Gynae Flashcards

Question

Types of fibroids

Answer 1

- Intramural (distort shape of uterus with growth) - most common - Subserosal (just beneath outer layer - grow out; get very large) - Submucosal (just below endometrium) - Pedunculated (any of the above but on a stalk) Remember all are within the myometrium

Answer 2

Oft asymp - **Menstrual dysfunction - typically HEAVY +/- PROLONGED (mc)** - Abdo pain (worse during period) - Bloating / fullness in abdo - subsequent urinary / bowel Sx - Deep dyspareunia - **Reduced fertility** - Occasionally acute pelvic pain due to fibroid degen during preg or peduculated fibroid torsion (rare) May feel palpable mass on abdo / bimanual palpation (tho uterus is non-tender)

Answer 3

- Obesity - Early menarche - Increasing age - FHx (2.5x risk if 1st degree relative) - Ethnicity (3x more likely in African-Americans than Caucasians)

Answer 4

IMAGING: - Pelvic US - typically for larger - MRI uncommonly - typically to get more info before surgery HYSTEROSCOPY if HEAVY BLEEDING - typically submucosal fibroids

Answer 5

For smaller fibroids (**< 3cm**) with menorrhagia: - **MIRENA COIL** - not if uertrine distorsion - Sx Mx e.g. Tranexemic acid + NSAIDs - cOCP OR Cyclical oral progesterones - Selective Progesterone Receptor Modulators - Surgical: - Endometrial ablation - Resection - Hysterectomy (Basically works in a similar way to trying to reduce endometrial proliferation to avoid endometrial cancer) If > 3cm REFER to GYNAE. Med management is same as above but consider following surgical: - Uterine artery embolisation - Myomectomy - Hysterectomy

Answer 6

GnRH AGONISTS (goserelin / leuprorelin) - induces menopause-like state -> reduced oestrogen Only temporarily used

Answer 7

Catheter inserted into (usually) Femoral artery -> go to uterine artery guided by x-ray -> inject particles causing blockage to fibroid blood supply (once in right place) -> ischaemic fibroid shrinks

Answer 8

- Anaemia from bleeding - Compression of pelvic organs - Bladder / bowel dysfunction: UTI, Incont, Hydroneph, Retention - Sub/INFERTILITY +/- preg complications - Red Degeneration -> necrosis of fibroid, typically in 2nd/3rd trimester of preg - Torsion of pedunculated - Malignant change

Answer 9

- Fibroid rapidly enlarges + outgrows blood supply - Blood vessels kink as uterus expands Typically in large fibroids > 5cm

Answer 10

Preg woman in 2nd/3rd trimester with: - SEVERE ABDO PAIN - Low-grade FEVER - TACHYCARDIA - VOMITING - Hx of fibroids

Answer 11

Supportive: Rest, fluids + analgesia

Answer 12

Fluid filled sac within ovary - common esp in premenopause (functional) Benign

Answer 13

Usually ASYMP + found incidentally on USS Otherwise still vague: - Pelvic pain - Bloating - Fullness in abdo - Palpable mass (if v large) Acute pain only in torsion, haemorrhage or rupture of a cyst - Acute UNILATERAL pain +/- intra-peritoneal haemorrhage with Haemodynamic compromise = cyst RUPTURE

Answer 14

NON-NEOPLASTIC Functional (main): - Follicular cysts (most common) - Corpus luteal cysts Pathological: - Endometrioma (from endometriosis) - Polycystic - Theca leutin cyst (temporarily caused by raised hCG) BENIGN NEOPLASTIC: Epitehlial: - Serous cystadenoma (Benign epithelial tumour) - Mucinous cystadenoma (also benign epithelial but can get very big) - Brenner tumour (unilateral solid grey/yellow) Germ cell tumours: - Dermoid cysts / Germ Cell Tumours (benign teratomas) - Sex Cord-Stromal Tumours (stromal/sex cells - malig or benign)

Answer 15

Assess if benign or malig - Abdominal bloating - Reduce appetite - Early satiety - Weight loss - Urinary symptoms - Pain - Ascites - Lymphadenopathy

Answer 16

Big thing is that risk is increased the more times you've ovulated: - Age - Nulliparity - Early menarche + Late menopause Also: - Oestrogen only HRT - SMOKING - Obesity - FHx +/- BRCA1 + BRCA2 genes OR HNPCC (Lynch syndrome)

Answer 17

- Later menarche / Earlier menopause - PREG esp miltiparity - cOCP - Breastfeeding

Answer 18

Oft in Post-menopausal females + vague: - Bloating - Change in bowel habit + urinary frequency (due to pressure from tumour) - chronic pressure can lead to chronic pelvic pain - Weight loss / loss of appetite - IBS - Vaginal bleeding - Ascites - Palpable mass - LUTS May press on obturator nerve + cause reffered HIP / GROIN pain

Answer 19

Triad of: - **Ovarian fibroma** - **Pleural effusion** - **Ascites** - uncommon but ~40% of people with Sex-cord stromal tumours / FIbromas present with this

Answer 20

- Torsion - Haemorrhage - Rupture + bleeding into peritoneum

Answer 21

- Epithelial cell ovarian cancer - Endometriosis - Fibroids - Adenomyosis - Pelvic infection - Liver disease - Preg

Answer 22

- Preg test to rule out ectopic - If pre-menopausal + simple ovarian cyst <5cm on US - DOESN'T NEED FURTHER Ix - Under 40 with COMPLEX OVARIAN MASS - requires tumour markers for a possible germ cell tumour - LACTATE DEHYDROGENASE (LDH) - Alpha-fetoprotein (a-FP) - human CHORIONIC GONADOTROPIN (HCG) - Diagnostic laparoscopy e.g. if patient unstable

Answer 23

Estimates the risk of an ovarian mass being malig: - **Menopausal status** - **USS FINDINGS** - **CA125 LEVEL**

Answer 24

Check guidelines + get advice from collegue - If suspecting cancer (complex cyst or raised CA125) - **TWO-WEEK WAIT** REFERRAL (gynae oncology) - Suspected **dermoid cysts -> gynae Ix + consider surgery** - Simple ovarian cysts in premenopausal - < 5cm = self resolve - 5-7cm = routine gynae referral + yearly USS - >7cm = consider MRI or surgiccal evaluation (hard to characterise with USS) - **Postmenopausal -> check CA125** - raised -> 2 week referral - small + norm Ca125 -> USS monitor 4-6 months - **Surgical resection/oophorectomy if enlarging/persistent**

