserted either 48 hours within giving birth or four weeks postpartum, is effective immediately, and can be reversed with immediate return to fertility, making it suitable for this patient's needs

Answer 308

Premenstrual syndrome (PMS) describes the emotional and physical symptoms that women may experience in the luteal phase of the normal menstrual cycle. Emotional symptoms include: anxiety stress fatigue mood swings Physical symptoms bloating breast pain

Answer 309

mild symptoms can be managed with lifestyle advice, includes regular, frequent (2-3 hourly), small, balanced meals rich in complex carbohydrates, CBT moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP) examples include Yasminµ (the systemic hormones will improve symptoms) severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI) this may be taken continuously or just during the luteal phase (for example days 15-28 of the menstrual cycle, depending on its length)

WOMENS HEALTH 2 - Breast, Gynae, Sexual Health Flashcards

(335 cards)