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Gynae > Benign and Malignant Gynae Conditions > Flashcards

Benign and Malignant Gynae Conditions Flashcards

1
Q

What are the top 4-5 gynae cancers in the UK? (in order of incidence)

A
  • Endometrial
  • Ovarian
  • Cervical
  • Vaginal + vulval
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2
Q

What is the most common ovarian tumour?

A

Carcinoma of the ovaries

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3
Q

What are the types of ovarian malignancy?

A
  • Primary: carcinomas, sex cord stromal tumours, germ cell tumours
  • Secondary: mets, Krukenberg tumours
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4
Q

What are the different subtypes of ovarian carcinoma? How common are they?

A
  • High grade serous (75%)
  • Mucinous (10%)
  • Endometrioid (10%)
  • Clear cell
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5
Q

Where do most serous ovarian carcinomas arise from?

A

The Fallopian tubes!!!

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6
Q

Psammoma bodies are a histological feature of which subtype of ovarian carcinoma?

A

High grade serous

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7
Q

Which mutations are most associated with high grade serous ovarian cancers?

A

p53, BRCA

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8
Q

Which precursor lesions can give rise to the different subtypes of ovarian carcinoma?

A
  • Endometriosis: endometrioid and clear cell

- Cysts: low grade serous

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9
Q

Name some risk factors for ovarian carcinoma

A

Nulliparity, endometriosis, PID, smoking, FHx

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10
Q

Name some preventative factors for ovarian carcinoma

A

COCP, multiparity, salpingectomy, oophorectomy

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11
Q

What is the recommended prevention of ovarian carcinoma in women with the BRCA mutation?

A

BSO when family completed

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12
Q

Name some signs + symptoms of ovarian cancer

A
  • Bloating, fatigue, early satiety, abdo+pelvic pain, change in bowel habits, urinary symptoms
  • Abdo distension/masses, ascites, prominent lymph nodes, pleural effusion
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13
Q

A 66 year old woman comes to the GP complaining of non-specific abdo pains, bloating, and feeling full quickly after eating for the past 4 months. How would you manage this patient?

A
  • Full history and abdo + bimanual exam
  • Bloods: FBC, U+Es, Ca-125
  • TVUSS
  • 2 week wait!!
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14
Q

What tumour markers are there for ovarian carcinoma (and what are they associated with)?

A 
CA 125: serous carcinoma
CA 19-9: mucinous carcinoma
Inhibin: GC tumours
AFP: teratoma
hCG: dysgerminoma, choriocarcinoma
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15
Q

How is ovarian cancer staged?

A

FIGO staging

1: confined to the ovaries
2: confined to the pelvis
3: positive lymph nodes or peritoneal implants
4: distant metastases

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16
Q

What is the prognosis like for ovarian cancer?

A

Bad. It is usually detected at a later stage, meaning it has the highest death rate of the gynae cancers

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17
Q

What is the management of ovarian cancer?

A
  • Debulking surgery: total abdominal hysterectomy, BSO, omentectomy, lymph node resection
  • Adjuvant chemotherapy: platinum based chemo (Carboplatin) + paclitaxel for 6 cycles
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18
Q

Describe the common side effects of chemotherapy for ovarian cancer.

A
  • Hair loss
  • N+V
  • Neuropathy
  • Myalgia, arthralgia, fatigue
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19
Q

What is the management for recurrent ovarian carcinoma?

A
  • Can use bevacizumab (anti-VEGF antibody)

- Palliative chemo

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20
Q

What are the types of sex cord stromal tumours? Which is most common?

A
  • Granulosa cell tumours (most common)
  • Thecal cell tumours
  • Fibromas
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21
Q

How can sex cord stromal tumours present?

A
  • Similar symptoms to ovarian carcinoma (bloating, early satiety, etc)
  • Symptoms as a result of oestrogen or androgen production (virilisation, precocious puberty, abnormal uterine bleeding, amenorrhoea)
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22
Q

How are sex cord stromal tumours managed?

A
  • Surgery is only treatment (unilateral or bilateral SO)

- Long term follow up for granulosa cell tumours (monitor inhibin)

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23
Q

In what age group are germ cell tumours most common?

A

Young women (teens)

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24
Q

Describe the classification of germ cell tumours. How common are the subtypes?

