Bleeding Problems & General Gynaecology Flashcards
What is the average absorbency of period products?
Menstrual disks - 61ml
Tampons/cups/pads - 20-50ml
Period pants - 2ml
How does an endometrial polyp appear on TVUS?
Hyperechoic lesions with regular contours in the uterine cavity, surrounded by a thin hyperechoic halo
What is the risk of progression from endometrial hyperplasia without atypia to endometrial cancer if left untreated?
2%
When is a fibroid classed as subserosal?
Subserosal, and <50% intramural
When is a fibroid classed as intramural?
Subserosal but >/= 50% intramural, or 100% intramural (no distortion into activity)
When is a fibroid classed as submucosal?
Any distortion of the cavity, irrespective how much it is intramural
Which histologic subtype of endometrial cancer is likely to confer the best prognosis?
Endometrioid adenocarcinoma
Why is shoulder pain common after a laparoscopy?
The diaphragm and the skin over the shoulder are supplied by the same set of nerves that arise from the cervical plexus
What is the standard for semen volume?
> /= 1.5ml
What is the standard for semen pH?
> /= 7.2
What is the standard for semen concentration
> /= 15 million per ml
What is the standard for total sperm number
> /= 39 million per ejaculate
What is the standard for semen vitality?
> /=58% live sperm
What is the standard for sperm morphology?
> /=4%
What is the standard for sperm motility?
40% or more motile or 32% or more with progressive motility
If a semen analysis is abnormal, when should it be repeated?
In 3 months
If azoospermia, or severe oligozoospermia i.e. <5 million sperm/mL detected, repeat analysis ASAP
Should antisperm antibodies be screened for in a semen analysis?
No
What level of progesterone is suggestive of anovulation?
<16
What level of progesterone confirms ovulation HAS taken place?
> 30
How do fibroids appear on USS?
- Solid, round and well defined
- Hypoechoic and heterogenous
- Distortion of the outer uterine contour
- Calcifications appear hyperechoic
- Circumferential flow on colour doppler
- Acoustic shadowing (large fibroids)
What is the microscopic appearance of fibroids on histology?
- Spindle cells arranged in fascicles
- Cigar shaped nucleus
- Normal mitotic activity
- Well differentiated
- Abundant extracellular matrix
What are the most common types of female pelvis?
Gynaecoid (>50%)
Anthropoid (25%)
Android (20%)
Platypelloid (<5%)
Which type of pelvis is most accommodating for childbirth?
The gynaecoid pelvis. Rounded pelvic inlet and a wide subpubic arch of 80-90 degrees.
The android being the least accommodating
What is the lifetime risk of uterine cancer?
1 in 36
In any woman with postmenopausal bleeding, what is the risk of endometrial cancer?
5-10%
What are the two categories of uterine cancer?
Type 1 cancers are associated with unopposed oestrogen
Type 2 cancers are oestrogen independent and often related to genetic mutations
What is the most common histological form of endometrial cancer?
Endometrial endometrioid adenocarcinoma - 80% of endometrial Ca
What % of endometrial cancers occur in women <40?
1%
What is ‘carneous’ degeneration?
Red degeneration
To what does cervical mucus become clear, stringy and alkaline in response to?
Rising oestradiol levels
What is the effect of progesterone on discharge?
Thick, acidic
In what proportion of cases of menorrhagia is no cause identified?
50%
What proportion of women with BRCA2 mutation develop ovarian cancer?
11-17%
Are endocervical polyps more common in pre-menopausal or post-menopausal women?
Post-menopausal
What are endocervical polyps?
Common, often asymptomatic growths due to glandular epithelial hyperplasia
Usually benign, however risk of malignancy is higher in postmenopausal women
Which is more common, endo- or ecto-cervical polyps?
Endocervical polyps
What is the most common site of LN mets in cervical cancer?
External iliac, internal iliac and obturator groups
How does endometrial hyperplasia WITH atypia present histologically?
Irregular, enlarged, rounded nuclear contours
Prominent, enlarged nucleoli
Coarse vesicular chromatin
How does endometrial hyperplasia WITHOUT atypia present histologically?
Nucleoli are NOT prominent
What are the different types of functional ovarian cyst?
Follicular (the most common)
Corpus luteal
Theca luteal
What is the 5 year survival with stage IV cervical cancer?
20-30%
From what cell type does adenocarcinoma of the cervix develop?