Answer 25

Endometrial tissue located outside of uterine cavity - ovaries - pouch of douglas - uterosacral ligaments - pelvic peritoneum - bladder - umbilicus - diaphragm (rarely)

Answer 26

1. Small Superficial lesions (may not even have visible endometrioma - just the associated blood vessels visible) 2. Mild but deeper lesions 3. Deeper + Ovarian endometriosis (chocolate cysts) + mild adhesions 4. Deep infiltrating endometriosis (invades into organs/ovaries) + extensive adhesions

Answer 27

Cyclical Sx - typically get Sx (/gets worse) during periods - Pelvic Pain (due to irritation + inflam of tissue surrounding endometriomas - particularly as can bleed into abdo cavity during periods) - Heavy / burning / dull - Menorrhagia - Deep dyspareunia - Sub-fertility Bladder Sx: - Cystitis (oft mistaken for UTIs - but NITRITES -VE) - Haematuria Bowel Sx: - Rectal bleeding - Change in bowel habit - Dyschaesia (difficulty pooping) Lung Sx: - Haemothorax - Haemotptysis - Dyspnoea - Chest pain Over time nerves get more sensitised -> pain -> low mood -> makes the pain feel worse - Also general pain due to muscle spasm (due to chronic inflam) Extent of disease doesn't correlate with severity of Sx

Answer 28

ADHESIONS formed due to localised bleeding + inflammation -> damage + scar tissue - possible cause of reduced fertility

Answer 29

- Visible endometrial tissue in vagina (esp in posterior fornix) - Fixed cervix on BIMANUAL examination - uterus fixed + retroverted - Tenderness of vagina, cervix + adnexa - *N/B: enlarged, tender + BOGGY UTERUS = ADENOMYOSIS*

Answer 30

- **PELVIC USS** - superficial endomet can't bee seen on scan and USS isn't diagnostic, but it's much safer than blindly doing laproscopy - Laproscopic surg (gold standard) + BIOPSY (diagnostic) - can remove any lesions they find during this

Answer 31

- Visceral injury (may need stoma) - Perforation of IVC or aorta - Death - Chronic pain - May not find anything (50% of endometriosis is diff to identify on surg)

Answer 32

- Early menarche - Short menstrual cycles - Long duration of bleeding - Heavy bleeding - Defects in uterus / fallopian tubes - FHx

Answer 33

- Explain, Educate, Discuss + ANALGESIA - HORMONES (can be given even without definitive Dx) - cOCP - progesterone only (mini pill) - Medroxyprogesterone acetate injection - Nexplanon - MIRENA coil - GnRH agonists (induces menopause-like Sx so must regularly check DEXA and change if osteoporotic changes) - goserelin - SURGERY - excise (ovarian cystectomy), ablate (diathermy) or adhesiolysis - may be done if trying to get preg but poor outcomes for deep infiltrating - Hysterectomy + bilateral salpingo-opherectomy (induces menopause so endometriomas don't respond to menstrual cycle - still may not resolve Sx)

Answer 34

Endometrial tissue inside the myometrium - hormone dependant More common in older age / in multiparosity - BUT - Sx tend to resolve after menopause

Answer 35

- Dysmenorrhoea - Menorrhagia - Dyspareunia - Potentially infertility / preg related complications 1/3 ppl asymp

Answer 36

ENLARGED + TENDER uterus but typically softer than with fibroids

Answer 37

- **Transvaginal USS* - Alt = MRI + transabdo USS - Best way to determine is actually histology post-hysterectomy - but not practical

Answer 38

- CONTRACEPTION: 1. MIRENA 2. cOCP 3. Cyclical oral progestogens 4. or any progesterone only meds - If contreception not wanted - Sx relief DURING periods: 1. Tranexemic acid (if no pain - antifibrolynitic only) 2. Mefenamic acid (if YES pain - this is an NSAID) - Other: - GnRH anologues (goserelin) - Endometrial ablation - Uterine artery embolisation - Hysterectomy

Answer 39

- Infertility - Miscarriage - Prem birth - Small for gestational age - Prem rupture of membranes - Malpresentation - need for C-section - Postpartum Haemorrhage

Answer 40

Technically - Blood loss > 80 ml during period is considered heavy (norm = ~40ml) In practice it is mainly from self reporting / going through a pad every 1-2 hrs or passing large clots

Answer 41

- DYSFUNCTIONAL UTERINE BLEEDING (ie idiopathic) - Extremes of reproductive age - FIBROIDS - Endometriosis / Adenomyosis - Endometrial polyps - PID - Contraception - esp COPPER COIL - Endometrial HYPERPLASIA / CANCER (think esp if post menopausal) - PCOS Systemic: - ANTICOAG meds - BLEEDING DISORDERS - Hypothyroidism - Liver/Kidney disease - Obesity - Connective tissue disorders

Answer 42

- Age at menarche - Cycle length + variation - INTERMENSTRUAL BLEEDING + POST COITAL bleeding - CONTRACEPTIVE Hx - SEXUAL Hx - PREG - possibility, future plans - Cervical screening Hx - MIGRAINES if on pill + all usual stuff: - PMHx + DHx - Smoking + alcohol - Fhx

Answer 43

FBC (anaemia) PELVIC EXAMINATION -> SPECULUM + BIMANUAL palpation - to assess for fibroids, ascites + cancer - Not necessary if young + not sexually active; or striaght forward Hx with no other Rfx/Sx Other: - Swab (infection suspected) - Coag screen (FHx of clotting disorder) - FERRITIN (if clinically anaemic) - TFTs (if hypothyroid features) / other endocrine tests as indicated - Transvaginal USS

Answer 44

- Suspect SUBMUCOSAL fibroids - Suspect endometrial pathology (hyperplasia/cancer) - Persistent INTERMENSTRUAL bleeding

Answer 45

- You feel a pelvic mass (**possible large fibroids**) - They have menorrhagia AND pelvic tenderness (**Possible adenomyosis**) - Examination was difficult to interpret (e.g. due to obesity) - They were recommended a hysterscopy but declined

Answer 46

1. Exclude underlying pathology + Tx anything identified (e.g. remove copper coil, tx hypothyroid etc) 2. CONTRACEPTION 3. If contraception not needed/wanted -> TRANEXEMIC / MEFANEMIC ACID 4. Refer to 2NDRY care if: - Tx unsuccessful - Sx severe - FIBROIDS > 3CM 5. If all medical fails: - Endometrial ablation - Hysterectomy

