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RCPSC > Gen Gynae > Flashcards

Gen Gynae Flashcards

1
Q

endometrial thickening + what other positive USS findings need referral to gynaecology

A
  1. increased vascularity
  2. inhomogeneity of the endometrium
  3. particulate fluid
  4. thickened ET >11mm
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2
Q

asymptomatic women on tamoxifen - screening?

A

NONE - do not do routine USS for ET

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3
Q

definition of asymptomatic ET

A

ET >5mm on USS in a postmenopausal woman who is not bleeding

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4
Q

asymptomatic ET of ____ in a postmenopausal women is not abnormal

A

8-11mm

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5
Q

ET should be measured in what plane

A

midline sagittal image by TV
bilayer measurement combining both anterior and posterior layers

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6
Q

ET in women on sequential therapy

A

+2mm may be normal

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7
Q

incidence of endometrial thickening (up to 4.5mm)

A

3-17%

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8
Q

incidence of Endo Ca in PM population

A

1.3-1.7/1000

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9
Q

incidence of endo ca in canada

A

19/100 000 women

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10
Q

% of women with endo ca that present with bleeding

A

90%

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11
Q

% of women that have stage I cancer at dx, when present with PMB

A

72%

ie, most women will have early stage ca

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12
Q

five year survival rates for localised, regional and metastatic endo ca

A
  • 95% localized
  • 67% regional
  • 23% metastatic
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13
Q

overall 5 years survival rate for endo ca

A

86%

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14
Q

Tamoxifen increases risk of developing endo ca by…

A

2.3/1000 women

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15
Q

Individual risk factors for endo ca

A
  • obesity
  • high-fat diet
  • nulliparity
  • PCOS
  • early menarche
  • late menopause
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16
Q

mean age of developing endo ca in carriers vs. non-inherited cancer

A

47yo vs. 60y

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17
Q

pre-test probability of endo ca with PMB

A

10%

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18
Q

pre-test probability of endo ca for a woman with PMB on HRT

A

1%

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19
Q

diagnosis of endometrial ca in absence of bleeding

A

5-10%

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20
Q

normal ranges of ET in menstruating women

A

3mm after menses to 15mm in luteal phase

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21
Q

increased ET after menopause may represent:

A
  • proliferative endometrium
  • hyperplasia (complex, atypical)
  • carcinoma of endometrium
  • structural abnormalities (septum, myxomas, polyps)
  • adenomyosis
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22
Q

Recommendation for women with bleeding on HRT undergo hysteroscopy/biopsy if ET > ____

A

8mm

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23
Q

tamoxifen may increase ET at what rate

A

0.75mm/year

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24
Q

mean ET after 5 years of tamoxifen use

A

12mm (6-21mm)

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25
Q

discomfort and distress reported in ___% of women who had hysteroscopy, and ___% women who had blind biopsy

A

16% and 10%

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26
Q

complicate rate for hysteroscopy

A

3.6%

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27
Q

when should menstrual suppression be initiated in women with developmental disabilities

A

after onset of menses

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28
Q

what can be used for menstrual suppression

A

CHC or POP products in extended or continuous manner

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29
Q

What to use for prevention of AUB/menstrual suppression prior to cancer treatment in pre-menopausal women at risk for thrombocytopenia

A

leuprolide acetate or CHC

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30
Q

define: menstrual suppression

A

use of various hormonal regimes prescribed in an extended or continuous fashion to achieve amenorrhea

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31
Q

goals of menstrual suppression

A
  • reduce blood loss
  • reduce cycles
  • eliminate menses all together
  • management of associated menstrual side effects

MAIN GOAL = reduce morbidity and improve QoL both for women and their caregivers

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32
Q

indications for menstrual suppression

A
  1. social choice
  2. severe dysmenorrhea/endometriosis
  3. AUB
  4. hemorrhagic diatheses
  5. hormonal withdrawal symptoms
  6. PMDD
  7. developmental disorders
  8. women with cancer/risk of thrombocytopenia
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33
Q

how common is a request for menstrual suppression from caregivers

A

32-43% of caregivers asked Drs for menstrual suppression pre-menarche

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34
Q

in adolescents with developmental disabilities, how common symptoms of AUB or other menstrual symptoms?

A

30% experienced heavy, painful or irregular bleeding

22% experienced behavioural or mood symptoms

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35
Q

most common concerns from caregivers asking for menstrual suppresion

A

coping with hygiene and possible behavioural changes

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36
Q

why wait for menarche prior to menstrual suppression?