A

Either undifferentiated (dysgerminoma) -commonest, 50%
or differentiated- divided into:
-Teratomas (mature- benign or immature- malignant)
-Choriocarcinoma
-Endodermal sinus/yolk sac tumours (15%)

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25
Q

How are germ cell tumours managed?

A
  • Fertility-sparing surgery with peritoneal biopsy, lymph node sampling
  • +/- adjuvant chemo with BEP (bleomycin, etoposide, cisplatin)
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26
Q

What is the most common type of endometrial cancer?

A

Carcinoma

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27
Q

What is the most common age to be diagnosed with endometrial cancer?

A

Early 60s (62)

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28
Q

What are the 2 histological types of endometrial cancer? Describe the aetiology of each.

A

Type 1: low grade. Includes endometrioid, mucinous, secretory. Arises on the background of endometrial hyperplasia.
Type 2: high grade. Includes serous, clear cell. Arises on the background of atrophic endometrium.

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29
Q

What are the risk factors for endometrial carcinoma?

A

Type 1: any high-oestrogen states. eg. obesity, PCOS, HRT, nulliparity, early menarche/late menopause
Type 2: older age, family history

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30
Q

Describe the signs + symptoms of endometrial cancer

A
  • Postmenopausal bleeding!!!!! or IMB if premenopausal, abdominal/pelvic pain, bladder/bowel symptoms
  • Bulky uterus, bleeding from os
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31
Q

A 59 year old woman attends the GP complaining of PV bleeding. She has not had periods in 6 years and is not on HRT. How would you like to manage this case?

A
  • Take a full history and perform an abdo + pelvic exam, including speculum
  • Bloods: FBC
  • TVUSS!
  • Refer to gynae 2WW clinic
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32
Q

A 59 year old woman attends the GP complaining of PV bleeding. She has not had periods in 6 years and is not on HRT. On TVUSS, endometrial thickness is 6mm. What would you do next?

A

-Hysteroscopy with biopsy

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33
Q

On TVUSS, what parameter will indicate if endometrial cancer is likely? What is the threshold?

A

Endometrial thickness. <4mm unlikely, >4mm suspicious

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34
Q

What is the best modality for staging endometrial cancer?

A

MRI

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35
Q

How is endometrial cancer staged?

A
  • FIGO
    1: confined to uterus
    2: invading cervix
    3: local/regional spread (serosa, vagina, lymph nodes)
    4: distant metastases, bladder/bowel invasion
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36
Q

Describe the management of endometrial cancer.

A

Total hysterectomy + BSO, lymph node dissection

-+/- radiotherapy and chemotherapy

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37
Q

What is the prognosis of endometrial cancer?

A

Usually quite good. Most are detected at stage I with 80% survival rate.

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38
Q

What are the types of endometrial sarcoma?

A
  • Pure sarcomas (eg. leiomyosarcoma)
  • Mixed epithelial (carcinosarcoma)
  • Heterologous
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39
Q

What are the high risk HPV strains?

A

Classically 16, 18

Also 31, 33, 45

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40
Q

Describe the relationship between HPV and cervical cancer

A

HPV is a very common sexually transmitted virus. In most cases, HPV infection is transient and is cleared by the immune system. However, in some individuals, the virus is not cleared. Persistent infection can lead to DNA damage in epithelial cells of the cervix -> CIN. This can eventually progress to carcinoma of the cervix.

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41
Q

Name several risk factors for persistent HPV infection.

A
  • Smoking
  • HIV positive
  • Immunocompromised
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42
Q

Which part of the cervix does HPV infection affect?

A

The transition zone. This is the area between the current + past squamocolumnar junctions (this changes over time).

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43
Q

Describe the cytological appearance of CIN

A

Immature, hyperchromatic cells with large nuclei and less cytoplasm:nuclei, abnormal mitoses

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44
Q

How is CIN graded?

A

1-3, depending on where the abnormal cells are.

1: lower 1/3 of the epithelium
2: lower 2/3s
3: full thickness

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45
Q

What is the term that refers to abnormal cells obtained from a cervical smear?

A

Dyskaryosis

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46
Q

Describe the cervical cancer screening pathway.