Answer 47

1. 1st gen = hysteroscopy + direct endometrial destruction (now replaced with...) 2. 2nd gen non-hysteroscopic techniques - Safer + Faster - e.g. Balloon thermal ablation

Answer 48

Not starting menstruation: - By 13 y/o if no other signs of puberty - By 15 y/o if other signs of puberty

Answer 49

Lack of sex hormones - oestrogen or testosterone Can be: - hypOgonadotropic hypodonadism (low LH + FSH) - hypERgonadotropic hypogonadism (gonads not responding to LH/FSH so LH+FSH high to try and compensate)

Answer 50

- hypogonadotropic hypogonadism - Damage to hptothalamus/pituitary - Reduced nutrition intake - Significant CHRONIC CONDITIONS (e.g. CF or IBD - only temporarily tho) - **Excessive exercise / dieting** - Extreme physical / psych STRESS - **CONSTITUTIONAL DELAY in gowth + development** (temporary) - **ENDOCRINE DISORDERS **(including adrenal hyperplasia) - **Genetic syndromes** e.g. - Kallman syndrome - Turner syndrome - Androgen insensitivity syndrome - Imperforate hymen -> haematocolpos - Uterine agenesis - Pregnancy

Answer 51

- Damage to gonads (torsion, mumps, cancer) - Congenital absence of ovaries - TURNER'S SYNDROME

Answer 52

- Imperforate hymen - Transverse vaginal septae - vaginal agenesis (vagina doesn't develop) - Absent uterus - Female genital May get cyclical abdominal pain if getting periods but the menses

Answer 53

Initial: - FBC + Ferritin - U+E (?CKD) - Anti-TTG / Anti-EMA (?coeliac) Hormonal: - FSH + LH - TFTs - Insulin-like growth factor (?GH deficiency) - Prolactin - Testosterone Genetic microarray test - Turner's Imaging: - X-ray wrist (?constitutional delay) - Pelvic US (assess ovaries + pelvic organs) - MRI brain (pit gland pathology / olfactory dysfunction -?kallman)

Answer 54

Oestrogen dependent cancer - most commonly adenocarcinoma (glandular) Consider in any post-menopausal woman with bleeding - more common in postmenopausal group

Answer 55

**Anything that increases exposure to unopposed oestrogen** - Increased age - Earlier onset of menstruation / Late menopause - Oestrogen only HRT - No / fewer preg - OBESITY - **PCOS (due to reduced ovulation -> less corpus leuteums to release progesterone + linked )** - Tamoxifen (blocks oestrogen receptors in breast but oestrogenic in uterus) Also: - **DIABETES (insulin / insulin-like growth factor -> pro-proliferative effect)** - Hereditary nonpolyposis colorectal cancer

Answer 56

- Adipose makes oestrogen - it contains AROMATASE -> converts androgens into oestrogen - more fat = more aromatase + more oestrogen - in post-menopause - no corpus luteum to make progesterone to oppose

Answer 57

Ovary twists in relation to surrounding structures (the adnexa)

Answer 58

Usually due to **ovarian MASS > 5 cm** - More likely to occur with benign tumours - esp in preg Sometimes occurs in pre-pubertal girls when **infundibulopelvic ligaments** are longer and can twist more easily (sort of mirroring testicular torsion in boys)

Answer 59

- SUDDEN onset SEVERE, UNILATERAL pelvic PAIN - constant + progressive - **associated N+V** - sometimes intermittant - sometimes milder + prolonged course LOCALISED TENDERNESS + **potentially PALPABLE** mass on examination

Answer 60

1. **Pelvic US** - ideally transvaginal but transabdo works too - 'whirlpool sign' - FREE FLUID in pelvic cavity - Ovarian OEDEMA 2. US Doppler -> lack of blood flow Dx = Laproscopic SURGERY

Answer 61

- Emergancy admission - LAPROSCOPIC SURGERY to do either: - Detorsion - Oophrectomy - Laprotomy (big cut surgery) if large mass / malig

Answer 62

- Loss of function of ovary - usually not infertility + early menopause because there is usually another ovary that can compensate If necrotic ovary not removed -> infection -> abscess -> sepsis - can rupture -> peritonitis + adhesions

Answer 63

- cOCP - Mirena coil - Increased preg - Cigarette smokin - in post menopause as it is ANTI-OESTROGENIC (despite increasing risk in breast cancer) - potentially oestrogen metabolised differently in smokers; or because smokers have less adipose tissue / smoking induces earlier menopause (destroys eggs)

Answer 64

**POSTMENOPAUSAL BLEEDING** - Postcoital bleeding - Intermenstrual bleeding - Unusual MENORRHAGIA - Abnormal vaginal discharge - Haematuria - **ANAEMIA** - Raised platelets

Answer 65

POST MENOPAUSAL BLEEDING Also - refer for **transvaginal US** in women **> 55 y/o** if: - Unexplained vaginal discharge - Visible haematuria + raised plts / anaemia / high glucose

Answer 66

- Transvaginal US (**endometrial thickness > 4mm post menopausal = abnormal**) - Pipelle biopsy (highly sensitive for endometrial Ca) - Hysterectomy + endometrial biopsy (if high risk / last resort) If 1st 2 are normal - v low risk

Answer 67

- Speculum exam - Insert pipelle (thin tube) through cervix into uterus - Fill with sample of endometrium - Examine for hyperplasia / cancer

Answer 68

International federation of gynae and obs (FIGO) staging system: 1. confined to uterus 2. Invades cervix 3. Invades ovaries, fallopian tubes, vagina OR lymph nodes 4. Invades bladder, rectum OR BEYOND pelvis

Answer 69

- Stage 1 = **TOTAL abdominal HYSTEROECTOMY with BILATERAL salpingo-oophrectomy** + peritoneal washing Other: - Radical hysterectomy (remove pelvic lymph nodes, surrounding tissue + top of vagina (from stage 2 onwards) / maximal debulking where possible - Chemo/Radiotherapy (usually in that order) - PROGESTERONE may SLOW PROGESSION

Answer 70

- Vulval: - Atrophy - Malignancy / pre-malig - Cervical polyps OR cancer - Endometrial: - Hyperplasia +/- cancer - Benign endometrial polyps - Endometrial atrophy

