4 - Gynaecology Flashcards by Rachel Barlow-Evans

Steps for administering an intracervical block

2ml mepivicaine in dental syringe
Inject 0.2ml under skin of anterior lip at 12 o’clock
Apply tenaculum to anterior lip
Insert needle at 3 o’clock into external os - parallel to canal
Withdraw and inject 0.9 ml
Insert needle at 3 o’clock into external os - parallel to canal
Withdraw and inject 0.9 ml
Wait 2 mins

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Risk factors for HPV

Increased number of sexual partners
Persistent infection
Immunocompromise
Higher viral load
Cigarette smoking
Lower socio-economic status
Prolonged use of COCP
Higher number of pregnancies

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How to protect against HPV infection

Condom use
Late first pregnancy
(Gardasil)

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Cell type of ectocervix

Non-keratinising stratified squamous epithelium

Resistant to low vaginal PH

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Cell type of endocervix

Mucin-secreting columnar epithelium

Undergoes squamous meta plasma when exposed to vaginal PH

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What is the transformation zone of the cervix

Where columnar epithelium has undergone metaplasia to become squamous epithelium.
Area between old and new squamo-columnar junction.

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Cytological feature of cervical dyskaryosis

Increased nuclear:cytoplasmic ratio
Mitotic figures
Nuclear pleomorphism
Nuclear hyperchromasia

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Cytological features of cervical HPV infection

Koilocytosis
Hyperkeratosis
Multinucleation

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Depth of changes in CIN1

Changes in basal 3rd of epithelium

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Depth of changes in CIN2

Basal 2/3 of epithelium

More marked nuclear atypia

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Depth of changes in CIN3

Entire epithelium

More severe changes

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Incidence of endometriosis

10-20% in F of reproductive age

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what is endometriosis

Extrauterine endometrial stromal and glandular tissue.

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Theories on pathophysiology of endometriosis

retorgrade menstruation
coelomic metaplasia
haematogenous or lymphatic dispersion
immunological dysfunction

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cyclical pattern of endometriosis

Respond to cyclical changes in oestrogen and progesterone.
Proliferation, shedding and bleeding.
In turn leads to inflammation, fibrosis, adhesions and scarring (and reportedly pelvic pain).

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Diseases which frequently co-exist with endometriosis

fibromyalgia, chronic fatigue syndrome, IBS.

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Symptoms of endometriosis

Incidental finding
Chronic or cyclical pelvic pain
Subfertility
Adnexal masses

Managment of endometriosis

pharmacological - COCP, GnRH analogues, progestogen implant, pill or inj, Mirena, aromatase inhibitors (less common)
surgical treatment - after 3-6m trial of ovarian supression

Prefered surgical managment of endometriosis

Excision if severe.
Alternative is ablation.
Cystectomy for endometrioma rather than aspiration.
Final option - TAH + BSO

What does uterine artery embolisation involve

Minimally invasive occlusion of the uterine artery is with polyvinyl alcohol beads.
Transfemoral approach
Local anaesthetic and light sedation

Causes of menorrhagia

40-60% no pathology
20% anovulatory cycle
Fibroids
Endometrial polyp
Endometriosis
Adenomyosis
Endometritis
PID
Endometrial hyperplasia
Endometrial carcinoma
Systemic disease-hypothyroidism, liver, kidney, obesity, von Willebrand disease
IUD

Medical management of menorrhagia

Mirena -1st line

Tranexamic acid / Mefenamic acid / POP/COCP - 2nd line

Types of eczema

Atopic - allergic
Allergic contact
Irritant contact

Symptoms + signs of vulval eczema

Vulval Itch and soreness
Excoriation
Erythema, lichenification
Fissuring and pallor or hyperpigmentation

Complications of vulval eczema

Secondary infection

Management of vulval eczema

``` Avoid precipitant Emollient Emollient soap substitute Topical corticosteroid Combined antifungal +/- antibiotic if required ```

Symptoms of vulval psoriasis

Itch, soreness and burning

Signs of vulval psoriasis

Well demarcated Erythematous plaques Often lacks scaling Frequent in natal cleft Fissuring

Management of vulval psoriasis

``` Avoid irritating factors Emollient Topical corticosteroid Week coal tar preparations Vitamin D analogues ```

Aetiology of VIN

May become cancerous if left untreated. Can be HPV related - may resolve May be lichen sclerosis or lichen planus related - higher risk of progression to SCC

Symptoms of VIN

Lumps, erosions, burning, itch, irritation, pain

Clinical appearance of V I N

Variable Raised white, erythematous , pigmented Lesions may be warty, moist, eroded Multi focal lesions common

Complications of VIN

Development of SCC Recurrence Psychosexual consequences

Diagnosis of VIN

Biopsy

Management of VIN

``` colposcopy Cervical cytology up-to-date Local excision Imiquimod cream Vulvectomy ```

Follow-up of VIN

Vulval clinic | Close follow-up

Most common type of cervical cancer

80% squamous cell carcinoma | 20% adenocarcinoma

Presentation of triple x (47XXX)

``` Female 1:1000 Neuromuscular delay Developmental delay Immature behaviour Reduced IQ Tall ```

Anovulation may be associated with what | 8

``` Drugs including some contraception Stress / depression Excess exercise Excess weight loss Chronic renal failure Asthma PCOS Cushing syndrome ```

``` Normal ranges for: Ostradiol LH FSH Prolactin Testosterone ```

``` Normal ranges for: Ostradiol 130 - 830 pmol/L LH 1-10 mu/L FSH 1 -10 Prolactin 50 - 450 U/L Testosterone <3 pmol/L ```

Common causes of PMB

``` Atrophy - 60% Polyps - 12% Endometrial cancer - 10% Endometrial hyperplasia - 10% Hormonal effect - 7% Cervical cancer <1% ```