A 
25-49: every 3 years
50-64: every 5 years
Cervical brush/broom used to collect cells from the transition zone of the cervix
Sent for high risk HPV testing
-Negative for hrHPV -> routine recall
-Positive for hrHPV -> send for cytology
Normal cytology: repeat HPV testing in 1 year
Abnormal cytology: colposcopy

Normal cytology recall:

  • If now hrHPV negative: routine recall
  • If still hrHPV positive: cytology
  • If cytology neg: 12 months recall. If STILL hrHPV positive, colposcopy.
  • Basically, they get 2 chances to have hrHPV. ON the third time, colposcopy no matter the cytology
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47
Q

Describe colposcopy like you would to a patient.

A
  • An examination of the cervix done to detect any abnormal cells. Takes 15-20 minutes. Done as outpatient
  • Uses a special microscope with a light. Apply special liquids to the cervix that help show any abnormal cells
  • +/- biopsy. This may be uncomfortable
  • If the doctor sees abnormal cells, they may remove them during the examination.
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48
Q

What is done during colposcopy?

A
  • Examine the cervix using a microscope
  • Apply stains:
  • Acetic acid: turns areas of turnover WHITE
  • Iodine: everything will turn brown except for CIN (because there is no glycogen)
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49
Q

What happens after colposcopy? *****

A
  • No dyskaryosis: routine recall
  • Low grade dyskaryosis: cytology and colposcopy in 6 months
  • High grade dyskaryosis: treatment
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50
Q

What are the management options for CIN? What are the advantages and disadvantages of each?

A

Loop diathermy (LLETZ- large loop excision of TZ)

  • Pros: LA as outpatient, short (15 mins), effective, sample for pathology
  • Cons: must be at least 7mm deep, can increase risk of miscarriage/preterm delivery if large/repeated

Cone biopsy
-Cons: GA, can cause cervical stenosis or incompetence in 5% of women

  • Also: cold coagulation
  • Follow up with ‘test of cure’ hrHPV test and cytology at 6 months
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51
Q

Which strains are included in the HPV vaccines?

A
  • Bivalent: 16 + 18

- Quadrivalent: 6, 11, 16, 18

52
Q

Describe the signs + symptoms of cervical cancer

A
  • Bleeding! PCB, IMB, PMB
  • Dyspareunia
  • Palpable mass
  • Advanced: pain, incontinence, anaemia, renal failure
53
Q

What are the common histological types of cervical cancer? What are their precursors?

A
  • 70% are squamous cell carcinomas –CIN

- The rest are adenocarcinomas –CGIN

54
Q

How is cervical cancer staged?

A

FIGO. Biopsy, MRI, CXR/CTCAP

1: confined to cervix. Both microscopic and clinical lesions
2: Involves vagina (upper 2/3) or parametrium
3: involves lower vagina, pelvic side wall, ureters
4: bladder/bowel/beyond pelvis, metastases

55
Q

Describe the management of cervical cancer.

A

-Depends on stage
1A (microscopic): excise using LLETZ/cone biopsy
1B/some 2: Wertheim’s hysterectomy (radical hysterectomy + lymph node dissection), or radical trachelectomy (cervix and vagina) to preserve fertility
Later stage: radiotherapy (external beam or brachytherapy) with adjuvant platinum-based chemo (cisplatin)

56
Q

What are the complications of surgery for cervical cancer?

A
  • Pain, bleeding, infection
  • Bladder dysfunction
  • Sex difficulties (dyspareunia)
  • Lymphoedema
57
Q

What are the risk factors for vaginal cancer?

A
  • HPV infection (VaIN)

- Pelvic radiotherapy

58
Q

Describe the presentation of vaginal cancer.

A
  • Usually presents in older women (60-70s)
  • Bleeding, discharge, pain, mass/ulcer
  • Haematuria, constipation, tenesmus
59
Q

How is vaginal cancer staged?

A

FIGO.

1: vagina only
2: subvaginal
3: pelvic side wall involved
4: bladder/bowel involvement, extends

60
Q

What investigations are needed for the workup investigations of vaginal cancer?

A
  • Examination under GA
  • Cystoscopy, rectosigmoidoscopy
  • MRI
  • CT CAP for mets
61
Q

What is the management of vaginal cancer?

A

Radiotherapy

62
Q

Which type of vaginal cancer presents in young girls?