Columnar epithelium
Cysts under what size in pre-menopausal women don’t require F/U?
50mm - will resolve within 3 cycles
What should the F/U of simple cyst between 50 and 70mm be?
F/U in 1 year - if not resolved, consider operative management
Group II ovulation disorders account for what % of ovulation disorders?
80-85%
PCOS accounts for what % of anovulatory infertility?
75%
What is the hormonal profile in PCOS?
Normal gonadotrophins
Normal oestrogen
Increased testosterone
Decreased SHBG
How do Nabothian follicles come about?
Benign, mucus containing cysts trapped within the cervical transformation zone
Occur following squamous metaplasia of columnar epithelium
What factors decrease the risk of ovarian Ca?
Oral contraceptive use
Higher Parity
Breast feeding
Hysterectomy
Tubal Ligation
Statins
SLE
What factor increases the risk of ovarian Ca?
HRT
What are the features of mucinous cyst adenomas?
Usually large
Multilocular
Thin walled septa
Locules may vary in echogenicity due to variation in fluid content
What are the features of serous cyst adenomas?
Usually unilocular
What is the origin of an ovarian dermoid cyst?
Purely ectodermal in origin, so contains dermal and epidermal elements
What is the origin of an ovarian mature cystic teratoma?
Tissue can arise from any of the three germ cell layers (mesoderm, endoderm and ectoderm). Normally 2 of the 3 are seen
What are the features of ovarian fibromas?
BENIGN
Ascites
Solid, hypo echoic mass on USS
A type of sex-cord stromal tumour
Histological appearances include spindle cells and collagen
What are the features of thecomas?
- Sex cord-stromal tumour, arising from theca cells
- Almost always benign
- USS features are variable, may be hypoechoic, solid or mixed
- Most common in postmenopausal women
- Oestrogen secreting so cause endometrial hyperplasia resulting in post-menopausal bleeding –> high risk for endometrial cancer
Aside from thecomas, what type of tumours are also oestrogen secreting?
Granulosa cell tumours (although not always benign, unlike thecomas)
An RMI of what suggests need referral for specialist MDT (according to NICE)?
> 250
How are PCO defined on USS?
One or both ovaries with 12 or more follicles (with a diameter of 2-9mm) or an ovarian volume greater than 10cm-cubed
How is RMI - RMI = U x M x Ca-125 - calculated?
USS features (1 point for each)
- Multilocular cysts
- Solid areas
- Metastases
- Ascites
- Bilateral lesions
USSscore:
0 points = 0
1 point = 1
2-5 points = 3
Menopausal status
Pre-menopausal = 1
Post-menopausal = 3
What is the lifetime risk of ovarian cancer?
2% - leading cause of death from gynaecological cancer
What is the 5 year survival for ovarian cancer?
35%
A Ca-125 > than what warrants further investigation?
35
In women <40 with suspected ovarian cancer, what other tumour markers should be requested?
Alpha fetoprotein (AFP)
Beta human chorionic gonadotrophin (beta-hCG) Serum CA125
What size hysteroscopes should be used in outpatients?
2.7mm with a 3–3.5mm sheath
What can be used for endometrial protection/withdrawal in oligo/amenorrhoea in PCOS?
A cyclical progestogen, such as medroxyprogesterone 10 mg daily for 14 days every 1–3 months
CHC
LNG-IUS
If unacceptable, regular USS 6-12 monthly may be required for surveillance
What additional antenatal considerations should be given for women with PCOS?
An OGTT, ideally pre-conceptually, but also before 20 weeks, and again 24-28 weeks
What surveillance should be in place for those with endometrial hyperplasia without atypia?
6-monthly
2 consecutive 6-monthly negative biopsies required prior to discharge
In those with high risk of recurrence, e.g. high BMI, consider annual biopsy
In whom with endometrial hyperplasia without atypia, may hysterectomy be indicated?
Not wanting to preserve their fertility and:
1. When progression to atypical hyperplasia occurs during F/U
- There is no histological regression of hyperplasia
despite 12 months of treatment - There is relapse of endometrial hyperplasia after completing progestogen treatment
- There is persistence of bleeding symptoms
- The woman declines to undergo endometrial surveillance or comply with medical treatment
In women with endometrial hyperplasia WITH atypia, whom decline hysterectomy, what should their F/U be?
Review intervals should be every 3/12 until 2 consecutive negative biopsies are obtained