Answer 71

- Epithelial cell tumours - Serous tumours (main) - Endometrioid carcinomas - Clear cell tumours - Mucinous tumours - Undifferentiated - Dermoid cysts / Germ cell tumours (benign teratomas) - (higher association with torsion - Sex Cord-Stromal tumours - Sertoli-Leydig cell tumours - Granulosa cell tumours - Mets - Krukengerg tumour = 'signet ring' cells; usually from GI cancer

Answer 72

Direct to 2-wk wait if: - ASCITES - PELVIC MASS (not clearly due to fibroids) - ABDO MASS Further Ix first (**CA125 bloods**) esp in women > 50 y/o with: - Change in bowel habit - Abdo BLOATING - Early SATIETY - Pelvic PAIN - Urinary frequency / urgency - WEIGHT LOSS

Answer 73

Initial (can be done in primary / seondary care): - CA125 blood test - Pelvic US Further (only in 2ndry): - CT (Dx + staging) - Biopsy + HISTOLOGY - PARACENTESIS if ascitic If under 40 with complex ovarian mass -> may be teratoma: - Alpha-Fetoprotein - Human chorionic gonadotropin

Answer 74

FIGO staging: 1. Ovary only 2. Outside ovary but still inside pelvis 3. Outside pelvis but still inside abdo 4. Distant mets (spread outside abdo)

Answer 75

Specialist gynae oncology MDT Usually = Surgery + chemo

Answer 76

- peaks in reproductive years - Most commonly squamous cell carcinoma - strong association with HPV (pretty much always related to HPV infection)

Answer 77

Increased risk of catching HPV - Early sexual activity / increased no. of sexual partners - Sexual partners who have had more partners - No condoms **Not engaging with cervical screening** Other: - SMOKING - HIV (get annual smears instead of every 3/5 years) - cOCP use for > 5 years - FHx - Increased number of full term preg - Exposure to dithylstilbesterol

Answer 78

Can just detect through screening (asymp) - **Abnormal vaginal bleeding** - Abnormal vaginal discharge - Pelvic pain - Dyspareunia (all non-specific)

Answer 79

- HPV +ve + Abnormal cytology on pap smear - Abnormal appearance of cervix on speculum examination: - Ulceration - Inflammation - Bleeding - Visible tumour

Answer 80

Inserted into vagina through speculum -> MAGNIFIES cervix + examine epithelium in detail Can use stains to differentiate abnormal areas: - **Acetic acid** -> abnormal cells = WHITE (acetowhite) - caused by INCREASED **nuclear to cytoplasmic ratio** - **Schiller's iodine test** -> only healthy areas stain brown Can also do PUNCH BIOPSY or LARGE LOOP EXCISION of TRANSFORMATIONAL ZONE

Answer 81

- Bleeding (tho the diathermy from the fact the loop is electric should cauterise it) - Abnormal discharge - Both potentially for severel weeks after Potential increase risk of pre-term labour depending on depth of tissue removed NB: AKA Large Loop Excision of Transformation Zone

Answer 82

Tx for CERVICAL INTRAEPITHELIAL NEIPLASIA + early stage cervical cancer - Remove cone-shaped piece of cervix with scalpel -> Histology

Answer 83

- Pain - Bleeding - Infection - Scar formation leading to cervical stenosis - Increased risk of miscarriage / prem labour

Answer 84

- Stage 1: Confined to the cervix - A = only **microscopic** - B = **Gross** lesions - Stage 2: Invades the uterus or upper 2/3 of the vagina - A = **No parametrial** involvement (connective tissue around uterus) - B = **Obvious parametrial** involvement - Stage 3: Invades the pelvic wall or lower 1/3 of the vagina - A = **No sidewall involvement** - B = Extension to sidewall / hydronephrosis - Stage 4: Invades the bladder, rectum or beyond the pelvis (ie mets) - A = Involves BLADDER / RECTUM - B = DISTANT ORGANS

Answer 85

Grading system for level of dysplasia (baso pre-cancerous) - Dx at colposcopy - CIN 1= Mild dysplasia (1/3 thickness of epithelial layer - will probs return to normal by itself) - CIN 2 = Mod (2/3 of thickness + likely to progress without Tx) - CIN 3 = Severe (very likely to progress to Ca without Tx)

Answer 86

Dysplasia can only be Dx on colposcopy Dyskaryosis can be determined from smear test (both are interchangeable words for cell changes)

Answer 87

Routine: - Every **3 years 25-49** - Every **5 years 50-64** Other: - HIV +ve = ANNUAL screening - If >65 can request one if not had one since 50 - Previous CIN needs further testing - More screening if on cytotoxic drugs, dialysis, organ transplant etc (immunocompromise) Don't do routine smear while peripartum (min = 12wks post-partum)

Answer 88

- Speculum exam + small brush to collect cells - Deposit cellls into perservation fluid - (Transport via liquid-based cytology) - Microscopy - 1st **high-risk HPV infection** - 2nd IF high-risk HPV present THEN -> cells exam for dyskaryosis Can also detect: - bacterial vaginosis - Candidiasis - Trichomoniasis - Actinomyces-like organisms in ppl with IUDs (no Tx required unless Sx)

Answer 89

- Normal = back to routine testing - Inadequate sample = repeat smear after at least 3 months - HPV +ve but NORMAL cytology = Repeat for HPV after 1 YEAR - HPV +ve with ABNORMAL cytology = COLPOSCOPY

Answer 90

- CIN and Early stage 1A = Loop biopsy / cone biopsy - 1A = can do trachelectomy (cervix + upper vagina only) -> fertility preservation - Stage 1B - 2A = RADICAL HYSTERECTOMY + removal of local LYMPH nodes +/- chemo/radio - Stage 2B-4A = CHEMO + RADIO - Stage 4B = Combination of surg, chemo/radio + palliative

Answer 91

Remove most/all of pelvic orgams (femal reporoductive, bladder + rectum) - in severe / recurrent cancer

Answer 92

- given ideally before kid becomes sexually active - Gardasil (current NHS version) protects against strains 6, 11, 16, 18 6+11 -> genital warts 16+18 -> cervical cancer

Answer 93

- every 4 MONTHS after Tx completion for FIRST 2 YRS - every 6-12 MONTHS for NEXT 3 YRS Must do vag/cervical exam each time if they haven't been removed