A

Sarcoma botryoides

63
Q

Name some risk factors for vulval cancer.

A
  • hrHPV infection

- Lichen sclerosus

64
Q

Describe the appearance of VIN and lichen sclerosus

A

VIN: multifocal pink/red/white area, can be itchy and irritated
Lichen sclerosus: figure of 8 leukoplakia

65
Q

Describe lesions that would make you worried about vulval cancer (opposed to non-malignant lesions)

A
  • Hard + craggy
  • Bleeding/easily friable
  • Raised/ulcerated lesion
  • Areas of premalignant change around
  • Palpable inguinal nodes
66
Q

Describe the staging of vulval cancer.

A

FIGO

1: confined to vulva
2: lower 1/3 urethra, vagina, anus involved
3: lymph node involvement
4: invasive disease or metastases

67
Q

Describe the management of vulval cancer

A

Radical surgical excision with neoadjuvant chemoradiation

-Sentinel lymph node biopsy to determine if lymph node resection is needed

68
Q

Name some differential diagnoses for a pelvic mass

A
  • Gynaecological: pregnancy, tumours eg. ovarian cancer or mature teratoma, ovarian cyst, hydrosalpinx, ectopic pregnancy, fibroids
  • Colorectal: appendix mass, constipation, colorectal malignancy
  • Urinary tract: renal or bladder malignancy
  • Other: lymphoma, aortic aneurysm
69
Q

List the different types of benign ovarian masses

A

Functional: follicular, corpus luteal, thecal
Inflammatory: endometrioma
Germ cell: teratoma (aka dermoid cyst)
Epithelial: serous and mucinous cystadenoma, Brenner’s tumour
Sex cord stromal: fibroma, thecoma

70
Q

The other name for a mature teratoma is ___

A

Dermoid cyst

71
Q

A Brenner’s tumour is ___

A

A type of epithelial ovarian cyst of urothelial-like epithelia that secretes oestrogen. Common in older age + perimenopausal women

72
Q

Functional cysts are common in which age group? Germ cell tumours?

A

Functional cysts are common in younger women of reproductive age
Germ cell tumours (eg. teratomas) are more common in young women around early 20s

73
Q

How can ovarian cysts present?

A
  • Incidental finding
  • When large can have pelvic pain and pressure symptoms eg. bladder + bowel
  • Can present acutely due to torsion, rupture, haemorrhage
74
Q

What is the syndrome associated with fibromas?

A

Meig syndrome. Fibroma + pleural effusion and ascites

75
Q

A 29 year old woman comes to the GP clinic complaining of a swelling in her right pelvis. What is your approach?

A

History:

  • Onset, progression, site, size
  • Discomfort/pain, bladder + bowels, fever
  • Periods: LMP, regularity, cycle length, HMB/painful
  • STIs: check active, last STI check, UPSI since then
  • PMH, gynae Hx, DHx, allergies
  • FHx of cancers

Examination: abdo pelvis with speculum and bimanual
Ix: hCG, TVUSS + TAUSS, Ca-125, FBC (for WCC), CRP.
Refer to gynae clinic, *2WW if the patient has risk factors

76
Q

How does ovarian torsion present? How is it diagnosed? Management?

A
  • Presents with acute unilateral pelvic pain, N+V, shock
  • TVUSS is key imaging
  • Management is emergency laparoscopy to untort the ovary and cystectomy +/- oophorectomy if severely necrotic
77
Q

Which type of cysts are associated with pregnancy?

A

Thecal luteal cysts (a type of functional cyst)

78
Q

Which cysts often require surgery?

A
  • Usually dermoid cysts, sex cord stromal tumours, epithelial cysts
  • Large cysts eg. >5cm
  • Symptomatic cysts
  • Rapidly enlarging
79
Q

What are the common sites for endometriosis?

A
  • Pouch of Douglas
  • Uterosacral ligaments
  • Pelvic peritoneum
80
Q

Describe the pathophysiology of endometriosis

A

Ectopic endometrial tissue that is responsive to cyclical changes in hormones
-> growth and bleeding as the uterine endometrium bleeds
-> cyclical pelvic pain typically starting before bleeding, dyspareunia, dyschaezia, blood in the stool or urine
+ fibrosis, scarring, adhesions, endometriomas, etc

81
Q

What are the 2 theories of pathogenesis of endometriosis?