A

confirms normal hormonal function and absence of an obstructive anomaly

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37
Q

key points to elicit for menstrual suppression history

A

1) menarchal status +/- menstrual symptoms
2) QoL and Rx goals
3) type of disability and degree of support required
4) medical history, comorbidities and medications

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38
Q

Contraceptive patch for suppression key points

A
  1. weekly transdermal application
  2. avoids first pass metabolism
  3. reduced efficacy in patients >90kg
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39
Q

vaginal ring for suppression key points

A
  1. monthly/every 3 weeks
  2. not studied in disabled population
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40
Q

DMPA injection for suppression key points

A
  1. admin every 10-12 weeks
  2. amenorrhea within 1 year in 50% of patients
  3. breakthrough bleeding and weight gain
  4. reduced BMD (reversible)
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41
Q

minimal uterine length for LNG-IUS

A

5-6 cm

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42
Q

Leuprolide - doses for menstrual suppression

A

3.75mg IM q4w
or
11.25mg IM q12w

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43
Q

Amenorrhea rates for GnRH analogues

A

73-96%

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44
Q

typically benign types of ovarian masses

A
  • simple or unilocular cysts
  • hemorrhagic cyst
  • endometrioma
  • mature cystic teratoma (dermoid)
  • fibroma
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45
Q

risk of malignancy for simple ovarian cystic masses

A

<1% for <10cm in diameter

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46
Q

increased risk for ovarian torsion with ___cm diameter ovarian mass

A

5cm

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47
Q

laparoscopic vs. laparotomy for surgical management of symptomatic benign ovarian masses

A
  • shorter hospital stays
  • faster recovery times
  • less pain
  • less bleeding
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48
Q

f/u for asymptomatic ovarian masses [benign]

A

initial repeat USS in 8-12 weeks
(preferably in proliferative phase)

THEN yearly for masses that remain stable and do not develop malignant features

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49
Q

laparoscopic management of ovarian mass should involve examination of:

A

1) the peritoneal surfaces
2) the appendix
3) upper abdomen
4) posterior cul-de-sac
5) bladder
6) uterus/tubes/ovaries

**pelvic washing for cytology, or biopsy for histopathology only if malignancy suspected

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50
Q

recommended management for post-menopausal women with symptomatic ovarian masses [benign]

A

BSO recommended

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51
Q

complication rate for surgical removal of cysts

A

2-15%

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52
Q

sensitivity of expert/specialist USS consultant

A

up to 96.7%

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53
Q

MRI sensitivity and specificity for ovarian malignancy

A

sens 96.6% and
spec 83-84%

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54
Q

risk of malignancy with a solid adnexal mass highest for ?

A

fibroma
in the 2% range

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55
Q

ovarian malignancy is associated with ovarian torsion in ___% of cases

A

<2%

but rate higher in post-MP population, anywhere 3-22%

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56
Q

pain from ovarian cyst rupture/hemorrhage associated with

A

peritoneal irritation caused by cyst fluid,
or,
from stretching of the ovarian capsule from haemorrhage into the cyst

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57
Q

indications for surgery with ovarian cyst rupture or hemorrhage

A

1) hemodynamic compromise
2) increasing hemoperitoneum or decreasing HB
3) persisting symptoms for 48h or more after presentation
4) uncertain diagnosis or suspicion of torsion

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58
Q

unilateral oophorectomy reduces ovarian cancer by

A

> =30%

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59
Q

chances that a borderline mass by frozen section analysis will result in a final dx of cancer

A

1/5

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60
Q

risk of cyst spillage during laparoscopy

A

12-25%

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61
Q

chance that dx of cancer on frozen section will remain the same at histo

A

94-99%

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62
Q

raised Ca-125 is present in what proportion of early stage and advanced stage cancers

A

50% early stage
80% advanced stage

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63
Q

sensitivity and specificity of RMI with cut-off value 200

A

75% sens
87% spec

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64
Q

physical examination in women presenting with an adnexal mass should include

A
  1. lymph node survey
  2. resp exam (r/o effusions or consolidation)
  3. breast and axillary exam (r/o breast ca)
  4. abdo exam (assess for ascites, omental caking, organomegaly)
  5. pelvic exam - bimanual + R/V
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65
Q

purpose of pelvic and R/V exam in women presenting with adnexal mass

A

assess mass for:
- size
- contour
- mobility
- parametrial, bladder, and rectal abnormalities

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66
Q

adnexal masses - who to refer to gynae onc

A
  1. solid component with strong or central colour flow
  2. > =4 papillary projections
  3. thick multiple irregular separations
  4. ascites and peritoneal nodularity

request tumour markers and CT as appropriate in mean time

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67
Q

tumor markers for adnexal mass in women <40yo

A

Ca125
hCG
LDH
AFP

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68
Q

additional tumor markers to request if bilateral masses with features of malignancy

