What is the treatment for PID
IM 500mg Ceftrixone (STAT)
100mg BD Doxyclcyine
400mg BD Metronidozole
For two weeks
Potential side effect of the COCP
Cervical polyp due to the action of the oestrogen on the squamous epithelium.
Weight gain
Mood changes
Breakthrough bleeding
Define prolapse and the clinical features associated with it
Protrusion of an organ or a structure outside its normal anatomical state
Clinical features
- Falling down sensation
- Lump/discomfort
- Sexual symptoms
State the muscles and ligaments of the pelvis
Muscles
- Levator ani muscles
- Internal obturator muscles
- perineal muscles
Ligaments
- Transverse cervical ligament
- Uterosacral ligament
- Round ligament
Management of prolapse
Conservative
- Persaries (shelf and ring pesaries)
Surgical
- Mesh repair
- Colposuspension
- Sacrospinous fixation
Discuss Ashermann’s syndrome in relation to causes, clinical features and treatment
Causes:
Intrauterine adhesions, scarring at the front and the back of the uterus wall stuck together
Clinical features:
Scanty absent periods
Pain
Infertility
Treatment:
Dilleete & cutrage
Ovarian stromal hyperthecosis
Hyperplasia of the ovarian storm
Clusters of lutenising cells within the storma
Increase in androstertenedione and testosterone
Clinical features of ovarian stromal hyperthecosis
Hirutisim Virulism Hyperoestrogenic state Endometrial hyperplasia Abnormal uterine bleeding
Discuss the clinical features of PCOS
Oligomenorrhaea Infertility Acne Hirutism Alopecia Obesity
Pathophysiology of POCS
Disordered LH production
Peripheral insulin resistance leading to increased insulin
Increase in both LH and insulin = Increase in ovarian androgens production
- Disrupts follicilogenesis: irregular periods
Increase in insulin= Increase in adrenal androgens and decreases production of SHBG
Increase in free androgens levels
Criteria used when diagnosing PCOD
Rotterdam Criteria
- irregular/absent cycle ( >42 days period free)
- Clinical or biochemical signs of hyperandrogpns
1) acne
2) Hirsutism
3) Alopecia - PCOS ovaries on USS (>12 antral follicles on one vary
List potential differential diagnosing PCOS and the subsequent treatment options that are available
Dx: Hypotharyoidism Hyperprolactinaemia Cushing's sysndrome Acromegaly CAH
Treatment: (If not planing pregnancy) Co-coypril (Acne or hirsutism) COCP (menstrual regulation) Metformin started in secondary care) Elformithne (hirsutism) Olistat (wt mamagement)
Treatment (if planning pregnancy)
Clomifene to induce ovulation
Metaformin ( as above)
Laparoscopic ovarian drilling
Define amenorrhea and classify the different types
Absences of menstruation
Primary: menstruation has not commenced by ~16years
Secondary: Previously normal menstruation ceases for 6 months or more
List the causes of the primary amenorrhea
+ve 2 sexual characteristics
- Constitutional delay
- GU malformation
- Testicular femenisation (androgen resistance and XY karotype)
- Hyper prolactinoma
- Pregnancy
- ve 2 sexual characteristics
- Ovarian failure
- Tumours
- Kallamanns
- Congenital adrenal hyperplasia
- Turners
List the causes of secondary amenorrhea
- ve androgen excess
- Pregnancy
- Lactation
- Premature ovarian failure
- Radiotherapy
- Contraception
- BMI <19
- Hyperprolactinaemia
- Sheehans syndrome
- Thyroid disease
- Post pill
- Iatrogenic
+ve androgen excess
- PCOS
- Cushings syndrome
- Late onset CAH
- Adrenal carcinoma
- Ovarian carcinoma
List the clinical features associated with androgen excess
Hiritusism Acne Temporal balding Thyroid disease Cushing's disease
Define menorrhagia
Heavy menstrual bleeding that interferes with a women physical, emotional, social quality of life
Possible causes Endometriosis Fibroids Malignancy Thyroid disease Haemostatic disorder
Define puberty
Onset of sexual maturity, marked by the development of secondary sexual charachteristics
~ @13years
State the endocrine axis and the hormones involved in the control of puberty
Controlled centrally by the hypothalamic-pituitary axis
GnRH pulses increase in amplitude and frequency
Oestrogen = development of 2 charachteristics (adrenarche and thelarche
Define menopause
Cessation of the menstrual period. Retrospective diagnosis made following one year of amenorrhoea
Define perimenopause
period leading up to the menopause , irregular periods and menopausal symptoms
Discuss the investigation which would help confirm the diagnosis of menopause
FSH: increases (few oocytes remaining)
TFT’s: exclude other causes of irregular periods
Glucose: exclude DM
Antimullerian: decrease AMH, decrease oocytes
Blood cholesterol: exclude any CV risk factors
Menopausal symptoms
Short term
- Hot flushes
- Night sweats
- Mood change
- Irritability
- Loss of memory
- Headaches
- Dry skin
Medium term
- Recurrent UTI’s
- Dysparenuria
- Bleeding
- Reduced libido
- Vaginal atrophy
Long term
- Osteoporosis (>2.5)
- Fractures of wrist, hip and spine
- CV disease
- Dementia
Discuss the clinical features of fibroids
- 30-50 yrs women
- Menorrhagia
- Intermittent bleeding
- Pelvic pain
- Subfertility
- Dysmenorrhae
- Palpable mass
List possible differential dx for intermittent bleeding
Dysfunctional uterine bleeding Endometrial Ca Endometrial lesion PID Ovarian tumor