Answer 94

Rarer - 90% SQUAMOUS cell carcinomas - Sometimes malignant melanoma

Answer 95

- AGE esp >75 yrs - ImmunoSUPPRESS - HPV INFECTION - **Lichen sclerosis**

Answer 96

Oft incidental e.g. found during catheterisation - Vulval LUMP - Ulcers - Bleeding - Pain - Itching - LYMPHADENOPATHY Most commonly in LABIA MAJORA - IRREGULAR mass - FUNGATING lesion - ULCER - Bleeding

Answer 97

Premalig affecting squamous epithelium - High grade squamous intraepithelial lesion is associated with HPV (typically in 35-50 y/o) - Differentiated VIN associated with LICHEN SCLEROSUS (typically in 50-60 y/o) Can only be Dx with BIOPSY

Answer 98

- Watch + wait (cloe follow-up) - Wide LOCAL EXCISION - IMIQUIMOD CREAM - Laser ablation

Answer 99

2-WK WAIT if suspected - BIOPSY - Sentinal NODE biopsy - CT abdo + pelvis for staging Tx: - Wide local EXCISION - **Lymph node dissection (groin)** - ideally removing deeper femoral nodes as superficial only = higher risk of recurrance - CHEMO / RADIO

Answer 100

1. vulval only 2. lower 1/3 of vagina, uterus / anus 3. upper 2/3 of vagina / urethra OR bladder/rectal mucosa OR non-ulcerated lymph nodes 4. Ulcerated lymph nodes, fixation to pelvic bone OR distant mets

Answer 101

- Wound dehiscence (seperation of previously approximated wound edges due to failure of proper healing) - Infection - LymphoCYSTs - LymphOEDEMA - Immobility - Prolonged hospitalisation

Answer 102

Inflam skin condition - mainly affecting GENITAL / ANAL areas - more common in women Vulvar lichan sclerosus involves inner vulva

Answer 103

Possibly autoimmune - associated with: - T1DM - Alopecia - Hypothyroid - Vitiligo Possible link with previous skin damage

Answer 104

Porcelain White patches which may scar - Shiny, tight, thin, slightly raised - Possibly papules / plaques Sx (can be asymp): - Itching - sometimes pain - May be worse on urination / sexual intercourse - Tightness - Erosions / Fissures KOEBNER PHENOMENON (made worse by friction on skin)

Answer 105

- Lichen planus (purplish, itchy, bumpy, white lacy, can be in mouth) - Psoriasis - Vitiligo

Answer 106

No cure - follow up every 3-6 months (gynae or derm specialist) - POTENT TOPICAL STEROIDS - Clobetasol propionate 0.05% (dermovate) - OD for 4 WKS then reduce in freq every 4 WKS till only using TWICE WEEKLY - Increase ti daily during flare-ups - Reduces risk of malig - EMOLLIENTS - Avoid soaps in affected areas

Answer 107

Mainly just clinical exam - can sometimes do biopsy to confirm - Bloods to rule out AI conditions

Answer 108

- 5% risk of Squamous cells carcinoma - Sexual dysfunction - Bleeding - Narrowing of vaginal / urethral openings

Answer 109

Gestational trophoblastic disease - caused by imbalance in no. of chromosomes from mother / father during conception basically forms a tumour

Answer 110

Extremes of age: - < 16 Y/O - >45 Y/O

Answer 111

- Complete mole - ie has no foetal tissue - But does have proliferation of chorionic villi - Only paternal DNA (the ova is empty) - either 2 sperm or 1 sperm which replicates (ends with 46 paternal chromosomes) - Partial mole: - some foetal tissue - 2 sperm + normal egg -> haploid cell with 3 SETS of chromosomes

Answer 112

- Vaginal bleeding - Nausea - Hyperemesis gravidarum - **Thyrotoxicosis** (due to hCG activating TSH receptors) - Enlargement of uterus beyond expected gestational size (excessive trophoblast growth + retained blood)

Answer 113

- Normal preg - Ectopic - Miscarriage

Answer 114

- B-hCG levels - HIGHER than in normal pregs - TRANS-VAGINAL US - Snow storm appearance if complete molar - Low resistance of blood vessel flow - Absence of foetus Confirm Dx retroscpectively from biopsy after mole removed

Answer 115

Specialist referral (gestational trophoblastic disease centre) to avoid complications (choriocarcinoma / invasion) - SUCTION CURETTAGE to Evacuate then Histology - Can do hysterectomy if not wanting to preserve fertility - SURVAILLANCE - **Bimonthly serum + urine hCG until levels normal** - 1st follow-up should be 4 wks after if a partial mole then can stop surrvailance if norm - if complete mole -> remeat monthly for 6 months even if normal levels It is possible for it to metastesise

Answer 116

Inflammation, thinning of genital tissue after menopause due to LOW OESTROGEN

Answer 117

Normally oestrogen stimulates vagina + urinary tract to become thicker, more elastic + producing secretions Low oestrogen -> thinner, less elastic, drier mucosa - becomes more prone to inflammation - causes change in vaginal pH + microbes -> contribute to localised infection Oestrogen also helps maintain pelvic connective tissue so postmenopausal people more prone to pelvic organ prolapse + stress incontinence

Answer 118

- Thinning of vaginal mucosa - Narrowing of opening - Loss of vaginal rugae (folds) - Vaginal dryness + itching - Dyspareunia - Post-coital bleeding - Vaginal discharge (due to inflam) - Dysuria / recurrent UTIs / other urinary Sx - (associated incontinence, prolapse) - Loss of pubic hair

Answer 119

- Clinical examination - Pale, dry mucose +/- erythema; inflam - Thin skin + sparse pubic hair - Reduced skin folds - Infection screen if itching + discharge If needed: - Transvaginal US + endometrial biopsy to exclude endometrial cancer - Biopsy abnormal skin

Answer 120

- Lubricants (short term for e.g. dyspareunia) - Moisterisers (regularly) - HORMONES (needs annual monitoring for endometrial complications): - Systemic HRT OR - TOPICAL OESTROGEN - Estriol cream (syringed in at bedtime) - Estriol PESSARIES (overnight) - Estradiol TABLETS (OD) - Estradiol ring (only replaced every 3 months)

Answer 121

- Breast cancer - Angina - VTE

Answer 122

https://zerotofinals.com/obgyn/gynaecology/differentialdiagnosis/

Answer 123

Abnormal growth of glands, stroma + vasculature affecting only endometrial layer - mainly in fundus (sometimes also cervix and rarely vagina) - usually immature endometrium so no menstrual cycle changes Can get during reproductive / postmenopausal years (esp in 40s) Potential link to oestrogen (higher incidence in ppl on HRT or TAMOXIFEN)