A

CEA
Ca19-9
Ca15-3

(+ referral to gynae-onc)

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69
Q

ovarian cancer is the ____ leading cause of cancer death in women

A

fifth

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70
Q

proportion of women with ovarian ca that have symptoms in the year prior to Dx

A

93%

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71
Q

IOTA B-rules

A
  • unilocular cyst
  • presence of solids <7mm
  • presence of acoustic shadows
  • smooth multilocular tumor <10cm
  • no blood flow
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72
Q

IOTA M-rules

A
  • irregular solid tumor
  • presence of ascites
  • papillary structures >=4
  • irregular multilocular tumor >=10cm
  • strong colour flow
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73
Q

IOTA indeterminata

A

no features from either B or M; or features from both

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74
Q

request image guided biopsy for adnexal mass + what feature?

A

diffuse metastatic disease awaiting consultation with gynae-onc

75
Q

recommended imaging approaches for evaluation of adnexal masses

A
  1. subjective pattern recognition by sonographer
  2. IOTA
  3. logistic regression model
76
Q

logistic regression model 2

A
  • age
  • USS variables
    1) blood flow in papillary structure
    2) irregular cyst walls
    3) ascites
    4) acoustic shadows
    5) max diameter of largest solid component
77
Q

management options for indeterminate masses

A
  • serial USS
  • application of established risk prediction models
  • correlation with MRI
  • referral to specialised USS HCP
  • referral to gynae oncologist +/- serum biomarkers
78
Q

MRI sens and spec

for diagnosis of malignancy (adnexal mass)

A

96.6% sens
83-94% spec

79
Q

sensitivity of expert USS

A

96.7% - same as for MRI!!!

80
Q

lab tests for women with adnexal mass

A
  1. pregnancy test
  2. gonorrhea/chlamydia if suggestive of TOA
  3. CBC ? leukocytosis
  4. Ca-125
81
Q

sens and spec of Ca125

(cut-off values of 35)

A

sens 73-79%
spec 82-86%

(higher in postmenopausal women because less benign conditions and more cancers)

82
Q

IOTA rules sensitivity

A

91%

83
Q

logistic regression model 2 sensitivity

A

93%

84
Q

OVA1 panel

A

Ca125
Transferrin
Transthyretin (prealbumin)
Apolipoprotein A1
B2 microglobulin

85
Q

serum biomarkers in dysgerminoma

A

hCG
LDH

86
Q

serum biomarkers in endodermal sinus tumor

A

AFP

87
Q

serum biomarkers in embryonal carcinoma

A

hCG
AFP

88
Q

serum biomarkers in polyembryoma

A

hCG
AFP

89
Q

Serum biomarkers in choriocarcinoma

A

hCG

90
Q

Serum biomarkers in immature teratoma

A

?AFP
?LDH
?Ca125

91
Q

Serum biomarkers in granulosa cell tumor

A

Inhibin
?Testosterone

92
Q

serum biomarkers in sertoli-leydig cell tumor

A

testosterone

93
Q

Ca125/CEA ratio >25

A

associated with primary ovarian tumors

94
Q

Ca125/CEA ratio <25

A

suggests metastasis to ovary from another site

95
Q

metastatic breast ca - features of adnexal mass

A
  • bilateral ovarian tumors
  • significantly raised Ca15-3
  • slightly raised Ca125
96
Q

AUB: who should have testing for coagulation disorders

A

only in women who have a Hx of HMB beginning at menarche;
or,
who have a personal or FHx of abnormal bleeding

97
Q

AUB: endometrial biopsy should be considered for?

A
  • women over 40y,
  • not responsive to medical rx.
  • younger women with risk factors
98
Q

HMB prevalence

A

30% of women throughout reproductive lifetime

99
Q

AUB definition

A

any variation from the normal menstrual cycle, including changes in regularity and frequency, in duration of flow, or in amount of blood loss

100
Q

infrequent bleeding

A

> 38 days apart

(1 or 2 episodes in a 90 days)

101
Q

frequent bleeding

A

<24 days apart

(>4 episodes in 90 days)

102
Q

prolonged bleeding (menses)

A

> 8 days duration

103
Q

shortened bleeding (menses)