List the types of urinary incontinence
Overactive bladder: sphincter muscles work as normal, increased bladder pressure above maximal urethral closure pressure
Stress incontinence: sphincter weakness
List the clinical features of overactive bladder
Urgency Urinary incontinence Frequency Nocturia Key in door Handwashing Intercourse
List the clinical features of stress incontinence
Involuntary leakage
Coughing
Lifting
Exercise
What is the innervation of the bladder
Parasympathetic: sacral nerve
List the investigations you would carry out to investigate urinary incontinence
Frequency volume chart
Urinanalysis (rule out STI,UTI)
Residual urine measurement
EPAQ questionnaire
Management of incontinence
Stress incontinence: Physio- Pelvic floor strengthen Weight loss Quit smoking Decrease caffeine
Medical
Anticholinergics (Oxybutin)
Mirabegron
BOTOX
Surgery
Calposuspension
Tension free vaginal T
Discuss the different grades of the Pelvic Organ Prolapse Quantification (POPQ)
Grade 0:No prolapse Grade 1: Prolapse halfway to the hymen Grade 2: To the hymen Grade 3: Halfway passed the hymen Grade 4: Maximum descent
List the risk and protective factors for ovarian cancer
RISK
- BRCA 1/2
- HPNCC
- Nulliparity
- Early menarche
- Late menopause
PROTECTIVE
- Pregnancy
- COCP
- Lactation
Pathology of ovarian cancer
Epithelial
- Clear cell adenomas
- Cystadenomas
Germ cell
- Teratomas
Clinical features of ovarian cancer
Vauge ( IBS/ DIVERTICULITS) Abdominal distentsion Bloating Early satiety Loss of appetite Urgency/ Frequency Weight loss
List the factors involved in the risk of malignancy index score
Uss findings
CA125 Level
Menopausal stauts
List the stages in CIN
I: Lower 1/3 of the epithelium
II: Lower 2/3 of eptihelium
III: Full thickness of the epithelium
If it invades the basement membrane = cancer
Risk factors for CIN
Cx: HPV
OCP
Smoking
Immunocompromised
Explain the protocol of the national cervical screening programme
> 25yrs
Smear every three years
50-64
Smear every 5 yrs
Normal: return to screening programme
Borderline: HPV triage
- -ve HPV: return to screening
- +ve HPV: colposcopy
Moderate : urgent colposcopy
Pathology of cervical carcinoma
Squamous cell carcinoma
Mixed pattern
Adenocarcinoma
HPV cause all
Management of CIN
Large loop excision of transformational zone (LLETZ)
Cone biopsy
Cryotherapy
Clinical features of cervical carcinoma
Post coital bleeding
Offensive vaginal discharge
IMB/PMB
Bladder symptoms
Management of cervical carcinoma
I: Local excision
II: Werthlien hysterectomy, chemotherapy
III: Chemo and radiotherapy (PALLIATIVE)
List the risk factors for endometrial cancer
Unopposed oestrogen therapy Tamoxifen PCOS Obesity Nulliparity Late menopause Ovarian granuloma TIIDM
Clinical features of endometrial cancer
Postmenopausal bleeding
Irregular/IMB
Atrophic vaginitis
Cervical smear ( will show abnormal columnar cells)
Investigations for endometrial cancer
Transvaginal USS Biopsy if - Endometrim is >4cm in PM - Endometrium is >10cm in Premen MRI for staging
Management of endometrial cancer
I: Hysterectomy and BS
II: Radical hysterectomy
III: Debulking surgery
Pathology of vulval cancer
Squamous cell carcinoma
Presentation
- Unepxlained lump
- Pruritus
- Bleeding
- Discharge
Treatment
- Local excision
- May required lymph node removal
Pathology of lichen sclerosis
Autoimmune disorder
Elastic tissue becomes collagen
Clinical features and treatment of lichen sclerosis
Clinical features
- Bruised red purpuric signs
- Vulvae becomes white , flat and shiny
Treatment
- Clobetasol propionate
Clinical features of ovarian torsion
Pain
May be intermittent as the ovary torts and releases
Features of ovarian haemorrhage
Shock
Treatment of a ovarian torsion
Surgery
If operated on within 6hrs tissue will remain viable
List the type of benign breast lumps
- Breast cyst
- >35 yrs
- Fluid filled
- Rounded lump
- Not fixed
- Rx: needle aspiration - Fibroadenoma
- <40yrs
- Overgrowths of collagenous mesenchyme of the breast lobule
- Firm, smooth, mobile lump
- Painless
- Rule of thirds (regress, stay the same, get bigger)
- Rx mammogram to examine lump - Intraductal papilloma
- Warty lesion behind the areola
- Small lump
- Sticky blood stained discharge
- Rx: Fine needle aspiration - Fat necrosis
- Large fatty breast lump
- Calcification of the lump
- Rx: refer for triple assessment
Breast cancer screening programme
Screen women every three years aged 50-70
Risk factors for breast cancer
Family hx Age Uninterrupted oestrogen exposure HRT BRCA Obesity
Clinical features of breast cancer
Lump
Nipple discharge
Nipple change
Skin contour changes
Explain the triple assessment of breast cancer
Clinical examination
Radiology (mammogram, ultrasound)
Histology or cytology
Management of breast cancer
STAGE 1/2 ( breast only)
- Surgery
- Radiotherapy
- Endocrine agents ( ER Tamoxifen, Aromatase inhibitors)
STAGE 3/4
- Radiotherapy
- DEXA scan
- Bisphosphanates
- Hormone treatments
Must carry out immunohistochemistry
Oestrogen +ve, HER +ve cancers
Treatment of HER2+ve cancers with perception watch the cardiac function
Pagets disease of the nipple
Rare malignancy of the nipple
Eczematous lesion of the nipple and is often associated with an underlying in-situ or invasive carcinoma of the breast