A
  • Sampson’s ‘implantation’ theory: retrograde menstruation up the tubes deposits endometrial cells in the peritoneum
  • Meyer’s ‘coelemic metaplasia’ theory: cells in the peritoneum undergo metaplasia to become columnar epithelium
82
Q

What are the signs of endometriosis on clinical examination?

A

Rectovaginal nodules (in the Pouch of Douglas), thickened uterosacral ligaments, adnexal masses, non-mobile uterus

83
Q

How is endometriosis diagnosed?

A
  • TVUSS can show endometriomas, ‘kissing ovaries’
  • MRI can show lesions >5mm
  • Diagnostic laparoscopy is gold standard. Can also do excision at the same time.
84
Q

What is the management of endometriosis?

A
  • Conservative: NSAIDs, paracetamol
  • Medical: hormonal contraception (eg. COCP back to back), progesterone only contraceptives, GnRH analogues (max 6 months)
  • Surgical: laparoscopy for excision of endometriosis lesions, cystectomy. Last resort: hysterectomy + oophorectomy.
85
Q

Define chronic pelvic pain

A

Intermittent or continuous pelvic pain lasting for >6 months not occuring exclusively with menstruation or pregnancy

86
Q

List some causes of chronic pelvic pain

A
  • Gynaecological: endometriosis, PID related adhesions, adenomyosis, fibroids, cysts
  • GI: IBS, IBD, constipation
  • Urological: bladder pain syndrome, recurrent UTI
  • MSK: joint pain, muscle pain
  • Functional pain syndromes
87
Q

A 25 year old woman attends the gynae clinic complaining of pelvic pain that started 8 months ago. What do you want to know?

A
  • Pain: progression, severity, character, timing, trigger, relieving + exacerbating factors (period, foods, opening bowels)
  • Bladder, bowels
  • Periods: LMP, regularity, cycle length, bleeding, dysmenorrhoea, IMB
  • Contraception, smears, sexual activity + pain during sex, discharge
  • Gynae Hx, PMH, DHx, allergies
  • FHx fibroids, gynae cancers
  • SHx
88
Q

Describe your approach to investigating + managing chronic pelvic pain

A
  • Examination: abdo pelvis
  • Ix: urine dip, vaginal swabs, TVUSS. Consider further tests as guided by indications eg. FBC, Ca125, anti-TTG
  • Management: depending on the findings eg. antibiotics for PID, laparoscopy for endo, laxatives, etc.
89
Q

Define cervical ectropion. When does it occur?

A

Occurs when the columnar epithelium (which is red) is visible around the external os on the ectocervix.
Due to pregnancy, pill, or puberty

90
Q

How is cervical ectropion managed?

A
  • If asymptomatic, no need to do anything
  • If bothersome eg. PCB/IMB, excessive discharge -> change off oestrogen based contraception
  • Important to smear and swab if experiencing symptoms
91
Q

Name some benign conditions of the cervix

A

Cervical ectropion, polyps, Nabothian follicles

92
Q

What is a complication of cervical stenosis?

A

Haematometra: build up of blood in the uterus but inability to drain via the cervix
Also pregnancy/labour related complications eg. poor progress in the 1st stage

93
Q

What are the symptoms of endometrial polyps? How are they diagnosed?

A

Asymptomatic, AUB eg. IMB, PMB or sometimes subfertility. They are not sensitive to hormones, so may bleed randomly.
-May be diagnosed incidentally or after TVUSS or hysteroscopy for AUB

94
Q

What is the best way to visualise endometrial polyps?

A

Hysteroscopy or saline infusion sonography (SIS)

95
Q

What is Asherman syndrome? What is it caused by? How is it treated?

A

Irreversible damage to the endometrium leading to scarring and fibrosis.
Caused by D&C, endometritis, 2ndary PPH
Treat with hysteroscopic adhesiolysis. Difficult operation.

96
Q

What is a fibroid? What are the risk factors for fibroids?

A

Also known as a leoimyoma, a benign tumour/proliferation of myometrium.
RFs: African origin, FHx, nulliparity, obesity

97
Q

How are fibroids classified?