Answer 124

Usually asymp - Bleeding - Infertility - Sometimes may progress to malig

Answer 125

- Transvaginal US - +/- Colour Doppler - SALINE INFUSION SONOGRAPHY (gold) - Can check histology

Answer 126

Conservative - usually self-resolving If infertility -> Surgical excision e.g. hysteroscopic polypectomy; lilation + curettage Consider Post surgical progesterone therapy or just progesterone HRT in general

Answer 127

When adhesions form WITHIN the Uterus following damage - Only considered Asherman's syndrome if SYMPTOMATIC Usually iccurs after pregnancy- related dilation + curettage (as it can damage basal layer causing scarring) - or uterine surgery or multiple pelvic infections these physical abnormalities cause obstructions / distortion

Answer 128

Typically after recent uterine procedure - 2ndry amenorrhoea - Lighter periods - Dysmenorrhoea Or infertility / recurrent miscarriages

Answer 129

- HYSTEROSCOPY (gold) - Hysterosalpingography - Sonohysterography (saline infusion sonography) - MRI scan

Answer 130

- dissect during hysteroscopy - commonly reoccur

Answer 131

Highest prevalence in sexually active women 15-24 (YOUNG SEXUALLY ACTIVE WOMEN)

Answer 132

Caused by spread of infection through cervix Most common causes = STIs - Neisseria gonorrhoeae tends to produce more severe PID - Chlamydia trachomatis - Mycoplasma genitalium Less commonly: - Gardnerella vaginalis (associated with bacterial vaginosis) - Haemophilus influenzae - Escherichia coli

Answer 133

- Sexually active: - No barrier contraception - Multiple sexual partners / recent new partner - existing / previous STIs - Younger age (15-24) - PMHx of PID - INTRAUTERINE DEVICE Can also get vis INSTRUMENTATION (e.g. in gynae surgery / insertion of IUD etc)

Answer 134

- Pelvic / lower abdo PAIN - Abnormal vaginal DISCHARGE - Abnormal BLEEDING - Deep DYSPAREUNIA - Dysuria If severe: - severe pain, FEVER, N+V

Answer 135

- Pelvic TENDERNESS - Cervical motion tenderness (cervical excitation) - Cervicitis - Purulent discharge Signs of sepsis if severe

Answer 136

- **ENDOCERVICAL SWABS (chlamydia + gonnorhoea) / HIGH VAGINAL SWAB (trichomoniasis + vaginosis)** - NAAT - microscopy for PUS CELLS - Full STI screen (**esp HIV, SYPHILIS**) - Urine dipstick +/- MSU (to exclude UTI) - Preg test (to exclude) - Transvaginal US (if severe / uncertainty) - Laparoscopy (+ peritoneal biopsy) - only if severe AND uncertainty - Bloods (RAISED INFLAM MARKERS)

Answer 137

GUM referral - EMPIRICAL ABx (before swab comes back) - e.g. combination of cefriaxone, doxy + metranidazole for broad cover (check local guidelines) - Consider analgesia - Rest + avoid sex - CONTACT TRACING - everybody in LAST 6 MONTHS

Answer 138

- If PREG - esp if risk of ECTOPIC - Severe Sx: N+V + FEVER (sepsis) - Signs of PERITONITIS - UNRESPONSIVE TO ORAL ABx (as will then need IV) - Need emergancy surg - e.g. PELVIC ABCESS drainage - Suspicion of other diagnosis

Answer 139

- Sepsis - Abscess - Infertility / Ectopics - Chronic pelvic PAIN - Fitz-Hugh-Curtis syndrome (perihepatic adhesions due to infalm of liver capsule -> RUQ pain -> Laparoscopy + adhesiolysis) esp if prolonged / recurrent

Answer 140

https://teachmeobgyn.com/gynaecology/menstrual/oligomenorrhoea/

Answer 141

Tumour of anterior pituitary gland -> excessive prolactin secretion from LACTOTROPHS - can be associated with **multpiple endocrine neoplasia type 1** (autosomal dominant) Can be: - Micro = <10mm - Macro = >10mm

Answer 142

If macro -> raised ICP / headaches + bitemporal hemianotopia etc Also: - High prolactin -> negative feedback to hypothalamus -> reduced GnRH -> reduced LH + FSH -> Reduced oestrogen / testosterone - Inhibits ovulation / spermatogenesis - a/oligomenorrhoea - Erectile dysfunction - Low oestrogen also leads to OSTEOCLAST PROLIFERATION (oestrogen usually inhibits osteoclasts) - Osteoporosis / frax - Vaginal dryness - Gynecomastia - GLACTORRHOEA - Low LIBIDO + INFERTILITY Microprolactinomas are often asymp

Answer 143

- Raised prolactin in blood - Raised Thyrotropin- releasing hormone (if 2ndry prolactinoma) - MRI BRAIN (classify)

Answer 144

Medical = DOPAMINE AGONISTS (oft enough to make tumour regress) - Bromocriptine - Cabergoline Surgery if macro / not responsive to dopamine +/- Radiotherapy

Answer 145

- Bicornate uterus - Imperforate hymen - Transverse Vaginal septae - Vaginal hypoplasia + agenesis

Answer 146

- uterus has 2 'horns' - Dx on USS - ADVERSE PREG outcomes tho USUALLY SUCCESSFUL PREG - Miscarriage - Prem birth - Malpresentation Usually no specific Mx needed

Answer 147

- no hole in hymen at entrance of vagina - Oft discovered when menstruation starts but menses unable to be expelled - Cyclical pelvic pain + cramping but NO bleeding - Dx with EXAMINATION - Tx = Surgical incision If not treated - could lead to retrograde menstruation + endometriosis

Answer 148

- Septum transversely across vagina - If perforate: - Menstruation can occur but difficulty with sex / tampons - If imperforate: - Similar to imperforate hymen - Associated with INFERTILITY / PREG COMPLICATIONS Dx via exam, US / MRI Tx = SURGICAL - complications = vaginal stenosis / recurrance

Answer 149

- Abnormally small vagina / NO vagina respectively - due to failure of Mullarian duct development - Can be associated with absent uterus / cervix as well - BUT OVARIES USUALLY NORMAL - Except in androgen insensitivity syndrome (internal testes) - Mx -> vaginal dilater over prolonged period; vaginal surgery etc