A

<3 days duration

104
Q

amenorrhea

A

no bleeding in a 90 day period

105
Q

normal frequency of menses

A

24-38 days

106
Q

normal variation in menses

A

+/- 2-20 days

107
Q

normal duration of menses

A

3-8 days

108
Q

precocious menstruation

A

before 9 years of age

109
Q

HMB definition

A

excessive menstrual blood loss which interferes with the woman’s physical, social, emotion, and or material QoL

can occur alone or in combination with other symptoms

110
Q

chronic AUB

A

present for most of the last 6 months

111
Q

PMB

definition

A

bleeding more than 1 year after acknowledged menopause

112
Q

ovulatory AUB is usually…

A
  • regular
  • associated with PMS and dysmenorrhea
113
Q

anovulatory AUB is usually…

A
  • more common near menarche/perimenopause
  • often irregular, heavy, prolonged
  • more likely to be a/w EH or ca
114
Q

Hx for AUB should include

A

HPI
- symptoms of anemia
- associated symptoms
- sexual and reproductive hx
- impact on social and sexual fxn and QoL

ROS
- symptoms suggestive of systemic causes

PMH:
- comorbid conditions
- list of medications

FHx:
- inherited coagulation disorders

115
Q

medications that can be associated with AUB

A
  • anticoagulants
  • Antipsychotics (first gen + risperidone)
  • CHC
  • corticosteroids
  • SSRIs and TCA’s
  • Tamoxifen
  • ginseng, chaste berry, danshen
116
Q

imaging studies in cases of AUB indications

A

1) examination suggests structural cause
2) conservative Rx failed
3) risk of malignancy

117
Q

average age for women with endometrial ca

A

61y

118
Q

proportion of endometrial ca occurring in pre-MP women

A

5-30%

119
Q

NSAID mechanism

A

reduce total prostaglandin production through inhibition of COX; promote vasoconstriction

120
Q

NSAID efficacy for menses

A

reduce menstrual loss by 33-55% compared to placebo

121
Q

NSAID efficacy for dysmenorrhea

A

improve for up to 70% of patients

122
Q

NSAID with highest risk of GI side effects

A

naproxen

123
Q

TXA mechanism

A

antifibrinolytic
(plasminogen activator inhibitor)

reversibly binds to plasminogen
reduces local fibrin degradation

124
Q

TXA efficacy

for HMB

A

overall reduction in menstrual loss 40-59% from baseline

125
Q

TXA doses

A
  • 1g QDS
  • 4g PO OD
  • 10mg/kg QDS IV
126
Q

AUB: efficacy of CHC

A

up to 40-50% menstrual blood loss reduced for cyclical use

127
Q

norethisterone - ___% of women with irregular cycles will achieve menstrual regularity

A

50%

128
Q

DMPA: amenorrhea rates

A

over 50% amenorrhea after 1 year

129
Q

LNG-IUS efficacy for HMB

A

reduction of
86% at 3/12
and
97% at 12/12

130
Q

LNG-IUS amenorrhea rates

A

20-80% at 12/12

131
Q

LNG-IUS discontinuation due to side effects

A

1-2% at 1 year

132
Q

LNG-IUS irregular bleeding

A

20% in the first month to 3% at 3 months

133
Q

LNG-IUS risk of perforation

A

<1/1000

134
Q

LNG-IUS risk of expulsion

A

1/20 over 5 years
(most likely to occur with the first menses)

135
Q

LNG-IUS risk of infection

A

<1%, greatest risk within 20 days of placement

136
Q

danazol mechanism

A

induces endometrial atrophy by inhibiting ovarian steroidogenesis through suppression of HPO

137
Q

danazol efficacy

(for HMB)

A

reduce loss by up to 80%

138
Q

danazol doses for AUB

A

100-400mg/day

20% of women will become amenorrheic at lower doses

139
Q

GnRH have been shown to reduce uterine and fibroid volume by up to:

A

60%

140
Q

indications for surgery for women with AUB

A
  • failure to respond to medical therapy
  • inability to utilise medical therapies
  • significant anemia
  • impact on QoL
  • concomitant uterine pathology
141
Q

surgical options for managing AUB

A
  • D&C
  • hysteroscopic polypectomy
  • endometrial ablation
  • myomectomy
  • hysterectomy
142
Q

AUB is reported by up to ___% of women with vWD

A

84%

143
Q

what proportion of women presenting with HMB will have an underlying bleeding disorder

A

10-20%

144
Q

what proportion of adolescents presenting with acute bleeding at menarche will have a coagulopathy

A

up to 50%

145
Q

IV estrogen for acute bleeding

A

25mg every 6 h

146
Q

PO estrogen for acute bleeding

A

2x 35mcg estrogen OCP tabs x 5/7, then reduced to one/day

147
Q

PO progestin alternatives for acute HMB

A
  • MPA 10-20mg BD
  • megestrol acetate 20-60mg BD
148
Q

what proportion of teens have HMB

A

12-37%

149
Q

within first year following menarche, % cycles that may be anovoluatory?