A
  • By location

- Submucosal, intramural, subserosal, cervical

98
Q

Describe the presentation of fibroids and the course

A

Fibroids often present in the 30s-40s. Can have HMB, pressure symptoms, subfertility, dysmenorrhoea

99
Q

What are the types of fibroid degeneration?

A

Red degeneration: occurs during pregnancy. Fibroid growth outstrips blood supply -> necrotic and painful
Hyaline: softens and liquefies. Asymptomatic
Cystic: asymptomatic central necrosis -> cysts -> calcification

100
Q

A 36 year old patient attends gynae clinic with HMB. What would you like to know?

A
  • Bleeding: quantify amount, length of bleeding, onset of HMB, progression, impact on life
  • Periods: LMP, cycle regularity + length, pain, IMB
  • Anaemic symptoms: SOB, dizziness, fatigue
  • Pressure symptoms
  • Contraception, smears
  • Gynae Hx, Obs Hx, PMH, DHx, allergies
  • FHx of fibroids
101
Q

Describe the management of fibroids. When are these options indicated?

A

Medical: for small fibroids <3cm

  • Non-hormonal: NSAIDs, tranexamic acid
  • Hormonal: COCP, LNG-IUS, GnRH analogues for confirmation prior to surgery

Uterine artery embolisation: for larger fibroids >3cm or failed medical management

Surgical: for larger fibroids or failed medical Mx

  • Hysteroscopic myomectomy, endometrial ablation
  • Laparoscopic myomectomy
  • Hysterectomy

For fertility preservation: non-hormonal contraceptives, UAE, myomectomy (hystero or lap)

102
Q

Define adenomyosis. How does it present?

A

Ectopic growth of endometrial glands and stroma within the myometrial layer.
Dysmenorrhoea, HMB, uterine enlargement

103
Q

The best imaging for uterine pathology is ___

A

MRI. This will show fibroids, adenomyosis, and other soft tissue abnormalities very clearly

104
Q

How is adenomyosis managed?

A

Medical: LNG-IUS, COCP, GnRH analogues
Surgical: hysterectomy

105
Q

Name some causes of vulval pruritus

A
  • Vaginal atrophy
  • Infections eg. Candida
  • Dermatological: lichen sclerosus, lichen planus, eczema, dermatitis
  • Malignancy
106
Q

Describe the management of vulval pruritus

A

Conservative management: stop using soaps/washes/lotions, use natural oils eg olive, loose fitting cotton underwear, non-bio laundry soap

Medical if indicated: antifungal treatment eg clotrimazole creams/pessary, oestrogen creams/moisturisers, steroid creams

107
Q

When should vulval biopsy be taken? What type of biopsy is taken?

A

-Concerns of malignancy
-Diffuse leukoplakia
-Erythema not resolving with steroids or emollients
-Persistent ulcer, pigmented lesion, raised area
Take a Keyes punch biopsy using LA

108
Q

What is lichen planus? How does it present? What is the management?

A

Common autoimmune condition affecting the skin around the vulva. Usually affects women in 40s or older
Presents with pruritus, discomfort, superficial dyspareunia, oral lesions, genital lesions -> scarring and stenosis
Managed with topical steroids, progressive vaginal dilatation if stenosis is present

109
Q

What is lichen sclerosus? How does it present? What is the treatment?

A

Destructive inflammatory skin condition affecting the anogenital area
Presents with pruritus, discomfort and pain, superficial dyspareunia, bleeding. Thin white epithelium
Managed with high dose topical steroids and emollients. Daily admin for 1 month -> alternative days for 1 month -> 2x weekly for 1 month

110
Q

Vulval cancer is associated with which skin condition

A

Lichen sclerosus

111
Q

Name some vulval cysts. How do they present? What is the management?

A
  • Bartholins most common, Skene gland cyst
  • Present with localised swelling +/- erythema, tenderness, dyspareunia due to infection (abscess)
  • Management:
  • Asymptomatic: monitor, excision
  • Symptomatic (abscess): incision and drainage eg. Word catheter, marsupialisation surgery. + antibiotics broad spectrum
112
Q

What is vulvodynia?

A

Vulval pain without skin disease or infection =functional disorder. May occur at rest, during sexual activity/speculum etc.

113
Q

What is the management of vulvodynia?

A
  • May need psychosexual medicine referral
  • Reduce allergens + irritating factors
  • Perineal massage
  • Neuromodulators eg. amitriptyline
114
Q

Define the types of dyspareunia and differential diagnoses.