Answer 150

Descent of one/more pelvic structures from normal anatomical position -> moving towards/through vaginal opening - common condition esp in postmenopausal + post childbirth

Answer 151

Anything that cuases stretched muscles / ligaments - Multiple vaginal delivaries - Instrumental, traumatic / prolonged delivery - Advanced age / postmenopausal - OBESITY - COPD -> Coughing OR Chronic constipation + straining (Chronic RAISED ABDOMINAL PRESSURE) - Hysterectomy - Heavylifting - Connective tissue disorders

Answer 152

- Feeling of 'something coming down' - Dragging / Heavy sensation - Visible protrusion - LUTS / recurrent UTIs - Defecatory Sx e.g. constipation / tenesmus - Sexual dysfunction (pain altered sensation)

Answer 153

- attempt various positions INCLUDING DORSAL + LEFT LATERAL - SIM'S SPECULUM - Ask to cough / bear down to assess full descent

Answer 154

Anterior vaginal wall: - Cystocele (may lead to stress incontinence) - Urethrocele - Cystourethrocele Posterior wall: - Enterocele (small intestine) - Rectocele Apical wall: - Uterine prolapse - Vault prolapse (roof of vagina - common after hysterectomy) - (cervical prolapse?)

Answer 155

- associated with CONSTIPATION - Can develop faecal loading in prolapsed part -> Constipation, urinary retention (due to compression), palpable lump (women may push lump back themselves)

Answer 156

Pelvic organ prolapse quantification (POP-Q): - 0 = Normal - 1 = Lowest part >1cm above interoitus (opening) - 2 = Lowest part within 1 cm of interoitus (above OR below) - 3 = Lowest part >1cm below interoitus but not full descended - 4 = Full descent + EVERSION of vagina Anything extending beyond interoitus = **uterine procidentia**

Answer 157

1. Conservative (if mild OR can't tolerate other options) - Physio (PELVIC FLOOR EXERCISES) - Weight loss - Lifestyle changes (e.g. reduced caffine intake / incontinence pad for associated stress incontinence) - Treat associated Sx e.g. anticholinergics for stress incont - Vaginal oestrogen cream 2. Vaginal pessaries (-> extra support + easily removed if needs) - Ring pessaries (around cervix) - Shelf + Gellhorn (flat disk with stem) - Cube - Donut - Hodge pessaries (almost rectangular - hooks around posterior cervix then extends into vagina) +/- Oestrogen cream to protect vaginal walls from irritation / erosion 3. Surgery (e.g. hysterectomy)

Answer 158

- Pain, bleeding, infection, DVT, anaesthesia risk - Damage to bladder / bowel - Recurrance - Altered experience of sex

Answer 159

Many associated complications: - Chronic pain - Altered sensation - Dyspareunia - Abnormal bleeding - Urinary / bowel problems

Answer 160

- Threatened (mild bleeding, pain may be absent, cervical is closed, foetus visible on uss) - Inevitable (heavy bleeding and pain, cervical os open, but foetus still currently inside) - Complete (all products of conception now fully expelled and cervical os usually closed again) - Missed miscarriage (foetus has died but cervical os remained closed so no symptoms)

Answer 161

Foetal causes: - genetic disorder - abnormal development - placental failure Maternal causes: - Physical uterine abnormality - Cervical incompetence - PCOS - Poorly controlled diabetes - Poorly controlled thyroid disease - Anti phospholipid syndrome

Answer 162

Loss of pregnancy before **24 weeks gestation**

Answer 163

- Vaginal bleeding - pain (potentially more than with normal period) - Vaginal tissue loss

Answer 164

In ectopics, pain is usually the initial and dominant feature and any bleeding that occurs is less so than in miscarriages Miscarriages are characterised by heavy bleeding and pain

Answer 165

- Transvaginal USS to check for any interuterine foetal components and check for foetal heartbeat - if not present start doing **serial serum hCG** measurements **48 hours apart** - falling hCG = no more foetal development / miscarriage - plateau / small rise = possibly ectopic - normal rise = foetus growing normally but may still be ectopic

Answer 166

Cannot be reversed so need to get rid of pregnancy - Expectant management = allow it to naturally expel - Medical = ** Misoprostol - synthetic prostaglandin** which stimulates expulsion of products of conception - ***Mifepristone*** is a progestérone receptor antagonist that is used to terminate pregnancy but it is also needed for a missed miscarriage - Surgical - dilation and curettage **Anti-D prophylaxis if mother is rhesus negative**

Answer 167

Loss of **3 or more consecutive pregnancies**

Answer 168

Loss of **3 or more consecutive pregnancies**

Answer 169

- Bloods - Anti phospholipid antibodies - Thrombophilia screen - Cytogenic analysis of products of conception - karyotype the parents if this is abnormal - Pelvic USS (check for uterine abnormalities)

Answer 170

Depends on underlying cause - Genetic = genetic counseling, consider prénatal diagnosis or donor egg/sperm if still trying for kids - structural abnormality = some can be surgically treated - cervical incompetence = regular USS monitoring; can use cervical cerclage - PCOS - Unsure of best treatment, follow local guidelines - Anti phospholipid syndrome = heparin / low dose aspirin - thrombophilia = try heparin - Diabetes = improve glycaemic control

Answer 171

- increasing age - obesity - smoking - excessive alcohol - illicit drug use - anabolic steroids and tight underwear more so in men

Answer 172

- increasing age - obesity - smoking - excessive alcohol - illicit drug use - anabolic steroids and tight underwear more so in men

Answer 173

- Genetic (Turner's / Kleinfelter's) - Ovulation / Endocrine (pcos, pituitary tumor, Sheehan's, hyperprolactinaemia, Cushing, premature ovarian failure) - Tubal abnormalities (congenital or adhesions) - Uterine abnormality - Endometriosis - Cervical abnormality - Testicular disorder - Ejaculatory disorder

Answer 174

- **Serum progesterone** **7 days before end** of menstrual cycle (usually day 21) - assess TFTs, prolactin, androgens - semen analysis - Imaging studies (uss, hysterosalpingography, laproscopy)

Answer 175

- Leuprorelin - Triptorelin Works by activating GnRH receptors for prolonged period till they get desensitized - eventually leading to suppression of gonadotrophin (FSH and LH) secretion Can be used to stimulate a menopausal state and switch off the ovaries e.g. to treat endometriosis (tho this is not the first line)