A

85%

by the 4th gynaecology year, 56% are ovulatory

150
Q

factor most predictive of persistent cycle irregularly

A

oligomenorrhoea at age 15

151
Q

average age of torsion

A

26

152
Q

which side is more often affected in torsion

A

right (66%)

153
Q

incidence of malignant lesions with torsion (adult vs child)

A

3% adult cases
0-6% pediatric cases

154
Q

most common adnexal lesions involved in torsion in adults

A

60% cystic teratoma
30% cystadenoma

155
Q

what proportion of PM women with torsion had a malignant tumor

A

22%

156
Q

adnexal volume ratio on USS suggestive of torsion

A

> 20

157
Q

CT findings that may be suggestive of torsion

A
  • uterine tube thickening 74%
  • eccentric or concentric wall thickening
  • eccentric septal thickening
158
Q

time to surgery for suspected ovarian torsion resulting in improved outcomes

A

<72h

159
Q

rate of torsion in pregnancy per trimester

A

1st - 55%
2nd - 34%
3rd - 11%

160
Q

risk of recurrence of torsion in a twisted but normal adnexa

A

63%

161
Q

risk of recurrence of torsion in a twisted but abnormal adnexa

A

8.7%

162
Q

cyst drainage or cystectomy reduced chance of re-torsion by:

A

50% and 75%

163
Q

whom to consider oophorectomy in torsion

A
  • congenitally long ovarian ligament
  • cases of repeat torsion
  • when no obvious cause found
164
Q

oophoropexy - where to fix and how

A
  1. pelvic side wall
  2. back of uterus
  3. ipsilateral uterosacral ligament

using absorbable or non-absorbable sutures

165
Q

paediatric cases of adnexal torsion involve normal ovaries in what % of cases

A

15-50%

(vs only 8-18% or less in adults)

166
Q

most common signs and symptoms of adnexal torsion

A
  • N/V in 60-70%
  • palpable mass 60-90%
  • sharp or stabbing lower abdo pain 60-70%
167
Q

independent predictors of ablation failure

A
  1. Age<40
  2. Prior tubal ligation
  3. preop dysmenorrhea
168
Q

false negative rate for office endometrial biopsy

A

5-15%

169
Q

CHC in bleeding disorders may increase levels of ____

A

Factor VIII and vWF

170
Q

incidence of vaginal vault dehiscence

A

0.24-0.31%

171
Q

The incidence of vault prolapse following hysterectomy without symptomatic POP

A

1-2%

172
Q

UPA for fibroid treatment, liver monitoring

A
  • LFTs (AST and ALT) prior to starting each treatment course
  • Monthly LFT during the treatment course
  • LFT 2–4 weeks after completing a treatment course
  • Signs or symptoms of liver injury should prompt testing
173
Q

UPA for fibroid treatment - when to avoid giving

A
  • do not start if LFTs >2x ULN
  • stop if LFTs >3x ULN
174
Q

leuprolide acetate for fibroid rx - indication?

A

concomitantly with iron therapy for preoperative hematologic improvement in women of reproductive age with anemia caused by fibroids

(up to 3/12)

175
Q

proportion of untreated fibroids that may regress in pre-MP population

A

3-7%
over 6/12 to 3 y

176
Q

GnRH agonist fibroid shrinkage
(ie. goserelin)

A

50% by 3/12

177
Q

Danazol fibroid shrinkage
(androgen)

A

20-25%

178
Q

UPA fibroid shrinkage

A

72%

Fibroid volume reduction maintained for 6/12 after end of treatment

179
Q

HRT in fibroids

A

ok to give, but may be associated with myoma growth/new symptoms

180
Q

HB for fibroid surgery

A

> 120

181
Q

recurrence rate following myomectomy

A

15%

10% will eventually have hysterectomy within 5-10y

182
Q

hysteroscopic myomectomy is suitable for which FIGO types

A

0, I, II,
up to 4-5cm

Type II more likely to need 2-staged procedure

183
Q

opportunistic salpingectomy at time of benign hysterectomy associated with what decrease in HGSC?

A

40% over 20y

184
Q

Incidence of urinary tract injury in benign hysterectomy

A

0.2-15/1000

consider, or have available, kit for selective cystoscopy

RCPSC (17 decks)

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