A

Superficial: pain on penetration, due to pathology in the vulva/vestibule.
-DDx: vulvovaginitis, vulvodynia, HSV, vaginal atrophy, dermatitis, lack of lubrication, Bartholins, vaginismus

Deep: pain after deep penetration, felt within the pelvis.
-DDx: cervicitis, PID, endometriosis, fibroids, cervical pathology

115
Q

A 29 year old patient comes to the GP complaining of pain during sex. What would you like to know? What is your approach to diagnosis?

A
  • Pain: site (superficial, deep), onset, progression, character, severity, how long it lasts, triggers (sex, tampons, etc), associated PCB
  • Other symptoms: dryness, discharge, itching, dyschezia
  • Periods: LMP, regularity, length, pain
  • Contraception + sexual activity
  • Smears
  • PMH, gynae Hx, DHx, allergies
  • ICE!! +screen for sexual abuse
116
Q

A 29 year old patient comes to the GP complaining of pain during sex. What would you look for on examination? What investigations would you do?

A

On examination: palpate for enlarged/tender uterus, inspect the vulva, speculum to visualise cervix, bimanual for fixed uterus+nodules, cervical excitation, vaginismus

Investigations: swabs for STIs including vag pH, TVUSS if deep

117
Q

Describe the advantages and disadvantages of different approaches for a hysterectomy

A

Abdominal (laparotomy):

  • Pros: better visualisation of structures, can do oophorectomy easily, can remove a large uterus (eg. fibroids)
  • Cons: less cosmetically appealing, greater risk of infection+pain from wound, longer recovery time

Vaginal:

  • Pros: less invasive, quicker recovery, better if frail/elderly
  • Cons: can’t remove large uterus or ovaries, limited visualisation
  • LAVH/TLH: reduces disadvantages of laparotomy
118
Q

Name some common and uncommon complications of hysterectomy, and how these are reduced

A

Common: pain, bleeding, infection, DVT, menopausal symptoms if oophorectomy, new bladder symptoms
-Give analgesia and antibiotics postop, LMWH if indicated

Uncommon: damage to surrounding structures (bladder/bowels/ureters), prolapse

119
Q

Name the different incisions that may be used during surgeries

A
  • Pfannenstiel: transverse suprapubic curved incision. For Caesarean section. Joel-Cohen (straight incision) is now preferred due to decreased risk of infection and pain
  • Midline vertical incision: for laparotomy. If dense adhesions in pelvis, emergency requiring better field of view, large fibroid uterus, cancer surgery
120
Q

What is ERPC? What are the risks associated with the procedure?

A
  • Evacuation of retained products of conception. Used for surgical management of miscarriage/surgical TOP
  • Patient under GA or LA
  • Cervix is dilated and suction curettage used to remove products
  • Risks: bleeding may last for several weeks, pain/discomfort during + postop, infection (give postop antibiotics), repeat procedure if products remain
121
Q

What is hysteroscopy? What are the indications and the risks?

A
  • Hysteroscopy is a procedure in which a camera is inserted through the cervix into the uterus
  • Allows visualisation of the endometrium +/- biopsy and therapeutic: myomectomy, polypectomy, adhesiolysis
  • Indications: PMB, IMB, abnormalities on TVUSS, suspicion of fibroids/endometrial pathology, etc
  • Risks: bleeding, pain, infection, perforation, damage to cervix
122
Q

Tranexamic acid is an ____ (type of drug)

A

Antifibrinolytic

123
Q

Why are NSAIDs used in the management of HMB?

A

They inhibit prostaglandin synthesis which is thought to inhibit inflammation and therefore bleeding (up to 30% reduction in blood loss).

124
Q

What is used to determine referral to 2WW in suspected ovarian malignancy?

A

RMI (risk of malignancy index)

  • CA125 level
  • Menopausal status (1 -pre or 3-post)
  • Ultrasound score (0, 1 or 3 if 2-5): multilocular cyst, solid areas, metastases, ascites, bilateral lesions
125
Q

What RMI would be referred?

A

Different number in NICE and RCOG.
NICE: 250
RCOG: 200

126
Q

Which is more common, BV or Candida?

A

BV

Gynae (6 decks)

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