Answer 176

Cluster of psychological, physical + behavioural Sx occuring in the LEUTEAL pahase of the menstrual cycle which causes DITRESS / DISRUPTION to patient's life

Answer 177

Varies widely but common Sx include: - Mood swings + irritability - Depression + anxiety - Fatigue + sleep problems - Change in appetite + food cravings - Difficulty concentrating - Physical Sx e.g. bloating, breast tenderness, headaches, joint / muscle pain

Answer 178

- Tyroid disease - Chronic fatigue syndrome - Depression / anxiety disorders

Answer 179

Clinical Dx - Sx diary for at least 2 menstrual cycles can be helpful Do further investigations if uncertain / suspect other conditions

Answer 180

Conservative: - Dietary modification - LESS fat, sugar, caffeine, alcohol - MORE fibre, fruit + more frequent snacks - Increase exercise - Vitamin supps (vit B) - Relaxation techniques to reduce stress - CBT Pharm: - cOCP (with short / no pill free interval to avoid progestogenic side effects) - Danazol (synthetic steroid + pituitary GnRH inhibitor) - Transdermal oestrogen - GnRH analogues (menopausal state) - Antidepressants (esp SSRIs / SNRIs)

Answer 181

- Urinalysis + culture to rule out infection - Frequency/volume chart - to assess severity - Urodynamics - to evaluate bladder muscle function (e.g. cystometry, pressure flow study / voiding pressure study)

Answer 182

- Behavioural modifications: - reduce oral intake, avoid caffeine + alcohol - Bladder retraining - ANTICHOLINERGICS - **Oxybutynin** - **Solifenacin** - Vaginal oestrogens if urogenital atrophy is a likely factor - Botulism toxin if REFRACTORY

Answer 183

Number of times person has been pregnant REGARDLESS of outcome, INCLUDING current pregnancies. Mutliple pregnancies are counted as 1 event.

Answer 184

Number of times person has given birth to a pregnancy with gestational age at least 24+0 weeks, regardless of if they were alive or still born, or method of delivery. Multiple pregnancies are counted as 1 event. NB if they have had terminations/miscarriages before 24wks, can write it as - number or of births (+ terminations/miscarriages)

Answer 185

Less than 24 wks gestation Can be more if meets certain criteria: - continuing preg would cause grave permanent injury to physical + mental wellbeing of woman - Continuing preg would involve greater risk to the life of the woman - Substantial risk child would suffer from physical or mental abnormalites and be seriously handicapped (e.g. spina bifida, Down's)

Answer 186

- Mifepristone (progesterone antagonist) blocks progesterone needed for preg to continue - oft 200 mg orally - Misoprostol (prostaglandin analogue) causes smooth muscle contraction to expel uterine contents - oft 800 micrograms vaginal, buccal, or siblingual Given within 24-48 hours of each other

Answer 187

- Suction termination - can be done if less than 14 wkjs preg - Dilation + evacuation / Curettage

Answer 188

- infection - inflam - stress - mechanical stress

Answer 189

- Foul smelling / greenish amniotic fluid - Maternal fever - Reduced foetal movements

Answer 190

- Urinary incontinence - Vaginal discharge / infection (can be ruled out if no other infective sx / no infected seeming discharge)

Answer 191

Oral progesterone receptor modulators - ***Levonorgestrel*** (1.5mg) - Needs to be taken **within 72** hours after unprotected sex (efficacy decreases with time) - One-off tablet; can't be used long-term - but can start hormonal contraception immediately after - Safe and well tolerated - can disrupt menstrual cycle; sometimes causes vomiting - If vomiting within 3 hours of taking pill -> repeat dose - ***Ulipristal*** (EllaOne) - (30mg) - Needs to be taken **within 5 days** after unprotected sex - One off tablet; can't be used long-term - can disrupt effectiveness of hormonal contraception so need to use barrier contraception for 5 days after - **Can cause side effects in patients with ASTHMA** - also need to stop breastfeeding for a week after taking ulipristal (don't have to with levonorgestrel) Copper Intrauterine device - most effective - Needs to be inserted within 5 days of unprotected sexual intercourse OR up to 5 days after estimated ovulation date (whichever comes later) - Can be left in situ to provide long-term contraception - can give Abx if patient at high risk of STI

Answer 192

day 21 after giving birth

Answer 193

**Progesterone only pill** - **Can be started at any point post-partum** - need to use additional contraception for 2 days after day 21 - only a small amount of progesterone enters breastmilk so it is **safe to breastfeed** while on POP **cOCP** - ABSOLUTELY CONTRAINDICATED if BREASTFEEDING less than 6 wks post-partum (UKMEC cat 4) - Some risk present if using while breastfeeding between 6wks - 6 months but generally advantages outweigh risk (UKMEC cat 2) - can potentially reduce breast milk production - CONTRAINDICATED in FIRST 21 DAYS for all mothers due to VTE RISK - If using after 21 days - need to use additional contraception for 7 days **IUD** - needs to be inserted EITHER within 48 HOURS post-partum OR postponed till 4 WKS post-partum (can't insert from 2 days till 4 weeks) **Lactational amenorrhoea** - less effective - only 98% effective if: - FULLY breastfeeding - AMENORRHOIC - less than 6 months post-partum

Answer 194

- more than 35 years old and smoking less than 15 cigarettes/day - BMI > 35 kg/m^2* - family history of thromboembolic disease in first degree relatives < 45 years - controlled hypertension - immobility e.g. wheel chair use - carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2) - current gallbladder disease - **DM diagnosed > 20 years ago (*tho if more severe = cat 4*)**

Answer 195

- more than 35 years old and smoking more than 15 cigarettes/day - migraine with aura - history of thromboembolic disease or thrombogenic mutation - history of stroke or ischaemic heart disease - breast feeding < 6 weeks post-partum - uncontrolled hypertension - current breast cancer - major surgery with prolonged immobilisation - positive antiphospholipid antibodies (e.g. in SLE)

Answer 196

- 4 or more per year - check if compliant with treatment - HIGH VAGINAL SWAB MS+C +/- blood glucose to check for diabetes - exclude differentials e.g. lichen sclerosus - try INDUCTION MAINTENANCE RÉGIME - Oral FLUCONAZOLE every 3 days for 3 doses - oral FLUCONAZOLE every week for 6 months

Gynae Flashcards

(223 cards)